Chronic or Recurrent Pain: the Nation's Leading Cause of Disability

More than 50 million Americans suffer from chronic or recurrent pain. It's the nation's leading cause of disability and costs employers more than $60 billion a year in productivity. It can rob a person of his or her ability to work, sleep soundly, have satisfying personal relationships or enjoy the simplest of pleasures. Yet only one in four sufferers will receive proper treatment according to the American Pain Foundation.
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"Pain remains one of the most undertreated ailments in society and very often pain complaints are swept under the rug," says Mark Allen Young, M.D., a physical medicine and rehabilitation specialist in Baltimore, author of Women and Pain and former editor-in-chief of the Journal of Practical Pain Management. That's because both doctors and patients tend to dismiss pain as the natural result of an injury or illness, which will end when they recover.
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But keeping a stiff upper lip can be disastrous: Recent studies show that pain that lingers untreated for more than three months can actually change the hard wiring in the brain, triggering permanent changes in the way the body responds to pain signals. This both intensifies the experience of pain and risks making the condition chronic. "If pain is not nipped in the bud with aggressive treatment, it becomes much more difficult to treat," Dr. Young says.
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Fortunately, a growing number of doctors recognize that pain is a debilitating medical condition in itself and sometimes must be treated separately from what triggered it What's more, some insurance companies may cover the costs of pain-management programs. And in California, to get their license renewed, physicians need to take a course in pain management, which enhances their ability to keep acute pain from becoming chronic.
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If you sense that you might be developing a chronic pain problem that your current pain regimen hasn't been able to stave off, start by asking your primary-care physician to refer you to a pain specialist or clinic. If your doctor doesn't know one, look for a pain-treatment center at local hospitals or medical centers.
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Although there is not one magic pill that will vanquish acute, recurrent or chronic pain, doctors now have a broad array of options that blend alternative therapies with traditional medicine. "We can't cure chronic pain," says Anthony H Guarino, M.D., a pain management specialist at the Washington University School of Medicine, in St. Louis, "but we can manage it and greatly improve a patient's quality of life."
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How Pain Can Become Permanent
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Once the wiring of the nervous system changes in response to prolonged pain, "the pain you feel doesn't correspond to what is going on in your body," says James N. Dillard, M.D., a rehabilitation medicine specialist in New York City and author of The Chronic Pain Solution. A few become so hypersensitive that even the slightest touch or vibration can be excruciating. "Fifteen years ago, people who had these complaints were sent to psychiatrists," says Dr. Dillard. "But now we know that the nervous system is very adaptable, and that the pain pathways can ramp up and amplify the signals."
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Every person has a unique susceptibility to pain. Some people can be seriously hurt yet recover quickly, while others are incapacitated by a relatively minor mishap. "People may be genetically predisposed, or a past history of injuries may make them more susceptible," says Linda LeResche, Sc.D., an epidemiologist and professor at the University of Washington in Seattle.
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Unrelenting pain can erode health and age people prematurely. The release of stress hormones in reaction to pain weakens the immune system, which compromises our ability to fight disease, A year or more of chronic pain can cause brain shrinkage that's 5 to 11 percent beyond what normal aging would take away, according to a 2004 Northwestern University study. Researchers suspect that the cumulative stress of coping with pain wears out brain nerve cells. "The long-term damage can trigger a self-perpetuating cycle of pain, making the condition more intractable," says A. Vania Apkarian, Ph.D., a pain specialist at the Northwestern University Feinberg School of Medicine, in Chicago.
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Chronic pain also spawns an escalating cascade of psychological and emotional problems. Pain sufferers can't sleep, which makes them irritable, anxious, and depressed. One-third report they can't function normally and sometimes feel so bad they want to die.
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Breaking the Cycle and Pain-Relief Resources

Breaking the vicious cycle of pain can be challenging.
"By the time patients are referred to our clinic, many of them have been in pain for five years or more," says Carmen R. Green, M.D., a pain-medicine physician at the University of Michigan, Ann Arbor. Once experts determine the source of trouble, they tailor a treatment program to a patient's medical and psychological history. Finding a pain solution is highly individual; what works for one person may not be successful for another, even when both have the same problem.
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Physicians usually employ a two-step process. Unless the pain is relatively mild, they first try to soothe-or at least lessen-it with an individualized combination of painkilling drugs and other techniques. Then they create a comprehensive pain-management plan that mixes traditional and complementary therapies to help people resume to a normal life.
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I. Step One: Lower the pain level. Before someone can get started on long-term strategies, his or her pain has to be at least manageable.

A. Physicians will start
by reviewing a patient's current ways of seeking relief. They may try upping the dosage of medications such as ibuprofen or acetaminophen. Specific problems can call up a wide range of other drugs: antiseizure medications to ease pain triggered by nerve damage (from shingles or neuropathy from diabetes) or steroid injections for arthritis or back pain to reduce swelling, which eases pressure on nerves. Antidepressants, such as Prozac, or sleeping pills can help people in pain get a restorative night's sleep so they start to feel better during the dayl For tension headaches and migraines, doctors may use the wrinkle-eraser Botox, and injectable toxin that paralyzes cramped muscles.
B. For people in constant, severe pain, specialists turn to opiates, though many physicians are reluctant to prescribe these medications because they can be addictive and leave users nauseated and groggy. But they can soothe pain that milder drugs don't help. Doctors may try morphine, oxycodone or the longer-acting methadone, better known afor weaning addicts off heroin. Skin patches containing fentanyl, another opiate, can also provide round-the-clock relief.
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II. Step Two: Establish a logn-term treatment plan. Once a person's pain has been stabilized, physicians experiment with an array of treatments, depending on the condition's root cause. If they can, they wean patients off opiates, substituting less-powerful medications if still needed. Their arsenal includes a range of mainstream and mind-body strategies.
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A. Mainstream Therapies
In addition to continuing some form of prescription drugs, patients may get some combination of the following:

1. Injections and nerve blocks. Local anesthetics, such as procaine, sometimes in combination with cortisone-like medicines, can be injected around nerve roots and into muscles or joints. These shots can ease swelling, irritation, muscle spasms and the abnormal nerve activity that can make people miserable.
2. Electrical stimulation. Transcutaneous electrical nerve stimulation uses a small battery-operated device that alleviates pain by externally stimulating nerve fibers through the skin. For more debilitating and intractable pain, doctors may surgically implant brain stimulators inside the spinal cord that deliver timed electrical impulses to interfere with the transmission of pain signals.
3. Physical therapy. All too often pain sufferers become sedentary because they're afraid of injuring themselves further. This contributes to weight gain and an overall physical deterioration that just exacerbates their pain. In fact, exercise may be as beneficial as heavy-duty medications at easing symptoms because it is energizing and may promote the release of endorphins, the body's natural painkillers. Doctors may prescribe exercise program, such as aquatic therapy, to get even patients crippled by agonizing pain moving again. "Regaining function is key to overcoming chronic pain," says Scott Fishman, M.D., and anesthesiologist and psychiatrist who is chief of pain medicine at the University of California, Davis, and past president of the American Academy of Pain Medicine.
4. Heat. In study of 110 men and women suffering from osteoarthritis of the knee, patients got a greater pain relief from using heat wraps that from taking ibuprofen, the usual treatment for this type of pain. "Heat wraps seem to work by blocking pain signals and they also stimulate healing by increasing blood flow," says John Mayer, Ph.D., an exercise physiologist and research director at San Diego's U.S. Spine & Sport Foundation.

B. Mind-Body Methods

1. Massage Therapy. Deep-tissue massage loosen clenched muscles and other tight tissues, which otherwise ratchet up pain. The rubbing sensation also seems to stop pain messages from reaching the brain. A 2004 study of 1,290 cancer patients at Memorial Sloan-Kettering Cancer Center, in New York City, revealed that a massage significantly reduced pain for two days or longer. "It was quite amazing," says sstudy author Barrie Cassileth, Ph.D., chief of Integrative Medicine Service at Memorial Sloan-Kettering. "human touch is extremely important and has physiological implications."
2. Acupuncture. The ancient Chinese therapy, which involves inserting very thin needles at pressure points in the skin, can ease intractable pain in some people. Experts don't know exactly why acupuncture works, but research suggests the physical stimulation triggered by the needles affects the nervous system and promotes the release of endorphins and other natural opiods produced by the body. Even pain caused by nerve damage, which is difficult to control with conventional pain meds, can be eased if not eliminated altogether with acupuncture, says Dr. Cassileth. In a landmark 1987 Kaiser Permanente study, for example, researchers compared four groups of women who had menstrual pain. They received either acupuncture, a placebo form of acupuncture, extra office visits or no extra treatment. Ninety one percent of the women in the acupuncture group cut their pain in half compared with only 36 percent of th econtrol groups. And the acupuncture patients were able to cut their use of painkillers by 41 percent in the nine months following the treatment. More recently a 2004 Duke University study involved 75 breast cancer patients who were treated wither a high tech acupuncture-like therapy or conventional medications to control postsurgical nausea and vomiting. A day after the procedure about three-quarters of the women who received acupuncture had no symptoms compared with half of the women who took drugs.
3. Other complementary-medicine techniques. These may divert sufferers' attention from pain to pleasurable thoughts. Options include hypnosis, meditation, music and art therapy, deep breathing and guided imagery (a method where a patient uses positive images to relieve pain.) In one 2005 study by Stanford University researchers, for example, patients were actually taught to watch their brain on pain via functional magnetic resonance imaging. Subjects saw a representation of their brain activity in the form of burning flame. They learned to make the flame fo up or down by thinking. Their pain would correspondingly go up or down. "over time, people slowly gained better control of the brain region--it is like going to a gym and working out a muscle," says researcher Sean Mackay, M.D.Ph.D., associate director of the Stanford University Pain Magagement Center, in Stanford, California. "These research results lend further validation to many of the techniques that pain psychololgists use, such as guided imagery and stress reduction, to bridge the mind-brain connection."
4. Psychological counseling. "Patients are often reluctant to see a pain psychologist because they feel doctors don't believe they have a physical problem," says Dr. Fishman. "But emotions like depression or anger can increase pain's decibel level." Counseling can help relieve these feelings and lower pain.

Endoscopic Ultrasonography-Guided Celiac Plexus Block for the Management of Pain from Chronic Pancreatitis:

The natural history and pathogenesis of painful chronic pancreatitis is still poorly understood. Management of pain resulting from chronic pancreatitis can be one of the most difficult challenges a clinician faces. A variety of therapeutic options exist, including:

1. suppression of pancreatic secretion (pancreatic enzymes, octreotide),
2. symptomatic pain control with narcotics or pain modifying agents (tricyclic antidepressants, serotonin reuptake inhibitors),
3. drainage procedures (ERCP, lateral pancreatojejunostomy), and
4. surgical removal of the diseased part of the pancreatic gland (Whipple resection or total pancreatectomy).

It is clear that no one therapeutic approach works in all patients.
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Unfortunately, all therapies for pain resulting from chronic pancreatitis have a variable success rate, and many patients become dependent on narcotic agents. Celiac plexus block has been used for pain relief in some patients with chronic pancreatitis. Celiac plexus block can be performed by using a blind translumbar fluoroscopic approach or by CT guidance using transposterior or transanterior approaches. The advances in endoscopic ultrasonography have allowed the development of endoscopic ultrasonography-guided celiac plexus block, a relatively simple and short (approximately 15 minutes) outpatient procedure. More importantly, paraplegia has not been described after endoscopic ultrasonography-guided celiac plexus block, probably because of the anterior transgastric approach taken during endoscopic ultrasonography-guided block, decreasing or even eliminating the risk of nerve or spinal cord injury.
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A combination of long-acting local anesthetics and steroids injected into the celiac plexus under endoscopic ultrasonography guidance in patients with chronic pancreatitis has been used for years (Hawes, Personal communication, February 2002), yet the published data are scarce. Gress et al. compared endoscopic ultrasonography-guided versus CT-guided celiac blocks in a prospective, randomized fashion. The conclusion of this small study was that endoscopic ultrasonography-guided celiac block in ten patients provided more persistent pain relief than CT-guided block in eight patients. The same group of investigators recently published their prospective experience with endoscopic ultrasonography-guided celiac plexus block in 90 patients with pain resulting from chronic pancreatitis. A significant improvement in pain score occurred in 55% of the patients. The benefit persisted beyond 12 weeks in 26% of patients and beyond 24 weeks in only 10%. Younger patients (<45>

The current evidence indicates:

1. The pathogenesis of idiopathic chronic pancreatitis remains poorly understood;
2. Genetic mutations or autoimmune processes account for the minority of cases in patients with idiopathic chronic pancreatitis;
3. The true value of endoscopic ultrasonography in diagnosing small-duct chronic pancreatitis remains to be fully defined;
4. Endoscopic ultrasonography-guided celiac plexus block can provide excellent short-term pain relief in some patients with chronic pancreatitis; and
5. Until long-term studies examine the safety and efficacy of celiac plexus block, its use should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities.

Pain-Relief Resources:

American Academy of Pain Medicine is a professional group that offers consumers information on pain-control methods and has a directory of pain-medicine physicians. www.painmed.org

American Chronic Pain Associations is a consumer group that provides pain-medicine information for professionals and patient guides that list pain-management options. ACPA sponsers more that 400 support groups nationwide. www.theacpa.org

American Pain Foundation is an advocacy and education group. It offers a pain-information library, provides pain-relief resources for military veterans and online chat rooms. www.painfoundation.org

The National Pain Foundation provides guides to pain-treatment strategies and links to online support groups. www.painconnection.org..

.. Good luck to all who suffer pain. May you each find a resolution.

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