Conquering Chronic Pain
When the ache just won't go away, there are a host of therapies that can help.
Nine years ago, I made a foolish mistake: I helped a delivery guy carry new patio doors and windows into my house. Since then, I have struggled while doing the most basic things—opening heavy doors, picking up my kids or pushing a cart full of groceries. Any of these activities can bring on a deep ache or burning sensation in my left leg, heel or foot. To keep the pain at bay, I’ve given up activities I love—running, tennis, skiing and rollerblading.
There’s a name for my problem: chronic pain, which is defined as pain that persists for more than three months. And I’m not alone. About 42 percent of adults who report pain have experienced it for longer than a year, according to the American Pain Foundation. It’s an expensive problem, estimated to cost $100 billion per year in healthcare expenses, lost income and lost productivity. It also takes a toll on relationships, and 30 to 60 percent of people with chronic pain experience depression and anxiety.
The good news is that chronic pain is treatable. “There are effective medications for a variety of conditions that cause pain, and there are more pain specialists in New Jersey than ever before,” says Richard Winne, M.D., attending anesthesiologist at Morristown Memorial Hospital and a physician at New Jersey Pain Consultants in Morristown and Basking Ridge.
How Pain Sets In
When you get hurt—stub your toe, for instance—nearby nerves send a message to the spinal cord, telling your brain to feel pain. The throbbing sensation forces you to rest so that your body can heal. But a more serious injury (such as one that involves nerve damage) or illness can actually change your nervous system, causing pain pathways to become overly sensitive, so that something that wouldn’t normally hurt—like getting a hug or playing a mean game of tennis—now causes a lot of pain.
The most common types of chronic pain include low back pain, migraines, neck pain and facial discomfort. The condition can develop as a result of a car accident, arthritis, fibromyalgia (in which joints, muscles, tendons and other soft tissues are hypersensitive), diabetes or other problems. About 10 percent of people who have surgery may develop chronic pain, and roughly 20 percent of cancer patients will feel discomfort two years after surgery or chemotherapy. Despite its prevalence, chronic pain is undertreated because many primary care doctors aren’t trained in pain management, and some are reluctant to prescribe pain medications because they’re worried about addiction and abuse.
“The earlier pain is diagnosed and treated, the better,” says Dr. Winne. “It may be more important to be treated in the first three months after the onset of pain, but that doesn’t mean you shouldn’t seek treatment after six months.” (At the three-month mark, untreated pain may cause nerve cells in the brain to become hypersensitive so that you hurt even though your injury has healed.) If your primary care doctor has prescribed treatment and you haven’t experienced improvement after four weeks, consider a pain management clinic. Many such clinics are affiliated with major medical centers. Research shows that if you receive treatment quickly, you may be able to prevent long-term chronic pain from taking hold.
Treatment Options
Experts agree that the best way to knock out chronic pain is to attack it from many angles. It may not be resolved with only one therapy because there are often multiple causes of pain— muscle spasms as well as a herniated spinal disk, for instance. Keep in mind that treatment is usually trial-and-error.
Physical therapy (PT) Many pain medicine experts recommend exercise programs that involve strength training and cardiovascular conditioning and stretching to increase your range of motion. Such programs help reduce discomfort and restore flexibility, strength and function. You may experience a flareup of symptoms during PT, though, so be sure to find a therapist who is knowledgeable about treating chronic pain.
Biofeedback can help you control bodily functions that you’re normally not aware of, such as muscle tension, heart rate and breathing. Using feedback from a computer or other device, you can learn how to relax muscles, and this can help reduce pain.
Acupuncture A recent study showed that acupuncture was more effective than anti-inflammatory drugs, exercise and physical therapy in reducing low back pain among osteoarthritis patients. Acupuncture appears to reduce inflammation and stimulate the body’s natural opiate production.
Massage is believed to reduce levels of the stress hormone cortisol, which is associated with pain. It may also decrease levels of a hormone that constricts blood vessels and raises blood pressure, both of which can boost pain.
Yoga may be able to reduce pain by stimulating the body’s natural opioids. Its calming effect may also be beneficial.
Herbal remedies The Chinese herb thunder god vine was recently shown to reduce joint pain more effectively than a common medication among rheumatoid arthritis patients. White willow bark (Salix) may help relieve low back pain, and devil’s claw root may be beneficial for low back pain and osteoarthritis. Of course, the U.S. Food and Drug Administration doesn’t regulate these products, so their effectiveness, purity and safety are questionable.
Psychotherapy Talking with a psychologist, social worker or counselor can help you reduce the impact pain is having on your life.
Treating pain with medication
The medications listed here can be used to treat different kinds of pain, but some are especially effective for certain conditions. Your primary care doctor will prescribe the medication he or she thinks will work best for your particular type of pain.
NONSTEROIDAL ANTI-INFLAMMATORIES (NSAIDS) such as ibuprofen (Advil, for example) or acetaminophen (Tylenol) may be recommended initially. These over-the-counter drugs are often useful for headache, muscle ache, backache and arthritis pain. Although these medications can be effective, NSAIDs can cause ulcers, and acetaminophen can be toxic to the liver if you take too much. Some doctors prescribe NSAIDs called CO X-2 inhibitors, which have a lower risk of gastrointestinal side effects when used for a short period of time.
OPIOIDS are also commonly prescribed. They include morphine, codeine, oxycodone and methadone. Side effects include constipation, nausea and vomiting, as well as drowsiness, and these drugs require careful medical management because there is a risk of developing a dependency. Long-acting opioids are best for chronic pain, since their effects last for eight to 12 hours.
Antidepressants are helpful for people who suffer from both chronic pain and depression, but you don’t have to be depressed to experience pain relief with them. The brain chemicals serotonin and norepinephrine play a role in both chronic pain and depression. Antidepressants can be helpful for fibromyalgia, headaches, nerverelated pain (like diabetic neuropathy), migraines, postherpetic neuralgia (pain after shingles) and rheumatoid arthritis. Duloxetine (Cymbalta) was recently approved for the treatment of diabetic nerve pain, fibromyalgia and chronic musculoskeletal pain due to osteoarthritis and low back pain. Other antidepressants used to treat chronic pain include venlafaxine (Effexor) and amitriptyline (Elavil). Typical side effects include nausea, drowsiness, constipation and dry mouth.
Anticonvulsant drugs such as carbamazepine (Carbatrol and Tegretol), gabapentin (Neurontin) and pregabalin (Lyrica) may also be useful, especially for pain after shingles, fibromyalgia, nerve injury and diabetic nerve pain. Lyrica was recently approved to treat fibromyalgia. (It is also approved for diabetic nerve pain and pain after shingles.) Common side effects are dizziness, weight gain, drowsiness and swelling of the lower extremities.
Muscle relaxants such as cyclobenzaprine (Flexeril and Amrix) are often prescribed for their pain-reducing properties and are good for back pain, musculoskeletal problems, neurological illness or injury. They can be helpful during a flare-up, but they should not be used on a long-term basis. These medications are typically sedating.
“Patches offer good pain reduction with almost no side effects,” says Christopher Gharibo, M.D., medical director of pain medicine at the New York University Hospital for Joint Diseases in New York City. “They can help you minimize your use of oral medications.” Patches can be useful for pain after shingles, osteoarthritis and rheumatoid arthritis. The lidocaine patch (Lidoderm) and the capsaicin patch (Qutenza) are both approved for pain after shingles. Lidoderm is only available by prescription, but you can apply the patch yourself. Side effects include temporary skin irritation and swelling. Qutenza can only be applied by your doctor. Side effects include redness, pain and itching at the site.
Anti-inflammatory steroid injections for joints may provide temporary pain relief for osteoarthritis patients. Steroids may also be injected into the epidural spaces of the back and neck. This can help reduce inflammation in and near spinal nerve roots, temporarily relieving neck and low back pain. Nerve and facet (the small joint that allows you to bend and twist your back and neck) blocks involve injecting a combination of a local anesthetic and a steroid to block pain. They are best used for temporary relief.
The power of distraction Finally, though it may sound simplistic, focusing your attention elsewhere can be part of the solution. Brain imaging research shows that taking your mind off the pain actually works. “When you’re busy, pain becomes secondary,” says Dr. Winne. “I tell my patients to continue to work and stay active. If they quit working or become sedentary, they will hurt more.” I can’t agree with him more. Although I do experience flare-ups (such as when I played Ping-Pong with my kids during a recent vacation), I try to ignore them. I stay as active as I can—playing with my kids and taking walks—and my pain eventually subsides.
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