We are taught at medical school that "Pain has a purpose"

  • It is a symptom of underlying condition
  • It serves as a warning that something is wrong
  • It immobilises for healing etc.

We were also taught that the management of pain is:

  • Pain > Analgesic
  • More Pain > more analgesic (More must surely be better)
  • Combine various analgesics √ (yes, this is good)
  • Avoid opiates!! (almost at all cost) - fear of addiction. This is all true - for acute pain.

But, no doubt in your practice you have seen patients with apparently "unstoppable pain" - pain that seems to be wildly out of control. Nothing works for it - despite your best efforts:

  • No pain medication or combinations of medications has any apparent effect anymore
  • Even intrathecal morphine or Spinal Cord Stimulators do not work.
  • It appears as if the patient's pain has reached a "point of no return" (and, yes, physical changes HAVE taken place in the spinal cord and brain)
  • Have you concluded that they MUST be putting on – and they need psychiatry or psychology

This is because of:

  • our insistence on thinking that chronic pain is simply acute pain lasting too long
  • we insist on treating chronic pain in the same say that we would treat acute pain.

The concept that "pain is pain"
and that chronic pain is
simply acute pain continuing
for too long is archaic and wrong.

This misconception, that pain is just pain, leads to:

  • General misunderstanding of what chronic pain is that it is a clinical entity, a pathology
  • Poorly / inadequately treated acute pain - often the main cause of chronic pain
  • Abysmal assessment of pain
  • Inadequate and inappropriate treatment of the pain
    1. Incorrect medication
    2. medication dose escalation - tolerance and dependence
    3. overdosing of medication - 60 000 deaths pa USA GIT bleeds from NSAIDs
    4. unnecessary special investigations - radiology costs! ("therapeutic MRI")
    5. unnecessary surgery or repeat surgery - especially spine surgery
  • General neglect of these patients:
    1. The doctor doesn't know what to do anymore and tries to get rid of the patient
    2. patients get told it's in their head - to psychologist or psychiatrist where they get told that they must "learn to live with it", OR must 'change their behaviour'.
  • Non-referral to pain clinic because people believe (in spite of their failures in treatment) that "pain management is easy" so what can they do at a pain clinic that I cannot do myself

As you no doubt know, here are different types of Pain.
Each requiring a specific type of treatment

Nociceptive Pain - Mainly acute but can be chronic as with arthritis
Neuropathic - Mainly chronic only real acute neuropathic pain is acute shingles
Mixed picture - e.g. herniated intervertebral disc and radiating leg pain.

The disc herniation is nociceptive but the leg pain is neuropathic due to pressure on the nerve.