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Pain occurs to alert the individual to potential or actual damage to the body. Pain can arise from injury as well as from disease. Pain can have a negative effect on a person's quality of life and can impede recovery from whatever is the cause of the pain.  Unrelieved pain can become in its own right, a cause of a downward spiral in a person's health and especially their outlook. The proper management of pain will help recovery, and prevent further complications in the health and well being of the individual and will improve their quality of life.

Before considering pain management it may be good to review the definitions and mechanisms of pain. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. The PNS includes all nerves throughout the body except the brain and spinal cord.

The message of pain is transmitted to the CNS by special PNS nerve cells called nociceptors. Which are are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, region in the brain.  The brain receives and processes  the pain message and the individual feels pain. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately deal with or take the edge off a continuing pain message. In addition, depending on how the brain has processed the information, certain hormones, such as prostaglandins, may be released. These hormones may actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually improves and will clears up  once the condition that caused it is resolved.

However, in the case of some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain, and when this occurs the pain is considered to be chronic. The time limit used to define chronic pain often ranges from three to six months, although some healthcare professionals are more flexible. and consider chronic pain as pain that endures beyond a normal healing time. 

The pain associated with persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that has no identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. It would appear that the underlying biochemistry of chronic pain is different from regular nociceptive pain.

There appears to be some evidence that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.Scientists have long recognized a relationship between depression and chronic pain. In 2004, a survey was held in California of adults who had been diagnosed with major depressive disorder, and it  revealed that more than one-half of them also suffered from chronic pain.

When considering the different causes and types of pain, as well as its nature and intensity, pain  management can require a number of approaches.  The elements of which may include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and sometimes invasive surgery. However, even though injuries are repaired, diseases diagnosed and treatment given, there is no guarantee of immediate relief from pain. Over time various pharmacological and other therapies have been developed to address various aspects of pain.

Pain-relieving drugs, called analgesics, include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, narcotics, antidepressants, anticonvulsants, and others. NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used along with to other drug therapies, which might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited.NSAIDs and acetaminophen are effective for most forms of acute pain, but moderate and severe pain may require stronger medication.

Narcotics handle intense pain effectively, and are used for acute pain that does not respond to NSAIDs and acetaminophen. Narcotics are classified as either opiates or opioids, and are available only with a doctor's prescription. Opiates include morphine and codeine, which are derived from opium, a substance naturally found in some poppy species. Opioids are synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodon, methadone, and meperidine
Narcotics may be ineffective against some forms of chronic pain, especially since changes in the spinal cord may alter the usual pain signaling pathways. In such situations, pain can be managed with the help of with antidepressants and anticonvulsants, which are also only available with a doctor's prescription.
Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating some chronic headaches, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, certain anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Other prescription drugs are used to treat specific types of pain or specific pain syndromes. For example, corticosteroids are effective against pain caused by inflammation and swellingDrug administration depends on the drug type and the required dose. Some drugs are not absorbed very well from the stomach and must be injected or administered intravenously. Injections and intravenous administration may also be used when high doses are needed or if an individual is nauseous. Following surgery and other medical procedures, patients may have the option of controlling the pain medication themselves. By pressing a button, they can release a set dose of medication into an intravenous solution. This procedure has also been employed in other situations requiring pain management. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug.
There are other options in the treatment of pain that do not use drugs and are often used together with rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to decrease muscle tension and reduce stress. Exercising and participating in normal activities can also help control pain levels. Through physical therapy, an individual can learn exercises that are beneficial in  reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged can be very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. However it is recommended that to be effective the use of TENS should be medically supervised.



By Hilary Heald - Editor
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