What is Chronic Pain

What is Chronic Pain? Dr. Ken Follet: Chronic pain is usually considered to be pain that lasts or persists longer than three to six months, but it's also convenient to think of it as a pain that outlasts the normal healing time following an injury or surgery. Dr. Nagy Mekhail: Actually, I would like to call chronic pain as a disease. It is not a symptom. Acute pain that happens after surgery or an injury is a good pain. The pain that, we call it acute pain, that's the pain that warns us about something wrong. If I get up two flights of stairs and I feel chest pain, that's a very good sign that tells me, go, check your heart. On the other hand, chronic pain is a disease by itself. People who had multiple back surgeries and everything by MRI, by examination is okay, but these people are suffering from lingering pain 24 hours a day. That starts to affect their quality of life, they become depressed. They cannot engage in the functions that they'd like to do everyday. That's chronic pain. Dr. Ken Follet: Many, if not most people, experience chronic pain at some point in his or her lifetime. Nagy Mekhail: Our brain and spinal cord is a structure that every part of the body has a representation. Representation in this spinal cord or the brain. And when this part is suffering, the areas of the brain and spinal cord start to discharge continuously. After a while, sometimes this discharge or then processing becomes autonomous. In the beginning you have to have a stimulus to cause the pain, an injury or herniated disc or shingles that starts the process, but after a while this process can go on, on, on, and on 24 hours a day by itself. And that's why we call it a disease, actually it is not, it is not just a symptom. And because the brain cells or the spinal cord cells become hyper excited, will become very sensitive. Sometimes actually, they go on and on without any evoked response. Dr. Ken Follet: There are seem to be two components. There is, what's called a discriminative component, that is where is the pain? How intense is the pain, but there's also an emotional component that we refer to as affective component which is more the emotional part, how bad does it hurt, the element of suffering. Both of those who work together in the brain to cause the overall pain experience. Nagy Mekhail: It is estimated that about 68 million Americans suffer from some sort of chronic pain. This is staggering statistics and actually pain -- people don't go to work because of pain more than common cold and that costs the American employers about $78 billion a year. There are about 500 million working days lost because of chronic pain. Dr. Ken Follet: Chronic pain is extremely common. Pain is one of the most common reasons that people see physicians in the United States. What are the two types of chronic pain? Dr. Ken Follet: I generally think of pain as one of two types; either nociceptive pain or neuropathic pain. The distinction is important because sometimes the strategies for treating each of those types of pain can vary a little bit. Nociceptive pain in a sense is tissue pain, if you break your arm it hurts. If cancer affects a certain part of the body, the tumor can injure or cause inflammation to the tissues surrounding the tumor, that hurts. But that's a normal type of pain, the body's own pain signaling mechanisms are activated as a result of that injury or disease and the body sends normal pain signals. So it's a good warning system. Dr. Nagy Mekhail: Neuropathic pain in simple terms is the pain that is either from damage or inflammation or injury of the peripheral or central nervous system elements. Dr. Ken Follet: In contrast, neuropathic pain comes from an injury or some kind of disorder of the nerves or the nervous system in the body. This function of the nerves somehow causes pain. So, a neuropathic pain is different and that it's really an abnormal function of the nervous system rather than the normal function of the pain signaling system, same with nociceptive pain. Dr. Nagy Mekhail: The old school actually of treating pain did not differentiate too much between nociceptive and neurophatic, just to give everybody narcotics and everybody would feel good. But we know now that nociceptive pain responses very well to morphine and anti-inflammatory medications. While neurophatic pain actually is sometimes resistant to opioid and when treated by medications or interventions that suppresses the hyper-excitability of the nervous system. Dr. Ken Follet: Both types can be incident related in the sense that neuropathic pain can occur after an injury, for example, some people have a slip disc that pinches a nerve, they may have surgery that removes the portion of slipped disc but they continue to have unrelieved pain from the nerve injury. But they are different in the sense that, that in one case nociceptive pain, the body is doing its normal job, signaling the pain, whereas with neuropathic pain, it's an abnormal function, that nerve has been injured and it's generating abnormal signals of pain. How is chronic pain treated? Dr. Nagy Mekhail: Actually there are several means to help you manage your pain other than -- the pain management you'll love. Dr. Ken Follet: When we treat chronic pain, we generally follow what's called a pain treatment ladder. We start with the simple safe things which maybe some over-the-counter pain medications, physical therapy, perhaps some behavioral strategies such as stress relaxation, biofeedback. Progress up the ladder if the simple safe things don't work, perhaps some physical therapy, some injections. As we move higher and higher up the ladder to deal with more difficult pain problems, for example, we had narcotic medications, mild pain medications, progressing to stronger ones such as morphine, hydromorphone. Eventually, we will reach a point at which patients who continue to have pain become candidates for one of the implantable pain therapies, either neurostimulation or Intrathecal Drug Delivery. Dr. Nagy Mekhail: Our goal in Pain Management is not to eliminate pain completely, because sometimes this is not an achievable goal. My goal is to improve the quality of life of people and improve their functionality. Dr. Ken Follet: It's important for people with chronic pain to understand that treatments are available for many, if not most types of chronic pain. If individuals have chronic pain that isn't being treated or managed adequately, I would encourage them to seek evaluation and treatment from a physician who has special recognition and expertise in the treatment of pain, for example, patients who are members of the National Pain Organization, such as the American Academy of Pain Medicine or physicians who have special certification in Pain Management, for example, those who've been certified by the American Board of Pain Medicine are those who've been certified by one of the other medical specialty boards such as anesthesiology, neurology or Physiatry as having special expertise in Pain Management. Dr. Nagy Mekhail: So, if I can help these people to decrease the pain so they can participate in their normal living activities and enjoy it, that's the key.