Chronic pain is not just pain. When pain persists and becomes chronic it places a huge burden on the patient, their family and loved ones as well as the health care services and the wider community.
This blog presents some statistics that have helped us understand the magnitude of this burden as well as looking at the biggest causes of chronic pain and their treatment approaches.
ONE IN FIVE OF US HAVE CHRONIC PAIN!
One in five Australian adults report persistent pain.
No matter how you look at it, the numbers are staggering. In 2007, around 3.1 million Australians (1.7 million females and1.4 million males) were estimated to experience chronic pain. These figures do not include children and adolescents, who also suffer from chronic pain. Remember, these numbers would have also increased since 2007.
One in five Australian adults with severe or very severe pain can also suffer from mood disorders like anxiety and/or depression.
The prevalence and complexity of pain present a huge challenge for health professionals especially those working in primary care.
“This is particularly important for general practitioners, where one in five consultations involve dealing with a patient with chronic pain.”
It is important that we find effective and efficient strategies for helping those with pain to reduce unnecessary suffering and reduce the burden on our community resources.
WHEN DOES PAIN BECOME CHRONIC?
Persistent (chronic) pain is usually considered daily pain for at least three months. Sometimes pain can even be considered chronic when it lasts for more than one month after expected tissue healing following a surgery or trauma.
THE PRODUCTIVITY COSTS OF CHRONIC PAIN
Pain is the third biggest cost to the Australian health system. In Australia, those 2007 statistics indicated that chronic pain costs:
- $34 billion per year to the economy in general
- $11 billion on productivity costs
- $7 billion on direct health care costs. This includes the cost of medical treatments including medication.
If we can prevent chronic pain, this will help reduce the suffering and related costs. From her research into chronic disease including back pain, respected health economist Deborah Schofield concluded that “prevention of long-term health conditions may help older Australians remain in the labour force longer, thereby increasing revenue to fund health care for the ageing population.”
For many patients chronic pain becomes a long-term health condition and if we are to reduce its burden on the person with pain as well as the community, we need to do things differently. We need to get better at assessing pain and quicker at referring people for expert care when it looks like pain is not improving.
TREAT CHRONIC PAIN AS A CHRONIC DISEASE
One of the key approaches to manage chronic pain is to treat it like a chronic disease.
A chronic disease is a long-lasting condition that can have persistent effects and can be controlled but not cured. Chronic pain can, and does behave in the same way as a chronic disease and hence should be managed the same way.
They key is to manage chronic pain as a chronic disease and not just a symptom of a disease yet to be diagnosed.
Crucial to effective chronic pain management is early detection and diagnosis. Have a high index of suspicion. Think about it early. Diagnose it early. Manage it early.
A good pain management strategy should comprise a medical specialist approach using medications and interventional pain procedures combined with an allied health multidisciplinary approach.
FIVE TOP CAUSES OF CHRONIC PAIN AND TREATMENTS
1. LOW (LOWER) BACK PAIN
Low back pain is the commonest cause of spinal pain but spinal pain can also include neck pain and both of these complaints together.
In Australia, evidence suggests that low back pain, more than any other condition, causes people to stop working and retire prematurely and also leads to low levels of income in older people putting them at risk of poverty.
It’s important to have a plan of action.
Treatments of chronic low back pain:
Simple analgesics Don’t forget to introduce antineuropathic agents if firsts line therapies are failing. Why? If the pain is persistent, by definition there is a neuropathic component, so treat it as such.
Physical therapy Physical therapy is a must. Get your patients to focus on core strength, improved mobility and flexibility. Make sure your patients see a physiotherapist that is more hands off, than hands on, and who is also an expert in empowering your patients.
Pain interventions While not appropriate for everyone, nerve blocks and radiofrequency neurotomy can help diagnose and manage some of the commonest causes of spinal pain like facet-mediated pain and sacro-iliac joint pain. Facet joint blocks are out of date and only provide short-term relief. Get your pain specialists to perform medial branch blocks and if greater than 60% pain reduction, they should move onto radiofrequency neurotomy.
Opioids Opioid should only be used as a last resort and this is the topic of another blog. This is a big topic but have a plan of action according to your college guidelines.
2. CHRONIC HEADACHES
Chronic headaches and migraines are a very common complaint by Australians.
If the headache occurs on at least 15 days/month and for at least 3 months, then it’s a chronic daily headache.
They key is to make the diagnosis of what type of chronic headache your patients are suffering from and this might be tricky. Sometimes you may need to use a senior neurologist or experienced pain specialist to make the sub-diagnosis of chronic daily headaches, which should include:
- Short duration chronic daily headaches (headaches occur for < 4hours)
- Chronic cluster headaches
- Paroxysmal hemicrania
- Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome
- Long duration chronic daily headaches
- Chronic migraine
- Chronic tension type headaches
- Medication overuse headaches
- Hemicrania continua
- New daily persistent headaches
- Cervicogenic headaches. Don’t forget about the neck as being a trigger for headaches
General approach to treating chronic daily headaches
- Exclude secondary causes of headaches with a detailed history, examination and relevant investigations like MRI (better than CT scan)
- If you are considering a primary headache disorder, classify and manage accordingly.
- General headache management includes:
- Headache diary.
- Address co-morbid conditions like depression and anxiety.
- Lifestyle changes like stopping caffeine, increasing exercise, stress management and improving sleep hygiene.
- Prophylactic medications, are best co-managed by a senior neurologist, for chronic daily headache and chronic migraine may be used and might include;
- Anticonvulsants like topirimate, gabapentin, valproate.
- Antidepressants like amitriptyline, fluoxetine, tizanidine.
- Neurotoxins like botulinum toxin A.
3. JOINT PAIN
This might include osteoarthritis (OA), rheumatoid arthritis and repetitive strain injury in athletes.
By far, the most common type of joint pain is osteoarthritis and its prevalence is getting higher as we are living longer.
Risk factors for OA include genetics, female sex, past trauma, advancing age, and obesity. The diagnosis of OA is based on a history of joint pain worsened by movement, which can lead to disability in activities of daily living. Plain radiography may help in the diagnosis, but laboratory testing usually does not.
Treatment of osteoarthritis might include:
- Physical activity
- Exercise is a useful adjunct to treatment and has been shown to reduce pain and disability.
- Physiotherapy and occupational therapy can provide a range of treatment options for pain management including: ways to properly use joints, heat and cold therapies, range of motion and flexibility exercises, assistive devices.
- Weight management
- The basic rule for losing weight is to eat fewer calories and increase physical activity.
- Slow, gentle stretching of joints may improve flexibility, lessen stiffness and reduce pain. Exercises such as yoga and tai chi are great ways to manage stiffness.
- Pain medications & anti-inflammatories
- Start with non-steroidal anti-inflammatories.
- The supplements glucosamine and chondroitin can be used for moderate to severe osteoarthritis when taken in combination.
- Corticosteroid injections
- These provide inexpensive, short-term (four to eight weeks) relief of osteoarthritic flare-ups of the knee, whereas hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods.
- Total joint replacement
- Of the hip, knee, or shoulder is recommended for patients with chronic pain and disability despite maximal medical therapy.
- A positive attitude
- Many studies have demonstrated that a positive outlook can boost the immune system and increase a person’s ability to handle pain.
4. NEUROPATHIC PAIN
Neuropathic pain is pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. This can affect the peripheral nervous system or the central nervous system.
Some examples of neuropathic pain are:
Diabetic polyneuropathy (DPN)
Our aim is primary prevention with early diagnosis, exclusion of underlying causes and good glycaemic control, combined with appropriate lifestyle changes that will delay progression and the development of complications. The current evidence for DPN supports the use of tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs) (venlafaxine and duloxetine), gabapentin, pregabalin, tramadol, morphine and oxycodone. Don’t forget about appropriate footwear and footcare.
Post herpetic neuralgia (PHN)
Firstly prevent and management acute herpes zoster infection proactively. Adult vaccination with Zostavax®, stimulates T-cell mediated immunity and may reduce the incidence of both herpes zoster and PHN. Treat acute zoster infection early because early antiviral therapy can reduce the severity and duration of an acute herpes zoster infection. Corticosteroids and oxycodone reduce the pain experienced during the acute infective period. Use antineuropathic agents too.
When you are managing PHN use antineuropathic agents like pregabalin, gabapentin, and TCAs (amitriptyline and nortriptyline). Capsaicin cream (Zostrix®) and 5% lignocaine patches (Versatis®) may also help reduce the pain of PHN. Try controlled release opioids cautiously. If this fails get your patients to a pain specialist.
If it’s true trigeminal neuralgia, and first line medications are not helpful, get the patient to a neurosurgeon for consideration for microvascular decompression. If this fails or patients are reluctant to have major surgical interventions, get them straight to a senior pain specialist.
Complex regional pain syndrome (CRPS)
Make the diagnosis early & get the patients to a pain specialist early. This is what we do. If we see CRPS early, this means weeks of the initiating event, it can be cured.
It has been said that CPSP can account for up to 20% of pain clinics referrals. Post surgical neuropathic pain is on the increase as surgical techniques become more aggressive and complex.
Look for the risk factors of chronic post surgical pain
Preoperative risk factors:
- Pain – moderate to severe >1month duration e.g. ischemic pre-amputation pain.
- Genetic predispositions may include single nucleotide genetic polymorphisms e.g. COMT.
- Female – gender is associated with greater pain intensity/severity (see topic on gender).
- Age – older people get less pain with hernia repair VS older people with PHN get more pain.
- Psychological vulnerabilities include catastrophizing, anxiety and depression.
- Reduced diffuse noxious inhibitory control (DNIC).
- Compensation system e.g. no fault compensation system.
Intraoperative risk factors:
- Types of surgery like – amputation, thoracotomy, mastectomy and inguinal hernia repair.
- Surgical approach – that risks direct nerve damage e.g. thoracotomy and intercostal nerves.
- Surgical technique – early evidence shows less risk of CPSP with nerve sparing techniques.
- Length of surgery >3hours.
Postoperative risk factors:
- Pain – acute, moderate to severe postoperative pain.
- Acute neuropathic pain – this may be a factor but is unsupported by evidence, yet.
- Chemotherapy–taxels, vincas, alkaloids and monoclonal antibodies, which cause neurotoxicity.
- Psychological vulnerabilities include catastrophizing, anxiety and depression.
- Pain – moderate to severe pain on discharge.
Diagnose chronic post surgical pain early. Treat it aggressively and get a team around your patient.
5. CANCER PAIN
In cancer patients, pain is one of the most feared symptoms. However, despite the clear recommendations for therapy avaliable, cancer pain still is a major problem (and sometimes still one of the most common symptoms). A recent systematic review found the following pain prevalences;
- 33% after curative treatment
- 59% during anticancer treatment
- 64% advanced metastatic or terminal disease
- 59% at all disease stages
Now that we are living longer with cancer pain and some cancers can now even be considered chronic illnesses, the prevalence of chronic pain in cancer patients is increasing and changing. Chemotherapeutic agents are also a common cause of neuropathic pain in cancer survivors.
Have a plan to treat the background pain and the breakthrough pain.
Use combination opioid and antineuropathic therapies and:
- Use the mouth
- Use the clock
- Use the ladder (analgesic ladder)
- Individualise therapy
- Pay attention to detail
Other non-opioid adjuvants include bisphosphonates, radiotherapy and steroids and antineuropathic agents. Use them! Work with a team of specialists that might include oncologists, surgeons and pain specialists.
If you are struggling with cancer pan, please get the patients to a pain specialist, where other options may include: nerve blocks or ablation, coeliac plexus neurolytic blocks for pancreatic or abdominal cancer pain, and of course a multidisciplinary approach. Sometimes even spinal cord stimulation has been used effectively for some forms of neuropathic cancer pain.
Be proactive for your cancer patients.
TREATING CHRONIC PAIN GP EBOOK
As one of Australia's leading multidisciplinary pain specialist clinics, we'll explain what chronic pain is and why it occurs. We'll also explain that chronic pain should be managed as a chronic illness and not just a symptom of an illness.