Painkiller use in Chronic Pain

Note, this article is written for the UK and things may differ in other countries

What is chronic pain

Chronic pain is pain that is not helpful for the sufferer. Acute pain is usually helpful as it tells the body something is wrong. For example, you put your hand on a hot surface, the pain quickly tells you to remove it. Afterwards you may have pain because you have a burn and you will do the right thing i.e. put cold water over it. Not so in chronic pain. Chronic pain often represents a pain stamp in the brain when the acute pain has long gone.

“but my pain is real, I know I have back pain, it is always there”

In some cases this is the case i.e. if you have a disk prolapse and therefore severe back pain. But this is not typical chronic pain. In typical chronic pain you have been investigated and little or no cause has been found and you still suffer the pain.

If chronic pain is not caused by a pain stamp in the brain it is often caused by the following

  • Physical inactivity (who doesn’t get back pain when they sit in a chair for 12 hours?)
  • Obesity (if you put 80 tons of the axles of a 40 ton lorry the axles wear out quicker)
  • Lack of exercise (classic example: Patients with dementia in a nursing home sitting in a chair all day. Studies have shown taking them out of the chair a few times a day is better than giving regular painkillers)
  • Other poor lifestyle choices (i.e. diet, smoking, alcohol etc – a classic example are osteoporotic fractures of the spine and elsewhere, terribly painful and often caused by smoking, alcohol and lack of core strength)
  • Aging (with all of the above – yes, sorry, but our joints degenerate and pain becomes more common in older age – I always say weaker joints need stronger muscles)

The classic example “Phantom Pain”.

There is no better example than a sufferer of so called phantom pain. This is for example a patient, who has had their leg amputated and still has severe ankle pain. This ankle pain may even get worse in cold weather etc, just there is no ankle. This usually represents a “pain stamp” in the brain

“So if I have pain, I’ll take painkillers – Right?”

Correct, in acute pain painkillers are a great relief and there is usually no problem with taking painkillers for a short time (unless you are allergic etc). However, again a good example on what not to do is my own son: He had shoulder pain when playing too much table tennis in training and we gave him painkillers instead of telling him to rest or sending him for physio. He continued heavy training sessions. This causes a lot more serious shoulder problems. So if your child has injured themselves on the trampolin, don’t give them more Nurofen just to go back onto the trampolin.

However, in chronic pain painkillers are better avoided. Why – 3 reasons:

  1. Tachyphylaxis.
    Tachyphylaxis means you are getting used to them and need more and more. Simple example. Today you take a Paracetamol for a stomache ache. You never take painkillers, it works perfectly. Over the next month you take it a lot more. Everytime you take more your brain feels cheated. They work less and less. You contact your doctor for more painkillers
  2. Hyperalgesia
    Hyperalgesia is another concept, which affects particularly Opioid Painkillers, for example Morphine, Tramadol, Pain patches of all sorts including Buprenorphine, Codein, Dyhydrocodein and more. This means the brain feels even more cheated and instead of reducing the pain the pain gets worse and worse and you need more and more painkillers yet have more and more pain.
  3. Side effects and long term effects. See example of a list below
Type of Painkillers Main issues
Paracetamol (US: Acetaminophen) Most commonly used painkiller, very toxic in overdose, can cause liver damage.
Ibuprofen and other anti-inflammatories Increases blood pressure, damages kidneys, reduces kidney function, can cause stomache ulcers and serious stomache bleeds.
Codein, (Co-Codamol (UK) Severe constipation, tachyphylaxis, hyperalgesia, nausea and sickness, addiction
Dihydrocodein, Co-dydramol (UK) Severe constipation, tachyphylaxis, hyperalgesia, nausea and sickness, addiction, driving offense*
Pain patches – usually opioid containing with few exceptions Constipation, tachyphylaxis, hyperalgesiia, driving offense*
Morphine Constipation, tachyphylaxis, hyperalgesiia, driving offense*
Gabapentin Tiredness, mood changes, tachyphylaxis,
Pregabalin Addiction, weight gain, memory problems, headaches, sleepiness, driving offense*
Amitriptyline Constipation, Dry mouth, heart problems, falls in the elderly, must not drink alcohol

*In the UK driving when on controlled drugs (most prescription painkillers) is not completely prohibited, but if you cause an accident while taking them you could be criminally prosecuted, particularly if others are involved.

So, in the table above you can see there is simply no painkiller that is good for you long term. They all have side effects to various degrees. When addressing chronic pain, alternative concepts should be applied.

 

Other methods, non-medical and non-pharmaceutical should be used and painkillers should be weaned as soon as possible. CBT (cognitive behavioural therapy) for example is a great way to train the brain to ignore pain