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Integrating Chronic Pain

There’s no mistaking it: every day, technology is changing our lives in ways that we probably never imagined. We’ve seen some astounding technological advances which have dramatically improved safety and patient outcomes. When medical interventions are required today, they are generally safer and less painful; patients get better more quickly and stay better longer.
Let’s follow the story of Henry, a typical 65-year-old man, from his first chest pains through heart surgery--all the way to his full recovery at home.

iStock 000014030479SmallIt’s a difficult conversation; one I have all too frequently with my aging patients. We have to be realistic. There are times when a diagnosis of chronic pain means that, no matter what we try, we will never achieve 100% relief. Instead, we turn our attention to helping the patient become as functional and pain-free as possible within the parameters of his or her condition. We focus on maximizing the quality of life and integrating the reality of ongoing pain management.

Here are some of the most frequent questions I get about chronic pain.
What is chronic pain? The distinction between acute, subacute, and chronic pain is made based on the duration of the pain. Generally:
  • Acute pain lasts less than 30 days and is usually due to some injury or other event.
  • Subacute pain lasts from a few weeks to a few months.
  • Chronic pain lasts for six months or more without any improvement.
A simple definition of chronic pain is any pain that lasts longer than the expected duration of healing. And it’s important to note that pain does not have to be consistent to be chronic. It can come and go, and may not affect you to the same extent every day. But it never goes away entirely.

What are some common types of chronic pain in older adults? By far, the most frequent one that I see is pain due to osteoarthritis (also known as degenerative arthritis or degenerative joint disease), the most common form of arthritis. 

iStock 000015143546SmallOthers include fibromyalgia, spinal stenosis, and pain related to falls or other injuries. In addition, conditions like multiple sclerosis, lupus, neuropathy due to diabetes, and depression can be associated with chronic pain.

How do you measure the degree of pain? The most commonly accepted pain measurement technique is a 0 – 10 scale. Zero means no pain at all, and 10 is the worst pain you can possibly imagine (patients who have had  a joint replacement, kidney stone, open heart surgery or given birth can relate to a level 10 pain experience!). Nurses often use a graphic illustration of faces that go from happy to weeping to help patients assess their current pain.

Now, this is somewhat subjective and arbitrary as everyone’s level of pain tolerance is different. What is an “8” to one person might be a “3” to someone else. But this scale can give us a general idea and a way to measure improvement in the individual patient. With patients who are unable to communicate due to dementia or other conditions, we watch for nonverbal cues and biological responses like increased heart rate and blood pressure.
What about pain tolerance? I think there is a misperception amongst the geriatric community that older folks are tough—that they can handle a higher level of pain because they’ve been there/done that. And that’s just not true. The reality is that your tolerance for pain has to do with your genetic makeup. 
How do you diagnose pain? First, we have to determine whether it is a skeletal, muscular, or neurologic problem. I can learn a lot in this regard just by asking the right questions: 
  • What is the quality and quantity of the pain? 
  • What makes it better or worse? 
  • What have you already tried?
  • Is the pain affecting your ability to eat or sleep?
  • How is the pain affecting your activities of daily living?
  • Is the pain affecting your mood?
Depending on the answers to those questions, I may decide to order imaging tests. X-rays are often helpful, but sometimes we need an MRI or CT scan to really see what’s going on. In some situations, nerve studies may be appropriate.  We may also call in specialists, such as neurologists, orthopedic surgeons, or others, to consult on specific conditions.
Why is a diagnosis important? For many patients, having a definitive (or at least probable) diagnosis brings a great deal of psychological relief. They may have been thinking that they are crazy or just feeling generally upset because they don’t know what’s wrong. Once we make a diagnosis, we can really concentrate on a plan of attack. 
What methods of treatment are employed? This will vary, of course, based on the diagnosis. 
  • First and foremost, Tylenol! For most people, to treat osteoarthritic and many other kinds of pain, the first line drug of choice is acetaminophen (commonly marketed under the brand Tylenol). Studies have proven it to be as effective as some narcotics in controlling pain and it is generally safe to combine with most other medications. But please check with your physician as there are some exceptions to this rule.
  • Prescription pain relievers.  Your physician will know if you need a narcotic medication to manage your specific type of pain. The important thing about taking medications--whether Tylenol or prescriptions--is to stay on top of the pain. They need to be scheduled and taken regularly, not on an as-needed basis. By the time you realize you need a dose, it’s probably too late. It takes about 45 minutes for your body to process the medication and feel the relief. For chronic pain, we often use a combination of a long-acting medication for overall pain management with a short-acting medication for breakthrough pain. I often see senior patients who are worried about becoming addicted to pain medications. Even though they may have a pelvic fracture, they don’t want to take a narcotic pain reliever. The fact is that it’s a long road to addiction. You have to be on consistent doses, multiple times a day for a prolonged period of time, before addiction and withdrawal could become concerns. 
  • Steroid injections and nerve blocks. These are administered by pain management specialists or trained physicians and can be very effective for some conditions.
  • Surgery. We usually try to exhaust all other options before turning to surgical interventions. However, surgery is sometimes necessary and can be the best solution for certain conditions.
  • Diet and exercise. Feeding your body a nutritious, healthful diet will support any healing process while exercising within your limitations and abilities (consult your physician!) will likely contribute to your overall improvement and enhance your mood. Physical therapy may also be an important adjunct to your healing regimen.
  • iStock 000025334367SmallComplimentary therapies. There is an increasing body of research showing that relaxation techniques, yoga, tai chi, meditation, homeopathic and naturopathic remedies, acupuncture, massage, and other alternative approaches to wellness can have a significant impact on pain management and enhancement of overall well-being. These can be used in conjunction with traditional allopathic treatments. Just be sure your primary care provider knows what you’re doing and is aware of any supplements you are taking (to ensure they will not conflict with your prescription medications).
How do chronic pain and depression relate to one another? This can really be a difficult chicken/egg situation. If you are depressed, your pain threshold is probably diminished. And when you are in chronic pain, you can become disheartened and depressed. They often go hand-in-hand, and it becomes important for us to address both issues concurrently. Chances are, improvement in one area will lead to improvement in the other. And some antidepressant medications have actually been shown to help alleviate physical pain, as well.
Where can I turn for help? Have thorough, honest, and regular discussions with your primary care physician about your condition. The more we know, the better positioned we are to help you. There are also chronic pain support groups, such as The American Chronic Pain Association, that provide information, tools, and community to help you through your personal pain challenges.
Remember, while you may not achieve 100% permanent freedom from pain, there are many approaches and techniques to help you manage and integrate your chronic pain and continue to live a happy, vital lifestyle!

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