Pain Treatment

Pain treatment is individualized: it depends on the pain, the illness causing it, the person suffering it, its effect on their activities, and so on. What works for one person may not work for another: so pain treatment always involves some degree of trial-and-error. Good pain treatment requires three main qualities. First, it needs to be knowledgeable. The doctor needs to know the treatment options available and not be a "one-pony" practitioner. This means being familiar with treatments going all the way from surgery to psychotherapy, from medications to meditation. Second, it needs to be flexible. A treatment may start out looking good, but not work so well after a while. So treatment programs need to be repeatedly revised, as we gain experience of each individual’s response. Third, good pain treatment should be fast. If a treatment needs to be changed, this should be done quickly, otherwise people end up spending a lot of time and money going down paths that don’t lead anywhere.

"Start with a winner"

The first treatments to try should be those that are quick, powerful, safe, inexpensive and convenient. They may include medications, home exercise programs, and certain fast-acting procedures such as acupuncture or injections. Only after we know how these are working, should approaches be considered that are more time-consuming, more chancy, more expensive and less safe (for instance, surgery). By paying close attention to the results of the fast-acting, powerful treatments, it’s often not even necessary to proceed to those that are slower, less powerful, less safe, etc.

Complementary medicine

"Alternative" or "complementary" treatments sometimes work better than the "orthodox" ones. We recommend them if we think they are the patient’s best choice. Getting the pain better is much more important than being dogmatic about which methods "ought" to work! On the other hand, it is also the doctor’s job to help you steer clear of scams, and well-meant but useless treatments.

Pain medications

Painkilling drugs are nowadays quite sophisticated. They can often be made to work much better than we used to think, by paying close attention to the exact dose, the timing, and to skilful combining of different medications used together. Most patients with chronic pain have not had serious trials of the best possible pain medications. All other treatments work better if the pain medicines are working as well as possible. So it makes sense to include "optimal pain medications" in any treatment plan.

Opioids for chronic pain

Opioids are also known as "opiates" and "narcotics." These are very powerful painkillers, used routinely after surgery and in serious pain emergencies. In recent years they have also been found useful for some people with chronic pain. Only a small proportion of people with chronic pain do best with opioids, but for those patients, they can be literally life-saving. A recent consensus statement concluded that "for many patients, opioid analgesics are the most effective way to treat their pain, and often the only treatment option that provides significant relief." This statement was endorsed by more than 40 medical organizations, and also by the Drug Enforcement Administration. However, despite this chorus of support, the use of these medications is necessarily limited because of their potential for illicit use, and their medical side effects. Prescribing and taking these drugs is also subject to many federal regulations, which are enforced with great enthusiasm by the Drug Enforcement Administration. So many doctors will not prescribe them at all for long term conditions. For these reasons, opioids are considered for long term use only after very careful deliberation, and only for a small group of patients.

Injections

Some pain problems are helped by injection treatments. There are several very different kinds of injection for chronic pain. Some help only for a few hours, but some can help for months, or even permanently. Practitioners using injection treatments for pain need to be highly skilled, and they also need to be very knowledgeable about the other treatments for each condition, so that injections can be given their proper place (if any) in the whole treatment plan.

Physical treatments

Treatments that are physical rather than chemical, like manipulation, massage, acupuncture, TENS units etc., have three general characteristics. First, they work only for specific conditions and specific patients, so much experience is needed to judge when to use them. Second, they are often very dependent on the skill of the practitioner, so it’s crucial to select someone with a good and proven track record. Third, when they work at all, they tend to work very quickly. For instance, the best chiropractors, massage therapists and acupuncturists can tell after (usually) only two visits, whether you are going to benefit from their approach. So we advise patients to beware of therapies that require signing up for many treatments right at the start.

Surgery

Some painful conditions should be treated surgically, without delay. An obvious example is acute appendicitis. But for many others, surgery is much more controversial. This is especially true for spinal conditions like ruptured discs. Spine surgery has become much more controversial in recent years, with the discovery that many spinal conditions get better on their own in time, with no treatment at all. For these conditions, surgery will, at best, only accelerate an improvement that would happen later anyway. For other conditions, the surgery itself may cause long term complications as bad as leaving the condition alone. For reasons like this, we advise that any surgery for pain be considered very carefully indeed, with more attention paid to the published scientific evidence than to the enthusiasm of the surgeon.

Nutritional and herbal treatments

These are helpful for certain specific conditions but not others. Used knowledgeably they can be helpful, but they can rarely be the sole treatment for serious pain problems.

Psychological approaches

Psychological therapies are very helpful for some people in pain, but irrelevant for others. Some people have psychiatric disorders as well as a disease causing pain. They deserve to have both treated, and treated well. Some people benefit from methods such as hypnosis or guided imagery, which can change the effect their illness has on them. Some people have been so ground down by the experience of living with pain for a long time, that the support of a counselor can help. But some people in pain are already coping with their illness as well as anyone could. So, as with other pain treatments, psychological approaches need to be individualized.

"Different strokes for different folks"

The doctor’s first priority is to listen carefully to the patient, make a thorough assessment, be clear about the priorities, and then be flexible and knowledgeable about how to realize those priorities. "One size fits all" doesn’t work nearly as well as "different strokes for different folks."