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Pain, Disease Management
By Stacey Colino

How to Manage Chronic Pain

Chronic pain doesn't go away, but treating it wisely and learning to live with it can alter its intensity.

After hitting her head at the pool and sustaining a mild traumatic brain injury when she was 10, Valerie Biscardi developed chronic migraines and trigeminal neuralgia (nerve pain) on the left side of her face. "I'm in pain every day; it's just a matter of degree and where it is in my body," says Biscardi, now 60, a retired public official in Long Island, NY, who also developed fibromyalgia in 2009. She manages her pain with medication and relaxation exercises and accepts that she'll never get rid of it completely. "I have to stay on top of the pain to keep it tamped down for a few hours before it ramps back up again," she says.

Illustration of woman meditating
Illustration by Gracia Lam

In 2004, Andy Viner Seiler developed Ramsay Hunt syndrome, a neurologic condition that's triggered by the virus that causes shingles. In his case, the syndrome has caused paralysis and drooping on the right side of his face and excruciating pain and tinnitus (ringing) in his right ear. "There's no cure, and the treatment for the pain is really inadequate," says Seiler, now 60, a retired reporter for USA Today who lives in Washington, DC.

Variable but Persistent

Chronic pain doesn't go away; by definition, it persists and lasts for more than 12 weeks, though it can ebb and flow over time. "It can be variable, constant, or intermittent," says Howard Fields, MD, PhD, FAAN, professor emeritus of neurology and physiology at the University of California, San Francisco. "Chronic pain is not a diagnosis—pain is the common denominator but the causes and mechanisms are different."

Chronic pain is surprisingly common: Approximately 25 million adults—11 percent of the population—had pain every day for the preceding three months, according to a 2015 report funded by the National Institutes of Health and published in The Journal of Pain. More recently, a June 2018 Harris Poll, commissioned by the American Osteopathic Association, found that 50 percent of the 2,041 adults surveyed reported experiencing chronic pain for three months or longer.

Chronic Pain Differs from Acute

Acute pain, a normal sensation that alerts you to possible injury or illness, usually resolves once the injury has healed or the repair process has been completed.

Chronic pain is different: Pain signals continue firing in the nervous system, even when there isn't a clear cause for pain, such as with migraine and fibromyalgia. And sometimes acute pain from an injury can evolve into chronic pain, often because of underlying inflammation, Dr. Fields explains. "Whatever is causing the pain is continuing," he says.

There are two primary types of chronic pain: nociceptive pain, which stems from damage to body tissue, such as with musculoskeletal conditions like low back pain and arthritis, inflammation, or mechanical/compression problems, and neuropathic pain, which is caused by nerve damage.

With neuropathic pain, which includes diabetic neuropathy, post-herpetic neuralgia, and post-stroke pain, the sensation of pain is ongoing because the nerve fibers in the central or peripheral nervous system are damaged or dysfunctional and continue to send pain signals to the brain, Dr. Fields explains.

Domino Effect

Increasingly, researchers are beginning to recognize that "there is not a single mechanism for chronic pain; it's a cascade of events," explains Misha Backonja, MD, professor emeritus of neurology at the University of Wisconsin and clinical professor of neurology at the University of Washington in Seattle. "The central nervous system becomes increasingly sensitized to pain, there's a failure of pain-inhibiting mechanisms, microglia [cells in the brain and spinal cord] promote inflammation, and stress hormones play a role."

With chronic pain, "the nervous system develops its own sense of what is normal," says Charles E. Argoff, MD, professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center in New York. "Changes in wiring occur in the brain, and the mechanisms become ingrained in the nervous system." The phenomenon of chronic pain is often compared to a faulty alarm system, Dr. Backonja says: Without good reason, the siren continuously goes off, and it may take less and less to trip the wiring, causing the pain to flare.

In addition, how people respond to chronic pain affects how they experience it, he says.

Custom Treatment

Thanks to increasing recognition that different receptors and substances are involved in different forms of pain, there has been a shift away from treating it all the same. "All pain should absolutely not be treated the same way—that's an oversimplified approach that doesn't work," Dr. Fields says. At the same time, there has been a shift toward recommending nonpharmaceutical options for managing chronic pain.

Opioid Treatment

In the 1990s, the use of prescription opioids for treating chronic pain increased dramatically, thanks largely to lobbying efforts by pain advocacy groups and pain specialists, says Gary M. Franklin, MD, MPH, FAAN, research professor in the departments of environmental and occupational health sciences, neurology, and health services at the University of Washington in Seattle.

Then the opioid abuse and overdose epidemic hit. From 1999 to 2014, more than 165,000 people died from overdoses of opioid painkillers in the United States, according to the US Centers for Disease Control and Prevention (CDC).

After that, public health officials and other experts began rethinking how, why, and when to prescribe these drugs, which led to the CDC issuing guidelines for primary care physicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Among the recommendations: When starting opioids for chronic pain, doctors should prescribe the lowest effective dose of immediate-release opioids (not extended-release or long-acting ones). They also should consider the benefits and risks within one to four weeks of starting opioid therapy for chronic pain and continue to re-evaluate at least every three months. The recommendations also note that "nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain." If opioids are warranted, the guidelines recommend that they be prescribed in conjunction with nondrug therapy and nonopioid medication.

Meanwhile, the American Academy of Neurology (AAN) issued a position paper about prescribing opioids for chronic non-cancer pain. These recommendations include monitoring the patient's daily use at every office visit and perhaps with random urine drug screening; screening for past and current substance abuse, depression, anxiety, and posttraumatic stress disorder; using a physician-patient treatment agreement that spells out the risks of using the drug and the patient's responsibilities; and avoiding prescribing more than 80 to 120 mg per day of morphine-equivalent doses unless the patient experiences sustained, meaningful improvement.

In the meantime, between 1999 and 2010, the number of prescription painkiller overdose deaths increased five-fold among women in the United States, according to the CDC, although more men still die of drug overdoses.

The Limits of Opioids

Whether opioids are even effective for chronic pain is a matter of debate. Some pain specialists contend that opioids have been so stigmatized that people who might benefit are not getting the treatment that would best manage their pain. "There are many patients for whom nonopioid therapies do not work very well, if at all," says Michael C. Rowbotham, MD, chief research officer for Sutter Health in San Francisco and adjunct professor of anesthesia and emeritus professor of neurology at the University of California, San Francisco. "These patients would be more functional if they had access to opioids."

Dr. Franklin, who wrote the AAN position paper on opioids for non-cancer pain, disagrees. He says that while opioids are "the ultimate weapon for acute pain, they are not very effective for chronic pain, especially musculoskeletal conditions like fibromyalgia, or headaches, where the locus of pain control is in the brain."

Also of concern is a phenomenon called opioid-induced hyperalgesia, in which some people who take opioids develop a heightened sensitivity to pain and a lower tolerance for pain, due to changes in the nervous system. "It's theoretically possible that some individuals may rapidly escalate their doses of opioid therapy because they are becoming more tolerant of the drug," Dr. Argoff says. "Others can remain on the same dose for years and be adequately treated."

"Patients should be able to have an open discussion with their physicians about their pain-control options," Dr. Argoff adds. "The optimal way to use opioids is to use nonopioids and cognitive behavioral strategies first and to recognize that the potential for addiction to opioids is real."

Personalized Prescriptions

Doctors increasingly acknowledge that people can have diverse responses to various pain treatments and that different receptors and pain-inducing substances are involved in the underlying causes of chronic pain. "We're moving toward targeted therapy and away from a general approach," Dr. Argoff says. Already, research is investigating therapeutic targets such as antibodies for cytokines and nerve growth factors that are involved in certain chronic pain processes. "Once we have better biomarkers for pain, like we have with cancer, pain management can be better targeted," says Dr. Rowbotham.

In the meantime, a multidisciplinary holistic approach that considers the entire person is considered the gold standard when it comes to treating chronic pain. "A purely pill-based approach is not the best practice," says Beth Darnall, PhD, clinical professor of anesthesiology, perioperative and pain medicine, and psychiatry and behavioral sciences at the Stanford University School of Medicine in Palo Alto, CA. "We need to address the whole person, to treat the pain more broadly. The focus should be on empowering the patient to best control his or her own pain and symptoms."

Multiple Treatment Options

As far as medications for chronic pain go, doctors have a wider array than ever before, says Dr. Argoff. Options include time-limited low doses of opioids, analgesics, muscle relaxants, anti-inflammatory drugs, antidepressants (particularly tricyclics such as amitriptyline and serotonin and norepinephrine reuptake inhibitors, such as duloxetine [Cymbalta]), and anticonvulsant drugs, such as gabapentin and pregabalin. All are FDA-approved to treat chronic pain, but some are used off label to treat certain forms of it.

"The best evidence shows that a combination of medications works better than any one alone does," Dr. Argoff says. A study published in the November 2016 issue of Pain Medicine found that when patients with chronic sciatica, a form of neuropathic pain, who were taking amitriptyline added gabapentin to their regimens, 56 percent reported a significant reduction in their pain. "Combining A and B can lead to more tolerated doses of A or B alone," Dr. Argoff notes. In addition to oral medications, there are injectable therapies such as steroids, anesthetics, or nerve blocks; topical agents such as capsaicin cream, lidocaine, or nonsteroidal anti-inflammatory patches; and implant therapies such as spinal cord stimulation for chronic neuropathic pain.

Meanwhile, physicians are increasingly encouraging their patients to try nonpharmaceutical interventions in conjunction with any pain medication. Here are nine strategies experts recommend adopting.

  1. SIGN UP FOR PHYSICAL OR OCCUPATIONAL THERAPY. Physical therapy can help improve mobility, comfort, and functionality, Dr. Fields says. By improving muscle strength and flexibility, physical therapy can help prevent muscle wasting, weakness, and stiffness, says Dr. Fields. It also can help people overcome fear of further injury.
    Occupational therapists can help people figure out how to adjust the height of their chair and computer monitor at work and alter their methods of lifting objects to ease strain on the body, Dr. Fields notes.
  2. AVOID CATASTROPHIZING. When people dwell on their pain or expect it to worsen, a phenomenon known as catastrophizing, they can slip into a negative mindset that can amplify their pain. "Pain catastrophizing can lead to changes in the nervous system that prime the individual for future pain, including experiencing it at greater magnitude," Dr. Darnall says. It also can trigger the body's fight-or-flight response, which can lower the pain threshold, Dr. Argoff notes.
  3. MANAGE YOUR EMOTIONS. If you're anxious or depressed, those states of mind can amplify pain; if you reduce anxiety or depression, with the help of therapy or medication, "that in and of itself will relieve pain," Dr. Fields says.
  4. CONSIDER COGNITIVE BEHAVIORAL THERAPY. Cognitive behavioral therapy (CBT) can help people with chronic pain change the thought patterns and behaviors that contribute to their pain and improve their self-efficacy for managing their pain, Dr. Fields says. With CBT, "people also learn soothing self-talk to de-escalate painful cycles and trigger a relaxation response," Dr. Darnall says. A study published in the March 2017 issue of The Clinical Journal of Pain found that after fibromyalgia patients who had a tendency to catastrophize completed four weeks of CBT, they experienced significant reductions in both their pain intensity and their catastrophizing.
  5. INCORPORATE MEDITATION. Engaging in meditation may help patients "get some distance from sensations in the body, which can help turn down the volume on their pain," Dr. Fields explains. A study published in the April 2015 issue of Pain Medicine found that patients with chronic pain who participated in a mindfulness meditation program had greater vitality, higher pain tolerance, more control of their pain, and better psychological well-being after six months than those in a control group.
  6. KEEP MOVING. It's important to continue to exercise regularly, doing an activity that's comfortable such as walking, swimming, yoga, or tai chi. Aside from improving aerobic and musculoskeletal fitness, exercise can reduce the sensation of pain by stimulating the release of the body's own pain-relieving chemicals such as endorphins and enhance the ability to cope with pain, Dr. Backonja says.
    Despite having pain on the left side of her body from central pain syndrome, a neurologic condition caused by damage to the central nervous system, Patti Gilstrap forces herself to ride a recumbent bike for 15 to 30 minutes every day. She also occasionally lifts two-pound weights and does chair exercises. "Exercise helps me feel better about my body, and the endorphins help with the depression that results from chronic pain," says Gilstrap, 59, of Medford, OR.
    If you don't exercise, "the body will start to atrophy, which predisposes people to future pain, health problems, and a downward cycle," Dr. Darnall warns.
  7. SLEEP SOUNDLY. Getting enough sleep is another key ingredient in the pain-reducing picture because "sleep deprivation makes pain worse," Dr. Fields says. A study published in the April 2012 issue of the journal Sleep found that partial sleep deprivation (staying awake from 11 p.m. until 3 a.m.) induced increases in self-reported pain, fatigue, depression, and anxiety in people with rheumatoid arthritis. Make a habit of practicing good sleep hygiene, Dr. Franklin says, by sticking with regular bedtime and wake-up times and giving yourself a chance to relax before bed.
  8. STAY SOCIALLY ENGAGED. Even when you hurt, try to stay in touch with friends and family. Engaging in activities you enjoy will help you see past your pain. Remember: being pain-free isn't the goal, Dr. Darnall says. "The goals are to increase functionality, to help you engage in more activities that are meaningful to you, and to optimize your ability to control your own pain and symptoms," she says.
    Biscardi agrees wholeheartedly. "Chronic pain isn't going to go away, so you really have to find ways to make yourself happy and be willing to adjust your life," she says. She practices yoga every week and discovered a love of painting after she retired. "It's all about trying to calm your central nervous system."
  9. EDUCATE YOURSELF. Understanding the neuroscience behind chronic pain can help you manage it better. A study published in the July 2018 issue of JAMA Neurology found that when people with chronic spinal pain participated in a program that combined education about the neuroscience of pain with a cognition-targeted physical therapy program, they experienced less pain, improved functionality, and had better physical health after three and 12 months than those who did traditional physiotherapy combined with education on back and neck pain. "It's important to understand the pain process and your role in it," Dr. Rowbotham says. "That way, you can maximize behavioral strategies for controlling the pain."

Turning Off Negative Thoughts

The brain and the body communicate in myriad ways, and chronic pain is no exception. Thoughts and expectations can send signals to the spinal cord, and vice versa, stimulating cells that either inhibit or facilitate the sensation of pain, says Howard Fields, MD, PhD, FAAN, professor emeritus of neurology and physiology at the University of California, San Francisco.

Release Negative Thoughts by Sachin Modgekar from the Noun Project

A review published in a 2017 issue of Current Rheumatology Reports concluded that positive attitudes can significantly diminish the experience of persistent pain through a variety of psychological and neurobiological pathways.

Rather than triggering or resolving chronic pain directly, your expectations can turn the volume on your pain up or down. "If you expect the pain to be there, that will allow whatever input is coming from the tissues to increase the intensity of the pain you feel," Dr. Fields says. "By contrast, when you expect pain relief, your brain turns on pain inhibitory signals."

Negativity Equals More Pain In a study published in the April 2018 issue of the European Journal of Pain, researchers had 211 people with severe chronic pain complete online daily diaries that assessed their thought processes, moods, and pain intensity for two weeks. Those who had stronger negative thoughts had greater emotional distress and more trouble adjusting to their pain.

These findings aren't a fluke, says Beth Darnall, PhD, professor of pain medicine at the Stanford University School of Medicine in Palo Alto, CA. "Your state of mind is a powerful predictor for how much pain you will feel and how well treatments work."