Finding Effective Treatment For Chronic Pain

January W. Payne

Acupuncture is thought to ease pain by raising the level of endorphins (natural pain relievers) in the body

Chronic pain is a problem that -- when healthcare, lost income, and lost productivity are taken into account -- is estimated to cost about $100 billion in the United States each year.

More than a quarter of Americans age 20 or older, or about 76.5 million people, say they've experienced pain that lasted longer than 24 hours, according to the American Pain Foundation -- and 42 percent have endured pain lasting longer than a year.

Nobody keeps good long-term national stats, but if North Carolina's experience is any guide, the numbers are on the rise: A just-published study in the Archives of Internal Medicine found that the prevalence of chronic low-back pain in the state more than doubled, to 10.2 percent, between 1992 and 2006.

Paul J. Christo, assistant professor and director of the Multidisciplinary Pain Fellowship at Johns Hopkins University School of Medicine (Baltimore, Maryland), calls undiagnosed, untreated, or undertreated pain a "significant public-health problem."

Chronic pain encompasses a multitude of ills, from back pain, headaches, neck pain, and conditions like arthritis and fibromyalgia to pain that develops as a result of cancer treatment and lingers for months or even years.

Low-back pain, migraines, and joint pain (particularly in the knees) are among the most common complaints, according to the National Center for Health Statistics.

Still, while it may have different origins, chronic pain "can be viewed as an illness in its own right because of its effect on function," says Russell Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York City.

Studies have shown that some people with chronic pain have brain abnormalities, though the connection between that and pain isn't well understood. One recent study, for instance, showed that women with fibromyalgia had blood flow abnormalities in a region of the brain known to discriminate the intensity of pain that weren't observed on CT scans done in healthy women. Another study showed that chronic pain may harm the wiring of the brain, as demonstrated on functional MRIs.

Chronic pain may also be caused by a problem with the "fight or flight" response, Christo says. "We believe that in certain pain conditions . . . the stress response can worsen pain because that stress response releases a chemical called noroepinephrine. . . . And noroepinephrine binds to certain receptors in the body that trigger pain."

"Pain is essentially an alarm system that is designed to grab your attention, and when it works properly, it signals harm or healing," says Scott Fishman, professor and chief of the division of pain medicine at the University of California-Davis School of Medicine. When the body heals, the pain should dissipate, but "the nervous system can become injured," Fishman says. "That's when the symptom of pain becomes the disease of chronic pain."

Finding relief can take quite an effort, since the causes are often not immediately clear and there isn't a sure-fire treatment. The battle can require a team of experts, so the multidisciplinary pain clinics or pain management programs that have sprouted up at hospitals, rehab centers, and in free-standing facilities over the past decade or so may be of particular help.

The clinics provide an all-in-one setting for care that, in addition to pain management specialists who may be trained as neurologists, psychiatrists, physiatrists, or anesthesiologists, may include physical therapists, family and vocational counselors, and massage therapists, for example. (The American Chronic Pain Association offers advice on selecting a pain clinic.)

After a full assessment, tailored treatment may include medications from anti-inflammatory drugs to antidepressants to opioids. Since commonly prescribed opioid medications such as oxycodone, fentanyl, and morphine can cause addiction, the American Pain Society and the American Academy of Pain Medicine have just released the first comprehensive clinical practice guidelines to help physicians make treatment decisions.

The guidelines, published in the Journal of Pain, suggest that physicians regularly assess people taking long-term opioids and do periodic drug screenings of patients who are considered to be at risk for abuse or addiction. Meanwhile, the U.S. Food and Drug Administration announced plans in February to require the brand-name and generic makers of morphine, oxycodone, fentanyl, and methadone to assist with a plan to reduce the risks associated with the drugs.

Other treatment options include injections of steroids or other medications, nerve blocks that interrupt pain signals, physical therapy, alternative therapies, and psychological interventions such as cognitive behavioral therapy, biofeedback, and guided imagery and other relaxation techniques. Acupuncture, which some people with pain find helpful, is thought to ease pain by raising the level of endorphins in the body, Christo says. "Endorphins are sort of like opioids. . . . They are natural pain relievers," he says. "They are released when the body experiences pain--when you sprain your ankle, cut your finger, in response to injury."

Still, research offers conflicting conclusions about the pain-relieving effects of acupuncture. A review of 13 studies published last month in British Medical Journal found that acupuncture offered only a small level of pain relieffor people with low-back pain, migraines, knee osteoarthritis, and postoperative pain.

Jennifer Phillips, 41, of Providence Forge, Virginia, saw 54 doctors before the fibromyalgia that caused her pain was diagnosed in 1996. Finally, after seeing an internist whose nurse had fibromyalgia, she found a routine that works for her: a combination of proper sleep (achieved, in part, using the tricylic antidepressant amitriptyline), daily supplements of vitamins, magnesium, and potassium, plenty of water, and a low-carb diet.

The search is on for greater relief. Studies are underway to look into the safety and effectiveness of alternative ways of delivering pain medications, such as an inhaled form of fentanyl that would get the drug into the patient's system more quickly. For older people who have fractures of the spine, vertebroplasty and kyphotlasty--two minimally invasive techniques in which bone cement is injected into the collapsed bone in the spine--can result in "significant pain reduction," Christo says.

In the ongoing debate over how best to handle back pain, a study just published in the Journal of the American Academy of Orthopaedic Surgeons finds that the most effective way to treat most degenerative disc disease cases is to combine physical therapy and anti-inflammatory medications, rather than having surgery.

While it may seem counterintuitive, people with chronic pain should try to get exercise. Experts say it's important to keep moving, both for the usual cardiovascular reasons and in order to avoid muscle atrophy. A supervised, individually designed exercise program, incorporating stretching or strengthening, may improve pain and functioning in people with chronic low-back pain, according to a 2005 study published in Annals of Internal Medicine. A physical therapist or personal trainer can offer the necessary advice. In fact, staying in bed for more than a day or two can make back pain worse, according to the National Library of Medicine's MedlinePlus.

Jeff Nance of Indianapolis, Indiana, whose chronic pain is caused by degenerative disc disease and spinal stenosis of his lower back, recalls that he barely wanted to leave his home three years ago. Then he discovered the Meridian Health Group pain clinic in Indianapolis. Now he's working full time again and recently participated in an annual bike ride across the state of Indiana. Nance goes back to the clinic every few months for a check of his medications, and he sees a psychologist a couple of times a month.

"What we try to do is really recognize that people can have pain for all kinds of reasons, (and we) find as many of those causes as possible and treat them in the most specific fashion as possible," says Michael Clark, associate professor and director of the Chronic Pain Treatment Program in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins Hospital. "Ultimately, you'd like to get somebody well."

IN CHRONIC PAIN? YOU MIGHT NEED PSYCHOTHERAPY

When people with chronic pain are advised by their physician to see a therapist, many balk at the idea. They often assume the message is that their pain is imaginary, all in their heads. But the services that a psychologist can offer--cognitive behavioral therapy and biofeedback, for example--can ease the misery by helping people learn to cope, says Robert Kerns, a professor in the department of psychiatry, neurology, and psychology at Yale University.

Kerns was coauthor of a 2007 review published in Health Psychology that found psychological interventions to have a positive effect on the chronic low-back pain that afflicts at least 70 percent of adults at some point during their lifetimes. The review authors examined 22 studies and found that cognitive behavioral therapy and self-regulated treatments (such as biofeedback and hypnosis) eased pain intensity, improved quality of life, and reduced symptoms of depression.

People sometimes report chronic pain continuing for months or years after an injury, illness, or surgery. The original cause of the pain has healed, yet the person still hurts. And these people are not "manufacturing the pain," says Dave Patterson, professor of psychology in the department of rehabilitation medicine at Harborview Medical Center at the University of Washington.

There are several different mechanisms, he says--among them that when people stop moving and/or guard their bodies because of pain, even after they heal, the lack of movement and the way they guard their bodies can cause pain. Also, after someone has experienced pain for a long time, Patterson says, "the brain seems to become rewired so that it responds as if the person is in pain, even though the initial injury might have healed."

That's where psychological interventions can be useful. Besides cognitive behavioral therapy and biofeedback, treatments may include meditation, guided imagery, and hypnosis, among others. The goal, says David Bresler, president of the California-based Academy for Guided Imagery and founder of the UCLA Pain Control Unit, is to teach people how to relax, raise their tolerance to pain, and better manage the stresses in their life.

These techniques "don't cause dependence or addiction," which can be a concern with narcotic pain medications, notes Bresler. "We believe that guided imagery," for example, can be used to elevate the "production and release of endorphins, the body's most powerful, natural pain relievers." Guided imagery, which involves focusing intently on relaxing images in your mind, has been used for treatment of pain, addictions, anxiety, phobias, panic disorders, cancer, depression, fertility problems, post-traumatic stress disorder, and other problems.

Psychological counseling can also foster good sleep habits, improve functioning and quality of life, and help people learn how to pace themselves. Many people with chronic pain say they feel worse when they sleep poorly or overdo it on work, school, or social activities. And "we do know that if people can reduce stress and sadness in their lives, learn to become physically active in a safe manner, and constructively alter the internal thoughts they have about their pain, that they can tolerate it much better regardless of its origin," Patterson says.

Among the tools used to accomplish this is cognitive behavioral therapy, a mainstay of psychological treatment that involves "breaking big problems into bite-size pieces, [which helps] in terms of improving coping and using stress management techniques," says Robert Jamison, a clinical psychologist and associate professor at Harvard Medical School.

CBT can teach people living with chronic pain that "how they think about their pain can make it worse," Patterson says. "If they catastrophize, with thoughts like 'My pain will never go away, I will always feel like this, I'm going to die because of this pain,'" that can make a person feel more miserable. So therapists teach patients to "modify their thoughts about the pain and replace them" with more positive thoughts, he says.

What's important to realize, Kerns says, is that the experience of seeing a therapist isn't like what you see on the movies or television. People "should know that it's a brief treatment, usually delivered in an average of 10 outpatient treatment sessions, typically delivered once a week, for less than an hour each," he says. "The treatment itself is more like a class, very focused on their pain, individually tailored to their problem and how their problem is impacting their functioning, and it's designed to provide them with real-life skills for improving their own management of their pain."

Three other common treatments:

--Meditation, the act of focusing attention on your breath, an object, or a word, or maintaining a specific type of posture, is intended to relax the mind and body. Goals of the technique include achieving psychological balance, mental calmness, or physical relaxation, according to the National Center for Complementary and Alternative Medicine. Scientists don't know whether meditation has a positive impact on health, but studies are underway to find more answers about how helpful it might be and, if so, for which diseases or conditions. The technique seems to reduce stress, which may result in decreased pain.

--Hypnosis is a focused type of concentration. It may involve saying a positive statement repeatedly or, in the case of guided imagery, thinking of relaxing images. It's considered to be a simple yet effective method of pain reduction for many people, as noted by the National Library of Medicine. The technique has been tried for relief of pain after surgery or during labor and for pain caused by arthritis, cancer, fibromyalgia, irritable bowel syndrome, and headaches.

--Biofeedback measures blood pressure, breathing, heart rate, muscle tension, and skin temperature. The goal is to adjust these bodily functions through relaxation techniques or by thinking of pleasing images. As these levels are shown on a screen, the practitioner working with you talks about stressful situations and then provides instructions on techniques for relaxation, in an effort to show you how your blood pressure and heart rate react.

The goal is for people to learn how to apply these techniques in real life when they feel themselves becoming stressed. Biofeedback is thought to help with chronic pain as well as high blood pressure, headaches, and urinary incontinence.

HOW BAD IS YOUR PAIN? ASK YOURSELF THESE QUESTIONS

Are you hesitant to seek medical advice about your pain? These questions may help you decide whether it's time to call the doctor:

-- Is your pain interfering with multiple activities (work, school, social life)?

-- Does your pain interfere with sleep?

-- Does your pain make you feel sad or depressed?

-- Is your pain interfering with your relationships with significant others?

If you answer yes to one or more of these questions, it may be time to talk with your doctor about treatment options. These questions are not intended to be used in place of medical advice or treatment. Please consult your personal physician.

HEALTH & WELLNESS ...

Health: Finding Effective Treatment For Chronic Pain