Relentless pain casts a shadow on daily life for millions of Americans. It tests their resolve and relationships, and often takes a village of therapies and treatments to find relief.
If you’re living with chronic pain, new treatment approaches can help you live more fully, with as few drugs as possible.
“The field of chronic pain is ever changing with new therapies on the horizon,” says Dr. Steven Feinberg, a pain medicine physician in Palo, Alto, California, and former board member and past president of the American Academy of Pain Medicine.
“We are coming to understand that even when the damage causing the pain cannot be fixed, the pain can still be managed through a variety of techniques administered not only by the health care professional but also from self-directed treatment and rehabilitation.”
Healing with Functional Restoration
Painkillers have their place, but the best medicine for chronic pain is an integrated, whole body approach, says Dr. Michael Robert Clark, Director of the Chronic Pain Treatment Program at The Johns Hopkins University School of Medicine in Baltimore, Maryland.
“I have about 25 years of experience and this is the only/best way for most people,” Clark says. “I’m sure there are some patients who have manageable conditions and function on low/moderate doses of opioids, but the majority of patients with chronic pain really need a more comprehensive approach.”
That approach centers on what pain specialists call “functional restoration,” which targets both the physical and psychological aspects of pain. Patients learn a regimen of movement and therapeutic exercises to return to a productive life, and change the way they think about pain by using psychological strategies to reduce anxiety and fear.
“Restoration of function is the key outcome measure,” Clark says. “Treatment should address any curable/treatable conditions. But rather than focus on symptom suppression, the rehabilitation process emphasizes function and quality of life despite or in the presence of (pain).”
A recent Wall Street Journal article notes that patients who engage in functional restoration show modest improvements in pain “but they make quite dramatic improvements in mood, flexibility, strength and endurance.” This person-centered approach also lessens the need for medication and more invasive procedures.
America’s Epidemic of Pain
An estimated 100 million Americans adults are living with chronic pain – more than the total affected by heart disease, diabetes and cancer combined, according to the Institute of Medicine (IOM), part of the National Academies of Sciences, Engineering and Medicine.
The economic costs are staggering: up to $635 billion annually in disability days, pain care expenses and lost wages and productivity, the IOM notes. And that doesn’t include military personnel or pain in children.
“Living in constant pain can be emotionally distressing and result in depression and anxiety, or can exacerbate existing mental disorders,” Feinberg notes. “This does not mean that the person in pain is weak, but rather it is a normal reaction to a stressful situation.”
Pain can be magnified by other psychological and lifestyle factors, including fear of movement and re-injury, chronic stress, substance abuse and negative thinking patterns.
Opioids: Not a Long-Term Solution
Opioid (narcotic) medications, when properly prescribed, can mitigate pain for people with severe, debilitating conditions. But they’re not an effective long-term solution, experts say.
Prolonged opioid use can distort pain receptors and actually make pain worse – a condition known as opioid-induced hyperalgesia. The narcotics trigger greater sensitivity to painful stimuli, which can increase in magnitude and duration with continued use.
“Opioid-induced hyperalgesia is a well-known phenomenon that is poorly understood. However, there is a pretty significant basic science and animal literature about it,” Clark says. “Patients appear to have worsening and more generalized total body pain despite increasing doses of opioids that then improve dramatically when weaned off opioids.”
Other risks associated with long-term opioid use include immune dysfunction, sleep disorders, endocrine deficiencies, sexual dysfunction, and side effects including chronic constipation, blurred thinking, fatigue and nausea.
There’s also the potential for addiction and overdose in a minority of patients.
Steps for Safer Use
Amid the current addiction crisis in America, opioid treatment for chronic pain is facing increased scrutiny. Opioids accounted for 28,647 deaths in 2014 – or 61 percent of all drug overdose deaths, according to the Centers for Disease Control. The rate of opioid overdoses (which include prescription painkillers and heroin) has tripled since 2000.
If a patient insists that only opioids provide relief, Clark says he asks the question: “How are you functioning?” He continues: “If the answer is something like, ‘I’m disabled, in pain, and do very little,’ then I ask, ‘why would you keep doing something that isn’t helping you?’ If the patient gets more adamant about taking opioids after you’ve provided education, reassurance, and a rational plan for helping them, you have to worry that patient has an addiction complicating their case.”
Feinberg notes that some patients on moderate doses of opioids can tolerate side effects and are “quite functional” with reduced pain. “On the other hand, we have been very successful at our practice in helping people wean off of opioids who in fact are more functional and actually had less pain off the drugs then when taking them,” he says.
To encourage safer opioid use, the federal government issued tighter prescribing controls in 2014, and more physicians are now co-prescribing naloxone, an effective antidote that prevents overdose deaths. Some doctors ask patients to sign a voluntary “opioid agreement” that outlines responsibilities for safe use.
Getting Pain Under Control: 7 Things You Can Do
Pain management experts advocate a combination of evidence-based treatments and self-help strategies to regain a productive quality of life.
“For each person the necessary combination of therapies and interventions will be different, based on individual need,” notes the American Chronic Pain Association (ACPA) on its website. “Unlike traditional medicine where the “patient” is a passive participant, living a full life with pain requires that we take an active role in the recovery process.”
Here are seven strategies that can improve your ability to manage chronic pain:
1. Make A Cognitive Shift: You’re in Control
The habit of being in pain is hard to break, and takes emotional fortitude to restore function and re-engage in meaningful activities. The idea, Feinberg says, is to learn to control the pain rather than having it control you.
You may not be able to do everything you could before, and there’s likely not going to be a cure or single optimal strategy – only a way to manage chronic pain. Some people give up and remain disabled and in pain. Or they dwell on anger or being fixed by pills. Others move forward and devote considerable emotional and physical resources to getting better.
Success requires shifting from a passive approach to taking charge of your health and acquiring new skills to control pain, Feinberg explains in his “Thoughts on Managing Chronic Pain: How to Have a Life: ”
“Making a change away from pain controlling your life is not so easy to do. When it comes to breaking the habit of chronic pain, it takes a change in one’s thinking – a “cognitive shift” – from being a patient with chronic, insurmountable pain to a person with a manageable problem. It really can be done!”
Chronic pain is not helped by complaining, resting, being inactive or by pain medications, injections, procedures or surgeries alone. Success is achieved by learning how to get on with one’s life by managing pain through physical rehabilitation, functional restoration, medication adjustments, limited selected procedures and a variety of psychological pain management techniques. It’s about reactivation and reanimation. It is about you taking charge again.”
People who participate in self-management programs significantly increase their ability to cope with pain, according to research by the National Institutes of Health (NIH).
Studies show the best self-management programs teach people different ways of thinking about and responding to pain, which gives them greater relief, NIH notes.
As an example, self-management of back pain might include “brief rests, resumption of normal activities, strengthening exercises, structured physical activity, application of heat and cold, use of over-the-counter medications and topical ointments and creams, sleep, yoga and caution in lifting and carrying,” according to the Institute of Medicine Committee on Advancing Pain Research, Care, and Education.
2. Treat Underlying Depression To Reduce Pain
Chronic pain’s heavy emotional and physical toll often leads to depression – affecting as many as half or more people who live with pain, research shows.
In fact, the same region of the brain that regulates mood also regulates pain reception. The two conditions share nerve pathways, so it’s a vicious cycle: depression can amplify the body’s sensitivity to pain, making it worse, which can drain mental well-being.
“Over time, the association between chronic pain and major depressive disorder (not grief/demoralization) only strengthens and often the specific treatments for major depressive disorder are overlooked,” Clark notes.
Getting depression under control is critical to improve pain, and there are newer, extended release antidepressants that are effective for both conditions. A psychiatrist or pain specialist can recommend other treatments for depression including psychotherapy, mindfulness practices and cognitive behavioral therapy, an evidence-based practice that helps people change negative thinking patterns (see #4).
3. Move Your Body
A sedentary life can make chronic pain worse. Even if it brings temporary relief, inactivity can lead to muscle atrophy and loss of motion, and perpetuate the pain cycle. “Most people with chronic pain fear exercise. But unused muscles feel more pain than toned flexible ones,” notes the American Chronic Pain Association.
“Staying active, within realistic limits, can help us remain flexible and strong and reduce our sense of suffering.”
Natural endorphins from exercise can improve mood and coping skills for chronic pain patients. Exercise also shapes a stronger, more flexible body that can boost your independence and ability to perform daily household and work tasks.
Consult with a physical therapist or pain professional to create a careful program of therapeutic exercise, tailored to your health needs.
Pain management experts recommend gentle, flowing exercise such as Tai Chi, contemporary Qigong, Gyrokinesis exercises on a mat or chair, or The Feldenkrais Method which is used in functional restoration programs. Modified Pilates can build core body strength, and a yoga practice may reduce stress and increase joint flexibility. Aquatic therapy has been shown to relieve the symptoms of chronic back pain and fibromyalgia.
An integrated pain management program may also include functional activity training. This involves progressing through daily tasks such as lifting, bending, reaching, etc., using correct form at a pace that adapts to your injured body.
4. Reframe the Pain with CBT
Cognitive Behavioral Therapy (CBT), a form of psychotherapy, is well-proven to help people with all types of chronic pain. A report by the University of Washington, published in the Feb-March 2014 issue of American Psychologist, concludes:
“CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. The efficacy of CBT for reducing pain, distress, pain interference with activities, and disability has been established in systematic reviews and meta-analyses. Although average effect sizes are small to moderate across pain outcomes, CBT lacks the risks associated with chronic pain medications, surgeries, and interventional procedures.”
CBT teaches practical skills to help people reframe negative self-talk before a downward spiral ensues. They learn to cope more effectively with pain and emotional distress by correcting distorted thinking and disabling beliefs.
One tenet of CBT helps chronic pain patients to stop “pain catastrophizing” – exaggerating and ruminating about the threat of pain and perceived inability to handle it. For example, a spike in pain does not necessarily signal disaster or further debilitation. But believing it does could lead someone to give up – with no motivation to continue rehabilitation or effective self-management strategies. CBT teaches people how to visualize and mentally detach from the experience of pain, as they create healthier, more functional responses.
Conditions such as fibromyalgia, low back pain, migraine headaches, cancer, orofacial pain and arthritis have shown benefit with CBT. Unfortunately, many people with chronic pain do not receive CBT, since they are treated in primary care settings that don’t incorporate this psychotherapy technique.
5. Embrace Whole-Person Care
Research supports a functional restoration approach to chronic pain relief. The focus is on treating the whole person – not just the injury or illness – and maximizing independence and function. In other words, the patient learns to thrive despite a persistent pain problem.
Functional restoration emphasizes self-empowerment and individual mastery of pain control, vs. passive and palliative approaches.
Care is coordinated across disciplines and may include pain medications, interventions and sometimes surgeries – but also education on managing chronic pain, active exercise, mind/body interventions such as biofeedback or hypnosis, pet and music therapies, tai chi, yoga, acupuncture and a plethora of psychological and behavioral strategies to reduce emotional distress and improve coping skills.
Clark sums up this holistic treatment philosophy: “In general, the approach to chronic pain rehabilitation is the same as an approach to living a healthy life: diagnose and treat diseases, take responsibility and make good choices to establish and reinforce healthy habits, address personal vulnerabilities with expert guidance and practice, and pursue virtuous goals striving to improve yourself and the world around you.”
As part of an overall treatment plan, holistic care may encompass some of today’s many advances in chronic pain relief, including:
- Radiofrequency ablation (rhizotomy), which heats nerve tissue to block pain signals and provide extended relief
- Low-doses of tricyclic antidepressants that can relieve pain whether the person is depressed or not
- Biofeedback, which helps control muscle tension and has been shown to be as effective as many medications in providing pain relief
- Botox injections that block nerve signals and can reduce chronic migraine headaches
- Infusion pain pumps that deliver medication directly to the spinal cord
- Cognitive Behavioral Therapy, shown in many studies to reduce pain intensity and improve quality of life
- Anti-seizure drugs that can relieve migraines, neuropathic and fibromyalgia pain
- Glove anesthesia, a self-hypnosis strategy that creates tingly numbness in the hand, which is then transferred to another body part to alleviate discomfort
- Lubricating injections into diseased knee joints (viscosupplementation)
- Interferential Current Therapy (IFC), a type of electrical stimulation that has been shown to be more comfortable and more effective than the TENS method for pain relief
- Trigger point injections that help people with fibromyalgia and myofascial pain syndrome
- Spinal cord stimulation and peripheral nerve field stimulation, which can provide pain relief after failed back surgery and other conditions
- Mind-body therapies such as guided imagery and mindfulness-based stress reduction that increase relaxation and may lessen the need for medication
6. Consider A Pain Clinic
Today there are dedicated pain clinics that can help you achieve the best outcome by providing an umbrella of “best practices” in chronic pain management. To restore function and productivity, these centers coordinate a team of therapies and specialists – which may include pain medicine physicians, physical therapists, psychologists, vocational counselors, nutritionists and alternative practitioners such as acupuncturists and hypnotherapists.
Many people visit pain clinics as a last resort, when they are in the later stages of chronic pain and it’s more difficult to treat. They may have tried only passive treatments, or visited many doctors without coordination of care. One study reveals that patients lived with pain an average of seven years before visiting a pain clinic (Flor, et. al., 1992).
7. Join A Support Group
Ongoing pain brings many challenges that can have a profound impact on your well-being. A support group may help you find emotional and practical support from others who understand chronic pain. You can also share what you’ve learned in your journey and help those with similar challenges.
The American Chronic Pain Association offers peer-led groups “to provide support, validation, and education in basic pain management and life skills.”
“The psychological dimension of disease is potent. I still believe many of our battles are fought north of the neck . . . Beware of thinking the worst. That can become a self-fulfilling prophecy.”
– American journalist Richard M. Cohen, author of “Blindsided,”
which chronicles his battles with multiple sclerosis and cancer