Pain Management Options

...by Maddie Smith

Is your aging body sending distress signals? If we neglect our bodies or fail to treat them with proper respect, they have an effective means of expressing their dissatisfaction—we feel pain. We feel pain in our joints, our muscles, our backs. We may feel pain any place a nerve exists that can fire off an urgent distress signal to the brain. As we age, those distress signals seem to become more frequent. The simplest of movements, such as bending over to pick up a fallen object, can create instant regret.

The CDC reports that over 20% of adults in the U.S. live with chronic pain. About 17% live with severe levels of pain, according to a National Health Interview Survey. There is a plethora of information circulating about pain management treatments, even alternative treatments that don’t get attention from the medical community. Treating chronic pain is essential in maintaining mobility, strength and a positive attitude— whether a patient is recovering from surgery, cancer treatment, coping with a chronic health condition or aging in general.

Public Broadcasting Service (PBS) hosted an informative panel discussion in Spokane (rebroadcast in 2020). Here is what some of the experts in the field have to say about managing pain, including alternatives to opioids.

It is very common for doctors to prescribe opioids to patients for their chronic pain, even if the patient is not aware of other options. Joan Maxwell is a patient advocate for alternative treatments for pain. After she was diagnosed with breast cancer, she needed nine surgeries including a double mastectomy. She said she did not have one conversation with her doctor about pain management options for any of her surgeries: “Nine times I had surgery and nine times I was prescribed opioids.” Doctors want to help their patients alleviate pain, but the over-prescription of opioids has become a crisis. Maxwell feels patients should be active participants in their care and pain management plans; opioids are just one piece of the puzzle. She stressed that making the time for patient education is vital.

Cheyenne Newsome, clinical professor of pharmacotherapy at WSE, acknowledged the severity of the opioid epidemic on the country. She wants patients to know that opioids are not a cure for pain, rather a way to manage it. The goal for prescribing opioids is to prescribe the smallest dosage for the shortest amount of time possible. Newsome’s job is to evaluate the severity of the patient’s pain and to use all available resources to manage their symptoms.

For example, if your doctor deems them safe for you, over-the-counter drugs like ibuprofen (sometimes in combination with other pain relief options) can be helpful in managing pain before jumping straight to opioids. Opioid patches deliver consistent levels of the drug rather than fast-releasing oral pills—patches are good for people who have trouble sticking to a schedule that oral pills require; they may also offer a steady, more level measure of pain relief. A wide variety of patches and creams are available that don’t require a prescription. From heat patches to creams made from peppers that block nerve receptors, over-the-county methods for pain management are plentiful at pharmacies. However, Newsome urges patients to consult with a health care provider before trying any new treatment as some of them do not react well with each other. For instance, patients should avoid putting a heat patch in the same place where they recently applied an opioid topical patch. Don’t forget the tried-and-true method of alternating ice packs with heat, which can be surprisingly helpful for some aches and pains.

Exercise and communication are key

So says Dr. Christopher Valley, a specialist in chronic pain and fibromyalgia. Listening to patients, educating them, and prescribing exercise regimens specific to patient symptoms are his specialty. Many chronic pain conditions, like fibromyalgia, mimic each other and patients can become frustrated by the lack of answers.

The absence of a diagnosis is a very challenging aspect of living with chronic pain. Treatments like physical therapy, exercise and diet are all ways to manage pain, even if the patient’s condition hasn’t been diagnosed—having a treatment plan can help not only pain levels, but frustration when lacking a diagnosis. In all cases, Valley works to deliver an accurate diagnosis. To do so, he pays close attention to information the patient is telling him; he looks at patient histories but does not take previous diagnoses made by other doctors at face value. Importantly, he performs a thorough physical exam on the patient. A careful intake of information from the patient and a good, complete physical exam are time-consuming—most primary care physicians do not have enough time to conduct thorough exams, said Valley, but he feels they are crucial in cases that are difficult to diagnose.

Education about pain and exercise is especially important, says Valley. He works to help patients know that pain can be manageable and that exercise is usually crucial in their recovery. Dr. Valley prescribes exercise just as a physician would prescribe a medication, writing it down on a prescription pad and starting with small doses. Valley takes into account the limits and boundaries of his patients and adjusts dosage of exercise accordingly. He also makes them schedule a time to do their exercise, writing it down in a planner. Condition-appropriate exercise is vital. Many seniors and those in chronic pain may look to gentle practices like swimming, walking, yoga, tai chi or exercises that can be done while sitting.

Clinical psychologist Sonya Wood offered a psychological perspective on pain management. Her work focuses on a holistic approach to pain by understanding how patients are feeling both physically and mentally. She evaluates all aspects of the patient’s life—relationships, school, work, etc.—to see which aspects are helping or hurting their pain levels. She adds that the patient’s attitude plays a huge role in their recovery... the way a patient thinks will determine how they feel and how they behave. Oftentimes, patients experience fear after having a surgery or an accident, which can prevent them from doing things to advance their recovery, like exercise and physical therapy. Furthermore, added stress in a patient’s life can make their pain worse and also impact their sleep schedule, further exacerbating the pain. Like Valley, Wood believes that taking the time to listen to patients and address their fears and stress aids in recovery.

Minimize use of opioids

As an anesthesiologist, Dr. David Burns offered insight about acute pain. Acute surgery-related pain often translates to long-term post-operative pain. If the acute pain is treated at the time of surgery, there is a lower chance of a patient experiencing chronic pain down the road. Burns works at Providence Anesthesia Services, which uses a ‘multi-modal’ approach to pain treatment. First, doctors deliver nerve blockers to prevent patients from experiencing the most acute pain after their surgery. Nerve blockers can last from several hours to days post-op. The patient’s lack of feeling for the worse part of the pain helps them in their recovery, in part, because they are more willing to participate in physical therapy. Physical therapy helps a patient’s chances of healing and gaining back their mobility. Burns discussed the importance of maintaining a healthy sleep schedule as part of the healing process, starting in the hospital. He advocates that hospital staff “cluster” patient care; instead of checking a patient’s vitals every hour throughout the night, for example, check them right before sleep-time, then minimize check-ins during the night. He advises keeping the blinds open during the day and providing an active regime of treatment and care when the sun is out.

Burns discussed hopeful news on the joint replacement front, and cited studies on stem cell and cartilage injections that may offer an alternative for knee, hip replacements and other joint replacement. Emerging research points to the hope that the need for joint replacement surgeries may eventually be eliminated.

Dr. Ryan Barnes, who specializes in physical therapy, also looks to an integrative healthcare practice, which emphasizes a patient-focused approach. Integrative health care may bring conventional and complementary approaches together in a coordinated way. Each patient is different, and while physical therapy is vital in most cases he sees, it is not the right choice in all cases. Integrative health looks to include alternative treatments like acupuncture in your recovery plans. He reminded us that physical therapy is a long process, especially for patients living with chronic pain. It is important to give patients detailed information on the goals for therapy. Like Dr. Valley, Barnes thinks that appropriate exercise is vital for treating chronic pain, but he acknowledges the difficulties of maintaining an exercise regime for some. Patients and their health care providers must make sure patients aren’t overexerting themselves, worsening the pain. While following up on physical therapy is vital, he says, keeping your body moving in any manner that helps mobility—even if it isn’t traditional exercise—is a positive outcome.

What should you eat to help with chronic pain?

Anecdotal information abounds that following an anti-inflammatory diet can be an effective treatment for chronic pain. Dr. Valley acknowledges that while research is still underdeveloped, a low-inflammation diet can help with pain management. Low-inflammation diets include vegetables and healthy fats; they cut out processed foods and refined sugars. A Seattle-area senior who lives with osteoarthritis and has had several joint replacement surgeries says her pain levels improved when she cut sugar and processed foods from her generally healthy diet, but that her pain disappeared completely when she added a daily turmeric supplement.

The Arthritis Foundation cites the Mediterranean diet for alleviating inflammation and joint pain. This diet avoids processed foods and is heavy in fish, nuts, beans and vegetables. Eating this way can alleviate pain by reducing inflammation, protecting joints and heart health, helping in weight loss and lowering blood pressure. This type of diet generally includes: omega-3 fatty acids, found in cold water fish like salmon but also in vegetarian sources such as flaxseed and algae-based supplements; nuts and seeds are packed full of protein, fiber, healthy fats and vitamins; fruits and vegetables (but especially veggies) provide antioxidants, which bulk up your body’s defense system by protecting cells—at least nine servings daily are recommended; olive oil contains heart-healthy fats and a compound that reduces pain sensitivity and inflammation— two-to-three tablespoons daily are recommended; beans (especially when prepared in a pressure cooker, which lower the lectins that can reduce nutrient absorption) are a great source of fiber and anti-inflammatory nutrients and have the added bonus of being cheap and loaded with protein—try for two cups per week. This list is not comprehensive but will get you started. Don’t forget to spice up your healthy diet with these anti-inflammatory herbs and spices: ginger, turmeric, garlic, cinnamon, cayenne and black pepper, cloves, basil...while parsley isn’t in this top list, sage, rosemary and thyme are.

Other alternative treatments

The National Center for Complementary and Integrative Health in partnership with the National Institutes of Health published a free eBook for consumers that discusses additional complementary approaches to pain management. (See link at the bottom of the page to download the 48-page booklet.) This publication educates consumers on acupuncture, massage therapy, meditation and mindfulness practices, relaxation techniques, spinal manipulation including chiropractic care, yoga and tai chi, dietary supplements and more—all of which show to be beneficial practices in pain management. Future files: Research on new approaches to pain management are always in the works. A surprising, high-tech alternative being investigated at the UW School of Medicine is research on the potential role of virtual reality goggles for pain management. Dr. Reza Firoozabadi, an orthopedic trauma surgeon who is conducting the research, reported that virtual reality goggles offers patients a distraction during a painful procedure (removing stabilizing pins from the patient), something that normally requires a sedative. We hope to soon learn more about this and other futuristic options for pain management.

Cannabis. Scientific research on the use of medical marijuana for pain treatment is still underdeveloped due to the chemical complexity of cannabis and the prohibition of the drug in most states. Dr. David Bearman discussed medical marijuana in the journal Practical Pain Management. The THC compound found in cannabis stimulates the brain’s cannabinoid receptors, which are responsible for pain reduction and a hazy “high” feeling, he writes. CBD is the other compound in cannabis, which communicates with pain receptors in the brain to relieve pain and inflammation. Dr. Bearman recommended a one-to-one ratio of THC and CBD for patients with concerns about feeling “high” after consuming cannabis. Every patient is different, but he generally recommends 15mg of each compound for pain reduction.

People who experience chronic pain are drawn to cannabis as a pain management treatment because it is easy to obtain in Washington and they can control how they use it, said Lisa Buchanan. Buchanan is a nurse and licensed medical marijuana consultant at Dockside Cannabis, a Seattle-based medicinal cannabis dispensary. She said many older adults choose the one-to-one THC/CBD ratio because “It feels good and doesn’t feel overly psychoactive.” Christine Cohen, marketing director for Hashtag Cannabis, agrees with the one-to-one ratio for older customers because there are several scientific studies showing that ratio provides the greatest health benefits. However, once a patient becomes comfortable using cannabis as a pain treatment, they are more likely to adjust dosage to a comfortable level for them. “In the world of medicine, we’d call that as needed.” Studies find that THC increases the bioavailability of CBD, which enhances the effects of the drug, according to Buchanan. To access cannabis products with THC content (or a combined THC/CBD content), you must visit a cannabis dispensary rather than a drugstore or the myriad other outlets that sell products containing only CBD.

Cohen said that most seniors walk out of medicinal cannabis dispensaries with a topical cream because they have localized pain like arthritis and they want to have maximum control over minimizing the psychoactive effects of cannabis. Still, many seniors may experiment with edible cannabis products once they are comfortable doing so. Both Cohen and Buchanan said they’ve witnessed older customers having tremendous success using medicinal cannabis products to treat pain. “Even our owner’s mother finds topicals to be really effective on some of her arthritic joints,” said Cohen. [Dockside Cannabis and Hashtag Cannabis & Supply Co. are Northwest Prime Time advertisers. Please see Dockside’s ad on page 13 of our print issue]

In summary

“Unfortunately, pain and aging are facts of life,” says Nicky Snazell, a physiotherapist expert in pain management and author of The 4 Keys to Health and other books. “The good news is that, ultimately, our quality of life doesn’t have to be ruled by age and pain themselves, no matter what we might think. Instead, our quality of life is determined by how we handle age and pain.” Snazell advocates those suffering from chronic pain—or really anyone wanting to maximize their health—to work on four fronts. “As we age, we need to put even more care into our diet, our exercise and our workload. It sounds simple but many of us fail to acknowledge that we have to change the way we use our bodies as we get older...so much of this is a choice. We have the power to change ourselves by transforming the way we think, what we eat, how we move and what kind of lifestyle we choose to lead.” She adds, “We eat too much of the food that enhances pain and too little that reduces pain. Also, hydration is necessary for mental agility, the immune system, healing, cleansing and detoxing. Being disciplined about getting exercise is your key to longevity, so exercise regularly and effectively,” she advises. Maintain check-ups and screenings with your doctor. Keep track of your blood pressure. Even small, simple things will help manage pain, such as setting aside time daily for meditation or quieting the mind, keeping your body moving in a way that works for you, setting purposeful goals, doing something nice for others, interacting with positive people, singing in the shower... Work hard on necessary changes like exercise and diet, but also find the simple things in life that make you feel good.

More Information

• To view the full NPR program, visit www.pbs.org/video/health-matters-television-life-pain-management/

• Download the National Center for Complementary and Integrative Health resource on alternative treatments for chronic pain: https://files.nccih.nih. gov/s3fs-public/Pain-eBook-201906508.pdf