Presented by: Ravi Prasad, PhD
Clinical Associate Professor of Anesthesia
February 27, 2014
The pain that comes from hitting a finger with a hammer or touching a hot stove serves an important purpose, warning our bodies to respond to danger. But for more than 100 million adult Americans, the pain never seems to go away.
Chronic pain affects more Americans than diabetes, heart disease, and cancer combined. It is one of the largest causes of disability in the United States, costing greater than $500 billion each year in lost productivity and health care treatment.
“The purpose of pain is to act as a warning system to protect the body from harm,” said Ravi Prasad, PhD, the assistant chief of the Division of Pain Medicine, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “It alerts you to react in order to avoid damage. The problem is, that is not true of all kinds of pain.”
There are two types of pain. Acute pain has a specific cause that can usually be resolved by following a protocol, such as taking medication or undergoing a procedure. The pain is a direct reflection of harm. For example, a fall can lead to a fractured ankle that can be put in a cast, treated short-term with mild painkillers, and/or strengthened with physical therapy.
Chronic pain, on the other hand, does not always have a specific or identifiable origin, and the brain continues to send out pain messages even though there is no longer a stimulus for danger. “It’s a like a false alarm to the body. The pain is real, but it is not a sign of active harm. There’s no imminent threat and yet it persists with no fixed endpoint,” he said. “Many people suffer for months or even years without any evidence of ongoing physical damage.”
For most people, life is filled with multitudes of activities and interests, from family to work to hobbies. For people suffering from chronic pain, that one aspect of life starts to take over everything else and becomes the central focus.
Facets of Treatment
“Acute pain and chronic pain are two different beasts. Using acute modalities to treat chronic pain is a disservice to the patient: It can lead to false hope and disappointment when standard approaches don’t deliver results,” Dr. Prasad said. “Chronic pain needs to be perceived and treated like other chronic conditions, using similar paradigms to optimize the condition.”
Treatment for chronic conditions like diabetes, high blood pressure, or asthma involve both behavior and lifestyle modification, and patients need to incorporate all recommendations.
“It’s a matter of balance— you can’t just pick and choose the things you like or think might work. Stress and emotions have a powerful effect on chronic pain as well, so it’s not just a matter of diet or exercise or movement. Treatment involves a multifaceted approach to improve quality of life,” he said.
The first step is medical optimization, a careful analysis by a medical specialist to make sure the condition is indeed chronic and not caused by an undiagnosed disease. Options can include surgical treatment or injection therapies, or the physician also may use pharmacologic interventions by prescribing the most appropriate medication(s) at the most appropriate level. In conjunction, they usually incorporate physical reconditioning with physical therapists to offset the tendency to minimize using the painful area or to overcompensate by favoring other parts.
Like other chronic conditions, behavior and lifestyle modification are fully integrated into treatment as well. These non-pharmacologic strategies include psychological and behavior-based therapies that incorporate the mind-body connection, such as biofeedback, breathing and relaxation training, and cognitive behavioral therapy.
Mind and Body
Pain is a complicated process that involves an intricate interplay of chemicals and signals in the body’s sympathetic and parasympathetic nervous system. The process serves as an on-off switch, a feedback system of excitation and inhibition—“the “fight or flight” response. When the sympathetic nervous system activates, it raises blood pressure, heart rate, and muscle tension. The parasympathetic system brings these functions back to normal.
Because pain’s effect on the brain affects the same regions associated with basic emotions, feelings like stress or anxiety can amplify the suffering.
“Stress and pain are intrinsically connected, “said Dr. Prasad. “The nervous system’s reaction to stressors is directly involved with physiological changes. The body doesn’t discriminate between physical and emotional stressors: The physiological response pathway is the same, whether we are responding to a threatening dog or an argument with a spouse. It creates a vicious cycle.”
The challenge with chronic pain, he added, is how to break the cycle since the pain itself cannot be alleviated. One of the most successful strategies is the application of breathing exercises, focusing in deep and slow inhalations and exhalations. Deep breathing activates the parasympathetic nervous system, cueing the brain to slow things down after a stressful event. But the process requires some mental discipline and concentration for it to work.
“It’s not just a psychological trick,” he said. “It’s a physiological response. It’s also a distraction since it helps to refocus your attention away from the pain. The pain still exists, but you’re giving your body a reprieve to stop the feedback system.”
He also emphasized the benefit of cognitive restructuring to learn how to reinterpret the situation and override one’s automatic reaction to a stimulus. Thoughts control emotional, physical, and behavioral responses, so changing perspective can have a powerful impact on outcomes. The process is not easy, he warned, since automatic responses tend to develop over a lifetime, and habits are hard to break.
Studies show that cognitive restructuring helps to reduce perception of pain as well as levels of anxiety and depression, he said, and shows an improved sense of control since its users are better able to recognize their triggers for pain episodes.
“It’s not as simple as, ‘Think positive,’ but there are ways to break the cycle by targeting your thoughts and asking some fundamental questions about their usefulness. Ask, ‘Is this helpful?’ or ‘Is this accurate?’ It can eventually lead to a different set of automatic thoughts,” he said. “The pain is still there but it may reduce the loop of activation.”
About the Speaker
Ravi Prasad, PhD, is a clinical associate professor of anesthesiology, perioperative, and pain medicine, assistant chief of the Division of Pain Medicine, and director of the Stanford Comprehensive Interdisciplinary Pain Program. He received his PhD from Texas Tech University and completed his internship at Salt Lake City Veterans Affairs Medical Center in Utah and his fellowship at Kaiser Permanente in San Francisco.
About the Stanford Pain Management Center
The Stanford Pain Management Center is an integrated, comprehensive program that treats more than 12,000 patients a year.. A team of anesthesiologists, physiatrists, neurologists, psychologists, nurses, and physical therapists assess each patient’s type and degree of pain, and develop personalized treatment plans. The Center is one of only a few institutions in the country that have received consecutive Center of Excellence awards from the American Pain Society.
For More Information:
Stanford Pain Management Center
Stanford Hospital Pain Clinic
Department of Anesthesiology