Chronic Pain

Acute pain is a predictable, short lived pain with a pattern, which is also easy to diagnose and treat.

Pain that lasts longer than 3 months, with no sign of getting better is referred to as Chronic pain. It is difficult to pin point the cause of this pain that can persist over a length of time.

There are different Classifications of Pain, each with their own examples:

1. Severity, i.e. mild, moderate, or severe
2. Duration, i.e. acute, of chronic
3. Location, i.e. lower back, abdomen, or head
4. Origin, i.e. nociceptive, or neoropathic
5. Body System, i.e. muscular, neorologic, or skeletal
6. Mechanism, i.e. central, or peripheral
7. Diagnosis, i.e. cancer, or non-cancer
8. Response to treatment, i.e. Opioid-responsive or opioid resistant

1. Nociceptive – This guards the body against any injury, and occurs because of the reaction of the peripheral pain receptors, which are activated when injured. The stimuli is conveyed by an electrical signal along the nerve cells in the spine or brain – where it gets relayed that there is an unpleasant sensation.
2. Neuropathic – This is caused by cause of injury or dysfunction in the nervous system, which has a variety of pain sensations which could be described as burning, crushing or “pins and needles” This pain persists for prolonged periods of time, even after the trauma or dysfunction has been addressed, seen that this pain is more complex, it is more difficult to treat.

These two go hand in hand, inflammation is caused by tissue injury which has a cascade of biochemical reactions that alert the nervous system for pain sensing.

• Long term inflammation causes changes in the nervous system which can cause the sensation of pain to escalate, for example inflamed tissue like an arthritic knee, and could become tenderer by touching the area.
• This pain is caused by a trigger in the nervous system and is not spontaneous, called nociceptors
• When someone experiences injury, mediators are released at the site of injury and react to nociceptors, which then signals pain through the nervous system.
• When you have Osteoarthritis there is an increased level of mediators at the affected site, which can predispose you to increased pain sensations.
• By taking drugs to treat the pain like ibuprofen will interfere with the sensation of pain, because of its anti-inflammatory nature, to relieve the pain.
• However these type of drugs reduce pain levels, they can have side effects which compromises the long term effect when used.
• By using natural anti-inflammatory compounds, which target inflammation and reducing pain levels and have powerful anti-inflammatory effects without unwanted side effects.

1. Exercise and behavioural therapy is effective in decreasing pain, and increasing the functioning of people who struggle with chronic pain.
2. Non pharmacologic methods to treat chronic pain like, meditation, biofeedback, acupuncture, electrical stimulation and surgery, are used when people cannot make use of medication to treat pain.
3. Pharmacologic therapy is very popular way to treat chronic pain in individuals, based on diagnosis of it being nociceptive or neuropathic pain.

• Non-Opioid analgesics
• Opioids
• Antidepressants
• Antiepileptic drugs
• Muscle relaxants
• Topical analgesic agents

As these drugs do not need a prescription from a doctor, people assume that they do not need to be careful in how they use the dosage as opposed to prescription drugs. It is important for chronic pain sufferers to be educated about the side effects of using non-prescription drugs. Non-prescription medication is safe when used appropriately, however it can be very dangerous for example when there may occur unintentional overdose, and is also the leading cause of liver failure.

1. Should not exceed the maximum dose prescribed per day.
2. Many prescription pain medications contain paracetamol, which should not be used without medical consent, as it increases the risk of kidney toxicity.
3. Do not take medication with alcohol, as this increases the risk of liver toxicity
4. Taking these type of meds can have adverse side effects such as gastrointestinal bleeding, peptic ulcers, high blood pressure, oedema, kidney disease, and heart attack, and using these meds over the long term can also cause renal failure, renal necrosis and glomerular filtration.
5. Aspirin is commonly used for aches and pains, which thins the blood and poses a greater risk of bleeding. This is also used for heart protection and stroke prevention in low doses. Other side effects to using aspirin are, heartburn, vomiting, nausea, stomach ache, ringing in the ears, hearing loss and rash, and also should not be used with other anticoagulant drugs and alcohol.
6. Other common side effects include, Constipation, excessive sleepiness, itchiness, respiratory depression

• It has been noted that using Opioids for a long term decreases the function of the endocrine system, and as a result causes hormone imbalances.
• This occurs in the hypothalamus and pituitary gland and the reproductive organs. This tends to decrease the hormone released in the hypothalamus, which then decreases the function of the pituitary gland.
• This will have a result of Hypogonadism if used over a long period of time.
• Opioids are also known to lower testosterone levels, which are associated with increased cholesterol levels, and a decrease in insulin sensitivity, this can also be detected via hormone testing and patient history.

1. Decreased body hait
2. Adrenal dysfunction
3. Decreased growth hormone
4. Miscellaneous hormonal abnormalities
5. Erectile dysfunction
6. Intertility
7. Decreased libido
8. Osteoporosis
9. Depression
10. Missed menstrual periods 

1. Try a different Opioids
2. Use a non-opioid analgesic
3. Hormone replacement therapy, Health Renewal offer Bio-Identical Hormone Replacement Therapy (BIHRT). 

• The chronic activation of pain sensors for example osteoarthritis, may alter the central pain processing overtime
• Chronic pain that is ongoing, can have an adaptive nature on the nervous system and contribute to altering the pain sensitivity and cause the brain to become used to the pain it processes. This is called Central Sensitization.
• When the nervous system becomes used to the pain, these sensations can be augmented as they are no longer being reinforced by the mechanisms in the brain and spinal cord.
• Thus causing the chronic pain to be peripheral and a central element.
• The brains of people who have chronic pain have adapted to processing the pain and have become hyper-sensitive to the pain stimuli.
• Traditional therapies like anti-inflammatory drugs do not work as well anymore, as it cannot identify where the pain is located anymore due to the sensitized nervous system
• Antidepressants and antiepileptic complement these drugs by changing the biochemistry
• This is also due to their mood altering affects, and the antiepileptic medication, change the calcium signals to the brain which control seizures.
• Centrally acting drugs are critical to neuropathic pain, in chronic patients.

Diet - Chronic pain can result in a decreased protein intake and increase in sugar and starch intake. There is a strong link between food and pain:

• Periods of fasting have been related to pain relief in many patients.
• For long term pain relief, a high protein low carb diet is recommended, which results in decreased pain sensitivity and inflammation.
• Vegan/Vegetarian diet is also beneficial to chronic pain conditions
• A diet rich in antioxidants neutralize free radicals and oxidative stress, play a role in which has an increase in pain sensitivity
• Studies have shown that a diet with a high protein intake may help chronic pain patients avoid muscle loss and weakness.

Omega-3 Fatty Acids – They are an important source of energy for the bodyand also have other biological functions

• By taking Omegas it helps to reduce both inflammatory and neuropathic pain, especially reducing the pain in patients with osteoarthritis, pain during menstruation, inflammatory bowel disease and neuropathy
• High levels of Omega 6 are associated with inflammatory activities.
• This can lead up to tissue destruction, chronic inflammation, and increase resistance of tumour cells.
• It can promote abnormal arterial blood clotting, causing heart attacks and strokes.
• Most health conscious people take these in by low doses of aspirin, curcumin, green tea and various flavonoids like resveratrol, to combat the occurrence of pain.
• Positive effect of Omega -3 on neuropathic pain is by their ability to block sodium channels that interfere with pain signalling.
• Omega – 3 has a positive change on cognition, mood and behaviour, and is also beneficial to central pain processing.
• Supplementation can reduce anti-inflammatory analgesic consumption, and thus reduce gastrointestinal side effects from developing.

Omega-6 fatty acid – Plant derived omega 6, and is found in seeds of an Eastern flower – borage.

• Plays an important role in modulating inflammation in the body, when it’s incorporated in the membranes of the immune system cells.
• It has been noted that it relieves pain from a variety of conditions such as neuropathy, breast pain and rheumatoid arthritis.

Vitamins

• B Vitamins – Vitamins B1, B6, and B12 are not only beneficial for managing pain as a result from Vitamin B deficiency, but is also effective when combined with medication for some painful diseases like degenerative spin disease, rheumatic diseases, lower back pain, and tonsillectomy pain
• Vitamin B1, 6 and 12 – have been shown to reduce neuropathic pain in both humans and animals, and can help to treat peripheral neuropathies.
• Benfotiamine - suggested for reducing inflammatory and neuropathic pain in humans. Neuropathic pain plays a considerable role in people with chronic pain, and B-vitamins provide relief by targeting pathways associated with central neural pain processing.
• Vitamin C– Vitamin C (ascorbic acid), an antioxidant, may act as another natural shield against pain. Free radicals play a role in increasing pain hypersensitivity; Vitamin C and E has a rapid pain relieving effect in animal studies, with peripheral injuries; Vitamin C reduces spontaneous pain associated with post peripheral neuropathic pain.
• Vitamin D – Inhibits inflammation by regulating some genes responsible for producing pro-inflammatory mediators; Vitamin D deficiency is linked to fibromyalgia, chronic widespread pain, and bone pain. It reduces pain in woman with chronically painful periods. If Vitamin D levels are low, Vitamin D supplementation can improve pain levels. Blood levels of 25-hydroxyvitamin D should be between 50/80ng/ml for optimal health.
• Vitamin E– Is associated with a reduction in the severity of cyclic breast pain, as well as being effective in relieving menstrual cramps. Vitamin E has been proven to improve neuropathic pain levels associated with diabetic and alcoholic neuropathy in animals; Vitamin E has an analgesic effect, through its antioxidant properties, by blocking the production of reactive oxygen species, involved in neuropathic pain. Its analgesic effect has the ability to make the brain less sensitive to pain.

• Curcumin – Component of Tumeric, that gives curry its unique colour and taste. It has been widely used as an herbal medicine, for its antioxidant and anti-inflammatory properties. It has been shown to decrease the levels of mediators, and contribute to nociceptor hyper-sensitivity. Curcumin has analgesic effects, and can be used for a variety of pathological pain conditions. It has been used for managing traumatic and postoperative pain, and linked to a reduction in chronic pain sufferers.
• Ginger – Analgesic and anti-inflammatory property which soothe progressive muscle pain. It has been used to treat toothache, muscle sprains, swollen cuts and sores. The regular consumption of ginger is effective for pain relief in arthritis patients, and muscle injury due to exercise, as well as menstrual pain with its analgesic effect. It has been noted that it relieves pain by suppressing inflammation.
• Proanthocyanidins – Are chemical compounds called Flavonoids, with a variety of functions. It’s known for the anti-oxidant and anti-inflammatory affects. Grape seed is a rich source, and has shown symptoms of reduction in a variety of painful diseases. Other sources include berries, seeds, flowers and leaves.
• Melatonin – Natural occurring hormone, which can reduce pain through its beneficial effect on sleep and its analgesic properties. It is a powerful antioxidant which reduces pain associated with chronic pain conditions. Its chemical structure is the basis for new analgesic drugs for treating pain associated with cancer, headache and surgical procedures
• Methylsulfonylmethane- (MSM) is an organic sulphur-containing compound. Found in fruits, vegetables, grains and meats. It has anti-inflammatory and antioxidant properties. Used to treat pain associated with Osteoarthritis, and does not have any side effects.
• Korean angelica– found in the roots of the Korean flower called Angelica gigas Nakai (Korean angelica). It has been used for pain associated with menstruation, arthritis, migraine, abdominal pain, and other miscellaneous injuries. It acts on the central nervous system for its analgesic effect.
• Capsaicin- This gives chili peppers their spicy taste, also has medicinal value as an over-the-counter topical pain reliever. Comes in different formulations like creams, gels, lotions, patches, and sticks. It’s an effective analgesic for lower back pain, and chronic pain from muscles, tendons and ligaments. It also has an analgesic effect due to its ability to reduce the amount of nerve fibres in the application area.
• DL-Phenylalanine – While L-phenylalanine is a naturally occurring amino acid that is a precursor to dopamine and related neurotransmitters, D-phenylalanine appears to slow metabolic breakdown of endogenous opioids. It provides an analgesic and mood-boosting effect. Some studies suggest that supplementation with phenylalanine might provide pain relief.
• Evidence is currently insufficient to draw firm conclusions as to the pain-relieving efficacy of DL-phenylalanine.

Saffron & L-Tryptophan – Antidepressant medication have an analgesic effect via various mechanisms, which include boosting serotonin levels, to help the brain control pain sensations. Saffron acts as a central pain reliever.

N-acetyl-cysteine & milk thistle extract- May provide means of reducing drug induced liver damage.