Chapter II: Theoretical Framework

Chronic Pain Definition

Chronic pain is defined as pain that persists or recurs for longer than three
months, exceeding the typical healing timeframe for tissues. It is a complex
phenomenon with no single unifying cause, often involving a combination of
biological, psychological, and social factors. The International Association for the
Study of Pain (IASP) defines chronic pain as "pain persisting beyond the usual
course of acute illness or injury, or that is associated with ongoing tissue damage
or pathology, inflammation, or a neurological lesion, persisting for at least 3
months." (Treede et al., 2019)
Symptoms of Chronic Pain
Chronic pain can manifest in various ways, including:
• Physical: Aching, burning, throbbing, shooting, tingling, numbness,
stiffness, and weakness.
• Emotional: Anxiety, depression, frustration, anger, and social isolation.
• Cognitive: Difficulty concentrating, sleep disturbances, and fatigue.
• Behavioral: Avoidance of activities, increased reliance on others, and
substance abuse.
The intensity and specific symptoms of chronic pain can vary significantly between
individuals and even within the same person over time.

Causes of Chronic Pain

Chronic pain can arise from various underlying conditions, including:
• Musculoskeletal disorders: Arthritis, back pain, fibromyalgia, and chronic
neck pain.
• Neurological disorders: Migraines, neuropathy, and spinal cord injuries.

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 • Cancer and cancer treatments.
• Autoimmune diseases: Lupus, rheumatoid arthritis, and Crohn's disease.
• Psychological factors: Stress, anxiety, and depression.
In many cases, the specific cause of chronic pain remains unknown, categorized as
idiopathic.

Chronic Pain Risk Factors

Several factors can increase the risk of developing chronic pain, such as:
• Genetics: Some individuals may have a genetic predisposition to
experiencing pain more intensely or developing specific chronic pain
conditions.
• Age: The risk of chronic pain increases with age due to wear and tear on the
body.
• Previous injuries: Injuries, even those that have healed, can sometimes
increase the risk of developing chronic pain.
• Obesity: Excess weight can put stress on joints and increase inflammation,
contributing to chronic pain.
• Psychological factors: Stress, anxiety, and depression can lower pain
tolerance and contribute to the development and persistence of chronic
pain.
• Lifestyle factors: Smoking, inactivity, and poor sleep can worsen chronic
pain symptoms.

Diagnosis of Chronic Pain

Diagnosing chronic pain can be challenging due to its subjective nature and
diverse causes. It often involves a multidisciplinary approach, combining:

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 • Medical history and physical examination: Identifying past injuries,
underlying medical conditions, and current pain characteristics.
• Pain assessment tools: Standardized questionnaires and scales to evaluate
pain intensity, location, and impact on daily life.
• Diagnostic tests: Imaging studies like X-rays, MRIs, or blood tests to rule out
specific conditions or identify damage.
• Psychological evaluation: Assessing for potential psychological factors
contributing to or maintaining pain.
The diagnosis is often based on a combination of these factors, and ruling out
other potential causes is crucial.
Complications of Chronic Pain
Chronic pain can lead to various complications, including:
• Physical: Sleep disturbances, fatigue, muscle weakness, decreased mobility,
and increased risk of falls.
• Emotional: Depression, anxiety, social isolation, and decreased quality of
life.
• Cognitive: Difficulty concentrating, memory problems, and decreased
productivity.
• Behavioral: Substance abuse, decreased physical activity, and increased
healthcare utilization.
• Economic: Difficulty working, lost income, and increased healthcare costs.
Early diagnosis and management are crucial to minimize these complications and
improve overall well-being.
Pain Prevention
Several strategies can help prevent chronic pain, including:

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 • Maintaining a healthy lifestyle: Regular exercise, healthy diet, good sleep
hygiene, and stress management.
• Addressing injuries promptly: Seeking proper medical attention for injuries
to minimize long-term complications.
• Maintaining good posture and ergonomics: Preventing musculoskeletal
pain through proper posture and workstation setup.
• Managing psychological factors: Addressing stress, anxiety, and depression
with therapy or other interventions.
• Vaccinations: Preventing infections that can lead to chronic pain, such as
shingles.

Treating Chronic Pain

There is no single cure for chronic pain, but various treatment options can help
manage symptoms and improve quality of life. These can include:
• Non-pharmacological interventions: Physical therapy, cognitive-behavioral
therapy, relaxation techniques, acupuncture, and biofeedback.
• Medications: Over-the-counter pain relievers, prescription medications like
opioids or antidepressants, and topical medications.
• Interventional procedures: Nerve blocks, injections, and spinal cord
stimulation.
• Surgical interventions: In rare cases, surgery might be considered to
address specific causes of pain.
The optimal treatment approach is individualized based on the cause of pain, its
severity, and the individual's preferences and needs.
Treating Chronic Pain: Pain Relieving Medications
Understanding the Role of Medications in Chronic Pain Management:

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Chronic pain management involves a multidisciplinary approach, with medications
playing a crucial role alongside other interventions like physical therapy,
psychological support, and lifestyle modifications. However, it's crucial to
understand that medications alone are not a cure and should be used judiciously
and in conjunction with other strategies for optimal outcomes.

Types of Pain Relieving Medications:

• Over-the-counter (OTC) medications: These include acetaminophen (e.g.,
Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
(e.g., Advil) and naproxen (e.g., Aleve). They are generally safe for short-
term use but may have side effects like stomach upset and bleeding,
especially with long-term use.
• Prescription medications: These can be categorized as:
o Opioids: Strong pain relievers like morphine and oxycodone. Highly
effective but carry significant risks of addiction, tolerance, and
overdose. Use with caution and under strict supervision.
o Antidepressants: Certain types like tricyclic antidepressants (TCAs)
and serotonin-norepinephrine reuptake inhibitors (SNRIs) can help
manage chronic pain, even in the absence of depression.
o Anticonvulsants: Originally developed for seizures, some
anticonvulsants like gabapentin and pregabalin are effective for
neuropathic pain (nerve damage pain).
o Muscle relaxants: Used for pain associated with muscle spasms but
not recommended for general chronic pain management due to
limited effectiveness and potential side effects.
• Topical medications: Creams, gels, and patches containing ingredients like
lidocaine or capsaicin can provide localized pain relief for specific areas.

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Considerations when using pain medications for chronic pain:
• Effectiveness: Different medications work for different types of pain.
Finding the right medication requires individualized evaluation and trial-
and-error.
• Side effects: All medications have potential side effects, and the risk
increases with long-term use. Careful monitoring and dosage adjustments
are crucial.
• Addiction and tolerance: Opioids carry a high risk of addiction and
tolerance. Use them only under strict supervision and guidelines.
• Interactions: Medications can interact with each other and other
substances. Inform your healthcare provider about all medications and
supplements you are taking.
Previous Studies on Chronic Pain:
Extensive research investigates various aspects of chronic pain management,
including medications. Here are some examples:
• Opioid effectiveness and risks: Studies continue to explore the
effectiveness of opioids for chronic pain while emphasizing their potential
risks and advocating for responsible prescribing practices.
• Non-opioid alternatives: Research focuses on identifying and evaluating
alternative medications like antidepressants and anticonvulsants for chronic
pain management.
• Combination therapies: Studies explore the effectiveness and safety of
combining different types of medications for synergistic pain relief.
• Personalized medicine: Research strives to develop personalized pain
management approaches based on individual genetic and pain response
profiles.

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References:
Books:
• Chronic Pain: A Comprehensive Guide for Physicians by Michael DeVivo
(2014)
• The Pain Relief Handbook: A Practical Guide to Understanding and
Managing Chronic Pain by David Hanscom (2023)
• Pharmacology of Pain by Richard P. Busto, Michael J. Paasche-Orlow, and
Steven P. Stanos (2020)
Articles:
• Effectiveness of non-opioid medications for chronic pain: A systematic
review and meta-analysis (2022) by Furlan AD, et al. JAMA Intern
Med. 182(8):833-844. doi:10.1001/jamainternmed.2022.1318
• Opioid prescribing for chronic pain: A review of the evidence (2020) by
Volkow ND, et al. JAMA Intern Med. 180(6):792-
804. doi:10.1001/jamainternmed.2020.0314
• Personalized medicine in chronic pain: Promises and challenges (2019) by
Staud R. Nat Rev Rheumatol. 15(10):630-639. doi:10.1038/s41579-019-
0242-8
• Treede, R. D., et al. (2019). Classification of chronic pain for ICD-11. Journal
of pain research, 12(1), 133-164.