Chronic Pain Management: Expert Perspective
Five specialists discuss the most effective treatments for chronic pain.
Nearly 100 million people in the US have chronic pain, but many do not receive effective treatment for it. The way chronic pain is understood and managed is changing rapidly. Treatment is becoming more multimodal – that is, to use a variety of therapies – and focused on improving function and overall health as well as pain control. To help understand these changes, we asked five experts to discuss how they treat chronic pain and what patients should expect from a comprehensive and effective pain management program.
Our panel included Asokumar Buvanendran, MD, professor of anesthesiology at Rush Medical College and a pain management specialist at Rush University Medical Center, both in Chicago; Vladimir Kramskiy, MD, a neurologist and director of the Ambulatory Recuperative Pain Medicine Program at Hospital for Special Surgery in New York City; Adam Perlman, MD, a specialist in chronic pain and autoimmune disease and executive director for Duke Integrative Medicine at Duke University in Durham, North Carolina; Kimberly Sackheim, DO, a pain management specialist at NYU Langone Medical Center in New York City; and Terence Starz, MD, a rheumatologist at the University of Pittsburgh Medical Center.
All the experts emphasize that chronic pain is a complex disease requiring an integrated, interdisciplinary approach. They routinely use various combinations of drug-based, interventional, psychological and nonmedical therapies. “It’s not unlike blood pressure medications,” Dr. Buvanendran says. “They don’t work very well if you don’t exercise and control your diet. In the same way, we take a multidisciplinary approach to chronic pain.”
Nonopioid Pain Medications
There’s a place for the judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, celecoxib and ibuprofen, many doctors say. The key, they say, is finding the most effective drug for each patient and using it only on an as-needed basis.
“There are many different NSAIDs, and patients respond to them differently. Finding the correct agent takes trial-and-error,” Dr. Kramskiy says. “Patients often think if one doesn’t work, we’ve failed, but that’s often not the case. NSAIDs should only be used when they are needed most – for example, first thing in the morning or after exercise – to avoid serious gastrointestinal, cardiac and renal side effects.” He also stresses that pain relievers should be used within the larger context of lifestyle changes and therapies that help slow disease progression. “We want to minimize symptoms and improve function to avoid long-term [use of painkillers],” he says.
Dr. Starz adds that although medications can block pain, they don’t change the underlying disease process. Finding and treating the source of the pain is an integral part of managing it, he says.
Certain people may get additional relief from drugs that aren’t typical pain medications. These include anti-convulsants such as pregabalin (Lyrica) and gabapentin (Neurontin) for fibromyalgia; the anti-depressant duloxetine (Cymbalta) for nerve, back and osteoarthritis (OA) pain; and muscle relaxants for spasms that can develop in response to arthritis pain.
Supplements such as glucosamine and chondroitin may also benefit some patients. Although results of most research have been mixed, a 2015 study in Annals of the Rheumatic Diseases found that a combination of glucosamine and chondroitin was as effective as celecoxib in reducing pain, stiffness and swelling in people with severe knee OA. “Patients often report that glucosamine and chondroitin work for a time, then stop working.” Dr. Perlman says. It’s challenging for patients to figure out what works and what doesn’t.”
Dr. Sackheim favors topical pain relievers – lidocaine or NSAID ointments and patches. She particularly likes specially formulated creams that contain gabapentin or stronger anesthetics. “Topicals may not always take away the pain, but they take the edge off, allowing oral medications to be more effective,” she says. “They work best for localized pain, especially in the small joints [such as the hand].” Topicals also avoid the systemic side effects associated with oral pain medicine, she says.
Injecting hyaluronic acid, which occurs naturally in cartilage, or a corticosteroid into painful joints may give some patients with osteoarthritis weeks or even months of relief. Dr. Kramskiy says that in the best scenarios, people with early disease may respond well to injections for years before the arthritis progresses to the point of needing surgery.
For more severe or acute pain, doctors may suggest a nerve block – injections of a local anesthetic or anesthetic plus steroids that interrupt pain signals. Nerve blocks allow some people to postpone joint replacement surgery or undergo more aggressive physical therapy before or after surgery, Dr. Buvanendran says. One newer treatment uses radio waves to destroy the small genicular nerves in the knee, which may provide complete pain relief for some people with OA.
Dr. Starz believes understanding the psychological and emotional aspects of pain is an integral part of pain therapy. “Some pain signals are processed in the same parts of the brain that control emotions and sleep, and these are important considerations in any pain management program,” he says. “We need to understand how the brain processes information and the enormous effect that can have on the rest of the body.”
A growing number of rigorous studies have found that a variety of nonmedical interventions, including meditation, relaxation techniques, massage and acupuncture can significantly reduce chronic arthritis pain. Dr. Buvanendran often recommends acupuncture to his patients, with the caveat that it is most effective when used in combination with a healthy lifestyle.
Dr. Perlman says “the next great frontier for health” is the effect of food and the microbiota – the trillions of bacteria in the human intestinal tract -- on inflammation and chronic pain. “Certain foods increase inflammation, and changing the diet may significantly decrease it,” he explains. “Unrecognized food intolerances may stimulate further inflammation, leading to increased intestinal permeability and a corresponding increase in systemic inflammation. So we are using elimination diets to try to identify foods that may be causing problems.” Like the other experts, Dr. Perlman says a healthy lifestyle – appropriate exercise, adequate sleep and stress reduction – is the cornerstone of effective pain management.
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