The Smart Patient's Guide to
Chronic Pain Management

The PPM Guide to Relieving Pain Without Medication

For chronic pain, there are several effective non-opioid alternatives including mind-body techniques, biofeedback, devices and ancient Chinese therapies. Learn more.

If you are one of the millions of Americans who endure chronic, daily pain, you may be aware that government agencies have released guidelines for safer medication prescribing for pain conditions. Last year, the Centers for Disease Control and Prevention (CDC) released medication guidelines to help reduce the misuse of opioid medications—powerful pain medications used for both acute and chronic conditions.1

These days, health care providers and pain specialists are looking beyond opioids for effective alternatives to treat most forms of chronic pain. In fact, many agree that nonopioid medications and non-drug therapies are the preferred treatment, only prescribing stronger pain medications when these options have failed.

So what other options are available to those who suffer chronic pain? Are they effective? Are they a better alternative? To follow, is a guide to some of the most common non-drug treatments used for the management of chronic pain conditions (in alphabetical order).

Mind-body techniques can be effective for treating chronic pain, notes Josie Znidarsic, DO, who runs the integrative pain management program at the Cleveland Clinic’s Wellness Institute. “It can be about the person realizing that some pain still exists but that they can learn ways to cope without taking a pill, whether through a quick meditation or deep breathing. We focus on the behavioral health aspect of pain management.”

Often, people who are in chronic pain become depressed, angry and frustrated, Dr. Znidarsic points out. If they have gotten to a point where everything hurts, they can experience isolation and depression, she says. “We try to help them learn ways to cope with the pain and depression that don’t involve taking a pill,” she says. “We try to help people shift focus from the pain and pay attention to the relaxation response.”

 It’s also important for the person in pain to feel empowered that he or she is in control, Dr. Znidarsic says. “Patients need to feel that they can help themselves,” she says. “By learning the techniques that embrace a holistic approach, like relaxation and breathing exercises, they learn that they do have control. Knowing this can make them feel better.”

Biofeedback

Biofeedback (“bio” means body and “feedback” refers to having information fed back to an individual) consists of using instrumentation to mirror psychophysiologic processes that an individual may not typically be attuned to but may be able to consciously control. When the “fight or flight” response occurs when an individual is subjected to severe stress, the heart rate increases, the person sweats, and the nervous system gears up. With biofeedback, patients are taught to dial back stress. Biofeedback devices provide information to an individual about her biological condition (like breathing and heart rate) and the person becomes an active participant in controlling her response.

“Biofeedback can be useful for helping with chronic pain,” says Kiran Patel, MD, director of Neurosurgical Pain at Lenox Hill Hospital in New York City. “Typically, biofeedback is conducted by a trained health professional, and it uses instruments like blood pressure and heart rate monitors.” Pelvic pain is one condition that can be alleviated with biofeedback, says Allyson Shrikhande, MD, a physiatrist at Lenox Hill Hospital in New York City. “It can help pelvic floor muscle dysfunction as well as rectal pain,” she says. “And most major insurances cover this.”

According to Hong Shen, MD, integrative pain management specialist at Cleveland Clinic’s Wellness Institute, patients with any chronic painful condition may benefit from biofeedback. “Many psychologists and mind/body therapists may incorporate biofeedback therapy into their psychotherapy,” Dr. Shen says.

Chinese (or Eastern) Medicine

Chinese medicine is actually an umbrella term for several treatments, including acupuncture, Chinese herbs, and tai chi, explains Jamie Starkey, LAc, manager of the Eastern medicine program and lead acupuncturist at the Cleveland Clinic's Center for Integrative and Lifestyle Medicine.“Of these, acupuncture is the go-to treatment for pain,” she says. “There is an overwhelming amount of clinical evidence looking at acupuncture for pain relief. It can be especially effective for pain in the low back, knees, neck, and shoulder.”

With acupuncture, she explains, “Whether you have acute or chronic pain, you are getting a pain-relieving effect from the release of endorphins from your brain, and there is also local anti-inflammatory effect.”

Insurance companies vary regarding coverage for acupuncture, Ms. Starkey says. “If an insurance company covers acupuncture, they will cover every diagnosis or they will cover specific codes,” she explains. “Patients should first determine whether their insurance company covers the treatment. If it does, then they should identify which specific codes are covered.” Acupuncture often is covered for chronic pain, migraines, and post-operative nausea and vomiting. For more information,

Acupuncture used in conjunction with traditional herbs can also be effective for treating pain, Ms. Starkey notes. Finding a Chinese herbalist is essential however due to their extensive knowledge about plants and their side effects which is especially important for patients taking medication. To find a practitioner, consult the National Certification Commission for Acupuncture and Oriental Medicine.

Caveat: Since Chinese herbs are not approved by the FDA, patients should check with their physician or pharmacist before taking a new supplement or herb. Many herbs and supplements may not react well with traditional Western medications.

Chiropractic Care

Chiropractic care has now become mainstream, and no longer viewed as “alternative or fringe.” In fact, studies have shown that spinal manipulation (the use of force to adjust a person’s spine that is misaligned) for chronic low-back pain is at least as effective as conventional medical care for up to 18 months.

Spinal manipulation (one of several options that include exercise, massage, and physical therapy), can provide relief from low back pain, according to the National Center for Complementary and Integrative Health (NCCIH), part of the NIH. When provided by a trained, licensed practitioner, spinal manipulation is believed to be a safe treatment for low back pain, with the common side effects, such as discomfort in the treated area, minor and likely to disappear within a day or two.

This form of treatment focuses on the relationship between the body’s structure, usually the spine, and its function. While most people will visit a chiropractor for the management of low back or neck pain, it can be helpful for headaches and upper- and lower-extremity joint conditions.  It has also been used to treat pain associated with fibromyalgia. Chiropractors may use spinal adjustments and treatments like electrical stimulation, relaxation techniques, rehabilitative and general exercise, and counseling on diet, weight loss, and lifestyle.

Cold and Heat

Most people know to ice an acute injury, like a bump on the head. But cold and heat are “extremely effective therapies” against chronic pain, says Dr. Shrikhande.  “Cold helps decrease inflammation and heat helps to relax muscles that are in spasm,” she explains. “One is not necessarily better than the other and many people can benefit from both.” She suggests starting with 10 minutes of ice, followed by 10 minutes of heat.  Research published by in 20143 focused on 87 patients with low back pain, which found cold and heat could be effective in the treatment of acute low back pain.

Hypnosis

In hypnosis, a health professional teaches you to respond to suggestions for changes in your feelings, behaviors, and sensations. You learn to use your mind to manage pain as well as anxiety. You can even be trained in self-hypnosis as a way of dealing with pain. “Hypnosis can relax an individual so that the person is in a nice, calm space,”  Dr. Znidarsic says. “From there they can tap into their feelings and work on some of the emotional feelings such as anger and frustration that accompany pain.”

Some practitioners of hypnosis, which is the induction of a very relaxed state, use it as an aid to psychotherapy. The theory behind this is that when in a hypnotized state, there are fewer barriers in the conscious mind for psychotherapeutic exploration. When an individual is hypnotized, for instance, the practitioner might suggest to the person that his or her arthritis pain can be turned down, much like the volume of a radio.

Meditation

“Meditation and simple breathing techniques are among the useful methods to help alleviate chronic pain,” says Kiran Patel, MD, director of Neurosurgical Pain at Lenox Hill Hospital in New York City.

“All types of meditation have been proven to be helpful against pain,” Dr. Znidarsic says. “Meditation gets the body to be relaxed and rested, so there is no longer the fight-or-flight response to pain.”  

Meditation can be effective whether you practice it for 10, 20, or 30 minutes daily, she says. If you’re not sure how to get started, there are many cell phone apps that walk you through a guided meditation, including Head Space and Insight Timer.

Relaxation and Breathing Exercises

The goal in relaxation and breathing exercises is to produce the body’s natural relaxation response, which is characterized by slower breathing, lower blood pressure, and a feeling of increased well-being, according to the National Institutes of Health.2 Relaxation techniques can help a variety of health conditions and may help with chronic pain and headaches in children and adolescents, according to the NIH. 

“We tend to breathe short breaths when we are in pain,” Dr. Znidarsic says. “Learning to breathe deeply can help alleviate the pain. It is important that you learn to relax your muscles and do deep breathing.”

Music Therapy

Could listening to tunes on your iPod help with pain? Some research shows that it may. Music can actually reduce opioid requirements and may lessen postoperative pain, research shows. 3

Investigators looked at the effect of music on acute, chronic, or cancer pain intensity as well as pain relief and analgesic requirements. Some studies found that study participants exposed to music had a 70% higher likelihood of having pain relief than unexposed participants. Other studies found that participants required less opioid medication two hours after surgery, as well as 24 hours post surgery.

Music therapists help people find whatever music holds meaning for them, and teach people how to fully listen to that music and how to engage their brain so that their perception of pain is overcome by many sources, on many levels. For pain management, music therapy could include not just listening to music but composing music, songwriting, playing instruments, and singing.4

“Music therapy can be useful when used in conjunction with a multimodal treatment plan,” says Dr. Patel. “It can help with muscle relaxation and when experiencing bouts of acute or chronic pain.” Additionally, music therapy can bring joy to a person suffering pain, adds Dr. Znidarsic. “Music therapy is a chance to be creative.”

TENS

wearable TENS deviceA wearable TENS device delivers a series of mild electrical pulses to the body that can alleviate pain caused by conditions like fibromyalgia and rheumatoid arthritis. The acronym, TENS,  stands for Transcutaneous Electrical Nerve Stimulation. Research shows that TENS is effective against pain, says Dr. Shrikhande, pointing to recent research in Current Rheumatology Reports.  “One meta-analysis was able to show the positive treatment effects of electrical stimulation for relief of chronic musculoskeletal pain, and randomized controlled trials consistently demonstrate the effectiveness of TENS for acute, emergent, and postoperative pain conditions,” wrote the authors in Current Rheumatology Reports.  “However, the effectiveness of TENS on individual pain conditions, such as low back pain, is still controversial, likely because of poor study designs and small sample size. Thus, continued research of TENS mechanisms and stimulation parameters in adequately characterized patient populations is critical.”

TENS can be used for any type of pain, Dr. Shen says. “It is very low risk,” she says. “Some people will benefit from it so try it to see if it helps you.” You can buy and use a TENS unit at home, Shrikhande says. “How long you would use it depends on the condition you are treating,” she says. “I don’t recommend a specific one as there have been no clinical trials comparing them.”

Therapeutic Massage

Therapeutic massage (which should never actually hurt) can be effective in providing relief for individuals who suffer from chronic pain, some studies show. Massage therapists employ a holistic approach in which they focus on the entire body system, not just on the site of the pain the person is experiencing. Massage therapy, which may relieve muscle and other soft tissue pain, can help individuals become more aware of their bodies. By virtue of human touch, therapeutic massage impacts the individual in a positive way. While additional research is needed to determine the optimal uses of massage, it stands to have a positive impact on patients with acute as well as chronic pain.4

Ultrasound

While one study found that there is still “limited effectiveness” in the treatment of lower back pain with ultrasound, many pain experts feel it can be effective. “There are three primary benefits,” says Shrikhande. “The first is speeding up the healing process from the increase in blood flow in the treated area. The second is the decrease in pain from the reduction of swelling and edema and the third is the gentle massage of muscle tendons or ligaments in the treated area.”3  Ultrasound would be administered by a trained professional such as a physiatrist.

Yoga and Tai Chi

Among the forms of exercise that can be helpful for pain is yoga, a meditative movement practice that is believed not just to reduce stress and improve fitness, but to reduce low back pain. Yoga, among other techniques, teaches the individual that his or her breath is the “bridge” that links body and mind. When practicing certain poses called asanas, which focus on the proper way to inhale and exhale, a deep sense of relaxation throughout the body can result.3

It’s important to find the appropriate form of yoga, says Judi Bar, yoga program manager at Cleveland Clinic’s Wellness Institute. “It is best to find an experienced yoga teacher,” she says. “The instructor needs to be experienced in order to guide the student through gentle moves so he or she can get accustomed to moving again and finding out what they can tolerate. Ultimately, through gentle movement, breathing, and relaxation, the goal is for the student to find they can manage pain better.”

Tai chi, on the other hand, is more of a daily meditative exercise that incorporates some breathing into the movements, says Dr. Shen. “It also includes some stretching and it can be effective against pain,” she says.

Updated on: 11/06/17
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Using Your Head to Control Your Pain
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