CHRONIC PAIN: AN INTEGRATIVE APPROACH TO EFFECTIVE PAIN MANAGEMENT COURSE DESCRIPTION Pain is a universal experience for virtually every human being and is an indication that something is wrong. Pain interferes with the enjoyment of life. It makes it difficult to work, socialize with friends and family, sleep, and accomplish activities of daily living. It may reduce productivity and create financial hardships in terms of lost work and high medical bills. Chronic pain can lead to a loss of appetite, depression, and many other physical and psychological consequences as well as a loss of the joy of life. The outcome of this course is for the learner to describe the scope of chronic pain, key historical events in pain management, the physiology of pain, types of pain, conventional pharmacological treatments for pain, and integrative approaches to pain management. COURSE OBJECTIVES Upon completion of this course, you will be able to do the following: 1. Describe the scope of pain and chronic pain in the United States. 2. Identify key events in the history of pain management. 3. Define pain and chronic pain. 4. Explain the physiology of pain. 5. Describe the types of pain. 6. Identify various pain behaviors. 7. Compare and contrast the various pharmacological methods for managing pain. 8. Compare and contrast the various integrative therapies useful in pain management. © ALLEGRA Learning Solutions, LLC All Rights Reserved INTRODUCTION Pain interferes with virtually every aspect of life—sleep, work, socializing with family and friends, hobbies, and activities of daily living. Pain is associated with injuries and disease. Sometimes pain is the cause of the disease (such as in headaches or neuropathic pain) and sometimes it occurs as a result of a specific condition (such as postoperative pain). Millions of people suffer from pain. It exacts a tremendous cost on our country in terms of health care costs, rehabilitation and lost worker productivity, as well as emotional and financial burdens for patients, families, and society. Consider these sobering statistics (American Academy of Pain Medicine, 2014; Cloud, 2011; Hart, 2010; National Center for Complementary and Integrative Health [NCCIH], 2017b; Suddath, 2011): Pain affects more Americans than diabetes, heart disease, and cancer combined. Over 100 million people suffer from pain, compared to 24 million people with diabetes, 23 million with heart disease, and 11 million with cancer. Most pain sufferers are women. The annual cost of chronic pain in the United States, including health care expenses, lost income, and lost productivity, is estimated to be between $560 billion and $635 billion. More than half of all hospitalized patients experience pain in the last days of their lives. Yet, while there are therapies available to alleviate pain, among those © ALLEGRA Learning Solutions, LLC All Rights Reserved dying of cancer, for example, 50% to 75% of patients die in moderate to severe pain. An estimated 20% of Americans report that pain or physical discomfort disrupts their sleep a few nights a week or more. The most common types of pain are low-back pain, severe headaches or migraine pain, neck pain, and facial pain. Back pain is the leading cause of disability in Americans under 45 years of age. More than 50% of individuals experiencing pain feel they have little or no control over their pain. Almost two thirds of individuals report that pain impacts their overall enjoyment of life and more than 75% report feeling depressed, 70% say they have trouble concentrating, and 74% say their energy level is impacted. Most pain sufferers have been to their family physician for assistance and almost half have been to a specialist (such as an orthopedist). There are an estimated 8,000 pain specialists in the United States—one physician for every 9,500 chronic pain sufferers. This is not nearly enough to address the need in this country. The most common reason cited for seeking complementary and alternative medicine (CAM) and integrative therapies was pain. © ALLEGRA Learning Solutions, LLC All Rights Reserved o More than 8% of Americans have received a massage in the past year, usually for back or neck pain. o Approximately 11% of Americans have used meditation or deep-breathing exercises for physical and emotional pain. o Approximately 1.4% of Americans have experienced acupuncture. The citizens of the United States are not unique in struggle with pain. The World Health Organization (WHO) states that one in five people globally suffer from moderate to severe chronic pain and one in three are unable or less able to maintain an independent lifestyle due to their pain (World Health Organization, 2004). Chronic pain is emerging as an important component of the global burden of disability (Croft, Blyth, & van der Windt, 2010). One of the most effective means of managing pain is to become educated about its causes and the wide variety of possible conventional and integrative therapies available to treat pain. Both consumers and healthcare providers must have a solid understanding about the causes of and treatments available for pain to effectively and compassionately address their concerns. THE HISTORY OF PAIN RELIEF Human beings have suffered from pain for as long as they have existed. It is the oldest medical problem and universal affliction of humankind. But little about it has been © ALLEGRA Learning Solutions, LLC All Rights Reserved clearly understood until recently. Religion, politics, and philosophical perspectives defined the meaning of pain for individuals for much of human history (Meldrum, 2003). The Greek goddess of revenge, Poine, gave us the word “pain.” According to mythology, she was sent to punish mortals who had angered the gods. This irony is clear to individuals who often feel that the suffering they experience as a result of their pain is a kind of divine vengeance (Lallanilla, 2005). Attempts to relieve pain have ranged from the bizarre to the visionary. The following timeline provides an overview of the key events in the history of man’s attempt to relieve pain (Lallanilla, 2005; NCCIH, 2015; Park, 2011; Suddath, 2011; Cloud, 2011): The Neolithic Age (approximately 10,000 B.C.)—trepanning, early acupuncture, and other methods were used. o A trepanning procedure involved boring a hole in the skull to relieve pressure and pain and to free the spirits. It was used by many ancient cultures throughout the world. o Early acupuncture involved using pieces of polished or flat stones that were placed in strategic parts of the body. By the 2nd century, the stone needles were replaced by metal needles. o Votive offerings and sacrificial animals were used to carry the sins of people out into the wilderness and thus relieve their pain. o Rattles, gongs, and other noisy devices were used to frighten painful devils out of a person’s body in an attempt to relieve pain. o Native American healers sucked on pain pipes held against a person’s skin to “pull” out the pain or disease. 3300 B.C.—Tattoos may have been used on certain body parts (such as the spine, knee, or ankle) to relieve pain. 2750 B.C.—Eels were used by the ancient Egyptians to produce pain-relieving shocks. The eels were laid over the wounds. This technique is considered a precursor to the modern transcutaneous electrical nerve stimulation (TENS). 100 A.D.—Romans used hot seawater baths and ointments that contained poppies (containing a form of opium) and wild cucumber to relieve pain. The Greek physician, Hippocrates, used willow bark and leaves to relieve pain and he told women in childbirth to chew them. The willow plant, a member of the plant genus Salix, contains a form of salicylic acid—the active ingredient in aspirin. 400-500 A.D.—The Middle Ages saw a generous use of herbs. Polypharmacy was widely used and one popular concoction was theriac—a honey-based compound with approximately 64 other compounds in it. © ALLEGRA Learning Solutions, LLC All Rights Reserved 1200 A.D.—Practitioners used a somniferous sponge during surgery to relieve pain. The sponge was steeped in a mixture of opium and herbs. 1774—Franz Mesmer, a German physician, began treating pain with magnets and “mesmerism” (a hypnotic technique). His theories were later debunked but certain aspects of his treatment remain today in modern hypnotherapy. 1846—William T. G. Morton, a dentist, used ether anesthesia for the first time at Massachusetts General Hospital when he removed a tumor from a patient during surgery. A short time later, the term “anesthesia” was coined by Oliver Wendell Holmes, Sr. Prior to that time, choking people with carotid compression or holding peoples’ faces over a gas stove until they passed out were other, rather bizarre techniques used to provide a form of anesthesia for surgery. 1853—Queen Victoria popularized the use of chloroform in childbirth when she successfully used it to deliver her eighth child, Prince Leopold. Chloroform had previously been considered controversial on religious and safety grounds. 1886—John Pemberton (a Georgia pharmacist) invented Coco-Cola. It contained cocoa leaves, which are the source of cocaine. The drink was marketed as a remedy for all types of ailments, especially headaches. 1899—Bayer introduced the “drug of the century”—aspirin—to the market. Early 1800s and 1900s—Magnets were used by many healers for their purported healing properties. In addition, a variety of other techniques such as electricity, wet plaster made from hot mustard, balms, liniments that were said to have contained magnetic properties, remedies with varying quantities of opiates, alcohol, and cocaine were also available. © ALLEGRA Learning Solutions, LLC All Rights Reserved Early 1900s—Physicians used gold salts injected into limbs to treat arthritis. 1951—Fernand Lamaze, a French obstetrician, observed the use of natural birthing techniques using psychoprophylaxis while on a visit to Russia.