In the chase to cure chronic pain, experts are developing holistic and technologically advanced treatments that could be the answer.
In this final part of a two-part series, we look at the current thinking and advancements in the treatment of chronic pain, and how patients can advocate for themselves. And in case you missed it, learn what causes and defines chronic pain in part one.
According to the Centers for Disease Control and Prevention, chronic pain contributes to an estimated $560 billion each year in direct medical costs, lost productivity and disability programs. The report is part of a national strategy that has been unfolding over the past decade to better recognize and address chronic pain.
James Giordano, Professor of Neurology and Biochemistry at Georgetown University Medical Center, has spent nearly 40 years studying chronic pain and its causes, treatments and effects. He says despite the benefits of medical treatments and technologies that exist in 21st century society, such advances also create an ethical paradox in the treatment of chronic pain.
“Because people are no longer dying from chronic diseases that we are able to treat, the incidents of chronic pain will likely go up, and the prevalence of chronic pain will likely go up. More people will have it, and they will continue to have it.”
However, thanks in large part to federal initiatives and funding, researchers and clinicians are innovating treatments that make living with chronic pain more endurable. “But the problem is these approaches are not universally available, and they’re not universally affordable," Giordano says.
Barriers to effective chronic pain treatment
Giordano describes a “crisis in chronic pain care.” He says many clinicians, whether neurologists or primary care doctors, are not equipped with the knowledge and resources to assess and treat chronic pain holistically.
“Frequently, a pain specialization center does not exist in all hospitals or clinics and in some cases pain care is handled by anesthesiology and palliative medicine,” Giordano says. “While these specializations are certainly viable and valid for treating pain, it’s quite a burden on a single provider to provide pain treatment, and not every clinician may have access to a network of co-providers that are specifically oriented to the treatment of chronic pain.”
Other barriers to treatment include a lack of financial resources. Many times insurance does not cover the range of treatments that may be effective in controlling chronic pain.
As a result, single clinicians faced with patients suffering from chronic pain are often left without the necessary breadth of resources, knowledge and approaches to help patients unravel complex chronic pain conditions; and more patients are at risk for becoming dependent on prescriptions, which may include opioids.
“Very often, the patient becomes tolerant and needs stronger drugs because the drugs they are on are not working and the patient is in pain,” Giordano says. He explains that because opioid dependence is classified as an addiction disorder, the individual becomes stigmatized and may fall out of the system of medical care because of the legal implications for their care providers. Patients can then become caught in a cycle of pain and opioid addiction that can be hard to treat, or even deadly.
Which is why it is important for patients and clinicians alike to be informed and advocate for access to healthcare that addresses chronic pain holistically and affordably.
High- and low-tech treatments
Giordano recommends a range of approaches to assessing and treating chronic pain. “We advocate use of patient history and physical exams, together with a high-tech approach that uses certain forms of neuroimaging that depict how the brain is responding to painful and non-painful stimuli,” Giordano says.
In cases that are more severe or are unresponsive to less invasive forms of treatment, researchers globally have seen promise with a technologically innovative neurological treatment called deep brain stimulation, which involves electrodes implanted in the brain, Giordano says. He adds that such a treatment may also be a good option in terms of time, cost and clinical efficiency for patients who are predisposed or extremely sensitive to chronic pain, and for those patients with an addictive disorder.
The technological advances made in recent years have been important to innovating both high- and low-tech approaches to chronic pain. “If researchers and clinicians better understand what is happening in the brain of patients with chronic pain, they can better treat it, and can better empower patients to engage in activities and behaviors that can change the neural pathways that transmit chronic pain sensations and perceptions,” Giordano says.
Pain exposure therapy
While there is no one cure for chronic pain for all people, there are some principles that can be helpful for many people to reshape the way the body and brain process pain using a technique called pain exposure therapy, says Tor Wager, Diana L. Taylor Distinguished Professor of Psychological and Brain Sciences at Dartmouth University.
People experiencing pain are often told to avoid any activities that cause pain. However, that can actually increase the sensitivity of the body and the brain to pain, which then results in increased pain, Wager says.
One of the most challenging characteristics of chronic pain is that the aspects of daily life most affected by pain can also actually become contributors to pain. For example, Wager explains, people in pain may begin to avoid personal and social activities, which means their dopamine system — the neurotransmitter that processes pleasure and reward — is not being engaged, which then leads to more pain.
Wager says that while prescription drugs may work for some, they are not always the most effective treatment. Instead, he says, psychological and behavioral therapies along with physiotherapy can actually be “quite effective” because of how they can reshape the neurological processes that control how the brain recognizes and responds to pain.
“One misconception is that if you are getting psychotherapy for pain that means your pain wasn’t real, but that isn’t how it works,” Wager says. “The sensitization process in the brain is partly, we think, due to basically fear avoidance, attention and vigilance to the pain.” This process is what is known as the pain cycle. But the pain cycle can be broken by a properly implemented integrated treatment plan that involves pain exposure therapy.
“Strangely enough the antidote is more pain,” Wager says. “Instead of avoiding the pain and being vigilant to the pain, do the thing that hurts.”
Whether due to a past injury or physiological change that may be identifiable through medical imaging or not, chronic pain is partially the result of the pathways that signal pain in the body having become overly sensitized to pain, as a result of the ongoing pain. Therefore, he says, this kind of pain may be unresponsive to surgery or medication, and instead require a more holistic approach.
“It’s not about trying to push the pain down, but to face it, to focus on it deliberately,” Wager says. “That’s what some of these physiotherapies and psychological and behavioral therapies can help people to do. Our brains learn what we practice. If what we’re practicing is avoiding the danger, it’s going to grow in importance, so to speak, in the brain.”
But if we take a different approach and say hey, I’m not going to avoid this, I’m going to explore it, I’m going to minimize its importance in terms of a threat signal, then it can get better over time. Over time you’re giving your brain more sensory input that signals a new level of normality and the brain learns to calibrate itself and to normalize.”
How patients and physicians can advocate
The most important thing that patients suffering from chronic pain can do is be proactive in talking to their doctors, Giordano says. It is also advisable to seek out healthcare providers who are specialists in the treatment of chronic pain.
He says informing and empowering people with knowledge is key so they can ask their doctors specific questions and point to specific sources of information. “They need to literally take this to their physicians and say, ‘How can you asses me to see whether this is what I have or not?’”
Likewise, Giordano urges clinicians to be honest when they don’t have the resources or expertise to treat chronic pain, and to refer the patient elsewhere. “It’s never comfortable when a physician has to say, ‘I can’t treat you, I’m not able.’ You feel like you’ve professionally failed the patient. The truth of the issue is you professionally fail the patient if you don’t admit it.”
Wager advises that patients search out providers who are able to connect with their individual situation. “Unfortunately, it all depends not just on what type of treatment it is, but on who the practitioner is,” Wager says.
Giordano acknowledges that it’s not an easy process for the current system that confronts patients and providers to evolve for the better. “Physicians are going to have to be brave in defending their prescriptions and referrals to other forms of care to insurance providers. They are going to have to advocate for what it is they’re doing, and for patients who are suffering,” he says.
Wager encourages patients to be proactive in their care by seeking out books as well as online resources or apps that are designed to educate and empower people suffering from chronic pain and see what resonates. (Wager himself is a consultant on one such app, called Curable.) He says there is a wealth of resources for information on the sensitization process and techniques on how to manage it.
“What you do with your behavior, how you sleep, how you eat, how you approach or avoid sensation and pain in activities are really important for a lot of people, whether or not the cause of the pain is local, in your tissue, or in your spinal chord, or your brain or all of the above.”
Lorinda Toledo is a writer and journalist in Los Angeles.