Pain management is a subspecialty of neurology (and of a few other specialties as well, such as anesthesiology, psychiatry and physiatry). There is a subspecialty board certification for pain management (you can verify board certification through the web). Pain management is a complex field and one that changes rapidly. Until very recently, there was little research into pain and pain was believed to be something people needed to accept. Today, we understand that pain is a medical condition that requires appropriate medical treatment. Because of new research, the various medications and interventions for chronic pain are evolving rapidly. It is important to make the diagnosis and institute treatment, but it is also important to review news and continually revise the diagnosis as more information becomes available.

Please feel free to click on one of the links to the right to access additional information. 

Pain management is a unique medical specialty because of the unique risks. In fact, pain management has risks greater than those in other fields of medicine. For example, many pain medications have been linked to liver disease or heart disease and other medications may be habit forming or fatal in overdose. Some interventions may cause rapid opioid tolerance and are no longer as common as they once were; other interventions seemed to make the pain worse down the line. Still others have been shown to help. More below...

Of course, the legal issues of pain medicine are problematic: a quick review of news on the web shows that law enforcement personnel, physicians, attorneys, the public and others all have differing views as to the appropriateness of various pain treatments. There is no clear national standard of care in pain medicine, which is one of the problems, but the standard of care is being developed rapidly. Dr. Anderson participates in Standard of Care committees and participates in guideline review to help establish the standard of care. Although we have made great strides in treating pain, we have a long way to go. 

One of the most significant changes recently is that society now recognizes pain as a legitimate medical problem, one that deserves treatment. 

There are several types of pain and the words used to describe them are often confusing; treatments likewise can be confusing. Therefore, we offer more written information, including a detailed informed consent, than physicians in other specialties may offer. Most patients are used to signing a long informed consent before having a major surgery, and because pain management is just as serious and because pain patients have a right to understand their treatments, a similar informed consent is provided in this practice. As discussed elsewhere, the information focuses on the negative. After all, the good news is obvious: the treatments are supposed to help. What patients often are not told is the negative. By providing the negative information, patients can then have information needed so that they can be a team member in the pain treatment. 

 

 

Definitions used in chronic pain: The various terms used for chronic pain can be confusing, especially when comparing addiction and dependence, which are completely different things!

Addiction: addiction is not the same as dependence. Although psychiatrists combine the two words and consider them the same, the pain management community separates them completely. Addiction is a medical disease involving the inappropriate use of a substance, resulting in harm and resulting in a decreased quality of life. The disease of addiction has a genetic component and those patients who do not have that genetic predisposition typically do not become addicted to pain medication.

Pseudo-addiction: this is an odd phenomenon created by the fear that the patient will run out of medications or will have extra pain. These behaviors are done in order to obtain adequate pain relief, but they LOOK like addiction: begging, hoarding, clock watching, etc. Because these behaviors also can occur with true addiction, it is noted that pseudo-addiction stops completely if the patient receives adequate pain control.

Dependence: addiction is not the same as dependence. Although psychiatrists combine the two words and consider them the same, the pain management community separates them completely. Dependence is a syndrome where the body becomes used to a medication and then reacts if the medication is suddenly taken away; that is called withdrawal. Patients become tolerant to many medications such as blood pressure medications, seizure medications and even insulin (perhaps you have heard of an "insulin-dependent diabetic"?). These patients are not "addicted" to their insulin, but if the insulin is suddenly taken away the body reacts in a very bad way. Dependence can occur in as quickly as one week after beginning pain medications; pain medications need to be tapered gently to avoid withdrawal.

Tolerance: this refers to the fact that some patients experience a reduction in pain relief or other symptom relief from the same dose of the medication. The medication doses, then, need to increase and increase over time as the patient gets used to them. Tolerance, per se, may or may not occur and its existence is debated scientifically. There are patients who have been on the same dose for years and other who always need to increase. The researchers are trying to find out why. Right now, we believe that there is some involvement of NMDA receptors, but research is ongoing.

Pseudo-tolerance: this is when the medications seem to working less and less, and the dose needs to go up and up, just like with tolerance above. However, the difference is that the reason for the need to increase medication is that the underlying physical problem is getting worse over time.

Nociceptive pain: this is the pain of the physical injury and is directly proportional to the amount of the injury. Nociceptive pain is the ache, the throb and the soreness.

Neuropathic pain: this is the pain related to nerve dysfunction. This occurs in long-standing cases of nociceptive pain. This type of pain is felt as burning, cold, hot, wet, tingly, electrical, etc. These are sensations created by nerves.

Central pain: this is pain resulting from a problem in the central nervous system. Common causes include spinal cord injury (not spine injury, but actual spinal CORD injury) such as quadriplegia. Another common cause is a stroke in a specific part of the brain, the thalamus.

RSD (reflex sympathetic dystrophy): when nerves malfunction and create a specific type of pain syndrome, with changes in the skin, nails, blood circulation and bone, the condition is called RSD. The new name is CRPS for Chronic Regional Pain Syndrome. The pain is a result of some injury, is worse than expected for the degree of injury, and is associated with other findings such as abnormal limb temperature, abnormal hair or skin, etc. RSD can be very difficult to treat.

Phantom pain: this is an interesting phenomenon where a body part that hurts, continues to hurt after it is amputated. The mere fact that this condition exists PROVES that pain can occur after the original cause is removed. After all, if there were a foot problem causing the pain, and the foot is amputated, and the patient still feels foot pain, then the pain is not actually arising from the foot physically. The reason is that pain starts arising closer and closer to the central nervous system the longer that pain is present.

Breakthrough pain: this is a specific type of pain related to very quick and usually short increases in pain. Breakthrough pain may occur because of some activity, such as pulling the back, etc., or it may occur without a clear cause. Because it comes so quickly, if it is going to be treated, the treatment should work quickly. It goes away fairly quickly, after a few minutes to a few hours.

Pain flares: flares are not breakthrough pain. Flares occur when something happens to temporarily worsen the pain over the next several days to a few weeks, such as overexertion while gardening.

Wind-up phenomenon: this is one name given to the phenomenon whereby pain transforms from a simple problem at the site of injury, to a self-generating disease unto itself, with pain generated from various nerves.

Allodynia: there are two definitions for this word, depending on whether the focus is neurological or is algological (pain-related). Neurologically, allodynia is perceiving one type of stimulus (cold) as another (hot). In pain terms, allodynia is perceiving a non-painful stimulus (light touch) as a painful stimulus (sharp pokes).

Hyperalgesia: this occurs when the nervous system is undergoing the wind-up phenomenon noted above. As time moves forward in chronic pain patients, a stimulus will be perceived as more and more painful. For example, let's pretend that we have a device that can hit the shoulder with three amounts of force: light, medium and heavy. A patient without chronic pain would find the light and medium hits annoying but not painful, but the heavy hit painful. A patient with some chronic pain would find the light hit annoying but not painful, but the medium hit painful and the heavy hit very painful. A person with many years' of chronic pain would possibly find ALL three hits (light, medium and heavy) very painful. When a stimulus is perceived as more painful than it really should be, that is hyperalgesia.

Opioid-induced hyperalgesia: there is evidence that the use of certain pain medications can cause hyperalgesia (defined above) to occur. That means that the treatment could actually worsen the patient although the treatment is designed to reduce pain. The concept and the possibility are the subject of research currently and it is not known how likely this is. We do know that headache patients are twice as likely to develop chronic daily headaches if they use certain pain medications more than 8 times in one month; we also know that surgically implanted medication pumps can cause hyperalgesia. What we don't know is whether the pain medications for chronic pain can worsen the pain over time, and if so, which ones, at what doses, and how quickly.

 

Chronic pain links: These sites are solely responsible for their content. 

• American Academy of Neurology
  The American Academy of Neurology is the society of neurologists.
• Neuroscience Institute at California Pacific Medical Center
  This office is a part of the Neuroscience Institute
• American Chronic Pain Association
• American Academy of Pain Medicine
• American Academy of Pain Management
• US Government / NINDS Pain Site
• Pain and the Law: a website examining the various legal issues associated with chronic pain management
• American Society of Law, Medicine and Ethics: a legal and medical society examining the various laws and ideas surrounding pain medicine

 

 

CHRONIC PAIN

 

Pain management is a subspecialty of neurology (and of a few other specialties as well: anesthesiology, psychiatry and physiatry). Pain management is a complex field and one that involves not only medical advances, but also legal issues, especially when controlled substances are employed as part of the treatment plan.

 

Important news and information

Introduction to chronic pain

Definitions used in chronic pain

Pain diagnosis

Pain modalities

Pain medications

Pain and other news

Chronic pain help & links