With a minor injury, say nicking your finger with a paring knife, pain begins to diminish almost as soon as it registers. With greater injuries—such as a broken bone—the pain can continue for a prolonged period. And sometimes the pain just refuses to go away or even gets worse.
Such chronic pain—whether from arthritis, diabetes-related neuropathy, cancer or even an accident—can be debilitating, affecting a person’s ability to function and leading to feelings of hopelessness and depression. Fortunately, there are ways to relieve even serious, chronic pain—and not all of them come in a prescription bottle.
When Things Go Wrong
Dr. Robert O’Leary is a Bonita Springs/Naples physician specializing in pain medicine and rehabilitation and medical acupuncture. In his practice, he treats patients with a wide range of pain complaints, from arthritis to carpal tunnel syndrome to cancer.
“You can’t treat pain without a diagnosis,” O’Leary explains. “You want to identify whether it’s acute pain or chronic pain. And remember: Pain is not a disease; it’s a symptom.”
Dr. Gregory Paine, a Naples pain medicine and anesthesiology specialist, says that acute pain generally is classified as pain that last less than three months and chronic pain as that lasting more than three months.
“With chronic or neuropathic pain, the pain is no longer serving as a warning sign,” Paine explains. “The nervous system is sending out spurious signals. Everybody is different in terms of pain thresholds, and there are things that can make pain seem worse: stress, always—that’s a huge contributor—also, a patient’s support system and substance abuse.”
Whatever the cause, the approach to treatment is fairly standard: Start with the least aggressive method and progress only if the pain persists. O’Leary uses a case of carpal tunnel syndrome as an example.
“Your hand is burning and twitching, you can’t type on the keyboard,” he says. “In that case, if you sleep on your hand, we can give you a splint to wear at night. We can give some hand therapy, stretching and exercising. The next step would be a cortisone shot. The final approach would be surgery to cut the nerve.”
But carpal tunnel is only one explanation of burning and pain in the hand and wrist, and distinguishing the true cause can affect the treatment. If an X-ray reveals the presence of arthritis, O’Leary might suggest an anti-inflammatory, such as aspirin or ibuprofen, provided the patient doesn’t have gastro-intestinal problems. Or perhaps the problem is tendinitis or a muscle strain. In that case, treatment consists of PRICES—protection, rest, ice, compression, elevation and support. Finding the right treatment begins with asking questions.
“It’s beaten into the head of every good doctor in medical school—you always take a complete history and conduct a physical evaluation,” O’Leary asserts. “And you have to listen to the patient and ask, ‘What have you done so far?’”
O’Leary often uses acupuncture to treat back pain, arthritis and pain from neuropathy. The ancient system eases muscle spasms and increases blood flow, helps to down-regulate the perception of pain in the spinal cord and stimulates the brain to increase the release of endorphins—the body’s built-in pain relieving system.
“Theses adjunct therapies can be very effective,” Paine notes. “Acupuncture is now medically endorsed for back pain. Yoga and massage can also be good for soft tissue pain. There are some good chiropractors out there, and manipulation certainly has a place in therapy.”
Transcutaneous electrical nerve stimulation, or TENS, units also can provide relief. Small devices worn outside the body, they use electric impulses to stimulate nerves.
“TENS units send electrical impulses to the spinal cord,” O’Leary explains. “The electric impulses block or confuse the (nerve) gate to get it to close. It’s similar to the way a nerve block works.”
TENS units, however, only work while the device is worn. Radiofrequency ablation, or RFA, is a little more invasive but provides ongoing relief. In RFA, a microelectrode is inserted through a needle to the site of the pain.
“We then use radiofrequency energy to heat the tissue and (cauterize) the nerve,” Paine explains. “It’s kind of like suspended animation. The nerve regenerates in about a month—hopefully without the pain. I was the first doctor to use (RFA) for treatment of the sacroiliac joint. I’ve had amazing results with the technology. ”
Kathy Wolfson, of Pennsylvania, can attest to the validity of that claim. For several years, she experienced such severe sciatic pain that she couldn’t sit for more than 10 to 15 minutes at a time, nor could she sleep. She consulted a local pain specialist, who recommended epidural steroid injections. They provided relief for about three months, but then she would need another.
But prolonged steroid use leads to bone-thinning and other problems. Fortunately, her specialist had attended a conference where Paine spoke about using RFA to relieve sciatic pain. After consulting with Paine, Wolfson flew to Naples in April to undergo the procedure.
“It was two to three weeks before I knew if it had worked for me,” Wolfson says, “but it’s wonderful now. I’m a big fan.” She adds that she’s been able to resume her active lifestyle, swimming and golfing regularly.
Many in our society have come to believe that the best pain relief comes in pill form. Medicines certainly have a place in treatment, but they often are accompanied by undesirable side effects. For terminal cancer pain or severe trauma, for instance, narcotics, such as morphine and oxycodone, may be the most appropriate and effective treatment. But narcotics can induce drowsiness, constipation, nausea and vomiting. Used improperly, they can also be addictive.
Similarly, aspirin and ibuprofen can relieve the inflammation and pain of arthritis, but they can also lead to kidney and gastrointestinal problems. Cymbalta, a drug used to treat depression, anxiety, fibromyalgia and diabetic neuropathy, was approved by the U.S. Food and Drug Administration in 2010 for the treatment of osteoarthritis and chronic low back pain. But its side effects range from dizziness and fatigue to liver damage and suicidal thoughts.
“In a recent pain medicine journal, there was a four-page ad for Cymbalta,” O’Leary reports. “Three of those pages were the fine print and potential side effects.”
Scientists are finding new ways to deliver medicines, however, that significantly reduce the side-effect problem. O’Leary points to diclofenac as an example. An effective pain reliever, the drug unfortunately was not well-tolerated in pill form. Now, though, it is available in a topical gel (Voltaren) and in a transdermal patch (Flector).
“You get the relief, but you’re not going to get ulcers,” O’Leary notes.
Sara Kachor, one of O’Leary’s patients, has nothing but praise for the two interventions. Diagnosed with bone marrow cancer in her hip and spine when she was four, she had to have one leg amputated and underwent rounds of radiation and chemotherapy. Years later, she began experiencing terrible residual pain from her now-collapsed vertebrae and in her hip.
“I can’t take things like cortisone or sulfites because of the side effects,” Kachor explains. “But (Voltaren and Flector) don’t give me any side effects. They’re really the only products out there that have helped with my pain. They allow me to do my job. They allow me to sleep. And they provide pretty much immediate relief.”
Kachor reports she happily shares her experience with many of the seniors with whom she deals as part of her job. “A lot of them can’t tolerate the pain medications their doctors prescribe,” she notes. “I’m able to educate them that there is something out there, without side effects, that can help.”
Paine adds that new medicines and new applications for existing medicines are continuing to be developed. Homeopathic injections (comprised of plant extracts) seem to be as helpful as steroid injections in some cases. Tapentadol is a surgical anesthetic now available in a short-acting, pill form (marketed as Lyrica and Nucynta).
“Tapentadol is as strong as oxycodone, but we haven’t seen the addictive qualities or euphoria you get with opiods,” Paine says. “We’re waiting for the extended release form of it. I think that’s the wave of the future.”