Rethinking chronic pain

There are many different ways to approach chronic pain, said Heather Tick, MD, at the 2019 Institute for Functional Medicine Annual International Conference in San Antonio, Texas.

In the U.S., $560-635 billion is spent annually on pain care, said Tick. This exceeds the annual expenditures for heart disease, cancer, and diabetes combined.

“There are huge costs to how we treat pain case now,” said Tick. “We have an epidemic of chronic disease and, as those figures grow, we’re going to have more pain.”

Pain can be acute or chronic. Acute pain can be life threatening or non-life threatening and has a consistent brain process. Chronic pain changes brain processes, and is facilitated by peripheral and central sensitization, descending inhibitory pathways augmenting pain microglia, chronic stress, post-traumatic stress disorder, adrenal activation, adverse childhood events, opioids, and chronic inflammation, Tick said.

Pain is a sensation, a signal of injury, a chronic disease, a brain process, or a need for drugs. Medicine attempts to connect the dots, but in doing so neglects the connectors, the root causes, of pain, said Tick.

There is a genetic predisposition to chronic pain as well, Tick said. A suite of RNA molecules has been identified in the bloodstream and is more likely to be elevated in women who develop chronic neck, shoulder, or back pain after a car accident. Many of the RNA molecules, Tick said, are encoded by genes on the X chromosome, of which there are two copies in most women.

Tricyclic, serotonin and norepinephrine modulators are commonly used in pain conditions. They can lead to neuropathic, migraine, and amplified pain disorders such as fibromyalgia and complex regional pain syndrome. Mood disorders, anxiety, and other psychiatric co-morbidities increase the suffering associated with pain. Further, antidepressants have adverse effects such as weight gain, emotional blunting, and suicidality.

The more serious psychiatric co-morbidities are more likely to end up on high dose, long-term opioids, Tick said. Even when prescribed opioids, 70 percent of patients still complain of moderate to severe postoperative pain. Unimodal pain care with opioids as the cornerstone of treatment can be considered disadvantage care, Tick said.

The Joint Commission revised its pain mandate in 2018, stating that “Hospitals provide nonpharmacologic options for patients with pain.” The American College of Physicians guidelines for treating low back pain recommends superficial heat, massage therapy, acupuncture, and spinal manipulation, noting if pharmacological options are desired, turn to nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants, and avoid opioids altogether. For chronic low back pain, they recommend exercise and multidisciplinary rehabilitation, acupuncture therapy, mindfulness-based stress reduction, tai chi, yoga, progressive relaxation, laser therapy, operant therapy, cognitive behavioral therapy, and spinal manipulation. In addition, the American Society of Clinical Oncology Clinical Practice Guidelines found acupuncture was effective in improving pain. The U.S. Department of Health and Human Services and the National Institutes of Health presented similar findings, Tick said.

Tick calls for comprehensive pain care, a multimodal approach to acute pain care that questions opioids as the cornerstone, regulates frequency, dosing, and timing of nonpharmacologic interventions for inpatient and acute care, and recognizes the need for ongoing research on comprehensive pain strategies.

This approach to pain care can utilize the therapeutic order or Six Principles of Naturopathic Medicine:

• First, do no harm—utilize the most natural, least invasive, and least toxic therapies
• The healing power of nature—trust in the body's inherent wisdom to heal itself
• Identify and treat the causes
• Doctor as teacher
• Treat the whole person
• Prevention

In addition, Tick shared four goals of the Consortium Pain Task Force in a 2018 call to action for evidence-based nonpharmacologic strategies for comprehensive pain care:

1. Increase awareness of effective nonpharmacologic treatments for pain
2. Train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice
3. Advocate for policy initiatives that remedy system and reimbursement barriers to evidence‐informed comprehensive pain care and
4. Promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short and long term therapeutic and economic impact of comprehensive care practices

To treat chronic pain, practitioners must become comfortable with uncertainty, and be willing to explore to find the root cause. Further, they must understand fascia, movement, mitochondria, and the microbiome, topics which are familiar in the functional medicine pain management communtiy, but not necesarilly in the general population. 

"We’re not going to have funding for a healthcare if we don’t change the way we treat pain,” said Tick. “We do have better solutions if we think differently about the problems.” 

Editor’s note: This article is part of Integrative Practitioner’s live coverage of the 2019 Institute for Functional Medicine Annual International Conference. For a full list of coverage, click here.