Chronic Pain Management: Finding the Right Treatment Mix

Chronic pain relief is a bit like major weight loss: It takes time, effort and often multiple methods to get noticeable results. Pain, like excess weight, is harder to shed when you’ve had it for many years. Finding the right blend of tactics or treatments can be challenging. There’s no magic wand to wave chronic pain away.

Pain specialists can tailor an individual plan to reduce and help manage your chronic pain. Realistic expectations are important: Just as you may never fit into size 0 jeans, you might always experience some level of pain or discomfort.

The key is to pinpoint individual approaches that allow you to feel better, function to your best ability and go about your day as well as possible. If you’ve been dealing with chronic pain, here’s what you should know.

What is chronic pain?

By definition, chronic pain is pain that lasts more than 12 weeks, as opposed to acute pain. “Historically, we’ve used a three-month cutoff,” says Dr. Naum Shaparin, director of the multidisciplinary pain program at Montefiore Health System and an associate professor of anesthesiology at the Albert Einstein College of Medicine in New York City. “When pain lasts longer than normal healing, that’s chronic pain — whenever pain lasts longer than it should.”

[See: 11 Ways to Cope With Back Pain.]

What are types of chronic pain?

Doctors use specific codes, known as ICD-10 diagnosis codes for chronic pain, on patients’ medical records. These include chronic pain due to trauma, like a bone fracture, chronic post-procedural pain (such as long-lasting pain after surgery), central pain syndrome and chronic pain syndrome, along with catch-all codes for diseases of the nervous system and for otherwise unclassified pain. Central pain syndrome involves damage to the central nervous system: the brain, brainstem and spinal cord. Stroke, multiple sclerosis, spinal trauma and Parkinson’s disease, among other conditions, can lead to central pain syndrome.

Which conditions cause chronic pain?

Back injuries and unsuccessful back surgery are notorious for causing persistent, hard-to-treat pain. Acute traumatic injuries can result in lingering pain. Chronic conditions such as diabetes, shingles and HIV can lead to nerve-related or neuropathic pain. Certain types of chemotherapy, such as cisplatin and vincristine, often cause neuropathic and other pain complications, as do conditions like bone cancer itself. Pain from rheumatoid arthritis can hamper people’s ability to function. Fibromyalgia is a chronic, complex pain syndrome, causing widespread muscle pain and tenderness throughout the body.

Can chronic pain be cured?

“It’s not unusual for a patient who has suffered from 20 years of pain to come to us at the pain clinic and say: I want you to make my pain disappear,” says Dr. Magdalena Anitescu, an associate professor and head of pain management within anesthesia and critical care at University of Chicago Medical Center. At that point, a deep discussion is needed to help patients realize that a 20-year-old pain cannot disappear overnight, says Anitescu, who is also director of the U.C. pain fellowship program.

“It’s making the patient understand that we are here to help with different tools to make the pain manageable, to teach them how to live with the pain, to try and find causes of the pain and make a better impact on what we can treat, and determine what are treatable or nontreatable causes,” Anitescu says.

What are first-line treatments for chronic pain?

When over-the-counter pain remedies — such as ibuprofen (Advil or Motrin) or naproxen (Aleve) — or home remedies aren’t enough, people seek professional treatment for chronic pain. Your primary health care provider may suggest strategies like gentle exercise or complementary therapies including acupuncture, yoga and tai chi. Physical and occupational therapy help many patients function better with less pain.

[See: Your Guide to Over-the-Counter Pain Relief.]

What is multimodal pain management?

“Treatment should be multimodal,” Shaparin says. Medication is only one facet of chronic pain management, he emphasizes. Physical and behavioral therapy, patient education and realistic expectations combined can help patients see improvement over time.

Diagnostic evaluations, including imaging tests such as MRIs, CT scans or ultrasound, may uncover clear-cut, treatable causes of pain. If that’s not the case, the focus shifts to optimizing the patient’s pain management. “We usually start physical or occupational therapy as soon as possible if they haven’t done that already,” Shaparin says.

Prescription-strength, anti-inflammatory medications may help. “Then, usually the next step is some medications that have shown success in dealing with nerve function,” Shaparin says. Although these medications fall into the antidepressant or anticonvulsant (anti-seizure) categories, he adds, they can help treat certain types of chronic pain.

When should you see a pain specialist?

If you and your primary care provider are keeping your pain under good control, that’s ideal. However, if chronic pain isn’t getting better or it’s worsening, then it’s time to ask for a referral to a pain management specialist or program.

“We welcome patients to come to us as soon as possible,” Anitescu says. “Because what we do is try to identify the cause of the pain and treat it as aggressively as possible in the beginning, with all the multimodal therapies we have available,” so it doesn’t become a chronic pain condition later on.

For example, Anitescu says, what started as a small injury to nerves or ligaments in your hand or neck could eventually develop into a central pain syndrome. “Your spine talks to the brain independently of any injury in the periphery,” she explains. “All types of pain that fall into this category are very hard to treat.”

At this point, Anitescu says, different types of nerve blocks such as sympathetic nerve blocks or epidural injections, or neuromodulation techniques like spinal cord stimulation may help, after carefully considering underlying pain causes and potential complications. Similarly, intravenous infusions of drugs such as ketamine or lidocaine could relieve pain, as well.

Physical therapy, muscle relaxants, psychotherapy and behavioral therapy are all possible tools in the multimodal regimen. “We try to look at pain as a disease and attack it from different angles,” she says.

How can counseling help with chronic pain?

“Pain is not just a symptom but also a state of mind,” Anitescu says. People with chronic pain express fear that they’ll always be suffering and never fully be able to enjoy their families, she says. Some worry that pain will leave them disabled. Depression is not uncommon.

Psychological counseling can help people come to terms with the limits of chronic pain treatment and the reality that pain might never completely go away. Cognitive behavior therapy provides practical and emotional strategies to work through pain and continue to function.

What about opioids and marijuana for chronic pain?

The use of opioids to treat chronic pain conditions when nothing else helps is highly controversial. The risks of opioid overdose and addiction and widespread consequences of the opioid epidemic are alarming. The goal is to address chronic pain before people are ever started on opioid drugs, Anitescu says. Opiates are rarely the complete solution for chronic pain conditions, she says.

Medical marijuana is gaining a lot of attention as a potential treatment for chronic pain. However, U.S. research on medical marijuana for pain control is scarce, so far.

[See: On a Scale of 1 to 10: Most Painful Medical Conditions.]

How can you tell if chronic pain is improving?

“We reframe the conversation about how the patient perceives pain to how it’s affecting them, and focus on that,” Shaparin says. That’s why physical therapy is emphasized to try and make people stronger and better able to function, even if they have some discomfort. “The important thing is to participate in activities, not just kind of isolate yourself and do less,” he says. “People should be as productive as possible and engaged in what they’re doing.”

Anitescu talks about “reorienting” a person to gauge progress. That, she says, might mean comparing how someone was virtually bedridden with pain a year ago to their recently enjoying a European vacation and walking around without pain. “Pain is subjective,” she says. “Pain is very personal. We have to treat it delicately and try to understand what patients’ goals are — how we can make their lives better.”

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