Pain exists as a symptom of many different conditions. Problems as simple as a cut finger and as complex as Diabetes Mellitus can result in pain. The most important distinction between types of pain is between pain that is acute and pain that is chronic. Often we attempt to define chronicity by the length of time that a condition or symptom has been present, but more accurately, chronic conditions are marked by pathological changes that occur in the chronic state of an illness and are not necessarily present in an acute state. These changes in a condition foretell a permanence of symptoms, where acute conditions are often thought to be reversible. Still this definition is inadequate because it is inevitable in certain acute conditions that the initial symptoms will pass into a state of chronicity. Probably the best way to define a painful condition as chronic is to look at both the length of time it is present and the pathological changes that have occurred that distinguish it from the acute state. By keeping this in mind, the most timely intervention in a painful condition to reduce the overall pain is the most likely to result in a reversible or well-controlled outcome.
To understand the Disease of Chronic Pain, we have to evaluate and treat the patient in the separate arenas of the physical injury, the psychological effect of that injury and the social adjustments that have occurred as a result of the injury. Although it is tempting to look at chronic pain as a purely physical event, this is rarely, if ever, the case. People who suffer with chronic pain experience a sequence of events that alters their lives and may manifest as a spectrum from the simple to most complex set of circumstances. Patients with chronic pain should be seen as going through a series of cascades, the biological, the psychological and the social. Successful treatment should take into account all three cascades and attempt to intervene in all three spheres. A typical pattern in each cascade would be as follows:

Biological:

• The symptom of acute pain presents as part of a complex set of symptoms related to tissue damage
• Anatomical, neurophysiological and neurochemical alterations occur at the site of injury and in the spinal cord
• Pain persists, as damage is either repaired, remains unchanged, or worsens
• Diagnostic tests either point to a treatment or reveal no findings
• Testing becomes more invasive
• Treatment becomes more aggressive
• Invasive and surgical interventions offer little or no long term pain relief and may worsen pain
• Doctors tell patients that there is nothing more that can be done

Psychological:
• Expectation of pain relief is replaced with realization of continued or increased pain
• Frustration and anger ensue and deepen as pain remains unresolved
• Preexisting psychological problems are activated by persistent pain
• Inability of physicians to effectively intervene causes fear and alarm
• Disbelief by physicians, family and friends increases frustration
• The patient fights off the threat of relentless pain with defenses of denial and repression
• Self-esteem deteriorates
• Depression and Anxiety develop
• Neurochemical and neurophysiological alterations occur in the brain
• Depression is reinforced by constant pain and intermittent flare-ups

Social:
• Temporary disability does not resolve
• Lack of work leads to financial deterioration
• Patients who work are often unable to have any other activities, due to increased pain
• Work relations deteriorate as sick days increase and work restrictions continue
• Recreational, social and family activities suffer
• Friends stop visiting
• Family members become frustrated and less supportive
• Medical Legal problems are confusing, counterintuitive and demoralizing
• Patients feel undermined, bitter and abandoned
• Spiritual beliefs can become undermined or abandoned
• Patients become passive in their own lives waiting for the cure that never comes

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Hence, the disease of chronic pain must be understood as a process that not only occurs over time and with pathological changes that distinguish the chronic condition from the acute condition, but also as a disease that has an effect upon the entirety of a persons life. If all treatment is directed at the biological manifestation of pain, there is little likelihood that the patient's condition will have a satisfactory resolution. A treatment plan for successfully treating chronic intractable pain should involve interventions at the biological, psychological and social level. The goal of this treatment should not be the complete end of chronic pain, but instead a reasonable level of pain control and improved function. An effective treatment plan would involve the following:

Biological:
• Non-medication noninvasive approaches
• Non-opioid medications
• Short acting opioids
• Long acting opioids
• Therapeutic blocks
• Surgery
• Invasive palliative approaches

Psychological:
• Thorough Evaluation
• Establish a Therapeutic Relationship
• Psychopharmacology- for depression, anxiety, sleep disturbance, Post Traumatic Stress Disorder, panic , Obsessive Compulsive Disorder
• Supportive psychotherapy, cognitive approaches, hypnotherapy, family therapy, group therapy
• Helping patient’s accept the change in their lives, while not accepting inadequate pain control

Social:
• Vocational Retraining
• Realistic adjustment of recreational activities
• Rejection of social isolation
• Conflict resolution
• Understanding Medical Legal issues
• Disability Activism

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These treatment approaches sometimes unfold in different order and the variations that occur with individual practitioners can represent the art of pain medicine, but the general ideal of touching upon all three life spheres is extremely important if good outcome to treatment is to be achieved.
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