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Medication and self management for chronic pain

Posted Nov 15 2010 10:26am

Last week a reader asked me for my take on using medications for chronic pain, so today I’m going to take a stab at this rather emotive and certainly very complex topic.  Before I do so, a word of warning – this is mainly my opinion and experience!  I’m also not a medical doctor, I don’t prescribe, I don’t want to have prescribing rights, and I must advise any reader NOT to change, reduce or increase medications without having a good discussion with your own medical practitioner first.

Strangely, I had trouble locating journal articles on combining medication and self management, so I either need to refine my search terms – or there may not be an awful lot of information out there about it.

Despite the lack of information that I could find, more people than not are taking medication for their chronic pain, even when also using self management.  The high rate of medication use is not surprising – medication is a mainstay for medical practitioners, and most people who want help for their pain go first to their doctor and, almost inevitably, are started on some sort of medication.  It’s also comparatively easy to take medications than do self management.

The aims of medication are usually to either directly affect pain intensity or to try to address any underlying conditions that might be influencing pain intensity.  Many medical practitioners follow the WHO ‘analgesic ladder’, and start with simple analgesics like paracetamol, work their way up through NSAIDs, and on to secondary analgesics and finally use opioids – starting with weak opioids like codeine, then bringing out the big guns like morphine and morphine derivatives.

It all sounds so logical, doesn’t it?! But for many people with chronic pain, medications don’t seem to do an awful lot. Either they don’t change the pain very much (and one study I read estimated that a 30% reduction in pain intensity was actually really good), or the side effects are too horrible for people to cope with – things like sedation, feeling foggy in the brain, nauseous and constipated are quite common.  For some people at least, medication is not the best way for them to manage their pain.  This can be a problem because we’re used to having some sort of pill, potion or procedure for almost every ailment, and it can be incredibly distressing to find out that there isn’t such a remedy for the very common problem of chronic pain.

Although I promote self management on this blog, I want to make it clear that I think if there is a medication that reduces pain intensity, doesn’t have unpleasant side effects, doesn’t need to have the dose progressively increased to obtain the same effect, and is taken on a time contingent basis (ie not just ‘as needed), then it’s a good thing and should be used.  After all, I take medication for low mood, people with diabetes use medication to reduce blood glucose levels, epileptics take medications to prevent seizures – so why shouldn’t people with chronic pain take medication to help manage their pain?!

At the same time, from paper by Nicholas, Molloy and Brooker (2006), it looks like medication use, particularly opioid use, for people with chronic pain is not always well managed.  And from the number of people I see at the Pain Management Centre in which I work who take a strange and often idiosyncratic concoction of tablets, I don’t think things have changed very much since this paper was written.

First things first, what are we trying to treat in chronic pain?

Remember that chronic pain by definition is pain that persists, and is often unrelated to the original causal factors.  Healing of any tissue damage has occurred, and so as time goes on we have fewer ‘issues in the tissues’ and more factors relevant to how the brain (nervous system in general) processes information about the state of the tissues.

Basically, we have a brain that is very good at noticing factors in the tissues and environment that could harm it and it rapidly brings this information to consciousness so we experience pain, attend to the matter and DO something.  This works well in acute pain – but in chronic pain the brain is working too effectively and instead of helping, lets us down.

In simple terms, the way in which pain medication works is to change the amount of information transmitted, or the ways in which that information can be received.

Chronic pain is just that, chronic.  It needs a regular supply of whatever medication is prescribed to address the problem.  Unless the pain is really low, what this means is a regular, time contingent amount of medication.  This ensures a consistent level of whatever the drug that is active is present all the time.  So it’s probable that using medication on an ‘as needed’ basis is not going to be terrifically useful.

Many people don’t like taking medications, and may leave using it until the pain has increased in intensity to quite a high level.  Others anticipate an increase in pain and may take it far too early.  In both cases, the amount that is required in the blood stream may either arrive too early to be useful, so the person ends up needing to take more after the first dose because it has worn off before the pain has settled down, or there isn’t enough on board soon enough so the person takes more to reduce the pain, again ending up with more on board but at the wrong time.

If the medication is effective, it can act quite quickly, and this can be a very rewarding (in the psychological conditioned learning sense), by reducing the presence of a negative/aversive stimulus, and this in itself can increase the use of medication.  At other times, when the pain level is quite high, distress can also increase – just by taking some sort of action (in this case, taking medication), distress can reduce, and this can also act to reinforce the action of taking medication.

So a regular, time-related use of medication is a good starting point.

What about flare-ups?

Flare-ups can go by several different names – I prefer to use the term ‘flare-up’ to represent a temporary (although it can feel like it’s going on forever!) increase in pain.  Other people call this ‘breakthrough’ pain, suggesting that the pain is ‘breaking through’ the analgesia – but for me, this isn’t a good term simply because in chronic pain the pain reduction is often not that high, so there is always a certain amount of pain present.

I think (note that this is my opinion!) that remaining on a baseline level of medication during a flare-up, and instead recruiting more self management, perhaps making some allowances in terms of expectations, perhaps increasing the use of breathing, positive self statements, setting temporarily smaller goals and so on, allows for a greater sense of control over the situation and a greater sense of confidence in the coping strategies that are used.  It’s like being able to say that ‘I got through’ fosters self belief rather than belief in something external.

I intend to write more about medication and self management through this week.  With any luck I’ll find some readings to supplement my thoughts!  In the meantime, I welcome comments, thoughts, questions – we can learn from each other!

Nicholas, M., Molloy, A., & Brooker, C. (2006). Using Opioids With Persisting Noncancer Pain: A Biopsychosocial Perspective The Clinical Journal of Pain, 22 (2), 137-146 DOI: 10.1097/01.ajp.0000154046.22532.fe

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