People with persistent pain often think of themselves as suffering from
a specific ailment, whether it’s arthritis, back pain,
migraines, or something else. But anyone who has
experienced pain for several months or longer also
happens to be among the millions of Americans with a
condition known as chronic pain.
Chronic pain is a complex condition that affects 42
million-50 million Americans, according to the American
Pain Foundation. Despite decades of research, chronic
pain remains poorly understood and notoriously hard to
control. A survey by the American Academy of Pain
Medicine found that even comprehensive treatment with
painkilling prescription drugs helps, on average, only
about 58% of people with chronic pain.
What causes chronic
pain, and what can you do about it?
Some cases of chronic pain can be traced to a
specific injury that has long since healed -- for
example, an injury, a serious infection, or even a
surgical incision. Other cases have no apparent cause --
no prior injury and an absence of underlying tissue
damage. However, many cases of chronic pain are related
to these conditions:
- Low back pain
- Arthritis, especially osteoarthritis
- Multiple sclerosis
- Nerve damage (neuropathy)
Treating your underlying condition is, of course,
vitally important. But often that does not resolve
chronic pain. Increasingly, doctors consider chronic
pain a condition of its own, requiring pain treatment
that addresses the patient’s physical and psychological
Psychological Impact of Chronic Pain
At a fundamental level, chronic pain is a matter of
biology: Errant nerve impulses keep alerting the brain
about tissue damage that no longer exists, if it ever
did. But complex social and psychological factors are
also at play, and they seem to help determine who fares
well despite even severe chronic pain -- and whose lives
Negative emotions, including sadness and anxiety,
seem to aggravate chronic pain. For example, people who
dwell on their discomfort tend to be more disabled by
chronic pain than people who try to take their pain in
stride. And among people with chronic pain stemming from
a work-related injury, those who report poor job
satisfaction fare worse than those who say they like
But negative emotions can be a result of chronic pain
as well as a cause. "If you had always been an active
person and then you developed chronic pain, you might
become depressed," says Roger Chou, MD, associate
professor of medicine at Oregon Health & Science
University in Portland and a leading expert on chronic
pain. "Depression is common in chronic pain patients,
but people who think chronic pain is ‘all in the head’
are not being realistic."
Because chronic pain affects all aspects of your
life, it’s important to treat chronic pain both
medically and emotionally.
People with chronic pain shouldn’t assume that they
have to tough it out. And they should not be satisfied
with a doctor who doesn’t want to treat it aggressively.
Drugs Used to
Control Chronic Pain
A wide variety of over-the-counter and
prescription medicines have been shown to help ease
chronic pain, including:
• Pain relievers. Many pain patients get
some relief from common pain medicines such as
acetaminophen, nonsteroidal anti-inflammatory drugs
(NSAIDs), and analgesics like aspirin, ibuprofen,
ketoprofen, and naproxen. These drugs are considered
safe, but they are not risk-free. For example,
taking too much acetaminophen can cause liver damage
or even death, especially in people with liver
disease. NSAIDs can cause ulcers and raise the risk
for heart attack and kidney trouble.
• Antidepressants. Several drugs approved
by the FDA to treat depression are also prescribed
by doctors to help relieve chronic pain. These
include tricyclic antidepressants such as
amitriptyline (Elavil), imipramine (Tofranil),
clomipramine (Anafranil), desipramine (Norpramin),
doxepin (Sinequan), and nortriptyline (Pamelor). The
pain-relieving effect of tricyclics appears to be
distinct from the mood-boosting effect, so these
drugs can be helpful even in chronic pain patients
who are not depressed.
Other antidepressants used to treat pain include
venlafaxine (Effexor) and duloxetine (Cymbalta),
which the FDA has approved to treat fibromyalgia and
diabetic nerve pain. These drugs are members of a
class of medications known as serotonin and
norepinephrine reuptake inhibitors (SNRIs). They
seem to be about as effective at treating chronic
pain as tricyclics, but are less likely to cause dry
mouth, sedation, urinary retention, and other side
When used at appropriate doses with careful
monitoring, these drugs can be safe and effective
treatment for chronic pain. But be sure to discuss
the risks, benefits, and research behind any drug
with your doctor.
• Anticonvulsants. Several drugs
originally developed to treat epilepsy are also
prescribed for chronic pain. These include
first-generation drugs like carbamazepine (Tegretol)
and phenytoin (Dilantin), as well as
second-generation drugs like gabapentin (Neurontin),
pregabalin (Lyrica), and lamotrigine (Lamictal).
Gabapentin and Lyrica are FDA-approved to treat
The first-generation drugs can cause an unstable
gait (ataxia), sedation, liver trouble, and other
side effects. Side effects are less of a problem
with second-generation drugs.
• Opioids. Codeine, morphine, oxycodone,
and other opioid medications can be very effective
against chronic pain, and they can be administered
in many different ways, including pills, skin
patches, injections, and via implantable pumps.
Many pain patients and even some doctors are wary
of opioids (also known as narcotics) because they
have the potential to be addictive. Except for
patients with a history of addictive behavior, pain
experts say the potential benefit of narcotic
therapy for chronic pain often outweighs the risk.
"It’s a matter of balance," says Chou. "People do
need to be concerned about the risk posed by opioids.
But as a physician, I think it is inappropriate not
to use medications that can help people, if the
risks can be managed."
Generally, doctors who prescribe opiod treatment
monitor patients with chronic pain carefully.
for Chronic Pain
In addition to drug therapy, several nondrug
treatments can be helpful for chronic pain,
• Alternative remedies. Although doctors
don’t know exactly how it works, there is good
scientific evidence that acupuncture can offer
significant relief from chronic pain. Other
alternative remedies proven to work against pain
include massage, mindfulness meditation, spinal
manipulation by a chiropractor or osteopath, and
biofeedback, in which a patient wearing sensors that
record various bodily processes learns to control
the muscle tension and other processes that can
contribute to chronic pain.
• Exercise. Low-impact forms of exercise
like walking, bicycling, swimming, and simply
stretching can help relieve chronic pain. Some
people find it particularly helpful to participate
in a structured exercise program given by a local
• Physical therapy. Pain patients who work
with a physical therapist or occupational therapist
can learn to avoid the particular ways of moving
that contribute to chronic pain.
• Nerve stimulation. Tiny jolts of
electricity can help block the nerve impulses that
cause chronic pain. These jolts can be delivered
through the skin via transcutaneous electrical nerve
stimulation (TENS) or via implantable devices.
• Psychological therapies. A form of
psychotherapy known as cognitive behavioral therapy
is particularly helpful for many people with chronic
pain. It helps them find ways to cope with their
discomfort and limit the extent to which pain
interferes with daily life.
Unlike some traditional forms of psychotherapy,
which focus on personal relationships and early life
experiences, cognitive behavioral therapy aims to
help people think realistically about their pain and
find ways to work around physical limitations.
"Cognitive behavioral therapy helps people
overcome the mistaken belief that they need to lie
in bed until their pain is gone, or that if they go
back to work they will cause permanent damage to
their body," Says Chou.
Picking the Right
Treatment for Chronic Pain
Given all the ways chronic pain can be treated,
how is one to know which treatment, or combination
of treatments, makes the most sense for your chronic
"We don’t have enough evidence from studies to
know just which approach is right for which
patient," says Portenoy. "Picking the right
treatment is a matter of clinical judgment, and it
involves talking with the patient" about the
specific nature of the pain and the effectiveness of
any treatments that have already been tried.