South of Okiwa Bay

Medication and self management for chronic pain


ResearchBlogging.org
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

5 comments

  1. My father in law takes about ten pills each day ranging from a vitamin to heart medication. He takes pills to help with arthritis and more pills because of the pain the arthritis causes. One pill leads to another pill that leads to another pill, an endless cycle of medicating the body. I’m not an all natural person but i do believe in balance. How does one draw the line on whats needed to give a better quality of life and whats needed to cover up existing medical conditions?

  2. I like the Canadian guidelines for phrmacology for chronic neuropathic pain It is a stepwise program and it is basically what has been followed in my case anti seizure and SSRI together then add mild opiod or tramodol the stronger opiods then 4th line lamotrigine, ketamine, marijuana.I take all 4 lines and have taken 2 drug holidays to get off and give my liver a chance to rest and restart in small doses and see what i now need on board to cope, I think there is nothing really new in the way of mneds for years but hopefullly research comes through. The side effects take a lot of tweaking of doses and a psychiatrist says i should not be on so many meds but i function OK at this level and want to be on top of my pain and not the other way around. There is a lot of research on opiods but not clear consensus. There are two articles in Pain Researh and Management Volume 12 (1) 2007 pages 13–19 (Moulin et al ) and for chronic pain same journal 11(1) 2006 11-37 Watson and Lynch

  3. I can’t speak for all pain patients, of course, but the terminology as defined here is not consistent with how either my doctors or my friends with chronic illness use it. Because of this, the conclusions seem confused as well.

    Breakthrough pain is not the same as a flare-up. Breakthrough is what the name implies – pain going over whatever analgesia is there. I happen not to like the term myself, but flare-up is something quite different – it’s a multi-day increase in average pain level. So I could have break-through pain on any given day, and experience day-to-day pain fluctuations without having a flare-up. We would call it a flare-up only if the combination of my normal medication and management strategies is not keeping it under control.

    I do stick to the constant dose on a regular basis – I agree with the reasoning that it is too difficult to manage otherwise, so I just have a stable amount that I take every day to keep my average pain within the tolerable bounds. But I will normally increase the dose if I have a flare-up – i.e., I have tried to do other things, and the pain is extending over multiple days and interfering with my function.

    And this is where the other problem with “don’t take extra painkillers during flare-ups” comes in. There is a very strong assumption there that it is possible to accept reduced expectations/commitments for the duration of the flare-up. This is not always the case. For example, I have spaced out various housework tasks over the week so that I don’t overdo it on any given day, and so that I can do what needs to be done even if the pain is at the “high” end of my normal range. But during a strong flare-up, I may be forced to let some things go. It’s ok if I miss a couple of days. But I live alone and have no one to do those for me. So eventually they will pile up, and then I will be forced to overdo it, going right back into “boom-bust” cycle. Daily job responsibilities are the same – sometimes tasks can be de-prioritized or given to other people, and I have arrangements in place to do that when needed. But inevitably there will be times when things really have to be done to schedule, and getting behind too far because of a flare-up will cause significant disruption to the whole team. So if extra painkillers can result in more work done, then there is every reason to take them.

    I say this being fully aware of the side effects – I cannot do my job if I cannot concentrate, and I certainly had painkillers that were worse than pain in terms of effect on my concentration. But I think there is a big middle ground here, between “no effect on pain” and “crippling side effects”, and you seem to imply there is none. I noted it in the next day’s post as well – there is a world of difference between “expecting pain reduction to take away the pain and therefore not doing pain management” and using pain reduction to keep pain within tolerable bounds, and using lifestyle management to deal with the remaining bit.

    I guess I just live with more adjusted people. I know several people through work or socially with various chronic pain conditions – back pain after an accident, chronic tension headaches, arthralgia – and I think everyone is using the variation of this approach. For that matter, I learned many of my coping strategies from them. But it still really surprises me that those people are invisible, and doctors I know keep talking about “either-or” approach and insisting that combination doesn’t really work very well.

    1. Hi Mary
      Actually, the terminology around ‘breakthrough’ pain and ‘flare-up’ is inconsistent across the board, as reflected in a previous post I made some time ago. (see the references below, the post is here<a href="https://healthskills.wordpress.com/2009/02/18/what-is-breakthrough-pain-and-what-about-using-medication-for-it/&quot; I prefaced the comments I’ve made with the point that this is my opinion, and that the literature is unclear and quite scant with regard to using medication and using self management. This is the approach used in the centre in which I work, and some of my thoughts about medication use. It’s also not the final word on medication and self management! There will be a couple more posts in which I’ll probably make reference to some of the points you raise.

      I prefer not to use the term ‘breakthrough’ pain because it suggests that pain relief can and almost should reduce the pain to next-to-nothing. Chronic pain is a condition in which fluctuations of pain is both commonplace and not an indication of further damage or harm. It’s reasonable to expect that pain will vary throughout the day and over weeks and months. To arbitrarily distinguish between ‘breakthrough’ and ‘flare-up’ may not be all that useful, in my humble opinion.

      I also need to point out that it’s the timing of when to move from a pain reduction approach to a pain management approach that seems to be a challenge. As I said, most of the people I see are using both medication and developing pain management skills. We have found out through experience that it’s difficult for people to be fully accepting of using self management strategies when they are still hoping for a future option of pain reduction to be effective. This doesn’t mean everyone is holding out hope – and as a result not ready for self management – but it does seem to have quite an impact on the ongoing use of strategies such as cognitive strategies (self talk, reducing catastrophising etc) and acceptance of pain as something that can be lived through. So the way we work is to ensure all the pain reduction approaches are completed before embarking on self management – then retaining these biomedical approaches (mainly medication) in a stable regime while the person starts to use self management. We encourage using medication as one part of a self management toolkit.

      I’ll be discussing what to do with a flare-up over future posts – I certainly don’t endorse ‘do less on bad days’, because this contradicts the concept of maintaining consistency and reliability. I think it’s really important to understand what it is about having fluctuations in pain that makes it difficult to manage, given the consistent finding that pain intensity alone doesn’t correlate with function, and this is what I intend to continue to explore.

      Thanks for taking the time to comment, it’s always good to know when a post is raising questions or discussion, and I hope to continue the discussion in the days ahead.
      cheers
      Bronnie

      J MARKMAN (2008). Not so fast: The reformulation of fentanyl and breakthrough chronic non-cancer pain Pain, 136 (3), 227-229 DOI: 10.1016/j.pain.2008.03.011

      Laulin JP, Maurette P, Corcuff JB, Rivat C, Chauvin M, Simonnet G. The role of ketamine in preventing fentanyl-induced hyperalgesia and subsequent acute morphine tolerance. Anesth Analg 2002;94:1263–9.

      Portenoy RK, Bennett DS, Rauck R. Prevalence and characteristics of breakthrough pain in opioid treated patients with chronic noncancer pain. J Pain 2006;7:583–91.

    2. I read two of references that you cited (Markman and Potenoy), and now I see where the confusion exists – they define “break through pain” as “intense flares of pain”. But I would still say that there is dangerous confusion of terminology here which you (or rather doctors in general) needs to be careful about. Those references specifically limit breakthrough pain to pain lasting less than 12 hours. Which is consistent with the definition of breakthrough pain as a short-term phenomenon. On the other hand, once you start talking about “setting temporarily smaller goals” during the flare-up you are talking about longer-term pain increases, with is not what those references are researching.

      This is what I was mainly trying to highlight – being clear about what is going on and what terminology is applicable is important in such discussion, because it affects what research is relevant and when. Maybe there are other sources that define it differently, but I do think that the terminology in the sources you cited is consistent with what I have heard from doctors, friends and online communities. “Break-through” pain evokes a short-term pain increase, while “flare-up” means something much longer and more persistent. These have very different implications as to what needs done: there is no sense in trying to micro-manage short-term fluctuations with medications, which is the point that those papers are making. But the reasoning may be different for longer-term flare-ups, and I do not think that research results would transfer.

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