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ain is the chief reason that people seek medical care. And
whether it is a tooth, ear, stomach, head, or back that
aches, people all want the same thing--relief. Since ancient
times, humanity has been preoccupied with finding ways to
relieve pain. For thousands of years, our ancestors had only
a few substances (mainly alcohol, opium, and the coca and
hemp plants) to help make the pain go
away.
But modern pharmacology changed all
that. Today, dozens of drugs mercifully eliminate, or at
least greatly reduce, the pain that comes with all types of
ailments. However, their effectiveness for chronic pain is a
different matter. Treating chronic pain is tricky; great care
and caution must be exercised because of the potential for
side effects and addiction associated with pain-relieving
drugs.
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What Is Pain?
Pain is the body's way of telling us
that something is wrong. If we place our hand too close to a
fire, we feel pain. When a bone is broken or the skin is cut,
if we have inflammation from arthritis, or tense muscles from
stress, a signal flashes from nerves in the distressed area
to a part of the spinal cord where cells called pain
receptors are located. These pain receptors send the signal
along different tracks in the spinal cord to the brain, where
the message of pain is registered.
Pain evokes emotion. Sudden, short-lived
pain can cause anxiety; constant, unrelenting pain can leave
us seriously depressed. Because of the emotional aspect of
pain, treatment may involve much more than common
painkillers, particularly for those in constant distress.
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Common Types of
Pain
For purposes of treatment, doctors
divide pain into the following three basic
types:
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Acute pain, which is usually
temporary and often the result of injury. Causes of acute
pain range from surgery, fractures, infections, and burns
to natural events such as
childbirth.
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Chronic pain, which is arbitrarily
defined as a pain that persists for more than three to
six months and threatens to disrupt the patient's normal
activities. Chronic pain is associated with a wide range
of long-lasting and permanent disorders (see
box).
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Cancer pain syndromes, which can
result from either the tumor itself or the surgery,
radiation, and chemotherapy used during
treatment.
In addition to these three major types
of general pain, headaches come in so many forms--and have so
many causes--that they are considered a category unto
themselves (see box).
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THE MYRIAD CAUSES OF CHRONIC PAIN
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A list of disorders that can lead to
chronic pain would be almost endless; but here is a
sample of some common culprits:
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Lower back problems, slipped
disks, and sciatica
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Arthritis, tendinitis, and
bursitis
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Sickle-cell anemia and
hemophilia
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Nerve damage caused by diabetes,
kidney failure, and many other problems
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Treating Acute
Pain
Because this type of pain is often the
result of a specific trauma or infection, your doctor's first
goal is to eliminate the underlying cause, if at all
possible. To relieve the pain while other measures take
effect, he or she will draw on a wide array of analgesics,
including the following:
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Aspirin, buffered or
plain
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Acetaminophen
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Narcotics
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Nonsteroidal anti-inflammatory drugs
(NSAIDs), such as Motrin
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Tranquilizers
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Muscle
relaxants
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Local anesthetics, applied to the
surface or injected
The choice of analgesic varies according
to the severity of the pain and the stage of the healing
process. Consider, for example, a
fracture.
The pain of a fracture results from
muscle, nerve, and soft-tissue damage. When the bone is first
being set, pain-killing measures vary with the severity of
the injury. They can range all the way from general
anesthesia to use of a local anesthetic and a narcotic
analgesic such as meperidine (Demerol). (A muscle relaxant
may be used to help stretch muscles and make it easier to set
the bone.)
As the fracture heals, painkillers
containing codeine are gradually replaced by milder pain
relievers such as aspirin or NSAIDs. Aspirin usually provides
sufficient pain relief for strains and sprains. However, if
the strain is chronic and doesn't respond to local heat
application, muscle relaxants may be
necessary.
Likewise, the intense pain typically
following surgery and childbirth is treated initially with
morphine-based analgesics administered intravenously,
intramuscularly, or epidurally (in the spine). These measures
may be followed with PCA (patient-controlled intravenous
agents), then oral painkillers, and finally milder aspirin
and acetaminophen compounds.
Treatment for other forms of acute pain
varies with the cause. Depending on the severity, pain from
burns is treated with anything from aspirin to narcotic-based
painkillers. Though pain occurs with most bacterial
infections, the first line of treatment is to cure the
infection with antibiotics. Analgesics are given only for
specific conditions--in the treatment of certain skin
infections, for example. The treatment of viral infections
ranges from acetaminophen for the head and muscle aches of
the flu to codeine compounds for the uncomfortable itching
and pain of shingles.
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HEADACHES
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Headaches are the most common pain
complaint. Ninety percent of all headaches are caused by
tension--muscular, vascular, or a combination of both
types. The remaining 10 percent result from underlying
intracranial, biological, or psychological disorders.
Migraines are severe, throbbing headaches that result
from the contraction and expansion of cranial arteries.
We don't know what causes migraines, but we do know that
they afflict about 10 percent of the population, tend to
run in families, and are more prevalent in
women.
Most people rely on over-the-counter
medications, such as aspirin or acetaminophen, to treat
simple headaches. Typically caused by fleeting conditions
such as fatigue, emotional strain, menstruation, or
environmental stimuli (bright lights, crowds, or noise),
these headaches usually subside when the stress
ends.
But if a headache persists for more
than a few days or recurs over an extended period of
time, it should be reported to a physician in order to
determine any possible underlying causes. These causes
may include glaucoma; diseases of the teeth, scalp,
extracranial arteries, external or middle ear; spasms of
the shoulder, neck, or face; systemic disease;
hypertension; intracranial bleeding; head trauma or
tumor; aneurysms; and abscesses. Vasodilators, such as
alcohol, histamines, and nitrates, can also cause
headaches.
Migraine headaches are characterized
by intense localized throbbing that usually spreads.
Migraines are often preceded by changes in vision (a
flashing blind-spot or the absence of half of the normal
field of vision), pins and needles on one side of the
body, or impaired speech. The headaches are frequently
accompanied by nausea, vomiting, loss of appetite, and
sensitivity to light. Sometimes migraines are a symptom
of the onset of menopause.
The best treatment for migraines is
a shot of the new drug Imitrex taken under the skin or,
if Imitrex can't be taken, the older drug ergotamine
(Cafergot, Bellergal-S), taken alone or with caffeine.
Drug treatment is most effective when the medication is
used in the early stages of an attack. If nausea and
vomiting are present, ergotamine may be given as a rectal
suppository. Propranolol (Inderal) and calcium channel
blockers, such as verapamil (Calan, Isoptin) and
diltiazem (Cardizem), can help prevent
migraines.
The treatment of chronic headaches
depends on the type of headache and may include anything
from aspirin to codeine or meperidine (Demerol). Acute
attacks often respond well to tranquilizers; chronic
tension headaches are sometimes alleviated by muscle
relaxants. An accurate diagnosis and elimination of
underlying causes of the problem are essential.
Psychotherapy may be necessary if the headaches are
caused by emotional distress.
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Treating Chronic
Pain
An estimated 80 million Americans suffer
from chronic pain. Though narcotic analgesics are extremely
effective in easing acute pain, their addictive properties
and side effects make these drugs a less desirable choice for
long-term use and often undermine the relief they bring.
That's why they must be used carefully, if at all, for
chronic pain. It is also the reason that other methods have
been developed to treat and manage the
problem.
Indeed, a new medical specialty known as
pain management has emerged in recent years. Pain management
employs a wide range of therapies to help people learn to
live with pain, using only a minimum of drugs. These
alternative treatments include exercise, deep-muscle
relaxation training, massage, biofeedback, cognitive therapy
for pain control, TENS (Transcutaneous Electrical Nerve
Stimulation), neural blockade, steroid therapy, and diet
counseling. Because chronic pain usually affects a person's
psychological well-being and his or her relationships,
individual, group, and family therapy are also advised in
most cases.
The full spectrum of analgesics and
muscle relaxants are prescribed for chronic pain, although
morphine-based drugs are generally replaced with NSAIDs to
minimize the possibility of addiction. Antidepressants have
also been found to be effective for some individuals
suffering from long-term pain.
To meet the needs of those with chronic
cancer pain, doctors are now using a variety of advanced
techniques. Painkillers can be delivered through home
intravenous infusion systems or implanted epidural catheters.
TENS systems may come into play, and neurolytic
(nerve-destroying) neural blockade has proved effective for
certain patients.
Despite all these advances, there's
still no perfect solution for pain. Many of our current
medications present one drawback or another, ranging from
gastric side effects to the potential of addiction.
Nevertheless, there's no denying we now have more ways of
providing effective control of pain than could be imagined
just a few decades ago.
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