The Multidisciplinary Approach to Pain

When does pain become chronic and intractable? What is the difference? Which threshold must be crossed before we can call it chronic? Many pain textbooks use an arbitrary period of six months duration to define pain as chronic, but this is just another magic medical number that looks good on paper, but has no real clinical value.

Most of us can tolerate severe pain such as childbirth, kidney stones, and migraines, for a short period of time. Few of us, however, can cope with severe unrelenting pain without sinking into a progressive spiral of irritability, depression, and despair. When the meaning of pain changes from a fundamental, necessary warning designed to protect the body, to a faulty alarm that continues to scream at the brain even after the danger is long gone, that's when the trouble begins. The problem is made worse by the fact that pain is a personal, subjective experience, which can't be measured any more than a mother's love for her child can, so doctors and other health care professionals may have trouble understanding the magnitude of the affliction, leading to inadequate treatment of chronic pain sufferers.

Over the past twenty-five years the treatment of pain has grown in importance and scope. When once a patient would be told "you just have to learn to live with it" or "it's all in your head", now specialists go to extremes to identify the source of pain, correct it when possible, and alleviate it when not. When, previously, medical students would devote perhaps no more than one day to the study of pain, now they have it as an integral part of their curriculum. Pain Clinics can be found in most major metropolitan areas in the US and many of those clinics have a team composed of specialized physicians, nurses, physical therapists, and mental health professionals, whose main job is to treat pain as a disease that affects the body as much as the mind. The pain specialist work is often made more difficult by patients who refuse to accept that pain, like many other chronic illnesses, can and does impair brain function, leading to personality changes, depression, and irritability, just to cite a few. Both depression and chronic pain still carry the stigma that somehow the patient itself is weak and at fault for being unable to "cope" with either one.

When simple pain relief methods don't suffice, medical care is often needed. The first step in managing chronic pain is to come up with the proper diagnosis. Due to the intrinsic subjective nature of pain there's no way to measure it and many times the cause of pain remains hidden and inaccessible to detection devices such as MRIs, scans, and blood tests. That doesn't mean that the pain is not "real", nor does it indicate that some horrible disease is lurking in the background, waiting to be found, like so many pain sufferers believe. Doctors in medical school are extensively trained to treat known diseases, but are ill prepared to deal with pain for which no clear cause exists. This leads to potential conflicts between patients and their physicians, both frustrated from the lack of a "label" for the pain. As important as obtaining a diagnosis, is knowing when to stop looking, for serious physical, psychological and financial damage can result. Depression and anxiety are major contributors to the suffering caused by pain. We may think about them as amplifiers that don't cause pain but increase its intensity. Since pain often leads to depression, patients may develop a vicious cycle of pain-depression-pain that must be interrupted before adequate results are seen.

By the time a patient reaches a pain specialist, weeks or months may have passed and perhaps several other doctors may have been consulted. As a result, the specialist is often confronted with difficult, frustrating cases, and patients who are emotionally debilitated from that merry-go-round. A team composed of physicians, nurses, physical therapists, psychologists, and others may be better prepared to deal with these challenging problems. Below are some of the most common problems facing the pain physician, and they exemplify the problems faced by a pain clinic team:

• Chronic neck and back pain

  Low back and neck pain are the most common type of painful ailment affecting adults of any age. It strikes millions of Americans and costs billion of dollars in medical care and lost productivity. Only a minority of people will have demonstrable cause for the pain, and most will improve with time and good sense. However, when pain is persistent and interferes substantially with daily activities more aggressive care is warranted. Many tools are available to the physician treating this type of pain: anti-inflammatories, pain pills, nerve blocks, braces, surgeries, and several more. One of the best, and often neglected, forms of treatment is through the use of exercises that increase strength, flexibility and stamina. A patient's search for instant relief gets in the way of a methodical program that may provide long-term benefit. Rarely does a person suffering from spine pain observe maximum improvement without the aid of exercises, with or without other modalities of physical therapy.

• Headaches

  We have a much better understanding of headaches than we had just a decade ago. The delineation of which headaches are migraines, and which are tension headaches or sinus headaches is much clearer and therefore new treatments for them have evolved. The development of a new, very effective, class of drugs called triptans has dramatically improved the therapy for migraines and it has also allowed us to realize that many, if not most, of the headaches we used to call tension and sinus are actually migraines. Today we define a migraine as any headache that is accompanied by nausea and light sensitivity, until proven otherwise. Often times a therapeutic trial with one of the triptan drugs will clarify the type of headache we are dealing with.

Women are affected by migraines three times as often as men, but men are more likely to develop a rather vicious type of headache called "cluster headaches", named for their tendency to strike several times a day for weeks or months, disappearing completely afterwards for variable periods of time.

Analgesic rebound headache is a fairly common type of headache that is due, in part, to the overuse of analgesics. It generally affects a person who suffers from occasional migraines and who, for one reason or another, progressively increases the use of over the counter or prescription medications for a period of months or years, to the point they end up developing a headache as soon as the medication wears off. The only treatment consists in reduction and discontinuation of the offending medications, often with dramatic improvement. The lesson for headache sufferers is that one has to be careful with analgesics and sedatives, and to use medications as prescribed, avoiding excessive self-medication.

• Nerve pain

  Few pains can match the severity of painful neuropathies, or so-called nerve pain. The typical example is trigeminal neuralgia, or tic doloreux, a severe lightning, lancinating pain that affects the face for a few seconds at a time, but repeats itself many times during the day. Other examples include shingles, diabetic neuropathy, and carpal tunnel. Nerve pain usually has a burning, shooting, electrical character that is very disturbing to the sufferer and rapidly leads to irritability, insomnia, and depression. Furthermore, nerve pain tends to create a "memory" for the pain by changing the chemistry and connections of the nervous system. That means that the pain may persist long after the initial injury is gone. This is often seen in people who undergo an amputation and develop pain in the limb that does not exist anymore, a condition named phantom limb pain.

• Cancer

  Around 60% of people suffering from a malignancy will develop substantial pain during the course of their disease. Some types of malignancy, such as cancer of the pancreas, are more painful than others. The treatment of cancer pain poses some unique challenges since often the disease is fatal and the physician must balance pain relief, sedation and side effects such as nausea and constipation, common with the use of strong analgesics. The main goal of the pain specialist when dealing with cancer is to provide the best relief, while allowing the patient to remain alert and functional. When the dose of narcotic analgesics necessary to control pain is so high that the patient can't function in his activities, the doctor may choose to administer the narcotic directly into the spine by means of an implantable pump, which delivers the medication automatically. It allows for a much lower dose of medication and, consequently, fewer side effects.

• Arthritis

  Arthritis comes in many forms. The most common, and the one most of us will eventually develop, is osteoarthritis. More than a disease, this can be seen as a natural aging of the joints that causes pain and stiffness, usually treated with anti-inflammatory medications. More serious types of arthritis include the rheumatoid type, which gradually destroys an inflamed joint. Until recently only palliative treatments were available, such as cortisone orally or by joint injections. Today we have new medications, the so-called "disease modifying agents", that, although unable to cure the disease, may delay the progression of rheumatoid arthritis.

• Fibromyalgia

  Often misdiagnosed and frequently shunned, patients with fibromyalgia are mostly young women, who suffer not only from generalized muscle and soft tissue pain, but are also plagued by fatigue, sleep disturbances, with memory and concentration difficulties. Since there is no test that can show whether the person has fibromyalgia, it all comes down to the doctor making a clinical diagnosis. Other diseases that cause the same constellation of symptoms have to be excluded before a diagnosis of fibromyalgia can be made, including lupus, depression, and low thyroid, among others.

  Scientists suspect that true fibromyalgia may be due to a central nervous system problem, as opposed to a muscle disease. The best evidence for this comes from the fact that some viral diseases that affect the brain, such as mononucleosis, can lead to long-term symptoms identical to fibromyalgia, and the same can happen to patients suffering from Lyme's disease, a bacterial infection transmitted by a tick.

  It is easy to see from the above examples why pain specialists rely on a team of health professionals to help and guide them to treat severe painful conditions in a successful manner.

© Dr. Moacir Schnapp and Dr. Kit Mays

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