Chronic Pain Management 101
In chronic pain syndrome, the main goal of treatment is to manage or lessen the pain for improved function. However, complete alleviation of pain is rarely seen and should not be expected. Management consists of many pillars, but the main ones are gentle exercise, stress management, focusing on sleep, improving diet, and optimizing medications. Narcotics should be avoided if at all possible since they can worsen the chronic pain syndrome even after just a few doses.
Sleep hygiene is a vital component of chronic pain management, and there are many online resources and a specialized version of psychotherapy called cognitive behavioral therapy for insomnia. You should discuss further resources with your PCP to begin with since many of them are very skilled at helping patients choose which treatments to focus on first. A quick search for sleep hygiene online will guide you to the Sleep Foundation website which is a good starting point, and I often recommend a book called “Say Goodnight to Insomnia”, though no one source is truly comprehensive. Until recently, most of the sleep monitoring apps and gadgets were too flawed to help patients track sleep, but newer versions of the Fit-Bit and other devices are at the leading edge of treatment.
Diet is likely one of the most important predictors of health and feelings of well being (especially in pain syndromes) and eating sugary, fatty, and processed foods has even been associated with the development of dementia. Unfortunately specific guidance is hard to give because it is very difficult to study scientifically. Therefore, any dietary changes should be common sense and based on the patient's own experience. Avoiding fast foods and fatty or greasy foods is nearly always smart. Some guidelines (like migraine or anti-inflammatory diets) will recommend removing a lot of types of food, which can initially help, but food variety and enjoyment is vital. Therefore, patients should always try to reintroduce foods one at a time and after a few days notice if the symptoms have worsened. Generally if you eat something and feels worse over the next day or two, it is probably a food to avoid.
Depression, anxiety, memory, and pain must be seen as interconnected since they involve overlapping brain networks. Emotional stress on the body can have the same effects as physical stress on the body. Many of the same brain networks and brain chemicals are involved in pleasure, motivation, mood, memory, and pain regulation. Therefore, it is vital that an attempt be made to identify emotional stressors and address them with your care team, and to treat any clinical mood or anxiety disorders. Memory is also fundamentally connected to the same brain network in people who have severe depression for a very long time or severe pain for a very long time typically develop a forgetfulness syndrome that can even look like dementia. In fact, it is often more distressing than primary dementias since patients with forgetfulness due to pain and depression are more aware of their deficits. The treatment is to focus on holistic treatment of comorbid mood and pain disorders as well as other conditions such as insomnia, blood vessel health, and overall self-care.
The usefulness of pain medication in chronic pain is limited and no amount of medication will make you pain free. Medications (including combinations) alone will only help your pain 30-50%. Stretching and exercise actually relieves pain better than medications thus you need to exercise and stretch your body both in the painful area and the surrounding areas. Especially at the beginning, you may have discomfort with gentle or moderate stretching. You are not causing harm or damage. In fact more damage is caused by avoiding exercise. I advise gentle yoga or a similar practice, thai chi, pilates, etc... - you can purchase a tape from Amazon or stream many free videos online. Start with 5 mins daily and increase by 5 mins q1-2 weeks as tolerated.
All of these interventions are more important than medication, but often medication is required to tolerate the physical therapies, work on sleep, and reduce stress. The most well studied options are low dose amitriptyline or nortriptyline (less sedating than amitriptyline), high dose SNRIs (venlafaxine, desvenlafaxine, or duloxetine), or in some cases Gabapentin or Pregabalin. Additionally, even in non-diabetic patients can benefit from Metformin which seems to reduce many types of chronic pain. Novel yet to be approved treatments, still being studied are IV ketamine infusions, low-dose opiate blocking or modulating medicines such as naltrexone and suboxone, and even small doses of psychedelic medication such as Psilocybin. Some of these and many other procedures and interventions such like acupuncture, trigger point injections, and other procedures done at a pain clinic.
Pain is complex, and patients also have a lot of trauma from trying to get help in our medical system. If your physician seems to doubt your pain or dismiss it, then they may not have much to offer for treatment. Other doctors are very compassionate, but cause harm by offering procedures or medications that are as likely to harm as to help. If you’d like a consult to discuss your pain history, the experiences you’ve had with different treatment options, and to get help navigating the medical system to receive care, request a consult today.
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