Living With Pain That Just Won’t Go Away

[Guest guest]

Living With Pain That Just Won't Go Away

http://www.nytimes.com/2007/11/06/health/06brod.html?ref=health

By JANE E. BRODY

Pain, especially pain that doesn't quit, changes a person. And

rarely for the better. The initial reaction to serious pain is

usually fear (what is wrong with me, and is it curable?), but pain

that fails to respond to treatment leads to anxiety, depression,

anger and irritability.

Stuart Bradford

At age 29, Walter, a computer programmer in Silicon Valley,

developed a repetitive stress injury that caused severe pain in his

hands when he touched the keyboard. The injury did not respond to

rest. The pain became worse, spreading to his shoulders, neck and

back.

Unable to work, lift, carry or squeeze anything without enduring

days of crippling pain, Walter could no longer drive, open a jar or

even sign his name.

" At age 29, I was on Social Security disability, basically confined

to home, and my life seemed to be over, " Walter recalls in " Living

With Chronic Pain, " by Dr. Schneider. Severely depressed,

he wonders whether his life is worth living.

Yet, despite his limited mobility and the pain-induced frown lines

in his face, to look at Walter is to see a strapping, healthy young

man. It is hard to tell that he, or any other person beset with

chronic pain, is suffering as much as he says he is.

Pain is an invisible, subjective symptom. The body of a chronic pain

sufferer — someone with fibromyalgia, for example, or back pain —

usually appears intact. There are no objective tests to detect pain

or measure its intensity. You just have to take a person's word for

it.

Nearly 10 percent of people in the United States suffer from

moderate to severe chronic pain, and the prevalence increases with

age. Complete relief from chronic pain is rare even with the best

treatment, which is itself a rarity. Doctors and patients alike, who

misunderstand the effects of narcotics, are too often reluctant to

use drugs like opioids, which can relieve acute, as well as chronic,

pain and may head off the development of a chronic pain syndrome.

Why Pain Persists

The problems with chronic pain are that it never really ends and

does not always respond to treatment. If the pain initially was

caused by an injury or illness, it can persist long after the injury

has healed or the illness defeated because permanent changes have

occurred in the body.

Mark Grant, a psychologist in Australia who specializes in managing

chronic pain, says the notion that " physical injury equals pain " is

overly simplistic. " We now know that pain is caused and maintained

by a combination of physical, psychological and neurological

factors, " Mr. Grant writes on his Web site, www.overcomingpain.com.

With chronic pain, a persistent physical cause often cannot be

determined.

" Chronic pain can be caused by muscle tension, changes in

circulation, postural imbalances, psychological distress and

neurological changes, " Mr. Grant says on his site. " It is also known

that unrelieved pain is associated with increased metabolic rate,

spontaneous excitation of the central nervous system, changes in

blood circulation to the brain and changes in the limbic-

hypothalamic system, " the region of the brain that regulates

emotions.

Dr. Schneider, the author of " Living With Chronic Pain " (Healthy

Living Books, Hatherleigh Press, 2004), is a specialist in pain

management in Tucson, Ariz. In her book, she points out that the

nervous system is responsible for the two major types of chronic

pain.

One, called nociceptive pain, " arises from injury to muscles,

tendons and ligaments or in the internal organs, " she writes.

Undamaged nerve cells responding to an injury outside themselves

transmit pain signals to the spinal cord and then to the brain. The

resulting pain is usually described as deep and throbbing. Examples

include chronic low back pain, osteoarthritis, rheumatoid arthritis,

fibromyalgia, headaches, interstitial cystitis and chronic pelvic

pain.

The second type, neuropathic pain, " results from abnormal nerve

function or direct damage to a nerve. " Among the causes are

shingles, diabetic neuropathy, reflex sympathetic dystrophy, phantom

limb pain, radiculopathy, spinal stenosis, multiple sclerosis,

Parkinson's disease, stroke and spinal cord injury.

The damaged nerve fibers " can fire spontaneously, both at the site

of the injury and at other places along the nerve pathway " and " can

continue indefinitely even after the source of the injury has

stopped sending pain messages, " Dr. Schneider writes.

" Neuropathic pain can be constant or intermittent, burning, aching,

shooting or stabbing, and it sometimes radiates down the arms or

legs, " she adds. This kind of pain tends " to involve exaggerated

responses to painful stimuli, spread of pain to areas that were not

initially painful, and sensations of pain in response to normally

nonpainful stimuli such as light touch. " It is often worse at night

and may involve abnormal sensations like tingling, pins and needles,

and intense itching.

Some chronic pain syndromes involve both nociceptive and neuropathic

pain. A common example is sciatica; a pinched nerve causes back pain

that radiates down the leg. In some cases, the pain of sciatica is

not felt in the back but only in the leg, making the cause difficult

to diagnose without an M.R.I.

Beyond Physical Problems

The consequences of chronic pain typically extend well beyond the

discomfort from the sensation of pain itself. Dr. Schneider lists

these potential physical effects: poor wound healing, weakness and

muscle breakdown, decreased movement that can lead to blood clots,

shallow breathing and suppressed coughing that raise the risk of

pneumonia, sodium and water retention in the kidneys, raised heart

rate and blood pressure, weakened immune system, a slowing of

gastrointestinal motility, difficulty sleeping, loss of appetite and

weight, and fatigue.

But that is hardly the end of it. The psychological and social

consequences of chronic pain can be enormous. Unremitting pain can

rob a person of the ability to enjoy life, maintain important

relationships, fulfill spousal and parental responsibilities,

perform well at a job or work at all.

The economic burdens can be severe, especially when the patient is

the primary breadwinner or holds a job that provides the family's

health insurance. Only about half of patients with chronic pain " who

undergo comprehensive multidisciplinary pain rehabilitation are able

to return to work, " Dr. Schneider reports.

As for the notion that chronic pain patients are often malingering —

seeking attention and escape from responsibilities — pain

specialists say that is nonsense. No one in his right mind — and

most patients were in their right minds before the pain began —

would trade a fulfilling life for the misery of chronic pain.

This is the first of three columns on chronic pain. Next week: How

family and friends can help.