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Pain Management.


What Is It?

Pain is a complicated combination of emotional, chemical and physical components. Treating and managing it often requires several approaches, including over-the-counter or prescription medications, physical therapy, lifestyle changes and coping skills.

Pain is one of the most common human experiences. Yet pain has never been fully accepted as a medical problem. One reason may be because pain is a subjective and highly individualized experience. You can measure pain even though you can't touch it, feel it (unless it's your own), image it or prove its existence. Even a pinprick creates differing sensations of pain for different people.

Nevertheless, chronic pain affects millions of Americans. Pain is the body's way of sending a warning to the brain that something is wrong. Aches are felt when pain messages, carried by chemicals called neurotransmitters, travel from the nerves along the spinal cord to the brain. In the brain, pain messages are meshed with thoughts, emotions and expectations that shape our interpretation and response to pain.

Both emotions and drugs can change the perception of pain because both affect neurotransmitter levels. Both emotions and chemicals also alter the amount of endorphins, the body's natural pain relievers, which block the relay of pain messages to the brain. Depending on your mood and mental state, pain messages can be slowed, strengthened or stopped entirely. For example, fear, anger and worry can heighten pain or make you momentarily not notice it, while calming, positive thoughts can ease it.

There are two main types of pain. Nociceptive pain basically represents pain associated with a pain receptor. This kind of pain is a signal to the body that it's being damaged in some way that needs immediate attention. Trauma, infection or illness can cause nociceptive pain. Toothaches, sprains, backaches or a broken bone are other common causes. Although unpleasant, most injuries resulting in nociceptive pain are short-lived and are easily treated with rest or medications.

Neuropathic pain refers to pain that is not associated with specific pain receptors and probably represents damage to or sensitization of the nervous system (this is when pain becomes the disease process itself, rather than representing a "warning" of underlying pathology). It is constant, often lasting for months after an injury or trauma, and can be disabling. Examples of neuropathic pain are the chronic pain that can linger after shingles or the pain that people with diabetes sometimes experience when nerve damage occurs. Diabetic neuropathies can cause pain, tingling or numbness in the hands, arms, feet and legs and also can affect other organ systems, including the digestive tract, heart and sex organs.

You may also hear pain referred to as "acute" and "chronic" pain. Acute pain is short-lived and usually diminishes as your body heals. Chronic pain persists for at least six months after your body has healed. Sometimes it is difficult to pinpoint where chronic pain is coming from. Because it persists, chronic pain can interfere with daily life and lead to depression, anxiety, anger and low self-esteem.


It isn't always easy to talk about pain. Some people think that complaining about pain is a sign of weakness. Studies on gender differences show that women are more likely to complain of pain and seek treatment for it than men.

Often, you can successfully treat your pain yourself with common over-the- counter (OTC) pain-relief medications or by making lifestyle changes.

For example, if you smoke, you should quit or ask your health care professional for guidance on how to quit. Smoking makes pain worse. Studies, especially for low back pain, have consistently shown that patients who smoke have a much poorer prognosis, regardless of the treatment offered, than nonsmokers and that smoking can affect the healing of injured discs. Also, there is some evidence from pharmacological studies that smoking interferes with the absorption and blood level of various medications, including analgesics.

If you have attempted to treat your pain or tried to make lifestyle changes and these approaches didn't relieve your pain or it became worse, you should seek help from a health care professional. Pain is a message that something is wrong, so don't wait more than a few days or a week to make an appointment. In fact, delaying an evaluation and treatment can make many acute pain problems worse.

In 2001, The Joint Commission developed new standards for the assessment and management of pain in hospitals and other health care settings. The American Pain Society has endorsed these standards, which affect all patients in hospitals, nursing homes and clinics. Health care facilities must:

* Recognize the right of patients to appropriate assessment and management of pain.

* Screen ffor the existence and assess the nature and intensity of pain in all patients.

* Record the results of the assessment in a way that facilitates regular reassessment and follow-up.

* Determine and ensure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff.

* Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications.

* Educate patients and their families about effective pain management.

* Address patient needs for symptom management in the discharge planning process.

* Maintain a pain control performance improvement plan.


Since pain is a complicated combination of emotional, chemical and physical components, treating and managing it often requires several approaches. Over- the-counter (OTC) or prescription medications, physical therapy, lifestyle changes, including quitting smoking, and learning coping skills may all be recommended.

Other treatments include ice, meditation, self-hypnosis, acupuncture, chiropractic, electrical stimulation, trigger point injections, nerve blocks, epidural steroid placement, spinal cord stimulators and intrathecal pumps, which deliver small doses of pain-relieving medication directly to the pain receptors in the spinal cords, blocking the message to the brain.

There are many types of pain medications, both prescription and OTC remedies, to help you manage your pain.

OTC remedies include:

* Acetaminophen and most nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are pain-relief medications available without a prescription. Tylenol, which contains acetaminophen, reduces pain and fever and is usually safe to use with other medications if necessary, although caution should be used when taking with alcohol because of potential for serious liver damage. (Always check with your health care professional if you are taking other medications.)

Ibuprofen (such as Motrin and Advil) and naproxen sodium (such as Aleve) are examples of nonprescription NSAIDs that help reduce aches and pains. However, NSAIDs can cause stomach irritation and affect kidney function. Plus, there is the potential for cardiovascular events associated with the use of NSAIDS. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs, and these medications are associated with serious gastrointestinal problems, including ulcers, bleeding and perforation. NSAIDs should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind. Higher-strength forms of ibuprofen (and other NSAIDS) are available by prescription. Aspirin, available as a generic and in brands including Bayer, Bufferin and Ecotrin, is also an NSAID but is used primarily for relieving short-term pain.

Prescription pain medications include:

* NSAIDs such as Naprosyn, Nalfon and Trilisate, which are useful for moderate to severe pain.

* Narcotic analgesics (opioids or opiates), a wide-range of medications that are typically used for acute pain after an injury or surgery.

* Narcotic-like medications, such as tramadol (Ultram)

* Antidepressants, medications used to treat depression, which also affect pain pathways in the brain.

* The COX-2 specific inhibitor (cyclooxygenase inhibitor) celecoxib (Celebrex), a type of NSAID.

* Topical pain relief agents applied directly to the skin, some available without a prescription.


Narcotics, such as morphine, also are used to treat cancer pain and other types of moderate to severe pain. Most people who take narcotics as prescribed by their health care professional for pain do not get high or become addicted to these drugs. Their bodies may become adapted to the narcotic, however, so they experience withdrawal if the narcotics are stopped abruptly.

Narcotic analgesics may be taken orally, by injection (intramuscularly), through a vein (intravenously) or by rectal suppository. There also are other methods of giving pain medicines for more continuous pain relief. Not all narcotics are available in each of these forms.

* codeine, most commonly prescribed with acetaminophen as Tylenol 3

* fentanyl (Sublimaze, Duragesic)

* hydromorphone (Dilaudid)

* methadone (Dolophine)

* oxycodone (OxyContin, Percocet)

* oxymorphone (Opana)

* morphine (Avinza, Kadian, MS Contin)

OxyContin, a form of oxycodone, was approved in 1996 for the treatment of moderate to severe pain associated with musculoskeletal conditions, and by 2001 it became the most frequently prescribed brand name narcotic medication for treating moderate to severe pain in the United States. The narcotic has come under intense scrutiny by the U.S. Food and Drug Administration (FDA) and the U.S. Drug Enforcement Agency due to widespread abuse. Abusers can bypass the time-release aspect of the drug by crushing, chewing, snorting or shooting OxyContin pills to get a quick morphine-like high. The abuse of OxyContin is associated with serious consequences including addiction, overdose and death. Therefore, the FDA requires the manufacturer of OxyContin to include the agency's highest level of safety warning on the label. The FDA has also collaborated with the manufacturer to develop and implement a risk management plan to help detect and prevent abuse and diversion of OxyContin. In addition, an abuse-deterrent form of OxyContin called Remoxy is currently awaiting FDA approval.

Because of potential adverse effects, many pain physicians now avoid prescribing two drugs once commonly used for pain relief: propoxyphene (Darvon) and meperidine (Demerol).


Antidepressants affect pain by changing the levels of neurotransmitters (brain chemicals) and altering the pain messages reaching the brain. When a woman is depressed and also in pain, these medications can both reduce pain and improve mood. The tricyclic antidepressants help to restore the body's normal perception of pain and may be recommended as a treatment option even when a patient is not depressed. Drugs that stimulate the feel-good brain chemicals serotonin and norepinephrine, such as duloxetine (Cymbalta), have been shown to improve both mood and pain.

Nonsteroidal anti-inflammatory drugs (NSAIDS)

Nonsteroidal anti-inflammatory drugs (NSAIDS) help reduce inflammation by lowering the release of prostaglandins. Prostaglandins are chemicals produced in the body that lead to pain, inflammation and fever.

A prescription medication in the class of NSAIDS is the COX-2 specific inhibitor (cyclooxygenase inhibitor) celecoxib (Celebrex). Celebrex is indicated for the relief of symptoms caused by arthritis, such as inflammation, swelling, stiffness and joint pain and other types of acute pain. It is designed to cause fewer gastrointestinal side effects (such as ulcers and bleeding) than other types of NSAIDs.

Celebrex can increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex, visit

Combination Drugs

Some medications used for pain are actually combinations of acetaminophen and an opioid, such as Vicodin (acetaminophen and hydrocodone), Ultracet (acetaminophen and tramadol) or Percocet (oxycodone and acetaminophen). Others may combine an acetaminophen with a relaxant (for example, Fioricet, which is a combination of acetaminophen, butalbital and caffeine).

Topical agents

These increasingly popular pain-relief products are applied to the surface of the skin. Some are prescription while others can be purchased over the counter. Examples include: capsaicin and lidocaine.

Alternative approaches

Some alternative or holistic pain management approaches include:

* Acupressure: The stimulation of healing sites (as in acupuncture) with finger pressure, rather than fine needles.

* Acupuncture: An ancient Chinese health practice that involves therapeutic insertion of thin, solid (generally metallic) needles in specific points along your nerve pathways, called acupuncture points. While Western researchers are not sure how acupuncture works to ease pain (and some doubt that it does work), several theories suggest that acupuncture may stimulate the release of endorphins, the body's natural pain relievers.

* Biofeedback: A technique used to gain control over a function that is normally automatic (such as blood pressure or pulse rate); the function is monitored, and relaxation techniques are used to change it to a desired level. Biofeedback uses electronic or electromechanical instruments to monitor, measure, process and feedback information about blood pressure, muscle tension, heart rate, brain waves and other physiologic functions.

* Chiropractic: A health care approach designed to improve the body's structure through adjustments to the spine and other parts of the body. The ultimate goal of chiropractic is to support the body's natural ability to heal itself.

* Cranial sacral therapy: This hands-on treatment involves gentle massage or manipulation of all bones of the skull (including the face and mouth), vertebral column, sacrum, coccyx and pelvis to ease restrictions to physiological motion. It's an osteopathic method that uses gentle massage to increase the flow of cerebrospinal fluids.

* Electrical stimulation, or transcutaneous electrical nerve stimulation (TENS): This therapy involves attaching a small transmitter to the skin around a painful area and emitting electrical impulses that block pain signals, giving you a tingling feeling rather than pain. It may work by stimulating the release of endorphins.

* Homeopathy: A natural, noninvasive system of medical treatment based on the theory that substances that cause certain symptoms in a healthy person can-in diluted amounts-cure those symptoms in an unhealthy person. The logic is that the similar substances promote healing by stimulating your body's natural healing mechanisms.

* Hydrotherapy: Also called hydropathy and aquatic therapy, hydrotherapy literally means using water in the treatment of disease. Using water for pain management typically involves hot and cold compresses, tub soaks, warm mud baths and other similar types of spa therapy to relieve pain and decrease swelling. Aquatic therapy is a form of rehabilitation that uses a heated therapeutic pool for exercising without stress on the joints. It does this by relieving the pull of gravity.

* Hypnosis: A technique that induces a deeply relaxed and focused state of mind- a form of intense receptive concentration. While often used to modify behavior, hypnosis also helps reduce pain and may speed healing.

* Massage: Massage involves rubbing or kneading muscles and other areas of the body to stimulate blood circulation, relieve pain and promote a sense of well- being.

* Meditation: A process to increase concentration and awareness and create a more relaxed state.

* Osteopathic medicine: This discipline focuses on the unity of all body parts, with special consideration to the musculoskeletal system. It recognizes the body's ability to heal itself and stresses preventive medicine, eating properly and keeping fit.

* Reflexology: This technique is based on the belief that pressure applied to specific points on the extremities benefits other parts of the body. Massage of the hands or feet is typically used.

* Supplements: There are a number of supplements that have shown some pain- relieving properties, such as fish oil, capsaicin and glucosamine. Research on these supplements is mixed. If you would like to try a supplement to aid in pain relief, be sure to discuss it with your health care professional first.

These approaches may be used as alternatives to medication or in conjunction with them.

Lifestyle approaches

Lifestyle changes may be necessary to help you relieve your pain.

* Exercise helps:

* relieve pain

* increase muscle mass, which reduces stress on joints

* promote weight loss, which also reduces stress on joints

* reduce stress, which aids in pain relief

* A healthier diet may:

* reduce swelling in joints and lead to better circulation

* lower cholesterol levels and blood pressure.

* assist in pain relief by providing a healthier body upon which medications can work

* minimize inflammation

While exercise and modifying your diet and eating habits may be difficult lifestyle changes, they may the most important steps you can take to manage your pain.

Always consult your health care professional before beginning a new diet or exercise program, especially if you are experiencing pain. Your health care professional may advise you not to exercise at all. However, if he or she recommends exercise, you should know that it might make your pain feel worse when you start. You may be afraid to exercise because of this increased pain. One strategy for managing this pain is to begin exercising slowly and gradually increase your activity.

Remember that there are many types of exercise available, and your health care provider can help you decide what is best for you. For example, jogging and other weight-bearing forms of aerobic exercise may not be appropriate for people with certain types of pain, but swimming or water aerobics can provide gentler aerobic exercise. A whole-body stretching program or a yoga program designed for people with arthritis may be just what you need.

When to Consider Using a Pain Clinic

You might consider visiting a pain clinic if your pain does not go away after medical treatment within the expected timeframe provided by your practitioner. Persistent nociceptive or neuropathic pain, in addition to causing physical suffering, alters a person's ability to function, which, without intervention, may lead to depression.

Pain clinics specialize in the prevention, evaluation, diagnosis and treatment of painful disorders. Treatment may include prescribing medication, physical and rehabilitative services, teaching and performing pain-relieving procedures such as massage and meditation, and counseling patients and their families.

Just as physicians differ by specialty, so do pain clinics. Some offer residential programs, where you stay at the facility. Others have outpatient programs. Generally, programs include a team of health care professionals from the disciplines of psychology, medicine, nursing, physiotherapy, occupational therapy, pharmacy and vocational counseling.

Most pain clinics will review your medical records and perform a medical evaluation, which includes a complete medical history, a physical examination and possibly medical testing, such as x-rays, if appropriate.

To treat your pain symptoms, choose a pain center that:

* offers a wide range of treatments; massage, acupuncture and other options should be considered along with conventional therapies because a variety of choices offer better chances of successful pain relief.

* has health care professionals who are specialists in pain management and pain medicine. They should be Diplomates of the American Board of Pain Medicine or members of the American Pain Society or International Association for the Study of Pain.

* is staffed by caring, qualified people. If possible, get a list of references from the pain clinic of former or current patients. If possible, interview some of the staff-either in person or by phone

* includes physical therapy and exercise programs.

* is conveniently located.

* is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is a private, not-for-profit organization that accredits programs and services in adult day services, behavioral health, employment and community services and medical rehabilitation.

A list of pain specialists who are Diplomates of the American Board of Pain Medicine is available from the American Board of Pain Medicine:

Common Pain-Causing Conditions

Women who feel they can do nothing to relieve their discomfort are more likely to be disabled by their pain and make more trips to a health care professional than those who believe they have some measure of control. Their lives may spiral to a point where daily routines revolve around their bed, the health care professional's office and the pharmacy.

Here are some typical health conditions that cause pain, along with some treatment options. Consultation with a health care professional is recommended for persistent nociceptive and neuropathic pain that doesn't subside.

Back Pain

The majority of back pain is muscular, caused by sprains, spasms and muscle imbalance. However, many women experience back pain during or before menstruation or during pregnancy.

Although it can be nagging (and even debilitating), most back pain clears up on its own. It can be eased or treated by modifying activity, using moist heat such as hot showers and doing exercises that strengthen the abdominal muscles to provide more support for the back.

Other keys to back pain relief include:

* using over-the-counter (OTC) medications such as ibuprofen, acetaminophen or aspirin for mild or moderate symptoms

* applying a cold pack five to 10 minutes at a time within 24 hours after back symptoms start or using a heating pad or hot shower if symptoms last longer

* wearing comfortable, low-heeled shoes

* using a chair with lower back support and working at a comfortable height

* keeping objects close to your body when lifting

* exercising to keep your muscles flexible and strong

* controlling your weight

* avoiding prolonged sitting in cars, at desks, and in front of computers or televisions

If you experience numbness in your hands and feet, or if the pain worsens or doesn't respond to OTC pain relievers, consult a health care professional.

Knee pain

If you are athletic, you may be more prone to certain types of acute or chronic injuries that cause pain, especially in the knee. Anterior cruciate ligament (ACL) injuries, for example, are common in women who play sports that involve stops and starts and quick turns, such as basketball, skiing, soccer and tennis. Both a sedentary lifestyle and a vigorous exercise program can aggravate weakened knees.

Managing knee or ligament pain is often the same as the treatment for relieving back pain:

* use OTC medications such as ibuprofen, acetaminophen or aspirin for mild or moderate symptoms

* use ice to reduce swelling

* rest

* avoid squatting and kneeling

* wear comfortable, low-heeled shoes

If pain shoots down your leg or is associated with numbness, weakness or tingling, see a health care professional.


Muscle tension, stress, anxiety, sinus infections and allergies can cause headaches. Certain foods, weather changes, hormonal cycles and emotions can also cause headaches. Although headaches can't always be prevented, there are things you can do to reduce their frequency, including:

* sleeping and waking up at regular times

* not skipping meals

* maintaining a healthy lifestyle that includes eating a balanced diet and exercising

Over-the-counter analgesic medications, like acetaminophen, ibuprofen or aspirin, can help relieve occasional headache pain. OTC pain-relief medications generally are safe when taken as directed, but if you drink alcohol or have specific medical conditions, be sure to tell your health care professional when discussing how to manage your headache pain.

If you want an alternative to medication, relaxation techniques, such as biofeedback, can be useful alternatives to drugs for both preventing and relieving headaches.

Biofeedback is a learned skill and, with practice, it can help you relax deeply when pain increases. Biofeedback may be used to relax muscles, restore circulation and redirect attention from the source of pain.

Occasional headaches are examples of acute pain-they generally don't debilitate you. These types of headaches may be caused by lack of caffeine (if you generally use a lot of caffeine-containing products and for some reason decrease your intake), tension or unknown sources. These headaches typically respond to OTC medication and stress reduction.


Migraines are more than headaches-they can be completely disabling. Lasting from hours to days, they may be accompanied by such symptoms as throbbing pain, nausea and visual symptoms, such as flashing lights, zigzag lines or partial loss of vision. Sensitivity to sound and smells can be another symptom experienced by migraine sufferers.

Migraines plague nearly 30 million Americans, and they affect women three times as often as men. Migraines are a biologically based disorder. Symptoms are the result of changes in brain chemistry.

There are many types of migraines including: hemiplegic migraines, in which patients suffer temporary paralysis on one side of the body; ophthalmoplegic migraines, which cause pain around the eyes and are associated with a droopy eyelid, double vision and other sight problems; basilar artery migraines, which include vertigo, double vision and poor muscular coordination; menstrual migraines, which are caused by fluctuating hormone levels; and several others.

When discussing your migraines with your health care professional, ask these questions about your migraines and getting treatment for them:

* What can I reasonably expect from treatment?

* What drug and non-drug treatments do you recommend?

* Will I have to be on medication indefinitely?

* What are the possible triggers of my migraines?

* Could my migraines be a symptom of other illnesses? If so, what are they?

* Will they get worse or better as I get older?

* How can I alter my diet or lifestyle to reduce my migraines?

Infrequent migraines-occurring once or twice a month-are usually treated with a fast-acting, acute-type medication that responds to the headache once it has developed. This type of medication relieves head pain, nausea and sensitivity to bright light or sound.

Women who have migraines more frequently need a different strategy; a preventive medication is often recommended. If you have frequent headaches-two or more times a month-a daily medication aimed at preventing the migraine may be recommended. Migraine-specific analgesics, as well as antidepressants, which adjust serotonin levels, are often prescribed. Some people experience fewer migraines after taking magnesium sulfate supplements, but the research on the use of them for migraines is inconclusive. Heart medications such as beta blockers and calcium channel blockers are commonly used for migraine relief. Sometimes seizure-controlling medications may be used to minimize migraine occurrences. The exact reason these drugs work is unclear. Your health care professional can advise you.

Triptans are one of the most commonly used classes of drugs for migraines. These drugs act on the artery-constricting chemical serotonin. Another drug that provides relief of migraine symptoms is ergotamine, a drug that constricts blood vessels, helping to counteract the painful blood dilation stage of the headache. For optimal benefit, the drug is taken during the early stages of an attack.

Other drugs used to prevent migraine include:

* propranolol (Inderal), which stops blood vessel dilation

* antidepressants, such as amitriptyline, a tricyclic antidepressant

* cyproheptadine, which counteracts serotonin (usually used in children)

If you experience a headache unlike anything you've ever had or if you get a "thunderclap" headache that starts and becomes extremely intense within a few seconds or minutes, get medical attention immediately. You should also see a health care professional if there's a change in the character of a headache or if you experience new headache symptoms.

It is also common to have "rebound" headaches. These occur in people who have daily headaches and who take prescription medications such as medicines to treat migraines or opiates, or OTC medications such as aspirin and acetaminophen, regularly because they seem to provide relief. (NSAIDs like Celebrex, ibuprofen and naproxen are considered low risk for the development of rebound headache.) In actuality, this constant cycle of medication is causing the next headache. Frequently, stopping all medications for about two weeks or gradually reducing the dose until you're taking the drug no more than twice a week gets rid of rebound headaches. To prevent future rebound headaches, you should take medications only as prescribed and avoid taking any medication more than two days per week. If this doesn't relieve the headache, see a headache specialist.


Arthritis, one of the more prevalent chronic health problems, affects more women than men, according to the Arthritis Foundation. The term arthritis comprises more than 100 diseases that affect the joints, causing pain, loss of movement and sometimes swelling.

Two types of arthritis are osteoarthritis and rheumatoid arthritis.


Osteoarthritis is the most common form of arthritis. It is the source of pain for nearly 27 million Americans. According to the Arthritis Foundation, osteoarthritis is more common in men up to age 55; after age 55, it is more common in women. The main symptom is stiffness and achiness in the joints, especially first thing in the morning or after using a joint for a long time. The hips, knees, back and fingers (especially closest to the tip) are the joints most likely affected.

Osteoarthritis usually begins in women between the ages of 45 and 60 and develops slowly over a year or more. Most commonly, osteoarthritis begins in joints on one side of the body and affects only some joints. Unlike other forms of arthritis, it doesn't cause inflammation or nausea.

Other risk factors include a family history of osteoarthritis, being overweight, joint injury or overuse and inactivity, which causes joints to lose flexibility and weakens supporting muscles.

Treatment options for osteoarthritis include OTC acetaminophen and NSAIDs, the prescription Cox-2 inhibitor Celebrex, topical creams such as capsaicin, use of hot and cold, lidocaine patches, exercise, weight loss, and in extreme cases, joint replacement surgery. Acetaminophen is less likely than aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to irritate your stomach, and acetaminophen causes fewer negative drug interactions than NSAIDs, a consideration for older women who may take a variety of medications. However, long-term use of acetaminophen may be associated with liver damage or inflammation of the kidneys (nephritis). It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.

In terms of exercise, be sure to avoid high-impact activities, such as jogging; instead, try walking, swimming and biking. Walking is especially good, because it helps keep bones strong. Don't forget to stretch, to keep joints flexible.

Losing weight can make a significant difference in pain caused by osteoarthritis. Excess body weight stresses joints, making osteoarthritis pain worse.

Joint replacement surgery is recommended only for severe, disabling osteoarthritis that interferes with your ability to carry out ordinary activities, such as dressing, bathing or climbing stairs.

Rheumatoid Arthritis

An estimated 2 million Americans have rheumatoid arthritis, and most of them are women; in fact, women are two to three times more likely to have the disease as men. Rheumatoid arthritis generally affects women in their 40s and 50s, but can strike women in their 20s and even children. It is an autoimmune disease, a disease in which the immune system attacks healthy tissues. Lupus, arthritis, scleroderma, Sjogren's syndrome and insulin-dependent diabetes are examples of autoimmune diseases. Rheumatoid arthritis is characterized by the inflammation of the membrane lining of the joint, called the synovium. Inflammatory cells release enzymes that may digest bone and cartilage.

Many people confuse osteoarthritis and rheumatoid arthritis. Although both are more common in women than in men, osteoarthritis may appear as early as age 40 but usually does not develop until age 55 or 60. Osteoarthritis only affects joints and not internal organs. Rheumatoid arthritis-the second most common form of arthritis-affects other parts of the body in attacking the joints. It generally begins earlier than osteoarthritis and causes inflammation.

Pain and swelling usually start in your hands and feet but also can affect your ankles, hips, knees, shoulders and elbows. With rheumatoid arthritis, pain generally develops suddenly, within weeks or months, and affects the same joints on both sides of the body. Your joints will be inflamed, and you may feel fatigued, feverish and nauseous. You also may develop bumps on affected joints called rheumatoid nodules.

If you have these symptoms, see your health care professional. A diagnosis can be made based on your symptoms, your medical history, a physical examination and a few lab tests and x-rays. One test will examine whether you have rheumatoid factor, an antibody found in the blood of many adults with rheumatoid arthritis. About 70 to 80 percent of people with rheumatoid factor have rheumatoid arthritis.

Because of the differences between rheumatoid arthritis and osteoarthritis, you need to be as descriptive as possible when explaining your symptoms to your health care professional.

* Is the pain a burning sensation or cramping?

* Does sitting too long make it worse?

* Is there swelling?

* Does the pain radiate? Does it start in one place and spread or "radiate" to another place?

* Is it accompanied by fatigue?

Common treatments for rheumatoid arthritis include NSAIDs, the COX-2 inhibitor Celebrex, aspirin and analgesics to reduce pain, swelling and stiffness. Etanercept (Enbrel) and infliximab (Remicade) were approved in the late 1990s to treat rheumatoid arthritis; both medications are believed to stop the progression of rheumatoid arthritis. Methotrexate (Rheumatrex, Trexall), a type of medication from a class of drugs known as disease modifying anti-rheumatic drugs (DMARDs) was commonly used for treating rheumatoid arthritis before the development of newer drugs and still is an option. Other DMARDs are also prescribed for the disease, as well as corticosteroids. And other medications, including some chemotherapy drugs, used in much lower doses than for treating other diseases, also may be prescribed. Talk to your health care professional about which medication would best suit your needs.

Rest, exercise and physical therapy also should be part of your pain management plan. Surgery, while available, is only advised in extreme cases.


Fibromyalgia syndrome is a pain-processing disorder of the central nervous system that causes mild to severe pain throughout the body. It does not affect joints. Fibromyalgia, which results in pain in the muscles, ligaments and tendons, is especially confusing and often misunderstood. Its symptoms are common to many other conditions.

Aching or burning pain and fatigue are the most common and prominent fibromyalgia symptoms. Pain usually comes in the form of tender points on the body where pain is the greatest. Many fibromyalgia sufferers have trouble sleeping, which leads to fatigue. Other symptoms include decreased attention span, abdominal pain, gas, nausea, headaches, depression and increased sensitivity to noise, odors and light. Feelings of numbness and tingling in hands, arms, feet and face and diarrhea are also common.

The cause of fibromyalgia is unknown, but recent evidence suggests that it is associated with abnormalities in the central nervous system processing of pain. Fibromyalgia patients develop an increased response to painful stimuli and experience pain from non-painful stimuli such as touch. This is thought to reflect enhanced pain processing that is characteristic of central pain sensitization. Patients with fibromyalgia have been found to have elevated levels of substance P in their spinal fluid, a chemical that helps transmit pain signals from the brain. Scientists are investigating how the brain and spinal cord process pain and how substance P and other neurotransmitters fit into the process. Recent studies have found that fibromyalgia runs in families, suggesting a genetic predisposition to the disorder.

If you have had pain in multiple areas of your body for more than three months, tenderness at specific locations on your body and fatigue, talk to your health care provider about the possibility of fibromyalgia.

Although currently there is no cure for fibromyalgia, often the pain can be effectively controlled with a combination of treatments including:

* antidepressants and muscle relaxants to relax muscles and improve mood and sleep

* exercise to reduce pain and fatigue and strengthen muscles

* relaxation techniques and massage to ease muscle tension

Cancer Pain

Pain, in general, is undertreated. Nowhere is this fact more significant than in cancer pain management. There are many causes of cancer pain. Bone pain is one of the most common. Tumors pressing on nerves also can cause pain, as can treatments such as chemotherapy, radiation and surgery.

Cancer patients have become a model for the medical management of pain. Pain management for patients with cancer has shown that using a variety of analgesics, especially opioids-narcotics such as morphine that dull the senses and relieve pain-can be given continuously without addiction becoming a major concern. If you take opioids for pain, you may need increasing doses over time. Narcotics must be discontinued slowly because people who have used them for long periods can experience withdrawal symptoms if the medication is stopped abruptly.

Nonprescription Pain-Relief Primer

With all the types of nonprescription pain relievers available today, it's hard to know which is best for which ailment. Pain relievers fall into the four categories described below. Remember to follow directions on the label as well as your health care professional's recommendation. If symptoms worsen, contact your health care professional.
1. Acetaminophen

Products:      Tylenol/Extra Strength Tylenol and generic and
               store-brand acetaminophen products

Usage(s):      Headache, body aches, backache, fever, menstrual cramps,

Adult Dosage:  Follow label directions, and do not exceed 1,000
               milligrams per dose or 4,000 milligrams per day. If you
               are treating a child, read the package carefully and use
               a pediatric form of the medication if possible.

Warnings:      Like aspirin, acetaminophen can cause liver damage in
               heavy drinkers.

Notes:         As effective as aspirin in relieving mild-to-moderate
               pain and in reducing fever, but less so when it comes
               to soft-tissue injuries such as sprains. Acetaminophen
               doesn't bring better or faster relief than aspirin, but
               it's gentler on the stomach and reduces fever without
               the risk of Reye's syndrome. It is also the only OTC
               pain reliever considered safe for use in pregnancy.

2. Aspirin

Products:      Anacin, Bayer and generic and store-brand aspirin

Usage(s):      Headaches, fever, muscle strains, minor arthritis pain

Adult Dosage:  Follow label directions.

Warnings:      Aspirin should not be taken by people who have ulcers,
               asthma, uncontrolled high blood pressure, liver or
               kidney disease, bleeding disorders or who are taking
               anticoagulant medication or any other anti-inflammatory
               medication (unless cleared by your doctor). Heavy
               drinkers, children (with chickenpox or flu) and pregnant
               women in the third trimester should also avoid aspirin.

Notes:         Buffered or coated formulas may take twice as long to
               work but are easier on the stomach. Some aspirin
               contains caffeine (the equivalent of one cup of coffee
               per two 325-mg tablets).

3. Ibuprofen

Products:      Advil, Nuprin, Motrin and generic and store-brand
               ibuprofen products

Usage(s):      Menstrual cramps, toothaches, minor arthritis, minor
               pain associated with headache and colds, muscle aches
               and injuries that cause tissue inflammation

Adult Dosage:  Follow label directions and do not exceed 800
               milligrams per dose or 3,200 milligrams per day (four
               maximum doses). Do not give this medication to a child
               without the advice of a doctor.

Warnings:      Same as those for aspirin. In addition, ibuprofen can
               increase your risk of life-threatening heart or
               circulation problems, including heart attack or stroke.
               This risk will increase the longer you use ibuprofen.
               Seek immediate medical attention if you experience any
               symptoms of heart or circulation problems, such as
               chest pain, weakness, shortness of breath, slurred
               speech, or problems with vision or balance.

Notes:         Somewhat gentler on the stomach than aspirin. Ibuprofen
               is a nonsteroidal anti-inflammatory drug (NSAID), used
               to reduce inflammation (swelling), pain and fever.

4. Naproxen Sodium

Products:      Aleve, Anaprox, Naprosyn, Naprelan and generic and
               store-brand naproxen sodium products

Usage(s):      Same as for ibuprofen

Adult Dosage:  Dosages differ based on the type of naproxen sodium
               taken; read label directions carefully for dosage
               information and daily limits.

Warnings:      Same as for aspirin.

Notes:         Same as for ibuprofen. Also, naproxen may cause
               vision problems; if you experience changes in your
               vision, inform your health care professional.


McNeil Consumer Health Care, Tylenol,

American Pain Foundation, 1-888-615-PAIN,

"Approval of Napraxon," Food and Drug Administration News, at


Communicating with your health care professional about your pain symptoms is vital to maintaining a healthy lifestyle. Ask questions about your condition, including side effects for both short-term and long-term medication use. Ask about all your pain management options-medical and nonmedical alternatives. Whenever possible, try to avoid activities that may cause pain or injury, or that worsen already existing pain symptoms.

Facts to Know

* Pain is the body's way of sending a warning to the brain that something is wrong.

* Both emotions and chemicals alter the amount of endorphins, the body's natural pain relievers, which block the relay of pain messages to the brain.

* Medications, lifestyle changes, positive emotions and holistic therapies can all help manage pain.

* Women are more likely than men to suffer from certain conditions that cause neuropathic pain, including migraine headaches, osteoarthritis, fibromyalgia and rheumatoid arthritis.

* Using narcotics for pain relief, under the supervision of a medical professional, will usually not lead to addiction.

* Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) work to relieve pain but can cause stomach irritation. As with other pain medications, your body adjusts to NSAIDs, so you may have to take increasingly higher doses to get the same effects. NSAIDs are not effective after a maximum dose is reached.

Questions to Ask

Review the following Questions to Ask about pain management so you're prepared to discuss this important health issue with your health care professional.

* What may be causing my pain symptoms?

* Can my pain be successfully treated? What should I expect?

* How long will my pain and treatment last?

* What medications will I need to take and are there any side effects from these medications?

* How might they affect the medications I am currently taking?

* Is the condition that is causing my pain hereditary?

* Is there anything else besides taking medication that I can do to help relieve my pain?

* What should I do if additional pain, symptoms or problems occur?

* Will my pain get worse with age?

* Do my symptoms, illness or progress need to be monitored in any way?

Key Q&A

* My sister and I both have back problems. But her back pain knocks her off her feet, and she stays in bed for a few days. Mine isn't quite so bad. Why is that?

Pain is a highly subjective experience. No two people feel pain the same way, whether they are related or not. Your pain threshold might be greater than your sister's. Or your sister's back pain might be more serious than your pain. Either way, both of you are having pain, and both of you should be treating it. Talk to your health care professional about the best ways to relieve your pain.

* What are the best pain relievers to use?

The best medicinal pain reliever to use should be determined based on your symptoms. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin are all over-the-counter remedies and should be helpful in managing aches and pains. However, make sure you don't take more than the recommended dose in the suggested time period. Too much medication could cause harmful stomach pain or liver or kidney problems, depending on the medication. Lifestyle changes including exercise and a healthier diet might also serve as indirect pain relievers.

* I have horrible headaches that sometimes even prevent me from seeing. Aspirin doesn't seem to help. Is there anything I can do?

Yes. You may suffer from migraines. These headaches are especially painful and require specialized treatment. An accurate diagnosis is key to treating migraines. Discuss your symptoms with a health care professional. Before you go for an appointment, take note of possible headache triggers, such as specific smells, noises, foods or emotional stressors, so that you can discuss these triggers with your health care professional. Remember: try to describe your pain and symptoms in as much detail as possible.

* My health care professional has told me to exercise to relieve my pain. But I don't like to exercise. Besides, exercising is sometimes painful. What am I supposed to do?

You don't have to run at a break-neck speed, do high-impact aerobics or power lifting to exercise. Exercise comes in many forms-walking, chasing your children around the house and housework are all considered exercise. After all, toting laundry up and down stairs is work. And if your exercise is painful, you're doing the wrong kind of exercise. First of all, don't overdo it. Pick an activity you like to do and try to do it every day, even if it is walking around your block. Try to do it once a day. Build from there. Also, be sure to consult with your health care professional before beginning any new program.

* I'm afraid of taking too many pain relievers and getting hooked on them.

Some prescription drugs can lead to addiction and other health problems if they are overused or not used according to a health care professional's instructions. If you suspect you are addicted to a prescription drug, ask yourself the following questions:

* Are there times I can't remember what happened because I was taking drugs?

* Does my personality change when I take the drug(s)?

* Have I ever changed health care professionals to get a prescription filled?

* Do I take the drug to get high?

* Do I take the drug even when I have not had any pain?

Talk to a health care professional about getting help if you answered "yes" to any of the above questions.

* I've been trying to quit smoking for months now. Smoking seems to make my pain worse. Could this be true?

Yes. Smoking makes pain worse. Studies, especially for low back pain, have consistently shown that patients who smoke have a much poorer prognosis, regardless of the treatment offered, than nonsmokers. Also, there is some evidence from pharmacological studies that smoking interferes with the absorption and blood level of various medications, including analgesics. If you can't quit smoking on your own, ask your health care professional for guidance and for information about different approaches to quitting that might be more successful for you.

Organizations and Support

For information and support on Pain Management, please see the recommended organizations, books and Spanish-language resources listed below.


American Academy of Orthopaedic Surgeons (AAOS)


Address: 6300 North River Road

Rosemont, IL 60018

Phone: 847-823-7186

American Chronic Pain Association


Address: P.O. Box 850

Rocklin, CA 95677

Hotline: 1-800-533-3231


American Council for Headache Education


Address: 19 Mantua Rd.

Mt. Royal, NJ 08061

Phone: 1-800-255-2243


American Occupational Therapy Association


Address: 4720 Montgomery Lane

P.O. Box 31220

Bethesda, MD 20824

Hotline: 1-800-377-8555

Phone: 301-652-2682

American Pain Foundation


Address: 201 N. Charles Street, Suite 710

Baltimore, MD 21201

Hotline: 1-888-615-PAIN (1-888-615-7246)


American Pain Society


Address: 4700 West Lake Ave.

Glenview, IL 60025

Phone: 847-375-4715


American Physical Therapy Association (APTA)


Address: 1111 N. Fairfax Street

Alexandria, VA 22314

Hotline: 1-800-999-APTA (1-800-999-2782)

Phone: 703-684-APTA (703-684-2782)

Association for Behavioral and Cognitive Therapies (ABCT)


Address: 305 7th Avenue, 16th Floor

New York, NY 10001

Phone: 212-647-1890

Bone and Joint Decade


Address: 6300 North River Road

Rosemont, IL 60018

Phone: 847-384-4010


National Headache Foundation


Address: 820 N. Orleans, Suite 217

Chicago, IL 60610

Hotline: 1-888-NHF-5552 (1-888-643-5552)


National Institute of Neurological Disorders and Stroke


Address: NIH Neurological Institute

P.O. Box 5801

Bethesda, MD 20824

Hotline: 1-800-352-9424

Phone: 301-496-5751

National Pain Foundation


Address: 300 E Hampden Avenue, Suite 100

Englewood, CO 80113

Spondylitis Association of America


Address: P.O. Box 5872

Sherman Oaks, CA 91413

Hotline: 1-800-777-8189

Phone: 818-981-1616


Texas Back Institute


Address: 3600 W. 7th Street

Fort Worth, TX 76107

Hotline: 1-800-247-BACK (1-800-247-2225)

Trigeminal Neuralgia Association


Address: 925 Northwest 56th Terrace, Suite C

Gainesville, FL 32605

Hotline: 1-800-923-3608

Phone: 352-331-7009



Acupuncture: Everything You Ever Wanted to Know, but Were Afraid to Ask

by Gary F. Fleischman and Charles Stein

Basics of Acupuncture

by Gabriel Stux, Brian Berman, Bruce Pomeranz, and P. Kofen

A Life Larger Than Pain

by Erv Hinds

Back Pain Helpbook

by James Moore, RN Kate Lorig, Michael Von Korff, M.P.H. Virginia Gonzalez and

Diana Laurent

The Back Pain Sourcebook

by Stephanie Levin-Gervasi and James F., M.D. Zucherman

Break Through Pain: A Step-by-Step Mindfulness Meditation Program for

Transforming Chronic and Acute Pain

by Shinzen Young

Mayo Clinic on Chronic Pain

by David Swanson

Pain Cure: The Proven Medical Program that Helps End Your Chronic Pain

by Dharma Singh Khalsa and Cameron Stauth

Pain Free: A Revolutionary Method for Stopping Chronic Pain

by Pete Egoscue and Roger Gittines

The RealAge Makeover: Take Years Off Your Looks and Add Them to Your Life

by Michael F. Roizen

Women and Pain: Why It Hurts and What You Can Do

by Mark Young

Yoga for Pain Relief: Simple Practices to Calm Your Mind & Heal Your Chroni c


by Kelly McGonigal and Timothy McCall

Spanish-language Resources

Medline Plus: Pain Relievers


Address: Customer Service

8600 Rockville Pike

Bethesda, MD 20894


American Chronic Pain Association



Address: The ACPA

P.O. Box 850

Rocklin, CA 95677

Hotline: 1-800-533-3231


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