We need pain – it’s part of our survival mechanism, a signal that something is wrong and we must attend to it and the source, whether it’s a stubbed toe (put on a plaster, and the light!) or stabbing pain in the chest (get your heart checked and cut that cholesterol).
But constant severe pain, whether from migraines, a bad back or conditions such as arthritis, endometriosis or shingles, can interfere with our life. It can affect our concentration, memory and mood, our ability to work, socialise, sleep and have sex, putting strain on our relationships. Untreated long-term pain may even alter the central nervous system, influencing the sensory, emotional and other circuits that would usually inhibit pain. There’s growing evidence that chronic pain is a neurological disease in its own right, sharing symptoms of anxiety and depression.
Given its complicated nature, chronic pain is still not fully understood, making it hard to treat. “Successful treatment depends on an accurate diagnosis of the source,” says Dr Elliot Shevel of The Headache Clinic in Johannesburg. Sometimes all you may need for a headache is meditation, relaxation, massage, gentle neck stretches or compresses.
But for severe pain, like a migraine, he advises a multidisciplinary assessment: “For example, a neurologist to examine the brain and nervous system; a physiotherapist, the muscles; a dentist, the teeth; and a psychologist, the stress factor.” A team can provide a co-ordinated treatment plan so that all contributing factors are addressed, and treatment options can be weighed. Here are some of the ways chronic pain can be tackled.
1. Painkilling drugs
These are the most common solution and used as directed can be an effective, convenient and affordable one. For milder short-term pain, relief can come just with over-the-counter painkillers. These include paracetemol (Panado, etc.) or NSAIDs – nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen (Nurofen, Advil, etc.), and naproxen sodium (Aleve, etc.). Creams, lotions or sprays are available for muscle pain and arthritis.
The downside of oral NSAIDs is they can irritate the stomach lining, and if you overuse them – taking more, more often or longer than directed – they can relieve pain then worsen it in a rebound reaction. The pain becomes greater as you build a tolerance to the painkillers and need to take more to get relief, in what becomes a vicious cycle, says psychiatrist Dr Shaquir Salduker, director of the Durban Pain Clinic at St Augustine’s Hospital.
Physical effects of overusing OTC painkillers can be equally alarming: “Not just constipation, but perforated gastric ulcers, gastrointestinal bleeding, hepatoxicity (liver damage) and inflammatory bowel conditions,” says Siphokazi Dada, a senior scientist at the SA Medical Research Council.
When pain is severe and OTC painkillers aren’t enough, you may be put on prescription medication – stronger NSAIDs, muscle relaxants, anti-anxiety drugs or antidepressants (which also address pain) or a short course of opioids (codeine, fentanyl). But these can be highly addictive and dangerous if overused, warns Dr Salduker.
“Codeine is effectively converted to morphine when you take it and can give a feeling of euphoria,” he says. “Opiates originate from opium and have a similar structure to heroin. Addiction potential is huge. They can produce changes in mood when they wear off, anxiety, irritability and restlessness. They affect cognition and are quite sedating, affecting reaction times.”
Dr Salduker reports that the incidence of opiate abuse is estimated to be higher than for cannabis and cocaine, and similar to alcohol abuse. “We detox patients with physiotherapy to help relax muscles, and have a psychologist who educates them on the nature of their pain and helps them reframe it using cognitive behavioural therapy.”
2. Injections
These can sometimes be given for pain in your limbs, lower back and neck, targeting knots formed when muscles don’t relax. Shots of a local anaesthetic, sometimes including a steroid or simply sterile saltwater, are administered, usually in a short course.
Injections can also be used for fibromyalgia, tension headaches and myofascial pain syndrome (inflammation in soft tissue). For migraine, Botox, as a paralysing toxin, can sometimes be injected to block pain signals between nerves and muscles.
3. Implants
When other medicines aren’t effective, a surgical implant may help. With intrathecal drug delivery, the surgeon inserts a tiny pump under the skin and a catheter that carries medication, such as a muscle relaxant or morphine, straight to the space around your spinal cord where pain signals lead. It’s more efficient than pills, so you need a smaller dose and have fewer side effects.
Alternatively, you can have a spinal cord implant, a mini device that delivers electrical signals you control using a remote control.
4. Tens
Transcutaneous electrical nerve stimulation therapy (TENS) also delivers an electrical current to counter pain, but through electrodes placed on your skin. The current ‘scrambles’ normal pain signals.
5. CBD oil
Today cannabidiol (CBD), a chemical compound in marijuana and hemp but without the ‘psychoactive high’, is trending for a range of health problems and pain relief. To date, there is insufficient hard scientific evidence to persuade many medical professionals to advise it, though some say it shows promise. A study in the Journal of Experimental Medicine found CBD reduced chronic inflammation and pain in rodents, and some countries have approved an oral spray to help relieve pain and spasticity for multiple sclerosis. Professor Motlalepula Matsabisa, head of the Indigenous Knowledge Systems research programme at the University of the Free State, is among those exploring claims for cannabis and CBD in relation to pain management.
New modalities of pain relief and refinements of old ones are constantly becoming available. Today no one should have to put up with pain. If your health professional can’t help, ask for a referral to a qualified pain specialist who can. “There are enough pain experts around, so ask for a referral,” says Dr Salduker. “And beware of the pain doctors who recommend long-term opiate use!”
Also read: 4 Things you need to know about heart attacks
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