The whys and wherefores of chronic pain

by Dr Deborah Lee, Dr Fox Online Pharmacy

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15.5 million UK adults are currently suffering from chronic pain, according to the charity, Versus Arthritis. That’s a huge 34% of the population, trying to cope with such a miserable, life-changing symptom. Perhaps one in three of anyone reading this article.  So why are so many of us in pain? This begs  the following questions –

– Chronic pain – what is it?

– How to manage chronic pain?

– What’s the link between sleep and chronic pain?

Read on and find out.

 

 

Chronic pain – what is it?

Around 5.5 million(12%) of the UK population have high-impact pain – defined as pain that’s been present for 3 months or more. 10 million (22%) have low impact pain – defined as pain that has been present for less than 3 months.

84% of chronic pain sufferers have musculoskeletal pain – affecting their neck, shoulders, or back, or their limbs affecting their hands, arms, feet, legs, or hips. But there can be many underlying causes.

 

Who gets chronic pain?

Chronic pain mostly affects the most disadvantaged in society. It is more common in

  • People who live in more deprived areas
  • Black people
  • Unemployed or manual workers

 

Risk factors

Other risk factors for chronic pain include –

  • Smokers
  • Inactivity
  • Excess alcohol
  • Psychological distress
  • Obesity
  • Those with more than one medical condition
  • A family history of chronic pain syndromes such as migraine, or fibromyalgia

Chronic pain is more common in women than men.

 

What causes chronic pain?

This is a very long list. Anything can result in chronic pain if there is inflammation, an abnormality, or dysfunction in a limb, a joint, or an organ. Some of the causes of chronic pain are listed below, but there are many more.

 

Musculoskeletal

  • Chronic or repetitive movements due to overuse – such as repetitive strain injury
  • Poor posture – sitting for long periods with poor posture weakens the muscles supporting the spine
  • Injury resulting in fractures – for example, vertebral fractures can lead to chronic pain
  • Muscular sprains – for example, an ankle sprain can lead to chronic ankle pain
  • Mechanical low back pain – pain arising from the spine, the intervertebral discs or soft tissues of the low back

 

Neurological

  • Polyneuropathies – nerves can be affected by many diseases that affect the whole body such as diabetes, autoimmune diseases and infections.
  • Postherpetic neuralgia – pain at the site of an episode of shingles
  • Trigeminal neuralgia – facial/mouth pain
  • Pernicious anaemia – B12 deficiency can cause joint pain
  • Thyroid disease – an underactive thyroid can cause joint pain

 

Rheumatological

  • Osteoarthritis – caused by acute inflammation in the joint
  • Rheumatoid arthritis – again, this gives rise to swollen, tender and painful joints
  • Polymyalgia rheumatica – this causes stiffness in the joints, with joint pain
  • Ankylosing spondylitis – this cause inflammation in the spine, and when severe, vertebrae can fuse together.

 

Psychological

  • Anxiety
  • Depression
  • Personality Disorders

 

Systemic illness

  • Cancer – both primary and secondary cancer
  • Diabetes
  • Blood disorders such as lymphoma and leukaemia
  • Infectious diseases such as HIV

 

Pain is unexplained

1 in 4 people who visit the GP with symptoms, including chronic pain, have no pathological cause for their pain identified. It can be hard to accept this is the case and have to learn to live with the pain.

 

Management of chronic pain

The National Institute for Health and Care Excellence (NICE) published guidance on the management of chronic pain (updated in April 2021).

  1. Treat the underlying condition as well as possible.
  2. Attend supervised group exercise sessions. GP’s can now prescribe gym membership for swimming and exercise classes. In the majority of cases, getting moving will help make pain feel better.
  3. Consider a course of Cognitive Behavioural Therapy (CBT). This is a type of talking therapy in which you learn more about your condition and get support to develop ways of coping with your symptoms. You can self-refer for CBT on the NHS.
  4. You may benefit from a course of acupuncture.
  5. Discuss the use of antidepressants with your GP. This might include amitriptyline, citalopram, fluoxetine or duloxetine, for example.
  6. Review your current medication with your GP or pharmacist. Check you are not taking any drugs that are not currently recommended. Agree on a shared plan with your GP about how to reduce and eventually stop taking unwanted or potentially harmful drugs.
  7. Consider asking for a referral to a chronic pain clinic.

 

 

What’s the link between sleep and chronic pain?

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One issue that does not appear in the NICE recommendations is the subject of sleep. Yet, improving sleep has many benefits for those with chronic pain.

Medical specialists have highlighted a definite association between chronic pain and insomnia. In one 2018 study, 53% of those with chronic pain suffered from insomnia – a level that is 18 times higher than in otherwise healthy controls. It seems to be a bidirectional relationship – with the pain affecting the sleep quality, but also the poor sleep quality, worsening the pain.

Improving sleep is a sometimes forgotten tool for managing chronic pain. This is one reason why cognitive behavioural therapy (CBT) is so helpful in managing the condition. It can lead to an improved quality of sleep, as well as better physical function/mobility – and lower pain scores. CBT helps patients understand their pain, and develop coping strategies, which often leads to a more positive approach, and helps them to become more mobile. Being more optimistic, and more physically active, then contributes to a better night’s sleep.

What might explain the link between sleep deprivation and pain? Researchers have found that when we do not have sufficient sleep, a part of the brain, known as the somatosensory cortex, becomes hyper-stimulated, leading to an over-exaggerated pain response, which makes the pain feel worse. Sleep deprivation can therefore intensify the pain.

In addition, lack of sleep results in under stimulation of the nucleus accumbens – a nucleus in the basal forebrain – reducing the production of dopamine. Dopamine is a neurotransmitter. High dopamine levels are associated with pleasure and the relief of pain. Hence sleep deprivation and lower dopamine levels can lower mood and tend to worsen the pain response.  

 

Final thoughts

Chronic pain is a miserable condition affecting around one-third of UK adults. Managing chronic pain is difficult. The basic steps do need to be followed – but don’t underestimate the need for a good night’s sleep. If you can improve your sleep, you are likely to see improvements in your pain.

  • If you are suffering from chronic pain, what could you do to improve it?
  • How could you improve your sleep?
  • Perhaps it’s time to discuss your sleeping patterns with your GP?

 

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