Usually, pain is considered chronic if it does one of the following:
Lasts for more than 3 months
Lasts for more than 1 month after the injury or disorder that originally caused pain has resolved
Recurs off and on for months or years
Is associated with a chronic disorder (such as cancer, arthritis, diabetes, or fibromyalgia) or an injury that does not heal
(See also Overview of Pain Overview of Pain Pain is an unpleasant sensation signaling actual or possible injury. Pain is the most common reason people visit their doctor. Pain may be sharp or dull, intermittent or constant, or throbbing... read more .)
Chronic pain can make the nervous system more sensitive to pain. For example, chronic pain repeatedly stimulates the nerve fibers and cells that detect, send, and receive pain signals. Repeated stimulation can change the structure of nerve fibers and cells (called remodeling) or make them more active. As a result, pain may result from stimulation that might not ordinarily be painful, or painful stimuli may seem more severe. This effect is called sensitization.
Also, areas of muscle or connective tissue may become very sensitive and tender to the touch. These areas are called trigger points because touching these areas frequently triggers unexplained pain that radiates to other areas of the body.
Chronic disorders (such as cancer Overview of Cancer A cancer is an abnormal growth of cells (usually derived from a single abnormal cell). The cells have lost normal control mechanisms and thus are able to multiply continuously, invade nearby... read more , arthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more 
, diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more , or fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more ) can cause chronic pain. Chronic pain can also result from an injury, even a mild injury if nerve fibers and cells have become sensitized.
Anxiety and other psychologic factors Psychologic Factors That Contribute to Pain Psychologic factors that commonly contribute to pain, particularly chronic pain, may include anxiety, depression, and insomnia. (See also Overview of Pain.) Psychologic factors can strongly... read more may help explain why some people experience pain as more unpleasant than others do and why pain limits their activities more. For example, people with chronic pain know it will recur and may become fearful and anxious as they anticipate the pain. Fear and anxiety can reduce the production of substances that reduce the sensitivity of nerve cells to pain. These changes in sensitivity to pain partly account for pain that persists after its cause resolves and for pain that feels more severe than expected.
Other factors may also influence pain perception. If people have to continually prove that they are sick to obtain medical care, insurance coverage, or time off from work, they may unconsciously exaggerate their perception of pain. This response differs from malingering, which is conscious exaggeration of symptoms to obtain a benefit. Family members and friends may unwittingly reinforce the person's perception of pain by constantly asking how the person feels or by doing things for the person.
Sometimes what originally caused the pain is obvious—for example, when people have had an injury that resulted in chronic back pain. Or the cause may be unknown—for example, when people have a chronic headache.
Symptoms of Chronic Pain
People with chronic pain often feel tired, have problems sleeping, lose their appetite and/or taste for food, and lose weight. They may become constipated, and their sex drive may decrease. These problems develop gradually. Constant pain can prevent people from doing what they usually enjoy. They may become depressed and anxious. They may stop their activities, withdraw socially, and become preoccupied with physical health.
Breakthrough pain is a brief, often severe flare-up of pain that may occur during treatment for chronic pain. It is called breakthrough pain because it occurs despite treatment that has been regularly scheduled and is intended to control pain. Breakthrough pain may differ from person to person and is often unpredictable.
Diagnosis of Chronic Pain
A doctor's evaluation
Sometimes a mental health evaluation
Doctors thoroughly evaluate the person to identify the cause of pain and its effect on daily life. If no cause is identified, doctors then focus on relieving pain and helping the person function better.
Doctors ask the person whether the person feels depressed Diagnosis A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more , has anxiety Diagnosis Anxiety is a feeling of nervousness, worry, or unease that is a normal human experience. It is also present in a wide range of psychiatric disorders, including generalized anxiety disorder,... read more about the pain, and is sleeping well. Identifying these symptoms is critical because they can make the pain worse and, if present, must be treated if the pain is to be effectively treated. A formal mental health evaluation Overview of Mental Illness Mental health (psychiatric or psychologic) disorders involve disturbances in thinking, emotion, and/or behavior. Small disturbances in these aspects of life are common, but when such disturbances... read more may be necessary.
Treatment of Chronic Pain
Drugs to relieve pain
Physical methods (such as physical therapy)
Psychologic and behavioral therapy
If a cause of chronic pain is identified, it is treated.
Treatment of chronic pain may include the following:
Drugs to relieve pain (analgesics)
Physical methods, such as physical therapy Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more or occupational therapy Occupational Therapy (OT) Occupational therapy, a component of rehabilitation, is intended to enhance a person's ability to do basic self-care activities, useful work, and leisure activities. These activities include... read more
Complementary and integrative pain-relieving techniques, such as acupuncture Acupuncture Acupuncture, a therapy within traditional Chinese medicine, is one of the most widely accepted CAM therapies in the Western world. Licensed practitioners do not necessarily have a medical degree... read more , massage Massage Therapy In massage therapy (a manipulative and body-based practice), body tissues are manipulated to reduce pain, relieve muscle tension, and reduce stress. Massage therapy involves a variety of light-touch... read more , and transcutaneous electrical nerve stimulation Nondrug Pain Treatments (TENS)
Psychologic and behavioral therapy
If treatments are ineffective, doctors may refer people to a pain clinic.
Drugs
Depending on the severity of the pain, the following types of drugs may be used to treat chronic pain:
Drugs called adjuvant analgesics Adjuvant Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (such as antidepressants Drug therapy for depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more or antiseizure drugs Antiseizure drugs In seizure disorders, the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction. Many people have unusual sensations just before... read more )
In most people taking pain relievers (analgesics) for chronic pain, the pain's intensity varies throughout the day. Intensity varies for several reasons, such as the following:
The characteristics of the affected nerves (for example, how quickly they send signals and where the nerves are located)
Activities that can cause pain (such as moving or touching the affected area)
Psychologic stress
Changes in the blood levels of pain relievers
To make sure that blood levels of pain relievers do not become too low, doctors may change the doses and the times these drugs are taken.
Combinations of drugs usually relieve pain more effectively than a single drug.
Opioids Opioid Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more are used most often to treat moderate to severe pain due to cancer or to other disorders that shorten lifespan (terminal disorders). Opioids are also used as part of hospice care Hospice Care Hospice is a concept and a program of care that is specifically designed to minimize suffering for dying people and their family members. In the United States, hospice is the only widely available... read more . Opioids are sometimes underused in people in these situations, resulting in needless pain and suffering.
Opioids may be underused because doctors
Underestimate the dose needed to be effective
Overestimate the risk of opioid side effects Side effects of opioids In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more , such as an opioid use disorder Substance Use Disorders Substance use disorders generally involve behavior patterns in which people continue to use a substance despite having problems caused by its use. The substances involved tend to be members... read more (addiction Substance Use Disorders Substance use disorders generally involve behavior patterns in which people continue to use a substance despite having problems caused by its use. The substances involved tend to be members... read more )
However, in people with pain due to cancer or another terminal disorder, concerns about side effects should not limit the use of opioids because side effects can usually be prevented or managed, and addiction is less of a concern.
Experts have recently revised the guidelines about how opioids should be used to treat chronic pain due to disorders that are not cancer and that do not shorten lifespan. The reason for this change is increasing awareness of opioid side effects, including an opioid use disorder Substance Use Disorders Substance use disorders generally involve behavior patterns in which people continue to use a substance despite having problems caused by its use. The substances involved tend to be members... read more (addiction), slowing of breathing (respiratory depression), and death due to overdose. As a result, doctors usually prescribe nondrug treatments Nondrug Pain Treatments In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (such as physical therapy) and nonopioid analgesics Nonopioid Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (such as NSAIDs and adjuvant analgesics Adjuvant Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more ) rather than opioids for people with one of these disorders.
However, for moderate to severe pain due to these disorders, doctors may consider opioids if all of the following are present:
The pain persists despite the use of other therapies and drugs.
The pain interferes with daily activities.
The benefits outweigh the risks.
The person is likely to return to the doctor's office for regular follow-up and monitoring while taking opioids
When deciding whether to use opioids for pain due to a disorder that is not cancer and does not shorten lifespan, doctors also consider how pain due to such a disorder is usually treated and whether other treatments may help. Guidelines are available to help doctors decide whether or not opioid therapy is appropriate.
Before prescribing opioids for any type of chronic pain, doctors ask the person questions to determine the following:
Whether the person is likely to misuse or abuse the drug—for example, whether the person has a history of alcohol or drug abuse or has or has had a major psychiatric disorder, such as depression
Whether the person is taking other drugs that may increase the risk of taking an opioid (such as antianxiety drugs or sleep aids)
Whether the person is likely to have side effects from an opioid Side effects of opioids In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (such as drowsiness, nausea, or an increased risk of falling)
Whether the person is likely to use the drugs for other purposes (for example, to sell them)
Opioids are usually used with other treatments, including nondrug treatments such as physical treatments and psychologic therapy.
When doctors prescribe an opioid for chronic pain, they typically give the person written information that describes the risks of taking opioids. They also ask the person to sign an agreement that specifies conditions required for opioid use, such as any special monitoring that may be needed. For example, doctors may periodically test the person's urine to determine whether the drug is being taken correctly, and they typically restrict the person to a single pharmacy for filling opioid prescriptions.
Doctors may refer people to a pain clinic or a mental health care practitioner who has expertise in substance abuse if the risk of having a problem is high. For example, people who have had an addiction usually need a referral.
Doctors explain the risks and side effects of opioids. People are advised
Not to drink alcohol or take antianxiety drugs or sleep aids when taking the opioid
To take the recommended dose at the recommended times and not to change the dose
To store the opioid in a safe, secure place
Not to share the opioid with anyone
To contact their doctor if the drug makes them drowsy or they have any other side effects (such as confusion, constipation, or nausea)
To dispose of unused pills as directed
To keep naloxone (an opioid antidote) on hand and to learn and teach family members how to administer it if an opioid overdose occurs
During treatment with opioids, doctors regularly evaluate how effective the drug is, whether it helps people function better, and whether side effects occur. Many people decide that they cannot tolerate the side effects of opioids or that the amount of relief the drugs provide does not justify continuing to take them. Opioids provide long-term relief for only some people who are treated with them, and usually, they only partially relieve the pain.
Opioids are typically taken by mouth or through a patch placed on the skin. If needed, they can be given by injection into a vein, a muscle, or directly into the space around the spinal cord through a pump. When given in these ways, opioids are usually given in a hospital or doctor's office.
Antidepressants and psychologic therapy are used to treat depression, if present.
Physical methods
Physical or occupational therapists use various techniques to try to relieve chronic pain and help people function better. If trigger points are present, practitioners may use a spray to cool the area, then stretch the muscle. This method (called stretch and spray) can help lessen pain. Wearing an orthosis (a device that supports damaged joints, ligaments, tendons, muscles, and bones) helps some people.
Sometimes doing exercises or increasing activity level helps. For example, walking regularly can help relieve lower back pain more effectively than resting in bed.
Physical therapists Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more and occupational therapists Occupational Therapy (OT) Occupational therapy, a component of rehabilitation, is intended to enhance a person's ability to do basic self-care activities, useful work, and leisure activities. These activities include... read more can help people with chronic pain find ways to do their daily activities with less pain.
Integrative medicine
Integrative medicine Overview of Integrative, Complementary, and Alternative Medicine Integrative medicine and health (IMH) and complementary and alternative medicine (CAM) include a variety of healing approaches and therapies that historically have not been included in conventional... read more (previously called complementary alternative medicine) may be used to treat chronic pain. For example, doctors may suggest acupuncture Acupuncture Acupuncture, a therapy within traditional Chinese medicine, is one of the most widely accepted CAM therapies in the Western world. Licensed practitioners do not necessarily have a medical degree... read more , mind-body techniques (such as meditation Meditation In meditation, a type of mind-body medicine, people regulate their attention or systematically focus on particular aspects of inner or outer experience. Meditation may involve sitting or resting... read more , yoga, and tai chi), manipulation and body-based therapies (such as chiropractic Chiropractic In chiropractic, a manipulative and body-based practice, the relationship between the structure of the spine and the function of the nervous system is seen as key to maintaining or restoring... read more or osteopathic manipulation and massage therapy Massage Therapy In massage therapy (a manipulative and body-based practice), body tissues are manipulated to reduce pain, relieve muscle tension, and reduce stress. Massage therapy involves a variety of light-touch... read more ), and energy-based therapies (such as therapeutic touch Therapeutic Touch Therapeutic touch, sometimes referred to as a laying on of hands, is a type of energy medicine. The philosophy behind therapeutic touch is to use the therapist’s healing energy (biofield) to... read more and Reiki Reiki Reiki is a type of energy medicine that originated in Japan. In Reiki, practitioners intend to manipulate energy through their hands and cause energy movement in the person’s body to promote... read more ).
Psychologic and behavioral therapy
Various psychologic techniques Relaxation Techniques Relaxation, a type of mind-body medicine, includes practices specifically designed to relieve tension and stress. The specific technique may be aimed at the following: Controlling the stress... read more (such as relaxation training, distraction techniques, hypnosis, and biofeedback Biofeedback Biofeedback, a type of mind-body medicine, is a method of bringing unconscious biologic processes under conscious control. In biofeedback, electronic devices are used to measure and report information... read more ) can sometimes help control pain. Distraction techniques may involve guided imagery. For example, people may be instructed to imagine a scene that is calming and comforting, such as resting on a beach or lying in a hammock.
Behavioral therapy can help people function better, even if it does not reduce pain. Doctors may recommend specific ways to gradually increase physical and social activities. People are advised not to let pain derail their commitment to better functioning. When this approach is used, many people report a decrease in pain. Doctors applaud progress, encourage people to continue improving, and continue to treat the pain as needed.
Doctors may also talk with family members or fellow workers to discourage them from doing anything that keeps the person focused on the pain. For example, they should not constantly ask about the person's health or insist that the person do no chores.
Pain rehabilitation programs
Doctors may recommend a pain rehabilitation program for people with chronic pain. These programs are managed by an interdisciplinary team, that includes psychologists, physical therapists, doctors, nurses, and sometimes occupational therapists and integrative medicine practitioners. The programs include education. cognitive-behavioral therapy, physical therapy, simplification of the drug regimen, and sometimes gradually decreased use of a pain reliever. They focus on the following:
Restoring function
Improving quality of life
Helping people control their own life, despite their chronic pain
Drugs Mentioned In This Article
| Generic Name | Select Brand Names |
|---|---|
naloxone |
EVZIO |
