Managing Chronic Pain. Part 2

Disease-specific drugs

Imitrex and the newer drugs in its class, Zomig, Amerge, and Maxalt, stop the transmission of pain in migraine headaches by acting directly on the facial nerve that studies have shown to be the main cause of the headache. Side effects include tightness in the chest and occasional difficulty in breathing. A new compound being tested by Eli Lilly eliminates these side effects.

Synvisc and Hyalgan are new drugs for osteoarthritis of the knee. Administered in a series of three to five injections into the knee, they work by substituting for hyaluronic acid, a naturally occurring lubricant and shock absorber in joints. Relief may last for more than 6 months. They are useful for people who can’t get relief from pain medication, exercise, or physical therapy. Studies are underway to determine whether repeated treatments offer continued relief and whether the treatment is effective for shoulders and hips.

The introduction of disease-modifying antirheumatic drugs or DMARDs, such as methotrexate, gold injections, hydroxychloroquine (Plaquenil), and the newer Enbrel, which interrupt the immune process that causes inflammation, have created a revolution in the treatment of rheumatoid arthritis. Increasingly, they are being used in the early stages of the disease to slow the progress of joint destruction.

Cortisone, a naturally occurring hormone, can be injected directly into a joint or other tissue to reduce swelling and inflammation. The corticosteroid drug, prednisone, can be taken orally for rheumatoid arthritis and lupus.

The topical cream, capsaicin, can help relieve pain from shingles, arthritis, and cluster headaches.

Pain relief without medication

One of the oldest pain treatments and two of the newest seem to work by stimulating the body’s production of its natural painkillers, the endorphins. Acupuncture is the 2,000-year-old Chinese technique of inserting fine needles into the skin at selected points in the body. The much newer transcutaneous electrical nerve stimulation (TENS) involves delivering brief pulses of electricity to nerve endings under the skin. Both have been shown at least temporarily to increase endorphins in the body. Surgery that implants electrodes in specific areas of the brain also affect endorphin levels. Sufferers of chronic pain have reported relief with all three procedures. There are also other surgical and anesthia procedures used to test chronic pain
Psychological treatment for pain runs the gamut from relaxation training to biofeedback to psychotherapy. Anything, in fact, that allows you to reduce stress and muscle tension, such as meditation, hypnosis, or just listening to music, will help relieve pain. Some patients find they can learn to control pain conditions involving tense muscles, like tension headaches or low back pain, using biofeedback techniques.

Lifestyle changes – better diet, more exercise, increased socialization – should be a part of any pain management program.

Why treatment often fails

Two centuries after morphine was first identified as a potent painkiller, millions of people still suffer needlessly from chronic pain. A survey released in February 1999 indicates that of those who suffer from non-cancer related chronic pain, more than 40% say their pain is out of control. The percentage may even be higher among the elderly and nursing home residents with chronic pain With all the medications and therapies, why the high failure rate?

The reasons are many. Some are due to the inexperience and lack of knowledge about pain and its management among doctors and other healthcare providers. Taking pain seriously, understanding it as a multifaceted condition requiring a multidisciplinary approach is a relatively new concept. Many doctors fail to assess and document pain routinely. Often they just don’t listen carefully enough to a patient’s complaints. Sometimes the problem lies with the patients themselves. Pain patients, particularly the elderly, frequently fail to make the full extent of their pain known. They may fear that increasing pain means a worsening of their condition, think they can tough it out, or expect pain with age.

Other reasons have to do with the limitations of the drugs themselves. Most non-narcotic pain relievers are only effective for mild to moderate pain. Many have intolerable side effects. And then there are the outdated and unfounded fears of prescribing narcotics on the doctor’s side and using them on the patient’s side – fears of addiction, tolerance, side effects, and prosecution due to strict regulations on these controlled substances. In 1997, the American Academy of Pain Medicine and the American Pain Society together endorsed a position that recognized opioids as “an essential part of a pain management plan.” Their statement noted that studies contradict the myths that have stigmatized opioid therapy. Such studies show that opioid use in pain patients does not lead to addiction or unmanageable side effects.

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