Effectively Managing Chronic Pain
Chronic pain is almost invariably a miserable medical condition to have, and learning to live with chronic pain by managing it effectively is one of the biggest challenges facing patients and their providers. By definition, chronic pain is pain that has lasted a long time, which means that it has been resistant to treatment. The medicines and medical procedures that normally reduce and eventually eliminate pain have not worked, which leaves the patient hurting and leaves both patient and doctor feeling enormously frustrated. Moreover, there is virtually no aspect of a pain sufferer’s life that is not negatively impacted by their pain: basic movements and day to day activities, the ability to work, emotional life, quality of relationships, appetite, sleep, energy level, and just the basic enjoyment of life are all undone to a large degree by ongoing or recurring pain. Pain makes us irritable, unhappy and withdrawn, to the point that it’s been observed repeatedly in clinic settings that patients with chronic pain are virtually indistinguishable from patients with severe, protracted depression.
By contrast, acute pain -- pain of relatively short duration -- is literally a life saver. We very much need our ability to register pain as a means of remaining safe and healthy. When we’ve sustained an injury or if we have an infected wound, it is our ability to perceive pain that alerts us to the problem, and tells us to look after the wounded body part and let it rest until it heals.
What happens though when pain signals continue to be generated by the body, long past the time that healing has taken place? This is another way to describe chronic pain and it may have multiple sources. It may be due in part to inflammation in muscles and connective tissue (ligaments and tendons) that are being unused or underused, perhaps as a result of the original injury. Some chronically painful conditions, such as migraines, can also be due to inflammation of blood vessels. And still others may be the product of injuries or viral infections in nerves, such as we see with phantom limb pain or neuralgias of various kinds. Whatever the source of the pain, it is described as “chronic” when it is long lasting (typically more than a few months’ duration) and when the tissue that hurts is now healed and is effectively healthy.
Why would I see a psychologist for pain?
First, you should know that in 30 years of working with pain patients, I’ve never seen anyone who didn’t have “real” pain. Pain is pain, and I want to highlight this point because pain patients are often concerned that they are being referred to a psychologist because their medical provider suspects that their pain isn’t real, or that it’s at least being exaggerated by the patient if not being imagined outright. If you have any concerns along these lines, I would encourage you to discuss them frankly with your provider. Every patient I see has real pain and deserves to be getting the most effective, and the most comprehensive, treatment they can.
Second, I want to make a distinction between traditional allopathic medicine and behavioral medicine. The pain patients I work with have typically reached a point in their pain treatment that is referred to as being “medically stable”. This means that, while they unfortunately still have a great deal of pain, all of the medical treatments that make sense to try have been tried, and have had only limited success. To say it differently, there does not appear to be anything else that someone can do to you that will fix the problem.
This does not mean that all treatment options have been exhausted, not by any means; but only that any progress you make from now on is going to have to do more with the behavioral changes you make and new habits you develop, than it has to do with any new therapy that you passively receive. This means that physical reactivation is likely to be a major component of your behavioral program for getting better and hurting less. For this reason, it’s important to coordinate treatment with your other providers – especially your primary care doctor and your physical therapist if you are working with one. You need to know that movement is safe and that with chronic pain, “hurt” is typically not the same thing as “harm”.
I also tend to spend a lot of time with patients working on relaxation and stress reduction, emphasizing that even a small amount of ongoing muscle tightness or tension can contribute to a great deal of pain over time. In other words, people who don’t think of themselves as being particularly stressed are often surprised at how much better they feel as their ability improves to relax, stretch and strengthen muscles and tendons. Regarding the feeling side of stress, experiencing strong negative emotion almost always tends to make pain worse for most people. Because of this, another key component of an overall behavioral package for managing pain revolves around recognizing and managing strong emotions more effectively. Like the physical dimension of stress, it doesn’t take much emotional upset to greatly exacerbate a given level of pain. On the plus side however, improving one’s ability to manage upsets more effectively can go a long way in reducing pain.
Finally, as I alluded to above, ongoing pain is literally depressing. When you ask pain patients to make a list of all the negative ways they have been impacted by pain, it tends to be nearly the same list that will be generated by seriously depressed patients regarding the negative changes associated with their depression. With both chronic pain and depression, mood takes a hit, but so do sleep, appetite, energy level, and overall quality of life. This means that, to the extent that daily life is suppressed or depressed by pain, a big part of the solution will be to get moving again. We know that physical activity alone is a very effective treatment for depression, in and of itself. In part this appears to be due to the direct effects of movement on brain chemistry, though it also seems pretty clear that quality of life improves when we begin to get going again. One of my mentors some years ago made the observation that “People who have something better to do don’t hurt as much”. What he meant by this is that we suffer less with pain, it begins to be less severe and less troublesome, as we begin to resume the activities that we love and that make us feel good about ourselves. From a behavioral standpoint, this means that full recovery from pain has to include being able to safely return to enjoyable and fulfilling activities that are emotionally nourishing.
To summarize, I would say that if you have chronic pain and have not had the opportunity to develop a package of behaviorally based tools for managing your pain more effectively, it’s possible that you’re hurting much more than you need to be. If you have any questions, or would like to have an initial no-cost consultation by phone, please do not hesitate to call or email me at your convenience.
A word about opiates and chronic pain:
Whether or not you are currently taking narcotic pain medications as part of your overall pain management regimen is a decision that has been worked out between you and your physician. Many of the patients I see are currently prescribed opiates, many aren’t, and many were in the past but no longer are. From a pain management perspective, the biggest single problem perhaps with using narcotics to treat chronic pain is something called “tolerance” – the process by which our bodies become accustomed to some medicines over time so that we need a bigger and bigger dose of the medication to get the same amount of pain relief. If you are currently taking opiates, are getting some relief, and are on a stable dose with minimal side effects, it would not necessarily be important to me that you discontinue those medications. On the other hand, if you're interested in considering stopping opiates, developing a behaviorally based program of pain management can provide a number of effective tools to facilitate tapering off narcotics under the supervision of your prescriber.