What is chronic pain?

• General somatic pain (pain from the outer body)
  • Pains from your skin and muscles are easily localised by the brain because these pains are common. You have experienced general somatic pain since childhood when you have fallen or been hit by a person or an object. Normally, somatic pain gets better in a few days.
  • Some people develop pain that never goes away. Fibromyalgia and chronic back pain are in this category.
  • General somatic pain is often treated with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen or with paracetamol. Sometimes, opioids, such as codeine or morphine, may be needed.
     
• Visceral pain (pain from the internal organs)
  • Pain in your internal organs is more difficult for you to pinpoint because your brain doesn't get much experience feeling pain from internal organs. The connections from pain sensors in your internal organs to your brain are less sophisticated than the nerve connections from your outer body.
  • You have experienced some visceral pains. Pain from acid indigestion or constipation is easy to recognise. These pains are easily treated and get better quickly either on their own or with treatment using non-prescription medicines.
  • The pain from chronic pancreatitis (an inflammation of the pancreas) or chronic active hepatitis (an inflammation of the liver) can last a long time and be difficult to treat.
  • Visceral pain from gallstones or appendicitis, for example, can be treated with surgery. Other visceral pains can be treated with various non-opioid pain medications. Sometimes opioids may be needed.
     
• Bone pain
  • Pain in the bones from a bruise or a fracture is temporary. Pain from bone cancer, osteoporosis (weakening of the bones that often appears in older people), osteomyelitis (an infection in a bone) or arthritis (inflammation of the joints) can last a long time.
  • Bone pain is gnawing and throbbing. If you suffer from this, you may need long-term pain treatment. Bone pain may be treated with hormonal therapy or with bisphosphonates, such as alendronate, which strengthen the bones. Often, NSAIDs (such as ibuprofen) are used. Sometimes opioids are needed.
     
• Muscle spasm (muscle cramps)
  • Muscle spasm can cause severe pain especially in the back. Pain medication alone may not be able to cure the pain. Muscle relaxants such as baclofen may be needed to relax the muscles.
     
• Peripheral neuropathy (pain arising in the nerves leading from the head, face, trunk or extremities to the spinal cord)
  • In a sense, all pain comes from nerves because nerves transmit painful impulses to the brain. But some painful impulses do not arise from the nerve endings that normally sense injury or illness. Some painful impulses come from irritation to the nerve along its length instead of at the nerve ending.
  • Sciatica, for example, is caused by a pinching of the sciatic nerve, which goes from the leg to the spine. The pinching often takes place near the lower part of the spine, but the brain "thinks" the pain came from the nerve endings in the leg because the sciatic nerve usually transmits feelings from the leg.
  • Other examples of illnesses that cause peripheral neuropathy or "nerve pain" are ruptured discs in the spine, which pinch nerves, cancers that grow into nerves and cause irritation, or infections, such as shingles, which can cause irritation to nerves.
  • Common diseases that often cause peripheral neuropathy are diabetes and AIDS.
  • Nerve pain can feel like a painful "pins and needles" sensation. This kind of nerve pain can be treated with tricyclic antidepressants. Other, more severe nerve pain can be described as a sharp, stabbing, electric feeling. Anticonvulsants (medicines that treat seizures) are used for this kind of nerve pain.
  • Some nerve pain is due to loss of a limb. The arm or leg that has been lost feels like it's still present, and hurts severely. This kind of nerve pain, called deafferentation, or " phantom limb pain", can be treated with clonidine (a blood pressure medicine that also relieves nerve pain).
  • Herpes zoster (shingles) causes an infection of the nerve endings and of the skin near the nerve endings. Local application of capsaicin, a prescription pain medication in the form of an ointment, is sometimes helpful for this. In addition, opioids, tricyclic antidepressants or anticonvulsant medication may be needed.
     
• Circulatory problems
  • Poor circulation is often a cause of chronic pain. Poor circulation is usually caused by tobacco use, diabetes or various autoimmune diseases (diseases where the body makes antibodies that fight against itself) such as lupus or rheumatoid arthritis.
  • Partial blockage of arteries by fatty deposits called plaques is also a common cause of poor circulation. The reason for the pain of poor circulation is that the part of the body that does not get good blood circulation becomes short of oxygen and nourishment. The lack of oxygen and nutrition causes damage to that part of the body, and the damage causes pain.
  • Pain from poor circulation may be treated by surgery to bypass the clogged arteries with artificial arteries to improve the blood circulation. Sometimes this is not possible, and blood thinners or opioids may be needed to control the pain.
  • Another common cause of poor circulation is complex regional pain syndrome (CRPS). This is a problem of both circulation and nerve transmission because painful nerve transmissions cause the blood vessels to get narrower. The narrowing prevents enough oxygen and nourishment from getting to the part of the body that is affected. CRPS can sometimes be treated with a surgical sympathectomy, an operation to stop the nerve impulses from causing a narrowing of the blood vessels. Often, non-opioid medication, either with or without surgery, is needed. Sometimes opioids are needed.
     
• Headaches
  • Headaches can be caused by many illnesses. There are several types of headaches, including migraine, tension and cluster headaches. Headaches can also result from sinusitis, trigeminal neuralgia, giant cell arteritis or brain tumours. The treatment of the various kinds of headaches differs depending on the kind of headache and the severity of the pain. Often, non-opioid medicines are used. But, in some cases, opioid therapy is needed.
  • Migraines are often on one side of the head. They can be associated with nausea and vomiting, photophobia (light hurting the eyes), phonophobia (sound hurting the ears), and scintillating scotomata (parallel lines that vibrate at the edges of objects, especially at the borders between light and dark places). Sometimes these auras appear before the headache starts and alert you that a migraine is coming. Migraine pain can vary in intensity from mild to severe. There are many specific medications for migraine. Sumatriptan is particularly useful for some, but not all, migraine sufferers.
  • Cluster headaches come in groups, sometimes several times a day, lasting for days to weeks. Many cluster headaches are severely painful. Oxygen therapy may be helpful for some cluster headaches.
  • Sinusitis can cause facial pain and is frequently worse in the morning. Sinus pain may respond to antibiotic treatment along with decongestants. Sometimes sinus surgery is needed.
  • Trigeminal neuralgia is actually a peripheral neuropathy (nerve pain) that is severe. It occurs on one side of the head and face and has a "trigger point", usually on the side of the face, which causes intense pain if it is touched. Anticonvulsants (anti-seizure medicine) are often helpful for this type of pain.

To view a video about the differences between Pain and Chronic Pain, please click here.

Stress relaxation and natural pain relief

Chronic pain is complex. Research over the past 25 years has shown that pain is influenced by emotional and social factors. These need to be addressed along with the physical causes of pain. Chronic stress is one factor that contributes to chronic pain. The good news is that you can get natural pain relief by making relaxation exercises a part of your pain-management plan.

The body's response to stress

To understand how natural pain relief works, it's important to understand how stress affects your body. Pain and stress have a similar effect on the body: your heart rate and blood pressure rise, breathing becomes fast and shallow, and your muscles tighten.

You can actually feel your body's response when you're faced with a sudden, stressful event, such as fearing that a car is about to hit you. The car misses you and, in time, your system returns to normal. You relax.

With chronic stress, such as worrying about health or finances, feeling stuck in a bad job or marriage, or fearing that something bad will happen, the nervous system keeps the body on alert. This takes a big toll on your body. Levels of stress hormones increase and muscles remain in a nearly constant state of tension.

For example, studies that measure site-specific muscle tension in patients with chronic back pain have shown that simply thinking or talking about a stressful event dramatically increases tension in back muscles.

Relaxation techniques for natural pain relief

Relaxation exercises calm your mind, reduce stress hormones in your blood, relax your muscles, and elevate your sense of well-being. Using them regularly can lead to long-term changes in your body to counteract the harmful effects of stress.

Don't get stressed trying to pick the "right" relaxation technique for natural pain relief. Choose whatever relaxes you: music, prayer, gardening, going for a walk, talking with a friend on the phone. Here are some other techniques you might try:

• Foursquare breathing. Breathe deeply, so that your abdomen expands and contracts like a balloon with each breath. Inhale to a count of four, hold for a count of four, exhale to a count of four, then hold to a count of four. Repeat for ten cycles.
• Guided imagery. Breathe slowly and deeply. For example, imagine a tranquil scene in which you feel comfortable, safe, and relaxed. Include colours, sounds, smells, and your feelings. Do five to ten minutes each day.
• Self-talk. Change how you think about your pain and yourself. For example, change "Pain prevents me from keeping the house the way I used to -- I'm a failure" to "No one will die if the house isn't perfect. I can get a lot done by breaking down tasks into baby steps."
• Hypnosis. Hypnotherapists can induce hypnosis and implant suggestions, such as, "You're going to sleep soundly tonight." Audiotape the session so that you can repeat it at home.
• Mindfulness meditation. Sit or lie quietly and notice your breathing without controlling it. If pain or thoughts interfere, simply notice them without trying to push them away. Think of them as a cloud passing over; then return to observing your breath. Do this for about 20 minutes.

When aches and pains disrupt sleep

Aches and pains can cause anyone a sleepless night now and then. It doesn't take much; a pulled muscle from an over-enthusiastic work-out or an afternoon spent helping a friend move furniture. The next thing you know, you're lying in bed at 3am staring at the ceiling, aching and hoping for sleep.

While most aches fade away quite quickly, painful and sleepless nights can be the norm for people living with chronic pain. "Between 50% to 90% of people with chronic pain say that they don't sleep well. They wake up feeling like they never went to bed", says Professor Gilles Lavigne, an expert on sleep and pain.

The British Pain Society tells patients “Living with long-term or chronic pain can be a particular challenge. Pain can make a disability more challenging and sometimes make it more severe. Like a stone in a pond, pain can cause ripples throughout your life. The continuing pain can affect mood, mobility, self-confidence and sleep patterns which themselves can impact on your working life, home life and social life.”

The good news is that there's a lot that you can do, either on your own or with your GP, to break the cycle. By changing your lifestyle and possibly any medicines you take, you may finally get the good night's sleep you crave.

Pain and sleep

During a normal night, we all go through cycles of light sleep, deep sleep and REM [rapid eye movement] sleep. This cycle is repeated three to five times a night.

Getting enough deep sleep and REM sleep are essential if you are to feel refreshed in the morning.

The problem is that pain interferes with this cycle. Sudden severe pain can make you bolt upright from a sound sleep. Even less severe pain can cause "micro-arousals". These are periods when your pain breaks through and bumps you back into the light sleep stage. You may not become conscious and the next day you won't remember waking up. Your fragmented sleep can leave you feeling like you didn't get any rest at all.

Any pain can interfere with sleep, but some common causes of disturbed sleep are:

• back pain
• TMJ pain, which is pain in the temporomandibular joint of the jaw
• arthritis
• fibromyalgia, which can cause pain throughout the body's muscles, ligaments, and tendons
• neuropathy or nerve pain
• premenstrual cramps

Acute injuries, surgery and more serious diseases such as cancer can also cause pain and sleeplessness.

It's not just the intensity of the pain that can make it difficult to sleep. Pain that varies, where it is worse some days than others, is often the most likely to cause sleeplessness.

"If you have constant pain for six months, you figure out how to cope with it. But if the pain level goes up and down, if it's unpredictable, you can't get used to it and it can really interfere with sleep", says Lavigne.

Finding solutions

Experts strongly recommend that people with chronic pain and insomnia practise good "sleep hygiene", which is a medical term for good sleep habits. This advice not only applies to people with chronic pain, but to anyone with sleep problems:

• Cut back on or cut out caffeine. If you're overtired, coffee, tea and caffeinated drinks may help you get through the day. However, they are probably making the problem worse as they disturb your sleep at night. So struggle through a few days without caffeine and see how you get on.
• Avoid naps. Napping during the day just reduces the amount you can sleep at night
• Exercise, but not too late. While physical activity is good for everyone, intense exercise, especially in the late afternoon and evening, can rev up your body and make sleeping at night difficult. So try a more moderate exercise routine and make sure you do it before the evening.
• Cut out alcohol in the evening. A nightcap might seem like the perfect way to put yourself to sleep. The problem is that alcohol can interfere with your sleep cycles and wake you up later.
• Don't overeat in the evening. Feeling very full may make it harder to sleep.
• Make your bedroom a calming place. It's very easy to let your bedroom become a multipurpose dumping ground. It might be filled with baskets of laundry, your children's toys and a TV. Experts say that you should make your bedroom a more neutral, soothing place. They recommend that you use your bedroom only for sleeping and sex. Get rid of the distractions.
• Relax before bedtime. Don't do anything before going to bed that could make you anxious or excited. Avoid doing work in the evening or even getting into serious discussions with your spouse. Instead, try focused relaxation or breathing exercises.
• If you can't sleep, don't lie awake in bed. Willing yourself to sleep won't work. You'll probably just make yourself anxious. So if you're not asleep within 15 minutes of lying down, get out of bed and do something else such as reading a book, having a bath or listening to relaxing music. Once you feel yourself getting tired, get back into bed
• Get up at the same time every day regardless of when you went to sleep. It's one way of getting yourself into a routine.

Using medicines

Medicines can be invaluable to people who have their sleep disturbed by pain.

For mild, temporary pain, over-the-counter painkillers such as paracetamol, or ibuprofen may be enough.

For more severe or chronic pain, speak to your GP. They may recommend prescription painkillers, such as opioids including codeine. Other medicines can also help with pain, such as some antidepressants and anticonvulsants.

If you are still having difficulty sleeping, speak to your GP. There are medicines that can be prescribed to treat insomnia, but in general these medications are not encouraged as part of the management of long-term insomnia secondary to pain.

The key is to find the treatment that works for you. While it may take a few attempts, you and your GP will probably find the right approach that will ease your pain and get you some sleep.

Even if you are prescribed a medicine, don't give up on good sleep hygiene. A combination approach may be best.

Taking action

Experts agree that you must take chronic pain and sleep problems seriously.

Pain can throw your whole life out of balance. It's not just the feeling of pain that's the problem. For instance, chronic back pain is more than just a pain in the back. Over time it can spill over and affect every aspect of your life. It can overwhelm you.

So don't assume that pain and insomnia will resolve themselves. Instead get help from your GP. Unfortunately many people don't.

Don’t become fixated on a single cure. A lot of people get stuck on the idea that one tablet or another operation will solve their pain.

With the help of your GP, you can find a treatment plan that will help.

Frequently asked questions about pain management

1) Should I take pain medication only when I have a lot of pain?

No. Don't wait until pain becomes severe to take pain medication. Pain is easier to control when it is mild. You should take your pain medication regularly, just as prescribed. Sometimes this means taking medicine on a regular schedule.

2) Will I become addicted to narcotic pain medications?

Not necessarily, if you take your medication exactly as prescribed. A person's likelihood of becoming addicted depends, in part, on his or her addiction history. Addiction is less likely if you have never had an addictive disorder. Ask your doctor about any concerns you may have.

3) Why do I need to keep taking more of my medicine to have the same effect?

This situation occurs when you have developed tolerance to a drug. Tolerance is a normal physiological response to narcotics and occurs when the initial dose of a substance loses its effectiveness over time. Changing the dose or the medication often solves the problem. Just because you have become tolerant to a drug does not mean that you are addicted to that drug.

4) Should I tell my medical provider that I am having pain?

Yes. Your provider needs to assess your pain, so it is very important for your health care team to know if you are in pain.

5) Some days my acute pain is much worse. What can I do?

You might notice at times that you are in more pain than usual (such as at the end of a tiring day or as a result of certain activities). If you notice that certain activities contribute to your pain, or that you feel worse at certain times of the day, medication can be taken prior to the activity (or time of day) to help prevent the pain from occurring. Always be sure to follow your doctor's instructions.

6) How can I tell my doctor how much pain I am in?

The best way is to describe your pain as clearly and in as much detail as you possibly can. Most doctors and nurses ask you to describe your level of pain on a scale.

7) What can my friends and family do to help with my pain?

Friends and family can benefit you by helping you to live as normally and independently as possible.

8) Do I have to suffer with chronic pain for the rest of my life?

Not necessarily. With proper treatment, people can live full, normal lives after having experienced chronic pain.

To read about some tips for living with Pain and Chronic Pain, please click here.