II. Pitfalls

  1. Avoid lumping
    1. Acute and Chronic Pain are not treated the same way
  2. Opioids are not a universal panacea
    1. Opioids are not significantly effective in Chronic Pain
      1. Only 20% will have good relief in some studies
      2. Opioid tolerance may develop within 2 weeks of start
      3. Opioids may paradoxically increase pain (Opioid-Induced Hyperalgesia)
    2. Opioid related adverse effects are common
      1. Nausea, Vomiting and Constipation
      2. Respiratory depression
      3. Lower quality of life and higher depression rate are associated with Chronic Opioid use
      4. Rates of misuse, abuse, diversion and Overdose have increased substantially since the late 1990s
  3. Constantly reevaluate therapy
    1. Discontinue or modify ineffective treatments
  4. Complete control of Chronic Pain is unrealistic
    1. Attempting complete pain control will lead to over-medication and complications
    2. Patients own their Chronic Pain condition and we help them treat it
    3. In some cases, patients may attempt to guilt a provider into the responsibility of eliminating pain
      1. I'll be forced to get Narcotics on the street
      2. You are not giving me good pain relief
      3. You give me Narcotics to control my pain, and I'll participate in your physical therapy plan
  5. Chronic Pain is unlikely to be completely cured or eliminated
    1. Consider as chronic disease such as diabetes or heart disease
    2. Do not expect to fine-tune pain or treat daily breakthrough pain
    3. At the best, expect 30-40% control of Chronic Pain overall with medical management
      1. It is patient's job to find ways to control the rest of pain
        1. Providers can help expand their non-medication toolkit
      2. Patient needs to establish non-medication strategies for treating the day-to-day flairs
  6. Do not prescribe longterm strategies (e.g. Opioids) to non-compliant patients
  7. Constantly assess for comorbid conditions
    1. Major Depression
    2. Anxiety Disorder (associated with Chronic Pain in up to a third of patients)
    3. Chemical Dependency
  8. References
    1. Belgrade (2009) Chronic Pain Management UMN CME Conference, Minneapolis

III. Protocol

  1. Complete thorough Pain Evaluation that is updated at each visit
  2. Consider referral to pain management specialists
  3. Periodic repeat review of treatment plan and outcomes (Mnemonic: 6 As)
    1. Analgesia: Pain relief
    2. Affect: Mood?
    3. Activities: Quality of Life and Activities of Daily Living
    4. Adjuncts: Nonpharmacologic and non-Opioid medications
    5. Adverse Effects: Medication side effects
    6. Aberrant behavior: Increasing tolerance, Drug Dependence, addiction
  4. Medical records should reflect systematic process of evaluation and treatment
    1. Document Pain Evaluation, treatment plan, Consultation, Informed Consent and contracts
    2. Document medication history
    3. Document high risk behaviors (e.g. drug seeking)
  5. Follow a written treatment plan
    1. Include both non-pharmacologic (e.g. lifestyle) and medications
    2. Establish realistic objectives of successful treatment
    3. Address future diagnostic testing if needed
  6. Obtain Informed Consent
    1. Risks and benefits are discussed
    2. Pain Contract should be a part of the normal process
    3. Discuss reasons for cessation of treatment (breaking contract)
    4. Consider Urine Drug Screening

IV. Management: Emergency Department Protocols

  1. Flag patients who meet criteria for a formal pain management plan
  2. Assign patients record for review by a patient care coordinator (e.g. RN, social worker)
    1. Review and summarize complicated history and prior treatment
  3. Establish Comprehensive care plan for Narcotic administration and pain management
    1. Emergency department staff
    2. Primary care team
    3. Pain management Consultation

V. Management: General

  1. Treat specific conditions (each condition has specific guidelines for non-pharmacologic pain management)
    1. No single pain reduction strategy works in every painful condition
    2. Low Back Pain
      1. General Exercise, motor control Exercises, Yoga and Tai Chi
      2. Cognitive Behavioral Therapy (CBT), Pain Physiology education, Mindfulness, Progressive Muscle Relaxation
      3. Spinal Manipulation, Acupuncture, dry needling, massage (short-term), low level laser therapy (short-term)
      4. Interdisciplinary pain rehabilitation
    3. Neck Pain
      1. Neck, upper back and Shoulder Exercises and motor control Exercises
      2. Cognitive Behavioral Therapy (CBT)
      3. Spinal Manipulation, Acupuncture, trapezius Trigger Point Injection, low level laser therapy (short-term)
    4. Radicular pain
      1. General Exercise, yoga
    5. Hip Osteoarthritis
      1. General Exercise, specific physicial therapy protocols (e.g. strengthening, flexibility, range of motion)
      2. Manual Therapy
    6. Knee Osteoarthritis
      1. General Exercise, aerobic, strength and aquatic Exercise, specific physicial therapy protocols, yoga
      2. Massage (short-term)
    7. Fibromyalgia
      1. General Exercise, aerobic, strength and aquatic Exercise, yoga, Tai Chi
      2. Cognitive Behavioral Therapy (CBT), Guided Imagery or Hypnosis
      3. Acupuncture, Myofacial release, low level laser therapy (short-term)
      4. Interdisciplinary pain rehabilitation
    8. References
      1. Flynn (2020) Am Fam Physician 102(8):465-77 [PubMed]
  2. Set realistic goals (complete elimination of pain is not realistic)
    1. Decrease physical limitations and improve occupational functioning
    2. Improve social, psychological and interpersonal functioning
    3. Improve quality of life by increasing pleasurable activities
    4. Patient Education regarding Pain Physiology
  3. Lifestyle changes
    1. Tobacco Cessation
    2. Weight loss
    3. Exercise
    4. Stretching and Yoga
  4. Treat Myofascial Pain
    1. Fibromyalgia
    2. Myofascial Pain Syndrome
  5. Consider physical rehabilitation methods
    1. See Chronic Pain Management with Physical Therapy
    2. Transcutaneous electrical nerve stimulation (TENS)
    3. Acupuncture
    4. Massage
    5. Stretch and Spray
    6. Trigger Point Injection
    7. Nerve Blocks
  6. Approach is similar to treatment of Somatization
    1. Non-Pharmacologic Management is critical
    2. See Somatization Management
    3. See Somatoform Disorder Management Pitfalls

VI. Management: Pharmacologic

  1. Medications augment non-pharmacologic management
  2. Analgesics
    1. NSAIDs or COX-2 Inhibitors
    2. Acetaminophen
  3. Tricyclic Antidepressants
    1. Nighttime only use (Tertiary amines)
      1. Amitriptyline (Elavil)
      2. Imipramine (Tofranil)
      3. Doxepin (Sinequan)
    2. Daytime and nighttime use (Secondary amines)
      1. Nortriptyline (Pamelor)
      2. Desipramine (Norpramin)
  4. Novel Antidepressants with efficacy in Chronic Pain
    1. Venlafaxine (Effexor)
    2. Duloxetine (Cymbalta)
    3. Bupropion (Wellbutrin)
  5. Anticonvulsants
    1. Indicated for sharp, lancinating, intermittent pain
    2. Potential Agents
      1. Gabapentin (Neurontin)
        1. Most studied anticonvulsant for neuropathic pain
        2. Titrate to effective doses (2400 to 3600 mg/day)
        3. Indications
          1. Diabetic Neuropathy
          2. Postherpetic Neuralgia
      2. Carbamazepine (Tegretol)
        1. Primary indication: Trigeminal Neuralgia
        2. Other indications with modest efficacy
          1. Diabetic Neuropathy
          2. Postherpetic Neuralgia
      3. Pregabalin (Lyrica)
        1. New agent pending FDA approval in 2005
        2. Indications
          1. Diabetic Neuropathy
          2. Postherpetic Neuralgia
          3. Fibromyalgia
      4. Phenytoin (Dilantin)
      5. Valproic Acid (Depakote)
      6. Lamotrigine (Lamictal)
      7. Topiramate (Topamax)
  6. Adjunctive agents
    1. Caffeine 65 to 200 mg
      1. Enhances Analgesic effect
      2. Use in combination with Analgesic
        1. Acetaminophen
        2. Aspirin
        3. Ibuprofen
    2. Hydroxyzine (Atarax, Vistaril)
      1. Enhances Opioid Analgesic effect
      2. Reduces Opioid associated Nausea and Vomiting
  7. Step-wise approach to pain management
    1. Start with Non-Opioid Analgesics (see above) and adjunctive agents (see above)
    2. Avoid Opioids if possible
      1. See Chronic Narcotic Guidelines
    3. Avoid Benzodiazepines
  8. Experimental protocols: Cannabinoids
    1. CT-3 appears to reduce neuropathic pain
    2. Karst (2003) JAMA 290:1757-62 [PubMed]

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