A Broader Look at Pain Management: Use Four-Legged Approach for Patients With Chronic Pain

By Dr. Michael Leong

A shocking 73% of young adults (ages 18–34) say they are in pain every day, according to results of a new Harris Poll survey conducted on behalf of the Samueli Foundation—and 22% of that same age group report using cannabis products to treat their chronic pain.

I am concerned about such high levels of chronic pain among young people. In addition, while I’m hopeful that fewer young people are using opioids as a first line of treatment, I’m troubled that so many are turning to cannabis for relief, given that researchers characterize recent findings on the efficacy of cannabis products for chronic pain as “modest.” And I am saddened that three-quarters of young adults say they don’t know what kind of healthcare provider can best help them manage their pain.

Taken together, these findings suggest that physicians must do a much better job communicating the availability and benefits of multimodal approaches for pain relief—especially the “four legs” of pain management. Just as the legs of a chair support a stable surface for sitting, the four legs of pain management serve as an effective foundation for a patient’s treatment.

Physical functioning assessment

While many people associate anesthesiologists with controlling pain during and after surgery, we are also specialists in pain management. In my experience, the first leg of pain management, for both postoperative and chronic pain, is a physical assessment to complement the patient’s reported pain level. Since we all must move to stay healthy and well, a physical assessment helps the care team determine an individual’s level of mobility or impairment. This assessment helps determine the right treatment approach in both the short and long term.

Over-the-counter and prescribed medication

After surgery, medication coupled with postoperative anesthesia is a safe, effective way to control pain and expedite healing. Over-the-counter prescription drugs such as Tylenol® are helpful in alleviating chronic pain for many conditions, while prescription medicines like Lyrica® (pregabalin) and gabapentin are often used to treat nerve and muscle pain, including fibromyalgia.

Although prescription opioids are the only way to control some types of pain, they should never be the first line of defense. Instead, they are an option when combined with or used as a backup for the other three legs of pain management. Approximately 125,000 deaths per year in the United States are due to not taking prescribed medications as directed, and opioid addiction is a very real risk. Therefore, physicians who prescribe these medications must emphasize the importance of using them as directed.

Targeted injections

Trigger point injection (TPI) provides pain relief by loosening persistent knots of muscle. Physicians typically administer TPI to the arms, legs, lower back, and neck, and athletes commonly make use of TPI to reduce pain and tension. Radiofrequency ablation (RFA) is a minimally invasive procedure that uses an electric current to heat a small area of nerve tissue, thereby disabling the transmission of pain. RFA is 70%–80% effective and can provide lasting relief for patients. Targeted epidural injections are root nerve blocks that can provide temporary or lasting pain relief.

Mind-body connection

Managing chronic pain can be a heavy burden for patients, and up to 85% of patients experiencing chronic pain are also affected by chronic depression. For patients experiencing behavioral impacts of chronic pain, mind-body therapy can be an effective treatment option. This approach includes self-regulated deep breathing, meditation, and other relaxation techniques like yoga. Clinically based options in this vein include mindfulness-based stress reduction and cognitive behavioral therapy.

Using the four legs to provide a stable foundation, a comprehensive approach to pain management is the best way to address the care of patients experiencing this life-altering challenge. When these pieces come together, they can be helpful in improving all patients’ overall quality of life.

Michael Leong, MD, is the director of neuromodulation and a clinical professor at the Stanford Pain Management Center.