Chronic Pain

Acute pain is often an indication that something needs immediate attention. However, chronic pain, those pains that have been thoroughly investigated but tend to recur with a variety of triggers, may often have a much more diverse psychosomatic make up.
Once a body has experienced acute pain of injury or disease, a neurological program remains available thereafter for the body to communicate 'dysfunction' more readily along the established pathways.
However this 'dysfunction' may be biological, psychological, sociological or spiritual. Psychosomatic medicine has delineated that men, for instance, subjected to physical abuse such as beatings across the back are most likely later in life to experience more of their anxiety and depression as bodily sensation, such as 'back aches'. Similiarly women sexually abused and vaginally traumatized early in life will be more likely at later times in life to express loneliness as pelvic discomfort.
The rationale for this is that neurologically a number of circuits were originally brought into play for the original acute injury or disease and later these same circuits can be used for the expression of psychological, sociological and spiritual discomfort. The mind is efficient.
To this end chronic pains while requiring an index of suspicion as a site for new physical disease often benefit more from less investigation, certainly less invasive investigation and more actual therapy.
An example is found in the acute back injury which is greeted with the recommendation of days of rest and no work initially but later when recurrence is noted, the recommendations drastically changes to 24 hour rest and then increasing exercise. Increasingly suicidal behaviour, acutely se en as a cry for help and need for massive life preserving intervention, later when it is chronic and recurrent is seen as a behaviour that requires education and redirection rather than responding as if this were the first suicidal episode. Suicide in this instance is a response to 'emotional pain".
Phantom limb pain is real however it may reflect emotional pain such as loss of a loved one or irritation and frustration with the inability to achieve one's goals.
Nothing is ever 'all in your head' but even fractures and amputations are experienced 'in your head'. The brain is the central physical processor and the mind is the overall understanding of all factors at play.
The DSMIV differentiates Pain Disorders into two, one where there is no physical basis noted, and another where a physical basis is noted but there is also a psychological and emotional overlay.
Treatment of chronic pain has advanced lightyears from where it was only 25 years ago. Much work has demonstrated that the degree of the chronic pain is directly associated with depth and quality of sleep. Pain often disrupts sleep and the next day anxiety and sleep loss are experienced as greater pain. So much of modern medicine focusses on addressing sleep in patients with pain disorders. Medications such as trazadone, gabapentin, mirtazepine are used for sleep and pain disorders.
Whereas in the past the tendency was to 'take away the pain' today pain is understood as beneficial and it's removal entirely can lead to serious side effects. Nerve severing studies found that people who'd had this neurological treatment to an arm for instance suddenly were at major risks for serious burns because they couldn't feel pain to react to. To that end today the pain is 'controlled' rather than eliminated.
In the past opiates were the mainstay of pain management. Today they are pre empted by first use of acetomenophen, nonsteroidal anti-inflammatories, and ASA's compounds. These are commonly today used in combination rather with three different pills from the different classes preferred over three times the dosage of just one medication. It was found these combinations of medications enhance the pain relief as each works on different sites in reducing pain but more importantly side effects are dramatically lessened as each has very different side effect profiles. ASA causes blood clotting to be reduced with no effect on the liver while Acetominophen causes liver enzymes to increase with no effect on the blood clotting. Therefore using two together one can get twice the pain relief with half the side effects.
Antidepressant medications and atypical major tranquillizers have been used as well more often to modulate pain control. Amitriptylline, a trycyclic antidepresssant has long been the treatment of choice for such conditions as fibromyalgia. Medications like cipralex and cymbalta address the depression commonly associated with pain. It was long ago noticed that combining coffeine with pain medications made them more potent. The antidepressants specifically work like this but for a longer period.
The opiates are for sure still used and yet the recognition was that people who took opiates could enter a pain free dream like state and be at increased risk for hurting themselves because of poorer judgement and lack of pain reception. This was especially true with musculoskeletal injuries. In contrast opiates have been seen as more beneficial in chronic 'organ' pain.
Exercise is central to pain management because commonly pain results in decreased exercise and risk of the consequences of this, obesity, disuse atrophy, and other side effects. Further, exercise is it's own antidepressant and the uplifting benefits help with maintaining and positive outlook which is central to the successful management of chronic pain.