Treating Pain
Without Opioids

Why You Should Consider Alternative to Opioids

While there are a time and place for opioids, other pain management techniques are available to help reduce pain without the fear of overdose or addiction. Some of the reasons to consider treating pain without opioids include:

It reduces the risk of overdose

Opioids do not address the source of the pain

Opioids do not increase function

Opioids may increase pain and pain sensitivity over time (doctors call this condition enhanced pain sensitivity)

Opioids don't relieve neuropathic (nerve) pain

An estimated 20 percent of Americans experience chronic pain.1 There are many non-opioid pain treatment alternatives. Frequently, a combination of pain-relieving techniques can help reduce reliance on opioids for managing pain.

If you or a loved one currently takes opioids for pain management, consider speaking to your physician about potential non-opioid treatment options. By working with your doctor and exploring new ways of relieving pain, you may find relief without using opioids.

Video: We Must Address Pain Beyond Opioids

Transcript: I haven't prescribed an opioid for chronic pain in at least a decade and I really very very rarely think that there would be any setting in which you would 00:15 use an opioid for conditions like fibromyalgia interstitial cystitis irritable bowel headache those types of things I think there are some other conditions for where you know made it maybe opioids are still useful for refractory patients but they really 00:29 should be used after you've used all the other pharmacologic and nonpharmacologic therapies in the chronic pain space there are a lot of drug and non drug treatments that can be a quite effective for chronic pains that are underutilized 00:44 in routine clinical practice there are classes of drugs like tri cyclic drugs gabapentin oeid serotonin norepinephrine reuptake inhibitors that can be quite effective in the treatment of individuals with chronic pain and are 01:00 not always considered or used in individuals with chronic pain and then there are a wide array of non drug therapies things like exercise cognitive behavioral therapy a number of complementary alternative therapies that can likewise be quite effective for 01:15 individuals with chronic pain so especially in light of this new evidence both that narcotics don't work for most types of chronic pain and that over prescribing of narcotics in the United States has led to a serious public 01:31 health problem with many deaths and overdoses we need to modify how we approach individuals with product seen and opioids really if they're ever used to treat chronic pain should be reserved 01:45 for individuals that have tried all of the other drug and non drug treatment options and only after people have failed all those other types of therapy should either the doctor or the patient really seriously consider an opioid for the management of chronic pain

Physical Non-Opioid Pain Management

Acupuncture 

Acupuncture is a traditional Chinese medicine that involves inserting small, thin needles into key areas of the body to re-direct energy flow in the body. Several studies suggest that acupuncture works particularly well at addressing chronic back and neck pain, knee pain, and headache. There is also some evidence to suggest that acupuncture may help prevent migraines.

Some people don’t like the idea of acupuncture because they’re afraid of someone sticking and leaving needles in their bodies. However, the needles are very small and thin. They aren’t meant to inflict pain, but instead, they relieve pain by releasing endorphins, the body’s natural pain-killing chemicals, and work to improve an overall sense of well-being.

Exercise 

Exercise involves moving, stretching, and engaging in physical activity. Though it may seem counterintuitive, exercise can help some people address chronic pain. Exercise helps maintain a healthy weight, which helps to reduce pain related to conditions like arthritis. Also, exercise helps to relieve stress and anxiety while also releasing chemicals in the brain called endorphins. These are feel-good chemicals that can help reduce pain naturally and increases a sense of well-being.

The Cochrane Database of Systematic Reviews conducted a review of studies about exercise and pain relief.1 They included 21 studies that enrolled more than 35,000 participants. Some of the pain-related conditions they studied included low back pain, rheumatoid arthritis, spinal cord injury, and patellofemoral (knee) pain.

Researchers found that exercise helped to reduce pain severity and improved physical function in people with chronic pain. Those with chronic pain who engaged in exercise also reported an improved quality of life compared to those who did not exercise.

It’s important to understand that some people may have medical conditions that prevent rigorous exercise. It’s always important to talk to your doctor before starting an exercise program if you have concerns about physical ability. Doctors may be able to suggest adaptive exercises or low-impact movements that would work better for you.

Nerve Blocks

Nerve blocks are a pain treatment approach where a doctor injects a local anesthetic into the skin and around nerves that are responsible for the pain. While doctors can’t block all nerves, they can typically block abdominal, knee, back, and shoulder pain. Sometimes, doctors will insert special catheters (small, thin plastic tubes) that can deliver continuous amounts of a local anesthetic to provide longer-lasting pain relief.

Non-Opioid Medications 

Opioid medications like morphine, fentanyl, and hydrocodone aren’t the only medicines that can relieve pain. There are over-the-counter(OTC) medications that provide pain relief. The benefit of these medicines is that they don’t have the addictive potential of opioids. While it is possible to overdose on some OTC medications, the amount you’d have to take is extremely high.

Examples of non-opioid medications used to treat pain include:

Ibuprofen (Advil, Motrin)

Acetaminophen (Tylenol)

Aspirin (Bayer)

Naproxen Sodium (Aleve)

These medications often work to relieve inflammation and reduce pain in the body. They’re inexpensive and usually available as generic options. When used in combination with other treatments, like physical therapy, non-opioid medicines can effectively help manage pain.2

Physical Therapy 

Physical therapy is the use of exercises and equipment like whirlpools, massage, and ultrasound therapy to help stretch and strengthen muscles and tendons in the body. Physical therapy can help build up muscles around injuries, so there is less demand on the injured area.

Physical therapy also helps address what’s causing pain in the first place. By rehabilitating an injured part of the body, a physical therapist can teach ways to improve overall functioning. This education has the power to help a person feel better long-term.

Radiofrequency Ablation 

This approach involves using radio waves to relieve pain. To do this, a doctor will insert a thin needle near the nerve sending pain signals to the brain. They then use electric current to damage or destroy the nerve. This will prevent the nerve from transmitting pain signals for some time.

If the approach sounds similar to nerve blocks, it is. However, according to the American Society of Anesthesiologists, using radio waves can last up to a year.

Spinal Cord Stimulation 

Spinal cord stimulation is a special device that doctors can implant near the spinal cord. The device itself is in the lower back and has special wires that go to the spinal cord. A special remote control can be used by the person when pain sensations occur. The spinal cord stimulator releases signals that help to “interrupt” traditional pain signals. Instead of feeling a sharp or stabbing pain, they may instead feel a tingling sensation.

In addition to treating problems like back pain, spinal cord stimulation also helps to reduce symptoms in people with peripheral neuropathy, which is a common source of pain and numbness in people who have diabetes with nerve damage.

Therapeutic Massage

Therapeutic massage involves using the hands to knead and rub the skin to help relieve muscle tension. Other benefits of therapeutic massage include:

Reducing joint pain

Relieving stress

Reducing anxiety

Some researchers think that therapeutic massage helps to reduce pain by stimulating the surrounding nerves that aren’t transmitting pain signals.3 Basically, the massage and stimulation to healthy nerves drown out the signals of pain, resulting in an overall improvement in well-being.

Several studies have shown the benefits of massage for those with chronic pain. A 2014 study published in the Annals of Family Medicine found that hour-long massage sessions two to three times a week helped to relieve chronic neck pain when compared to shorter massage sessions or no massage at all.3

There are many different types of massage. Sometimes, a person may be afraid the massage will be too “deep” or strenuous on their body. That’s why doctors recommend finding a licensed massage therapist that can help a person identify the best approach to massage with consideration to overall health and pre-existing medical conditions. If there is an active or inflamed area of skin, the massage therapist should know to avoid that area of skin to prevent the further transmission of the infection.

Transcutaneous Electrical Nerve Stimulation Therapy

Transcutaneous electrical nerve stimulation therapy involves using special devices that send out low-voltage electrical signals. The device is typically worn and is called a TENS unit. The device has small electrodes on it that can transmit electricity to the skin.

Doctors are the first to admit, they don’t know exactly why TENS units work. They think that the therapy may stimulate the feel-good chemicals called endorphins and that it interrupts pain signals between the brain and body.

Yoga

Yoga is a therapeutic approach that involves engaging in a series of stretching exercises. Yoga practitioners also commonly engage in breathing exercises to focus the minds while bending and stretching in different poses.

There are many options to participate in yoga, including taking a yoga class at a gym, exercise studio, or community center. There are also a variety of yoga videos available on streaming sites and YouTube that anyone can watch at their home. This makes yoga a low-cost option to relieve chronic pain. Typical yoga sessions include deep breathing and moving through several different poses.

Yoga doesn’t have to mean a person can bend and twist like a pretzel. A lot of different adaptive yoga positions are available for people of all movement abilities. Some people can even perform yoga from a seated position, which is very helpful for those with chronic pain who are wheelchair-bound.

According to the Harvard University Press, several studies support the use of yoga in treating chronic pain.4 For example, an analysis of 17 studies found yoga helped improve daily functioning for patients with fibromyalgia with osteoporosis-like symptoms and back pain. Another study found that weekly yoga sessions helped improve mobility and reduced pain in people with chronic lower back pain.

Mental Non-Opioid Pain Management

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a therapy approach where a person learns how to recognize emotions, thoughts, and behaviors and adjust their perspective on them. According to an article in the journal Medicine (Baltimore), cognitive behavioral therapy is one of the most effective psychiatric interventions for addressing chronic pain.5 CBT works to reduce chronic pain by adjusting how a person responses to physical sensations and behaviors that may contribute to the pain. For example, when a person starts to recognize pain or starts to feel anxious, depressed, or nervous due to the pain, CBT teaches relaxation techniques, distraction activities, mantras, or other options that help reduce the feelings of pain.

CBT understands that some people with a chronic pain syndrome, including complex regional pain syndrome (CRPS), have a variety of causes that contribute to the sensations of pain. Examples include immune system sensitivity, how a person senses and responds to pain, and responses from the central and peripheral nervous system. Fortunately, CBT is a common therapeutic approach. Many therapists can provide this therapy to help people learn how to identify and deal with their pain.

Hypnosis

Hypnosis is a lot more than waving a watch back and forth. Hypnosis helps a person achieve a state of deep relaxation and comfort. In the treatment of chronic pain, hypnosis helps a person find a relaxing state when they feel pain or discomfort. Examples could include teaching a person to close their eyelids and take deep, full breaths to help themselves relax.6 Hypnotists call this practice “self-hypnosis.”

In a review of 13 studies on hypnosis, researchers concluded the following:6

Cancer Pain

Patients who used self-hypnosis along with group therapy participation experienced significant pain reductions when compared to those who participated in group therapy without self-hypnosis.

Lower Back Pain

Patients who use self-hypnosis to promote relaxation said they felt greater reductions in lower back pain when compared with patients who did not. 

Arthritis Pain

A small study of patients with arthritis found those who participated in hypnosis had lower pain intensities compared to those who did not participate in hypnosis. 

Fibromyalgia

Patients with fibromyalgia reported reductions in muscle pain, problems sleeping, and fatigue over the course of three months with the practice of self-hypnosis. 

In most instances, self-hypnosis or hypnosis was more effective than no intervention at all in relieving pain.6 When used in coordination with other methods, such as cognitive-behavioral therapy, physical therapy, and over-the-counter medications, hypnosis helps to reduce chronic pain.

Meditation 

Meditation, or what some doctors call mindfulness meditation, is a practice that involves focusing on breathing while blocking out the surrounding environment.7 A study from the National Center for Complementary and Integrative Health asked patients to engage in meditation while also getting a magnetic resonance imaging (MRI) scan.7 Then, the researchers gave participants the medication naloxone (Narcan). This medicine blocks opioid receptors in the brain. Participants then engaged in meditation while they underwent another MRI.

At the end of the study, researchers found that people reported pain relief from meditation, even when they had taken naloxone to block opioid receptors. The researchers concluded that there are many other pathways in the body, other than opioid receptors, that could help relieve pain. This is promising for those who want to relieve pain using other approaches besides opioid pain relievers.

Pain Skills Workshops 

Pain skills workshops are workshops designed to help patients who experience chronic pain. You may see these workshops advertised as “Chronic Pain Self-Management Programs.” Some of the key services that these workshops provide include:

Exercises that can help with chronic pain and advice on how to pace one's self

Communication skills to teach how to best communicate with others about pain

Aspects of nutrition in pain management

Strategies to avoid common frustrations and concerns in those with chronic pain, such as fatigue, frustration, and problems sleeping

A study published in the journal Patient Education and Counseling studied the effects of a Chronic Pain Self-Management Program on 74 women and 13 men from Denmark who reported having chronic pain for more than ten years.8 The six sessions program focused on helping teach non-opioid methods to relieve pain.

The researchers followed up with the patients five months after completing the program.

75% of the people who participated said they would recommend the program to other chronic pain patients.
75%

They reported reductions in:

Pain

Depression

Anxiety

Worries about health

The researchers concluded that pain skills management could help a person better self-regulate pain.

Video: A Better Way to Manage Chronic Pain

Transcript: My name is Katie coselli and I'm 62 years old I've been dealing with chronic pain most all of my life you get cranky and you tire easily and 00:15 you wonder why God are you making me hurt like this why can't you take this away the Depression was horrible my type she came to me she was very 00:29 upset she said her pain was much worse I explained to her some things that we could try and that one of them would be this new pain program called the P pact program and I thought another pain glass 00:43 I've only been to three and none of them done any good at all but for some reason I just said all right I'll give it one more shot one more shot 01:03 if you're attune to your body you can feel when your muscles starting to tighten that's the first red flag and at that point you need to just sit back and relax and just kind of unwind your muscles and do a little yoga or a little 01:16 imaging and that kind of stops it right there I think she will continue to have her painful condition and struggle from that but even in a day to day but it seems that she is much more able to manage it I can manage my own pain and I 01:31 don't have to rely on narcotics on a daily basis I have activities I have energy I can volunteer not much but five hours a week a volunteer I was actually thinking of maybe going back to work it's like night 01:47 and day I have a whole new life now day-to-day life

A Note on Marijuana and CBD

Marijuana and cannabinoid (CBD) oil are a growing area of research for pain management. Currently, many states have approved the use of medical marijuana to reduce pain as well as stimulate appetite in people with chronic illnesses, such as cancer.

CBD Versus THC

Marijuana contains a compound called tetrahydrocannabinol (THC) along with cannabinoids (CBD). CBD isn’t the same as THC. CBD isn’t psychoactive, meaning a person can’t get high from CBD alone. THC may have some pain-relieving effects, but it also causes mind-altering effects. For some people, this may include feelings of euphoria or being “high.”

How CBD Works

Doctors think that CBD products act on a different set of pain receptors in the body known as the endocannabinoid receptors.9 By targeting these receptors, doctors think that some CBD products may help to relieve pain.

A Word of Caution 

While many doctors think the field of marijuana and CBD for pain management has a lot of promise, they are cautious until there’s more research available. Currently, the U.S. Food and Drug Administration (FDA) hasn’t approved CBD as a medication. CBD is viewed as a supplement and is not regulated. Unfortunately, that means that it’s hard for people to know what kind of CBD or how much is actually in a product they buy.

A common misconception among Americans is that an organization regulates CBD. According to the American Society of Anesthesiologists, an estimated 40 percent of participants surveyed incorrectly believed that CBD found in medical marijuana and health food stores was FDA-approved. In reality, none of it is FDA-approved.

Even in states where marijuana is legal, doctors admit they can’t know what is in marijuana when they consider factors like pesticides, chemicals, and metals commonly found in marijuana.

While marijuana and CBD have a lot of promise in pain treatment, it’s important to remember that marijuana isn’t without its side effects. People with a history of addiction may want to consider alternative pain management practices rather than marijuana, as there is an increased risk of addictive behaviors with marijuana use. If you or a loved one is thinking about adding it to your overall pain management strategy, talk to your doctor first.

Factors That Can Make Pain Worse

Different people experience pain in different ways. Two people can have the same surgery, with one person experiencing significant pain afterward, while the other quickly recovers. While the person who is still in pain isn’t at fault, this example shows how pain is a complicated issue that affects both the mind and body.

Some of the factors that doctors have found can make pain worse includes:

Anxiety

Sometimes fear and worry about pain can be as crippling as the pain itself. Treating anxiety has been shown to reduce reliance on pain medications.10 Using techniques such as distraction, creating a non-threatening medical environment, and helping patients learn how to deal with feelings of anxiety can be extremely helpful in addressing chronic pain.

Inactivity

While there is a time to rest an acute injury, not moving usually does more harm than good when it comes to chronic pain.11 When the body isn’t active, there is a tightening of muscles and tendons that can cause additional stress. Also, people who don’t engage in regular exercise are more likely to be obese. Carrying extra weight and not engaging in physical activity can increase pain, especially in the lower back and knees.

Mood Disorders

An estimated 61 percent of patients who take opioids and struggle with chronic pain experience major depression.10 The conditions are closely linked, and doctors think depression can cause chronic pain just as chronic pain can cause depression.

If you find you are struggling with depression, it’s important to talk to your doctor about your feelings. Some people end up accidentally self-medicating with opioids as a means to escape feelings of sadness and depression.10 Medications and therapies are available to help address feelings of depression. These strategies can decrease opioid use and address chronic pain more effectively. This isn’t always true for all people, but it can be worth trying if you struggle with chronic pain and depression.

Stress

Chronic pain and chronic stress are closely related. In fact, one article published in the journal Chronic Stress described the two conditions as “two sides of the same coin.” 12 Doctors believe that chronic stress can lead to a dysregulation in the brain. This means that too much or too little brain activity is experienced in response to stress. This can aggravate a number of conditions, including chronic pain in the body.

Stress is a common experience for many individuals, but daily and continued stress overwork, social interactions, health conditions, and chronic pain can impact a person’s overall perception of health and well-being. The results can be an increased pain experience. People who experience chronic pain should take steps to reduce overall stress levels, which can often lead to a mild to dramatic improvement in overall health and well-being.12

Video: Lifestyle Strategies for Managing Pain

Transcript: Pain affects every aspect of our life not just our physical existence it can affect how we manage our tasks day to day can affect how we interact with our friends family and coworkers it has an emotional and mental impact on our lives 00:15 so looking at our day to day activities can really give us some good clues and tools for how to manage our pain overall someone might have some challenges during their day maybe not sleep so well and those are places that we can do some work with to again help improve their 00:31 quality of life lifestyle modifications are very important for helping someone manage their overall pain two important aspects to think about up front are your healthy diet and maintaining a healthy weight and these two things can make great impacts on how someone deals with 00:46 their pain pain and stress feed off of each other and this can lead to a vicious cycle for some patients pain again as a physical experience for patients and stress exacerbates that for a lot of our patients as well so looking 01:00 at your day to day activities on what our common stressors for you can be a great starting point for helping reduce your stress and likely reducing your overall sense of pain as well it is often really helpful to have a patient jot down their stressors and their triggers to look at the ways that they 01:16 can improve those things in their lives for example if someone were to find that their morning routine was really a big source of stress for them looking at that routine to figure out if there are ways that they can alter that perhaps even change some of those activities to the nighttime to alleviate the stress in 01:31 the morning can show us if that will help reduce their stress and help with their pain overall other techniques that can be helpful for reducing your day-to-day stress can be things like breathing exercises 01:44 meditation visual imagery and relaxation techniques so learning these things can be helpful for managing those acute moments of stress in your day-to-day life

How Sleep and Nutrition Benefit Healing and Pain Treatment

Good Sleep and Good Health

According to the National Sleep Foundation, pain, stress, and poor health are all connected.13 People with chronic pain sleep on average 42 minutes less than those who do not have chronic pain. Of those with chronic pain who report that it affects their sleep, 50 percent say their chronic pain also impacts their daily lives and work.

50% of Those With Chronic Pain Say it Impacts Their Daily Lives
50%

Doctors connect the ability to sleep well with good health. According to the National Sleep Foundation, people who report overall health and well-being at the highest levels sleep 18 to 23 minutes longer than people who report their health as good, fair, or poor.

Some tips to help people with chronic pain sleep well include:

Stopping caffeine consumption or refraining from consuming caffeine close to bedtime.

Refraining from drinking alcohol later in the evening.

Implementing a sleep schedule and bedtime routine.

Using relaxation techniques to help a person go to sleep, such as deep breathing and meditation before going to sleep.

Sleeping in a cool, dark, and comfortable location.

If opioids are being taken to relieve pain, caution should be used with any prescription or over-the-counter sleep aids. Always talk to your doctor before starting a sleep-promoting medication to see if the medicines could interact with current prescriptions.

Nutrition: Fuel for Healing

In addition to sleep, nutrition is another key aspect that may affect overall health and wellbeing when dealing with chronic pain. Doctors have found that chronic inflammation in the body can contribute to pain. A person’s diet – good or bad – can affect the levels of inflammation in the body, thereby impacting pain levels.

Inflammation is essentially damage and irritation of healthy cells that can lead to pain. According to Harvard University, inflammation in the body can increase the likelihood of a number of health conditions, including diabetes, cancer, heart disease, and Alzheimer’s disease.14 Studies also indicate that a healthy diet can strengthen the immune system, while an unhealthy one can negatively affect it, causing inflammation in the body.

Foods to Reduce Pain

The solution can be to follow an anti-inflammatory diet. One of the best-known anti-inflammatory diets is the Mediterranean diet. This is a meal plan that includes a high amount of foods like berries, dark and leafy green vegetables, nut, whole grains, and legumes. These foods are high in inflammation fighters called antioxidants. Foods that have omega-3 fatty acids, such as fish, olive oil, and flaxseed oil may also help reduce inflammation and pain.

Foods to Avoid

In addition to eating beneficial foods, it’s a good idea to avoid some foods that are known to contribute to inflammation. Examples include soda, foods with high-fructose corn syrup, processed meats, and foods that have refined carbohydrates, such as white pasta, white bread, and white rice. The good news is that following this meal plan not only reduces inflammation (and, therefore pain), it can also help improve overall health.

While a healthy diet and good sleep aren’t the only ways to improve chronic pain, they are lifestyle changes that can make a big difference. Taking steps to improve both can help to improve overall health.

Finding Pain Relief Free from Opioids

Opioid pain relievers aren’t the only option when it comes to treating pain. While they may represent a beneficial treatment for some, taking steps to better respond to pain and increasing overall health through movement, diet, and better sleep can also help reduce pain.

If you aren’t quite sure where to start, talk to your doctor about your pain and overall health. You can discuss some of the interventions mentioned in this article and determine what will help you live better with your chronic pain. While you may not get the same immediate results that you might with a pain pill, non-opioid strategies can provide a safer and longer-lasting solution to managing chronic pain.


Resources

  1. Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A. & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, 2017(4): CD011279.
  2. Non-opioid treatment. (n.d.). Retrieved December 21, 2019 from https://www.asahq.org/whensecondscount/pain-management/non-opioid-treatment/
  3. Therapeutic massage for pain relief. (2016, July). Retrieved December 21, 2019 from https://www.health.harvard.edu/alternative-and-complementary-medicine/therapeutic-massage-for-pain-relief
  4. Yoga for pain relief. (2015, April). Retrieved December 21, 2019 from https://www.health.harvard.edu/alternative-and-complementary-medicine/yoga-for-pain-relief
  5. Lim, J. A.C., Choi, S. H., Lee, W. J., Jang, J. H., Moon, J. Y., Kim, Y. C., & Kang, D. H. (2018, June). Cognitive-behavioral therapy for patients with chronic pain. Medicine (Baltimore), 97(23): e10867.
  6. Elkins, G., Jensen, M. P., & Patterson, D. R. (2009). Hypnotherapy for the management of chronic pain. International Journal of Clinical and Experimental Hypnosis, 55(3): 275-287.
  7. Chen. W. G. (2016). Mindfulness meditation reduces pain, bypasses opioid receptors. Retrieved December 21, 2019 from https://nccih.nih.gov/research/blog/mindfulness-meditation-pain
  8. Mehlsen, M., Heegarrd, L. & Frostholm, L. (2015). A prospective evaluation of the Chronic Pain Self-Management Programme in a Danish population of chronic pain patients. Patient Education and Counseling. 98(5): 677-680.
  9. Non-opioid treatment. (n.d.). Retrieved December 21, 2019 from https://www.asahq.org/whensecondscount/pain-management/non-opioid-treatment/
  10. Hansen, G. R. & Streltzer, J. (2005). The psychology of pain. Emergency Medical Clinics of North America, 23(2005): 339-348.
  11. Non-opioid treatment. (n.d.). Retrieved December 21, 2019 from https://www.asahq.org/whensecondscount/pain-management/non-opioid-treatment/
  12. Abdallah, C. G. & Geha, P. (2017). Chronic pain and chronic stress: two sides of the same coin? Chronic Stress. Retrieved December 22, 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546756/
  13. Pain and sleep. (n.d.). Retrieved December 22, 2019 from https://www.sleepfoundation.org/articles/pain-and-sleep
  14. Can diet heal chronic pain? (2018, July). Retrieved December 22, 2019 from https://www.health.harvard.edu/pain/can-diet-heal-chronic-pain