Latest treatment options for chronic pain

Chronic pain is associated with decreased function and also affects the patient’s emotional wellbeing and quality of life. Unlike acute pain, chronic pain often does not have an obvious physiologic cause and this can make effective treatment difficult.

The first-choice treatment for chronic pain is usually pharmaceutical in nature and often consists of opioid therapy, particularly if the pain is severe. However, there is little conclusive evidence of the efficacy of opioids in the treatment of chronic pain. Furthermore, this class of medication is highly addictive and the serious issues surrounding its use are by now well-known. Non-opioid pharmaceutical options for chronic pain include non-steroidal anti-inflammatory drugs, steroids, antidepressants and muscle relaxants. However, none of these options is particularly effective in anything other than a minority of patients, although improvements have been seen in other parameters, such as quality of sleep, reduction in fatigue and mood. In addition, several of these drugs are associated with side effects, including gastrointestinal ulcers and bleeding or tolerance and dose escalation, which may themselves cause the patient considerable problems.

In recent years, there has been considerable interest in the use of cannabinoids as a therapy for chronic pain. Compared to a placebo group, patients treated with synthetic cannabinoids reported a significant decrease in pain and other symptoms; however, the benefits did not persist once treatment stopped. Side effects were also common, and led to around a quarter of the patients discontinuing therapy. The short timescale of the study means that the long-term effects of cannabinoid therapy also remain poorly understood.

Non-pharmacological treatment options for chronic pain include exercise, psychological and behavioural interventions and alternative therapies. The latter, including acupuncture, have been in use for hundreds of years but their place in mainstream medicine remains controversial. Despite this, up to 90% of patients feel that such treatments are helpful in controlling their pain. Furthermore, a meta-analysis based on nearly 18,000 patients with chronic pain found that acupuncture was more effective than sham treatments or no acupuncture in controlling their condition. However, for many individual conditions, such as chronic regional pain syndrome (CRPS), the evidence is based on single case reports and remains inconclusive. It is likely that alternative therapies are not a complete replacement for pharmacological measures in the management of chronic pain, but they may be useful as adjuvant therapies and may potentially reduce a patient’s need for treatments such as opioids.

It is now widely accepted that some form of physical exercise is an important part of a treatment programme for chronic pain and is particularly useful for conditions such as fibromyalgia and CRPS. While there is some evidence that the exercise needs to be at a moderate level of intensity for appreciable benefits to be seen, recent studies suggest that gentler mind/body exercise regimes such as tai chi and yoga also show significant benefits compared to patients taking no exercise. One major issue with exercise programmes is adherence: patients find it difficult to stick to a long-term regime of home exercise. Furthermore, some patients are intolerant to exercise and may experience an exacerbation of their symptoms in response to it. In order to overcome these problems, many exercise programmes begin at a low level and gradually increase in intensity.

The influence of the patient’s psychological status in both causing and maintaining chronic pain has become generally accepted in recent years and treatments addressing these aspects are now commonplace, although their efficacy is still under debate. Therapies such as biofeedback, hypnosis and mindfulness appear to have limited effects on pain itself, but they may have a positive effect on the patient’s quality of life. Cognitive-behavioural therapy (CBT) addresses maladaptive pain-related coping strategies through both behavioural and cognitive changes. When given alone, CBT consistently shows a positive effect on aspects such as maladaptive thinking, mood and quality of life. The effects on the pain itself appear limited, although when CBT is combined with other therapies as part of a multidisciplinary treatment regimen, it is a more useful tool in pain management.

Many chronic pain conditions are complex and multifactorial. Therefore, they tend to respond best to therapy approaches that encompass multiple aspects of their causation, and recent evidence supports this view. In a multidisciplinary approach, a patient may be offered a combination of pharmacological intervention, education, exercise and psychological therapy. While it has limited effects on its own, education has been shown to play a vital role in enabling the patient to self-manage their condition, thus augmenting the effects of other therapies. Programmes aimed at acquiring coping and pain management skills seem to be particularly useful. Furthermore, the effects persist for at least 12 months after therapy has ceased.

While most of the treatments available for chronic pain are effective for a minority of patients, there is no universally accepted therapy and for many, the improvements are marginal. This may reflect the heterogeneous nature of pain conditions; symptoms vary from patient to patient and within the same patient over time. Treatments that target broader areas, as with the multidisciplinary approach, appear to have the greatest success. This may be because as well as providing some relief from the pain, they bring about behavioural changes that in themselves allow the patient to cope with their condition and promote overall well-being.

About Dr Jenner

Further reading:

Okifuji, A., Gao, J., Bokat, C., & Hare, B. D. (2016). Management of fibromyalgia syndrome in 2016. Pain management, 6(4), 383–400. https://doi.org/10.2217/pmt-2016-0006

Urits, I., Schwartz, R. H., Orhurhu, V., Maganty, N. V., Reilly, B. T., Patel, P. M., Wie, C., Kaye, A. D., Mancuso, K. F., Kaye, A. J., & Viswanath, O. (2021). A Comprehensive Review of Alternative Therapies for the Management of Chronic Pain Patients: Acupuncture, Tai Chi, Osteopathic Manipulative Medicine, and Chiropractic Care. Advances in therapy, 38(1), 76–89. https://doi.org/10.1007/s12325-020-01554-0