Chronic pain is one of the toughest conditions to live with – either it’s unrelenting and impossible to get normal activities done, or it comes back often and unpredictably, forcing you to cancel work or social plans. It's defined as persistent or episodic pain lasting more than three months. It’s a complex area of medicine, and very difficult to treat, as your nervous system adjusts to this, with sensations becoming heightened and more widespread. The complexity comes from our higher processing, where pain can start to prevent everyday activities and dominate normal life. Our world becomes smaller. With less to distract us and living in fear of pain, our pain sensation becomes even more heightened. Chronic pain is more likely to come about from the slow pain fibres, which are loudly telling you that there’s injury: you should rest and recover by not moving much. This is as opposed to the fast pain fibres that let you know your toe has been stubbed and makes you move away from the external threat (with much hopping and howling). But resting for months on end is not likely to serve any useful purpose, and often sets up new problems, both mentally and physically.
As a practising GP, I often get asked for scans. People perceive this as the gold standard in providing an answer to the cause of their pain. Sometimes it is, but often it’s much more accurate to get a diagnosis from your doctor listening to your symptoms and examining you. Many are disappointed if a scan fails to show any definitive answer, and sometimes it can throw up new things that confuse diagnosis and treatments. It’s more important to focus on your doctor’s advice to get better, as a scan is not treatment in itself.
Many with chronic pain complain that painkillers that helped when an injury was new are less effective as the months go by. Some of this can be explained by a concept called tolerance, where certain drugs, especially benzodiazepines like diazepam or lorazepam, and opioids like codeine and tramadol, cause your body to get used to them. You need to increase the dose with prolonged use to get the same effect, until you’ve reached the maximum dose but you still experience pain. They also have an addictive effect called dependency, where you suffer withdrawal effects if you stop them suddenly. Painkillers aimed at tackling neuropathic, or nerve, pain, such as gabapentin, pregabalin, amitriptylline and nortriptyline can help but often cause side effects such as feeling dizzy, groggy or sleepy. If painkillers provide less relief it may also relate to a reorganisation of the nerves that form the pain pathway: we still experience pain even though the initial injury has healed. It suggests that you need to tackle things in a different way. If painkillers aren’t helping, there’s little point in continuing to take them and exposing yourself to side effects and potential risks.
It’s common in western medicine to want a definitive diagnosis and evidence to prove both a cause and treatment. We seem fairly reluctant to consider that psychology plays an important role in health conditions. But the mind and body should not be considered separate: they work together as one, and treatment should aim to address both. The sensation of pain that you experience is real: no one is suggesting otherwise. But with chronic pain, it may be that the best treatment is to tackle it with psychological techniques that aim to distract, to cope and to relax, rather than medication. Put simply, these techniques work to reduce your sensitvity to pain, and therefore reduce your response and your distress. With time, you can overcome the pain that is interrupting your life. Living with constant or unpredictable pain can take a toll on your mood, making you feel lonely, anxious or depressed. This needs addressing, either by regaining control of the pain, or speaking to your doctor about psychological interventions for depression or anti-depressants. Pain and depression can make motivation plummet, making steps to recover more difficult. Not being able to go out or do the things you want to will add to the mental burden. You need to work hard to break this cycle. But it is possible, keeping in mind the end-goal of being pain-free and medication-free.
First and foremost: keep moving. If you don’t, you will set yourself up for new stiffness and injuries, and consequently new pain. Gentle movements and stretches help the blood to bring oxygen, nutrients and warmth to the area of pain, nurturing it to help it heal. You may have a better time of the day or after certain medications that allows you to optimise the benefits of this. More rigorous exercise will help your body and mind feel better, getting oxygen flowing to the brain, lungs and everywhere else, stretching the muscles out, and releasing endorphins that help us feel positive and in control. Gentle yoga, walking or swimming are a good start. Heat packs might help to recover afterwards. Nurture your mind with a combination of busyness and relaxation. Maintaining your work, even with modifications, can give you routine and a sense of purpose and accomplishment. To wind down, you know what works for you: mindfulness, listening to music or podcasts, or even a crossword or Sudoku. Some find massage or acupuncture can help with certain pain – acupuncture can be particularly effective for arthritic pain from wear and tear on joints, and nerve pain left after shingles (post-herpetic neuralgia).