Sunday, May 26, 2019

Chronic Pain Treatment

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Undergoing Physical Examination and Diagnostic Testing

After completing your health history, your health-care provider will give you a thorough physical examination and review any diagnostic tests you’ve had in the past.

A general physical examination is appropriate for anyone with chronic pain, but the history may lead to an examination that focuses on one area. For example, if your health-care provider suspects that your pain is caused by nerve damage (neuropathy), a careful neurologic examination (including tests to evaluate muscle strength, reflexes and sensation) may be best, whereas careful joint examination is more important if your pain is thought to be caused by arthritis.

If you haven’t had any diagnostic tests before, your health-care provider may order specific tests such as X-rays, magnetic resonance imaging (MRI), computed tomography (CT), nerve function tests or blood tests. The tests that your doctor orders will depend on your type of pain:

  • X-rays are particularly good for seeing problems with bone that can cause pain, such as fractures or arthritis. They are also useful for diagnosing certain types of cancer.
  • MRI is better for looking at soft tissues and organs. An MRI can reveal some types of nerve problems, such as pinching or compression. It can also spot any unusual growths, such as a malignancy. Some people, however, cannot have MRI because they are claustrophobic or have metal in their bodies (such as a pacemaker). These people may need to have an “open MRI” or CT instead.
  • CT provides better bone detail than MRI does, but it is similar to MRI when used to determine the cause of pain.
  • Nerve function tests measure how electrical signals travel along nerve pathways. They are used to help diagnose nerve damage.
  • Blood tests may show evidence of inflammation, infection or another illness that may be causing your chronic pain.

These tests can also rule out some diagnoses. For instance, if your health-care provider suspects that a tumor may be the cause of your chronic headaches, he or she may order an MRI. If the test shows no tumor, your health-care provider needs to explore other possible causes for your pain.

Sometimes, a health-care provider will repeat a test, particularly if your pain has changed in some way. In other cases, a health-care provider won’t order any tests because earlier exams already answered the key questions, and further testing is unlikely to turn up anything new.

Treating Pain With Medications

In the past 20 years, a host of new pain medications have become available. These new formulations give people with chronic pain more options than ever. But all drugs can have side effects that limit how they’re used.

Two strategies can guide your use of pain medications:

  • First, if you’re taking pain medications, you’ll want to find the lowest dose that controls your pain. The lower the dose, the fewer and less severe the side effects.
  • And second, it’s often better to “stay ahead” of chronic pain by taking your medication at regular intervals, rather than waiting until the pain becomes intolerable. If the pain is predictable, as migraine pain can be, taking your medication before the pain begins may be the best approach.

The following are among the most common drugs used for chronic pain:

Acetaminophen

Example: Tylenol

Description: Acetaminophen is a safe and mild pain reliever when used in moderation.

Side effects: If you drink alcohol regularly, high doses of acetaminophen can cause liver damage, so be sure to tell your physician if you drink.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Examples: Aspirin, ibuprofen and naproxen

Description: NSAIDs reduce inflammation. They also relieve pain, even if there’s no inflammation.

Side effects: Minor side effects associated with NSAIDs are common and include rash, nausea and heartburn; however, ulcer disease (with complications such as bleeding and perforation of the stomach) is the most common of the serious side effects. The risk of ulcers appears to be slightly lower with newer NSAIDs, such as celecoxib (Celebrex). However, celecoxib use may come with more cardiovascular risk than other NSAIDs.

Capsaicin

Trade name: Zostrix

Description: Capsaicin is a cream that is applied to the skin. Usually applied sparingly three or four times each day, capsaicin is used to reduce pain in the treated area. It is mostly used for nerve pain (neuropathy) or arthritis (in the fingers).

Side effects: Capsaicin can cause burning sensation on the skin. Contact with the eyes should be avoided, as it is quite irritating.

Corticosteroids

Examples: Prednisone, methylprednisolone and dexamethasone

Description: Corticosteroids are powerful anti-inflammatory drugs. They may be taken orally or injected directly into the site of nerve irritation or inflammation. They can also be injected into a muscle or vein to provide systemic (body-wide) treatment. In some cases of chronic back or leg pain caused by spinal stenosis, degenerative joint disease or disk disease, injecting corticosteroids into the spine (often along with an anesthetic) can reduce or eliminate the pain for weeks or months. Usually, no more than three injections per year are recommended because of the risk of side effects.

Side effects: Regardless of how you take corticosteroids, the higher the dose and the longer the therapy, the greater your risk of serious side effects, including weight gain, diabetes, hypertension, facial puffiness, osteoporosis and infection. If corticosteroids are injected, side effects include discomfort, infection and thinning or discoloration of the skin at the injection site, but these problems are quite rare when injections are not frequent.

Muscle Relaxants

Examples: Cyclobenzaprine, methocarbamol and carisoprodol

Description: Muscle relaxants are particularly good for treating muscle spasm, which contributes to many cases of back pain. These drugs may reduce pain by acting directly on certain chemical messengers in the brain rather than by directly relaxing muscles.

Side effects: Because muscle relaxants may act on chemical messengers in the brain, this may explain why they also cause drowsiness.

Antidepressants

Examples: Amitriptyline, nortriptyline, desipramine and doxepin (tricyclic antidepressants); fluoxetine (Prozac); duloxetine (Cymbalta)

Description: Antidepressants likely act on chemical messengers in the brain. By doing so, they can dull pain perception. In some cases, antidepressants work by treating accompanying depression that is making chronic pain more difficult to tolerate. These drugs sometimes work well even in doses too low to treat depression.

Side effects: Side effects include dry mouth, sedation (drowsiness) and heart rhythm disturbances.

Anticonvulsants

Examples: Carbamazepine, phenytoin, gabapentin, pregabalin (Lyrica)

Description: Anticonvulsants (antiseizure medications) may be particularly helpful for pain caused by neuropathy (nerve damage). Unlike antidepressant drugs, which affect certain chemical messengers in the brain, anticonvulsants also act directly on nerve tissue. They can also be effective in the absence of neuropathy.

Side effects: Sedation, liver damage and blood cell changes are the most common side effects that limit the use of anticonvulsants.

Narcotics (Opioids)

Examples: Codeine, hydrocodone, morphine and meperidine

Description: Narcotics are often used to treat severe, unrelenting pain, such as cancer pain. They are the most powerful pain relievers available and are generally used when other treatments have failed. Narcotics can be given by mouth, can be injected or can be administered by a patch, which delivers the drugs through the skin. In some cases, patients can wear a small device that feeds a trickle of narcotics into the spinal fluid through an implanted tube, or the painkiller can be delivered by a pump implanted directly into the abdomen. In general, narcotics are not used alone for chronic pain. They are often part of an approach that includes nondrug options (such as counseling and physical therapy), as well as other nonnarcotic drugs.

Research shows that many people who do not have adequate pain relief with narcotic analgesics are either receiving prescriptions that undertreat their pain or are not following the recommendations for those prescriptions because they fear side effects. For example, a study from the University of California at San Francisco interviewed cancer patients in their homes and found that fear of side effects was a major cause of inadequate drug use. In addition, fewer than a third of patients had been prescribed both as-needed and around-the-clock pain drugs as recommended by current guidelines.

Side effects: Unfortunately, narcotics can cause constipation, sedation, confusion and nausea. In susceptible persons (especially people with lung disease), these drugs may dangerously slow breathing. They can also be addictive and may require steadily increasing doses to remain effective; in the past, however, the risk of addiction for people with chronic pain may have been overestimated. Although side effects and the risk of addiction have caused some patients and their health-care providers to shy away from using narcotics, even when they may be the best way to treat severe pain, this anxiety about narcotics is gradually changing. More health-care providers are willing to prescribe these drugs when needed.

Tramadol

Trade name: Ultram

Description: Tramadol is a fairly new nonnarcotic pain reliever that acts in a similar way on the brain as narcotics do; it also affects levels of the chemical messenger serotonin in the brain.

Side effects: Stomach upset, an increased risk of seizures (in susceptible persons) and harmful interactions with other drugs are the most common side effects.

Anesthetic Nerve Blocks

Examples: Lidocaine and bupivacaine

Description: Similar to novocaine, anesthetic nerve blocks may be injected into specific nerve bundles to interrupt pain signals before they are sent to the brain. The relief is usually temporary but may provide information that can lead to better treatment; if the nerve block works, for example, a second injection in the same area with a chemical that damages the involved nerve can block the signals and provide longer relief.

Side effects: The most common side effect is an allergic reaction; in addition, the insertion of a needle to inject the medication may occasionally be complicated by nerve damage, bleeding or infection.

FAQ: OxyContin

What Is OxyContin?

OxyContin is the brand name for a particular formulation of the prescription pain drug oxycodone (ock-see-KOH-done) hydrochloride. OxyContin tablets are controlled-release, which means the drug dispenses its relief in a continuous manner for up to 12 hours. OxyContin is used to treat moderate to severe pain and is valuable for use in people with chronic pain or pain from cancer.

Do Other Drugs Contain Oxycodone?

Many pain-relieving drugs contain oxycodone. Percocet, for example, is a combination of oxycodone and acetaminophen. (Acetaminophen is found in some over-the-counter pain relievers such as Tylenol.) Percodan, another painkiller, is made of oxycodone and aspirin.

How Is OxyContin Different From These Other Drugs?

OxyContin is plain oxycodone containing anywhere from two to 32 times the amount of oxycodone found in Percocet or Percodan. For people with chronic pain or pain related to cancer, OxyContin is one of a few drugs that can provide many hours without break-through pain. The others include MS-Contin (long-acting morphine sulfate), methadone, and transdermal fentanyl (Duragesic patch).

How Does OxyContin Work To Relieve Pain?

OxyContin tablets are designed to be swallowed whole. They should never be cut in pieces or chewed. The tablet is designed so that the dose of oxycodone is slowly absorbed in the intestines to provide a steady, pain-relieving level in the bloodstream.

Why Is There So Much Concern About OxyContin?

OxyContin tablets easily can be crushed and abused to create a narcotic “high.” Once the tablet’s cover is broken, the contents then become short-acting and can be ingested for rapid absorption in the intestines, snorted, or mixed with fluid and injected with a needle directly in to the blood. As with any potent narcotic taken in a high dose, the consequences can be deadly.

Treating Pain Without Medications or Surgery

Sometimes, simple approaches work best for those with chronic pain: rest, stretching, a change in your exercise routine, new running shoes. Devices such as a heating pad for sore muscles or a wrist brace for arm pain associated with typing may work well.

However, many people with chronic pain have already tried and failed these simple options. If you do not find relief after making such simple adjustments, you may need to further investigate ways to treat your pain that do not involve drugs or surgery.

Physical Therapy

Revisiting the simple approaches that you have tried may produce better results under the guidance of a health-care professional. A physical therapist may be able to tailor a fitness program exclusive to you that includes stretching, as well as strengthening. For example, certain types of exercise (such as swimming instead of running) can reduce or even cure chronic back pain.

Complementary or Alternative Therapy

Examples of complementary or alternative therapies include acupuncture, chiropractic care, biofeedback, meditation and massage therapy. Although complementary or alternative therapy may relieve chronic pain in some situations, there are two important things to keep in mind:

  • Many complementary or alternative therapies have not been proven effective. Many alternative therapies have not been carefully studied by researchers, at least not as thoroughly as many conventional treatments. Claims about their effectiveness are often based on stories from individual patients (some of whom may be paid spokesmen for the treatment they are praising), rather than on carefully conducted clinical trials. This doesn’t mean that complementary or alternative treatments won’t work for you, just that there is not yet scientific proof that these approaches are effective.
  • Occasionally, complementary or alternative therapy may be dangerous. Although most alternative therapies that people try for chronic pain are, at worst, harmless, a few may be dangerous. For instance, if you have chronic neck pain, having a sudden neck manipulation (a chiropractic procedure) can be dangerous if you do not know what’s causing your pain. Thus, it’s very important that you discuss with your health-care provider any alternative approaches that you are using. Ideally, you should talk with your health-care provider about alternative therapies before you begin any new treatment. Many health-care providers feel that if conventional treatments aren’t working and complementary or alternative approaches seem safe, there’s no harm — and there’s possible benefit — in trying them.

Question: I get mail promoting the great benefits of chelation therapy. The claim is that it removes calcium and other metals from the walls of arteries.

Answer: Chelation therapy uses chemicals that combine with metals or other toxins in the body, creating less harmful compounds that are discharged in the urine. It’s the standard way of treating serious cases of lead poisoning and certain medical conditions such as iron overload.

For several years, chelation with a chemical called EDTA has been promoted as a sort of “vascular Drano” that will remove harmful metals from your arteries. And this would lower your risk for heart attack, stroke, and other blood vessel diseases. It’s an interesting idea. But so far, it hasn’t panned out. Most studies have not shown benefits from chelation therapy.

Chelation can have serious side effects. Some include kidney damage, dangerous heart rhythms and seizures.

You asked about vinegar. EDTA stands for ethylene diamine tetra-acetic acid. It’s a synthetic compound with a little “pocket” that attracts metals. That’s why it is used to pull lead and other metals out of the bloodstream. Acetic acid is the naturally produced chemical that gives vinegar its distinctive sour smell and taste. Although EDTA is an acid, and part of its structure resembles acetic acid (thus the name), it’s really an entirely different compound.

I suppose vinegar might have some health benefits. But there is no reason to believe that it could remove metals from the walls of arteries.

Electrical Stimulation

Electrical stimulation may reduce pain. In electrical stimulation, a device (called a transcutaneous electrical nerve stimulator, or TENS unit) is applied to the skin to deliver an electrical current to a painful area. It is thought to trigger a response from the spinal cord that reduces pain signals. A similar effect probably occurs when you rub a painful area after an injury.

Counseling

Both group therapy and one-on-one counseling can be important in managing chronic pain by helping to lift depression and anxiety that can accompany the pain. Group therapy offers a forum for people with chronic pain to support and encourage each other. And it allows a newcomer to see others with similar problems getting better and to hear about coping strategies that can help. In addition, many people with chronic pain find that family and friends may have difficulty fully understanding or sympathizing with their condition; in time, family and friends may become less supportive or may be unwilling to listen. Counseling, group therapy in particular, can provide a sympathetic ear and the comfort of shared experience.

Relaxation

Whether on your own or in a supervised setting (such as with a psychologist), relaxation techniques can have a beneficial effect for people with chronic pain. For some, simply going on vacation and being relieved of daily responsibilities leads to a reduction in pain or improved coping.

Application of Heat or Cold

For many people with chronic pain, the application of heat or cold to the painful area provides relief, although the reasons are not so clear. Examples of this include the use of ice for back pain and the use of a heating pad for neck pain.

Time

Finally, time itself may be a treatment option for those with chronic pain, because even chronic pain may be self-limited — that is, it can sometimes resolve on its own, even without treatment.

Treating Pain With Surgery

In general, health care providers and patients turn to surgery for pain relief only when other, simpler approaches have failed or for serious conditions that requires aggressive  treatment (such as an infection near the spine). Some conditions that cause chronic pain can be effectively treated with surgery; others cannot. For example, surgery can completely eliminate back or radiating pain in 80 percent to 90 percent of people with severe disk disease, which presses on a nerve in the spine. Yet surgery rarely improves back pain caused by muscle spasm or back pain that has no known cause, even if a minor disk problem is present.

Rarely, patients may be offered surgery to cut nerves or remove damaged areas of the brain involved with pain signals. Another approach is to implant tiny electrical wires (electrodes) into the spinal cord or brain. These devices provide pain relief when the patient turns them on. However, these aggressive treatments don’t always work. They should be considered a last resort in cases of severe chronic pain, such as cancer pain.

Additional Resources

American Chronic Pain Association
P.O. Box 850
Rocklin, CA 95677
Toll-Free: 1-800-533-3231
Fax: 916-632-3208
http://www.theacpa.org/

American Fibromyalgia Syndrome Association (AFSA)
7371 E Tanque Verde Road
Suite D
Tucson, AZ 85715
Phone: 520-733-1570
Fax: 520-290-5550
http://www.afsafund.org/

American Pain Foundation
201 N. Charles St.
Suite 710
Baltimore, MD 21201-4111
Phone: 410-783-7292
Toll-Free: 1-888-615-7246
http://www.painfoundation.org/

Arthritis Foundation
P.O. Box 7669
Atlanta, GA 30357-0669
Toll-Free: 1-800-283-7800
http://www.arthritis.org/

National Headache Foundation
820 N. Orleans
Suite 217
Chicago, IL 60610
Phone: 312-274-2650
Toll-Free: 1-800-643-5552
http://www.headaches.org/

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Jonathan
Medically trained in the UK. Writes on the subjects of injuries, healthcare and medicine. Contact me [email protected]

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