What is the best treatment for chronic pain?

The short answer is “they all are”. So far we have not found a silver bullet for treating patients with chronic pain. This is in part because we fully do not understand biology of development of chronic pain in humans and in part due to the fact that research studies on patients with chronic pain are difficult to conduct as we do not have a way of measuring pain and have to rely on self-reporting.

Unfortunately investigations do not tell us what treatment is likely to help a patient with pain. XRays, MRI’s and Ultrasound scans are there to rule out broken bones and dangerous medical conditions. They will also tell you whether or not you are a candidate for surgery, however with the exception of patients with fractures, most patients with abnormalities on imaging can also respond to other treatments with fewer side effects. Also, although surgery can be very helpful, a large minority of patients do not respond even to surgery. Risks of surgery are of course far greater than risks of any other approach. In terms of orthopedic surgery, hip surgery has the highest success rate in my experience.

Because of difficulty predicting which patient will respond to a specific approach I typically start with the safest approach and then progress to more invasive and dangerous approaches if the safest one does not work. I typically advise patient to start with physical modalities such as physiotherapy or chiropractic or acupuncture or massage combined with exercise program. The reason I like this approach is safety, you are not putting anything into your body so risk is almost zero, and long term benefit. In other words, if you improve with physiotherapy, typically the benefit does not go away the day therapy is stopped. If patients have access to psychological counseling, I also recommend that especially if patients feel anxious or depressed. There is literature to support various forms of counseling such as CBT for both pain and depression.

No approach is perfect and that includes physical approaches. With physical approaches the improvement is often gradual, taking months or even years. Also, it is a big time commitment as treatments are long and frequent (2-3 times per week). Coverage can also be an issue as these services are not covered by many provincial health plans for patients under the age of 65. As with most approaches to pain, there are many types of physiotherapy/acupuncture/massage therapy and therefore results of treatment will vary from practitioner to practitioner. So, if one approach does not work try a different approach. Because improvement is often slow and gradual you do not expect cure in two weeks, however you do expect improvement over the course of 1-2 months and if you are not seeing it, time to change treatment or provider. Finally, some patients just do not respond to physical modalities or only respond for a few hours.

In those cases the next step is to consider treatments medical doctors can offer. There are fundamentally three approaches medical doctors use for patients with chronic pain: medications, injections and surgery. Each one has advantages and disadvantages.

In terms of medications typically patients start with over the counter medications such as Tylenol, Robaxacet or Advil. As the Tylenol is the safest, I usually advise patients to start with that medication. If that does not work patients typically try other over the counter medications, however, remember that just because something is over the counter does not mean that it is safe. Medications like Advil, Aleve or Ibuprofen can cause stomach ulcers, bleeding and kidney damage.

If these medications do not work or cause side effects, medical doctors can try patients on prescription medications. Make sure to let your doctor know if you are also taking any over the counter medications as those may interact with prescription medications. There are multiple medications to try and many can be tried at multiple doses. Some can be taken intermittently while others have to be taken constantly. Those that have to be taken constantly to work take 2-4 weeks to help so do not expect to feel better right after taking the first pill. I would advise trying to avoid Opioid medications if at all possible.

There are a couple of things to keep in mind about medications for chronic pain. First of all, like all other approaches to pain management whether or not you take medications is a matter of personal choice. Medications do not help “heal” chronic pain, but rather they just reduced severity of the pain while they are in your body. As soon as you stop the medications, the pain will return. Also the goal of taking medications is not bringing the pain down to zero (most effective medications only reduce pain by 20- 40%) but rather to improve function and sleep. So if you find medication reduces your pain by 20%, but it makes you so dizzy and drowsy that you can not function during the day it is not worth taking. So it is up to the patient to weigh side effects and benefits they are experiencing in order to decide if the pill is worth taking. If the pill does not help then either the doctor raises the dose or switches the patient to the next medication.

If medications do not help or patient chooses not take any then additional options to consider next are Medical Marijuana (discussed separately) or more aggressive interventional pain treatments.

Typically, interventional pain therapies in Ontario are provided either in the hospital based pain clinics or community based pain clinics. To see a physician at a pain clinic one requires referral from your family doctor. There are fundamentally two types of interventional pain management offered in Ontario: Canadian approach and US approach. The first one is high frequency nerve blocks and trigger point injections-a treatment developed in Canada 40 years ago and offered by vast majority of pain clinics in Ontario. The goal is to reduce muscle spasm as well as inflammation and sensitivity of nerve endings in joints and muscles causing pain. It is one of the safest approaches available in interventional pain management because typically the needles are small, the needle tip sits in muscle and there are no hormones used in the injection. The risk is not much higher than risk of acupuncture or injection of local anesthetic prior to a dental procedure. On the downside it is a gradual treatment requiring typically weekly injections for the first 2-3 months. Also like any other treatment it does not help for every type of painful condition.

The second type of interventional pain clinic offers US style pain management. The procedures they offer range from cortisone epidural injections in which hormone which reduces inflammation is injected around the spinal cord to spinal cord stimulation where electrode leads are permanently implanted around your spinal cord. Another approach used in the US and offered at this type of clinic is radio frequency ablation where nerves are actually destroyed by burning them. These procedures are typically performed with Xray or Ultrasound guidance. Needless to say these interventions are much more aggressive and involve risk to the spinal cord ranging from infection to stroke and paralysis. On the positive side the side effects are rare and the procedures do not have to be repeated on weekly basis.

Interventional pain clinics can also offer lidocaine or ketamine infusions which tend to be used for pain caused by nerve damage such as diabetic neuropathy or nerve pain after shingles.

Finally there is another category of injections which can be of benefit , but is sadly not covered by OHIP.

These include:

1. Botox injections for migraine, bladder pain and dystonia (a type of severe muscle spasm) which can help for 3-6 months
2. Visco supplementation injections (Durolane etc.) which are mostly used for knee osteoarthritis and help for around 6 months
3. Regenerative medicine injections including Prolotherapy injections, Prolozone injections, Platelet Rich Plasma injections and Mesenchymal Stem Cell injections (see separate question for more details)-all of these reduce pain , but in addition there is some evidence that they may stimulate healing.

If more conservative approaches do not work then surgery can be quite helpful but is associated with the highest risk of complications. Couple of things about surgery-in most cases surgical treatments of pain are optional (in other words this is about quality of life rather than health) and outcomes are not guaranteed. In my experience hip replacement surgeries have the highest success rate while surgeries on other joints and spine seem to be less effective. The good thing about surgery is when it does work the pain is often not just reduced, but completely gone.

This list is not exhaustive but simply lists most common approaches. There are many more approaches including supplements and all manner of devices and manual therapies, however it is not possible to review them all or try them all in one lifetime.