Can you make it go away?
Pain isn’t something you want to experience. Unfortunately, some people live with it on a daily basis. While there are many different treatment options, some are better than others. How do you determine the best one? Are there new options available?
Pain is something that we’ve all experienced at some point in our lives. Typically, it’s the result of an injury or illness. When either of these occurs, pain sensors get turned on and send messages in the form of electrical signals that travel along your nerves to your brain. Your brain processes the signal and sends out the message that you hurt. Usually, the signal stops when the cause of the pain is resolved. This is referred to as acute pain. Sometimes, the pain continues after the injury or illness is gone because the nerves keep signaling that you have pain even though the area is healed. This is known as chronic pain and is ongoing, keeps returning, or lasts longer than the normal healing course. It can last from several months to many years, with doctors defining it as any pain that lasts for 3 to 6 months or more. Symptoms can range from mild to severe and can feel like a dull ache, throbbing, burning, shooting, squeezing, stinging, soreness, and stiffness. Some individuals experience other symptoms, such as feeling very tired or wiped out, not feeling hungry, trouble sleeping, mood changes, weakness, and a lack of energy. Without a doubt, chronic pain can significantly impact your daily life and mental health. It can keep you from doing things you want and need to do. It also can take a toll on your self-esteem and make you feel angry, depressed, anxious, and frustrated. This is concerning since the National Institutes of Health (NIH) estimates that 25.3 million adults have chronic pain and another 40 million suffer severe levels of pain.
There are many possible causes of chronic pain. Per the Institute for Clinical Systems Improvement, it can be grouped into four main types.
- Neuropathic pain is related to the nerves and is caused by damage to or malfunctioning of the somatosensory system, which is the system of sensory receptors and neurons in the nervous system. An example of this type is sciatica.
- Muscle pain results from problems with the skeleton’s muscles and can affect areas like the lower back, hips, legs, feet, neck, shoulders, arms, and trunk of the body. It usually occurs after an injury or following repetitive motions.
- Inflammatory pain is triggered by certain chemicals that interact with the main sensory nerves causing them to send pain signals to the spinal cord. Some examples of this are arthritis, tissue injury, infection, or surgery.
- Mechanical/compressive pain happens when nerve cells that are sensitive to pain are stimulated. This can happen due to a fracture, disc degeneration, or compression of tissue by tumors, cysts, or bony structures.
Some individuals have multiple conditions that can result in chronic pain. Other times, a person can have chronic pain when there is no apparent underlying cause. This is known as psychogenic pain. This doesn’t mean that the pain isn’t real, just that psychological factors, such as anxiety, depression, excessive stress, or environmental factors are the major contributing source. Another possible basis for chronic pain that doesn’t have an apparent cause could be changes to the nervous system that can occur after a disease or injury. These changes seem to make people extra-sensitive to pain and may produce sensations of pain well after the injuries are healed and is known as central sensitization. Unfortunately, it’s difficult to reverse these changes. There’s also some thought that autoimmune response could cause chronic pain because infections or injuries can prompt them and they’re often invisible.
One area of research that has recently caught scientists’ attention is the influence certain mental factors and emotions have on chronic pain. There is some thought that it might be a phenomenon of perception, not just a biological reaction. Experts are beginning to be able to predict who’s likely to suffer from chronic pain based on brain structure and personality. Scientists at Northwestern University’s Feinberg School of Medicine’s pain clinic used questionnaires and brain scans to predict a person’s susceptibility to developing chronic pain. They found that the more pain you have, the more anxiety, depression, catastrophizing, and fear you have. Their study was reported in 2016 in the journal Brain. It followed 39 people who had injured their backs and looked at brain scans across three years to look for changes. They found that the brain’s corticolimbic network structure, which is involved in memory and emotion, was different in people who developed chronic pain before the pain ever started. The scans also showed that people with a smaller hippocampus and amygdala, responsible for stress, anxiety, and emotional learning, were also at greater risk of developing chronic pain. This implies that certain people might be predisposed to developing chronic pain. In a more recent study, the team discovered that how people react to chronic pain is different than expected. Some people with chronic pain have more positivity, openness, and extroversion, making them more likely to connect with others. It seems that these individuals have found a way to compensate for and cope with chronic pain. The researchers did point out one potential flaw, which is that chronic pain sufferers who are optimistic may be more likely to volunteer for a study like theirs. In contrast, people who aren’t might be more likely not to participate. The Center for Neuroscience and Regeneration Research at Yale University School of Medicine research has demonstrated that the nervous system is flexible. This means that neurons in the spinal cord and the brain can reorganize and make new connections, creating abnormal signals, which result in things like chronic pain. Neuropathic pain and inflammatory pain might overlap. Chronic inflammatory pain can lead to neuronal plasticity. When immune cells that are related to inflammation talk with neurons, it causes them to change. These changes become chronic. It’s not known yet if they can be reversed. One way to look at is that pain is like a memory. Hence, this is why the phenomenon is called neuropathic pain memory.
While there are many different reasons for chronic pain, there are just as many, if not more, treatment options. The first step in treating chronic pain is to treat any underlying conditions. Often, once these are managed, pain can dramatically improve. The methods to accomplish this will vary depending on the specific disease/medical condition and on the type of chronic pain. When developing a plan to treat chronic pain, the focus should be on acquiring self-management skills and lifestyle changes that improve physical and mental health. Typically, this involves many different factors, including psychological and behavioral therapy. Medication is used in conjunction with these other options to achieve the best outcome possible. Chronic pain management can be very complex and usually involves a multidisciplinary approach, involving physicians, psychologists, and physical therapists. The goal is to alleviate pain and teach the chronic sufferer how to come to terms with pain and function despite it. Pain clinics are centers dedicated exclusively to dealing with intractable pain. Some have inpatient and outpatient treatment available.
According to the Mayo Clinic, there are three main things besides medication that can help lessen pain. The first is to eat a healthy diet because chronic pain is often the result of chronic inflammation. There is increasing evidence that your diet can contribute to increased systemic inflammation. So, eating foods that don’t cause it can be helpful. Further evidence is needed to determine whether dietary supplements, such as fish oils and SAMe, provide any benefit. The second key factor is sleeping well. When you don’t get enough sleep, your levels of stress and anxiety are higher and these are known to accentuate pain. In addition, sleep loss blocks your brain’s natural analgesia centers, which means not getting enough is a double whammy. The third component is exercise. Not only does it make you stronger and help you sleep, it reduces stress. Weightlifting, intense aerobics, and walking briskly encourage the release of natural opioids in your brain. Light to moderate exercise may be especially helpful for those who suffer from low back pain, arthritis, and psychogenic pain. Some individuals find that applying heat and/or cold regularly to a sore area can be very effective. Others have success with chiropractic treatments, massage, or acupuncture. Additional options involve stimulating the nerves in the area that is painful in hopes of reducing the signals that they’re sending. One method is to use ultrasound to direct sound waves into the tissue. This can improve blood circulation, decrease inflammation, and promote healing. A commonly used option is transcutaneous electrical nerve stimulation therapy (TENS), which uses low-voltage electrical current delivered through electrodes placed on the skin near the source of pain. For those with more centralized pain, spinal cord stimulation might be the way to go. This entails placing electrodes inside the epidural part of the spinal cord. Using an implanted electrical pulse generator, the patient can send electrical pulses to the spinal cord, interrupting the pain signal to the brain. Individuals who don’t respond to more conservative measures might consider deep brain stimulation, which requires surgical stimulation of areas of the brain, usually the motor cortex or thalamus. Cold laser therapy (low-level laser therapy) is approved by the Food and Drug Administration (FDA) to treat pain conditions. During the procedure, the cold laser emits pure light of a single wavelength that is absorbed into an injured area to reduce inflammation and stimulate tissue repair.
Besides physical changes, psychological and behavioral treatments are vital to chronic pain sufferers achieving relief or better managing their condition. Psychotherapists, psychologists, and social workers can provide counseling with the goal being to improve coping skills and develop strategies to reduce stress, anxiety, depression, and sleep problems. A widely used method is cognitive-behavioral therapy (CBT) because it focuses on identifying and changing negative thoughts and learning relaxation techniques. This will help the person gain more control over their emotions and moods, ultimately impacting pain perception. To help with this, many experts recommend keeping a diary of your pain episodes. It’s a good idea to list the events that precipitated each episode and techniques you used to resolve it. By reviewing your diary regularly, you’ll gain insight into how to manage your pain better, so you have less intense episodes. One thing that you can do right now without the help of a professional is to practice mindfulness. It comprises paying attention to the present moment without judging. This helps you to relax, focus, and step back to examine your own thoughts and habits as if from a third-person perspective. This has been shown to lessen repetitive thinking and reaction to pain while fostering a sense of acceptance. Some other helpful therapies are meditation, yoga, tai chi, biofeedback, healing touch, Reiki, guided imagery, aromatherapy, hypnosis, visualization, music, art therapy, and pet therapy. Laughter and holding hands have also been associated with a reduction in pain. Researchers discovered that when loved ones hold hands, their brain waves synchronize and they essentially share the pain one individual is experiencing. In the past few years, several studies promote these healing approaches’ efficacy in easing pain/anxiety and improving health. However, alternative therapies aren’t always benign, so make sure to talk to your doctor before trying them.
As far as medications, it’s usually best to start with over-the-counter options. When it comes it pills, these are non-narcotic pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen, are useful when pain is mild or moderate because they work by blocking pain near its origin. Acetaminophen is a non-NSAID pain reliever that blocks pain perception in the brain. Besides pills, over-the-counter creams and ointments are available. These are usually applied to the skin over the painful area. Some contain capsaicin (an active compound in chili peppers has been touted for its pain-relieving properties since its discovery in the early 1800s), which generates heat and may be applied directly to the skin three to four times per day. Others have lidocaine (a local anesthetic). If these don’t work, your doctor can prescribe something stronger. One class that has often been prescribed are opioids or opioid-like agents. These work in the brain, central nervous system, and other areas of the body to block the sensation of pain. Due to the chemical links between chronic pain and depression, some doctors prescribe antidepressants, such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). For individuals with neuropathic pain conditions, they might be given anticonvulsants. If you’re having trouble sleeping, your doctor might prescribe sedatives/anti-anxiety agents for a short period. If your pain is from your muscles, you might need to take muscle relaxants. If your pain is triggered by inflammation, corticosteroids can help. A newer option is to inject onabotulinumtoxina (Botox) because it blocks signals from the nerves to the muscles. Another type of injection is trigger point. This is used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles don’t relax. Infusion pain pumps (intrathecal drug delivery) provide pain medicine from a pump to the intrathecal space around the spinal cord, where pain signals travel. This can deliver significant pain control with a fraction of the dose that would be required with pills.
A concerning factor with opioids is that they were routinely prescribed for chronic pain despite a lack of evidence that they work on this type of pain, according to the Centers for Disease Control and Prevention (CDC). In fact, the body becomes tolerant to the drugs and they can make the body even more sensitive to pain, even raising the risk of chronic pain in the long run. Instead, they’re better suited to work on acute pain, such as that occurs after surgery. This is why health experts now say they should only be used at the lowest dose possible for just a few days. Unfortunately, this change in view has come after overprescribing of opioids led to a public health crisis. With over 2 million people having “substance use disorders” as a result, the need for creating safer alternatives to opioids is paramount. The National Institute of Health (NIH) is investing in new therapeutic options. The plan, HEAL (Helping to End Addiction Long-term), included new grants for 2018 and 2019 for academic groups and companies to fund the discovery of new drug targets and devices to safely treat pain. The plan also created new partnerships between the NIH, FDA, and companies to share data and assets on new non-addictive pain therapies that might be just sitting on shelves, uncover new biomarkers for pain, and construct a clinical trials network focused on conducting phase 2 trials of some of those collective assets.
In accordance with this, the FDA announced in 2018 that it was withdrawing its existing analgesic guidance for developing new pain drugs and was issuing new comprehensive guidance in 2019. In summary, some of these changes are:
- Charging drug makers with assessing the benefits and risks when new opioid pain drugs are put into development.
- Encouraging the development of extended-release local anesthetics.
- Assisting sponsors with the development of new non-opioid pain medications for chronic pain as alternatives to opioids.
The agency is also supporting the development of prescription opioids with abuse-deterrent formulations (ADFs). While these aren’t abuse- or addiction-proof, they’re a step toward products that might reduce abuse. One of these ADF medications is Troxyca ER, which is manufactured by Pfizer and was approved by the FDA in 2016. It’s an oxycodone hydrochloride and naltrexone hydrochloride extended-release capsule for oral use. It is indicated for controlling pain severe enough to require daily, around-the-clock, long-term opioid treatment, and for which alternative treatments are inadequate. Another product that might help manage chronic pain is cannabidiol (CBD), an extract of cannabis that doesn’t get you high. More research needs to be done on how and whether it might reduce pain and the extent of any side effects. However, in 2018, the FDA approved Epidiolex (cannabidiol) [CBD] to treat seizures associated with two rare and severe forms of epilepsy in patients two years of age and older. There is some thought that doctors might prescribe it for chronic pain as an off-label use.
New research brings some much-needed hope when it comes to the treatment of chronic pain. One group of researchers created a new compound that may soon replace opioids. Their findings were published in the journal Science Translational Medicine. They broke down a botulinum molecule and reconstructed it using an opioid called dermorphin to create a compound that they call derm-bot. They used this to switch off the pain signals that spinal cord neurons send to the brain. The derm-bot can do this because the dermorphin binds to the opioid receptors on the neurons’ surface, which gives the derm-bot access to inside the cell, where botulinum blocks the release of the neurotransmitter that carries the pain signal to the brain. The study was conducted on 200 mice, with each one receiving a shot of either derm-bot, sp-bot (a differently modified botulinum molecule), or morphine. The behavior of all the rodents was tracked for 5 years. During this time, the rodents’ responses to pain, as well as the location and binding properties of the two botulinum-based compounds, were observed. A single injection of derm-bot reduced hypersensitivity to the same extent as morphine, but without the adverse events of tolerance and addiction. It seemed to have a long-lasting effect in both inflammatory and neuropathic pain, successfully silencing neurons without causing cell death.
Researchers from Charité — Universitätsmedizin Berlin and the Zuse Institute Berlin have developed a new generation of opioid pain medications that’ll only work at sites affected by injury or inflammation. These drugs can avert the brain- and gut-related side effects typically associated with conventional opioids. They’ve been shown to be successful in preclinical studies.
Scientists at Wake Forest School of Medicine are working on finding a non-addictive pain killer. They are looking at the compound known as AT-121, which suppresses oxycodone’s reinforcing effects and exerted morphine-like analgesic effects. In studies on nonhuman primates, AT-121 treatment didn’t bring about the side effects commonly associated with opioids, like respiratory depression, abuse potential, opioid-induced hyperalgesia, and physical dependence. The treatment also was effective at blocking the abuse potential of opioids, similar to how buprenorphine does for heroin.
A research group at Hiroshima University detected a potential new target for chronic pain treatment. Normal pain transmission activates signaling modules to cause a sensation of pain. In chronic pain, activated astrocytes cause an increase in these signaling molecules’ production, which leads to more intense or longer-lasting pain. Previous research had shown that activating a type of cell receptor (REV-ERBs) that sends chemical signals inside the cell to block the production of certain genes regulates pain-causing and inflammatory molecules inside the body. However, until now, research had only looked into one type of pain model at a time. REV-ERBs would allow it to be reduced across multiple mechanisms simultaneously. The study was conducted on mice and the main finding shows that simulating REV-ERBs in spinal cord astrocytes with an agonist leads to pain relief. If this holds in human studies, it could benefit many types of chronic pain sufferers.
For the past decade, researchers at the University of Copenhagen have been working on a new way to treat chronic pain with a compound, a so-called peptide named Tat-P4-(C5), that they designed and developed. The treatment has only been tested in mice so far. It doesn’t affect the general neuronal signaling but only influences the nerve changes caused by the disease because it penetrates the nerve cells of the spinal cord but not the surrounding cells. The peptide can also reduce addiction. Since the compound works very efficiently and there are no known side effects, the researchers hope that the compound may potentially help pain patients who have become addicted to opioids.
Another area being studied in relation to chronic pain control is placebos because they’ve been shown to initiate the release of natural opioids in the brain and often work as well as actual medications in many cases. In the past, the effect was attributed solely to the power of positive thinking, but now, scientists have realized there’s more to it than that because it still works even when people know they’re being tricked. The people most likely to be affected by placebos have different emotional brain components on the right and left sides. In addition, they’re more emotionally self-aware, sensitive to painful situations, and mindful of their environment. All of this makes their brain primed to respond. This is why there’s no need to fool them. There is a biology behind the placebo response. A good example of this is doctors who have a positive bedside manner, meaning they believe in a treatment and communicate it through facial expressions, which causes patients to experience less pain. The placebo effect is so powerful that it even works with surgery. To test this, scientists have actually cut into volunteers and performed sham operations, which skipped only the step that’s supposed to be therapeutic. Afterward, these individuals were compared to people who had the full-on real surgeries. While it’s no surprise those who had real surgeries felt better after, it was amazing that those who got the sham surgery improved at the same rate.
Chronic pain can seem like a heavy burden to bear. The good news is that there are plenty of treatment options and new research is promising even more. In the meantime, strive to view it as only one part of, not your entire life. If you’re struggling with chronic pain, the American Chronic Pain Association has a significant amount of valuable information. For those who have found that chronic pain has taken an emotional toll on their health, the U.S. Pain Foundation provides listings of awareness campaigns and online support groups.