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Rethink Chronic Pain: Opioid painkillers can be addictive and are not always appropriate for long-term use. Experts say an alternative is to think about—and treat—pain differently.

Hiscott, Rebecca

doi: 10.1097/01.NNN.0000470756.41753.3a
Departments: The Waiting Room

This Way In: Experts say non-drug strategies may be most effective for managing chronic pain.



One-third of Americans—an estimated 100 million people in the United States—experience chronic pain, and 5 to 8 million of them treat it with prescription opioid drugs such as hydrocodone, oxycodone, or morphine, according to a recent paper from the National Institutes of Health (NIH). As the number of prescriptions rises, so does the death toll. In 1999, 2,700 people died from an overdose. In 2012, that number swelled to 16,000, according to the Centers for Disease Control and Prevention.

And those who don't die from opioid overdoses often experience serious side effects, including slowed breathing, physical dependence, and addiction. In fact, chronic opioid use may actually make pain worse. All of this has prompted some experts to employ a different approach: helping people rethink their attitudes and expectations—which may, in turn, make alternatives to opioids more effective.

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The way you think about pain can have a profound impact on how you experience it—and how you recover. A 2015 study published in The Journal of Clinical Pain, for instance, found that people with low back pain who did not expect their acupuncture treatments to be effective had more pain-related disability than those who went into the therapy with a positive attitude.

“Chronic pain is always a combination of behavioral and biological factors,” says Gary M. Franklin, MD, MPH, a neurology research professor at the University of Washington in Seattle and a Fellow of the American Academy of Neurology (FAAN). “A lot of people have to deal with psychological barriers to recovery, such as fear-avoidance [shunning exercise and other activities based on fear of pain], catastrophizing [convincing yourself the pain is worse than it is], and low expectations of recovery.”

These behaviors and barriers can actually make pain worse, while dulling the benefits of the treatment regimen. For example, sometimes people can't accept their condition and won't do the physical and emotional work required to manage the pain, says Charles E. Argoff, MD, a professor of neurology at Albany Medical College, director of the Comprehensive Pain Center at Albany Medical Center, and a member of the AAN.

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“Complete pain relief is not reasonable, nor is expecting to be able to return to the same degree of activity that you had previously,” says Dr. Argoff. “However, you and your doctor can outline meaningful and realistic expectations. If you achieve those goals, look at what more you can do.”

Treatment is not just about pain relief, adds Dr. Franklin; it's also about improving your ability to do more on your own. A type of physical therapy program called activity coaching, for instance, “focuses on doing more every day: walking more, standing more. The goal is to get your life back.”

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Managing chronic pain requires a comprehensive approach that might include physical therapy, cognitive behavioral therapy, non-opioid medications, and even diet and exercise programs, says Dr. Argoff. The goal is to optimize pain relief, improve outcomes, and reduce dependence on drug treatments.

Other potential treatments include yoga, tai chi, acupuncture, massage therapy, meditation, and biofeedback, a technique that teaches people how to monitor and control biological functions like heart rate and muscle tension.

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Cognitive behavioral therapy (CBT) and other forms of psychological intervention help patients accept and deal with pain, says Miroslav “Misha” Backonja, MD, an emeritus professor of neurology at the University of Wisconsin School of Medicine and a member of the AAN.

In particular, CBT helps patients recognize and challenge negative beliefs that may interfere with their ability to live a fuller, more pain-free life and replace them with more positive ones.

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People with chronic pain often avoid even mild exercise because they fear it will be too painful. But research shows that exercise, especially a plan developed by a physical or occupational therapist, helps relieve pain, improve physical function, and increase independence, says Dr. Franklin.

The exercise doesn't have to be strenuous, and, in some cases, it shouldn't be. Taking regular walks or doing slow, practiced movements like tai chi can be enough, says Dr. Backonja. As an added bonus, exercise can ease the anxiety and stress that often accompanies chronic pain.

The bottom line? Don't let chronic pain control you, says Dr. Argoff. “Be vigilant, be realistic, and don't give up.”

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What Is Chronic Pain?

Chronic pain is defined as pain that lasts for more than 90 days or pain that doesn't go away when it should. It is often associated with conditions such as migraine, peripheral neuropathy (which can cause numbness, tingling, and pricking sensations, as well as more severe burning pain), and trigeminal neuralgia (which causes sudden, sporadic burning or shock-like facial pain).

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Pay Attention to Painkillers

Schedule regular appointments with your doctor when taking opioids.

Doctors should carefully monitor any patients taking opioids to make sure they are safely prescribed, says Charles E. Argoff, MD, director of the Comprehensive Pain Center at Albany Medical Center in Albany, NY, and a member of the AAN.

“We have no way of knowing who will benefit, and everyone is at risk of having a bad outcome,” he says. That's why it's so important to see your doctor regularly to evaluate your progress and talk about alternative therapies if your current regimen isn't working.

Tell your doctor about any over-the-counter medications you're taking, including supplements, vitamins, and herbs, to prevent potential drug interactions and adverse side effects, says Teshamae Monteith, MD, director of the headache program at the University of Miami School of Medicine and a member of the AAN and the Neurology Now editorial advisory board.

To be safer still, include family members or close friends in conversations with your doctor, advises Gary M. Franklin, MD, MPH, FAAN, a research professor in neurology at the University of Washington in Seattle.

People taking opioids often think they're improving, but they're still profoundly disabled and aren't actually exercising or participating in social activities more each day. “Ask your spouse how you're doing,” Dr. Franklin recommends. “You may be satisfied with that little bit of pain relief, even though you're not functioning very well, but your spouse might recognize that you're sicker than you think.”

© 2015 American Academy of Neurology