How to Manage Chronic Pain
A guide to the treatments and strategies you might consider
We are a nation in pain. Pain is the most common presenting symptom for all who seek medical counsel. At best, pain is an immediate sensation signaling that something has gone wrong and needs closer attention. At worst, it disables, depresses and impairs quality of life.
The degree of an individual's pain is a predictor of stress as it lowers feelings of mastery and effectiveness in moving through day-to-day activities.
Historically, pain has been identified by its cause: injury, illness or infection. Because pain is a fully subjective experience — one person's pain cannot be felt by another — a common language provides a level playing field.
The generic definition of pain, issued by the International Associate for the Study of Pain, states that "pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
This guide is designed to help explore choices for conservative yet effective treatment, management and remediation of pain.
Acute pain comes on suddenly, like a sprained ankle. It can be easily diagnosed and treated, is self-limiting and is confined to a finite period and severity. Chronic pain is more resistant to treatment and is widely believed to represent a disease state. This type of long-lasting pain rewires the brain and is significantly disruptive to quality of life.
I am a psychologist working with those who have chronic illnesses. It's a common occurrence to see people struggling with the presentation of pain: post-procedural chronic pain, fibromyalgia, the list goes on.
Many of my patients were actively treated with opioids until it was learned that this class of medications has serious additive implications and, over time, provides diminishing and poorer pain control for many chronic ailments. Because opioids were considered front-line courses of treatment for many years, patients had little information on other forms of pain treatment.
This guide is designed to help individuals explore contemporary choices and options for conservative yet effective treatment, management and remediation of pain. No single technique or intervention is guaranteed to produce complete pain relief, nor is this article intended to replace medical observation, consultation and diagnosis.
Mild forms of pain may be relieved by over-the-counter (OTC) medications such as acetaminophen (e.g., Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs; such as aspirin, ibuprofen or naproxen, like Aleve). OTC medicines relieve pain caused by muscle aches and stiffness, with NSAIDs also addressing swelling and irritation. Topical pain relievers, such as Voltarin, also relieve inflammation.
If OTC drugs do not provide relief, physicians may prescribe stronger medications, such as muscle relaxants, anti-anxiety or anti-depressant medicines like Cymbalta, prescription NSAIDs such as Celebrex or a short course of stronger pain killers from the class of narcotic drugs.
If the stronger pain medicines (including opioids) are prescribed, patients are cautioned that such drugs have a high risk of side effects, including the increased potential for heart attack, stroke and addiction. Such prescriptions are carefully monitored for habituation and physical complications that might compromise the provision of pain relief.
Injections may also be prescribed for pain management. A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation. An epidural may be given for spinal stenosis or lower back pain. With this intervention, a group of nerves causing pain to a specific body region may be blocked by an injection of a nerve-numbing substance. Nerve blocks have particularly limited utility and are considered only in careful consultation with a physician.
Trigger point injections are procedures employed where muscles do not relax. During the procedure, the physician uses a small needle to inject a local anesthetic combined with a steroid into a trigger point, rendering it inactive and leading to alleviation of pain. Usually, a brief course of treatment results in sustained relief. Trigger point injections are used to treat muscle pain in extremities, fibromyalgia and tension and chronic headaches.
Recent advances in pain treatment include surgical transplants for patients when standard medicines and physical therapy have failed. These treatments are still relatively rare and fall under three categories:
The first is known as an intrathecal drug delivery system, also called an infusion pain pump or spinal drug delivery system. A pump is placed under the skin with an attached catheter taking pain medication directly to the spinal cord, the highway for pain signals. A fraction of the dose of oral medication is required; therefore, fewer side effects are noted (because less medicine is required to control pain).
"People dealing with chronic pain need an extra layer of support."
The second are spinal cord stimulation implants. Low level electrical signals are transmitted to the spinal cord or specific nerves to block pain signals from reaching the brain.
Finally, TENS units (transcutaneous electrical nerve stimulation therapy) use electrical stimulation to diminish pain. Low voltage electrical current is delivered through electrodes that are placed on the skin near the source of the pain, which scrambles normal pain signals sent to the brain.
TENS has proven effective to mask pain for problems such as diabetic neuropathy, but not for chronic low back pain as this treatment has been more frequently prescribed, according to the American Academy of Neuropathy.
Because surgical implantation is provided only after more standard treatments fail or are ineffective, insurers may or may not subsidize the service.
Contemporary treatment for chronic pain focuses on integrative care, known by its team-based, multidisciplinary approach blending traditional Western medicine with alternative practices.
The synthesis of physical, psychological and intangible concepts of body, mind, spirit and community are employed to support multiple theories about healing. The goal of integrative care is not to cure a disease, but to help a person suffering from chronic pain manage and control its impact on daily living.
Dr. Laura Bowman, a pediatric oncologist and board-certified medical acupuncturist practicing in Atlanta at Metro Acupuncture and Haven Healthcare, says: "Everything should be done through integrative care. In truth, all medical care is a participation sport. Particularly with pain, active patient participation and a feedback loop is required to offer multiple options to find and treat the cause of the pain."
With integrative care, several classes of treatment may be prescribed, including (but not limited to) what's outlined here:
Physical therapy helps to relieve pain by using techniques that improve movement and function impaired by an injury or disability.
A physical therapist will prescribe regular exercise to diminish pain in the long term by improving muscle tone, strength and flexibility. Proper exercise causes a release of endorphins — the body's natural painkillers. Typically, lower impact exercises such as yoga or swimming are preferred.
"Acupuncture works by intervening in the body's communication system, not unlike the childhood game of 'connect the dots,'" says Bowman.
Acupuncture, now often covered by health insurance providers, is thought to decrease pain by increasing the release of endorphins. Acupuncture points, called meridians, are found near nerves and employed to change communication patterns to the brain. When stimulated, these nerves cause the stimulated limbic system to send messages through the central nervous system to release the brain chemicals that block the pain messages from being delivered.
Acupuncture is a useful treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, fibromyalgia, osteoarthritis and myofascial pain. Acupuncture may be considered as an acceptable stand-alone treatment or can be included as part of comprehensive pain management.
Chiropractic Treatment and Massage
Chiropractic treatment is the most common nonsurgical treatment for back pain.
Massage is a popular alternative for pain sufferers and more often of utility to those managing chronic back and neck problems. Massage reduces stress and relieves tension by enhancing blood flow and reducing the presence of substances that may generate and sustain pain.
There is limited, though promising, research data that these two methods help manage back pain.
As one patient said to me, "I can't control all of the stress in my life, but I can be in charge of how I respond to it."
The sensation of pain is a subjective state and dependent on several psychosocial factors contributing to the experience of pain, including attitudes, beliefs, cultural norms, mood, focus of attention, motivation and personality traits.
A psychologist trained in cognitive-behavioral therapy (CBT) can evaluate and treat the personal experience of pain intensity, functional capacity, active and passive coping mechanisms, medication usage, mood and personality.
A psychologist can also help an individual reduce pain intensity, enhance physical functioning, adhere to proper use of medication, improve sleep, mood and interaction with other people as well as facilitate a return to work or to normal activities of daily living (ADLs).
Psychologists can assist with complex problem solving, comfort measures, stress and anxiety management and assertiveness training.
Alternative and At-Home Treatments
Self-healing processes can be found with one click all throughout the internet. Therapeutic touch, reiki and other "energy-based" techniques are offered as viable treatments for pain. These and similar techniques do not require actual physical contact but do involve close physical proximity between practitioner and patient. There is little mainstream research documenting the efficacy of such treatments, though they are touted to have beneficial effects with no significant adverse side effects.
Dietary supplements such as fish oil and SAMe plus other herbal remedies such as white willow bank and turmeric have just enough evidence in the alternative literature to promote their use with pain patients. However, the lack of bona fide evidence of effectiveness for pain relief is also true for dietary approaches. Some naturopath practitioners advise changing dietary fat intake or eating a plant-based diet containing anti-inflammatory agents.
Further research is needed to determine the efficacy of alternative treatments, so they cannot be recommended with any degree of confidence.
When You Need a Pain Specialist
Health care is too often complicated by its fragmentation among specialties, clinics and what insurance does and doesn't cover.
A primary care or palliative care physician and team may rely on pain specialists with advanced training in interventional radiology, interventional anesthesiology or physiatry (physical medicine and rehabilitation).
"People dealing with chronic pain need an extra layer of support, particularly for more serious illnesses that contribute to pain," says Dr. Ali John Zarrabi, an internist, palliative care specialist and assistant professor of family and preventive medicine at Emory University Medical Center in Atlanta.
Palliative care is employed when "a patient needs a quarterback to coordinate personal preferences, values and goals regarding health and the type of medical care they want to receive," says Zarrabi. "When a patient comes to me with serious illness, including pain, I act as a Sherpa to guide that person through the health care system and to help weigh the risks and benefits of treatment options in the context of their treatment goals."
Zarrabi notes a significant challenge in pain management: "Because the opioid epidemic resulted in such widespread addiction and premature death, these medicines are used sparingly and with great caution. Practitioners now live with an inadequate 'tool kit' to treat pain. Research is being conducted and will yield new options, such as the utility of cannabis or ketamine, but it isn't there yet."
People seeking more help with pain management should start with a primary care provider, who may refer to a specialty care practitioner.
"Find a pain specialist through a personal referral from someone you know and love," recommends Bowman. "The practitioner should be state licensed at the highest level possible. Pick someone whose bedside manner works for you alongside their credentials."