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Chronic Pain Reference

Chronic pain is pain that persists or recurs for more than three months. It may remain after an injury has healed, accompany an ongoing disease or disability, arise from damage or disease in the nervous system, or occur without one sufficient structural explanation. Pain is a personal sensory and emotional experience. The absence of a visible injury, abnormal scan, verbal description, or expected outward behavior does not establish the absence or severity of pain.

Terminology and Classification

The International Association for the Study of Pain distinguishes pain from nociception, the nervous system’s encoding of potentially harmful stimuli. Pain cannot be inferred solely from nerve activity, and a person’s report of pain should be respected. Verbal speech is only one means of expressing it; nonspeaking people, infants, people with intellectual disabilities, and people whose communication changes during illness can experience pain without describing it conventionally.

The World Health Organization’s ICD-11 classification divides chronic pain into chronic primary and chronic secondary categories. Chronic primary pain is a health condition in its own right and is associated with significant distress or interference in daily life without another diagnosis fully accounting for it. Chronic secondary pain is linked to another condition, such as cancer, surgery or trauma, musculoskeletal disease, neurological disease, headache or facial pain, or visceral disease. Primary and secondary do not mean real and unreal, severe and mild, or important and unimportant.

Pain mechanisms can overlap:

  • Nociceptive pain arises from actual or threatened damage to non-neural tissue and activation of nociceptors. Musculoskeletal injury, inflammation, arthritis, fractures, and some cancer pain can involve nociceptive mechanisms.
  • Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system. It may be burning, shooting, electric, stabbing, numb, tingling, or painful in response to an ordinarily nonpainful stimulus.
  • Nociplastic pain arises from altered nociception when there is no clear evidence that tissue damage or a somatosensory lesion fully explains the pain. Fibromyalgia is a common clinical example.
  • Mixed pain involves more than one mechanism. A person with a spinal injury, joint damage, muscle spasm, migraine, or cancer can have several pain qualities and sources at the same time.

‘’Allodynia’’ is pain from a stimulus that does not ordinarily provoke pain. ‘’Hyperalgesia’’ is an increased response to a stimulus that is ordinarily painful. ‘’Dysesthesia’’ is an unpleasant abnormal sensation, whether spontaneous or evoked. These clinical terms describe experience and do not by themselves establish a single mechanism.

Presentation and Functional Effects

Chronic pain may be continuous, intermittent, or episodic. Baseline pain and flares can have different qualities and causes. Severity can change with movement, position, sleep, illness, temperature, barometric pressure, exertion, sensory load, medication timing, stress, or another condition without becoming a simple psychological reaction.

Pain can affect mobility, balance, dexterity, concentration, speech, signing, AAC access, appetite, nausea, sleep, self-care, driving, school, employment, intimacy, and social participation. One activity may remain possible only because the person reduces other activity or accepts a later flare. A successful performance, work shift, class, or appointment does not demonstrate equivalent capacity before or afterward.

People express pain differently. Possible signs include guarding, bracing, reduced movement, agitation, rocking, stillness, altered breathing, sweating, nausea, vomiting, irritability, reduced speech, increased vocalization, withdrawal, or a change in routine. No one behavior is universal. Familiar communication partners may recognize small changes that strangers miss, but observation does not replace the person’s own report or established communication.

Pain scales can help compare one person’s symptoms across time, but a number is not a laboratory measurement and does not translate identically between people. Assessment also considers pain quality, location, timing, triggers, relief, sleep, medication effects, function, personal goals, and what a change from that person’s baseline means.

Diagnosis and Assessment

Assessment begins with the person’s history and goals. It may include physical and neurological examination, medication review, functional assessment, sleep and mental-health screening, and targeted imaging, laboratory, electrodiagnostic, or specialist evaluation. Testing looks for treatable causes and co-occurring conditions without making an abnormal result a prerequisite for belief.

The same diagnosis does not create one fixed pain pattern. Cerebral palsy, spinal cord injury, Ehlers–Danlos syndrome, fibromyalgia, migraine, cancer, arthritis, and traumatic injury each contain wide variation. Conversely, similar words such as ‘’burning’’ or ‘’aching’’ do not prove the same diagnosis in different people.

Depression, anxiety, trauma, grief, expectation, safety, attention, social support, discrimination, and economic conditions can influence pain, function, and access to treatment. This biopsychosocial understanding does not make pain imaginary or reduce a physical evaluation to psychotherapy. Psychological care can treat distress, trauma, sleep, fear, or coping while medical and rehabilitative care address the body and the underlying condition.

Treatment and Management

Chronic-pain care is individualized. Useful outcomes may include lower pain intensity, fewer crises, improved sleep, safer movement, greater independence, preserved work or art, reduced medication harm, or more control over when and how activity occurs. Complete pain elimination is not always possible, and function is not improved when a treatment merely forces activity at the cost of later deterioration.

Physical, Environmental, and Rehabilitative Care

Depending on the condition, management can include positioning, pacing, physical or occupational therapy, strengthening, range-of-motion work, heat or cooling, massage, braces, splints, compression, TENS, mobility equipment, seating changes, pressure relief, sleep treatment, and changes to work or performance technique. An intervention that helps one pain source can aggravate another. Stretching that is useful for spasticity may be unsafe when applied indiscriminately to an unstable joint; cold that numbs one pain may intensify neuropathic pain for another person.

Mobility aids can reduce pain, falls, joint stress, and energy use. Wheelchair use is not evidence that treatment failed, and walking during one period does not make part-time or later wheelchair use unnecessary. Personal assistance, accessible bathing and transfer equipment, reclined work, remote participation, flexible schedules, and planned recovery time can be pain treatment as directly as medication.

Medication and Procedures

Medication selection depends on the pain mechanism, underlying diagnosis, age, other conditions, and prior response. Options can include acetaminophen, nonsteroidal anti-inflammatory drugs, topical agents, selected antidepressants or antiseizure medicines for neuropathic pain, muscle relaxants, migraine-specific treatment, corticosteroid or anesthetic procedures, and condition-specific disease treatment. Each carries contraindications, interactions, and adverse effects; combinations require review rather than automatic escalation.

Opioids can be appropriate for selected acute, cancer-related, palliative, end-of-life, or chronic pain situations. For most subacute and chronic outpatient pain, the CDC recommends maximizing appropriate nonpharmacological and nonopioid treatments and using shared decision-making when considering opioids. The guideline is not a rigid dose rule, does not apply to sickle-cell pain, cancer treatment, palliative care, or end-of-life care, and warns against abrupt discontinuation or rapid forced tapering in a person already receiving opioids.

Tolerance, physical dependence, opioid use disorder, and addiction-related behavior are not interchangeable. Physical dependence can occur with prescribed use and means withdrawal may follow abrupt cessation. Opioid use disorder is diagnosed from a broader pattern of impaired control, harm, and continued use despite consequences; exposure alone does not make it inevitable. Care also addresses overdose risk, sedation, breathing, constipation, nausea, falls, medication storage, interactions, and the person’s own history and preferences.

Psychological and Integrative Care

Cognitive behavioral therapy, acceptance-based approaches, relaxation, biofeedback, mindfulness, and trauma-focused care may help some people manage distress, sleep, activity planning, or the effects of pain. These are not proof that pain is psychological. Evidence for acupuncture, massage, movement practices, and other complementary approaches varies by condition and is generally modest; safety and joint, neurological, cardiac, or medication risks still matter.

Historical Context

Pain has been treated with plant medicines, heat, cold, surgery, ritual, immobilization, and physical methods across recorded history. Morphine was isolated from opium in the early nineteenth century, and anesthesia, hypodermic delivery, antisepsis, radiology, neurology, and rehabilitation later changed both acute and chronic pain care.

The 1965 gate-control theory described pain as active nervous-system processing rather than a direct meter of tissue damage. The biopsychosocial model later emphasized interacting biological, psychological, and social conditions. Both frameworks broadened care, although clinicians sometimes misused them to dismiss pain as emotional when testing did not supply an easy explanation.

Late-twentieth-century campaigns addressed widespread undertreatment of pain while pharmaceutical marketing and prescribing practices contributed to opioid-related harm. The later response included overly rapid tapers, refusal to treat pain, and suspicion toward patients who had used medication safely. The 2022 CDC guideline replaced the 2016 guideline and explicitly warned against inflexible policy use, abrupt discontinuation, and rapid forced tapering.

In 2020, IASP revised its definition of pain to recognize personal experience, multiple forms of communication, and the distinction between pain and nociception. ICD-11’s chronic-pain categories gave chronic primary pain and several forms of chronic secondary pain dedicated diagnostic recognition.

Associated Characters

Andy Davis

Andy lived with chronic pain and painful spasms associated with spastic diplegic cerebral palsy. Stress, cold, fatigue, illness, school demands, prolonged positioning, and overexertion could increase spasms and pain. Wheelchair mobility, heat, careful positioning, rest, stretching, and family assistance reduced the physical cost of movement and daily care. A severe baclofen reaction in 1997 required emergency treatment and became part of his later medication history rather than evidence that his pain had resolved.

Medical racism shaped whether clinicians believed and adequately treated Andy’s pain. His later writing and work with Logan Weston centered what patients reported rather than treating visible spasticity as a complete measure of pain. Their collaborations included the CP Pain Protocol and ‘’Pain, Presumption, and Power’‘.

Charlie Rivera

Charlie’s chronic pain included migraine, hEDS-related joint and muscle pain, ME/CFS pain, recurrent injuries, and pain associated with POTS and nutritional compromise. In the original hEDS development, he described a manageable day as approximately three to four out of ten and a bad day as seven to eight, with unstable shoulders, hyperextending knees and fingers, back pain, and muscles overworking to stabilize his joints.

Pain and post-exertional malaise affected rehearsals, travel, instrument technique, and recovery. Bracing, positioning, mobility equipment, reclined work, scheduled rest, heat, hydration when tolerated, and changes to touring preserved access without making every flare preventable. Pain and fatigue could also reduce speech and signing access, making AAC and reduced conversational demand part of pain support.

Michael Bell

Michael lived with chronic pain associated with years of physical and mechanical restraint, prolonged forced positioning, untreated or inadequately treated injuries, chronic muscle tension, and institutional neglect. Seclusion and sedating medication used without meaningful consent compounded his fear of confinement and loss of bodily control. Medical settings could activate those memories and make examination or treatment harder to tolerate. Concrete explanations, consent before touch, predictable sequencing, genuine choices, and the presence of trusted people helped him receive care without treating trauma as the sole explanation for physical pain.

Jacob Keller

Jacob experienced chronic migraine, later cluster headaches, chronic sinus pressure, and later joint and musculoskeletal pain. Bright performance lighting, sleep loss, stress, sustained physical demands, and seizure recovery could worsen different parts of the pattern. Migraine and cluster attacks required distinct recognition and management; a successful concert or teaching day could be followed by prolonged recovery.

Gavin Worth and Jon Williams

Gavin and Jon both lived with fibromyalgia. Gavin’s symptoms included widespread aching, tactile allodynia, burning and electrical dysesthesia, fatigue, nonrestorative sleep, and flares during intense emotional or cumulative stress. He was diagnosed during the 2025–2026 academic year after a severe flare led to emergency evaluation and outpatient workup. Learning to pace required him to stop treating rest as something earned only after collapse.

Jon’s fibromyalgia and migraine affected daily capacity, and Portland’s colder, wetter climate worsened his symptoms. Chrissie Williams learned his pain and fatigue cues, while Jon learned her seizure, sleep, and distress cues; their household routines made support reciprocal rather than one-directional.

Logan Weston

Logan developed chronic neuropathic pain after his December 2025 incomplete spinal cord injury and extensive orthopedic trauma. The pain could be burning, electric, texture-evoked, and constant at baseline, with severe flares that caused sweating, trembling, reduced speech, nausea, and vomiting. His first uncontrolled home neuropathic crisis occurred during early home recovery, after Charlie and Jacob returned to Juilliard at the end of their March 2026 midterm recess. Oxycodone reduced the otherwise unmanageable pain but caused severe nausea, vomiting, sedation, and cognitive fog.

Logan subsequently used a qualitative four-level system without fixed numeric bands. ‘’Background Noise’’ covered ordinary baseline management with medications for neuropathic pain and spasticity, TENS, topical measures, positioning, and heat or cooling. ‘’Flare Warning’’ marked escalating pain requiring more rest and nonopioid intervention. ‘’Emergency Use Only’’ covered severe pain requiring prescribed rescue medication, nausea treatment, minimal stimulation, and help. ‘’Nuclear Option’’ was an uncontrolled crisis in which oxycodone was a last-resort medication and another person remained with him through the most sedating period. He could still give a separate numeric rating when it was clinically useful, but the number did not define the level. Strong opioids could require twelve to sixteen hours before he could function safely again.

During severe winter months, pain-induced vomiting could occur once or twice a week; outside winter it occurred roughly every few weeks during the worst flares. Logan and Charlie kept emesis supplies and used the darkly affectionate name “duet in D minor” for episodes in which Charlie’s sympathy vomiting joined Logan’s pain response.

Other Established Presentations

  • Alastair Hargreaves lived with hEDS-related joint instability, recurrent injuries, chronic pain, fatigue, migraines, and osteoporosis. He used a wheelchair as needed for pain, fatigue, mobility, and injury prevention.
  • Amari Burns developed chronic pain during late-stage metastatic prostate cancer. His son Caleb Burns cared for him during his final illness.
  • Chris Russell developed chronic back, knee, shoulder, and hand pain after approximately two decades of dock work and years of lifting and carrying Levi Russell. Recurrent kidney stones added acute pain to that longstanding musculoskeletal burden.
  • Darren Ross experienced recurrent knee and ankle pain and swelling that contributed to his move from catcher to first base in baseball.
  • David Graves managed chronic lower-back pain associated with years of clinical work through physical therapy and stretching.
  • Elliot Landry lived with severe arthropathy, stiffness, and chronic pain associated with pituitary gigantism and years of physically demanding work. Pacing, reinforced furniture, climate control, and later power mobility reduced strain.
  • Nelson Taveras had migraine and cluster headaches as well as chronic pain after a stage-collapse injury in his late thirties.
  • Rafael Cruz sustained a permanently disabling back injury after a construction-site fall. His pain could cause vomiting, and prescribed opioids formed part of treatment. Substance dependence later developed within a wider history of injury, depression, grief, inadequate care, and drug exposure; prescription treatment alone did not make that outcome inevitable. Rafael died from an accidental fentanyl overdose in 2022.
  • Tre Martin developed chronic pain after the December 2026 Camp Pendleton incident caused an incomplete spinal cord injury and multiple additional injuries. During recovery, he asked the team to reduce hydromorphone because he preferred greater alertness despite increased pain; the team discussed other ways to support pain control without removing his agency.

Accessibility and Daily Life

Pain access can include flexible attendance, remote work, reduced or redistributed hours, permission to change position, rest spaces, extended deadlines, predictable breaks, low-sensory rooms, mobility and transfer equipment, ergonomic instruments or tools, temperature control, medication storage, and transportation plans that account for flares and sedating medication.

Communication access is part of pain care. A person may need ASL, AAC, writing, gesture, yes-or-no questions, additional processing time, silence, or a familiar supporter during severe pain. Repeated questioning, forced eye contact, unnecessary touch, demands for a conventional pain number, and disbelief based on calm behavior can all reduce access to accurate assessment.

Care partners require clear boundaries and backup. Andy and Cody, Logan and Charlie, Jon and Chrissie, and Jacob and Elliot each developed reciprocal systems in which both people retained disabilities, needs, and autonomy. Professional or paid support, accessible equipment, and a wider network prevented love from being treated as an unlimited physical resource.

Medical-System and Community Context

Racial bias, gender bias, disability stereotypes, communication barriers, poverty, insurance rules, incarceration, and prior psychiatric diagnoses can alter who is believed and who receives treatment. Black patients have repeatedly received less or different pain treatment than white patients under otherwise comparable circumstances. Nonspeaking people and people with intellectual disabilities may have pain attributed to behavior, while people with trauma histories may have physical symptoms reduced to anxiety.

The opioid crisis created simultaneous harms: addiction and overdose, aggressive pharmaceutical marketing, and unsafe prescribing on one side; abandonment, abrupt tapering, forced withdrawal, and untreated pain on the other. Effective care distinguishes medication risk from moral judgment and substance-use treatment from denial of pain treatment.

Disabled and chronic-pain communities have challenged the idea that productivity proves health, that visible injury is required for credibility, and that using medication or mobility equipment represents personal failure. Logan’s clinical work and Andy’s writing made those principles explicit, while Gavin’s, Michael’s, Rafael’s, and Elliot’s histories showed different consequences when pain was misread, moralized, or ignored.

Sources

Medical Conditions Chronic Conditions Neurological Conditions Pain Conditions