Acupuncture Today
November, 2002, Vol. 03, Issue 11
 
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The Fifth Vital Sign: Pain

Facts and Fictions about Pain and How to Evaluate it

By Julia Busching

The typical questions we ask regarding pain during a patient intake in traditional Chinese medicine are: where is the pain located; how long have you been suffering with it; is the pain sharp or dull; what makes it better (or worse); and - sometimes - how would you rate your pain on a scale from 1 to 10?

I believe there is much more to know about pain to really understand what our patients are going through.

The first fact is that chronic pain does not manifest itself the same way as acute pain. Chronic pain patients may have adapted to their situation, and may even have a smile on their face while describing pain as a nine on a scale of 1-10. For that, they experience anxiety; insomnia; poor memory and concentration; irritability; and depression.

Much confusion about chronic pain arises from the mistaken belief that absent an underlying organic disease, such pain is largely imaginary. It is a misconception that medical dependency is addiction, and that too many painkillers are used. My own observations (and studies) have shown that this is not true. The fact is that less than 0.1% of patients without a history of previous substance abuse run into problems with addiction. Addiction occurs when someone takes a substance that causes harm. That harm can be financial; psychological; social; physical; or legal. Because of a dearth of knowledge, addiction is confused with pseudoaddiction, a drug-seeking behavior that occurs not to get a "high," "buzz" or as a diversion, but for pain relief. This is a typical sign of undertreatment. It is accepted by practicing physicians that cancer pain needs to be treated, but still, up to 56% of cancer outpatients do not obtain adequate relief. Non-cancer pain is even more poorly managed. Attitudes; beliefs; lack of knowledge; and fear of laws and regulations create barriers to proper pain relief.

Another fact is that almost all patients with chronic pain are depressed. This is normal. It does not mean that the patient must have had some psychological issue(s) before getting sick, thus explaining why the patient isn't improving. According to psychiatrist Nelson Hendler, patients progress through a four-stage response to pain:

Acute stage (0-2 months): In this time period, the patients expects to get well. The patient received treatment as anticipates a full recovery with few, if any, residual effects. Although the pain may be severe, the patient believes it is only transient, and he/she is not clinically depressed.

Subacute stage (2-6 months): Concerns begin to emerge and, contrary to expectations, the patient still hurts. Questions arise as to whether there was a misdiagnosis or error in treatment. The patient tells the truth when claiming to have more body pain than other people. In this phase, patients are often diagnosed as hypochondriacal and hysterical.

Chronic stage (6 months-8 years): Marked depression, triggered by the realization that the pain appears to be permanent, is the rule during this stage. This is usually a full-blown case of depression, with sleep disturbance; sexual dysfunction; loss of self-esteem; guilt; and increased risk of suicide.

Subchronic stage (3-12 years): The patient becomes reconciled to the situation and starts to adjust to it. Acceptance and accommodation are the motives of this stage. The patient realizes the pain will probably persist for life, no matter what medical intervention is attempted. The patient is not happy with the situation, but nevertheless begins devising strategies for dealing with the pain and functioning despite it, rather than fighting it. The depression scale is usually lower.

Another problem the public does not understand is that although the chronic pain patient looks normal, that person is really very sick and often disabled (as with cases of fibromyalgia and complex regional pain syndrome). The fact is that chronic pain is irritating, unpredictable and ever-present. It supersedes the thoughts of anything else and interferes with concentration, even on the most basic level. Most pain is exacerbated by stress. Pain itself is stress, and is very exhausting. It causes anxiety and sleep disturbance, and the consequence is severe lethargy during the day.

It is also widely believed that non-cancer pain is not life-threatening, but studies show that it is. Chronic pain suppresses your immune system and shortens your lifespan by up to five years. Due to undertreatment, many patients with chronic pain consider suicide as a relief to their suffering.

Considering all of the abovementioned secondary symptoms caused by chronic pain, it is important to ask for more detailed information about the patient's condition. These are the sample questions I use in my intake form to evaluate pain:

SAMPLE PAIN EVALUATION FORM

1. Where is the pain located? Does it radiate?

2. What caused the pain? Is there a diagnosis?

3. Description of pain (please underline all those that apply)
Aching, throbbing, gnawing, tender, shooting, stabbing, penetrating, burning, exhausting, tiring, numb, nagging, sharp, continuous, miserable, unbearable, tight

4. What kind of treatment(s) have you tried? (please underline all those that apply)
Medications, physical therapy, manipulation, acupuncture, massage, exercise, TENS, special diets, injections/nerve blocks, rehabilitation, operation, herbs/vitamins, chemotherapy,
other _________________________________________

5. What medications are you currently taking for your pain? (include dosage)_____________________________________________
___________________________________________________

6. Does this problem interfere with your daily functioning? (if yes, please underline)
Work, mood, sleep, social life, appetite, digestion, sports, sex, walking, grooming, enjoyment of life, concentration,
other _________________________________________

7. Please rate below the severity of your pain on a scale of 1 (very slight) to 10 (unbearable)
Worst pain this month:
Least pain this month:
Average pain this month:
Pain right now:

8. What increases/triggers/aggravates your pain? (please underline all those that apply)
Stress, activity, rest, cold, heat, rainy weather, touch, sugar, noise, alcohol, smoking, walking, sitting, typing,
other _________________________________________

9. What makes it feel better?_______________________________________________
_______________________________________

In most cases, TCM can complement the treatments already prescribed or even offer an alternative where necessary. Many times where traditional medicines have been contraindicated, the pharmacopoeia of Oriental and naturopathic medicine has produced a solution. Following up on this intake helps to understand patients more and helps to notice even subtle improvements in a patient's condition. It also clarifies when the treatments are successful enough to improve the patient's quality of life, or when it necessary to refer the patient to a conventional pain specialist or psychologist that specializes in chronic pain.

References

  1. Cleary JF. Principles of pain management. Audio Digest Internal Medicine November 22, 1999; vol. 46, issue 22.
  2. Dorsch P. Lehrbuch der Neuraltherapie Nach Hunecke, 14. Auflage: Erweiterte.
  3. DRCet Drug Reform Coordination Network. Chronic pain treatment. Website update May 2002.
  4. Foubister V. Oregon doctor cited for negligence for undertreating pain. American Medical News September 27, 1999.
  5. Hendler N. Depression caused by chronic pain. Clinical Psychiatry March 1984;45(3)[Sec. 2].
  6. Hendler N. The four stages of pain. In: Hendler, Long, Wise. Diagnosis and Treatment of Chronic Pain. Littleton, MA: John Wright PSG, 1983.
  7. Herbst LH. Modern pain management. Augio Digest Internal Medicine May 1, 1998;vol. 45, issue 9.
  8. Herget HF. Neuro- und Phytotherapie Schmerzhafter Funktioneller Erkrankungen Band 1, 1. Auflage: Pascoe Giessen, 1979.
  9. Hooshmand H. Chronic Pain: Reflex Sympathetic Dystrophy. Prevention and Management. CRC Press, 1983.
  10. Liebeskind JC. Pain can kill. Pain Jan 1991;44(1):3-4.

 

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