Understanding Pain

Most of us have experience of everyday pain including headaches, pain from minor injuries and muscular pain for example following exercise. These pains don’t last long and often don’t need treatment. All pain we feel is affected by how we are feeling generally, our past experience of pain and any concerns we have about the cause of the pain. If we are worried and distressed about how pain may affect us in the future, our pain will feel worse. Also, unpleasant thoughts, feelings and memories (even if these are not to do with pain) can influence how we feel pain. Anxiety, depression, Post-Traumatic Stress Disorder, previous emotional upsets or other mental health problems, are likely to worsen our experience of pain and make it more difficult to treat. 

Types of pain 

Pain is usually described as acute (short term) or chronic (long term) pain (usually more than three months). 

Acute pain is usually related to an obvious injury such as dental infection, bone fracture or operation. 

Chronic pain sometimes begins with an injury but the pain doesn’t get better as expected: often it is not clear how a chronic pain has started. Common types of chronic pain include low back pain, pain related to arthritis and pain related to injury to a nerve or other part of the nervous system (neuropathic pain). Chronic pain is usually not a sign of on-going injury or damage but may be to do with changes in the nervous system that occur over time so that the pain signalling becomes self-sustaining over a prolonged period. 

Both types of pain can range from mild or severe with the difference being how long the symptoms last. 

  • Cancer pain is usually described separately and may be short or long lasting. The pain can relate to the cancer itself or the cancer treatment. Additionally, people with cancer may experience acute or chronic pain unrelated to their cancer. 

Treatments for different types of pain 

You may have more than one type of pain

  • Acute pain can be severe but usually gets better quite quickly (days or weeks). Treatments usually only need to be given for a short time while healing of the injury begins. Acute pain is often straightforward to treat with a range of medicines and other treatments depending on how severe the pain is. Opioid medicines are useful for treating acute pain and usually only need to be given for a period of a few days. The dose of opioid should be reduced as healing occurs. 
  • Chronic pain can cause low mood, irritability, poor sleep and reduced ability to move around. Unlike acute pain, chronic pain is difficult to treat with most types of treatment helping less than a third of patients. Most treatments aim to help you self-manage your pain and improve what you can do. Different treatments work for different people. Medicines generally and opioids in particular are often not very effective for chronic pain. Other non-medicine treatments may be used such as electrical stimulating techniques (TENS machine), acupuncture, advice about activity and increasing physical fitness, and psychological treatments such as Cognitive Behaviour Therapy and meditation techniques such as mindfulness. Helping you understand about chronic pain is important and in particular helping you understand that physical activity does not usually cause further injury and is therefore safe. It is important that you understand that treatments tend not to be very effective and that the aim is to support you in functioning as well as possible.  

Have a look at our Willow Chronic Pain Page for resources and weblinks to further help ****link**** 

  • Neuropathic pain is a type of chronic pain associated with injury to nerves or the nervous system. Types of neuropathic pain include, sciatica following disc prolapse, nerve injury following spinal surgery, pain after infection such as shingles or HIV/AIDS, pain associated with diabetes, pain after amputation (phantom limb pain or stump pain) and pain associated with multiple sclerosis or stroke. Neuropathic pain is usually severe and unpleasant. Medicines may be used to treat neuropathic pain but are usually not very effective and work for a small proportion of people. You may not benefit from the first drug tried so you may need to try more than one drug to try and improve symptoms. 
  • Cancer pain is usually associated with an obvious source of tissue damage and may be acute or chronic. Neuropathic pain can occur with cancer diagnoses and treatments (such as radiotherapy). Because cancer pain treatment, particularly at the end of life, is often for a short duration, it is usually more successful than chronic pain treatment. People who recover from cancer or who survive a long time with cancer may have pain that is more difficult to treat. 

Thinking about Opioid Treatment for Pain 

It is easier to treat pain after surgery or an injury with painkiller medicines, however it is rarely possible to relieve long-term pain completely by using painkillers. The aim of treatment is to reduce your pain enough to help you get on with your life.  

In trials most medicines for long-term pain only benefit around one in every four or five people and on average only provide 30 % reduction in pain.  

Medicines work best if you combine them with other ways of managing symptoms such as regular activity and exercise, and doing things that are satisfying or enjoyable, such as work or study, and social activities. Setting goals to help improve your life is an important way to see if these drugs are helping.  

’Why don’t my painkillers work?’ is a commonly asked question, and often one without any easy answers. Long-term pain arises through many different mechanisms, and most drugs only work for one of these. Some pains do not seem to respond to any painkilling medicines. You can get used to painkillers, including opioids, so that you need more and more to have the same effect. (This is called building up tolerance.) However, we know that high doses of opioid medicines taken for long periods are unlikely to give better pain relief and are associated with a number of problematic adverse effects. 

Reference: Faculty of Pain Medicine of the Royal College of Anaesthetists 

https://fpm.ac.uk/opioids-aware/information-patients [external link]

Your Opioid Prescription 

Opioid medicines come in many different forms, such as tablets, capsules, liquids, patches and injections. They include drugs like codeine[Zapain], dihydrocodeine, Tramadol, Bupenorphine, Morphine, Oxycodone, Fentanyl and Diamorphine [Heroin]. 

If you have been prescribed an opioid medication, the correct dose of any medicine is the lowest dose that produces a noticeable benefit. It is not usual to get complete relief of pain from opioids.  

You should always take the correct dose of prescribed medicines. If you feel the dose isn’t enough, or if the side effects interfere with your life, you should discuss this with your healthcare team. 

For Acute pain you should aim to take opioids for no longer than 2-3 weeks. This will reduce the risk of: 

  • Tolerance – where the opioid can become less effective with time. 
  • Hyperalgesia – where a person experiences worsening or new pain as a result of taking opioids 
  • Dependence – This means that if you stop taking the drug suddenly, or lower the dose too quickly, you can get symptoms of withdrawal.  

If you run out of medicine, you can experience the same symptoms that include: tiredness, sweating, aching muscles, increased pain, a runny nose, stomach cramps, diarrhoea 

For Chronic Pain, remember that, in trials, most medicines for long-term pain only benefit around one in every four or five people and on average only provide 30% reduction in pain.  

Opioids are not recommended for Chronic Low back pain or Fybromyalgia. 

If you have had no benefit from moderate opioids like Zapain or Tramadol, this means you have a non-opioid responsive pain and stronger opioids will not have any benefit either. 

After consideration of all the risks vs potential benefits and Opioid trial may be agreed with your prescriber. This is usually for 2-3 weeks. 

Rather than focusing on the pain levels it helps to set yourself little goals and focus on whether the medicine helps your achieve these. 

After the Opioid trial the medication may be stopped if treatment goals have not been met. 

These may be: 

  • No improvement in your personal goals on what you can do. 
  • No clear evidence of improvement in pain levels 
  • Side-effects to medication 
  • If rapid tolerance develops necessitating high-dose opioids 

Ten Opioid Safety Messages  

1. Ensure you know:  

  • Why the opioid medicine has been prescribed for you.  
  • How long you are expected to use the opioid medicine for.  
  • How long the opioid medicine will take to work.  
  • How to use the opioid medicine if sustained-release and immediate-release formulations have been prescribed together.  
  • Requirements for the review and monitoring of treatment.  

2. Be knowledgeable about opioids and their short and long term risks by reading the patient information leaflet ‘Taking Opioids for Pain’ which can be accessed on:   https://fpm.ac.uk/opioids-aware/information-patients [external link]

3. Always read the manufacturer’s patient information leaflet.  

4. Be aware that opioids, pain and tiredness may affect your ability to drive. See ‘Taking Opioids for Pain’ Leaflet for more information to ensure you are familiar with the UK law.  

5. Always take prescribed opioids as instructed from your prescriber – never take more doses than what has been prescribed. Do not stop taking your opioid suddenly, you may experience withdrawal symptoms. Speak to your healthcare professional (doctor, practice pharmacist, nurse) who will be able to supervise a gradual reduction. 

6. Always avoid taking opioids to help you fall asleep or manage anxiety or distress.  

7. Understand the risks of taking opioids with sedatives, anti-anxiety medications, pregabalin, gabapentin and alcohol.  

8. Your prescribed opioid medicine must only be used by you – never share or sell your prescription opioids with others regardless of the situation.  

9. Be vigilant with the safekeeping of both opioid prescriptions and medicines to minimise the risk of other people having access to them. Consider a lockable storage box.  

10.Always ensure manufacturer’s recommendations on storage and safe disposal are followed to reduce the risk of access to children, pets or anyone who might misuse them. 

Chronic Pain 

See below for a list of useful websites and resources that may help you in your pain journey. 

Useful Information [external links]: 

Book: ‘Pain Heroes. Stories of Hope and recovery’ by Alison Sim. This book shares stories of people with Chronic Pain and their journey that you may relate to. 

After reviewing this information, you may wish to ask for a Pain review with one of our Willow team practitioners 

1. Willow Clinical Practice Pharmacists can help with your pain journey and reviewing your medication. 

What if I want to stop taking my medication? Do not stop taking suddenly, you may experience withdrawal symptoms. Speak to your healthcare professional (pharmacist, doctor, nurse) who will be able to supervise a gradual reduction. 

2. Willow Physiotherapists review, assess and guide you with appropriate self-help exercises. Provide advice on pacing and goal setting to steadily work towards improving your fitness and get you back to doing things that are meaningful to you.  

3. Willow Health & Wellbeing Coaches can help you identify and set your own personal goals for lifestyle changes on a 1-to-1 basis. This could be support with Weight Loss or Maintenance; Bereavement; Low Mood; Smoke Cessation; Healthier Eating – for you & your family & Physical Exercise or just Moving More to name just a few areas of their expertise. 

Did you know if you are overweight, a 10% weight-loss has been shown to reduce chronic pain by up to 50% [More effective than pain medicines]. This is one of the many areas where our health coaches might help you achieve some of your goals, which you have previously struggled with.  

4. The Pharmacist, Physiotherapist or GP can also refer you to the local NHS Persistent Pain Service if you would like further support. 

NHS Persistent Pain Service 

The Persistent Pain Service provides group-based or online education and support for patients who have a history of persistent pain and who are increasingly disabled and distressed. Patients must be continuing to experience functional limitations and/or distress, which have lasted for a minimum of three months (i.e. difficulties with work/sleep/function or with social interaction etc.) 

What is persistent pain management? 

Pain management aims to improve people’s understanding of their pain and reduce problems that pain causes. The Persistent Pain teams work with people to improve their ability to manage pain. This covers both physical and psychological aspects of coping with pain. We look at things such as understanding pain, managing activity, achieving goals despite pain, and emotional wellbeing. Pain management is not trying to cure pain, although some people say their pain has reduced afterwards. 

We hope that after coming to our Persistent Pain service you will experience some, or all of the following: 

  • A better understanding of what persistent pain means and what can cause pain to persist 
  • Improved confidence about ways in which pain can be managed 
  • Better physical functioning 
  • Greater confidence in moving 
  • Improvements in mood 
  • Better sleep 
  • Better relationships 
  • Meeting other people who experience living with persistent pain, helping you build a widened support network. 

https://www.solent.nhs.uk/msk/our-services/persistent-pain/ [external link]

The Pain Cycle
The Self-Care Cycle