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By Michelle Meadows
Helen Dearman, 52, of Houston, had a broken back for more than a decade and didn't know it. After falling from a ski lift in Mt. Hood, Ore., when she was 23, Dearman was diagnosed with a broken left arm and thought that was her only injury. Her arm healed. But she developed excruciating back pain that made it hard to sleep and move around. "I worked as a teacher, so some doctors suggested that the problem was from standing on my feet all day," Dearman says. "Others told me it was all in my head. For years, I left doctors' offices feeling desperate for help."
The pain grew worse during her 30s. One morning, Dearman woke up with stabbing pains in her back and could barely walk. This time, her husband took her to an orthopedic surgeon who specialized in back problems. The doctor ordered X-rays that revealed three old fractures in Dearman's spine.
"When the doctor showed me the X-rays, I cried," Dearman says. "Someone had finally given me the words and understanding for all the pain I had been suffering from for so long."
By definition, acute pain after surgery or trauma comes on suddenly and lasts for a limited time, whereas chronic pain persists. "Acute pain is a direct response to disease or injury to tissue, and presumably it will subside when you treat the disease or injury," says Sharon Hertz, M.D., deputy director in the Food and Drug Administration's Division of Anti-Inflammatory, Analgesic, and Ophthalmologic Drug Products. "Chronic pain goes on and on--for months or even years."
Common types of chronic pain include back pain, headaches, arthritis, cancer pain, and neuropathic pain, which results from injury to nerves. In Dearman's case, her untreated back injury caused her spine to twist out of place, not only resulting in severe back pain, but also putting intense pressure on the nerves in her legs. "I often felt pain shooting down my legs," she says, "like a jolt of electricity."
Experts say the first step in treating chronic pain is to identify the source of the pain, if possible. Many people with chronic pain try to tough it out, according to research from the American Academy of Pain Medicine. But persistent pain should never be ignored because it could signal disease or injury that will worsen if left untreated. Sometimes, it turns out that the cause of pain is unknown. Fibromyalgia, for example, is characterized by fatigue and widespread pain in muscles and joints. While scientists have theorized that the condition may be connected to injury, changes in muscle metabolism, or viruses, the exact cause is unclear.
Regardless of the type of chronic pain, the physical and emotional effects can be devastating. Dearman says, "My teaching career suffered, my children were confused about why I always felt bad, and our finances were ruined." Sometimes, she says, she even considered suicide.
Dearman believes the first two surgeries she had to repair the fractures in her back and realign her spine were necessary. But she questions the four surgeries that followed. "I talked myself into the operating room more than once because I was desperate to feel better," Dearman says. "Even when doctors told me there was only a small chance another surgery would help, I wanted to take the chance." But after several surgeries, Dearman's pain only seemed to be getting worse.
The turning point occurred in 1995 when a physical therapist referred Dearman to a pain management specialist, a professional who takes a multidisciplinary approach to managing pain. She was treated by a team of pain experts. Doctors and nurses worked with her to manage pain medications. Psychologists addressed her depression and anger, and physical therapists helped improve her strength and mobility.
Dearman finally found effective drug treatment with a pump implanted into her abdomen that delivers morphine through a catheter into the fluid surrounding her spine. The pump, called an intrathecal drug infusion pump, is used for severe pain only after other oral and intravenous drug therapies have failed. The pump is programmed to deliver a controlled amount of medication continuously. Risks include surgical complications, such as infection, and complications with the catheter or pump. "It doesn't take away all the pain, but it's a drastic improvement and allows me to be in control of the pain," says Dearman, who also takes other pain medication as needed.
Seddon Savage, M.D., a pain specialist on the faculty of Dartmouth Medical School in Hanover, N.H., says there are times when it's impossible to eliminate pain. "The goal of pain management is to provide as much pain relief as possible and improve functioning," Savage says.
Because pain varies from person to person, treatment is individualized. Someone with arthritis may do well with occasional use of an over-the-counter pain reliever, whereas someone else with arthritis may need a prescription pain reliever and regular aerobic exercise to feel good.
"Treatment for chronic pain is about much more than medication," Savage says. It can also involve stress relief and relaxation, physical therapy, improved sleep and nutrition habits, and exercise. Dearman says that through a multidisciplinary approach to pain management, she also learned to pace her activities so that she is realistic about how much she can do in a certain time period.
Savage recommends that people seek professional help for chronic pain when they feel that pain is interfering with their quality of life. "Start with your primary care physician, who may refer you to other specialists," she says. "Consider asking your doctor about a pain management specialist if you feel that your pain is just not getting better over time." Another reason to seek advice from a specialist is if you are experiencing intolerable side effects from medications.
One of Dearman's biggest fears was of becoming addicted to pain medications. "It's a common concern for both patients and health providers," says Savage, who specializes in addiction.
"Most forms of chronic pain respond to non-opioid drug treatments," she says. Examples of non-opioid pain relievers, which don't have addiction potential, include aspirin, acetaminophen, ibuprofen, naproxen, and other non-steroidal anti-inflammatory drugs. A combination of different types of analgesic medications at lower doses is often more effective than a single high-dose medication.
"But if opioids are prescribed for your pain, you are not abusing drugs if you are taking the medication as prescribed," Savage says. "Taking doses of drugs to relieve pain is not the same as taking drugs to get high."
Opioids are controlled substances that are potentially addictive. Pain medications containing opioids include Vicodin (hydrocodone), OxyContin and Percocet (oxycodone), MS-Contin (morphine), Tylenol #2, #3 and #4 (codeine), and the Duragesic Patch and Actiq (fentanyl).
June Dahl, Ph.D., director of the American Alliance of Cancer Pain Initiatives and professor of pharmacology at the University of Wisconsin-Madison Medical School, says she recently took a call from a man with cancer who said he stopped taking an opioid pain medication on his own for fear that he was becoming addicted. "But what he described were not signs of addiction, but signs of physical dependence," Dahl says.
Addiction is characterized by craving and compulsive use of drugs. Physical dependence occurs when a person's body adapts to the drug. If someone has become physically dependent on a drug and suddenly stops taking it, withdrawal may occur. These symptoms can include muscle aches, watery nose and eyes, irritability, sweating, and diarrhea. Physical dependence is a normal response to repeated use of opioids and is distinct from psychological addiction.
Savage says that in prescribing potentially addictive medications, doctors should consider patients' personal and family histories of addiction, as well as psychological and social stressors that may affect medication use. Also, some people who begin taking opioid medications for pain as prescribed may later discover that they are using the medication for its psychic brain effects. Physicians need to be aware of this potential adverse effect, and should educate patients and their families about appropriate use of addictive drugs.
To better guide physicians, the Federation of State Medical Boards adopted guidelines for the use of controlled substances for pain treatment in 1998. The guidelines advise physicians on patient evaluations, treatment plans, and medical records.
The use of opioids in pain treatment remains controversial for several reasons. The rate of addiction in the properly treated pain population is unknown. The media has highlighted problems of addiction to pain medicine among celebrities. And there has been considerable drug abuse involving OxyContin, which the FDA approved for moderate-to-severe pain in 1995. The FDA strengthened warnings for oxycodone in 2001, while continuing to recommend appropriate pain control for people living with severe pain.
But experts say that finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle. "Some doctors fear regulatory scrutiny for over-prescribing these drugs," Dahl says. "And concerns about the small segment of people who abuse drugs ends up interfering with effective pain management for others."
Sheryl Kaufman, 40, of Boston, who uses oxycodone and a fentanyl patch for severe pain associated with breast cancer, says she recently filed a grievance with a pharmacy over her struggles to get prescriptions filled. "They made me feel like a criminal," she says. "Sometimes I've had to go without pain medication for two to three days because of delays in filling prescriptions."
Dearman's experiences with chronic pain led her to establish the National Chronic Pain Society in 2002. The organization provides peer support for people with chronic pain and their families.
"We give people support for dealing with all of the issues that can go along with chronic pain-not having your pain taken seriously, frustration over not finding relief, how to communicate your pain to your doctor, and how to maintain relations with your family," Dearman says.
Penney Cowan, executive director of the American Chronic Pain Association, another peer support organization in Rocklin, Calif., says support systems are important because they give people with pain the coping skills needed to take an active role in their recovery. "Sometimes doctors tell people they'll have to learn to live with the pain," Cowan says. "But too often they stop short of telling them how to accomplish that."
Dearman says finding effective treatment and gaining the skills to live with her pain made all the difference. "It's about being a person first and not letting pain define who you are," she says. "Our motto is: Pain may be unavoidable, but suffering is optional."
Michelle Meadows is a staff writer for FDA Consumer.
American Academy of Pain Management
13947 Mono Way #A
Sonora, CA 95370
(209) 533-9744
American Pain Society
4700 W. Lake Ave.
Glenview, IL 60025
(847) 375-4715
American Pain Foundation
201 N. Charles St., Suite 710
Baltimore, MD 21201
(888) 615-7246
American Chronic Pain Association
PO Box 850
Rocklin, CA 95677
(800) 533-3231
National Chronic Pain Society
PO Box 903
Tomball, TX 77377
(281) 357-4673
More than 45 million Americans have chronic headaches, according to the National Headache Foundation. The most common types include tension headaches, which are associated with muscle tension. These are sometimes described as feeling like a tight band squeezing the head. Cluster headaches are marked by severe pain around one eye. Migraines are characterized by throbbing pain on one side of the head. Most people with migraines also experience nausea and sensitivities to light and sound.
Andrew Fano, 38, of Lincolnshire, Ill., who has had migraines since he was 12, says headaches used to wipe him out for days. But things improved in 1992 when the FDA approved Imitrex (sumatriptan), the first drug in a class known as triptans. This class of drugs marked a huge leap forward for headache sufferers. Unlike some previous drugs that dulled the perception of pain, triptans stop the pain by narrowing blood vessels in the brain and reducing inflammation.
Fano's migraine treatment now includes a newer triptan called Frova (frovatriptan). Side effects include nausea, dizziness, and dry mouth. He also takes the pain reliever Vicodin as needed, sticks to a regular sleep schedule, and avoids red wine and other migraine triggers.
Migraines, tension headaches, and cluster headaches are considered primary headaches because they are not caused by underlying illness. "But it's important to rule out disease, especially when headaches are resistant to treatment," says Seymour Diamond, M.D., founder and executive chairman of the National Headache Foundation.
Diamond performed an MRI (magnetic resonance imaging) on Fano a couple of years ago. "We assessed him for a possible brain aneurysm, but luckily, there wasn't a problem," he says.
Most headaches can be successfully treated with over-the-counter pain relievers. But you should seek professional help for headaches if they persist or get worse or if the headaches are keeping you from work and social activities. "You should also see a doctor if you've never had headaches before and you start having them, if you get headaches upon exertion, or if headaches are accompanied by a stiff neck, fever or neurological symptoms like dizziness or blurred vision," Diamond says.
For more information, contact the National Headache Foundation at (888) 643-5552, www.headaches.org/consumer/.
People usually feel pain when receptors in skin, bones, joints or other tissues are stimulated by an injury or threat to the body. Neuropathic pain is triggered by changes in the nerves themselves, or caused by changes in the brain or peripheral tissues.
Pain involves the interaction between several chemicals in the brain and spinal cord. These chemicals, called neurotransmitters, transmit nerve impulses from one nerve cell to another. Neurotransmitters stimulate receptors found on the surface of nerve and brain cells, which function like gates, allowing messages to pass from one nerve cell to the next. Many pain-relieving drugs work by acting on these receptors. For example, opioid drugs block pain by locking onto opioid receptors in the brain.
Other drugs control pain outside the brain, such as non-steroidal anti-inflammatory drugs (NSAIDs). These drugs, including aspirin, ibuprofen, and naproxen, inhibit hormones called prostaglandins, which stimulate nerves at the site of injury and cause inflammation and fever. Newer NSAIDs, including Celebrex (celecoxib) and Vioxx (rofecoxib) for rheumatoid arthritis, primarily block an enzyme called cyclooxygenase-2. Known as COX-2 inhibitors, these drugs may be less likely to cause the stomach problems associated with older NSAIDs, but their long-term effects are still being evaluated.
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