The data of Korean chronic pain
Korean Pain Society 2022: 25% of Korean adults have chronic pain (3+ months). 35% in their 50s~60s, 50% in their 70s. Main sites: back (40%), knee (25%), neck / shoulder (20%), headache (15%). Of chronic pain patients, 40% have clinical depression, 30% anxiety, 60% sleep disorder. Suicide rate 3× general population. Annual medical cost ~₩3~5M/person. Patients call it "can't die, can't live".
The new understanding — pain is brain-made
Classic pain model: tissue damage → nerve signal → brain perception. But 60%+ of chronic pain persists without tissue damage (or after healing). Current model: pain is a brain-generated "protective signal". Patterns learned as threats by the brain produce pain even without damage. Chronic pain = a "faulty alarm system" in the brain. This isn't "pain is fake" — pain is real, but the cause sits more in nervous-system learning than in tissue.
Implications: ① "normal" MRI doesn't mean fake pain ② pain = integrated result of brain, psychology, environment, physiology ③ drugs and surgery alone hit limits ④ the brain's learning must be reversed.
The pain-depression-sleep triangle
Pain → depression: helplessness, ↓ activity, ↓ relationships, pessimism. 4× depression risk.
Depression → pain: in depression, pain perception ↑ (amygdala, ACC active). Same stimulus reports 2× pain.
Pain → sleep: hard to fall and stay asleep. Average 5.5h.
Sleep ↓ → pain ↑: 1 night of sleep loss = -25% pain threshold. More pain from same stimulus.
Depression → sleep ↓: a core depression symptom.
Treating only 1 of the 3 fails. Integration is essential.
Korean-context specifics
① Access: Korea has excellent pain-clinic access (orthopedics, pain medicine). But the "fast diagnosis-drugs-revisit" model fits poorly with multidisciplinary chronic pain.
② Drug dependence: NSAID / muscle relaxant prescription rate 2× OECD average. Short-term works, chronic-term hits limits + GI / kidney side effects.
③ "Endure it" culture: pain expression seen as weakness. Patients can't say "it hurts" → late psychiatric referral.
④ Somatization: in Korea, depression / anxiety often presents as physical pain (e.g., hwa-byung chest pain). Refusing psychiatric care lets somatic symptoms grow.
⑤ Polypharmacy in elders: 65+ average 5+ medications. Risk of pain-med / psychiatric-med interactions.
Biopsychosocial model
Proposed 1977 by George Engel. Standard for chronic pain, depression, chronic disease. Three axes:
- Bio: tissue damage, nervous system, inflammation, genetics
- Psycho: depression, anxiety, pain perception, memory
- Social: family, work, culture, economy, healthcare access
Skipping any axis = no chronic-pain improvement. Standard = meds + exercise + CBT + social support.
5 approaches
① Pain diary: 3~5 min daily. ① pain 0~10 ② location ③ triggers (weather, posture, food, emotion) ④ activity ⑤ mood. 2~4 weeks accumulated = patterns. Examples: "shoulder when angry", "back at desk", "headache day after <5h sleep". Patterns guide trigger avoidance.
② Graded exercise: first-line non-drug treatment. Start: even at 7/10 pain, 5 min walk. Week 2: 7 min. Week 3: 10 min. +10%/week. "Worse → next-day normal" pattern = normal. Don't stop exercise on pain spike — exercise reverses brain pain learning.
③ Pacing: 100% activity on good days → 200% pain next day. 0% on bad days → deconditioning → more pain. Answer: average 70% consistency. Good day 70% (save 30%); bad day still 70% (hard start, finish through). Consistency is the key to improvement.
④ CBT: verified non-drug treatment for chronic pain. Reframes pain thoughts ("my life is over" / "movement breaks me more"). Pain diary + activity plan + thought journal. 12 sessions standard. Some Korean pain clinics / psychiatry offer. Youth Mental Health Voucher applies.
⑤ Multidisciplinary pain clinic: pain medicine + rehab + psychiatry + PT + clinical psychology as one team. Some Korean tertiary hospitals run them (SNUH, Asan, Severance). 6~12 weeks. Higher cost but more effective than 1 year of solo visits.
Medications — what and how
- NSAIDs (ibuprofen, diclofenac): acute / inflammatory pain. Avoid daily 6+ weeks in chronic (GI / kidney).
- Acetaminophen: ↑ safety, ↓ effect.
- Antidepressants (amitriptyline, duloxetine): first-line in chronic pain. Lower dose than for depression. Strong for neuropathic / fibromyalgia.
- Anticonvulsants (gabapentin, pregabalin): first-line for neuropathic pain (diabetic, post-herpetic).
- Opioids (tramadol, oxycodone): short-term only. Avoid chronic — dependency and paradoxical lowered threshold.
- Injections (steroids, nerve blocks): strong short-term, weak long-term, side effects on repeat.
Drugs are "tools to lower pain so activity, exercise, therapy become possible". Drugs alone don't solve chronic pain.
Comorbid depression — integrated care
40% comorbid. Don't treat depression alone, don't treat pain alone — both simultaneously. SSRIs are weaker on pain but help depression. SNRIs (duloxetine, venlafaxine) help both (common Korean prescription). Standard = pain clinic + psychiatry co-care.
5 daily habits
- Sleep 7h: priority #1 for pain patients. Discuss meds.
- 30-min walk daily: ↓ intensity, ↑ consistency. Rain → indoors.
- 5-min stretch: morning, noon, night. Painful area + opposite.
- 10-min breathing meditation: ↓ emotional pain reaction. MBSR is verified for chronic pain.
- Social connection: weekly in-person friend / family. Loneliness ↑ pain.
Emergency signs — get care now
- Pain-driven suicidal thoughts
- Opioid dependence (extra doses beyond prescription)
- Daily alcohol / drug use
- 2+ weeks of daily-life paralysis
- Cutoff from family / work / hobbies
1577-0199 or pain clinic + psychiatry simultaneously. Chronic-pain suicide is reported 100+ times/year in Korea. Don't reject treatment — multidisciplinary care improves 70%+ of patients.
