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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 176-179

The lingering agony of chronic pain

1 Department of Anaesthesiology and Critical Care, Command Hospital, Western Command, Chandimandir, Haryana, India
2 Department of Psychiatry, Command Hospital, Western Command, Chandimandir, Haryana, India

Date of Submission20-Jul-2021
Date of Acceptance30-Aug-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Shibu Sasidharan
Department of Anaesthesia and Critical Care, Command Hospital, Western Command, Chandimandir, Haryana - 134117
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_74_21

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How to cite this article:
Sasidharan S, Dhillon HS. The lingering agony of chronic pain. J Orthop Traumatol Rehabil 2021;13:176-9

How to cite this URL:
Sasidharan S, Dhillon HS. The lingering agony of chronic pain. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Aug 10];13:176-9. Available from: https://www.jotr.in/text.asp?2021/13/2/176/333569

  Introduction Top

Managing pain has humanitarian dimensions. Pain, both acute and chronic, can adversely affect the quality of life of an individual. Anesthesiologists and pain physicians were thought to be wholly responsible for the treatment of pain. However, the role of other health-care professionals, including psychiatrists, occupational therapists, nutritionists, and social workers, in the management of chronic pain is gaining growing importance. Cognitive behavioral therapy (CBT), traditionally used for the treatment of anxiety, depression, and other psychiatric disorders, has found a place of pride in the management of chronic pain as well, with promising results.

Chronic pain (persistent or frequently recurring) has a significant debilitating impact on an individual's life. Pain is labeled chronic when it persists for more than 03 months and has significant emotional distress and functional disability.[1] Chronic Pain (CP) is a highly prevalent condition, with an estimated 20% of the worldwide population suffering from it and is responsible for 15%−20% of visits to the physician.[2],[3] In an International survey (18 countries, 42,249 respondents), the 12-month prevalence of CP was 37% in developed countries and 41% in developing countries.[4] CP has a significantly negative impact on psychological state, physical health, and social functioning.[5] Since CP is a complex medical condition, it requires a broad array of health-care professionals for optimum management. “Active self-management” is a crucial factor, along with targeted psychosocial and medical support.

In an attempt to systematically classify, CP has been coded into the International Classification of Diseases (ICD), 11th revision as chronic primary pain, widespread chronic pain, chronic primary visceral pain, chronic primary musculoskeletal pain, chronic primary headache or orofacial pain, and complex regional pain syndrome.[6]

Historically, pain was viewed as a medical symptom, which should respond to physical treatment (pharmacological and surgical management). However, due to inadequate response to conventional treatments, a shift in perspective and a biopsychosocial effect and causes model was proposed.[7] The experience of CP is designed by a multitude of biological, psycho-social (e.g., patients' beliefs, affective state, and expectations), and behavioral factors (e.g., circumstances and the behavior of significant others). CP impacts all ages and sociodemographic groups in a multidimensional manner and hence management of CP entails a multi-disciplinary approach.[8],[9] In this article, the authors have tried to understand the magnitude, psychology, implications, and management of CP, emphasizing CBT.

  Psychology of Chronic Pain Top

Various psychological models have been applied to advance our understanding of causation, perpetuation, and management of CP.

The operant model advocates that the frequency of any behavior is contingent upon the response that it elicits from the environment. A favorable response (affection, sympathy, support, and sanctioned time out) increases the frequency of particular behaviors, while unfavorable (neglect/aversion/punishment) responses reduce the frequency. Pain behaviors tend to sustain or even increase in frequency when they elicit favorable responses. However, if such favorable responses are substituted with alternate behaviors (or better known as “well behaviors“), it can lead to a reduction in the frequency of pain behaviors. These “well behavior” includes graded physical exercise, active lifestyle, activity tolerance, focus on self-efficacy, and independent functioning despite chronic pain. On the other hand, maladaptive pain behaviors contribute to the maintenance of pain and prolonged disability. Hence, the management of CP as per the operant model involves identifying factors that precipitate, perpetuate, and relieve pain with the final aim to reduce the reinforcing behaviors and boost the “ well behaviors“. It involves educating the patient and significant others to identify and practice the well behaviors while ignoring the reinforcing behaviors.[10]

The peripheral muscle relaxation-training model with the help of biofeedback was initially advocated for the treatment of stress and anxiety disorders. However, certain CP conditions (chronic low backache and tension-type headache) are also attributable to persistent and excessive muscle tension. Hence, it is worthwhile to educate CP patients to regulate their autonomic nervous system through relaxation training and biofeedback. Relaxation training coupled with biofeedback thus forms an essential component of multi-disciplinary CP management.[11]

The cognitive and coping model argues that the pain behaviors of an individual can be better predicted and influenced when his cognitions (beliefs, motivation, attribution, intentions, etc.) are taken into account. Thus, during the management of CP, patients are educated to become more aware of their thoughts accompanying the pain, maintain a log, and identify the adaptive/maladaptive thoughts based on their overall helpfulness/unhelpfulness. They are then instructed to focus and strengthen the adaptive thoughts and avoid/ignore the unhelpful ones. There is extensive literature supporting CBT efficacy in reducing CP and improving overall physical and psychological function.[12]

  Assessment Top

An inherent problem in assessing pain is that there are currently no objective measures to determine/validate the extent of an individual's pain except the subjective self-reporting by the patient. However, CP affects not only the patient but also the significant others (partners, friends, relatives, employers, and coworkers) around him and thus necessitates evaluating a comprehensive biopsychosocial profile of the patient, including physical, psychological, and financial implications. The health-care providers need to conduct a thorough clinical examination and diagnostic investigations to locate any biological etiology of pain while concurrently assessing the patient's cognitions and coping, emotional impact and dysregulation, expectations, responses of significant others (caregiver burden), and functional as well as financial disability.[13]

The psycho-social and behavioral factors can be screened with the acronym “ACT-UP” (Activity, Coping, Think, Upset, and People's responses) to guide a brief screening interview for clinicians. This can be summarized as follows.

  1. Activities: How is your pain affecting your life (i.e. sleep, appetite, physical activities, and relationships)?
  2. Coping: How do you deal/cope with your pain (what makes it better/worse)?
  3. Think: Do you think your pain will ever get better?
  4. Upset: Have you felt worried (anxious)/depressed (down and blue)?
  5. People: How do people respond when you have pain?

The standardized CP assessment tools available to assess the sensory and affective qualities of CP are Numerical Rating Scales; Visual Analog Scales; Faces Scale; Verbal Descriptor Scales; Brief Pain Inventory, Graded Chronic Pain Scale, McGill Pain Questionnaire; Pain Detect; Neuropathic Pain Scale; Neuropathic Pain Symptom Inventory; Leeds Assessment of Neuropathic Symptoms and Signs and Dolor Neuropathique-4 Questions. These are easy to use in routine clinical settings.[14]

  Implications of Chronic Pain Top

CP has a significant association with psychological states and psychiatric disorders. CP poses a greater risk for having depression, and also up to 75% of depressed patients reports CP.[15] The incidence of depression among patients with CP is estimated to be 30%–45% compared to 5%–7% in the general population.[16] Furthermore, depressed patients with CP report worse sleep disturbances, fatigue, psychomotor retardation, impaired concentration, and poor quality of life than people without CP. Moreover, depressed patients with CP respond poorly to antidepressant therapy.[17]

There has been an increase in the use of opioids to manage chronic and acute pain because the effect of opioids tends to wear off following prolonged use, necessitating increased dosages. There has been a 198% increase in hydrocodone prescriptions, a 588% increase in oxycodone prescriptions and a 933% increase in methadone prescriptions from 1997 to 2005.[18] More than 10 million Americans aged more than 12 years were using opioid analgesics without medical prescription in 2014.[19] Although opioids are effective for short-term management of acute and cancer pain, the evidence for long-term management of chronic noncancer pain is lacking.[20],[21] Second, unregulated long-term use amplifies the risk of addiction and severe side effects. Moreover, patients with existing psychiatric comorbidities (anxiety and depression) tend to experience higher pain intensity, thus demanding higher doses of opioids and an increased likelihood of developing opioid dependence.[22]

  Management Top

The comprehensive management of CP entails addressing the biomedical, psycho-social, and behavioral domains of CP.

There are many pharmacological and nonpharmacological interventions for CP. This includes surgery, analgesics, antiepileptics, antidepressants, capsaicin, epidural steroid injections, nerve blocks and local anesthetics neurotoxins, N-methyl-D-aspartate receptor antagonists, and opioids. Intrathecal drug delivery systems, spinal cord, and peripheral nerve stimulators are more invasive modes of intervention but with limited results. The nonpharmacological interventions include acupuncture, tai chi, reiki, prayer, graded physical exercise, CBT, magnetic stimulation, relaxation training, biofeedback, and mindfulness-based stress reduction.[23] They are classified as complementary alternative medical therapies.

CBT has been primarily utilized in psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder; however, it is effective in patients with CP [Table 1]. The principle behind CBT is to identify and change thought patterns accompanying maladaptive behaviors into adaptive ones. The success of CBT techniques in the management of CP is attributable to its ability to alter brain function and connections in nociceptive and nonnociceptive areas of the brain, reduction in posterior cingulate cortex activity, pain-related cognition, and anxiety related to pain.[24] Multiple randomised controlled trials demonstrate that CBT successfully improves CP across a broad spectrum of syndromes, including headaches, arthritis, cancer, fibromyalgia.[25] The various CBT techniques available for CP are summarised in the following table.
Table 1: Overview of cognitive-behavioral therapy techniques

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The impact of positive psychological factors (individual adjustment to persistent pain, pain acceptance, hope and optimism) has been studied in patients with CP. Hope has been associated with reduced chronic pain, functional disability, psychological distress, and physical weakening in multiple sclerosis and cancer patients.[26],[27] Acceptance-based behavioral interventions recommend engaging in meaningful activities despite the pain and have been shown to significantly lower pain levels, pain-associated distress, and disability.[28]

Occupational therapists, through their partaking in everyday activities, can assist patients in their well-being. Nutritionists can educate patients about the role of food and its effect in regulating chronic inflammation. Therapies based on naturopathic nutrition and diet are widely being researched. They can also give suggestions on effective weight management. Social workers can assist by advising patients about available public health services, health-care plans, and benefits of each. They can also help improve the practice and ethical standards of the multi-disciplinary team approach.

  Recommendations Top

  1. More training: Clinicians, including (but not limited to) those working in primary care, may lack sufficient teaching and training about the treatment and management of chronic pain. This lack of good teaching and training can result in poor treatment choices.[29] Coding CP into ICD-11 has allowed us to devise uniform treatment guidelines. Furthermore, the primary assessment, evaluation, and management of CP should be included in the basic medical education teaching curricula
  2. Expand management team framework includes psychologists, psychiatrists, social workers, nutritionists, and occupational therapists in the treatment of chronic pain
  3. Extending follow-up periods. Chronic pain, in many cases, is a prolonged disability. This protracted agony can cause psychological, behavioral, and financial repercussions. Hence, a long-term follow-up is suggested to track these changes
  4. Relaxation Techniques: Techniques customized to help the patient to relax both mentally and physically is effective in CP. While mental relaxation eases mental stress, physical relaxation techniques can ease the tense muscles consequent from pain.
  5. Somatic anchoring (SA): SA has been found useful in somatic, visceral, and neuropathic pain. It involves cognitive restructuring and mindfulness meditation as a tool in cases where medications have been ineffective.
  6. Acceptance and commitment therapy (ACT): Mindfulness, along with ACT, is a branch of CBT. It focuses on training the individual on accepting the things that are out of one's control and committing to psychological interventions targeted at improving the quality of one's life.

  Conclusion Top

Chronic pain is a significant public health problem with massive health resources and suboptimal outcomes. Psychosocial factors and biological factors play a significant role in patients with chronic pain; therefore, therapeutic interventions must include psychological therapies, especially CBT. CBT, SA, and ACT are effective in alleviating chronic pain across a broad spectrum of chronic pain syndromes.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health 2011;11:770.  Back to cited text no. 2
Koleva D. Paininprimarycare: An Italian survey. Eur J Public Health 2005;15:475-9.  Back to cited text no. 3
Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, et al. Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. J Pain 2008;9:883-91.  Back to cited text no. 4
Van den Berg-Emons RJ, Schasfoort FC, de Vos LA, Bussmann JB, Stam HJ. Impact of chronic pain on everyday physical activity. Eur J Pain 2007;11:587-93.  Back to cited text no. 5
Smith BH, Fors EA, Korwisi B, Barke A, Cameron P, Colvin L, et al. The IASP classification of chronic pain for ICD-11: Applicability in primary care. Pain 2019;160:83-7.  Back to cited text no. 6
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Buenaver LF, Campbell CM, Haythornthwaite JA. Cognitive behavioural therapy for chronic pain. In: Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica's Management of Pain. Philadelphia, PA: Wolters Kluwer; 2010. p. 1220-30.  Back to cited text no. 11
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Agu ·Era-Ortiz L, Failde I, Mico JA, Cervilla J, Lo ´Pez-Ibor JJ. Pain as a symptom of depression: prevalence and clinical correlates in patients attending psychiatric clinics. J Affect Disord 2011;130:106-12.  Back to cited text no. 15
Demyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, Kovess V, Angermeyer MC, et al. Mental disorders among persons with chronic back or neck pain: Results from the World Mental Health Surveys. Pain 2007;129:332-42.  Back to cited text no. 16
Bair MJ, Robinson RL, Eckert GJ, Stang PE, Croghan TW, Kroenke K. Impact of pain on depression treatment response in primary care. Psychosom Med 2004;66:17-22.  Back to cited text no. 17
Manchikanti L. National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician 2007;10:399-424.  Back to cited text no. 18
Pezalla EJ, Rosen D, Erensen JG, Haddox JD, Mayne TJ. Secular trends in opioid prescribing in the USA. J Pain Res 2017;10:383-7.  Back to cited text no. 19
Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. J Pain 2009;10:113-30.  Back to cited text no. 20
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