Persistent headaches and back pain. Achy bones, especially feet and hands. Gnawing, cramping guts. Whole-body soreness. So many people live with various flavors of chronic pain, and often go months or years without finding relief.
Some 20 percent of Americans are affected by chronic pain, according to the Centers for Disease and Prevention (CDC) — making it one of the most common reasons adults seek medical care. Chronic pain can be caused by ailments like fibromyalgia, rheumatoid arthritis, and inflammatory bowel diseases, or it can spring from stubbornly lingering injuries. Left untreated, pain can limit mobility, curb daily activities, and lessen quality of life — often leading to anxiety and depression.
Chronic pain is different from its cousin, acute pain. The latter occurs in response to tissue damage and inflammatory processes that follow, where the pain is viewed as part of the healing process, Steven P. Cohen, MD, chief of pain medicine at the Johns Hopkins School of Medicine in Baltimore, wrote in an overview of chronic pain published in May 2021 in The Lancet.
Once the immediate and intense period has passed — generally said to be roughly three to six months — pain that continues is a burden, increasingly viewed as a disease in and of itself.
For years, the quest to battle chronic pain led doctors to prescribe opioid medications, although the drugs proved to be addictive, which is why prescriptions for opioids are now declining. That drastic decrease, though, left many so-called “legacy” chronic pain patients without the medications they had come to depend on, sometimes leading to terrible consequences. The CDC acknowledged as much in February 2022, when it released a draft of new, more nuanced guidelines for dispensing opioids, including the removal of controversial dose ceilings.
Are Pain Treatment Recommendations Changing?
For people who have never used opioids, the CDC’s draft pain treatment guidelines recommend that nonopioid therapies be tried first, including medications like ibuprofen, acetaminophen, or gabapentin — and also various nondrug therapies, such as cognitive behavioral therapy (CBT), massage, physical therapy, and other evidence-backed modalities.
Effective Alternatives to Pain Medications Exist — but Are They Accessible?
These more holistic approaches may be valuable for some types of pain, but society has a long way to go before enough Americans can access them, says Shravani Durbhakula, MD, an interventional pain physician at the Johns Hopkins School of Medicine and host of the American Academy of Pain Management’s podcast Pain Matters. Insurance coverage, access issues, and social barriers are limiting factors, she says. Realistically, many drug-free pain relievers are out of reach for some people.
Still, people with chronic pain should not feel alone, nor should they feel hopeless, Dr. Cohen says. Doctors are increasingly recognizing the importance of treating pain in its own right, and research continues to test various modalities. “There are numerous resources available for chronic sufferers,” he says.
Chronic Pain Falls Into 3 Categories
Chronic pain resulting from injury to tissue in the body is likely the most well-known type of pain. And indeed, this “nociceptive pain,” as it’s called by medical professionals, is very common. This category includes all types of musculoskeletal pain, which means pain affecting bones, muscles, joints, tendons, or ligaments, such as osteoarthritis, rheumatoid arthritis, and cancer pain.
Experts categorize a second type of chronic pain as “neuropathic pain,” meaning it results from injury to nerves, as in carpal tunnel syndrome, diabetes, and Parkinson’s disease.
Finally, there’s “nociplastic pain,” which results when the pain-sensory pathways themselves become altered. Fibromyalgia, irritable bowel syndrome, chronic pelvic pain, and tension headaches are in this group. As Cohen and his colleagues noted in a separate article in The Lancet in May 2021, this pain is as real as any other. Brain-imaging scans have proven as much, with documented activation of pain-processing brain regions in people who experience this type of pain.
Patients with many conditions that cause chronic pain — especially but not limited to those with pain caused by sensory pathway alterations — too often complain that their doctors don’t take their pain seriously enough, in some cases dismissing their distress as all in their head. In a study published in December 2021 in the Journal of Psoriasis and Psoriatic Arthritis, for example, people with psoriasis used terms like “being on fire” to describe how their disease feels, but their doctors focused more on symptoms like itching, leading to inadequate pain management and unnecessary physical and emotional strain.
Undertreating pain is especially a problem for Black and brown patients, studies have found, and often results from implicit biases held by medical providers. A research study published in the Proceedings of the National Academy of Sciences, for example, found that out of 135 first- and second-year white medical students, those who held more false beliefs about Black patients (such as the 60 percent who believed Black people had thicker skin than white people) rated the pain of a mock Black patient lower than the pain of a comparable mock white patient, and consequently, offered insufficient pain management.
These biases can persist after clinicians complete their training, and it even affects children. A review published in JAMA Pediatrics found that for children hospitalized with appendicitis, Black children were less likely to receive any kind of medicine for moderate pain, and less than half as likely to receive opioids for severe pain when compared with white children.
A Variety of Treatments Should Be Available for Chronic Pain, Especially Early On
Chronic pain should be treated early in the disease process so it does not have the opportunity to become intractable and complex, according to remarks from Robert Bonakdar, MD, a pain management expert at the Scripps Center for Integrative Medicine in La Jolla, California, at the 2021 conference of the Academy of Integrative Health and Medicine (AIHM). It’s best to try a variety of modalities as early as possible, he said.
Medications may indeed be one of those approaches, as they are necessary in some cases. But they often don’t work, experts point out. “Drugs provide meaningful relief in a relatively small percentage of the population,” the overview in The Lancet stated. Pain-sensory pathway dysfunction is the least likely to respond to medications.
Because of this lack of widespread effectiveness, as well as concern about opioids, doctors are increasingly turning to nondrug approaches, especially those modalities with a body of research to support them.
Mind-Body Medicine: Working With the Mind Is Crucial
Psychological treatments are a key component of pain management. While people in pain sometimes assume that being referred to a therapist or behavioral therapies means the doctor thinks the pain is imagined, mental health therapies are crucial for reducing pain, experts say. These techniques work by helping people “change the way they manage pain [and] minimize disability and distress,” according to a review published in August 2020 in the Cochrane Database.
The most common psychological intervention for pain is cognitive behavioral therapy (CBT), according to the review in The Lancet. This method involves identifying and replacing beliefs, attitudes, and behaviors that otherwise make pain worse — like thinking your pain is “unbearable” or “will never end.”
Having these unhelpful reactions is called “catastrophizing,” and they can literally, physiologically increase pain intensity. “The brain responds by shifting pain levels higher and increasing inflammatory markers in the body,” according to Eve Kennedy-Spaien, an occupational therapist at the Chronic Pain Neurorehabilitation Program at Cleveland Clinic.
For example, a study of people with rheumatoid arthritis (RA) presented in June 2021 at the annual conference of the European Alliance of Associations for Rheumatology (EULAR) concluded that people who are most extreme when describing pain levels are less likely to have their disease in remission compared with those who don’t (34 percent versus 70).
Some Factors That Worsen Pain Can Be Managed
But these reactions to pain aren’t inevitable. “We have to teach the brain that chronic pain is like an alarm that just keeps going off. It doesn’t necessarily signal danger,” Kennedy-Spaien says. Calm the mind and the alarm subsides, and often the chronic pain along with it.
The Cochrane review confirmed that CBT, one method of learning to minimize catastrophizing, provides some benefits in the short term. But fewer than 4 percent of U.S. adults experiencing extended pain use this approach, according to a study examining government data on 32,000 Americans published in February 2022 in JAMA Open Network.
Kennedy-Spaien says patients may also find benefits from biofeedback and mindfulness-based stress reduction (MBSR), techniques that also train the mind to reframe. MBSR is recommended by the American College of Physicians in their guidance for treating chronic low back pain.
Other modalities that have been shown to be effective in reducing brain activity around some types of chronic pain are pain reprocessing therapy (PRT) and pain neuroscience education, which use education and psychological techniques to retrain the brain to better respond to bodily signals and encourage positive sensations and feelings instead. A study published in JAMA Psychiatry in December 2021 found PRT eliminated or nearly eliminated chronic low back pain in two-thirds of participants.
Lifestyle Interventions Ease Chronic Pain, Too
Most people with chronic pain are acutely aware that it can cause sleep problems and other psychological distress, including depression and anxiety, Cohen says. “But many do not realize that these associations are bidirectional,” meaning insomnia and distress also worsen the pain.
Improving your daily health habits is something every pain expert agrees is key, Cohen says. “Getting enough sleep, eating a healthy diet, staying active, and not smoking” should be on the top of every pain patient’s to-do list, he says.
Exercise is especially important. Although years ago, pain patients were instructed to take to bed, doctors now know that movement is a crucial component for healing the body and the mind. “There’s a widespread consensus that exercise seems to be beneficial across the board,” and especially for musculoskeletal conditions and nociplastic pain, Cohen says.
No one form of exercise has been found to be better than others, but working with a physical therapist or occupational therapist could help you choose safer activities or modifications. Since a major goal of PT is to help people overcome issues that prevent them from being more active, physical therapy can help people exercise more, which can benefit a host of physical and mental health conditions. Learning to feel more comfortable moving the body can also reduce catastrophizing. For these reasons, physical therapy is one of the main approaches recommended in the CDC’s new draft guidelines for treating pain.
Many pain patients find relief by doing yoga, a practice that soothes both the body and the mind. Research shows the benefits for pain mostly derive from the fact that it is a form of exercise, the review in The Lancet noted, so if yoga is not appealing, taking up any activity is fine.
Changing up your diet can also be surprisingly effective: Research confirms that dietary changes have pain relieving effects. A review published in 2020 in the Journal of Clinical Medicine, for example, shows that plant-based diets especially reduce musculoskeletal pain. The same review found reducing fat and sugar aids “wear and tear” osteoarthritis.
Several Healing Techniques Help Chronic Pain
Complementary and alternative medicine approaches can also aid some types of chronic pain, but there’s no one right technique for everyone. The following therapies have science behind them to support their effectiveness.
- Acupuncture One of the most popular integrative medicine techniques in the United States is acupuncture, the ancient Chinese technique of inserting very thin needles along energy pathways. The American College of Physicians recommends this modality in their guidance on chronic back pain, citing moderate-quality evidence. The federal government’s Agency for Healthcare Research and Quality calls acupuncture an effective technique for pain, noting that while researchers don’t fully understand how acupuncture works, “one possibility is that it activates the body’s pain-killing chemicals.” Preliminary research supports its therapeutic value for ulcerative colitis and Crohn’s disease. Some research suggests acupuncture helps lower pain intensity in cancer patients and the technique shows potential for helping psoriatic arthritis (PsA) symptoms. A growing number of insurers now cover acupuncture, per a study published in January 2021 in JAMA Network Open. Still, half of users have to pay for it out of pocket.
- Chiropractic Therapy Another approach is chiropractic therapy. This manual treatment involves stretching and pressure applied by a credentialed chiropractor, usually involving quick and gentle thrusts to the spine and other joints. Chiropractic therapy was found to be helpful for nonspecific low-back pain, according to a review of the method published in 2018 in the Spine Journal. Preliminary research suggests it may help ease chronic pain in people with multiple sclerosis (MS).
- Qigong and Tai Chi These centuries-old Chinese techniques combine different postures and gentle movements with mental focus, breathing, and relaxation. One review published in 2020 in Complementary Therapies in Medicine reviewed more than 800 (mostly small) studies and concluded that qigong often results in pain reduction as well as improved physical function and quality of life in people with chronic obstructive pulmonary disease (COPD) or other conditions.
The Best of All Worlds Combines Pain Therapies
The ideal for patients is to visit one location that offers a variety of these approaches, known as “an interdisciplinary pain program” or IPP. These typically feature a team of doctors, psychiatrists, physical therapists, occupational therapists, exercise therapists, and other practitioners under one roof, who together create and oversee an individualized plan for each patient.
While only a few such programs currently exist in the United States, they’ve proven especially effective. Hospitals that offer outpatient programs include the Spaulding Outpatient Center in Medford, Massachusetts, the Pain Treatment Program at Johns Hopkins University in Baltimore, and the Chronic Pain Neurorehabilitation Program at Cleveland Clinic.
People without access to such programs can assemble their own multipronged approach by seeking out various providers. It can be helpful if your primary care doctor communicates with your outside therapists, to make sure everyone is united in the same goal, experts say. Such team-based care is promoted in the CDC’s draft guidelines.
If you are interested in a more integrative approach and are unable to find an IPP, consider seeking a physician who specializes in a more holistic approach. Some physicians may have had additional training in integrative approaches (such as through the fellowship program at the University of Arizona’s Andrew Weil Center for Integrative Medicine) or in lifestyle medicine. These doctors may take more time in your appointment to discuss nonpharmacological approaches to pain management.
Promising New Pain Treatment Techniques on the Horizon
Scientists are continually on the hunt for additional options for people with chronic pain. By definition, these newer methods don’t have a lot of research yet to prove they are effective. But doctors and patients say some of the methods are worth keeping an eye on.
That said, make sure to speak to your doctor about newer tools before using them. In reality, cures found online or on social media can drain vulnerable people in pain of their money and time.
- Prescription Digital Therapeutics Prescription digital therapeutics (PDT) are virtual programs prescribed by a physician that may be reimbursable by insurance. One example is a product by Pear Therapeutics in partnership with Cincinnati Children’s Hospital Medical Center that incorporates cognitive behavioral therapy and patient education. The company offers a similar product for people diagnosed with chronic insomnia, called Somryst.
- Specialized Apps Graded Motor Imagery (GMI) smartphone apps, which engage the brain to help with complex pain, are also intriguing, Kennedy-Spain says. Apps like Recognise employ techniques such as explicit motor imagery (thinking about moving without actually doing it to stimulate the brain).
- Cranial Electrotherapy Stimulation Delivering a microcurrent through the brain, via clips worn on the earlobes, to stimulate nerve cells may sound strange, but the Alpha-stim cranial electrotherapy stimulation (CES) device is something some pain experts are watching. Its current $1,300 cost makes it prohibitive for now, although it’s hoped the price will come down over time.
- Virtual Reality and Telemedicine Finally, two modern tools have the ability to bring a great deal of relief. One is virtual reality, which can immerse patients in an otherworldly journey that may aid both physical pain and accompanying stress, as is done in the VR game Cool! by Firsthand Technology. Then there’s telemedicine, which was rapidly adopted by care providers during the COVID-19 pandemic. It allows people in more parts of the country to access pain programs they might not have had the ability to take advantage of before. For example, Spaulding recently began using telemedicine for its interdisciplinary pain program.
Access Is a Big Issue With Integrative Approaches
However much promise various methods hold, the reality is that structural barriers prevent many Americans from taking advantage of even well-accepted nondrug approaches.
Insurance is the biggest limitation, experts say. If Medicare and other insurers don’t cover a technique, it’s not accessible for most people, Dr. Durbhakula says. She notes, for instance, that she has so far been unable to get a single one of her pain patients’ insurers to cover virtual reality treatments.
The CDC recognizes this problem in its draft pain guidance. “These therapies are not always or fully covered by insurance, and access and cost can be barriers for patients,” the draft document says.
Another barrier is there are simply not enough practitioners, especially in less populated locations, Durbhakula says. “CBT is amazing, but it’s very hard to get a patient into a provider, especially in a rural area” with few therapists, she says.
Telemedicine Isn’t a Solution — Yet
Telehealth is often pitched as a fix for access issues, but one still needs trained therapists with open appointment times — and dependable Wi-Fi. As the COVID-19 pandemic illustrated, far too many Americans lack reliable internet access. Licensure rules also prohibit many practitioners from seeing patients outside of their state, experts point out. Relaxing these rules and increasing government funding for incentives to encourage psychiatrists and other practitioners to locate in rural areas would go a long way, Durbhakula says.
“Congress needs to ensure wi-fi access across the country,” so people can log in for telehealth appointments and apps that help with pain, she says.
And for in-person treatments, transportation also must be improved, she says. If someone can’t get to a physical therapist or another alternative practitioner (or even to a pain physician), none of their offerings will be helpful.
