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Transcript of yourguideto painmgmt
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Kevin L. Zacharoff, M.D.
Emil Chiauzzi, Ph.D.
Evelyn Corsini, M.S.W.
Pravin Pant
Synne Wing Venuti, M.S.W.
Roanne Weisman
Your Guide toPain Management
A Road Map for painACTION.com
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Your Guide toPain Management
A Road Map forpainACTION.com
ISBN # 978-0-9740093-3-9
Copyright 2009, Inexxion, Inc. All rights reserved
320 Needham Street, Suite 100 Newton, MA 02464
Kevin L. Zacharo, M.D.
Emil Chiauzzi, Ph.D.
Evelyn Corsini, M.S.W.
Pravin Pant
Synne Wing Venuti, M.S.W.
Roanne Weisman
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Acknowledgement
Supported through a grant rom the National Institutes o Health.
NIH Grant #5R44DA022779-03 (Supplement)
No part o this product may be reproduced in any orm. These
materials are protected under ederal copyright laws; they are not
to be reproduced by any electronic, mechanical, or other means,
including storage or retrieval systems, or any use, except with the
express written permission o Inexxion, Inc.
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Preace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Part I: The Pain Management Journey . . . . . . . . . . . . . . . . . . .7
Chapter 1
Productive Partnerships: Working With YourHealthcare Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Chapter 2Take Control o Your Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chapter 3Knowledge is Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Chapter 4
Communication is Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 5Coping with Your Feelings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Chapter 6Your Medication: Staying Sae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Part II: Your Personal Pain Profle . . . . . . . . . . . . . . . . . . . . . . . . . .51Chapter 7Back Pain: Finding Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Chapter 8Migraine Pain: You in the Drivers Seat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 9Cancer Pain: Changing Your Destination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
In Closing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Reerences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Table o Contents
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1A Road Map orpainACTION.com |
When you are in pain, nothing else seems to matter. All o your atten-
tion is ocused with a laser-like intensity on the sensations within
your body. Whether your pain comes rom an aching back, throbbing
in your head or the total body discomort o cancer and its treatment,
you eel as i your world has been circumscribed: You may not be able
to go to work or participate in the relationships and activities you
enjoy. You may nd yoursel eeling depressed or hopeless becauseyou see no end to your suering.
Help is at hand. This Guide to Pain Management, along with the
painACTIONwebsite, on which it is based, will give you the
inormation and unique tools you need to understand your pain,
choose the best treatments, adopt eective liestyle changes, and
nd a supportive, inormed community to help you.
Your Road Map to Pain Management
At times, you might eel as i you are the helpless victim o your pain.
We atpainACTIONwant to help you change that perspective. With
the inormation and tools available to you in this Guide and on the
website, you can try to take control o your pain. Think o yoursel asan explorer in search o the best ways to manage your pain and live a
ull, satisying lie. This journey may lead you to new places that are
unamiliar to you, but you can use this book as your road map and
travel guide. It will direct you to the resources and inormation you
need on your journey, while helping you avoid pitalls and
wrong turns.
In particular, this Guide will give you detailed inormation about
building a productive partnership with your healthcare provider, as
well as developing eective skills or sel-management, communica-
tion and coping. You will also learn about the sae use o prescription
pain medications. While there are many kinds o pain that people
experience, our ocus here is specically on back pain, migraine pain,
Preace
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2 | Your Guide to Pain Management
and cancer-related pain. However, you will nd that much o the
inormation is useul even i you are dealing with other kinds o pain.Are you ready to set o on your journey to eective pain management?
I so, read on to learn more about thepainACTIONwebsite and this
companion Guide to Pain Management.
painACTION: Helping You Take Control
ThepainACTIONwebsite is a useul online resource that helps people
with chronic pain take control o their pain and live ullling, satisy-
ing lives. Together with this companion Guide to Pain Management,
painACTIONwill provide you with the tools and resources you need
to manage back pain, migraine pain and cancer-related pain:
The latest scientically proven pain treatment strategies
including complementary/alternative methods
Expertadvice tailored to your personal needs
Inormativearticles, comprehensive lessons, and interactive
sel-assessment and sel-help tools to use in your journey toward
eective pain management
Inspiring storieso people who are successully managing
their chronic pain
Asupportive communityo ellow travelers and renowned
pain experts to call upon whenever you need them
Turn the page to learn more about pain and the eective techniques
that will help you take control o your pain!
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Not all pain is bad, and sometimes it serves an important purpose.
Sudden pain can warn you that a stove is too hot or be an early warning
sign o a potentially serious illness or a tumor. Chronic pain1, however,
usually serves no useul purpose. The International Association or
the Study o Pain denes pain as an unpleasant sensory and emo-
tional experience associated with actual or potential tissue damage, or
described in terms o such damage.It is always subjective in nature.What does this mean, Always subjective in nature? It means that
your pain is real, and you have the right to treatment, even i your
healthcare provider cant nd a physical cause or your discomort, or
even test or it. Recently, in act, pain has been categorized as the th
vital sign, meaning that duringevery medical encounter, health care
proessionals should ask i you are in pain, in addition to checking your
pulse, temperature, blood pressure, and respiratory rate.
Chronic painpain that persists or three months or longer, even
ater the original cause has healedcan itsel become a major ocus
o disability or dysunction. Chronic pain can evoke an overlay o ear,
depression and hopelessness (because we can see no end in sight),
despair and isolation. These emotions may be coupled with the eeling
o being out o control and the victim o your body. Because o this
complex interplay o emotions, the eective treatment o chronic pain
requires a broad, multi-dimensional approachocusing not only on
the physical cause, but also on your eelings, belies and lie-coping
skills. This approach is precisely what thepainACTIONwebsite and
Guide oer you. Beore we begin, however, lets take a closer look at
chronic pain.
1. Acute pain, which generally has a specic cause such as injury, disease or surgery and
lasts or less than a month, is not the ocus o this book or thepainACTIONwebsite.
Introduction
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4 | Your Guide to Pain Management
All About Chronic Pain
You are probably reading this book because you are experiencing some
orm o chronic pain. I so, you are not alone. Pain aects more Ameri-
cans than diabetes, heart disease and cancer combined, according
to the American Pain Foundation. In 2006, more than one quarter o
Americans over 20an estimated 76.5 million people reported that
they have had a problem with pain o any sort, though this number
does not account or acute pain. About one-third o people who report
having chronic pain indicate that their pain is disabling, dened as
both severe and having a high impact on unctions o daily lie.
I you are experiencing back pain or migraine pain, you also have
plenty o company. These are the two most common orms o pain.
In addition, among people undergoing active treatments or cancer,
an estimated 30 to 50 percent experience signicant levels o pain.This rises to 70 percent or those with advanced stages o the disease,
according to the National Cancer Institute. This is whypainACTION
ocuses on these three main causes o pain. The annual cost o all
kinds o pain in the United States, including healthcare expenses, lost
income, and lost productivity, is estimated to be $100 billion.
O course, this does not include the additional tolls that pain may be
taking on your amily lie, your social relationships, your sel-esteem,and your happiness. In act, the psychological component o chronic
pain is so important that it is eatured in apainACTIONarticle titled
Pain and the brain.
You will nd many articles that are equally inormative on
painACTION, so be sure to take time to explore the website as
you read this book.
Pain and the Brain
Pain is complicated. It is a result o much more than the initial dis-
ease or injury that sets it o, writes psychologist Robert N. Jamison,
Ph.D. In the past, explains Jamison in his article onpainACTION
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5A Road Map orpainACTION.com |
entitledPain and the brain, people believed that pain signals traveled
only one wayrom a nerve injury up to the brain. Scientists have nowlearned that the brain has the ability to act like a gate, controlling
the messages that are received and sent out rom it. They call this
the Gate Control Theory o pain. An important part o this theory is
that in addition to receiving pain signals rom the body, the brain can
also sendmessages that block painul sensations to dierent parts o
the body.
The power o the brain to block painul sensations is one o the
reasons why pain is such a deeply personal experience, so the more
you understand about your pain and its particular triggers, the
more you can play a role in blocking them. And the more active a
role you can take in managing your pain, the better your chance o
success. Research, or example, tells us that people who eel a sense
o controlo ownershipo their health actually do better clinically
than those who eel that they are helpless victims o their illness.
One way to take control o your pain, is to use physical, mental and
emotional actors to close the gate, on pain, thus reducing pain
sensations. The same article gives several examples o these pain
gatekeepers, and the rest o this Guide, as well as the website, tellsyou how to use them:
Physical gatekeepers include:
Medications
Surgery
Stimulation by heat, massage or acupuncture
Techniques to reduce muscle tension
Emotional gatekeepers include:
Your optimistic eeling that things will get better
Social support rom amily, riends, co-workers and
healthcare providers
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6 | Your Guide to Pain Management
A healthy mental attitude
A lowered level o anxiety
Management o depression
Mental gatekeepers include:
Distraction (taking your mind o the pain)
Humor
Actively taking charge, rather than passively waiting to seewhat happens
Having eelings o control over the pain
An important part o thepainACTIONprogram is to help you break
the vicious cycle o chronic pain: The pain makes you eel anxious or
depressed, which then contributes to more pain, which then causes
more anxiety and depression
Dr. Jamisons article shows how you can break the cycle and take
control o your pain by using thepainACTIONprogram to gain a bet-
ter understanding and control o how you perceive pain. You will also
identiy how your personality, amily history and level o emotional
distress contribute to your pain. Pain experts have discovered thatpeople who are not too anxious, worried, or depressed, have strong
social support, and a generally optimistic outlook, are better able to
be distracted, keep a more objective, realistic outlook, and nd good
ways to actively cope with their pain.
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Part IThe Pain Management Journey: Starting O
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8 | Your Guide to Pain Management
No matter what your chronic pain experienceback pain, migraine,
cancer-related pain, or some other orm o painthe chapters in this
section will help with several aspects o your journey to pain manage-
ment. The skills and ideas in this section apply to all orms o chronic
pain. Topics include working with your healthcare team, nding reli-
able inormation, taking responsibility or your pain, dealing with your
emotions and understanding your prescription medications.
Part II o this book gets more specic, with chapters ocused specically
on back pain, migraine pain and cancer-related pain. Beore you delve
into the chapters most relevant to you, however, it is a good idea
to read the introduction to that section. It will help you understand
what these kinds o pain have in common and how they are dierent,
and will give you a better understanding o your own personal journey
to pain management.
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10 | Your Guide to Pain Management
Physician assistant
Pain specialist
Bodywork or massage therapist
Physical therapist
Alternative practitioners such as an acupuncturist
Psychologist or social worker
The second column should include your own name, as well as any
amily members or riends who are, or could be, helping you. These
two columns orm the two sides o your partnership team. This
chapter will describe the roles and responsibilities on each side o
this team to help you create kinds o health care partnerships that
will help you manage and control your pain.
Ideally, each side o the team should have equal responsibility, split
50-50 between you and your amily or riends on one side, and all o
your healthcare providers on the other.
You should have a say in every decision that is made about your pain
and how it is managed:
Medications
Exercise plan
Special procedures
Other treatments
Surgery
I there is more than one provider on your team, it would be good
to pick the one best personmost likely your primary care doctor or
nurse practitionerto oversee the big picture. This person should
coordinate all prescription medications, medical advice, exercise
programs, and your diet (including herbal supplements and over-
the-counter medicines). In order or this to happen saely, you should
share all inormation about what you are doing and taking with this
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11A Road Map orpainACTION.com |
big picture provider. This person should be the one who knows you
best, understands your needs and concerns as well as the details oyour home and work lie. AMedical Home is a new way to reer to
thisbig picture provider and his or her ofce, which simply means
that this is the person (or clinic) you go to or trusted medical advice.
Your medical home is a source you can rely on to help you sort through
all the inormation you may be hearing on TV or reading in the news
or on the Internet. (For details about nding medical inormation you
can trust, please also see Chapter 3 about knowledge-based skills.)
What to Expect From Your Medical Home
The provider you choose to coordinate your care has several responsi-
bilities. Here are some ideas o what you can expect. You should
eel ree to discuss with this provider how you would like to work
together to:Figure out what is causing your pain
When you have unexplained chronic pain, it is a good idea to make
yourrst visitto the person you have chosen as your medical
home provider, such as your primary care doctor or nurse. By
listening and talking with you, this provider will have the best
chance o determining the source o your pain and helping you
choose the best combination o ways you can help yoursel, along
with medicine or treatments. (For more about taking control o
your pain, please see Chapter 2.) Whenever you talk to your
medical home provider, it is very important that youreely ask
every question that occurs to you, as well as share details about
your lie, your dietincluding supplements and over-the-counter
medicinesand your regular activities. This is the kind o inor-mation that will help your provider make an accurate diagnosis
o your pain.
Help you decide on realistic treatment goals
As mentioned earlier, it may be difcult to eliminate your pain
completely. However, it is the responsibility o your provider,
always in consultation with you, to recommend the best ways to
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12 | Your Guide to Pain Management
at least reduce the pain and improve your ability to live a satisy-
ing lie. In order to do this, your provider needs to know what yourgoals are and the ways in which the pain is preventing you rom
reaching those goals. This destination o your pain management
journey will change over time, so it is important or you and your
provider to keep talking and listening to each other. There are
several articles and lessons on thepainACTIONwebsite that help
you communicate with your provider. One example is the lesson
How to work eectively with your doctor.
One way to think about your partnership with your provider is as i
you were working together to ght a orest re. Even i you cant com-
pletely put out the re, you can stop it rom burning out o control or
at least you can slow it down, so that it only ares up once in a while.
In working with your provider to control your pain, you will always be
balancing two goals:
1. What you would like to do: or work, amily lie, recreation, etc.
2. What you needto do or your pain: including medication, exercise,
diet, and cutting down on some activities
The trick is to nd the best balance or you at any given time.
Personal Perspective: Your Half of the Partnership
You, as the patient, have as much responsibility as your healthcare
provider team or managing your pain. Even i you share this respon-
sibility with a amily member, riend, spouse or other non-medical
person, you should have the big picture view, just like your medi-
cal home provider. No one else is in your body, so no one else knows
exactly how you are eeling. This is especially important in the
treatment o pain, since pain is the only medical condition in which
the patient has the nal say in how successul the treatment is. Here
are some ways you can take charge o your pain treatment:
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13A Road Map orpainACTION.com |
Coordinate your team
You may decide, in the course o your treatment, that you wish to addanother provider to your team, such as a chiropractor, a massage
therapist, an acupuncturist, psychologist or other mental health
proessional. This is ne, as long as you keep your Medical Home
provider inormed o what you are doing and whom you are seeing,
and make those decisions together.
Keep it goingNo matter whom you bring onto your team, however, the key to
successul pain management is along-term relationship with your
medical home provider. Ideally, this person has known you or some
time and understands your lie goals, treatment preerences, stresses,
relationships and history. You trust and respect each other and eel
comortable challenging and raising questions in an open discussion
o treatment options.
An Expert Opinion
Some examples of productive partnerships
Here are examples o some questions you might ask your health
care provider as part o a productive partnership discussion
about your pain:
QWhy cant my healthcare providers relieve my paincompletely when there are so many miracles thatmedicine can provide, like organ transplants?
AThis is an excellent question, and a source o distress or many
patients, who see live photographs o Mars on their TV set,
yet can hardly walk because o their aching backs. The simple
truth is contained in your question: the act is that despite all
available medical technologies we are oten able to control
chronic pain, but are almost never able to completely get rid
o a chronic pain problem, unless the reason behind it is easily
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14 | Your Guide to Pain Management
correctable. In act, the patients who succeed most in benet-
ing rom pain management techniques are the ones who acceptthat they will not be able to get rid o their pain problem, and
seek help to reduce their level o pain and improve their level o
unctioning. Why have we not done better? This is a matter or
speculation, and people will have dierent opinions. One im-
portant reason is that very little unding has gone to improving
the understanding and treatment o chronic pain: or example,
only a tiny raction o ederal unding or medical research goesto pain research.
QIve been told to exercise, but every time I do, my painincreases. Doesnt my healthcare provider understandI cant exercise?
AIt would be very helpul or you to communicate with your
healthcare provider about your difculty with exercising, i
you havent done so already. Pain experts tend to encourage
their patients to exercise because exercise can help patients
with chronic pain in many ways: exercise can increase your
ability to unction in your day to day lie, help reduce pain,
improve mood, improve sleep, etc. O course, i you cant
exercise because it increases your pain, you will not be able to
reap these benets. The good news is that there are a variety
o things you can do to get around this problem. The rst thing
is to take small bites, beginning with exercises that you can
do beore moving onto the more difcult ones. Next, use ice or
heat beore, during, or ater the exercise; take a pain medi-
cation an hour beore you plan to exercise. A good physicaltherapist, and an attentive healthcare provider, should be able
to guide you through this problem.
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In Summary...
Identiy your destination - with regard to what you want
to achieve when managing your pain
Construct a list o your healthcare providers, and
their role in managing your pain
Find a Medical Home that can coordinate all o your care
and understand all o the pieces o the puzzle
Understand your responsibility in managing your pain
Become a partner in your pain management, not
a passenger
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Chapter 2Take Control o Your Pain
When you are in pain, do you sometimes eel like a helpless victim,
just waiting or it to go away? Many people have this experience. It is
easy to become overwhelmed and hopeless when it seems like pain
has taken over your body.
This chapter is about a new way to deal with your pain, by taking
control and directing your own journey to pain management. Whileyou may not be able to eliminate your pain entirely, you can, with the
sel-management skills you will learn in this chapter, manage it and
eel less helpless.
What Are Sel-Management Skills and How Will
They Help Me?
Sel-management skills can be learned. They are not based on who
you are, but on what you are able to do or yoursel. The painACTION
lesson on sel-management skills, How to take control: sel manage-
ment and pain, explains it this way: Sel-management means taking
care o yoursel and your needs, in a healthy way. A person with sel-
management skills understands how to keep track o her symptoms
and treatments. She also knows that her thoughts and actions canchange how her illness behaves on any given day.
Sel-management does notmean taking over rom your healthcare
providers. It means working as an equal partner with them to manage
your pain. Ater all, you only see your healthcare provider or about
teen minutes or hal an hour at a time. What about the hours, days
and weeks between your appointments? During these times, you needto be able to take care o yoursel, just as a savvy traveler may head
o to a destination without a tour guide or parts o the trip. Yes, you
need to take the prescribed medication and ollow the advice you are
given, but there is much more you can do as well. Here are
some examples:
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18 | Your Guide to Pain Management
Notice How You Are Thinking About Your PainWhat you believe really does make a dierence in how you eel.
For example, do you believe the ollowing acts about pain?
(Hint: they are all true.)
Successul pain management usually takes several dierent
approaches, rather than one magic bullet.
Studies show thatpassive methodsusing only rest, hot/cold packsand medications to treat pain are less eective and are linked to
more chronic pain and disability than active treatments (exercise,
or example).
Condent people usually have better results with pain management.
Getting more control over your stress and eelings like depression
and anxiety can help to manage your pain.
I you would like help with changing the way you think about your pain,
talk to your healthcare provider or ask or a consultation with a social
worker or psychologist.
Keep Track Of Your PainIn order to help you, your providers must learn how, when, and where
youre hurting, and you are the only one who can tell them. The Daily
Tracker, which can be ound on thepainACTIONMy Page, will help
you to gather the inormation you need to bring to your medical
appointments. This includes:
The intensity o the pain
How well your medications work
Your ability to manage the pain
How the pain intereres with your daily routines, sleep, mood
and relationships.
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TheDaily Trackerwill also teach you accurate ways to describe your
pain, because some days it may be worse than others. You can think othis as your travel journal.
Take an Active Role
There are many ways to be active in your pain management program.
Here are just three o them:
Become physically active by exercising
Exercise is truly the most active part o sel-management,
although it works best when its started gradually and paced prop-
erly. Exercise builds strength and exibility and gives a natural
antidepressant eectwhich is important, as many people with
chronic pain become depressed. Need more motivation? I you
dontexercise, this can lead to stier joints, weak muscles, less
staying power and lower pain tolerance.
Become an active learner
Find out everything you can rom your providers and the sources
they recommend about your diagnosis and your medications
(including side eects and the dangers o missed doses).
Become a problem solver
Problems are inevitable. These might include pain are-ups,
medication that no longer works, or difcult lie events. How are
you going to deal with them? First, take a deep breath, then
consider the ollowing steps:
Clearly identiy the problem. This may take some time, as the
actual problem may not be immediately obvious.
Decide on your goals. What do you want to accomplish inthis situation?
Figure out your options.What are the possible solutions?
Pick the most likely solution.
Take action.
Part IVHealth care coverage in the Hispanic population
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20 | Your Guide to Pain Management
Be Your Own Advocate
Advocates are those who ght or the rights o others. You, as theperson who knows your pain best, are your own best advocate. So
dont be shy! Ask questions. State your preerences, and let your voice
be heard. I, or example, you preer not to take pain medications, ask
i there are alternatives. Sometimes exercise programs, such as back
pain boot camp, or changes in your diet to control migraines, can help
avoid or limit the need or pain medications. Other options, described
onpainACTION, include bioeedback, and alternative treatmentssuch as massage and acupuncture.
Another important advocacy role is preparing to participate ully in
your visit to your healthcare provider. An article rompainACTION,
Medical appointments: making the most o your visitlists ways you
can do this. Items on this list are: transerring your records, collecting
and bringing important inormation, making a list o questions, bring-
ing someone with you to take notes and remember what was said,
scheduling enough time, repeating back what you hear in summary at
the end o the visit, and requesting a copy o any important materials.
The article also discusses ways to make important medical decisions,
how to keep a pain diary, and how to make your ollow-up plans.
Even as you advocate or yoursel, there is always a community o oth-
ers to support you. This can be your personal relationships, including
amily, riends, or clergy, or it can be pain organizations and support
groups, such as those listed onpainACTION. I you join the website,
you will also nd a ready-made community o proessionals and other
patients, always available or questions, guidance and support.
Taking Control of Pain
Here are examples o questions rom patients who are taking control
o their pain. These questions show patients ollowing some o the
advice in this chapter by acting as advocates or themselves, becoming
active learners, and making their preerences known.
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An Expert Opinion
Some examples of taking control of pain
QMy pain keeps me rom sleeping. What can I do to help me getat least one good night o sleep?
A
Difculty sleeping is one o the main problems experienced
by patients with chronic pain. Sleeplessness in turn seems to
make pain worse, causes anxiety, irritability, depression, and
daytime atigue, and makes it much more difcult to cope with
the pain problem. Thereore, getting a decent nights sleep ev-
ery night is a critical goal or patients with chronic pain. There
are many ways to approach this problem, and your physician
should be able to provide you advice on this.
The basic approaches, called sleep hygiene, are those ol-
lowed by any patient with insomnia. Such approaches include
avoiding napping during the day, avoiding caeine, exercising
during the day (but not close to bedtime), avoiding stimulating
activities (such as TV) in bed, and reserving the bed or sleep-
ing. A nighttime snack or glass o milk or tea may also help.
For patients with chronic pain, other techniques may be
needed. First, it is worthwhile remembering that many medi-
cations, and some medical problems, may cause insomnia
as a side eect. When it is the pain itsel keeping you awake,
changing your sleep surace (e.g. a dierent mattress) may
help. Finally, a number o medications may help with this
problem. Taking an extra dose o a pain medication at bedtime
may help keep your pain rom waking you up in the middle o
the night, although its worth remembering that short-acting
medications may wear o in the middle o the night, and some
may even cause a rebound eect, leaving you with more
insomnia when they wear o. For that reason, long-acting pain
medications are better or maintaining sleep than short-acting
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ones. Finally, there are a number o sleeping pills that can be
used to help with this problem. It is important to rememberthat none o these strategies are intended or you to try on your
own. These are issues you need to discuss with your healthcare
provider and decide to try together.
QEver since my pain began I have been steadily gaining weight.What can I do to lose weight? Is there a special diet?
AFirst remember that there are many reasons a person withchronic pain may gain weight, and it is important to gure outthe correct reason. Weight gain can be caused by a variety o
medical problems, such as hypothyroidism or edema (swell-
ing), so you need a thorough medical evaluation, including
blood tests, i you are starting to have unexplained weight gain.
Second, some medications can cause weight gain as a side e-
ect. People who develop mood disturbances, such as anxiety
or depression, can have changes in their weight. Finally, the
most common reason or weight gain in a patient with chronic
pain is that they are eating more, exercising less, or both. This
can be caused by a change in daily routine, such as not working
any more, or not sleeping as well, which creates more oppor-
tunities to eat. There are many ways to deal with this that your
healthcare provider can direct you to. Finding a good nutri-
tionist to help on the eating side, and a physical therapist to
help on the exercise side, may be useul.
QPhysical therapy only makes my pain worse, but every doctor
prescribes physical therapy. Why do they keep prescribingtreatments that dont work?
AYou may have a legitimate complaint, in that healthcare pro-viders who are not as aware o all the options or pain manage-ment may continue to prescribe in vain the only treatments
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they know about, including physical therapy. But there may be
another explanation: providers know that exercise is criticalor the recovery o most patients with chronic pain. A good
physical therapist will try to help you gradually increase the
amount and type o exercise you do, and will give you specic
advice on tricks you can use in order to tolerate your increas-
ing exercise (such as ice, heat, massage, exercising in water,
and pacing yoursel). Many patients ear exercise because
they are concerned about harming themselves; it is critical toget a clear statement rom your healthcare provider that even
though you may eel increased pain while exercising, it does
not mean you will harm yoursel. Finally, your provider may
be able to work with your physical therapist to nd medical
strategies (such as taking your pain medication an hour beore
exercise) that allow you to tolerate your increasing level
o exercise.
In Summary...
Notice how you are thinking about your painKeep track o your pain
Take an active role in managing your pain
Be your own advocate
Take control o the situation; dont let it control you
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your treatment.It is important to realize, however, that this is not a
one-way ow o knowledgerom provider to you. It is also importantor knowledge to ow in the other directionrom you to your provider,
especially about any treatments you are having (such as chiropractic,
massage or acupuncture), and any over-the-counter supplements or
medications you are taking. You can also ask or clarication about
inormation you received rom another source, or example, my
massage therapist thinks that I would benet rom a yoga class, what
do you think?
Questions to Ask
Now that you know where to begin your act-nding journey, what
other kinds o questions should you ask? Here are a ew examples.
The answers may be spoken during a conversation, or your provider
may give you written materials or direct you to a reputable website
or more inormation:
What is my exact diagnosis?
What are the likely causes o my pain?
What can I do on my own, including diet, exercise, and stress
reduction? (Please see Chapter 5 on Emotional Coping.)
What tests do you recommend (e.g. MRI, CT scan)? Can you
explain how they are done?
What procedures do you recommend? Can you explain them?
What medications do you recommend? What are the side eects?
When would surgery be indicated, and what kind? (You wouldalso want to talk to a surgeon in this situation.)
What can I expect, realistically, in terms o eeling better?
What websites do you recommend?
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Second Opinions
I you are not satised with the answers to these questionsor eveni you areyou might want to hear rom another healthcare provider.
This is a good idea because it gives you dierent perspectives on
the same problem. You dont have to worry about hurting someones
eelings by asking or a second opinion. Any reputable healthcare
provider would welcome your right to talk to another provider, and
would not be threatened or insulted in any way. Ater all, you are the
boss o your own body and you need to be completely comortableabout any treatments.
A ew guidelines about second opinions however:
Domake sure that any second opinion that you seek is rom an-
other provider o the same type as your rst one.
Dont, or example, seek a second opinion rom a chiropractor and
try to compare that to the opinion you received rom a primary
care doctor. These people have dierent types o training, so it
would be like trying to compare apples and oranges! I you are
comparing opinions rom specialists, make sure they are o the
same kind: For example, two neurologists, two pain specialists,
or two surgeons.
Your Internet Guide
In addition to talking with your provider and reading any written ma-
terials you are given, you might join the millions o people who turn
to the Internet every day or medical advice and inormation. While
the Internet is a wonderul resource, it can also be difcult to sort out
act rom ction and to nd inormation you can trust and rely on.
Here are a ew guidelines. For more detailed Internet advice, see the
painACTIONarticle, The Internet made easy!
Check the URL
Ater you type your question or topic into a search engine, you will see
a list o relevant Internet sites. Instead o just clicking, begin by doing
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some screening. First, look at the URL, or the web address ater the
name o the website. Generally, the more reliable sites end with .gov(or government agencies), and .edu (or academic medical centers).
You can also look or national organizations that provide inormation
on the condition you are interested in, which will end with .org. Just
make sure these are nonprot organizations, such as The American
Cancer Society, (www.cancer.org).
Other reliable sitesEven i the sufxes gov, edu and org dont appear in a URL, the
site still might be useul and sae, as www.painACTION.com is, or
example! Here is a way to evaluate other sites: Is the site easy to navi-
gate? Is the organization reputable? You can oten determine this by
doing a search on the organization itsel to see i there are complaints
or lawsuits. Is the site trying to sell you a product to improve your
health? I so, warning bells should go o! View with suspicion any site
that is trying to sell you something, whether it is a medicine, a ood or
a health-related device. At a minimum, ask your healthcare provider
or advice.
Evaluating Internet information
Once you are satised with the site itsel, look closely at the
inormation on it:
Is it current? Always check on the date that the inormation was
posted. This usually appears at the bottom o each screen. I there
is no date, beware! This might indicate that there is disproved or
outdated inormation, or a sloppy, untrustworthy website.
Is the inormation actual (rather than opinion or ranting),and backed up with reerences to primary sources, such as
research studies?
Are experts cited? Even i there are no research studies to back up
the advice, there should be some other reliable source, such as a
reputable expert who is associated with a major academic medical
center, or a reliable research organization.
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Internet Tips
Want to learn more? Here are some ideas rom the painACTIONarticle, Sae Surng: nding online pain support.The guidelines in
this article should help you become a smart inormation-gatherer and
a savvy consumer, all o which will increase your chances o dealing
successully with your pain.
Other suggestions:
The Medical Library Associations Users Guide to Finding andEvaluating Health Inormation on the Web - http://www.mlanet.org
(search on users guide)
MEDLINEplus is a consumer-oriented website established by
the National Library o Medicine. It includes an online illustrated
medical encyclopedia and dictionary. http://medlineplus.gov/
For evidence-based inormation about complementary andalternative therapies, visit the website o the National Center or
Complementary and Alternative Medicine, part o the National
Institutes o Health, which also has an excellent consumer health
inormation website. http://nccam.nih.gov
In Summary...
Your medical home should be the rst stop on
your journey
Its important to know what questions to ask your
healthcare providerSecond opinions can be helpul
Choose your Internet resources careully
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Chapter 4Communication is Key
In your journey to pain management, the healthcare providers you
meet along the way can serve as helpul tour guides. In order to help
you, however, they need to know where you are goingyour destina-
tion: What are the goals o your pain management and what would
you like to be able to accomplish? This chapter is about how to help
your healthcare provider help you during this important lie journey.
You might think, as many people do, that your doctor, nurse, physi-cian assistant or other medical proessional knows everything about
your pain. But this is only partly true. Your healthcare providers may
know a great deal about pain in general, and how to treat it. But they
probably dont know the details about yourpain and its eect on your
lie. So it is important or you to tell them, to communicate with them
about what your pain is doing to you in your own lie. Ater all, you
are the only person in your body, so you are the expert about your ownpain! For example, is your pain:
Making it harder or you to do your job?
Preventing you rom enjoying your avorite activities?
Interering with your sleep or your relationships?
Aecting your ability to take care o your children or other
amily members?
Causing you to become depressed or anxious?
No two people will answer these questions in exactly the same way,
so that is why it is a good idea to share this inormation with your
healthcare provider. Why is this so important? Because, as discussed
earlier in this book, one key to successul pain management is shareddecision-making between you and your healthcare provider about the
course o treatment. Part o shared decision-making is setting realis-
tic goals and expectations. I your provider does not know how your
pain is preventing you rom reaching your goals, how can he or she
give you a good idea o what the treatment should be and what kind o
relie you can expect? And later on, how can you together decide i the
treatment is working? I you want to take a journey, you need to know
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where you would like to end up! For tips about starting that conversa-
tion, you might want to look at thispainACTIONarticle, Are theylistening?: talking about your pain.
Pain is Not a Score; It is an Experience
As they evaluate your pain, many providers will ask you to rate it on a
scale o 0 to 10, 0 being no pain, and 10 being the worst pain imag-
inable. This is important inormation, but it is not enough, because
pain is not a score; it is an experience. For example, i you have back
pain, it is not enough or your provider to know that the treatment
brought it down rom a 9 to a 6. Your provider also has to know i
your goal was to be able to play 18 holes o gol, (or repair a transmis-
sion, sit at a desk or 8 hours or pick up your grandchildren). Have
you reached your goals? I not, the treatment has not been successul
and you and your provider need to re-evaluate and come up witha dierent plan.
What You Can Say
There is an old saying that i a healthcare provider simply listens and
gives the patient enough time to talk about his or her problem, the
diagnosis will become clear, even without a lot o expensive tests. But
what i your provider is not a good listener, or doesnt give you enough
time to talk? Here are some things you can say:
I know you are in a rush, but I would really like to tell you how this
pain is making it hard or me in my lie right now. Do you have a
ew minutes to listen?
Thank you or this pill prescription, but what else can I do to helpthis pain go away?
How long beore I can realistically expect to eel better?
I really dont like taking pain pills i I dont have to. Is there some
kind o exercise program, like back pain boot camp, that I can do
to see i it helps instead? Are there any other non-pill treatments
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like acupuncture or bioeedback? (These are all described
onpainACTION.) Here is what Id like to be able to do in a ew weeks; is this realistic?
How about in a ew months? [insert your goal here] For example:
take a dance or yoga class; do weight training at the gym; start jog-
ging; go hiking; take a car trip.
It has been two months, and my pain is really not going away. I am
getting discouraged and rustrated. Can we talk about a new plan?
Communicating With Family and Friends
In addition to communicating with your healthcare provider, there are
other people in your lie: amily, co-workers and riends. Oten, these
people might not realize how pain is aecting your lie. Perhaps you
even eel that pain is in control o your lie, but people dont see this.
They also may not understand that you are on a personal journey to
control and manage your pain. It can be very difcult or many people
suering rom chronic pain to communicate with others about their
experiences. People in acute pain, such as rom a sprain or racture,
oten show visible signs o their distress: You might look upset or moan
and groan, or always be trying to nd a comortable position. Health-
care providers might measure a ast pulse or heart rate, high bloodpressure or other obvious physical signs o discomort and discuss
these ndings with amily members so that they understand the pain
more clearly.
People with chronic pain dont usually show such obvious signs,
however, which may lead an inexperienced observer, such as a riend
or amily member, to think that the problem really isnt that bad. It ishelpul to explain to your riends and amily members that people with
chronic paineven i it is severemay not show it. But you dont want
to overdo these explanations either, or some people might say that you
are always complaining. So it is a good idea to ask your healthcare
provider, or a psychologist, to help you communicate in a positive way
with your loved ones so that they understand about your pain and the
ways in which they can be supportive to you in your journey.
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Sometimes the biggest causes o rustration, anxiety or depression are
what you dontknow, rather than what you do know. That is why com-munication is so important. I, or example, you thought your sprained
ankle would get better in a week, but the pain is dragging on or a
month, wouldnt it have been helpul to know rom your healthcare
provider that ankles can take three months to heal? The only way to
know this kind o inormation is to ask outright, since many providers
might not want to give you discouraging news. But once you do have
the acts, you can take steps to cope with them, and that is what thenext chapter is about.
An Expert Opinion
Communicating with your healthcare provider
Here are some examples o questions you might want to ask your
provider, and some possible answers. Try these questions and seewhat answers you get!
QWhy cant my healthcare provider give me complete painrelie when there are so many miracles that medicine canprovide, like organ transplants?
AThis is an excellent question, and a source o distress or manypatients, who see live photographs o Mars on their TV set, yet
can hardly walk because o their aching back. The simple truth
is that despite all available medical technologies we are oten
not able to control chronic pain, and are almost never able to
get completely rid o a chronic pain problem. In act, the pa-
tients who succeed most in beneting rom pain management
techniques are the ones who accept that they will not be able to
get rid o their pain problem, and seek help to reduce their level
o pain and improve their level o unctioning. Why have we
not done better? This is a matter or speculation, and people
will have dierent opinions. One important reason is that very
little unding has gone to improving the understanding and
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treatment o chronic pain: or example, only a tiny raction o
ederal unding or medical research goes to pain research.
QMy healthcare provider just prescribed an antidepressant orme. Why? Im not depressed, I have pain!
AMany medicines have benets or more than one condition.Antidepressants have eects in depression, o course, but alsohave eects on certain types o chronic pain. For example,many antidepressants are eective or neuropathic pain (i.e.
pain resulting rom nerve injuries); antidepressants can be
eective or other types o pain as well. On the other hand,
patients with chronic pain do in act requently suer rom
depression as well. So a pain patient who does have depression
also may be prescribed an antidepressant. The bottom line is
that there are many good reasons or a patient with chronic
pain to be prescribed an antidepressant, and it certainly does
not mean your healthcare provider thinks you are crazy, or
your pain is all in your head.
Q
Ive been told to exercise, but every time I do, my pain
increases. Doesnt my healthcare provider understandI cant exercise?
AIt would be very helpul or you to communicate to yourprovider about your difculty with exercising, i you haventdone so already. Healthcare providers tend to encourage their
patients to exercise because exercise can help patients with
chronic pain in many ways: exercise can increase your abil-ity to unction in your day to day lie, can help reduce pain,
can improve mood, improve sleep, etc. O course, i you cant
exercise because it increases your pain, you will not be able to
reap these benets. The good news is that there are a variety o
things you can do to get around this problem. Some examples
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are to begin with exercises that you can do beore moving onto
the more difcult ones; use ice or heat beore, during, or aterthe exercise; take a pain medication an hour beore you plan to
exercise. A good physical therapist and an attentive healthcare
provider should be able to guide you through this problem.
In Summary...
Pain is not a score, it is an experience
Try to think about what you want to say to your
healthcare provider
Communication is key
With your healthcare provider
With your amily and riends
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Beore you set o on a car trip, you might consult a travel agent or seek
advice rom riends and amily about where to go and what to see.
But, in the end, you have to take the wheel. This is your journey, and
you are in charge o both your nal destination and your route. The
same is true o pain management. You can and should seek help rom
a number o sources, but you do have to direct your own path. You are
the only one inside your body, so trust your instincts when somethingdoesnt eel right. From time to time, you may have to redesign your
itinerary or travel planseeling a sense o control will actually help
you to cope emotionally with the difcult moments. This chapter will
give you the tools you need to plan a successul emotional journey to
managing your pain. You will learn about stress, anxiety and depres-
sion and discover tips on how to develop more positive eelings, even
when you are coping with pain.
First, a little background on the connections between emotions and
pain: Does your body know what is going on in your mind? Surprising
as this may sound, the answer is yes. When you are eeling stressed
or anxious, or example, your brain triggers the release o chemicals
called stress hormones in your body. These include adrenalin and
cortisol, and they can have powerul eects on your pain. You may be
eeling stressed or anxious as the result o your pain itsel, or the reac-
tions o those around you to your pain, or because o thingssuch as
work or amily troublesthat have nothing to do with your pain. But
whatever the cause, the result is the same: it can make it harder or
you to cope with your pain. Feeling sad and depressed can also make
your pain worse.
What is Stress and How Can it Make Pain Worse?
Stress is the response we have to situations that demand that we
ocus our minds and bodies in some way. Some stress can be thrilling,
such as the exhilaration o skiing down a steep mountain or holding
Chapter 5Coping with Your Feelings
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on during a roller coaster ride. Other stress can be unpleasant, such as
the anxiety o being late or a presentation at work, or the rustrationso a amily disagreement. No matter where it comes rom, stress gen-
erally creates a ght, ight or reeze response, as stress hormones
ood our bodies to help us meet the challenge. In response to these
hormones our muscles tighten, we breathe aster and we take smaller,
shallower breaths, and our hearts speed up. I the stress is acute,
meaning it does not last long, these eects soon disappear. But i you
are eeling stress every day, or weeks or months at a time, thisis called chronic.
Chronic stress or anxiety can make pain worse. It can cause your body
to continue to hold muscles tighter than they need to be. At the same
time, your shallow breaths bring less resh oxygen to those over-
worked muscles. As you know i you clench your st or hunch your
shoulders or any length o time, tight muscles contribute to pain. Not
only can stress and anxiety make back pain worse, it can also contrib-
ute to migraine pain, as thepainACTIONarticle, The link between
stress and migrainedescribes.
Coping With Stress and Anxiety
I youve ever experienced signicant stress while on vacation, youknow that it can make it much harder to enjoy a trip. Chronic stress
or anxiety will have a similar negative eect on your journey to pain
management, so its important to learn how to control these eelings.
There are several ways to manage stress and anxiety: Identiy the
causes; talk about it; take ownership o your situation; and use proven
stress reduction techniques. The tips in the rest o this chapter will
help you reduce your stress, allowing you to continue your journey
more comortably. Your healthcare providers can give you a great deal
o helpul guidance, but always remember that you are in charge o
mapping out your voyage.
Identify the Causes
The rst step in lowering your stress and anxiety levels is to gure out
where they are coming rom. You can think about this on your own or
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ask your healthcare provider to help you. As pointed out in the last
chapter, sometimes the unknown is more difcult than the known, sothe more reliable inormation you can nd out, the better. You would
not simply head to an unamiliar country without learning something
about your destination (talk about stressul!), so take the same proac-
tive steps when it comes to this journey. I you have some realistic
inormation about your path to pain management, you may be less
stressed or anxious about it. I your stress is coming rom eeling that
your pain is lasting too long, or example, ask some rank questionso your provider: How long can I expect this to go on? Will my pain
ever completely go away?
Talk About It
I your stress is coming rom your amily relationships, it might be
a good idea to gure out what people can do to help you and then
brainstorm with them about ideas that might help: At the end o the
day, my back is really sore and it would be really nice i someone else
would do the dishes. I can nish cleaning up ater I sit down or a ew
minutes. Even i you dont come up with practical solutions, just talk-
ing about your pain with a trusted person helps to ease the burden.
Some people have ound support groups or advocacy organizations
helpul as well. You can nd links to such resources on the
painACTIONwebsite.
Take Ownership
Evidence shows a direct link between your mood and your ability
to cope with pain. I you are eeling down in the dumps, and like a
helpless victim o your pain, you might actually nd your pain levels
increasing. I, on the other hand, you can eel good about yoursel assomeone who is taking control o your lie and your situation, you will
very likely nd that you are eeling less pain. Easier said than done?
Heres how you can take control o your pain:
Be creative about changing the sources o your stress.
I you are eeling overscheduled, see what can be eliminated.
Create a one-night oasis o calm each week, when you stay
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home and relax. Since sleep has been shown to be important in
coping with pain, pick one night a week to go to bed by 10 PM.
Get the ght out
I you eel that anger is bursting out o you, try to tame it by doing
some regular do-able orm o exercise every day, such as stretch-
ing, walking, jogging, or a spinning, yoga or aerobics class.
Keep a travel journal
Many people nd that keeping a journal while traveling enhances
their enjoyment o the trip and allows them to sort through their
eelings and experiences. The same is true o emotional coping;
writing your worries down has been shown to reduce stress and
alleviate some pain.
Calm your body down
You cant be anxious and calm at the same time, so try to let the
calm eeling take over. Do whatever eels most comortable to
you: Sign up or classes in meditation, yoga, or Tai Chi (also called
moving meditation), or nd a trained bioeedback therapist.
Read thepainACTIONarticle, Using bioeedback to manage
migraines. Practice deep, slow breathing, or go or a long walk or
bike ride in nature.
ThepainACTIONwebsite has several tools you can use to eel calmer,
less stressed and more relaxed. These kinds o eelings have been
shown to make pain more bearable. ThepainACTION Relaxation
Response Tool, or example, teaches a proven meditation method,
called the relaxation response that is used in medical centers through-
out the country to help people cope with pain and discomort. You can
also usepainACTIONs Guided Imagery Tool, to take your body on a
mini vacation.
What About Depression?Its common or people with chronic pain to have depression. Depres-
sion can worsen and prolong the pain. Pain and depression can take
over a persons thoughts and eelings with more pain leading to more
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depression, creating a cycle that is difcult to break. Pain and depres-
sion can take over a persons thoughts and eelings with more painleading to more depression, creating a cycle that is difcult to break.
In thepainACTIONarticle, Depression and pain: break the cycle,
you can learn more details about this. The lesson, How to deal with
depression gives tips on dealing with depression.
These are just suggestions or ways that others have successully
reduced their stress, anxiety and depression on their journeys tobetter pain management. You are a unique individual, however, so it
is important to nd what works best or you. One way to do this is by
looking back at your lie to nd out how you have successully coped
with emotional problems in the past. A mental health provider can
also be helpul in guring out the best ways or you to eel better. In
the meantime, the ollowing lessons and tools on thepainACTION
website will be helpul:
How to develop a positive rame o mind(Lesson)
How to handle stress in your lie(Lesson)
How to ace the challenges o living with pain(Lesson)
My Coping (Sel-check)
An Expert Opinion
Coping with emotions
QMy pain specialist says I have to see a psychologist beorehe will take me on as a patient. I am not crazy. Do you thinkI should have to do this?
AChronic pain causes major problems or many patients, inaddition to pain itsel, which is bad enough. Patients with painthat lasts or a long time may get depressed, develop anxiety,
have trouble sleeping, or may have trouble in relationships
with spouses, riends, and employers. Recognizing this, many
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healthcare providers suggest that patients see a psychologist
to help with any emotional problems while the pain itsel isbeing worked on. In addition, there are a number o techniques
that a psychologist can help you learn to do or yoursel, to help
reduce the pain, such as relaxation exercises, bioeedback, and
sel-hypnosis. So being reerred to a psychologist doesnt mean
that anyone thinks you are crazy it usually means that your
healthcare provider is trying to nd every possible way
to help you.
QIm told that I need to reduce the stress in my lie to help withmy pain management. How can that help?
A
Stress is a part o lie, and cannot be completely escaped.
This is even more the case when you have chronic pain. As you
have seen in this chapter, stress, and the anxiety and irritabil-
ity it may lead to, may make pain more intense, and may also
make it harder to cope with the pain you have. There are many
dierent ways to cope with stress, and learning healthy ways
to manage stress can decrease the impact that stress has on
managing your pain. This chapter and its links to the
painACTIONtools and lessons will give you useul stressmanagement techniques.
In Summary...
Chronic stress or anxiety can worsen pain
Managing stress is important to successul
pain management
Take ownership o your mood and ability to cope with pain
Depression may occur with chronic pain
Talking about depression with a mental healthcare
provider can help
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When you are traveling in unamiliar territory, you take a number
o precautions to ensure your saety and the saety o the people
with you. When you drive a car, you ollow the rules o the road. It is
important to bring that same caution and respect or saety rules to
your pain management journey. The prescription pain pills in that
little bottle may look innocent, but they can be as dangerous as a
car accident i used improperly. In this chapter, you will learn someimportantand possibly surprisingacts about pain medication,
particularly opioids, which will help ensure your saety.
Prescription Medications Saety Guidelines
The inormation in this chapter can be summarized in a ew
important rules o the road about prescription medicine,
especially pain medicine:
Follow the dosage and requency instructions EXACTLY.
Never change your medication schedule or dosage (even i
you think it is not working) without consulting with your
healthcare provider.
Contact your healthcare provider i you experiencetroubling medication side eects.
Read thepainACTION Medication Side Eects Toolto nd out
the possible side eects o dierent medications.
NEVER give your medication to anyone else
Under any circumstance, and keep it concealed in a sae place
where casual visitors are unlikely to see it.
NEVER keep the medication ater you no longer take it
Discard it saely. ThepainACTIONarticle, Getting rid o
unneeded medications: Out o sight is not out o mindwill
give you specic suggestions.
Chapter 6Your Medication: Staying Sae
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What are Opioids?
I you have pain that is not responding to other medicine, your health-
care provider may prescribe opioids or you. Opioidsamong the
oldest medicines in the worldbelong to a group o medications called
analgesics, which give relie rom pain. Opioid is a medical term that
describes what are commonly reerred to as narcotics. The natural
opioid, morphine, which comes rom the opium poppy plant, has been
used as a pain reliever or centuries. Other opioids, such as codeine,
entanyl and oxycodone, are manuactured synthetically.
Opioids are prescribed by healthcare providers to treat pain, control
coughs, and treat diarrhea. Some are taken by mouth in pill orm,
while others are given transdermally (skin patches), intranasally
(nose spray), or by injection. In the thousands o years that opioids
have been used to treat pain, no other pain medication has been oundthat is as eective. This is because our bodies have natural receptors
in our cells that respond to them. It is as i the opioid medicine is the
key that ts perectly in the lock o our cells, to open the door to
pain management. So ar, so good, but there are some problems with
opioids, i they are used in ways that are not prescribed. As weve
talked about in previous chapters, good inormation is a key to travel
saety. Here are some denitions to help understand the potentialproblems with opioids.
Tolerance
This can happen naturally when your body gets used to a particular
medication. As a result, the medication does not work as well as it
used to and you might eel that you need to take more o it to get the
same relie. You should never make your own decision about this how-
ever, but always discuss the situation with your healthcare provider.
(Tolerance is very dierent rom addiction, which is discussed be-
low.) Sometimes the solution is simply to change medications or add
a new medication.
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Dependence
This is another naturally occurring state that happens when yourmind andbody get used to a medication, but in a dierent way rom
tolerance. When you become physically dependent on a medication,
your body actually needs this medication in order to continue working
properly. This means that you should never suddenly stop taking any
medication without rst talking to your healthcare provider.
MisuseThis reers to taking a medication in a way that it was not prescribed,
or or a condition other than the one or which it was prescribed. I
you have medication or your back pain but decide to take it to help
you sleep, or example, that is misusingit. This is something you
should never do because it is unsae.
Abuse
I you use a prescription pain medicine to get a result that has noth-
ing to do with the pain it was intended to treat, this is abuse. You are
abusing your pain medicine, or example, i you take it to eel better,
or get high.Like medication misuse, abuse is very dangerous. You
are not trained to understand the ways in which medications interact
with anything else you are taking or with your physical condition.
Abusing your medication is just as dangerous as driving recklessly or
ignoring saety warnings while traveling. Respect the rules laid out
by your healthcare provider, and protect the saety and health o
your body.
Addiction
People who become addicted to a prescription pain medication areabusing the drug uncontrollably, to the point where it is causing
physical harm. Unlike tolerance and dependence, addiction is an
unnatural state.I you eel you are becoming addicted to your medica-
tion, meaning that you eel the need to take more and more o it and
cannot control yoursel, seek immediate medical help.
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Diversion
You wouldnt hand your car keys to an unlicensed driver, and youwouldnt send a riend into a dangerous or unamiliar city alone. Use
these instincts about saety when it comes to your prescription pain
medication. Your medication is meant only or you. You should never
give it to anyone else, either or money or because you think it might
help him or her. You are not a trained pharmacist, so you cant possibly
know which medications work saely or each person. There is much
more inormation about medication saety on thepainACTIONweb-site, including articles, tools, and lessons. Here are some suggestions:
Opioid medication basics(Lesson)
How to start an opioid saely(Lesson)
How to discuss opioids with your doctor(Lesson)
How to travel with opioids(Lesson)
Sae Storage and Disposal
When you are behind the wheel, you are not only responsible or your
own saety, but also or the saety o the other people in your car. I you
took your riends or amily on a trip, you would do your best to keep
them as sae as possible. Accidents happen, but taking the right saety
precautions reduces the risk. When it comes to pain medication, theseprecautions are not just limited to proper usage: Not only is important
to use your prescription pain medication saely, you must also know
what to do when you are notusing it. These are powerul drugs and i
they all into the wrong hands they can cause severe physical damage
and even death.
Abuse o prescription pain medications is reaching almost epidemic
levels in this country, especially among people between ages 18 and
33. Most o these young people get the medications rom their riends
or amily. In 2007 in Utah, o 467 drug-related overdoses, 317 were
attributed to legal drugs and 261 o them involved prescription pain
medications. So i you have these powerul prescription pain
medicines in your possession, you have a responsibility to prevent
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anyone else rom nding and using them. You can do this by storing
them in a hiding place that only you know about, and disposing o anyletover medications in a way that makes sure no one will get them.
ThepainACTIONarticle. Letover medications: is out o sight, out o
mind?has some useul suggestions or how to do this.
An Expert Opinion
Medication safety
QI I take this medication you are prescribing or me,will I become addicted?
AI you ollow the medication guidelines, the risk o addiction isvery low. You might, however, become dependenton the medi-cation, which means you should never stop taking it suddenly;you also might become tolerant, which means we might need to
change your prescription. It is important to use the drug ONLY
as it is prescribed, without misusing or abusing it. I you eel
you are becomingaddicted, tell your healthcare provider so
you can get the help you need. And certainly remember never
to divertthis medication to anyone else because you would be
giving them a very powerul substance that could do harm.
QAre there limitations on my ability to travel outside o theUnited States i I am taking prescribed opioid medication?
AWhen traveling abroad with prescribed controlled substanceslike opioids it is important to consider two sets o laws; thelaws o the home country, and those o the countries to which
you will be traveling. The United States Code o Federal
Regulations allows an individual to have in his/her possession
a controlled substance i it was lawully obtained or personal
medical use. This can be shown by having the medication
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in the original container in which it was dispensed to the
individual. The container should have the trade or chemicalname o the substance or the name and prescription number
o the pharmacy that dispensed it. The traveler should make a
declaration o this possession to a US Customs Ofcial when
leaving the United States. Upon return to the United States the
traveler can bring in the remainder o the medication they had
when they let the country. There is a 50-dosage unit limita-
tion on bringing into the U.S. controlled substances that wereacquired abroad or personal medical use. The International
Narcotics Control Board has published guidelines concern-
ing travel with internationally controlled drugs. The laws in
individual countries vary widely so the traveler should obtain
the specic inormation about their destinations. Usually they
must have in their possession the documents required by that
country demonstrating that the medications are or personal
medical use and have been appropriately prescribed.
For more inormation on this topic, go to the Uni-
versity o Wisconsin Pain & Policy Unit website at
http://www.painpolicy.wisc.edu/
QThe last time I took a narcotic, I was constipated or a month.Is there anything I can take or do ater my upcoming surgeryto prevent that?
AAll narcotics (the correct medical terms are opioids oropioid analgesics) can cause constipation. In act, it is themost common side eect o these medicines. This side eect ismore o a problem or some people than others. Uncontrolled
constipation is a leading reason that patients dont take their
pain medicines as instructed. The rst thing to do is to it tell
your healthcare provider that opioid-related constipation
is a big problem or you, and ask that a stimulant laxative be
prescribed along with the pain medicine. Most laxatives are
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taken by mouth and some can also be taken as a suppository.
The usual advice about preventing constipationincreas-ing uids and ber in the dietare probably not helpul or
opioid-related constipation. Some laxatives, known as stool
soteners, may be helpul, but are not enough. Opioid-related
constipation requires a stimulant laxative that encourages
the bowel to move the stool along and makes it easier to have a
normal bowel movement. Most laxatives are available without
a prescriptionask your doctor and pharmacist or specicrecommendations. It is very important to prevent and treat
constipation. I it becomes a problem or you, let your health-
care provider know so the treatment plan can be changed.
Q
Ive been on the same opioid now or a year, and it seems that
my pain is worsening. Is it possible that the medication is no
longer working or me?
AThere are many things that can aect how well a medication isworking to control the pain. I you have been on the same drugand dose or a long time and notice a change that lasts more
than a ew days, here are some things to discuss with your
healthcare provider: Have you changed your diet or changedother medicines recentlyincluding herbals and natural prod-
ucts? Have you changed brands o pain medicine? Have you
had unusual stress? Have you been sick? I there is a known
cause or your pain, when was the last time you had a checkup?
It is possible that the underlying condition that caused the
pain has worsened. In the case o cancer, or example, this
could be a warning that the cancer treatment needs to bechanged. (See also the denition o tolerance in the article,
since this could be a actor as well.)
Another possibility is that there has been a buildup o metab-
olites, which can actually increase pain. Almost all drugs are
processed in the body and changed in some way as they move
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through the liver. Sometimes this processing creates byprod-
ucts or metabolites. For most patients this is not a problem,because the byproducts are removed by the kidneys and leave
the body in the urine. I the kidneys do not remove enough o
the metabolites, they can build up and make the nerves more
sensitive to things that wouldnt normally cause pain. Chang-
ing to a dierent opioid usually takes care o the problem, and
your pain will be under better control again.
In Summary...
Tolerance, dependence, misuse, abuse, addiction, diversion
have dierent meanings
Opioids can be very eective to treat some types o pain,
and it is important or them to be taken as directed
Follow medication instructions exactly
Contact your healthcare provider i you have side eects
NEVER give medication to anyone else
ALWAYS store your medication in a concealed, sae placeDiscard unused medication saely
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Part IIYour Personal Pain Profle
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This part o the book is where our travel guide gets more specic. I
you are dealing with back pain, migraine or cancer-related pain, reer
to the appropriate chapter or chapters in this part. First, however,
please take a moment to read this overview, since it will help you take
better advantage o the inormation in the chapters.
The three types o chronic pain discussed in this section are, o course,quite dierent, but they also have several common eatures. Each o
them can be with you or many years. However, like any long journey,
the more you travel, the easier it gets. Each o these types o pain re-
quires baggage, but the type o load you are carrying may be dierent.
I you have back pain, or example, you probably eel as i you are car-rying some sort o burden every day, because your back never gets a day
o! It must work all day long, and even when you lie down, to support
your body. With back pain, the only dierence rom day-to-day is, how
much pain will I be in today? Will I be able to do the things I want
and need to do? So in the back pain chapter, we discuss how to modiyyour lie to minimize and manage the pain you might be dealing
with every day.
By contrast, migraine pain may leave you ree o baggage or days or
weeks at a time. The question here is Will I get a migraine today? The
uncertainty is o course a difcult burden to carry, but you can be sure
that i you do notget a migraine, you will be able to have a normal day.
So the challenge here is what can be done topreventthe headache rom
beginning, and how to minimize the pain i you do get one; these are the
questions we ocus on in the chapter about migraine pain.
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Cancer-related pain is quite dierent rom the other two types o
chronic pain. Because o advances in cancer treatment, people are living
longer and many achieve remission or cure rom the disease. Rather
than worrying about survival, many cancer patients now are shiting
their attention to the pain that results rom either the treatment or the
long-term eects o the disease itsel. In the cancer chapter, thereore,
we ocus on the causes and types o cancer-related pain and the most
eective ways to manage them.
To sum up the chapters in this section, there are three dierent ways
you might wake up in the morning: I you have back pain (Chapter
7), you might be thinking, How bad is today going to be? I you havemigraines (Chapter 8), your question might be, Is today going to be a
good day or a bad day? And i you have cancer-related pain (Chapter
9), your eelings might be mixed: Im happy to be alive and cancer-ree
today, but how do I cope with the long-term pain that remains?
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I you are on a journey to manage your back pain, you have plenty
o traveling companions. Government surveys report that back pain
is the second most common neurological ailment in the United
Statesonly headache is more common. Nearly everyone at some
point has back pain that intereres with work, routine daily activities,
or recreation. And back pain is expensive: it is estimated that Ameri-
cans spend at least $50 billion each year on low back pain, which is themost common cause o job-related disability and a leading contributor
to missed work. Other research has ound that one quarter o Ameri-
cans report that they suer rom back pain, especially low back pain
that lasted at least a whole day, and almost 14 percent report neck
pain.
So now that you know you are not alone, what is this problem allabout? This chapter tells you some o the main causes o back pain, as
well as where you can go to nd more inormation about prevention
and treatment on thepainACTIONwebsite.
Your back extends rom the top o your neck down to your tailbone,
and you can have pain anywhere along that long stretch o spine.
Sometimes, the pain might even radiate into your arms and legs. The
spine is a collection o bony rings, called vertebrae, whose major unc-
tion is to provide support or the body and protection or the spinal
corda kind o scaolding or your body. The vertebrae are stacked
on one another, separated by rm, pliable cushions called discs. The
stack o bones and discs is held together by ligaments and moved by
muscles. The vertebrae orm a kind o tunnel that houses the spinalcorda collection o nerves that orm a communications center,
sending and receiving messages rom your brain, and branching
o to the rest o your body. The Anatomy o the Backtool rompain-
ACTIONhas helpul diagrams and explanations.
Chapter 7Back Pain: Finding Support