Chronic Pain and Acupuncture

Chronic Pain and Opioids #

In the last decade, the number of people living with chronic pain has shown a constant and steady rise. The use of pain killers, sick days (absence from work) along with increases in the number of operations performed are showing a painful reality.

The numbers from the NHS illustrate the harsh truth — 43% of British are living with chronic pain, with 11% of them reporting they are suffering severe or debilitating pain. [1,2]

Dr. Andreas Goebel, lead of the British Pain Society’s Research Day’s Organizing Committee, said: “Chronic pain affects a vast number of people in the UK, it is often destructive to peoples’ lives”. The British Pain Society published an article on the 7.3.2018 stating: “Patients with many long-term medical conditions put ‘Pain Relief’ at the TOP of their Priority list!” [3]

When discussing pain, we need to first understand what the definition is. “Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain’s location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain”. [4] Sometimes the brain’s interpretation of pain is not accurate making it hard to stop, intensifying without further damage and at times seeming to appear for no obvious reason.[5]

Persistent = Chronic #

Nowadays clinicians and therapists refer to pain that is longer than 12 weeks (not related or connected to the initial injury/problem, sensitised, often resistant to medications) as persistent pain rather than chronic, the use of ‘chronic’ terminology has a negative influence on the patients perspective (turning the problem/injury to something they need to embrace and live with) to the point it can impair their recovery and rehab progress.

Past Vs Present #

In the past the quick ‘fix’, easy and supposedly cheap way to address this matter was prescribing pain killers.

As the pain persisted and intensified, the prescriptions increased both in quantity and strength, often making them worse than the initial problem, with side-effects ranging from nausea & dizziness to diarrhea and impaired concentration, often becoming addictive in the process.

Opioids are being prescribed across the UK in growing numbers; 75% more in the last decade, from 14 million prescriptions in 2008 to 24 million prescriptions in 2018. [6]

Recently the medical establishment is waking up to the ugly truth — opioids are becoming a huge burden on the public expenditure with an estimated cost to the NHS of 10 billion pounds a year, while providing no solution to the problem of chronic pain or even assisting in effective management. [7] It is the largest and the most alarming silent epidemic the UK had suffered in decades.

Acupuncture as a Pain Relief #

However, not all is lost. More and more Doctors, Consultants and other Clinicians stress the importance of using a more holistic non pharmacologic approach, avoiding both the costs and the harsh side effects of opioid prescriptions.

Great news is emerging from NICE — The National Institute for Care and Excellence who are updating the Guidelines on ‘Chronic pain: assessment and management” and for the first-time placing the use of opioid pain killers at the bottom of the list and recommending exercise, acupuncture, and manual therapy before touching opioids. [8]

Indeed, it is a refreshing move towards a more conservative approach, backed up by strong, researched evidence, to tackle the chronic pain epidemic.

It has been shown in several studies that acupuncture (compare with ‘sham’ / inaccurate acupuncture and placebo or even no acupuncture) may help relieve, reduce and control pain and tension in several conditions.

The studies suggested that the stimulation by the acupuncture needle activates the inhibitory brainstem system and therefore blocks pain signals, along with the release of endogenous opioids and ATP, making the link between acupuncture and signaling mediated by neurotransmitters [9,10].

One study suggested (Grissa et al. 2016 effectiveness of acupuncture Vs morphine in the management of acute pain) a 24% increase in reduction of pain in favor of acupuncture and had a much faster pain recovery time [11]

Furthermore, the NCCIH, National Centre for Complementary and Integrative Health, and the World Health Organization (WHO) listed several conditions that acupuncture can help and has been proven effective [12,13]:

1. low back pain

2. neck pain

3. osteoarthritis

4. knee pain

5. headache and migraine

6. high and low blood pressure

7. painful periods

8. facial pain

9. rheumatoid arthritis

10. sprains

11. tennis elbow

12. sciatica

13. dental pain

Process and Origins #

Acupuncture originated thousands of years ago in ancient China, using all sorts of tools to achieve good health and wellbeing; what we call today, Traditional Chinese Medicine.

Acupuncture points are located on meridians, energy lines across the body – also known as ‘Qi’ or ‘Chi’. By inserting needles or even manually work on these points (Shiatzu — Japanese’s method replacing the needles with the ‘thumb and finger’). The therapist activates them causing a cascade of body-energy reactions — getting rid of energy (Qi) stasis or stagnation, increase blood and Qi flow to the affected area (‘organs’ in Chinses medicine literature), starting the healing process by bringing balanced flow of that energy (Qi).

Studies suggest that acupuncture stimulates the release of the body’s natural painkillers and affects areas in the brain involved in processing pain along with the stimulation of the afferent nerve fibre (nerves that are traveling into a nervous system structure). [14]

Throughout the years the methods and tools got more sophisticated and different approaches formed schools that specialized in treating different illness and conditions. Nowadays there is an array of different techniques, methods, and approaches to treat a certain problem.

My own clinical approach would be a combination of the ancient Chinese medicine wisdom (Qi, Meridians and energy flow) with a touch of western dry needling (targeting neuromuscular conditions to restore function, range of motion and reduce pain).

My protocol of acupuncture will usually consist of several methods:

Chinese medicine acupuncture points

By activating the points, the body is aspiring for balance. Areas that are considered stagnate are a source of illness and pain, causing discomfort and disharmony (locally and widely in the body) when opened with a healthy flow of energy the pain and illness can be controlled and managed.

Local points

Targeting certain muscle groups and joints regions to accelerate healing, by bringing fresh blood to the area helping the body’s natural ability to dispose of muscle waste and inflammation.

Triger/’Ashi’ (in Chinese medicine literature) points

Fighting pain with pain is a common method to desensitize the nervous system, decreasing the overwhelmed sensitivity of the peripheral and central nervous system.

Distal/Remote/Mirroring approach

At times, depending on the situation and severity of the pain/injury, I would use acupuncture on the opposite side or very distal from it, I would aspire to balance the other limb or region to avoid the body’s natural course of compensating causing at times more problems and pain.

What to expect? #

The therapist will examine the patient and assess their pain and limitations (location, reason, duration etc.) allowing them to establish a treatment plan. Once the therapist has established the protocol for treatment, they will insert several needles (thin, sterile needles) at various points of the body and monitor their effect.

The patient might feel a brief stinging or tingling sensation, although acupuncture is usually relatively painless. Sometimes the needles will be manually stimulated after insertion, to activate the nervous system and the meridians (the TCM points).

The needles will stay in place for anywhere from 5 to 30 minutes depending on the effect the clinician is aiming for. During this time, patients may feel sleepy and relaxed.

The number of treatments needed depends on the individual. Patients with persistent pain may require 1 – 2 treatments a week over several weeks, treatments will include a comprehensive overall plan:

Pain-Education — the source, reason and how to self-manage the day to day.
Exercise plan — maximizing the patient’s recovery process with either a Physiotherapist or a Strength and Conditioning Coach.
Second opinion/Consultation — a Consultant in Sport, Exercise & Musculoskeletal Medicine might refer the patient to further investigation to thoroughly understand the pain mechanism.

All while having a clear and open communication between the patient and Clinicians involved — from our multidisciplinary team (MDT) — to achieve the desired outcome.

If you are suffering from persistent pain, I would urge you to book an initial appointment with a member of our MDT team, in order to gain a greater understanding of your problem, experience a different approach as part of your overall management strategy and see what role acupuncture may play in helping you manage your pain, tension and stress.

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