Chronic pain is one of the most debilitating conditions we experience. We can’t exercise or sleep or focus. We may gain weight and become irritable, if not downright depressed. Yet the ability to perceive pain is vital to species survival and protects us by helping us detect injury and by initiating the body’s response to acute damage. Our longevity is made possible by the ability to heal, restoring traumatized tissue and calming inflammation. Unfortunately, this ability diminishes over time. When this healing capacity is disrupted, that can play a role in the development of chronic tissue degeneration and pain.

Acute and Chronic Pain

Sudden, immediate pain is a response to tissue trauma, detected in the tissues by nociceptors that can identify thermal, pressure, or chemical injury and transmit that information along ascending sensory nerves to the spinal column and the brain. An accurate diagnosis of the cause of the pain is critical because if recognized and diagnosed early on, that can prevent the development of chronic pain.

Treatment of acute pain. Pain control for acute pain generally involves a series of steps, including reduction of inflammation with ice and anti-inflammatory medications, interruption of pain signals with an anesthetic nerve block or cortisone injections, and stronger opioid pain medication, used in the short term to mask the pain, temporarily allowing some degree of increased mobility and activity.

Pain brain. In the case of repeated trauma, nerve damage, and/or chronic inflammation, the pain pathway can go awry, resulting in increased pain sensitivity, nerve inflammation, and the development of chronic neuropathic pain sometimes referred to as “pain brain.”

Unchecked chronic pain. In these disorders, multiple segments of the pain pathway have become dysfunctional or neuropathic, reflected in chronically swollen tissue, pain receptors that have become hypersensitive to pain, nerve endings that preferentially pass along pain signals, and central/brain processes leading to depression.

Incidence. Pain disorders increase as we age, with 7% of chronic pain sufferers between the ages of 18 and 24, growing to 22% between 45 and 64. From at least 65 on, 27% of the population is afflicted by chronic pain, which is an enormous economic burden costing over $500 billion (2010 US), including direct healthcare costs, and disability programs, as well as incalculable human cost.

Pain Syndromes

A detailed listing of all the causes of chronic pain and chronic pain syndromes is beyond this article’s scope. However, we can draw many commonalities from familiar pain syndromes, including lumbar disc degeneration and osteoarthritis.

Low back pain. Estimates of the prevalence of low back pain have ranged from 22% to 48%, with surveys that found 26% of respondents reported low back pain lasting at least one day in the last three months. Risk factors associated with back pain complaints include smoking, obesity, age, physically strenuous work, sedentary employment, psychologically strenuous work, workers’ compensation insurance, and job dissatisfaction. Psychological risk factors include anxiety, depression, and somatization disorder (stress and emotions expressed through the mind-body connection).

The most common diagnosis is non-specific low back pain. These are conditions in which no specific tissue injury can be diagnosed, but the underlying cause is likely to be a combination of muscle, disc, tendon, and/or ligament strain. The vast majority of patients will recover within two weeks with brief episodes of rest (but avoid bed rest), NSAIDs, and muscle relaxants. If sciatica is present, a short course of oral steroids may be appropriate and may provide relief.

If the pain persists beyond two to four weeks and is not improving, then medical evaluation is needed with possible referral for physical therapy, massage, and chiropractic treatment, as well as a review of imaging studies and pain management referral.

Disc pain. Nearly everyone experiences some level of lumbar pain from disc degeneration by the age of 40. Initial causes are usually related to repeated strains and overuse. There is emerging evidence that infection may also play a role in the development of lumbar disc degeneration. Younger men tend to suffer more from disc and vertebral joint inflammatory processes, whereas older men will suffer more from spinal stenosis (see Sidebar).

The lumbar spine has a normal aging process that accelerates as the disc loses cushioning:

• Tears occur in the disc’s outer annulus surface.
• Subsequent damage results in the inner disc nucleus.
• Ultimately this trauma induces loss of water content from the disc.
• The resiliency and cushioning of the disc are reduced.
• The disc then loses height.
• Vertebra may shift, and inflammation ensues.
• Nerves and spinal joints become inflamed, causing pain and/or spasms.
• Nerve compression can occur, resulting in sciatica and nerve injury.
• As the spine ages further, degenerative arthritis and bone spurs result.
• This narrows the spinal canal (spinal stenosis). which further compresses spinal nerves.

Osteoarthritis. This is a classic age-related disorder of the joints, a form of chronic degeneration. In osteoarthritis, degradation and loss of joint cartilage are central features of wear and tear on the joints. The prevalence of osteoarthritis increases from 10% at age 45 to 30% at age 60 and 50% by the age of 80.

Effects of aging. In all degenerative diseases, cell and tissue aging results in age-related loss of the ability to heal and repair cells. Those who have excess weight gain or joint misalignment will develop a maladaptive response to joint stress resulting in osteoarthritis.

Smoking as a trigger of chronic pain. Cigarette smoking is strongly associated with increased chronic pain, including low-back pain from lumbar disc degeneration. Less well known is the negative effect of cigarette toxins on immune response and tissue regeneration (due to carbon monoxide, nicotine, and other chemical additives), which weaken discs and joints, inhibit cell growth within the disc, cause localized constriction of blood vessels surrounding the lumbar disc, damage collagen production, and weaken the outer lining of the disc (the annulus).

Obesity as a factor in inflammation. Addressing obesity is key in preventing and treating chronic pain because excess weight contributes to chronic inflammation (increasing pro-inflammatory mediators such as tumor necrosis factor—TNF-alpha). We know that patients undergoing gastric bypass procedures have a measurable decrease in inflammatory markers within 12 months of surgery.

The links between stress, depression, and inflammation. Both stress and depression are common in people with chronic pain. There is considerable evidence that those with diagnosed depression have higher markers of pro-inflammatory mediators, suggesting a link between depression and inflammation: Vagal nerve tone is reduced, diminishing opportunities to reduce inflammation. This results in increased stress response, which dials down the relaxation response and slows cellular healing.

Lifestyle Strategies

Exercise. It may seem like common sense to exercise, thereby reducing the risks of cardio- vascular disease and obesity, improving metabolism, and strengthening the heart, muscles, and bones. Studies have also shown that as little as 20 minutes a day of exercise can reduce blood levels of pro-inflammatory chemicals, allowing the body to heal injured tissues more efficiently.

Breath work. The use of breathing techniques to improve the control and tone of the vagus nerve is a simple approach that can be practiced by anyone. As humans, we breathe up to 20,000 times per day, so we have ample opportunities to perfect this pain-relieving skill.

Mindfulness meditation. Functional MRI studies have found that mindfulness meditation rapidly increases the ability to tolerate pain. This has been demonstrated in research studies involving patients with no prior experience with meditation. Imaging studies have shown that meditation improves blood flow to critical brain areas involved in pain processing. Efforts at meditation can be supported by an app on the phone (such as The Headspace), books, podcasts on meditation, and HeartMath devices and software.

Anti-inflammatory diet. Dietary interventions to manipulate or optimize the gut flora (the microbiome) could play an increased role in inflammation control. The goal is a simple diet of anti-inflammatory foods, such as the Mediterranean diet, which is high in fresh fruits (berries and stone fruit such as cherries and peaches), vegetables and leafy greens, whole grains, healthy oils such as olive oil, nuts (almonds and walnuts), and fatty fish. These foods are rich in natural antioxidants, polyphenols, and other protective compounds that reduce inflammation. Coffee, which contains polyphenols and other anti-inflammatory compounds, can also reduce free radicals and protect against inflammation.

The gut-inflammation connection. Recent studies have focused on the role of the gut microbiome on osteoarthritis:

• We now have evidence of a genuine relationship between certain gut bacteria and low-grade inflammation in the knee (as well as arthritic knee pain, independent of obesity).
• Differences are also evident in the spine suggesting that certain gut flora may be more favorable in minimizing disc inflammation.
• It also suggests that disc infection may be one possible initiator of lumbar disc disease.

Foods to avoid. The goal is to find healthy substitutes for refined carbohydrates, fried foods (such as French fries), sodas, red meat, processed meat such as luncheon meat, margarine, and lard. By modifying the Western diet, it is possible to facilitate a healthier gut microbiome, cutting down on unhealthy fats and eating significantly more fiber-rich foods (such as fresh fruits and vegetables). Healthy lifestyle habits that promote a more diverse gut microbiome also include fermented foods such as sauerkraut and miso, probiotics, the avoidance of unnecessary antibiotics, reducing stress, and getting adequate sleep.

Medications

NSAIDS. Nonsteroidal anti-inflammatories are commonly used to treat acute and chronic inflammation pain. Diclofenac 150 mg/day has been reported in some studies as the most effective NSAID for pain relief for osteoarthritis or rheumatoid arthritis. The studies compared diclofenac with naproxen (1000 mg/day), ibuprofen (2400 mg/day), celecoxib (200 mg/day), and acetaminophen (4000 mg/day). Since side effects include renal and hepatic toxicity and gastrointestinal (GI) bleeding that can be potentially fatal, diclofenac is not available over the counter and physician-directed lab monitoring will be required periodically.

Over-the-counter NSAIDS such as 200 mg naproxen 1-2 capsules as needed every 12 hours may be preferable due to naproxen’s longer duration of action.

Antidepressants and anti-seizure medications. Gabapentin (Neurontin) and pregabalin (Lyrica) are prescribed for neuropathic pain. These medications work by reducing nerve transmission along the pain pathway of the central nervous system, but can cause side effects of drowsiness.

Topical preparations. These medications include topical Voltaren, lidocaine, capsaicin, and Traumeel to reduce pain of painful joints, the lumbar region, or smaller areas of inflammation. Diclofenac 1% in a topical formulation can be effective for smaller joints near the skin surface, such as those of the hands, elbows, and knees. Formulated as a gel, there is less systemic uptake, so the risk of toxicity is less when taken at the prescribed dosage.

Supplements and Botanicals

Meta-analysis of nutritional supplements for osteoarthritis (the knee, hip, or hand) reported pain reduction in the short term (less than three months). Clinically significant effects were reported for several supplements: L-carnitine (an amino acid), pycnogenol (an extract of the peeling of passion fruit), and collagen hydrolysate.

Note that, in the long-term, no supplement was found to have clinically significant effects on pain.

Magnesium deficiency. Insufficient levels of magnesium are often a major contributor to chronic low-grade inflammation, and a magnesium oxide supplement in a 500 mg dose has been shown to reduce inflammatory markers such as IL-6 (interleukin 6). Magnesium supplements have also been shown to improve endurance in magnesium-deficient athletes.

Zinc. This critical mineral appears to support the immune system, while reducing several markers of inflammation.

Curcumin. The key ingredient of turmeric, curcumin has been shown to benefit inflammatory conditions and pain. It is a polyphenol that has antioxidant and anti-inflammatory effects. A typical dose is 400-600 mg, three times daily.

Frankincense. Studies have shown that frankincense (Boswellia serrata resin) can reduce both inflammation and pain and is a relatively fast-acting supplement that may help with osteoarthritis pain within as little as five days. The typical dosage is an extract containing 30% to 40% boswellic acids, 300–500 mg doses two to three times per day.

Curcumin and frankincense in combination. Using these two botanicals together increases potency, suggested in studies on patients with knee osteoarthritis. Patients sensitive to the gastrointestinal side effects of NSAIDs may tolerate this supplement combination better and still get meaningful pain relief.

Prescription Opioids

The use of opioids to treat chronic non-cancer pain is controversial due to limited evidence of long-term efficacy and the potential risk of serious harm. For patients with chronic non-cancer pain, opioids should only be used when non-opioid therapies have not provided sufficient pain relief, resulting in reduced function and/or compromised quality of life. In terms of decision-making, the potential benefits of opioid therapy should outweigh potential harms.

Risk factors. The use of opioids for pain relief requires additional levels of monitoring to assess medication misuse or abuse. Risk factors for misuse of opioids include a personal or family history of substance use disorder, younger age (less than 45 years of age), more severe pain, and/or co-occurring mental health disorders.

Complementary therapies. To minimize the amount of opioids required, opioids should be provided in tandem with nonopioid medication and physical treatments including acupuncture, chiropractic, and physical therapy. Treatment should be accompanied by improved physical functioning.

Alternative medications. A variety of medications are typically prescribed before a trial of opioids, including NSAIDs, and certain antidepressants (Cymbalta-duloxetine, Elavil-amitriptyline) or antiseizure medications (Gabapentin, Lyrica-pregabalin) to target neuropathic pain.

Intrathecal administration. For patients who require particularly large doses of opioids, resulting in intolerable side effects such as fatigue or drowsiness, implantable spinal delivery systems that provide intrathecal administration of opioids can be considered. Intrathecal analgesic therapy should be reserved for intractable severe pain with significant impact on quality of life that is resistant to all other appropriate treatments.

Newer formulations. Opioids that stimulate opioid kappa receptors in peripheral tissue (for example, kappa receptors in knee joints) and do not cross the blood-brain barrier may be more effective and safer than traditional opioid drugs and are currently in development.

Working with a Pain-Management Physician

Seek out a physician who is fellowship-trained and board-certified in pain medicine. Other credentials relevant to pain medicine include residency training in fields such as anesthesiology, neurology, physical medicine and rehabilitation, family medicine, psychiatry, or radiology.

A qualified pain management physician will be comfortable performing a number of different interventional procedures, including nerve blocks, joint injections, and spinal injections. They will be able to evaluate and treat a variety of acute and chronic pain problems, prescribe or optimize appropriate medications, and refer patients for physical therapy and rehabilitation. No single physician is an expert in every treatment and technique, so a qualified doctor should also know when to refer to other experts and subspecialty physicians.

Preparing for a visit. Patients should be prepared in advance to discuss their medical history and pain symptoms in detail:

• When the pain started
• Where it is located
• The quality, intensity, and timing of the pain
• The radiation pattern, if any
• Aggravating and alleviating factors.

Medical records. The patient should collect relevant imaging studies and have a list of treatments, surgeries, and medications tried thus far. Important considerations include the diagnosis, the prognosis, and appropriate treatment, starting with the most conservative options.

Assessing the physician’s expertise. The patient should make sure that the physician is highly skilled in performing any interventional treatments being offered. The patient should get an understanding of what needs to be done to optimize his health and lifestyle to prevent or minimize further pain episodes.

Pain Management Interventions

Injecting local anesthetics and cortisone. Injections, applied along nerve pathways, interrupt the pain signal, allow restored mobility, and can “reset” a dysfunctional pain pathway. Spinal injections include epidural and facet joint injections that reduce inflammation around compressed spinal nerves and joints due to herniated discs, vertebral degeneration, or spinal stenosis.

Nerve blocks. These are relatively brief treatments that often take only a few minutes to perform. If specialized x-ray equipment is involved and a number of nerves are being injected, the procedure usually takes 10 to 15 minutes. X-rays are usually taken using a fluoroscope, which creates a live image with different viewing angles. Imaging makes the injection process much safer and faster. Most nerve blocks and injections are not overly painful and can be performed in an office setting with just a local anesthetic. However, some spinal injections are performed at a surgery center with light intravenous sedation combined with local anesthetic for patient comfort.

Pain relief should occur relatively quickly, even before you leave the office, because of the rapid onset of the local anesthetic. The addition of a steroid is designed to promote a longer-lasting anti-inflammatory effect on inflamed nerves and tissues.

Shockwave therapy. Treatment of greater trochanteric pain syndrome, patellar tendinopathy, and Achilles tendinopathy, as well as plantar fasciitis and calcific tendinopathy of the supraspinatus or Achilles tendon, with ESWL shockwave therapy can provide meaningful pain-relief. This is typically performed by a sports medicine doctor.

Minimally invasive surgical treatments. This type of treatment includes nerve ablation (with radiofrequency energy applied through a small needle) and neurostimulation (using small, implanted electrodes to minimize nerve transmission along the pain-pathway without causing weakness). Delivery of imperceptible electrical stimulation pulses at specific frequencies across the spinal cord can inhibit the pain circuitry responsible for the transmission of pain. This stimulation reduces the hyperactivity of neurons implicated in chronic pain. Spinal cord and peripheral nerve stimulation is used in a variety of pain syndromes, including persistent spinal or sciatic pain after failed spinal surgery, persistent nerve pain syndromes such as chronic regional pain syndrome (CRPS), extremity pain from ischemia, post-amputation pain, and other peripheral nerve pain syndromes.

Advancements in spinal neurostimulator technology and algorithms. High-frequency spinal stimulation can be provided at a level that is imperceptible yet offers substantial pain relief in a variety of chronic nerve pain conditions, including peripheral neuropathy and chronic spine and sciatic pain. This type of treatment also includes PRP (platelet rich plasma) injections to facilitate improved local tissue healing and remodeling and to promote nerve axon healing and recovery.

Implanted vagal nerve stimulators. Targeted vagal nerve stimulation (VNS) has been demonstrated to reduce pain. A decrease in severity of a variety of pain conditions has been documented in pelvic pain, visceral pain, headaches, chronic rheumatoid arthritis pain and inflammation, epilepsy, and depression.

The vagus nerve is the longest of the cranial nerves, extending from the brain to the abdomen. Many important autonomic functions in the brain and the body are affected by vagal function. Influencing the vagus nerve can normalize neurotransmitter levels, reduce inflammation levels, and regulate metabolism. While implantable vagus nerve stimulation (VNS) is an emerging technology, there are a number of commercially available non-invasive devices that externally stimulate the vagus nerve at the ear or at the neck. The mechanism of VNS pain relief points to anti-inflammatory effects working in conjunction with both central and peripheral pain pathways.

Radiofrequency energy. This type of treatment creates heat generated by radio waves, which can be directed through small needles to lesion sensory nerves, for example to the knee (genicular nerve ablation). Radiofrequency energy can also be applied to lesion areas of inflammation inside spinal discs and vertebral bodies (intradiscal nerve ablation and basivertebral nerve ablation).

Minimally invasive spinal surgery. Other surgical and radiographic advances have allowed the development of minimally invasive spinal surgery (MISS), which can be performed with 3D CT guidance, using small incisions and specialized techniques to minimize tissue disruption and promote rapid recovery.

Conclusion

Pain tolerance is an interesting area of study. The research involving experimental pain has found measurable differences in individual pain tolerance, apparently related to mutations in proteins responsible for opening sodium channels on nerve endings. Some patients may simply transmit pain signals much more readily than others. On the other end of the spectrum, certain mutations of the sodium channel gene SCN9A, for instance, results in the inability to perceive pain, termed congenital insensitivity to pain (CIP).

Chronic pain is extremely common, especially in midlife, and can lead to significant distress and lifestyle limitations. Lifestyle factors that minimize chronic inflammation and promote tissue healing and restoration are key in mitigating the risks of developing or worsening chronic pain. Emerging high-tech devices, medications, and lifestyle behavioral therapies focus on reducing chronic cellular inflammation. The continued development of the biology of longevity will hopefully allow for the means to prevent the development of chronic pain in the first place.

This article is excerpted from The 21^st Century Man, curated by Judson Brandeis, MD, reflecting emerging perspectives in men’s health, sexual healing, and rejuvenation medicine.