Can medication be harmful or useless? Some medications commonly prescribed for chronic pain are actually harmful and may worsen the pain. Others affect moods or may cause death or coma with overusage. Many medications are taken together and, in fact, have opposite effects to one another.

Some drugs contribute to the chronic pain experience by making the sufferer seek more and more bed rest. This increases the immobility, which leads to further muscular wasting and weakening and a decrease in necessary exercise.

Pain patients often build their lives around their pain and their medication. Withdrawal of medication can be simple for some and incredibly difficult and traumatic for others. It is always an additional therapy best carried out voluntarily and with the patient’s total commitment.

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Magnetic resonance imaging or MRI is a method of producing images of the internal structures of the body. Unlike X-Rays, MRI does not use harmful radiation and in many ways is capable of producing better and more detailed images making it another way of safely investigating the causes of pain. MRI scans of the spine may be used to detect damage to the discs between the vertebrae and to demonstrate soft-tissue masses such as spinal tumours.

MRI works by placing the person inside a powerful magnetic energy field. This magnetic energy causes all the cells of your body to resonate, and this can be tracked by the emission of pulses of radio-frequency energy.

This highly technical data is then put together by a computer and pictures of the inside of the body are created. This is a totally safe investigation although some people become quite claustrophobic when they have to lie still for long periods of time inside a tube which almost touches the nose.

Due to the cost of the machines (several million dollars) and the special provision in the buildings in which they are housed (because of the intensity of the magnetic fields) in Australia they are as yet only available in major public hospitals. Hence there are long waiting lists and in some centres referrals will only be accepted from orthopaedic surgeons or neurosurgeons.

Despite the lack of rebates for private MRI investigation a handful of private services have sprung up in Australia with the cost of an MRI scan of a segment of the spine about $250 to $500.

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Michael’s story shows how he had to withdraw from opiate narcotic medication as a necessary first step to managing his pain. His history illustrates the complications which may arise from chronic low back pain — particularly its potential to produce habituation to potent narcotic drugs.

Michael’s story also shows how someone’s conviction that there is a surgically correctable cause for their pain can lead to obstructions to becoming a well person again.

‘My head went through the window and my feet went under the dashboard. I was aware of pain in my right knee and found that the ignition key had driven through the cartilage of my knee, ‘ recounted Michael, 26, a doctor.

Michael had a legacy of chronic back pain from the accident which happened on his way to work in the early hours on a wet morning when driving conditions were treacherous and a taxi sped through a stop sign.

‘It all happened so quickly. It was just a blur and then my car was hit and went out of control into a power pole. I arrived in hospital by ambulance but was able to walk into casualty where I was supposed to work the next week.

‘Three days after the accident I noticed back pain. At first it was in the middle of my lower back radiating out to my right hip. I also had pain on the left side slightly higher up which radiated into my tail bone. But I was determined to get up and about.

‘Within a week I was on crutches and discharged. A week after getting back to work, my back was sore so I consulted the orthopaedic surgeon on duty. X-rays showed I had a mild crush fracture.’

Michael began to realise he had the beginnings of a long- term pain problem.

‘I had a week off lying flat on my back. It didn’t help. I had various treatments including TENS therapy, and then a full plaster jacket.

‘I kept on trying to work wearing a low-back brace. But my back was still bad. Then, in virtual desperation, I agreed to have a spinal fusion operation.

‘The convalescence meant being an in-patient for two weeks and then having to wear a brace. I still had persistent low-back pain. At times it was excruciating backache down the centre of the spine.

‘It hit like lightning . . . Because I continued to have problems, I was referred to other specialists who gave me powerful medications including Percodan, Fortral injections and Palfium (a highly addictive narcotic drug).’ While this would make him feel euphoric, the back pain continued to dog him. He was even given morphine and pethidine injections without benefit and with increasing tolerance to very large doses.

His pain was becoming more agonising and his left leg felt strange. He was next given Methadone. When that had little effect, Omnopon, another potent narcotic, was tried. In growing desperation he returned to the surgeon who had originally operated on him.

Infection of the operation site was excluded by a radioactive bone scan. But Michael was still in agony. He believed that one of the injections used to diagnose his pain (a myelogram) had caused him further problems by affecting nerves in his back.

Before coming to the pain clinic 18 months after the accident Michael had seen various other doctors. Nerve blocks were performed, without avail. His main concern was about taking Omnopon three times a day. He had been taking potentially addictive medications for a very long time to help him through each day, despite which he had worked as a hospital intern on and off.

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Arthritis is a term that encompasses many different conditions and affects millions of people throughout the world. It is probably the most common source of pain in the joints.

Usually an inflammation of the joints, arthritis attacks the hands, fingers, knees, elbows and any other joints in the body. Arthritis pain can be due either to the swelling of the joints which in turn exert pressure on the joints and ligaments and other soft tissues, or from stiffness which limits the use of the joint.

Rheumatoid arthritis is a particularly severe form of arthritis causing destruction of the joints and also causing the soft tissues, and the skin surrounding affected joints, to thicken into deformities. These deformities are associated with changes in the muscles and in the connective tissues of the body.

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Some ethnic communities encourage their members to express pain, whereas others are admonished to ‘take it in your stride’ and ‘don’t be a baby’.The British psychiatrist and pain researcher, Dr Michael Bond, found that the degree of pain experienced is associated with the degree of severe anxiety and the complaint of pain with the characteristic which makes people seem outgoing. The expression of pain thus appears to be a characteristic of extroversion and the inhibition of pain expression, with introversion.

Some anxious individuals may suffer silently. But those with an outgoing personality have little difficulty in expressing their pain. In other words, they may just open their mouths and scream the roof down! Cultural background also has a powerful effect on the pain perception threshold. American pain researchers, Sternbach and Tursky, report that women of Italian descent tolerate less electrical shock than women of old American or Jewish origin.

In a similar experiment in which Jewish and Protestant women served as subjects, the Jewish women increased their tolerance levels after they were told that their religious group tolerated pain poorly compared with others. These differences in pain tolerance reflect different ethnic attitudes towards pain.

Another American pain researcher, Dr M.Zborowski, found that ‘Old Americans’ have a matter-of-fact attitude towards pain and pain expression. They tend to withdraw when the pain is intense and cry or moan when alone. Jews and Italians tend to complain loudly in openly seeking support and sympathy, as do other southern European and Middle Eastern groups. This behaviour is natural and entirely acceptable in their society.

The evidence that pain is influenced by cultural factors naturally leads to an examination of the role of early experience in adult pain behaviour. It is fascinating how each patient attaches various meanings to pain-producing situations. This greatly influences the degree, and severity, of the pain felt. For example, if your attitude is focused on a potentially painful experience, you will tend to perceive pain more intensely than usual. The mere anticipation of pain is the perceived pain. It is well known that distraction of attention away from pain can diminish or even abolish it.

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Many pain patients are obsessional. An inability to cope with their pain is a reflection of this trait. Many of these people are perfectionists. They feel that their pain makes them seem less perfect — a fact that many cannot tolerate. This in turn leads to an accompanying loss of self-esteem which further leads to deepening depression.

Both cultural and psychological factors are reflected in the ability to communicate pain. They represent the effects of both social learning and relatively stable personality factors. Any pain behaviour followed by a favourable response will be reinforced, just as any behaviour that is followed by an unfavourable response will be avoided.

A decrease in pain is always a positive reinforcer. Thus, in therapy, abnormal or sick behaviour is ignored and appropriate behaviour is both rewarded and encouraged.This led Dr W. Fordyce, of the United States, to introduce the treatment of operant conditioning, which has become the model for in-patient programs throughout the world. An important concept here is that of operant and respondent behaviour. Respondent behaviour is produced by unpleasant or harmful stimuli. It is normally reflex in nature. For example, withdrawal and calling out. This behaviour is usually conditioned by repeated stimuli, such as attending the doctor’s surgery. Where needed, pain-killing medication may be freely given. Operants are observable types of behaviour which lead to repetition of that behaviour — for example, the repetition of such behaviour as moaning, family rewards for illness, being allowed to rest from unpleasant duties — and are conditioned in many ways.

The complaint of the pain may be the final expression for physical, emotional and financial stress and is often compounded by an economic system where pain and disability are rewarded by the insurance industry and by governments.lt has been suggested that being poor and engaging in physical labour predisposes an individual to pain. Unskilled labourers may perceive the doctor and the lawyer as authority figures and resent them. The doctor is seen as wealthy and not in pain. The doctor is able to grant compensation and gives information to agencies which further decide amounts for compensation. So, it can be easily seen how pain causes frustration leading to the doctor rejecting the patient and to patients ‘doctor shopping’. Patients often complain that their previous doctors have just thrown up their hands and told the patient ‘the pain will eventually go away’ or ‘you’ll just have to learn to live with it’.

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Pain management poses many problems for the doctor. The American psychiatrist, Thomas Szasz, who has written extensively on pain and what it means to pain sufferers, studied what he termed ‘pain-prone’ patients suffering repeated physical disability with, or without, detectable injury or illness. He described many of them as having excessive guilt feelings, their pain often serving as an unconscious punishment. Some of them even feel at their healthiest when life is at its worst! Szasz proposed that pain results from a threat to the body, either real or imagined.

Thus, the doctor assessing the patient with chronic pain should be aware of both the psychological as well as the physical threat. With the exclusion of a physical cause of pain, both a psychiatric and social history should be taken as well as an appropriate psychological assessment. In addition, a full medical examination should be made and the appropriate investigations undertaken.

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Acute pain

Acute pain is caused by an illness or injury and persists until the condition is healed. Typically associated with the changes of the automatic nervous system activity (changes caused by the action of the nerve cells and fibres which cannot be controlled at will) it is roughly proportional to the intensity of the stimulus. For example, moving a broken arm. Symptoms may include increased muscular tension, blood pressure, heart rate and sweating. Some people may become vegetable-like, with decreased interests, libido, appetite and sleep.

Chronic pain

Chronic pain, defined as pain that persists for six months or more, involves both physical and psychological suffering. Chronic pain problems following acute conditions such as tendonitis, bursitis or low back pain, can develop if the pain cause persists for more than three to six weeks without improvement. The lack of specific techniques in treating the cause, and the resulting inability to prevent weakness, loss of mobility and resultant abnormality, leads to the stiffening of joint structures and then to uncontrollable or intractable low back pain and immobility of other areas. The longer pain persists, the greater the chance that it will travel away from the lesion. This can promote involvement of other areas and mislead the medical examination.

Chronic pain can even be detrimental to human survival. Suicide among patients suffering prolonged, unremitting pain is not unusual.

Chronic pain and excessive surgery It is important to realise that cutting pain pathways, and the usual analgesics, are ineffective against chronic pain. They may actually intensify it! There’s often no adequate way to explain the phenomenon of chronic pain. The patient’s own description and experience of pain, medication usage, the limitation in daily activities, and the use of health care delivery systems, all seem well in excess of those expected on the basis of actual illness or injury.This has been found to lead to unnecessary surgery, which can further complicate the situation with scar tissue and nerve pathway disturbance.

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