There is one undeniable fact about chronic pain: More often than not, it is untreated or under-treated. In a survey last year by the American Pain Society, only 55 percent of all patients with noncancer-related pain and fewer than 40 percent with severe pain said their pain was under control.
But it does not have to be this way. There are myriad treatments - drugs, devices and alternative techniques - that can greatly ease persistent pain, if not eliminate it.
Chronic pain is second only to respiratory infections as a reason to seek medical care. Yet because physicians often do not take a patient's pain seriously or treat it adequately, nearly half of chronic-pain patients have changed doctors at least once, and more than a quarter have changed doctors at least three times.
In an ideal world, every such patient would be treated by a pain specialist familiar with the techniques for alleviating pain. But "very few patients with chronic disabling pain have access to a pain specialist," a team of experts wrote in a supplement to Practical Pain Management in September.
As a result, most patients have to rely on primary care physicians for pain treatment, obliging them to learn as much as they can about treatment approaches and to persist in their search for relief.
COCKTAIL OF PILLS
Most chronic pain patients end up taking a cocktail of pills that complement one another. There are three categories of drugs useful for treating chronic pain:
* If the pain is not severe, nonsteroidal anti-inflammatory drugs (Nsaids) are often tried first. Some, like ibuprofen and naproxen, are sold over the counter. Others, like diclofenac (Voltaren) and celecoxib (Celebrex), are available by prescription. All have risks, especially to the heart and gastrointestinal tract, and may be inappropriate for those prone to a heart attack, stroke or ulcers. Nsaids must not be combined with one another or any aspirin-like drug, but they can be used safely with acetaminophen (Tylenol).
* Several classes of drugs originally marketed for other uses are now part of the pain control armamentarium - antidepressants, especially the Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (Effexor) and duloxetine (Cymbalta); anti-epileptics like gabapentin (Neurontin) and pregabalin (Lyrica); and muscle relaxants like baclofen (Lioresal) and dantrolene sodium (Dantrium). These are often used in combination with specific pain-relieving drugs.
* By far the most important class of drugs for moderate to severe chronic pain are the opioids: morphine and morphine-like drugs. Patients often reject them for fear of becoming addicted, a rare event when they are used to treat pain. Doctors often avoid prescribing them for fear of addicting patients, being duped by drug abusers or being raided by the US Justice Department. Pain societies have established clear-cut guidelines to help doctors avoid such risks, including ways to identify patients who could become addicted.
Many patients and physicians do not know the difference between physical dependence on a drug (withdrawal symptoms result if the drug is abruptly stopped) and addiction (loss of control over drug use, cravings and continued use despite harm). As with other medications, like steroids and antidepressants, patients have to be gradually weaned from opioids to avoid withdrawal symptoms.