If medication is to be part of a toolkit for self managing chronic pain, then it seems to me that it’s important to know as much about the medication and how it should be used as possible. Once again, today I’m not directly referring to the literature because I haven’t found an awful lot discussing this integration approach, so please bear this in mind when you read what I’ve written. 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.
There are two main paths in pain management – one focuses on pain reduction, and this is where I think medication (and surgery and procedures like injections) fit in. The other path is pain management where increased function and learning to live alongside pain is the main focus. For if there is one thing that struck me when I read Nicholas, Molloy and Brooker, it was the finding that simply reducing pain does not necessarily improve the ability to do things. It’s a finding I’ve seen time and time again – and reminds me that pain is a complex thing, it involves a person who processes and interprets everything that is happening, has happened and could happen in the future – and as a result if clinicians fail to address those interpretations, improved function is not necessarily going to follow reduced pain.
Back to medication. All medications involve balancing the intended effects (hopefully beneficial effects) with the unintended effects (or side effects). Because each person metabolises medications differently, we can never be entirely sure of the usefulness of any specific medication. It truly is a process of trial and error, albeit based on some fairly strong evidence for specific groups of drugs. At the same time, while the pharmacological effects may be reasonably well known, what is often less appreciated is that people often don’t take the drugs in the way the prescriber expects.
One thing nonmedical clinicians can do is understand some of the pharmacokinetics of medications in order to help patients understand why the medication is prescribed the way it is, and at times, to help work out the best timing for taking a medication. As I mentioned yesterday, chronic pain is a chronic condition, so if a medication is found to be effective, it’s likely to need to be taken regularly for a long period of time. It also means that it works best if taken at the same time each day, and consistently every day.
When should self management be integrated with pain reduction efforts? Well, the jury remains out on this. In practical terms I have found it really difficult to help people focus on the hard work of self management when they are still anticipating that pain reduction may abolish their pain. There are pain management centres where people are helped to withdraw from all medications before embarking on self management – at the centre in which I work this is not the case, but we do strongly encourage doctors and patients to complete the pain reduction approaches before starting pain management.
Some of the reasons for this are pragmatic – if people are still working with new medications while learning self management, they may find it very difficult to cope with the daily demands of the three week programme because of side effects. Participants may credit any changes in coping or function to the medication rather than their own coping skills. Participants may find it difficult to have confidence in their self management skills because medication is readily available and it is much easier to use medication in a flare-up or setback period than draw on newly developed self management strategies.
We have also found that people who may be working through further pain reduction options find accepting that pain fluctuations are common while developing self management skills quite difficult – and it seems clear that acceptance of a certain amount of pain is an important part of reducing disability and distress (see McCracken & Zhao-O’Brien, 2010).
To sum up so far, pain medication can be part of a toolkit of coping strategies for managing chronic pain. It’s best if medication is taken on a time contingent basis, and there needs to be a balance between side effects and positive effects for it to be worthwhile. It can be difficult for people to be confident to use pain management strategies when pain reduction options are still in the running because self management requires a degree of acceptance that pain will be present, and it will fluctuate – and self management is difficult. It’s also important for clinicians to be confident to discuss how to and when to take medications to make the most of the pharmacokinetics of the drugs.
But wait! There’s more to come tomorrow! And hopefully I’ll be able to dig out some readings on the topic as well.
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
McCracken, L., & Zhao-O’Brien, J. (2010). General psychological acceptance and chronic pain: There is more to accept than the pain itself European Journal of Pain, 14 (2), 170-175 DOI: 10.1016/j.ejpain.2009.03.004