September is Pain Awareness Month

Pain types and chronic pain classification

Many pain specialists recommend that the term “chronic pain” be referred to as “persistent pain – which can be continuous or recurrent and of sufficient duration and intensity to adversely affect a person’s wellbeing, level of function, and quality of life.” Given its universal acceptance, the following information uses the term “chronic pain.”

Acute pain is characterized as being of recent onset, transient, and usually from an identifiable cause. Chronic or persistent pain can be described as ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury healing, more than three to six months, and which adversely affects the individual’s wellbeing. Another definition for chronic or persistent pain is pain that continues when it should not.

Chronic pain is classified by pathophysiology (the functional changes associated with or resulting from disease or injury). It can be nociceptive (due to ongoing tissue injury), neuropathic (resulting from damage to the brain, spinal cord, or peripheral nerves), or a mixture of these.

Central Pain Syndrome is a neurological condition caused by a process that specifically affects the central nervous system (CNS), which includes the brain, brainstem and spinal cord. The disorder occurs in people who currently have or who have experienced strokes, multiple sclerosis, Parkinson’s Disease, brain tumors, limb amputations, brain injuries or spinal cord injuries. It may develop months or years after injury or damage to the CNS.

This also includes conditions such as chronic headaches, Fibromyalgia and Complex Regional Pain Syndrome (CRPS). Continuous pain is pain that is typically present for approximately half the day or more. Flare-up pain (the term break-through pain was coined to refer to cancer-related flare-ups) can be described as a transitory increase in pain in someone who has relatively stable and an adequately controlled level of baseline pain.

It may be caused by changes in an underlying disease, including treatment, or involuntary or voluntary physical actions such as coughing or getting up from a chair or other changes in activity level. It can also be caused by stress and emotions such as anxiety, anger, fear, or worry. Activity imbalance—doing too much or too little—can also cause flare pain.

Understanding more about the underlying causes of pain can help improve treatments and alleviate suffering. Johns Hopkins researchers are working on everything, from the molecular causes of pain to the latest advances in pain treatment.

Pain in older persons

Persistent or chronic pain is common in older adults. While medications are certainly an important part of treating chronic pain, use in older persons is fraught with potential problems. Physical rehabilitation and other interventional therapies, which may include targeted injections and acupuncture, can be helpful to reduce pain, maximize physical function, and decrease the need for medications. In fact, medical literature is full of studies showing the advantage of regular physical exercise in older adults. Additionally, psychological supports, including relaxation techniques, mindfulness practices and positive self-talk should always be considered for managing pain in elderly people.

In addition to chronic pain, older adults are more likely to have multiple medical conditions and to be taking multiple medications. Medication risks are greater for an individual when multiple medications are taken. It is important to discuss all medications (including over-the-counter or verbal/medications) with your healthcare provider. Certain medications carry greater risks than others, especially when used in combination.

Some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs. In general, 30 percent of hospital admissions among the elderly may be linked to an adverse drug-related event or toxic effect from opioids and sedatives (i.e., a tranquilizer).

Nearly one-third of all prescribed medications are for persons over the age of 65. Unfortunately, many adverse drug effects in older adults are overlooked, considered to be age-related changes (general weakness, dizziness, and upset stomach) when in fact the person is experiencing a medication-related problem. In all persons, medication should be initiated at a low dose and adjusted slowly to optimize pain relief while monitoring and managing side effects. Multi-modal analgesia, which is the careful use of multiple pain-relieving drugs known to be hazardous.

The American Geriatrics Society, www.americangeriatics.org provides guidance on      Pharmacological Management of Persistent Pain in Older Persons, at www.americangeriatrics.org/files/documents/2009_Guideline.pdf.

How medications can help and harm

Many people with chronic pain are able to manage adequately without medications, and can function at a near-normal level. Others find that their overall quality of life, in terms of comfort and function, is improved with medications. However, even the most potent medications used for pain rarely completely eliminate pain, but may reduce the severity of pain. As such, medications are rarely adequate alone and should be considered as an optional part of a comprehensive approach to pain management and functional improvements.

While medications can help relieve symptoms, they also can cause unpleasant side effects that at a minimum can be bothersome and at their worst can cause significant problems including death. These side effects can often be avoided or at least managed with the help of a health care professional. It is important that the health care professional be aware of all prescription medications, over-the-counter (OTC) medications, and fitness, nutritional and herbal supplements that are being taken for general health or for pain or other medical conditions. This can ensure these are being taken appropriately and safely and that they do not interact with other prescribed medications or therapies.

Some substances and drugs may cause serious side effects if they are combined with other medications. Even over-the-counter and herbal preparations have possible side effects and the potential to cause serious interactions with other nonprescription and prescription medications and with each other. These include various OTC supplements and vitamins, homeopathic remedies, items grown in a home garden or bought in a store, and other substances, such as caffeine, alcohol, tobacco, and even marijuana and elicit drugs. It is strongly advised that all current medications, in the original bottles or boxes or tubes, and other items that are taken (including non-prescribed medications, vitamins and supplements) be brought to any appointments with the health care professional.

It is essential that the health care professional be told about all substances that are being taken (even if they are not legal, or if obtained from someone other than the prescriber). Even medications that may be used only occasionally such as cough and cold medications can have significant medication interactions. People with any medical condition including pain should keep a list of all of their medications in their wallet or purse. This list may be useful in an emergency.

To find out more about chronic pain, visit the American Chronic Pain Association website and view their 2016 Resource Guide to Chronic Pain Treatment.