Chronic pain is hard to treat — as profound an understatement as I can imagine. Like cancer, pain is not one thing. Nothing works for everyone or in every situation, and perversely even short-term success often leads to long-term failure.1 Pain is so deeply integrated into our biology that it is nearly impossible to stop without numbing the person at the same time — which is why the only true analgesia is anaesthesia.
Fixing the cause of the pain is the ultimate treatment, like Androcles removing the thorn from a lion’s paw. Unfortunately, the metaphor of the thorn only applies to some cases of chronic pain. It is startling and terrible how often no “thorn” can be found, and how many more can be found but not removed.
What then for the rest of us?
The problem is immense. As of the early 21st Century, what are the best solutions for the most common problems? What is the most evidence-based and plausible? What actually works for well-defined groups of suffering people?
Since 2001, I have worked to debunk the pseudoscience and quackery that dominates the options for pain patients. I have been very “negative.” Since 2015, I have ironically been a chronic pain patient myself, seeking answers as desperately as any of my readers over the years. This page is a long overdue optimistic collection of what definitely works.
It’s not a long enough list, obviously — especially if I exclude (as I will) quite a few experimental therapies and speculative strategies that truly are “worth a shot” due to their lower costs and risks and high plausibility (see Pain & Injury Survival Tips). This article is not about what might work for a few people, it’s about what definitely works for many people. Though never everyone, and always with caveats.
The search for obscure “thorns”
Nothing beats actually identifying a treatable problem that is causing the pain. My favourite simple example is my friend with intractable back and hip pain who was finally completely cured by the removal of a small tumour from a nerve root — after years of wrong theories, failed therapy, and escalating misery. One day it was just over, because the tumour was identified by looking in the right place with the right kind of technology. “Well, there’s your problem.”
The single best thing that modern medicine has to offer to anyone with unexplained chronic pain is a deep catalogue of hard-to-diagnose pathologies that cause pain. Not all of them can be treated, but many can. The search for such a diagnosis remains the single best hope for many chronic pain patients. The failure to find a thorn — a persistent source of nociception (noxious stimuli) — even after many years, does not mean it isn’t there.
This isn’t a “treatment,” per se, and it barely even counts as a strategy. You can’t even go to one doctor to hunt a tricky diagnosis, because there is no such thing as an specialist in all possible causes of pain. And medicine undoubtedly has much more to learn. But! There is far more relevant knowledge out there today than there was a hundred or even thirty years ago. It is legitimate cause for hope.
To help you get started on the search, I have compiled a fairly large list of diverse examples of surprising causes of pain.
Opioids are the “nuclear option” in pharmacological analgesia — and perhaps the ultimate perfect example of something that works especially well in a specific context only. They are ideal for dying people, because their grim side effects cannot threaten people who won’t exist in a few weeks or months. The existence of this option is one of the least appreciated greatest hits of modern medicine, arguably as big a deal as anaesthesia, vaccination, antibiotics, and so on. For the dying, it’s a really big deal.
For everyone else? It’s more complicated, problematic, and fiercely controversial. But opioids are also extremely effective for many not-dying-yet chronic pain patients, for whom the risks are very much the lesser of evils. The demonization of opioids has disastrously limited access for many patients who truly can benefit from them, and also stigmatized them.
There’s a ton of bad news about opioids too — not just the addiction problem, but the disturbing truth that they aren’t as universally potent as we’d like to thing. They can be surprisingly ineffective for some people and for some kinds of chronic pain.
Over-the-counter analgesics work
For every chronic pain patient who sneers at this option — and they do! — there’s another one who has no idea what they would do without it. My own father has had impressively good results treating rheumatoid arthritis with naproxen (though not, of course, without side effects). The OTC pain-killers absolutely can work quite well for many conditions — and in some cases they are even amazingly safe (most notably acetaminophen, if you stick to recommended dosages).
The over-the-counter analgesics mostly work by inhibiting various aspects of inflammatory signalling, in contrast to the narcotics which alter perception of pain regardless of how it’s being produced. So in general they can only do so much. But they definitely do some.
The prostaglandin inhibition of the NSAIDs is particularly effective for preventing one of the worst pain plagues suffered by humans: menstrual cramping (another fine example of something truly effective for a very specific context, but also an extremely common one).
Another modern standout is topical diclofenac, one of the NSAIDs. Taking it orally is madness, rife with serious side effects. But in tiny doses absorbed through the skin, right where it’s needed? chef’s kiss A truly good option for many, many kinds of pain.
Counterstimulation works (not much, but a little bit for a lot of people)
Counterstimulation is a basic neurological mechanism for minor temporary pain relief, a sensory “distraction” from pain. It’s not a potent thing, but it is a real thing, and it is probably responsible for the modest efficacy of many, many pain treatments that supposedly work some other way, but actually work this way.
You could call it another tool for the pain treatment toolbox, but it’s not an impressive tool — maybe just like a small screwdriver or a tack hammer.
It’s also why many kinds of chronic pain can and probably should be routinely treated with all manner of minor sensory pleasures and self-grooming: routinely, cheaply, and slightly fighting pain with other sensations, from the “spicyness” of a hot lotion, to the pleasure of hot tub jets, to squirming around on a foam roller.
It will never work any miracles, but it will also never stop being at least a little bit useful for many people.
Exercise and fitness work
It has been said that exercise is the closest thing there is to a miracle cure. What makes exercise such a wonder drug? For those who can do it, exercise provides both short-term pain relief and long-term, widespread health benefits that are both inherently analgesic and also support recovery from most injuries and many ailments. It’s also nearly infallible, if you are persistent and sensible about not overdoing it.
The big “but” is that quite a few people with chronic pain are also exercise intolerant, and simply cannot exercise enough to reap the rewards. Fibromyalgia patients are highly variable in their response to exercise, ranging from “very helpful if cautious” to “backfires almost every time,” probably because they have a wide variety of underlying conditions driving similar-ish symptoms.
But for many, many people with chronic pain, exercise works because it is biologically “normalizing,” pushing systems to work the way they are supposed to work. Biology is all about clever homeostatic mechanisms that nudge tissue state back to average. Those systems all rely on negative feedback loops based on molecular signalling (hormonal, neurological, etc), and exercise produces a lot of stimulation … raw “data” to feed to those loops. It’s not a universal principle, and exercise cannot normalize everything. But it does stimulate an incredible array of adaptive and homeostatic mechanisms — way more than any medicine, supplement, or superfood.
Increased fitness is probably the ultimate way to reduce systemic vulnerability to pain, through the mechanism of reduced systemic inflammation. Poor fitness correlates strongly with an array of disease risks which are mostly all about chronic, subtle systemic inflammation. Fitness is the antidote.
Progressive loading works
A lot of chronic pain is caused by failure of recovery from tissue overload — repetitive strain injury — usually because the source of tissue stress is never reduced enough. Basically, people just keep or re-injuring themselves. Poor “load management.”
The body can recover from almost anything if you give damaged tissue an adequate rest and then slowly give it more functional challenges, starting very easy and working your way back up (“progressive training”). Baby steps almost never fails to bring a person back to normal. If it does fail, it’s usually because the problem isn’t actually that tissue was overloaded to begin with.
This is a basic principle of rehab that has no direct evidence, because the strategy is too complex to meaningfully test, but it is supported by powerful “circumstantial” evidence and high biological plausibility. In my opinion, it doesn’t get enough credit because of a strong culture of excessively aggressive rehab strategies that routinely doesn’t allow enough recovery time to be successful. When done methodically, and carefully avoiding overload, it’s highly effective.
Drugs for neuropathy
Neuropathy is a malfunction of the nervous system itself: pain caused by dysfunction of the pain system. Many drugs that tinker with neurological function, often suppressing it in some way, are helpful for some of these patients. However, it generally takes rather a lot of experimentation to find the right drug — something that works well enough, with tolerable side effects.
Arguably, we do not have effective enough drug therapy for neuropathy to put it on any list of “what works for pain,” and some of the drugs generally touted as efficacious for neuropathy probably don’t deserve their reputation. However, it’s equally clear that drug therapy does work well enough for some patients that the world would be a much more desperate place without it. It’s far from a silver bullet for neuropathy, but a lot of people have been saved by just the right drug.
Neurostimulation with implants, especially spinal cord stimulation
The modern era of electrical therapy began when deep brain stimulation was introduced in 1987, and it’s been steadily improving since then, mostly thanks to better surgical techniques, but also with much greater understanding of the neurology of pain. In just the last decade, I think it has improved enough to qualify for this list.
There are many types of neurostimulation, but I’m referring mainly to spinal cord stimulation (SCS). Peripheral nerve stimulation is much too mediocre, and brain stimulation — while extremely promising — is not quite ready for prime time.
Any invasive treatment has major risks, of course, and it’s generally only a good option for specific kinds of patient with particularly great need. But SCS can be almost miraculous for many patients. Interestingly, it’s largely based on counterstimulation (discussed above) — the “potency” is just much, much higher than you can get from any superficial stimulation.
Pain relief in the future
There are two areas of major promise in the future of exciting, high-tech pain medicine:
- Deep brain stimulation. We already have spinal cord stimulation and some brain stimulation that is at least somewhat effective (see above). But the future is bright for more advanced neurostimulation, as we push further into the mysteries of the brain, stimulating neural pathways with much greater precision. Consider a 2021 study that demonstrated substantial pain relief with a mini-computer implanted in rat brains, modulating pain in real time, as needed.2 Amazing, and quite likely to help people in time. (And there’s also a substantial what-could-possibly-go-wrong factor as well.34)
- Regenerative medicine. Genuine regenerative medicine is legitimately promising, and someday it may effectively cure many painful pathologies and injuries that we can’t do anything about today — cure in the same way that vitamin C cures scurvy, pulling pain out by the roots on a large scale for the first time in history. But for now it remains primitive… and a magnet for profiteering charlatans. The proliferation of bogus “stem cell clinics” is particularly appalling.
But the greatest potential in health care is always with the boring basics, and that applies as much to pain as any other medical issue. The “root causes” of most chronic pain go deep: poor health and inadequate care, which are in turn driven by poverty, social injustice, and dysfunctional institutions and governance. Improving these things is not a “pain treatment,” per se, but it’s as important to pain as sanitation is to public health. Systemic changes have by far the greatest potential to relieve pain… and, of course, they are also the least likely to actually happen. Because, as basic as these things are, they can only be produced by a more advanced and better-organized society: progress, the hardest thing there is.
Notes on notable exclusions
Some things will probably get added to the list above in time. But not many, and not these: several exclusions that many people will ask about if I don’t mention them.
- Acupuncture has been studied to death, with consistently negative or damned-with-faint-praise results in every higher quality study.
- Massage therapy has great untapped potential, but disappointing preliminary results for major specific indications like back pain and trigger points, and such a complex mess of confounding factors and mythology that it makes no sense to endorse it as an efficacious therapy.
- Chiropractic generally, and spinal manipulative therapy specifically, for many reasons.
- No, sorry, definitely not cannabis. The evidence on THC for pain is thoroughly discouraging, and the evidence on CBD barely exists.
- Psychotherapy in generally, represented mainly by cognitive behavioural therapy, has a major theory versus practice problem, and is thoroughly damned with faint praise.
- Lifestyle medicine, including and especially treatment for stress and anxiety, has the potential to reduce systemic vulnerability to many mechanisms of chronic pain. It has extremely high general plausibility, but it is extremely messy and virtually untestable and thus too experimental. I extracted one critical element for the list above: exercise and fitness.
- Meditation, mindfulness, and yoga are just underwhelming on average. Fine for a few people who particularly like their “vibe,” annoying and disappointing for many.
- Low-dose naxolone is very interesting, certainly seems to work for some folks with chronic widespread pain, but not exactly a solid option yet.
- Regeneration therapies in general, but most notably autologous chondrocyte implantation and platelet-rich plasma. Regeneration therapies may get there someday, but these are weak early options that haven’t panned out.
- Several popular and seemingly promising but particularly disappointing options:
There are, of course, many many more that I could mention. But these are the ones that people are most likely to believe should have made the cut.
Is there something you think should have made the cut, but you don’t see anywhere on this page? Feel free to ask.
What’s new in this article?
Jul 8, 2021 — New section: “Pain relief in the future.”
June — Publication.
- I am referring specifically to the paradox of downregulation of opiate receptors. Any artificial stimulation of the firing of inhibitory nerve pathways — one of the most potent ways to relieve pain — also desensitizes those pathways, crippling them for your future self.
- Zhang Q, Hu S, Talay R, et al. A prototype closed-loop brain-machine interface for the study and treatment of pain. Nat Biomed Eng. 2021 Jun. PubMed #34155354 ❐
This study advances the science of brain-machine interfaces with a test of an implanted computer chip in rat brains, designed to treat chronic pain. The chip reads the rat’s minds: it detects patterns of brain activity in the cingulate gyrus that are consistent with pain, and then stimulates part of the frontal lobe to mute pain: specifically, to “exert top-down nociceptive regulation.” Obviously this is very invasive, and even if it works there’s a risk of adaptation and dependence, and human applications are many years off.
Doing this for humans is probably still many years away. But if it works? It’s extremely precise, responding in real-time, only working when there’s pain to treat — completely unlike the continuous, always-zapping approach that has dominated the field so far.
And it really did work amazingly well. The treated rats withdrew from painful stimuli about 40% slower, and greatly preferred spending time in a chamber where the implant was functional to one where it wasn’t. These were strong results, and a very promising demonstration of the principle.
This kind of approach is likely to improve as we continue to improve brain-machine interface technology, and knowledge of brain circuity gets more precise.
See neurologist Dr. Steve Novella’s more detailed explanation of this experiment.
Science fiction is full of cautionary tales about a brain interface tech that is still decades away (if ever). Yes, you might get used as a battery by our robot overlords. Meanwhile, back in the early to mid 21st Century…
The obvious problem with a technique like this is that it’s about as invasive as invasive can get — it’s a brain implant. There are going to be complications.
Technological glitches aren’t out of the question either. This is not a simple device. “Have you tried rebooting it?” is not what patients want to hear when they call tech support for their brain implant.
Here’s a less obvious and more interesting concern: this could cause adaptation and dependence just like opioids. Any time you overstimulate an inhibitory neurological function, there’s a chance that it will get a bit numbed to the input… and no one wants a pain inhibition system that isn’t working at full power. Understatement.
We know this phenomenon extremely well from opioid dependence, but the inexorable logic of “downregulation” applies to anything that tinkers with nerves to kill pain. Pick a pathway that inhibits pain, any pathway, give it a boost with some kind of artificial stimulation, and gosh darn it if it doesn’t start downregulating and become less responsive to natural stimulation… et voila, you become either dependent on the artificial stimulation, or seriously sensitized without it.
But “it’s complicated,” of course. This will just have to be studied over time to find out if that happens.