This article aims to highlight some common varieties of chronic pain and current treatment options available to deal with them effectively including orientation about the advanced pain therapies. Pain and suffering remains a significant dilemma of mankind. Pain continues to be one of the most common reasons why patients seek medical attention. It is an unpleasant feeling that warns something may be wrong. It can be anything from a slight nuisance such as a mild headache to something excruciating such as a facial neuralgic pain condition called trigeminal neuralgia which can make the sufferer miserable to the extent of having suicidal thoughts.
Chronic pain - long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition such as arthritis. It may be intermittent or continuous and it is considered a major medical condition that can and should be treated. It is now considered to be a disease in its own right!
Although the prevalence of chronic pain world over is high the problem still remains under diagnosed and mismanaged. It is estimated as per WHO figures that chronic pain afflicts one out of every five individuals. It may affect people to the point that they cannot work, eat properly, participate in physical activity, or enjoy life. This can translate into a huge ongoing burden on the healthcare economy. Chronic pain management is a recognised speciality in the western world, our country is lagging behind still in full utilization of these services. First step in bringing our country at par in this field is by making our population and all our doctors aware of the existence of pain clinics. This is where many of these suffering patients can seek relief from their longstanding pain and significantly improve their quality of lives.
What causes chronic pain?
There are many causes of chronic pain. It may have started from an illness or accident, from which a person has since long recovered. Or there may be an ongoing cause of pain, such as arthritis or cancer. Many people suffer chronic pain in the absence of any past injury or evidence of illness. A pain clinic can offer considerable alleviation of pain in patients with cancer where it has inevitable presence in almost 9 out of 10 patients during terminal phase of their lives.
What is the "terrible triad?"
When pain becomes such a problem that it interferes with life's work and normal activities, a person may become the victim of a vicious circle. Pain may cause a person to become preoccupied with the pain, feel depressed, and irritable. Depression and irritability often leads to insomnia and weariness, leading to more irritability, depression, and pain. This state is called the "terrible triad" of suffering, sleeplessness, and sadness. The urge to stop the pain can make some people drug-dependent, and may drive others to have repeated surgeries, or resort to questionable treatments.
The goal of pain management programmes is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally and socially. Pain management techniques assist in reducing the suffering experienced by a person with chronic pain. It includes the following:
Medical management of chronic pain [drugs]
OTC medications may include non-steroidal anti-inflammatory drugs (NSAIDs), Aspirin, Paracetamol.
Prescription pain medications may be needed to provide stronger pain relief than aspirin, including narcotics. However, these drugs are reserved for more severe types of pain, as they have some potential for abuse and may have unpleasant side effects.
Prescription antidepressants can benefit some patients because these medications can increase the supply of a naturally produced neurotransmitter, serotonin, which has been found to be an important part of a pain-controlling pathway in the brain.
Interventional pain procedures [nerve blocks, ablation and implantation]
" Physical and occupational therapy interventions such as massage and whirlpool treatments. Exercise to reduce spasticity, joint contractures, joint inflammations, spinal alignment problems, or muscle atrophy (weakening and shrinking) to prevent further problems, heat and cold treatments to reduce the stiffness and pain, especially with joint disorders such as arthritis
" Local electrical stimulation involving application(s) of brief pulses of electricity to nerve endings under the skin to provide pain relief in some chronic pain patients
" Emotional and psychological support for pain, which may include Psychotherapy, Group therapy, Relaxation, Hypnosis, Biofeedback etc.
" Surgery
" Alternative therapies/ Acupuncture/Acupressure
"
Interventional pain relief techniques
These can range from simple clinic based nerve blocks to sophisticated advanced pain therapies which require a full-fledged hospital infrastructure. Jaslok Hospital offers the entire spectrum of these treatment options by trained and experienced multidisciplinary team all under one roof. There are newer techniques can many a times help avert the need for surgery. Most of these procedures are performed in the sterile operating room under live X-ray guidance for precise targeting of appropriate nerves and to obtain a more reliable and long-lasting outcome. The hospital offers relief for patients by a special approach epidural under X-ray guidance for small size disc bulges [slipped disc/sciatica], for patients not willing or suitable to undergo back surgery and patient with tight bony canal due to changes of spondylitis.
Patients with osteoarthritis of joints of spine can be offered long-lasting relief with a special machine by delivering radiofrequency energy to numb the involved nerves. One very distressing pain syndrome called trigeminal neuralgia can also be treated by radiofrequency thermocoagulation which is one of the most rewarding procedures.
Sympathetically maintained pain presenting with features like burning, sensitivity, swelling and skin colour changes mainly involving arm or leg can be handled by targeting groups of special nerve cells called stellate or sympathetic ganglion.
For patients with cancer pain with limited life expectancy, we offer long-lasting relief by destroying nerve bundles with strong drugs like alcohol and phenol. The next option in the stepwise approach is with advanced pain therapies.
Intrathecal drug delivery systems
This is sophisticated, programmable and titrable system which can be implanted for long term, effective and administration of analgesic drugs. These have the benefit of reducing the dose of the drug and thereby also side effects to the bare minimum. They are also good from the compliance point of view.
Spinal cord stimulation therapy [pain pacemakers]
This is another form of advanced pain therapy which is immensely useful for patients suffering from chronic, disabling nerve pains due to numerous causes. It has been used for over past thirty years in the developed nations but now getting popular in our country also due to the expertise available with our hospitals. This is a safe, effective and reversible therapy mainly useful for patients with persistent or recurrent pain after back surgeries. Failed back surgery syndrome is a name given to this problem which occurs in almost 3-4 out of 10 patients undergoing back surgeries. These patients end up having disappointing results with repeat surgeries and are desperate to find solace somewhere. They can now be offered a new ray of hope with the availability of this wonderful therapy. It can also help patients with pain due to vascular disease where surgery cannot be offered, certain complex pain problems with predominant burning and abnormal sensations. Some of the other indications for this therapy include Complex Regional Pain Syndrome, Phantom Limb, Arachnoidits, Peripheral Ischemic pain, Peripheral Neuropathies, Post Herpetic Neuralgia, and Stump Pain.
The therapy comprises of two main phases. First there is a testing phase where insulated wire with contact points is introduced thro' the skin without surgery into a space surrounding the spinal cord under image guidance. It is connected to an external battery for 3-5 days to test the efficacy and patient satisfaction. This can deliver a minute current [pleasant] into the vicinity of group of nerve cells which conduct pain messages. This blocks the common route [pathway] through which all sensations pass to the brain [like jamming a telephone line]. So the patient instead of perceiving pain feels a pleasant sensation in the distribution of pain. Next, once the patient is convinced about the benefit, the wire is connected to a permanent battery [pacemaker] fitted and concealed in the patient's body. Once the system is in place it is not even visible from outside. If for some reason patient is not satisfied with testing the wire is simply pulled out without any residual damage. The latest technological advance is rechargeable pacemakers which can be charged from outside the body. It proves to be more cost effective therapy in long run. The patients can recharge the pacemaker as and when required from outside the body.
The therapy can have many programming options to tailor to the individual patient needs. It offers flexibility to the patient to vary the strength of current, switch on, switch off the pacemaker as the need may be.
There are still reservations in the minds of patients about having this devices implanted in their bodies permanently. One needs to understand that in fact these are similar to having cardiac pacemaker or joint prostheses which are so widely and routinely implanted and accepted. If it makes a world of difference to one's functionality and quality of life especially when the options have narrowed down, we feel our patients should be more open to receiving these therapies as is being done world over and certain other parts of our country to relieve their agony.
Thus, the scenario of offering pain relief has been changing now in India, with emerging newer, safer and sophisticated options and availability of centres with trained and experienced doctors in this field. There is no need to succumb to the multiple ill effects of pain. Pain relief is a basic human right!! One must seek relief from pain.
(The author is an interventional pain specialist, Jaslok Hospital)