There’s a lot we don’t know about chronic pain, loosely defined as any pain lasting longer than 12 weeks. Because its causes are still being studied, and because the opioid crisis has motivated more cautious use of pain medication, clinicians don’t always see eye to eye on the best treatment approach. In the meantime, people who have chronic pain confront uncertainty inside the exam room and cultural stigmatization outside of it.
To learn more about chronic pain, and what people get wrong about it, we talked to five pain specialists. Here’s what they said are the biggest misconceptions about the condition.
Family medicine, University of Utah Community Physicians Group, Salt Lake City
There are a lot of misconceptions concerning what chronic pain is and the best way to treat it. The first misconception is that chronic pain is the same as acute pain but it just lasts longer. Acute pain is usually due to tissue injury (e.g., a broken bone, a cut, crushed soft tissues, etc). Chronic pain, on the other hand, is pain that persists despite very little or no ongoing tissue injury. While the mechanism of acute pain is pretty well understood, the way in which chronic pain arises is still being worked out. It is thought that there is some kind of rewiring of the central nervous system that creates the impression of pain (the very real impression!) despite the lack of signals from the tissues indicating that tissue damage is happening.
The implications of this first misconception for treatment are significant. There is pretty good evidence that medications are effective for acute pain. These medications might include acetaminophen and non-steroidal anti-inflammatory medications (NSAIDs, or medications like ibuprofen); opioids can be used for the most severe pain (e.g., Norco, Percocet, etc). But there is much less support in the medical literature for long-term effectiveness of these medications, and especially for opioids, in treatment of chronic pain. Most clinicians have had patients who have done very well with opioids for their chronic pain. But many more end up on higher and higher doses of opioids despite still having pain. It is worth noting that many kinds of chronic musculoskeletal pain can be relieved with non-medication options such as physical therapy and spinal manipulation. There is a lot of emerging support for mindfulness in the treatment of chronic pain.
Another misconception is that all chronic pain is the same. There are actually several varieties of chronic pain: musculoskeletal (affecting bones, joints and muscles), neuropathic pain (nerve-like pain) and cancer pain. There are different kinds of treatments for different kinds of chronic pain. For example, in treating osteoarthritis, a common kind of musculoskeletal pain, physical therapy to strengthen the muscles around the affected joint and cautious use of acetaminophen or NSAIDs are probably most effective. Diabetic neuropathy, on the other hand, is a neuropathic kind of pain caused by damage to nerves from diabetes. This is best treated by blood-sugar control and medications that target nerve pain such as the serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine and venlafaxine), gabapentin and the tricyclic antidepressants (e.g. amitriptyline). Cancer pain often requires opioids for effective pain relief.
More and more, clinicians are focusing on preserving function as a primary target of chronic pain treatment. Getting a pain score down sounds great, but if the pain still limits a person’s ability to function, there is still a problem to be addressed.
Therapist, Lyn-Lake Psychotherapy and Wellness, Minneapolis
MS, CRC, LPC
One common misconception about chronic pain is that pain is “bad” or indicates that something is wrong. Pain is actually a necessary function of our central nervous system. It usually protects us, warns us and gives us valuable feedback about what is happening. But sometimes these signals are complicated, and the CNS misfires. The experience of pain is complex and is not only impacted by physical stimuli. It is also affected by cognition, mood, beliefs and genetics. Similarly, pain in a certain part of the body does not always mean that something is wrong in that part of the body. Chronic pain does not always provide reliable information about illness or injury.
There’s also the misconception that if someone is receiving psychotherapy or counseling services, then the pain must be “in their head.” As a therapist, I see frequently how chronic pain can create a vicious psychological and physical cycle. For example, people avoid activity that causes pain and become progressively deconditioned. But less movement causes more pain, so people continue to increase their level of avoidance. Eventually, they have lost all of the things that they value, and their chronic pain condition is the same or worse. It is the same with psychological responses. People in chronic pain experience anger, anxiety, fear and distress, which contributes to a compromised mood and, ultimately, depression. Studies show that depression is a significant contributor to increased perceptions of pain. A psychotherapist can help unravel all of that.
Finally, there’s a perception that if a doctor cannot find the “cause” of the pain, that it must not be real. Pain is whatever the experiencing person says it is, and occurs when said person says it does. It is real and multidimensional; people do not want to be in pain.
Family medicine, University Medicine Associates, and associate medical director, UHS Ambulatory Rehab Services, San Antonio
Some healthcare providers believe that, in the wake of the opioid epidemic and in this new era of much-tightened regulations, instead of wasting time in screening patients for abuse or doing my due diligence, it’s easier to stop prescribing controlled substances as much as possible and leave them either to patients’ primary care providers or pain clinics. These providers assume that the majority of, if not all, patients are either pain-medication seekers or drug traffickers, and it’s not worth their time to weed them out from their practice or formulate alternate multimodal pain management strategies for them. These misconceptions and reactive approaches may [divert] those abusive patients from their practices, but unfortunately, the patients with genuine pain and compliance with prescribed instructions will suffer.
On the other hand, similar misconceptions among patients about their chronic pain and HCP [high-impact chronic pain] don’t help it either. The majority of patients believes that their doctors are insensitive to their pain. Some patients believe that there is no other option outside prescription medication and are reluctant to explore alternate means such as physical therapy or exercise, massage, hydrotherapy or counseling. Even worse, some chronic pain patients falsely conclude that they are stuck with their pain for life and there is no life with pain for them. Understandably enough, these misconceptions among patients will further widen the gap and disconnect between them and their provider, helping no one in the game.
This bitter state of chronic pain management in our country calls for a more comprehensive evaluation offering a more holistic, multimodal management plan by the provider, as well as better participation and compliance by the patients, with an open mind toward various options and willingness to try more than pain medications. This can be achieved only through better communication and care coordination, to balance needs and resources for the optimal care that our patients deserve.
Clinical director, Yorkville Sports Medicine Clinic, Toronto
CSCS, FCE, D.C.
People often think that in order to feel pain, there has to be some definite finding, either discovered in imaging or another type of test. The truth is, people are all different and experience pain differently. There is a common misconception that people who suffer from chronic pain are exaggerating or have an ulterior motive, which is absolutely ridiculous.
Pain is a hard thing to measure. It comes and goes as it pleases, and the result is that patients just have to find a way to manage it the best they can. Just because someone said their pain is improved doesn’t mean it may not bother them months or even years down the road. Chronic pain especially has such an impact on a person’s life that they change many of their daily habits.
Chronic pain is something that is hard to understand from the outside. Many people have loved ones who have been suffering from it for years, and although it’s easy to normalize their situation, it’s important to remember to provide support whenever needed. There will be better days ahead.
Stephanie G. Vanterpool
Director of comprehensive pain services, University of Tennessee Medical Center, and assistant professor of anesthesiology, University of Tennessee Graduate School of Medicine, Knoxville, TN
I think that one of the biggest misconceptions about chronic pain is that it must be treated with an opioid in order to get any relief. The thing to remember about opioids is that they don’t actually treat the source of the pain, but rather just cover up the pain. The underlying cause of pain is still there, and if the cause is not treated, the pain will continue and possibly get worse. Using an opioid to treat pain is like covering up a bleeding stab wound with just a Band-Aid. If you don’t stop the bleeding, you’ll need a bigger and bigger Band-Aid!
That’s why [my program], Targeted Pain Treatment, is such a game changer for so many patients. Targeted Pain Treatment is the process of accurately diagnosing the cause of pain and then targeting the treatment to the cause. By working with your provider to accurately identify the cause(s) of your pain, we can come up with a treatment plan that treats those specific causes. We then can use a combination of targeted medications, injections, physical therapy and even psychosocial treatment, if needed, to treat the cause of the pain. The end result is that you get true relief from pain, and reduce or even eliminate the need for opioid medications, while at the same time improving your function and quality of life.
Responses have been condensed and lightly edited.