Managing long-term pain

A doctor prescribing painkillers to a patient

As more people live with long-term pain, Senior Cardiac Nurse Christopher Allen looks at how it can be managed, including prescription painkillers.

Acute versus chronic pain

Different medications are needed to treat different types of pain. Acute pain is often managed with medications such as paracetamol and ibuprofen, which are usually taken for a short time until the pain is gone.

Some medicines, such as ibuprofen, which is a non-steroidal anti-inflammatory drug (NSAID), can be bought over the counter. However, to manage more severe or chronic pain, a doctor can prescribe higher-strength versions of these tablets.

Other anti-inflammatory drugs like celecoxib or colchicine (often used to treat gout) are only available on prescription.

“When inflammation happens in your body, there are many steps in the process. Some drugs act on different parts of the process to achieve similar results,” explains Professor Justin Mason from Imperial College London.

“Chronic pain is long-term and can often be severe, so over-the-counter pain relief may be given in partnership with medications that are only available by prescription. This can include conditions such as rheumatoid and osteoarthritis, gout, kidney or gallstones, and symptoms associated with cancer.”

Managing long-term pain

If you’re living with long-term pain, ask your GP if you’re eligible for a pain clinic referral.

Sister Heather Williams is a nurse consultant in chronic pain management at Newcastle-upon-Tyne Hospitals NHS Foundation Trust. “Before being referred to this type of service, people with persistent pain need to have had all investigations relating to their pain carried out,” she explains.

“For example, if a scan is needed, this must be done and any options for surgical procedures or treatment for the cause of pain ruled out or completed before a referral can be accepted.

Most plans for managing long-term pain include simple pain-relief medication

“Pain can affect every aspect of your life and it’s often quite difficult for people to cope with. Our teams are there to assess every individual’s pain and determine what treatments we need to consider to help them better manage their pain.”

It can be a difficult process to handle, with increasing numbers of people experiencing multiple long-term health problems. “Sometimes the pain relief we prescribe is designed to complement other treatment that the person might be having,” says Sister Williams.

“For example, a person who has heart failure and fluid retention would be given diuretics by their GP or specialist, but they might also have chronic pain. The medication we prescribe won’t treat their fluid retention, but it will help to reduce any pain while their diuretics help to reduce the discomfort from the fluid.”

Specialist pain teams help patients manage their own pain, but it’s important to look at overall wellbeing.

“Treatment won’t always take the pain away completely,” says Sister Williams. “We have to look at the whole picture. If sleep is affected, we’d need to look at sleep patterns and even caffeine intake to make sure patients get the best possible outcome from their treatment. It isn’t all about the medication, though medications are a vital part of any treatment plan.”

Most plans for managing long-term pain include simple pain-relief medications: paracetamol and NSAIDs. However, if pain continues or becomes more severe, stronger medication may be needed. This will usually be opiate-based and can include codeine, tramadol or morphine.

Opiate-based medications

“Opiates work by reducing the amount of pain messages sent through the brain and the spine,” explains Sister Williams. “This can dampen down the sensation of pain that people feel.” It’s unusual for any medication regime to erase pain entirely, but opiates reduce it more than most.

The higher the dose, the more likely you are to experience side effects

Patients usually start on a weaker opiate, such as codeine, and only increase the dosage or change to a stronger opiate, such as morphine, if the pain persists or gets worse. “You should be on the lowest effective dose of pain relief possible,” says Professor Mason.

“The higher the dose, the more likely you are to experience side effects. But your pain should also be well controlled so you can stay as active as possible, which reduces the risk of cardiovascular disease (CVD).

Mostly, pain-relief medications are taken in tablet form, although sometimes they are given in liquid form or as a suppository. Occasionally, some are injected, but this is less common outside hospital and is rare for chronic pain.”

Long-acting opiates, released slowly through the day and night, are common. These may come in patch form and are applied to your skin.

Shorter-acting formulations are only used when someone experiences breakthrough pain – occasional pain that occurs despite using your regular pain-relief medications.

Dependency and addiction

People who are dependent on a medication can still suffer symptoms of withdrawal if they suddenly stop taking it

When starting a course of pain-relief medications, some patients are concerned about the possibility of addiction.

“It’s very rare for people with pain to become addicted to medications such as paracetamol, NSAIDs, COXIBs [COX-2 inhibitors] and colchicine,” says Professor Mason.

“Dependency is much more common than addiction. This is where your body becomes used to a medication and it becomes less effective, meaning you might need a higher dose. People who are dependent on a medication can still suffer symptoms of withdrawal if they suddenly stop taking it.”

Opiates are different, says Sister Williams. “They can be addictive, meaning you develop a compulsion to take them even if they don’t help the pain, and they begin to cause side effects or even harm. That’s why anyone taking opiate medication needs to be regularly reviewed by their healthcare professional.”

Despite the challenges associated with managing pain, most people referred to a pain management clinic will experience an improvement in their quality of life. The services offered by these clinics give many patients a better understanding of how to have a direct impact on their own wellbeing. Patients therefore often benefit from the sense of empowerment gained by making positive changes to control their condition.

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