context: The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, there are a lot of approaches. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options. Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs ( NSAIDs) such as aspirin, ibuprofen, and naproxen. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, and additionally NSAIDs reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain and inflammation from sore muscles and arthritis. If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as diazepam [ Valium]), antidepressants (like duloxetine [ Cymbalta] for musculoskeletal pain), prescription NSAIDs such as celecoxib ( Celebrex), or a short course of stronger painkillers (such as codeine, fentanyl [ Duragesic, Actiq], oxycodone and acetominophen ( Percocet, Roxicet, Tylox) or hydrocodone and acetominophen ( Lorcet, Lortab, and Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation. An epidural might be given for spinal stenosis or lower back pain. In July 2015, the FDA asked that both prescription and over-the-counter NSAIDs strengthen their warning labels to indicate the potential risk of heart attacks and strokes. The risk increases with higher doses of the drugs. In addition, there is also the possibility of developing bleeding stomach ulcers. Patient-controlled analgesia ( PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self-administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain. Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you. Trigger point injection is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. During this procedure, a health care professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point (sterile salt water is sometimes injected). With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment. Onabotulinumtoxin A ( Botox) is a toxin that blocks signals from the nerves to the muscles. It can also be injected to alleviate chronic migraine headaches. The procedure involves multiple injections around the head and neck every 12 weeks and may alleviate pain for up to three months. When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. When they are used, which is rare, there are two main types of implants to control pain: Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines such as morphine or a muscle relaxant directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain. Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. This method being especially used for back and limb pain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Some devices cause what's described as a pleasant, tingling sensation while others do not. Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body. Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS, uses electrical stimulation to diminish pain. During the procedure, low-voltage electrical current is delivered through electrodes that are placed on the skin near the source of pain. The electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that "scramble" normal pain signals. TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, says the American Academy of Neurology ( AAN). Bioelectric therapy relieves pain by blocking pain messages to the brain. Bioelectric therapy also prompts the body to produce chemicals called endorphins that decrease or eliminate painful sensations by blocking the message of pain from being delivered to the brain. Bioelectric therapy can be used to treat many chronic and acute conditions causing pain, such as back pain, muscle pain, headaches and migraines, arthritis, TMJ disorder, diabetic neuropathy, and scleroderma. Bioelectric therapy is effective in providing temporary pain control, but it should be used as part of a total pain management program. When used along with conventional pain-relieving medications, bioelectric treatment may allow pain sufferers to reduce their dose of some pain relievers by up to 50%. Physical therapy helps to relieve pain by using special techniques that improve movement and function impaired by an injury or disability. Along with employing stretching, strengthening, and pain-relieving techniques, a physical therapist may use, among other things, TENS to aid treatment. Although resting for short periods can alleviate pain, too much rest may actually increase pain and put you at greater risk of injury when you again attempt movement. Research has shown that regular exercise can diminish pain in the long term by improving muscle tone, strength, and flexibility. Exercise may also cause a release of endorphins, the body's natural painkillers. Some exercises are easier for certain chronic pain sufferers to perform than others; try swimming, biking, walking, rowing, and yoga. When you are in pain, you may have feelings of anger, sadness, hopelessness, and/or despair. Pain can alter your personality, disrupt your sleep, and interfere with your work and relationships. In turn, depression and anxiety, lack of sleep, and feelings of stress can all make pain worse. Psychological treatment provides safe, nondrug methods that can treat your pain directly by reducing high levels of physiological stress that often aggravate pain. Psychological treatment also helps improve the indirect consequences of pain by helping you learn how to cope with the many problems associated with pain. A large part of psychological treatment for pain is education, helping patients acquire skills to manage a very difficult problem. In the past decade, many people have found relief for their pain in mind-body therapies, acupuncture, and some nutritional supplements. Others use massage, chiropractic and osteopathic (bone) manipulation therapies, therapeutic touch, certain herbal therapies, and dietary approaches to alleviate pain. However, there is little if any scientific evidence supporting these therapies for pain relief. Mind-body therapies are treatments that are meant to help the mind's ability to affect the functions and symptoms of the body. Mind-body therapies use various approaches including relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis. Relaxation techniques can help alleviate discomfort related to chronic pain. Visualization may be another worthwhile pain-controlling technique. Try the following exercise: Close your eyes and try to call up a visual image of the pain, giving it shape, color, size, motion. Now try slowly altering this image, replacing it with a more harmonious, pleasing -- and smaller -- image. Another approach is to keep a diary of your pain episodes and the causative and corrective factors surrounding them. Review your diary regularly to explore avenues of possible change. Strive to view pain as part of life, not all of it. Electromyographic ( EMG) biofeedback may alert you to the ways in which muscle tension is contributing to your pain and help you learn to control it. Hypnotherapy and self-hypnosis may help you block or transform pain through refocusing techniques. One self-hypnosis strategy, known as glove anesthesia, involves putting yourself in a trance, placing a hand over the painful area, imagining that the hand is relaxed, heavy, and numb, and envisioning these sensations as replacing other, painful feelings in the affected area. Relaxation techniques such as meditation or yoga have been shown to reduce stress-related pain when they are practiced regularly. The gentle stretching of yoga is particularly good for strengthening muscles without putting additional strain on the body. Acupuncture is thought to decrease pain by increasing the release of endorphins, chemicals that block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins that block the message of pain from being delivered to the brain. Acupuncture may be useful as an accompanying treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis (especially of the knee), and myofascial pain. Acupuncture also may be an acceptable alternative to or may be included as part of a comprehensive pain management program. Chiropractic treatment is the most common nonsurgical treatment for back pain. Improvements of people undergoing chiropractic manipulations were noted in some trials. However, the treatment's effectiveness in treating chronic back and neck pain has not been supported by compelling evidence from the majority of clinical trials. Further studies are currently assessing the effectiveness of chiropractic care for pain management. Osteopathic doctors, those with a " D. O." after their names, are also trained in bone manipulation techniques similar to that of chiropractors. Massage is being increasingly used by people suffering from pain, mostly to manage chronic back and neck problems. Massage can reduce stress and relieve tension by enhancing blood flow. This treatment also can reduce the presence of substances that may generate and sustain pain. Available data suggest that massage therapy, like chiropractic manipulations, holds considerable promise for managing back pain. However, it is not possible to draw final conclusions regarding the effectiveness of massage to treat pain because of the shortcomings of available studies. Therapeutic touch and reiki healing are thought to help activate the self-healing processes of an individual and therefore reduce pain. Although these so-called "energy-based" techniques do not require actual physical contact, they do involve close physical proximity between practitioner and patient. In the past few years, several reviews evaluated published studies on the efficacy of these healing approaches to ease pain and anxiety and improve health. Although several studies showed beneficial effects with no significant adverse side effects, the limitations of some of these studies make it difficult to draw definitive conclusions. Further studies are needed before these approaches for pain treatment can be recommended. Dietary supplements, such as fish oils and SAMe, also show some evidence of benefit, although more research is needed. It has been difficult to draw conclusions about the effectiveness of herbs, though there are a few, such as white willow bark, devil's claw, cat's claw, ginger, and turmeric, that have some evidence supporting their use. If you decide to use herbal preparations to better manage your pain, tell your doctor: Some herbs may interact with drugs you are receiving for pain or other conditions and may harm your health. Some people believe that changing dietary fat intake and/or eating plant foods that contain anti-inflammatory agents can help ease pain by limiting inflammation. A mostly raw vegetarian diet was found helpful for some people with fibromyalgia, but this study was not methodologically strong. One study of women with premenstrual symptoms suggested that a low-fat vegetarian diet was associated with decreased pain intensity and duration. Weight loss achieved by a combination of dietary changes and increased physical activity has been shown to be helpful for people suffering from osteoarthritis. Still, further research is needed to determine the effectiveness of dietary modifications as a pain treatment. Alternative therapies are not always benign. As mentioned, some herbal therapies can interact with other medications you may be taking. Always talk to your doctor before trying an alternative approach and be sure to tell all your doctors what alternative treatments you are using. Many people suffering from chronic pain are able to gain some measure of control over it by trying many of the above treatments on their own. But for some, no matter what treatment approach they try, they still suffer from debilitating pain. For them, pain clinics -- special care centers devoted exclusively to dealing with intractable pain -- may be the answer. Some pain clinics are associated with hospitals and others are private; in either case, both inpatient and outpatient treatment are usually available. Pain clinics generally employ a multidisciplinary approach, involving physicians, psychologists, and physical therapists. The patient as well should take an active role in his or her own treatment. The aim in many cases is not only to alleviate pain but also to teach the chronic sufferer how to come to terms with pain and function in spite of it. Various studies have shown as much as 50% improvement in pain reduction for chronic pain sufferers after visiting a pain clinic, and most people learn to cope better and can resume normal activities.