Dr Austin Leach, a consultant anaesthetist at the Royal Liverpool University Hospital who has run a pain clinic for more than 20 years, explains: ‘A lot of chronic pain is to do with what’s going on inside the patients’ heads.
‘Everything is integrated; body and mind. It’s not about just one medical fix for a physical problem — it’s also about the patient gaining a deeper understanding of the causes of their pain.’
Chronic pain is defined as continuous long-term pain that either lasts more than 12 weeks, or persists for an unusual length of time following trauma or surgery.
PAINKILLERS MAY ACTUALLY CAUSE PAIN
The mainstay treatment is normally painkillers.
However, a swathe of new studies shows that our most frequently used strong pain medications are not only ineffective for common conditions, they are also dangerous — and may even themselves cause chronic pain.
Last month, it was reported that opioid painkillers — prescription drugs that include morphine, tramadol and oxycodone — provide only ‘minimal benefit’ for lower back pain.
Prescribed to around 40 per cent of back pain patients, they do reduce pain, but not enough to be effective, according to a review of studies published in the journal JAMA Internal Medicine.
The same would be true for codeine — the mildest opioid, which is available over the counter — said the study leader Chris Maher, a professor of muscular disorders at the George Institute for Global Health in Sydney.
He also warned that, taken long-term, the drugs can have severe side-effects, including dizziness and falls, as well as deaths from overdose.
‘We know of no other medication routinely used for a non-fatal condition that kills patients so frequently,’ Professor Maher said.
Perhaps still more disturbingly, new evidence this month suggests that opioid drugs may actually cause chronic pain in patients prescribed them for short-term pain.
A study of rats, by neuroscientists at the University of Colorado Boulder in the U.S., showed that a short course of morphine can spark a chain reaction in the body’s immune system which makes it produce dangerous amounts of inflammatory proteins.
These cause nerve damage that can cause chronic pain.
The researchers warn in the journal Proceedings of the National Academy of Sciences that ‘prolonged pain is an unrealised and clinically concerning consequence of the abundant use of opioids in pain’.
Meanwhile, even paracetamol, which is frequently prescribed by GPs for chronic pain, is also being exposed as ineffective and dangerous.
In March, a study of more than 58,000 patients published in The Lancet concluded that it does little to ease hip and knee pain caused by osteoarthritis — paracetamol has been the main treatment for the joint condition.
Other research has shown that its long-term use is linked to heart, kidney and intestinal problems.
Prompted by such findings, NICE — the clinical guidelines watchdog — has advised doctors to stop prescribing the pills for long-term treatment of osteoarthritis.
And last month the authoritative U.S. body, the Centres for Disease Control and Prevention, advised doctors to try non-drug therapies for pain first.
Indeed, there is now plenty of research showing that the answer to chronic pain lies not with (ineffective and potentially harmful) drugs, but instead often inside our brains — and changing patients’ expectations about pain.
The potential of changed attitudes to alter pain levels was highlighted last month by a study at Julius-Maximilians University in Germany.
Psychologists subjected a group of male volunteers to heat stimuli via a band on their forearm, then asked them to rate the pain.
The next day, some volunteers were informed that men are more sensitive to pain than women; the others were told women were the more sensitive gender.
The experiment was then repeated. Those who had been told men were less sensitive rated their pain as much less intense than on the previous day.
Those told men were more sensitive now felt more pain, reported the journal Trends in Cognitive Sciences.
As the psychologists explained, the effect of changes in attitude can actually be measured ‘physiologically’.
WORRYING ABOUT IT MAKES PAIN WORSE
‘Our work shows that being anxious or depressed can make pain worse,’ explains Professor Tracey.
‘Your beliefs can override the most powerful painkillers. In one experiment we told chronic pain patients we had stopped giving them a strong opioid, when actually we were still giving it — suddenly they said their pain levels were rising.’
Long-term negative beliefs may create a devastating spiral: the more anxious and depressed you become about your pain, the more you may physically rewire your brain so that it becomes hypersensitive.
As a result, even normal touch can piggyback on to the pain system, firing off widespread pain responses across the brain. ‘Even putting on clothes can cause burning sensations,’ says Professor Tracey.
Dr Leach sees similar cases in his pain clinic. ‘One patient came in who was convinced that his terrible back pain was cancer,’ he recalls.
‘After talking through his problems he realised that a relative’s recent death from cancer had convinced him of this. It was intensifying the pain in his mind.’ Understanding this helped to reduce his pain.
IS IT TIME TO TRY MEDITATION?
This understanding is central to the work of the specialist clinics that help patients trapped in chronic pain.
With psychologists, physiotherapists and doctors often on staff, these take a ‘biopsychosocial’ approach — combining biological, psychological and social factors.
But while treatment may include prescribing pain medication (for instance, stronger forms of pain relief such as nerve blocks) and specialist physiotherapy (to teach patients how to move with their pain), the psychology of pain and coping with it are also key.
Dr Amanda Williams, a reader in clinical health psychology at University College London, has worked in these clinics for 30 years, and much of her work involves changing patients’ attitudes.
‘If a person is under stress, they’re not going to manage their pain well. It is going to make it worse,’ she explains.
The traditional view that pain has only physical causes that require drugs can make patients resistant to psychological therapy.
‘When patients are told the answer is in their mind, too often they think they are being told they are faking or malingering,’ she says.
‘But many are relieved to hear there may be a psychological element to their pain, and are open to talking about their emotions.’
Unfortunately, as an audit of pain clinics sponsored by the British Pain Society concluded recently, provision of these services is patchy and waiting times are often 18 weeks.
This is a problem in itself, says Dr Leach. ‘Often by the time patients finally get seen, their pain syndrome has consolidated in their brains and is significantly harder to treat.’
Given this, Dr Williams believes GPs could be doing more.
‘It would be a help for GPs to teach patients to manage their pain early on by, for example, distracting themselves with something as simple as watching comedy programmes on TV.’
Another option is mindfulness meditation, where patients are taught to become aware of their breathing, thoughts and physical sensations and view them without judgement.
This can help people learn to stop fearful thoughts of pain running amok.
Two recent trials of more than 600 patients, published in the journal JAMA by the University of Pittsburgh and the Group Health Research Institute in Seattle, showed that mindfulness meditation can help reduce chronic lower back pain.
LISTEN TO MUSIC AND DON’T SLOUCH
Pain stops people from moving. This sedentary behaviour may explain why people with chronic pain have a much higher level of cardiovascular disease and premature death from all causes.
However, movement also helps patients to reduce their pain by ‘unfreezing’ their bodies, as well as preventing them becoming isolated, another factor that feeds into the negative psychology of chronic pain.
To address this, experts such as Joanne Marley, a clinical specialist in physiotherapy at the University of Ulster, are developing exercise programmes for people with chronic pain.
The aim isn’t to make them athletes, but to make small steps that stop them being frozen by pain.
‘It’s about improving activity levels,’ she explains. ‘For some that may be simply getting out of bed in the morning and sitting down less during the day.
Getting patients to stand up and march on the spot every time the adverts come on the television can actually get them up to 3,000 steps a day.’
Researchers are discovering simple ways to trick pain-prone brains into calming down.
One of these is simply to stand straight: a boldly upright posture rather than weakly slouching actually makes you less pain-sensitive.
Research by the University of Southern California in the Journal of Experimental Social Psychology in 2011 shows that adopting more dominant poses makes people feel more able to handle pain.
Changing your language may also help. Brain scans by psychologists at Jena University in Germany found that words such as ‘tormenting’, ‘gruelling’ or ‘plaguing’ fire up the pain-processing areas in your brain.
Using more positive terms may dampen down the responses, suggests the study in the journal Pain in 2010.
You could try listening to classical music.
In 2011, researchers at York University reported in the journal Music and Medicine that listening to the complex melodies of Bach or Mozart is more effective at reducing pain levels than other sorts of music.