South of Okiwa Bay

Medication and Self Managing Chronic Pain (ii)


ResearchBlogging.org
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

5 comments

  1. Hi Bronnie,
    I agree with you, reduced pain doesn’t always equate increased functioning, but I think that a large part of that is due to patients still expecting to be pain free.

    In my corner of the world, no one ever tells you that a fibromyalgia diagnosis means, you WILL always have pain to some degree, and you need to learn to accept the pain as a variation of normal. It takes reducing your expectations to “pain reduced to allow maximum function” which, of course, varies from person to person. I had a doctor put me on a low dose of sustained release morphine for my fibromyalgia, and low back pain (before sciatica) but I am allergic to it.
    Now that I have had a spinal fusion and still have severe sciatica, which is SO much fun, I am reduced to taking 5-40 mgs of Percocet, maximum per day, which is insane to me.
    I had to ask to see a sports medicine physical therapist, to help me maximize my workouts and make sure I am not doing anything to cause more pain.

    It is beyond me how a doctor who sees me 2-3x a year, can look at all I have been through, all the procedures, and say that the opiates are causing increased sensitivity to the pain, so we need to reduce the opiates. Uh, no doc, the pain and the fibro are causing increased sensitivity to pain. Give me a couple of really pain reduced weeks, and I may be able to shore up for a few more months. But if I hear how sciatica is usually very easy to treat, or that I “look good so it can’t be that bad” one more time….

    So, I think they need to look at the addiction rates amongst the chronic pain population, instead of looking at the
    few drug-seeking patients who think pain medication is a panacea.

    This doctor says it all for me:
    http://ajp.psychiatryonline.org/cgi/content/full/163/7/1299

    I may reprint this and bring it to my next visit and ask if I have suffered enough to placate my doctor’s fears that the medication is increasing my pain, and I am not doing my part. I am sure my muscles will show that I have done MY part, and hopefully he will do his.

    Thank you again,

    Yvonne Henderson

    1. Yvonne, there is a world of difference between developing tolerance to opioids and addiction! And it is clear that opioids do tend to increase overall sensitivity to pain, leading to wind-up. Addiction, certainly in the way that we use it in the clinic in which I work, means an almost compulsive demand for increasing amounts of the medication with associated tendency towards using whatever means necessary to obtain it such as stand-over tactics and crime. Tolerance means requiring the same amount of the drug to obtain the same degree of effect. It’s not associated with stand-over tactics and crime, and is a function of the ways in which our bodies process things like opioids. Most people with chronic pain don’t become ‘addicted’ to medication – but may certainly become tolerant of a particular dose, then require increased amounts over time, and can’t abruptly stop medications because a withdrawal effect will be experienced.
      Increasing doses of opioids tend to increase the unpleasant side effects while only achieving the same level of pain reduction. This, along with the wind-up or sensitisation, is one of the main reasons I think our medics don’t willingly prescribe opiates for chronic pain.
      I’ll dig out some references for you to look at – and I do want to say that reducing opioids doesn’t necessarily leave you without pain relief, or without ways to cope. More on this later!
      Here are a couple I found: L. A. Colvin, M. T. Fallon. Opioid-induced hyperalgesia: a clinical challenge. BJA: British Journal of Anaesthesia, Volume 104, Number 2 (February 2010), pp. 125-127,
      K.-H. Konopka, M. van Wijhe. Opioid-induced hyperalgesia: pain hurts?. BJA: British Journal of Anaesthesia, Volume 105, Number 5 (November 2010), pp. 555-555,
      Shurman J. Koob GF. Gutstein HB., Opioids, pain, the brain, and hyperkatifeia: a framework for the rational use of opioids for pain. Pain Medicine. 11(7):1092-8, 2010 Jul.
      I hope these readings help!

      1. Again, you are the best!
        Tolerance and the need for increasing doses to maintain the same level of pain relief are easily, in my humble and slightly well trained opinion, handled by taking medication breaks. I was trained to do this a decade ago and still practice it, regardless of the pain I have to deal with during the break, as it has proved to have the best results for me.
        I was able to go off of 40 mgs of oxycontin in 5 days, methadone in 3 days because I am allergic to it (I was told NO ONE goes off of that), and the same with any other medication, including morphine. I can stop, take an NSAID for 2 weeks, then go back on my same old dose, here comes the IF, if my pain has not changed dramatically.
        Muscle pain from fibromyalgia, easy, general low back pain, a breeze, sciatica… death defyingly dramatic.
        I walked 5 miles last night, did 100 push ups elevated on a ball, and 100 crunches. When I was finished, the pain was so severe, I limped into the shower. And I do this 5 times a week, 3-5 miles.
        I can’t begin to comprehend the attitude that I should buck up and deal, because “sciatica is easily treated”, with my stellar track record medication wise.
        But the dark ages mentality continues! Hopefully these conversations and using appropriate studies to show the need to use medication, behavioral therapy, and lifestyle adjustments combined, will get chronic pain patients the individual help they need to live “normal” productive lives.
        Hopefully!

        Warmest regards,

        Yvonne

      2. Hi Yvonne
        I don’t have any opinion on drug holidays, although I am aware that it used to be popular for psychotropic medications. I’ll certainly take a look at the literature to see what has been published, but the main thing is that you have found it helpful.
        Sciatica, like any pain, can be experienced by different people in different ways, so simply having a label or diagnosis means little in the face of individual characteristics – there are different histories, memories, beliefs, attitudes, contexts etc so two people with the same diagnosis can have very different experiences. As I mentioned in the post today, two people taking part in body piercing will have vastly different experiences – one might frame her experience as thrilling and exhalting, while another might view it as scary, horrible and nauseating.

        As I also mentioned, the Centre in which I work doesn’t recommend opioid medication for nonmalignant pain. This is because of the potential side effects, the tolerance effect, and the risk of opioid-induced hyperalgesia. It’s a vexed question as to whether opioids are useful or not so useful for people with chronic pain, and I don’t think there is any resolution to this debate currently. What is important is to determine how to get through periods of increased pain, and to have the confidence that if push comes to shove, it’s possible to manage if any specific drug is removed from sale for whatever reason. Medications do come and go in availability, whether because of ‘market forces’ (indomethacin is a good example in NZ, where it is not available now because the drug company says it’s no longer commercially viable to market it here), or because of unexpected side effects (remember the Cox II inhibitor Vioxx was withdrawn because of increased risk of other health problems?) or legislative changes (at least in NZ it’s possible for Pharmac, the national drug purchaser to decide that a less expensive generic substitute can be made freely available while the branded version is withdrawn from access). To know that you are able to manage at least some aspects of a normal life despite fluctuations in pain is, I think, a positive thing.
        cheers
        Bronnie

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