Antidepressants use for chronic pain on the rise, but are they effective?

by University of Sydney

Credit: Unsplash/CC0 Public Domain

Many people are unaware that some antidepressants (medications used to treat people living with depression) are also being prescribed to treat certain chronic pain conditions.

26 fev 2023--One in five people experiences chronic pain in Australia and globally, and treatment of chronic pain is often suboptimal, with commonly used medicines having limited or unknown benefits. The use of antidepressants to help manage a person's pain is on the rise, even when they do not have a mood disorder like depression.

An international team of researchers has found that some classes of antidepressants were effective in treating certain pain conditions in adults, but others were either not effective, or the effectiveness was unknown.

Published in The BMJ, the study reviewed the safety and effectiveness of antidepressants in the treatment of chronic pain.

The researchers say the results show that clinicians need to consider all the evidence before deciding to prescribe antidepressants for chronic pain management.

"This review, for the first time, brings together all the existing evidence about the effectiveness of antidepressants to treat chronic pain in one comprehensive document," said lead author Dr. Giovanni Ferreira from The Institute for Musculoskeletal Health and Sydney Musculoskeletal Health at the University of Sydney.

The review examined 26 systematic reviews from 2012 to 2022 involving over 25,000 participants. This included data from 8 antidepressant classes and 22 pain conditions including back pain, fibromyalgia, headaches, postoperative pain, and irritable bowel syndrome.

Serotonin-norepinephrine reuptake inhibitors (SNRI) antidepressants such as duloxetine were found to be effective for the largest number of pain conditions, such as back pain, knee osteoarthritis, postoperative pain, fibromyalgia, and neuropathic pain (nerve pain).

By contrast tricyclic antidepressants, such as amitriptyline, are the most commonly used antidepressant to treat pain in clinical practice, but the review showed that it is unclear how well they work, or whether they work at all for most pain conditions.

The use of antidepressants as a treatment for pain has recently gained attention globally. A 2021 guideline for chronic primary pain management published by The National Institute for Health and Care Excellence (NICE) recommends against using pain medicines with the exception of antidepressants. The guideline recommends different types of antidepressants, such as amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline for adults living with chronic primary pain.

Dr. Ferreira said a more nuanced approach to prescribing antidepressants for pain is needed.

"Recommending a list of antidepressants without careful consideration of the evidence for each of those antidepressants for different pain conditions may mislead clinicians and patients into thinking that all antidepressants have the same effectiveness for pain conditions. We showed that is not the case."

Co-author Dr. Christina Abdel Shaheed, from The School of Public Health and Sydney Musculoskeletal Health at the University of Sydney, said, "The findings from this review will support both clinicians and patients to weigh up the benefits and harms of antidepressants for various pain conditions so that they can make informed decisions about whether and when to use them."

Dr. Ferreira said that there are multiple treatment options for pain, and people should not rely solely on pain medicines for pain relief.

"Some pain medicines may have a role in pain management, but they need to be considered as only part of the solution. For some pain conditions, exercise, physiotherapy, and lifestyle changes may also help. Speak to your health professional to learn more about what alternatives might be appropriate for you," Dr. Ferreira said.

Professor Christopher Maher, Co-Director of Sydney Musculoskeletal Health at the University of Sydney, said, "This review distilled the evidence from over 150 clinical trials into an accessible summary that clinicians can use to help them make better decisions for their patients with chronic pain."

The current status of antidepressants in Australia and globally

Most antidepressant prescriptions for pain are "off-label," which is when antidepressants have not been approved to be prescribed for pain.

Many antidepressants are thought to help with pain by acting on chemicals in the brain that can assist with pain relief, such as serotonin. However, it is unknown exactly why some antidepressants improve pain. In Australia, the only antidepressant approved for treating pain is duloxetine, which is approved for diabetic neuropathic pain (nerve pain caused by diabetes).

Amitriptyline is approved in the United Kingdom for some pain conditions, such as neuropathic pain (nerve pain), tension-type headaches and migraines, but it is not approved for treating any pain conditions in Australia.

The use of antidepressants has doubled in OECD countries from 2000 to 2015, and the use of "off-label" prescriptions of antidepressants for pain is considered a contributing factor to this increase. Data from Canada, the United States, the United Kingdom and Taiwan, suggest that among older people, chronic pain was the most common condition leading to an antidepressant prescription, even more so than depression.

Currently, no data from Australia shows how many antidepressant prescriptions are for pain.

More information: Giovanni E Ferreira et al, Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews, The BMJ (2023). DOI: 10.1136/bmj-2022-072415

 

How older adults and their caregivers view pain, depression and other patient symptoms

by Regenstrief Institute

Credit: Unsplash/CC0 Public Domain

Adults, especially older adults, may be in pain or depressed but not able to convey details of their symptoms and quality of life to their doctors for various reasons including cognitive impairment. A new study from Regenstrief Institute and Indiana University School of Medicine researchers investigates whether adult patients and their proxies—typically spouses, children or other family caregivers—agree on what they tell physicians about a patient's symptoms and quality of life, information critical to clinical care.

31 jul 2022--The researchers found that patients and caregiver proxies agreed on severity of symptoms of pain, depression and anxiety as well as functional status between 50 to 60 percent of the time, with agreement on physical symptoms (pain and functionality) more likely than agreement on psychological symptoms (depression and anxiety).

Proxies tended to overestimate patient impairment at lower levels of symptom severity and underestimate at higher levels. Caregivers who were under a lot of stress were more likely to over-report their patient's symptoms.

"Unlike blood pressure and blood sugar, symptoms like pain, depression or anxiety can't be objectively measured," said Regenstrief Institute and IU School of Medicine faculty member Kurt Kroenke, M.D., who led the study. "Our group is very interested in symptoms—signs you can't measure with an X-ray or a lab test. The only way to determine severity is with validated scales and if patients can't report for themselves, then the proxy's report is an important tool available to the clinician treating the patient."

Even when a patient is able to self-report, complementary observations from a proxy providing a confirming or disagreeing perspective may inform treatment decisions, according to Dr. Kroenke, a primary care physician.

The study of 576 older adult and proxy participants (188 patient-caregiver pairs as well as 200 patients without identified caregivers) also found that when looking at group averages, patients' self-reports and caregivers' reports on patients were in line with each other because over and under reporting averaged out. Dr. Kroenke notes that this confirms the value of using proxy reports in research studies.

Paired patients and their caregivers who were White were 50 percent of study participants. An almost even percentage, 47 percent of the paired patients and 48 percent of their caregivers, respectively, were Black.

"Similar to what occurred during the pandemic, when we used rapid COVID tests rather than the more accurate PCR tests to make decisions about travel or attending events or other issues, because rapid tests were the best we had on hand, when patients can't complete a symptom scale, proxy reports, while not the best, are the best available and provide valuable information," said Dr. Kroenke.

Dr. Kroenke, a pioneer in the field of symptomology, has developed multiple patient-reported outcome measures that have been translated into 80 languages, including the PHQ-9 depression scale, GAD-7 anxiety scale, PEG pain scale and P4 suicidality screener. In this study patient-caregiver agreement was evaluated using four commonly-used scales, the PHQ-9, GAD-7, the PEG, and the SymTrak multi-dimensional symptom and functional impairment scale. SymTrak was also developed and tested by Regenstrief and IU School of Medicine researchers.

The research is published in the Journal of Patient-Reported Outcomes.

More information: Kurt Kroenke et al, Agreement between older adult patient and caregiver proxy symptom reports, Journal of Patient-Reported Outcomes (2022). DOI: 10.1186/s41687-022-00457-8

Provided by Regenstrief Institute 

100 million Americans live with chronic pain, but treatment research is insufficient

An estimated 100 million Americans live with chronic pain. A new report by an independent panel convened by the National Institutes of Health has found a need for evidence-based, multidisciplinary approaches to pain treatment that incorporate patients' perspectives and desired outcomes while also avoiding potential harms.

19 jan 2015--"We learned that sufficient clinical research doesn't exist to show physicians how best to treat chronic pain in adults, many of whom suffer from multiple health problems," said the founding director of the Indiana University Center for Aging Research and Regenstrief Institute investigator Christopher Callahan, M.D., who served on the seven-member panel.

While opioids are frequently prescribed for chronic pain, the panel noted the absence of pain assessment and treatment guidelines. The panel also reviewed reports that suggest insufficient data exists on drug characteristics, dosing strategies and tapering options.

"Are opioids the appropriate treatment? And, if so, at what dose and for how long? Could other, less dangerous treatments work for some people? The panel found that, in spite of what many clinicians believe, there is no evidence that pain narcotics—with their risks of dependency, addiction and death—are an effective long-term pain treatment. More research is needed to guide effective care for chronic, often debilitating, pain," Dr. Callahan said.

The panel identified barriers to implementing evidence-based, patient-centered care, including what Dr. Callahan described as the important emotional aspects of pain, including the perceptions of suffering endured by people with chronic pain.

"Ten years ago, the medical community spoke of pain as the fifth vital sign," Dr. Callahan said. "Even though we know that treatment should be tailored to individual patients, there is no existing algorithm that helps researchers or clinicians determine which patients with which type of pain should be treated with which available approach.

"We heard information presented that there has been a dramatic increase in opioid overdoses by individuals who illegally obtain and abuse these prescription drugs—often family members or family friends who take the medications from the patient," Dr. Callahan said.

"The panel did hear suggestions of what providers might do in the face of the limited available evidence. For example, physicians might prescribe smaller quantities of opioids. This could potentially require individuals in pain to travel more frequently for prescription refills, but it would also decrease the amount of drugs potentially available to abusers.

"In educating their patients, providers might also tip the balance of their cautions about these drugs to highlight that they are important drugs with important dangers to both the patient and those who might obtain them accidentally or illegally. At the same time, the panel heard testimony that patients who responsibly use these medications should not be treated like criminals."

Dr. Callahan, who is the Cornelius and Yvonne Pettinga Professor of Medicine at the IU School of Medicine, calls for funding for clinical trials designed with input from both patients and those who treat pain. An internist and geriatrician who is an expert in health services research, health care systems and policy, Dr. Callahan has conducted several studies that have found the multidisciplinary team approach recommended by the panel has been effective in the care of older adults, who, like many chronic pain patients, often have multiple health problems and needs.

More information: The panel's report, "National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain," published online first at www.annals.org by the Annals of Internal Medicine,

Provided by Indiana University

Understanding and managing chronic pain

Acupuncture, exercise and massage and physical therapy are among the ways to deal with chronic pain that don't require narcotic painkillers, says Nancy Elder, MD, professor of family and community medicine at the University of Cincinnati.

06 july 2014--"A lot of patients think, 'Oh, I hurt a lot, I hurt a lot all the time, the doctor should give me OxyContin and Vicodin,'" says Elder. "I think the most important thing that doctors and patients need to know is there is much we can do to help patients with chronic pain outside of narcotics.

"That doesn't mean narcotics aren't appropriate for some people in certain situations, but there are a whole lot of people that can get better without them," she adds.

Elder says more doctors must have initial conversations with patients to manage expectations in dealing with chronic pain.

"Part of it is understanding the natural course of chronic pain and some of it is understanding the difference between being cured and being able to 'do what I want to do with pain that is manageable,'" says Elder.

"I may not be able to cure somebody of their chronic pain, but I can make them feel a whole lot better and help them do more of the activities they want to do."

Elder says whenever possible, physicians should involve a multimodality team that may include specialists in physical therapy, massage therapy, acupuncture and chiropractic treatment to address chronic pain. Acupuncture may relieve pain caused by conditions such as fibromyalgia, osteoarthritis and back injuries.

Exercise under a doctor's supervision can improve energy levels and mood and relieve chronic pain, while chiropractic treatment may work well in treating certain types of lower back pain, says Elder. Addressing behavioral/mental health is also important when dealing with chronic pain.

"Pain can worsen depression and depression may make chronic pain worse," says Elder.

There are also surgical possibilities and nerve injections that address some types of chronic pain so collaborations with anesthesiologists are also important, says Elder.

"There are medicines besides narcotics to help chronic pain such as antidepressants; even if you are not depressed, they can help," says Elder.

Medicines that were originally developed for epilepsy may have a benefit in chronic pain. Depending on the type of pain, there are even some cardiac medications that are very helpful, explains Elder. "A lot of other medicines from various areas of medicine have also been found to help with chronic pain," she says. "We call them adjuvant medications because they aren't painkillers, but they work to help decrease chronic pain.

"People with chronic pain, both doctors and patients, need to think outside of the opioid/narcotic pain box," Elder says.

Pioneering study reveals association of chronic pain and broad epigenetic changes

Injuries that result in chronic pain, such as limb injuries, and those unrelated to the brain are associated with epigenetic changes in the brain which persist months after the injury, according to researchers at McGill University. Epigenetics explores how the environment – including diet, exposure to contaminants and social conditions such as poverty – can have a long-term impact on the activity of our genes.

19 feb 2013--The team led by Prof. Laura Stone, a professor at the Faculty of Dentistry and the Alan Edwards Centre for Research on Pain, and Prof. Moshe Szyf, a professor at the Faculty of Medicine's Department of Pharmacology and Therapeutics, have discovered a mechanism that embeds the memory of an injury in the way the DNA is marked in the brain by a chemical coating called methyl groups or DNA methylation. The researchers report in the journal PLOS One, that if the symptoms of chronic pain are attenuated, the abnormal changes in DNA methylation could be reversed.

Research pioneered at McGill has previously shown that experiences and not solely chemicals alter the way genes are marked epigenetically, impacting our behavior and well-being. DNA methylation, an epigenetic mark on the gene itself, can therefore serve as a "memory" of an experience that will alter the way the gene functions long after the original experience is gone. The crucial difference between "genetic" and "epigenetic" causes for disease is that genetic changes are inherited and fixed, while epigenetic changes in contrast are possibly reversible.

The McGill research is the first to link chronic pain to genome-wide epigenetic changes in the brain. "Injury results in long-term changes to the DNA markings in the brain; our work shows it might be possible to reverse the effects of chronic pain by interventions using either behavioral or pharmacological means that interfere with DNA methylation, says Prof. Szyf. "Our findings have the potential to completely alter the way we treat chronic pain."

In this study, the researchers show that behavioral interventions that reverse chronic pain also remove differences in DNA methylation in the brain.

The team report alterations in global DNA methylation are observed in the prefrontal cortex (PFC) and amygdala of mice many months following injury to a nerve, and that environmental enrichment reduces both the pain and the pathological changes in PFC global methylation. They also found that the total amount of global methylation in the PFC significantly correlates with pain severity.

"These results suggest that epigenetic modulation mediates chronic pain-related alterations in the central nervous system (CNS), forming a "memory trace" for pain in the brain that can be targeted therapeutically, says Stone. Sinceepigenetics respond to environmental changes, these mechanisms represent a mind-body link between chronic pain and the brain at the genomic level. "The implications of this work are wide reaching and may alter the way we think about chronic pain diagnosis, research and treatment".

Provided by McGill University

Chronic Pain Gene Discovery May Spark Treatments

10 aug 2010- Nearly 20 percent of American adults suffer from persistent, chronic pain, but a new genetic clue may aid in the understanding and treatment of the debilitating condition.

Chronic pain can affect all aspects of life, from sleep, to work, to exercise. Some individuals are more susceptible to pain than others, but the reason for this has not been understood. For example, the amount of pain two patients experience after the same surgery can differ greatly.

An international team of researchers sought to find out if there is a genetic basis for susceptibility to pain. Using animal models, they were able to link mouse chromosome 15 with pain. Using two fine-mapping approaches, they narrowed it down to one gene: Cacgn2, which was previously know to be associated with cerebral function and epilepsy. Before now, no other gene has ever been associated with pain.

To further test the gene, scientists used a mouse strain harboring the mutant gene, previously used for epilepsy research, and the findings were consistent; the mice experienced different behavioral and electrophysiological characteristics linking the chronic pain to Cacgn2.

Researchers wanted to know if the Cacgn2 gene is responsible for chronic pain in humans as well. To find out, they studied a cohort of breast cancer patients that had all or partial removal of the breast, and found genetic polymorphisms in Cacgn2 were significantly associated with chronic pain experienced after surgery.

"The immediate significance is the mere awareness that differences in pain perception may have a genetic predisposition," Ariel Darvasi of the Hebrew University of Jerusalem in Israel, was quoted as saying. "Our discovery may provide insights for treating chronic pain through previously unthought-of mechanisms."

SOURCE: Genome Research, published online August 4, 2010

AGS Foundation For Health In Aging Tip Sheet About Persistent Pain In Later Life, Now Available In Spanish

20 oct 2009--The AGS Foundation for Health in Aging (FHA) Tip Sheet about persistent pain -- pain or discomfort that lasts for a long time, or comes and goes over the course of months or years -- is now available in Spanish translation. The pain tips, initially released in May in English, are the first in a series of Spanish language tips, to become available by the FHA. The tips offer Spanish-speaking older adults who suffer from ongoing pain, and their caregivers, advice on getting treatment and relief. Persistent pain is common among older people, particularly those with chronic health problems such as arthritis. However common, persistent pain isn't a "normal" part of aging and shouldn't be ignored. If untreated or improperly treated, persistent pain can make it hard to sleep, walk, and carry out daily activities. It can contribute to falls and lead to disability. It can take the joy out of living.

Fortunately, there are many effective treatments for persistent pain and FHA's new Spanish version of the easy-to-read "tip sheet" explains this in detail.

Written by experts with the American Geriatrics Society, the Spanish-language tip sheet explains how older adults, and their caregivers, can describe pain and their experiences with pain so their healthcare providers can better understand and treat it. Among other things, it describes signs of pain in older adults with dementia, who may be unable to communicate.

The tip sheet provides an overview of the different classes of pain medications -- including acetaminophen (Tylenol,® for example), nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and naproxen, and opioid pain medications such as Vicodin, Percocet, Ultracet, Lortab and morphine. It explains which types of pain these medications treat most successfully, and the risks associated with their use. And it offers advice on working with your or your loved one's healthcare providers to find the right medication. In addition, the tip sheet includes information about non-drug pain relief options, such as massage, acupuncture, and transcutaneous electrical nerve stimulation (TENS), physical therapy and exercise.

The tip sheet, which advises older adults and their caregivers to alert their healthcare providers immediately if treatment isn't working or is causing side effects, can be downloaded, printed, and shared at no cost.

About The FHA

In 1999, the American Geriatrics Society reached beyond its traditional role as a professional medical society and launched the AGS Foundation for Health in Aging (FHA). The FHA aims to build a bridge between geriatrics health care professionals and the public, and advocate on behalf of older adults and their special needs: wellness and preventive care, self-responsibility and independence, and connections to family and community. The FHA champions initiatives in public education, clinical research, and public policy that advance the principles and practice of geriatrics medicine; educate policy makers and the public on the health care needs and concerns of older adults; support aging research that reduces disability and frailty, and improves quality of life and health outcomes; encourage older adults to be effective advocates for their own health care; and help family members and caregivers take better care of their older loved ones and themselves.

Source
American Geriatrics Society

Mayo Clinic study suggests those who have chronic pain may need to assess vitamin D status

ROCHESTER, Minn., 21 mar 2009 — Mayo Clinic research shows a correlation between inadequate vitamin D levels and the amount of narcotic medication taken by patients who have chronic pain. This correlation is an important finding as researchers discover new ways to treat chronic pain. According to the Centers for Disease Control and Prevention, chronic pain is the leading cause of disability in the United States. These patients often end up taking narcotic-type pain medication such as morphine, fentanyl or oxycodone.

This study found that patients who required narcotic pain medication, and who also had inadequate levels of vitamin D, were taking much higher doses of pain medication — nearly twice as much — as those who had adequate levels. Similarly, these patients self-reported worse physical functioning and worse overall health perception. In addition, a correlation was noted between increasing body mass index (a measure of obesity) and decreasing levels of vitamin D. Study results were published in a recent edition of Pain Medicine.

"This is an important finding as we continue to investigate the causes of chronic pain," says Michael Turner, M.D., a physical medicine and rehabilitation physician at Mayo Clinic and lead author of the study. "Vitamin D is known to promote both bone and muscle strength. Conversely, deficiency is an under-recognized source of diffuse pain and impaired neuromuscular functioning. By recognizing it, physicians can significantly improve their patients' pain, function and quality of life."

Researchers retrospectively studied 267 chronic pain patients admitted to the Mayo Comprehensive Pain Rehabilitation Center in Rochester from February to December 2006. Vitamin D levels at the time of admission were compared to other parameters such as the amount and duration of narcotic pain medication usage; self-reported levels of pain, emotional distress, physical functioning and health perception; and demographic information such as gender, age, diagnosis and body mass index.

Further research should document the effects of correcting deficient levels among these patients, researchers recommend.

This study has important implications for both chronic pain patients and physicians. "Though preliminary, these results suggest that patients who suffer from chronic, diffuse pain and are on narcotics should consider getting their vitamin D levels checked. Inadequate levels may play a role in creating or sustaining their pain," says Dr. Turner.

"Physicians who care for patients with chronic, diffuse pain that seems musculoskeletal — and involves many areas of tenderness to palpation — should strongly consider checking a vitamin D level," he says. "For example, many patients who have been labeled with fibromyalgia are, in fact, suffering from symptomatic vitamin D inadequacy. Vigilance is especially required when risk factors are present such as obesity, darker pigmented skin or limited exposure to sunlight."

Assessment and treatment are relatively simple and inexpensive. Levels can be assessed by a simple blood test (25-hydroxyvitamin D [25(OH)D]). Under the guidance of a physician, an appropriate repletion regimen can then be devised. Because it is a natural substance and not a drug, vitamin D is readily available and inexpensive.

In addition to the benefits of strong muscles and bones, emerging research demonstrates that vitamin D plays important roles in the immune system, helps fight inflammation and helps fights certain types of cancer.

###

Other study authors from Mayo Clinic include W. Michael Hooten, M.D., Department of Anesthesiology; John Schmidt, Ph.D., Department of Anesthesiology Research; and Jennifer Kerkvliet, Cynthia O. Townsend, Ph.D., and Barbara Bruce, Ph.D., all from the Pain Rehabilitation Center.

Chronic Pain: A Burden Often Shared

By JANE E. BRODY
Chronic pain is a family problem. When people experience unrelenting pain, everyone they live with and love is likely to suffer. The frustration, anxiety, stress and depression that often go with chronic pain can also afflict family members and friends who feel helpless to provide relief.
Healthy family members are often overworked from assuming the duties of the person in pain. They have little time and energy for friends and other diversions, and they may fret over how to make ends meet when expenses rise and family incomes shrink.
It is easy to see how tempers can flare at the slightest provocation. The combination of unrelieved suffering on the one hand and constant stress and fatigue on the other can be highly volatile, even among the most loving couples — whose burdens are often worsened by a decline of intimacy.
“Family members are rarely considered by doctors who treat pain,” said Dennis C. Turk, a pain management researcher at the University of Washington in Seattle. “Yet a study we did found that family members were up to four times more depressed than the patients.”
But pain experts say there is much that family members and friends can do to improve the situation.
Step one is to recognize that chronic pain is not an individual problem. Let the patient know that you are in this together and will fight it together. When the patient is moody and irritable, try not to take it personally.
Step two involves learning as much as you can about the condition and how to treat it. Eliminating the pain may not be possible, but there often ways to reduce it. (See next week’s column on treating chronic pain.)
Some of the ideas below were adapted from the American Chronic Pain Association’s Family Manual, written by Penney Cowan, the association’s founder and executive director.
“Twenty-five percent of the calls we get are from family members looking for help,” Ms. Cowan said in an interview last week. “Family members are just as isolated, controlled, frustrated, guilt-ridden and confused by chronic pain as is the person in pain.”
Acknowledge your feelings. You may feel guilty about not being able to relieve the distress of someone you love. You may be anxious about financial problems.
You may be distressed by the reactions of other people, who might lack an understanding of chronic pain and suggest that the patient is malingering — faking the pain to avoid work or family responsibilities. At a time when you most need the understanding and support of others, they may seem unsympathetic, even hostile.
But the most common reaction is resentment, over a withdrawal of the patient’s affection and sexual intimacy, the unending care required by the patient, the need to add the patient’s responsibilities to your own, the decline or loss of a social life and time spent with friends. You may resent having to abandon an enjoyable lifestyle or plans for the future.
If the patient was the family breadwinner and is now unable to work, you may have to find a job and, at the same time, do most or all of the chores at home and care for the patient. Chronic exhaustion can erode your temper as well as your own health.
It is all too easy to react to such feelings in emotionally destructive ways. Owning up to them can help you cope more successfully.
Help the patient stay involved. Chronic pain can rob people of their abilities and force them to be cared for by others, leaving them to feel worthless and guilty over not contributing to the family’s welfare. Whether you are the patient’s primary or intermittent caregiver, it is important not to contribute to feelings of helplessness.
Encourage patients to participate as fully as possible in family plans and activities, household chores, discussions and decisions. Perhaps they can no longer do yardwork, but they may still be able to help with cooking, setting the table, washing the dishes, caring for children, handling family finances, making phone calls or shopping by phone. Feeling useful can bolster a patient’s self-esteem and mood.
“For each action the pain person says he or she can no longer do, point out something he or she can do,” the pain association’s manual suggests.
Don’t become a go-for. Chronic pain patients should be encouraged to do whatever they can do for themselves. It is important for you to know when to step in and when to step back. Recognize the patient’s abilities and limitations — consider having an evaluation made by an occupational therapist — and let the patient participate as much as possible in daily activities and self-care.
Communicate. “Open, two-way communication is crucial to dealing effectively with chronic pain,” said Dr. Turk, of the University of Washington. “Family members need to know how they can be helpful and what might be hurtful.”
Failure to communicate honestly and openly can become a cancer on a relationship, be it with a spouse, parent or child. If chronic pain has disrupted family plans, discuss a reordering of priorities. It may be possible to do more than you think.
You have a right to say that you are tired and need to rest, that you need a break from the routine lest you burn out, and that you need to maintain friendships and pursue enjoyable activities outside the home from time to time.
Likewise, the patient has a right and responsibility to express fear, disappointment, guilt and bad feelings about the behavior of some people, as well as gratitude for the help you and others provide.
Ask periodically what the patient might like to discuss with you or do with you. And try not to rise to the bait when the patient is critical or lashes out at you despite all you do. Most often, you are not really the target. But there may be no one else with whom the patient feels safe to express distress.
Take care of yourself. Enlist all the help you can get from family members and friends. Older children can clean the house and prepare meals. Friends and relatives who offer to help can be given tasks that fit their abilities, even if it is just accompanying the patient to a medical appointment. If they haven’t offered, ask.
When necessary, hire others, including neighborhood teenagers, to help out. If you are reluctant to leave the patient home alone, ask a friend or neighbor to stay for a few hours or to look in on the patient every so often so that you can get out for a while.
Don’t neglect your own physical well-being. Eat regular meals, get enough sleep and get regular physical exercise. And be sure to keep up with medical checkups and screening exams. If you get sick, you won’t be much use to the patient in pain.