While it may be of little condolence to those of you suffering from pain, you are not alone as this is an enormous problem globally. The World Health Organization (WHO) and the National Center for Complementary and Integrative Health (NCCIH – a division of the National Institutes of Health) estimate that as many as 20-40% of adults globally suffer from some form of chronic pain, 8% have “high-impact” or life/activity limiting chronic pain and up to 10% of the world’s adult population will be newly diagnosed with chronic pain each year.
Additionally, pain conditions in children and adolescents have become a focus of recent increasing concern because of growing evidence that implicates childhood pain as a predictive factor for significant pain issues in adulthood. Nevertheless, the problem of pain through the years has primarily been regarded as a “medical problem” with little attention focused in the area of general health or even underlying causes.
What is pain then and why do we experience it? The International Association for the Study of Pain and the WHO define it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Three distinct pathophysiologic types of chronic pain are recognized.
Pain that is related to damage of somatic (skin, joints, muscle, etc.) or visceral (deep internal organs) tissue due to trauma or inflammation is labeled nociceptive pain. Examples would be rheumatoid arthritis, gout, osteoarthritis, trauma, surgery, etc.
Pain related to the damage of peripheral or central nerves is referred to as neuropathic pain with prime examples being painful diabetic peripheral neuropathy, postherpetic neuralgia and others.
Pain without an identifiable nerve or tissue damage source is hypothesized to result from persistent neuronal dysregulation or malfunction and is called sensory hypersensitivity. The main example of this type of pain is fibromyalgia and a discreet etiology for the pain often is difficult or impossible to determine. It also is important to recognize that multiple pain conditions may coexist, and chronic pain may change over time.
In addition to being “a pain”, pain is a serious clinical, social and economic problem. What makes pain so difficult to address is the subjective nature of the problem and, at times, unclear therapeutic endpoints. Additionally, the wide-ranging nature of painful conditions including back/spinal pain, neuropathic pain, musculoskeletal pain, fibromyalgia, chronic widespread pain, traumatic pain, postsurgical pain and other sources can limit the ability of clinicians and practitioners to effectively diagnose and address the problem from a practical treatment standpoint.
While there is not a clear relationship between age and onset of pain there does appear to be a higher prevalence in older age groups. Given that the world’s population is aging and that the number of adults older than 65 years is likely to double in size in the next 30-40 years, treatment approaches need to consider pain related comorbidities and the potential risks for polypharmacy (multiple drugs).
Finally, the emotional, financial, physical and social impact of chronic or recurrent pain can not be understated.
As briefly discussed earlier, the presence of life-limiting or activity-limiting chronic pain affects a significant portion of the population. This may result in associated anxiety, depression, loss of self-worth, isolation and other emotional and mental components. Often, those with chronic pain limit their interaction with others, further amplifying the problem.
The economic burden of chronic pain has an undeniable impact on the patient’s quality of life and financial resources. It has been estimated that individuals with moderate to severe chronic pain lose an average of 8 days of work every 6 months and almost a quarter lose at least 10 workdays. In addition to lost income and productivity, patients with pain conditions consume approximately twice as much healthcare resources as the general population. The estimated annual medical cost of pain related maladies ranges from $600 to more than $700 billion rivaling the annual cost of heart disease, cancer and diabetes combined.
Another “cost” of pain has been the creation of the opioid crisis. The terms opiate and opioid frequently are used interchangeably because they essentially have the same effect on receptors in the brain tissues and central nervous system. However though, there is a difference between the two terms. Opiates are naturally occurring substances derived from the opium poppy plant and include drugs like opium and morphine. Opioids are man-made or synthetic drugs manufactured from morphine and include medications such as oxycodone, hydrocodone and fentanyl.
Embarrassingly, as a physician I’m afraid the medical profession must accept a significant amount of responsibility for the opioid crisis. While opiates are frequently prescribed to relieve acute pain, prolonged use can lead to addiction and abuse. Common prescription painkillers such as oxycodone, hydrocodone, morphine, codeine and fentanyl can be prescribed after surgery or traumatic injury. Not infrequently these medications are overprescribed, and the toll is substantial.
Opiates and opiate derivatives are highly addictive drugs which enter the brain through the bloodstream creating a flood of artificial endorphins and dopamine. These neurotransmitters are responsible for feelings of reward, pleasure and satisfaction. They also create a rush of euphoria. After repeated use though, the brain decreases or ceases to create dopamine and endorphins naturally thus limiting a person’s ability to experience these feelings. Because of the strong and desirable effects that flood the brain with opioid use and because these effects are no longer present naturally the person may crave repeated opiate highs.
This need for a persistent high results in a series of steps leading to opiate addiction including the development of tolerance (requirement of increasingly larger doses to experience the same effect), physical dependence (removal of the medication results in withdrawal) and psychological dependence (cravings are so intense that even in the absence of pain continued need for the drug is present). Once a person becomes addicted little else can be done until professional drug dependence intervention is initiated.
Here at Strata we offer multiple noninvasive options for managing chronic and recurrent pain. Utilizing the skill sets of our board-certified chiropractic physicians, functional neurologists, acupuncturist, massage therapists, meditation, mindfulness, behavioral and emotional therapies we develop a care plan designed to help manage chronic and recurrent pain in a holistic and complementary fashion.
Use of narcotics in the management of pain can be likened to “painting rotten wood – it looks (feels) better on the outside but what’s going on underneath is still there”. Our skilled professionals peel back the layers to determine the root cause of the problem, assess the mechanisms and directly attack and impact the underlying issue.
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By MICHAEL J. BARBER, MD, PHD, FACC, FAHA, FHRS