Pain Management Service

The word “chronic” means “persistent” or “long-term”. Many people take the word to mean “severe”, but this is not necessarily the case. However, many people who attend our service would describe their pain as both persistent and severe. The pain conditions that we see in our clinics often have a major impact on the lives of our patients.

Often we associate pain with injuries or illnesses.  We expect the injury or illness to heal and the pain to subside.  However, sometimes pain can continue after the healing has taken place – as if the pain has stayed ‘switched on’.  In some cases it is hard to identify any injury or illness that has triggered the pain.
In order to understand how this happens, we need to think about pain differently.  We need to think of pain as the end result of a complex array of different factors.  The nervous system is particularly involved in our pain response – imagine the nervous system as a sensor system that is constantly monitoring the state of our body and its environment.  It serves a protective mechanism by warning us (via pain) if it perceives a potential threat (note that this may be a potential threat rather than any actual damage).  It drives our behaviour, making us act differently in response to pain (eg limping if our leg hurts).  But the nervous system does not act in isolation.  It interacts with other systems in the body such as the immune, the emotional system and the muscular system.  And in certain circumstances, the combined effect of all these systems working together is to produce pain.

So pain is all about the body’s response to what is happening.  Now we can start to see why there is often very little correlation between the level of tissue injury and the level of pain.  It also helps us understand why sometimes we can have very severe pain but X-Rays, MRI scans and other investigations cannot find any structural cause.

We can also start to understand how stress, changes in mood and changes in our environment can alter the nervous system’s responses and therefore the levels of pain we feel.  This is not to say that the pain is ‘psychological’ – but that stress and mood can feed into the pain experience, just as our pain will sometimes impact on our mood.
 

Physiotherapy in chronic pain management aims to help improve fitness, flexibility, endurance and general activity. 

Most people living with chronic pain find activity levels are reduced and that even very modest amounts of activity can flare pain up for hours or even days. Out of frustration it is quite common for people to fight through the pain in a spirit of ‘I won’t give in’ or ‘I won’t let it beat me’. Unfortunately this strategy often causes more frequent flare ups and an escalation of pain over time by winding up the pain nerves. This strategy often leaves people feeling out of control as the pain can vary so much from day to day or even hour to hour. This is often referred to as boom/busting.

Physiotherapy can help guide you through a more effective strategy by pacing activity and planning tasks to reduce flare ups and calm the pain nerves over time. Physiotherapy can help you find a suitable starting point to exercise and advice on how to gradually increase activity over time.

Chronic pain tends to make people move awkwardly or avoid movements that hurt. It is very understandable that if a particular movement such as bending caused the onset of your pain or flares it up that you would avoid it. Over time these can become fixed habits which put more stress on other parts of the body and can make the area of pain more vulnerable to flare ups. Movement is good for our bodies but often people living with chronic pain find ‘conventional’ physiotherapy exercises has made their pain worse. Physiotherapists specialising in chronic pain can analyse the way you move and guide you through gentle specific exercises to help your unique problems. The aim is to restore more natural movement which can help reduce flare ups and even reduce pain longer term.

What is Pain Psychology?
There are biological, psychological, emotional and social factors involved with persistent pain and this is why adopting a biopsychosocial understanding and model for persistent pain is so important to understanding and managing persistent pain. 

Living with pain can bring about wide ranging changes in and individuals’ life. Living with ongoing pain can cause feelings such as anger, hopelessness, sadness and anxiety. To treat pain effectively, it is important to address the physical, emotional and psychological aspects.

The psychological and emotional impact of living with ongoing pain can be very challenging to manage and sometimes distressing to cope with. In spite of this, people can and do build rich and fulfilling lives in spite of pain. 

How can a Clinical Psychologist help me with persistent pain?
A psychologist’s role is to assist individuals who are experiencing difficulties associated with their pain. They specialise in helping people cope with the effects of chronic pain and the distress that can accompany this. Sometimes this will require a person to accept that nothing further can be done medically for their pain and that it can be more valuable to focus on learning how to best manage their pain and build the best life possible. For example, the psychologist can help you to learn how best to live with and accept those things that may be beyond your control. 

Our clinical psychologists have specialist training and skills in pain management and are members of the health professional council and follow guidelines by their professional body (British Psychology Society).

Psychological approaches and treatments for persistent pain
Research has shown the psychological treatments such as Cognitive Behavioral and Acceptance and Mindfulness-Based Therapies are beneficial an effective for persistent pain. These treatments are recognized integral to pain management services (BPS, NICE and APA). It is important to acknowledge that that there a different psychological approaches and treatments for pain and that not all treatments can work the same way for everyone. 

What does the Clinical Psychologist Provide in a Pain Service?
The Clinical Psychologists within the service use a range of psychological therapies to help people with pain to adjust, adapt and build skills to help cope with managing pain. They provide specialist psychological assessment and therapeutic treatments that include Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Mindfulness, Compassion Focused Training and Motivation Interviewing.

We work closely alongside the other members of the team such as the pain nurse specialist, physiotherapist, occupational therapist and medical pain consultants. This multidisciplinary and interdisciplinary way of working is integral to providing pain management and supporting individuals with pain and their families.

What the Pain Psychologists does not provide

• Crisis Management – the psychologist will consultant and liaise with the appropriate professionals and can refer to services that would best support you in a crisis.  
• They do not prescribe medications.
• They do not provide high intensity, frequent and open-ended sessions.
• They do not provide therapy for mental health difficulties or counselling for non-pain related difficulties. 
   

Medication is one of a number of strategies that may help with your pain, however it is unlikely that medication alone will treat or cure your chronic pain. Some medication may reduce the intensity or the frequency of chronic pain but do not completely abolish it. This means that they may “turn the volume of pain down” and should be part of a wider Pain Management Plan, your personal Pain Management “Toolkit”.

Each medication works differently for each person and may result in some side effects and sometimes longer-term risks which must also be considered when deciding to take them.  Sometimes they help, others may have no benefit or simply cannot be tolerated. If they help to a small degree, this effect may also be short lived. It’s unlikely that medication will reduce the pain as much as we would all ideally like. 

What medication should I take?
As there are different types of pain there are also different types of medication, which work in a variety of ways. Selecting the most appropriate medication requires an understanding of the characteristics of your pain, meaning what type of pain it is, how intense it is, how often you have it and for how long. It is also important to know what has worked in the past and what has not. Some medications are organized in specific groups according to their properties and how they work. For example we tend to use neuropathic medication to treat neuropathic pain, also known as “nerve pain”.  If this is the case we may recommend a trial of an anti-neuropathic drug which requires titration to an effective dose, whilst still trying to keep to the lowest possible dose. The aim is to achieve the desired effect without causing too many side-effects. If such a trial is not helpful, we will advise you to reduce in steps and stop, i.e. “wean down” slowly until it can be safely stopped.

Our recommendations are always based on clinical evidence and up to date research which is based on scientific clinical trials.  The use of medication requires a careful weighing up of the benefits, the side effects and the long term consequences of its use.  There are upper limits to the dosing of the medication we can use and this is because it prevents unwanted side effects or even potential life-threatening risks, so always use it as indicated.

Paracetamol
Paracetamol is normally used for mild to moderate pain relief. It also has anti-pyrexia properties meaning it can be used to treat fever. It is classified as a mild analgesic with no significant anti-inflammatory activity.  It is thought that beyond its own analgesic effects it has a synergistic effect by enabling other medications to become more effective. It is generally safe at recommended doses and has few side-effects when compared to the majority of other pain medication. It appears to be safe during pregnancy and when breastfeeding.  In those with liver disease, it may still be used, but in lower doses 

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Nonsteroidal anti-inflammatory drugs (NSAIDs) is a class of drug that is used to reduce pain and inflammation but also decrease fever and even prevent blood clots. The exact mechanism of how NSAIDs work is by blocking the production of prostaglandins which are our body’s natural chemicals that promote inflammation, pain, and fever. The side effects depend on the specific drug, although uncommon these include an increased risk of gastrointestinal ulcers, bleeding, heart attacks, and kidney disease. The most common NSAIDs used are Aspirin, Ibuprofen, Naproxen and Diclofenac, some of which may be available to buy over the counter. 

Opioids 
Opioids are substances that work by activating specific opioid receptors and have similar effects to those of Morphine. They are primarily used for the treatment of pain but they can also be used for a variety of other reasons. The side-effects of opioids, can include itchiness, sedation, nausea, respiratory depression, constipation, and hallucinations, however long-term use is associated with increased tolerance (same dose progressively produces a lesser effect) and physical dependence (abruptly discontinuing the drug leads to unpleasant withdrawal symptoms). As opioids can rapidly become addictive and cause fatal overdoses if used inappropriately, they have become controlled substances in the UK.

Opioids can be divided into weak opioids such as Codeine or Dihydrocodeine and stronger opioids such as Tramadol and Morphine. Some are semi-synthetic and synthetic opioids such as Oxycodone and Fentanyl. Some are quick acting such as Fentanyl or Morphine or long acting such as Buprenorphine patch or MST.
Opioids are usually more effective in treating Acute Pain (such as pain following surgery or injury) than they are in helping with Chronic Pain. Several clinical studies have suggested that the risk of using opioids is sometimes greater than their benefits when treating non-cancer chronic conditions such as Chronic Headaches, Back Pain or Fibromyalgia.

If used for prolonged periods of time and in high doses they can actually make the pain worse by increasing “sensitivity” to pain. This is termed Opioid-Induced Hyperalgesia or Opioid-Induced Abnormal Pain Sensitivity. This is a paradoxical hyperalgesia phenomenon associated with central mechanisms of pain processing and is especially relevant when on long-term use of opioids such as Morphine, Fentanyl, Oxycodone, Tramadol and even Dihydrocodeine.

Topical Agents
These normally include substances used superficially such as on the skin. They can have different properties and therefore are used to help treat different types of pain. The most common agents we use are topical anti-inflammatory gel/cream such as Ibuprofen gel or Diclofenac (Voltarol). These tend to help reduce pain and inflammation within the joints and the surrounding tissues and is therefore commonly used for back pain, joint pain arthritis and other inflammatory conditions. When used regularly they provide a good alternative to systemic or oral medication which usually carries significant more side effects.
Another common agent we use is Capsaicin. This is actual a natural element of the chillies (what makes them hot and tingling). When used on intact skin, it may help block some of the pain messages in the local nerves causing some pain relief. Studies show that capsaicin creams and patches can help relieve pain in a variety of conditions and its side effects tend to be minimal apart from eye or mucosal irritation if used inappropriately. Ask your pharmacist for more details in how to use it before trying it on.

Neuropathic Agents
Anti-neuropathic medication is usually used to treat nerve pain, known as neuropathic pain. These drugs can be used to treat other conditions as well and are sometimes referred to as antidepressants or anticonvulsants. Within the group of anticonvulsants used in chronic pain, the most common drugs are Gabapentin, Pregabalin and Carbamazepine. Within the group of antidepressants we commonly use Amitriptyline, Nortriptyline, Imipramine and Duloxetine. They are usually started at the minimum dose possible which may be slowly increased until there is a beneficial effect. Higher doses can be better at managing the pain, but on the other hand carry more side effects. The most common side effects of these drugs include drowsiness, tiredness, dizziness, blurred vision, low mood, weight gain and feeling "spaced out”. It is important to avoid driving or operate any heavy machinery once you started them, however after a period of time, you normally become increasingly more tolerant to their side-effects. 

Cannabinoids
Cannabis-based medicinal products with or without tetrahydrocannabinol (THC) are not recommended for managing chronic pain. The use of CBD is also not recommended unless is part of a clinical trial. 

How do you get your medication?
We normally write to your GP with recommendations, after we have discussed them with you. We copy you into the letter, so once you receive our letter you can discuss this with your GP. Your GP is the one who will write your prescription if you both decide on a trial.

Some of the medication principles:

• Make one change at time so you can monitor the effects.
• We recommend trying to get a balance between any pain reduction and potential side-effects. 
• Side-effects can be related to the amount of the drug you take and therefore a reduction in the amount you take, may lead to a reduction in side-effects.
• We may recommend building up in slow steps, to reach a therapeutic dose (helpful dose). 
• If a drug is helpful, we recommend taking the lowest, tolerated amount.
• If a drug is not helpful, we recommend reducing in steps and stopping. There is a higher chance of interactions the more drugs you take, so it’s important to only take the necessary drugs.
   

Steroid injections, also called corticosteroid injections, are anti-inflammatory medications used to treat a range of conditions. Common examples include hydrocortisone, triamcinolone and methylprednisolone.  They can reduce inflammation within a particular area of the body or a joint and therefore reduce the pain associated with it. They are only given by highly trained clinicians to treat problems such as joint pain, facet joint arthritis or sciatica.

The injections normally take a few days to start working, although the local anesthetic used alongside the steroid will work within a few minutes. The effect usually wears off after a few weeks to a few months and therefore they should be used within a wider Pain Management Plan which should focus on Physical Rehabilitation and Graded Exercise.

These procedures are usually done under local anesthetics and in day surgery, meaning you should be able to go home soon after the injection. 

The possible side effects of steroid injections depend on where the injection is given and they may include: 

• pain and discomfort for a few days
• temporary bruising or a collection of blood under the skin
• flushing of the face for a few hours
• infection, causing redness, swelling and pain, however this is very uncommon mainly because we use very strict antiseptic measures to prevent any infection.
• paler skin around the site of the injection  which can permanent
• if you have diabetes, your blood sugar level may go up for a few days
• if you have high blood pressure, your blood pressure may go up for a few days

Epidural injections can also occasionally give you a very painful headache that's only relieved by lying down. This should get better on its own, but you must tell your specialist if you get it.

Steroid injections may not always be suitable in some of these cases, although your clinician may recommend them if they think the benefits outweigh any risks.

Please note that steroids can affect your immune system and therefore potentially place you at increased risk from the effects of COVID19 infection or other communicable infections.
 

What are the Facet Joints?

The spine is a column of bones arranged one on top of the other. The bones are linked at the back by joints called facet joints, one on each side. The facet joints hold the bones together and stabilize the spine, while also allowing movement.

The facet joints may become painful either due to wear and tear (also called degenerative changes), stress or injury, although the reason is not always clear. Pain is felt around the facet joints and in the surrounding area. For example, pain starting from the joints of the lower back will often be felt in the buttocks and upper legs. When the facet joints are tender and sensitive, the muscles nearby can become tight to protect them. When this continues for some time, this also becomes painful.

What is a facet joint denervation and how does it work?
Facet joint radiofrequency denervation is a procedure in which nerve fibres supplying the painful facet joints are selectively destroyed by heat produced by radio waves and delivered through a needle. The treatment is usually performed after an injection of local anaesthetic close to the affected joints has helped to reduce feeling and pain.

The denervation treatment involves placing a special needle (radiofrequency probe) near the nerve of the joint; when a radiofrequency current is passed down the probe, a very small area of heat is created that causes a break in the nerve. This procedure does not affect any other part of the body.
In order to make sure that the probe is close enough to the nerve, we will pass a small amount of electricity down it and ask you for feedback, which is why the procedure requires you to be awake. This will also help to avoid the placement of the needle too close to other (major) nerves of the spine. Once the procedure is completed in one area, then it is repeated in any other areas that require treatment.The aim of the treatment is to reduce pain coming from the joints in the lower back. This will, in turn, help to reduce spasm in the muscles, improve mobility and reduce stiffness. It should provide longer lasting pain relief compared to a simple anaesthetic injection.

Pain Education Sessions
We offer a one off education group which can help to give a better understanding of chronic pain and how a pain management service can help. There are two, one hour sessions and it consists of a small group of patients and is led by one of the team.  It can also be a forum for discussion as many patients find a group environment very helpful and supportive.

Pain Management Program
The Group Pain Management Programme, which currently runs online, offers patients an opportunity to explore different strategies for managing their pain, alongside other people who may share similar difficulties. The programme looks at the impact that pain has on peoples’ lives and how people come to terms with this.  Patients are supported to consider their own values and develop meaningful goals to work towards. The programme covers some of the physiological mechanisms underlying pain and how we adjust our activity to manage our pain better, as well as introducing patients to psychological approaches to pain management.

Medication Optimisation Clinic
We run a Medication Optimisation Clinic to support patients to get the best from their pain medication. We also offer support if they start an opioid trial and also if they are trying to reduce their medication.
 

We have close links with the Neuromodulation service based in Southampton General Hospital. 

Neuromodulation is a therapy that has been used for over 40 years to help with the reduction of chronic pain and improve quality of life. 

It may be used as part of a pain management toolkit for the management of chronic pain. It is approved by the National Institute for Health and Clinical Excellence (NICE) for neuropathic pain (burning, tingling or numbness), where other treatments have not been successful.

It is not a treatment that is suitable for everyone but this may be an option that is discussed with you.
 

Other Useful Pain Management Videos:

• Understanding pain in 5 min
• How does your Brain respond to Pain?
• Understanding the complexity of Pain
• Introduction to Chronic Pain "Good Brain and Bad Brain" by Michael Coupland
• Pain and me by Prof Tamar Pincus
• Jennifer Brea on her experience with​​​​ ME (Myalgic Encephalomyelitis)
• Pain, the brain and your amazing protectometer by Lorimer Moseley
• "Why things hurt" by Lorrimer Moseley

• Living with Chronic Pain 
• My Live Well With Pain
• The Pain Toll Kit
• Pain UK
• Action on pain
• Pain concern
• Healthtalk.org on Chronic Pain
• Living with Pain 
• Fibromyalgia Action UK
• British Pain Society
• Faculty of Pain Medicine for Patients
• Opioids Aware