Treatment

Now that we have broken pain down into acute versus chronic and somatic (musculoskeletal) versus neuropathic (nerve-based), we can turn our attention to how they are treated.

Acute pain tends to respond to short-acting medications since it is expected that once the injury heals, the pain will resolve. Chronic pain may persist long after tissue injury has resolved and will require both long-acting and short-acting medications. Somatic pain tends to respond well to the opioids (initially defined as medications derived from the poppy or opium plant).

The former term for “opioids” is “narcotics” and these potent classes of medications are tightly controlled by the federal government because of their abuse potential. Opioids are very effective at managing somatic pain as from a tooth ache or a pulled muscle. Ice, heat, and massage also help a great deal. Opioids, as a class, are unpredictable when treating neuropathic pain; individuals with herniated lumbar discs, a neuropathic pain state, will often indicate that the medications dull their brain but do not decrease the pain. Chronic neuropathic pain is more often treated with medications that are in the class of “anti-seizure” medications.  

Medications
The following are medications commonly used to assist with treating pain

1. Opioids: as mentioned in the preceding paragraph, opioids are highly effective in somatic pain and unpredictable in neuropathic pain. As a consequence, one will frequently find opioids as the only medication for somatic pain and one of several medications for neuropathic pain. Opioids come as short and long-acting and frequently are used together to stay ahead of the pain and to allow for the treatment of breakthrough pain.

2. Muscle relaxants: this class of medications slows the firing of muscle fibers and tends to cause the muscle to be less tense which may help mitigate the pain of somatic origin and allow for more complete range of motion or movement of the muscle group helping to rehabilitate the injured part.

3. Anti-seizure medications: Anticonvulsants are medications that stabilize nerve membranes and keep irritable nerves from firing which is perceived as pain. There are numerous examples of this class of medication and are used almost exclusively in neuropathic pain states. This class of medication has very specific side effects and need to be monitored closely when prescribed.

4. Anti-inflammatories:  This group of medication is familiar to everyone as some can be purchased without prescriptions and is ubiquitous in its consumption. Aspirin and ibuprofen are examples of this group of medications and are very effective in the treatment of somatic pain states. There is no clinically-based evidence to support their continuous use in neuropathic pain states although it is common to prescribe them for nerve-based pain states.

Other Treatments of Pain
Medications alone are insufficient in the treatment of acute or chronic pain, somatic or neuropathic pain. Other physical modalities can and should be used to decrease pain and to enhance function. Examples include:

1. Physical & Occupational Therapy: use of physical and occupational therapy supervised by skilled therapists assist the individual with restoring function to a dysfunctional limb or part of the body. Through graded exercises, restoration of normal posture or normal range of motion of a limb, one can recruit muscles to enhance function and reduce pain. Part of this therapy might include use of exercise in a pool or working against resistance in a pool, or the application of external electrical stimuli to the skin to reduce pain, enhance blood flow to the muscle, and to restore function.

2. Manual Modalities: the transcutaneous nerve stimulator, massage, and acupuncture are very effective in enhancing function and reducing pain for musculoskeletal injuries (somatic pain).

3. Behavioral Therapies: by a pain oriented psychologists can help restore function and reduce pain by concentrating on the cognitive issues that increase pain as with stress, depression, and sleep deprivation. Pain affects the whole body and the entire family and psychologists can assist with restoring interpersonal and interfamily homeostasis (normalcy). Biofeedback can be utilized to retrain the body to have the mind control the pain as opposed to the pain controlling the mind.

4. Interventional Pain Approaches: these modalities are carried out by pain specialists and may include injections, or use of electronic implantable devices like a pain pump with a spinal catheter or a spinal cord stimulator (pacemaker of the spinal cord or peripheral nerve). These modalities are very effective when other modalities have been ineffective or when the cause of the pain state requires advanced treatment.