This section addresses general pain that is located throughout the body. For specific areas of pain, or fibromyalgia, see the sections on those topics. Pain is considered chronic if it has been present for more than three to six months. Numerous factors can cause pain, including injury, disease, poor posture, aging, and psychological problems. Having chronic pain can also cause many psychological disturbances such as anxiety, depression, anger, and stress. We don’t know why pain becomes chronic, but we do know that chronic pain is very different from acute pain, both in how the body reacts to it and how it is treated.

Common Symptoms

There are dozens of ways to describe pain but the most common are sharp, dull, aching, burning, stabbing, or tearing. Pain can be constant or intermittent, with flare-ups that can last a few hours to several weeks. Muscle spasms, stiffness, or swelling can accompany chronic pain.

What You Need to Know

When pain becomes chronic, many changes occur in the brain and body tissues that can perpetuate the pain. These include a heightened sensitivity to pain in both the spinal nerves and brain, and an increase in particular chemicals (NMDA, Substance P) that increase the pain messages going to the brain. In addition, receptors in your soft tissues that usually detect non-painful stimuli (such as wetness, heat, cold, light touch) are converted into pain receptors, which is why such stimuli often cause your pain to worsen. There are also many nonphysical factors that play a role in pain, such as stress, mood, emotion, and motivation. Treatment for chronic pain involves much more than just giving pain medication. In fact, pain medication can perpetuate and even worsen chronic pain.

General Recommendations

Diet: Many foods can affect pain both positively and negatively. Foods that contain tryptophan can increase a brain neurotransmitter, serotonin, which can block pain. Foods high in tryptophan include turkey, chicken, cheddar cheese, halibut, eggs, peanuts, and nuts. Foods containing omega-3 fatty acids, such as cold-water fish (e.g., mackerel, tuna, sardines, salmon, herring, cod, trout, and halibut), have natural anti-inflammatory properties. Foods high in calcium and magnesium, such as dairy products, salmon, and whole grains, can relax muscles. Avoid saturated fats because they contain prostaglandins, which increase the inflammatory response.

Exercise: Regular exercise is very important in reducing chronic pain. Exercise stimulates large neurons (brain cells) to help reduce the perception of pain and stimulate the production of natural pain-killers from the brain. Inactivity causes increased stiffness and loss of muscle tone, which can increase and perpetuate the pain. Aerobic, resistance, and stretching exercises are all important, and you should perform all three types at least three times a week. You may feel that you cannot perform exercises because of the pain, but you will find out that exercise will decrease your pain.

Meditation: Because anxiety and stress can increase pain, meditation is invaluable in helping reduce these factors.

Your balanced healing action plan for Chronic Pain

Step 1: Undergo Acupuncture

I always recommend acupuncture first for chronic pain, because it can address both the area of pain and the part of the brain that perceives pain (the hypothalamus). Acupuncture also can address factors that may be underlying the pain. Principal points depend on the area affected, as well as specific syndromes that underlie your pain, which must be determined by traditional Chinese medicine tongue and pulse diagnosis. Always seek evaluation and treatment from a practitioner certified in acupuncture. You should notice improvement within 6 treatments, but you might need up to 12 or 15 additional sessions for maximum benefits.

Step 2: Undergo Psychological Counseling

Chronic pain can cause a variety of psychological problems, especially anxiety, frustration, anger, and depression. These in turn can make the pain worse. I recommend counseling with a therapist who works with chronic-pain patients to help you learn to cope better with your chronic pain, so you can participate in more activities and generally feel better Counseling also helps improve your relations with family, friends, and work. This does not mean that you are “crazy,” simply that you need help in dealing with the changes that are inevitable with chronic pain. Often, your pain will also decrease as a result of dealing with your emotions.

Step 3: Undergo Feldenkrais Method, Alexander Technique, or Rolfing

If you are still suffering from chronic pain, the Feldenkrais method, Alexander techmque, and Rolfing are all forms of bodywork that might relieve chronic pain that doesn’t respond to other treatments. Bodywork involves realigning, rebalancing, and retraining the structures of the body, which have become dysfunctional due to pain, injury, disuse, or misuse. The Feldenkrais method focuses on retraining how you move your body, to interrupt unhealthy patterns of movement that have become habits. The Alexander technique concentrates on correcting faulty posture in daily activities (sitting, standing, and moving). Rolfing involves manipulating and stretching the body’s fascial tissues (deep connective tissues that hold your body together), thus allowing correct realigning of the body. These bodywork methods require a therapist certified in these techniques. It may take several months to notice improvement from these methods. You can use them in combination with the first two steps.

Step 4: Undergo Hypnosis, Guided Imagery, and/or Interactive Imagery

If your pain continues, I recommend trying some mind-body methods. Hypnosis can reduce pain by addressing the emotional and psychological factors that can either cause pain or make it worse. Hypnosis can work quickly, often in two to three sessions. Guided imagery can influence the amygdala, the area of the brain that receives pain messages, teaching the brain not to perceive the pain. This method may take several weeks to months to be effective. Interactive imagery is a mind-body method in which you mentally interact with images that represent your emotions. It is a powerful way to uncover and deal with subconscious psychological issues of which you may not be aware, but that may be causing your pain. It may take several weeks to a few months to notice improvement in your pain using interactive imagery.

Step 5: Practice Appropriate Yoga Postures

If you are still suffering from chronic pain, I recommend practicing yoga. Yoga promotes relaxation and stretching, both of which are important in healing and preventing pain. Because there are many different types and different levels of yoga, with some better for chronic pain than others, I recommend working with a qualified yoga instructor. It may take several months (sometimes sooner) to notice improvement.

Step 6: Take Appropriate Chinese Herbal Remedies

If your pain continues despite the above measures, I recommend trying Chinese herbal formulas to address the syndromes that may be perpetuating or underlying your pain. Consult a practitioner qualified in Chinese herbal medicine to determine which Chinese herbal formulas are the best for your particular syndromes. You should notice improvement within three weeks, but you may need to take the formulas longer for complete relief.

Step 7: Take Naproxen or Ibuprofen

If you are still hurting, you can take nonprescription medications to control your chronic pain. Over-the-counter naproxen and ibuprofen are the safest long term and should be tried first when other methods fail to relieve your pain, but they may not be effective if your pain is severe or has been present a long time. Avoid acetaminophen long term because it can cause liver problems.

Step 8: Take Prescription Amitriptyline or Trazodone

For some people, low-dose antidepressants, such as amitriptyline (Elavil) 25mg to 50mg daily or trazodone (Desyrel) 50mg to 150mg daily, can decrease chronic pain through effects on the pain center (hypothalamus) and neurotransmitters in the brain. Your doctor can prescribe them if the previous steps don’t help you, but it may take four to six weeks for your pain to decrease.

Step 9: Take a Prescription NSAID

For continued pain, your doctor can prescribe nonsteroidal anti-inflammatory drugs (NSAIDs), such as Naprosyn, Feldene, Daypro, Orudis, Mobic, Cataflam, Relafen, and Arthrotec. Prescription NSAIDs are more powerful than over-the-counter products, but they also have a higher risk of side effects, primarily stomach irritation and bleeding. If these side effects occur, NSAIDs known as Cox-2 inhibitors have less risk of stomach problems. However, they are more expensive and may increase your risk of heart attack if you already have heart disease, especially if you are also taking naproxen (Aleve). All NSAIDs are equally effective, although one may work better for you than another. You may need to try several (ask your doctor for samples), and it can take three weeks or longer for any of these drugs to decrease your pain.

Step 10: Take Tramadol, Propoxyphene, or Narcotic Prescription Pain Relievers

If prescription NSAIDs fail to relieve your pain, a stronger pain reliever may be necessary, However, these drugs do have side effects, can be addictive, and can cause your pain to continue. You should use them only if the other methods are not effective and your pain prevents you from engaging in your usual activities. Your doctor may first prescribe tramadol (Ultram), which is a non-narcotic and so has less addiction potential. The next option may be propoxyphene, which has an addictive potential, although less than codeine-containing narcotics. However, taking more than six to eight per day can have harmful effects (to kidney and liver) when used long-term.

Next are codeine-containing drugs, which range in potency from Tylenol with codeine (Tylenol 3) to hydrocodone (Lortab) to oxycodone (Percodan, OxyContin), These drugs can cause stomach irritation and constipation when used long term, and they are highly addictive. You may be able to decrease your dosage of these narcotics by taking acetaminophen (Tylenol) or ibuprofen with them or between doses. Highly potent narcotics (morphine, Demerol) should be reserved for the worst cases. Some pain medications (kappa opiates) are far more effective in relieving pain in women than in men. There are several devices, including the morphine pump, which can allow easy control of pain for people who require potent narcotics.

For medication management of chronic pain, I highly recommend that you be evaluated and treated by a physiatrist, a specialist in medical pain management, especially if controlling your pain requires more potent pain medications.

Step 11: Enter a Multidisciplinary Pain Program

For chronic pain that continues, I recommend entering a multidisciplinary pain program. Although such programs are not designed to reduce pain specifically, they do improve functional and back-to-work ability, and they teach you how to cope better with your pain. Treatment in these programs includes evaluation and treatment by pain-management specialists, physical and occupational therapists, and psychologists or psychiatrists.

Step 12: Enter a Drug Addiction Treatment Program If Addicted to Narcotic Pain Relievers

Unfortunately, many people with chronic pain become addicted to medications they take for pain relief. Pain medications, especially narcotics, can actually cause an increase of your pain perception through their effect on the brain, making you feel more pain, not less. Reducing the amount of medication you take can often reduce your pain, but this can produce psychological difficulties and physical withdrawal. If you are dependent on or addicted to pain medication, I recommend that you enter a drug addiction treatment program.