Treatment options for chronic pain?

1. What general options do I have to treat my pain? 

There are a variety of options for the treatment of chronic pain. Under the general category of medications, there are both oral and topical therapies for the treatment of chronic pain. Oral medications include those that can be taken by mouth, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and opioids. Also available are medications that can be applied to the skin, whether as an ointment or cream or by a patch that is applied to the skin. Some of these patches work by being placed directly on top of the painful area where the active drug, such as lidocaine, is released. Others, such as fentanyl patches, may be placed at a location far from the painful area. Some medications are available over the-counter (OTC) while others may require a prescription.

There are many things that may help with your pain which do not involve medications. These things may help relieve some pain and reduce the medications required to control your pain. Examples include exercises, best performed under the direction of a physical therapist. There are also alternative modalities, such as acupuncture. Transcutaneous Electro-Nerve Stimulator (TENS) units use pads that are placed on your skin to provide stimulation around the area of pain and may help to reduce some types of pain symptoms.

Finally, there are interventional techniques that involve injections into or around various levels of the spinal region. These can involve relatively superficial injections into the painful muscles, called trigger point injections, or may involve more invasive procedures. There are multiple procedures that range from epidural injections for pain involving the neck and arm or the back and leg, facet injections into the joints that allow movement of the neck and back to injections for burning pain of the arms or legs due to a syndrome called Complex Regional Pain Syndrome or Reflex Sympathetic Dystrophy (CRPS).

2. What are some of the typical medications used for the treatment of chronic pain? What are some of the common side effects associated with these medications?

There are several categories of medications that are used for the treatment of chronic pain. In general, your primary physician, patient management specialist, or pharmacist may be to answer any questions about the dosage and side effects from these medications. The most commonly used medications can be divided into the following broad categories:

  1. Nonsteroidal Anti-inflammatory Drugs and Acetaminophen: There are many different types of nonsteroidal anti-inflammatory medications (NSAIDs), some of them (such as ibuprofen) may be obtained over-the-counter. NSAIDs can be very effective for acute muscular and bone pain as well as some types of chronic pain syndromes. When taken for an extended period of time or in large quantities, they may have negative effects on the kidneys, clotting of blood, and gastrointestinal system. Bleeding ulcers is a risk of these medications. Long-term use of cyclooxygenase II (COX II) inhibitors may be associated with an increase in cardiovascular (heart) risks. Acetaminophen is easily obtained over-the-counter, however, care should be taken not to take more than 4000 mg in 24 hours; otherwise, several liver failure may occur. There are some opioid medications that combine acetaminophen within the medication. You should be aware that many over-the-counter medications have acetaminophen as one of their ingredients and when taken in combination with prescribed medication, this may result in an overdose of acetaminophen.
  2. Antidepresssants: Some of the older categories of antidepressants may be very helpful in controlling pain; specifically the tricyclic antidepressants. The pain relieving properties of these medications are such that they can relieve pain in doses that are lower than the doses needed to treat depression. These medications are not meant to be taken on an “as needed” basis but must be taken every day whether or not you have pain. Your physician may attempt to lessen some of the side effects, particularly sedation, by having you take these medications at night. There are some other side effects like dry mouth that can be treated with drinking water or fluids. These medications may not be given to patients with certain types of glaucoma. In addition, these medications should never be taken in larger doses than are prescribed.
  3. Anticonvulsants (Anti-seizure) Medications: These medications can be very helpful for some kinds of nerve type pain (such as burning, shooting pain). These medications also are not meant to be taken on an “as needed” basis. They should be taken every day whether or not you feel pain. Some of them may have the side effect of drowsiness which often improves with time. Some have the side effect of weight gain. If you have kidney stones or glaucoma, be sure to tell your doctor as there are some anticonvulsants that are not recommended to be given under those conditions. The newer anticonvulsants do not need liver monitoring but required caution if given to patients with kidney disease.
  4. Muscle Relaxants: These medications are most often used in the acute setting of muscle spasm. The most common side effect seen with these medications is drowsiness.
  5. Opioids: When used appropriately, opioids may be very effective in controlling certain types of chronic pain. They tend to be less effective or require higher doses in nerve type pain. For pain is present all day and night, a long acting opioid is usually recommended. One of the most frequent side effects is constipation, which if mild may be treated by drinking lots of liquids, but may need to be treated with medications. Drowsiness is another side effect which often gets better over time as you get used to the medication. Excessive drowsiness should be discussed with your physician. Nausea is another side effect which may be difficult to treat and may require changing to another opioid.

3. If I am taking narcotic (opioid) medication for chronic pain, does that mean I am addicted? 

Taking opioids in the way that they have been prescribed by your doctor for the treatment of chronic pain is associated with a very low risk of becoming addicted to those opioids. There are some predisposing factors to opioid addiction. These include having a history or a family history of substance abuse or of certain psychiatric illnesses. The following are definitions for addiction, tolerance, and physical dependence according to the American Pain Society: 

  • Addiction has a genetic basis in addition to a psychological aspect to the behavior. Addiction is associated with a craving for the abused substance (such as an opioid), and continued, compulsive use of that substance despite harm to the person using the substance. In addition to having a genetic predisposition, there may be an environmental influence affecting both the development and manifestation of the additive behavior. 
  • Tolerance occurs after prolonged exposure to a drug. The effects of that drug results in progressive decrease in its effectiveness. 
  • Physical Dependence is usually seen in the form of drug withdrawal after the drug has been abruptly stopped or rapidly reduced. It can also be seen when an opioid antagonist is given to someone who is taking an opioid. It is a state of adaptation. Withdrawal symptoms last from approximately 6 to a peak of 24 to 72 hours after the drug has been withdrawn. Some of the symptoms include nausea, vomiting, sweating, abdominal pain or diarrhea and can occur after taking the opioid for as short a period as 2 weeks. It is not a sign of addiction.

If you are prescribed opioids by your doctor, you are to take the opioids as they have been prescribed. If your pain continues despite taking the opioid, it is inadvisable to take more opioid than prescribed without first seeking the advice of your doctor. Taking a long-acting opioid a few times per day is less likely to give the sensation of euphoria that may be associated with some short acting opioids. Long-acting opioids are not meant to be taken on an “as needed” basis and should be taken whether or not you have pain and should not be taken more frequently than prescribed by your doctor. Constipation is one of the more frequently seen side effects of chronic opioid use, remedies, such as stool softeners and stimulants, are available.

4. What are some of the more common nerve block procedures for the treatment of chronic pain? What are some of the common side effects associated with these nerve blocks? 

The vast majority of injections done for the diagnosis or treatment of chronic pain are performed on an outpatient basis. Some are performed on inpatients, who may be already hospitalized for other reasons. All of them may be performed under fluoroscopic (x-ray) guidance but are sometime performed in the office without x-ray. For any nerve block, you need to tell your doctor if you are allergic to contrast dye or if you think you may be pregnant. Below is a brief description of some of the more commonly performed nerve blocks by pain management specialists.

  • Epidural Steroid injection: Epidural steroid injection is an injection performed in the back or neck in an attempt to place some anti-inflammatory steroid with or without a local anesthetic into the epidural space close to the inflamed area that is causing the pain. These injections are generally done for pain involving the back and leg or the neck and arm/hand. They may be done under x-ray guidance. Common side effects include soreness of the back or neck at the point where the needle enters the skin, there may be some temporary numbness in the involved extremity but persistent numbness or weakness (lasting over 8 hours) should be reported to your doctor. Epidural steroid injections may be placed in the lumbar (low back), thoracic (mid back), or cervical (neck) regions.
  • Facet Joint Injection: The facet joints assist with movement of the spine both in the neck and back. Injection into these joints can provide relief of neck and back pain; these injections are always performed under x-ray guidance. Common side effects include soreness in the neck or back when the needle was inserted. You will be on your stomach for this injection if it is done for back pain; however you may either be on your stomach or back if the injection is performed for neck pain, depending on the preference of the physician. A needle is placed in your neck or back and advanced to the level of the joint under x-ray visualization. Contrast dye is used if the needle is put within the joint, and sometimes used if the injection is designed to numb the nerves to the joint. This block is often a diagnostic block and a more long lasting injection may be indicated if you have significant pain relief from this injection.
  • Lumbar Sympathetic Block: A lumbar sympathetic nerve block is performed for pain in the leg that is thought to be caused by complex regional pain syndrome type I (or CRPS I). These injections are often performed under fluoroscopic (x-ray) guidance. Local anesthetic is placed near to the lumbar sympathetic chain in order to relieve the pain. Your leg will likely become warm immediately following the injection: this is an expected effect and not a complication. Back soreness is one of the more common side effects. If you feel any sharp pains down your leg or to your groin during the injection, you should let the physician know immediately. There may be some temporary numbness following the injection but if there is persistent numbness or weakness (> 8 hours) the doctor should be notified. You will be lying on your stomach for this injection. The injection is done from the back, in the lower aspect of the back. A needle is placed, often under x-ray guidance, to a spot just to the side and approaching the front part of the spine where the ganglion is located. If it is done under x-ray, a small amount of dye is injected to make sure the needle is in the right spot. After the doctor is satisfied that the contrast dye is in the right place, they will inject numbing medicine then remove the needle.
  • Celiac Plexus Block: A celiac plexus block is generally performed to relieve pain in patients with cancer of the pancreas or other chronic abdominal pains. A needle is placed via your back that deposits numbing medicine to the area of a group of nerves called the celiac plexus. This injection is often performed as a diagnostic injection to see whether a more permanent injection may help with the pain. If it provides significant pain relief then the more long lasting injection may be done. This injection is usually performed under x-ray guidance. You will be lying on your stomach for this injection. The needle is place via the mid back and placed just in front of the spine. Contrast dye is injected to confirm that the needle is in the right spot; followed by some numbing medicine.
  • Stellate Ganglion Block: A stellate ganglion block is an injection that can be performed for the diagnosis of complex regional pain syndrome of the arm or hand or for treatment of pain to that area. It can also be used to help to improve blood flow to the hand or arm in certain conditions that result in poor circulation of the hand. Side effects may include soreness in the neck where the needle was placed. In some instances the side effects may include droopiness of your eyelid on the side that is injected, along with a temporarily stuffy nose and sometimes temporary difficulty in swallowing. This injection is performed with or without x-ray guidance. You will be lying on your back for this injection with your mouth slightly open. It is very helpful to the doctor if you try not to swallow during the injection. If this injection is performed under x-ray the doctor will first inject a small amount of contrast to confirm the placement of the needle then inject some numbing medicine.

5. Will I receive a bill from the pain management specialist?

Your pain management specialist is a physician specialist like your surgeon or internist, and you probably will receive a bill for your pain management specialist’s professional service as you would from your other physicians. If you have any financial concerns, your pain management specialist or an office staff member will answer your questions.

How to Take Painkiller Drugs Safely?

If your doctor has prescribed you painkillers, you should be aware that pain drugs can be safe. Pain-relieving drugs, whether they are prescription or non-prescription, can help you feel better. But for a variety of reasons, painkillers can be dangerous,

As you’re probably aware, some people become dependent on painkillers or addicted to painkillers. Other dangers and side effects include stomach upset, dizziness, blurred vision, and liver damage. And if they’re taken incorrectly, painkillers can even cause death.1

Learn how these problems occur and the steps you can take to prevent them so you can be sure that your painkillers are safe.

Problems With Painkiller Prescriptions

Even if you strictly follow the instructions, sometimes problems with painkillers can arise for the following reasons:

  • Other medications. Your new pain drug prescription may conflict with a drug you already take. It’s possible that every drug or supplement you take hasn’t been recorded in the prescribing doctor’s records, or he or she may have overlooked a potentially conflicting drug. Or, you may have forgotten to mention a supplement you take that conflicts with the prescription.
  • An allergic reaction. You may have an allergy to an ingredient in a pain drug that hasn’t shown up before.
  • Your tolerance. You may be opiate naive, which means that your body is not used to opioids and does not tolerate them well. 
  • Pharmacy error. When you purchase the drug at your pharmacy, they may accidentally give you the wrong drug or the wrong dose.
  • Counterfeit pills. This is a growing issue, particularly with internet pharmacies.4 Your pharmacy may sell you a counterfeit version of a drug without realizing it.

Common Painkiller Safety Mistakes

It’s important to always follow the directions about how a painkilling drug should be taken.

Mistakes can lead to difficult symptoms, temporary or permanent health damage, addiction, dependency or even death.

Here are some of the mistakes people make with painkillers that can cause problems:

  • Taking the drug incorrectly can mean you either end up with too much of the drug in your system, or too little.
  • Taking drugs with other drugs can cause drug conflicts or contraindications.2
  • Not taking the drug with food, or vice versa can make you sick, depending on the directions.
  • Taking the next dose too soon can mean you overdose. Doing that frequently can lead to dependence and/or addiction.
  • Using a second pain reliever may lead to toxic levels.
  • Waiting too long between doses may allow pain to breakthrough, or you may have withdrawal symptoms.
  • Eating or drinking some foods and beverages can interfere with pain drugs. This can lead to gastrointestinal symptoms and can even be dangerous. Alcohol, in particular, can be highly dangerous when mixed with many pain drugs.6 But even something seemingly benign like grapefruit juice can interfere with the pain-killing effect of your drugs.
  • Abruptly stopping an opiate drug can cause withdrawal symptoms like an increased heart rate, profuse sweating or anxiety.

Taking Painkillers Safely

Making sure your painkillers are safe begins from the moment your doctor writes you a prescription or you make a choice off the shelf in the drug store. It’s your responsibility to take these steps to keep yourself safe:

  1. Be sure to read the labels and inserts when you purchase an over-the-counter pain reliever (like aspirin, acetaminophen or ibuprofen) or a prescription drug. These materials will warn you about everything from drug interactions to food interactions to possible damage from extended use. Use a magnifying glass to read them if necessary. If a painkiller you have been prescribed is new to the market, you should learn about the important steps to consider before you take a new drug.
  2. Remind your doctor about your other medications. If your doctor writes you a prescription, speak up about the other drugs and supplements you already take. Don’t rely on your medical records because the information may be incomplete or your doctor could miss it.
  3. Ask the prescriber lots of questions. You’ll find a master list of general prescription questions here. Some of them are specific to pain-killing drugs. It’s important to ask things like: Is it OK to drive on this drug? Can I consume alcohol while I’m taking this drug? And what steps can I take to avoid becoming dependent on or addicted to this drug?
  4. Find out which side effects are concerning. Once you begin taking the drug, you may experience side effects. Ask your doctor which side effects he wants to be informed about immediately.5 Vomiting profusely should probably be reported right away, for example, while dry mouth might be something you just have to live with. Be extra vigilant about side effects if you have not taken painkillers before because your body won’t be used to them.
  5. Follow the directions for taking the drug exactly as prescribed. If you find your pain breaks through before it’s time for the next dose, don’t just go ahead and take it early. Instead, contact your doctor’s office and ask what you should do. They may adjust the dose accordingly.
  6. Never just stop taking a painkilling drug on your own. Withdrawal is a nasty process and there are different ways to step down your dosage to make it easier on your body. If you feel it’s time to give up your painkiller, speak to your doctor and ask about the best way to wean yourself off the drug.5
  7. Consider keeping a journal of your experience with the drugs you take. You may be taking painkillers for a period of time, especially if you have been badly hurt in an accident, or if you have developed a chronic pain disease. This is a good time to start a medication journal. Rate your pain against your pain drugs, doses, times of day, foods you eat and anything else that may factor in. If problems occur, you may be able to pinpoint when and why they began. Share your journal with your doctor, too.
  8. Finally, never take someone else’s prescription pain drugs. They weren’t prescribed for you, and you can’t know whether they will conflict with some other drug, supplement, beverage, or food you have consumed.7 Further, with advances in technology, like the use of databases to track who has been prescribed certain drugs, you may be caught—which will leave you with no legal way to get the medications you need.

Consider Alternatives to Painkillers

There may be other ways to relieve your pain that will work instead of, or in conjunction with, painkillers. You might consider complementary and alternative medicine (CAM) options or mind-body approaches to controlling pain. Or, read more about how to relieve pain without drugs.

Chronic pain: can treatment over the Internet help?

Key message: The Internet offers a means of delivering therapies to people in their homes to help them manage chronic pain and a new Cochrane review has explored the evidence on how well these work. Current evidence suggests that psychological treatments delivered in this way may help adults with non-headache pain, reducing pain, disability, depression and anxiety, but more research is needed before we can be confident about these results.

Using the Internet to deliver therapies has obvious benefits, including its reach free from geographical constraints, convenience and low costs. People living with chronic pain, lasting longer than three months, are in it for the long haul and should be able to access support to help them manage their condition away from expert healthcare centres. A new review from the Cochrane Pain, Palliative and Supportive Care Group has just been published, which explored whether pain management therapies can be successfully delivered via the Internet to reduce pain and disabilty and improve anxiety and depression in adults with non-cancer chronic pain. The reviewers were also interested in whether people liked the programmes and whether they improved their quality of life. They found 15 randomized controlled trialsA trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’). (RCTs) with just over 2000 adults and compared those having internet-delivered therapies with those on waiting lists.

What did they find?

  • People with headache conditions had less pain and disability after treatment; it wasn’t clear if they were less depressed or anxious
  • People with non-headache conditions had less pain, disability, depression and anxiety after treatment and the positive effects on disability were maintained at follow-up
  • It’s not known whether the therapies improve quality of life in people with headache pain; three RCTs reported on this for people with non-headache pain and did not find an improvement
  • No studies reported on adverse effects of treatment

It sounds promising, but how good was the evidence?

Overall, the studies were judged to be at low risk of bias, but the results come from a small number of trials. Only two RCTs were included in the analysis of pain and disability in people with headache conditions and there’s just not enough evidence to be able to draw conclusions about the treatment for this patient group with any confidence. We don’t know whether people liked the treatments. There were other weaknesses we should consider too, as one of the review authors, Dr Emma Fisher from the University of Bath’s Centre for Pain Research, explains below. I asked her to talk about their findings:

“We really enjoyed reading the trials and seeing the innovative ways that psychological treatments can be delivered via the Internet. Technology is becoming increasingly important and dominates much of how we retrieve information and communicate. However, only a small number of trials were included in this review so we are cautious of our findings. Further, of the 15 included trials, four of them were carried out by the same author group. Another issue that stuck out for me in particular was the recruitment methods used which I believe may have had an impact on the results. Many of the trials asked participants to self-select (i.e. they were recruited via adverts or in the community, rather than being recruited through a clinic or hospital).

Despite these limitations, I think the review delivers an important message – evidence to date shows that psychological treatments can be beneficial and reduce pain and disability post-treatment for adults with chronic pain, and in adults with non-headache pain it has a beneficial effect for anxiety and depression. We need more trials (from varied author groups) to raise our confidence in the estimate of outcomes. The benefits of receiving therapy via the internet is clear; it can reach more people, in more places, and is flexible. However, this is likely to be beneficial for certain populations and more research is needed to determine which group of chronic pain adults would benefit most.”

What about traditional methods of delivering these treatments?

This review complements one on psychological therapies for adults with chronic, non-headache pain delivered in other ways. Since this blog was published, it has been updated (12 August 2020). It now has moderate- to low-certainty evidence on cognitive behavioural therapy (CBT) from 59 studies with over 5000 people, showing that CBT probably has very small beneficial effects for reducing pain, disability, and distress compared with an active control (alternative interventions that engage people, such as exercise or education). Compared with ‘treatment as usual’, CBT probably has small benefits for reducing pain and distress at the end of treatment and may have small benefits for reducing disability. These effects were largely maintained at follow-up for the comparison with treatment as usual but not active control. There remains uncertainty about any harms that might be associated with treatment.

There is growing support for the effectiveness of psychological therapies, and particularly CBT, for the management of chronic pain and its delivery via the Internet shows promise. Clearly there is more work to be done to increase our understanding of the usefulness of these therapies and means of delivery.

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