Chronic Pain

Biomedical and Spiritual Approaches

Harold G Koenig

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136402036
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

Help your clients achieve victory over chronic pain and lead more fulfilling lives!This insightful and informative book will help you deliver better pain management services to the people you care for. Incorporating biomedical, surgical, psychological, social, and spiritual perspectives, it provides vital, up-to-date information about how to reduce physical pain and explores techniques for improving people's ability to cope with it. Helpful tables provide easy access to information on medications for pain and managing side effects.Chronic Pain: Biomedical and Spiritual Approaches is filled with resources for the person in pain and for the health or religious professionals working to help them. It gives you very specific suggestions on how to manage chronic pain, including detailed information about medications, alternative therapies, psychological treatments, and spiritual strategies for pain management. The book is completed by two thoughtful appendixes: one examining pain medications and ways to manage their side effects and the other providing scriptural passages that can comfort those in pain.In addition to his experiences treating patients with chronic pain, the author suffers from chronic pain and disability himself. In this very personal book, he explores ways to help people coping with:

• low back pain
• fibromyalgia
• rheumatologic pain
• headaches
• the pain of multiple sclerosis
• other types of chronic unrelenting pain

Chronic Pain: Biomedical and Spiritual Approaches can help people in pain and their families by showing them how to lead satisfying, joy-filled lives--whether their pain goes away or not. It is an essential reference book for everyone who works with pain sufferers as well as patients and their families!

Chapter 1

Pain Is a Common Problem

As I struggle with pain in my own world, I frequently forget how many others also suffer from this problem—many with much worse symptoms and more constant pain than I have. Those of us who have pain are indeed not alone. A recent survey by the American Pain Society found that approximately 10 percent of Americans experience moderate to severe non–cancer-related chronic pain,¹ a figure that may reach 20 percent if milder forms of chronic pain and cancer-related pain are included (nearly 50 million people, half of whom have suffered for more than five years).² Studies show that chronic pain is a major health care and social problem³ and is perhaps the most common reason that people see doctors. Nearly 90 percent of all persons over age forty show beginning signs of arthritis or rheumatism, and 70 percent of persons over age sixty-five have X-ray evidence of osteoarthritis.⁴

Furthermore, the number of elderly people in the United States and around the world is rising rapidly. In 1999, according to a recent United Nation’s report, there were approximately 45 million persons aged sixty or older in the United States and nearly 600 million worldwide. By 2040 to 2050, those numbers will increase to nearly 100 million in the United States and 2 billion worldwide. In some areas of Europe, over 40 percent of the population will be over age sixty by that time (Italy, Spain, Czechoslovakia, Romania, and others).⁵ This means millions and millions of people in my generation (baby boomers born between 1945 in 1967) and in the generation before mine (born between World War I and World War II) either suffer or will suffer from long-term pain of some kind. Chronic pain is becoming a huge international problem.

PAIN COMPLAINTS IN THE COMMUNITY

Studies have examined the frequency of pain complaints in the general population and the kinds of conditions that cause pain. In 1993, a study of 13,538 randomly selected persons of all ages living in the United States found that the top three physical symptoms (excluding those related to the menstrual cycle) were joint pain (36.7 percent), back pain (31.5 percent), and headache (24.9 percent).⁶ Of the pain symptoms reported, 84 percent either interfered with daily living, prompted the taking of medication, or forced the person to see a physician. Physical causes for the pain could not be identified for nearly one-third of symptoms. Other studies indicate that nearly 80 percent of Americans will experience low back pain at some point in their lives and in 30 percent that pain will be chronic, making it the third leading cause of disability for those of employment age.⁷

Pain is also common in populations outside of the United States. A recent World Health Organization survey of 26,000 medical outpatients from around the world found that 22 percent indicated they had experienced several months of pain during the previous year. More than 25 percent of patients attending primary care centers in Germany, Brazil, Turkey, France, and the Netherlands reported that pain was present most of the time for a period of six months or longer during the previous year.⁸ In Santiago, Chile, no fewer than 33 percent of patients reported chronic pain (41 percent of women patients).

Many, then, suffer from conditions that cause chronic pain. These people frequently go from doctor to doctor, desperate to find relief. In fact, some experts believe that the increase in the popularity of complementary or alternative medicine in this country is primarily due to these people seeking help outside of the traditional health care system. Despite the hundreds of thousands who swear they have been helped, little scientific evidence shows that alternative or nontraditional methods of pain relief have persistent benefit.⁹

PAIN IN THE YOUNG AND OLD

Studies have shown that no significant differences exist between the way that young and older people perceive pain. However, when studies compare younger and older subjects with similar kinds of conditions, older persons are less likely to complain about pain.¹⁰ This is true for a number of reasons. Impaired memory, decreased concentration, depression, difficulty hearing, and other problems with communication interfere with the reporting of pain.¹¹ Underreporting of pain may also be a problem in older adults belonging to minority groups (African Americans, Hispanics, etc.) because of differences in emotional expression or language. Members of these groups may also lack knowledge about pain treatment and sometimes have excessive fears regarding addiction to pain medication. The conditions that cause pain are a lot more common in later life, when 25 to 80 percent of people experience pain symptoms (depending on setting).¹² The most likely causes of chronic pain in older adults are arthritis, bone and joint disorders, back problems, and other chronic health conditions.

Pain is especially common among people who live in nursing homes, where between 45 percent and 80 percent of residents report substantial pain that is not adequately treated.¹³ In fact, 34 percent of these patients indicate that they are in constant pain.¹⁴ In a review of fourteen studies concerning the treatment of pain in nursing homes, pain was present in 49 percent to 83 percent of residents.¹⁵ Reports of pain increase as people approach death. About two-thirds of all people have pain in their last month of life (compared to about 25 percent of people in the general population).¹⁶ According to several studies, pain reaches its greatest intensity approximately two days before death.¹⁷

USE OF PAIN MEDICINE

Roughly 20 percent (one in five) of persons aged sixty-five or older take painkillers (called analgesics) several times per week.¹⁸ Almost two-thirds (65 percent) of those 7.5 million seniors have taken analgesics for more than six months. Almost half (45 percent) of those taking pain medicine have seen three or more doctors for help-with their pain in the past five years.¹⁹ Among seniors who take medication for chronic pain, seven of ten take over-the-counter (OTC) drugs, the most common of which is acetaminophen (Tylenol) followed by nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Although many also take prescription drugs, more than one in four experience side effects from those drugs. It is not surprising, then, that when a new pain-relieving arthritis drug such as Celebrex (celecoxib) or Vioxx (rofecoxib) is approved for general use, it becomes the best-selling drug in America within six months. Treatment of pain has become a huge pharmaceutical industry.

There is much room for optimism, however, as safer and more effective drug treatments for pain are being marketed by pharmaceutical companies almost every year. Studies suggest that even among cancer patients, appropriate use of the World Health Organization’s treatment protocol can provide pain relief for 90 percent using relatively simple drug therapies²⁰ (see Chapter 13). Despite this, many people with cancer—both on general medical/surgical wards and oncology wards—continue to suffer with pain.²¹ This may be especially true for older patients with cancer who often receive their postacute care and rehabilitation in nursing homes, where the quality of care may be the poorest of any place in the health care system.²²

Among older nursing home patients with cancer, a significant percentage has daily pain and unfortunately receives no pain medicine. In a study that examined the treatment of pain in nearly 14,000 elderly cancer patients admitted to nursing homes in the United States between 1992 and 1995, approximately 30 percent reported daily pain—including 38 percent of the young elderly (aged sixty-five to seventy-four) and 24 percent of the old elderly (aged eighty-five or over). More than one-quarter of these patients received no pain relievers. Patients over age eighty-five, African Americans, persons with memory or concentration difficulties, and those receiving multiple other medications were at greatest risk for receiving no treatment for their cancer pain. Although pain-relieving medication is taken by 27 percent to 44 percent of nursing home residents, it is evident that many more do not receive adequate treatment.

Thankfully, pain is receiving more and more attention in our health care system, according to an Associated Press report on December 26, 2000. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits acute-care hospitals, nursing homes, and even some outpatient clinics, has adopted new standards concerning the diagnosis and treatment of pain that all health care facilities have had to comply with since January 1, 2001. JCAHO wants to ensure that people have their pain assessed and managed in a state-of-the-art manner. If a health care institution fails to meet those standards, it may lose its license to operate. This move has finally given patients and family members some ammunition against an unconcerned health care system in their battle against pain. In fact, a jury recently awarded $1.5million to the family of an eighty-five-year-old man dying of lung cancer because his doctor did not prescribe adequate pain medication during his final days.²³

DEFINITION AND CAUSES OF PAIN

According to the International Association for the Study of Pain (IASP),²⁴ pain is the unpleasant physical sensation or emotional experience that is associated with either actual or possible damage to body tissues or nerves. This definition emphasizes both the physical and psychological components of pain. Deeply embedded in the skin, muscles, and internal organs are tiny receptors (called nociceptors) that are sensitive to heat and cold, pressure, and anything that causes damage to these tissues (cuts, pricks, blunt trauma, or rapidly growing cancerous tumors that crowd out or destroy normal cells and organs). From these tiny receptors come nerve fibers that transmit this information to the spinal cord and eventually to the brain.

Nerve fibers are divided into A-delta fibers and C-type fibers. A-delta fibers transmit information rapidly and are responsible for acute or sudden pain sensations. C-type fibers transmit sensory information more slowly and are responsible for more chronic types of pain. Once they reach the spinal cord, the pain impulses are modified and then transmitted to the brain. The brain interprets these signals to determine the severity and location of the pain. Interestingly, the brain also sends nerve fibers down the spinal cord to the cell bodies of the nerves from which the pain originated and in this way has the potential to either increase or decrease the intensity of the pain. Nerve fibers traveling down the spinal cord from the brain can release a substance called enkephalin, which prevents pain signals that come from the legs and arms from ever reaching the brain and awareness.

When a person presents with a complaint of pain to their physician, evaluation usually consists of a physical examination and laboratory tests to determine the underlying cause of the pain (see Chapter 8). Even though a true physical cause for the pain exists, in many cases the physician may not detect it. There are many reasons for this. The doctor may lack the skill and training to diagnose the problem. Alternatively, medical science may not have evolved sufficiently to provide the physician with the adequate tools to diagnose the cause. It may simply be too early in the course of the disease for it to be recognized. If the doctor finds no physical or biological cause for the pain, then it is usually attributed to psychological factors. Consequently, pain is often categorized by physicians as either due to physical causes or to psychological problems.

Most current research indicates that pain cannot be so neatly classified into these two groups.²⁵ Although sudden or acute pain usually has an identifiable physical cause, the severity of chronic pain is seldom equal in intensity to the extent of tissue damage present. Some causes are simply unknown, such as certain types of chronic back pain or recurrent headache. It is indeed strange that careful physical and X-ray examination of persons with no pain nevertheless reveals underlying tissue damage in 30 percent of such individuals, whereas no structural damage is found in many persons with severe pain.²⁶

According to some anesthesiologists (pain specialists), objectively verifiable tissue damage is not required for a report of pain to be real, and therefore there is no need for a direct linear relationship between reports of pain and physical findings.²⁷ Therefore, the primary role of the chronic pain specialist is as physician-educator, not as expert in performing technical procedures or administering pills. This does not mean that medication or surgical procedures such as nerve blocks play no role in pain management, but only that they should be performed as part of a comprehensive pain treatment program. The fundamental intervention of the pain specialist, then, is effective communication with language, not nerve blocks or medication. In fact, these pain specialists suggest that beliefs, expectations, and quality of interaction between patient and doctor are more important than specific medical or surgical techniques. For that reason doctors who care for people with chronic pain should receive special training in doctor/patient communication.²⁸ Unfortunately, few ever do.

For many conditions associated with chronic pain (i.e., pain lasting three months or longer, according to IASP), relatively little is known about the underlying biological or physical mechanisms responsible for the pain. Long-term, unrelenting pain can often result from changes in the nervous system that occur in response to earlier tissue damage. These changes may continue to send pain impulses to the brain even after complete healing of tissue has taken place. Changes in the processing of pain signals within the nervous system may cause a person to experience severe pain in the absence of a physical cause (or in the absence of ongoing tissue destruction). Attempts to relieve the pain in such circumstances through surgical methods directed at the painful body part often fail to bring relief. Nevertheless, chronic pain may result from a number of identifiable biological, anatomic, or physiologic causes. Knowing that the pain may have a physical cause is very important for chronic pain patients because it helps combat the humiliating notion that the pain is “all in their head” or somehow due to defects in these individuals.

TYPES OF PAIN

In general, there are three basic types of pain. None of these are completely independent or separate from the other two.

Physiologic Pain

Physiologic pain (pain resulting from physical causes) results from inflammation around nerves, injury to nerves, or physical irritation of nerves. This kind of pain, whose origins can be directly linked to physical causes, is called nociceptive pain (from the Latin verb nocere which means “to injure”). Injury or damage can occur anywhere along nerve pathways—from nerve endings in the skin, to ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• About the Author
• Contents
• Introduction: What Is This Book About?
• Chapter 1. Pain Is a Common Problem
• Chapter 2. A Giant Called Mr. Pain
• Chapter 3. Back Pain—Bob’s Story
• Chapter 4. Headache Pain—Penny’s Story
• Chapter 5. Rheumatologic Pain—Laura’s Story
• Chapter 6. Generalized Pain—Jackie’s Story
• Chapter 7. Long-Term Chronic Pain—Joan’s Story
• Chapter 8. Assessment of Pain
• Chapter 9. Medication for Pain
• Chapter 10. Psychosocial and Behavioral Treatments
• Chapter 11. Alternative and Complementary Treatments
• Chapter 12. Surgical and Other Procedures
• Chapter 13. Specific Disease Conditions
• Chapter 14. Spiritual Approaches to Pain
• Chapter 15. Ten Practical Steps for Slaying the Giant
• Appendix I. Healing Scriptures for Those in Chronic Pain
• Appendix II. Medications for Pain and Managing Side Effects
• Notes
• Index