There are two main types of pain:

• Nociceptive pain arising from the stimulation of the pain receptors, due to injury, surgery or disease that affect the tissues, such as arthritis
• Neuropathic pain caused by a malfunction in the nervous system that leads to a pain signal being sent to the brain, without obvious physical cause, such as diabetic neuropathy, phantom limb pain and post herpetic neuralgia (a chronic pain condition that can occur after shingles)

Pain may be acute (short term) or chronic (long term). Acute pain (also known as warning pain) is the discomfort or signal that alerts you something is wrong in your body (e.g. a cut finger, stomach ache). Acute pain usually lessens as the underlying problem is treated.

Other pains are long-lasting or chronic and, as yet, have no cure. Chronic pain is often defined as pain which lasts for a prolonged period of six months or more (this can even be years).

Chronic pain is a devastating problem, leaving sufferers’ lives in ruins, with depression and problems in work and relationships common. The pain is generally caused by conditions such as arthritis, back problems or cancer.

Achieving effective pain relief
Pain management needs to be undertaken as part of a multidisciplinary approach that addresses the pain itself, as well as the underlying cause. Indeed, in many cases (such as arthritis), the disease is incurable, so symptomatic relief becomes the primary goal of treatment. Effective management to moderate to severe pain is generally achievable if these steps are followed:

• Accurate assessment of pain
• Consideration of non-pharmacological options
• Appropriate selection of analgesia

Accurate assessment of pain
This is the first step in improving pain management. National guidelines do exist in some cases which recommend that careful assessment and diagnosis of the type of pain, its severity and its effect on the patient are necessary to plan appropriate treatment and should therefore form an integral part of the overall clinical assessment¹.

There is no simple, direct measure of pain but it is generally recommended that pain should be assessed by the patient¹. It has been suggested that, “because pain is inherently subjective, a patient’s self-report is the gold standard for assessment”².

Several techniques have been developed for people to asses their pain. The simplest pain measurement techniques require patients to rate their pain on visual scales – such as lines ranging from ‘no pain’ to ‘worst pain imaginable’ – or on verbal or numerical scales. A simple verbal rating scales with the patient rating pain as ‘none’, ‘mild’, ‘moderate’ of ‘severe’ has been shown to correlate well with a more complex visual analogue scale³.

Appropriate selection of analgesia
A simple, well-validated, and effective method of assessing therapy (originally for cancer pain) has been devised by WHO (World Health Organization, 1990).

This approach is based on the concept of an analgesic ladder (see figure).
The five essential concepts in the WHO approach to drug therapy are:

By the mouth, By the clock, By the ladder, For the individual, With attention to detail.

Current methods of managing chronic pain

Medication
There are a large number of drugs that are widely used for the control of pain, ranging from pain killers bought from the pharmacist to those that can only be prescribed by a doctor.

Paracetamol
For people with mild or moderate pain, paracetamol may prove sufficient for pain control. Often undervalued, paracetamol is a highly effective analgesic, with no gastrointestinal adverse effects, and is available in a variety of formulations, including in combination with codeine⁴.

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs have a threefold action: relieving pain, reducing inflammation and reducing fever. They can be particularly useful in conditions where the pain is accompanied by inflammation, such as rheumatoid arthritis. They can cause serious side effects such as stomach ulcers or kidney failure.

Opioids
The strongest of all painkillers (analgesics) used today are opioids. Opioid drugs are traditionally used for patients with more severe pain. They vary from weak opioids such as codeine and propoxyphene, to the stronger drugs such as morphine. Strong opioids should be considered when other options have failed to control a patient’s pain; patients should not be continued on a less effective drug when an opioid could significantly improve their pain management.

Physiotherapy
Pain often stops many people from using the part of the body that hurts leading to muscle wasting and joint stiffness (which in turn may make pain and disability worse). Physiotherapy helps the treatment of the disease or injury by physical means, which in turn will lead to an improvement in pain relief.

Stimulation
Transcutaneous Electrical Nerve Stimulation (TENS) is often used to treat patients with chronic pain, including those with neuropathic pain (such as post-herpetic neuralgia). TENS involves a small, battery-powered instrument that delivers rapid pulses of a mild electrical current to pairs of electrodes applied to the skin. The treatment is adjustable depending on the level of pain that a patient is experiencing at a particular time.

TENS machines provide only immediate relief rather than a long-term solution. For this reason, TENS is usually used as part of an overall pain management programme rather than as a stand-alone treatment.

Psychological treatments
Psychotherapy, hypnosis, music and art therapy, imagery, distraction therapy and sharing experiences in support groups can all help patients cope⁵.

Nerve blocks
In some cases, when pain cannot be controlled by any other means, the nerves can be irreversibly disrupted by chemical or surgical processes to block the pain.

Complementary Therapies
There are many types of complementary therapy available aimed to help people with chronic pain including acupuncture, reflexology and therapeutic touch. Chiropractors and osteopaths use manipulation of joints and soft tissues for relief of symptoms. Some chronic pain sufferers have been helped by homeopathic remedies, by massage and by the Alexander Technique, which focuses on correct posture.

References:

1. Scottish Intercollegiate Guidelines Network, Scottish Cancer Therapy Network. Control of Pain in Patients With Cancer. Edinburgh: SIGN 2000
2. Portenoy RK, Lesage P. Management of cancer pain. Lancet 1999; 353: 1695-1700.
3. Working Party on Pain after Surgery. Commission on the Provision of Surgical Services. Report of the Working Party on Pain After Surgery. London: The Royal College of Surgeons of England – College of Anaesthetists, 1990.
4. Chronic Pain and Its Impact. Research Study Conducted for Action on Pain, Funded by Pharmacia Ltd and Pfizer Ltd. London: MORI Social Research Institute, 2001.
5. Zara C, Sellick SM, Willan A, Reyno L, Browman GP. Health care professionals’ familiarity with non-pharmacological strategies for managing cancer pain. Psychooncology 1999; 2: 99-111.