Rx for Change: Alternatives for Chronic Pain

Article taken from page 10 of January/February Newsletter 2018

By Adriane Fugh-Berman and Charlea Massion

We’ve previously discussed the risks of opioids, and how pharmaceutical companies have encouraged over-prescription of these drugs that has created an opioid addiction epidemic. But what’s a person in pain to do?

First of all, drop the idea that opioids are the best treatment for chronic pain. Except for end-of-life care, opioids should not generally be used for chronic pain. Not only are they dangerous and addictive, but opioids also actually increase pain over time; by increasing sensitivity to pain, they worsen the problem they are supposed to solve.   And, don’t be fooled that tramadol isn’t an opioid. Many physicians don’t know that it is an opioid, but it is. It’s weaker than other opioids but it is still an opioid and it’s still addictive.

Manage your expectations, as well as your pain. The goal is not to be entirely pain-free – an impossibility in many chronic pain cases — but to manage pain so that it doesn’t interfere with work, sleep, and/or recreation.

Use non-steroidal analgesics; over-the-counter analgesics include ibuprofen, naprosyn, aspirin, and acetaminophen.  Prescription versions include diclofenac, ketoprofen, indomethacin and celecoxib.

Exercise! Even if you don’t want to. Numerous studies show that exercise, on land or in the water, improves multi-site pain and pain from osteoarthritis of the hip and knee.[1] [2] [3] (Exercise doesn’t seem to do much for arthritis in the hands.[4]) Pilates,[5] and yoga[6] have been studied for low back pain and found to be effective; yoga was found to be as effective as physical therapy for pain and function.[7] There’s no good evidence that any particular type of exercise is better than another type. The best kind of exercise is the kind you will do, so develop or rediscover a love of swimming, walking, dancing, or whatever else (literally) moves you.

Consider cannabinoids. A systematic review of 28 studies of various cannabis preparations in more than 2,000 patients found that cannabis generally improved chronic pain, especially neuropathic pain.[8] If medical cannabis is legal in your state, find a knowledgeable health care provider to help you navigate the different formulations.

For low back pain[9] or neck pain,[10] consider spinal manipulative therapy (osteopathic or chiropractic treatment). Studies show that it improves pain and function for both conditions. And, while physicians have had concerns that spinal manipulative therapy could increase the risk of stroke, a recent study shows that isn’t the case. [11]

Systematic reviews have shown that acupuncture is effective for pain that is associated with fibromyalgia,[12] temporomandibular disorder (TMD),[13] herpes zoster,[14] endometriosis[15] and post-stroke shoulder pain.[16] Acupuncture has been found to improve some kinds of cancer-related pain, as well.[17]

In addition, Transcutaneous Electrical Nerve Stimulation (TENS) treatments help neuropathic pain,[18] and cognitive behavioral therapy can help improve mood.[19]

Ginger extract may be as effective as over-the-counter analgesics for pain[20] if you like the taste of ginger, try drinking ginger tea or eating candied ginger. If you don’t like the taste, take ginger in capsules (1-4 grams a day.)

For arthritis, S-adenosyl methionine (SAM-e) can help with pain and function;[21] the usual dose is 300 mg three times a day. Glucosamine (500 mg three times a day) and chondroitin (400 mg three times a day) are popular supplements for arthritis. There is stronger evidence for the benefits of chondroitin than for glucosamine,[22] and their main effect may be on preventing further cartilage loss rather than treating pain.[23]

There are many treatments to try instead of using opioids, and combining modalities can be helpful; obviously, it is fine to combine say, ibuprofen, ginger, acupuncture, and exercise.

 

References

[1] Babatunde OO, Jordan JL, Van der Windt DA, et al,m “Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence,: PLoS One 2017;12(6):e0178621.

[2] Fransen M, McConnell S, Harmer AR, et al., “Exercise for osteoarthritis of the knee,” Cochrane Database Syst Rev. 2015;1:CD004376. doi: 10.1002/14651858.CD004376.pub3.

[3] Fransen M, McConnell S, Hernandez-Molina G, et al., “Exercise for osteoarthritis of the hip,” Cochrane Database Syst Rev. 2014(4):CD007912. doi: 10.1002/14651858.CD007912.pub2.

[4] Osteras N, Kjeken I, Smedslund G, et al. “Exercise for Hand Osteoarthritis: A Cochrane Systematic Review,” J Rheumatol. 2017;44(12):1850-1858. doi: 10.3899/jrheum.170424. Epub 2017 Oct 15.

[5] Yamato TP, Maher CG, Saragiotto BT, et al. “Pilates for low back pain,” Cochrane Database Syst Rev. 2015(7):CD010265. doi: 10.1002/14651858.CD010265.pub2.

[6] Wieland LS, Skoetz N, Pilkington K, et al, “Yoga treatment for chronic non-specific low back pain,” Cochrane Database Syst Rev. 2017;1:CD010671. doi: 10.1002/14651858.CD010671.pub2.

[7] Saper RB, Lemaster C, Delitto A, et al., “Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial,” Ann Intern Med. 2017;167(2):85-94. doi: 10.7326/M16-2579. Epub 2017 Jun 20.

[8] Whiting PF, Wolff RF, Deshpande S, et al., “Cannabinoids for Medical Use: A Systematic Review and Meta-analysis,” JAMA 2015; 313(24):2456-73. doi: 10.1001/jama.2015.6358.

[9] Paige NM, Miake-Lye IM, Booth MS, et al., “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis,” JAMA 2017;317(14):1451-1460.

Franke H, Franke JD, Fryer G, “Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis,” BMC Musculoskelet Disord. 2014;15:286.

[10] Gross A, Langevin P, Burnie SJ, et al., “Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment,” Cochrane Database Syst Rev. 2015(9):CD004249. doi: 10.1002/14651858.CD004249.pub4.

[11] Cassidy JD, Boyle E, Cote P, et al., “Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study,” J Stroke Cerebrovasc Dis. 2017;26(4):842-850.

[12] Deare JC, Zheng Z, Xue CC, et al., “Acupuncture for treating fibromyalgia,” Cochrane Database Syst Rev. 2013 May 31;(5):CD007070. doi: 10.1002/14651858.CD007070.pub2.

[13] Fernandes AC, Duarte Moura DM, Da Silva LGD, et al., “Acupuncture in Temporomandibular Disorder Myofascial Pain Treatment: A Systematic Review,” J Oral Facial Pain Headache 2017;31(3):225-232. doi: 10.11607/ofph.1719.

[14] Coyle ME, Liang H, Wang K, et al., “Acupuncture plus moxibustion for herpes zoster: A systematic review and meta-analysis of randomized controlled trials,” Derm Therapy 2017; 30 (4). doi: 10.1111/dth.12468.

[15] Xu Y, Zhao W, Li T, et al., “Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis,” PLoS One 2017;12(10):e0186616. doi: 10.1371/journal.pone.0186616. eCollection 2017.

[16] Wu P, Mills E, Moher D, Seely D, “Acupuncture in poststroke rehabilitation: a systematic review and meta-analysis of randomized trials,” Stroke 2010;41(4):e171-9. doi: 10.1161/STROKEAHA.109.573576. Epub 2010 Feb 18.

[17] Paley CA, Johnson MI, Tashani OA, et al., “Acupuncture for cancer pain in adults,” Cochrane Database Syst Rev. 2015(10):CD007753. doi: 10.1002/14651858.CD007753.pub2.

[18] Gibson W, Wand BM, O’Connell NE, “Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults,” Cochrane Database Syst Rev. 2017;9:CD011976. doi: 10.1002/14651858.CD011976.pub2.

[19] Williams AC, Eccleston C, Morley S, “Psychological therapies for the management of chronic pain (excluding headache) in adults,” Cochrane Database Syst Rev. 2012;11:CD007407. doi: 10.1002/14651858.CD007407.pub3.

[20] Terry R, Posadzki P, Watson LK, Ernst E, “The use of ginger (Zingiber officinale) for the treatment of pain: a systematic review of clinical trials,” Pain Med. 2011;12(12):1808-18. doi: 10.1111/j.1526-4637.2011.01261.x. Epub 2011 Nov 4.

[21] Rutjes AW, Nüesch E, Reichenbach S, et al., “S-Adenosylmethionine for osteoarthritis of the knee or hip,” Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007321. doi: 10.1002/14651858.CD007321.pub2.

[22] Singh JA, Noorbaloochi S, MacDonald R, et al., “Chondroitin for osteoarthritis,” Cochrane Database Syst Rev. 2015;1:CD005614. doi: 10.1002/14651858.CD005614.pub2.

[23] Gallagher B, Tjoumakaris FP, Harwood MI, et al., “Chondroprotection and the prevention of osteoarthritis progression of the knee: a systematic review of treatment agents,” Am J Sports Med. 2015;43(3):734-744.