Chronic Pain

Chronic pain is that which lasts beyond the normal time required for healing following tissue trauma or that associated with a pathological condition that does not heal. Examples include low back pain, fibromyalgia syndrome, phantom limb pain and arthritis.

Chronic pain is an extensive problem that contributes on a large scale to disability in the industrialized world and represents an untold amount of suffering. At least 50 million Americans have some form of persisting or recurring pain. Bonica (1990) summarized his extensive review of the epidemiology of chronic pain as follows, "... more than a third of the American population has chronic painful conditions, and of these, 50 - 60% are partially or totally disabled for periods of days (e.g., recurrent headaches), weeks (e.g., reflex sympathetic dystrophies, myofascial syndromes), months (e.g., low back pain), and some permanently (e.g., arthritis) ... I have estimated that as a result of chronic pain, in excess of 400 million days of work were lost in 1986. This, together with the cost for health care, compensation, litigation, and quackery, totaled $79 billion for that year." Clearly, chronic pain is a large scale medical and and social problem.

The dominant medical model assumes that the presence of pain signals tissue damage or pathological process. Strictly interpreted, this model holds that the severity of an individual's pain is in proportion to the extent of the tissue trauma. In fact, the cause of pain is unknown for most of the common types of chronic pain such as low back pain. Competing (and anachronistic) psychological models hold, that when pain complaint exists in the absence of a definable organic cause, the pain is an expression of unconscious psychological conflict, personal distress or an attempt to achieve secondary gain. Neither of these approaches serves patients well -- they simply do not lead to either pain relief or rehabilitation.

The best solution for most chronic pain problems lies with recognition of the multi-factorial nature of chronic pain, an abandonment of the implicit mind-body dichotomy (if there's no evident organic cause, the problem must be psychological), and an appreciation of the fact that pain impacts and engages not only the physiology of the patient, but also the psychosocial self. Moreover, it is essential to recognize that patients are not passive entities in the processes of disability, healing and rehabilitation -- they are ultimately the masters of their own rehabilitation. Often pain relief and rehabilitation are less what medicine bestows upon a patient than what the patient achieves for him- or herself with the skilled guidance of compassionate health care providers.

Acute Low Back Problems in Adults, Clinical Practice Guideline, Agency for Health Care Policy and Research, 1994

Bonica, JJ The Management of Pain, (2nd Ed), Philadelphia: Lea and Febiger, 1990.