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Fighting Chronic Pain

New treatments are in the pipeline, but what works best now?

En español l Plagued for decades by chronic back problems, lupus and several other painful health conditions, Mary Crossman, 59, a retired geriatric nurse in Federal Way, Wash., hardly remembers a day when she hasn't hurt. Over the years, she's tried to find relief with over-the-counter medications, prescription pain pills, physical therapy "and just about everything else they can offer," she says. "Some days I'm OK. Others, I can barely get up and move."

Meditation acupuncture chronic pain treatment coping cope

Yoga may help alleviate symptoms of chronic pain. — Mango Productions/Corbis

An estimated 100 million Americans suffer from chronic pain each year, according to a landmark 2011 report by the Institute of Medicine. Back injuries are a common cause, but there are many others, including arthritis, shingles, nerve damage from diabetes, and the aftereffects of surgery. The United States spends up to $635 billion annually to treat chronic pain. Yet millions go on suffering.

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While there is still no magic bullet, researchers have gained important new insights into the nature of pain and the process that turns the acute pain from an illness or injury into persistent, chronic pain.

Why me?

"Given exactly the same injury, some people get well. Others develop chronic pain. The question is why," says A. Vania Apkarian, a neuroscientist at the Northwestern University Feinberg School of Medicine in Chicago. In the first study to look at what happens in the brain when chronic pain develops, he and his colleagues followed people who had just suffered a back injury, using brain scans. The team found that the brain's architecture actually changes in response to persistent pain. More startling still, the scientists discovered that the greater the interaction of two specific areas of the brain — the medial prefrontal cortex and the nucleus accumbens — the greater the chance that patients will develop chronic pain.

"The injury itself is important, of course," says Apkarian. "But what's happening in the brain predicts with 80 percent accuracy who will go on to develop chronic pain." Apkarian hopes the discovery will lead to new drugs that could head off the switch from acute to chronic pain.

The most effective approach to pain

For now, the most effective way to ease chronic pain is a holistic approach that involves both body and mind — one that begins with a dose of reality. "A lot of patients come to us hoping that we can get rid of their pain," says Richard W. Rosenquist, M.D., an expert in pain management at the Cleveland Clinic. "But the reality for many patients is that we can't. We can't cure their arthritis. We can't make them young again. But we can help them manage chronic pain and get back to their lives."

Indeed, many experts now encourage chronic pain sufferers to focus less on their pain and more on function. "I used to routinely ask chronic pain patients to rate their score on a scale of 1 to 10," says Rosenquist. "Now I want to know what people would like to do that they can't do because of their pain. Then we can look for ways to help them manage the pain and do what they want to do."

The benefits of exercise

Staying as active as possible is crucial. In fact, recent research shows that physical activity — done safely — is one of the most effective treatments for chronic pain.

In a 2012 study by researchers at the Hospital for Special Surgery in New York, 200 patients with osteoarthritis who participated in a weekly exercise program reported a significant drop in pain and an improvement in quality of life. The program included tai chi, yoga, dance and other forms of exercise, tailored to people with osteoarthritis. Other studies have shown that exercise eases chronic back pain. Almost any form of activity seems to help. When scientists at Tel Aviv University compared six-week programs of brisk walking versus strength training workouts in patients with chronic low-back pain, both improved functioning and reduced pain.

Antidepressants can help those with chronic pain

Treating the psychological consequences of chronic pain is equally important. Acute pain is typically a symptom of injury or disease. But when pain persists, it becomes a disorder in its own right, with its own set of symptoms, researchers say. These often include depression and anger. Many pain centers now offer psychological counseling, stress-reduction techniques and anger management courses. Antidepressant medications such as duloxetine (Cymbalta) and desipramine (Norpramin) have proved particularly helpful for some chronic pain sufferers. The pills not only improve mood but also seem to take the edge off pain.

Pain medications, used judiciously, are often the first line of defense. But it's important to be realistic about how much relief they can offer. "At best, people get about a 20 to 30 percent reduction in pain from opioid pain medications," says Rosenquist. Like many pain specialists, he cautions against using escalating doses to ease pain, a practice that can lead to dependence.

Yoga, meditation, massage and more

Complementary approaches such as yoga, massage, meditation, biofeedback and acupuncture also help some patients feel better. A recent study of acupuncture, for instance, found that it helped ease pain in patients with osteoarthritis of the knee. Massage therapy may be helpful for lower-back pain. "But the available evidence is very limited on what works and what doesn't," says Michael Weinberger, M.D., who directs the Pain Management Center at New York-Presbyterian Hospital. Like many pain specialists, he takes a pragmatic approach. "If something helps a particular patient feel better, I encourage them to use it."

New meds in the pipeline

As for new medications, some promising drugs that attack pain in novel ways are in the research pipeline, according to Clifford Woolf, M.D., professor of neurobiology at Harvard Medical School. One approach would block pain signals at their source. Researchers also now know that a predisposition to chronic pain is partly inherited. Eventually, treatments may be found that can turn off those genes.

Retired nurse Mary Crossman knows better than most the accommodations required to make it through the day. "I use a heating pad, which helps. On especially bad mornings I may take a pain pill or two. I try to schedule activities around the times I feel good," she says. She tries to walk every day and keep up her social connections.

But when pain flares up, "I sometimes just have to say no, I can't do that today." Like most chronic pain sufferers, Crossman has had to accept that she'll never be completely pain-free. But, she says, "I've learned that I can live with that."

The problem with pain meds

Prescription opioid painkillers are now the leading cause of drug overdose deaths in America, taking more lives than heroin and cocaine combined. To better control the flow of pain drugs, an advisory panel to the Food and Drug Administration in January recommended tighter restrictions on a group of popular pain medications that includes Vicodin and Lortab, meds that contain hydrocodone and acetaminophen. They would be placed in the most highly regulated drug category, which now includes oxycodone pain meds such as OxyContin and Percocet, along with morphine and opium. Pills in this category are much harder to obtain, with each refill requiring a new prescription.

Aside from the risk of addiction or overdose, pills with the opioids oxycodone and hydrocodone pose other hazards, especially when taken over the long term. Studies show they increase the risk of falls, a real concern for older patients. They also can cause men to lose interest in sex. Paradoxically, opioid pain medications can actually increase sensitivity to pain, a condition called hyperalgesia. "In some patients on these drugs, all their other pains begin to hurt more," says C. Richard Chapman, professor at the Pain Research Center at the University of Utah. The potential dangers of opioid pain meds are so serious that some leading pain clinics now focus on getting patients off pills. At the Mayo Clinic's Pain Rehabilitation Center, for instance, one of the program goals is tapering chronic pain sufferers off all pain meds. Some 57 percent of patients entering the program take opioid painkillers. Fewer than 7 percent are on opioid medications when they leave.

Peter Jaret is a freelance writer in Petaluma, Calif., who writes for many national publications.

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