The Truth about Chronic Pain

​By Brian Morrison, DC

The American Chronic Pain Association reminds us that the month of September has been declared Pain Awareness Month.  “Pain Awareness Month is a time when various organizations work to raise public awareness of issues in the area of pain and pain management.”

Chronic pain treatment has been in the spotlight recently due to rising concerns about the dangers of taking opiate medications in an attempt to manage it.  Issues include addiction, over-dose and death, gateway to illegal drugs and “opiate induced hypersensitivity” whereby exposure to opiates causes the patient to become more sensitive and experience more pain.

Chronic pain also presents a substantial economic and public health burden. The following map, based on current figures and census data on state populations, estimates that 116,000,000 Americans experience chronic pain.  Imagine every human being in the shaded states experiencing ongoing pain. (1)
Imagine the entire shaded region, 116 million people, where every single individual experiences ongoing pain every day. Every person you see on the street, on a bus, at home, at work… including you, is in pain almost all of the time.  I think we need more than a Pain Awareness Month to address this, but it’s a start!

Chronic pain creates a major economic burden, at a cost of $560-635 billion annually in direct medical treatment costs and lost productivity. By comparison, the entire annual US 2015 Military Budget was $601 billion.

By definition pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (2)
When an injury first occurs and pain is experienced we call it “acute”.

Acute pain is a message from our internal alarm system, using pain to protect the injured area and create actions that get us out of danger.  The amount of pain we experience is NOT directly related to the amount of tissue damage, rather it is influenced by perception, thoughts, beliefs, fear, society, health care system, culture.  Our alarm is activated!
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Chronic pain is pain that persists longer than the normal time required for tissue healing – about 3-6 months. In other words, the body’s alarm system stays in alarm mode after tissues have healed.  MRI and other brain studies show that changes occur in the brain’s form, electrical activity and neurochemistry that perpetuate the pain sensation. (3)

​The truth about opioids

​Currently, opioids are the intervention most often used for management of chronic pain in the United States.  The idea is to inhibit the signals associated with pain in the brain.

There are many problems associated with opioid use and abuse. A recent article in the New England Journal of Medicine highlighted the current problems in detail:
 
“We at the Food and Drug Administration (FDA) continue to be deeply concerned about the growing epidemic of opioid abuse, addiction, and overdose – an epidemic directly related to the increasingly widespread misuse of powerful opioid pain medications.”  (4) And opioid overdose deaths have quadrupled in the US  between 1999 and 2014 with 165,000 people dying over this period.

Ironically, taking opioids can actually make a patients pain worse. “Opioid-induced hyperalgesia (OIH)” is defined as a state of nociceptive sensitization caused by exposure to opioids. (5)

​What is being done to better address the issue of chronic pain?

​In the past, medicine has viewed pain as a 16th century “cause and effect” relationship between the noxious stimulus, tissue damage and the experience of pain.  This is incorrect.  A new model that addresses many of these concerns has emerged:

By permission: Anoop Balachandran, MS. 01/08/2014

Unfortunately traditional medical education does not adequately prepare physicians for handling the complexities of chronic pain. “One in 3 patients sees a primary care physician (PCP) for chronic pain yet most PCPs receive no training in this field.” (6) More medical schools are offering courses that provide advanced pain education.
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In reality, chronic pain has social, psychological and physical (genetic, biological, nutritional, etc.) components each contributing in varying degrees to the experience of pain and whether or not the person will go on to develop chronic pain.  Patients, health care providers and society need to become educated about all these aspects of chronic pain in order to create meaningful change, improve outcomes and curtail costs.

Treating a pain patient can be like fixing a car with four flat tires. You cannot just inflate one tire and expect a good result. You must work on all four. —Penny Cowan, American Chronic Pain Association, an advocate for people with chronic pain

​So, what can you do about it?

I recommend all persistent pain patients visit http://www.neuroplastix.com/, pick up the Neuroplastic Transformation work book, and get a guided self-care program to follow along with the workbook at the website.  Lots of self-soothing techniques, activities and exercises in a concise, understandable format.

Other excellent resources I use with patients: 

• The Institute for Chronic Pain
• The Retrain Pain Foundation
• Mindfulness Meditation

​You could watch this 5 minute cartoon video or this awesome 14 min TedTalk with the entertaining Lorimer Moseley.

You can try to identify which of these pain modulators (below) is most likely a contributor or trigger for you and visit a practitioner who can address these problems:

• Fear avoidance of movement/exercise
• Personal beliefs about pain
• Poor Sleep
• Anxiety/Stress/Depression
• Catastrophization
• Physical Triggers like certain movements or postures that increase pain
• Social/Family triggers
• Cultural beliefs about pain
• Poor diet/nutrition

At the Center for Integrative Health and Healing, we have the opportunity to assist many patients with chronic pain problems. The vast majority of these patients have what is termed chronic musculoskeletal pain.  These patients do not have underlying nerve or spinal cord damage following a surgery, trauma or disease which is termed neuropathic pain nor do they have cancer related pain.  Typically their pain problem started as some form of acute muscle or joint injury or persistent biomechanical stress or some times for no reason at all and now their pain persists well beyond the normal tissue healing time of a few weeks to a few months.  This pain can be unrelenting, spreading and quite severe.
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We help pain patients by:

1. Providing comprehensive, understandable pain education to overcome fear and learn self-efficacy.
2. Identifying and addressing movement, positional, postural pain triggers and work to calm these and allow the tissues to become less sensitive
3. Cognitive Behavioral Therapy
4. Integrative Medicine to address social, family support
5. Addressing GI disorders and nutritional deficiencies
6. Assess and eliminate possible dietary and environmental toxins
7. Medication evaluation
8. Genetic factors, ie “personalized medicine”
9. Diagnose and treat endocrine imbalances
10. Use of acupuncture to address energy system
11. Other healing touch modalities such as Reiki, Massage and Rolfing

To make an appointment for a consultation to help manage your chronic pain, please call us at 410-448-6361 or email us at CIMClinicInfo@som.umaryland.edu. 

​“It made no sense to me that with all the modern miracles in medicine there was no way to relieve my pain. What I did not realize then was how complex chronic pain is. I did not know how many areas of my life and my family’s lives the pain invaded.”
​— An advocate for people with chronic pain

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References

1. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press
2. IASP, 1994. IASP (International Association for the Study of Pain). 1994. Part III: Pain terms, a current list with definitions and notes on usage. In Classification of chronic pain, 2nd ed., edited by H. Merskey and N. Bogduk. Seattle, WA: IASP Press. Pp. 209-214.
3. Louw, A., Butler, D. S., Diener, I., & Puentedura, E. J. (2013). Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. American Journal of Physical Medicine & Rehabilitation, 92(5), 446-452
4. Califf R, Woodstock J, Ostroff S. A Proactive Response to Prescription Opioid Abuse. February 4, 2016. DOI: 10.1056/NEJMsr1601307.
5. Angst MS, Clark JD. Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570- 587
6. Clin J Pain. 2013 Mar 1. 

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​About the Author:  Brian Morrison, DC

Dr. Brian Morrison, clinical instructor at the University of Maryland School of Medicine in the Department of Family & Community Medicine, is a licensed chiropractor with over 27 years of experience in private practice. Dr. Morrison realized early in his career that manipulation and manual therapy were healing arts spanning many disciplines. In addition to chiropractic, he studied the manipulative techniques of osteopathy, orthopedic manual therapy, and various methods of rehabilitation. His practice offers a variety of techniques that feature state of the art manual therapy combined with corrective rehabilitation. He believes providing both pain education and correction of biomechanical dysfunctions can reduce or eliminate pain and restore comfortable, healthy, efficient movement.  He recently co-authored a chapter on Integrative Management of Pain in Practical Management of Pain, 5th Ed. H. Benzon Ed. In 2005, the Maryland Chiropractic Association honored him as “Chiropractor of the Year” for his role in creating collegial relationships between the chiropractic and medical communities in Maryland. Dr. Brian Morrison earned his B.S. in biology at the State University of New York at Binghamton. He attended Logan College of Chiropractic in Chesterfield, MO where he graduated magna cum laude, valedictorian from. He went on to complete a residency in Chiropractic Family Practice at Lindell Hospital in affiliation with Barnes and Jewish Hospitals in St. Louis, MO. Dr. Morrison is a featured presenter for the University of Maryland Center for Integrative Health and Healing’s Annual Wellness Conference, Maryland Chiropractic Association, Maryland Massage Therapy Association, DC Dental Society and the Howard County Dental Hygiene Association. He is a member of the Columbia Association Medical Advisory Board.

Dr. Morrison and his colleague, Dr. Reza Eftekhar, see patients at the Center for Integrative Health & Healing, the clinical practice of the University of Maryland School of Medicine Center for Integrative Medicine. Call 410-448-6361 or email CIMClinicInfo@som.umaryland.edu for an appointment.  Most health insurances are accepted.  Reach them directly at info@morrisonchiropractic.com.

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