Treatments for
Chronic Pain
Diagnosing and treating
Chronic Pain
Diagnosing the cause of pain and treating it may involve seeing numerous specialists, such as pain physicians, neurologists, rheumatologists, and orthopaedic surgeons. Diagnosis and assessment may involve physical examination, medical history review, pathology tests and medical imaging, as well as psychological and physical assessment.
Treatment of chronic pain depends on the type of pain and its underlying cause, and will be different for each person. Unfortunately, there is no magic solution or cure. Treatment aims to decrease the pain and suffering and minimise its impact it on quality of life. Typically, a combination of therapies that treat different targets and symptoms may be required.
Medications To Treat
Chronic Pain
Medication can be an important part of pain management; however it is only one part. In fact, there are three main components to comprehensive pain management. The first is medication, the second is physical therapy and third is cognitive therapy.
Getting the best results from medication will involve also putting the other two strategies into practice.
The main forms of medication are:
- Over-the-counter medicines: nonsteroidal anti-inflammatory drugs (NSAIDS), paracetamol, codeine
- Opioids: codeine, morphine, tramadol
- Anti-epileptic drugs: pregabalin, gabapentin, carbamazepine
- Anti-depressants: amitriptyline, duloxetine
INJECTIONS
FOR CHRONIC PAIN
If one or more joints are causing you pain, then it may be possible to focus treatment on the problem joints. A joint block is an injection of anaesthetic (numbing medicine) and steroid that is used to help diagnose and treat joint pain.
Joints are either small, such as the facet joints that run up and down the spine, or large, such as the hip joint. Specialised needles are used to deliver local anaesthetic or steroid medication, such as cortisone injections, directly to the joint causing you pain. If the pain subsides, it means the joint is the most likely source of the pain. Once that is known, longer-term interventional treatment can be focused on the joints causing your pain.
A nerve block is a specialised injection that targets a certain nerve or group of nerves to help diagnose and treat nerve pain. The purpose of the injection is to turn off a pain signal coming from a specific area in the body and to reduce inflammation in that area.
RADIOFREQUENCY
ABLATION
Radiofrequency therapy is a proven, low-risk treatment option for chronic pain. Radiofrequency is a type of energy that is used during the procedure to heat the nerves that are causing the pain. The heating stops the nerve’s ability to send pain signals to the brain, and thereby reduces the sensation of pain.
OVER-THE-COUNTER
MEDICINES
A range of pain relief medicines can be purchased without a prescription as over-the-counter pain relievers, including paracetamol, aspirin and ibuprofen. Simply because they are available over-the-counter does not mean they are completely free of side effects. You should always check with your pharmacist or doctor if you are unsure whether these drugs are safe for you. If you have allergies, chronic illness or are on any other medicines, always check before taking these medicines.
PARACETAMOL
One of the most commonly used medicines, paracetamol is effective for mild to moderate pain, if used correctly. When taking paracetamol, make sure none of your other medicines contain the same active ingredient, as it can cause serious liver damage if taken in larger doses than recommended.
ASPIRIN
Aspirin is taken for mild to moderate pain. It should be taken with caution if you suffer with indigestion, reflux or ulcers. Aspirin may affect the way your blood clots. If you are taking anti-coagulants, always check with your doctor before taking aspirin.
IBUPROFEN
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are effective against moderate pain. They should be used at the lowest dose that improves your symptoms and only be used for a short time. These medicines may not be suitable for people with stomach troubles, heart problems, kidney impairment, high blood pressure or asthma. You should consult your doctor if you need to take these drugs for more than one week.
NSAIDS
Non-steroidal anti-inflammatories (NSAIDs) are a common category of pain medication. This category includes medications containing aspirin, ibuprofen, diclofenac and naproxen. Popular brands of NSAIDs include Nurofen, Naprogesic, Disprin and Voltaren. These medications work by altering the body’s response to pain and swelling. As a result they are particularly effective in reducing muscle and joint pain. NSAIDs can also be effective in treating period pain and in a low dose aspirin may assist in reducing the risk of stroke or heart disease. NSAIDs are generally safe when taken as directed for short periods. However, long term, repetitive use can cause damage to the stomach and liver. Patients also should be mindful that NSAIDs can also interact with other medications and alcohol. Some medications contain a combination of active ingredients and as such it is important to be aware of the differing components of the medications you are taking to avoid taking more than the recommended dose. Always discuss all medications you are taking with your doctor, including over-the-counter products as well as complementary medicines, nutritional and herbal supplements.
OPIOIDS
Opioids are a class of medication that takes its name from the opium poppy, from which opioids were originally derived. One of the main functions of opioids is to produce pain relief. They have been the mainstay of pain relief strategies for thousands of years.
An opioid is a natural or synthetic chemical, similar to morphine. Opioids work by binding to opioid receptors in the central nervous system. Opioids reduce the nerve transmission to the brain and reduce feelings of pain and affect those brain areas controlling emotion. They are used to treat moderate to severe pain.
The body quickly develops a physical dependence to opioids. Even when they are taken for only a few weeks. There are other medications that produce physical dependence, including anti-hypertensive and anti-epileptic medications. Physical dependence should be differentiated from addiction. However, opioid dependence can lead to withdrawal symptoms when the opioid is stopped, so discontinuation should only occur under doctor supervision.
The side effects of opioids can be strong, and potentially serious, including sedation, respiratory depression, constipation, and a sense of euphoria (profound wellbeing). Opioids such as morphine are well known for their addictive properties, so they need to be taken judiciously and responsibly. The rate of addiction amongst people taking opioids for chronic pain is unknown in Australia. The number of hospitalizations, however, has risen with the increased prescription rate for strong opioids.
ANTI-EPILEPTIC DRUGS
Anti-epileptic medication is used to treat neuropathic pain, sometimes in combination with other medication and in concert with physical and cognitive therapies. This class of medication was previously referred to as anticonvulsive medication. Neuropathic pain arises from injured nerves caused by disease or trauma. This pain is different to nociceptive pain, such as musculoskeletal pain, and as a result, its treatment requires different medication. Simple medications, such as paracetamol or ibuprofen, may not be effective for neuropathic pain, while medicines that are used to treat epilepsy can be very effective with treating neuropathic pain.
CARBMAZEPINE (TEGRETOL)
Carbmazepine is used to control sudden attacks of facial pain (trigeminal neuralgia) by regulating nerve function in the body. In most cases, the cause of trigeminal neuralgia is unknown. However, other causes may be a compressed nerve, aneurysm or tumour. The pain of trigeminal neuralgia is severe and may be an isolated episode or recur every few hours, minutes or seconds. There can be months or years between attacks, although in some patients, it can become chronic, interfering with daily life. Though it can affect people of any age, trigeminal neuralgia tends to affect people older than 60 years of age.
GABAPENTIN (NEURONTIN, GANTIN, GABAHEXAL)
Gabapentin may be used to treat shingles pain and other neuropathic pain conditions, such as diabetic neuropathy, peripheral neuropathy, trigeminal neuralgia and restless legs syndrome. In animal studies, gabapentin could prevent allodynia (pain in response to a normally non-painful stimulus) and hyperalgesia (exaggerated response to a painful stimulus).
PREGABALIN (LYRICA)
Pregabalin is effective in some people with neuropathic pain conditions such as post herpetic neuralgia and cancer related neuropathic pain. Pregabalin can also improve sleep. There is evidence of effectiveness in central neuropathic pain after stroke, as well as in fibromyalgia. Pregabalin has been associated with less side-effects and it may also mean that less analgesics, such as opioids can be used. If Epilim or Tegretol are prescribed, you will have tests performed for the first couple of months to check your blood count and liver function. This enables physicians to make sure you’re not developing any unwanted, but uncommon, side effects to this medication. Gabapentin and pregabalin do not require this monitoring and are frequently prescribed at pain management clinics in public hospitals.
ANTI-DEPRESSANTS
Amitriptyline is a tricyclic antidepressant drug which was originally developed to relieve symptoms of depression. It is known as an adjuvant medication, which means, its medicinal properties have been found useful in treating neuropathic pain even though its formulation was developed to treat depression.
Antidepressants have two roles in managing chronic pain. The main role is to provide pain relief when conventional analgesics such as NSAIDS, from paracetamol through to morphine, haven’t been effective. Or when these analgesics have been found to have intolerable side effects. The failure of conventional analgesics for neuropathic, for example, spinal cord injury (pain in a numb area) may justify a trial of amitriptyline, which has shown to be effective for both burning and shooting pain.
A secondary role of antidepressants in treating chronic pain is their use in combination with conventional analgesics. This can be effective in people with chronic pain, such as cancer patients, who have pain at multiple sites or have a combination of both nociceptive and neuropathic pain. Antidepressants may also Improve sleep, which is highly important
The process by which this drug works is by increasing the levels of particular chemicals in the brain, which affects the central nervous system (CNS). In clinical trials, Amitriptyline has been tested on neuropathic pain including: postherpetic neuralgia, diabetic neuropathy, irritable bowel syndrome, temperomandibular joint disorder, facial pain and fibromyalgia. It has been found to benefit pain, sleep, and fatigue levels.
IS RADIOFREQUENCY THERAPY
RIGHT FOR ME?
Most people who are candidates for Radiofrequency therapy have already tried other treatments, such as medication and injections, and now require a longer-term solution. Radiofrequency therapy procedures have high success and low complication rates. But as with any surgery, there are also risks.
Talk to your doctor about your specific condition, and together you can decide if Radiofrequency therapy is right for you. Your doctor can perform a series of tests to diagnose the origin of your pain and determine if you might benefit from Radiofrequency therapy.
DOES IT MATTER
WHERE MY PAIN IS LOCATED?
Radiofrequency therapy can be used to treat chronic pain in several areas of the body:
NECK
SHOULDER
UPPER BACK
LOWER BACK AND BUTTOCKS
HIP
KNEE
HEEL AND FOOT
CLINIC LOCATOR
Find a Pain Practice near you and learn more about treatment options for managing your chronic pain.
HOW DOES RADIOFREQUENCY
THERAPY WORK?
What happens during the Radiofrequency therapy procedure?
During the procedure, your doctor will place a thin Radiofrequency needle at the site of your pain. The needle will be connected to a generator, which produces the Radiofrequency energy needed for the procedure.
What happens after the Radiofrequency therapy procedure?
After a brief time in a recovery room to allow the sedative to wear off, you will be able to go home. You will receive discharge instructions, and you will need to have someone drive you home due to the medications you were given.
When should I start to feel pain relief?
Depending on the procedure and area of pain, complete relief may come within a few days or up to six weeks.
How long will my pain relief last?
In clinical studies, patients have reported pain relief for six to 12 months, and in some cases as long as two years.1 Radiofrequency therapy can be repeated if symptoms return.
What are the benefits of Radiofrequency therapy?
Many people who receive Radiofrequency therapy experience:
- Long-lasting pain relief
- Increased functionality
- Reduced pain medication use
- Improved quality of life
IMPLANTED
MEDICAL DEVICES
Intrathecal Morphine Pump
An intrathecal pump is a battery-operated device which delivers medication directly into the spinal canal. Intrathecal pumps may be used to treat chronic pain or spasticity, and are sometimes used to treat cancer-related pain. The spinal canal contains a large amount of cerebrospinal fluid, or CSF, in which the nerves bathe. By inserting a small tube which is connected to a programmable reservoir, medications such as pain-killers can be directly delivered to these nerves. The reservoir (or chamber) is implanted under the skin of the abdomen or back, and can be refilled from time to time by inserting a small needle through the skin.
Conditions that can be treated using an intrathecal pump include:
- Chronic pain conditions
- Complex regional pain syndrome (CRPS)
- Multiple sclerosis pain
- Failed back surgery pain
- Cancer-related pain
- Spasticity
Peripheral Nerve Stimulation
Peripheral nerve stimulation, frequently referred to as PNS, is a commonly used approach to treat chronic pain. It involves surgery that places a small wire-like electrode next to one of the peripheral nerves. These are the nerves located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles, referred to as paresthesias. The electrode is connected to an external device during a trial period. If the trial is successful, a small generator is then implanted into the patient’s body. Similar to heart pacemakers, electricity is delivered from the generator to the nerve or nerves using one or several electrodes. The patient is able to control stimulation by turning the device on and off and adjusting stimulation parameters as needed.
Occipital Nerve Stimulation
Occipital nerve stimulation, or ONS, is a peripheral nerve stimulation that involves using an implanted electrical device. Occipital nerves emerge from the spinal column at the base of the neck and extend beneath the scalp, where they transmit most of the feeling at the back and top of the head. ONS has been primarily used for treatment of severe migraine headaches, occipital neuralgia, cluster headaches and other difficult-to-treat pain conditions that involve the head and neck. It has also been investigated for treatment of pain in patients with fibromyalgia.
Spinal Cord Stimulation
Spinal Cord Stimulation, or SCS, has been used by doctors to provide pain relief and help patients get back to their lives for more than 50 years! SCS is proven to provide relief for both mental and physical aspects of pain. SCS works by using mild electrical pulses to dull pain signals as they travel from the spinal cord to the brain.
The longevity of an SCS system can depend on several factors, including rechargeable or recharge-free battery options.1 Recharge-free batteries can last up to 10 years and remove the hassle of frequently charging the SCS system.2 That means extra time to do the things you love. Most SCS systems have a patient controller, which you can use to adjust the therapy. Some patient controllers come in the form of an Apple digital device, which connects to your SCS system via Bluetooth.
One of the advantages of SCS is that before you commit to an implanted system, you can undergo a temporary trial that allows you to see if the therapy provides meaningful pain relief.
Dorsal Root Ganglion
(DRG) Therapy
Dorsal Root Ganglion (DRG) Therapy is a novel neurostimulation technology that targets and relieves pain at the source. Traditional neurostimulation has been used safely for decades, but it doesn’t always work for people with focal neuropathic pain.2
DRG systems can utilize recharge-free technology, relieving you from the time and hassles of recharging, unlike rechargeable neurostimulation systems that require frequent charging sessions. By focusing electrical stimulation specifically on the Dorsal Root Ganglion, a DRG system will work to interrupt pain signals before they reach the spinal cord, so you don’t feel pain in the same way. Interrupting these pain signals at the source enables the use of low-energy levels on a recharge-free platform and helps eliminate unnecessary stimulation throughout the body, unlike spinal cord stimulation (SCS) systems.2
REFERENCES
1. https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=9218.
2. Van Buyten J-P, Wille F, Smet I, et al. Therapy-Related Explants After Spinal Cord Stimulation: Results of an International Retrospective Chart Review Study. Neuromodulation. 2017;20:642-649.
3. Deer T, Patterson D, Baksh J, et al. Novel Intermittent Dosing Burst Paradigm in Spinal Cord Stimulation. Neuromodulation. 2020.