Should we worry about “how much it hurts” in Chronic Pain?

History of pain management suggests strong value of focusing on pain intensity as the goal of treatment. This is true for cancer pain towards the end of life and probably for acute pain with injury or pathology. However, for pain without obvious pathology or trauma, addressing elimination of pain may not be right goal of management. Chronic pain is any pain lasting for longer than three months when the normal tissue healing is over. This says that the local tissue is no longer at fault, but the problem lies somewhere else other than the tissues.

In a recent article titled “Must we reduce pain intensity to treat chronic pain?” by Sullivan and Ballantyne (published ahead of print) in Pain, they give reference to a very interesting case of Mr. Harris. Read the case at the end of the article.

So should we target pain intensity for the management of chronic pain?
Assessment of pain and management has been considered important. Pain is also often considered the 5th vital sign. It is recommended to use a Numerical Pain Rating Scale (NPRS) and any pain that scores more than 4/10 warrants pain management. Recent recommendation for the low back pain research is to assess at least pain intensity, pain interference and physical function. Other aspects that can be assessed are depression, sleep quality, catastrophization, fear avoidance, work disability etc. These factors are more related with suffering and or disability due to chronic pain than pain intensity.

Pain severity can have different meanings and implication. I always remember a patient who had lower extremity trauma during Nepal Earthquake in April 2015, who was highly catastrophic of pain and did not want to move out of the bed after surgery. In another big tremor, the patient ran out of the hospital building without feeling any pain on the injured leg. Women take extremes of pain during labour as this is a reward, however, they find difficult to take a pain that she gets in her lower back when she washes her mother in law’s clothes. I am sure the pain is not as much as the labour pain. So, pain intensity is something not the sole thing that has to be targeted, when managing chronic pain that is so complex and is multifaceted.

In the course of pain - cognitive factors take over nociception. This means pain perception is more linked with central experiences such as emotions, stress, catastrophizing, fear avoidance than actual pain in the tissue (nociception). Tissue generally heals by three months before the pain becomes chronic. Many of these central factors contribute to ongoing pain though the tissue is healed locally. It is also believed that anxiety increases pain rather than pain increasing anxiety.

So what should we target while managing chronic pain?
Interventions to target the function rather than pain could be of more value. If the person is doing his or her work/ task/ function well, they feel better, they have less avoidance of activity due to fear, they do not heighten their pain experience, become more active and functional and thus decrease pain. Active life style is recommended for chronic pain. But, when we target pain intensity in these patients, we are concerned about pain, we ask patient to be more cautious and probably also ask to avoid painful activities (which is not required most of the times), they become scared to move the body, when they have to move- they know that will harm them. When they believe movement will cause harm, it will for sure hurt/ cause pain. They again become more scared of this activity and rest. Rest is not good for chronic pain.

Thus, acceptance of pain as a normal phenomenon is useful pain management strategy. We can help the patients by talking to them about pain with examples and metaphors, convincing them to accept their painful state, explaining them that stressful situations may lead to some pain, which will subside when the stress is removed. Low back or the neck hurt just like headache during stress, or appearances of cold sore or pimples in stressful situations. Just as getting more stressed about a pimple over the face causes to occur, stress about low back pain and neck pain increases the pain more. Most of the times, they do not even require treatment. Thus, we should address the false understanding about the patients regarding chronic pain more effectively rather than using analgesics, TENS, or other passive techniques to manage chronic pain.

Implication for patient: Do not worry about how much it hurts, that will increase the pain more, accept the pain as normal part of life, stay active which is the best way to cope with chronic pain.

Implication for clinicians: Do not worry much about getting rid of all the pain, but try to maximize their potential to be functional. Explain them why it hurts and counsel them to accept the pain in the best way possible.

Case example in the article by Sullivan and Ballantyne in Pain:
(Mr. Harris is a 41 y/o male who has had axial low back pain for 1 year. He has just moved into town and comes for his first appointment with you, his new primary care physician. A previous lumbar MRI showed a disc bulge at L5-S1 and some degenerative changes at other levels, but there is no evidence on physical exam of nerve root irritation. He rates his average pain intensity as 10/10. He takes oxycodone SR 20mg BID which used to provide him significant relief, but does no longer. He wants his opioids increased until they relieve his pain. He explains that this was the treatment goal that he agreed on with his previous physician who had called it the “titrate to effect principle.” When you express doubt as to whether an opioid dose increase is the right treatment, he responds, “Don’t you believe I am in pain? Don’t you believe that I deserve relief? Do you just want me to suffer?” You are confused. You do believe Mr. Harris is in pain and deserves relief, but you doubt that escalating his opioid dose will provide him lasting and overall benefit.)