EMS World

JUL 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 43 of 51

EMSWORLD.com | JULY 2018 43 pain is non-cancer pain that lasts more than 3–6 months or longer than would be expected for an injur y to heal. It's usu- ally not documentable by tests or physi- cal findings but is quite real and can be debilitating. Chronic pain may begin with an injur y and persist after healing, or it may devel- op without a clear cause. Sy mptoms such as fatigue, sleeplessness, reduced appetite, and mood changes may accom- pany and exacerbate it. Genetic s and env ironm ent may contribute. Suf fer- ers can become frustrated, angr y, and depressed. It is, at its hear t, a chronic illness, not unlike diabetes, asthma, or hypertension, and requires similar long- term management. What it doesn't necessarily require is an endlessly increasing spiral of addic- tive painkillers. "What we've done for so long is tried to give people opioids for chronic pain, and this has really been a flat-out disas- ter," Bobrow told Phoenix radio station KJZZ in Januar y; "Opioids for chronic pain was more…a marketing mar vel than it was a medical mar vel," added Cynthia Townsend, director of the Chronic Pain Rehabilitation Center at the Mayo Clinic's Arizona campus. "And opioids [are] the only medication where, when someone reports worsening symptoms and declin- ing functioning, the response has been to increase the dose." 2 When tissue is injured it releases ara- chidonic acid. As this is metabolized it p ro du ce s eicos an oids su ch a s p ros- taglandins and leukotrienes, signaling molecules that are par t of the body's inflammator y and immune responses. They also stimulate pain. Pain medications work by inhibiting this process at various points. NSAIDs impede the enz y mes that trig ger the arachidonic cascade. Opioids attach to ner ve cell receptors in the brain, spinal cord, and elsewhere and block pain mes- sages from the body to the brain. With chronic pain those signals can remain active af ter or without an inju- r y. This is a ssociated with substantial changes to the brain's structure and neu- rochemical composition. These chang- es may cause the brain to "oversense" routine, nonthreatening ner ve signals as threats. 3 Besides pain this can lead to muscle tension, mobility limitations, and low energy/motivation—but the key point is that chronic pain can literally alter the brain. "We know now from functional MRI studies that when people have chronic, long-la sting pain, the ac tual func tion and s truc ture of the brain change s ," says Bobrow. "Certain parts of the brain become more active, other parts become less active. And par ts of the brain that are involved with emotions, the limbic system, actually become a lot more over- active. And the other things we see are neurochemical changes: different levels of neurotransmitters like serotonin and norepinephrine and dopamine, and these are the same neurotransmitters that are associated with, for example, depression. So a lot of the same changes in the brain that are seen when people have depres- sion and anxiety are seen when people have chronic pain." What's more, even emotional trauma can rewire the brain, which is par ticu- THE OPIOID CRISIS • 37% of adults live with knee, shoulder, or hip pain that adversely affects their daily lives. • 16% of adults experience regular headaches. • As many as 40% of patients with migraine headaches also experience depression. • 28% of adults live with lower back pain, and 15% have chronic neck pain. • Between 20%–35% of children have some form of chronic pain. • Suicides among people suffering from chronic pain increased from 4,000 in 1999 to 13,800 in 2006. Chronic Pain in the U.S.

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