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210 Part Four Seeking and Using Health Care Services

chronic pain and psychopathology are so frequently associated is not fully known. One possibility is that chronic pain activates latent psychological vulnerabil- ities (Dersh, Polatin, & Gatchel, 2002).

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What is pain control? Pain control can mean that a patient no longer feels anything in an area that once hurt. It can mean that the person feels sensation but not pain. It can mean that he or she feels pain but is no longer concerned about it. Or it can mean that he or she is still hurting but is now able to tolerate it. Some pain control techniques work because they eliminate feeling altogether (for example, spinal block- ing agents), whereas others succeed because they re- duce pain to sensation (such as sensory control techniques), and still others succeed because they en- able patients to tolerate pain more successfully (such as psychological approaches). It will be useful to bear these distinctions in mind as we evaluate the success of specific pain control techniques.

Pharmacological Control of Pain The traditional and most common method of control- ling pain is through the administration of drugs. Mor- phine (named after Morpheus, the Greek god of sleep) has been the most popular painkiller for de- cades (Melzack & Wall, 1982). A highly effective painkiller, morphine has the disadvantage of addic- tion, and patients may build up a tolerance to it. Cur- rently, opioid medications are widely prescribed for chronic pain, but their side effects, risks, and even effectiveness raise cautions about their widespread use (Gatchel et al., 2014). Any drug that influences neural transmission is a candidate for pain relief. Some drugs, such as local anesthetics, can affect the transmission of pain im- pulses from the peripheral receptors to the spinal cord. The application of an analgesic to a wound is an ex- ample of this approach. The injection of drugs, such as spinal blocking agents, is another method. Pharmacological relief from pain may also be provided by drugs that act directly on higher brain re- gions. Antidepressants, for example, combat pain not only by reducing anxiety and improving mood but also by affecting the downward pathways from the brain that modulate pain. Sometimes pharmacological treatments make the pain worse rather than better. Patients may consume

large quantities of painkillers that are only partially ef- fective and that have undesirable side effects, including inability to concentrate and addiction. Drug-poisoning deaths involving opioid analgesic drugs have been ris- ing steadily over the past 15 years (Chen, Hedegaard, & Warner, 2014). Nerve-blocking agents may be adminis- tered to reduce pain, but these can also produce side effects, including anesthesia, limb paralysis, and loss of bladder control; moreover, even when they are success- ful, the pain will usually return within a short time. The main concern practitioners have about the pharmacological control of pain is addiction, and a subset of pain patients are very vulnerable to addic- tion. On the other hand, even long-term use of pre- scription pain drugs for such conditions as arthritis appears to produce very low rates of addiction. The concern over addiction can lead to under- medication. One estimate is that about 15 percent of patients with cancer-related pain and as many as 80  percent with noncancer chronic pain do not receive sufficient pain medication, leading to a cycle of stress, distress, and disability (Chapman & Gavrin, 1999).

Surgical Control of Pain The surgical control of pain also has a long history. Surgical treatment involves cutting or creating lesions in the so-called pain fibers at various points in the body so that pain sensations can no longer be conducted. Some surgical techniques attempt to disrupt the trans- mission of pain from the periphery to the spinal cord; others are designed to interrupt the flow of pain sensa- tions from the spinal cord upward to the brain. Although these surgical techniques are sometimes successful in reducing pain temporarily, the effects

About 116 million people in the United States experience

chronic pain that requires treatment.

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Chapter 10 The Management of Pain and Discomfort 211

are often short-lived. Therefore, many pain patients who have submitted to operations to reduce pain may gain only short-term benefits, at substantial cost: the risks, possible side effects, and tremendous expense of surgery. It is now believed that the nervous system has substantial regenerative powers and that blocked pain impulses find their way to the brain via different neural pathways. Moreover, surgery can worsen the problem be- cause it damages the nervous system, and this damage can itself be a chief cause of chronic pain. Hence, whereas surgical treatment for pain was once relatively common, researchers and practitioners are increasingly doubtful of its value, even as a treatment of last resort.

Sensory Control of Pain One of the oldest known techniques of pain control is counterirritation. Counterirritation involves inhibit- ing pain in one part of the body by stimulating or mildly irritating another area. The next time you hurt yourself, you can demonstrate this technique on your own (and may have done so already) by pinching or scratching an area of your body near the part that hurts. Typically, the counterirritation produced when you do this will suppress the pain to some extent. This common observation has been incorporated into the pain treatment process. An example of a pain control technique that uses this principle is spinal cord stimulation (North et al., 2005). A set of small elec- trodes is placed or implanted near the point at which the nerve fibers from the painful area enter the spinal cord. When the patient experiences pain, he or she ac- tivates a radio signal, which delivers a mild electrical stimulus to that area of the spine, thus inhibiting pain. Sensory control techniques have had some success in reducing the experience of pain. However, their effects are often only short-lived, and they may therefore be appropriate primarily for temporary relief from acute pain or as part of a general regimen for chronic pain. In recent years, pain management experts have turned increasingly to exercise and other ways of increas- ing mobility to help the chronic pain patient. At one time, it was felt that the less activity, the better, so that healing could take place. In recent years, however, exactly the opposite philosophy has held sway, with patients urged to stay active to maintain their functioning. We now turn to psychological techniques for the management of pain. Unlike the pharmacological, surgical, and sensory pain management techniques

considered so far, these more psychological tech- niques require active participation and learning on the part of the patient (Jensen & Turk, 2014). Therefore, they are more effective for managing slow-rising pains, which can be anticipated and prepared for than for sudden, intense, or unexpected pains.

Biofeedback Biofeedback, a method of achieving control over a bodily process, has been used to treat a variety of health problems, including pain control (see Chapter 6) and hypertension (see Chapter 13).

What Is Biofeedback? Biofeedback involves providing biophysiological feedback to a patient about some bodily process of which the patient is usually un- aware. Biofeedback training can be thought of as an operant learning process. First, the target function to be brought under control, such as blood pressure or heart rate, is identified. This function is then tracked by a machine, which provides information to the patient. For example, heart rate might be converted into a tone, so the patient can hear how quickly or slowly his or her heart is beating. The patient then attempts to change the bodily process. Through trial and error and continuous feedback from the machine, the patient learns what thoughts or behaviors will modify the bodily function. Biofeedback has been used to treat a number of chronic pain syndromes, including headaches (Duschek, Schuepbach, Doll, Werner, & Reyes del Paso, 2011), Raynaud’s disease (a disorder in which the small arteries in the extremities constrict, limiting blood flow and producing a cold, numb aching), temporomandibular joint pain (Glaros & Burton, 2004), and pelvic pain (Clemens et al., 2000). How successful is biofeedback in treating pain patients? Despite widely touted claims for its efficacy, there is only modest evidence that it is effective in re- ducing pain (White & Tursky, 1982). Even when bio- feedback is effective, it may be no more so than less expensive, more easily used techniques, such as relax- ation (Blanchard, Andrasik, & Silver, 1980; Bush, Ditto, & Feuerstein, 1985).

Relaxation Techniques Relaxation training has been employed with pain pa- tients extensively, either alone or in concert with other pain control techniques. One reason for teaching pain patients relaxation techniques is that it enables them to



212 Part Four Seeking and Using Health Care Services

cope more successfully with stress and anxiety, which may ameliorate pain. Relaxation may also affect pain directly. For example, the reduction of muscle tension or the diversion of blood flow induced by relaxation may reduce pains that are tied to these physiological processes.

What Is Relaxation? In relaxation, an individual shifts his or her body into a state of low arousal by progressively relaxing different parts of the body. Con- trolled breathing is added, in which breathing shifts from relatively short, shallow breaths to deeper, longer breaths. Anyone who has been trained in prepared childbirth techniques will recognize that these proce- dures are used for pain management during early labor. Meditation, slow breathing, and mindfulness also reduce pain sensitivity and can produce analge- sic effects, possibly through a combination of relax- ation and self-regulatory skills (Grant & Rainville, 2009; Zautra, Fasman, Davis, & Craig, 2010). Spiri- tual meditation tied to religious beliefs can aid in the control of some pains such as migraine head- aches (Wachholtz & Pargament, 2008).

Does Relaxation Work? Relaxation is mod- estly successful for controlling some acute pains and may be useful in treating chronic pain when used with

other methods of pain control. Some of the beneficial physiological effects of relaxation training may be due to the release of opioids (McGrady et al., 1992; Van Rood, Bogaards, Goulmy, & von Houwelingen, 1993).

Distraction People who are involved in intense activities, such as sports or military maneuvers, can be oblivious to pain- ful injuries. These are extreme examples of a com- monly employed pain technique: distraction. By focusing attention on an irrelevant and attention- getting stimulus or by distracting oneself with a high level of activity, one can turn attention away from pain (Dahlquist et al., 2007).

How Does Distraction Work? There are two quite different mental strategies for controlling discom- fort. One is to distract oneself by focusing on another activity. For instance, an 11-year-old boy described how he reduced pain by distracting himself while in the den- tist’s chair:

When the dentist says, “Open,” I have to say the Pledge of Allegiance to the flag backwards three times before I am even allowed to think about the drill. Once he got all finished before I did (Bandura, 1991).

The other kind of mental strategy for controlling stressful events is to focus directly on the events but to reinterpret the experience. The following is a description from an 8-year-old boy who confronted a painful event directly:

As soon as I get in the dentist’s chair, I pretend he’s the enemy and I’m a secret agent, and he’s torturing me to get secrets, and if I make one sound, I’m telling him secret information, so I never do. I’m going to be a secret agent when I grow up, so this is good practice (Bandura, 1991).

Is Distraction Effective? Distraction is a useful technique of pain control, especially with acute pain (Dahlquist et al., 2007). For example, in one study, 38 dental patients were exposed to one of three condi- tions. One-third of the group heard music during the dental procedure; one-third heard the music coupled with a suggestion that the music might help them reduce stress; and the third group heard no music. Patients in both music groups reported experiencing less discomfort than did patients in the no-treatment group (Anderson, Baron, & Logan, 1991).

Biofeedback has been used successfully to treat muscle-tension

headaches, migraine headaches, and Raynaud’s disease.

However, evidence to date suggests that other, less expensive

relaxation techniques may be equally successful.

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Chapter 10 The Management of Pain and Discomfort 213

Distraction is most effective for coping with low- level pain. Its practical significance for chronic pain management is limited by the fact that such patients cannot distract themselves indefinitely. Moreover, distraction by itself lacks analgesic properties (McCaul, Monson, & Maki, 1992). Thus, while effective, distrac- tion may be most useful when used in conjunction with other pain control techniques.

Coping Skills Training Coping skills training helps chronic pain patients man- age pain. For example, one study with burn patients found that brief training in cognitive coping skills, in- cluding distraction and focusing on the sensory aspects of pain instead of its painful qualities, led to reduced

reported pain, increased satisfaction with pain control, and better pain coping skills (Haythornthwaite, Lawrence, & Fauerbach, 2001). Active coping skills can reduce pain in patients with a variety of chronic pains (Bishop & Warr, 2003; Mercado, Carroll, Cassidy, & Cote, 2000), and passive coping has been tied to poor pain control (Walker, Smith, Garber, & Claar, 2005).

Do Coping Techniques Work? Is any particu- lar coping technique effective for managing pain? The answers depend on how long patients have had their pain. In a study of 30 chronic pain patients and 30 recent-onset pain patients, researchers found that those with recent-onset pain experienced less anxiety and depression and less pain when employing avoid- ant coping strategies rather than attentional strategies.

Cognitive Techniques

Supportive Educational Techniques

Other Techniques

Behavioral Techniques

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