Ovarian Cancer

Treating Persistent Pain

When a part of your body is damaged or stressed, nerves from the affected area carry a message to the brain of an unpleasant sensation or feeling, which we know as pain. Pain is an individual human experience that is entirely subjective and can only be truly appreciated by the person experiencing the pain. Pain has diverse effects on different people, depending on their mood, emotions, beliefs about pain and other symptoms that may co-exist with pain such as nausea and poor sleep.

Nociceptive pain is the most common type of pain. It arises from actual or threatened damage to body tissues. It can be described as hot, sharp, stinging, dull, aching, throbbing or cramping. This pain is often caused by trauma (e.g. sprain or strain). Neuropathic pain is caused by disease of the nervous system. It can be described as burning, shooting, electric, stabbing, shooting or tingling. Examples include neuralgia caused by shingles and neuropathy caused by diabetes.

Pain may be acute or chronic (persistent). Acute pain is pain that starts suddenly and lasts for a short time. The cause of pain is usually known, such as surgery, bites, burns, broken bones and headaches. Acute pain acts as a warning to the body to seek help. Effective timely treatment is essential to prevent transition to chronic pain.

Chronic pain is pain that lasts beyond the time expected for healing following surgery or trauma. It can be due to a long-lasting medical condition (e.g. arthritis, cancer). It can also exist without a clear reason at all. If left untreated, chronic pain can interfere with daily activities including sleep, work, exercise and routine self-care, which can have a negative effect on personal relationships, social interactions and lifestyle. About 20% of Australians suffer chronic pain, and this will increase as the population ages.

Chronic pain management aims to relieve pain, but the pain may never totally stop. Management often includes learning how to live well and enjoy life despite the pain. Health professionals when treating a patient with chronic pain adopt a multidisciplinary approach with a focus on appropriate combinations of physical, psychological and pharmacological (drug) therapies.

Physical therapy may be passive e.g. thermotherapy (hot and cold application), manipulation by a physiotherapist, massage or acupuncture. These passive therapies can be helpful short term to help initiate improvement, but longer-term use should be discouraged to avoid over-reliance. The main focus of physical therapy for chronic pain is to encourage self-management through active therapies such as – general strengthening and aerobic exercise, specific exercises or stretches (e.g. yoga) and hydrotherapy.

Psychological treatments can be used as an adjuvant in the management of pain; sometimes they can be the first form of therapy. Treatments include hypnosis, relaxation/meditation, attention techniques (distraction from pain). One of the best and most widely used psychological therapies is cognitive behavioural therapy (CBT). This approach helps patients identify unhelpful thoughts (cognitions), emotions and behaviours that may be contributing to their pain, and encouraging changes to behaviour to address these. Patients who use CBT are less troubled by pain and are able to do more things despite living with pain. A psychologist specialises in delivering CBT.

In chronic pain there is no such thing as a ‘pain killer’ because medicines may not always stop the pain, but rather reduce it to a level that does not interfere with daily life. The choice of pain reliever (analgesic) depends on factors such as:

  • A persons age, medical conditions and other medicines
  • The type of pain, where it occurs and its intensity
Some medicines used in chronic pain are available without prescription in the pharmacy. Advice on their use can be obtained from a discussion with our qualified pharmacists.

Chronic pain sufferers are encouraged to take regular paracetamol as an adjunct to non-drug therapies. It may not relieve the pain completely, but can modify its severity. Paracetamol is suitable for all ages, has a low risk of side effects and is available in many dosage forms. Over the counter non-steroidal anti-inflammatory drugs (NSAIDS) can reduce pain and inflammation (e.g. in arthritis). Examples include ibuprofen (Nurofen, Advil) and diclofenac (Voltaren). These drugs should be used in as low a dose as possible for the shortest possible time due to the possibility of serious side effects. Check with our pharmacists if NSAIDS are right for you.

Opioids (morphine-like) pain relievers work well in acute pain, but their role in chronic pain is limited. Experience suggests that opioids work in only one in three patients and they reduce pain intensity by 30-50% at best. Codeine is an opioid analgesic available without prescription in pharmacies. It may give stronger relief than paracetamol or non-steroidal anti-inflammatories. However, codeine is not suitable for everyone. An adverse effect will occur in 80% of patients taking opioids long term. Dependence and withdrawal symptoms can occur if opioids are not used correctly.

Nerve pain (neuropathic pain) is difficult to treat with traditional analgesics. Your doctor may prescribe anti-depressants or anti-epileptic medications which have been clinically trialled to reduce the level of pain in some neuropathic conditions.

Because of the side effects, interactions, suitability and possible dependence of regular analgesics; many people are open to the idea of using complementary and herbal medicines to manage their chronic pain. All our pharmacists are highly trained in these products and encourage their patients to consider this approach to their chronic pain management.

There is strong evidence that glucosamine delays the progression and improves the symptoms of osteoarthritis. Glucosamine therapy is well tolerated. Omega-3 long chain fatty acids, eicosapentaenoic acid (EPA) and docasahexaenoic acid (DHA) have anti-inflammatory properties. Fish and Krill oil supplements contain high amounts of Omega-3s. Their anti-inflammatory effect can enable use of lower doses of non-steroidal anti-inflammatory drugs (NSAIDS).

Devil’s claw assists with the relief of pain and inflammation of musculoskeletal conditions such as osteoarthritis of the spine, hip and knee. Curcumin from Tumeric may help down-regulate inflammatory mediators and reduce joint inflammation associated with arthritis.

Key points for patients with chronic pain:

  • Chronic pain is a common, complex condition that affects up to 1 in 5 Australians.
  • There are many medicine and non-medicine ways to manage chronic pain.
  • It is best to slowly increase activity in small measured steps despite pain. Remember that ‘hurt’ does not always mean ‘harm’.
  • Psychological therapies provide an additional option for limiting the impact of pain on the patient and assisting them to resume normal activities.
  • There are a number of different types of pain relievers that suit various types of pain. Our pharmacists can advise you on the best pain relievers for your pain.
  • Community Pharmacy staff are highly trained in evidence based complementary medicine use in chronic pain management.
  • A doctor or pharmacist can help you to find the best ways to manage your pain.

References

  1. ‘Chronic Pain’ Self-care Card, Pharmaceutical Society of Australia, April 2013
  2. ‘Pain Relievers’ Self-care Card, Pharmaceutical Society of Australia, February 2013
  3. Australian Pharmaceutical Formulary (APF) 20th Edition, Pharmaceutical Society of Australia, 2006
  4. Therapeutic Guidelines, www.tg.org.au, accessed 15/06/14
  5. Bioceuticals Application, accessed on iPhone5, 15/06/14
  6. Pain Australia website, www.painaustralia.org.au, accessed 15/06/14
  7. ‘Chronic pain-what can I do?’ fact sheet, National Prescribing Service,
    http://www.nps.org.au/conditions/nervous-system-problems/pain, accessed 15/06/14
  8. Declaration of Montreal, International Association for the Study of Pain,
    http://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1821, accessed 15/06/14
  9. ‘Pain management-adults’ fact sheet, Better Health Channel, http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pain_management_adults, accessed 15/06/14
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