Dear Friends,

When I think about chronic pain, I think about my patient Margaret and her back pain. She wasn’t sure how it started – maybe she lifted her grandson wrong or it was the extra hours on her feet at the shop.

Her doctors prescribed medications and physical therapy. She had X-rays and an MRI, which revealed arthritis in her spine. Then she developed intense sciatica – pain shooting down her leg. She received an injection and a prescription for an opioid medication to take when the pain was unbearable, which was often at night.

Other medications followed – for sleep, for the nerve pain, and finally to lift her mood. By the time she came to me, she was taking five different prescription medications, including a daily opioid. She could no longer exercise and had gained 50 pounds in the past 10 years. Margaret was miserable. When she didn’t take her opioid medication, she became agitated and irritable – classic signs of opioid dependence. My goal in creating and now updating A Guide to Optimizing Pain Treatment Through Whole Person Health is to help other people avoid the misery and pain that Margaret experienced.

As you will read, people with chronic pain need three things:

1. A health care team whose members work together and share information – with each other and with the patient.
2. Non-drug approaches to help improve function, cope with pain, and reduce pain.
3. Medication management, with the goal of stopping or reducing opioid use and special consideration for the risks of synthetic opioids like fentanyl. Drugs such as oxycodone purchased “on the street” may actually contain other drugs, including fentanyl, in amounts that can cause serious harm or death.

For patients with cancer pain, the needs are slightly different but just as critical. With cancer, pain can stem from both the disease itself and its treatments, and the role of opioid medications is different, particularly for advanced cancer.

Finally, today’s telehealth environment offers new opportunities for clinicians to provide whole person pain management guidance, even from a distance. Read on to learn more about these three pillars of whole person pain relief with updated approaches for all patients, including those navigating cancer-related pain.

Yours in health,
Wayne Jonas, M.D.

Pain is an unpleasant sensory and emotional experience. No two people feel pain the same way, even if the reasons for their pain are alike.

— National Institute of Neurological Disorders and Stroke, 2025.

When you break your leg, undergo surgery, or burn your hand, you experience pain – acute pain. With treatment and time, the pain usually disappears. But chronic pain is different. It hangs around even after the original illness or injury has improved, reminding you every day that it has no plans to vacate the premises. Technically, chronic pain is diagnosed if it persists three to six months or more after an injury or disease resolves.

Sometimes there is a clear cause of the pain, such as arthritis, but other times there is no specific trigger or underlying illness or condition. For instance, current science suggests fibromyalgia is a chronic pain condition without a specific cause. Instead, it’s likely related to changes in how the brain processes pain. Sometimes people may feel pain in places distant from where the original injury occurred, something called “referred” pain.

Often, chronic pain begins with an acute pain event. The pain can develop and intensify to become chronic pain. If you have chronic pain, you’re not alone. More than 50 million American adults – about 20% – have chronic pain. It is one of the most frequent reasons for physician visits and among the most common reasons for taking medication.

But pain is more than just a physical hurt. It’s an unwanted guest that takes over your life, interfering with your ability to work, your relationships, your mental health, and your overall quality of life. It affects your entire being.

For example, people with low back pain are three times more likely to have limited functional ability and four times as likely to suffer psychological distress as those without low back pain. Unfortunately, finding the answer to your pain can feel like searching for a unicorn in a horse stable; the answer may not even live there.

A Unique Challenge

“While pain care has grown more sophisticated, the most effective care still is not widely available. Some cases of acute pain can be successfully treated but are not; others could be dealt with promptly, but agonizing delays occur. And most people with severe, persistent pain still do not receive – and often are not offered – systematic relief or the comprehensive, integrated, evidence-based assessment and treatment that pain care clinicians strive to provide.”

— Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, 2011.

For patients with cancer, pain represents a particularly complex challenge. Approximately 45% of people who have cancer experience pain, and roughly 80% of patients with advanced cancer have moderate to severe pain. This can result from:

• Direct tumor invasion of bones, nerves, or organs
• Treatments such as surgery, chemotherapy, or radiation
• Secondary complications like infection or muscle spasms
• Psychological factors including anxiety and depression

The experience of cancer pain differs from many other chronic pain conditions in that it often involves multiple pain mechanisms simultaneously and may change dramatically as the disease progresses or treatments evolve. The Resources section below lists several sources to learn more about how opioid medications may be an appropriate part of cancer treatment. At How We Heal Campaign, you can learn about and download our free pocket guide to cancer pain.

The Multidisciplinary Approach to Pain Management

It takes a village to manage chronic pain – or at least a team of health care professionals with you (and your own self-care) at its center. Yet one of the things the U.S. health care system as a whole still needs to work on is coordinated care. Most care is still provided piecemeal, with too little communication among providers.

One result is that people with chronic pain are left to jump from provider to provider, often repeating unnecessary and expensive procedures, taking medications that don’t work well, and experiencing more stress and anxiety every time a treatment fails. Often, they may feel as if they are the ones who have failed and lose hope. In reality, it is the health care system that has failed them.

Another possible result is “doctor shopping,” in which people become dependent on their medications and may visit multiple clinicians and use multiple pharmacies to obtain extra pills and prescriptions. Without a primary care clinician to oversee medications, prescriptions may simply be renewed over and over with no one to ask, “Is this still helping you? Is there a better option?”

Finally, some clinicians still dismiss or minimize their patients’ reports of pain – particularly if those patients are women or belong to racial and ethnic minorities. Indeed, there is evidence that women are more likely to be prescribed psychological treatments for their pain than men and are more likely to be viewed as overreacting and exaggerating their pain.

Until very recently, few clinicians received training in managing acute and chronic pain. Though medical education has improved, and the International Association for the Study of Pain even provides a sample curriculum on pain management, there is still room for progress. Many courses lack a multidisciplinary approach involving both medical and behavioral interventions.

This leaves people with chronic pain undiagnosed, undertreated, and continually searching for a health care provider who can truly help them. Some pain sufferers give up on health care and never find adequate relief.

The Evolving Opioid Crisis

The issue of pain has become an almost daily headline given the ongoing opioid epidemic. Though prescription opioid rates have fallen since their peak in 2012, the crisis has changed rather than abated. The emergence of synthetic opioids, particularly illicit fentanyl, has dramatically changed the risk profile associated with opioid dependence and misuse.

Fentanyl, a synthetic opioid 50 to 100 times more potent than morphine, has become the primary driver of opioid-related deaths. Unlike previous waves of the opioid crisis, which were largely driven by prescription medications, today’s crisis primarily involves illicitly manufactured synthetic opioids that are often mixed with other substances without the user’s knowledge.

For health care professionals, this reality makes careful pain management and opioid prescribing even more critical. Patients who develop opioid dependence and cannot obtain prescriptions face unprecedented risks if they turn to illicit markets.

In addition, despite decades of concern, there is still limited evidence that opioids are effective for people with chronic pain, like Margaret. As we know, these drugs are highly addictive, and over time, you need higher and higher doses just to get the same relief. They also have serious side effects, including depression, overdose, death, constipation, and withdrawal symptoms when you stop taking them, like the irritability Margaret experienced. Opioids also mask rather than address the underlying cause of the pain.

Given all this, the Centers for Disease Control and Prevention (CDC) has strengthened its guidance since the original 2017 guidelines, maintaining that opioids should not be first-line treatment for most chronic pain conditions. The CDC, American College of Physicians, and other medical organizations recommend starting with non-opioid alternatives, such as acetaminophen (Tylenol), nonsteroidal anti-inflammatories (Motrin, Aleve), antidepressants, and anticonvulsants.

The CDC’s 2022 guideline update, which remains current as of this writing, emphasizes individualized care and recognizes that certain populations, including cancer patients with active disease, may have different needs and benefit profiles.

For people without cancer pain, attempts to reduce opioids without treating the source of their chronic pain simply do not work. Patients may turn to alternatives, like heroin or fentanyl, or begin looking for someone who will write an opioid prescription. This is why whole person approaches to pain reduction and management are so important.

Telehealth Support for Pain Management

The expansion of telehealth services since 2020 has created new opportunities for pain management, particularly for patients with limited ability to visit the clinic in person, those in rural areas without pain management specialists, and those with cancer who may have compromised immune systems. Clinicians who provide telehealth consultations can provide several valuable pain management services.

Assessing Pain Remotely

• Use validated numerical rating scales and pain diagrams.
• Conduct thorough pain histories, including pattern, quality, intensity, and factors that trigger, aggravate, and relieve the pain.
• Evaluate pain’s effect on the patient’s daily functioning with structured questions about daily activities.
• Assess the psychological impact of pain, including sleep, mood, and anxiety.
• Guide patients through simple movement assessments via video.
• Request pain diaries between sessions to identify patterns.

There are many apps available to track pain, including several designed to help patients with specific conditions, such as cancer or migraine.

At the Healing Works Foundation, we also recommend using the HOPE Note, a whole person health tool that helps clinicians assess their patients’ quality of life, circumstances, needs, and wants from many different angles. It can have a revolutionary impact on patients’ and clinicians’ decisions about how to manage pain. You can find this free tool at healingworksfoundation.org.

Remote Pain Interventions for Whole Person Health

• Guided progressive muscle relaxation and breathing techniques
• Mindfulness meditation instruction and referral to videos
• Counseling on healthy sleep habits
• Gentle movement programs tailored to patient capabilities
• Nutritional guidance to reduce inflammatory factors, such as our Pocket Guide to Nutrition for Chronic Pain.
• Support for a medication plan, monitoring of side effects

Telehealth can relieve pain as effectively as in-person care, even for people with advanced cancer. It has also been shown to be effective for people with chronic pain.

Building Your Pain Management Team

If you’re like most people, the doctor you see most often is your primary care clinician. This person might be a physician (MD), a naturopathic physician (ND), nurse practitioner (NP), or have a different degree. Regardless of how that person was trained, this “family doctor” is usually the first one to talk with when you’re dealing with pain. For people with cancer, talking to your main cancer doctor – your oncologist – is a good place to start.

Estimates are that primary care clinicians treat about half of all people living with chronic pain. However, if your pain remains uncontrolled, it might be time to seek out other practitioners.

In an ideal world, everyone dealing with pain would have access to a pain management specialist. This is a clinician, usually but not always an MD, who is board certified in pain management. The American Board of Anesthesiology, the American Board of Psychiatry, the American Board of Neurology, and the American Board of Physical Medicine and Rehabilitation all offer certification after physicians complete a fellowship in pain management.

These physicians typically work in pain management centers. They tend to take a whole person health approach to pain that includes medical treatment, counseling for mental, emotional, and behavioral health concerns, and other approaches like those described below.

At the Mayo Clinic, a three-week patient-oriented pain management program involved physical and occupational therapy, education to better understand the person’s pain, and breathing and meditation exercises to reduce anxiety related to flares. One study of 373 patients who attended the program – half of whom had been taking opioids before enrolling – found significant improvement at six months after the program ended, regardless of the amount of opioid medication they were taking before starting treatment.

However, few of these physicians and teams are available, with one study estimating that just 2% of people living with chronic pain receive care from these professionals in a typical month. Even though nearly 1 in 4 U.S. adults lives with some form of chronic pain, according to the CDC, some medical specialties have seen a recent decline in the number of trainees choosing to specialize in pain medicine.

While a physician should be an important part of your pain management team, you shouldn’t stop there.  Studies show that a whole person health approach that combines conventional medicine with self-care and complementary approaches is more effective at addressing chronic pain than conventional medicine approaches alone. Whole person health approaches include cognitive behavioral therapy – in which you learn to think differently about your pain – physical therapy, movement therapy or exercise, acupuncture, massage, and chiropractic services.

If there are no pain specialists or teams in your area, ask about telehealth consultations. Studies find that these approaches can be just as effective as in-person visits.

Who is Treating Your Pain?

You may see several physicians as you search for pain relief. These include:

• Primary care physicians. Pain is one of the main reasons people see their primary care physicians. They treat all conditions and should view your condition holistically.
• Pain management specialists. These physicians are often trained in anesthesia with additional training in pain management. They include interventional anesthesiologists who can implant pumps and other devices to help relieve your pain.
• Neurologists. These physicians focus on the central nervous system. They are most likely to treat pain related to the nerves.
• Orthopedists and sports medicine doctors. These physicians address the skeletal system, including bones, joints, and tendons.
• Physiatrists. These physicians treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons.
• Rheumatologists. These physicians address the immune system. They are likely to treat people with painful autoimmune diseases like lupus, scleroderma, and fibromyalgia.
• Oncologists and palliative care specialists. For cancer patients, these specialists play crucial roles in pain management. Oncologists coordinate cancer treatment that may indirectly improve pain, while palliative care specialists focus directly on quality of life and symptom management regardless of treatment stage.

Whole Person Health Clinicians for Pain Management

There are a number of clinicians who can help with pain.

Chiropractors (Chiropractic Physicians)

Chiropractors see approximately 40% of people living with chronic pain, with one study finding that about a third of patients with chronic back or neck pain turned to a chiropractor. A survey from Consumer Reports found that 59% of people with chronic pain who saw a chiropractor were highly satisfied compared with 34% who saw only a primary care physician. Research published in 2024 further supports spinal manipulation for certain pain conditions, with particular effectiveness for persistent low back pain.

Acupuncturists

There is good evidence for the long-term benefit from acupuncture on chronic pain from some causes. Multiple systematic reviews published between 2020 and 2024 have strengthened the evidence base for acupuncture in managing various pain conditions, including migraine, osteoarthritis, and cancerrelated pain.

A 2024 neuroimaging study demonstrated that acupuncture produces measurable changes in brain activity in pain processing regions, providing further biological plausibility for its effects. For cancer patients specifically, acupuncture has shown promise for chemotherapy-induced peripheral neuropathy and postsurgical pain.

Physical Therapists

Physical therapists specialize in restoring function to people living with chronic pain. For instance, if you have arthritis of the knee, they work with you to strengthen the muscles that surround the knee, which can help with the pain.

Recent advances in physical therapy include greater emphasis on pain neuroscience education – helping patients understand how the brain processes pain signals and developing strategies to retrain these pathways. For cancer patients, specialized oncology physical therapists provide interventions that address unique needs like radiation fibrosis, surgical scarring, and chemotherapy-related deconditioning.

Massage Therapists

About half of those who get a massage every year are doing it for some medical reason – primarily pain relief – or soreness and stiffness. A 2023 survey of more than 1,000 adults found that 94% believed that massage was effective in reducing pain, with 30% stating they used massage therapy for pain relief.

Newer research has identified specific massage protocols for various pain conditions, moving beyond generic approaches to targeted interventions. A 2023 systematic review found moderate evidence supporting massage therapy for cancer-related pain, particularly post-surgical discomfort and general cancer pain.

Cognitive Behavioral Therapists

Dozens of studies attest to the benefits of this psychological approach in which you work with a therapist to reframe how you think about and react to your pain. You can also use a cognitive behavioral therapy (CBT) app to practice the techniques you’ve learned between sessions or when virtual or in-person therapy isn’t available.

For cancer patients, specialized pain-focused behavioral therapy addresses the unique aspects of cancer pain, including fear of disease progression, treatment anxiety, and even concerns about the nature of existence, why the cancer happened, and what happens after death. Acceptance and commitment therapy, a newer therapeutic approach related to CBT, has shown particular promise for helping patients live meaningfully even when they have persistent pain.

When using whole person health approaches, make sure all of your team members are communicating with each other. Simply substituting a healing practice, such as massage, for your prescription medication does not make for good care. Your medication might not be safe to stop suddenly or have a benefit you didn’t realize, such as reducing inflammation as well as pain. Or you might need to avoid certain styles of massage due to the source of your pain, whether it’s cancer or a bad back.

Instead, the whole person health practice must be integrated – worked into – your treatment to be safe, effective, and provide you with the most benefit. You, a caregiver, or a family member can share information across the health care team to make sure your treatments work well together and aren’t harmful.

A whole person approach to cancer pain includes some special considerations.

Understanding How Cancer Pain Works

Cancer pain typically comes from multiple sources. These can include:

• Direct tumor effects (bone pain, tumor pressing on nerves or growing into an organ)
• Treatment-related pain (from surgery, chemotherapy-induced neuropathy, or radiation)
• Pain from procedures, such as a biopsy or bone marrow sampling
• Psychological components (anxiety, depression, fear of disease progression)

A Whole Person Approach for Cancer Pain

Recent research supports several specific interventions:

• Mind-body practices like guided imagery show particular benefit for procedure-related anxiety and pain.
• Gentle movement therapies modified for cancer patients improve function while reducing the perception of pain.
• Acupuncture can have specific effectiveness for chemotherapy-induced peripheral neuropathy.
• Music therapy can reduce pain scores and the amount of pain medication that hospital patients with cancer require.

Telehealth Support for Cancer Pain

Clinicians who provide telehealth support can help cancer patients by:

• Doing regular, structured pain assessments between oncology appointments
• Sharing with patients, families, and caregivers about expected pain patterns during treatment
• Teaching self-management and pain relief techniques that patients can use at home
• Tracking how well medications are working and any side effects
• Coordinating care among multiple specialists
• Identifying early warning signs that require immediate medical attention

Communicating with Your Health Care Team

In this day of 15- or 20-minute office visits, many clinicians find themselves rushing from exam room to exam room or from one virtual visit to another. This can make it difficult for them to take the time required to manage chronic pain. Here are some strategies to make it easier on you and your clinician.

• Write down your concerns before your visit.

Stay focused on one thing that’s bothering you. Is it that you can’t sleep because of the pain? You can’t play with your children? You are missing work? Tell your clinician what matters to you in addition to what’s the matter.

Describe the pain precisely. Saying “it hurts” doesn’t help. Many clinicians use a 1-10 pain scale, with 10 being the worst pain you’ve ever felt and one being no pain. A more helpful way to describe your pain is to put it in terms of your normal life. For instance, “I used to be able to walk up and down six flights of stairs with no problem. Now I have to take the elevator.”

Track your pain. For a week before your visit, keep a pain diary in which you rate your pain every couple of hours on a scale of 1 to 10 and write down what you were doing at that time. Also track all pain medications you take. Write down any non-medical approaches you use to cope with your pain, such as resting, stretching, using an ice pack or heating pad, or something else.

Ask your pharmacist questions about your medications. They know how each medication works, how well it works for different types of pain, and what side effects it can cause. You can also talk with the pharmacist to make sure none of your medications conflict with each other.

Be honest with your clinician about any alcohol and drug use, diet, exercise, and other clinicians you see. The more they know, the easier it is to work together to create whole person health.

Bring a friend or family member to your appointment who can take notes. If you are nervous or in pain, it’s easier to forget what you wanted to say.

For telehealth appointments, additional strategies include:

• Testing your technology before the appointment to make sure your sound and picture will be clear.
• Choosing a well-lit area where the clinician can see you clearly.
• Having your medication bottles on hand to show them.
• Being ready to demonstrate some motions or show where the pain is, if asked.
• Sharing your pain diary with your health care team ahead of time, if possible.

Your Rights and Responsibilities as a Person with Pain

As someone with pain, you have certain rights and responsibilities when it comes to the health care system.

You have the right to:

• Have your pain taken seriously.
• Be treated with respect.
• Have your pain evaluated based on how it affects your life, not just on the injury or condition.
• Understand why you have pain.
• Receive information about your pain and treatments and be part of any treatment decisions.
• Refuse treatment, such as medications, additional tests or repeated tests, procedures, and surgery.
• Receive care based on scientific evidence. For example, there is no evidence that bed rest helps back pain. In fact, it’s one of the worst things you can do for it!

You are responsible for:

• Treating your health care team and clinician with respect at all times.
• Sharing your goals and values related to the pain. For example, it might be an important goal to go back to playing tennis, even if you still have some pain.
• Following the treatment plan you and your clinician agree on, including any treatments, exercises, or other programs you do on your own.
• Telling your clinician when something is not working or you have side effects.
• Knowing what your insurance will pay for (cover), which providers are in your insurance company’s network, and if you need approval, called “authorization,” before treatment.
• Having realistic expectations. For example, you may never find a “cure” for your pain. Instead, you can shift your perspective and work with your health care team to learn to manage your pain.

Make the Most of Your Insurance Coverage

Here are a few things you can do if your health insurance company denies your claim or requires that you first use opioids to treat your pain:

• Know your benefits. Before you make an appointment for a treatment, check to see if your insurance covers it.
• Obtain all necessary pre-authorizations before undergoing any procedures.
• Appeal the decision and get your doctor to write a note. If it’s denied, appeal again. There are often several levels of appeals.
• Talk to someone in your company’s human resources; they may be able overrule any insurance decision in large companies that are self-insured – meaning they pay claims directly.

Check to see if you have a health savings account or flexible savings account, which allow you to use pretax dollars to pay for non-covered health care costs.

Connect with Others Living with Chronic Pain

Look for organizations that support people living with pain and/or people with your particular pain condition. Networking with others who have similar symptoms or access the same health care services has many benefits.

• Networking with people who live with similar symptoms lets you know you are not alone.
• Hearing the variety of tools used by other people with pain may give you some ideas of other options to discuss with your health care team.
• Learning about research pertinent to your symptoms or condition.
• Accessing references and resources on your own schedule.

Embracing Whole Person Health for Pain Management

Managing pain, whether it’s from cancer or from other causes, requires a comprehensive approach that goes beyond simply treating symptoms. Whole person health recognizes the interplay of physical, emotional, social, and spiritual factors that contribute to pain and its relief.

By building a supportive health care team, exploring evidence-based whole person health approaches, and being an active part of your treatment, you can develop a pain management strategy that gives you the best quality of life with the least risk from medications and other treatments.

If you are a clinician who supports patients with pain, the whole person approach offers a way to assess and begin treating them effectively, even at a distance.

As we keep learning more about pain and develop new approaches to treatment, the basics stay the same: coordinated care that addresses the whole person, treatments other than medication, and careful medication management. These principles apply whether pain stems from cancer, injury, or other chronic conditions and provide the foundation for effective pain relief.

Cancer Pain

• National Cancer Institute. Cancer Pain PDQ – Health Professional Version. Updated July 25, 2024. Available at www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-hp-pdq#top.
• National Cancer Institute. Cancer Pain (PDQ®)–Patient Version. Updated January 8, 2025. Available at www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-pdq.
• What Really Works for Cancer Pain? From the How We Heal Campaign
• Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline, December 2022. Available at ascopubs.org/doi/10.1200/JCO.22.02198.

General Pain Resources from the How We Heal Campaign

www.howwehealcampaign.com

• Mind-Body Approaches to Pain Relief (includes patient tool)
• Pocket Guide to Nutrition for Chronic Pain (Free downloadable PDF)
• Women Have More Chronic Pain than Men (article; links to free downloadable PDF Women and Pain: Taking Control and Finding Relief )

HOPE Note for Including Whole Person Health in Clinic Visits

• Healing Works Foundation. The HOPE Note.
  healingworksfoundation.org/resources/hope-note/hope-visit

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