Pain Management

Overview

Pain in the neck. Royal pain. Pain and suffering…Pain rarely refers to anything good! Yet, pain is one of the most common human experiences. In fact, about 100 million Americans struggle with chronic pain.

Pain is the body's way of sending a warning to the brain that something is wrong. It's a necessary evil, and it helps keep us safe from harm. Think of what would happen if you didn't feel pain when you touched a hot stove, for example, or a sharp knife. You feel pain when pain signals travel from the nerves along the spinal cord to the brain. Once they get to the brain, these pain signals combine with thoughts, feelings and expectations to shape the way we think and respond to that pain.

Pain can be "acute" or "chronic."

• Acute pain can be mild or severe. It can last for just a minute or two or for months. Acute pain is caused by something specific and often goes away as your body heals.
• Chronic pain lasts for at least six months. Sometimes it is hard to pinpoint the source of chronic pain. Over time, chronic pain can affect your daily life and lead to depression, anxiety, anger and low self-esteem.

When an injury has healed, but the brain is still responding to signals of pain, pain becomes a medical condition.

Diagnosis

Studies show that women are more likely to seek treatment for pain. This is probably because women experience pain more than men. and they also are more likely to speak with their healthcare providers about pain. It isn't always easy to talk about pain. Some people think talking about pain is a sign of weakness.

Some of the most common causes of chronic pain are back pain, leg/foot pain, arm/hand pain, headache, and pain caused by diseases. Most patients who report chronic pain say they have more than one type of pain.

Pain cannot be measured objectively; only the person with the pain can say how much pain she is feeling. A healthcare provider will try to assess the pain by asking the patient where she feels the pain, how long she has felt the pain, if the pain is constant, and how she would rate the pain on a scale of 0 to 10. A patient will also be asked to describe the pain, whether it's sharp or dull, throbbing or shooting, hot or cold.

Tests to diagnose pain may include:

• A physical exam
• Blood, urine and spinal fluid tests
• Reflex, balance and coordination tests
• Imaging tests, such as an MRI of the brain, and x-rays of the bones and joints to look for disease that may be causing pain
• Electromyography (EMG) to test muscle health to see if there is a problem with muscle response.
• Nerve conduction studies (NCS) to test whether a nerve has been damaged.

Some patients may have emotional conflicts that make it hard for them to cope with physical pain. If a person has trouble at work, in their marriage, or with other family issues, she may not be able to handle the physical pain the same as someone without other stress in her life.

Treatment and Prevention

Finding treatment that works can take time and effort. Often, pain can be managed or treated through a mix of tactics, such as medicine, alternative therapies and lifestyle changes. For some, surgery may be an option. Pain treatment and management are personal, since what works for one person may not work for someone else.

Medicines
There are many types of pain medications, both over-the-counter (OTC) and prescription, to help you manage pain.

Analgesics (pain relievers):

• Nonsteroidal anti-inflammatory drugs (NSAIDS) block pain near the pain site and are useful for mild to moderate pain, as well as for fever. They reduce the amount of prostaglandins made by the body, which reduces inflammation. Prostaglandin is a substance produced in the body that is released when you are injured; in turn, the body responds with inflammation and fever. Many NSAIDs can be found over-the-counter, and some higher-strength forms of NSAIDS for moderate to severe pain need a prescription. NSAIDs have a number of side effects, risks, and potential drug interactions. So speak to your healthcare provider before taking NSAIDs for pain relief.NSAIDs include:
  • Aspirin
  • Ibuprofen (Motrin, Advil)
  • Naproxen (Aleve)
  • COX-2 inhibitors (Celebrex). Celebrex, a prescription drug, is used to relieve symptoms caused by arthritis, such as swelling, stiffness and joint pain, as well as other types of acute pain. It can cause fewer side effects (such as ulcers and bleeding) than other types of NSAIDs.
• Acetaminophen (such as Tylenol) works by blocking pain in the brain. It controls pain and fever but is not used for inflammation. Acetaminophen does not affect the stomach as a side effect, but too much acetaminophen can damage the liver.
• Narcotics (opioids or opiates) and narcotic-like medications, such as tramadol (Ultram), are used for acute pain after an injury or surgery, or for pain from health conditions such as cancer. Narcotics include:
  • codeine, most commonly prescribed with acetaminophen as Tylenol 3
  • fentanyl (Sublimaze, Fentora)
  • hydromorphone (Dilaudid)
  • methadone (Dolophine)
  • oxycodone (OxyContin, Percocet)
  • oxymorphone (Opana)
  • morphine (Avinza, Kadian, MS Contin)
  Prescription misuse and overdose have been growing in the United States since the 1990s, when the number of opioids prescribed to patients began to increase. Between 1999 and 2017, the rate of prescription overdose deaths grew five-fold. In fact, nearly 218,000 people died in the U.S. from prescription opioid overdoses during this time. Discuss the risks and benefits of using narcotics for pain relief, along with possible alternative treatments, with your healthcare professional. If you are prescribed opioids for your pain, be sure you learn how to take opioids properly and keep these medicines out of the hands of others.

Antidepressants
Antidepressants can help treat pain by changing the levels of neurotransmitters (brain chemicals) and altering the pain messages reaching the brain. When a woman is depressed and also in pain, these medications can both reduce pain and improve mood. The tricyclic antidepressants, such as desipramine (Norpramin) and imipramine (Tofranil), help to restore the body's normal perception of pain and may be a helpful treatment option even when a patient is not depressed. Drugs that stimulate the feel-good brain chemicals serotonin and norepinephrine, such as duloxetine (Cymbalta) and venlafaxine (Effexor XR), can improve both mood and pain.

Anxiolytics
Anxiolytics are used to prevent and treat anxiety. A type of anxiolytic often prescribed is called benzodiazepines; common names for these medicines are Valium, Xanax, Lithium, Ativan, and Klonopin. Some people benefit from anxiolytics for muscle spasms. Women are at increased likelihood for being prescribed Valium or another benzodiazepine with opioids; this combination increases the potential for overdose.

Anti-seizure Medications
Anti-seizure medicines work by causing changes in signals in the brain. They work best for pain caused by nerve damage, such as pain from diabetes, shingles, herniated disk, fibromyalgia, cancer treatment, and other types of nerve pain. Older anti-seizure or anticonvulsant drugs have more side effects than newer drugs. Medicines like gabapentin (Gralise, Neurontin) and pregabalin (Lyrica) can relieve pain caused by damaged nerves.

Muscle Relaxants
Muscle relaxants work through your brain and spinal cord to help relieve pain and decrease muscle spasms.

Combination Drugs
Some medications used for pain combine acetaminophen and an opioid, such as Vicodin (acetaminophen and hydrocodone), Ultracet (acetaminophen and tramadol) or Percocet (oxycodone and acetaminophen). Others may combine acetaminophen with a relaxant (for example, Fioricet, which is a combination of acetaminophen, butalbital and caffeine).

Therapeutic Injections
A number of injections may be used to relieve pain.

• Epidural steroid injections. Corticosteroids mimic the effects of the hormone, cortisol. Cortisol helps lower levels of prostaglandins and control inflammation. Cortisone shots in the area around the spine can reduce irritation and provide relief.
• Nerve root blocks. Numbing medicine to block pain is injected into an area where the nerve roots exit the spine. X-ray helps guide placement.
• Trigger point injections. Trigger points are painful areas in the muscle. A mixture of anesthetic and steroid injected into the trigger point can soothe muscle pain.
• Radiofrequency ablation heats up a small area of nerve tissue with an electric current. Radio waves are sent through a thin needle into the painful area to heat the nerve tissue. Relief can last from 6 months to years but varies by patient.

Topical Relief
In addition to cold and heat therapy (ice packs and heating pads), there are many pain-relief products that can be applied to the surface of the skin. Some are prescription, while others can be purchased OTC. These products include capsaicin, lidocaine and diclofenac.

Physical and Occupational Therapy
Physical therapy (PT) can help a person increase their activity level by improving strength, flexibility, and endurance. The focus of occupational therapy (OT) is to help a person return to activities needed for daily life, such as those for work, school, self-care, housework, and sleep. Ultrasound, cold laser therapy, and spinal cord stimulators are all tools that may be used during PT and OT.

Psychotherapy
Psychotherapy can offer pain relief by altering how your brain processes pain messages and sensations. Different types of therapy can help a person see and experience their pain in a new way. By changing your thoughts, behaviors and understanding of the pain, you may be able to process the pain differently. Interventions that have shown promise for pain relief include:

• Cognitive behavioral therapy: a type of talk therapy that helps people find new ways to behave by changing their thought patterns and learning new skills
• Mindfulness: technique used in meditation and certain kinds of therapy that focuses on observing thoughts and feelings and staying present in the moment
• Acceptance and commitment therapy: focuses on accepting experiences and committing to change the way we feel about and view these experiences.
• Emotional awareness and expression therapy: approach that begins with understanding the source of the pain and expressing suppressed emotions; then work is done to recognize avoided feelings and retell the way we see our stories and how we view our relationships.

Alternative Therapies

Types of alternative or holistic pain management include:

• Acupressure: The stimulation of healing sites with finger pressure, rather than fine needles as used in acupuncture.
• Acupuncture: An ancient Chinese health practice that involves insertion of thin, solid needles in specific points along your nerve pathways, called acupuncture points. While Western researchers are not sure how acupuncture works to ease pain (and some doubt that it works), several theories suggest that acupuncture may stimulate the release of endorphins, the body's natural pain relievers.
• Biofeedback: A technique used to gain control over a function that is normally automatic (such as blood pressure or pulse rate). By monitoring function and using relaxation techniques, patients who use biofeedback can change that function to a desired level. Biofeedback uses electronic or electromechanical instruments to monitor, measure, process and provide feedback about blood pressure, muscle tension, heart rate, brain waves and other physiologic functions.
• Chiropractic: A health care approach designed to improve the body's structure through adjustments of the spine and other body parts. The ultimate goal of chiropractic adjustment is to support the body's natural ability to heal itself.
• Craniosacral therapy: Involves gentle massage or manipulation of all bones of the skull (including the face and mouth), vertebral column, sacrum, coccyx and pelvis. The goal is to ease restrictions to movement by increasing flow of the cerebrospinal fluids.
• Electrical stimulation, or transcutaneous electrical nerve stimulation (TENS): Involves attaching a small transmitter to the skin over a painful area. The transmitter emits electrical impulses that block pain signals, giving you a tingling feeling rather than pain. It may work by stimulating the release of endorphins or interrupting pain signals.
• Hydrotherapy: Also called hydropathy and aquatic therapy, hydrotherapy literally means using water in the treatment of disease. Using water for pain management typically involves hot and cold compresses, tub soaks, warm mud baths and other similar types of spa therapy to relieve pain and decrease swelling. Aquatic therapy is a form of rehabilitation that uses a heated therapeutic pool for exercising without stress on the joints. It does this by relieving the pull of gravity. There is some strong evidence to support use of mineral or herbal hot baths and other spa therapies for treating arthritis and fibromyalgia.
• Hypnosis: A technique that induces a deeply relaxed and focused state of mind. Often used to modify behavior, hypnosis also helps reduce pain and may speed healing.
• Massage: Involves rubbing or kneading muscles and other areas of the body to stimulate blood circulation, relieve pain and promote a sense of wellbeing.
• Meditation: A process to increase concentration and awareness and create a more relaxed state.
• Reflexology: Based on the belief that pressure applied to specific points on your body, usually the hands and feet, benefits other parts of the body.
• Supplements: There are a number of supplements that have shown some pain-relieving properties, such as fish oil, capsaicin and glucosamine. Research on these supplements is mixed. If you would like to try a supplement to aid in pain relief, be sure to discuss it with your healthcare professional first.

These approaches may be used as alternatives to medications or in conjunction with them.

Lifestyle approaches

Lifestyle changes may be useful in helping to relieve pain, as well as prevent pain.

• Stay physically active. Remember that there are many types of exercise, and your healthcare professional can help you decide what is best for you. Jogging and other weight-bearing forms of aerobic exercise may not be appropriate for people with certain types of pain, but walking, swimming or water aerobics can provide gentler aerobic exercise. A whole-body stretching routine or a yoga or tai chi program designed for people with pain may be just what you need. Always consult your healthcare professional before starting a new exercise program, especially if you have any pain. Exercise can:
  • Help relieve pain
  • Increase muscle mass, which reduces stress on joints
  • Promote weight loss, which also reduces stress on joints
  • Reduce stress, which aids in pain relief
  • Improves mood, which also aids in pain relief
• Eat a healthy diet. Good nutrition and weight management can help:
  • Reduce swelling in joints and lead to better circulation
  • Lower cholesterol levels and blood pressure
  • Minimize inflammation
• Reduce stress. Decreasing stress helps you to cope better with pain. Reduced stress also allows for better sleep and often leads to better health habits, both of which help with pain management.
• Get sleep. Getting enough sleep allows your body to better manage pain.
• Quit smoking. Smoking is one lifestyle choice that worsens pain, If you smoke, you should quit or ask your healthcare professional for guidance on how to quit. Studies, especially those on low back pain, have shown that patients who smoke have a harder time recovering from injury than non-smokers, regardless of the treatment offered. Smoking can also affect the healing of injured discs. And there is some evidence that smoking interferes with the absorption and blood level of various medications, including analgesics.

When to Consider Using a Pain Clinic

You might consider visiting a pain clinic if your pain does not go away after medical treatment.

Pain clinics specialize in the prevention, evaluation, diagnosis and treatment of painful disorders. Treatment may include medication, physical and rehabilitative services, massage and meditation, and counseling for patients and their families.

Just as doctors and nurses differ by specialty, so do pain clinics. Some offer residential programs, where you stay at the facility. Others have outpatient programs.

To treat your pain symptoms, choose a pain center that:

• Has a team of healthcare professionals that are experts in psychology, medicine, nursing, physical therapy, occupational therapy, pharmacy and vocational counseling.
• Offers a wide range of treatments, such as massage, acupuncture, physical therapy, and exercise programs.
• Employs healthcare professionals who are specialists in pain management and pain medicine. They should be Diplomates of the American Board of Pain Medicine or members of the International Association for the Study of Pain.
• Is staffed by caring, qualified people. If possible, talk to former or current patients and interview some of the staff—either in person or by phone.
• Is conveniently located.
• Is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is a private, not-for-profit organization that accredits programs and services in adult day services, behavioral health, employment and community services and medical rehabilitation.

You can find a list of pain specialists who are Diplomates of the American Board of Pain Medicine on the American Board of Pain Medicine web site: abpm.org.

Facts to Know

1. Pain is your body's way of sending a warning to the brain that something is wrong.
2. Both emotions and chemicals alter the amount of endorphins, the body's natural pain relievers, which block the relay of pain messages to the brain.
3. Medications, lifestyle changes, positive emotions and holistic therapies can all help manage pain.
4. Women are more likely than men to suffer from certain conditions that cause pain, including migraines, osteoarthritis, fibromyalgia and rheumatoid arthritis.
5. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) work to relieve pain but can cause stomach irritation. As with other pain medications, your body adjusts to NSAIDs, so you may have to take increasingly higher doses to get the same effects. Speak with your healthcare provider if you are no longer getting pain relief with lower doses of medication.

Questions to Ask

Here are some questions to ask yourself before going to your healthcare provider.

• Where is my pain? Is my pain in one place or throughout my body? Does it move?
• Is there anything that triggers my pain?
• What does my pain feel like (stinging, throbbing, burning, numbness)?
• Is my pain constant, or does it come and go?
• How intense is my pain on a scale of 1 to 10, with 10 being the worst?
• How is my pain interfering with life (work, sleep, appetite, other activities)?
• When did my pain start and did something specific cause it?
• What makes my pain better or worse?
• What am I doing now to manage or reduce my pain?
• What have I tried in the past that worked or didn't work to relief pain?

Review the following Questions to Ask so you are ready to talk to your healthcare professional.

1. What may be causing my pain?
2. Can my pain be treated or only managed? What should I expect?
3. Should I see a pain specialist?
4. How long will my treatment last?
5. What medications will I need to take, and are there any risks or side effects?
6. Will pain medicine affect other medications I am taking?
7. What level of relief should I expect from the treatment?
8. Are there other therapies that may relieve my pain?
9. Are their lifestyle changes I should make to help reduce my pain?
10. Are there certain triggers that may make my pain worse that I should avoid?

Key Q&A

Organizations and Support

For information and support on Pain Management, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Orthopaedic Surgeons (AAOS)
Website: https://www.aaos.org
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-823-7186

American Chronic Pain Association
Website: https://www.theacpa.org
Address: P.O. Box 850
Rocklin, CA 95677
Hotline: 1-800-533-3231
Email: acpa@pacbell.net

American Council for Headache Education
Website: https://www.achenet.org
Address: 19 Mantua Rd.
Mt. Royal, NJ 08061
Phone: 1-800-255-2243
Email: acheq@talley.com

American Occupational Therapy Association
Website: https://www.aota.org
Address: 4720 Montgomery Lane
P.O. Box 31220
Bethesda, MD 20824
Hotline: 1-800-377-8555
Phone: 301-652-2682

American Pain Society
Website: https://www.ampainsoc.org
Address: 4700 West Lake Ave.
Glenview, IL 60025
Phone: 847-375-4715
Email: info@ampainsoc.org

American Physical Therapy Association (APTA)
Website: https://www.apta.org
Address: 1111 N. Fairfax Street
Alexandria, VA 22314
Hotline: 1-800-999-APTA (1-800-999-2782)
Phone: 703-684-APTA (703-684-2782)

Association for Behavioral and Cognitive Therapies (ABCT)
Website: https://www.aabt.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212-647-1890

Bone and Joint Decade
Website: https://www.usbjd.org/index.cfm
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-384-4010
Email: usbjd@usbjd.org

National Headache Foundation
Website: https://www.headaches.org
Address: 820 N. Orleans, Suite 217
Chicago, IL 60610
Hotline: 1-888-NHF-5552 (1-888-643-5552)
Email: info@headaches.org

National Institute of Neurological Disorders and Stroke
Website: https://www.ninds.nih.gov
Address: NIH Neurological Institute
P.O. Box 5801
Bethesda, MD 20824
Hotline: 1-800-352-9424
Phone: 301-496-5751

PainPathways Magazine
Website: https://www.painpathways.org
Address: 145 Kimel Park Drive, Ste 350
Winston-Salem, NC 27103
Phone: 336-765-6181, ext 124

Spondylitis Association of America
Website: https://www.spondylitis.org
Address: P.O. Box 5872
Sherman Oaks, CA 91413
Hotline: 1-800-777-8189
Phone: 818-981-1616
Email: info@spondylitis.org

Texas Back Institute
Website: https://www.texasback.com
Address: 3600 W. 7th Street
Fort Worth, TX 76107
Hotline: 1-800-247-BACK (1-800-247-2225)

Trigeminal Neuralgia Association
Website: https://www.fpa-support.org
Address: 925 Northwest 56th Terrace, Suite C
Gainesville, FL 32605
Hotline: 1-800-923-3608
Phone: 352-331-7009
Email: patientinfo@tna-support.org

Books

Acupuncture: Everything You Ever Wanted to Know, but Were Afraid to Ask
by Gary F. Fleischman and Charles Stein

Basics of Acupuncture
by Gabriel Stux, Brian Berman, Bruce Pomeranz, and P. Kofen

A Life Larger Than Pain
by Erv Hinds

Back Pain Helpbook
by James Moore, RN Kate Lorig, Michael Von Korff, M.P.H. Virginia Gonzalez and Diana Laurent

The Back Pain Sourcebook
by Stephanie Levin-Gervasi and James F., M.D. Zucherman

Break Through Pain: A Step-by-Step Mindfulness Meditation Program for Transforming Chronic and Acute Pain
by Shinzen Young

Mayo Clinic on Chronic Pain
by David Swanson

Pain Cure: The Proven Medical Program that Helps End Your Chronic Pain
by Dharma Singh Khalsa and Cameron Stauth

Pain Free: A Revolutionary Method for Stopping Chronic Pain
by Pete Egoscue and Roger Gittines

The RealAge Makeover: Take Years Off Your Looks and Add Them to Your Life
by Michael F. Roizen

Women and Pain: Why It Hurts and What You Can Do
by Mark Young

Yoga for Pain Relief: Simple Practices to Calm Your Mind & Heal Your Chronic Pain
by Kelly McGonigal and Timothy McCall

Spanish-language resources

Medline Plus: Pain Relievers
Website: https://www.nlm.nih.gov/medlineplus/spanish/painrelievers.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov