What is Pain Management?

The British Pain Society estimates that almost 10 million people in Britain suffer from pain almost every day which impacts their daily life. The BPS also states that chronic pain is highly debilitating as well as being distressing. Shockingly, it is suffered by over a third of the population. Many people who suffer from chronic pain are unable to work and often lose their job.

Having suitable pain management should be achievable for all. No one should have to live with being in pain. Yet, unfortunately, in the UK there is a huge gap between the pain management that people need and what they receive.

According to information obtained by the Pharmaceutical Journal, most people living with chronic pain in the UK are having to wait for much longer than they should to receive specialist pain management treatment. Some have had to wait up to two years after they have been referred by their GP. Indeed, the Pharmaceutical Journal reports that “average waiting times from referral to treatment range from 6 to 112 weeks”.

Pain specialists agree that the longer a person waits, the more their health deteriorates which, in turn, means that their pain becomes harder to treat. This is why rapid access to pain management treatments and services is essential.

What is pain?

Before looking into ways of managing pain, it is important to understand what pain is, as, according to experts, understanding what pain is will help someone in their suffering by reducing their anxiety and fear surrounding it (Moseley and Hodges, 2001). The current definition of pain is explained as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”.

Pain specialists favour this definition as it realises the sensory experience of pain as well as affirms the emotional component. Additionally, it makes clear that pain is not always caused by actual damage but can also be caused by potential damage to tissues in the body.

Traditionally, most people believe that pain is caused by an injury or by damage and that it serves to warn us of risking further damage if we continue a pursuit that causes pain. Most of the time, we adapt our behaviours in response to pain to avoid further injury as well as avoid further pain.

These are called ‘adaptive behaviours’. However, pain can linger and persist, outlasting any actual tissue damage or injury due to changes that have occurred in the central nervous system. Your injury may have healed completely, but the pain remains.

Understanding pain is therefore not as simple as we may first have believed. We need to consider it as multi-faceted.

Melzack and Casey (1968) outlined pain as being three dimensional:

• Sensory – The feeling of pain, its location and nature.
• Cognitive – How we interpret the meaning of the pain and what we think about it.
• Affective – How we alter our behaviour in reaction to pain.

In essence, we all understand pain to be a feeling in our bodies, yet typically we have not considered our thought processes and behaviours about pain despite these facets being a large part of our pain experience. In thinking of the answer to the question “what is pain?”, this multi-faceted approach may go some way towards our understanding of why pain may persist despite an injury or damage having healed. In having a more in-depth understanding of pain, we are better equipped to manage it.

What causes pain?

To add further to our understanding of pain and therefore in thinking of the best pain management techniques, we need to understand what causes pain in a scientific sense. We all know that if you burn your hand by touching an iron it will hurt, but not many of us know the mechanisms behind the feeling of pain within the body. If we learn more about how our bodies feel pain and how they respond to it, we are in a better position to be able to manage it.

When someone injures a part of their body, chemicals are released into the area around the injury. For example, if you have injured your ankle by twisting it, chemicals are released in the ankle area. These chemicals ‘irritate’ and sensitise the pain receptor nerve endings (called nociceptors) in the ankle and send a message to the spinal cord which then goes up to the brain. Once these chemicals have irritated the nerve, the nerve can then send further pain messages spontaneously.

As the injury begins to heal, fewer chemicals are released into the area which means the nerve becomes less sensitised or irritated by them. The nerve returns to its normal state and stops sending the pain signals to the brain. If an injury does not heal fully, the nerves continue to be sensitive to the chemicals and can cause prolonged pain.

With most injuries, the pain eventually resolves. However, with prolonged pain, the nerves remain irritated and go on to irritate nerves nearby in healthy areas of tissue. This results in the person feeling pain in an area that has not previously suffered damage or an injury.

The person feels like their pain is ‘spreading’. This is one reason we should adapt our behaviours in response to pain so that we allow our tissues to heal. This way, the nerve sensitivity is reduced as is the sensitivity of the surrounding tissues.

How does pain affect the body?

“Pain affects every aspect of our life, not just our physical existence. It can affect how we manage our tasks day-to-day […and] affect how we interact with our friends, family and co-workers. It has an emotional and mental impact on our lives.” Dr Tina Ardon, Mayo Clinic.

Many of us wrongly believe that pain only affects a small area of our bodies – the site of an injury or damage to tissues. However, pain has a much bigger impact on the body as a whole. The body and mind work together in every facet of human existence and, as such, we cannot separate one from the other when dealing with pain. The way a person’s mind controls their attitudes and thoughts affects how their body feels and controls pain.

Pain (or the fear of causing or exacerbating it) can cause someone to avoid physical as well as social activities. This avoidance can then lead to increased weakness and loss of strength in the body as well as ‘weakness’ in relationships with others too. This then leads to a further increase in pain and lack of functioning. In time, a person can find themselves falling deeper into a world of isolation and pain. Effective and early pain management is important for precisely this reason.

Prolonged pain can also cause additional stress outside of the normal human experience. Stress brings with it its own physical and emotional difficulties such as an increase in breathing rate, heart rate and blood pressure, which may all lead to muscle tension.

This brings increased fatigue, changes in appetite and problems sleeping. A person can therefore end up ‘trapped’ in a cycle of pain and stress, which results in feelings of depression.

Depression, even mild depression, affects a person’s tolerance to pain and can often result in maladaptive behaviours – behaviours that inhibit successful pain management.

What are the types of pain?

Not all pain is the same. People experience pain in diverse ways and describing our perception of pain to others is often fraught with difficulty. Understanding the different types of pain often makes it easier for us to seek help and support from doctors to help manage our pain. It is also possible to experience distinct types of pain simultaneously, which can make describing it even more difficult.

Acute pain

Acute pain refers to pain that is short in duration, and which comes on suddenly due to an identifiable cause such as an injury – a broken bone, burns, surgical procedure, tooth abscess etc. For most people, acute pain is present only for as long as the injury persists and resolves once the injury has been treated and recovers. In terms of how acute pain feels, it is usually felt intensely initially and characterised by a sharp pain that improves over a short space of time.

Chronic pain

Chronic pain is pain that continues after an injury has resolved and lasts for at least three months. Chronic pain can be relatively mild in severity or severe and this can fluctuate depending on the area of the body or the person’s condition.

Chronic pain also brings associated symptoms such as fatigue and a lack of energy, muscle tension and limited mobility. Without proper pain management, chronic pain can also result in a reduced quality of life, bringing about symptoms of depression or anxiety.

Many chronic pain sufferers end up feeling isolated and can suffer from insomnia due to pain. Therefore, pain management by a pain specialist is essential for chronic pain sufferers.

Chronic pain falls into different sub-categories:

• Arthritis pain.
• Lower back pain.
• Frequent headaches.
• Fibromyalgia.
• Pelvic pain.
• Nerve pain.
• Abdominal pain.
• Spinal pain.
• Joint pain.
• Cancer pain.
• Post-surgery pain.

Nociceptive pain

Many types of pain fall into what medics call nociceptive pain. This is the most common type of pain experienced where damage to tissues stimulates a reaction in the pain receptors – the nociceptors.

Visceral pain

Visceral pain happens when the pain receptors are activated in the internal organs, such as in the chest, intestines, pelvis or abdomen, and occurs when these areas are injured. This type of pain is not often localised and takes up a more vague area within the body. Many doctors cannot easily define or understand visceral pain. Visceral pain is often described as pressure, aching or a deep squeezing pain.

The cause of visceral pain is often an organ injury but can also be caused by medical conditions such as endometriosis, prostate damage, menstrual pain, acid indigestion, digestive complaints such as constipation as well as cancers and problems with specific organs such as gallstones within the gall bladder.

Somatic pain

Somatic pain is caused by stimulation of the pain receptors typically due to force, vibrations, swelling or temperature. It can occur in the muscles, skin, joints, connective tissue and skeleton. Somatic pain is often reported as a cramping, gnawing, sharp or aching pain usually localised to a particular area. Somatic pain itself can be separated into superficial and deep somatic pain.

Superficial somatic pain is common and caused by everyday injuries to the skin and mucous membranes. Deep somatic pain is deeper in the body such as in the joints or bones and can feel more like an aching pain. Bone fractures, trauma, falls, muscle strains, connective tissue diseases including osteoporosis, and arthritis are all causes of somatic pain.

Neuropathic pain

Neuropathic pain is caused by damage or dysfunction in the nervous system causing the misfiring of pain signals within the nerves. Damaged or injured nerves can send pain signals to the brain where there is no cause for pain or when the cause of the pain has long since healed.

Neuropathic pain is typically felt as numbness, burning sensations, excruciating pain beyond what is expected for a certain injury, pins and needles and extra skin sensitivity. People experiencing this type of pain may also have difficulty sensing other things such as temperatures and may have difficulty wearing certain fabrics or clothing. According to Portenoy and Cruciani (2009), neuropathic pain patients “often say that the pain is unfamiliar, like any pain experienced before.”

This type of pain is fairly common and can be related to other health conditions such as diabetes (diabetic neuropathy), multiple sclerosis, or cancer, particularly those who have undergone chemotherapy which can cause damage to the nerves.

Nerve pain can also be the result of certain medications and in some rare cases, it is not possible to find the root cause. Booking an appointment with a pain specialist who is highly experienced in treating neuropathic pain is important when it comes to pain management.

What is pain management?

Pain management is a field of medicine that works towards reducing a person’s pain. It is an approach that involves many different disciplines to treat pain. The aim of pain management begins with evaluating the person’s pain before rehabilitating and treating the patient.

Speciality pain doctors are required to manage pain optimally due to their approach in treating pain, approaching the problem from different directions rather than just the medication route. However, accessing a specialist doctor to manage pain is not always easy or possible.

As mentioned, many people in the UK experience long waiting lists to see pain specialists and so seek to manage their pain themselves in the meantime. Others seek out their own treatment privately in clinics such as the London Pain Clinic on Harley Street. Such clinics work with the leading pain specialists in the country.

Who needs pain management?

Pain management can be for anyone experiencing pain. The level of management is dependent on the level of pain experienced. For example, someone with a straightforward pain problem such as a headache or ankle pain caused by a recent injury can be treated with simple pain relief medications such as paracetamol and/or anti-inflammatory drugs like ibuprofen.

For those with more severe acute pain, such as pain associated with a recent injury, GPs can prescribe stronger opioid medications such as codeine or tramadol. However, these are usually limited to short periods due to their addictive properties.

For the management of chronic pain, a person typically needs to have experienced chronic pain for three months or more and for that pain to be associated with significant distress and/or disruption of everyday activities before a referral to NHS pain management services is usually pursued.

This usually means that they also meet certain other criteria, such as:

• The cause of their pain has not been identified.
• All other potential causes of their pain have been treated or excluded.
• If the person is not well enough to undergo a procedure that would resolve the cause of their pain.
• The person does not want to undergo a surgical operation that would treat the cause of their pain.
• The pain continues to be distressing and/or intrusive.

Someone who meets these criteria is typically referred to a pain management clinic from their GP or by a consultant in another field treating a different condition.

However, there are also restrictions on who is not eligible to be referred. If the suffer only wants minimally invasive pain treatments such as injections or acupuncture, pain management through a pain clinic is not usually suitable. Likewise, if a person has already completed a pain management programme for the pain that they are suffering, then they are ineligible to be re-referred for the same course of action.

What are the types of pain management?

“Chronic pain is a widespread global health burden with insufficient therapeutic options which leads to an over-reliance on opioid pain killers which only give limited relief to patients with chronic (particularly neuropathic) pain, while potentially generating severe adverse effects, such as respiratory depression and addiction.”  News Medical Sciences, 2021.

This quotation explains some of the limitations when it comes to pain management. Typically, there is no ‘one size fits all’ approach when it comes to managing pain. Many types of pain management are effective, and it is often a case of trial and error when it comes to treating pain.

Some of these are:

• Exercise.
• Pain killers – Medically referred to as analgesics.
• Physiotherapy.
• Minimally invasive pain management procedures.
• Invasive pain management techniques such as surgical procedures.
• Clinical pain psychology treatments.
• A Pain Management Programme (PMP).

Exercise

Cardio or aerobic exercise works as a pain management technique by using the larger muscles in the body and increasing the heart rate which, in turn, releases endorphins – the body’s natural painkiller and ‘feel good’ chemical.

Pain killers

Pain killers are often the first port of call when it comes to managing pain. Some of the more common pain killers include paracetamol, ibuprofen, co-codamol, codeine, naproxen and tramadol. There are also specific pain killers that work on neuropathic pain such as amitriptyline and gabapentin. Look at the pain medications section below to read more about managing pain with medication.

Physiotherapy

Physiotherapy encompasses a range of techniques intending to treat and/or prevent worsening of pain. A physiotherapist may approach treating a person’s pain through advice and education, exercises and movement as well as manual ‘hands-on’ therapy.

Physiotherapists look at the body as a whole rather than focussing on an individual injury on its own. Exercises and movement are often their first port of call as they are an excellent way of improving someone’s mobility and function, reducing their pain in the process.

Manual therapies help by relieving stiffness and pain and improving blood circulation to affected areas. It can also help to improve the movement of certain areas of the body and also promotes relaxation. Occasionally, physiotherapists also use other techniques such as ultrasound treatments and acupuncture.

Minimally invasive pain management techniques

Minimally invasive pain management techniques include epidurals, facet joint injections, sacroiliac joint injections, Botulinum Toxin A (Botox) injections, nerve root injections, radiofrequency techniques (radiofrequency denervation or pulsed radiofrequency), or trigger point injections. These techniques often work by stopping the nerves from firing dysfunctional pain signals or by stopping the sensation of pain. These techniques are usually carried out in hospitals working with pain specialists.

Invasive pain management techniques

Invasive treatments for pain management are often the last port of call after other options have been exhausted or if there is a clear and definitive problem that surgery would correct. An example of such techniques includes surgery on the joints for arthritis suffers.

Clinical Pain Psychology

Many chronic pain sufferers do not like the idea of being referred to a clinical pain psychologist due to the mistaken belief that this means that their pain is ‘all in their head’. The reason that clinical psychologists treat those with chronic pain conditions is due to the pain affecting almost all aspects of life, including completing tasks of everyday living, going to work and socialising. Clinical pain psychology involves a range of techniques to help those suffering from pain to be able to cope better, which may help to resolve the severity of their pain.

These therapeutic approaches may include:

• Cognitive Behaviour Therapy (CBT).
• Acceptance and Commitment Therapy.
• Solution-Focused Therapy.
• Narrative Therapy.
• Family Therapy.

Pain Management Programme

Those who have suffered from pain for an extended amount of time may be referred to a pain management programme (PMP). These programmes are a great option for those who have tried other treatments that have not worked.

A PMP can help someone who:

• Finds daily tasks difficult due to pain.
• Feels stressed and worried by pain.
• May have low mood due to pain.
• Is open-minded when it comes to trying new things to help their pain.
• Is willing to participate in a group setting.

Pain management programmes help the sufferer to understand their pain and how they experience it. It teaches the person through a system that helps them pick up activities that they may have abandoned due to their condition.

The programmes incorporate a multi-faceted approach and so help to improve the fitness and strength of those participating but in a way that suits them. The programme aims to improve the sufferer’s mood and increase their quality of life. It also helps to challenge unhelpful thinking and reduces the reliance on medications (particularly those that are addictive and have unwanted side effects).

What are the different types of pain medicine?

As mentioned above, pain medicine (analgesia) is a go-to reliable method of treating pain.

“There is a wide range of medications to relieve pain. Each class and type of drug work differently, while some may be more suitable for certain people than others.” News Medical Sciences, 2021.

There are both advantages and risks in taking certain medications.

Let us look at the different types of pain medications available:

• Paracetamol: The most common name for the drug acetaminophen. It is an effective pain reliever used to treat headaches and most non-nerve pains.
• NSAIDs (non-steroidal anti-inflammatory drugs): Ibuprofen, diclofenac, naproxen and aspirin. Some of these can be used in topical forms including gels and creams.
• Antidepressants: Amitriptyline, nortriptyline, imipramine and clomipramine, which are good at providing relief from nerve pain. These typically take a few weeks to begin working.
• Anti-seizure medications: Gabapentin and pregabalin, which can be effective in treating nerve pain. These typically take a few weeks to begin working.
• Steroids: Dexamethasone and prednisone which alleviate inflammation and pain.
• Opioids: Codeine, oxycodone, buprenorphine. These are the strongest form of pain medicines. As such, many of them are prescribed for short amounts of time and are controlled due to their addictive nature. However, they are often used by those who suffer from chronic pain who have exhausted other options in terms of medications to relieve pain. These pain medicines are available in different forms including transdermal patches.

How do pain medicines work?

Pain killers work in different ways depending on their type:

• NSAIDs work by stopping the effects of certain chemicals in the body which reduces the presence of other chemicals that are involved in how we feel pain.
• With paracetamol, nobody really knows how it works! It is thought to work in a similar way to NSAIDs, though it does not reduce inflammation like NSAIDs do.
• With opioid medications like codeine, they work by binding to certain receptors in the nervous system and other parts of the body. This means that there is a decrease in how you feel pain and how you react to it, increasing the pain threshold and tolerance.

What are the advantages of pain medicine?

There are many advantages to taking pain medicines. For most, the first advantage is that they relieve pain. They are usually inexpensive to buy or prescribe too, so they tend to be accessible to everyone. Additionally, there are many types to choose from, which is useful if someone has an adverse side effect or cannot take a particular form for other reasons. For example, asthmatics or those with stomach complaints should not take NSAIDs as they can affect and exacerbate these conditions.

Taking pain medicines is a non-invasive and usually straightforward way of managing pain. However, there are limitations to the current drugs that are available. Many have side effects, for example, codeine use causes constipation in most people.

What are the side effects of pain medicines?

Choosing which pain medicine is right for a patient is often a balance between how effective it is in treating the pain combined with any side effects. As you would expect, different pain medicines have different side effects.

• NSAIDs are generally safe but they may cause stomach pains, nausea and ulcers in the stomach. They are also contraindicated in those who have diabetes, a history of stomach ulcers or reflux, kidney disease and asthma.
• Paracetamol is generally safe for most people to use, including children in reduced doses. There are typically no side effects but taking more than the recommended dose is incredibly dangerous.
• Antidepressants and anti-seizure medications such as amitriptyline and gabapentin often take a few weeks to have an effect and, as such, many give up on them easily. They can cause nausea, dizziness and drowsiness.
• Opioid medications often have the side effect of sedation – Meaning that people are unable to drive or concentrate for long periods due to taking the medicine. Opioids also often cause constipation and respiratory depression. The most significant risk with taking opioid pain medicines is the physical dependence on them and a build-up in tolerance which can result in addiction.

How to choose the right pain medicine?

Choosing the right pain medicine for your needs is extremely important. You need to maximise the benefits of any medicines with the risks involved in taking it. There is not always a set approach when it comes to deciding which pain medicine is right as different medications work better for different people and different pain conditions.

If the pain is neuropathic, choosing a medication specific to nerve pain such as amitriptyline or gabapentin would be a much better choice than an NSAID such as naproxen. Equally, it is important to start with the minimal pain relief necessary before increasing it if necessary.

Starting with a powerful drug comes with additional worries and side effects, so before jumping straight to oxycodone, start with paracetamol, NSAIDs, or co-codamol. That said, before taking any medications it is really important to consult with a doctor as he or she knows your situation best.

What are the side effects of pain medicines?

As with any medicine, pain medicines often come with a range of side effects whether they are prescribed or bought over the counter. The side effects of such drugs are typically individual to the medicine, and some have many more side effects than others. Therefore, it is important to take pain relief under the guidance of a doctor or pain specialist.

With simple analgesia such as paracetamol, there are few side effects, which is why it is such a popular drug. However, even NSAIDs come with a range of side effects and contraindications as mentioned above, such as nausea, stomach pain and other stomach symptoms.

Antidepressant and anti-seizures medicines that are often used for those with nerve pain bring about different side effects such as drowsiness, dizziness and nausea.

Opioid medications such as codeine and oxycodone commonly cause constipation and sedation, with chronic use often associated with depression and/or sexual dysfunction. Opioids are also narcotic drugs that bring with them a risk of addiction that can be powerful and difficult to overcome.

When should someone be referred to a pain specialist?

Pain specialists aim to diagnose then treat the root cause of someone’s pain rather than treating the pain as just a symptom. A referral to a pain specialist is usually considered when a person has experienced chronic pain for three months or more and has exhausted most of the usual options for treating the pain. This means that the person will have tried the usual pain medications and is not feeling any benefit from them.

A pain specialist is exactly that – they specialise in treating pain and, as mentioned, they look at the whole person when treating the pain rather than just trying to solve the pain symptom. However, in the UK the waiting lists to see pain specialists on the NHS can be extremely long, with people waiting years before they receive an appointment.

Many patients opt to go privately if they can afford it whilst others seek to try to alleviate the pain as much as possible themselves through self-help techniques and in some unfortunate cases, illicit drug use.

How can someone try to manage their chronic pain at home?

Whilst waiting for a pain specialist appointment, there are things that people can do to help manage their chronic pain.

The London Pain Clinic suggests 10 Easy Steps that could offer some relief, support and encouragement in managing pain that they have abridged from the Pain Association of Scotland.

1. Learn about your pain condition. Learning about the condition can help with understanding your pain and help you deal with the frustration and anger it may bring. Above all, you need to be realistic about your pain and how it may or may not resolve.

2. Involve yourself. By taking these steps, you can begin to deal with your pain actively by finding other things that you can try to do to help.

3. Relax. This one is often harder said than done! By learning relaxation techniques, you can help to distract yourself from the pain. This is one of the most effective and simple steps you can take.

4. Become self-aware when it comes to your feelings and thoughts. The mind plays a huge role in how we experience pain. Notice your thoughts and identify negative feelings. This will help you change the way you relate to pain.

5. Movement. Moving safely and breathing deeply while doing so will help to mobilise you which can help to relieve pain in the long run.

6. Decide on your priorities. With chronic pain, it is impossible to achieve everything. Set realistic goals and decide on how you will work towards the things that are most important to you.

7. Pace yourself. Break tasks into manageable chunks that are achievable.

8. Know your rights. When it comes to treatment options and support.

9. Discover hope. You must have hope that you can gain control of your pain, regain control over your life and break the pain cycle. Remaining hopeful helps you do this and reduces your suffering.

Final thoughts

Pain management is extremely complex. What works for one person to manage their pain will not necessarily work for another. What is clear, though, is that there are too many people living with chronic pain in the UK today. We can only hope that there are soon more choices and shorter waiting lists for those suffering from pain.