Chronic
Pain: The silent epidemic
Chronic pain is pain persisting or recurring even after treatment for more than 6 months. Chronic pain includes persistent headache, neck and shoulder pain, non cardiac chest pain, low backache, pain in the hands and legs, pain in the joints etc. Three groups of people need special mention: people with pain due to cancer or chemotherapy (cancer pains), people with severe pain in the legs due to diabetes (diabetic neuropathy), and people who had had surgery for back pain before but has no relief of pain (Failed Back surgery syndrome).
Anything from a bad mattress to bad posture to major problems like tumours (including cancers) or degenerative diseases can cause chronic pain. Unfortunately chronic pain carries with it a psychological component which can lead to anxiety/ depression and further problems. So treatment needs to be individualised and specialised. Chronic pain interferes with every aspect of life, including work, sleep, relationships etc. Studies in students have shown a strong relationship between chronic pain and academic performance. Many studies have shown the direct negative relationship between career growth and chronic pain. There are also studies which have shown chronic pain in the young could cause infertility. Thus chronic pain affects our day to day quality of life and also causes financial and other family problems.
Treatment of chronic pain is highly specialised and involves drug therapy, psychotherapy, physical therapy etc. Many countries have specialised pain centres and university departments. Infact the American Congress had declared the ten-year period that began January 1, 2001, as the Decade of Pain Control and Research. Unfortunately in our country chronic pain is not considered a big issue because of lack of awareness of its consequences; patients go from doctor to doctor seeking relief but never get the cure.
Majority of patients with chronic pain can be treated by medical and physical means. This is done in a series of steps. Initially oral medications including adjuvants are tried along with physiotherapy, rehabilitation and psychological therapy as necessary. If there is no relief, then oral opioids may be considered especially in cancer pain. Simultaneously therapeutic nerve blocks may be recommended in selected cases. If these are not effective or the side effects are severe, then advanced therapies are indicated. These include:
1. intrathecal drug delivery
2. neurostimulation,
Intrathecal drug delivery systems can deliver drugs like morphine directly into the cerebrospinal fluid or CSF (the fluid around the brain and spinal cord) . The advantage is that the drug acts directly on receptors in spinal cord. So the dose of drug required is much less (about 1/200th of oral dose with morphine). As a result side effects like constipation/drowsiness do not occur. Also there is no systemic absorption so no problem with tolerance and addiction liability. There are many studies that have shown that intrathecal morphine pumps are effective in reducing pain in more than 80% of patients. Also many studies have shown the very good safety profile of this treatment. Intrathecal morphine is indicated in diffuse cancer pain, failed back surgery syndrome, osteoporotic pain etc. Intrathecal baclofen is indicated in spasticity due to cerebral palsy, spinal cord injury, multiple sclerosis, brain hypoxic injury, severe head injury, and metabolic diseases. Several articles have shown that intrathecal baclofen has significant functional benefits and worthwhile acceptable cost / benefit ratio. We have a good number of patients who were unable to walk due to weakness / stiffness of legs but have improved well after baclofen pump insertion.
Spinal cord stimulation is Indicated in conditions like failed back surgery syndrome, intractable diabetic neuropathy pain, complex regional pain syndromes (CRPS) , pain in brachial plexus injuries, pain due to peripheral vascular disease, refractory angina (where bypass or angioplasty is not possible and drugs are not effective). It is also useful in pain in the arm, phantom limb pain (after amputation), neuralgias like trigeminal neuropathies etc. The method is to introduce stimulating electrodes in the dorsal extradural space which stimulate the dorsal column. The results show that this is very effective in 60 – 80% of patients especially in failed back surgery syndrome, diabetic neuropathy, refractory angina etc.
Chronic pain is pain persisting or recurring even after treatment for more than 6 months. Chronic pain includes persistent headache, neck and shoulder pain, non cardiac chest pain, low backache, pain in the hands and legs, pain in the joints etc. Three groups of people need special mention: people with pain due to cancer or chemotherapy (cancer pains), people with severe pain in the legs due to diabetes (diabetic neuropathy), and people who had had surgery for back pain before but has no relief of pain (Failed Back surgery syndrome).
Anything from a bad mattress to bad posture to major problems like tumours (including cancers) or degenerative diseases can cause chronic pain. Unfortunately chronic pain carries with it a psychological component which can lead to anxiety/ depression and further problems. So treatment needs to be individualised and specialised. Chronic pain interferes with every aspect of life, including work, sleep, relationships etc. Studies in students have shown a strong relationship between chronic pain and academic performance. Many studies have shown the direct negative relationship between career growth and chronic pain. There are also studies which have shown chronic pain in the young could cause infertility. Thus chronic pain affects our day to day quality of life and also causes financial and other family problems.
Treatment of chronic pain is highly specialised and involves drug therapy, psychotherapy, physical therapy etc. Many countries have specialised pain centres and university departments. Infact the American Congress had declared the ten-year period that began January 1, 2001, as the Decade of Pain Control and Research. Unfortunately in our country chronic pain is not considered a big issue because of lack of awareness of its consequences; patients go from doctor to doctor seeking relief but never get the cure.
Majority of patients with chronic pain can be treated by medical and physical means. This is done in a series of steps. Initially oral medications including adjuvants are tried along with physiotherapy, rehabilitation and psychological therapy as necessary. If there is no relief, then oral opioids may be considered especially in cancer pain. Simultaneously therapeutic nerve blocks may be recommended in selected cases. If these are not effective or the side effects are severe, then advanced therapies are indicated. These include:
1. intrathecal drug delivery
2. neurostimulation,
Intrathecal drug delivery systems can deliver drugs like morphine directly into the cerebrospinal fluid or CSF (the fluid around the brain and spinal cord) . The advantage is that the drug acts directly on receptors in spinal cord. So the dose of drug required is much less (about 1/200th of oral dose with morphine). As a result side effects like constipation/drowsiness do not occur. Also there is no systemic absorption so no problem with tolerance and addiction liability. There are many studies that have shown that intrathecal morphine pumps are effective in reducing pain in more than 80% of patients. Also many studies have shown the very good safety profile of this treatment. Intrathecal morphine is indicated in diffuse cancer pain, failed back surgery syndrome, osteoporotic pain etc. Intrathecal baclofen is indicated in spasticity due to cerebral palsy, spinal cord injury, multiple sclerosis, brain hypoxic injury, severe head injury, and metabolic diseases. Several articles have shown that intrathecal baclofen has significant functional benefits and worthwhile acceptable cost / benefit ratio. We have a good number of patients who were unable to walk due to weakness / stiffness of legs but have improved well after baclofen pump insertion.
Spinal cord stimulation is Indicated in conditions like failed back surgery syndrome, intractable diabetic neuropathy pain, complex regional pain syndromes (CRPS) , pain in brachial plexus injuries, pain due to peripheral vascular disease, refractory angina (where bypass or angioplasty is not possible and drugs are not effective). It is also useful in pain in the arm, phantom limb pain (after amputation), neuralgias like trigeminal neuropathies etc. The method is to introduce stimulating electrodes in the dorsal extradural space which stimulate the dorsal column. The results show that this is very effective in 60 – 80% of patients especially in failed back surgery syndrome, diabetic neuropathy, refractory angina etc.
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