When discussing medication and pain reduction for chronic pain, it’s not surprising there are some very strong opinions and emotions. After all, having pain is universally known to be unpleasant, very few people really want to have pain (except those who like the rush of acute pain – vis a vis body suspension!), and the first person many people go to discuss their pain is a medical practitioner.
The way the centre in which I work views medication is that it forms part of a toolkit for managing pain, alongside all the self management strategies that we also endorse. So, by and large, most of the people we see are on a stable regime of medication targeting the underlying mechanisms thought to be influencing the nervous system’s sensitivity to stimuli.
A reader suggested that there is a difference between ‘breakthrough’ pain and ‘flare-up’ pain. I had a look in the literature, and it’s very clear that the terms are not used consistently – so here is the way I use the terms.
Breakthrough pain to me is a term that has most usefulness in acute pain (eg post-operative pain), or in cancer pain. A regular amount of analgesia is used, with additional medication available when the pain ‘breaks through’ that analgesic cover. Most of the additional medication is short-acting, and is designed to act quickly to provide that analgesic cover. I use the term breakthrough pain when there are regular variations of pain through a day, and the pain ‘breaks through’ because the overall level of analgesia is not quite sufficient - perhaps because of side effects being unpleasant, or because of a progressive element in the underlying disorder. NB – this is the way I use this term, and as I’ve noted, definitions vary, but I’ve mainly found literature describing breakthrough pain in cancer pain rather than non-cancer chronic pain. (This is one of the journal articles that discusses it quite nicely – a little old, but none-the-less explores many of the issues – Portenoy & Hagen, Breakthrough Pain: Definition, prevalence and characteristics. Pain, 1990 (41:3), pp 273-281. )
Flare-ups, on the other hand, I describe as variations from a baseline level of pain. Flare-ups can be any length of time, short or long, and can be influenced by numerous factors, psychosocial and biophysical. Flare-ups can occur periodically, intermittently, erratically, or regularly. Flare-ups don’t represent a new ‘injury’ or disorder, or even necessarily a change in the underlying disorder. Flare-ups generally settle down, and are commonly more difficult to handle if the person experiencing them feels they have no control over duration or intensity, or no control over how to cope with them.
The basic question, I think, is whether medication is useful for managing exacerbations of pain,. whether temporary or longer term.
Before I discuss that particularly thorny issue, I want to consider the other tools in the toolkit – and the cognitive behavioural approach within a biopsychosocial model, because without viewing pain in this way, I think it can be really difficult to consider ways to manage pain aside from reducing pain intensity.
The first tool in a pain management toolkit is understanding something about the neurophysiology of pain, or having a model or framework on which to hang various aspects of pain and how it affects people. This helps in many ways – it makes the experience more understandable, particularly when considering the multiple body systems that get involved in pain; by making it more understandable at least part of the anxiety/fear associated with pain reduces – the threat value diminishes as the evolutionarily younger parts of the brain are able to influence the more primitive areas of the brain. This can explain why someone can voluntarily sit through a body suspension and reinterpret the sensations as exhilarating rather than fear-provoking. It’s important to move beyond just a neurophysiological model too, because we’re also psychosocial animals. While I’m sure that at some stage we’ll find out how psychosocial factors directly influence neurophysiology, I don’t think the science is yet far enough advanced to be used in patient education (hey, some clinicians still don’t think psychological factors influence neurophysiology!).
The second tool is having ways to reduce physiological arousal. To me this comes before thoughts/beliefs work, because even if someone doesn’t ‘get’ the model of pain, and can’t access their own thoughts and emotions readily, they can still use practical strategies like breathing, deliberately reducing muscle tension, relaxation and so on.
The third tool is developing an understanding of, and using, activity management. This means understanding how to establish a baseline, how to progress a baseline, and how to use this on a daily basis to manage the physical demands of an ordinary life. There are several tools in this part of the toolkit because activity management also involves planning, goal-setting, problem solving and working with thoughts and beliefs about what needs to get done and how it can be done. It can even mean working on communication, self esteem and relationships because when changing behaviour, all these things are likely to be influential.
The fourth tool is developing an awareness of the influence of thoughts and emotions on behaviour, and on the experience of pain. This is one of the critical skills for self managing chronic pain, IMHO, because it helps people develop flexible ways of coaching themselves to manage situations. It also, when all elements line up, means the person may not need much more from health professionals and can live as a person who just happens to have pain, rather than a patient. This aspect of the coping toolkit involves learning how we appraise situations, the effect of these appraisals on our emotions, and how this in turn can influence our actions. And yes, recognises that each one of these factors operates on the others!
How we, as clinicians help people develop these tools is the focus of the Healthskills blog. It’s my intention that these posts help clinicians and people with pain to learn as much as possible about the psychosocial aspects of pain and the underlying neurobiology because it’s by learning this we are able to help people live more fully in the world without experiencing overwhelming distress, despair or demoralisation. AND without limiting their lives so that they’re able to have very little of what makes it all worthwhile to be alive.
I’ll continue this series on medication and self management over the next week – but it’s vital to me that when we’re looking at the use of medication, whether as a way to reduce some of the pain intensity, or as a way to minimise painful exacerbations, we also appreciate the need to fully use the other tools that we have to influence pain.
’nuff said – flare-ups will be on the menu next week when I start discussing set-back planning.