Update on chronic pain management: Pain medication is OUT! Exercise, psychological therapy, and acupuncture / dry needling are IN!
What is chronic pain, and what impact does it have?
Chronic pain (AKA persistent pain) is a common and complicated condition characterised by persistent pain on most days of the week. It affects 1 in 5 Australians aged 45 and over (Australian Institute of Health and Welfare, 2020). Chronic pain can be disabling and stressful, often limiting us from being able to do the things we enjoy most in life and even the things that we must do on a day-to-day basis such as getting out of bed, going to work, sitting, etc. Chronic pain is defined as pain that lasts beyond normal healing time (generally >3-6 months). Sometimes it is associated with a clear event, injury, or health condition (e.g. osteo or rheumatoid arthritis), but sometimes it can come on gradually for no apparent reason. When it comes on gradually with no clear diagnostic explanation, it is referred to as chronic primary pain with no underlying cause. This is the type of chronic pain that I will be discussing in this article. It is arguably the most frustrating type of pain for people to deal with and can progress over time to become extremely disabling over time.
Pain is defined by the IASP (International Association for the Study of Pain) as an unpleasant sensory and emotional experience associated with or resembling that associated with, actual or potential tissue damage. Without going into too much scientific detail, the most important parts of that definition are that pain is a sensory and emotional experience, and that pain can occur with OR without actual tissue damage.
What does this mean?
Think of pain as an alarm system that is designed to notify our body about potential physical harm…when it’s working properly that is. When we experience pain that exceeds normal tissue healing and repair times (approximately 3-6 months) something has caused this alarm system to malfunction, and it is now being triggered by stimuli that should not be causing it to go off under normal circumstances.
Why does this happen?
This is where it gets complicated….do you want the good news or the bad news first? We’ll start with the bad – there are thousands of biological, social, and psychological factors that can cause the transition from acute to chronic pain to happen, including stress, anxiety, lack of activity/exercise, development of fears, or psychological barriers to certain movements, disrupted sleep patterns, poor dietary habits, long term use of painkillers, and many more. The underlying driver for chronic pain can differ significantly from person to person and it is usually due to several factors rather than just 1 or 2 (spoiler alert: current physical damage is not always one of the main factors!). And now what you’ve all been waiting for….the good news! The good news is that most of these factors can be easily identified and treated successfully through communication and properly administered health care.
What is the best approach to treating chronic pain and where do I start?
The most recent NICE (National Institute for Health and Care Excellence) guideline for Chronic pain in over 16’s was published on April 7, 2021 (see https://www.nice.org.uk/guidance/NG193). This document provides a great summary of the most up-to-date, scientifically proven strategies that can be used to overcome persistent pain. While everyone wants a “quick fix” in today’s society, unfortunately, there is no shortcut for treating chronic pain. However, the more that we learn about the cause and risk factors for chronic pain, the more successful we are becoming at treating chronic pain. The NICE guidelines recommend an approach that combines one or more of the following modalities to be the most effective way to overcome the burden of chronic pain: exercise programmes and physical activity, psychological therapy, acupuncture, and pharmacological (medication) management.
Non-pharmacological management:Physical activity has endless benefits for those suffering from chronic pain, and while it may cause some discomfort getting your body moving again it is the most important aspect of a rehabilitation program as it will improve your confidence, reduce fear/avoidance of certain movements, lower your pain threshold, and allow your body to become more resilient over time. Psychological therapy, specifically through the use of acceptance and commitment therapy (ACT) and cognitive behavioural therapy (CBT) for pain has also been shown to be extremely effective in treating the psychological factors that contribute to chronic pain. Anxiety, stress, fear of movement, and depression are a few of the common psychological conditions that can intensify the physical sensation of pain in the body when it has been present for longer than the normal tissue healing times. By addressing these underlying psychological barriers, you can open up a whole new understanding of how the mind is so closely connected to the body and can directly affect the way our “alarm system” reacts to perceived threats. Acupuncture or dry needling that is delivered in a community setting by a healthcare practitioner that is well trained in this area has also been shown to be effective in treating chronic pain. This form of therapy can help reduce the body’s sensitivity to stimuli that shouldn’t cause pain under normal circumstances but have become painful due to an increase in sensitivity / heightened pain response in our body’s sensory system.
Pharmacological management:
According to the NICE guidelines, the most recent research states that there is little to no evidence that treating chronic primary pain with no underlying cause that has lasted for longer than 3 months with painkillers makes any difference to the person’s quality of life, the physical pain that they suffer, or their psychological distress. The classes of medications that should not be administered to people that fit this specific classification of chronic pain include gabapentinoids, antipsychotic drugs, corticosteroid injections, non-steroidal anti-inflammatory drugs, opioids, or paracetamol. When administered for a prolonged duration, opioids can actually contribute to chronic pain through a mechanism known as opioid induced hyperalgesia in which our body develops an increased pain response to stimuli that should not normally cause pain.
According to the guidelines, the only class of medications that is suitable in some cases of chronic primary pain with no underlying cause that has lasted for longer than 3 month are antidepressants for people aged 18 years and over assuming a medical professional has made the decision that the individual is an appropriate candidate. Antidepressants may help improve quality of life, pain levels, sleep and psychological distress, even in the absence of a clinical diagnosis of depression for those suffering from chronic pain.
Summary
Chronic pain is one of the most prevalent and disabling conditions that exists in our society – it has a massive physical and emotional burden on those who are suffering from it, and it has a huge financial impact on our healthcare system. Pain is a complex sensory and emotional experience that can occur with or without actual damage to the body, and the most recent NICE guidelines have done a fantastic job of summarising the most up to date evidence based approaches to treating chronic pain (that has persisted for longer than normal tissue healing/repair times). It is important to take into account that everyone experiences chronic pain differently, therefore, those who are seeking treatment for their pain may need to explore numerous interventions (as recommended by the NICE guidelines) in order to find an approach that works best for them to begin the journey towards overcoming their condition. If you or anyone you know is struggling with chronic pain and wants to learn more about how we may be able to assist you, please get in touch with one of our staff members or your local health care provider to learn more about what can be done to start the process!
Kurt Drinkwater
Physiotherapist (DPhty)
References:
- “Chronic Pain (Primary and Secondary) in over 16s: Assessment of All Chronic Pain and Management of Chronic Primary Pain NICE Guideline [NG193] Published: 07 April 2021.” NICE, www.nice.org.uk/guidance/NG193.
- “Chronic Pain in Australia, Summary.” Australian Institute of Health and Welfare, www.aihw.gov.au/reports/chronic-disease/chronic-pain-in-australia/contents/summary.
- “Chronic Pain Sufferers Should Take Exercise, Not Analgesics, Says Nice.” The Guardian, Guardian News and Media, 6 Apr. 2021, www.theguardian.com/society/2021/apr/07/chronic-pain-sufferers-should-take-exercise-not-analgesics-says-nice. “IASP Terminology.” IASP, www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
