Chronic pain: what is it, treatment, management

We all experience pain. From spraining your ankle during a basketball game to waking up with a headache, pain is simply a part of life. It’s also important as sudden pain can alert you that something is wrong. Chronic pain, however, is different.  

In many cases, chronic pain continues well after an injury has healed—at least three to six months—, and sometimes there’s no apparent physical source of the pain at all. This is not to say chronic pain is “in your head,” but persistent pain affects our emotions and the very chemical makeup of the brain.

Let’s look at what healthcare providers define as chronic pain, its causes, and what the medical community uses to treat it. 

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Medical experts divide pain into three types (Armstrong, 2021):

• Nociceptive: An injury triggers nerves to signal to the brain that you are hurt.

• Inflammatory: Immune cells flood damaged tissue in an attempt to heal it.

• Neuropathic: The nervous system itself is damaged, such as with diabetes, a stroke, or a brain injury, causing what’s called neuropathy.

When pain first strikes, it’s called acute pain. But when pain recurs or lasts for more than three to six months or lasts longer than the typical healing time, it’s considered chronic (Treede, 2015). 

Around 20% of people suffer from chronic pain. It can have different causes and can involve a mix of the different types of pain listed above (Treede, 2015; Freynhagen, 2019).

Chronic pain is sometimes a relatively straightforward symptom of an underlying health condition or injury. But in many cases, it is the main source of a person’s complaint—frequent headaches or back pain are two of many examples—with no easy-to-identify cause (Treede, 2019). 

How long chronic pain lasts and how intense it is depends on much more than the injury or illness that might be the cause of it. Persistent pain can change our brain chemistry in ways that make it more likely to become chronic. A person’s physical and mental status, social situation, and even emotions can all play a role (Mills, 2019). 

While chronic pain is not imagined, the brain and the rest of the central nervous system, including the spinal cord, develop perceptions of pain that go beyond what a person should feel based on their physical condition. 

For example, brain-scan research shows that people with a smaller hippocampus and amygdala, areas of the brain related to stress and anxiety, are more likely to develop chronic pain and that these brain differences are at least partly genetic (Vachon-Presseau, 2016).

Additional studies show that people with a lot of anxiety are more likely to develop chronic pain than people who are optimistic, less sensitive to loss, or who are better at mindfulness—being present in the moment and accepting of what comes their way (Vachon-Presseau, 2019). There is also a link between catastrophizing, a tendency to expect the worst outcomes, and the development of chronic pain (Petrini, 2020; Vachon-Presseau, 2019).

Stress can make chronic pain worse or even be the source of chronic pain. One study shows a link between financial stress in midlife and a risk of chronic pain 30 years later (Wickrama, 2021).

Finally, older adults are in some cases more susceptible to the onset of chronic pain, in part because some health problems that cause pain, such as arthritis and many diseases, become more likely (NIH, 2018). 

The list of underlying drivers of chronic pain is nearly endless. Here are just a few of the most common causes (Mills, 2019; NIH, 2018):

• Stress, anxiety, depression, and other negative emotions

• Back injuries or misalignments

• Other injuries

• Arthritis

• Nerve damage

• Cancer (both cancer pain itself and pain caused by treatment)

• Irritable bowel syndrome

• Fibromyalgia

• Headaches or migraines

• Endometriosis

• Surgery

Among the proven ways to deal with chronic pain are lifestyle changes and psychological approaches. There are various things a person can consider, though it’s important to work with a healthcare professional to find the right mix of solutions for your condition. Generally, the treatment of chronic pain should always include non-pharmacological approaches to pain management (Tauben, 2021)

Physical activity

In the past, medical advice for dealing with chronic pain often boiled down to medication and rest. But science has since shown that exercise is linked to improved quality of life in people with chronic pain. (Geneen, 2017). 

One study of 139 women, for example, found that exercise improved their physical function and lessened their pain catastrophizing, which includes feeling helpless in the context of pain (Sato, 2021). A broader study of survey data on 36,625 students links exercise to lower levels of chronic pain. (Grasdalsmoen, 2020). Scientists caution, however, that many of the studies are small, or they reveal links but not necessarily cause-and-effect.

Sleep

Lack of sleep can amplify any pain you might have. After just one bad night’s sleep, the part of your brain that senses pain gets amped up, while the area of the brain that releases pain-fighting dopamine underperforms (Krause, 2019).

Mindfulness meditation and cognitive behavioral therapy

Mindfulness and mindfulness meditation can reduce pain, according to two separate reviews of research on the technique (Hilton, 2017; Creswell, 2019). Mindfulness is thought to work by reducing anxiety and, more broadly, helping people take control of how they think about bad things. Separately, positive thinking has been shown to reduce the perception of pain (Finan, 2015).

Another remedy, typically done with the help of a professional guide, is cognitive-behavioral therapy (CBT). The therapy comes in many forms but involves helping you recognize your thoughts and expectations and develop strategies to replace negative emotions and behaviors with helpful and positive thoughts and actions. 

CBT is the preferred type of psychosocial treatment for chronic pain, and it’s meant to complement other physical and medical treatments (Gatchel, 2014). In one study, people with chronic low back pain participated in CBT or another therapy called “mindfulness-based stress reduction.” After 26 weeks, both groups had less back pain and a greater ability to function than a control group that received usual care (Cherkin, 2016).

There are also many complementary therapies and treatments that are generally considered safe and can be effective, but may not, on their own, be as effective as a more comprehensive approach with a healthcare provider or pain specialist (NIH, 2018):

• Acupuncture

• Physical therapy

• Massage therapy

• Hypnosis

• Music therapy

Pain medication can be vital for acute pain, but with chronic pain, treatment options are much more complicated, and you should reach out to your healthcare provider before trying any prescription or over-the-counter drug (Tauben, 2021). 

Here are some examples of the various medications healthcare providers use to treat people with chronic pain:

• Over-the-counter painkillers: Healthcare providers do not recommend acetaminophen for chronic back pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can reduce inflammation, but ibuprofen is minimally effective for chronic pain (Tauben, 2021).

• Opioids: Opioids were once a go-to medication for all manner of pain relief, but one of the side effects of opioids is that they are highly addictive, so healthcare providers have grown more cautious about prescribing them. They still sometimes prescribe them for those who don’t respond to other treatments for chronic pain, but in low doses and only if they will improve quality of life (Tauben, 2021). 

• Antidepressants: When other drugs don’t help, healthcare providers sometimes prescribe antidepressants to treat chronic pain. But there’s no conclusive evidence that they work for chronic back pain, and it remains an open question if they’re helpful for osteoarthritis (Ferreira, 2021).

Whether pain medicine actually works on chronic pain can be really hard to figure out, given the placebo effect, which can cause a treatment to work because a person hopes or thinks it will. In one study, people with chronic back pain were given either a painkiller or a placebo. Half of the people who got the placebo reported as much pain relief as those who got the painkiller (Vachon-Presseau, 2018).

Living with chronic pain can be frustrating and can affect your mental health. But know that several lifestyle changes might lessen your pain or at least your perception of it, and pain specialists can help you figure out a basket of approaches to reduce or eliminate the pain and, at the very least, improve your quality of life.

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Current version

November 05, 2021

Written by

Robert Roy Britt

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.