If you suffer from chronic pain, it may be small consolation to know that an estimated 1.5 billion people worldwide, including 25 million in the U.S., are similarly afflicted. In the past, an instinctive solution many doctors chose was to prescribe an opioid pain reliever. This was when such drugs were considered largely harmless, a mindset that no longer applies. Still, chronic pain costs the healthcare system more than $600 billion a year even as existing treatments fail to provide relief for many people.

And while there are still circumstances where pharmaceuticals are appropriate treatment, non-drug strategies have emerged as alternatives for certain kinds of chronic pain. We will discuss two such alternatives here.

Pain Reprocessing Therapy

Pain Reprocessing Therapy (PRT) is a technique that uses cognitive behavioral therapy to help you “unlearn” pain. According to the Pain Reprocessing Therapy Center, neuroscientists have found that most chronic pain results from the brain misinterpreting safe messages from the body as if they were dangerous. “Research has found that the brain has the power to generate pain even in the absence of physical damage,” the Center says. “PRT is a system of psychological techniques that retrains the brain to accurately interpret and respond to signals from the body, breaking the cycle of chronic pain.” The Center states that PRT may not only manage pain but also be able to eliminate it.

The National Institutes of Health (NIH) backs up this optimistic potential, as well as the basic rationale for PRT. “The most common type of chronic pain is chronic back pain,” the NIH notes. “In about 85% of cases, no physical cause for the pain — such as arthritis or disk damage — can be found. Such unexplained pain is thought to be caused by brain changes after an injury that persist even after the damage heals.”

The NIH goes on to explain that changes in the brain are thought to serve an important purpose immediately after tissue damage. “They provide a warning signal to restrict movement and let the body recover. However, if they continue to send that signal after the injury has healed, the result can be chronic pain.” PRT is designed to redirect such signals that perpetuate pain or, as some put it, “unlearn” them. The result being that pain signals sent to the brain are perceived as less threatening. As a practical matter, therapists utilizing PRT help participants do painful movements while helping them re-evaluate the sensations they experience. The treatment also includes training in managing emotions that can often make pain feel worse.

Colorado Pioneered Pain Reprocessing Therapy Testing

The NIH’s National Institute on Drug Abuse (NIDA), National Institute of Mental Health (NIMH), and National Center for Advancing Translational Sciences (NCATS) funded the first clinical test of PRT, which was conducted by a team at the University of Colorado, Boulder. The test enrolled 151 people with mild to moderate chronic back pain for which no physical cause could be found. Participants received one of three treatments: four weeks of intensive PRT, a placebo injection of saline into the back, or a continuation of care as usual.

Participants rated their pain before and four weeks after starting treatment. They also underwent fMRI (functional magnetic resonance imaging) scans to look at brain activity before and after treatment. The team followed up with participants one year later. Results were published in 2021 in JAMA Psychiatry.

After 4 weeks of PRT, 66% of people who underwent the therapy reported being pain-free or nearly pain-free. In contrast, only 20% of people who received placebo injections and 10% of those receiving usual care reported similar improvements. The reductions in pain after PRT were largely maintained a year after treatment. The fMRI scans revealed that, compared with the other two groups, people who received PRT had substantial reductions in brain activity in several regions associated with pain processing.

“For a long time, we have thought that chronic pain is due primarily to problems in the body, and most treatments to date have targeted that,” said Dr. Yoni Ashar, one of the study’s leaders. “This treatment is based on the premise that the brain can generate pain in the absence of injury or after an injury has healed, and that people can unlearn that pain. Our study shows it works.”

“This isn’t suggesting that your pain is not real or that it’s ‘all in your head,’” observed Dr. Tor Wager, another of the study physicians. “What it means is that if the causes are in the brain, the solutions may be there, too.”

Coloradans can seek out PRT therapists through a directory at PRT Therapists.

Transcutaneous Electrical Nerve Stimulation Devices

Another non-drug approach to pain treatment goes by the unwieldy name of Transcutaneous Electrical Nerve Stimulation Devices, or TENS devices. A key plus for these devices is that they are available over-the-counter at relatively low-cost. Functionally they bear some resemblance to PRT.

The Cleveland Clinic explains that TENS uses low-voltage electrical currents to relieve pain. “A TENS unit is a small device that delivers the current at or near your nerves to block or change your perception of pain,” the Clinic states. “Healthcare providers use TENS to treat a range of conditions, including osteoarthritis, tendinitis, and fibromyalgia.”

The Clinic goes on to say that TENS therapy tends to work better for some than for others. Research is still working to learn why. “Most experts believe the electrical current helps release pain-reducing chemicals [endorphins] that your own body produces,” says the Clinic. Another theory is that the electrical current stimulates nerve cells that block the transmission of pain signals, which changes the way you perceive pain.

About TENS Units for Chronic Pain

A TENS unit is a battery-powered device with electrodes that deliver electrical impulses through the surface of the skin. A provider (or you) places the electrodes at or near trigger points or affected nerves. Healthcare providers might offer TENS therapy in office or hospital settings, or they might give you a prescription for a TENS unit to use at home. You also have the option of purchasing an over-the-counter (OTC) TENS unit at your local pharmacy or other retailer without a prescription.

The Clinic describes these details more specifically:

“A TENS device is about the size of a small cell phone. It comes with several sets of electrodes, wires, and end pads. Here’s how it works:

  • The electrodes connect to the TENS unit at one end and have 2-inch by 2-inch pads at the other end.
  • Each pad has adhesive backing so it’ll stick to your skin.
  • You (or your provider) position the pads on your skin along nerve pathways in the affected area.
  • The TENS unit delivers pulses of electrical energy.
  • You can adjust the intensity, frequency, and duration of the pulses. (The goal is to adjust the settings until the electrical impulses feel strong but comfortable.)”

Cleveland Clinic advises that “Regardless of the type of TENS unit you choose, it’s a good idea to talk to your healthcare provider first. Many of these units have FDA approval, but it’s important to choose the right device for your needs. Your provider can also give you guidance on how and where to apply the electrodes.”

Pain Conditions TENS Can Be Used For

Cleveland Clinic says TENS can be used to treat a wide range of acute (short-term) and chronic (long-term) conditions, including back pain, osteoarthritis, fibromyalgia, tendinitis, bursitis, pelvic pain, diabetes-related neuropathy, and peripheral artery disease.

However, TENS should NOT be used if you have an implantable device (e.g., pacemaker) or have been diagnosed with cancer, epilepsy, deep vein thrombosis (DVT), bleeding disorders, or heart disease. TENS should also not be used near damaged skin; varicose veins; on face, neck, or head; near genitals; or areas of numbness or body areas that have received radiation therapy. “Always check with your healthcare provider before using TENS, especially if you have existing health conditions,” the Clinic says.

Results of TENS Are Variable for Chronic Pain

According to Cleveland Clinic, TENS therapy usually helps ease pain during the treatment. But the level of pain relief following the session varies from person to person. Some people claim that they feel better for up to 24 hours after the session. Others say their pain returns as soon as they turn off the TENS unit. Some users find the tingling sensation uncomfortable. Users are advised to tell their healthcare provider if they experience skin rash or itchiness, dizziness, headaches, or nausea.

Of note, the National Library of Medicine (NLM) at the National Institutes of Health at one time did a comprehensive literature search focused on studies of commonly marketed forms of electronic stimulation (ES) for treatment of pain and improvement of function. TENS was among the methods examined. The NLM stated: “Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement.” The NLM added: “Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES.”

Cleveland Clinic generally agrees, saying “We need more research to fully understand TENS and find out exactly how it works. Some existing studies show that TENS relieves pain in many people. Others suggest that a placebo (a treatment that appears real but isn’t) works just as well. It’s likely that success depends on several factors, including the existence of underlying conditions, placement of the electrodes and TENS unit settings. There’s still a lot to learn about it. But if you have short-term or long-term pain, it’s likely worth a try. It’s important to check with your healthcare provider [to] find a solution that works for your unique situation.”

Where Coloradans Can Find TENS Devices

To find a TENS device on your own, simply do an online search for “TENS devices.” You’ll see a wide selection and price range, many for under $50. Reviews are also available. But bear in mind the advice to consult your healthcare provider about the best device to address your pain effectively and safely.