Updated: Feb 9, 2018
If you have been in pain for a period of more than 3 months then you would be categorised as suffering from chronic pain - and it is far more common than many would think. A large study published in 2016 reported that 43% of the UK population suffer from chronic pain (Fayaz et al., 2016). From a marketing perspective, the idea that something or someone can take the pain away is a lucrative one – one that has led to an opioid crisis in America and a growing opioid crisis in the UK as so many people reach for over-the-counter ‘painkillers’ or badger their GP for prescription pain relief medication.
Some people taking regular pain medication for a long period of time are still in considerable pain and it is too easy to assume that the pain is so bad that even the medication can’t keep it under control. However it is definitely worth bearing in mind that pain medication is not effective for everyone who takes it. For any medication there is a statistic known as Number Needed to Treat (NNT), for painkilling medication, the NNT refers to the number of people who need to take the medicine in order for one of them have their pain reduced by 50%. If a medication has an NNT of 5, it would mean that for every 5 people taking it, only 1 would have the benefit of 50% pain reduction.
The data in the table above shows that just because you are taking the medicine, doesn’t mean that it will work for you. If it doesn’t work for you, it may be time to discuss with your doctor whether it is worth continuing taking it as there are many reasons why it is good to take as little medication as possible. Some people have a stronger response to pain medication when it is taken in combination with other pain medications so your doctor may recommend you keep taking it, but have the discussion with either your doctor or your pharmacist.
When taken for a long time, pain medication can sensitise parts of the nervous system, modifying the way your brain interprets signals from the body and providing a mechanism for your pain sensitivity to increase. The outcome of that scenario is that you will gradually become more sensitive to pain, and if you try to come off your pain medication the pain you subsequently feel could be due to a lower level of natural endorphins. Add to this the knowledge that taking paracetamol regularly will harm your liver, taking ibuprofen regularly will harm your stomach lining and increase your risk of kidney disease and opioids such as morphine and codeine and tramadol are risky for anyone with an addictive tendency and interfere with your own natural endorphin production. Many people are being prescribed gabapentinoids for chronic low back pain even though such use is off-label and research suggests that the risk of harms outweighs the benefits (Shanthanna H et al, 2017). Another warning comes from a large epidemiological study from Denmark evaluated the long term outlook for people suffering with chronic non-cancer pain; they found that people taking opiods (eg Tramadol) were more likely to have higher levels of pain, be able to do less and have a poorer quality of life than those not taking them (Eriksen et al. 2006).
Fortunately killing your pain with medicine is not the only response option you have for chronic pain. One very useful piece of advice is to find a way to change your relationship to your pain. Pain is a physiological symptom which indicates that you need to change something you are doing in order to protect yourself from potential harm. It is a warning system, an alarm that goes off to trigger a change in how you move or a change in how you are living your life in order to avert the possibility of harm. It doesn’t mean that harm is inevitable, but the perceived risk of harm is enough to trigger the pain response. The crucial word in the previous sentence is ‘perceived’. In chronic pain conditions, this perception of risk is over-sensitised so the pain response is being triggered far too easily; it is like having an over-zealous smoke detector in the kitchen going off every time you make a piece of toast rather than only going off when there is a chip fire on the stove.
Once you understand that pain is a protective mechanism designed to help prevent harm it is easy to assume that the harm is one of a physical nature, harm to the tissues of the body. It could be argued however that systemic, chronic pain may be also be brought into being to force you to stop and reconsider some of your deeper habits and thought patterns that are continually causing harm to the psyche. It is not unusual for people suffering from chronic pain conditions to have a history of a difficult life or specific trauma that has deeply affected the way they move through their life. If such events have left someone with self-destructive thought patterns, if their inner voice is still echoing with the pain of their distant past, eventually a physical pain response may be created as the system tries to find a way to protect itself from this unresolved emotional pain. Many professionals working extensively with chronic pain understand that the most successful approach will involve psychotherapy, mindfulness or acupuncture, all therapies that can teach someone how to soften their inner voices, how to ease their sense of unspoken emotional damage. When release and repair of the physical body occurs alongside release and repair of the inner psyche, the path to a better life can become a reality.
Acupuncture has an increasing evidence base to support its role in the treatment of chronic pain (Vickers et al, 2017). From an acupuncturist perspective this seems entirely logical as it is a therapy which can be used effectively to tackle both musculoskeletal pain and emotional pain (Hopton et al, 2014).
So what can you do to start moving in the right direction . . .
The first step in the process is to set aside the goal to live your life pain free, but instead to gently turn toward the pain to try to understand what it is trying to tell you. If broke your arm it would hurt, the pain would tell you to stop moving it but if you try to medicate the pain away so you can carry on moving it in the same way you would only prolong the problem. If pain is deeply connected with un-recognised remnants of a previous injury or long-standing internal trauma, attempting to remove the pain with medication will not heal you.
The second piece of advice is to really get to know your pain. Instead of raging against it, or being defeated by it and desperately wanting it to be taken away from you, start exploring it, getting to know it better. Find out when it is worse, when it is better; find out where it is, and where it isn’t. Learn to really notice it and feel it more clearly – is it hot or cold, is it hard and defined or fuzzy and indistinct, is it moving or staying still, is it pulsing? To take this one step further, take a moment to sit gently with your pain and find some big, descriptive words to help yourself to really get to know it; does it feel like it is sucking you into a dark abyss, does it feel like snakes are writhing around in your muscles? When you sit gently with your pain like this, paying curious attention to it and finding out more about it you may find the nature of the pain changes. Pay attention to this too.
The third piece of advice is to seek help from someone who understands the complex nature of chronic pain. If pain is seen as purely physical, then you may expect a doctor to be able to remove it with medicines or with an operation; if your chronic pain has a deeper root, you need to work with a practitioner who has time and space to help you to explore your pain, help you to really get to know it, why it is there, and ultimately what needs to shift to allow healing. This healing process is not easy to do alone, the clues to how to unwind and resolve your pain may not be easily recognised by you, if you had the innate ability to do it alone you would have done it by now.
Fayaz A; Croft P; Langford RM; Donaldson LJ; Jones GT Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies BMJ Open 2016;6:e010364; doi: 10.1136/bmjopen-2015-010364
Finnerup, NB; Attal, N; Haroutounian, S; McNicol, E; Baron, R; Dworkin, RH; Gilron, I; Haanpaa, M; Hansson, P; Jensen, TS; Kamerman, PR; Lund, K; Moore, A; Raja, SN; Rice, ASC; Rowbotham, M; Sena, E; Siddall, P; Smith, BH; Wallace, M Pharmacotherapy for neuropathic pain in adults: systematic review, meta-analysis and updated NeuPSIG recommendations Lancet Neurol. 2015 Feb; 14(2): 162–173; doi:10.1016/S1474-4422(14)70251-00
Shanthanna H; Gilron I; Rajarathinam M; AlAmri R; Kamath S; Thabane S; Devereaux PJ; Bhandari M Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials PLOS August 15, 2017; doi.org/10.1371/journal.pmed.1002369
Eriksen J; Sjøgren P; Bruera E; Ekholm O; Rasmussen NK Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain. 2006 Nov; 125(1-2): 172-9.
Vickers AJ; Vertosick EA; Lewith G; MacPherson H; Foster NE; Sherman KJ; Irnich D; Witt CM; Linde K; Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2017 Dec 2. pii: S1526-5900(17)30780-0; doi: 10.1016/j.jpain.2017.11.005
Hopton A; Macpherson H; Keding A; Morley S Acupuncture; counselling or usual care for depression and comorbid pain: secondary analysis of a randomised controlled trial. BMJ Open. 2014 May 2;4(5):e004964; doi: 10.1136/bmjopen-2014-004964.