Should I be taking painkillers?

Pain is such a difficult topic and in all of the people that I have asked, no-one is really able to give any clear answers. I have written some other blogs on pain itself. In this blog, I wanted to explore the topic of when to take painkillers. It is the question that I have asked every single medical practitioner that I have come into contact with and not really got any consistent or clear answer.

So here is my summary.

Pain as the protector

Pain is there for a reason – it is there to protect our tissues from damaging actions. So taking painkillers in order to be able to ‘push through’ and walk/sit/stand or even do more energetic actions is likely to be a bad thing. The physiotherapists generally seem to sign-up to the ‘listen to your body’ school of understanding the pain signal.

When we are trying to release the tension in over-active, tight muscles with stretches/releases, there are some tricks like using the contract/relax form of stretching that uses the inverse stretch reflex, or activating the antagonist muscle during the stretch to use reciprocal inhibition to enable the muscle to ‘turn-off’ and stretch.  But if the releases and exercises (to activate the under-active muscles) hurt such that you have trouble adhering to the physiotherapy regime, then the GPs seem often to recommend taking enough painkillers to get through these in order to support recovery.

Pain as the problem

When pain stops you sleeping and leaves you in a permanent state of stress (racing heart-rate, perspiring etc), then this is clearly a problem for your body as well as coping with life. For the body to have any chance of healing, it needs the parasympathetic nervous system activated (the one that goes with calm and balance), not the sympathetic nervous system (the fight-or-flight system). Therefore, if you are not sleeping or not reaching a state of calm, then it would seem necessary to take enough painkillers to manage this situation. Certainly the osteopaths and chiropractors seem to subscribe to this view of management – ideally without synthetic drugs, but definitely calming the system and getting it out of the hyper-vigilant or over-alert state that it can get into. Homeopaths will also suggest treatments that can help here.

Which is fuzzier – pain or painkillers?

A lot of painkillers seem to leave you feeling mentally very fuzzy and unable to focus and concentrate, but pain can also leave you feeling like the world is a long way away down a dark tunnel. So you need to find the type and dosage of painkillers (or none) that give you the best effect physically and mentally. Obviously, painkillers are more effective if you take them over a period, so taking them as the pain comes on, rather than when it is totally unmanageable will help – which I know is sometimes easier said than done.

Drugs are not the only solution

Research that shows that pain is worse when we are low and lonely, less active or less busy and feeling less good about ourselves. For some great explanation of the science behind pain check out these brilliant and simple explanations of understanding and managing pain at  https://www.retrainpain.org/

There are also all sorts of mental and physical techniques that you can try and see what works for you and your situation. There is no simple solution that works for everyone.

But what about the question of if/when to take painkillers?

You need to find what works for you. But I think that the principle of listening to and understanding your pain, and then recognising what you need to give your body in order to manage the pain and the recovery is really important. Painkillers may have to be a part of this, especially in the early stages, but the quicker you can get to other, more sustainable, solutions the better it is likely to be for your body.

I hope that you get out of pain soon. I know just how exhausting and enervating it is.

How do musculoskeletal injuries heal?

Following my blog on how the body heals from invasive surgery (http://www.injuredathlete.co.uk/how-do-you-heal-after-invasive-surgery/) , I thought that it would be useful to do the same for musculoskeletal issues, since these are common injuries for athletes. This is a really huge topic, and I have struggled to get down the most relevant parts into something that I think may be useful for injured athletes and coaches to understand what questions they will ask of the medical team treating them. I have not covered musculoskeletal diseases such as osteoarthritis, carpal tunnel syndrome, tendonitis etc (many of which qualify as a disability under Social Security, if the symptoms reach a certain level of severity), as these are much more complex and long-lasting.

The challenge of most of musculoskeletal injuries is that they generally involve tendons (which connect bones to muscles), ligaments (which connect bone to bone) and/or cartilage (the soft, gel-like tissue that provides cushioning and enables movement in joints). The white colour of these tissue types give a clue to the fact that they do not have their own blood supply. This means that they heal much more slowly than damaged skin or muscles (which have their own blood supply). The surgical view is that they do not regenerate and this is why often surgery is offered – mending torn tendons and ligaments and replacing ruptured ones.

You need to play an active role in healing musculoskeletal injuries

Whilst the fundamental phases of healing are the same as a cut or muscle tear, there are a couple of key differences that you need to act on:

  1. the pain signals through the healing phases are very different and you need to actively manage your way through this – at times managing the pain to protect the healing of the correct Range of Movement for your body. It seems counter-intuitive not to listen to the pain in your body, but this is the reason.
  2. you do need to actively rehabilitate the area through each of the 3 stages, as it is unlikely to heal correctly without your active focus and support: initially using the ‘POLICE’ protocol (see below) and then with range of movement for that joint and then specific strengthening of that area. When you are in a lot of pain, the constant health professional exhortations of ‘keep moving’ may not seem to be very helpful, but this is the reason why.
  3. this is a long-term game, and you can expect to need to focus on this for a period of 12 to 24 months. But for those who stay the course and do the right things, the results do come.

Stage 1 of musculoskeletal healing – Inflammation.

The swelling and redness may be hidden inside the joint, but the symptoms will be such that no time day or night is pain-free and you may be able to detect the heat coming from the joint, as well as the tenderness, pain and loss of range of movement. If rest or a change of position gives relief, then the healing has progressed to the repair stage. The inflammation stage generally lasts 3-5 days, but can last a lot longer and if you re-injure or re-inflame the same area, then you go back into this stage.

The point of this stage for the body is protecting the area with swelling whilst it lays the foundations for the healing – clearing out the damaged cells and starting to spin webs of protective tissue that bind the wound together and stop the flow of liquids through the area.

This is the stage that you really need to apply the ‘POLICE’ protocol. This has replaced the old ‘RICE’ protocol (see the table below). So that in the past, the recommendation was Rest, get an Ice pack on the area, use Compression and Elevate the limb. All of these are designed to reduce the inflammation and allow the body to get through this first stage. Interestingly, anti-inflammatory medications do reduce the inflammation, but interfere with the body’s natural management of inflammation – so as soon as you are out of the immediate pain it is best to stop taking these in order to encourage the cellular-level healing process to begin.

The new ‘POLICE’ protocol reflects the fact that the latest medical studies suggest that some movement is good, even at these early stages. So ‘Protect ‘the joint from the bad motion that has caused the injury (eg twisting), with support, splinting or bracing as needed. Then work to get ‘Optimum Loading’ – moving the joint through the range of movement in every-day activities, but not causing additional pain. This is why we see increasing numbers of people in protective boots and slings, instead of full plaster-casts. The view on ‘Icing’ has also developed – and the guidance is that you should not apply it for longer than 10 minutes and more than 3 times per day (as too much icing can also damage the tissues).

P = Protect
OL = Optimum Loading
R = Rest
I = Ice I = Ice
C = Compression C = Compression
E = Elevation E = Elevation

Stage 2 of musculoskeletal healing – Repair or Proliferation.

During this stage the body develops the new tissue, initially haphazardly and then starting to align these cells correctly. This stage usually starts from a week after the injury and lasts 6-12 weeks or longer. Pain usually comes and goes, according to the position or movement of the body. If pain or fear of pain inhibits movement in this stage, then the pattern with which the scar tissue is laid down can inhibit movement significantly and reduce your body’s ability to function. Failure to stretch and move at this time will lead to weak, but tight muscles that are intermittently painful and vulnerable to re-injury. Therefore you really need to consistently (and gently) put the body through a normal range of movement and the unhelpful cross-fibres will be broken and the useful fibres that support the usual range of movement will be strengthened.  If this repair stage does not lead to correct healing, the danger is that the body will start to develop workarounds and compensating movements, which can lead to aches and injuries elsewhere as the body moves into the third stage of healing with the wrong fundamental structure in the injury area.

Stage 3 of musculoskeletal healing – Remodelling or Maturation.

In this stage the tissues build their flexibility and strength, and this lasts at least 6 months and can be two years or more. Even now, you may get some pain with certain movements (especially when you take the movement to the end-zones of the Range of Movement – which you do need to do), or you may be pain-free. This is why usually from around 4-12 weeks after injury (depending on the injury: follow your surgeon’s or physio’s advice), you should be adding in some strength-based training – starting very gently and slowly building up to 3 sets of 10 repetitions (working to failure), with a day or two of rest between sessions for the body to recover and rebuild (in line with the progressive overload model of development) and obviously backing off if the level of pain increases.

If you do not keep rehabbing the area, there is a very strong probability of significantly reinjuring it because it is so far below strength. This is very challenging, as it is usually just one or two exercises that you need to do over and over again, gently progressing them. And before you have done this, it may well be too premature to go back to a repetitive loading activity like running, or even cycling. Many people do not have the patience to do this progressive strengthening over the period of 12-24 months that it takes, and this is one of the reasons why re-injury is common. Even with the correct rehab, the area often stays 20% weaker than before the injury.  Hence you will need to keep looking at your form to check that there are not compensation behaviours that will cause other injuries, and look at your activities to check that you are giving it the protection that it needs.

Why pain makes this all so much harder

The challenge for many people in chronic pain* is that the correct level of managing the inflammation, mobilising the joint to get the range of movement and strength building across the 3 phases is hard to do. The pain makes them avoid exercise and stretching required for correct healing. At times the level of incorrect healing in stage 2 can need significant manipulation (even under general anaesthetic) to break up the adhesion and re-stimulate inflammation. You then effectively start back at phase 1 of healing, and need to ensure that stretching (for Range of Movement) and exercise (to stimulate the limited blood supply to the area) then begin the process of rehabilitation.

As well as medications, guided corticosteroid injections into the area are common and can bring very significant short-term relief. You need to make the decision on these with your Orthopaedic Consultant. The only anecdote that I would pass on is one where an athlete had a number of injections into the tendon over a 2-year period, and the tendon did rupture. One of the questions was whether the perforations from the multiple injections had played a role.

* The definition of chronic pain varies, but it is long-term pain and most seem to define it as having lasted for over 3 months or over 6 months. I think that the key definition is having been in pain for that length of time, you get to the stage where you adapt your physical, mental and emotional approaches to life (whether consciously or unconsciously) as a consequence of the pain. As well as these external impacts on your life, the internal impacts of your body swimming in the chemicals associated with inflammation and the nerve pain patterns can also have significant impacts on your healing.

The other side of the opioids crisis

Following Andrew Gregory’s article in the Sunday Times on 24th February 2019:

https://www.thetimes.co.uk/article/britains-opioid-crisis-we-are-sleepwalking-towards-carnage-in-our-communities-7tjlzzq7x

And the British Medical Journal’s research that shows that between a third and a half of all UK adults live with chronic pain (defined as pain lasting more than 3 months), with a trend towards increasing prevalence with increasing age from 14% in 18–25 years old, to 62% in the over 75 age group. Hence the proportion of people suffering can be expected to increase, in line with an ageing population.

https://bmjopen.bmj.com/content/6/6/e010364.full

These made me feel the need to write to Andrew – and here is the text from my email:

Dear Andrew –

I felt the need to write to you after your articles on the opioid epidemic that you suggest is hitting the UK, as it has hit the USA. I agree with your concerns. But I think that the other half of the story is one that needs to be told too – our societies are simply are not managing chronic pain and the unintended consequences of not managing this are showing at the moment in opioids, but will move somewhere else if the solution is simply to cut down prescriptions. A friend who is a member of the Police Department in one of the northern states of the USA talks of the significant increase in the number of suicides that he now attends where people killed themselves because they could not find relief from the pain when they were no longer prescribed the painkillers.

Perhaps there is a follow-up feature with case studies of those in chronic pain who could be jeopardised by culling prescriptions and some case studies of the equally sad stories of those whose chronic pain was not addressed (which had outcomes equally, or perhaps even more sad than those featured in this week’s Sunday Times). The goal has to be for a real look at the challenges and potential solutions to this multi-faceted problem – as hopefully my comments below lay out.

My own experience is that I had an accident 15 months ago and have been in debilitating pain. I went from someone who was a keen marathon runner and representing Great Britain for my age group for Triathlon at World and European level to someone whimpering in pain, whilst lying on the floor. I freely admit that in my whole life what I thought was pain was really a little discomfort – for instance, taking ibuprofen for an ear infection, or massaging sore muscles after a marathon. And that is what is hard about pain – you can only know once you have experienced the jagged, searing, burning pains that make you think that your body will die of them (and sometimes lead to extended shuddering of the muscles, an inability to breathe properly and a racing heart-rate that implies that you are running a 10K race flat-out) and then when you realise that your body is not going to die of them, you  wonder if you would prefer that it did – as any quality of thought, life or enjoyment is out of the question. To those who simplistically suggest lighting an aromatherapy candle and practising breathing and mindfulness exercises, they are not talking of the pain that I talk of.

And so painkillers are what give you hope – after lying, shuddering for 16 hours on a bed in A&E counting up to 30 over and over and over, with a perspiration outline around you on the bed and then being told that it will be 5 weeks before you can see a spinal surgeon, it is painkillers that eke you through the sleepless hours, days and weeks to get to that appointment.

Or after surgeries, as you lie alone whilst the world merrily carries on and you try to get through just one hour at a time – sometimes not knowing whether that hour is a daytime hour or a night-time hour. Having sat with others in chronic pain, I know that people turn to alcohol and illegal drugs to escape their personal prison of agony. And sadly some people take their own lives as the ultimate escape. Taking away painkillers will only increase these other unofficial solutions. 

Through all of this the GP is the frontline. In the British medical system they are the lead contact who coordinates the rest of the treatment). The challenge is that with the pressure on the medical system, the waiting times for appointments are very long (even when you are in chronic pain) and the ageing population means that there are more people suffering. So what is the alternate option for the GP to prescribing painkillers? Who will take up the slack in the system to address the gap?

It is fair to say that the current approach with painkillers for chronic pain is a blunt tool. But if that tool is confiscated, what takes its place?

25th February 2019