A pioneering team of pain specialists in Cape Town is achieving remarkable success with a new approach to a scourge that affects one in three adults.
Groote Schuur Hospital's pain clinic uses neuroscience education, movement and mindfulness to treat musculoskeletal pain and move patients off painkillers.
Take a 51-year-old academic and adventurer who asked to be identified only as "Jack": by December last year the geologist, who has had two major back operations after accidents, was virtually bedridden and felt like a zombie on opioids.
More surgery was recommended, he had not worked for more than a year, felt depressed, and had lost his libido and motivation. Within weeks of consulting the clinic, however, he was hiking on Table Mountain, doing Pilates and stretching daily, and his family life and marriage had improved.
"I've noticed that the amount of chronic pain is inversely related to the amount of activity for me. I'm not sore when I'm out there. I feel sore when I'm resting," said Jack.The damage to his back had not been diagnosed after the first accident, in which a bus crushed his car, killing his girlfriend and causing him multiple fractures. Poor acute pain management raises the risk of chronic pain later.
After the second trauma to Jack's back, when he jumped out of a helicopter in Antarctica, circumstances forced him to stay active. Only later did he feel the crippling pain.
Chronic pain - lasting for more than three months - differs from acute pain, which has the protective purpose of signalling damage. And before treating pain, it is critical to rule out causes such as cancer.
Associate Professor Romy Parker, director of the chronic pain management unit at the University of Cape Town's department of anaesthesia and perioperative medicine, said: "Pain is something the brain produces, a perception like thirst."
Teaching patients about the brain's role and doing exercises with them had produced amazing results, she said.
"Our bodies produce morphine 100 times stronger than the morphine we can swallow. But the drug cabinet in your brain gets locked with chronic pain.
"When you understand that pain is something your brain produces and not necessarily a message that there is damage in your body, that drug cabinet gets unlocked and you start to produce your own painkillers again."
Learning about pain decreases people's fear of it and this reduces their perception of the pain they feel, she said. "Pain does not stop us doing things. It is what we think pain means that stops us doing things."
Chronic pain is like a faulty alarm system that keeps going off even after the body has healed and the threat - physical or emotional - is gone, said Parker.
Many people with intractable chronic pain would get no medical diagnosis however many investigations they did, because their pain stemmed from their over-sensitised alarm system.
But this does not mean pain is all in the mind or that people can simply control it: the brain's messages for pain are unconscious, like those which make people blush...