Working at iCare Pharmacy I have developed a special interest in Chronic Pain. I was quite lucky to have a couple of great mentors in my life such as Dr.Rambaransingh from Body Restoration. They have allowed me to bounce ideas off of them and to learn what is best for patients who do present with symptoms chronic pain.
Pain has an important function in the body. Pain is the instant reaction of your body towards any injury or illness. It’s like a warning sign from your body to tell you that something is wrong. Usually, the pain subsides when the illness or injury is cured and healed. But sometimes the pain can still continue long after the illness is cured and even after the cause of the pain is treated. If your pain has lasted for more than 3 to 6 weeks, the pain is known to be chronic pain. Your nerves are sending pain signals to indicate that you are in pain even though there is no structural damage. Some people having severe chronic pain continue to suffer from an advanced condition called Chronic Pain Syndrome (CPS).
Chronic pain can range from being mild to severe pain. One can suffer from an ongoing acute pain for several months long after recovering from an injury. Another type of chronic pain is when the pain keeps triggering irregularly due to an unidentified cause. Nociceptors are sensory nerves located under the skin that carry pain signals up to our central nervous system to our spinal cord and brain. In patients with chronic pain Nociceptors become overly sensitized and send pain signals when they are presented with stimuli that are typically not harmful. For instance some patients may experience extreme pain just putting on clothing or even a brisk wind. This is because of the over sensitization of our pain receptors. Other than the stinging or burning pain, patients may also experience the following symptoms:
Medications from a pharmacy provide about 30% pain relief for a person suffering from chronic pain. There are a variety of different medications that can help with Chronic Pain. Some of the classes of medications that help with Chronic Pain include:
Although traditionally used for prevention of seizures this class of medication is helpful in the management of chronic pain in that they prevent your nerves from sending too many pain signals to your Central Nervous System. Examples of anticonvulsants include Gabapentin as well as Lyrica.
The active ingredient in Botox is Botulinum. I find it really interesting as it is actually an anti-paralytic. In high doses it can causes paralysis and can be deadly. But medically we use it in much smaller doses. And as such it was initially used for patients who were suffering from extreme involuntary contractions. By causing a partial paralysis to a muscle it prevents it from sending pain signals to our central nervous system.
A side effect of patients receiving this injection for contractions was that these patients had smoother skin with less wrinkles! That is how it was discovered that Botox also had a cosmetic indication. So dermatologists started injecting it to help patients look younger.
But further still they found patients who were getting Botox injections for cosmetic purposes were suffering from less migraines! By preventing contractions of certain facial muscles you can reduce or prevent the occurrence of a migraine and when they do occur they are less severe then what they would be normally.
Antidepressants serve dual functions in that they can help with both mood as well as pain. There are generally two classes of Antidepressants when it comes to pain. There are Tricyclic antidepressants as well as as a class known as SNRI’s.
Tricyclic antidepressants at lower doses help more with with pain rather then with depression. One of the benefits of using Tricyclic Antidepressants is that one of their side effects is that they can cause drowsiness and as such can also help patients who are suffering from insomnia. Example of Tricyclic Antidepressants are Amitriptyline, Nortriptyline and Desipramine.
SNRI’s are helpful in the management of Chronic pain because they are also helpful in the management of Neuropathic Pain, Depression as well as Anxiety. Example of SNRI medications are Effexor (Venlafaxine) and Duloxetine (Cymbalta). Cymbalta is one of the few medications that is officially indicated for use in Diabetic Neuropathy.
Anti-Inflammatories can help reduce pain through a reduction in inflammation and swelling. We can reduce the amount of pain in patients with Chronic pain through a reduction in inflammation. Furthermore, they can be helpful in regards to Chronic Pain in that by reducing inflammation in a muscle we can reduce the amount of pressure that an inflamed muscle is exerting on a nerve. Anti Inflammatories are readily available. Example of Anti Inflammatories are Ibuprofen (Advil) and Naproxen (Aleve). However, because they are are so readily available they are sometimes over used. There is a risk with Anti inflammatories of increasing your blood pressure and also increasing your risk of developing an ulcer.
Anti Inflammatories are sometimes used in combination with muscle relaxants in regards to Chronic Pain. Muscle relaxants can also be used on their own in the management of Chronic Pain. Muscle relaxants can help patients who are suffering from muscle contractions or tightness. They can also help in the management of patients who are suffering from Chronic muscle pain
A compound is a medication that is prescribed by your physician but is not available commercially. As such the pharmacy has to make the medication for you. This is a type of medication that I feel in Chronic pain is often underutilized. The benefit of having a medication that is not commercially available is that it can be tailored to your needs.
For example in medications for Chronic Pain we will often use creams and ointments to help the management of any localized pain a patient may be experiencing. If the patient is experiencing any inflammation we can add an anti-inflammatory. If a patient is suffering from neuropathic pain we can add an anticonvulsant or an anesthetic. The advantage of this is you can deliver a localized effect tailored to your need and because the medication is not being ingested orally you avoid some of the side effects you can experience such as dizziness, drowsiness and mental clouding that sometimes is associated with taking certain medication orally.
Opioids is the most controversial class of medications that is used for the management of chronic pain. Opioid dependency and addiction is major issue currently as there is an opioid epidemic. This issue is quite complicated and I will not be able to do it justice in discussing it here. There is no quicker way to divide a room of health care providers then a discussion of opioids.
Opioid receptors are all throughout the body and opioids exert their effects through inducing analgesia and euphoric effects. Although they can be helpful in regards to management of chronic pain how well they work for a patient has to be weighed in regards to its potential side effects and the risk for dependence and addiction.
That being said opioids are appropriate for some patients as they do help manage their pain. Because there has been a crusade against opioids, patients who do benefit from its use in some cases have been stigmatized. It is not uncommon for patients who are suffering from Chronic Pain to be stigmatised as someone who has drug seeking behavior rather than actually helping the patient in their management of their immediate needs. I understand the need to vigilant because opioids have definitely been over prescribed in the past but there needs to be fine line between being vigilant and helping patients in Chronic pain who do find relief from opioid treatment. It is our job to do a better job in being able to negotiate this fine line.
With Cannabis recently being legalized there is a lot of interest in its use in regards to Chronic Pain. It has been used medically for some time but there has been a delay in adoption because of the traditional stigma surrounding its use. Now that it is legal there is more of a curiosity by patients as to whether it can be helpful in the management of their pain.
Currently medical Cannabis can not be sold at a pharmacy. It is something our college is hopefully working with Health Canada behind the scenes. I think there are a variety of reasons why it is important for pharmacists to be involved in the distribution and the education on medical cannabis. By having it dispensed at pharmacies it would provide some clarity for the patient in choosing which type is best for their needs. If you purchase from some suppliers you may see all types of names such as purple kush or pineapple express but what does that really tell you about what the product does for you? We need a medical system that is standardized and less confusing so patients can have a clear indication of what they are using. While there are a variety of different types of cannabis as a health professional I am mainly interested in what the content of THC and CBD is within the product. I will go more into detail in regards to know which product is best suited for your needs in our Cannabis Blog.
There can be potentially drug interactions with other medications you already taking. It is best to check with your pharmacist or physician to ensure that they do not interact with other medications or conditions. I have talked to some pharmacists who had no idea that their patients were also on medical cannabis. Being on medical Cannabis is great if it works for you. But as a pharmacist I want to make sure that you are getting the most out of it and it is not a detriment to your current therapy. I think medical Cannabis is very important in the management of Chronic Pain especially for patients on opioids. Although medical Cannabis is not strong enough for some patients to completely stop taking opioids it is considered opioid sparing meaning that you will need less opioids to achieve your desired effect when medical cannabis is used as an adjunct. This overall can help to decrease the side effects of using opioids and increase tolerability by reducing reliance on opioids.
Psychological therapies have become a mainstay of chronic pain treatment. New advances in psychology have made therapy a widely used multidisciplinary management for chronic pain. People suffering from chronic pain may also experience mental problems such as feeling isolated, anxiety, sleep disorder, depression, relationship distress, disability to work, and many more. Similarly, people that have psychological problems may develop chronic pain. Sometimes, psychological concerns are converted into physical symptoms of chronic pain. This condition is called somatization.
Chronic pain treatment through psychology is categorized as cognitive and behavioral strategies that aim to reduce mental suffering. Psychological therapy promotes active engagement with life by bringing up to a 40% reduction in chronic pain.
Psychological therapies include counseling, mindfulness, self-management, support groups for mental health, and biofeedback. This helps a patient in being more cognizant of their body and their environment and how their body responds in relation to the environment. This can help a patient identify triggers and attempt to desensitize their pain to the stimulants in the environment.
Anxiety and Chronic Pain are very much related in that patients who are suffering from Chronic Pain are going to be on edge because they worry about how their Chronic Pain can cripple their independence and make them feel like a burden onto others. And Anxiety feeds into Chronic Pain by making it worse by sensitizing our pain receptors which makes us more prone to over react to even non-noxious stimuli. That is why it is very important to do our best to make sure we are healthy both physically and mentally.
Chronic pain patients can benefit from physical therapies and treatments. In some patients we can see a 30 to 40% reduction in Chronic Pain. Chronic pain treatments include physiotherapy, chiropractors, acupuncture and massages. The idea behind these treatments is to increase blood flow and to increase your strength so you can get more active. Patients with Chronic pain struggle with exercise but exercise is such an important component of healing. That it is why it is important to have a physiotherapist part of your team that can help to build an exercise program for you to help promote an increase in your activity and quality of life.
Interventional therapies are more invasive in that they typically involve injections to areas such as facet joints or they are providing nerve blocks. They can provide a 30 to 50% reduction in Chronic Pain in patients.
A facet joint injection occurs at segments of your spine that help with stability and guide motion. The idea with a facet injection is that we want to decrease inflammation in the joint.
A nerve block is exactly what it sounds like in that you are interrupting a nerve from sending pain signals. It can be an important component of the management of Chronic Pain as with Chronic Pain we do see our nervous system unnecessarily sending pain signals even though there is no sign of structural damage to the body.
Spirituality is very important in the management of Chronic Pain. Spirituality can account for a decrease in pain up to 20%. Spirituality of course means different things to different people. It could mean meditation at home, going to church or going for a nice walk and enjoying nature. The beauty of spirituality is that it is whatever gives you peace and purpose and that definition will vary from person to person. What is more important you do take that time for yourself daily to be spiritual. It might not be necessarily for everyone but I do think it is worth exploring.
Out of all the different pillars in pain management the one with the greatest impact on chronic pain is your overall lifestyle. This includes:
Positive lifestyle changes can produce up to a 50 percent reduction in daily Chronic Pain. For example, patients who smoke tend to have higher levels of pain and this pain decreases once they stop smoking. Also exercise is very important. We want to keep your body moving and active. Otherwise it becomes rigid and stiff. For patients who have difficulty with even simple levels of exercise such as walking half a block it may be helpful for them to start off in the pool as this can be easier on your joints as you exercise. Any regimen that you have for Chronic Pain exercise should be dose on the advice of a health professional so we can build a program tailored to your needs.
As you can see the management of Chronic Pain can be quite complicated and intensive. For that reason you should use all the different approaches that are available to you. You should not rely just on medication. You should do other things as well such as take care of yourself both Spiritually and Mentally and also make exercise a regular part of your regimen. More importantly Chronic Pain can be a difficult road to travel but you never have to travel it alone. There are many people and support groups out there that can help guide you on your road back to recovery.