• Dr Shawn M. Carney

Shining A Light on Pain Management: Don’t Miss the Pain Paradigm Shift!

Updated: Aug 1

Naturopathic physicians are able to offer physical medicine and natural treatment options for pain that don’t have the undesirable side effects commonly heard about with pharmaceutical treatments. And since new research published just this year found that early prolonged treatment for acute pain with steroids or NSAIDs has a higher risk of transitioning into chronic pain persistence, these are important alternatives to consider.



Discontent and Drawbacks from Conventional Pain Management

Naturopathic physicians are often sought out by patients who are frustrated with the superficial quality of care they receive from conventional medical doctors; those seeking pain relief are no exception. Perhaps even more discouraging are the well-established side effects for pain management treatments which range from gastrointestinal bleeding1 or liver toxicity2 to immunosuppression3, osteoporosis3 and even addiction4, depending on the type of pain being treated and type of medication used. Steroids, for example, have so many side effects that during the COVID-19 pandemic their use has come with an elevated level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids possible, resulting in the term "steroid distancing".5


As a naturopathic physician, our clinic has been able to offer physical medicine management options that don’t have these undesirable side effects commonly heard about and actually move a person closer to healing, instead of just suppressing inflammation. And since new research published just this year found that early prolonged treatment for acute pain with steroids or NSAIDs has a higher risk of ultimately transitioning into chronic pain persistence, these options are more important than ever to know about.6


Types of Pain

Pain can be classified in different ways; clinically, pain conditions are often described as either nociceptive or non-nociceptive and by duration as either acute or chronic.7 'Nociceptive pain' is caused from normal tissue injury like a crushed finger or burned forearm and can be caused mechanically or thermally. This type of pain can also be either organ derived, or 'visceral', as well as 'somatic', which relates to the body. 'Non-nociceptive' pain is often considered either psychogenic or neuropathic, which itself can be further subdivided into categories from where it originates, as either peripherally or centrally. Referred pain is transmitted from one part of the body to another, often of visceral origin and the region experiencing the pain is supplied by the same spinal segment, allowing for impulses from many local and superficial or visceral neurons to converge.


Of course any of these sub-categories can be additionally considered from a temporal standpoint as mentioned above, which is an important point because duration of the condition and interventions used requires consideration for many conventional medications due to the severity of their side effects.


Acupuncture

Acupuncture has been well established as effective pain relief with evidence showing applications for acute as well as chronic conditions and our scientific understanding of its efficacy continues to grow. The evidence has been so substantial that back in 2002 the World Health Organization (WHO) Consultation on Acupuncture concluded a review of over 200 clinical trials and deemed acupuncture as effective for 28 diseases and beneficial for 63 others, though not all of these were pain-related issues.8 Acute pain conditions which have shown benefits to acupuncture include post-operative pain, acute back pain, labor pain, primary dysmenorrhea, tension-type headaches and migraines.9 With regard to chronic pain, acupuncture has provided relief for low back pain, knee osteoarthritis, headache, shoulder pain, and neck pain.9


Studies on the mechanisms of action for acupuncture have revealed that endogenous opioid peptides in the central nervous system (CNS) play a key role in mediating the analgesic, or pain relieving, effect and that different kinds of neuropeptides are released by electroacupuncture performed using different frequencies.10 Acupuncture has also been shown not only to increase desired signal markers but also to decrease over-expressions of the pain peptide substance P in dorsal horn of spinal cord.11,12 Other acupuncture-induced analgesic effects in the CNS include neurotransmissions of serotonin, norepinephrine, orexin and endocannabinoids; however, it also reduces cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2) peripherally, stimulating opioid release in this other area as well.9


Low Level Laser Therapy

Though not nearly as old as acupuncture, low level laser therapy (LLLT) has been used clinically for over fifty years. With regard to light therapy, both light absorption and scattering in tissue are wavelength dependent, and tissue containing melanin has exponentially high absorption bands at wavelengths shorter than 600nm.13 Thus the preferred treatment for use in animals and patients almost exclusively involves red and near-IR light (600–1070nm).


LLLT, also called ‘cold laser therapy’, is a type of photobiostimulation. It acts on the mitochondria in the cell to increase adenosine triphosphate (ATP) production, modulate reactive oxygen species, and induce transcription factors, including nuclear-factor kappa B (NF-kB), that can then itself increase transcription of many gene products associated with known beneficial effects of LLLT.14 “For instance anti-apoptotic and prosurvival proteins, proteins involved in cellular proliferation and migration and increased collagen synthesis and myofibroblast differentiation respond to NF-kB activation”.14 The net effect is to cause protein synthesis, thereby modulating the levels of cytokines, growth factors and inflammatory mediators and increasing tissue oxygenation.12


These are some of the ways by which LLLT is believed to be an effective method for relieving acute and chronic pain. LLLT has been shown to be effective enough to receive Food and Drug Administration (FDA) approval for several health concerns including acute and chronic muscle and joint pain of the neck, back and shoulder while increasing range of motion, hand and wrist pain associated with carpal tunnel syndrome, stiffness associated with osteoarthritis, wound healing, acne and male pattern hair loss. Even a recent study this year found that use of LLLT over acupoints significantly reduced post-operative pain and the need for morphine!12


By way of safety, “LLLT has no reported adverse effects, and no reports of adverse events can be directly attributed to laser or light therapy”,15 with the notable exception of potentiating tumor cells, as they could respond to many of the stimulatory effects as well as other tissues do.16,17


The Paradigm Shift for Acute Pain Management

An intriguing study published earlier this year in the journal Science Translational Medicine and mentioned above explored some of the immunology around management of low back pain (LBP) and what differed among people and animals that progressed into a chronic state of pain instead of those whom had to pain dissipate acutely.6 They found that some level of immune system activation was important for the long-term pain relief and this was reinforced multiple ways by the team of researches using clinical as well as animal data. This type of immune system activity is hindered by many common pain medications. Their work involved human transcriptomics, which is the study of ribonucleic acid (RNA) and its actions in a cell, and their findings included that neutrophil activation–dependent inflammatory genes were up-regulated in subjects with resolved pain, whereas no changes were observed in patients with persistent pain. These findings were then replicated among people with temporomandibular disorders (TMD). Furthermore, among rodents, dexamethasone, a corticosteroid that suppresses inflammation, treatments were ultimately shown to prolong pain duration and this effect was abolished later by neutrophil administration. Lastly, they reviewed clinical data and showed that the use of anti-inflammatory drugs was associated with increased risk of persistent pain, suggesting that anti-inflammatory treatments might have negative effects on pain duration.


If these findings hold up in clinical trials, it could revolutionize the mainstream approach to acute pain, moving from a focus on suppression to one of more comprehensive healing, which is something naturopathy has long been known for.


References:

1. Huang ES, Strate LL, Ho WW, Lee SS, Chan AT. Long-term use of aspirin and the risk of gastrointestinal bleeding. Am J Med. 2011;124(5):426-433. doi:10.1016/j.amjmed.2010.12.022.

2. Bessone F. Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?. World J Gastroenterol. 2010;16(45):5651-5661. doi:10.3748/wjg.v16.i45.5651.

3. Coutinho AE, Chapman KE. The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Mol Cell Endocrinol. 2011;335(1):2-13. doi:10.1016/j.mce.2010.04.005

4. Klimas J, Gorfinkel L, Fairbairn N, et al. Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain: A Systematic Review. JAMA Netw Open. 2019;2(5):e193365. Published 2019 May 3. doi:10.1001/jamanetworkopen.2019.3365

5. Manchikanti L, Kosanovic R, Vanaparthy R, et al. Steroid Distancing in Interventional Pain Management During COVID-19 and Beyond: Safe, Effective and Practical Approach. Pain Physician. 2020;23(4S):S319-S350.

6. Parisien M, Lima LV, Dagostino C, et al. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022;14(644):eabj9954. doi:10.1126/scitranslmed.abj9954.

7. McCance, K. and Huether, S. Pathophysiology: The Biologic Basis for Disease in Adults and Children 5th ed. St. Louis, Missouri: Elsevier Mosby; 2006.

8. Zhang, X. Acupuncture: Review and Analysis of Controlled Clinical Trials. Geneva, Switzerland: World Health Organization; 2003.

9. Lin JG, Kotha P, Chen YH. Understandings of acupuncture application and mechanisms. Am J Transl Res. 2022;14(3):1469-1481. Published 2022 Mar 15.

10. Han JS. Acupuncture and endorphins. Neurosci Lett. 2004;361(1-3):258-261. doi:10.1016/j.neulet.2003.12.019.

11. Lee HJ, Lee JH, Lee EO, et al. Substance P and beta endorphin mediate electroacupuncture induced analgesic activity in mouse cancer pain model. Acupunct Electrother Res. 2009;34(1-2):27-40. doi:10.3727/036012909803861095.

12. Huang CH, Yeh ML, Chen FP, Wu D. Low-level laser acupuncture reduces postoperative pain and morphine consumption in older patients with total knee arthroplasty: A randomized placebo-controlled trial [published online ahead of print, 2022 Apr 9]. J Integr Med. 2022;S2095-4964(22)00048-6. doi:10.1016/j.joim.2022.04.002.

13. Ou-Yang H, Stamatas G, Kollias N. Spectral responses of melanin to ultraviolet A irradiation. J Invest Dermatol. 2004;122(2):492-496. doi:10.1046/j.0022-202X.2004.22247.x

14. Chen AC, Arany PR, Huang YY, et al. Low-level laser therapy activates NF-kB via generation of reactive oxygen species in mouse embryonic fibroblasts. PLoS One. 2011;6(7):e22453. doi:10.1371/journal.pone.0022453.

15. Hashmi JT, Huang YY, Osmani BZ, Sharma SK, Naeser MA, Hamblin MR. Role of low-level laser therapy in neurorehabilitation. PM R. 2010;2(12 Suppl 2):S292-S305. doi:10.1016/j.pmrj.2010.10.013.

16. Bamps M, Dok R, Nuyts S. Low-Level Laser Therapy Stimulates Proliferation in Head and Neck Squamous Cell Carcinoma Cells. Front Oncol. 2018;8:343. Published 2018 Aug 28. doi:10.3389/fonc.2018.00343.

17. Frigo L, Luppi JS, Favero GM, et al. The effect of low-level laser irradiation (In-Ga-Al-AsP - 660 nm) on melanoma in vitro and in vivo. BMC Cancer. 2009;9:404. Published 2009 Nov 20. doi:10.1186/1471-2407-9-404.


The content and any recommendations in this article are for informational purposes only. They are not intended to replace the advice of the reader's own licensed healthcare professional or physician and are not intended to be taken as direct diagnostic or treatment directives. Any treatments described in this article may have known and unknown side effects and/or health hazards. Each reader is solely responsible for his or her own healthcare choices and decisions. The author advises the reader to discuss these ideas with a licensed naturopathic physician.