Chronic Pain

Treatment

Treatment for chronic pain depends on the cause and on the individual needs of the patient. Complete pain relief is not always possible; it is important for patients and physicians to work together to find the best treatment plan.

Proper exercise can strengthen muscles throughout the body, improve bone strength, reduce the risk for injuries, and enhance feelings of well being. It is important to speak with a doctor before starting an exercise regimen.

Physical therapy and massage therapy can reduce pain, improve function, and prevent recurrences. Other types of treatment that can be used to manage chronic pain include relaxation and behavior modification therapy, meditation, hypnosis, and biofeedback. Spinal manipulation (adjustment) can be used to relieve chronic pain caused by musculoskeletal conditions (e.g., osteoarthritis).

Acupuncture, which involves inserting and manipulating fine needles under the skin at selected points in the body, may be used to relieve chronic pain.

As many as 35% of patients may respond favorably to treatment with a placebo (e.g., sugar pill, saltwater injection). Precisely how a placebo works is unknown. Pain relief may result from the power of suggestion, distraction, or optimism, or from a neurochemical reaction in the brain.

Medications

Over-the-counter analgesics (e.g., aspirin, ibuprofen, acetaminophen) may be used to treat chronic pain. These medications should not be used to relieve pain for longer than 10 days without consulting a physician. Side effects of nonsteroidal anti-inflammatories (NSAIDs) include nausea, abdominal pain, dizziness, and rash. Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.

When over-the-counter medications are ineffective, stronger prescription medications may be used. Medications commonly used to treat chronic pain include the following:

• Muscle relaxants (e.g., Zanaflex®)–May cause drowsiness, dry mouth, and constipation.
• Nonsteroidal anti-inflammatories (e.g., Celebrex®)–May cause indigestion, diarrhea, and stomach pain, and severe cardiovascular and gastrointestinal side effects.
• Opioids (e.g., codeine, morphine)–May lead to tolerance, dependence, and addiction.

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Duragesic® (fentanyl transdermal system) delivers the opioid analgesic fentanyl through a patch that is worn on the skin. It is used to treat moderate-to-severe chronic pain that does not respond to other medications (e.g., nonopioid analgesics, opioid-acetaminophen combinations) and provides continuous pain relief for 72 hours.

Various doses of the fentanyl transdermal system are available and the dose should be individualized to each patient and evaluated at regular intervals. Duragesic is not used to treat postoperative or acute pain and is not prescribed for children under the age of 12, or patients under the age of 18 who weigh less than 110 lbs.

Duragesic may cause life-threatening hypoventilation (reduced breathing rate and depth of breathing). Repeated administration may result in tolerance and physical and psychological dependence. Other side effects include the following:

• Confusion
• Constipation
• Dry mouth
• Excessive sleepiness (somnolence)
• Excessive sweating
• High blood pressure (hypertension) or low blood pressure (hypotension)
• Nausea and vomiting

Adjuvant drugs may be used to treat chronic pain that does not respond to other pain relievers and to reduce the side effects of other medications. Adjuvant drugs include antidepressants, anticonvulsants, and corticosteroids.

Other Treatments

Other treatment options for chronic pain include the following:

• Neurostimulation
• Corticosteroid injections (may reduce chronic pain caused by inflammation and nerve compression)
• Transcutaneous electrical nerve stimulation (TENS)
• Trigger point injection

Neurostimulation (e.g., brain stimulation, spinal cord stimulation, transcutaneous electrical nerve stimulation) may be used to treat some types of chronic pain (e.g., RSD/CRPS). This treatment involves using painless electrical impulses to interrupt pain signals.

There are two types of neurostimulation systems. One system is powered using a battery that is surgically implanted beneath the skin, and the other system uses a battery that is worn outside the body. Both types are controlled using an external device and deliver electrical stimulation to the nervous system (e.g., brain, spinal cord, nerves) to interrupt pain signals.

Internal/external neurostimulation systems include leads (electrodes) and a receiver, which are implanted in the skin, an antenna that is placed over the receiver on the skin, and an external battery. The antenna delivers electrical stimulation from the battery to the receiver.

In the completely internal neurostimulation system, the electrodes, receiver, and battery are implanted in the skin, often in a two-step surgical procedure performed under local anesthesia and sedation.

In transcutaneous electrical nerve stimulation (TENS), brief pulses of electricity are applied to nerve endings to block pain transmission. This procedure has proven effective for many different types of chronic pain, and is safe and noninvasive.

Surgery (e.g., joint replacement, tumor excision, discectomy) may eliminate some types of chronic pain. Cordotomy may be used in severe cases of lower body pain when other treatments are ineffective. This procedure involves severing the nerve fibers on one or both sides of the spinal cord, eliminating the sensations of pain and temperature.

Chronic Pain, Treatment reprinted with permission from neurologychannel.com
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