Chronic Pain

Is this topic for you?

This topic is for people with chronic pain caused by problems other than cancer. If you are looking for information on pain caused by cancer, see the topic Cancer Pain.

What is chronic pain?

Pain that lasts for 3 months or longer is called chronic. Pain is your body's way of telling you that something is wrong. It’s normal for you to have pain when you are injured or ill. But pain that lasts for weeks, months, or years is not normal.

Chronic pain can occur anywhere in your body. It can range from being mild and annoying to being so bad that it gets in the way of your daily activities.

Anyone can get chronic pain. It’s more common in older adults, but it’s not a normal part of aging. Older adults are more likely to have long-term medical problems, such as diabetes or arthritis, which can lead to ongoing pain.

What causes chronic pain?

The cause of chronic pain is not always clear. It may occur because brain chemicals that usually stop pain after you get better from an illness or injury are not working right. Or damaged nerves can cause the pain. Chronic pain can also occur without a known cause.

What are the symptoms?

Common symptoms of chronic pain include:

• Mild to very bad pain that does not go away as expected.
• Pain that is shooting, burning, aching, or electrical.
• Soreness, tightness, or stiffness.

What other problems can chronic pain cause?

If you have pain for a long time, it can make you feel very tired and may lead to depression. It can get in the way of your usual social and physical activities. You may have so much pain that you can't go to work or school. The emotional upset may make your pain worse. Your body’s defense system (immune system) may get weak, leading to lots of infections and illnesses.

How is chronic pain diagnosed?

Your doctor can find out if you have chronic pain by asking about your past illnesses and your overall health. He or she will also do a physical exam.

You may have tests to find out if a medical problem is causing the pain. Your doctor may check for problems with your nervous system and may order blood tests. He or she may also ask you questions to check your mood and mental health and to see how well you are able to think, reason, and remember. In most cases, test results are normal. This can make it hard to know the exact cause of the pain. But this doesn't mean that your pain isn't real.

How is it treated?

You can use home treatment for mild pain or pain that you have now and then. Exercising, getting enough sleep, and eating healthy foods may help reduce chronic pain. Using over-the-counter pain medicines such as acetaminophen, aspirin, or ibuprofen may also help. You may want to try complementary therapies such as massage and yoga.

Talk to your doctor if your pain does not go away or if it gets worse. You may need to try different treatments to find what works for you. Medicines you take by mouth, shots of numbing medicine, acupuncture, nerve stimulation, and surgery are used for some types of chronic pain. It is important to make a clear treatment plan with your doctor. The best plan may include combining treatments.

Living with chronic pain can be hard. Counseling may help you cope. It can also help you deal with frustration, fear, anger, depression, and anxiety. Chronic pain often can be managed so that you can get on with your life and do your daily activities.

Frequently Asked Questions

The cause of chronic pain is not clear. When you have an injury or illness, certain nerves send pain signals to your brain. With chronic pain, these pain signals continue for weeks, months, or even years after you recover. Chronic pain can develop after a major injury or illness, such as a back injury or shingles, or it can develop without a known cause. It is also possible that certain brain chemicals that usually suppress pain may not work properly. The pain may be:

• Neurogenic pain, or neuropathic pain, which occurs when the peripheral nerves or central nervous system are somehow damaged. The nerves themselves cause the pain, and this kind of pain may not respond well to treatment.
• Psychogenic pain, which is pain that may be caused by an emotional or mental health issue. This pain is not caused by a disease, injury, or damage to the nervous system. Psychogenic pain is not common, but stress, depression, and other mental health factors can make the pain worse.
• Unidentifiable pain. It may be impossible to find or identify the cause of your pain. Tests may not reveal any injury, illness, or tissue change that could have triggered the pain.

The symptoms of chronic pain include:

• Pain that does not go away as expected after an illness or injury.
• Pain that may be described as shooting, burning, aching, or electrical.
• Discomfort, soreness, tightness, or stiffness.

Pain can lead to other problems, such as:

• Fatigue, which can cause impatience and a loss of motivation.
• Sleeplessness, often because the pain keeps you awake during the night.
• Withdrawal from activity and an increased need to rest.
• A weakened immune system, leading to frequent infections or illness.
• Depression, which is common and can make your pain worse.
• Other mood changes, such as hopelessness, fear, irritability, anxiety, and stress.
• Disability, which may include not being able to go to work or school or perform other daily activities.

In some cases, chronic pain develops after an injury or illness. The pain continues even after you have recovered from the injury or illness. For example, many people who have had a limb amputated report feeling chronic pain in the missing limb (phantom limb pain). Chronic pain can also develop even though you have not had an injury or illness. The result, however, is often the same—a cycle of sleeplessness, inactivity, irritability, depression, and more pain.

Chronic pain may be mild to severe. You may develop pain that comes back from time to time over several weeks, months, or years. Occasional, mild to moderate pain can usually be managed at home. Exercise, good nutrition, regular massages, and pain-relieving drugs—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin—may be enough to manage your symptoms.

On the other hand, you may develop constant chronic pain that is severe. You may be unable to work, and physical activity may be too painful or exhausting. Sleeping at night may be difficult, resulting in fatigue and irritability. Your outlook on life may change and strain your relationships with family and friends. Prolonged pain may restrict your daily activities and eventually lead to disability.

After treatment begins, many things can interfere with your recovery, such as dependency on drugs or alcohol, overwhelming stress, lack of motivation, depression or other mental health problems, or ongoing litigation because of a workers' compensation claim. If your pain is disabling, you may want to seek an evaluation at a pain management clinic, where a team of health professionals works together to treat your pain.

The lives of your family members, friends, or caregivers can also be affected. The people you count on to help you may also need some support. Family therapy or involvement in a caregiver support program may help.

Factors that may increase the risk of chronic pain include:

• Aging. Older adults are more likely to suffer from chronic conditions such as arthritis, diabetes, shingles, and other causes of nerve problems (neuropathy). However, chronic pain is not a normal part of growing older.
• Smoking. Nicotine use can increase pain and decrease the effectiveness of medicines.
• Health problems. These include:
  • Existing health conditions, such as fibromyalgia, shingles, arthritis, depression or anxiety disorders, or having a limb amputated (phantom limb pain).
  • Past health problems, such as joint injuries. Also, previous surgery may cause new pain or may not work to relieve pain (such as back surgery that does not relieve pain).
  • Overall general health condition. You may have a weakened immune system, which can lead to frequent infections or illness.
  • Conditions that are difficult to treat, such as nerve pain from shingles (postherpetic neuralgia).
• Lifestyle, such as not eating healthy foods, not exercising regularly, smoking, or having a substance abuse or alcohol dependency problem.

Other factors that may increase your risk for developing chronic pain include injury, stress, inactivity, relationship problems, or a history of physical, sexual, or emotional abuse. Daily activities that may contribute to chronic pain include repetitive motions at work or at home, such as lifting, or being in awkward positions for long periods of time.

Call a doctor about chronic pain if:

• Your pain has lasted more than 3 months without a clear reason.
• You are feeling down or blue or are not enjoying the activities or hobbies that you have enjoyed in the past. You may be experiencing depression, which is common with chronic pain.
• You are unable to sleep because of the pain.
• You had an illness or injury that healed, but the pain has not gone away.
• You have a family member or friend who appears to be suffering from chronic pain, and you would like information about treatment.

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. If you are able to control occasional, mild to moderate pain with exercise, healthy eating, massage, and pain relievers—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin—you may not need further treatment from a health professional. However, watchful waiting is not appropriate if your pain is severe or if persistent pain interferes with your life. If you delay treatment, the pain may get worse.

Who To See

If you have mild to moderate recurring pain that cannot be managed at home, you may need to consult one of the following health professionals:

• Family medicine doctor
• Internist
• Nurse practitioner
• Physician assistant
• Doctor of osteopathy

If your chronic pain is moderate to severe and constant, or if treatment does not control the pain, your primary health professional may recommend that you see a specialist, such as one or more of the following:

• Pain management specialist
• Physiatrist
• Physical therapist
• Neurologist
• Obstetrician or gynecologist (for chronic pelvic pain)
• Anesthesiologist
• Psychiatrist, psychologist, or a licensed mental health counselor
• Orthopedic surgeon
• Rheumatologist
• Chiropractor

Often more than one specialist will treat your chronic pain. For example, a primary physician may manage your medicines, and a physical therapist may help you restore function through exercise or other therapies. A professional counselor may help you with coping and depression, and a complementary medicine practitioner may provide alternative therapies such as acupuncture or yoga.

If chronic pain persists and interferes with your daily life despite treatment, you may want to seek an evaluation at a pain management clinic. A pain management clinic is a setting where you receive treatment and learn to cope with chronic pain. Treatment is usually provided by a team of health professionals who work together to address all the possible causes of your chronic pain.

To prepare for your appointment, see the topic Making the Most of Your Appointment

Many exams and tests are used to evaluate chronic pain. An initial assessment includes:

• A detailed medical history. Your doctor will ask you about your general medical history, past illnesses, and overall health. He or she will ask you questions about your pain, previous pain episodes, how they were treated, and whether treatment was successful. Also, your doctor will note any family history of chronic pain. In order to identify activities that cause pain, how you treat pain when it occurs, and whether the treatment relieves the pain, your doctor may ask you to start keeping a pain diary (What is a PDF document?).
• A physical exam. Your physical well-being will be evaluated, which will help your doctor identify areas of pain. You may be asked to move your limbs to help identify painful areas. A physical exam may uncover health conditions that contribute to chronic pain. As part of your physical exam, you may also have:
  • A neurologic exam to identify possible nervous system problems. You may be asked to complete a few physical tasks, such as walking up and down a hall or getting up from a chair. By checking your reflexes and your ability to feel light touch, the exam can help determine whether you have a nerve problem. The doctor may also ask you to repeat a series of numbers or to answer simple questions about dates, places, and current events.
  • A mental health assessment. This test evaluates your emotional functioning and ability to think, reason, and remember. You will be asked questions to determine whether such conditions as depression, insomnia, or stress are contributing to or happening as a result of your chronic pain. These conditions often occur with chronic pain. You may also be asked about your use of alcohol and drugs. Answering these questions fully and honestly may help your doctor and you identify the sources of your chronic pain.
• Diagnostic tests. These tests are often used to rule out other health conditions that can cause chronic pain. Tests may include:
  • Blood tests or other laboratory tests. A small sample of your blood is taken and then evaluated to see if you have an infection or other condition that could be causing your pain.
  • X-rays or other imaging tests (such as CT scans, MRIs, or ultrasounds). These tests take pictures of the inside structures of your body to look for disease and injury.
  • Electromyogram (EMG) and nerve conduction studies or other nerve tests. These tests measure muscle and nerve function to determine whether your chronic pain is related to muscle or nerve problems.
  • Angiogram or other vascular studies. This test injects a dye and inserts a small tube into your arteries to trace the movement of blood within your body.
  • Diagnostic nerve blocks. One example is an injection of a local anesthetic into or around a nerve to identify whether that nerve is causing the pain.

Treating chronic pain can be challenging. Often the reason for the pain is not clear, and it may take several types or combinations of treatments before you find relief. When treatment is started, some people may have increased pain because their chronic pain has caused them to be inactive and they have lost strength and flexibility. However, over time treatment should decrease the pain and increase your ability to function. You may learn new ways of doing ordinary tasks to reduce pain. Often chronic pain cannot be cured, but it can be managed well enough to significantly improve the quality of your life.

Be sure to seek treatment if your pain lasts longer than 2 to 3 months. Early treatment may prevent the pain from getting worse.

Some chronic pain is caused by specific conditions that can be treated. For example, there are treatments for headaches, arthritis, neck pain, low back pain, or depression.

Initial treatment

The goals of treatment are to reduce chronic pain and increase your ability to function. This includes improving your sleep and coping skills and reducing stress so you can return to your regular activities. Initial treatment depends on what kind of pain you have and how severe it is, as well as whether your pain is related to an illness, injury, or an unknown cause. Often, the best approach is a combination of therapies.

You may be able to control your pain at home by:

• Getting appropriate daily exercise, such as walking or swimming.
• Eating a balanced diet. This includes getting enough vitamins such as vitamin B and vitamin D. Talk to your doctor or a registered dietitian about a healthy diet for you.
• Getting enough sleep.
• Using pain relievers—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, for example) or aspirin. Always take these medicines exactly as prescribed or according to the label. Do not take a nonprescription NSAID for longer than 10 days without talking to your doctor.
• Using complementary therapies, such as acupuncture or meditation.

A licensed mental health counselor, psychologist, or psychiatrist can help with your emotional well-being while you are dealing with chronic pain. It is common to respond to chronic pain with feelings of frustration, depression, anxiety, fear, and even anger. These feelings can make it tough to conquer chronic pain, especially if you use alcohol or drugs to manage your symptoms. Pain affects both your physical and emotional well-being. Untreated depression or anxiety can make your pain worse. A counselor may use treatments such as cognitive-behavioral therapy to help you cope with your pain.¹

If the above treatments do not relieve or reduce your pain, your health professional may:

• Treat existing health problems that may contribute to the pain.
• Recommend that you reduce stress with relaxation techniques, such as guided imagery, and exercise, such as yoga.
• Prescribe physical therapy to relieve pain and improve movement and function.
• Prescribe medicines, such as tricyclic antidepressants, anticonvulsants, or opioid analgesics. At first, you may be given medicines that cause the fewest side effects.
• Increase the strength of your medicines, change medicines, or add new ones as needed.
• Prescribe electrical stimulation therapies, such as transcutaneous electrical nerve stimulation (TENS), to alter pain signals as they travel to the brain. This treatment has had mixed results and may not work for everyone.

Ongoing treatment

It is important to develop a clear treatment plan for chronic pain with your health professional. Part of this plan includes identifying ways for you to manage your pain. Only you know the severity of your pain and how it affects your life. Be sure to ask your health professional if you are not clear about what steps you can take when pain occurs or gets worse.

For occasional flare-ups of chronic pain, making lifestyle changes (such as exercising, getting enough sleep, and eating a healthy diet) and taking pain relievers (such as acetaminophen or nonsteroidal anti-inflammatory drugs) may be all that is needed. If your pain is constant, severe, or interferes with your daily activities, your health professional may prescribe additional treatment.

Medicines or a combination of medicines and other therapies may be used to relieve pain, inflammation, depression, and sleeping problems associated with chronic pain. The medicines and other treatments most often used to treat chronic pain include:

• Acetaminophen, such as Tylenol, Panadol, or Tempra.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, for example), ketoprofen, and naproxen (Aleve, for example). Always take NSAIDs exactly as prescribed or according to the label. Do not take a nonprescription NSAID for longer than 10 days without talking to your doctor.
• Tricyclic antidepressants, such as amitriptyline (Elavil).
• Corticosteroids, such as prednisone. Sometimes, steroids are injected around the base of the spine to relieve low back pain (epidural steroid injections).
• Oral medicines that act like a local anesthetic, such as mexiletine (Mexitil).
• Anticonvulsants, such as gabapentin (Neurontin) and pregabalin (Lyrica).
• Pain relievers that are applied directly to the skin (topical analgesics), such as EMLA cream or a lidocaine patch (Lidoderm).
• Capsaicin, a naturally occurring substance that is found in chili peppers and is used to make certain topical analgesic creams.
• Creams or gels containing medicines or combinations of medicines are being studied for pain control. The cream or gel is rubbed directly on the painful area. Nonsteroidal anti-inflammatory drugs such as ketoprofen, the antiseizure medicine called gabapentin, and tricyclic antidepressants such as amitriptyline are among the medicines being studied.
• Opioid analgesics, such as morphine, oxycodone (such as OxyContin), hydrocodone with acetaminophen (such as Vicodin, Lortab, or Norco), or acetaminophen with codeine (such as Tylenol with codeine).
• Nerve block therapy, which is an anesthetic that is injected into the affected nerve to relieve pain.
• Trigger point injections, which are injections of a local anesthetic into trigger points or specific tender areas.

If you continue to experience chronic pain, you may be:

• Referred to one or more health professionals who specialize in rehabilitation and pain management (such as an anesthesiologist, a neurologist, or a physiatrist).
• Offered electrical stimulation therapies (such as TENS), which seem to decrease the feeling of pain for some people.
• Given injection therapy (such as corticosteroids), which can sometimes reduce pain and inflammation, or nerve pain.

For some people, complementary therapies can help reduce chronic pain. These therapies include:

• Acupuncture, a treatment based on traditional Chinese medicine, where very thin needles are inserted into the skin at certain points on the body to produce energy flow.
• Aromatherapy, or essential oils therapy, which uses a plant's aroma-producing oils (essential oils) to treat disease.
• Biofeedback, a method of consciously controlling a body function that is normally regulated automatically by the body, such as skin temperature.
• Chiropractic therapy, a hands-on therapy based on the theory that many medical disorders (especially disorders of the nervous system) may be caused by dislocations in the spine.
• Guided imagery, a series of thoughts and suggestions that direct a person's imagination toward a relaxed, focused state.
• Healing touch, which influences a person's physical or emotional health without physically touching the person.
• Homeopathy, or homeopathic medicine, which is a medical philosophy and practice based on the idea that the body has the ability to heal itself.
• Hydrotherapy, which uses water, in any form, to treat a disease or to maintain health.
• Hypnosis, which is a state of focused concentration during which a person becomes less aware of his or her surroundings. Some people learn to manage pain through concentrating in this special way.
• Magnet field therapy, a treatment which uses magnets to stimulate areas of the body in an attempt to maintain health and treat illness.
• Massage, which is rubbing the soft tissues of the body, such as the muscles, to help reduce tension and pain, improve blood flow, and encourage relaxation.
• Meditation, which is the practice of focusing your attention to help you feel calm and give you a clear awareness about your life.
• Naturopathy, which promotes using organic foods and exercise; maintaining a healthy, balanced lifestyle; and applying concepts from other areas of complementary medicine (such as ayurveda, homeopathy, and herbal therapies) in an attempt to improve health, prevent disease, and treat illness.
• Yoga, which uses meditation and exercises to help you improve flexibility and breathing, decrease stress, and maintain health.

A licensed mental health counselor, psychologist, or psychiatrist can help you cope with chronic pain. Chronic pain may affect all aspects of your life, straining your relationships and making it difficult for you to keep up with work and home responsibilities. You may feel angry, fearful, depressed, anxious, or frustrated because of chronic pain. These feelings can make it tough to conquer chronic pain, especially if you use alcohol or illegal drugs to manage your symptoms.

The best approach is usually a combination of treatments. If one treatment has stopped working, another treatment or combination of treatments may improve your pain. Try to stay ahead of the pain: don't wait until your pain is severe to begin treatment. Lifestyle changes such as getting daily exercise, eating a healthy diet, getting enough sleep, and trying complementary therapies and cognitive-behavioral therapy may help you reduce the pain or prevent it from getting worse.

Treatment if the condition gets worse

If your chronic pain is not relieved after you have tried numerous treatments, you may wish to consider seeking an evaluation at a pain management clinic. Treatment is provided by a team of health professionals who work together to address the variety of factors that may contribute to chronic pain.

Treatments that are commonly used for prolonged chronic pain include:

• Physical therapy, which may include using hot and cold therapy to relieve painful areas of the body, and exercises to maintain strength, flexibility, and mobility.
• Transcutaneous electrical nerve stimulation (TENS), which uses a wire in a skin patch to apply brief pulses of electricity to nerve endings in the skin to relieve pain.
• Professional counseling, such as cognitive-behavioral therapy. Stress and depression may contribute to or occur as a result of chronic pain. It is important to be healthy emotionally as well as physically to recover from chronic pain.

You may also wish to consider surgical options for relieving chronic pain.

• One option is surgery to implant a small pump that continuously delivers pain-relieving medicine (for example, spinal drug delivery).
• Another option is to implant a device that controls pain through spinal cord stimulation. This device administers small electrical currents to the spinal cord. The electrical current can be adjusted with an external control device. This technique may be successful in treating chronic low back pain.
• Radiofrequency lesioning (also called radiofrequency ablation) is a procedure that can disrupt the flow of pain signals. First, you will need to have a test that uses a nerve block, which numbs specific nerves, to help your health professional locate the nerves that are causing your pain.

What To Think About

Your chronic pain may improve more if you have a combination of treatments at the same time.

It is important to find a doctor with whom you feel comfortable, and to keep in regular contact with this doctor. If your doctor is unable to provide effective treatment to reduce your pain, ask about a referral to a pain management clinic. There, a team of health professionals can help you set realistic expectations and identify potential treatments.

Chronic pain cannot always be prevented.

Maintaining good physical and mental health may be the best way to prevent chronic pain or help you cope with the constant pain. It is important to get enough sleep every night. Treat your health problems early, learn to alternate activity with rest throughout each day, exercise, eat a balanced diet, and try to reduce stress in your life to prevent chronic pain from developing.

The following ideas can help you manage your chronic pain.

• Take your medicines as prescribed.
• Eat a balanced diet, and consider taking a daily multivitamin that contains vitamin B and vitamin D.
• Participate in a physical therapy or exercise program that includes stretching several times throughout the day.
• Keep your appointments with your health professional, especially if you have moderate to severe or constant chronic pain.

Make lifestyle changes, such as:

• Get enough sleep every night. If you are tired during the day and have trouble sleeping, try to:
  • Set a bedtime and a wake-up time—and stay with these times, even on weekends. This helps your body get used to a regular sleep time.
  • Get some exercise during the day.
  • Avoid taking naps, especially in the evening.
  • Avoid drinking or eating caffeine after 3 p.m. This includes coffee, tea, cola drinks, and chocolate.
• Treat medical conditions and mental health concerns early, before they get worse and become harder to treat. Untreated health conditions (such as shingles) or mental health problems (such as depression or anxiety) can make chronic pain harder to treat.
• Exercise regularly with aerobic exercise—such as swimming, stationary cycling, and walking—to build your strength and health. Water exercise may be especially helpful in reducing pain that gets worse during weight-bearing activities, such as walking. Talk to your doctor before you begin an exercise program. At first, try frequent short periods of exercise (5 to 6 minutes at a time) rather than long ones (20 minutes or more). If your joints are stiff, try taking a warm bath or shower beforehand to loosen up. Also, do some stretching exercises each day.
• Schedule your day so that you are most active when you have the most energy. Learn to move in ways that are less likely to make your pain worse.
• Eat a balanced diet. Good nutrition will help you stay healthy and strong.
• Stop smoking. Smoking may affect your level of pain and reduce the effectiveness of treatment for chronic pain.
• Reduce stress in your life. Try a relaxation therapy such as breathing exercises or meditation. For more information, see the topic Stress Management.

Other ideas include:

• Trying assistive devices, if recommended by your health professional, that help you do your daily activities. These devices can help you to be more mobile and independent. For example, use a cane or crutch, braces, splints, or devices such as doorknob extenders or an elevated toilet seat.
• Joining a support group. A support group is made up of people with similar experiences who can understand your feelings and provide comfort. A support group can keep you from feeling isolated and alone. Being around others who share your problem can help you and your family learn how to accept and manage chronic pain. To find a group near you, contact the American Chronic Pain Association at 1-800-533-3231 or online at www.theacpa.org.
• Doing self-massage or trigger point massage therapy.

If you are a caregiver for a person who has chronic pain, your own stress and worry can also cause you to have symptoms of depression, vague body pains, digestive disorders, or headaches. Experts say that it is important to take care of yourself, too, and not to feel guilty about it. For more information, see the topic Caregiver Tips.

Medicines can often help control chronic pain. Many different drugs, both prescription and nonprescription, are used to treat chronic pain. All these medicines can cause side effects and should be taken exactly as they are prescribed. In some cases, it may take several weeks before medicines work to reduce pain. It is important to let your health professional know all medicines you are taking (including herbal and other complementary medicines) to avoid dangerous drug interactions.

Medication Choices

You will likely be given medicines that cause the least significant side effects first (such as acetaminophen) to treat chronic pain. The dose will be increased or the medicines will be changed as needed. Older adults are more likely to experience adverse side effects, so medicines may be started at even lower doses and increased more slowly. Medicines used to treat chronic pain include the following:

• Pain relievers (analgesics)—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (for example, Advil)—which may be prescribed for mild to moderate pain and to reduce inflammation. Always take these medicines exactly as prescribed or according to the label. Do not take a nonprescription NSAID for longer than 10 days without talking to your doctor.
• Antidepressants, such as tricyclic antidepressants (for example amitriptyline), which may be used to treat chronic pain, although not all antidepressants are effective at reducing pain. Duloxetine (Cymbalta) is another type of antidepressant that is approved by the U.S. Food and Drug Administration to treat pain from peripheral neuropathy.
• Corticosteroids, such as prednisone, which are used to reduce inflammation and pain.
• Oral medicines, such as mexiletine (Mexitil), that act like a local anesthetic to dull pain.
• Anticonvulsants, which may ease pain that starts in the nerves (neuropathic pain). Examples are:
  • Gabapentin (Neurontin) for postherpetic neuralgia (nerve pain from shingles).²
  • Pregabalin (Lyrica) for postherpetic neuralgia and diabetic neuropathy (nerve pain from diabetes).³
  • Carbamazepine (Tegretol) to help control the episodes of facial pain in trigeminal neuralgia.⁴ If you take carbamazepine daily, you should be checked periodically to be sure you don't develop serious side effects (such as an allergic reaction or liver problems).
• Pain relievers that are applied directly to the skin (topical analgesics), such as EMLA cream or a lidocaine patch (Lidoderm), which can numb the skin and decrease pain.
• Capsaicin, a naturally occurring substance that is found in chili peppers and is used to make certain topical analgesic creams. Capsaicin changes the pain signals in the skin, blocking pain without blocking other sensations. Capsaicin may cause a burning sensation when it is first applied. Always wear gloves when applying capsaicin and do not touch or rub your eyes until you have washed your hands.
• Opioid analgesics, which may relieve moderate to severe pain.⁴ Examples of opioids include morphine, oxycodone (such as OxyContin), hydrocodone with acetaminophen (such as Vicodin, Lortab, or Norco), or acetaminophen with codeine (such as Tylenol with codeine). Opioids are sometimes combined with other medicine, such as gabapentin, for nerve pain.⁵

Other therapies that may be used to treat chronic pain include:

• Nerve block injections. An anesthetic is injected into the affected nerve to relieve pain. The anesthetic may relieve pain for several days, but the pain often returns. Although nerve blocks do not normally cure chronic pain, they may allow you to begin physical therapy and improve your range of motion.
• Epidural steroid injections (injecting steroids around the spine). Although these injections have been used for many years and may provide relief for low back or neck pain caused by disc disease or pinched nerves, they may not be effective for everyone.
• Trigger point injections. These may relieve pain by injecting a local anesthetic into trigger points (or specific tender areas) associated with chronic facial pain or fibromyalgia. For many people, nerve blocks or other injections can relieve chronic pain for good. However, it is not completely clear how this type of treatment works. These injections do not relieve chronic pain in everyone.

What To Think About

Medicine may work best when it is used in combination with other types of treatment, such as physical therapy and counseling, to address the different causes of chronic pain. Each person tolerates and responds to medicines differently.

Medicines can reduce or provide temporary relief of chronic pain. At first, you may be given medicines that cause the fewest side effects. Then, if needed, the dose will slowly be increased or you will be switched to a different medicine.

In general, avoid drinking alcohol while taking pain medicines, and do not take higher doses of any medicine than your doctor prescribed.

Daily medicines can be an effective part of long-term treatment for chronic pain. However, sometimes a medicine loses some or all of its effectiveness when it is used daily over a long period of time, because your body develops a tolerance to it.

Surgery is not often used to treat chronic pain. The decision to have surgery depends on your condition and the cause of your pain. Surgery is usually considered only after other treatments have failed, or if it is considered medically necessary.

Surgery may provide pain relief, but it also may permanently damage your ability to perceive other sensations, such as light touch and temperature changes. It can also cause a different pain to occur.

Surgery Choices

Surgically implanted pain control devices may be an option if you have severe chronic pain. These devices deliver drugs or a mild electrical current to the spinal cord. However, they are not effective or appropriate for everyone. Your doctor may recommend that you try a temporary device to see if it helps you.

The most common, effective implanted pain control systems include:

• Intrathecal drug delivery, which injects a medicine such as morphine or ziconotide (Prialt) into the spinal fluid through a small, adjustable, implanted pump.
• Spinal cord stimulation, which administers a small electrical current to the spinal cord from an implanted power source. The electrical current is adjusted with a controller.

A technique called chemical or surgical sympathectomy prevents the flow of pain signals. In surgical sympathectomy, the malfunctioning nerve or nerves are cut, usually stopping or reducing the pain. However, this procedure may also destroy other sensations besides pain, or create other sensations such as burning or numbness. This treatment may be used for a type of chronic pain called reflex sympathetic dystrophy, which is a condition that affects the nervous system. This procedure is not commonly done because it can cause side effects that include new pain and sweating. Your doctor may want to try a sympathetic nerve block first, in which local anesthetic is injected into the nerve to relieve pain.

Radiofrequency lesioning (also called radiofrequency ablation) is another procedure that can disrupt the flow of pain signals. First, you will need to have a test that uses a nerve block, which numbs specific nerves, to help your health professional locate the nerves that are causing your pain.

What To Think About

Surgically implanted devices are not commonly used to treat chronic pain. They may not always control chronic pain in the long run and can lead to other problems that can complicate chronic pain or sometimes make it worse.

In addition to medicine or surgery, other treatments can be helpful in reducing chronic pain.

Other Treatment Choices

Additional treatments for chronic pain may include:

• Physical therapy. This may include hot and cold therapy to relieve painful areas of the body. It may also include stretching and range-of-motion exercises to maintain strength, flexibility, and mobility.
• Transcutaneous electrical nerve stimulation (TENS). TENS applies brief pulses of electricity to nerve endings in the skin to relieve chronic pain.
• Professional counseling (such as cognitive-behavioral therapy). This treatment focuses on your mental health and conditions such as stress and depression, which can accompany chronic pain and make it worse. It is important to be healthy emotionally as well as physically, to recover from chronic pain.

Your health professional may refer you to a pain management clinic to receive these treatments. These clinics provide a setting where you can receive treatment and learn to cope with chronic pain. Treatment is usually provided by a team of health professionals who work together to address the many possible causes of your chronic pain. You may also receive these treatments from your own health professional or from specialists who treat chronic pain.

Complementary therapies

Complementary therapies may reduce pain, help you cope with stress, and improve your emotional and physical well-being. These include:

• Acupuncture, a treatment based on traditional Chinese medicine, where very thin needles are inserted into the skin at certain points on the body to produce energy flow.
• Aromatherapy, or essential oils therapy, which uses a plant's aroma-producing oils (essential oils) to treat disease.
• Biofeedback, a method of consciously controlling a body function that is normally regulated automatically by the body, such as skin temperature.
• Chiropractic therapy, a hands-on therapy based on the theory that many medical disorders (especially disorders of the nervous system) may be caused by dislocations in the spine.
• Guided imagery, a series of thoughts and suggestions that direct a person's imagination toward a relaxed, focused state.
• Healing touch, which influences a person's physical or emotional health without physically touching the person.
• Homeopathy, or homeopathic medicine, which is a medical philosophy and practice based on the idea that the body has the ability to heal itself.
• Hydrotherapy, which uses water, in any form, to treat a disease or to maintain health.
• Hypnosis, which is a state of focused concentration during which a person becomes less aware of his or her surroundings. Some people learn to manage pain through concentrating in this special way.
• Magnet field therapy, a treatment that uses magnets to stimulate areas of the body to try to maintain health and treat illness.
• Massage, which is rubbing the soft tissues of the body, such as the muscles, to help reduce tension and pain, improve blood flow, and encourage relaxation.
• Meditation, which is the practice of focusing your attention to help you feel calm and give you a clear awareness about your life.
• Naturopathy, which promotes using organic foods and exercise; maintaining a healthy, balanced lifestyle; and applying concepts from other areas of complementary medicine (such as ayurveda, homeopathy, and herbal therapies) to try to improve health, prevent disease, and treat illness.
• Yoga, which uses meditation and exercises to help you improve flexibility and breathing, decrease stress, and maintain health.

What To Think About

If you decide to try one or more of these complementary therapies to treat your chronic pain, find a health professional who has special training and, whenever possible, certification in the particular therapy. You may get a referral from someone you trust such as your health professional, family, or friends. Make sure all of your health professionals know every type of treatment you are using to reduce chronic pain.

Organizations

• Cancer Pain
• Cluster Headaches
• Depression
• Fibromyalgia
• Headaches
• Low Back Pain
• Migraine Headaches
• Neck Pain
• Osteoarthritis
• Rheumatoid Arthritis
• Temporomandibular (TM) Disorders

Citations

1. Max MB (2004). Pain. In L Goldman, D Ausiello, eds., Cecil Textbook of Medicine, 22nd ed., vol. 1, chap. 29, pp. 138–145. Philadelphia: Saunders.

2. Gabapentin (Neurontin) for chronic pain (2004). Medical Letter on Drugs and Therapeutics, 46(1180): 29–31.

3. Pregabalin (Lyrica) for neuropathic pain and epilepsy (2005). Medical Letter on Drugs and Therapeutics, 47(1217): 75–76.

4. Drugs for pain (2004). Treatment Guidelines From the Medical Letter, 2(23): 47–54.

5. Carver A (2005). Pain. In DC Dale, DD Federman, eds., ACP Medicine, section 11, chap. 14. New York: WebMD.

Other Works Consulted

• Davies PS, Galer BS (2004). Review of lidocaine patch 5% studies in the treatment of postherpetic neuralgia. Drugs, 64(9): 937–947.

• Woolf CJ (2004). Pain: Moving from symptom control toward mechanism-specific pharmacologic management. Annals of Internal Medicine, 140: 441–451.

• Ziconotide (Prialt) for chronic pain (2005). Medical Letter on Drugs and Therapeutics, 47(1223/1224): 103–104.