Asked to describe their pain, especially chronic, noncancer pain, patients often appear perplexed, stating, “I don’t know. It just hurts.” Clearly, more information is needed, and obtaining the necessary details is an art. While subjective and objective methods of psychological evaluation provide one of the cornerstones of diagnosing factors important in the perpetuation of pain beyond the otherwise apparent state of healing—not to mention executing and monitoring the results of multimodal and interdisciplinary approaches to pain control and functional rehabilitation—it is vital that the treating medical professional develops a sound rapport with the patient independently of the mental health specialist. This comes about via empathy and an understanding of the patient that is best summed up by stating that the person suffering from chronic, noncancer pain needs to be heard and his or her pain validated as real. Only then can an accurate diagnosis be made to form the foundation upon which a rational treatment program can be built.

By the time most patients are referred to a pain specialist, they are often frustrated, sleep deprived, anxious, and depressed and feel angry toward those they feel have not really listened to how they have been compromised by persistent pain. To many sufferers, the message has come across as “it is in your head,” even when not intended as such. Much of that anger dissipates when patients truly feel as if they have been heard. They are then far easier to work with, and the likelihood of progress significantly increases. When such a rapport is achieved, patients generally become more open to understanding that the locus of control lies within themselves to a considerable degree and cannot be expected to appear magically from an outside source even if that source is able to guide and to provide tools useful in the healing process.

A few basic pointers are worth emphasizing here. These are not insignificant and are often noted by patients as some of the reasons that they did not feel heard. It is important to maintain eye contact and body language that emphasizes that, at least for the time spent together, the patient is the clinician’s sole concern. Typing or dictating into an electronic medical record should be avoided while the patient is talking or before the interview and examination are complete. Furthermore, providing verbal feedback shows that the clinician has really grasped the essence of the patient’s experience of suffering as well as the details of the pain syndrome in terms of its time of onset and the events leading up to it. Such feedback supports the notion that the patient is being taken seriously with respect to what he or she feels is important, regardless of whether or not the clinician wishes to steer the focus over time in a different direction. This cannot be emphasized enough, and the extra time taken will pay off in making future interviews shorter, mainly because trust and hope will have been established.

It is worth noting here that teenage and adult patients with cancer often fear insufficiently treated pain more than they fear death. Younger children, on the other hand, generally fear potentially painful procedures more than the disease or condition for which the intervention is indicated. Procedures should, therefore, not be performed on pediatric patients outside of a procedure room, making their hospital bed a relatively safe place. Parents often fear the presence of a cerebral tumor that might explain a child’s headache but may be too afraid to ask about this. They might also assume that opioids given in a pediatric setting may predispose their children to illicit drug use in adolescence. As a final point, geriatric patients may associate opioids with the imminent end of life, just as they may fear addiction even when a terminal illness has been diagnosed. These points should always be brought up and clarified, even if the questions or fears have not been vocalized.

Before we focus in more detail on the patient with chronic pain and a general approach to pain management, basic nosology and terminology require clarification. There is much confusion over this, both within the lay public and within the medical and associated professions.

There are a number of ways to classify pain. Some pain specialists broadly separate it into cancer pain and noncancer pain (the term “nonmalignant pain” can be misinterpreted as benign when clearly the risk of medication overuse and even suicide strongly suggests otherwise). Others divide it into acute, recurrent acute, and chronic pain. Acute pain is short-lived and follows disease, injury, or near injury to tissue. It resolves with healing. Recurrent-acute pain is similar in duration but tends to recur. It need not involve injury. Examples are migraine headache and sickle cell vasoocclusive episodes, previously known as “sickle cell crises.” Depending on the injury, chronic pain is variably defined as that persisting 1 to 6 months after the tissue has healed. One example of chronic, noncancer pain is postherpetic neuralgia following a breakout of shingles.

Pain can also be classified in terms of mechanism. Nociceptive pain denotes pain arising from tissue injury, and the degree of pain is usually somewhat proportional to the degree of injury. Nociceptive pain itself may be subcategorized into visceral pain, a dull, crampy, and poorly localizable discomfort—as might be experienced in gastroenteritis—or somatic pain, a sharper and more localizable sensation of the body wall—as might be felt after a laceration. Each type of pain may be mild or intense.

Neuropathic pain is not nociceptive, and the degree of pain is not proportional to the degree of injury; it is caused by disordered sensory processing of the nervous system and is a pathologic persistence of normal sensitizing mechanisms that can, under normal circumstances, be useful in the setting of acute pain. Neuropathic pain can be subcategorized into central neuropathic pain, which can originate at any level of the central nervous system, and peripheral neuropathic pain, which is generated at the level of a nerve, plexus, or nerve root. The most famous example of central pain is poststroke thalamic pain; common examples of peripheral neuropathic pain are neuromas, diabetic neuropathy, and complex regional pain syndrome, types 1 and 2 (previously known as reflex sympathetic dystrophy and causalgia). As with central pain, a number of different mechanisms may be involved. Even when the damage occurs in the periphery, such as injury to a nerve, the constant bombardment of sensory neurons in the spinal cord with pain signals from the periphery renders the wide-dynamic-range (WDR) sensory neurons in the spinal cord hypersensitive to all input, even to non-noxious stimuli from distal regions to which little attention is usually paid. Neurons then almost continuously “fire up” the pain pathway, no matter the type of sensory input, resulting in allodynia (discussed later). Although this is a normal sequence of events in acute injury (i.e., temporarily sensitizing injured areas so that they may be protected from further harm), when it fails to abate with healing, it becomes pathologic. This process is called central sensitization of pain and is related to the concept of wind-up, both of which are discussed elsewhere in this textbook.

Other relevant terminology includes:

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  Hyperpathia: an elevated sensory threshold above which is generated an abnormally intense and prolonged response to pain.

  
  
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  Hyperalgesia: which is secondary to a lowered threshold to pain.

  
  
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  Allodynia: a painful response to a nonpainful stimulus.

  
  
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  Hyperesthesia: caused by a lowered threshold to any stimuli.

  
  
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  Hypoesthesia: the opposite of hyperesthesia.

  
  
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  Analgesia: without pain.

  
  
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  Anesthesia: without sensation.

Incident pain is generated by mechanical factors characteristic of movement and position. Incident pain commonly occurs in cancer patients in whom, for example, metastatic spread of the cancer involves the skeleton. Such pain may be neuropathic or nociceptive, depending on the structures involved. For example, a pathologic or metastatic rib fracture results in nociceptive bone pain and neuropathic pain in the distribution of the rib’s intercostal nerve.

INFANTS AND CHILDREN

Patients within certain age groups are often subjected to unnecessary pain and suffering that may have long-term consequences. Children are still relatively undermedicated compared with adults, and although the situation is improving, there continues to be room for improvement. Surgeons were operating on infants who were only partially anesthetized as late as the early to mid-1980s.

Misconceptions about pain and the consequences of its treatment continue to impede patient care. For example, nurses concerned about the risk of addiction may read a physician’s “prn” order to mean “as little as possible” rather than “as needed.” Or they may rely too much on changes in vital signs, such as quickened heart rate or increased blood pressure, to decide if a child’s complaint of pain is “real” or not and may thus withhold “prn” medications inappropriately. We are aware of no evidence that appropriate opioid use in pediatric pain management leads to addiction in childhood or adulthood. And we now know that there is great variability in individual pain thresholds and ability to cope with pain, so that vital signs may not correlate as well with the level of pain as previously thought. This is especially so in newborn babies. Even in infants and children, fluctuating levels in vital signs may be a better indicator of pain than absolute levels. It is, therefore, wise to combine several methods of pain evaluation, no matter the patient’s age. Verbal or visual analog pain scores (from 0 to 10), a developmentally sensitive analysis of general behavior and body language, and recording of facial expression can provide valuable information for the assessment of pain.

Some practitioners believe that infants feel little pain because their nervous systems are immature. This is a false assumption. The anatomic, biochemical, and physiologic apparatus necessary for the perception of pain is present 2 to 3 months before term, but because the descending inhibitory modulating system is immature, and because of a higher-than-adult level of cutaneous pain receptor density, babies and infants may, in fact, be hyperalgesic. They may have a lower average threshold to pain than adults. The main consequence of immature central and peripheral myelination is not poor transmission of pain signals, given that such pathways are unmyelinated or only thinly so, but poorly coordinated nocifensive (defensive) motor behavior, which is reflexive and modified by experience. Newborns quickly learn to squirm and kick during a heel stick blood draw. Facial grimacing and fluctuating vital signs belie their experience of pain. There is even growing evidence that infants subjected to long and painful treatments without pain management in intensive care units are more likely to develop problems of somatization in school compared with those given intermittent or constant infusions of carefully adjusted opioid medications.¹

ELDERLY PATIENTS

Geriatric patients also suffer from caregivers who have been misinformed about pain management. Although those aged 70 or older may, in general, be more susceptible to medication side effects, it does not mean that they should be left untreated for pain. It is wise to note that older generations might associate pain medication, especially those related to morphine, as a sign that they have little time left to live. Historically, in many settings, it was offered only at the time of death. Clarification here is the responsibility of the prescribing clinician.

Careful dose adjustment is key to good pain management, as is awareness of the various delivery systems that might minimize systemic side effects. “Start low and go slow” is a principle worth attending to. Realize, as well, that elderly patients long treated with controlled substances may have developed a high level of physical tolerance to medication effects such that aggressive treatment can be used with some in this age group, at least within reason. Each person must be assessed individually.

Selected patients who experience intolerable side effects from high-dose oral opioids prescribed for persistent cancer or noncancer pain—spinal pain being a common example—may benefit from the implantation of an intrathecal opioid pump through which relatively tiny amounts of medication are placed directly into the cerebrospinal fluid. It then enters the spinal cord and brain quickly and efficiently, minimizing spread to other systems and thereby minimizing side effects. Falls with potentially fatal hip fractures may be averted. Similarly, a well-placed epidural catheter may provide better, short-term, postoperative analgesia with fewer side effects than intermittent, nurse-given intravenous or oral opioids or even boluses delivered by a patient-controlled analgesia (PCA) device. When dementia is of concern, the dose must be titrated even more carefully and adjuvant medications or techniques employed that might prove opioid sparing. It must be remembered that in this group of patients, even normally well-tolerated medications may have adverse effects on mentation, as well as on the gastrointestinal and cardiovascular systems.

It is a little appreciated but important concept that chronic pain is not merely a protracted form of acute pain and is often preventable. Chronic pain is not a symptom, from this perspective, but rather a disease and should be treated as such. There is a general consensus that a multimodal, interdisciplinary, or multidisciplinary approach to pain management is most effective. Nonetheless, prevention is still the key to minimize the likelihood of avoiding the development and consequences of chronic pain.

In addition to the effect that persistent pain has on the sufferer and his or her immediate family, it affects the greater community. The financial burden to society from lost productivity resulting from recurrent acute and chronic pain is staggering. Estimates range from $50 billion to $100 billion yearly for headache and low back pain alone. But the problem is wider and more serious than that. Failure to alleviate unnecessary suffering creates distrust between clinicians and patients, and this, in turn, diminishes the efficacy of our medical system. If patients feel forced to seek alternative and what they often interpret as more personal and caring forms of treatment, they may fail to seek appropriate care for other serious conditions when an allopathic approach is needed. The systems can work in harmony. More people than ever before are seeking alternatives to allopathic medicine because prevention, healing, and caring are emphasized over the concept of cure, but it is not always to their advantage. Missing the opportunity for early cancer detection, for example, may have tragic consequences. The modern concept of integrative care is important because it affords communication between all concerned, both patients and caregivers, and because the combination of allopathic and alternative approaches to care employed in concert may maximize positive results while minimizing the side effects of what might otherwise be a need for higher doses of allopathic medication with unwanted side effects. It is a more thorough form of interdisciplinary care where acupuncture, osteopathic, or chiropractic manipulation and herbal medicine, among other modalities, may assist with pain management and even the curative process. Employing a rational mixture of different treatments can decrease the daily amount of medication, as well as the duration of time spent taking controlled substances, thus minimizing the likelihood of accidental overdose or illicit drug use.

The public’s trust must be regained. It has been lost with respect to allopathic medicine in many quarters for complex reasons, many of which can be traced to feelings of lack of control. This can lead to aberrant behavior sometimes unconsciously induced by the clinician, resulting in a loss of connection and, therefore, communication. Ultimately, the patient may be blamed when the problem was really the result of a dynamic between the treating staff and the patient. Medical providers must be willing to examine their own roles in the breakdown of communication and trust, eschewing the routine blame of patients.

Patients become anxious and distraught as their pain persists, and they become frustrated with the inability of medical professionals to alleviate it. Therefore, realistic expectations should be offered and periodically clarified or reinforced. Clinicians, in turn, become frustrated with their own lack of understanding of pain and their inability to control it. Sometimes, these feelings of frustration and inadequacy are turned against the patient in the form of “there is nothing more that can be done” or “obviously something else is going on, so I’m sending you to a psychiatrist.” At such times, it may be more appropriate (and less worrying to the patient) to state that “there is little more that I am able to do” or, preferably, “your situation is quite complex and involves suffering beyond that of the physical pain alone, so we need to have it assessed more fully to formulate a better plan for pain management.” This last comment, of course, needs expansion and explanation because a common interpretation of it is that “the doctor thinks that it is all in my head.” Trust takes considerable effort and risk on both sides. It requires empathy. The adage “to hear about pain is to have doubt, but to experience it is to have certainty” is poignant and true.

There are certain concepts that need emphasis to answer this question. The first of these is that pain and suffering are not synonymous. Although pain has been described as an unpleasant sensory and emotional experience arising from actual or potential damage to tissue, only when the consequences of pain—usually prolonged—begin to interfere negatively with the physical and emotional experience of life is suffering said to occur. In this way, pain may be likened to stress. A little pain is not necessarily a terrible thing. It may serve to focus attention on a stimulus and foster an appropriate response to it, but too much pain may prove overwhelming, exhausting, and demoralizing. It may lead to depression, which may further intensify the experience. And depression is not benign. With little warning, it may lead to suicide. Saying that “there is nothing more that can be done” may take away the only hope the patient has that he or she can keep going.