Pain and Its Treatment

Whether you are 27 or 72, pain can cause a significant problem in your life. This informational handout is being offered to you so that you may better understand the process and treatment of pain. It may also help you understand the reasons why your provider may or may not prescribe you the drugs that you are used to taking.

What is pain?

Who really needs to have this answered for them? If you have pain, you know what it is! Right? We all feel pain, so we all know what pain is. However, you might be surprised to learn a few things about pain that you may not have already known… so keep reading!

Pain happens when our nerves receive a signal from a stimulus, transmit that signal to the brain, and then respond to the brain’s interpretation of the stimulus. Certain chemicals in our body are responsible for the electrical impulses that must occur in this process. Other chemicals in our body must be present for a painful feeling to occur. Put simply: pain is a response to electrical and chemical processes in the body.

Is all pain the same?

All pain is not the same. Some pain comes from true outside sources, like when a hot stove causes you to feel a burn. The pain may be short lived; maybe for a week or so, but eventually the body part heals and the pain goes away. We call this “acute pain.”

Other pain can come from damaged nerves, like when diabetes has harmed the nerves in a leg, and therefore the nerves cause electrical impulses to occur irregularly, causing a feeling of pain even though an outside source is not causing a painful stimulus. This is called “neuropathy” pain.

Another type of pain occurs when nerves overreact to simple stimuli. If you have ever pulled up your bed sheets at night and draped them lightly over your body, and felt pain from that simple maneuver, you probably have overactive nerve receptors! Overactive nerve receptors are still not understood very well. It is believed they are a form of “neuropathy.” People who have fibromyalgia may have a form of this type of pain.

Some pain comes from nerves firing impulses simply because they are used to sending the signal regularly. Such is the case with some people who have had the same pain for a very long time. The brain is so used to the signals occurring, that it fires the impulse of pain perception, even if the stimulus isn’t there any longer! For instance: people who have hip pain for years, can get their hip replaced and still feel the pain, because the body was so “used” to firing the signal, that the pain didn’t stop even when it should have stopped. This is called “central pain syndrome.” You may have heard of “phantom limb pain.” This is an example of central pain syndrome: a leg has hurt for so long, that even after the leg is gone, the person feels as though their non-existent leg is hurting. OUCH!

Another type of pain can occur if you ARE NOT feeling pain when your brain thinks that you SHOULD be feeling pain. Imagine this: If you broke your back, you would be hurting, right? In fact, while your back was damaged, a chemical would be in your body that told your brain that pain WAS occurring. Let’s say you were taking pain medicine at the same time, and you were feeling NO PAIN because the medicine was working. The brain might interpret this to mean that you weren’t feeling pain because there weren’t enough chemical receptor sites around the damaged area. The brain would then send out a signal to the area to “ramp up” the number of pain receptor sites. Can you believe that? Your brain would actually WANT you to feel pain when it thought that you should be feeling pain! The truth is, the brain wants to protect you from hurting yourself. If it thinks you should be feeling pain when you aren’t actually feeling pain, it will send down an army of receptors to fix your “no pain” problem.

This type of pain happens when people use certain types of medicines to treat their pain on a long-term basis. It is called “up regulation” pain. This can be a real dilemma because your goal for pain management is NO PAIN, but a medical provider’s goal for pain management is optimal health for the patient. This might mean that they stop prescribing pain medications when they know that the medications might actually be making your problem worse, even though it feels to you that you are better. This can be a real problem!

Do all people feel pain?

Some people do not feel pain. This is abnormal and actually causes them many problems. Imagine if you put your hand on a hot stove and didn’t feel pain; eventually you would have no hand!
In the olden days, this was a problem for people who had leprosy.

Pain is the body’s defense mechanism against bodily harm. If you do something that would harm you, the pain causes you to stop. This helps you understand why your brain would WANT you to feel pain.

This also hits on an important aspect of pain management: When you treat a patient for a back injury, the goal should be to not only treat the pain, but also to treat the problem that causes the pain. If you take away all of the pain associated with the injury, you also take away the defense mechanism of the body that tells the patient to stop doing the physical activity that makes their problem worse. This means that they are less likely to have a speedy recovery and more likely to harm themselves on a long-term basis. This sets them up for MORE pain in the long run; NOT less pain. This is why treating pain is so tricky!

There needs to be a balance between treating pain that exists NOW and preventing pain that might occur BECAUSE of treating pain now. The answer to this dilemma is treating acute pain for a very short amount of time, as well as treating the cause of the immediate pain with much fervor and careful planning. The patient must adhere to the full plan of care to get 100% of the benefit of the plan.

Why might I hurt more than someone else even though we have the same things wrong with us?

Your perception of pain has everything to do with your nerve endings. If they are overactive or damaged, you will hurt more than the average person. Your nerves may simply be over-firing pain signals in otherwise normal situations.

A second reason you might hurt more than the average person is if you have a higher level of inflammation in your body. This also relates to whether you have a high level of certain chemicals in your body that allow inflammation to happen. Treating your inflammation level, as well as the level of these chemicals is a key aspect of treating pain.

A third reason that you may hurt more than others is related to your stress level. Studies prove that tense muscles (tense shoulder muscles, clenched jaws, flexed arms and legs) actually experience more pain than relaxed muscles. This is because muscles that are tense are more fully involved in the nerve and chemical processes of pain perception. A tense muscle LITERALLY hurts more than a relaxed one.

Take note of yourself as you read this. Are your shoulders pulled back and up, or are they relaxed and limp? Is your jaw clenched as you read this or is your mouth open and hung low? Are your calf muscles or thigh muscles tight, or are your legs extended and relaxed? Are your arms flexed or are they lying to your sides? Are you thinking thoughts like, “This stuff is just a bunch of bologna!” or are you thinking, “This information is really helpful.”? (Yes, even your own mind can be tense!!)

Another reason you may hurt more than another person is if you have LEARNED to hurt more. Imagine a child who gets pampered every time he falls down; he might learn to get attention by hurting! He might cry to mother every time he bumps his knee simply because he likes the hugs that come from mother!

No one wants to believe this is why they hurt, but if you are in pain, do not ignore that there are emotional aspects to hurting that cannot, and should not, be ignored. Even if you do not seek attention for hurting, there is probably an aspect of your life that has been emotionally impacted by your pain. If you realize this, you MAY be able to address that particular issue; whatever it may be. For example: if you hurt so badly that you ask others to always do things for you, you may find that over time you rely on others to always do everything for you. This causes a dependent attitude for you. That new attitude may blend in to other areas of your life. Eventually, your pain may actually be made worse by your emotional dependence on others when they get tired of waiting on you! Makes sense!

Does pain cause any other diseases?

People who live with pain often end up with depression. What has come first? Has depression caused overactive nerve fibers or has pain caused enough emotional pain to cause depression? The jury is still out on this issue, but one thing is for sure: depression and pain are VERY closely linked. In fact, many medicines that treat depression also lessen pain. Again, which comes first? Is there less pain because the depression is made better? Or is there less depression because the pain is better? It doesn’t really matter, though, as long as you get to feeling better in both areas of your life! Physical and emotional pain are both a burden on a person.

What are the different treatments for pain?

The key to treating pain is to treat the processes that cause the pain, and not just the pain itself. There are many ways to do this. Medicine is often used to treat pain, so let’s discuss this first.

There are many types of medicines used to treat pain.

Steroids are often used to treat acute inflammation, which is an outside source of pain. Steroids can be VERY helpful in stopping pain. Someone who hurts his or her back very badly might be put on a steroid to reduce the swelling that is causing the pain. Steroids can’t really be used longterm, though, so their use is somewhat limited for chronic pains.

NSAIDS, also known as Non-steroidal anti-inflammatory drugs, work a lot like steroids but they can be used on a longer-term basis. NSAIDS block some of the chemicals that help send pain signals. Without these chemicals, pain is improved.

NSAIDS also work to shrink tissues that are swollen. Swelling of tissue is often the actual outside source (like the hot stove) of pain. When NSAIDs do their job, swollen tissues become more normal, and therefore stop hurting. NSAIDS are some of the best painkillers because they treat the actual SOURCE of the pain (inflammation) and not just the pain itself. Think about it: if you were cutting off your finger with a knife, you wouldn’t want to just stop the pain; you would want to stop the knife first! NSAIDs work by stopping the actual swelling that causes pain so often. Whenever an NSAID is prescribed, you may not THINK it is helping, but if you chemically let it do its job, it can be one of the most potent and healing medicines. Anyone who has longterm pain should be on some form of an NSAID. If your provider hasn’t offered you a trial of this type of medication, be sure to ask for some!

A third medicine used to treat pain is called an anti-pyretic. You know this drug as Tylenol. Tylenol is a very effective pain killer because it blocks some very potent nerve firing signals at the source of the pain. Believe it or not, Tylenol is the main ingredient in most of the narcotic pain medicines, and it is responsible for the pain killing aspect in all of the drugs such as Lorcet, Vicoden, and Percocet. Tylenol does NOT treat the actual outside source of the pain, so in the instance of the finger-knife scenario, you’d only be treating the pain, and not the action of the knife. For this reason, although it’s a great pain killer, it’s not the best to use if you want to treat the source of your pain.

A fourth type of medicine used to treat pain is a neuroleptic medicine. Neuroleptic medicines help treat nerve fibers that are not acting appropriately. As you learned earlier, if nerves fire incorrectly, or overreact, you may experience painful stimuli. A good reason to use neuroleptic medicine is if you know that you have nerve damage and you want to prevent it from becoming worse. Nerves cannot regenerate, so you want to prevent as much damage as possible. If you have burning pain, it is often a sign that you may respond very well to this type of medication. Be sure to ask your provider if a neuruoleptic might help you.

A fifth type of medication used to treat pain is an antidepressant. Antidepressants help pain in a couple of ways: first, they “calm the nerve fibers down” if they are over-reactive nerves. Over-reactive nerves fire their signals more often and with more fury. If you can interrupt this over-reactivity, you can reduce the pain signal. Second, antidepressants can also help treat pain because they can help the person “deal” with the existing pain with a more upbeat and helpful attitude. Anyone who has long-term pain can tell you that pain is depressing. It keeps you from functioning fully, it pulls you down into the “dumps,” it takes away your hope for a happy life, and it is a general energy sucker! Antidepressants help the person who suffers from chronic pain to function at a higher mental level. They give the individual more energy and a more positive outlook on life while living with pain.

Please don’t ignore the opportunity to feel better on an antidepressant. They really do help.

Often a person will be offered an antidepressant for their pain and they will react the following way: “my pain is not in my head. I’m not depressed and I don’t need medicine for depression.” If you are thinking the same thing, realize you are not alone in this reaction, but the fact of the matter is that whether you are depressed or NOT, an antidepressant can reduce your physical pain. If you have no mental pain, then don’t worry about whether it COULD reduce mental pain. It DOES reduce physical pain.

The last type of medicine that is commonly used to treat pain is one that can block the chemical signal that eventually leads to nerves firing into pain signals. These medicines are widely known as opiates, or other similar receptor blocking agents. These medicines help the user feel less anxious, feel less pain, and even may cause a drunken feeling that often “numbs” the person’s perception or worry about the pain.

These medicines do in fact help pain quite greatly. However, their use should be fairly short-term for a couple of reasons. First, when the body doesn’t feel adequate pain in the presence of injury, the brain causes an increase in the pain receptor sites. What this means is that the individual will actually feel MORE pain when they stop using the medication. In essence, the medications can make the pain WORSE in the long run. In FACT if you use an opiate long enough for a short-term problem to resolve (say, 14 days) you WILL by the end of that 14 days, have at least a slight addiction and up-regulation of receptors from the drug.

What this leads to is the second reason for only using the mediations on a short-term basis. When the body starts to hurt WORSE, the person is driven to use the medication again in order to obtain the same amount of pain relief. This cycle continues day after day, and eventually the individual becomes dependent and addicted to the medicines.

This usually poses a problem for the person if they cannot get an adequate and regular supply of the medicines. This is often the case in our medical system: a person is prescribed a prescription drug, they get addicted to its effect, and, once they start exhibiting signs of this, the prescriber stops being willing to prescribe the medications because they perceive that the individual is abusing the medication. This may lead to obtaining the drugs illegally, which has major implications for not only the individual, but society as well.

Are there treatments for pain that don’t involve medicines?

There are many non-medicinal treatments for pain, and in fact, any plan of care that doesn’t involve at least ONE of these types of treatments, really isn’t a proper plan of care at all!

Physical Therapy is VERY beneficial for musculoskeletal problems. Most often, a pain of the muscle or skeleton is because of a nerve being “squished” by a physical structure (most often a bone) that is somewhat out of place. Physical therapists are VERY GOOD at fixing these problems. In fact, you are probably in the best hands while under the care of a physical therapist if you have pain.
See a PT long before you see a surgeon, and long before you consider taking anything besides an NSAID if you have muscle/skeletal pain. Ask for a referral from your health care provider if your insurance requires one.

Accupuncture has been shown to be very helpful for individuals who experience long-term or refractory pain (pain that doesn’t respond to other treatments). In Camden, there is an acupuncturist near Osprey Cove: Dr Mixson.

Chiropractic care can be beneficial for headaches, low back pain, neck pain, shoulder pain, leg pain, foot pain… you name it, they might help it! Particularly if you have disc issues ask for Vax-D, a procedure that involves decompression of the discs that is very beneficial. Dr. Amato does this procedure in Camden.

Therapeutic Massage can be helpful. Tense and un-worked muscles can be an additional source of pain for many individuals. Sometimes massage can also make an issue feel worse in the short term, so be sure to communicate your issues with a licensed and trained provider who is experienced with sports-related issues. Joe Durant in Brunswick does a very good job, and he also incorporates acupressure and electrical stimulation, which is very helpful.

Electrical Nerve Stimulation can be done by a physical therapist and is very helpful to treat pain.
Ultrasound can also increase healing chemicals in the area of injury. Physical therapists can perform this.

Steroid injections and trigger point injections can be done to target specific areas of need. Steroid injections must be limited, but they are very helpful when applied in the appropriate situation.

Nerve Blockade and ablation of nerves can be done by medical doctors who specialize in the treatment of pain.

What should I do if treatment doesn’t work?

If you don’t respond to treatment, behavior therapy can teach you effective pain relief methods that help you place “mind over matter.” These therapies take a lot of practice, but they DO WORK if you are dedicated enough to put your energy into utilizing them.

Consider any dietary changes you can make. Dairy and gluten are 2 sources that are hypothesized to contribute to pain in some people. If you don’t have any relief from pain associated with fibromyalgia, consider altering your diet to exclude dairy and gluten. Although it hasn’t been proven, it may help you.

What should I do if my provider doesn’t treat my pain the way I want it to be treated? Not all providers are the same regarding what medicines they will prescribe you, but you DO have a choice. If you do not agree with your plan of care, find another provider who will service your needs in a different way.

If you find that provider after provider has the same opinion about what is good for you, you may want to rethink your ideas about what you expect from the prescriber. Prescribers have your best interest at heart. They also have society, as well as their license to protect. If they make decisions that you don’t understand, ask them what they base their decisions on. When you have a good understanding of their decision-making process, you may also better understand why you may disagree with them.

Are there any real humane reasons why a provider would refuse to give me pain medication?

Not all providers believe that patients should use narcotic pain medicines to treat pain. Those beliefs are based on evidence and experience. Pain is real. It can be treated. But not all medicines are the same and not all providers are the same. Neither are all patients the same. You may be using your medicines sparingly and honestly, while others are not. Your children may not be using your pain medicines, but your neighbor’s child might be high on his father’s back pain medicine. Providers must balance the benefits and risks to prescribing narcotics to people who are in pain. This is a very difficult and ethics-driven issue. If your provider doesn’t use narcotics to treat pain, it’s because they have probably seen the misuse, abuse, and poor outcome of their best prescribing efforts. It is much better to prevent one problem in ALL patients, than to have to see one person die from abuse, or to have to see one family fall apart from narcotic addiction. You may not think these problems can happen to you, but it may not be YOU that the provider has to worry about.

It’s my body, shouldn’t I be allowed to use whatever medicine works best for me?

If this were true, the medicines would not be by prescription only. The prescribers of these medicines are trained to know their use and abuse potential. You may be glad to know that they are protecting you from what you may not know is potentially harming you.

I’m not concerned about the social concerns of using pain medicine. Pain medicine seems to help me. What should I do so that I can get my pain medicine?

If after reading this, you still believe the only route to pain relief is narcotic pain medication, talk to your provider. They may be willing to prescribe these medications as long as they are not being relied on daily or regularly. Do your best to use the many opportunities for pain relief before reaching for the narcotic bottle. You will find that most prescribers aren’t against their use altogether, only when they see the medicine is being overused. DAILY REGULAR USE IS OVERUSE.

Speak with your provider. Communication may be the key. If that doesn’t work, you may just need to find a provider who does meet all of your needs. After all, the goal of treatment is more that just physical treatment; it’s also the need for you to agree on the plan of care.