Is chronic pain preventable?
George just turned 75 but he can’t enjoy his birthday. Nine months ago, he had shingles. The skin rash is gone, but the burning pain is still there. He can’t even tolerate having his bed sheets touch his chest. Nancy had a mastectomy, and it seems like they successfully removed all the cancer. The only problem is, two years later, she still has aching pains in the area.
Would it surprise you to know that George and Nancy’s chronic pain might have been preventable? There is a growing body of medical literature that suggests that chronic pain, which can ruin a person’s life long after the underlying disease has been cured, may be preventable.
For years, medical researchers found it impractical to study the causes of chronic pain. There are many factors that affect the development of chronic pain such as age, level of disability, depression, or the presence of nerve damage. The only way to examine these factors seemed to be to study enormous populations in order to track the few people who would develop chronic pain, a daunting task. But then, a new idea developed--how about studying groups of patients with acute pain who are at risk of developing chronic pain? The idea spread and a number of exciting new studies were conducted.
Some of the groups studied have included those patients with acute herpes zoster (shingles), patients with acute bouts of low back pain, patients who have just undergone amputations (including mastectomies), patients with chest wall incisions (thoracotomies), as well as hernia repairs. The research is new and the results are not yet conclusive, but there are definite themes that run through the results of this literature.
More Acute Pain = More Future Chronic Pain
The most important result so far is that the more intense and prolonged an acute pain episode is, the more likely it will lead to chronic pain. This makes sense given the information that we are beginning to learn about how the central nervous system changes in response to intense pain. As a result of intense pain, neurons in the spinal cord that help to prevent pain transmissions actually die. At the same time, pain transmitting neurons grow more connections to other nerves, become more sensitive, and react more strongly to a painful stimulus.
This remolding of nerve physiology and micro-anatomy is called neuroplasticity. The study of neuroplasticity is one of the hottest new areas in neuroscience since in seems to be the basis for the processes of learning and memory. It appears, however, that the nervous system doesn’t only learn useful information, but also “learns” or remembers pain, leading to the development of chronic pain.
This new data suggests that we have been given a wonderful new opportunity to easily prevent much chronic pain from ever occurring.Unprecedented Opportunity for Preventing Chronic Pain
This finding has enormous implications for the development of strategies to prevent chronic pain. If we can reduce the number of patients who initially suffer with prolonged, intense pain then we can reduce the number of patients who will suffer with chronic pain.
- For patients who suffer a bout of SHINGLES, pain control is crucial. The research evidence is strongest for these patients regarding the risk factors for chronic pain. Advanced age and the duration and intensity of the initial bout all increase the risk. I advise patients and colleagues that painful shingles in patients over 70 years old should be immediately treated with anti-viral and analgesic medicines together with nerve blocks.
- For patients who experience a severe bout of LOW BACK PAIN, a thorough evaluation should be followed with every effort to rapidly bring the pain under control. Pain medicines, in effective doses, should be used early. Muscle relaxants and physical therapy might also be helpful. Again, epidurals and other nerve block techniques can often help to rapidly reduce the pain. If progress is not seen within 4-6 months, and if the problem is amenable to surgical repair, then many experts are advocating proceeding with surgery sooner rather than later.
- For patients who are undergoing MAJOR SURGERIES, every effort should be made to control their postoperative pain. This can be done with effective use of pain medications such as opioids, anti-inflammatory medicines, acetaminophen, and muscle relaxants. In cases where the pain is difficult to control, epidurals or other continuous nerve block techniques can be helpful.
- For patients who require AMPUTATIONS, their pain should be well controlled for at least 24 hours before the surgery, and effective analgesia should be maintained after the amputation surgery. This is often best accomplished with an epidural or some other prolonged nerve block technique. The epidural should be put in 24 hours (some experts say 72 hours) before the amputation, then the epidural can be used to supplement the surgical anesthesia, and finally, use of the epidural should continue for several days after the surgery.
Fred is enjoying his 70th birthday. A year ago, he had shingles. The doctors immediately started anti-viral and pain medications, and within days sent Fred for an epidural injection. The pain was only partially reduced, so over the next two weeks, the pain specialist did two more epidural injections. The skin rash is gone, and other than a few twinges, so is the pain.
Alice had a mastectomy, and it seems like they successfully removed all of the cancer. The doctors aggressively treated Alice’s pain from the minute that she awoke in the recovery room. Alice was surprised that the procedure was so painless, and she is still free of pain a year later.
We hope this exciting news about “nipping pain in the bud” travels fast!
Steven Richeimer, M.D.
Richeimer Pain Medical Group