Pain can be classified as acute or chronic
The definition of pain is an ‘unpleasant, noxious sensation in response to an insult’. It is a subjective sense of discomfort. Acute pain is simple, uncomplicated and responds to conventional medication. Conversely, chronic pain, is complex, multi-dimensional and represents a global change in the status quo. It persists for longer than the expected duration, usually in excess of three months. It is poorly responsive to traditional medicine and the outcomes are generally poor.
Doctors need to be cognisant that the chronic pain patient may present in many ways. These patients usually have repeated complaints of pain over a long period of time. They may be on multiple medications, with progressively increasing dosages and frequency. Psychosocially, there is diminished productivity, dysfunction in relationships and a resulting major impairment in quality of life (QoL). There may be evidence of ‘doctor shopping’, and multiple unnecessary investigations, operations and procedures. Patients may be moody, irritable, combative and described as ‘high maintenance’.
The management of pain is varied, with the choice depending on duration and severity of the pain.
Pain management ranges from paracetamol and aspirin, NSAIDs, certain classes of antidepressants, spinal/regional blocks, pumps, patches and opiate medication. Opiates are currently a hot topic in medicine, and in the news in general, with several countries verging on an opiate crisis due to abuse. Long term abuse of opiates can lead to cognitive fallout, changes in personality, rebound pain phenomena, respiratory depression and GIT symptomatology. However, when used correctly, opiates are a very effective treatment option for short term pain control (less than two weeks) but have no place in chronic pain management. Long term use merely perpetuates the condition as it may lead to rebound phenomena via a negative feedback loop. Endorphin production is lowered which results in a lower pain threshold and subsequently more chronic pain.
The main goal, whether the patient is in an in- or outpatient setting, is to improve the quality of life of the patient with chronic pain.
Dr Salduker has been managing a pain clinic in Durban since 2008, with an astounding success rate. From his experience, 60 – 70% of patients report a 70% decrease in pain within two to four weeks. The management is mainly non-interventional and includes a multidisciplinary team, including a psychologist, physiotherapist and a biokineticist.
In addition, the clinic adopts a holistic approach, and yoga, mindfulness, relaxation techniques and core exercises are part of the program.
In conclusion, the general practitioner should be aware of the complexity of chronic pain, and the chronic pain patient. Questions should be asked around the pain, in order to establish the underlying cause, as well as the stress or anxiety which may accompany the condition. Ask about current analgesic use and never write repeat scripts for opiates.