Chronic Pain – Pradeep Chopra MD’s Blog
Pradeep Chopra MD’s Blog on Chronic Pain.
This blog is the first of a series of blogs on the disease of chronic pain, medicine, and truths in medicine.
Pain management has become a controversial topic in the last year or so. The controversy is based mostly on the fact that there is a single drug or therapy that can control pain. This notion has come from physicians who are not trained in pain medicine. It has come mostly from people who have never experienced the cruel, burning of chronic pain. Most people undergo short bursts of pain after a trauma (surgery, cuts, scrapes and falls) which respond to standard pain therapies.
Pain, as we know is a protective reflex. It’s pretty simple – when our body sustains an injury, we feel pain, we take measures to protect it till the damage heals. This pain will respond to standard analgesics (pain medicine). Once the injury heals, we don’t feel the pain anymore.
Chronic pain is a disease by itself. It is no longer a protective reflex. The original injury was a long time ago, but the pain has persisted. Chronic pain is no longer protective. Standard analgesics no longer provide the same relief and in most cases, no relief at all.
The above concept of the difference between pain and chronic pain is something that most people do not understand (physicians included). I have met dozens of patients with severe chronic pain who have been told: “If the pain from my ankle sprain felt better after taking ibuprofen, I don’t see any reason why your chronic pain from CRPS (Complex Regional Pain Syndrome) cannot get better with ibuprofen.”
I believe the treatment of pain lies in finding what is broken and fixing it. This principle applies to acute and chronic pain. For example, if someone has a broken bone, the treatment lies in stabilizing the fracture. No amount of ibuprofen, applying creams and lotions or acupuncture is going to make the pain go away.
The same principle applies to treating chronic pain. The difference here is that finding what is broken is far more challenging. For example, if someone develops low back pain after surgery, the fix would be looking for the cause of the pain. It could be a muscle spasm, nerve damage, joint pain. Treating the muscle spasm or the joint pain would help the most. Treating it as “low back pain” with blind therapies does not make sense. Surprisingly enough there are drugs that have been approved for the treatment of low back pain. Duloxetine (CymbaltaÒ) has been one of the drugs. When it was first approved, it did not make sense. How can one medication that works on the brain treat back pain from a disc bulge or arthritis of the back or muscle spasm all the same time? What was even more baffling was that the drug would work only on the lower back. Would it not work on the upper back? What about the neck? What about pain in other parts of the body? Apparently, it works only on the lower back because that is what the FDA said and insurance companies have taken that to deny patients the medicine for other pains, including upper back and neck. Clinical experience has shown that duloxetine does not do a good job for even low back pain. More on this later.
In chronic pain finding the exact cause of the pain is challenging. One has to remember that there may be more than one cause. For example, in someone has a shoulder joint pain, the pain could be from wear and tear of the cartilage, ligament damage or muscle spasms around the joint. Once we find the cause of the pain, it may not be possible to repair it. But treatments targeting ‘what’s broken’ will get better results. Treating it blindly with acupuncture, physical therapy or electrical currents such as scrambler therapy without understanding the underlying problem will not be effective