Chronic Pain Management Options: What a Pain Specialist Does

What does a pain management specialist do?

Pain management (or pain medicine) is a recognized medical specialty. Specialists in this field are typically anesthesiologists, neurologists, or physiatrists who have completed additional training in diagnosing and treating complex or refractory pain conditions.

A pain management specialist can:

• Perform a detailed evaluation of your pain, including its type, severity, and contributing factors
• Prescribe and manage medications that primary care clinicians may be less familiar with
• Perform or oversee interventional procedures (injections, nerve blocks, spinal cord stimulation)
• Coordinate interdisciplinary care with psychologists, physical therapists, and other specialists
• Help people with chronic pain who have become dependent on opioids transition to safer alternatives

Referral to a pain specialist is typically considered when pain has not responded adequately to first-line treatments, when complex procedures are needed, or when opioid management requires specialized oversight.

What non-opioid medications treat chronic pain?

Several medication classes are used for chronic pain, depending on its type:

NSAIDs (like ibuprofen and naproxen) are appropriate for musculoskeletal pain and inflammatory conditions 1Ref 1MedlinePlus / U.S. National Library of Medicine (2024).Ibuprofen: MedlinePlus Drug Information.NSAIDs (ibuprofen) used for musculoskeletal pain with awareness of long-term risk profile. They carry risks with long-term use — gastric irritation, kidney effects, and cardiovascular considerations — so are generally used for flares or at the lowest effective dose.

Acetaminophen has a different risk profile and may be suitable for some patients with musculoskeletal pain 2Ref 2MedlinePlus / U.S. National Library of Medicine (2024).Acetaminophen: MedlinePlus Drug Information.Acetaminophen as an option for musculoskeletal pain with different risk profile than NSAIDs.

Antidepressants with analgesic properties: - Duloxetine (an SNRI) is FDA-approved for diabetic neuropathy, fibromyalgia, and chronic musculoskeletal pain 3Ref 3Price R, Smith D, Franklin G, et al. (2022).Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.Duloxetine and other non-opioid medications for neuropathic chronic pain - Tricyclics (amitriptyline, nortriptyline) have longstanding evidence for neuropathic pain and headache prevention, at lower doses than used for depression

Anticonvulsants: Gabapentin and pregabalin reduce nerve pain signals. They are used for neuropathic pain conditions including diabetic neuropathy and postherpetic neuralgia.

Topical agents: Lidocaine patches and capsaicin cream can reduce localized neuropathic pain without significant systemic effects — useful for patients who cannot tolerate oral medications.

Muscle relaxants: Sometimes used for musculoskeletal pain with significant spasm, usually for short-term use.

What interventional procedures are available?

Interventional pain management uses targeted procedures to reduce pain at its source or block the pathways carrying pain signals:

Epidural steroid injections: Inject anti-inflammatory medication near the spinal nerve root. Commonly used for disc herniation causing leg pain (sciatica) or spinal stenosis causing leg symptoms. Provides relief for weeks to months in some patients; not effective for everyone.

Facet joint injections and medial branch blocks: Target the small joints of the spine that can become arthritic. If a nerve block confirms these joints are a pain source, radiofrequency ablation (which uses heat to interrupt the pain-carrying nerve) can provide longer-lasting relief.

Spinal cord stimulation (SCS): An implanted device delivers low-level electrical impulses to the spinal cord, interrupting pain signals before they reach the brain. It has evidence for complex regional pain syndrome, failed back surgery syndrome, and neuropathic leg pain.

Trigger point injections: Inject local anesthetic into tender muscle knots (trigger points) — used for myofascial pain.

Nerve blocks: Local anesthetic injected near a specific nerve or nerve group to temporarily interrupt pain. Can be diagnostic (confirming the source) or therapeutic.

What role does physical therapy and exercise play in long-term management?

Exercise and physical therapy are the most consistently evidence-backed long-term treatments for chronic pain across multiple conditions 4Ref 4Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH (2017).Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews.Exercise and physical activity reduce pain and improve function across multiple chronic pain conditions. A Cochrane overview of reviews found physical activity reduces pain and improves function — and the benefits extend beyond the musculoskeletal system to mood and sleep.

A physical therapist can: - Identify movement patterns that contribute to pain - Design a graded exercise program that begins where you are and builds capacity - Use manual therapy techniques (joint mobilization, soft tissue work) alongside exercise - Teach postural and ergonomic adjustments for daily life

The goal is not just short-term pain reduction but building durable capacity — so activity becomes more possible rather than less over time.

What psychological treatments are used for chronic pain?

Chronic pain involves the nervous system, and the brain is the organ that interprets and responds to pain. Psychological treatments are not about pain being "in your head" — they are about training the brain to process pain differently and helping people engage with life despite pain.

Cognitive behavioral therapy (CBT) for chronic pain has strong evidence 5Ref 5Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A (2012).The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses.CBT has strong evidence for chronic pain, targeting catastrophizing, avoidance, and sleep disruption. It targets catastrophizing (the expectation that pain will always be severe and uncontrollable), activity avoidance, and sleep disruption — all of which sustain and amplify pain.

Acceptance and commitment therapy (ACT) helps people build psychological flexibility — the ability to act according to their values even in the presence of pain, rather than allowing pain to dictate every decision.

Mindfulness-based stress reduction (MBSR) has growing evidence for chronic pain conditions, reducing both pain intensity and the emotional suffering surrounding it 6Ref 6Goldberg SB, Tucker RP, Greene PA, et al. (2018).Mindfulness-Based Interventions for Psychiatric Disorders: A Systematic Review and Meta-analysis.Mindfulness-based interventions reduce pain intensity and emotional suffering in chronic pain.

These therapies can be delivered in person, in groups, or increasingly via digital programs — making them more accessible.

What about acupuncture and other complementary approaches?

Acupuncture has the most robust evidence of the complementary approaches. A large individual patient data meta-analysis found it reduces pain across chronic musculoskeletal, headache, and neuropathic pain conditions compared to sham and no-acupuncture controls 7Ref 7Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K; Acupuncture Trialists' Collaboration (2018).Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis.Acupuncture reduces pain compared to sham and no-acupuncture controls across multiple chronic pain types. It is a reasonable option for people whose pain has not responded fully to other approaches.

Massage therapy has evidence for short-term pain and tension relief, though its long-term effects are less clear. It is generally low-risk and can complement other treatments.

What about opioids for chronic pain?

Opioid medications are not recommended as first- or second-line treatment for most types of chronic non-cancer pain. The risk of dependence, tolerance (requiring higher doses for the same effect), and side effects is significant over the long term, and evidence for long-term efficacy is weaker than for many non-opioid approaches.

For people already on opioids, pain specialists can help develop a safe tapering plan and transition to alternatives. For cancer-related pain or certain severe conditions not responsive to other treatment, opioids remain an important tool when carefully managed.

A Gale primary care clinician can coordinate pain evaluation, initiate appropriate non-opioid treatments, and determine when a referral to a pain specialist is the right next step.