Editor’s note: This is the first of a two-part article. In the next issue (Vol. 19, Issue 4), Egan will discuss treatment of chronic pain.

Oh, My Aching Head!
You have seen patients all afternoon, the documentation has yet to be done and you have a blinding headache. You’ve had them before, when the pressures of demanding inmates, harried correctional officers and overstretched medical staff don’t give you a chance to relax all day.

You figure this headache might stem from the frustration of the last four packed hours and the workload ahead. Three-fourths of the patients you saw in the clinic today complained of some type of pain. You have your doubts about the “realness” of their pain and the goal of their visit. This makes you feel used and maybe even manipulated.

You, however, have no doubt about the realness of your pain. You know your head hurts! What’s the difference?

The Nature of Pain
The difference is this: You feel your pain, and you don’t feel theirs. Plain and simple, right? Plain, yes, but not so simple.

Pain is a complex, private experience, never really visible to others. Sometimes we think we “see” pain, but what we see are either behaviors that communicate that pain is occurring, or anatomical abnormalities in an imaging study that might be connected to the pain. But we don’t actually see it, and we can’t be sure. We guess. With our own headache, we see nothing, nor would anybody else. But none of us would say that means our pain isn’t real.

Acute Versus Chronic Pain
Acute pain is a warning that something is wrong, that something needs to be “fixed” or rested or protected until healing can occur.

In contrast, chronic pain has lost its value as a signal of ongoing tissue damage. It has acquired a life of its own. In the literature, chronic pain is variably defined as any pain that lasts longer than three to six months. This is not necessarily the steady, ongoing experience of pain. Rather, it’s pain that comes and goes, that reoccurs at intervals, like chronic back pain—like, perhaps, your headaches.

The treatments for chronic pain differ dramatically from the treatments for acute pain. By the time pain becomes chronic, it is no longer maintained by the same mechanisms that triggered it initially. Treating chronic pain as if it is acute (and that’s what we typically do) makes it progressively worse. Treatments will be discussed in Part 2 of this series.

More ‘Normal’ Than ‘Not Normal’
John J. Bonica, my former colleague and a pioneer in pain management, noted, “If you live long enough, you will have a chronic pain problem.”

Regardless of age, chronic pain is very common among the nonincarcerated population. In fact, 70% to 85% of all people report having had an extended period of low back pain that interfered with their ability to work or to pursue recreational activities over a period of at least three days.

Chronic pain (including headaches and pain of the low back, shoulder, neck, elbow, knee and foot) is said to be the single most costly health problem in America. Three out of four visits to primary care are because of pain. That makes the inmates who show up in our clinics with complaints of pain pretty much average health care consumers.

Complexity of the Pain Experience
All pain has social, emotional, physical and often financial contributors and consequences. This is one way in which acute and chronic pain do not differ. The types of social, emotional and physical components are different and have different intensities, but such feelings as fear and threat of loss are part of all pain experiences.

The International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” I’ve italicized the words to emphasize that the world’s pain specialists do not distinguish between pain that is real tissue damage and pain that is described by the patient in those terms. In addition, this “gold standard” definition does not separate the sensory experience from the emotional experience of pain.

Pain in Prison
As you’ve guessed from all the inmates coming to your clinic, the prevalence of chronic pain is even higher in prison than in the outside world.

Many correctional health care providers automatically assume that pain complaints are an effort to gain access to opiates. Certainly that is true for some patients, but it’s just not that simple. Prison tends to bring out the most chronic pain difficulties possible. A Canadian study found that inmates have 2.4 times the prevalence of chronic pain than the general population.

Contributing Factors
This has been attributed to a combination of (1) environmental conditions of confinement,( 2) crowded living conditions, (3) lack of exercise opportunities, (4) increased social stress (remember your headache) and (5) boredom. As my University of Washington colleague, Bill Fordyce, says, “People who have something better to do, don’t hurt as much.”

Many other factors come into play. For instance, clinical depression and chronic pain share many of the same characteristics and some of the same underlying neurotransmitters. And trauma associated with sexual abuse is highly correlated with development of chronic abdominal pain in women.

Additionally, the world is aging, and the prison population is aging faster. Aging is associated with increased incidence of arthritis, muscle aches and pains, shingles, nerve pain and other problems.

The Provider’s Response
Unfortunately, we lack a model for dealing with chronic pain in prison. It is either treated as acute pain or it is ignored, or inmates are considered to be soliciting special treatment or special drugs and, therefore, are treated with disdain.

Some—perhaps many—are interested in gaining something. Still, there are things we can do to respond to their pain, to provide treatment that doesn’t make things worse and has a longer term benefit both to the inmate and to the institution.

Back to your headache: What are you going to do about it? Will you rest awhile? Will you get a massage from a sympathetic partner? Will you take aspirin or a nonsteroidal? Will you do neck stretching exercises? Do some yoga, or practice systematic relaxation? Sit in a hot tub?

Most of these options are not available to inmates. They typically have to see a health care provider just to get an aspirin. And, of course, first they have to wait to see the provider. No wonder they appear in clinics in what appears to be droves!