From lower-back issues to osteoarthritis, chronic pain can be debilitating – and hard to treat. We asked top pain doctor James Dillard, M.D., to explain how a combination of conventional and alternative treatment can relieve suffering and what to look for when choosing a pain specialist. Hurting? You’re not alone. According to the American Academy of Pain Medicine, more than 76 million Americans live with chronic pain. The problem costs the U.S. workforce $1.2 billion a year in lost productivity.
Whether chronic pain affects the back or neck – the two most common areas – a lot of people are seeking relief. And their discomfort isn’t just persistent, it gets worse over time.
“Acute pain happens when you burn your hand on the stove – that goes away after a while. But when pain is chronic, it’s like turning up the volume,” says James N. Dillard, M.D., D.C., CAc, author of The Chronic Pain Solution (Bantam).
Dillard, who practices in New York, has been treating pain for 25 years. He combines alternative and conventional treatments to manage pain, drawing on his background as an acupuncturist, chiropractor and physician.
In this exclusive interview, he reveals what causes chronic pain and the most effective ways to treat it.
Why is pain much worse in some people than others?
They have sensitized nervous systems.
Some people may be genetically predisposed to experiencing changes in their brain stem and nerve cells that turn up the volume on pain.
According to [Harvard neuroscientist] Clifford Woolf, this type of pain takes on a life of its own. It’s out of sync with any tissue damage.
Pain that lives in the nervous system is known as centrally mediated pain.
How do nervous system changes affect the pain we feel?
They amplify pain. And it will actually spread, so pain in the foot begins to spread to the whole limb.
[Patients] go to their doctors and get MRI [magnetic resonance imaging] scans to find the cause of pain. The doctors keep looking for what’s wrong in the tissues, but what’s wrong is in the nervous system.
They see a bulging disk and think that’s the problem. Truth is, almost everyone has abnormalities in their spine. In fact, 63% of people who have no pain have abnormal MRIs.
What’s the next step?
If you’re not getting any relief from your primary care physician, you should see a pain specialist.
I recommend [someone who incorporates] integrative pain medicine, which involves a combination of nerve-quieting medications, complementary and alternative medicine, and conventional physical therapy.
He or she should be someone who thinks acupuncture, massage and dietary changes are reasonable to try.
Why do some people develop chronic pain following an injury?
A big part of the reason is that they haven’t really rehabilitated the body part, so there’s not enough normal sensory stimulation.
You wind up losing your range of motion, and your muscles are full of tissue knots. Many people become afraid to injure the part again. They become excessively protective, and that ramps up the pain.
To be fully rehabbed, you need normal sensations. That requires physical therapy and a full return to the use of the injured part. You’ve got to move it and use it.
What are the alternative treatments?
There’s no one recipe for this – every patient has to have individualized care.
I use a combination of acupuncture, massage and certain pain-quelling nutritional supplements and herbs.
Omega-3 fatty acids are the best. They help limit inflammation. [So do] anti-inflammatory herbs like turmeric. [Read more about the benefits of turmeric in our article 10 Essential Superfoods for Women.]
The treatment might also involve relaxation work and stress-management techniques.
Which pain medications do you prescribe?
When I use medications, it’s usually as part of an integrative approach.
I tend to use anti-epileptics like gabapentin [Neurontin] and pregabalin [Lyrica], or a class of antidepressants known as SNRIs – selective norepinephrine reuptake inhibitors – that includes duloxetine [Cymbalta].
Also, older antidepressants – tricyclics like amitriptyline [Elavil] and nortriptyline [Pamelor, Aventyl] work. I usually start people on low dosages and then ramp them up slowly.
I also practice what I call rational polypharmacy. It’s a well-targeted use of medications, and I use a combination of as few drugs as possible.
I don’t dismiss drugs like narcotic painkillers or long-acting morphine. I still prescribe those, as well as anti-inflammatories and steroidal anti-inflammatories.
Do you worry that your patients could become addicted to these painkillers?
Everything can be habit-forming, even herbal medicines. But drugs aren’t the problem [on their own]. It’s not the wine, scotch or [oxycodone] Oxycontin.
It’s about the personality. You have to be aware of your potential to become addicted, and manage that. And your prescriber has to know you have the potential to become addicted.
Can changing your diet help reduce pain?
Well, you certainly can’t be eating an inflammatory diet – getting lunch handed to you through the car window.
Eliminating fast food, refined sugar and white bread would help.
I recommend following the anti-inflammatory food pyramid by Andrew Weil [director of the University of Arizona’s Center for Integrative Medicine].
It involves eating a lot of fruits and vegetables, whole grains, beans and healthy fats from foods like walnuts, canola oil and flaxseed.
Exercise is important. But how do you become more physically active when you’re hurting?
In all honesty, a lot of people can’t exercise. They’re a 7 or 8 on the pain scale [a 1-10 scale doctors use to measure patient discomfort], and they’re the worst tangled ball of yarn you can imagine.
I have to figure out how to get them down on the pain scale before talking to them about breath work, meditation or exercise.
So how do they know when they’re ready to exercise? And what should they do?
You have to take every person on a case-by-case basis. When they’re ready, they might want to start trying to swim a bit.
If pain isn’t an issue, what are the best exercises to keep it from becoming one?
My bottom line is that you should balance exercise and stretching in healthy quantities. Mix up your exercises – have a variety. Get in the water; do a little biking or rowing. Climb a hill.
We talk about low, medium and high impact. Particularly for women, in terms of osteoporosis, you want to have a little impact. Walking is an ideal impact [activity], or even jumping jacks.
Do some yoga to stay flexible. People feel old not because they’re getting old, but because they’re getting stiff.
One study found that glucosamine may not work to prevent osteoarthritis. Do you agree?
The papers on glucosamine and chondroitin are mixed. A 2006 study in the New England Journal of Medicine, for instance, found that the two supplements didn’t reduce pain in the overall group of patients who were studied.
But what the press didn’t pick up on was the fact the supplements did have a significant effect on patients in the moderate to severe group. And there are five other studies that say they’re helpful.
What forms of alternative medicine can patients practice on their own?
Anything that works on the mind-body connection is helpful. That includes relaxation exercises, breath work, meditation and mindfulness-based stress reduction [MBSR], which involves a merging of yoga and meditation.
MBSR, which was developed by Jon Kabat-Zinn [founder of the Stress Reduction Clinic at the University of Massachusetts Medical School], is one of the most robust techniques for chronic pain and chronic illness.
It’s offered in medical centers all over the country now.
If you need to see a pain specialist, what should you look for?
You want someone who takes a multidisciplinary approach to treating pain. These doctors follow the guidelines issued by the major medical pain organizations, like the American Pain Society and the North American Spine Society.
They’ll do physical therapy, but also involve social workers and psychologists. In other words, they treat the whole person.
Speaking of psychologists, what’s the role of mental health in pain treatment?
Depression, anxiety and catastrophizing [fearing the worst] are major factors in pain, because pain is a catastrophe.
Pain feeds depression, and depression feeds pain. It’s a question of which came first. You have to untangle the ball and figure out what happened.
The emotional fallout of pain is a huge hurdle for sufferers. I sometimes have to convince people to see my psychological colleagues if I think they need support. It helps if I joke with them and they can start laughing.
So laughter is important in alleviating pain?
Absolutely. Hanging out with funny friends or watching a weekly sitcom can make a world of difference. There’s a huge amount of research on that.
For more on alternative treatments to pain, visit the National Center for Complementary and Alternative Medicine website.
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