Pain Relief Pharmacy

Richard Chapman and Mandy Leighton-Bellichach say that patients with chronic wound pain are suffering worldwide

Mandy Leighton-Bellichach, President of the European Pain Network and Chairperson of the Society for Fighting pain, Israel says “Within the millions of Europeans suffering from chronic pain, there is a shockingly large group of people who have been overlooked for years: those suffering from chronic wound pain. This an unexpectedly common problem affecting not only the elderly and those immobilized but many others. All speak of the pain as the most debilitating part of living with chronic wounds. Despite being the main problem they have to deal with, this devastating pain has been neglected and overlooked.

“Clearly something must change. The time has come for the medical world to acknowledge the seriousness of this issue and the vast amount of people afflicted with chronic wound pain. As nurses are those who actually treat the wounds and are in constant contact with those suffering from chronic wound pain, there is a great need for further training for nurses dealing with this complex issue.

“Despite suffering in the past from chronic wound pain, I myself was not aware of the magnitude of this problem. As President of the European Pain Network, I have now taken the matter to heart. I will do my best to raise the level of awareness regarding chronic wound pain, together with my colleagues across Europe.”

Richard Chapman, Director of the Pain Research Center, University of Utah, explains:

What is a chronic wound?

Most wounds heal, but those that do not heal within three months are defined as chronic wounds. The vast majority of chronic wounds consist of venous and arterial leg ulcers, pressure ulcers and diabetic foot ulcers. Leg ulcers and pressure ulcers are most common among elderly patients. Diabetic foot ulcers are very common among all patients suffering from diabetes. Chronic wounds differ in size and nature; some will heal within six months whilst others will never heal. There are patients who have wounds for 20-30 years. Overall, 35 % of the chronic wounds do not heal within 5 years.

The characteristics of chronic wound pain

Two kinds of pain exist in a chronic wound. First of all there is the pain due to tissue damage. This pain is called nociceptive pain and is the most common type of wound pain. The nociceptive pain is relieved by conventional analgesics like paracetamol, NSAIDs, local anesthetics and opioids and is often described as a burning or rubbing pain. The second kind of pain — neuropathic pain — is caused by nerve damage. It may occur following nociceptive pain and injuries. The neuropathic pain is characterized by a stabbing sensation and is often treated with antidepressants or antileptics.

Today, in the UK more than 380,000 people suffer from chronic leg ulcers. The pain from these wounds seriously affects quality of life. Approximately 63% of all patients with chronic wounds may at some point suffer depression due to the ulcer.

Nearly 2% of us, a million people in the UK, will suffer from a chronic wound in our lifetime. Yet, chronic wounds are probably one the most neglected health problems. Pain is by far the worst aspect of having a leg ulcer. But it is a neglected disease; there is a severe lack of resources, attention and adequate means for the treatment of chronic wounds and chronic wound pain. Consequently, patients do not get the best treatment: Why does this happen? Why are these patients suffering in silence?

The elderly suffer in silence

The majority of people suffering from chronic wound pain are elderly, and they are less likely to complain. The elderly accept pain, and see relief as being almost impossible. Chronic wound patients are primarily treated in the community and are not transferred to pain clinics.

A call for action

For our part, we are planning to undertake research into chronic wound pain at the Pain Research Center in Utah and this year EFIC – the European arm of IASP (The International Association for the Study of Pain) – is focusing on “Pain in the Elderly”. During this initiative, we will try to create awareness within the pain community of the problem of chronic wound pain. Special thanks must go to the organization Pain Concern, which has helped us publicize this issue.

Professor Richard Chapman is Director of the Pain Research Center, University of Utah, Salt Lake City, USA and former President of the American Pain Society.

Mandy Leighton-Bellichach is President of the European Pain Network and Chairperson of the Society for Fighting Pain, Israel.

Grief, anger and depression are normal emotions. They only cause problems when we are unable to “work through” our feelings or if negative feelings stay with us most of the time. Here clinical psychologist Kate McGarva outlines some strategies which can make a real difference.

Chronic pain usually means you are less able to do some of the “normal” things in life. Things you used to be able to do – without thinking. This is frustrating and a loss. When we suffer loss we experience a range of emotions such as sadness, despair, anxiety, frustration and anger – at different times and at different levels. These are normal feelings – we are grieving. All human beings have these feelings. They only become a problem if they are too intense, happen too often and last too long – because they then interfere with everyday living.

Cognitive behavioural strategies can be a useful weapon in your daily fight against the difficulties chronic pain brings. Why? Because –

And cognitive behavioural strategies are about what we think and what we do (our behaviour).

Stress and muscle tension

Every day we meet situations which demand something from us. Sometimes we feel that what is being asked of us is more than we can give. When this happens, our stress levels rise, leading to tension and anxiety. Anxiety is a normal emotion which we all feel. What else is happening in our lives at the time will affect how we “manage” our anxiety. Anxiety causes unpleasant physical symptoms, including muscle tension, headaches, pins and needles, general aches and pains. It also makes us feel tired, irritable and forgetful. Because of the extra tension levels present in chronic pain, it is easier for a person to become even more stressed. The body¡¦s natural mechanism of producing the stress hormone adrenalin is the reason for this.

Frustration, anger and depression

Having chronic pain means that everyday activities cost you more effort. This, combined with your high level of muscle tension, means that anxiety can reach a high level quite quickly. You are then more sensitive to stress which makes it more likely for you to also feel frustration and anger. In chronic pain, anxiety can arise because a person has lost a “normal” life and they may also lose confidence in themselves, feeling “less of a person”. When frustrated and angry, people often feel under-confident with high tension levels – leading to lower tolerance to everyday “hassles” – such as noise, people “not understanding”, unfairness. Being constantly tense, anxious and frustrated makes us very tired, both physically and mentally. We are then less able to cope, and this can lead to further undermining of our belief in ourselves as worthwhile people.

In these circumstances you can see that depression can easily take hold. A person feels they have lost their “self” and have also lost control over their lives. This is frightening – because we have no sense of what the future holds – but it looks bleak!

Negative automatic thinking

When this happens we tend to begin to think in a very specific way. When we are anxious, angry or depressed, our thoughts become very negative. We get Negative Automatic Thoughts or NATS – these thoughts come into our head very quickly and are very believable. These NATS start off the “bad” feelings and keep them going – often long after the event which triggered them in the first place. Like the insects (GNATS) these thoughts or NATS eat away at us. Or as they say in Scotland they “nip oor heid” so we don’t think clearly or logically. Our thoughts begin to follow a pattern of being rather rigid, self-blaming, catastrophising and jumping to conclusions. These thoughts – because we feel bad about ourselves – seem believable but are not accurate. Because we are thinking emotionally we are not as able to reason things out – we react rather than think things through. We completely miss any positive or good aspects of things (events, people, the world). We don’t do this on purpose. Rather we get caught up in a vicious cycle of tension, bad feelings, negative thoughts – which lead to more pain – we feel less able, more hopeless, more helpless, and so get even more negative thoughts.

Sometimes medication is needed

When this takes a hold it is often the case that we become clinically depressed and the balance of neurochemicals in the brain shifts. This makes it even harder for our mood to lift and we stay in the depressed circle of negative thoughts. Antidepressant medication will be needed to restore the balance. In turn this gives us a kick start in tackling the NATS.

What can we do to break the negative cycle?

This takes energy – which you don’t have a lot of – but you need to do it!

1. First of all you need to become aware of negative thoughts. You can begin by thinking of a situation when you felt “bad” (anxious/angry/depressed etc). You can then use a Thoughts Diary. A plain sheet of paper divided into three columns.
   

   EXAMPLE

   What happened / How did I feel?	What was I thinking? (negative automatic thoughts)	Alternative/other way of looking at things
   Walking down street – saw Jane. She walked straight past – didn’t say hello. Feeling upset.	She walked past me – she isn’t talking to me – I must have done something to upset her – this is awful – it’s all my fault.	Jane probably didn’t see me – her mind was on something else – she did look in a hurry – besides I couldn’t have upset her – I haven’t seen her for weeks.

   You always need to challenge the negative thoughts in the middle column. Asking questions such as, “What’s the evidence for this thought? What’s another way of looking at this? What am I doing here – jumping to conclusions – personalising – catastrophising? With practice, this technique can become almost second nature and you no longer need to write things down. You become able to turn the negative thoughts around whilst you are still in the situation.

2. You can also learn to talk to yourself in a more helpful way, using coping self-statements. For example, “It’s OK – I can handle this – as long as I keep my cool – I’m in control”. Or “I won’t take this personally – easy does it – look for the positives”. Or “I have nothing to prove – it’s not that serious – I know how to deal with it”.
3. Breathing control and relaxation will help you manage anxiety and anger problems. It isn’t possible to be anxious or angry and relaxed at the same time. Relaxation also helps to rest the body and the mind, so it benefits depression too. Used together with the cognitive approach – that is tackling negative thinking – you will get back control of your emotions. In turn you will experience less muscle tension, will feel better and so be able to manage your pain better.
4. Another weapon is to make sure that you have distractions – things to do to occupy your mind, things which you can look forward to and enjoy. We all need them, every day, so make a “hit list” of things to do. These can be things you really need to do but must include the fun things too. Work your way through your list. Remember – goal setting and pacing! Passive things such as watching TV or even reading are not ideal because you can sit and still carry on with any negative thinking quite easily. Try to find something that you will need to think about while you are doing it – that is, actively distract your mind.

Success gives you confidence!

When you have chronic pain everything takes more effort and feels more tiring than usual. Practising pacing yourself in everything you do will become second nature to you and will save you energy. Challenging the NATS will help you see things more clearly and rationally and you will be less inclined to “react” to people or events. This gives you some balance in life and the successes you get will also make you feel more confident and lift your mood.

Managing chronic pain means lifestyle change. It also includes changing the way you think about things, for example not feeling guilty about doing nothing or about doing relaxation. This isn’t giving in to pain – it is being sensible and kind to your body and your self. Successes will also make you feel less frustrated, less tense and less likely to become angry. You will feel more in control of your pain. None of this is easy but as you know, there are no easy answers to chronic pain. You will need to have patience, particularly with yourself – accepting you have pain – there is no cure – but not giving up on yourself – or on life!

Any consultation with a doctor is a two-way process. The doctor brings his/her clinical expertise to the meeting and the patient his/her personal experience of the problem and how it is affecting his/her life.

The experience of pain is a very personal issue and it is important that you consider and make note of the following:

• What is our main reason for consulting the doctor?
• If your pain is unchanged, do you have other symptoms and if so are these making you more anxious? If so, list them in order of concern, i.e. stops me sleeping, stops me working, prevents me taking part in social activities, etc.
• If the pain is unchanged despite any self-help activity or treatment prescribed by your doctor, keep a diary to show when your pain is better or worse, what activities you have undertaken and what you have done to try to relieve your pain. This may help your doctor to suggest other treatments which may be helpful to you.
• If the pain is different or more intense, try to think of the following:
  • When did the change occur, can you pinpoint what may have caused the change?
  • Is the pain actually worse, if so by how much and when, i.e. all the time, at night, after exertion or change in position?
• If the pain is different, try to find words to describe the change, i.e. it was an aching pain which is now stabbing, throbbing, burning, etc.
• If this is your first visit to the doctor to discuss the pain think about the questions contained in questions one and three as well as the following:
  • Is there anything in your medical history that could explain your pain, i.e. have you recently suffered from an infection?
  • What worries you most about the pain?
  • What do you hope to get from your doctor, e.g. relief of anxiety, acceptance that the pain exists, relief of pain, investigation of the cause of the pain, other help?

Trigeminal neuralgia (TGN) is an agonising shooting pain, which starts on one side of the face for no reason. It is more common in the elderly but it can start at any age. Attacks can last for a few seconds to a few minutes, and can occur at any time. Often everyday things can trigger an attack such as touching the face, chewing and eating or even a breeze blowing on the face. There can be long periods between attacks.

TGN may be treated successfully with drugs in many cases. There are also surgical treatments available.

Many cases of TGN are caused by a blood vessel pressing on the trigeminal nerve inside the skull. In these cases relieving this pressure on the nerve by surgery can often, but not always, relieve the pain for long periods of time. The Pain Research Institute has been at the forefront of research into the use of this technique.

There are many causes for shoulder pain. Most shoulder pain is due to problems with muscles, ligaments and tendons. Pain may be caused by arthritis, tendonitis or bursitis, or injury or instability.

Treatment may include rest, physiotherapy, medicines such as paracetamol and ibuprofen, injection or surgery.