neurologic disorders
Chronic Pain
Treatment of Chronic Pain
Often multimodal therapy (eg, analgesics, physical methods, psychologic treatments) Specific causes of chronic pain should be treated. Early, aggressive treatment of acute pain is always preferable and may limit or prevent sensitization and remodeling and thus prevent progression to chronic pain. However, once chronic pain is established and persists, multimodal treatment strategies are needed. Drugs or physical methods may be used; psychologic and behavioral therapies are usually helpful. If patients have marked functional impairment or do not respond to a reasonable attempt at management by their physician, they may benefit from the multidisciplinary approach available at a pain clinic. Goals shift from totally eliminating pain to limiting its effects and optimizing function and quality of life. Analgesics include Nonopioid Analgesics ) Opioid Analgesics None Adjuvant Analgesic Drugs (eg, antidepressants, antiseizure drugs—see table Use of one or more drugs with different mechanisms of action (rational polypharmacy) is often necessary for chronic pain. Adjuvant analgesics are most commonly used for neuropathic pain. Opioid analgesics are useful in managing chronic pain due to cancer or other terminal disorders. There is insufficient evidence to support opioid therapy for long-term management of chronic pain due to nonterminal disorders; nondrug and nonopioid drug treatments are generally preferred. However, for persistent, moderate-to-severe pain that impairs function, opioids may be considered, usually as adjunctive therapy, when potential benefits are expected to exceed risks. Opioids should not be used to manage fibromyalgia. The Centers for Disease Control and Prevention (CDC) has publishedguidelines for prescribing opioids for chronic pain. Factors to consider before prescribing opioids include the following: What conventional treatment practice is Whether other treatments are reasonable Whether the patient has an unusually high risk of adverse effects from an opioid Whether the patient is at risk of misuse, diversion, or abuse ( Opioid Use Disorder and Rehabilitation ) If opioids are prescribed for chronic pain, physicians should take several steps: Provide education and counseling:Patients should be counseled about the risks of combining opioids with alcohol and anxiolytics and of self-adjusting dosing. Patients should be taught about the need for safe, secure storage and ways to correctly dispose of unused drugs. They should be instructed not to share opioids and to contact their physician if they experience sedation. Assess risk factors for misuse, diversion, and abuse:Risk factors include prior or current alcohol or drug abuse; family history of alcohol or drug abuse; and a prior or current major psychiatric disorder. Presence of risk factors does not always contraindicate opioid use. However, if patients have risk factors, they should be referred to a pain management specialist, or the physician should take special precautions to deter misuse, diversion, and abuse; these measures can include prescribing only small amounts (requiring frequent visits for refills), not refilling prescriptions allegedly lost, and using urine drug screening before first prescribing opioids and periodically (eg, at least yearly) thereafter to confirm that the prescribed opioid is being taken and not diverted to others. Check data in monitoring programs for controlled substance use:The patient's history of controlled substance use can be reviewed through state prescription drug monitoring programs (PDMPs). Current recommendations are to screen with the PDMP when prescribing opioids initially and when refilling each prescription or at least every 3 months. Have the patient sign an opioid contract and give informed consent:An opioid contract includes safety precautions for prescribing opioids, the patient's responsibilities to ensure safe use, and measures to prevent aberrant use (ie, opioid tapering). Informed consent is obtained, when possible, to help clarify the goals, expectations, and risks of treatment, as well as the possible use of nonopioid treatment alternatives. Current guidelines emphasize that when starting opioids for chronic pain, clinicians should prescribe immediate-release opioids instead of long-acting opioids ( Treatment reference ). Also, using the lowest effective dose (even for immediate-release opioids) is preferred over transitioning to a long-acting opioid (see tables The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain ( Opioid analgesics references ) recommend the following: milligram equivalents ( Equianalgesic Doses of Opioid Analgesics*,† ) to < 50 when possible Considering the individual harm/benefit ratio at doses > 50 OMME daily When possible, avoiding doses > 90 OMME daily Weighing the needs for analgesia and functional improvement against the risks of higher-dose therapy before justifying daily doses > 90 OMME Tapering and then stopping opioid therapy if the goals for pain relief and functional improvement are not met or if maintaining them requires dose escalation Buprenorphineormethadoneshould be prescribed only by clinicians trained in the unique qualities and risks of these drugs. Follow-up includes regularly reassessing the extent of pain reduction, functional improvement, and adverse effects and checking for signs suggesting misuse, diversion, or abuse. For example, patients should be reassessed within 4 weeks of starting opioids, when the dose is increased, and at least every 3 months. Potential benefits and risks of opioid dose should be reassessed if the opioid dose exceeds 50 mg OMME/day. Doses exceeding 90 mg OMME/day should be avoided when possible. Naloxoneshould be considered if patients are at risk of overdose but still require opioid therapy: Clinicians should discuss the risks of overdose and respiratory depression with the patient and family members. Risk factors for overdose include comorbidities, unavoidable concomitant drug usage (eg, benzodiazepines), prior history of overdose or substance use disorder, and use of high-dose opioids (≥ 50 OMME). The patient and family members should be taught how to administernaloxone. Opioids have different potencies based on their ability to bind to opioid receptors and the efficiency of oral absorption of the opioid versus direct injection into the vasculature. Understanding the interrelationship of these potencies is essential if patients need to be transitioned from one opioid to another or from an oral to an IV form. For example, 30 mg of oralmorphineis equivalent to 10 mg of IVmorphine(a 3:1 oral-to-IV ratio) 20 mg of oraloxycodone 7.5 mg of oralhydromorphone To allow comparison of opioid use and risk, clinicians should consider the overall dosage of different forms as a uniform variable. TheCenters for Disease Control and Prevention (CDC)structured its guidelines for opioid use and risk around the daily oralmorphinemilligram equivalents (OMME) taken by a patient. For example, a patient taking 10 mg of oraloxycodone4 times a day is taking 40 mg of oraloxycodonea day. Based on the equianalgesic dosage conversion in the table below (20 mg oraloxycodoneequals 30 mg of oralmorphine), 40 mg of oraloxycodoneis equivalent to 60 mg of oralmorphinea day (60 mg OMME). A patient taking 4 mg of oralhydromorphone4 times a day (16 mg a day) is taking an OMME of 64 mg (from the table below); 7.5 mg of oralhydromorphoneequals 30 mg of oralmorphine(simplified to 1 mg of oralhydromorphoneequals 4 mg of oralmorphine). As pain lessens, patients usually need help reducing use of opioids. If depression coexists with pain, antidepressants should be used. Many patients with chronic pain benefit from Physical Therapy (PT) or Spinal cord stimulation may be appropriate. Electrical stimulation (TENS) uses low current at low-frequency oscillation to help manage pain. Overview of Integrative, Complementary, and Alternative Medicine (previously called complementary and alternative medicine) can often be used to treat chronic pain. Techniques include Behavioral therapy can improve patient function, even without reducing pain. Patients should keep a diary of daily activities to pinpoint areas amenable to change. The physician should make specific recommendations for gradually increasing physical activity and social engagement. Activities should be prescribed in gradually increasing units of time; pain should not, if at all possible, be allowed to abort the commitment to greater function. When activities are increased in this way, reports of pain often decrease. Various cognitive-behavioral techniques of pain control (eg, Relaxation Techniques , distraction techniques, Behavior of family members or fellow workers that reinforces pain behavior (eg, constant inquiries about the patient’s health or insistence that the patient do no chores) should be discouraged. The physician should avoid reinforcing pain behavior, discourage maladaptive behaviors, applaud progress, and provide pain treatment while emphasizing return of function. Pain rehabilitation programs are multidisciplinary programs for patients with chronic pain. These programs include education, cognitive-behavioral therapy, physical therapy, drug regimen simplification, and sometimes detoxification and tapering of analgesics. They focus on Restoring function Improving quality of life Helping patients control their own life, despite chronic pain 1.Centers for Disease Control and Prevention: 2019 Annual surveillance report of drug-related risks and outcomes—United States. Surveillance special report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018. Accessed 9/21/21. 