Pain Management

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"The greatest evil is physical pain." - Saint Augustine

Summary

  • Between 11% and 40% of the U.S. population report some level of chronic pain, pain lasting > 3 months.
  • Evidence supports short-term efficacy of opioids for reducing pain and improving function in noncancer nociceptive and neuropathic pain.
  • Few studies have assessed the long-term benefits of opioids for chronic pain.
  • Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

Strategies

  • Complementary and Alternative Medicine (CAM)
    • Acupuncture
    • Aromatherapy
    • Chiropractic manipulation
    • Guided imagery
    • Herbs and dietary supplements; nutritional support
    • Magnets
    • Massage therapy and muscle manipulation
    • Yoga, Tai chi, movement therapies
  • Medications
    • Adjuvant analgesic medications: anticonvulsants, muscle relaxants, serotonin and norepinephrine reuptake inhibitors
    • Non-opioid analgesic medications: acetaminophen, NSAIDs
  • Psychological therapies
    • Cognitive-behavioral treatment and behavioral treatment alone
    • Biofeedback
    • Meditation and relaxation techniques
    • Hypnosis
  • Regional anesthetic interventions
    • Invasive
    • Sacroiliac joint injections; epidural steroid injections; facet joint nerve blocks; implantable devices
  • Rehabilitative/physical therapy
    • Physical and functional restoration techniques
    • Massage ultrasound
    • Neurostimulators and TENs
    • Hydrotherapy
  • Surgery
    • Joint replacement
    • Nerve decompression (e.g., for carpal tunnel syndrome or trigeminal neuralgia)
    • Spinal decompression procedures (e.g., laminectomies, discectomy), disc replacement, and spinal fusion

Barriers

  • System-Level Barriers:
    • Clinical services (and research endeavors) generally are organized along disease-specific lines.  Acute and chronic pain are features of each of these specialties; in a sense, however, because pain belongs to everyone, it belongs to no one.
    •  The existing clinical (and research) silos prevent cross-fertilization of ideas and best practices.
    • Pain clinics that implement comprehensive, interdisciplinary approaches to pain assessment and treatment that appear to work best in managing chronic pain are few in number and increasingly constrained by a reimbursement system that discourages interdisciplinary practice.
  • Clinician-Level Barriers:
    • Well-validated evidence-based guidelines on assessment and treatment have yet to be developed for some pain conditions, or existing guidelines are not followed.  
    •  Health care professionals are not well educated in emerging clinical understanding and best practices in pain prevention and treatment.
    • Should primary care practitioners want to engage other types of clinicians, including physical therapists, psychologists, or complementary and alternative medicine practitioners, it may not be easy for them to identify which specific practitioners are skilled at treating chronic pain or how they will do so.
    •  A lack of understanding of the importance of pain management exists throughout the system, starting with patients themselves and extending to health care providers, employers, regulators, and third-party payers.
    •  Regulatory and law enforcement policies constrain the appropriate use of opioid drugs.
    • Restrictions of insurance coverage and payment policies, including those of workers’ compensation plans, constrain the ability to offer potentially effective treatment.
  • Patient-Level Barriers:
    • Adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and the societal stigma that is applied, consciously or unconsciously, to people reporting pain, particularly if they do not respond readily to treatment.  Is he really in pain? Is she drug seeking? Is he just malingering? Is she just trying to get disability payments?
    • Religious or moral judgments may come into play: Mankind is destined to suffer…
    • Popular culture: Suck it up; No pain, no gain.

References

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