2. What are some of the typical medications used for the treatment of chronic pain ? What are some of the common side effects associated with these medications. May 11, Everyone feels pain from time to time, but chronic pain is different. Find out what causes chronic pain and how it can affect your emotional. Nov 28, Pain is your body's normal reaction to an injury or illness, a warning that something is wrong. When your body heals, you usually stop hurting.
Relief 2. Chronic Pain
Tools for assessing chronic pain: Kaiser Permanente Care Management Institute. This severity is defined as whatever the patient says it is—not how you as clinicians perceive the severity on the basis of patient behavior. However, we all have seen patients who rate their pain as being a 10—a number typically associated with hospitalization—despite their continued ability to function. Often, patients fear that using a smaller number will lead to their pain being given less priority.
Teaching patients how to effectively use the NRS is a first step toward making your patient your partner in their care. Tracking trends in functional progress is as important as evaluating the pain score.
Tracking progress in this way also helps fulfill documentation for regulatory requirements related to prescribing opioid therapy. Using KP HealthConnect, clinicians will soon easily track and record pain scale and functional scale just as is done currently for patients' vital signs. The basis of your care plan—ie, typical characteristics of pain sought while obtaining the medical history—can be remembered by using the mnemonic PAIN BASE Figure 3 , bottom: Pertinent physical examination is a critical part of any evaluation for pain.
Having these facts makes the resulting treatment plan more likely to succeed. This tool has the benefit of crosscultural reliability and validity and is available in multiple languages, including Spanish, Chinese, and Tagalog. Although not required, use of such tools better documents the severity of pain and its persistence. In patients with acute herpes zoster, acute low back and neck pain, or acute musculoskeletal pain, the likelihood of having chronic pain is increased by several risk factors:.
As these risk factors show, many of the criteria for moderate-to-severe risk relate to pain-related distress and to the patient's ability to function Figure 4. How can you screen for this risk and identify patients at higher risk? Analytic tool for assessing a patient's pain-related distress in relation to sensation and function. Neuropathic pain is defined as abnormal processing of sensory input by the peripheral and central nervous system.
This abnormality may be the critical process in development of chronic pain. Allodynia is diagnosed when normally nonpainful sensations eg, light touch or temperature changes are painful. Sunburn is a good example of a condition causing allodynia. In clinical practice, neuropathic pain is common in painful diabetic neuropathy and in postherpetic neuralgia and may occur as a result of orthopedic injury. However, physical examination of the patient may show no obvious cause of the pain.
Neuropathic pain is an important symptom to recognize, because delayed or otherwise ineffective treatment can result in chronicity and in permanent change in the nervous system.
Neuropathic pain often responds more fully to adjuvant medication eg, antidepressants or anticonvulsants than to opioid analgesics. Benefit may be seen within two weeks after initiation of treatment or may be delayed for several weeks.
Opioid analgesics may be needed; if so, higher doses may be necessary because of changes in the nervous system that produce resistance to the effect of the drugs. Patients suspected of having complex regional pain syndrome CRPS, previously known as reflex sympathetic dystrophy, RSD who do not respond rapidly to adjuvant treatment should be referred to a pain specialist.
Signs of possible CRPS in an extremity include. When suspected neuropathic pain does not respond to treatment, early referral to a pain specialist is recommended. Addiction is defined as a psychic compulsion to continue taking a drug on an ongoing basis—and despite harm—to obtain effects other than pain relief. Addiction is a major problem in the general population, but most patients are not at risk for substance abuse. Patients at low risk include middle-aged or older patients with no prior drug or alcohol abuse and a stable family and social history.
Concerned about potential addiction, many clinicians fear prescribing opioid analgesics; however, the actual risk of opioid abuse is comparable to the incidence of alcohol abuse in the general population. When considering long-term opioid use for chronic, noncancer pain, you must assess your patient's potential for and risk for abusing these drugs. Cancer experts also are beginning to recognize that addictive disease can be a problem in some cancer patients because these patients are living longer and therefore, receiving long-term analgesic drug therapy even if not cured.
You should be cautious about prescribing long-term opioid analgesics for young patients, patients with severe psychological pathology eg, personality disorders or schizophrenia , and patients with a history of chemical dependency.
Before initiating long-term opioid therapy, clinicians can use the CAGE-AID tool to assess for risk of addiction or whether a patient may already be addicted to alcohol or drugs. A single positive response suggests that the clinician should exercise caution in prescribing opioids to the patient; two or more positive responses suggest the need for increased vigilance by the physician prescribing opioid analgesics to the patient.
If long-term use of opioid analgesics is considered appropriate, do discuss the pros and cons of this therapy with patients and document their informed consent. Some physicians find useful a written agreement of the opioid therapy plan with specification of the conditions under which opioid analgesics will be prescribed. An easy-to-use template of an opioid therapy plan will be readily accessible for your use in KP HealthConnect. Monitoring your patients receiving opioid therapy is of paramount importance.
This is called pseudoaddiction because it is often mistaken for the true drug-seeking behavior of addiction. Other common signs of pseudoaddiction and inadequate analgesia include. Whereas pseudoaddiction resolves when the patient obtains adequate analgesia, true addictive behavior does not. Some patients with a history of substance abuse or the potential for it also have chronic pain and may need opioid therapy.
Do not hesitate to seek the advice of an addiction medicine specialist whenever you are concerned about the risk of addiction. Reassess your patients periodically for adequate pain control and side effects. If pain is continuing, check to see if they are taking their medications correctly and following the prescribed care plan before you try a new approach or increase medication dosage. Patients might not volunteer the information that they have stopped taking a medication because of a side effect, fear, cost, or the disapproval of a family member or friend.
Treatment of pain is an expected part of good medical management, and all physicians should therefore address the problem to the best of their ability. Sometimes, however, despite your best efforts—and just as for any medical condition—consultation will be needed. This need will vary, depending on the physician's knowledge and skills and on availability of support systems for monitoring pain. For patients with chronic pain lasting more than three months and unresponsive to conventional treatment, consider referral to a Pain Management Program.
Moderate- to high-risk patients with either acute or chronic pain unresponsive to an optimized multimodal treatment should be given this referral early to try to minimize development of nervous system hypersensitivity. Treatment of pain is an expected part of good medical management …. Treatment may include medical evaluation and consultation, highly technical interventional and implantable techniques, and cognitive-behavioral intervention as indicated.
However, because internal services vary from region to region, you should educate yourself about your local resources for pain management within and outside KP. Intranet resources include our National Clinical Library. Internet resources include http: Members can also go to http: Risk stratification characteristics for patients with acute and chronic pain 6. In an ideal scenario, most patients who undergo specialty evaluation return to primary care for ongoing management.
Good communication between all clinicians is crucial for providing consistency of care during and after treatment and therefore cannot be overemphasized. Consider using cognitive behavioral therapy CBT for any patient who presents a challenging pain management situation or who has poor social, occupational, physical, or psychological function.
CBT is a psychotherapeutic approach delivered in a series of group and individual sessions focusing on the interrelation of cognition, mood, behavior, and symptoms. Contrary to popular misconception, CBT is not a health education class. Based on complex theory of personality and psychopathology, CBT includes an integrated program of well-defined therapeutic strategies and techniques interventions for use by trained psychotherapists. Of great importance is that you assure your patient upfront that using CBT does not mean that the pain is not real or that the patient has a psychological problem.
Educate the patient that every illness has psychological as well as physical components and that a comprehensive approach is intended to help the patient to regain function. Remember that CBT represents only one modality for treating chronic pain. Unless their pain is already optimally controlled, patients with this diagnosis are likely to benefit from full consultation at your Pain Management Program. Pain exists on a continuum, and acute pain sometimes leads to chronic pain as it molds the nervous system and your patient's life.
To treat these patients effectively, clinicians should not expect success from simply prescribing medication; early, effective pain management is the best preventive therapy for chronic pain. For patients who already have chronic pain, multimodal treatment is key and must address not only pain relief but also the negative impacts of chronic pain and analgesic medications on the patient's life, sleep patterns, psychosocial distress, conditioning, retraining, and pacing.
Under your care, with optimal pain management, your patients can get their lives back. Christine M Evans, PhD, assisted development of the assessment strategies.
Adapted and reproduced by permission of the publisher: Chronic pain management guidelines [monograph on the Intranet]. National Center for Biotechnology Information , U. Journal List Perm J v. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Open in a separate window. Higher-Acuity Patients Need More Aggressive Medical Management As with any medical condition, pain can be graded across a continuum as presenting low, moderate, or high risk of poor clinical outcome on the basis of the patient's affective, behavioral, and physical functioning; use of medications; comorbid conditions; and ability in self-management.
Chris should be evaluated and treated as indicated in the following grid: Patient at Moderate Risk for Poor Clinical Outcome level 2 Joe has a long history of low back pain and has had two back surgeries in the past five years. Joe should be evaluated and treated as indicated in the following grid: Pat should be evaluated and treated as indicated in the following grid: Good pain control may prevent development of chronic pain ….
Room for Improvement As is true for managing any condition, good assessment is key. The goals of assessment are to obtain the physical and historical information needed to reach a diagnosis. S ide E ffects: Risk Factors for Development of Chronic Pain: Care Management Institute Chronic Pain Guideline 7 In patients with acute herpes zoster, acute low back and neck pain, or acute musculoskeletal pain, the likelihood of having chronic pain is increased by several risk factors: Unrelieved moderate-to-severe pain an evidence-based determination.
Lack of active coping skills, eg, realistic goal setting, pacing, realistic beliefs about condition an evidence-based determination. Deficits in the following: Be on the Lookout for Neuropathic Pain!
Signs of possible CRPS in an extremity include allodynia, hyperesthesia, or both. Fears of Addiction and Monitoring for Abuse Addiction is defined as a psychic compulsion to continue taking a drug on an ongoing basis—and despite harm—to obtain effects other than pain relief. Wanted or needed to C ut down on drinking or drug use? Pain has been shown to interfere with self-management activities, sleep , physical functioning, work, family relationships, mood, and quality of life.
To make matters worse, pain is often invisible to others, so family members, coworkers, and health-care professionals often have no idea what a person in pain is going through. Acute pain is what a person feels from an injury like a burn or a medical problem like an earache. Rest the part that hurts! Acute pain is a lifesaver. Without it, we would have to watch out all the time to keep from injuring or killing ourselves accidentally. This is why people with diabetes are advised to check their feet visually or manually every day: Chronic pain is different from acute pain.
Sometimes there is ongoing inflammation or irritation, and sometimes not, but in chronic pain, the nervous system amplifies pain signals or misinterprets sensations as being much worse than they are. We can see from brain mapping that chronic pain uses very different nerve paths from acute pain. In fact, the brain maps of chronic pain look just like the brain maps of intense emotions like anger, or sadness, or fear.
Like all sensations, pain is created by the brain from all kinds of input. The actual signals from nerve endings are part of the input. But those signals get blended with other sense signals and with thoughts, feelings, and memories. Then the brain organizes all this data and tries to make sense of it. Chronic pain is a whole body—mind experience. It always has a physical component, and it always has an emotional component, and there may be other factors as well.
More often, it is caused by nerves that have become oversensitive or by a brain that is misreading the signals it receives. If acute pain goes on too long, nerves and brain can tire of the constant signals and just decide the injury is permanent. A good way to understand the many causes of chronic pain is by considering phantom limb pain.
When people lose an arm or leg in an accident or surgery, about half of them will still feel that the limb is there. About half of those people develop serious pain in the phantom limb.
The brain figures the signals add up to something seriously wrong, so it sends out an urgent pain message. The same thing applies to the chronic back and leg pain so many people have. There may be a few pain signals coming up from tired muscles or joints toward the brain. In people with chronic pain, the gates amplify the signals over and over until the pain is severe. Anything that makes nerves more sensitive can increase pain. Feelings of stress, fear, helplessness, or anger can increase pain sensitivity.
Trauma — such as a physical injury or psychological or sexual abuse — often leads to chronic pain later on. It may be that trauma causes nerves to become oversensitive as a way of trying to prevent further injury. This may be why military veterans have the highest rates of chronic pain. Chronic pain creates several vicious cycles. For one, people tend to tense their muscles in response to pain, which often makes the pain worse. Pain also leads people to stop moving, which leads to increasing stiffness and more pain.
Pain can interfere with sleep, and restless nights can increase pain. Pain also can contribute to depression and painful emotions such as anger, grief, fear, and frustration, which in turn contribute to pain. Since chronic pain has so many contributing causes — physical, mental, and emotional — there are many ways to break into the pain cycle, reduce pain levels, and gain comfort. There may not be a cure for chronic pain, but a person can gain some control over his pain. Feeling more in control, even a little bit, can help people relax, try new things, and gain even more control.
In this way, even severe chronic pain can be managed, and the person with pain can gain better health in the process.
There are five main approaches for treating and self-managing pain: Physical treatments for chronic pain can include applying heat or cold to the part that hurts, massage , exercise, and rest. Sensations of heat, cold, and touch travel on the same nerves as pain sensations, but they travel faster. A sensation of gentle touch, heat, or cold will therefore beat a pain signal to the next pain gate and block the pain from getting through.
Certain substances including capsaicin chili pepper extract provide a sensation of heat when rubbed on the skin that may keep a pain gate blocked for hours. Exercise is often one of the best treatments for pain. I do horizontal and inclined bench presses. I started with 50 lbs and built to lbs.
The benches provide complete back support. Strengthening muscles eases pressure on the joints and tendons. It also gives you a greater sense of control, which really helps people deal with pain.
Stretching to increase your flexibility can also be helpful for pain relief, when done as part of a regular exercise routine. Walking, sitting, and moving with good posture and balance can take pressure off tender muscles and nerves. You may want to consult a physical therapist to find exercises that are right for you. Massage and other kinds of bodywork can greatly relieve pain.
Bodywork can include acupressure, shiatsu, and various other types of therapeutic touching or manipulation of the body. Certain drugs may also help to control pain.
These include anti-inflammatory medicines such as ibuprofen, aspirin, naproxen, indomethacin, and many others. While some of these are sold over the counter, they can have side effects, most notably gastrointestinal bleeding. A newer anti-inflammatory, celecoxib Celebrex , may have fewer gastrointestinal side effects.
Many drugs can help calm down overactive pain nerves. These include antiseizure medicines such as gabapentin brand name Neurontin and pregabalin Lyrica.
Since seizures are the most obvious case of oversensitive nerves, it makes sense that seizure drugs might help chronic pain. Lyrica seems to have fewer side effects than Neurontin and another drug, Topamax, which often cause mental fogginess.
Electrical stimulation can sometimes block pain signals from traveling up the nerves. The most commonly used system is called TENS , which stands for transcutaneous electrical nerve stimulation. TENS works by sending electrical pulses across the surface of the skin into the nerves. The stimulating pulses help prevent pain signals from reaching the brain. They also help stimulate your body to produce higher levels of its own natural painkillers, called endorphins. Relaxation exercises, meditation, and prayer also help nerves calm down.
So can doing relaxing things like spending time in nature, playing with a pet, or engaging in a hobby like knitting or painting. Chronically high blood glucose levels are known to damage nerves, so keeping blood glucose levels close to the normal, nondiabetic range can greatly reduce neuropathic pain.
Sometimes, however, if nerve damage has caused numbness in the feet, legs, hands, or arms, improving blood glucose control can cause pain in these areas as the nerves start to heal and regain function. The pain is usually temporary.
About Chronic Pain
Feb 14, COX-2 inhibitors are commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps. pain syndromes; Narcotics; Nociceptors; Pain; Physical fitness; Physical medicine. CHRONIC PAIN SYNDROME. 2. I Objective.-Dtflerentiate patients with acute. Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is.