A: “Failed surgery” refers to continued physical pain and physical impairments after surgery. The goals of surgery are not only to stabilize bones & joints, but also to reduce physical pain & physical impairments (limitations). Even when the bones heal well, sometimes physical pain & physical limitations continue to be more severe than was hoped for.
Q: What are the characteristics of “chronic pain behavior”?
A: “Chronic pain behavior” refers to behavior that is observed by others of the person who suffers from a chronic pain condition. “Chronic pain behavior” includes not only the behavior that results directly from physical pain & physical impairments, but also the anticipatory anxiety & avoidance of doing activities that are expected to cause or worsen the pain. Other “chronic pain behavior” includes impaired energy, impaired ability to focus attention & concentration, decreased pleasure & motivation for things a person would normally enjoy doing, and increased frustration & irritability regarding not being able to do things that the person wants or needs to do.
Q. How can we tell if pain is real?
A: We don’t have a specific blood test or x-ray that shows pain, but we do have blood tests, x-rays, & other tests that show the presence or absence of underlying conditions that would be expected to cause pain. For example, if someone complains of a particular type of pain and their x-ray or MRI shows severe arthritis or a ruptured disc, the physician can comment as to whether their pain complaints are consistent with that x-ray finding. If the x-ray or MRI is normal with those same pain complaints, it would raise the question as to whether the person was accurately reporting their pain experience.
It is important to screen for medical conditions that can cause “real” physical pain when the x-ray or MRI is normal. For example, low thyroid functioning, systemic infection, and low vitamin B12 are treatable causes of “real” physical pain
Psychological testing can also be used to determine if the person’s responses on the testing are consistent with those of “malingerers” or with those whose stress tends to affect them physically (“somatization”) more than the average person.
Q: What are the effects of dependence on opioids?
A: Dependence on narcotic pain medications (also called “opioids” or “opiates”) results from taking narcotic pain medication on a regular basis for several weeks, months or even years.
Medication side effects can include headaches, increased muscle spasm, nausea, constipation, disrupted sleep, decreased energy, increased fatigue, impaired concentration, increased anxiety, irritability, apathy, and mood swings.
“Dependence” on narcotic pain medications also implies that suddenly stopping or decreasing the medication may cause “withdrawal” symptoms. These include return of the underlying pain at increased severity, generalized joint & muscle aches (“my bones hurt”), nausea, diarrhea, restlessness, sweating, disrupted sleep, decreased energy, irritability, & apathy.
“Withdrawal” is a temporary condition, so any persistent symptoms are considered part of their underlying condition. (If a person stops taking blood pressure medication and their blood pressure increases, are they “dependent” on the blood pressure medication, or has their underlying condition returned due to the lack of treatment?).
Q: What is the relationship between chronic pain & “psychiatric disorders”?
A: “Psychiatric disorders” include mood disorders, anxiety disorders, and sleep disorders.
This is an important issue. Fortunately, these symptoms and impairments usually are much improved or in remission with appropriate treatment.
When a person suffers from a chronic pain condition, the physical pain causes some of the same symptoms that are common symptoms of mood disorders. These include decreased energy, increased fatigue, impaired ability to focus attention & concentration, and decreased pleasure & motivation for activities one would ordinarily enjoy.
Then there is the normal “emotional” reaction to chronic pain and associated physical limitations. These may include anxiety about the future (i.e., “what’s going to happen to me?”), irritability & frustration about not being able to do things one wants or needs to do, and sadness (“depression”) about the losses that have occurred due to the chronic physical pain and physical limitations.
In my experience, the emotional reaction component is dependent on the changes in a person’s ability to do things that they want & need to do, in life roles that may include parent, spouse, helping aging parents, social activities, leisure activities (sports), religious activities, & participation in community organizations. The more adversely these are effected, the more severe the normal emotional reaction to the losses and changes.
Once again, these symptoms and impairments usually are much improved by appropriate treatment, including medication management and lifestyle adjustment to find new ways to perform important life roles that do not worsen physical pain.
Q: What are some of the limitations that can result from chronic pain?
A: Obviously, this depends on the nature of the cause of the pain. But the same physical injury can have different effects on different people (i.e., a knee injury in a construction worker who likes to play sports vs. an accountant who likes to read). Once again, the most devastating part of the physical limitations are the losses of ability to things that they want and need to do, in life roles that may include parent, spouse, helping aging parents, social activities, leisure activities (sports), religious activities, & participation in community organizations.
Q: What is the relationship between chronic pain and depression?
A: “Depression” is a term that can be confusing at times because it can refer to 2 different things.
“Clinical Depression” is a term used to refer to the diagnosis of “Major Depressive Disorder,” which is defined by the presence of a number of symptoms and impairments (at least 5 out of 9). These may include sleep disturbance, impaired energy, impaired concentration, persistent focus on negative thoughts, depressed mood, loss of pleasure or motivation for things one would ordinarily enjoy, irritability, anxiety, impaired energy & fatigue, and/or thoughts of suicide. In order to be diagnosed with “Clinical Depression” (or “Major Depressive Disorder”), at least 5 out of 9 of these symptoms must be present on a daily basis for several weeks AND cause significant impairment in functioning.
“Depression” is also sometimes used to refer only to depressed mood, which is only one of the 9 symptoms that may occur with “Clinical Depression” (or “Major Depressive Disorder”). The classic triad of depressed mood is feeling helpless, hopeless, and worthless. Feeling helpless refers to the feeling that “there’s nothing I can do to get better;” feeling hopeless refers to the feeling that “I don’t see any light at the end of the tunnel;” feeling worthless refers to the feeling that “what good am I to myself or the people I care about in the condition that I’m in?”
Fortunately, just because a person with Clinical Depression has these thoughts does NOT mean they are true. With effective treatment, people are often surprised at how much better that they can feel (physically and emotionally), and that their sense of helplessness, hopelessness, and worthlessness are greatly reduced, if not resolved completely.
Q: What is a behavioral Rx for chronic pain & psychiatric disorders?
A: Behavioral treatments for chronic pain and psychiatric disorders can include medication, nutritional interventions, stress management, lifestyle adjustment, and non-medication treatments to reduce anxiety, insomnia, and muscle tension/spasm.
Non-habit-forming medications include “antidepressants,” “anticonvulsants,” muscle relaxants, & analgesics. Many people are surprised that several medications in the “antidepressant” & “anticonvulsant” categories are approved by the FDA as being effective for certain chronic pain conditions.
Potentially habit-forming medications include narcotic pain medications, certain muscle relaxants, some anti-anxiety medications, & some medications for sleep. As with all medications, they should be monitored carefully for side effects as well as benefits.
Counseling, stress management, and “psychotherapy” have been shown in the scientific literature to be effective in reducing suffering by helping people to find new ways to deal with difficult life changes that often accompany a chronic pain condition.
This often means finding new ways to perform one’s important life roles, such as parent, spouse, helping aging parents, social activities, leisure activities (sports), religious activities, & participation in community organizations. Sometimes this means “if you get lemons, make lemonade.”
Behavioral techniques that have been shown in the scientific literature to be effective in reducing chronic pain include biofeedback & various types of relaxation training. Stress & emotional suffering “pour gasoline on the fire” of “real” physical pain, and these techniques help to “pour water on the fire.”
Adrian Blotner, MD
Board Certified, Pain Medicine & Psychiatry
6401 Poplar Ave, Suite 316
Memphis, TN 38119
(901) 761-3255 (phone)
(901) 761-3257 (fax)