Last of Jane Brody's NYT article "Chronic Pain"

November 20, 2007 Many Treatments Can Ease Chronic Pain By JANE E. BRODY

There is one undeniable fact about chronic pain: More often than not, it is untreated or undertreated. In a survey last year by the American Pain Society, only 55 percent of all patients with noncancer-related pain and fewer than 40 percent with severe pain said their pain was under control. But it does not have to be this way. There are myriad treatments -- drugs, devices and alternative techniques -- that can greatly ease persistent pain, if not eliminate it. Chronic pain is second only to respiratory infections as a reason patients seek medical care. Yet because physicians often do not take a patient's pain seriously or treat it adequately, nearly half of chronic-pain patients have changed doctors at least once, and more than a quarter have changed doctors at least three times. In an ideal world, every such patient would be treated by a pain specialist familiar with the techniques for alleviating pain. But ''very few patients with chronic disabling pain have access to a pain specialist,'' a team of experts wrote in a supplement to Practical Pain Management in September. As a result, most patients have to rely on primary care physicians for pain treatment, obliging them to learn as much as they can about treatment approaches and to persist in their search for relief. Medications Most chronic pain patients end up taking a cocktail of pills that complement one another. These are three categories of drugs useful for treating chronic pain: If the pain is not severe, nonsteroidal anti- inflammatory drugs, Nsaids for short, are often tried first. Some, like ibuprofen and naproxen, are sold over the counter. Others, like diclofenac (Voltaren) and celecoxib (Celebrex), are available by prescription. All have risks, especially to the heart and gastrointestinal tract, and may be inappropriate for those prone to a heart attack, stroke or ulcers. Nsaids must not be combined with one another or any aspirinlike drug, but they can be used safely with acetaminophen (Tylenol). Several classes of drugs originally marketed for other uses are now part of the pain control armamentarium - - antidepressants, especially the S.N.R.I.'s like venlafaxine (Effexor) and duloxetine (Cymbalta); antiepileptics like gabapentin (Neurontin) and pregabalin (Lyrica); and muscle relaxants like baclofen (Lioresal) and dantrolene sodium (Dantrium). These are often used in combination with specific pain-relieving drugs. By far the most important class of drugs for moderate to severe chronic pain are the opioids: morphine and morphinelike drugs. Patients often reject them for fear of becoming addicted, a rare event when they are used to treat pain. Doctors often avoid prescribing them for fear of addicting patients, being duped by drug abusers or being raided by the Justice Department. Pain societies have established clear-cut guidelines to help doctors avoid such risks, including ways to identify patients who could become addicted. Many patients and physicians do not know the difference between physical dependence on a drug (withdrawal symptoms result if the drug is abruptly stopped) and addiction (loss of control over drug use, cravings and continued use despite harm). As with other medications, like steroids and antidepressants, patients have to be gradually weaned from opioids to avoid withdrawal symptoms. For patients with chronic, continuous pain, using a slowly released opioid like oxycodone (Oxycontin), morphine or fentanyl (administered through a skin patch or lozenge on a stick) is preferred. These drugs minimize or eliminate the hills and valleys of pain and reduce the medication patients need. The usual side effects -- sedation, nausea, confusion - - soon disappear except for constipation, which can be treated. Pain specialists also recommend that patients taking slow-release opioids have on hand a fast-acting one like Percocet (oxycodone with acetaminophen) to treat breakthrough pain. Methadone, a synthetic opioid, is another option for managing chronic pain, especially neuropathic pain, but it has to be taken several times a day. It is metabolized in the liver, along with other drugs that can affect blood levels of methadone. Other Remedies Some patients in chronic pain use a technique called TENS, for transcutaneous electrical nerve stimulation, in which pulses of low-intensity electric current are applied to the skin. The theory is that the pulses transmit signals to the brain that compete with the pain signals. Unlike drugs, TENS has no side effects or interaction with drugs, and it can be used at home. Acupuncture, another increasingly popular treatment for persistent as well as intermittent pain, is thought to work by increasing the release of endorphins, chemicals that block pain signals from reaching the brain. It may be effective in relieving headaches, facial and low back pain, and pain caused by shingles, arthritis and spastic colon. Guided imagery, meditation, relaxation therapy and hypnosis or hypnotherapy are often useful adjuncts to pain treatment, because they can reduce stress and take one's mind off the pain. Likewise, cognitive behavioral (''talk'') therapy can help patients think and behave differently with respect to their pain. Other options include massage and hydrotherapy, the use of hot or cold water to reduce inflammation and promote healing. Many chronic pain patients can benefit from physical therapy and exercises to strengthen weak supporting muscles and relax tight joints (which for the last two years has helped me control sciatic pain), or occupational therapy to learn new ways of moving, sitting and lying down to reduce irritation of or dependence on painful body parts. Finally, a mental adjustment may be necessary to improve the quality of life of chronic pain patients, who have to accept that they may always have some degree of pain. Chronic pain tends not to go away, and changes may have to be made both at work and at play. The goals should be to reduce pain to an acceptable level and to learn how not to make it worse. For Further Information Here are some groups that can provide information on managing chronic pain: AMERICAN CHRONIC PAIN ASSOCIATION E-mail: ACPA@pacbell.net; Web site: www.theacpa.org. P.O. Box 850, Rocklin, Calif., 95677-0850; (916) 632-0922 or (800) 533-3231. AMERICAN PAIN FOUNDATION info@painfoundation.org; www.painfoundation.org. 201 North Charles Street, Suite 710, Baltimore, Md., 21201-4111; (888) 615-7246. NATIONAL FOUNDATION FOR THE TREATMENT OF PAIN Pain@cwo.com; www.paincare.org. P.O. Box 70045, Houston, Tex., 77270; (713) 862-9332.