New advances in drugs and technology mean there are now better solutions for chronic pain relief.
By Jeanie Lerche DavisWebMD Feature
Reviewed by Brunilda Nazario, MDIf you're living with chronic pain, here's important news. Today's pain specialists have sophisticated new treatments -- from effective drugs to implants and electrical stimulation -- to provide chronic pain relief. There's much that can be done to tame the beast.
These advances have emerged in the past several years, as researchers have gained a greater understanding of chronic pain and how it develops. The origins of chronic pain are all too familiar: sports injuries, back injuries, car accidents -- or health conditions like migraines, diabetes, arthritis, shingles, and cancer.
At times, however, there is no obvious cause of the chronic pain, no trauma or injury people can point to as a source of their chronic pain problem -- which has been frustrating for both patients and their doctors.
The Roots of Chronic Pain -- and Relief
In past generations, people often heard that chronic pain was "all in their heads," says Rollin M. Gallagher, MD, MPH, director of pain management at the Philadelphia VA Medical Center.
Today's pain specialists understand how the sensation of pain occurs -- how the nervous system, including the spinal cord, interacts with the brain to create that sensation, Gallagher says.
Insights into the neurotransmitter system -- the chemical messengers that pass nerve signals -- have opened the door for important new modes of chronic pain relief, he explains. In recent years, scientists have learned how to manipulate those chemical messengers to change the way they interact with the brain's signals.
That's led to use of antidepressants and other drugs that work with specific brain chemicals that affect emotions, and help with perception of pain. "We now have a whole new host of medications that are very effective" for chronic pain relief, Gallagher tells WebMD.
And with advances in MRI imaging, researchers can clearly demonstrate that the changes are very real in the brain, he says. "We can show exactly where the sensation of pain is occurring in the brain when it is activated by stimuli. We can see the effects of pain on emotion -- and emotion on pain."
There's new understanding, too, of a process called "central sensitization," says Kwai-Tung Chan, MD, a pain specialist and professor of physical medicine and rehabilitation at Baylor College of Medicine in Houston. "If initial pain from an injury is not adequately treated, those pain signals are sent repeatedly -- which leads to changes in the central nervous system, making it more and more sensitive. Over time, even the gentlest touch can become very painful."
Pain Specialists: Experts in Chronic Pain Relief
With these insights, pain specialists now prescribe treatments that attack moderate-to-severe chronic pain from different angles -- innovative drugs, targeted nerve-zapping procedures, and drug pumps that deliver strong painkillers to the nerve root. Doctors also endorse the use of psychotherapy, relaxation techniques and alternative therapies, supported by growing evidence of the mind-body connection in chronic pain relief. It's an exciting time in pain management -- and there are more advances coming. "Our knowledge has increased tremendously in the last few years," says Salahadin Abdi, MD, PhD, chief of pain medicine at the University of Miami School of Medicine. "We still have a lot to learn, but research has given us clues in developing even newer treatment options."
There's one big problem: Many people don't know that there are medical doctors who specialize in treating pain, Abdi tells WebMD. "We do exist and we can help. But unfortunately, we see many patients in the later stages of chronic pain when it is more difficult to treat. The earlier we start treatment, the better chance we have of being successful in relieving pain."
Medications: First Step in Chronic Pain Relief
When treating pain, doctors typically start with oral painkillers like acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil, Motrin, Naprosyn, and Voltaren. These reduce inflammation and relieve pain, especially related to arthritis, tendinitis, nerve injury, mild to moderate cancerpain, and other forms of chronic pain.
Finding which drugs work for your chronic pain will likely be a trial-and-error process -- although specialists are honing in on the solutions. "There is no magic bullet," Chan says. "Some medications work better with specific types of pain. We try different drugs or combinations of drugs until we arrive at what is optimal. Individualized treatment is very important."
When pain is severe, doctors turn to stronger pain relief medications:
Anticonvulsants. Drugs used to treat seizure disorders have been effective in chronic pain relief. It's still unclear how they control pain, but the drugs are believed to soften the effects on nerve-related pain such as postherpetic neuralgia from shingles. These include Lyrica, Neurontin, and Tegretol.
A new generation of anticonvulsant drugs is looking promising for chronic pain relief, says Gallagher. "There's a lot of work being done to improve these drugs, make them more convenient to take -- with fewer side effects."
Antidepressants. Low doses of common antidepressants are being prescribed for many chronic pain problems. These drugs adjust levels of brain chemicals, which is thought to be their mechanism for helping to control pain.
Antidepressants often help when patients don't get complete chronic pain relief from other treatments. They relieve pain whether the person is depressed or not. The doses needed to treat pain are usually lower than doses used for depression treatment.
Elavil, Pamelor, and Norpramin are tricyclic antidepressants prescribed to help treat pain, especially cancer pain, nerve pain from diabetic neuropathy, and postherpetic neuralgia pain from shingles. They affect levels of the brain chemicals norepinephrine and serotonin.
Cymbalta is a serotonin and norephinephrine reuptake inhibitor (SNRI), which increases availability of the brain chemicals serotonin and norepinephrine. Cymbalta is FDA-approved for the treatment of diabetic neuropathy and fibromyalgia. Pain relief creams. Topical painkillers like Zostrix, which contains capsaicin, are often helpful. Capsaicin works by reducing transmission of a pain-relaying chemical called substance P to the brain. Products with these ingredients also work: salicylate (found in products like Aspercreme and Bengay), a substance that decreases inflammation and relieves pain; and counter-irritants like camphor, eucalyptus oil, and menthol, which relieve pain by causing either coolness or heat at the pain site.
Skin patches. A transdermal patch that contains lidocaine can offer chronic pain relief. The patches are FDA-approved for chronic nerve pain from shingles, a condition known as postherpetic neuralgia. Lidoderm and Lidopain are two lidocaine skin patches, available by prescription.
Narcotics: Serious Medicine for the Worst Chronic Pain
When pain is severe, pain specialists take treatment to the next level. Narcotic pain medications like codeine, fentanyl, morphine, and oxycodone work on the nerve cells' pain receptors and are very effective in controlling severe chronic pain.
But use of narcotics has always been controversial. "There's been a perception among many doctors that they will get into legal problems if they undertreat or overtreat pain with opiates," Chan tells WebMD. "That is a factor of not having adequate education about these medications. These are very effective for the right patients. We have to use them carefully, but they can be used long-term."
"There is a small risk of addiction," Chan says, "but studies show that used appropriately, the risks are small."
When prescribing narcotics, pain specialists often prescribe combinations of medications -- taking advantage of new extended-release antidepressants, for example.
"Combining medications lets us reduce the amount of narcotic," Abdi tells WebMD. "It also lets us provide better pain relief, because the mechanism of narcotics is different from drugs like antidepressants and anticonvulsants." This approach is critical in treating nerve injury-related pain, as with diabetic neuropathyneuropathy, he adds.
Chronic Pain Relief With Synthetic Opioids & More
Ultram ER is a non-narcotic drug which works on opioid receptors. It is indicated for moderate to moderately severe chronic pain when continuous pain treatment is needed.
The synthetic narcotics don't seem to have a risk of addiction, Abdi tells WebMD. "They are very effective in treating a lot of different types of pain syndromes. A lot of physicians prefer to utilize them before progressing to narcotics."
Among the newest narcotics for chronic pain relief:
The Duragesic transdermal skin patch is a narcotic treatment for moderate to severe chronic pain. It provides continuous delivery of the narcotic fentanyl for 72 hours.
More options for pain flare-ups. There are also two fast-acting medications containing the narcotic fentanyl. It was developed for cancer patients who have breakthrough pain -- and who are already taking opioid medications for cancer pain. Actiq comes in a "lollipop" form and Fentora is a tablet that dissolves in the mouth. For some, these procedures can also help with chronic pain relief:
Nerve blocks. When a group of nerves is causing pain to a specific organ or body region, the pain can be blocked with injection of a local anesthetic. That's a nerve block.
Injections and nerve blocks are more effective for treating acute pain. "But for people with a pinched nerve, nerve block injections can dampen pain so the patient can function ... get into physical therapy," Chan tells WebMD. "If they're used early on for a pinched nerve, they can prevent chronic pain from developing."
Radiofrequency ablation. In this outpatient procedure, a small area of nerve tissue is heated to decrease pain signals from that area. The procedure is conducted under guided CT imaging. A needle is inserted at the offending nerve site, then an electrical current produced by a radio wave is used for the heat-and-destroy mission. The chronic pain relief lasts for a relatively long period, from three to six months.
"This is a big advance because it is very localized, very specific, pain treatment," says Gallagher. "It's not a cure-all, but it can really make a difference in specific cases."
TENS. Transcutaneous electrical nerve stimulation (TENS) therapy is helpful for short-term pain relief. The treatment involves a small device to deliver low-level electrical current when it's needed to help block pain. "TENs is especially helpful in treating various types of muscle pain, and is often used with trigger point injections," says Abdi.
Trigger point injection. Trigger points are painful sites in muscle or connective tissue. These trigger points can irritate the nerves around them and cause pain in other parts of the body. Extreme tenderness can also develop in nearby muscles or regions of the body.
In a trigger point injection, a local anesthetic (sometimes with a steroid) is injected into trigger point to relieve the pain. It typically takes only a few treatments to resolve trigger point pain.
"Patients can get good muscle pain relief from these injections," Abdi says. "It's a relatively simple, safe procedure. It gives them enough relief that they can go to physical therapy. That's important in preventing a reinjury."
Pumps & Pacemakers: New Generation of Chronic Pain Relief
Pain specialists also turn to more sophisticated technology to offer chronic pain relief.
Pain pacemakers. The technique is called spinal cord stimulation, and it involves a pacemaker-type device that is implanted in the body. The body delivers low-level electrical signals to the spinal cord or to specific nerves, which helps block pain signals from reaching the brain. The patient can adjust the on/off button and adjust the intensity of the electrical signals.
Spinal cord stimulation is often used when other treatments have failed -- as with failed back surgery, says Abdi. "It is also used when cancer pain infiltrates a nerve root," he tells WebMD. "When medications don't work, we advise patients to try the stimulator. If it works well, then they can get a permanently implanted stimulator." Pumps & Pacemakers: New Generation of Chronic Pain Relief continued...
Spinal drug pumps. These are also called intrathecal pumps, because they send pain medication to the spinal cord. Local anesthetics, narcotics, and other painkillers can be delivered via these implanted pumps. With the push of a button, a painkiller is delivered to the site -- to block the nerve from sending a pain signal to the spinal cord.
"Often these are used with cancer patients, but also with patients who have tried pain medications but developed side effects," says Abdi. "The dosage is much, much less than an oral dose, so the side effects are less."
There's also a psychological benefit to the pumps, Gallagher says. "You can imagine if you're in agonizing pain after a major injury, and you're being transported to a hospital. If you have control over the pain, you can help prevent posttraumatic stress disorder (PTSD) due to the injury."
Surgery. While most severe pain is treated with medicine, surgery can also help in some cases. Removing a tumor can provide pain relief, as can shrinking a tumor using radiation therapy. In neurosurgery, pain nerves are cut to relieve pain.
Counseling to Cope Better With Chronic Pain
Living with chronic pain is hard, and depression, anxiety, stress, and anger can make pain worse. These negative emotions reduce the body's natural painkillers and increase the body's sensitivity to pain.
When chronic pain sets in, your life shrinks to fit your pain. You're less active, don't exercise. "That perpetuates the pain cycle, because it makes the perception of pain worse," Chan explains. "Your health, work, and relationships all suffer. You can't sleep. You're depressed. When your sleep and mood are affected, it perpetuates the feeling of pain."
With counseling, patients can learn coping skills in dealing with chronic pain. They can also figure out solutions to life problems that are causing stress or depression -- and regain a sense of control and pleasure in life.
Patients who get psychological counseling are also more likely to follow through with their treatment program, says Abdi. "Therapy keeps people actively involved in their physical therapy. Also, we need to make sure we involve family members in psychotherapy. They need to know what the treatment involves, and understand what the patient is going through. Families need to know they are part of the solution."
Alternative Approaches to Chronic Pain Relief
Stress makes pain worse, so learning to relax is a goal for patients. "If you're upset about something, your pain will go up several points on the pain scale," Gallagher explains. "Stress control techniques are very helpful for all types of pain."
Biofeedback, for example, helps people learn to train their minds to control body functions such as muscle tension, breathing, and heart rate -- all of which helps reduce anxiety and stress reactions. Studies have shown that biofeedback reduces frequency and duration of headaches, and works as well as many medications in providing chronic pain relief. A new twist in biofeedback is being developed, Gallagher says. One group of Stanford researchers is working on an experimental technique in which patients retrain the part of brain involved in uncontrolled pain.
The treatment happens while the patient is having a functional MRI scan, he explains. "They learn to control activation of the brain's pain center... so they can turn off the pain. They are, in effect, teaching the brain to unlearn that pain response. This is very exiting for the field of pain management. They're helping the brain rewire and unlearn the bad signal activation -- the pain signal activation."
Relaxation techniques are an important part of pain treatment. Deep breathing, meditation, guided imagery, hypnosis -- all these allow mind to help the body. Through regular practice, they help to reduce stress and promote relaxation, which helps with chronic pain relief.
Acupuncture, a traditional Chinese practice, has gained respect in Western medicine. The National Institutes of Health recognizes acupuncture as an effective pain reliever particularly for headache pain and back pain -- and suggests that the practice may help with other chronic pain conditions, including arthritis, fibromyalgia, and muscle pain.
"Acupuncture is definitely helpful with pain, and increasingly more and more insurance companies are covering acupuncture treatments," says Gallagher.
The bottom line from Chan: If you have an injury that causes pain, get the pain under control right away. "The attitude in this country is you need to suck it up," he tells WebMD. "But you're not doing yourself any favors if you do that. You need to see a doctor right away. If pain is addressed early on, it is much easier to treat -- before it becomes chronic." |
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