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Pain: Advocating for Yourself in a Maze of Discomfort
Betsy Rothley, RN, MSN, FNP, BC
Pain can be all encompassing and possessive; stealing our emotions, good moods, sexual desire, and invading our capabilities for a good night’s sleep. Those who suffer pain know that it literally changes the world that we live in day to day.
Pain has two major components that we focus on: the physical and the emotional. We understand that when we experience pain, the sensation is delivered to our brain and can affect our emotions. We also often see emotional stress/difficulties show themselves as physical ailments. Modern medicine is focused on improving the care options offered to pain patients in two ways: pharmaceutical companies are developing new medications to aid the physical control of pain, and pain centers are now offering emotional support to help patients develop skills for coping with the effects of pain in every day life. Although this article describes the physical management of pain, both components need to be recognized and addressed aggressively and appropriately to achieve a better quality of life.
Types of Pain
As science has shown us, ‘Pain’ is a disease process that if untreated, can turn into an out-of-control beast that modern medicine has difficulty controlling. To better manage pain, we must understand and recognize the type of pain that is being suffered.
Nociceptive pain is defined as pain that originates from tissue damage in the somatic or visceral structures (Cherny, 1998). This kind of pain can be caused by inflammation of skin or tissue, or simply straining a muscle. Visceral pain refers to discomfort in your organs, such as: lung, heart, stomach, small bowel, colon, gallbladder, pancreas, uterus, spleen, and liver. The pain from visceral or somatic damage is often described as: “aching, constant, cramping, gnawing, and throbbing.”
Treatment options for nociceptive pain include: non-opioids, such as acetaminophen, aspirin, and ibuprofen; opioid management; and adjuvant or adjunctive medications, such as muscle relaxants and anti-anxiety medications.
Neuropathic pain or deafferentation is defined as “an excitatory nerve state” that is a result of injury or irritation of the peripheral or central neural structures, (Cherny, 1998). A common example is pain that is felt when a patient herniates a disk in their back and pain goes down from the site of injury into their legs and feet. Neuropathic pain is often described in electrifying terms, such as “burning, prickling, tingling, shooting, radiating, and stabbing.”
Treatment options for neuropathic pain include: anticonvulsant therapy, tricyclic antidepressants, and other adjuvant or adjunctive medications. Opioids are used, but not thought of as first line treatment.
Pain Management Barriers
The management of chronic pain with opioids is still under debate among caregivers. This ongoing battle results in more and more patients with unrelieved pain, (Gladjchen, 2001). Patient issues, such as attitude, lack of communication skills, and psychosocial barriers, are other reasons that many patients’ pain is not fully relieved or well managed, (Gladjchen, 2001).
Addiction to pain medication is much more rare than most people think. Addiction means that someone loses control and becomes preoccupied with their pain medications, despite the fact that they are receiving good pain relief. It also means that the person continues to use these drugs, in spite of adverse consequences, (Savage, 1999). What is far more common an issue, but not well understood, is the phenomenon of ‘pseudoaddiction.’ Clinicians sometimes misunderstand the patient’s request for opioids as drug-seeking behavior, rather than a true need for good pain control, (Savage, 1999). The difference between pseudoaddiction and addiction is, those who are pseudoaddicted stop seeking additional medication when their pain is well controlled and stop the manipulative behavior that they might have used before.
Pain in Gastrointestinal Diseases
Unfortunately pain seems to be common with gastrointestinal (GI) diseases, and often complicated, because both nociceptive and neuropathic pain are contributing. Visceral pain happens when we have stretching and contraction of our GI organs. This can feel like bloating or cramping associated with irritable bowel syndrome (IBS) and Crohn’s disease, or the contraction of the gallbladder when we eat too many fatty foods. Mostly our bodies can control the pain/discomfort we feel, but sometimes we have to supplement our bodies with drugs such as opioids to compensate.
Neuropathic pain is common in those patients who have continued inflammation and tissue damage. The damage causes a “remodeling” of our central nervous system and pain signals are continually sent to our brain, not only from the areas where the damage occurred, but areas other than those involved with our disease process, (Marcus, 2000).
When treating pain in GI diseases, one must also understand how absorption can affect the type of medication that a patient is receiving. For example, a medication that is supposed to release itself over 8 to 12 hours can be very appropriate for maintaining a consistent blood level of the drug in a ‘normal patient’, but when the patient experiences absorption or dumping issues, they aren’t likely to receive the full effect of the medication. Discussions with your prescribing physician/ provider will help to clarify these issues and determine the best type of medication (long-acting vs. short-acting) and the best way to deliver it (i.e. patch, IV, pill, liquid analogs, or oral lozenges).
How to Advocate for Yourself
When discussing your pain with your physician or nurse, it is best to communicate directly about how the pain feels and how it affects you and your daily activities. Your clinician will typically ask you to rate your pain on a scale from zero to ten, with zero being no pain and ten being the worst pain you can ever imagine. When this question is asked, be specific to describe where the pain is. The average person with chronic pain issues has three to four sites of pain. You need to identify where it actually hurts and also how it feels. For example, “tingling, burning, shooting, stabbing, radiating” are important descriptors that identify neuropathic pain and will help steer your doctor to proper medication for management.
It is also very important to describe when the pain is at its worst and what, if anything, helps to relieve it. Describe what activities are you able to do, and what you have given up, because of the pain. Keeping a “pain diary ” helps to show your physician what time of the day is worst and hopefully reveals a pattern for better treatment options. Take the diary with you on your routine visits to help with communication.
Nausea and vomiting can be an issue associated with your disease process and taking a pain medication that increases that symptom can make you less likely to take the medication. This can alter your medication levels and interfere with your pain control. Because some opioids may enhance the feeling of nausea and vomiting, discussing this issue with your caretaker may lead to more appropriate medication choices.
Pain is debilitating and can take over your life very quickly. Increased knowledge and good communication with your doctor or nurse can help with proper identification and management. Set goals with your provider and track your success; with good teamwork you can expect to reduce your pain and increase your functional capability.
Quality of life, as defined by David Roy, is the “experiences that make life meaningful.” Becoming a team member with your provider allows everyone to focus on conditions that provide such experiences.
Cherny, N.I. (1998). Cancer pain: Principles of assessment and syndromes. In A. Berger, R.K. Portenoy, & D. Weissman (Eds.), Principles and practice of supportive oncology.Philadelphia: Lippincott- Raven.
Glajchen, M. (2001). Chronic pain: Treatment barriers and strategies for clinical practice. J Am Board Family Practice, 14(3): 178-183.
Marcus, D.A. (2000). Treatment of nonmalignant chronic pain. American Family Physician, 61(5): 1331-1338.
Roy, D. HIV / AIDS Palliative Care Module.
Savage, S.R. (1999). Opioid use in the management of chronic pain. Medical Clinics of North America, 83(3): 761-786.
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