About not getting chronic pain in the first place.

And not getting ill at all. Chronic pain like all chronic ailments, is to some extent preventable. That's what this site is largely about, I hope.

Why does pain become chronic? The cause is presumably still operating, or has been supplanted by a new cause.

People talk a lot about wind-up or sensitization in the pain perception mechanisms of our brain, spinal cord and peripheral nerves.

These chemical and functional changes are secondary to some continuing primary cause. Conventional medicine often fails to find the cause or treat it (or them) adequately. Really important areas thus neglected include food intolerances and vertebral joint derangements.

If you have what looks like becoming chronic pain, seeing a chiropractor and a clinical ecologist could be very worth while.

(Having said all that, there is a contrary view. We have very efficient brains, capable of complicated learned automated behaviour such as car driving. It is proposed that in chronic pain, the process of pain perception, interpretation and behaviour can become automated in the same way and so self perpetuating.)

Chronic pain can often be helped, better than you think.

Everyone's different, colour of hair and chronic pain tolerance included. Variations of one gene on chromosome 22 were found to affect experimental pain, in experiments at the University of Michigan1.

Our genes do different things in different circumstances, and changing the supply of nutrients can alter their action. My naturopath mentor was mostly able to relieve peoples' pain this way.

I didn't learn enough from him, to do this. Most naturopaths cannot, but it is possible.

Pain management always needs much more than nutrients. There's room for everything here, as long as expectations are reasonable and everyone concerned is honest.

I've seen quite convincing home movies of a Filipino psychic surgeon doing operations with bare hands. I've personally benefited from Reiki hands-on healing. One of my dogs benefited from absent healing without meeting the healer (and without my knowing the healing was to be sent.)

Cherche le Guérisseur - every place has its' local healers.

Self management is essential

State your intention to yourself, that you will take control over what happens to your body. Search out and listen to advice, then withdraw and quietly consider what you feel best doing.

An excellent workbook to guide you in self help, is "Controlling Chronic Pain" by Connie Peck (Fontana/Collins.)

The Pain Toolkit site is good value if you prefer stuff on-line.

One needs to learn to respond to pain in an entirely different way.

The medical approach to chronic pain.

I'm an idealist and a pragmatist. I sometimes admit defeat, accept peoples' condition as chronic and incurable, and maintain them on long term analgesics. Long term treatment with any drug is dangerous3 to some degree, and chronic analgesic prescribing is a bit like walking a tight rope.

One is not aiming at total pain relief. I was quite surprised when I first heard pain management specialists say they aimed for 30-50% relief of pain. I would have thought it would be more like 80%

Their reason for limiting to this, is that experience has shown aiming for more relief causes too many side effects.

Even with my particular interest in pain, I would dearly love to have more access to help and advice from pain specialists.

Such specialists are few and far between however, with long waiting times before someone is seen.

If you suffer from chronic pain, you will probably have experienced unsatisfactory relief at times. When you have the energy, consider lobbying your government representatives for higher priority for this area.

Its' overall cost to society is second only to cardiovascular disease, and greater than cancer.

The small number of doctors in this field, have little political clout. This needs large numbers of people to have any effect, so please consider adding your voice.

Analgesic drugs in chronic non cancer pain

Trial and error, or suck it and see - any new treatment of any sort is always an experiment. The massive advances in the field of genomics will reduce this uncertainty in the future, but for now it is just give it a go and see if you feel better.

It's best to start one drug at a time, at the lowest dose initially so any "side effects" (toxicity) will be less severe and their cause correctly identified. Ideally the dose should be increased until adequate relief is felt or side effects become a bother.

Only then another drug can be added or substituted for the first.

The dose increments (increases) and the time interval between them, will be different for each drug, so ask your doctor for these details and be sure you're seen often enough to discuss how it is going.

No one drug works in everyone. One way to express this is by the number of people needed to be treated, to achieve one useful result.

Similarly one can express safety or otherwise by a number needed to harm.

Here are some results (figures rounded)...

Tricyclic antidepressants (eg amitriptyline)
NNT 3, NNH 15
Carbamazepine (Tegretol etc)
NNT 2, NNH 22
Phenytoin (Dilantin etc)
NNT 2, NNH not measurable in this study
Gabapentin & Pregabalin (lyrica etc)
NNT 5, NNH 18
Opioids (morphine etc)
NNT 2.5, NNH 17
Tramadol (Tramal etc)
NNT 4, NNH 9

In this study5, NNT was for >50% pain relief and NNH was for people who withdrew from the trial because of side effects.

Common practices which cause problems include... Using short acting painkillers and waiting for pain to become bad before taking them. This means one is in pain a lot, waiting to take the dose or waiting for the dose to work.

Short acting opioids are inappropriate for long term treatment of persistent pain.

It is also possible that they may actually increase pain. The perception of pain is only possible by comparison with our past experiences of comfort or pleasure. Sudden intense analgesia can make the subsequent return of pain harder to put up with.

Years ago I was talking with a local surgeon and commented that with the arrival of effective medical treatment for ulcers, I assumed that he was doing fewer gastrectomy operations. He replied that on the contrary, more people wanted the operation, now that they had experienced what it was like to be without pain on the cimetidine tablets. They wanted a permanent fix.

Taking a mixture of different drugs may be a problem.
Often it is a good method, if the different drugs all have the same desired effect but have different "side effects."
Acetaminophen (paracetamol) and an NSAID may be useful with an opioid.
This is less likely with mixtures of opioid drugs, however. Sometimes it causes undesireable drug interactions with unexpected ill effects.
It also gives fewer options for rotating different opioid drugs to avoid tolerance developing.

Neuropathic pain

Your pain may come from some injury or illness stimulating (not damaging) the peripheral nerve endings which are there for that purpose, to indicate noxious conditions. This is called nociceptive pain.

Some conditions result in pain arising from actual damage to the nerves, or in the central nervous system where they lead to. This is called neuropathic pain. It becomes more common as pain becomes more chronic, due to the "wind up" mentioned earlier.

The quality of pain may indicate a neuropathic component. Burning or electric shock like stabs of pain are typical. Abnormal sensations are often felt as well, such as pins and needles and numbness. Even the touch of clothing can be uncomfortable. Creeping, tickling and pressure feelings can occur without apparent cause.

This type of pain is often worse at night and can wake one from sleep.

The reason we are interested is that analgesic drug treatments may be different depending on this distinction. Acetaminophen (paracetamol) and ibuprofen don't usually work here.

Musculoskeletal pain and substance abuse.

Australian figures4 discount this worry. The prevalence of any mental disorder in the surveyed people with MSK conditions was 25%, and of this substance abuse contributed only 5% - pretty similar figures as in the general population.

Possible alternatives to drugs in chronic pain states.

I've not put this after the drugs as an indication of preference, just so you see what the nutrients are alternatives to.

Instead of benzodiazepines to block N-Methyl-D-Aspartate - consider magnesium supplements.

Antidepressants (alter monoamines) - perhaps 5-hydroxytryptophan or phenylalanine supplementation.

Correction of local and systemic acidosis, by improving tissue oxygenation and 80% alkaline forming food diet, alkali supplements. Correcting dehydration or oedema improves tissue oxygenation, as can elevation of a dependant part of the body and gently exercise.

If you have started on this page, this website emphasizes the use of stretching muscles. Any pain coming from structures deep in our body, will inevitably be accompanied by muscle spasm. This will generate further pain if it is not kept under control.

Vitamin D deficiency probably aggravates chronic pain.

The journal "Pain Medicine" published a study on this, by Turner et al, in November 2008.

Vitamin D deficient pain sufferers needed twice the dose of opiate medications, and had needed this for nearly twice as long. They felt less well and functioned less well.

It's hard to know which came first, the chicken or the egg. People in chronic pain probably don't get out in the sun as much.

Despite this uncertainty, it's very sensible to get your vitamin D tested and to take it if indicated. If this improves your pain, write in and tell everyone.

References for chronic pain page

1. Jon-Kar Zubieta et al Science 299 (5610) pp 1240-1242 21st Feb 2003 COMT val158mete Genotype affects Opioid Neurotransmitter Responses to a Pain Stressor.

2. 3. doctorsaredangerous.com

4. AIHW analysis of ABS 2007 Survey of Mental Health and Wellbeing, reported in AIHW bulletin 80, September 2010

5. Finnerup et al Pain 2005 118(3) pp289-305

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The contactpage.

Tolerance is the need to increase the dose to achieve the same result, as the body gradually gets used to a particular drug over a long time of use.

NMDA is a neurotransmitter - a chemical which passes messages between brain cells.

Serotonin, noradrenaline and dopamine are other neurotransmitters called monoamines.
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