• Caring for patients with chronic benign pain

    January 2008

    More than 50 million Americans are partially or totally disabled by chronic, non-cancer-related pain. The annual health care cost for these patients is more than $60 billion. Yet despite the numbers affected and the financial burden, the proper management of chronic benign pain remains a challenge for practitioners because it is complex and may not respond well to therapy.


    A survey of more than 700 primary care physicians revealed that most of the physicians were not comfortable treating patients with chronic benign pain. 


    The results, published in the February 2007 issue of The American Journal of the Medical Sciences, found that intensive education after residency in the treatment of pain significantly improved the physicians’ comfort level.

    Most of the respondents to the 4P (Patient-Physician Perception of Pain) Study felt they should manage these patients’ cases regardless of their training. However, when given the option, they preferred the multidisciplinary team approach of a pain center.

    Diagnosing pain

    Pain is the most common complaint that propels patients into a doctor’s office. But it is a universal, complex issue that involves hundreds of syndromes or disorders. The two basic types — acute and chronic — differ greatly. Acute pain usually is the result of an injury, inflammation or disease and is limited in time and severity, although it can sometimes develop into chronic pain. Chronic pain persists for longer than six months and often significantly limits a person’s activities of daily life or work.

    There are no specific tests that can actually “measure” pain, so doctors must rely on the patient’s own description and history. A number of technologies, including MRIs and X-rays, may be able to pinpoint the cause.

    Various musculoskeletal, neurological, reproductive, gastrointestinal and urologic disorders can cause or contribute to chronic pain. In addition, cardiovascular diseases such as angina or peripheral vascular disease may be the cause. Sometimes multiple contributing factors may be present in a single patient. Headaches and back pain are among the more common types of chronic benign pain.

    Treatment options

    No matter what the type or origin of a person’s pain, treatment must be tailored to the individual. Some of the treatment options for chronic benign pain include the following:

    • Exercise
    • Non-opioid medication
    • Nerve blocks, using drugs, chemical agents or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain
    • Physical therapy and rehabilitation
    • Behavioral techniques
    • Electrical stimulation, including implanted electric nerve stimulation and deep brain or spinal cord stimulation
    • Intrathecal drug delivery with implanted devices
    • Corrective surgery

    Hope for the future

    Advances in pain research are creating improved treatments and a better understanding of chronic benign pain. Here are just a few areas researchers are looking into:

    • Neurostimulation has improved rapidly and has more applications today.
    • Intrathecal drug delivery, in which drugs are introduced directly into the spinal fluid, is a more effective use of some medications.
    • Stress reduction. Investigators are studying the effect of stress on the experience of chronic pain.
    • Medication. Chemists are synthesizing new analgesics and discovering painkilling virtues in drugs not otherwise prescribed for pain.
    • Electro-acupuncture. Chronic pain patients often have lower-than-normal levels of endorphins in their spinal fluid. Investigations of acupuncture include wiring the needles to stimulate nerve endings electrically, which some researchers believe activates endorphin systems.
    • Research supported by the National Institute of Neurological Disorders and Stroke is also revealing new information about how genetics, the immune system and the skin contribute to pain responses.
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Page last updated: 5/22/2014 3:21:52 PM
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    What the news means for you

    The experience of pain

    William O. Witt, MD
    Anesthesiology/Neurosurgery

    Wright, Heather, MDWe can’t see pain and we can’t take pictures of it. Patients have told me they would rather be in wheelchairs because at least everybody would know what their problem is. Most people don’t understand chronic pain.

    Pain is highly individualized. The human sensory threshold is identical in everyone, but the pain threshold varies with age, race, sex, previous experiences, country of origin and basically any other variable you can imagine. Pain perception is a learned behavior. The pain transmitting circuits are anatomically consistent from one individual to another, but the modulation of the pain stimulus is extremely variable and a product of our environment, making each person’s perception of pain different.

    Pain is also modulated differently in the same individual under different circumstances. If you think your pain is an indication of a life-threatening condition, it is usually perceived as being more severe. If a child is in pain in the middle of the night, the parents may go to the emergency room, whereas during the day, they may give the child some Tylenol and send him to bed. The anxiety and fear of the unknown all affect pain, as do life experiences. You can’t treat all pain patients the same and expect to get good results.

    The narcotics issue

    There is a public perception today that if you take enough narcotics, you won’t have to feel pain. Although this may be true in certain types of acute pain, cancer pain or end-of-life care, research has not proven narcotics to be of any value in treating chronic benign pain. The difference is primarily with the duration of therapy. Several studies have shown that when opioids are given regularly over a long period of time for chronic benign pain, they have the potential to make pain worse by inducing hyperalgesia, which causes even ordinarily non-painful stimulation such as light touch to become painful.

    Addiction is not a major concern in the acute or end-of-life situations, but up to 16 percent of patients taking opioids over a long period of time become addicted. Additionally, abuse of prescription opioids is responsible for more than 4,000 deaths annually in the United States — more than from heroin and cocaine combined. Finally, chronic opioid use impairs immune function and interferes with endocrine function, which contributes to depression and sexual dysfunction.

    Controlling the pain switch with neuro stimulation

    One of the more fascinating areas of pain management is neuro stimulation. We can now implant electrodes virtually anywhere in the body — deep brain, surface of the brain, spinal cord, nerve root, peripheral nerve, autonomic nerve, cranial nerve — basically on any neural structure.

    The body is an infinitely complicated computer that contains millions of electrical circuits. If you can find the right circuit and put an electrode on it, you can do interesting things by electrically modulating the pain conduction circuit.

    By applying extrinsic electrical fields to these nerves, we can turn off pain circuits or turn on pain inhibitory circuits, sometimes simultaneously. At UK Interventional Pain Associates, we are treating everything from back pain to angina in this way. We currently have more than 250 patients who are having excellent success with these implanted devices.  

    Over the last 10 years, these devices and their applications have improved significantly. Today, they are about the size of the stopwatch and implanted just under the skin, usually on the hip. They are rechargeable and last nine years before needing to be replaced.

    Spinal cord stimulation

    Spinal cord stimulation is now showing promise for angina patients who have not responded to other therapies. Many have had stents or bypasses and still suffer from chest pain. Studies out of Europe show that these patients often do very well with spinal cord stimulation. They report decreased pain, increased exercise tolerance and improved quality of life. The morbidity and mortality is comparable to that seen with coronary artery bypass grafting.

    Another common cause of chronic benign pain that frequently responds to spinal cord stimulation is complex regional pain syndrome type I — an inflammatory condition of the nerves that can follow fractures or other trauma, often to an extremity. Patients with this problem often compare the pain to having their hand held constantly in boiling water. I treated a woman with a wrist fracture who was referred to me by an orthopedic surgeon. The fracture had healed completely, but her hand was swollen twice its normal size, making it impossible for her to work. With spinal cord stimulation, she regained full function of her hand and returned to her job.

    We also implant the devices into patients with headaches who have not responded to other treatment. For example, one of my patients suffered headaches for 40 years, another for at least 30 years. One was implanted with a peripheral nerve stimulator and the other with a peripheral as well as a cranial nerve stimulator. Both are now pain free.

    Caution for patients in pain

    There are doctors who hold themselves out as “pain specialists” who do nothing more than prescribe narcotics. This is not good for their patients, and it is certainly not good for medicine or society as a whole. Pain medicine is a recognized specialty of the American Board of Medical Specialties. Patients may want to consider this when looking for a pain management specialist.

    Dr. Witt is director of UK Interventional Pain Associates, as well as chairman emeritus of the department of anesthesiology and professor of anesthesiology, neurosurgery and hematology-oncology at the UK College of Medicine.

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