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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 3. - Chronic Pain
RADIO 4
THURSDAY 10/03/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
CHARLES PITHER
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
MYERS
Hello. Chronic or persistent pain is defined as pain that lasts for more than three months and isn't getting any better, with or without treatment. So whatever your illness or injury if your worse symptom is the pain what can you do about it? Do you need different or stronger painkillers? If so are you worried about side effects? Two widely prescribed drugs have recently been taken off the market because they've been found to be unsafe. Would you benefit from a treatment at a specialist pain clinic? Or does there come a point where you have to learn to live with pain? Pain management programmes offer psychological as well as physical techniques of coping but rest assured no one will accuse you of imagining your pain.
If you're among the estimated one in seven people living in pain call us now with your questions or your comments - 08700 100 444 or e-mail checkup@bbc.co.uk.
My quest expert today is Dr Charles Pither, a pain specialist, who joins me on the line, he's in Edinburgh. Dr Pither you're in Edinburgh for the British Pain Society Annual Conference, so thanks very much for taking time out. What incidentally is the value of a big conference like this?
PITHER
Well the British Pain Society is a very active society now and we have over a thousand people attending this conference in Edinburgh and they're from all different disciplines - we have doctors and nurses and psychologists and basic scientists - all people who are interested in this fascinating area of pain and it is a very complex and fascinating topic.
MYERS
Indeed. Well let's go to our first caller - the first of many. Lynn Robinson is waiting to talk to us, she's in Leeds and I think is indeed suffering from chronic pain. So your question please or comment for Dr Charles Pither Lynn.
ROBINSON
Oh good afternoon. I've been suffering from what I'm told is neurological pain for about five years, it's all down the left hand side, it ...
PITHER
Is it in your hand as well as your ...
ROBINSON
It is, it goes down the side of my face, my neck under my - down the side of my ribs, into my arm, hip, down the leg into the foot. And my joints feel swollen, although they're not swollen.
PITHER
And do we know what caused it Lynn?
ROBINSON
No we don't, it came on - I was at that particular time under severe stress. I've had two cervical ribs removed and that eased the pain to a certain amount. I've had continual physio, I've had acupuncture, I've had Bowen's technique...
PITHER
And have you been to see a pain specialist or a pain clinic?
ROBINSON
I have yes and they put me on all sorts of drugs and they tried all sorts of things and we just come to a dead end every time.
MYERS
Well never say die because there's always something is I think hopefully going to be the message and Charles how are you going to help Lynn and perhaps others who might identify with her difficulty - this sort of longstanding unrelenting pain? Various things have been tried already ...
PITHER
Yes and it sounds as if this is a central pain problem, where you get half of the body with this unpleasant nervy burning pain and it is a - Lynn I really do sympathise because it really is a horrid sensation and I think we'd all agree that it really is a rotten affliction. We normally find that some of the drugs - some of the drugs that are specifically useful for nerve damage pain which are not always conventional painkillers - they're not always the morphine drugs, they're the other drugs such as you may have tried gabapentin or some of the antidepressant drugs like amitriptyline. I mean most people with this condition, more than half, will find that they do get some benefit from some drug combination and it's obviously disappointing if you haven't found that, but perhaps you have but found you couldn't take them because of side effects.
ROBINSON
Well I've taken them and they either made me so groggy I couldn't function or ...
PITHER
Right, well normally we can try and change them around and find a better combination. I think it's disappointing if we really come across somebody who hasn't been able to find a drug regime which produces some benefit.
ROBINSON
I mean I've had one of those drugs that's been recently taken off the market, well I mean ...
PITHER
Because I wouldn't have thought they were the first line drugs ...
ROBINSON
No they weren't, they were just...
PITHER
... I would have thought it was more the gabapentin drugs and the - as we call them - the tricyclic antidepressants.
ROBINSON
That's right, yes I've done those.
MYERS
So the message I'm hearing therefore, people who may not have tried some of these different classes of drugs, then if they have nerve pain these anti-epileptic drugs, the antidepressant drugs, could be valuable, don't seem to be tolerated very well by Lynn, but generally speaking can have a real role in this kind of nerve pain?
PITHER
Exactly. We would say that, as I suggested, roughly half - half of the population with this pain would find some benefit from those drugs. But they often do need to explore different combinations and it may take some time to get the best dosing combination.
MYERS
We need to move to another caller, but is there a last word perhaps for Lynn - I hope you'll stay listening by the way because I think there may be quite a lot of information that comes out.
PITHER
Well it obviously does sound as if you're getting a bit to the end of your tether because these treatments haven't worked and it may be that some more help along the lines of pain management is going to be important to you. I mean it sounds like you've tried physio and other things but obviously somehow learning how to cope with this and keep cheerful and keep doing things is going to be very important.
MYERS
Okay, thank you for that.
PITHER
And help can be provided for that.
MYERS
Let's go to Kate who's waiting in - I'm not sure where she is - but she's Kate Haines and is worried about becoming reliant on painkillers. Are you taking a lot of painkillers, different types?
HAINES
Not too many. I'm on a combination - I have bad back pains and sciatica - so I've been on a combination sort of the last year of sustained-release ibuprofen and also different codeine, paracetamol combinations.
MYERS
And are they working?
HAINES
They - yeah, they sort of damp it down, so I can still feel - there is still some pain there but it's definitely not as bad when I'm taking the painkillers as when I'm not taking them.
PITHER
Kate, what are you able to do? Are you managing to do the things you need to do?
HAINES
Pretty much yeah, yeah, I mean the worst of it's over, I think hopefully, for now anyway but the pain is still constant, even at the very best it just sort of subsides to a dull ache really.
PITHER
And have you had any other treatments?
HAINES
Yeah, I had physio for about three months on the NHS and they sort of reached a point where they said that really that was as much as they could do for me and I've also tried privately a chiropractor and an osteopath. I got good results with them but only as long as I was having treatment from them, which got quite expensive after a while.
PITHER
Right, I think there's two issues here. One is your particular question about am I going to get hooked on these drugs or are they dangerous in the longer term and the second is what can one do to help you with your particular pain problem. Now this kind of back pain that persists even it goes into the leg a bit is very common and what one would say is that you need to be able to get a good information pack, you need to get good advice on how to manage that pain and you need to look at non-drug techniques as much as possible. And I suspect there are some things that can be done there, I suspect that you may need to move from what sounds like a rather passive physio to a more active back exercise approach, you need some information to help you with that, you may find some acupuncture or some stimulation analgesia beneficial. And we have to ask the bigger question which is well am I going to go on taking these tablets forever - and mostly when I put that to patients they say I don't want to and I say - right, that's fine, well look we can help you to wean yourself off these tablets. And I'm not saying that they're dangerous or they're going to do some harm but you don't want to go on taking them. There's not a risk of you being suddenly addicted, and you shouldn't worry about that but I do think that we need to move from the situation you're in at the moment which is, if you like, look I'm stuck not quite sure where to go, to a much more active position which puts you in control and you're able to say - look, hey great in three months time I shall be off these tablets, I shall be doing these things differently. I'm not saying you wouldn't ever have a twinge of back pain because as we know back pain's awfully common and many people in your situation will say look I do have a bad back but it shouldn't stop you doing things.
MYERS
This raises the question for me, I don't know about you Kate, but where do you go for that kind of holistic approach, someone's going to take all of this into consideration, particularly since it doesn't sound as though you're in the most extreme pain and so perhaps not really going to be referred to a pain clinic or could you ask for a referral?
HAINES
I'm not sure, I mean my GP is sort of - she's not taking it terribly seriously so she sort of waves me away and gives me another prescription ...
PITHER
Well I think ...
HAINES
What I've been doing so far is going privately and they've given me exercises to do and so on and they are helping but it's been going on for sort of a year and half or so and it's still not fixed.
PITHER
Well look I acknowledge there is something of a black hole at times in this sort of zone. If we ask the question well what can your GP do - probably him or herself they can't necessarily do very much. But what we need is good active rehab providers who can give you the kind of care you need and I have to say there aren't that many of them around. But that's still the way we need to go and I think you should push for that if you can.
MYERS
Okay, we'll leave it at that if we may and go to Ann Beasley who's in Ashford. Ann has got pain from shingles, which I seem to understand is a very severe pain. What's your question around that, apart from telling us about it Ann?
BEASLEY
I had shingles 20 months ago and I'm still in considerable pain. I've tried everything I can try, including the epileptic drugs and homeopathic and various things. I wear a pain patch but nothing gives relief. Sometimes it's better than others but not pain free at all and people don't help when they say - well you never get rid of that pain.
MYERS
Oh dear.
BEASLEY
I'm wondering if amputation is a possibility.
MYERS
Oh that would be desperate.
BEASLEY
Well I am.
PITHER
Where is the pain Ann?
BEASLEY
It's now on the left shoulder blade. It went from the front, under the bust, down the side, round to the spine.
PITHER
So it was on the chest really was it ...
BEASLEY
On the back actually more so - more pain.
PITHER
Well what happens with shingles, as you know, is that the infection is in the nerves and the nerves become very inflamed and that inflammation, an intense inflammation, damages the nerves and what you have is a nerve damage pain - shingles pain is the classic nerve damage pain. And all the things that I said to Lynn apply again here. We know that this is a rotten pain. Now the more modern drugs and we've mentioned a couple - gabapentin is one, a new one pregablin is another - they certainly can help and some people have found that the lignocane patches, which I think is the one you're using, the pain patch you're referring to, again they can all add up to providing somebody with okay relief. I think that it's difficult to say to somebody look your pain's not going to get better, if we look over a number of years what we find is these pains don't get worse and they often settle down a bit. But I think that it is fair not to say to somebody oh don't worry just wait another year and it will suddenly go because I don't think it will. And so I think that we do then have that difficult task of how to help you manage with this jolly difficult problem and drugs are certainly a part of that and other techniques can also play a role. But it is tough.
MYERS
So it would be back to the doctor certainly and hopefully to a pain specialist clinic and really keep pushing for more and better and hopefully more efficient sort of treatment. Can I bring in Paul Smith now, who's on the line from Harrogate because Ann said, and she said jokingly I suppose, amputation, but - sorry it's Mark Smith I should be speaking to. Mark you were interested in surgery, hopefully not talking about amputation, which would be desperate stuff, but nerve blocking, for what sort of pain - are you thinking this might be helpful Mark?
SMITH
Well I've actually had nerve blocking done. I've had nerve blocking - I've had quite a few operations including having a spinal cord stimulator put in. I'm still taking quite a high lot of drugs - OxyContin, gabapentin, amitriptyline - in quite high doses but the pain is still there. What my question was - is there any other surgery that can be thought of to get rid of the pain completely, to stop taking the drugs, which would be the ideal situation?
PITHER
Yes Mark, I'm sure, I agree it would be. But tell me, your pain was sort of primary back pain was it, is that how it started out?
SMITH
No, it was in the groin, the testes area.
PITHER
Right and the surgery you've had was a spinal ...
SMITH
I've had a spinal cord stimulator put in.
PITHER
Oh I see yes okay.
SMITH
Which obviously tries to control the pain but you still - like the other people - you go to sleep with the pain and you wake up with the pain.
PITHER
Yes indeed.
SMITH
I work to try and keep going but obviously it becomes difficult.
PITHER
I think that's very important because I've seen too many people unfortunately who've felt that they couldn't go on working and stopped working and then felt worse because they've not had the distraction and the interest that work provides and the - something to add to their life. And so I think that we would try and recommend people, even when they have rotten pain like this, to try and keep going as much as possible and to live a normal life. And we then would need to try and offer them the support and help to enable them to do that if you like. I mean I have to say I think the short answer is no, I think that if you've had a spinal cord stimulator and that hasn't worked that there would be very few further procedures that we would recommend that you should consider. As you'll be aware they'll get more and more drastic sounding.
SMITH
That's right, I mean I did promise the pain consultant that I wouldn't have any more ops without her say so, if you like, but you still look - with waking up with it, going to sleep with it, you think is there anything else, you clutch at straws a bit.
MYERS
Is this where you have to really - I mean this is terribly difficult to say because it must be so miserable when you are in that position - but is there any way of turning this whole thing round and trying to work through this idea that the pain won't beat you, and I don't think it's just mind over matter, that's not what I'm saying. But Charles in your work, I know it's been very important pioneering work to do with pain management, the techniques of coping with pain, not getting rid of it, because that sometimes isn't possible. Can you say a little bit more about that and how it might apply to Mark and others?
PITHER
Well it is absolutely crucial and underpinning it I suppose is this understanding that pain isn't just a sensory experience, it's a perception. Now what do I mean by that? I mean that actually pain - intrinsic somehow in the pain experience is aspects to do with what we understand and whether it frightens us and what we - how we respond, if you like. And it's quite difficult to sort of conceptually understand this but we know that we can help people to get more in control and the more in control they can feel and by using some other perhaps seemingly slightly strange techniques using relaxation techniques and using cognitive behavioural techniques we can help people to reduce some of the fears and the stress and the awfulness of the pain if you like. And many of those people do find ultimately that the pain troubles them less, they're able to get on with their lives better, they feel more in control, they're able to do more and they can report that the pain management programme can be jolly helpful. And sometimes, I have to say, it is all that is left on the list, if we start with the simple things and go through the more complicated things and then go to nerve blocking techniques and they still don't work, sometimes we're just left with the pain management programmes. But they can be jolly helpful.
MYERS
Can you quantify the results in any way Charles, to give people encouragement?
PITHER
Well yes we can. We can do that in a number of ways. We can say that something like 70% of people going through one of these programmes, intensive programmes, will make worthwhile changes to their quality of life - what they can do, how depressed they feel, how confident they are, and their pain will actually go down, it won't go away but their pain does go down. So we can generally say that with somebody with longstanding pain who's had some simple procedures that a pain management programme is probably a more effective technique than pursuing another sort of rare or strange procedure or a change of drugs.
MYERS
Okay, we'll leave it there. Thank you Mark for that call. Go to an e-mail, and I think this may be relevant in what you were just saying Charles because it's about exercise and having seen the way the pain management clinics can work, exercise seems to be something that is tried. But Caroline is making the point that she has chronic fatigue syndrome and fibromyalgia. She can be bedridden with her pain for weeks at a time, so that she gets muscle wasting. Now the problem, she says, is that when she starts to stretch her muscles to try and exercise them she gets very sore, in fact overwhelming pain and exhaustion and this deters her. So how do you break this vicious cycle? If exercise is good and yet it seems to make your pain worse ...
PITHER
Right, well there's two really important things which - I don't know whether Caroline's had help with this but she's almost certainly going to need help with it, she's not going to do it herself. The first is what the pain means, what she understands is causing the pain because if she's got some ideas that the pain is related to damage or that the pain equates to sort of tearing of muscles or doing something damaging in the muscles then we know that psychologically that's a big brake on us performing, it's the reverse of sport psychology, if you like, it's unhelpful messages slowing us down and making the pain worse. The second thing is she's going to need to work on a very gradual regime and pace things up. The problems that people with fibromyalgia and this type of pain have is that they get into an all or nothing cycle, they feel good, they get up, they say hey I'm not too bad today, they go and do things, they have an increase in pain as a result and then they're flat on their back for two or three days. And the way we would start to help is to start to standardise her at a level that she can always manage, now that may not be a very high level to start with but everyday she'd be just getting up, getting dressed, going for a little walk or whatever it is, and then we'd use that to build up. And that way we take out the pain as being the controlling variable, the pain at the moment is ruling her life - she can only do things when the pain lets her, we have to get her back in control so she's in control and putting the pain back in the box.
MYERS
Okay, thanks for that. We're going to go to Rachel David next and rather picking up what we heard from Mark Smith in Harrogate, he was talking about having tried spinal cord stimulation, amongst the various things he'd tried. Rachel are you - is this something you're considering using?
DAVID
Well I just really wanted to know more about it. I've been using a Tens machine for about 15 years for back pain and I've become allergic to the electrodes and I'd heard that you could have something implanted.
MYERS
Okay, Charles do you want to just briefly fill us in on Tens?
PITHER
Yes, what's the nature of the cause of the pain Rachel, can you give us a little bit more information?
DAVID
It's chronic spinal degeneration.
PITHER
You have back pain really is it?
DAVID
And it's back pain and sciatica yes.
PITHER
Yes, I mean there's two things. Firstly spinal cord stimulation can be of help for pain and it can be a very useful technique but it really only works for nerve damage pain, it doesn't work for conventional back pain, so it sounds like it might help the leg pain but I don't think it would help the back pain, that's the first thing. The second thing is that it actually is quite an invasive idea, not everybody wants to have - likes the idea of having wires implanted in the back with a little machine under the skin and it is expensive and it is invasive. And some people once you tell them a little bit more about it and it sounds like you do need some more information about it, they think actually hey not for me thank you very much, other people are enthusiastic. So it is much more of an undertaking than putting a Tens unit on. But one other thing, which is that - you presumably have tried some different electrodes and tried all the hypoallergenic ...
DAVID
Yes and it was the hypoallergenic ones that I actually ended up being allergic to as well.
PITHER
Well that's bad luck.
MYERS
Generally speaking would you say that the Tens machines - these little sort of electric vibrators, is how I tend to think of them - have a place in pain control Charles?
PITHER
Absolutely, yes and they're simple, they're non-invasive and apart from Rachel's problem, which is rather tiresome, usually they have a very low risk of side effects and they can be an adjunct to effective pain management.
MYERS
And is that because they somehow block the pain messages or distract you from them?
PITHER
That's what they're doing really, they're - they call - we often refer to the spinal gate, the pain gate, they're shutting the pain gate on these pain signals and instead of the pain you feel the other - the sort of tingling sensation.
MYERS
Okay, we'll leave your question Rachel at that I'm afraid that's as far as we can go with that. But it takes me to Philip Nearop [phon.] who is wanting to talk about acupuncture and perhaps that does tie in with this nerve stimulation because I suppose the acupuncture needle is in a way a form of stimulation. However his question, which is by e-mail, is that he has a frozen shoulder, is in considerable pain all the time, has just started acupuncture, have you any advice about this?
PITHER
Well frozen shoulder is usually a self-limiting condition and that is really important I think and unlike Ann's situation where I have to say look I don't think it is going to go away, what we can reassure Philip is that it will go away, it will get better, it may take a year but it will get better. We've shown surprisingly that a lot of medical treatments don't really make much difference to this and so pain relief is a valid goal in its own right, if you like, so in other words it isn't like you need a definitive treatment because nobody's worked out what the difference of treatment is but it is absolutely logical to keep the shoulder moving with some physiotherapy and acupuncture, if it's helpful, and painkillers, especially anti-inflammatories, can be helpful and occasionally injections can be helpful. So within that context acupuncture has been shown in a number of different conditions - back pain more recently and a lot of other conditions - to produce worthwhile benefit and it again is simple and has a low risk of side effects.
MYERS
We'll take a very quick call, if we may, to finish Judith Jones, who has had some experience of pain clinics and some success?
JONES
Yes that's right. Hi. I've suffered from back pain for about seven years and in fact I actually resigned from my job as a head teacher - one of the significant factors for giving up work was this pain I was under. Fortunately I was referred to the pain clinic in Birmingham and it's just been brilliant, absolutely brilliant to be treated as a whole person rather than just a back. It was so refreshing. They phone you up at home, they check the treatment's okay and now I've discovered medial branch blocks for my back, which has been very successful. I just cannot speak highly enough of the service, I think it's brilliant.
MYERS
Well on that ringing endorsement we'll have to finish our programme, but that's music to your ears I'm sure Charles. Thank you very much to Dr Pither, who's taken time out from the British Pain Society Conference to answer all your questions today. And thanks to everyone who's phoned or e-mailed with their questions. If you missed anything you can listen again, you can go to our website bbc.co.uk/radio4 and follow the trail or you can ring our help line - 0800 044 044. Next week: it's that time of the month and we'll be getting advice about dealing with pre-menstrual syndrome.
ENDS
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