How Pain Management Specialists Can Help You Treat Chronic Pain
Here's what causes chronic pain and how pain specialists use medications and treatments to help manage symptoms.
Pain is a normal response—sometimes. It’s our body’s signal that something is wrong.
But too often pain from certain conditions (or no condition at all) can go on for a long time without serving a useful function and with no end in site.
Many people deal with chronic pain: According a 2020 report, an estimated 1 in 4 Canadians over the age of 15 live with chronic pain.
“Chronic pain is fairly common,” says Kim Mauer, MD, medical director of the Oregon Health and Science University (OHSU) Comprehensive Pain Center and associate professor of anesthesiology and perioperative medicine in the OHSU School of Medicine in Portland, Oregon.
Given the tremendous impact pain has on both people and society, a medical specialty has been developed to handle pain not only as a symptom, but also as a condition. It’s called pain management, and its practitioners come from many fields.
They go through at lease an extra year of training after board certification in their primary specialty, which prepares them to diagnose and treat painful conditions, says Seth A. Waldman, MD, anesthesiologist and director of pain management at the Hospital for Special Surgery (HSS) in New York City.
“The longer one has chronic pain, the more we often find that it needs assistance in management,” Dr. Mauer says. “Usually, if you can be aggressive with acute pain management, your risk of chronic pain and needing further help is lessened.”
Read on to find out how chronic pain affects the body, and how you can manage it.
What causes chronic pain?
An injury, such a broken bone, can cause acute pain. That means it’s severe and comes on suddenly but only lasts for a limited amount of time.
“The sensation of pain is initially a signal to the brain that there is actual or impending injury to the body,” says Dr. Waldman. “A complex cascade of events follows the initial signal to the brain, including withdrawing from the source of injury—think quickly removing your hand from a hot stove—but also avoiding the painful area, and spasm of muscles around the area.”
This goes away as the injury heals. There’s a problem when the source of the pain is ongoing.
“When the signal persists, changes begin to occur in the nervous system, including the peripheral nerves, which supply the skin, muscle, and bone, as well as in the spinal cord and brain,” Dr. Waldman says. “This can cause the signal to spread to other areas in the nervous system, causing what is known as a ‘chronic pain state.'”
When this happens, the pain won’t just go away.
Many conditions can cause chronic pain
Many incurable (although treatable) diseases and conditions can cause chronic pain, such as osteoarthritis, rheumatoid arthritis, headaches, endometriosis, and fibromyalgia.
Back pain and spinal problems also cause ongoing pain. As does cancer. Sometimes, the cause of the pain is never even identified.
Chronic pain can also be caused by damage to the nerves themselves as a result of another condition. For example, diabetes and other conditions can cause nerve damage known as peripheral neuropathy, which can cause numbness, tingling, and stabbing pain in the hands or feet.
Shingles—a reactivation of the herpes zoster virus—can sometimes cause postherpetic neuralgia, a problem where pain lasts for months or years. Other conditions can also cause nerve pain.
“It can come from the central nervous system, such as post-stroke pain or pain from multiple sclerosis,” Dr. Mauer says. With chronic pain coming from the nervous system itself, the unpleasant sensations can be felt in other areas of the body, far from the original site of the injury, Dr. Waldman says.
Chronic pain can set off a cycle of problems
With these ongoing conditions, pain becomes a vicious cycle in the body.
“Over time, the limbic system is more and more activated,” Dr. Mauer says. “Our limbic system, which processes our emotional responses, also processes pain signaling. So they are kind of like the chicken and the egg—it is hard to tell sometimes which one came first or is bothering a patient more.”
The pain begins to create far-reaching consequences in the body, which can be both mental and physical.
“There are behavioral changes that can become difficult to reverse the longer pain is present, such as avoidance of usual daily activities, and mood changes such as anxiety or depression, which can become independent problems and worsen the underlying pain,” Dr. Waldman says.
Pain that wakes you up at night can also cause lost sleep, which makes depression and inactivity worse. “Untreated pain can also cause other physical problems, such as weakness, bone loss, and even an increase in the sensitivity of the affected area from disuse,” Dr. Waldman says.
Diagnosing chronic pain
If you have unidentified pain, you should start by talking to your primary care doctor because pain can be a symptom for many illnesses, Dr. Waldman says.
The first step may be to diagnose your underlying condition, which might involve X-rays or other tests.
If your condition is already diagnosed, treating the underlying disease may improve pain symptoms, but sometimes it’s not enough.
“A patient whose pain has persisted, is severe and resistant to treatment of the apparent underlying condition, or which is thought to be neurologic in origin is often referred to a pain specialist,” Dr. Waldman says. “If you have severe or persistent pain, ask your primary care physician about a referral.”
How pain doctors can help
Pain management providers can have many different backgrounds, Dr. Mauer says.
Most are anesthesiologists or sports medicine specialists (called physiatrists). Often physiatrists are called rehabilitation specialists, she says, and they tend to focus on chronic musculoskeletal conditions, such as arthritis, and strokes.
Before you set an appointment, confirm that your pain management doctor has the proper credentials. Dr. Waldman suggests that you ensure their fellowship training program has been certified by the Accreditation Council for Graduate Medical Education (ACGME).
They should also be trained in the use of medications, rehabilitation, and behavioral therapy, he says. Behavior therapy can help change unhealthy mental or physical behaviors.
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Chronic pain treatments
When you visit a pain center, you’ll likely be treated by a team that includes a pain management doctor, plus possibly a physical therapist, occupational therapist, and psychiatrist to help address all aspects of your pain care.
“Most pain centers or pain clinics now focus on what we like to call integrative or complementary therapies,” Dr. Mauer says. “This means the pain center is providing more than just medications and injections. More and more, we are incorporating all modalities of care.”
After assessing your pain, providers will recommend a treatment program tailored to your needs.
Medications may be part of your treatment, but pain management isn’t just about popping a pill for relief.
“Simply providing injections or opioid pain medications is not pain management,” Dr. Waldman says. That said, some medical treatments may be part of your program, including steroids, anticonvulsants, and antidepressants, he says.
You may be directed to take over-the-counter medications like NSAIDs (nonsteroidal anti-inflammatory drugs, like ibuprofen) as well.
As mentioned, you may also have rehabilitation with a physical and/or occupational therapist. If your underlying condition is not already being treated, “we also refer for other medical or surgical evaluation when appropriate, such as to a surgeon, neurologist, oncologist, or rheumatologist,” Dr. Waldman says.
Is opioid addiction a risk?
With the ongoing opioid crisis in Canada, you may be cautious about taking these prescription pain meds, which include oxycodone (Percocet, OxyContin), hydrocodone (Vicodin), and others.
“There is a trend away from prescribing opioids, although we definitely still use them,” Dr. Mauer says. “We are trying to use more of the opioid antagonist/agonist medications instead of full agonists, as the former are a little safer.” One such partial opioid agonist/antagonist is buprenorphine (Bunavail, Suboxone, Zubsolv).
If you’re prescribed opioids, before you take them ask your doctor which type they are and how long you’d be taking them for. If you or a family member has a history of addiction, make sure to mention that as well.
Dr. Waldman says opioids are very effective particularly for severe short-term pain, such as after trauma or surgery, but it’s important to minimize their use. In addition to concerns about substance use disorder, they can actually make chronic pain worse over time.
“While opioids can provide great relief, because they change the way the body’s self-regulating endorphin system responds to pain, they can at times cause an increase in pain called opioid hyperalgesia,” he says. With this condition, the body gets hyper-sensitive to pain, so the drugs have the opposite of their intended effect.
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Lifestyle changes that may help
The commitment to reducing pain also will likely involve some everyday changes on your part.
“There are numerous treatments for pain, including simple things such as heat and cold,” Dr. Waldman says. “We also prescribe lifestyle changes, including weight loss.” Your physical therapist may give you exercises to practice, and a plan for a program of physical activity.
Although you might not feel like getting active, in many cases it may actually improve pain.
In addition, depending on the triggers for your pain, Dr. Mauer says you may be directed to a gluten-free, vegan, or anti-inflammatory diet. You may also be given alternative therapies including acupuncture, massage, Reiki, or Rolfing, she says.
Reiki is a type of touch often known as “energy healing.” Rolfing is similar to massage but aims to realign the body’s tissues.
Pain has a psychological aspect, so you may also meet with a psychiatrist or psychologist, who can give you mental strategies for how to respond to pain, including relaxation and mindfulness techniques.
Psychological techniques including cognitive behavior therapy (CBT), which teaches you how to recognize and change thought patterns. An offshoot acceptance and commitment therapy (ACT), may also be used.
Another technique, called biofeedback, can help you gain control over normally involuntary functions of your body, such as your heart rate. You may also begin a mind/body practice like yoga, meditation, or deep breathing.
Why are there so many aspects of pain management?
It may seem like a lot, but that’s because pain is so multi-faceted.
“Pain can be difficult to assess and treat, but regardless of the primary specialty of the pain specialist, the most effective therapy results from a combined approach,” Dr. Waldman says.
Because of this, treating pain requires more than just medical methods. “We believe that treating the entire patient will go further in treating their pain than just focusing on the uncomfortable sensation,” Dr. Mauer says.