The Top Tools for Pain Management

Veteran addiction physician Dr. Melissa Lee Warner recently rejoined The Farley Center, as the new director of its program for professionals. Warner previously served as Farley's medical director from 2000–2013. One of Dr. Warner’s treatment specialties is pain management. 

Chronic pain patients—especially those with a genetic predisposition—may be at a higher risk of addiction because of the stress they are suffering. Persistent pain tends to interfere with the enjoyment of life, participation in social activities, general mobility, and healthy sleep patterns. Over prolonged periods of time, this can lead to depression and substance misuse. 

Until recently, many pain patients were routinely prescribed potent narcotic drugs to manage their chronic pain condition. The ongoing opioid epidemic is widely blamed on the over-prescription of pain pills. Some medical professionals ended up misusing opioid pain relievers because they had easy access to those drugs. However, substance use disorder (SUD) is often driven by co-occurring mental health issues. Availability is not the whole story. People with addiction tend to self-medicate emotional pain and the reason for the mental distress could be physical pain.  

“Pain is a perception, not a sensation,” explains Dr. Warner. “There is also an emotional aspect to the experience. It really is all in the mind. There exist powerful descending modulatory influences that can either attenuate or enhance pain.” The pain signal transmits a localized stimulus to be experienced in the brain. 

Not all pain is the same. It can be modified by cultural influences and personal attitude. Certain magnifiers, such as fear, anxiety, depression, sleep deprivation, and apprehension can intensify pain perception and trap the individual in a vicious cycle.  

As Warner explains, pain can cause muscle tension and intensify anxiety both of which can reinforce the pain perception which in turn will escalate the muscle tension and anxiety further. It doesn’t have to be that way. “The experience of pain is malleable, says Dr. Warner. “You can change the experience without changing the stimulus.” She doesn’t even like to call it pain but prefers to ask patients about distress, discomfort, unpleasant feelings, or tension. 

Areas of Focus for Treatment of Pain Without Narcotics

Pain perception can be attenuated without using opioid pain relievers or similar medications. In order to avoid the risk of addiction, the focus should be shifted toward healthier treatment methods. 
Working on establishing a healthy sleep pattern is a good start. Persistent pain can severely disrupt a patient’s sleep pattern with devastating consequences. Lack of sleep may lead to mood disorders, exacerbating the inability to sleep and intensifying pain perception. 

Sleep hygiene starts with a cool, dark, and quiet bedroom. “Avoid activation in the evening, like drinking caffeinated beverages,” Dr. Warner recommends. “Have a consistent wake time. An appropriate cardio workout supports healthy sleep as well.” 

If there are mood problems, they should not be ignored because of the feedback loop described above. Two medications, in particular, have been used to improve the mood of pain patients. Cymbalta (duloxetine) and Wellbutrin (bupropion) are antidepressants primarily used for treating depression. Cymbalta is also used to treat anxiety disorder, and pain associated with diabetic peripheral neuropathy or fibromyalgia. Wellbutrin is also used to treat seasonal affective disorder.

Various physical therapies may be employed to check tension and discomfort. “Acupuncture can affect the body’s endorphin system,” says Dr. Warner. There is thermal therapy: heat and ice have long been used to counteract aches and pains. Stimulation methods like TENS and E-stim are available. Orthotics such as splints and braces that protect and immobilize may be used to improve chronic pain conditions.

Manual Therapy includes massage, manipulation, and stretching. There are also topical treatments, including lidocaine, capsaicin (an active component of chili peppers), menthol or peppermint oils, and Voltaren gel. 
A fourth area of focus is psychotherapy, explains Warner. Treatments include cognitive behavioral therapy (CBT), Insight-oriented psychotherapy, and keeping a gratitude journal.  

The fifth area is psycho-physiologic modulation such as biofeedback, neurofeedback, hypnosis, acoustic therapy, guided imagery, deep relaxation, eye movement desensitization and reprocessing (EMDR), and meditation. 

Number six is exercise. The mental health benefits of physical activity are well established. It can help with anxiety and depression, minimize the effects of stress, and improve sleep—all of which can modify pain perception. Among the activities Dr. Warner recommends are cardio, weightlifting, and yoga. 

The seventh area is group support. Helping others or enjoying the help of others often has a strong impact on emotional well-being. Helping others can ease your own pain and theirs as well of course. 

The last two areas are self-care strategies. Warner calls the eighth area “pleasure promotion,” meaning that going to a live show or a movie can improve your mood and distract from any discomfort. The final treatment approach is one Americans typically struggle with: good old rest and relaxation. Taking time off without checking emails, fretting about meetings, or worrying about deadlines is just not on the radar for many people who are “plugged in” all the time. Rest and relaxation—taking some time for self-care, even if it’s only 30 minutes—is important, though, and not only for people with pain conditions.