Jos Journal of Medicine

Pain specialists consider chronic pain to be the most costly health problem in America today. In terms of medical expenses, lost income, and lost productivity, the total cost easily passes the $60 billion mark. Low back pain alone accounts for 93 million lost workdays each year. Migraine sufferers lose another 65 million. People with osteoarthritis visit the doctor 7 million times, lose 36 million working days, and spend over $4 billion on over-the-counter remedies and prescription drugs.

The impact on you, the patient, is even more overwhelming. It can keep you from being active, from enjoying family and friends, from sleeping, and from eating. It can make you depressed, anxious, or irritable. You need to seek help before the pain gets too severe. Getting help early on can make the pain more manageable. More important, chronic pain has a life of its own and is truly a disease in its own right.

Evaluating pain

Because pain is a private, unique experience, it is subjective. There are no blood tests or objective means to measure pain. Doctors rely on the patient’s description of pain to help determine treatment. They may ask you to locate your pain on a picture of a body and select words, like burning, aching, throbbing or stabbing, that best describe it. Or they may have you rate your pain on a numerical scale from 1 to 10, a verbal scale from no pain to the worse possible pain, or even a visual scale using smiling and frowning faces.

It’s important to convey the amount and type of pain to your doctor not only at the time of your visit but in a normal day. A pain diary where you jot down the type of pain you’re feeling, when you feel it, and what relieves or doesn’t relieve it can help you keep track.

Your pain management team

If your regular doctor cannot find an effective way to reduce your pain, he or she should refer you to a specialist, say a rheumatologist if arthritis is suspected, or even better to a pain clinic that offers a team approach to pain management. There, specialists in anesthesiology, neurology, rheumatology, orthopedics, psychology, psychiatry, physiatry, and physical therapy will evaluate and diagnose you so that all aspects of your pain and its underlying cause may be treated. Their goal is to create a pain plan just for you that will control your pain and improve your quality of life through medications and complementary therapies.

Perhaps the most important member of the team is you. Starting with describing your pain accurately and openly, you are taught to take control. Keeping a positive attitude, practicing healthy habits like eating right and getting enough sleep, reducing stress, and taking your medications as instructed will help manage your pain.

Pain-relieving medications

Nonsteroidal anti-inflammatory drugs without a prescription, or NSAIDs, including aspirin, ibuprofen, naproxen, and ketoprofen in both over-the-counter and prescription strengths, relieve pain due to inflammation. They work by lowering the production of prostaglandins in your body, chemicals that are involved in the inflammation process. Prostaglandins also make nerve endings more sensitive, which intensifies pain. Unfortunately, some prostaglandins also help protect the lining of the stomach and esophagus from normal irritations, so when their production goes down with NSAID use, the risk of ulcers and other gastrointestinal bleeding goes up. Increasingly, physicians are questioning the safety of traditional NSAIDs. Citing the risks, which are especially high in the elderly, some have even called them the “double-edged sword.” New forms of NSAIDs, with reduced risk of such side effects, are now coming on the market. Called Cox-2 drugs to indicate their specificity for one of the chemicals involved in joint inflammation (cyclo-oxygpnase), they include Celebrex and Vioxx.

Acetaminophen (e.g., Tylenol) is an aspirin-free pain reliever that the American College of Rheumatology now recommends as the first-line drug defense against osteoarthritis pain. Since it does not reduce swelling or inflammation, it has little effect in rheumatoid and other forms of arthritis. While it does not cause the gastrointestinal side effects that NSAIDs do, long-term use at high doses has been linked to liver and kidney problems.

The most effective painkillers are narcotics, or opioids, available only by prescription. They include morphine, codeine, hydromorphone, oxycodone, and meperidine (Demerol), and work by blocking pain signals traveling to the brain. Long accepted for use in pain associated with cancer and surgery, only recently have pain specialists begun to advocate their use for chronic pain. New controlled-released formulations are convenient and very effective. Side effects include drowsiness, constipation, slowed breathing, and mood changes, but rarely addiction or tolerance in pain patients without a history of substance abuse.

Tramadol is a synthetic analgesic that acts a bit like a narcotic and is effective in treating moderate to severe chronic pain. However, it causes fewer side effects than narcotics and, unlike the NSAIDs, does not irritate the stomach lining or aggravate high blood pressure or congestive heart disease, making it a useful painkiller for the elderly patient.

Antidepressants, anticonvulsant drugs, muscle relaxants, and tranquilizers can also help control chronic pain. Each must be closely monitored and most should only be used for a short time.