Chronic pain

Pain is one of the most common reasons why people seek medical advice. Chronic pain is pain that:

• lasts longer than 3 to 6 months
• persists following an injury despite the injury itself being healed

The perception of pain differs significantly between individuals and may be influenced by social and psychological factors.

Chronic pain affects all areas of a person’s life and impacts their daily routine. Individuals with chronic pain often develop anxiety, depression or sleep disorders.

This can have a negative impact on their perception of pain and their body’s processing of the pain, so that their symptoms worsen.

Therefore, chronic pain is most effectively treated not only by various types of medication but also by taking account of the person’s psychological and social circumstances.

Pain can be felt in many different ways.

Pain in internal organs may be dull, deep-seated or spasmodic (cramping). People are often unable to pinpoint the precise origin of the pain.

Pain in the musculoskeletal system is often described as a stabbing, dragging or burning pain and is easier to pinpoint.

Pain resulting from nerve damage may be experienced as sudden attacks of shooting pain and may be associated with tingling sensations and numbness or oversensitivity.

Older people in particular can sometimes find it difficult to describe their pain. They frequently talk about “unpleasant” feelings or symptoms.

People with diseases such as dementia are often completely unable to express their pain in words. Signs of pain then include:

• a facial expression that is contorted in pain
• making moaning and groaning sounds
• holding the painful area protectively
• labored breathing
• confusion

Possible causes of chronic pain include a nervous system disturbance, impaired pain processing or chronic inflammation.

The following conditions are frequently associated with chronic pain:

• osteoarthritis
• back problems
• rheumatoid arthritis
• fibromyalgia
• diabetes mellitus

Different causes can produce different types of pain:

• Nociceptive pain: The pain signals originate in the nociceptors – structures that play an important role in how pain is perceived. This type of pain can be triggered, for example, by injuries, burns, kidney stones or a heart attack.
• Inflammatory pain: This occurs as a result of inflammation in the tissues when inflammatory messengers stimulate pain receptors. This type of pain can be triggered by infections or autoimmune disorders.
• Neuropathic pain: This results from direct damage to the nerves. It may be triggered by nerve injuries, damage to nerve roots, metabolic disorders like diabetes, cytoxins (cell-killing toxins) like alcohol, or viral infections such as shingles.
• Central pain: This is caused by a change in the way that pain is processed in the brain or spinal cord. In this case, the brain produces pain even though no organic cause is present. This type of pain occurs, for example, in fibromyalgia, irritable bowel syndrome or chronic pelvic pain.

Pain can take on a life of its own. In other words, it may persist even after the trigger is removed. Persistent pain can also make nerves more sensitive, so that pain signals are transmitted sooner and faster. New neural connections can then produce a “pain memory”.

Furthermore, persistent stress can cause a person to perceive pain sooner or more strongly than before.

Several factors increase the risk of developing chronic pain. These include:

• genetic predisposition
• prior treatment for acute pain that was not sufficiently effective
• mental illness, such as depression or post-traumatic stress disorder
• living in socially disadvantaged circumstances
• older age
• long-term use of painkillers, in particular opioids
• alcohol and drug abuse

Around 3 in every 10 people in developed countries report having moderate to severe pain lasting longer than 6 months.

Over 40 percent of older people complain of chronic pain. The most common causes are joint pain and back pain.

Children can also suffer with chronic pain.

For people with chronic pain, their quality of life often remains restricted to a certain extent. While treatment helps relieve the pain, it is often unable to eliminate it entirely.

In most cases, more than one type of medication is required as pain relief. As a result, patients take several different substances, often in increasing doses. These frequently have side-effects.

For example, excessive amounts of paracetamol can cause severe liver damage. Taking strong painkillers like opioids on a regular basis can lead to drug dependency.

It is also possible to overdose on opioids, which suppresses breathing and can be fatal. Taking opioids can also sometimes cause patients to become oversensitive to pain.

An important first step is to pinpoint the precise cause of the pain. Imaging techniques, such as x-ray, computed tomography (CT) or magnetic resonance imaging (MRI) can be used for this purpose. Certain blood values can also provide an indication of the cause.

Nerve blocks or measurements of nerve conduction velocity are sometimes used for diagnosis.

However, it is not always possible to locate the trigger, even if the pain is severe.

For treatment purposes, it is essential to pinpoint the origin of the pain and assess it. Doctors will therefore ask the patient specific questions, such as:

• When and where did the pain first occur?
• What does the pain feel like?
• How bad is the pain on a scale of 1 to 10?
• How does the pain affect daily activities?

Doctors use a physical examination to determine whether any physical functions are restricted due to the pain. They also ask the patient about their mood, the quality of their sleep, and any family-related or work-related stress they may be experiencing in order to find out whether aspects of their lives could be affecting their perception of pain or are being impacted by chronic pain.

Where possible, chronic pain should be treated using multi-modal therapy, which combines medical treatment with psychotherapy, physiotherapy and occupational therapy. Treatment is ideally administered by experts in pain therapy. People with chronic pain also benefit from advice from experts in the area of social medicine.

Non-pharmaceutical treatment

• Behavioral therapy: This helps patients to manage their pain more effectively and to sleep better.
• Physical activity and movement exercises: This is done under the guidance of a physiotherapist to improve physical functions and reduce pain.
• Acupuncture: This is used to treat localized pain and pain in the body as a whole.
• Dietary advice and weight loss: This is beneficial if excess weight plays a role in the patient’s pain.
• Patient aids, such as walking aids, splints or orthopedic shoes
• Peripheral nerve stimulation: Gentle electrical impulses are used to reduce pain. A small surgical procedure is required to enable continuous stimulation.

Drug therapy

• Injections with local anesthetics or the application of ointments and gels containing anti-inflammatory pain medication can help with localized pain.
• Antidepressant medication, even if the patient is not depressed, can influence the perception of pain. It may take several weeks for some drugs to produce a pain-relieving effect.
• Drugs used to treat epilepsy (anti-epileptics) are used to treat nerve pain caused by nerve damage.
• Muscle-relaxing medication may be used to treat pain associated with muscle cramps.
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or paracetamol should only be taken to treat acute flare-ups of pain symptoms. It can be useful to try out different types of painkillers, as their level of effectiveness varies from person to person.
• Strong painkillers like opioids or medication that affects pain processing in the brain (e.g., sedatives in the benzodiazepines group) should be taken on a temporary basis only.

It is always best to decide on treatment measures in collaboration with your doctor. A trust-based doctor-patient relationship is essential to ensuring satisfactory treatment of chronic pain.

Chronic pain requires long-term treatment. The condition often improves temporarily and repeatedly flares up from time to time.

It is important for people with chronic pain to learn to manage their symptoms on a daily basis – this involves finding out what they can do to influence and control their pain.

Support is available from doctors and therapists, as well as information and advice centers and self-help groups.

You can find self-help groups through the database provided on the website of the National Contact and Information Point for Encouraging and Supporting Self-Help Groups (NAKOS).

More information about chronic pain is provided on the website of the German Society for Psychological Pain Therapy and Research (Deutsche Gesellschaft für psychologische Schmerztherapie und -forschung e.V.) and the German Pain Association (Deutsche Schmerzgesellschaft e.V.).

Summarized information about various pain disorders and answers to frequently asked questions are provided on the website of the German Brain Foundation (Deutsche Hirnstiftung e.V.).