Chronic-Pain Help: Finding Relief with Treatment and Management

Long-lasting, debilitating pain can result from everyday tasks or health conditions - and sometimes for no apparent reason. But do you have to live with it? We asked a specialist about how to ease chronic pain and manage pain's fellow passenger, depression... Picking up the kids, doing laundry, even driving carpool can lead to the most common type of chronic pain – an aching back. Osteoarthritis, chronic fatigue syndrome, endometriosis and fibromyalgia top women’s lists of chronic-pain complaints, according to expert Magdalena Anitescu, M.D., Ph.D., and assistant professor of anesthesia and critical care at the University of Chicago Medical Center. In fact, about 50 million Americans are affected. And the financial toll — from loss of income, lost productivity, lawsuit expenses and workman’s compensation cases — is significant. Chronic pain costs the U.S. about $100 billion annually, according to the American Pain Foundation (APA). But the personal impact is even greater. Here, Anitescu explains how to treat the most frequent chronic-pain conditions. Why do so many of us have back pain? Women often work on their feet all day. With lifting, twisting, and toting children, there’s a lot of loading and unloading of weight on the spine. As a result, discs between the spine’s vertebrae lose their cushionability and degenerate earlier. I see patients as young as 35 or 40 lose joint cartilage [osteoarthritis] for various reasons, including poor posture that doesn’t properly support their weight. Additionally, constant driving vibrates and jolts everything, including the vertebrae, muscles, ligaments or discs of the spine, which erodes joints. That arthritic condition causes bone-to-bone friction in the back, contributing to pain. How does chronic pain start? When you injure skin, muscles or joints — say you cut your hand with a knife — that injury information is transmitted to the brain, which signals the spine and hand to drop the knife. The brain determines whether pain messages require immediate action to reduce the pain. With chronic pain, your brain can get many messages about that same spot. Unless your brain blocks that pain message, your spine starts to sense that injury without actually experiencing it. You feel damage, but none is actually there. Is that phenomenon connected to fibromyalgia, a source of pain for a lot of women? Fibromyalgia usually is not treated right away because the triggers are not easily identifiable. It may be hard for primary care physicians to identify and treat ‘constant pain’ when they can’t pinpoint the origin. While waiting to get treated, the spine continues sending pain messages to the brain and the pain becomes chronic. When a patient sees her doctor for chronic pain, what happens? First, we try to identify the cause, not just treat symptoms. [For example,] is it coming from nerve injury related to diabetes? Or osteoarthritis triggers? Can chronic pain be diagnosed with a medical test, such as magnetic resonance imaging (MRI)? That’s the problem with chronic-pain. With some conditions, such as fibromyalgia, the injury is invisible. Even a MRI might not show where pain originates, so finding an appropriate treatment is difficult. MRI is most successful at locating arthritic changes in the back. It can identify disc herniation [bulging] and stenosis [narrowing of the spinal canal, causing compression of the spinal nerve cord]. Once pinpointed, pain from nerve inflammation can be helped with steroid injections. Functional MRI (fMRI) — a specialized scan that maps brain function — identifies spots in the brain where sensory and emotional components of the pain are processed, resulting in a specific pain sensation. This procedure is expected to be widely used for diagnosing a variety of pain syndromes and pinpointing appropriate treatments. Once you determine the cause, what’s next? We treat pain with medication. There are several options: steroid injections in the back and knees, or infusion therapies [medication delivered through a needle or catheter] such as lidocaine [Xylocaine] and ketamine HCI [Ketalar]. At low doses these therapies retrain the brain and spinal cord to lower pain thresholds. Prescription anti-seizure medications are also useful for pain. Should sufferers start with aspirin and ibuprofen (non-steroidal anti-inflammatory drugs) and work their way up the medication ladder? NSAIDs are good to start with, but they can cause side effects, such as gastric ulcers and bleeding intestines. I prefer a combination of muscle relaxers and NSAIDs. It depends on the source of pain and symptoms. Can you give an example? For back pain, the first step is physical therapy. Many patients have bad posture, such as slouching with shoulders hunched forward or having too large an inward curve in the lower back. Physical therapy can improve adjacent muscles and keep the spine straight. Next would be medications — NSAIDs and muscle relaxants. If pain runs down the leg, such as sciatica, we prescribe an oral anti-epileptic drug, which calms nerves everywhere in the body, including the spine. Then we use steroid injections in the space surrounding nerve roots in the spine. The medication helps reduce inflammation and allows patients to build spine strength with physical therapy. Opioids [like Vicodin] come much later. The very last resort is ketamine HCI. Patients get daily treatments of the anesthetic on an outpatient basis for two weeks, then are weaned from the drug over time. Most patients sleep during the infusion procedure. The FDA released warnings about combination painkillers such as Vicodin. Why are Vicodin and ketamine harmful? We try to avoid Vicodin [a combination of hydrocodone, a narcotic, and acetaminophen, an over-the-counter pain and fever reducer] as a first-line pain treatment. It has lots of acetaminophen and is liver toxic. If you take three a day today, and 20 per day in two months, then in four months you could have liver failure. That’s a problem. Ketamine is good for chronic pain management; low doses can reduce pain by 60%. But it has a lot of side effects, such as hallucinations (we use anti-anxiety medications for that) and nausea. It’s used as a last resort for pain. Do you recommend a combination of treatments, like medication and lifestyle changes, for pain management? Absolutely. Pain physicians prefer a multipronged approach that includes physical therapy, exercise, losing weight, improved posture, aqua therapy, medication management, steroid injections and minimally invasive surgeries. Psychotherapy and learning coping mechanisms are important. We also recommend biofeedback and group therapy. Why does depression often accompany chronic pain? Should sufferers take medication for it? There’s a definite connection between depression and pain. As many as one-third of chronic-pain patients may also suffer from depression. Depression is a depletion of neurotransmitters in the brain. It’s exacerbated by lack of sleep. If you’re in pain, you can’t sleep, so you’re always depressed because the neurotransmitters can’t rejuvenate or pump themselves up. In this pain cycle, patients would benefit from psychotherapy and antidepressants. Seeing a psychiatrist for depression may help you elevate mood, sleep better and ease pain. Is chronic pain ever curable, or just managed? The reality is, we can make pain manageable. But we can’t get rid of it completely. Patients learn to deal with pain once we establish an allowable level for them. It sounds very grim, but we see happy results. Who should be on the pain-treatment team? Start with a primary care physician, add a psychotherapist, physical therapist and rheumatologist for undiagnosed connective-tissue disease. The primary care physician can establish a diagnosis and arrange follow-up exams and any necessary interventions. These might include a trip to a psychiatrist for sleep solutions or anxiety remedies. Are there new tools in the treatment arsenal? The types of tools are increasing rapidly. For example, we can now insert pumps under the patient’s skin to deliver medicine continuously to the spine for several months. It’s beneficial for patients with relentless pain and has fewer side effects than oral medications. Spinal cord stimulators are now more widely used. Small electrodes placed near the spine vibrate and trick the brain and spinal cord into thinking the sensations aren’t pain. Since the brain can’t process pain, patients don’t feel any. This is a last-resort treatment when nothing else works. It’s effective with certain back syndromes, when patients have had 4-5 back surgeries and still feel pain. Unfortunately, they have to undergo surgery again to insert the device, then replace the battery or alter the prescription. Other risks include infection, hardware breakage and allergic reactions. What else? Kyphoplasty – a minimally invasive surgery in which cement, similar to that used in knee replacement, is injected into a patient’s vertebrae. It reshapes the vertebrae’s form and alleviates pain. This treatment is effective with osteoporosis patients and those with cancer metastases to the spine. Similarly, minimally invasive lumbar decompression, a new technology, uses instruments to remove small portions of calcified ligaments in patients with severe back pain due to arthritic changes. On the horizon are nerve-pain medications. It’s a very dynamic field, always changing. Let’s talk about chronic-pain help from non-medical treatments. What if someone is in too much pain to exercise? You do the best you can. [Patients undergoing] aggressive physical therapy may benefit from a catheter in the epidural space near the spine. That provides local anesthesia before physical therapy. Do certain foods have healing properties? Not for pain, but for weight loss. It’s recommended that overweight patients lose weight to decrease weight on the spine. Low-back pain is often caused by excess weight, especially around the midsection. A Body Mass Index (BMI) of greater than 25 makes you more prone to osteoarthritis of the spine. The BMI is a mathematical formula that calculates a person’s weight in kilograms and height in meters to determine amount of body fat. [Use our Body Mass Calculator to find out yours.] Which alternative therapies offer chronic-pain help? Muscular pain can benefit from acupuncture, a practice of inserting needles into the body to stimulate certain locations on or in the skin. Physicians also may recommend electrical stimulation, which uses electrodes to invigorate the skin. They sometimes help. Does insurance cover those therapies? Acupuncture may be covered, depending on your health plan. Services provided at pain clinics usually require pre-approval by the insurance carrier. Ketamine, pumps and spinal therapies are very expensive, so insurance companies typically want proof of medical necessity and whether other treatments have failed. Your doctor’s office may help you get approvals for these types of treatment options. Physical therapy usually is covered, but for a limited time. After 15 visits or so, insurance companies figure you know how to do the exercises on your own. What about support groups? Some patients find them depressing. It’s important to join a support group with those who share your problems. For some cancer patients, the prognosis is grim. Looking at others and seeing themselves six months from now is hard. If you have back pain, though, it’s important to talk to others. It may prevent you from feeling alone and getting more depressed, which could exacerbate pain. What’s the bottom line on chronic-pain help? It’s easier to treat pain earlier rather than later. Take ownership of your treatment: If your doctor recommends something that doesn’t work, tell her and change it.