Chronic Pain

Chronic-Pain Management -- A Timely Opportunity

G. Davis Kloeffler, DDS, and Parker E. Mahan, DDS

Copyright 2001 Journal of the California Dental Association.

During the past decade, there has been an intense debate among pain management specialists in medicine over the appropriate use of medication. This controversy centers around pain control and appropriate narcotic dosage. Dentistry’s role in treating chronic pain has become complex because of differing views on pain management protocols. The dental literature regarding chronic-pain management is limited, and dentistry has only a minimal role in pain management. It is time for dentistry to take a larger role in treating chronic pain. The effective use of medications is only one aspect of chronic-pain management. The success rate for managing intractable pain can be substantially improved if practitioners take advantage of early diagnosis, aggressive physiotherapy, and multiple sympathetic blocks, as well as other blocks and antidepressants. For dentists to take an active role in this arena, they need broader education in treatment regimens. Interdependence with physicians and cross-referral between these two professions may lead to more-favorable outcomes, including improved function and quality of life.

The dental profession has become extremely effective in managing most forms of acute orofacial pain, but orofacial pain of a chronic pathologic nature is more problematic. To diagnose and manage such pain disorders effectively, the clinician must have a solid understanding of the processes underlying these disorders.¹ Since pain is a subjective rather than objective experience, its character varies considerably among patients, making it one of the most difficult problems dentists and physicians face in everyday practice.

The Pain Experience

The history of the dental profession illustrates dentists’ involvement in pain management. From the time that Horace Wells discovered the application of nitrous oxide as an anesthetic until the present, dentists have worked long and hard to diminish or eliminate patient pain.²

The pain experience consists of a number of elements: a noxious stimulus, neuropeptide modulation, and the patient’s emotional state. Dentists have been taught a primitive, unimodal pain-perception model. An example is a person burning his or her finger on a stove. There are nerve pathways that run from the finger to the brain, initiating the pain experience and a noxious flexion reflex. This is a simplified way of looking at pain. It is now understood that there are many factors that modulate neural transmission. Pain has a complex and circuitous path.³ The sensation of pain is triggered by signals from nerve endings at the injury site (nociceptors) that are then processed in a feedback loop between the spinal cord and the brain. For example, there are nerve endings in the finger that send pain signals up to "control centers" in the spinal cord, where they are processed before the messages are relayed to the brain. Pain-inhibiting signals are now recognized as well. The brain evaluates the importance of the information coming from the spinal cord and sends back signals causing the spinal cord to mute the body’s response to the pain.⁴ This process of evaluation continues as long as the pain persists. The spinal cord acts as a kind of arbiter of signals coming from the injury site and the brain.

Acute Pain

Following Crue’s classification of pain (based on the temporal factor of pain duration),⁵ acute pain can be considered the first classification of pain in dentistry. Acute pain is the most common form and is a simple somatic defense of a transient nature. By and large, acute pain is benign. It is typically associated with an injury or disease of rapid onset and produces sometimes severe symptoms over a short time.⁶ Pain of several days’ duration may start as an acute abscess, for example. A dentist’s primary job with regard to pain is to look for the noxious stimulus, i.e., the pathology, and eliminate it. With the techniques now available, that can usually be done efficiently and readily. A dentist can identify the tooth causing the pain, take a periapical film, find the abscess, and perform a root canal treatment or extraction or provide an antibiotic treatment; and the pain will be managed. Treatment focuses on eliminating the cause of the pain.

Subacute Pain

Subacute pain is pain that lasts a little longer, but less than two weeks, for which the patient does not or cannot immediately see a dentist. An example would be a fulminating cellulitis. The patient may think the pain will go away, so he or she lets it linger before finally having to make an emergency appointment. The basis of these pain complaints is the same as for acute pain. Again, dentists are experts at diagnosing and managing this type of pain.

Chronic Pain

For many years, chronic pain was defined as pain that has lasted more than six months. This definition is no longer correct. Pain becomes chronic in nature when it continues beyond the expected duration of the initiating pathology.⁷ Pain patients can become chronic-pain patients two months after onset. Chronic pain begins as acute pain that was not successfully treated.

Chronic pain is often triggered by acute events, such as surgery or traumatic injury. However, chronic pain is perpetuated by factors beyond the triggering event, including pathologic changes in the nervous system in response to the original trauma.⁸ The basis for the pain is not clearly understood, and multiple contributing factors are often considered. Chronic pain need not be miserable nor intractable. Older people often wake up with chronic aches and pains. However, when chronic pain becomes complicated, it becomes hard to control. It can adversely stimulate multiple areas of the nervous system.

Because of misconceptions about chemical dependency and addiction, dentists may be under- or overmedicating their pain patients. Dentists who treat chronic head, neck, and facial pain disorders need to understand and appreciate the difference between the addicted and the dependent chronic-pain patient. Nociceptive pain and neuropathic pain are separated by a neuroplasticity in the central nervous system that accompanies persistent pain. Pain disorders that have a constant input are more likely to develop symptoms of chronicity. Chronic or persistent pain is related to neuropathic pain resulting from central nervous system and peripheral nerve dysfunction.

The preceding observations do not indicate a lack of interest or concern by dentists because they have been well-trained in anesthesia and pain management for dental and surgical procedures. The pain management problems may begin when the clinical examination reveals no reason for the pain condition. These pains can be confusing since they arise from the neural structures themselves and may reveal no somatic tissue changes.

Neuropeptide modulation of pain is a very active field of research. There are new types of medications that affect the metabolism of these patients and can reduce pain. The emotional and psychological state of the patient becomes increasingly important as the pain becomes more and more chronic.

Many of these patients respond to tricyclic antidepressants. The one most frequently used and studied is Elavil (amitriptyline).⁹ The therapeutic window for analgesia with Elavil is from 10 mg to 75 mg per day. Frequently, patients from physicians’ offices will be taking from 150 mg to 200 mg of amitriptyline a day for depression. They will have already lost the analgesic potency because they have gone beyond the therapeutic window.

Patients taking more than 75 mg per day lose the analgesic potency, and it frequently takes approximately 21 days before they experience the antidepressant effect. Elavil does not affect acute pain.^10-12 Elavil also does not affect certain chronic pain states such as degenerative arthritis.

With regard to the use of antidepressants and other drugs to treat pain, it is extremely important that the clinician be prepared to recognize and effectively deal with toxicity, drug sensitivity, drug interactions, drug dependency, side effects, and possible complications.^4,10 There is a potential for a serious adverse outcome if tricyclic antidepressants are combined with other drugs, especially in patients with a history of cardiac disease.¹² Ultram (tramadol) is another example of an antidepressant used for pain. It should be used with caution and in reduced dosage when administered to patients receiving central nervous system depressants such as alcohol, opioids, anesthetic agents, phenothiazines, tranquilizers, or sedative hypnotics.¹³

The prescribing doctor should know about the potentiation, synergism, dependence, and possibility of addiction of other medications. When more than one drug is administered, drug interactions can lead to unexpected and serious adverse effects. Responsibilities for the adverse effects rest on the prescribing doctors, and they cannot be ignored.^14,15

Articles about the inadequate use of narcotics and synthetic narcotics in chronic-pain patients are beginning to appear in the lay literature.¹⁶ The day may not be far off when a general dentist or oral surgeon will be sued for pain and suffering for refusing to write a prescription for enough narcotics or synthetic narcotics. Although most pain specialists now endorse the use of long-term opioid therapy for selected patients with chronic nonmalignant pain, this issue remains controversial and will not be adequately resolved without a clear understanding of the risks associated with addiction.^17,18 Dentists and physicians may become fearful of the Drug Enforcement Administration and be reluctant to write a prescription for a narcotic, even though it may be indicated.¹⁹

Chronic pain is distinctly different and more complex than acute pain and has no time limit. Chronic pain often has an insidious onset and serves no useful purpose. It may trigger multiple psychological problems. Feelings of helplessness and hopelessness can create an urge to do almost anything to stop pain and make some drug-dependent patients behave like addicts. Others are driven into seeking repeated operations, and many may submit to the mercies of anyone promising a cure.⁷

Pain patients can become depressed, disabled, or dependent on the pain regardless of the event that initiated the pain problem.²⁰ For example, patients who have had TMJ surgery that did not relieve their pain typically have complex pain and may have had more than one or two bilateral TMJ surgeries. These chronic-pain patients are characterized by preoccupation with pain, loneliness, passivity, lack of insight, and inability to take care of their own needs.⁷ As indicated previously, they may become polysurgical addicts and may come to the dental office and simply want to be fixed. Often they will not accept any responsibility for their therapy.

Some of these patients may even be suicidal. It is essential for the health care practitioner to recognize a patient’s depressed mood because extreme depression is the most common cause of suicide.²¹ Such patients may not be able manage the real or imagined stresses of life. Qualified mental health professionals may need to enter into the treatment process. The suicidal patient may be intent on either dying or trying to control treatment. The No. 1 indicator of serious suicidal ideation is a previous attempt. In these cases, the mental state may be worse than the pain. Eighty percent of successful suicide victims have made a previous attempt.

The Chemically Addicted Pain Patient

Loss of control is a major characteristic of all addictions; it is also a major characteristic of chronic-pain syndrome.

Addictionists have found that the patient needs to take back command and responsibility. Coming to terms with addictive disease is difficult for patients who face the cultural legacy of the stigma that addiction is a failure of will and moral character. It is challenging to take on a new paradigm.²²

Some patients with chronic pain are able to cope with this continuous and unpleasant perception and live productive lives.²³ Severely debilitated chronic-pain patients often need narcotic medication to manage their pain. Doctors who are aware of the addiction potential of their patients are hesitant to prescribe narcotics or psychotropic drugs, and this creates a dilemma for doctors who treat pain patients.

As a result of the phenomenon of conditioning and the advent of new medications, there are some notable changes in the way prescriptions should be written. Okeson¹⁴ said, "Narcotics are best administered on a regular time schedule rather than as needed (PRN) to minimize unnecessary periods that may require increased dosage with attendant overmedication and increased toxicity." Narcotic prescriptions should be written on a temporal rather than as-needed basis. For example, in the past, a prescription might be written for 30 mg codeine and 300 mg of acetaminophen with two tablets to be taken immediately and then one tablet every four hours as needed for pain. The patient would then wait until the pain returned before taking the next tablet and thus gets a reward because he or she took the medication. This cycle would tend to condition the patient to take medication. It is better to write the prescription on a temporal basis and tell the patient to take two tablets immediately and write down the time of day. Then, when the pain returns, the patient should write down the time and note how much time has elapsed since the first dose. The patient should then take the third tablet immediately. If it has been five hours, the patient should take the next tablet in four hours. After three days, the patient should wait until the pain begins again to take the next dose. The pain problem may resolve on the second or third day. This procedure is less likely to condition a patient to take narcotic medication.

It is, therefore, extremely important for the dentist to understand the problem of addiction. Dentists must understand that tolerance and dependence will develop in almost all patients given repeated doses of opioids to relieve pain. However, dependency should not be confused with addiction. Addictive behavior is characterized by preoccupation with drug use, loss of control, euphoria, and deterioration of values. The acquisition of drugs becomes more important than harmonious relationships, integrity, or interpersonal responsibility.

When prescribing medications, the dentist should watch for tolerance, physical dependence, and/or addiction, which involves psychological dependence. Tolerance means that larger doses are required to obtain a satisfactory analgesic effect. Physical dependency means that withdrawal symptoms accompany abstinence. Addiction means the patient has developed a compulsive craving for the drug and the need to use it for effects other than pain relief.

One subset of the chronic chemically dependent pain population are individuals who manifest a physical dependence and meet the diagnostic criteria for both an addictive disorder and a pain disorder. The addiction typically includes use of prescription medication -- such as opioids, steroids, and sedative/hypnotics -- but can also include over-the-counter aids, commonly used street drugs such as marijuana and amphetamines, and alcohol. Chemically addicted chronic-pain patients medicate not only the physical pain but also any psychological discomfort that magnifies the pain experience. The addictive use of pain-relieving medication increases drug tolerance and lowers pain thresholds.¹⁴ Such a patient may be dangerous to him- or herself and people in the medical-dental community. He or she may be in a self-defeating, destructive, cyclical pattern, leading to personal despair, occupational impairment, with frustration and anger developing within both the patient and the dentist. After once receiving medications for dental pain, these patients may then demand the next medication. If they do not receive it, they may threaten violence. This can happen in the doctor’s office or the pharmacy.

In cases involving addiction, it is necessary to clearly assess and treat the underlying pain. However, the addictive disorder should be treated concurrently. Referral to an addictionist for the concurrent management of addiction and pain is highly advisable. Addictive disease is a chronic relapsing condition, as pain often is. These conditions may be disabling even in the absence of clear physical impairment. Both chronic-pain patients and individuals with addictive diseases often are exceptionally challenging to the doctor, and both types of patients have difficulty finding compassionate and effective dental care. To be successful in the treatment of both conditions requires a cooperative role on the part of these patients. It is well for the physicians and dentists treating these patients to remember that 12-step Alcoholics Anonymous and Narcotics Anonymous model programs have been effectively used in the treatment of chemically dependent pain patients.

Conclusion

Since medical specialists often feel unqualified to diagnose and treat head, neck, and facial pain complaints, more and more chronic-pain patients are referred to facial pain centers, TMD centers, or dentists who deal with TMD and orofacial pain patients.

If, indeed, head, neck and facial pain represent a large portion of the total chronic pain problem, then dentistry has an opportunity to help control pain complaints. This opportunity in pain management in the dental office should stimulate dental schools and all dental educators to provide advanced education in the newer concepts in pain management.

If dental practitioners go to the heart of the problem and focus their efforts on providing pain relief for chronic-pain patients, they can avoid political discourse and specialty narcissism. They can do this by training their own members about chronic-pain treatment as well as chemical dependency and addiction. In this way, dentists will increase their knowledge base and their ability to provide effective, compassionate care for chronic-pain patients.

Finally, there seems to be a new interdependence between physicians and dentists regarding chronic pain. This cross-referral between professions may lead to more-positive outcomes in chronic-pain management.

Authors

G. Davis Kloeffler, DDS, is an assistant professor in the Department of Advanced Education in Prosthodontics at the Loma Linda University School of Dentistry. He is a past chairman of the Maxillofacial Prosthodontic Department at the University of California at Los Angeles. He is a fellow of the American and International Colleges of Dentists. His private practice in San Diego is limited to craniofacial pain and temporomandibular disorders.

Parker E. Mahan, DDS, taught at Emory University School of Dentistry for 16 years and at the University of Florida College of Dentistry for 21 years. For many years, Maham served as director of the Dental Occlusion and Facial Pain Center at the University of Florida. In 1992, the Pain Center was renamed the Parker E. Mahan Facial Pain Center in his honor.

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To request a printed copy of this article, please contact/G. Davis Kloeffler, DDS, 10715 Tierrasanta Blvd., Suite F, San Diego, CA 92124 or at kloeffler@juno.com.