According the American Chronic Pain Association, Chronic pain is better described as persistent pain is a condition which can be continuous or recurrent and of sufficient duration and intensity to adversely affect a person’s well-being, level of function, and quality of life.
Chronic or persistent pain can be described as ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3 to 6 months, and which adversely affects the individual’s well-being.
A simpler definition for chronic or persistent pain is pain that continues when it should not.
Chronic pain is classified by pathophysiology (the functional changes associated with or resulting from disease or injury) as nociceptive (due to ongoing tissue injury) or neuropathic (resulting from damage to the brain, spinal cord, or peripheral nerves), with mixed or undetermined causes as well.
Pain relievers (analgesics) are generally effective for nociceptive pain but may be less effective for neuropathic pain.
Persistent or chronic pain is prevalent in older adults and the first line of treatment is analgesics including morphine.
The use of analgesics (pain relievers) and other medications is the most common method of chronic pain treatment. Pain medications can be helpful for some patients in chronic pain, but they are not universally effective. In fact, in some individuals, pain medications may worsen their condition or cause unwanted or dangerous side effects.
Medication-related problems would rank fifth among the leading causes of death in the United States if they were considered a disease. Although opioid pain medications can be a useful tool in the treatment of pain, the misuse of opioid (narcotic) pain medications has become a national issue.
In general, thirty percent of hospital admissions among the elderly may be linked to an adverse drug related event or toxic effect from a drug. Nearly one third of all prescribed medications are for patients over the age of 65 years. Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the patient is experiencing a medication-related problem.
Some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs.
It is important to remember, each person may respond in a different manner to any medication. Therefore, each person with chronic pain should be medically managed individually, and medication use should be determined by benefit, cost, potential side effects, and the person’s other medical problems.
Opioid Analgesics, the Opioid Dilemma
Considerable controversy exists about the use of opioids for the treatment of chronic pain of noncancer origin. Many health care professionals think that chronic pain is inadequately treated and that opioids can play an important role in the treatment of all types of chronic pain, including non-cancer pain.
Others caution against the widespread use of opioids, noting problems with tolerance, loss of benefit with time, and escalating usage with decreasing function in some individuals.
The use of opioids (or for that matter any treatment) makes sense when the benefits outweigh the risks and negative side effects. Benefit is suggested when there is a significant increase in the person’s level of functioning, a reduction or elimination of pain complaints, a more positive and hopeful attitude, and when side effects are minimal or controllable.
Opioids are not harmless drugs. The dilemma with the long-term use of opioids is that while opioid treatment may be prescribed to reduce pain and improve function, the treatment may actually result at times in just the opposite.
It is well known that in the opioid naïve (someone new to opioid use) patient, the use of opioids may heighten the risk of accidental death from respiratory depression.
It is well known that prolonged use of opioids may result in problems including tolerance, hyperalgesia (increased pain sensitivity), hormonal effects (decreased testosterone levels, decreased libido and sex drive, irregular menses), depression, impaired sleep patterns, and suppression of the immune system. The long-term use of opioids may also impair functional improvement in an individual’s recovery from surgery or with long-standing musculoskeletal disorders.
The Effects of Cigarette Smoke on Pain
Smoking causes blood vessels to become constricted, smaller and narrower; this restricts the amount of oxygen rich blood flowing to areas of pain. Smoking not only reduces blood flow to your heart but also to other structure such as the skin, bones, and discs. Due to this, you may get accelerated aging leading to degenerative conditions.
The lack of blood supply caused by cigarette smoke is also responsible for increased healing time after surgery.
After a back fusion surgery, smoking cigarettes can increase the risk of your fusion not healing properly. Cigarette smoke triggers the release of pro-inflammatory cytokines, increasing inflammation and intensifying pain. Smoking makes the bones weak and increases the prevalence of osteoporosis, spinal degenerative disease, and impaired bone and wound healing. Symptoms of depression are more commonly seen among smokers.
Chronic Pain Types and Treatment
Chronic Back and Leg Pain
Chronic back and leg pain is described as pain that has been felt in the back or leg for six months or longer. Pain is most often located in the lower back, but it may extend to other areas, such as the thighs, calves, and feet.
Chronic back and leg pain can result from a number of spinal conditions, including:
- Degenerative disc disease
- Lumbar disc herniation
- Failed back surgery syndrome
- Epidural fibrosis
Symptoms of chronic back and leg pain can range from mildly uncomfortable to completely disabling. You may feel a sharp or stabbing pain, a burning sensation, or a dull muscular ache. Affected areas may feel tender or sore to the touch and the pain may increase with movement.
Painful neuropathy is a neurological disorder where people experience severe chronic pain due to nerve damage. Nerves connect the spinal cord to the body and help the brain communicate with skin, muscles, and internal organs.
Painful neuropathies are caused by damage to the nerves. This damage may be a result of:
- Nutritional imbalances
- Illnesses, such as kidney failure or cancer
- Trauma of the nerves
Although there are many different causes of painful neuropathies, they have common symptoms, such as:
- Stabbing or sharp pain
These symptoms most often appear in the hands or feet.
Complex Regional Pain Syndrome (CRPS)
Complex regional pain syndrome is a chronic pain condition that most often affects the arms, legs, hands, or feet. Complex regional pain syndrome is also known as reflex sympathetic dystrophy or causalgia.
Complex regional pain syndrome usually develops in a limb after an injury (such as a broken bone) or surgery that may have involved nerve damage.
The overriding symptom is extreme pain, frequently described as burning. Other symptoms can include:
- Sensitivity to touch
- Skin changes
- Decreased function of the hand/foot
Pain in cancer may arise from tumor compression or infiltration of tissue; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by the body’s immune response or hormones released by the tumor.
Most acute (short-term) pain is caused by treatment or diagnostic procedures, though radiotherapy and chemotherapy may produce painful conditions that persist long after treatment has ended.
At any given time, about half of all patients with malignant cancer are experiencing pain and more than a third of those experience moderate or severe pain that diminishes their quality of life by adversely affecting sleep, social relations and activities of daily living. Pain is more common in the later stages of the illness
Modern Treatment Options for Chronic Pain
Medical Devices. Neurostimulators and Pumps.
Medical devices, such as Medtronic neurostimulators or drug pumps (intrathecal drug delivery systems), are surgically placed devices that modulate pain signals before they reach the brain:
- Neurostimulators – send mild electrical impulses to the spine, masking the perception of pain messages to the brain
- Drug pumps – deliver pain medication directly to the fluid around the spinal cord (called “the intrathecal space”), requiring only a fraction of the medication that would be needed and reduce the side effects of the medication.
Unlike some surgeries, these treatments are reversible. Your doctor can turn it off or surgically remove the system. In addition, you can try these therapies before you receive a permanent implant.
What Is a Neurostimulator?
A neurostimulator is a surgically placed device about the size of a stopwatch. It delivers mild electrical signals to the epidural space near your spine through one or more thin wires, called leads. The electrical signals cause a tingling sensation in the area of your chronic pain.
How It Works
Neurostimulation provides pain relief by blocking the pain messages before they reach the brain. The neurostimulator sends out mild electrical impulses that reach the brain faster than the pain signal can arrive. In other words, it outsmarts your pain. Instead of pain, you feel a tingling sensation.
You can adjust the strength and location of stimulation using a handheld programmer. For example, you can regulate different levels of stimulation at different times of the day or for various activities – such as walking, sleeping, or sitting. If your neurostimulator features AdaptiveStim® technology, then it will automatically adjust stimulation when you are upright (sitting or standing), lying down, or active while in an upright position.
About the Neurostimulation System
A complete neurostimulation system includes several components:
- Neurostimulator – The device that generates the electrical impulses (usually placed under the skin in your abdomen or upper buttock)
- Leads – Thin, insulated medical wires that deliver electrical pulses to the epidural space near the spine
- Physician’s programmer – A computer at your doctor’s office that lets your doctor adjust the neurostimulation system and its settings
- Patient’s programmer – A handheld device you can use at home to customize the stimulation (within the settings your doctor has selected)
The neurostimulation system does not make any noise. It may be felt as a small bump under your skin, but does not normally show through your clothes.
Advantages Over Other Therapies
Neurostimulation provides advantages over other therapies for chronic pain:
- Unlike other chronic pain treatments or surgeries, you can experience neurostimulation and see if it relieves your pain before committing to the long-term therapy
- A screening test serves as a temporary evaluation period. The screening test is much like an injection, but instead of medication being placed into the epidural space, leads are positioned and connected to an external neurostimulator (battery pack)
- It does not have to be a permanent procedure. The neurostimulator can be surgically removed if you do not like it or if you decide to pursue a different treatment
- Unlike oral medications that circulate throughout your entire body, neurostimulation targets the precise area where you are feeling pain
- A neurostimulator may provide relief when other treatments – like medications or injections – have not.
What Is a Drug Pump?
Unlike medications that circulate throughout your body in your bloodstream, drug delivery therapy releases medication directly into the fluid surrounding your spinal cord which may lead to fewer or more tolerable drug side effects.
SynchroMed II Drug Pump. About the Drug Delivery System
The system consists of a pump and catheter, both of which are surgically placed under the skin. The pump is a round device that stores and delivers pain medication. It is placed in your abdomen. The catheter (a thin, flexible tube) is inserted into your spine and connected to the pump.
During the small surgery, your doctor fills the pump with pain medication using a needle. The pump sends the medication through the catheter to the spinal area where pain receptors are located. You return to your doctor’s office for more medicine when the pump needs to be filled.
How It Works
The pump releases prescribed amounts of pain medication through the catheter directly to the fluid around the spinal cord, in an area called the intrathecal space. The pain medication approved for use in the pump includes morphine sulphate and ziconotide.
Many people experience significant improvements in their pain symptoms and quality of life after receiving Medtronic drug delivery therapy. However, realistic expectations are essential to satisfaction with any pain treatment. Drug delivery therapy cannot eliminate the source of your pain or cure any underlying disease, but it may help you to better manage your pain.
Advantages Over Other Therapies
Drug delivery therapy offers advantages over other therapies for severe chronic pain:
- A screening test serves as a temporary evaluation period so you can see if drug delivery therapy relieves your pain before committing to long-term therapy
- It does not have to be a permanent procedure like back surgery. The system can be turned off or surgically removed if you do not like it or of you decide to pursue a different treatment
- Unlike oral medications, drug delivery therapy releases medication directly into the fluid surrounding your spinal cord rather than traveling throughout your body in your bloodstream. This may lead to fewer side effects, such as nausea and constipation
- Drug delivery therapy may provide relief when other treatments – like medications or injections – have not.
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