|April 25, 2014||
Breaking the Cycle of Chronic Pain
Dr. Todd Born explores various treatments for chronic pain, both conventional and integrative.
Pain is considered chronic when it lasts for weeks, months, and even years. Etiologies include trauma and conditions such as arthritis, cancer, infection, degenerative disc disease, and neuropathies. Common complaints are headaches, low back pain, arthritis, and neurogenic pain (pain that results from damaged central nervous system or peripheral nerves).
According to the American Academy of Pain Medicine, more than 1.5 billion people worldwide suffer from chronic pain, and approximately 3-4.5% of the global population suffers from neuropathic pain, with incidence rate increasing complementary to age. In 2011, the Institute of Medicine of the National Academies stated that 116 million Americans suffer from chronic pain. The next closest condition is diabetes – at 25.8 million Americans (this is the total of diagnosed with an estimate of undiagnosed).
The total annual cost of health care due to pain ranges from $560 billion to $635 billion (in 2010) in the United States. More than half of all hospitalized patients experience pain in the last days of their lives. Although therapies exist to alleviate most pain for those dying of cancer, research shows that 50-75% of patients die in moderate to severe pain. An estimated 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more.
In 2006, a National Institute of Health Statistics survey indicated that low back pain was the most common chronic pain (27%). This was followed by severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%). Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience frequent back pain.
How does chronic pain impact quality of life? The NIHS survey revealed that almost two-thirds (59%) of respondents reported deleterious impact on their overall enjoyment of life. More than three-quarters (77%) reported feeling depressed; 70% said they have trouble concentrating; 74% said their energy level is impacted by their pain; and 86% reported an inability to sleep well.
Chronic pain is very complex and a difficult health concern to treat. One reason is that the longer it goes on, the more systems become affected. Then there’s the phenomenon of pain sensitization syndrome. This is where sensitization of receptors is related to inflammatory and other non-inflammatory mediators at the nerve ending. Basically, the nerve fires at a lower threshold than before and even mild or relatively noxious stimuli activate the receptors, causing more pain. This can happen to the point where pain can be constant even without a triggering event. It can also increase in intensity and in other regions of the body.
Pharmaceutical strategies include non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, topical and oral steroids, narcotics, opioids (in the class of narcotics), anticonvulsants, and antidepressants. These may help with acute pain but are not very effective with chronic pain. And, the side effects tend to be worse than what they’re treating.
A lot of people take acetaminophen because they think it’s safe. When the maximum recommended dose is not exceeded, it is. However, it has to be used at relatively high doses for effective pain control, and it is often combined with other medications. Thus, it is easy to overshoot the maximum amount in a 24-hour period. Acetaminophen toxicity is actually the number one cause of acute hepatic (liver) failure in the U.S. I saw this a few times during my rotations in the emergency department. The treatment is N-acetyl-cysteine (NAC), which naturopathic physicians use all the time for other health issues!
NSAIDs such as ibuprofen (Advil, Motrin) have cardiovascular and gastrointestinal side effects, including ulcers and GI bleeding.
Oral steroids suppress the immune system, leaving one more prone to infection. They also have blood sugar regulation issues and can cause insomnia, bone loss, and thinning of the skin, which in turn can cause easy bruising and bleeding, along with swelling.
Narcotics make people extremely tired, constipated, and spacy. They’re also highly addictive.
Anticonvulsants (e.g., gabapentin and pregabalin) have common side effects of constipation, difficulty walking or controlling muscle movements, nausea, slurred speech, tremors and weight gain.
Antidepressants can cause nausea, increased appetite and comcomitant weight gain, sexual side effects, fatigue, drowsiness, insomnia, dry mouth, blurred vision, constipation, dizziness, agitation, restlessness, and anxiety.
In my experience, by the time patients seek out a naturopathic physician they are usually on a combination of the aforementioned medications, which normally aren’t working very well and/or the side effects are too debilitating. My treatment strategies are usually two-fold: 1) decrease the side effects of the medications, and 2) target pain management so the drugs work better and therefore can be decreased, which gets us back to #1.
The science and mechanisms of how natural therapeutics address chronic pain are beyond the scope of this article. Instead, I will discuss ways to address chronic pain from a therapeutic order standpoint—i.e., least invasive/least forceful interventions first, drugs and surgery last. My patients have usually been dealing with chronic pain for many, many years. This necessitates being very aggressive with natural agents to get ahead of the pain, and then backing down.
If you’re overweight, attempting to lose those extra pounds is a must. I have never not seen a food allergy or intolerance play a role in chronic pain. Therefore, it is prudent to put patients on a gluten-free, casein-free, allergy elimination diet. This involves removing a number of “usual suspects” of food intolerances for 2-3 weeks. Then they are systematically challenged every 72 hours to see if there is a reaction. A reaction can take on almost any form, from irritability to sleep issues to increased pain. Patients keep track of any reactions in a journal. If there is a reaction, the next food or food group cannot be challenged until the reaction has subsided. I do this regularly with my patients and have seen diminution of pain along with weight loss.
Exercise, physical therapy, massage therapy, chiropractic care and acupuncture
I’ll lump these together for simplicity. Exercise – even a little – is a must. More movement equals the less pain. The rationale is twofold: 1) endorphins are released that improve mood and decrease pain, and 2) studies consistently show that sedentary lifestyles exacerbate pain. PT and massage can help strengthen bones, ligaments, tendons, fascia (fibrous tissues that surrounds muscles and groups of muscles). Chiropractic therapy is based on the premise that much musculoskeletal dysfunction is from misalignment of the spine. It stands to reason that if nerves coming out of the spine to feed muscles are impinged upon, there will be a deficit in how that nerve and muscle work. Clinical trials have shown chiropractic treatments to be superior to placebo and medication in the treatment of low back pain. Acupuncture has been around for thousands of years in Asia. It has been proven effective in hundreds of clinical trials and is now used in many hospitals and pain clinics throughout North America to treat pain.
Mind-body medicine and yoga
Most people with chronic pain also end up suffering from depression. Clinical trials have shown that craniosacral therapy, talk therapy, counseling, etc. can reduce the depression as well as the pain and help decrease dependence on medications. Yoga can help with balance, stress, pain, and the insomnia that usually accompany chronic pain.
Homeopathy is considered an “energetic” medicine which does not interact with other medications, supplements, or herbs. Much like naturopathy, it takes a person’s physical, mental, and emotional picture and puts the pieces together like a jigsaw puzzle to match them to one of about 5,000 remedies – a seemingly daunting task. Although the science and art behind homeopathy are very challenging, a good naturopath can usually find the right remedy. Constitutional homeopathy also uses the jigsaw philosophy, but is different in that it doesn’t just target just the pain. The classic homeopathics for pain are Arnica, Rhus toxicedron, Ruta graveolens, Hypericum and Bryonia. A very helpful and informative book is Homeopathy for Musculoskeletal Healing by Asa Hershoff.
Herbs really do win this one over pharmaceuticals. This is because there are so many and they cover different actions and types of pain. Botanicals include anti-spasmodics, anodynes, analgesics, adaptogens (enable the body to better adapt to stress), nervines (calm the nerves), anti-inflammatory, inflammation modulating herbs, etc. They have affinities for certain organs and tissues, but can be combined to effectively treat all different types of pain. Some of the more popular ones that have shown efficacy in clinical trials are Boswellia serrata (Indian frankincense), Curcuma longa (turmeric), Eschscholzia californica (California poppy), Corydalis, Salix alba (white willow), Withania somnifera (ashwagandha), Hypericum perforatum (St. John’s wort), Viburnum opulus (cramp bark). Some of the most powerful herbs for pain are very toxic and should only be used by a skilled, well-trained, and licensed naturopathic physician. 4
Calcium and magnesium are vitally important. Both are involved in muscle contraction and relaxation; calcium more so in the former, magnesium in the latter. Not all calcium and magnesium forms are created equal. Calcium carbonate, although high in elemental calcium, is poorly absorbed and more likely to cause constipation, kidney stones and bladder stones. Calcium and magnesium compete for binding sites of absorption. In the body they are found in a 2:1 ratio, and that’s the way they should be taken in supplements. If you want just the anxiolytic and muscle relaxation portion, magnesium should be taken away from calcium by at least a few hours. Magnesium oxide is common in supplements. It is poorly absorbed, has a low elemental profile, and usually causes diarrhea and cramping.
Omega-3 essential fatty acids, mostly derived from fish oils, are crucial in pain management. To be effective, they must be taken in very high doses. This can cause easy bruising and bleeding, and therefore should be supervised by a physician. Furthermore, the oils should be molecularly distilled to be free of contaminants and heavy metals. Fish oils that are not molecularly distilled are nothing more than concentrations of these toxic substances. That is why high-quality fish oil supplements cost more than their low-budget counterparts.
Vitamin D plays a pivotal role as an anti-inflammatory, and it helps the body absorb and utilize calcium and magnesium properly. However, too much vitamin D can lead to kidney stones, bladder stones, and arteriosclerosis (hardening of the arteries).
Finally, a tried and true home remedy that is almost always overlooked is Epsom salts. Using 3-4 cups in a warm, not hot (as this stimulates the nervous and cardiovascular systems), bath for 20 minutes can help in more ways than you can imagine. The magnesium in the salts goes to the muscles for relaxation, and the sulfate from the salts can donate a sulphur amino acid to aid in liver detoxification.
All of this is just a snapshot into an integrative approach to chronic pain. There are many, many more options. With naturopathic medicine, which is tailored to the individual patient and the specific cause or causes of the pain, much can be done for this complex condition. Here is an interesting example:
When I was a second-year medical student my neighbor injured his knee playing hockey. He was walking with a decided limp and using crutches. His primary care doc said to take ibuprofen and/or naproxen every few hours for the pain. Weeks went by and he wasn’t any better. He had an MRI which showed some grade 2-3 tears in his menisci and anterior cruciate ligament. Not surprisingly, an orthopedist scheduled him for surgery. My neighbor knew I was in medical school asked my advice. So, I recommend the only thing I really knew at that point – Arnica. He dissolved 5 pellets of 30C (the strength or potency) in his mouth for a week. After a few days he wasn’t using his crutches. After a week, 90% of his limp resolved. He took it for another week and was completely symptom free. I don’t know if it corrected the damage to the ligaments, but he canceled his surgery. He lived near me for another year or so and had absolutely no problems with his knee.
Chronic Pain References
About Dr. Todd Born
Dr. Todd A. Born is in private practice with his wife, Dr. Lindsay Jones-Born, at Born Naturopathic Associates, Inc., in Alameda, CA (www.bornnaturopathic.com). He is licensed in California & Connecticut. He is also Product Manager at Allergy Research Group, LLC and a Thought Leader for UK-based “Clinical Education,” a free peer-to-peer service that offers clinicians a closed forum to ask clinical questions and receive evidence-based responses by experts in their fields. Dr. Born graduated from Bastyr University in Seattle and completed his residency at the Bastyr Center for Natural Health and its thirteen teaching clinics, with rotations at Seattle-area hospitals. He may be reached at email@example.com.