Treatments for Pain

How is Pain Treated?

The goal of pain management is to improve function, enabling individuals to work, attend school, and participate in day-to-day activities. People with pain and their physicians have a number of options for treatment; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods may be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that, while not all pain is curable, all pain is treatable. The following treatments are among the most common.

Treatment varies depending on the duration and type of pain. For the most part, the medications listed below have been shown in clinical trials to relieve or prevent pain associated with a specific condition(s), but none have been proven fully effective in relieving all types of pain. A health care professional should be consulted to determine which medication is effective for a given pain condition and what to expect for pain relief and side effects. Evidence for the procedures listed below is variable in its quality. In some cases, evidence suggesting that some treatments are effective is anecdotal—or based on personal experience—and in other cases it is collected from well-designed clinical trials.

Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).

Acupuncture involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese medicine. The mechanism by which acupuncture provides pain relief remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored. Evidence of the effectiveness of acupuncture for pain relief is conflicting and clinical studies to investigate its benefits are ongoing.

Analgesic refers to the classes of drugs that includes most “painkillers”. This includes classes of non-steroidal anti-inflammatory agents such as aspirin, ibuprofen, and naproxen as well as acetaminophen and opioids. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers (e.g. aspirin, ibuprofen, acetaminophen) are generally used for mild to moderate pain. Prescription opioid pain relievers, sold through a pharmacy under the direction of a physician, are used for moderate to severe pain.

Anticonvulsants are used to treat seizure disorders because they dampen abnormally fast electrical impulses. They also sometimes are prescribed to treat pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Other antiepileptic drugs, including gabapentin and pregabalin, are also used to treat some forms of pain, including neuropathic pain. Some, such as valproic acid and topiramate, are helpful in preventing migraine headaches.

Antidepressants are sometimes used to treat chronic pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs.

Anxiolytics include medications in the class of benzodiazepines (which are used to decrease central nervous system activity). These drugs also act as muscle relaxants and are sometimes used for acute pain situations. Physicians usually try to treat the condition with analgesics before prescribing these drugs.

Beta-blockers are medications which inhibit one arm of the sympathetic nervous system and adrenal “fight or flight” hormones. Propranolol and timolol are used to prevent migraine headaches.

Biofeedback is used to treat many common pain problems, most notably headache and back pain. Using a special electronic machine, individuals are trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to change his or her responses to pain, for example, by using relaxation techniques. Eventually, these changes can be maintained without using the machine. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques to treat pain can increase a person’s feeling of well-being.

Capsaicin (pronounced cap-SAY-sin) is a chemical found in chili peppers that is also a primary ingredient in prescription or over-the-counter pain-relieving creams available as a treatment for a number of pain conditions, such as shingles. This topical cream may be particularly good for deep pain. It works by reducing the amount of substance P found in nerve endings and interferes with the transmission of pain signals to the brain. Individuals can become desensitized to the compound, however, perhaps because of long-term capsaicin-induced damage to nerve tissue. Some individuals find the burning sensation they experience when using capsaicin cream to be intolerable, especially when they are already suffering from a painful condition, such as postherpetic neuralgia, which occurs in some people after a bout of shingles. Soon, however, better treatments that relieve pain by blocking vanilloid receptors (also called capsaicin receptors) may arrive in drugstores.

Chiropractic care may ease back pain, neck pain, headaches, and musculoskeletal conditions. It involves "hands-on" therapy designed to adjust the relationship between the body's structure (mainly the spine) and its functioning. Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and adjacent tissues. Such care may also involve therapeutic and rehabilitative exercises. Numerous clinical trials have been done to assess the effectiveness of spinal manipulations. A review of these trials concludes that evidence of their benefit for acute and sub-acute low back pain is of low quality. For chronic back pain however, there is evidence for small to moderate treatment relief.

Cognitive-behavioral therapy is a well-established treatment for pain that involves helping the person improve coping skills, address negative thoughts and emotions that can amplify pain, and learn relaxation methods to help prepare for and cope with pain. It is used for chronic pain, postoperative pain, cancer pain, and the pain of childbirth. Many clinical studies provide evidence for the effectiveness of this form of treatment in pain management.

Counseling can give an individual suffering from pain much needed support, whether it comes from family, group, or individual counseling. Support groups can provide an important supplement to drug or surgical treatment. Psychological treatment can also help people learn about the physiological changes produced by pain.

Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves or muscles are subjected to a variety of stimuli, including heat or massage. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:

TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.

Peripheral nerve stimulation uses electrodes placed surgically or percutaneously (through the skin using a needle) on a peripheral nerve. The individual is then able to deliver an electrical current as needed to the affected nerve, using a controllable electrical generator.

Spinal cord stimulation uses electrodes surgically or percutaneously inserted within the epidural space of the spinal cord. The individual is able to deliver a pulse of electricity to the spinal cord using an implanted electrical pulse generator that resembles a cardiac pacemaker.

Deep brain stimulation is considered a more extreme treatment and involves surgical stimulation of the brain, usually the thalamus or motor cortex. It is used to treat chronic pain in cases that do not respond to less invasive or conservative treatments.

Exercise also may be part of the pain treatment regime for some people with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise—even light to moderate exercise such as walking or swimming—can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, to work with a physician or physical therapist to create an appropriate routine.

Hypnosis was first approved for medical use by the American Medical Association in 1958. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the person into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight—and research—into the mechanisms underlying human consciousness.

Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.

Magnets are increasingly popular with athletes who are convinced of their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.

Marijuana or, by its Latin name, cannabis, continues to remain highly controversial as a pain killer. In the eyes of many individuals campaigning on its behalf, marijuana rightfully belongs with other pain remedies. Scientific studies are underway to test the safety and usefulness of cannabis for treating certain medical conditions. Currently, smoking marijuana is not recommended for the treatment of any disease or condition. In fact, federal law prohibits the use of cannabis. However, a number of states and the District of Columbia permit its use for certain medical problems.

Narcotics (see Opioids, below).

Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade.

Nerve blocks may involve local anesthesia, regional anesthesia or analgesia, or surgery; dentists routinely use them for traditional dental procedures. Nerve blocks can also be used to prevent or even diagnose pain and may involve injection of local anesthetics to numb the nerve and/or steroids to reduce inflammation.

In the case of a local nerve block, any one of a number of local anesthetics may be used, such as lidocaine or bupivicaine. Peripheral nerve blocks involve targeting a nerve or group of nerves that innervate a part of the body. Nerve blocks may also take the form of what is commonly called an epidural, in which a drug is administered into the space between the spine's protective covering (the dura) and the spinal column. This procedure is most well known for its use during childbirth. However it is also used to treat acute or chronic leg or arm pain due to an irritated spinal nerve root.

Sympathectomy, also called sympathetic blockade, typically involves injecting local anesthetic through a needle next to the sympathetic nervous system. The procedure is often performed to treat neuropathic pain of a limb (e.g. complex regional pain syndrome) as well as vascular disease pain, and other conditions. In some cases, a drug called guanethidine is administered intravenously in order to accomplish the block.

Neurolytic blocks employ injection of chemical agents such as alcohol, phenol, or glycerol - or the use of radiofrequency energy - to kill nerves responsible for the transmission of nociceptive signals. Neurolytic blocks are most often used to treat cancer pain or to block pain in the cranial nerves (see The Nervous Systems).

Surgical blocks are performed on cranial, peripheral, or sympathetic nerves. They are most often done to relieve the pain of cancer and extreme facial pain, such as that experienced with trigeminal neuralgia. There are several different types of surgical nerve blocks and they are not without problems and complications. Nerve blocks can cause muscle paralysis and, in many cases, result in at least partial numbness. For that reason, the procedure should be reserved for a select group of patients and should only be performed by skilled surgeons. Types of surgical nerve blocks include:

Spinal dorsal rhizotomy, in which the surgeon cuts the root or rootlets of one or more of the nerves radiating from the spinal cord. Other rhizotomy procedures include cranial rhizotomy and trigeminal rhizotomy, performed as a treatment for extreme facial pain or for the pain of cancer.

Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin, ibuprofen and naproxen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. NSAIDS can also adversely effect the kidneys and heart and should be taken with caution by people with kidney dysfunction, heart disease, or hypertension.

Aspirin may be the most widely used pain-relief agent and has been sold over-the-counter since 1905 as a treatment for fever, headache, and muscle soreness.

COX-2 inhibitors may be effective for individuals with arthritis. COX-2 inhibitors are a type of nonsteroidal anti-inflammatory drug (NSAID). NSAIDs work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins, which in turn cause inflammation, fever, and pain. COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs. Due to possible increased cardiovascular risk and gastrointestinal bleeding, the American Geriatic Association recommended in 2009 that NSAIDs and COX-2s be considered rarely for older people, and with extreme caution,. Individuals taking any of the COX-2 inhibitors should review their drug treatment with their doctors.

Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.

Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known opioid of all, morphine. Morphine can be administered in a variety of forms, including a pump for self-administration. Opioids are extremely effective in treating acute pain. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting. Opioids are addictive, with severely unpleasant and potentially dangerous withdrawal symptoms occurring when drugs are stopped. Chronic opioid use is a major health problem, stimulating research to develop a less addictive alternative for severe pain. For these reasons, people given opioids should be monitored carefully. Research is still needed to determine which patients will most benefit from opioids and which patients are most vulnerable to their addicting properties.

Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and gain full recovery.

Placebo is not a treatment for pain but is an effect generally used in clinical studies as a control factor to help determine the effectiveness of an active treatment. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries. Placebos offer some individuals pain relief although how they have an effect is mysterious and somewhat controversial. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo response, which is defined as the observable or measurable change that can occur in people after administration of a placebo. One large component responsible for the effect of placebo is the degree to which people expect the treatment to work. Placebos work, in part, by stimulating the brain's own analgesics.

R.I.C.E.—Rest, Ice, Compression, and Elevation—are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint injuries, such as sprains or strains. Ice is used to reduce the inflammation associated with painful and acute injuries. Ice or heat may be recommended to relieve subacute and chronic pain, allowing for reduced inflammation and increased mobility. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.

Serotonergic agonists—the triptans (including sumatriptan, naratriptan, and zolmitriptan)—are used specifically for acute migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.

Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for pain due to a vertebral disc pressing on a nerve root or spinal cord include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the part of or the entire disc is removed; laminectomy, a procedure in which a surgeon opens up the arched portion of a vertebra thereby allowing the nerve root to exit more freely; and spinal fusion, a procedure where two or more vertebral segments are fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord are burned or cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the individual’s pain are destroyed surgically. Microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves, is helpful for some individuals suffering from trigeminal neuralgia who are not responsive to drug treatment. Because surgery can result in scar tissue formation that may cause additional problems, people are well advised to seek a second opinion before proceeding.

Surgical procedures are not always successful. The related risks associated and other treatment options should be explored and considered. There is little measurable evidence to show which procedures work best for their particular indications.

Source: NINDS (NIH)1

   •   •   •

Back to: « Pain

   •   •   •

Pain in the Elderly and Children

Pain is the number one complaint of older Americans, and one in five older Americans takes a painkiller regularly. Pain management in older people differs from than in younger people. For example, older persons are much more likely to experience medication-related side effects than younger ones. In 1998, the American Geriatrics Society (AGS) issued guidelines* for improving the management of pain and quality of life in older people. The guidelines contained several non-drug approaches to treatment, including exercise, and recommended that, whenever possible, people use alternatives to aspirin, ibuprofen, and other NSAIDs because of the drugs' side effects, including stomach irritation and gastrointestinal bleeding.

The guidelines were updated in 2002 and again in 2009. In the updated guidelines, the AGS recommends that NSAIDs and COX-2s be considered rarely, and with extreme caution, in highly selected individuals due to possible increased cardiovascular risk and gastrointestinal bleeding.

For older adults, acetaminophen is the first-line treatment for mild to moderate pain, according to the guidelines.

Pain in children also requires special attention, particularly because young children are not always able to describe the degree of pain they are experiencing. Although treating pain in children poses a special challenge to physicians and parents alike, children should never be undertreated. Special tools for measuring pain in children have been developed that, when combined with cues used by parents, help physicians select the most effective treatments.

Nonsteroidal agents, and especially acetaminophen, are most often prescribed for control of pain in children. In the case of severe pain or pain following surgery, acetaminophen may be combined with codeine.

  • Journal of the American Geriatrics Society (2009; 57:1331-1346).

Source: NINDS (NIH)2

   •   •   •

Treating Pain

Treating, or managing, chronic pain is important. The good news is that there are ways to care for pain. Some treatments involve medications, and some do not. Your doctor may make a treatment plan that is specific for your needs.

Most treatment plans do not just focus on reducing pain. They also include ways to support daily function while living with pain.

Pain doesn’t always go away overnight. Talk with your doctor about how long it may take before you feel better. Often, you have to stick with a treatment plan before you get relief. It’s important to stay on a schedule. Sometimes this is called “staying ahead” or “keeping on top” of your pain. As your pain lessens, you can likely become more active and will see your mood lift and sleep improve.

Source: NIA (NIH)3

   •   •   •

Medicines to Treat Pain

Your doctor may prescribe one or more of the following pain medications:

  • Acetaminophen may help all types of pain, especially mild to moderate pain. Acetaminophen is found in over-the-counter and prescription medicines. People who drink a lot of alcohol or who have liver disease should not take acetaminophen. Be sure to talk with your doctor about whether it is safe for you to take and what would be the right dose.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) include medications like aspirin, naproxen, and ibuprofen. Some types of NSAIDs can cause side effects, like internal bleeding, which make them unsafe for many older adults. For instance, you may not be able to take ibuprofen if you have high blood pressure or had a stroke. Talk to your doctor before taking NSAIDs to see if they are safe for you.
  • Narcotics (also called opioids) are used for severe pain and require a doctor’s prescription. They may be habit-forming. Examples of narcotics are codeine, morphine, and oxycodone.
  • Other medications are sometimes used to treat pain. These include antidepressants, anticonvulsive medicines, local painkillers like nerve blocks or patches, and ointments and creams.

As people age, they are at risk for developing more serious side effects from medication. It’s important to take exactly the amount of pain medicine your doctor prescribes.

Mixing any pain medication with alcohol or other drugs, such as tranquilizers, can be dangerous. Make sure your doctor knows all the medicines you take, including over-the-counter drugs and herbal supplements, as well as the amount of alcohol you drink.

Remember: If you think the medicine is not working, don’t change it on your own. Talk to your doctor or nurse. You might say, “I’ve been taking the medication as you directed, but it still hurts too much to play with my grandchildren. Is there anything else I can try?”

Source: NIA (NIH)4

   •   •   •

Pain Specialist

Some doctors receive extra training in pain management. If you find that your regular doctor can’t help you, ask him or her for the name of a pain medicine specialist. You also can ask for suggestions from friends and family, a nearby hospital, or your local medical society.

Source: NIA (NIH)5

Treatments for Pain

Massage therapy: Some common reasons for getting a massage are to relieve pain, heal sports injuries, reduce stress, relax, ease anxiety or depression, and aid general wellness.

Source: NIH News in Health (NIH)6

Coping with Pain

Attitudes About Pain

Everyone reacts to pain differently. Many older people have been told not to talk about their aches and pains. Some people feel they should be brave and not complain when they hurt. Other people are quick to report pain and ask for help.

Worrying about pain is a common problem. This worry can make you afraid to stay active, and it can separate you from your friends and family. Working with your doctor, you can find ways to continue to take part in physical and social activities despite being in pain.

Source: NIA (NIH)7

   •   •   •

Helping Yourself

There are things you can do yourself that might help you feel better. Try to:

  • Keep a healthy weight. Putting on extra pounds can slow healing and make some pain worse. Keeping a healthy weight might help with knee pain, or pain in the back, hips, or feet.
  • Be active. Try to keep moving. Pain might make you inactive, which can lead to a cycle of more pain and loss of function. Mild activity can help.
  • Get enough sleep. It will improve healing and your mood.
  • Avoid tobacco, caffeine, and alcohol. They can get in the way of your treatment and increase your pain.
  • Join a pain support group. Sometimes, it can help to talk to other people about how they deal with pain. You can share your ideas and thoughts while learning from others.
  • Participate in activities you enjoy. Taking part in activities that you find relaxing, like listening to music or doing art, might help take your mind off of some of the pain.

Source: NIA (NIH)8

   •   •   •

References

  1. Source: NINDS (NIH): ninds.nih.gov/ disorders/ chronic_pain/ detail_chronic_pain.htm
  2. ibid.
  3. Source: NIA (NIH): nia.nih.gov/ health/ pain-you-can-get-help
  4. ibid.
  5. ibid.
  6. Source: NIH News in Health (NIH): newsinhealth.nih.gov/ issue/ jul2012/ feature2
  7. Source: NIA (NIH): nia.nih.gov/ health/ pain-you-can-get-help
  8. ibid.

   •   •   •

Note: This site is for informational purposes only and is not medical advice. See your doctor or other qualified medical professional for all your medical needs.