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treating chronic pain

Treating Chronic Pain

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The number of patients diagnosed with chronic pain conditions continues to rise in the United States, topping 51 million in 2021. 1

Chronic pain is defined as pain that lasts for more than 3 months, a time frame that under normal circumstances should accommodate the body’s normal healing process. But when the body doesn’t respond how we expect it to, lives can quickly be interrupted, and for many, it can be life-shattering.

Chronic pain is treatable and there are many effective options available, so why are millions of people being left behind?

One of the biggest challenges in diagnosing and managing chronic pain is the fact that providers have to rely almost exclusively on the individual’s description of their pain and the disability it causes. Pain is subjective – there is no biomarker, blood test, or imaging study that can objectively detect the presence and severity of pain.

However, research that looks at the way our brains and nervous systems initiate and sustain severe chronic pain continues to point to the same conclusion – that chronic pain, in and of itself, is not the problem to be treated. Instead, chronic pain should be seen as a symptom of an underlying medical problem, and it is to this underlying problem that treatment must be targeted.

Specifically, chronic pain is a symptom of inflammation in the brain, or what I call “a brain on fire”. This inflammation is triggered by the body’s own immune system, which is designed to respond to any kind of assault. For example, physical injury, infections (such as Lyme disease or COVID-19), exposure to environmental toxins, concussions, celiac disease, loss of oxygen to the brain caused by sleep apnea, and even long-term emotional trauma, can set off an inflammatory response in the brain and central nervous system. Identifying the source(s) of inflammation is critical to breaking the cycle of chronic pain; and frequently, the sources are multiple, compounding, and cumulative.

To accurately diagnose and treat the causes of neuroinflammation that manifest as chronic pain, providers must:

  • Take a comprehensive medical history of each individual.
  • Work to correctly identify and treat the underlying root cause(s) of chronic pain.
  • Educate people about their relationship with chronic pain. Like all relationships, how this is managed can make life substantially better or worse.

Pain Management Programs

Intensive pain management programs can be an extremely important tool in helping patients manage their pain and live a better life. They typically involve a treatment schedule that spans several weeks, during which time attendees are typically seen by a team of healthcare providers with a variety of specialties. Although programs vary somewhat from one to another, each is likely to include:

  • Initial consultation with a provider who has pain management experience.
  • Specialized lab tests.
  • Nutritional intervention, including anti-inflammatory elimination diets and consultations with nutrition experts.
  • Behavioral health techniques, such as meditation and relaxation therapies.
  • Acupuncture.
  • Movement therapies, such as yoga (especially restorative yoga and yogic philosophy training), and physical therapy, including core strengthening and biomechanics.

The goal of this type of intense programming with an emphasis on education is to help individuals think differently about their pain while providing them with new tools to manage their pain and re-engage in their lives. Additionally, if the programs are designed to approach pain as a symptom of an underlying medical condition and the treatment aims to resolve the root cause of the pain, there is a very good possibility that the pain will go away.

The Bottom Line

  1. Chronic pain is not a disease but a symptom.
  2. The way we treat pain now has, for the most part, been a costly, abysmal failure. Opioids are the most pressing issue but there are also serious concerns about the number of unsuccessful and unnecessary procedures (surgeries in particular) and the proliferation of the use of dorsal column stimulators (implanted electronic devices placed near the spinal cord to treat chronic pain), and the overutilization of spinal blocks (injections of anesthetic into the spine). The research evidence for these approaches for the treatment of chronic pain ranges from fair to poor. 2,3,4,5
  3. Behavioral health programs have some of the strongest data and the greatest success in treating chronic pain conditions. And, more importantly, when these programs are not successful, they don’t make the situation worse (unlike surgery and other invasive procedures).

What Needs to Happen

Individuals suffering from chronic pain must, in every single case, be offered a comprehensive workup with an individualized treatment approach.

We need to continue with research into the causes of inflammation in the brain, while also working on developing a treatment for brain inflammation that leads to chronic pain. We also need to develop testing that will provide us with an objective indicator of the chronic pain/underlying disease and its response to treatment.

In the interim, we should focus on improving the lives of our patients by using targeted therapies that address the biology of the pain, rather than its symptoms; anything short of this is like putting a Band-Aid on a bullet hole.

–Dr. Gary Kaplan

Sources:

1. Rikard SM, Strahan AE, Schmit KM, Guy GP Jr.. Chronic Pain Among Adults — United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72:379–385. DOI: http://dx.doi.org/10.15585/mmwr.mm7215a1.

2. PMID: 24308846
3. PMID: 25840040
4. PMID: 26824399
5. PMCID: PMC3777049

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This article was originally published in September 2016. It was reviewed and updated in September 2023.

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Is Depression Ever Just Depression?

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A modified model for understanding depression and anxiety ought to involve a whole person, integrative approach.

Public acts of violence seem to fill the news media streams these days and are typically followed by outcries for greater access to mental health care for those that need it most. And although almost all individuals with serious mental illness are not dangerous, many of the perpetrators of these heinous crimes later turn out to have a documented history of depression or mental illness, which often went untreated.

So, what can we do to stop the anguish? What is it that we are missing?

The Cost of Failure

Unfortunately, the number of Americans affected by serious depression and anxiety disorders is enormous, as are the costs to society due to failure to treat and/or treatment failure. Tens of millions of Americans suffer from depression, including chronic, low-grade depression (dysthymia) and anxiety. 21 million of those Americans have been diagnosed with major depressive disorder (MDD), the leading cause of disability for people ages 15 to 44.

The cost of failing to effectively treat these conditions is not just the individual’s inability to complete college, hold a job or cultivate positive relationships; it also includes the toll taken on an entire family and community when a despairing person takes their own life. And in other cases, the costs of acts of public violence – in terms of suffering, municipal expenses, personal medical and legal expenses, and lost human potential – are immeasurable.

Michael, a 17-year-old high school student, came to see me with a long history of hospitalizations after attempting to take his own life. Despite undergoing intensive psychiatric treatment, he remained depressed and suicidal. Like 40 percent of those who suffer from major depressive disorder, Michael was not responding to treatment.

When contemplating a situation like Michael’s, the question “What am I missing?” is never far from my mind. Statistics show that only about one-third of patients with MDD respond to antidepressant medication, with about the same number responding to psychotherapy alone. If we combine the two approaches the numbers improve slightly, but the fact remains that most people with MDD respond only partially to medical interventions, with almost half remaining entirely unresponsive.

A Central Nervous System in Turmoil

There is a mountain of scientific research demonstrating that neuropsychiatric conditions such as depression, anxiety disorders, and possibly bipolar disease are, in a very high percentage of cases, the result of inflammation occurring in the brain.

There is a great deal of research linking generalized inflammation to heart disease, chronic pain, and obesity. Inflammation in the body takes many forms: When we have an allergic response to pollen or food, our bodies’ inflammatory response includes the release of histamine, which makes our eyes itch and noses run; we see the inflammation associated with a skin wound when the white cells of our immune system respond to a bacterial infection. Inflammation in our brains, however, is unique in that it is mediated by tiny cells called microglia.

Microglia are the innate immune system of the central nervous system (CNS). Their job is to respond to trauma and damage to the brain. In response to brain injury, the microglia release a virtual symphony of chemical mediators that orchestrate the destruction of bacterial invaders, the elimination of damaged neuronal tissue, and the initiation of the repair process.

After responding to an assault on the brain, microglia typically return to a resting state. But ongoing and cumulative assaults to the brain will cause the microglia to remain chronically up-regulated, causing them to continuously spew out inflammatory, tissue-destroying chemicals. Examples of ongoing assaults include fever, physical assault, and emotional trauma. It can also be infections like Lyme disease or COVID-19.

Since the beginning of the COVID-19 pandemic, researchers have been studying how the SARS-CoV-2 virus affects the CNS as well as other body systems. What they are finding out is that it too heightens the activity of microglia leading to the release of inflammatory cytokines and a sequence of damaging events that can affect the brain and have other long-term effects on health.

Brain inflammation can produce a wide range of symptoms including depression, anxiety, chronic pain, difficulty focusing and concentrating, fatigue, and sleep disturbances.

Further compounding the issue is the fact that a solid understanding of the role of microglia in brain health is sadly lacking among most medical professionals, with the result that they continue to treat what are in fact “symptoms” as separate and unique “diseases.”

Looking Beyond the Symptoms

A better framework, where physicians look beyond the symptoms, involves giving priority to the discovery of the root causes of an individual’s depression or anxiety. This primarily requires an understanding of what caused the microglia to up-regulate.

Research has shown that anything that can damage neuronal tissue can be a trigger. So, an exploration of a patient’s depression may include asking them about possible traumatic head injuries, psychological traumas (acute events and chronic stress), infections (as mentioned above, tick-borne diseases, other bacteria, and viruses like Covid-19), and even biotoxins that may have entered the body from exposure to toxic molds, celiac disease, and hypoxia (usually related to sleep apnea). The list of triggers is long, and as such, the process of identifying the possible underlying causes of the disease requires putting together a thorough medical health timeline for each patient. By using this approach, treatment options expand due to the greater understanding of the origin of the illness, thereby increasing prospects for recovery.

As for Michael, my 17-year-old patient who was depressed and suicidal, it turned out that he has celiac disease. But how could a food allergy be related to his depression? Celiac disease is far more than an allergy to gluten – it is a very serious autoimmune disorder that’s triggered when even the smallest amount of gluten is ingested. As we know, with autoimmune disorders the immune system mistakenly attacks the body’s normal cells. In the case of celiac disease, when gluten is consumed the immune system goes into attack mode and causes damage to the healthy villi of the gut lining. Villi are responsible for absorbing nutrients and keeping food particles and toxins from entering the bloodstream. When the gut lining is compromised and toxins enter the bloodstream, widespread inflammation can occur, and this inflammatory response can affect more than the digestive system – it can cause inflammation in the brain. Research shows that people with celiac disease are at greater risk of neurological damage and mental health issues in addition to other serious chronic health conditions.

Michael, now gluten-free, is no longer depressed and he has re-engaged in life. He continued with antidepressant medications for a period of time, but slowly weaned himself from them under medical supervision (it takes time for the brain to heal after the assault is removed). His life has been changed, for the better, forever.

It is my hope that, with a modified model for understanding depression and anxiety, involving a “whole” person, integrative approach, more patients will be correctly diagnosed and treated, as Michael was. In his case, and I suspect in many more, we’re learning that all too often, depression is not just depression.

This article originally appeared in US News and World Reports, May 12, 2015. It was reviewed and updated in May 2023.

We are here for you, and we want to help.

Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2

Additional references

InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Depression: How effective are antidepressants? [Updated 2020 Jun 18]. 

Mohammadkhanizadeh A, Nikbakht F. Investigating the potential mechanisms of depression induced-by COVID-19 infection in patients. J Clin Neurosci. 2021 Sep;91:283-287. doi: 10.1016/j.jocn.2021.07.023. Epub 2021 Jul 20. PMID: 34373041; PMCID: PMC8289699.

Low-Dose Naltrexone: A Little Known, But Effective Treatment For Chronic Pain

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Low-dose naltrexone (LDN) is often confused with naltrexone, which is a pharmaceutical medication used in doses of 50 mg or more to treat alcohol and narcotic pain pill addiction or other opiate abuse. Low-dose naltrexone is a specially compounded capsule of 1.5 to 4.5 mg of naltrexone to help the body combat chronic illness states. It must be specially made by a reliable compounding pharmacist.

LDN acts by reducing inflammation in the brain caused by over-active microglia.

Microglia are a type of glial cell of the Central Nervous System (CNS) and an important line of defense. When there is an assault on the CNS, the microglia are activated and release inflammatory substances to destroy the foreign invaders. When the assault is over, the microglia go back to their normal resting state. However, when they react too often – from repeated injury, infection, toxins, traumas, or emotional blows – they can sometimes remain hyper-active keeping the brain in a chronic state of inflammation. Research on LDN suggests that it’s able to suppress the inflammatory response of the microglia.

Some of the inflammatory conditions that have shown to benefit from LDN include fibromyalgia, multiple sclerosis, Crohn’s disease, complex regional pain syndrome, and cancer.

You can read more about inflammation of the brain and central nervous system as a major component of pain and illness in Dr. Gary Kaplan’s book Total Recovery.

LDN also improves the body’s immune system by blocking opioid receptors.

This, in turn, boosts the body’s endogenous endorphins, our natural painkillers, and important regulators of cell growth.

You can read more about low-dose naltrexone for auto-immune disorders, and other illnesses at www.lowdosenaltrexone.org.

Because low-dose naltrexone interferes with opiates you cannot continue on narcotic pain medication.

Otherwise, it has virtually no side effects and is very well tolerated by most patients. Most people notice an increase in dreaming, and some people notice a bit of sleep disruption during the initial few days of treatment but this improves over time.

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Questions about LDN? Call and speak with a nurse today. Call 703-532-4892, ext. 2.

Patient Q&A on Low Dose Naltrexone:

Q: Does the Kaplan Center offer low-dose naltrexone treatment for fibromyalgia patients? I know of a number of patients with fibromyalgia, MS, and Hashimoto’s thyroiditis who claim to have seen improvement with LDN.

A: Yes, Low-dose naltrexone is a prescribed therapy for a variety of conditions that we treat here at The Kaplan Center. If you would like to learn more about low-dose naltrexone, call the office and schedule an appointment to discuss the possible benefits for your health condition.

Q: I am allergic to NSAIDS, so would I be allergic to this?

A: Low-dose naltrexone is not an NSAID (non-steroidal anti-inflammatory), therefore any allergy to such would not apply. The higher doses of naltrexone can rarely cause liver toxicity, depression, and somnolence, but the low dose naltrexone or LDN has fewer if any side effects in our experience.

Q: The standard dose appears to be 4.5 mg in almost all the information I can find. There are a few chronic pain MDs in the U.S. that seem to be using higher doses with success — a couple say to go up as high as 10 mg while another one is using it up to 4.5 mg 3xday with great success for those who do not respond to one dose of 4.5 mg. Do you have any thoughts on this? What I’ve read is that one should not give up on this medication if not getting benefits at 4.5 mg.

A: At a low dose, the side effects are minimal. Higher doses can cause sleep disturbances and may cause elevation of liver enzymes. Although I don’t usually go higher than 4.5 mg, most likely the doses you are talking about – 10-14 mg – are far from the 50 mg or higher dose that is used to block opioid overdose, and are therefore probably safe. I don’t see any research on the efficacy of using higher doses, however.

Q: I have read that Low-Dose Naltrexone (LDN) should not be taken by people who have had organ transplants. Does this include an artificial aortic heart valve? Also, does it affect INR levels? And should Warfarin dosage need to be readjusted?

A: The short answer is that low-dose naltrexone should not be taken by someone on immunosuppressant drugs because it boosts the immune system by stimulating the body’s own endorphins. There are no known interactions with Coumadin but it is always a good idea to check the INR more often when starting a new medication. Therefore if someone has a valve replacement, yet is not on an immunosuppressant, LDN should be safe.

We are here for you, and we want to help.

Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2

8 Reasons Your Pain Won’t Go Away

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by Julia Westbrook | As first seen on RodaleNews.com.

What you don’t know is hurting you.

Gary Kaplan, DO, author of Total Recovery and founder of The Kaplan Center for Integrative Medicine, recently held “office hours” during a Rodale News Facebook chat. One of only a handful of physicians in the country who is board-certified in Family Medicine and Pain Medicine, Dr. Kaplan was able to apply his pioneering perspective to help answer one of the most difficult questions plaguing our country: What is causing my pain? If you weren’t able to make the chat, we’ve pulled out 8 key takeaways to consider when you’re trying to figure out why your pain just won’t go away.

#1: Inflammation, part of the normal repair process, may have gone awry.

Cytokines are chemical messengers secreted by the body. They have effects ranging from inciting nerve repair to causing inflammation. In the case of chronic pain, we know that the microglia, which are the innate immune system in the central nervous system, are “stuck” in a mode where they continue to excrete predominantly inflammatory cytokines. Under normal circumstances, microglia will shift from producing inflammatory cytokines to making anti-inflammatory cytokines and call in other cells to initiate the normal repair process.

Balance is restored by eliminating all of the factors that caused the microglia to get turned on in the inflammatory state and then doing things such as meditation, exercise, getting adequate sleep, and using things such as low-dose naltrexone (LDN) and turmeric to get the microglia to go back to their resting state.

#2: Allergies can make your pain worse.

Anything that incites an inflammatory response in the body has the potential to spill over into the brain and worsen the inflammation in the central nervous system, as with fibromyalgia. The allergies are not the cause of the fibro, but something that is further aggravating it.

#3: Your diet can cause inflammation.

I would start by thoroughly looking at your diet and make sure there is nothing still in your diet causing inflammation. I saw one woman who is a vegan, and it turned out she was allergic to blueberries. For ongoing inflammation in the brain, turmeric may be helpful.

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#4: Your fatigue may be a symptom. Don’t ignore it.

Sleep is not a thing, but rather a series of different brain waves divided into stages 2, 3, 4, and REM. People who are deficient in 3 to 4 sleep will present with chronic pain. If you have sleep apnea, where you stop breathing at night, it can cause chronic pain. If you have restless leg syndrome, it can also cause chronic pain. A proper evaluation of the quality and amount of sleep is necessary for anyone suffering from chronic pain and depression.

#5: A migraine problem isn’t just in your head–it’s in your nervous system.

Dehydration, alcohol, bright lights are all triggers that can cause migraines. The underlying cause of the migraine is an irritated nervous system. The nervous system is irritated because of an underlying inflammatory condition in the brain. The key to preventing migraines is to identify what it is that’s causing the inflammation. I would start with an anti-inflammatory diet of rice, fish, chicken, fresh fruits, and vegetables.

#6: Overlapping problems can come from the same source.

  • Migraines and depression: Brain inflammation
    The basis of both migraines and depression is inflammation in the brain. I address this at length in my book, Total Recovery. Yes, the two are related and the cause of the inflammation needs to be identified.
  • Chronic pain and weight loss problems: Gut imbalance
    One of the reasons that you may not be able to lose weight might be related to either food allergies or sensitivities or mold toxicity. We know that the composition of the bacteria in your gut has a very significant effect on your ability to lose or maintain weight. Skinny people have different gut flora than people who are overweight. If you have other symptoms, it’s very likely you have a chronic inflammatory condition but the cause has not been discovered or addressed.

#7: The underlying root cause may still need to be identified.

  • Arthritis (…which isn’t always arthritis)
    Sometimes arthritis in knees and joints can be from Lyme disease, sometimes from rheumatoid arthritis, and sometimes from tendinitis. It can also be associated with food allergies and food sensitivities. The first issue is getting a clear diagnosis.
  • Complex regional pain syndrome
    Also known as CRPS, it is a horrific pain condition. I see a number of patients who suffer from CRPS, and the solution can, unfortunately, be elusive. Again, it’s important to try and understand what it is that has caused the nervous system to be so hyper-reactive. Get evaluated for Lyme disease and its co-infections, celiac disease, gluten intolerance, and neurotoxins associated with mold, along with a number of other conditions that I address in my book. I am familiar with Calmare therapy, and the research on it looks very exciting. While we do not do this therapy in our office, I have referred patients for this therapy. It is certainly worth the trial for anyone suffering from CRPS.
  • Tinnitus
    Tinnitus can be an extremely difficult problem to address and can be a result of multiple issues and not a single problem. Meditation and yoga are extremely effective in reducing inflammation, as is curcumin. You also need to identify the causes of the inflammation, such as the trace mineral imbalances, as well as eliminate anything that may be poisoning your system.

#8: Your body may be more responsive to alternative therapies.

We find that acupuncture can be extremely effective for a large number of pain conditions. But most commonly our treatments are layered, involving a number of therapeutic approaches, which work synergistically for a comprehensive solution. I also recommend meditation or yoga.

We are here for you, and we want to help.

Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2