"Before I am fully awake I can feel the pain. I feel weighed down and stiff. I am afraid I will not be able to move or get out of bed. The fingers on my right hand feel numb, and there is an arc of pain, beginning in my shoulders and ending in my fingertips. A second arc begins at my tailbone and ends mid-calf in both legs. It is very hard to move at all, and it is like that every single day." These are the words of Ashley G.*, a 55-year-old woman with advanced osteoarthritis. She is not alone: Every morning about one quarter of Americans wake up with pain, many with pain so severe they can hardly get out of bed. According to the American Pain Society (APS), chronic pain -- defined as pain that lasts for weeks, months, or even years -- is the country's leading health problem. Pain is the most common reason that people seek medical help. It costs the nation more than $100 billion a year in lost wages, medical procedures, disability payments, and ongoing medications. And that price tag doesn't include the misery and suffering of patients, or the impact on their families.

"While pain doesn't kill, it can make life almost unbearable," says Michael Potter, MD, a family practice physician and associate professor at the University of California Medical Center who has researched and written about the treatment of chronic pain. "One thing is certain: We don't do a good enough job in treating it."

But many patients can find a new source of hope, thanks to the recent attention and funding given to chronic pain. Recognizing that pain is a serious medical issue, health professionals now call it the "fifth vital sign." Doctors and researchers no longer consider pain an unavoidable part of illness and injury. Although there is still a long way to go, the push is on to understand pain better and find ways to treat it.

To begin with, the federal government has taken notice. Congress has declared 2001 to 2010 the Decade of Pain Control and Research, and a bill to make pain research and treatment a national health priority is under consideration by the House of Representatives. If voted for, the National Pain Care Policy Act of 2005 would allot up to $60 million for research and for the creation of a pain research center at the National Institutes of Health. In addition, legislators are considering an another bill, the Conquering Pain Act of 2005, which would set up a national Web site to make information on practice guidelines and the Surgeon General’s report on pain treatment easily accessible to the public. If passed, it would set aside money to establish the National Family Support Networks in Pain and Symptom Management as well. However, even if these legislative efforts are approved, pain research will still lag behind other national health priorities. For example, the National Institutes of Health spent over $4.6 billion on cancer research in 2003.

Closer to home, if you have to spend time in the hospital, you'll probably find that in addition to checking your other vital signs -- heart rate, blood pressure, temperature and breathing rate -- your doctor will ask whether you're having any pain. If you say yes, you'll likely be asked to rate your level of pain. Doctors use a number of different rating scales to better understand patients' level of pain, including one based on facial expressions for people who do not speak English.

Most of the time, however, you'll be asked to rate your pain on a scale of 0 to 10, with 0 indicating no pain and 10 being the most severe pain imaginable. But if you're in pain -- whether you're in the hospital or in your doctor's office -- don't wait to be asked about it. Speak up. Tell your doctor about your pain in as much detail as you can. Make sure that by the end of the visit your doctor has a plan in place to try to find the cause of your pain, and that you have a method to reduce the pain while you're getting better.

Before your doctor can treat your pain, he or she must determine the type of pain you're feeling and whether an underlying disease might be causing it. Dozens of medical conditions can cause pain, but there are only two main types: neuropathic and nociceptive.

Neuropathic pain occurs when nerve tissue is injured, as in diseases like diabetes or shingles. It tends to cause a stabbing or burning sensation. Nociceptive pain is caused by illness or damage to actual body tissues, and is usually due to inflammation of muscles or the tissue within joints. Burns, cuts, arthritis pain, or pain from surgery are some examples. It is often felt as an ongoing ache or pressure. Some people feel a combination of both types of pain.

Knowing which type of pain you have will help your doctor decide on the right treatment. Drugs that are effective for diabetes pain, for example, may be worthless for postoperative pain. To identify any disease that might be causing your pain, you will need a physical examination, including a complete medical history. Your medical history alone will usually tell about 80 percent of the story, with the physical exam filling in at least another 10 percent. If necessary, your doctor will order lab tests, X-rays, or other diagnostic imaging to help get a clearer picture of the problem.

You might also see a physical or occupational therapist, who will evaluate your current physical strengths and weaknesses. Pain almost always causes some physical limitations. But after a proper evaluation, your therapist can help improve your physical functioning so you can get through your day more easily. Many pain clinics now include a psychological assessment, consisting of an interview and various psychological tests to assess the impact the pain has had on your emotional life. Even if this isn't part of your evaluation, be sure to tell your doctor if you feel anxious or depressed. Depression can intensify the pain you feel, and conversely, pain can negatively affect your emotional outlook. This can be a vicious cycle if both aren't addressed at the same time.

If an underlying condition is identified and successfully treated, that could be the end of your pain. Often, however, the cause of pain simply cannot be found. That doesn't mean it is any less real or should be taken less seriously than pain that is traced to an illness or injury. It just means that treatment will focus on the pain itself. At this point, it's important to have realistic treatment goals. Chronic pain may not go away completely, and it might take a while to figure out the best way to treat it.

Once your evaluation is complete, your doctor or health-care team will design a treatment plan for you. Your doctor might prescribe new medications, continue the medications you've been taking, or even set a goal to wean you off medications entirely.

In any case, medication is usually only one part of successful pain management. Depending on your diagnosis, your insurance coverage, and what you are able to pay, your doctor may recommend that you try any of several alternative treatments such as biofeedback or acupuncture.

No complementary methods are guaranteed to help, but through trial and error you may find one or several that work for you. Following are some common alternative therapies:

* Biofeedback, hypnosis and self-hypnosis, relaxation techniques, or other methods that teach you conditioning techniques and imagery to manage your pain

* Acupuncture

* Cold or warm compresses

* Anesthetic ointments or lotions

* Massage

* Transcutaneous electrical nerve stimulation (TENS), a gentle electrical current applied to the painful area

* Yoga, which improves muscle tone and flexibility to help support painful joints

* Physical therapy

Exercise, in fact, may go a long way toward relieving certain kinds of chronic pain. In one study, researchers at the Center for Physical Activity and Nutrition at Tufts University divided a group of people with arthritis in their knees in two, with one group doing progressive strength training for four months and the other receiving pep talks and instructions on better eating.

The results were striking: After four months, pain among the exercisers dropped by 43 percent, compared to 12 percent in the control group. "All of a sudden, people who had found life's daily activities more and more challenging and painful were able to participate in life in ways they hadn't been able to for years," the lead researcher wrote.

Be sure to follow the treatment program your doctor has devised for you. If you want to try something like yoga or massage that isn't part of your program, get your doctor's approval first and make sure you are being taught or treated by a professional certified to do so. In some cases, if no other treatments work, your doctor may suggest surgery.

Besides proper diagnosis and a treatment plan, you can do plenty to improve your life with chronic pain. The American Chronic Pain Association offers these suggestions.

Dr. Jerome Groopman is a physician and author who made a slow recovery from agonizing pain as a result of a back injury. Once worried about his chances of improvement, he was encouraged to find that physical therapy, stretching, and exercise, along with some changes about how he viewed his pain, helped him get better. In his book, The Anatomy of Hope, he writes, "I began to walk -- five blocks, then 10, then 15, then a mile. I challenged myself to travel longer distances, to hike one or two steep hills. Advancing to each new level caused days of spasm and pain, but I tried to ignore it all. My body was relinquishing an old form of memory and acquiring a new narrative. After a little over a year, the daily pains all but passed."

Our emotional and physical selves are closely linked, especially where chronic pain is concerned. The Stanford University Pain Management Center says that people suffering chronic pain may feel hopeless, angry, or sad, and their personal and work relationships can suffer as a result.

Individual or group therapy can help. In individual sessions, you might learn cognitive techniques to help you conquer your fear of being active again, to learn that hurt doesn't always equal harm. When you have chronic pain, it hurts to exercise or move your body, and it's hard to realize that the pain isn't a warning sign that you're harming yourself. Once your doctor has confirmed that movement and exercise won't cause harm, you may be able to accept that pain isn't something to fear, and you can begin to enjoy some of your favorite activities again in spite of it.

With persistence, improvement is possible. Most important, don't give up hope. Groopman says, "We are just beginning to appreciate hope's reach and have not defined its limits. I see hope as the very heart of healing. For those who have hope, it may help some to live longer, and it will help all to live better."

-- Dorothea Z. Lack, Ph.D. is a clinical psychologist in private practice in San Francisco. She was the first staff psychologist at the Stanford Pain Center and is a voluntary clinical assistant professor at the UCSF School of Medicine, where her course about the doctor-patient relationship earned an award for excellence in teaching.

* This patient's name has been changed.

References

First published March 24, 2005
Last updated January 31, 2007
Copyright © 2001 Consumer Health Interactive