A Menu of Strategies for Chronic Pain Treatment in Primary Care

Chronically, [patients] become accustomed, tolerant of the medications, and then ultimately dependent on them…The medications start to cause their own types of pain.

Heather Tick, MD

Throughout her career, Heather Tick, MD, has focused on how to bring relief to patients with many types of pain, especially myofascial pain. As co-founder and director of one of the first interdisciplinary pain centers in Toronto from 1991-2008 to her current role as a clinical associate professor at the University of Washington, Dr. Tick has made a difference for countless chronic pain patients. One of the areas she emphasizes is the need for an array of pain management strategies in primary care. Integrative and complementary approaches are varied, and many show good results for patients.1-5

Dr. Tick was one of the presenters at IFM’s 2019 Annual International Conference, which focused on the treatment of stress, pain, and addiction. In this interview, IFM’s Director of Medical Education Dan Lukaczer, ND, discusses non-pharmacologic approaches to pain treatment with Dr. Tick. They cover perspectives ranging from patient education, the role of the primary care clinician in pain treatment, nutritional and lifestyle interventions for pain, endocannabinoids, and much more.

It is very widely acknowledged that pain education, certainly in medical schools, is woefully inadequate… That does raise a problem and puts the onus on practitioners to try to develop skills and have a menu of strategies that they’re going to be able to utilize in order to help their pain patients—which are now at epidemic proportions.

Heather Tick, MD
Friends eating

One can literally change the brain by changing [one’s] behaviors and responses.

Heather Tick, MD

Dr. Tick often works with patients on nutrition first. As she says,

I’m fond of telling my patients that they change their body chemistry every time they eat. They either make it more inflamed or less inflamed.

Nutrition plays a huge role in the regulation of pain, as Dr. Tick’s publications attest.6 One Italian working group called the potential for nutrition to help patients with chronic pain “formidable and promising.”7

I see people every day who have stopped moving because they have pain, and year by year, they get worse unless they turn that around.

Heather Tick, MD
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Beyond nutrition, lifestyle plays a large role in pain management,8 particularly exercise.9 However, both low-income9 and rural populations10 face barriers to some of these lifestyle interventions. Exercise can combat comorbid depression,11-12 which frequently accompanies chronic pain. Psychosocial factors are also a key facet of successful pain management.13

Patients have long sought non-pharmacologic approaches for pain, and they report that they often bring relief.14,15 Yet in one study, 40% of chronic pain patients did not feel like they were treated as equal partners for decisions about their care.16 Functional Medicine’s focus on the therapeutic partnership offers a potential path forward, where these lifestyle interventions can be personalized and paired with other strategies for pain management, such as mitochondrial support.




  1. Lin YC, Wan L, Jamison RN. Using integrative medicine in pain management: an evaluation of current evidence. Anesth Analg. 2017;125(6):2081-2093. doi:10.1213/ANE.0000000000002579
  2. Tick H, Nielsen A, Pelletier KR, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care: the Consortium Pain Task Force white paper. Explore (NY). 2018;14(3):177-211. doi:10.1016/j.explore.2018.02.001
  3. Chen L, Michalsen A. Management of chronic pain using complementary and integrative medicine. BMJ. 2017;357:j1284. doi:10.1136/bmj.j1284
  4. Hamlin AS, Robertson TM. Pain and complementary therapies. Crit Care Nurs Clin North Am. 2017;29(4):449-460. doi:10.1016/j.cnc.2017.08.005
  5. Delgado R, York A, Lee C, et al. Assessing the quality, efficacy, and effectiveness of the current evidence base of active self-care complementary and integrative medicine therapies for the management of chronic pain: a rapid evidence assessment of the literature. Pain Med. 2014;15(Suppl 1):S9-20. doi:10.1111/pme.12412
  6. Tick H. Nutrition and pain. Phys Med Rehabil Clin N Am. 2015;26(2):309-320. doi:10.1016/j.pmr.2014.12.006
  7. De Gregori M, Muscoli C, Schatman ME, et al. Combining pain therapy with lifestyle: the role of personalized nutrition and nutritional supplements according to the SIMPAR Feed Your Destiny approach. J Pain Res. 2016;9:1179-1189. doi:10.2147/JPR.S115068
  8. De Gregori M, Belfer I, De Giorgio R, et al. Second edition of SIMPAR’s “Feed Your Destiny” workshop: the role of lifestyle in improving pain management. J Pain Res. 2018;11:1627-1636. doi:10.2147/JPR.S160660
  9. Turner BJ, Rodriguez N, Valerio MA, Liang Y, Winkler P, Jackson L. Less exercise and more drugs: how a low-income population manages chronic pain. Arch Phys Med Rehabil. 2017;98(11):2111-2117. doi:10.1016/j.apmr.2017.02.016
  10. Eaton LH, Langford DJ, Meins AR, Rue T, Tauben DJ, Doorenbos AZ. Use of self-management interventions for chronic pain management: a comparison between rural and nonrural residents. Pain Manag Nurs. 2018;19(1):8-13. doi:10.1016/j.pmn.2017.09.004
  11. Tawashy AE, Eng JJ, Lin KH, Tang PF, Hung C. Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study. Spinal Cord. 2009;47(4):301-306. doi:10.1038/sc.2008.120
  12. Steiner JL, Bigatti SM, Ang DC. Trajectory of change in pain, depression, and physical functioning after physical activity adoption in fibromyalgia. J Health Psychol. 2015;20(7):931-941. doi:10.1177/1359105313504234
  13. Jamison RN, Edwards RR. Integrating pain management in clinical practice. J Clin Psychol Med Settings. 2012;19(1):49-64. doi:10.1007/s10880-012-9295-2
  14. Takai Y, Yamamoto-Mitani N, Abe Y, Suzuki M. Literature review of pain management for people with chronic pain. Jpn J Nurs Sci. 2015;12(3):167-183. doi:10.1111/jjns.12065
  15. Bruckenthal P, Marino MA, Snelling L. Complementary and integrative therapies for persistent pain management in older adults: a review. J Gerontol Nurs. 2016;42(12):40-48. doi:10.3928/00989134-20161110-08
  16. Mann EG, Harrison MB, LeFort S, VanDenKerkhof EG. What are the barriers and facilitators for the self-management of chronic pain with and without neuropathic characteristics? Pain Manag Nurs. 2017;18(5):295-308. doi:10.1016/j.pmn.2017.04.006

A Menu of Strategies for Chronic Pain Treatment in Primary Care
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