Pain Suffering and Pain Relief
By Vijaya Polovaram, MD

Feeling pain is normally having an awful, hurtful, ‘painful’ experience. Pain is the most common reason patients seek medical care. Pain has both sensory and emotional components. Nociceptive pain is usually localized and occurs with bruises, sprains, fractures, inflammations from infection, etc. Experienced as throbbing or aching, nociceptive pain normally subsides when the affected part of the body heals. Neuropathic pain occurs when there is damage to either the central nervous system or peripheral nerves of the body. Experienced as a burning sensation or a shock, neuropathic pain is often chronic and signals damage to the nervous system.

Although pain of predominantly psychological origin is far less common than nociceptive or neuropathic pain, psychological factors commonly contribute to chronic pain and may contribute to pain-related disability. Pain thought to be caused predominantly by psychological factors is sometimes called psychogenic pain. This type of pain can be categorized in terms of defined somatoform disorders (e.g., chronic pain disorders, somatization disorders, hypochondrias).
Many pain syndromes have multiple factors and symptoms. Reporting pain is more socially acceptable than reporting anxiety or depression, and appropriate therapy often depends on sorting out these divergent perceptions. Pain is suggested by facial grimacing, frowning, or repetitive eye blinking. Sometimes caregivers can describe behaviors that suggest pain (e.g., sudden social withdrawal, irritability, grimacing). Pain should be considered in patients who have difficulty communicating and who inexplicably change their behavior.

Types of Pain
Pain can be classified as acute or chronic. The distinction between acute and chronic pain is not based on its duration of sensation, but rather the nature of the pain itself. Acute pain serves to protect one after an injury. Chronic pain does not serve this or any other purpose. Acute pain is the symptom of pain while chronic pain is the disease of pain.

Acute Pain
Acute pain is frequently associated with anxiety and hyperactivity of the sympathetic nervous system (e.g., tachycardia, increased respiratory rate and blood pressure, diaphoresis, dilated pupils). Acute pain has as its source soft tissue damage, infection and/or inflammation. It can be modulated and removed by treating its cause and through combined strategies using analgesics to treat the pain and antibiotics to treat the infection. In general, while it is uncomfortable to experience, it is easy to treat; is distinguished by having a specific cause and purpose, and generally produces no persistent psychological reaction.

Chronic Pain
American pain associations estimate that 40-80 million Americans live with chronic pain. At the same time, there are only 8,000 qualified pain management specialists. Chronic pain has no time limit, often has no apparent cause and serves no apparent biological purpose. Chronic pain can trigger multiple psychological problems that confound both patient and health care provider, leading to feelings of helplessness and hopelessness. The most common causes of chronic pain include low-back pain, headache, recurrent facial pain, cancer pain, and arthritic pain. Sometimes chronic pain can have a psychosomatic or psychogenic cause.

Chronic pain was originally defined as pain that has lasted six months or longer. It is now defined as “the disease of pain.” Its origin, duration, intensity, and specific symptoms vary. The one consistent fact of chronic pain is that, as a disease, it cannot be understood in the same terms as acute pain, and the failure to make this distinction (particularly in those who suffer chronic pain) has been and continues to be the cause of multi-dimensional suffering, depression, social isolation, helplessness, loss of appetite and loss of libido. The failure to recognize chronic pain as substantially different from acute pain cannot be blamed on the medical profession.

Chronic pain, no matter how debilitating it is in one's life, continues to be considered by most insurance carriers as a 3-17% disability. There have been some theories that not treating acute pain properly can lead to chronic pain.

Neuropathic Pain
Peripheral nerve injury or dysfunction can result in neuropathic pain. Examples are mononeuropathies such as carpal tunnel syndrome; radiculopathy; plexopathies (typically caused by nerve compression, as by a neuroma, tumor, or herniated disk); and polyneuropathies (typically caused by various metabolic neuropathies). Chronic pain does not involve sympathetic hyperactivity but may be associated with fatigue, loss of libido, loss of appetite and depressed mood. People vary considerably in their tolerance for pain

Relief of Pain Suffering
For acute pain there is always a cause. Treatment is directed towards the finding the cause and getting it treated before the tissue damage occurs. These types of pain usually resolve once treated and healed. Chronic pain, on the other hand, is generally of unclear pathology and unpredictable prognosis, and can be caused by countless diseases, syndromes, injuries, or surgeries.
Pain costs the nation an estimated $100 billion annually in medical claims, disability payments and lost productivity. In an effort to improve on these shortcomings, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued guidelines in their 2000-2001 Standards Manual that recommend screening for the presence of pain, assessing its nature and intensity, keeping records of assessment so that follow-up can be performed, and establishing procedures to provide appropriate medication to patients in pain.
Today, the approach most pain management programs embrace is to respect pain, treat it intensively, address the patient’s psyche, and to adopt an integrative multidisciplinary approach, incorporating the following: patient education, medications, physical therapies, relaxation techniques, psychosocial counseling, surgical procedures, injection techniques, and alternative medicine. Under drug therapy, we have non-steroidal anti-inflammatories such as aspirin, Motrin, Naprosyn, etc. We need to be aware of side effects of these meds. Older populations with cardiovascular issues should be cautious about taking NSAIDs as well as other drugs used for cancer and other chronic pain conditions. Side effects to keep in mind are constipation, abuse potential and occasional nausea. Some alternative medical treatments for pain management such as massage therapy, chiropractic, stress management, guided imagery, yoga, biofeedback and acupuncture may be included for coverage under some insurers such as Blue Cross/Blue Shield. Check your policy for pain management coverage.

Dr. Polavaram specializes in internal medicine and is the owner of Capital Primary Care with offices in Cary and Raleigh.

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