Effectively Treating Pain from Chronic Conditions

[TW: chronic pain and opioids]

[UPDATED with patient feedback]

For those who have painful chronic conditions, the extent of pain can prove debilitating for normal functioning. In this article, we will touch on two types of neuralgic pain and pain experienced by those with cancer and discuss some options for pain management. Patients Rising acknowledges that chronic pain patients have difficulty accessing pain management for a number of reasons. By normalizing conversations about pain management options we hope to improve the likelihood that the needs of chronic pain patients will be met.

Trigeminal Neuralgia

This chronic condition is characterized by intense sensations of pain on one side of the face that may be triggered by the slightest of stimulations, such as touching one’s face or brushing one’s teeth. This stabbing or electrical pain sensation may last for a few seconds in the early stages but may progress to several minutes as the condition progresses.

More common among women, and frequently observed in those over 50, this progressive condition can be managed with medications, injections, or surgery. Here are some common pain management options that your doctor will prescribe:

Oral medications: Medicines that control seizures (anticonvulsants) are typically prescribed:
- Carbamazepine
- Oxcarbazepine
- Lamotrigine
- Valproate and phenytoin
- Clonazepam
- Topiramate
- Pregabalin
- Gabapentin

Some of these medications may require regular monitoring of your white cell count, platelets, sodium levels, and liver function. Your physician may need to adjust the dose to find an ideal balance between pain relief and minimal side effects.

Injections: Nerve block injections may be needed in some patients. This is a steroid that is injected in various parts of the nerve to reduce pain. The procedure may last about 30 minutes and you can go home the same day. While the length of pain relief may vary from one patient to another, a series of injections may be needed for long-term pain relief.
Surgery: Surgery may be needed for those who do not respond to medications or whose condition worsens with time. The type of procedure will depend on various factors such as the person’s age, overall health, and pain level. The options are:
- Microvascular decompression
- Gamma knife/brain stereotactic radiosurgery
- Rhizotomy
  - Glycerol injection
  - Balloon compression
  - Radiofrequency thermal lesioning

Detailed information on these various techniques can be found here.

Occipital Neuralgia

This is another headache disorder. The occipital nerve runs through the scalp and that’s where the sharp, stinging, or burning pain is typically felt. It may result from a pinched nerve or muscle tightness. Occipital neuralgia may be triggered in those who suffer from:

Degenerative disk disease
Diabetes
Gout
Osteoarthritis of your upper spine
Vasculitis/inflamed blood vessel

Treatment to manage the associated pain is similar to trigeminal neuralgia and may include:

Non-surgical options include heat to the affected area, massage, nerve block injections, or Botox injection
Medications such as anticonvulsants, muscle relaxants, or non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or diclofenac)
Surgical options such as occipital nerve stimulation or spinal cord stimulation

Cancer

Pain felt by patients with cancer can vary from localized pain at the site of their tumor to pain in other areas of the body if the cancer has spread. Intensity of the pain will also vary among individuals. Patients may also experience pain associated with their treatment: chemotherapy, radiation, or surgery.

A combination of medicines can help relieve pain:

NSAIDs like aspirin and ibuprofen for mild-to-moderate pain
Opioids such as morphine, hydromorphone, oxycodone, codeine, etc. for moderate to severe pain
Antidepressants or anticonvulsants for tingling and burning pain
Steroids such as dexamethasone or prednisone for pain caused by swelling

Non-medicinal options can be combined for pain relief, such as breathing exercises, hot/cold packs, TENS machine, etc.

Need for Caution Around Opioid Use

Use of opioids can be dangerous because of the risk of overdose and death. Overdose-related deaths have been steadily rising over the years and the annual rate of death nearly doubled from 2015 (52,404) to 2020 (91,799) for both prescription and illicit opioids—men and women combined. While the rate held steady over the years for women, there was a sharp rise in death among men. Synthetic opioids (other than methadone) were identified as the biggest culprit for the significant increase in death, along with psychostimulants like methamphetamine.

If we tease out prescription opioids from the above statistics, deaths from these drugs saw an increase from 1999 (about 3,000) to 2008 (about 13,000) and have since then remained somewhat steady—16,416 in 2020.

Additional Resources

The VA has developed a useful pain management guide
Treatments to Relieve Chronic Pain
Chronic Pain Patients: What to do when you can’t get care
Standing up for those in chronic pain

NOTE FROM THE EDITOR:

I’d like to thank the patients who reached out to us about this article, sharing your thoughts. Patients Rising is always on the side of the patient, always. While this article discusses pain and pain management, using examples and generalizations – deliberate because our target audience for this article was primarily new-pain patients looking to understand options – we are keenly aware of how sensitive a topic chronic pain is.

feedback from patients on this article

Patients – on first and second lines of treatment

Regarding Trigeminal Neuralgia and Occipital Neuralgia: “It’s important to note that 60-70% of patients will experience relief from first line medications (typically anticonvulsants) however, breakthrough pain may occur. This pain is typically treated using low dose opioid therapy. Low dosages are used to leave room to safely titrate to higher dosages, if necessary.

“The treatment of chronic pain, just like treating any other condition, is not one-size-fits all. What works for some may be contraindicated for others. While surgery and injections can be helpful in some cases, it can also lead to a worsening of pain in some patients. Some patients also may have an intolerance to certain medicines (i.e. NSAIDS or steroids) so it is important to be vocal about your concerns and specific needs.

“Always document your side effects, symptoms, and pain levels. Studies have shown intrathecal pumps to be a viable treatment method for patients whose pain did not respond to or was exacerbated by surgical interventions or other invasive means. Intrathecal Pumps allow for medications to be distributed directly to the spinal fluid for maximum impact, and in lower dosages. They can also be utilized to deliver other types of medications for targeted treatment of various different chronic conditions ranging from MS to chronic migraines.” – trigeminal neuralgia patient

Patients – on the need for caution with opioids

“While it is important to imbue a sense of caution to those who are new to opioid therapy, it also needs to be said that opioid therapy can be done safely and effectively. Safety stems from open and honest communications between patient and prescriber. But that also is much more difficult to achieve when we are living in times that treat chronic pain patients like addicts who are “drug seeking”, when in reality they are desperate for relief. We need to remove the fear from the exam room, so patients can communicate their needs effectively and without fear of judgement, and physicians can monitor and treat their patients the way they should be.” – chronic pain patient

resources for different types of pain support

Patients Rising will always be listening for what you have to say. As we revisit this article I direct you to read Additional Resources #3 and #4 above, which stand very clearly in full support of patients living with chronic pain and the many injustices they have had to face. – Jim Sliney Jr

Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.