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According to the Centers for Disease Control (CDC), nearly 50 million Americans live with chronic pain, defined as experiencing pain most days or every day in the past six months. 19.6 million of those chronic pain patients suffer with what is called high-impact chronic pain – pain that limits life or work activities on most days or every day in the past six months. The goal of treatment for these patients is to reduce their experience of pain so that pain no longer controls their lives.
In the early 2000s, opioids were prescribed to chronic pain patients to reduce their pain symptoms. Unfortunately, there was little-to-no emphasis on safe prescribing practices. As a result, opioid medications were over-prescribed, while alternative pain management treatments were underutilized due to lack of insurance coverage for these more effective modalities. Subsequent research revealed that opioids are not the best course of treatment for chronic pain, but translation of these research findings to practice takes time. In addition, we also have many primary doctors who learned to rely on opioids as the go-to method for treating pain who now are faced with finding safe and more effective interventions to treat their patients’ chronic pain.
Approaching chronic pain management in a new way
Primary care physicians do not have to manage chronic pain alone. Chronic pain is best approached with the support of a multi-disciplinary team that, in addition to the primary care provider, may also include specialists who can address the physical and emotional aspects of pain, as well as practitioners of complementary and alternatives therapies to alleviate symptoms.
Research shows that motion is one of the most effective ways of treating chronic pain. While many patients are at first resistant to movement, physical therapy and exercise slowly introduced into the patient’s selfcare regimen is part of chronic pain management. Providers treating chronic pain would do well to provide their patients with a list of convenient recreational centers, fitness centers and health clubs in the area that offer classes and workout spaces to support their exercise needs.
Primary care physicians who have a strong referral base of complementary and alternative practitioners, such as chiropractors, acupuncturists and yoga instructors, will help their chronic pain patients to engage in these safer pain management modalities for years to come. Nutritionists can also be helpful because diet can affect many chronic pain conditions. One of the largest barriers to people getting effective relief through these alternative strategies is the expense, and insurance often doesn’t cover it. If primary care providers can point to a set of reasonably priced alternatives, they are doing their patients a great service.
Addressing the most common forms of chronic pain
Headaches, abdominal pain and musculoskeletal pain are probably the three most common pain conditions that drive people to their doctor. Learning how to address these conditions – and what to avoid – will also help physicians better manage their patients’ pain.
Musculoskeletal pain: Pain in the muscles and joints, most frequently in the neck, shoulders, upper back, mid back, lower back, hips, knees, hands and ankles from various arthritis conditions or de-conditioning usually get better relief from movement therapies – whether exercise, stretching, yoga or physical therapy. There are a host of non-narcotic medications such as topical medicines, anti-inflammatories, aesthetic agents and medications that increase circulation to painful areas that are very effective for this type of pain. This is especially true when used in combination with complementary therapies.
Abdominal pain: There are many reasons for abdominal pain. For some there are dietary exacerbators and identifying these can help avoid abdominal pain flare. Stress can also exacerbate abdominal pain conditions, so stress reduction – through exercise, group therapy, cognitive behavioral therapy, spiritual practice, or breathing exercises – can be both preventive as well as therapeutic during a flare and may preclude the necessity to use opioid medications.
For chronic diseases such as Crohn’s disease and ulcerative colitis, or a rarer diagnosis referred to as abdominal migraine, the pain is intermittent and acute. With relapsing remitting diseases like these, chronic opioid use should be avoided. Opioid use for even three weeks may cause withdrawal and one of the symptoms of opioid withdrawal is abdominal pain.
Headaches: The cause and type – tension, migraine or pressure – of chronic headaches can be difficult to diagnose. In addition, a number of standard medicines to treat these may contain codeine, which may not have quite the abuse potential as oxycodone and hydrocodone, but that doesn’t mean it is innocuous. One of the more common medications for migraine headaches and tension headaches is a combination of butalbital (a barbiturate), codeine, acetaminophen and caffeine, and it’s been used for many, many years. This combination is potentially problematic for those who have the right genetic predisposition for substance use disorder. Headaches frequently benefit from various relaxation techniques, including breathing exercises, yoga, exercise or meditation.
The role of marijuana in pain management
In many states, chronic pain is one of the conditions for which marijuana can be used. However, as my colleague Kate Appleman recently explained, marijuana is not an FDA-approved medicine nor has it been fully vetted or researched for the treatment of pain. Evidence for the use of marijuana is primarily anecdotal. Other medicines that we recommend or prescribe have been thoroughly tested and researched with significant amounts of data. We know what the dose should be, we know what the frequency of administration should be, but we know none of those things about marijuana. Therefore, I cannot prescribe marijuana to treat chronic pain because it is not in the same category as other FDA-approved chronic pain medicines. Some chronic pain patients claim they get symptom relief from use of marijuana. However, there are too many unknowns to advocate its use.
Get to know your local addiction specialist
As Dr. Travis Rieder suggests in his book, In Pain: A Bioethicist's Personal Struggle with Opioids, it’s important for primary care physicians to know their local addiction medicine specialists, not only for substance use disorder referrals but also for strategies in managing chronic pain. Addiction medicine specialists receive training on pain management based on using alternatives to opioids. There is a broad array of pain management strategies available and a patient who works with a team of specialists has a greater likelihood of managing their pain successfully. All health systems benefit from having an addiction medicine specialist available to patients with chronic pain, as well as for those with substance use disorder.
Many Americans have come to expect a quick fix to pain. Understandably, someone in pain wants to feel better immediately. Chronic pain is a different animal that requires ongoing management and a multi-faceted approach. Primary care providers who explain how alternative approaches work and why they require time and effort set realistic expectations that will lead to a better outcome.