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Introduction to Clinical Pain Management Chronic Pain

Chronic pain has traditionally had the negative connotation of psychogenic etiology and an arbitrary time domain. It has also been a pejorative term to the extent that chronic pain syndrome was deliberately omitted from the IASP Taxonomy of Chronic Pain Syndromes. This new volume gathers together the scientific and clinical evidence that confirms chronic pain as an identifiable syndrome, the final common path of many etiologies. Consistent with any clinical syndrome, there are common neurophysiological, neuroanatomical, and functional changes throughout the organism regardless of the precipitating factors. These changes are addressed in the early chapters of this volume. In addition, there is physical, psychological, and psychiatric deconditioning resulting from central and peripheral nervous system dysfunction. Socioeconomic impairment and reduction in quality of life almost invariably accompany these changes. There has also been a recent paradigm shift from the curative medical...

Vie Problem of Chronic Pain

Health care providers are seeing larger numbers of patients with chronic, persistent pain than ever before. The causes of the pain are varied, but they all still have the potential for disability, decreased functionality, and decreased quality of life. The number of patients with chronic pain has increased nationally to the point that many health care providers consider chronic pain to be a major national public health problem (Trescot et al., 2008). What we do know about most nurse practitioners is that they feel that their basic nurse practitioner education did not prepare them to treat patients with chronic pain. In a survey of 400 nurse practitioners, 62 of the respondents felt they had been prepared to assess patients with chronic pain, whereas 38 indicated they did not feel prepared. When treatment of chronic pain was queried, only 44 of the respondents felt they had been prepared to treat chronic pain, whereas 56 felt they had not been prepared (D'Arcy, 2009a). When asked to...

Prevalence Of Chronic Pain

A patient with chronic pain may be anyone you see or know. They may be young or old, wealthy or homeless. Chronic pain does not respect age, race, financial status, or gender. It can affect anyone at any time, and the effects of the pain can be life changing. The pain can be the result of surgery, an injury, disease, or treatments such as chemotherapy, or it may just start for no apparent reason. Once the pain occurs, it will affect every aspect of the person's life. Every patient with chronic pain has a story to tell of how the pain has changed their lives and how they have learned to adapt and cope with it. Chronic, persistent pain accounts for 40 million patient visits annually and is the most common reason that patients seek help from health care professionals. On average, chronic pain patient has There are many different types of chronic pain. Responses to a survey by Research America indicate that the most common types of chronic pain include the following Low back pain, the...

Costs Of Chronic Pain

Thie cost of chronic, persistent pain cannot be fully measured, because it includes not only lost work time, or increased health care utilization, but also personal and quality-of-life issues, which have costs that cannot be calculated. Patients with chronic pain are often misunderstood and undertreated for the pain. As they seek relief for their pain, the health care system may view them as drug seeking rather than relief seeking. This may cause the chronic pain patient to present a social mask to the public that hides the full extent of the pain. Assessing pain in a patient who is trying to hide the effects of chronic pain is much more difficult and requires a comprehensive set of questions to obtain the needed information. Most patients with chronic pain report pain that exists at some level throughout the day. The patients with low back pain may have episodes of pain in which the pain increases and then returns to a lower, more tolerable level. Along with the pain, patients can...

The Complexities Of Determining Genetic Risk Factors For Chronic Pain

An additional caveat to assessment of familial aggregation is that environmental or cultural factors can lead to familial clustering and risk in the absence of a genetic component. Both acute and chronic pain states are known to be influenced by a variety of environmental, social, and cultural factors. Therefore, these factors will need to be considered and measured as part of studies that evaluate the genetics of pain and pain treatments. Currently, there are no published reports of multi-generational family studies of pain. This approach might

Role Of Economics In Developing Strategies For Managing Patients With Chronic Pain

The burden of suffering pain imposes on individuals and the enormous costs, which society has to bear as a result, demonstrate that policy-makers, commissioners, and healthcare decision-makers should adopt a broad, strategic, and coherent perspective in determining issues relating to service provision and resource allocation. Fragmented, budgetary-based interventions and programs based on at best inadequate evidence do little to alleviate the problems associated with chronic pain and deprive patients of those services that would have a positive impact. Differentials between the demands placed on health services for treatments for pain relief, and other aspects of health care and the resources available to meet such needs, continue to be major headaches for those involved in policy-making, decision-making, commissioning services, and the provision and delivery of healthcare services. It has therefore been advocated that decisions relating to patient management are made with regard to...

The Measurement Of Chronic Pain Impairment And Disability

In addition to the aforementioned fact that there are often complex interactions among chronic pain, impairment, and disability, what makes this issue even more complicated is that there are three broad categories of measures - physical, psychosocial, and overt behavior function -that have all been used to assess patients.1 Again, however, these three major category measurements (or biopsy-chosocial referents) often do not display high concordance with one another when measuring a construct such as chronic pain, or impairment, or disability. Therefore, this creates a second layer of complexity. For example, if one uses a self-report measure (e.g. a visual analog rating scale) as a primary index of a construct such as pain, and compares it to the overt behavior function measure (e.g. total distance walked during a certain amount of time) of this same pain construct, direct overlap or perfect correlation cannot be automatically expected. Moreover, two different self-report indices (e.g....

Pain Augmenting Mechanisms and the Emergence of Chronic Pain

When acute pain is inadequately treated, there is an increased risk of emergence of chronic pain. Several mechanisms are postulated to play a role in the development of chronic and enduring pain (see Table 2-4). Trauma and injury can produce reflex motor activity in the vicinity of the injury, producing spasm. This process may initially serve a protective function in acute pain states, but in chronic pain states it can lead to aggravated muscle tension that exacerbates painful states (Zimmerman 1979). The dorsal horn can become sensitized by a number of mechanisms that can potentiate chronic pain. Changes that occur within the dorsal horn may account for the maintenance of pain sensation that loses its relevance in its ability to signal danger. This sensitization appears to be related to changes mediated by CNS neurotransmitters, especially the excitatory neurotransmitter glutamate. With repeated stimulation (e.g., in poorly treated acute pain or in

Should Every Chronic Pain Patient Be Assessed Psychologically

One of the controversial issues in chronic pain management today is whether every chronic pain patient who is being treated should first receive a psychological evaluation. The arguments against this are practical in nature there are increased costs associated with this as well as limited resources (access to mental health professionals with pain expertise may be quite limited). Additionally, the fear of communicating to the patient that their pain is in their head,'' as well as resistance on the part of referring doctors (particularly in settings where referrals are made for specific procedures to be done) are all very practical and significant considerations. The other side of the argument, however, is based on clinical experience as well as research. Almost all practicing pain management specialists today would agree that there is a high incidence of comorbid psychopathology associated with chronic pain, such as depression and posttraumatic stress disorder. Treating the emotional...

Managing Chronic Pain Using Nonopioid Medications

Tie mainstay for treating chronic pain is medication management. Most patients expect to receive a medication prescription when they see their primary care provider with a pain complaint. However, for some conditions, such as low back pain, the current recommendations for the acute phase is acetaminophen nonsteroidal anti-inflammatory drugs (NSAIDs) and continued activity, rather than opioids and bed rest. About 15 of the patients who have acute low back pain progress to chronic low back pain. Medication management for chronic low back pain is recommended, accompanied by a plan of care that includes medications along with other therapies, such as physical therapy and counseling (D'Arcy, 2009b). Opioids are in most cases reserved for severe level pain that is impairing functionality. Treatment of chronic pain with medications requires a comprehensive pain assessment, history and physical examination, and medication review that includes over-the-counter medications, herbal supplements,...

Developments In Psychological Models Of Chronic Pain Over Time

There is a 40-year history of development in the behavioral and cognitive approaches to chronic pain, beginning with the operant approach,1 including the cognitive-behavioral approaches,2 up to the present day. As this history continues, any description of the psychological effects of chronic pain will be a snapshot in time and in a process of change. It is fortunate for this purpose, however, that interest in the contributory causes of chronic pain has been more changeable over time than interest in the effects of chronic pain, which has tended to yield greater consensus. In other words, psychologists and other professionals have considered an ever wider range of variables in the search for where suffering, disability, and life disruption come from, as opposed to what they are made of or how significant they are. If there is doubt about these trends, notice our changing interest in conversion disorders, pain behavior, reinforcement, social support, and responses from significant...

Psychological Domains Of Chronic Pain Assessment

Pain sufferer thinks, what they feel in their body and in their emotions, and, perhaps most importantly, what they do or do not do, including how they speak about their experiences, and what they do to seek relief. Standard self-report inventories administered along with these clinical encounters help to quantify some of these experiences. In turn, empirical analyses of large clinical databases, using factor analysis, show some consistency in the factors underlying the information collected for clinical purposes. These analyses reliably demonstrate that emotional distress, disability, and pain description are key domains.3,4 56 These domains are validated further by their inclusion in attempts to produce an integrated psychosocial assessment model for chronic pain,7 in attempts to standardize a comprehensive assessment procedure from both the physician and patient perspec-tive,8 in attempts to develop comprehensive assessment instruments for young people with chronic pain,9 and in...

Psychological Effects From Patients Seeking Treatment For Chronic Pain

It may come as no surprise that among the most well-documented effects that come with chronic pain is emotional distress or mood disturbance. In their very useful review paper, Banks and Kerns11 reported that depression is disproportionately prevalent in sufferers of chronic pain compared to other chronic medical conditions, that depression is most likely to be a result and not cause of chronic pain, and that 30.0-54.0 percent of patients seeking treatment for chronic pain suffer with a diagnosable depressive disorder. There is also evidence that patients with chronic pain have high prevalence rates of anxiety disorders, including panic disorder and generalized anxiety disorder, and substance use disorders, although the prevalence figures appear varied across studies.12 Rates of current anxiety disorders may range from 16.5 to 28.8 percent and current substance use disorders from 15 to 28 percent.12 In comparison with the clinical data, a recent nationally representative sample of the...

Processes In Chronic Painrelated Disability And Suffering

And stages of change,62 among others.63 Discussing all of these is well beyond the scope of the present chapter. However, there are a small number of other processes that have been the focus of work for our group, first in Chicago, and now in Bath. These are both effects of chronic pain, in the sense that they are changes in quality of behavior patterns resulting from the experience of chronic pain, and processes of suffering and disability, as they appear to lead to higher levels of emotional distress and greater restrictions in patient functioning. These processes include experiential avoidance, values-failures, and disturbances of awareness.64 When pain occurs, the pain sufferer naturally will try to avoid it. When chronic pain leads to painful emotions, memories, and other unwanted experiences (e.g. feelings and thoughts that come with facing unwelcome changes in life or from challenging social situations), the pain sufferer will naturally attempt to avoid these as well. This is...

The complexity of chronic pain

Severe pain creates fatigue, impairs concentration, compromises mood, degrades sleep and diminishes overall activity level. The goal of intervention for chronic pain must include alleviating the functional impairment that pain produces as well as its discomfort. Evaluating treatment outcome requires 50 m), weight gain due to inactivity, medication use or dose reduction, and number of physician visits will also be of interest in some studies. McCracken and Eccleston23 have noted that acceptance of chronic pain predicts physical function and this is yet another dimension to be taken into account. Psychological - there are many measures of depression and cognitions, such as pain beliefs, negative thoughts, or catastrophization (see also Chapter 10, The psychological assessment of pain in patients with chronic pain and Chapter 13, Psychological effects of chronic pain an overview, as well as Ref. 24). It is well established that depression affects the...

The Adult With Chronic Pain

Adults with chronic pain present to healthcare settings primarily with the symptom of persistent or recurrent pain. The overall population reporting chronic pain is large (see Chapter 5, Epidemiology of chronic pain classical to molecular approaches to understanding the epidemiology of pain). However, we are concerned here with those who report chronic pain but who are also highly distressed and disabled, and who repeatedly present for a wide range of treatments. Chronic pain patients often complain of disability and enforced inactivity associated with poor sleep patterns and fatigue. Chronic pain and disability may lead to an impoverished social environment and loss of valued work, family, and social roles.6 Particularly distressing can be an unwanted and countertherapeutic reliance upon social care and medical support systems. It is common, for example, for people to continue to seek and receive ineffective treatments over long periods of time.7 The constant demand to react and...

Acute and Chronic Pain Management with a Focus on Occupation

Occupational therapy treatment of clients with pain is dependent on the client's personal experience, occupational background and functional status, diagnosis, symptoms, and duration of pain. Broadly, an occupational therapist seeks to understand the client's pain experience from its onset. Typically, acute pain can occur instantaneously and its duration can be from momentary to days, while chronic pain duration is much longer (Bracciano 2008). Acute pain is associated with inflammation, damage to surrounding tissue, and normal injury or disease process while chronic pain persists beyond usual healing time and can become a separate diagnosis (Bracciano 2008, National Institute of Neurological Disorders

Management of Chronic Pain

Persons who experience chronic pain have reported the life changing (Fisher et al. 2007) characteristic of its presence and changes in their relationships (Fisher et al. 2007), quality of life (Fisher et al. 2007, Neville-Jan 2003), ability to function (Fisher et al. 2007, Neville-Jan 2003), and psychological well-being (Fisher et al. 2007, Neville-Jan 2003). Within the context of chronic pain, occupational therapy offers treatment interventions intended to facilitate clients' adaptation to pain and enhancement in functional engagement, physically and psychologically. To address this, many occupational therapists implement a biopsy-chosocial foundation that also includes behavioral, cognitive-affective, and environmental factors (Bracciano 2008). Due to the holistic nature of treatment, occupational therapy is an important partner on the multidisciplinary pain management team.

Visceral chronic pain mechanisms

A number of chronic perineal pelvic pain syndromes may involve chronic infection or inflammation that cannot be identified. The evidence that such pathologies cause chronic pain is hotly debated and there is a general trend away from diagnoses which imply undected infection or inflammation.

Chronic low back pain or chronic pain syndrome

The International Association for the Study for Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.22 Chronic low back pain is defined and distinguished from acute pain by symptom duration, treatment responses, the concept of neuroplasticity (sensitization) of the central nervous system, and the relationship of symptoms to the initial noxious stimulus. In contrast, in chronic pain syndrome, the balance between the sensation of pain and the emotional experience associated with it is far out of balance in favor of the emotional side.23 The criteria are as follows

Chronic pain after breast surgery

In the UK alone, 42,000 new patients are diagnosed with primary breast cancer each year and most undergo surgery, either mastectomy or breast conservation surgery with sentinel node sample or clearance. Chronic pain was initially reported in the 1970s as a rare consequence of breast cancer treatment.62 There are now many epi-demiological and clinical studies reporting the prevalence and characteristics of persistent pain which suggest that it occurs commonly, with subsequent impact upon quality of life. There are several types of pain suffered by women after breast surgery.9,63,64 Although prevalence varies by methodology used and timing of follow up,10 post-mastectomy pain is thought to affect up to half of women undergoing surgery up to one year after their surgery.12 Chronic pain is also common after breast reduction and augmentation operations.63,65 It is also important to recognize that pain is not the only symptom that may be bothersome for patients after breast surgery...

Supraspinal Engrams Relevant In Transition From Acute To Chronic Pain

Nociceptive simuli originating in the head or the face are conveyed via the trigeminal nerve to the trigeminal nerve nucleus in the brain stem. There, all afferent signals are being modulated after which they cross to the opposite side, further ascending to the thalamus. From there, fibers ascend rostrally to lemniscal and thalamic structures, before they reach the somatosensory cortex (Figure I-44). Each long-term or even a paroxysmal increase of activity of afferents to the posterior column of the spinal cord or to the trigeminal nerve nucleus also induce an activity-dependent adaptation of the rostrally located thalamic and neocortical structures 86 . In the process of development of chronic pain, besides adaptive peripheral changes, also an alteration at the cortical level is instigated resulting in central sensitization (Table I-4). For instance, hyperexcitability of cortical neurons was documented in patients with chronic pains, where...

Chronic pain after hernia surgery

The epidemiology of chronic pain after inguinal hernia surgery is well documented. Indeed, the volume of literature reporting CPSP after hernia surgery has increased dramatically in the last two decades. Many studies have been specifically designed to investigate persistent pain as an outcome rather than the traditional outcomes of hernia recurrence, wound infection, or return to work. Guidance on laparoscopic and open hernia surgery published by the UK National Institute for Clinical Excellence (NICE) acknowledged chronic pain as a common postoperative adverse event and recommended that future studies assess persistent pain along with recurrence and other adverse outcomes.59 Two systematic reviews of the epidemiology of chronic pain after inguinal herniorrhaphy have been published since 2003. First, Poobalan et al.7 reviewed data on chronic pain from 40 experimental and epidemiological studies published up to the year 2000. Using strict inclusion criteria, with chronic pain defined...

Long Term Management of Chronic Pain

Diabetes Type Treatment Ladder

If during the therapy of chronic pain, sufficient attenuation of nociception can not be achieved with a peripheral analgesic (i.e., acetaminophen, NSAIDs), an opioid has to be added in order to reach the therapeutic goal (Figure IV-1). However, it is also possible to start with opioid therapy in those patients who complain of intense tumor-related pain or in patients with other severe painful symptoms. In such cases, one immediately can start with an opioid Step 3 of the analgesic ladder (Table IV-2). Such strategy has to be carefully weighed in particular if pain is due to the extension or the progression of the underlying disease, where peripheral analgesics and or weak opioids are insufficient in action. 4. All patients with moderate to severe cancer pain, regardless of etiology, should receive a trial of opioid analgesia. Chronic pain in patients with cancer is usually

Causes Of Potentiation And Transition From Acute To Chronic Pain

Sympathetic Sprouting

The posterior column of the spinal cord can be regarded as a gate, through which nociceptive afferents must travel, in order to reach higher supraspinal pain-processing centers in the CNS. However, it is also the gate, where modulation of pain impulses takes place, resulting in either in diminution or fortification. Also, it is a commonly accepted belief, that opioid receptors and their endogenous ligands, endorphins or enkephalins, play a critical part in the reduction of incoming pain impulses 66, 67, 68 . In particular pro-nociceptive transmitters are of importance, as they cause a fortification of arriving nociceptive afferences 65 . The principle pronociceptive mediators are related to the group of excitatory amino acids, comprising of glutamate, aspartate and the tachykinin group. The latter consists of substance P, the endogenous ligand for the NK1-receptor, as well as neurokinin A, B and C, which bind to the NK2-, NK3- and NK4-receptor respectively. Thus, besides initial...

Types Of Chronic Pain And Differences Between Acute And Chronic Pain

A patient who has chronic pain is very different from a patient who has acute pain. Acute pain is pain that is the result of tissue injury, such as injury from trauma or surgery (American Pain Society APS , 2008). Patients expect that when their injury heals, the pain will resolve. As the pain decreases, the patient is able to resume their normal everyday activities and level of functioning. Acute pain serves the purpose of warning the person that an injury has occurred and appropriate action is needed (e.g., treatment or moving away from the source of the pain). Chronic pain is a different life experience. Chronic pain is pain that lasts beyond the normal healing period of 3 to 6 months (APS, 2008). It is the result of injury or potential tissue damage (APS, 2008). Chronic, persistent pain has many different sources, and the pain that the patient complains of may be in several different areas of the body. Chronic, persistent pain may exist even though there is no detectable physical...

Clinical trial design for chronic pain treatments

We focus on clinical trials of treatments for chronic pain, conventionally defined as pain that persists beyond 3 months or the normal time of healing 2 . Chronic pain is typically classified based on its presumed etiology, specifically, neuropathic pain versus non-neuropathic inflammatory and musculoskeletal pain. Neuropathic pain is caused by a lesion or disease affecting somatosensory pathways of the peripheral or central nervous system 3 , whereas non-neuropathic (i.e. nociceptive) pain reflects stimulation of specialized nociceptors in somatic tissue, with visceral pain often classified separately. We focus on trials of phar-macologic interventions for both of these types of chronic pain in this chapter, although many of the issues we address are also relevant to studies of psychologic therapies, nerve blocks, spinal cord stimulation, Evidence-Based Chronic Pain Management. Edited by C. Stannard, E. Kalso and J. Ballantyne. 2010 Blackwell Publishing. physical therapy, acupuncture...

Chronic Pain

Chronic pain, as has been agreed arbitrarily, is pain which persists for more than 3 months or which persists past the time of healing (Merskey and Bogduk 1994). After severe trauma, major surgery, or painful diseases such as pancreatitis, severe acute pain can persist more than 10-14 days and become essentially chronic (Bonica 1985). Chronic pain progressively leads to limitation of physical, mental, and social activities, and it is not uncommon for it to cause anger, depression, and family and socioeconomic perturbation (Siddall and Cousins 1998). In chronic pain, sympathoadrenal responses are not apparent and are seemingly habituated or exhausted, and vegetative responses such as irritability, loss of appetite, sleep disruption, depression, or attenuation of motor activity emerge. Patients may be sad, subdued, or sleepy secondary to excessive consumption of medications. Such affect may mask the presence of pain. Psychological disturbances may result from severe refractory chronic...

Management Clinical Situations321

30 Chronic pain after surgery 405 William Macrae and Julie Bruce 43 Psychiatric diagnosis and chronic pain 614 Stephen P Tyrer 44 Chronic pain in children 623 Navil F Sethna, Alyssa Lebel, and Lisa Scharff 45 Principles of chronic pain therapy in elderly patients 641 John Hughes and Chris Dodds

Types of clinical trials

Successful randomization of a large group of patients controls for baseline factors, resulting in groups that are essentially identical except for the study treatment. RCTs are therefore the only type of clinical trial for which inferences of causality are appropriate. For example, outcome differences between an active treatment and a placebo group in a large, well-designed placebo-controlled RCT can be inferred to have been caused by the intervention. In general, the results of RCTs should be considered to overrule contradictory findings from other types of studies an exception to this statement is that most RCTs of treatments for chronic pain are not adequately powered to detect between-group differences in uncommon adverse events. Investigations of treatments for chronic pain have typically compared the efficacy, tolerability, and safety of a single treatment with placebo. Few RCTs have compared different treatments 17, 18 and even fewer trials have examined whether...

Understanding The Basic Principles Of Epidemiology

Chronic pain from work-related stress was assessed using longitudinal data from the National Population Health Survey in Canada (n 6571). The investigators found that relative risk for developing chronic pain was 1.39 (95 percent CI 1.01-1.91) for medium stress and 1.80 (95 percent CI 1.28-2.52) for high stress.49

The Challenge Of Assessing Pain

In a recent survey of 3,000 nurses and another survey of 400 nurse practitioners, pain assessment was cited as a major source of concern and knowledge deficit (D'Arcy, 2008 2009). Many of the nurses who responded to the survey felt that they were not getting a pain assessment that was accurate. In the nurse practitioner survey, the respondents indicated that they felt that their nurse practitioner education had not prepared them to assess or treat pain in patients with chronic pain. There were repeated requests in the comment sections of the surveys about learning to perform an accurate pain assessment and how to assess pain in patients with chronic pain and or a history of substance abuse. Despite the years of education on pain assessment that has been provided to nurses and other health care professionals, pain assessment still remains difficult. Pain assessment is problematic because of the following may, in some cases, result in a difficult-to-treat chronic pain condition, such as...

Crosssectional studies

Studies of chronic pain are predominantly cross-sectional studies. In these studies, participants are sampled, and information related to pain and its risk factors is measured at a single point in time. Prevalence is estimated as the proportion of subjects with pain in the whole study sample. Because information relating to the disease state and risk factors is assessed at the same point in time, causality cannot be inferred, and biases regarding exposure exist. There are several data collection methods

Pain Assessment Tools

Many of the first pain assessment tools were developed for assessing experimentally induced pain, chronic pain, or oncology pain (Jensen, 2011). The multidimensional scales were extensions of the one-dimensional scales. The multidimensional tools were developed to assess more complex pain and included measurements of mood and psychological elements. Today, there is a wide variety of valid and reliable pain assessment tools. More recently, because The Joint Commission required that all patients have their pain assessed and adequately treated, tools for assessing pain in special populations, such as the cognitively impaired, nonverbal patients, and infants, have been developed.

Interpretation of results

In analyzing data from clinical trials, establishing the statistical significance and confidence intervals of group differences in treatment outcome is a pivotal first step. It is well known, however, that statistical significance reflects both the magnitude and variability of the treatment effect as well as the sample size. A statistically significant improvement may therefore reflect a benefit that is clinically unimportant. For this reason, determinations of statistical significance must be supplemented by consideration of the clinical importance of changes in outcome measures. Such information provides a basis for evaluating and comparing the impact of chronic pain treatments on pain and health-related quality of life. Because most measures of treatment response in chronic pain trials involve the patient's subjective experience, the patient is the most important judge of whether changes are important or meaningful. For this reason, patient evaluations of overall improvement have...

Efficiency and equity

The extent of chronic pain poses a significant economic burden for patients, their families, health services, and societies. Cost of illness studies in pain tend to distinguish between direct costs and productivity or indirect costs, where direct costs represent the costs to the health services of patients suffering chronic pain (direct medical costs) and costs to the patients themselves in terms of travel The vast majority of these were for nonopioids (34 million prescriptions and cost of 120 million (US 220 million)) and NSAIDs (18 million prescriptions and cost of 150 million (US 280 million)).40 However, a significant number of people with chronic pain may not actually consult anyone about their condition or choose to self-medicate. A survey of nearly 6000 people across Europe found that up to 27 percent of respondents had never sought medical help for their pain, and at least 38 percent of this group were in constant or daily pain.41 The extent to which people took...

Impact of pain on quality of life

Estimates of the economic burden associated with pain fail to do justice to the extent of suffering and reduced quality of life experienced by patients and warrants pain relief being regarded as a universal human right.18 Chronic pain, along with musculoskeletal disorders, has been shown to be associated with some of the poorest quality-of-life states.60,61,62,63 In patients referred to a Danish multidisciplinary pain center, the severity of impairment was equal to or lower than patients with cardiopulmonary diseases and major depression, and their Psychological General Well-being Scale scores were lower than those with hypertension and gastrointestinal problems, while they also displayed high levels of anxiety and depression, as measured by the Hospital Anxiety and Depression Scale.63 In a study of over 600 patients attending a chronic pain clinic in Sydney, Australia, there were greatly reduced SF-36 domain scores between clinic patients and Australian norm values, as shown in Table...

Pain And Suffering What Are They

Emphasizes his view that the self is not so much an entity as a process of constant redefinition in reaction to a changing world.'' He describes the loss of integrity as a failure of coherence, noting that awareness of incoherence within one's self is a powerful negative experience.'' He observes that there is perhaps no more powerful source of human incoherence than the failure or loss of the relationships that bind us to others, including not only family and loved ones, but also peoples, nations, deities, or even cherished abstract versions of otherness, such as justice and freedom. Suffering understood as an experience of radical incoherence may prove ultimately to be a more useful concept than self-hood regarded as the possession of integrity, wholeness, or harmony. Unfortunately, a review of the pain literature by Fishbain et al.38 showed that personality states were influenced both by personality trait and the presence of chronic pain. They cautioned that post-pain personality...

Understanding The Matrix Of Biology And Culture

Beliefs about pain illustrate a broader interdependence between biology and culture, i.e. human pain implies continuous processes of conscious and nonconscious interpretation.72, 73 (Nonconscious interpretation occurs, for example, when we process traffic signals without awareness.) Meaning helps to constitute pain, even if only in the nonconscious acknowledgment that a scratch is usually meaningless. We cannot name or discuss pain except by employing a language that exists only at a specific moment in its historical development and inevitably colors our understanding.74 Pain thus always comes already interpreted by the social world we inhabit. Meanings not only encompass articulate beliefs, such as the conviction that pain is a punishment, but in less obvious ways, they also interpenetrate our inarticulate attitudes, unexpressed emotions, habitual behavior, and even nonconscious knowledge. Pain-killing drugs may temporarily circumvent conscious meaning-making processes, but meaning...

Pain Suffering And Other Semantic Points

The subject matter of this volume is chronic pain, as distinguished from acute pain and pain associated with terminal illness. Pain is, of course, distinguishable in a number of important ways from suffering. It is virtually axiomatic that pain can exist in the absence of suffering and that the opposite is equally true. There have been efforts, ultimately misguided, to characterize pain as physical and suffering as mental. Such characterizations have given rise to what David Morris refers to as the myth of two pains.''7 Unfortunately, the myth has also engendered the tendency among health professionals to label physical pain, i.e. that which can be directly and objectively related to an identifiable lesion, as real, and all other reported pain, consequently, as in one's head'' and unreal. As we shall see, the regulatory climate, particularly in the USA, has encouraged medicine's search for an identifiable physiologic cause that would legitimize the pain reported by the patient and...

The failure of clinicians to identify pain relief as a priority in patient care

Instances of pseudoaddiction among chronic pain patients. Pseudoaddiction is an iatrogenic condition caused by the failure of physicians to provide adequate pain relief that forces the patient to employ (legitimate) drug-seeking behaviors to obtain analgesics they are entitled to. Kleinman's work with chronic pain patients, as physician, psychiatrist, and medical anthropologist, provides a number of important maxims for those who seek to provide compassionate care to such individuals. One half of all patients with chronic pain syndrome, like many others afflicted with chronic illness, meet the official criteria for major depressive disorder. More than anything else, the depressive mood represents demoralization from the life of pain and the persistent questioning by others, including healthcare professionals, of the authenticity of the patient's experience of pain.

Key Learning Points

The evaluation of pain in the chronic pain patient must be multidisciplinary. As important as the psychological assessment of the chronic pain patient is in general, it takes on added significance with the patient who presents with a history of past or present substance abuse. One of the controversial issues in chronic pain management today is whether every chronic pain patient who is being treated should first receive a psychological evaluation.

Assessing Pain In Specialty Populations

Older patients have experienced pain before. They have any number of chronic pain conditions and comorbidities that can make selecting pain medication difficult. The older patient is reluctant to be seen as a com-plainer, and they may fear adding costly medications for pain to their already crowded medication regimen (D'Arcy, 2007, 2010b).

Objectives Of Psychological Evaluations

The objectives of the psychological evaluation of the patient with chronic pain are not to determine whether the patient's pain is real or imagined (all pain is real'') but rather to determine the degree of psychological adaptation to chronic pain which includes mood state, coping skills, effect on family, and particularly level of physical functioning to identify environmental reinforcers of chronic pain and illness behaviors, such as family, litigation status, and disability insurance status to evaluate the likelihood of the development of chronic pain-related disability.

Structured clinical interview

It represents a good opportunity to review the data obtained on the pain questionnaire, which often may be incomplete or inconsistent. It is an even better opportunity to observe the patient and his her subjective experience of pain, as well as any illness behavior (facial expressions, frequent posture change, and guarding bracing). It is an excellent idea to evaluate the patient together with their significant other and their interactions with each other and the interviewer. This facilitates evaluation of the response of the significant other to the patient's pain - whether it is a solicitous, punishing, or distracting response,12 and can be a valuable educational tool for the patient, significant other, and interviewer. Patients with chronic pain often have a traumatic onset etiology. A significant number of patients seen by chronic pain specialists may therefore experience considerable amounts of psychological distress and some may have...

Pain assessment measures

Confirmatory factor analyses of the MPQ have shed some doubt on the original three subscales of the test.20 Holroyd et al.,21 conducting a multicenter evaluation of the MPQ with 1700 chronic pain patients, showed that a factor analysis revealed a four-factor model instead of three factors one affective, one evaluative, and two

Beck Depression Inventory

Most widely used tests with chronic pain patients because state closely interlinked with chronic pain.25 The most prevalent psychological characteristic of chronic pain patients is depression. Depression and chronic pain occur together so frequently it is often difficult to determine whether the depression is a precipitant of the pain or a dal ideation. In an unpublished study, the author has found that 25 percent of 821 chronic pain patients score in the moderate to severe range of depression on the BDI. The BDI is a 21-item questionnaire requiring the patient to endorse various symptoms of depression that produces ideation is helpful in assessing suicidality in chronic pain patients. The BDI is predictive of many aspects of patient functioning.26 Comparing the BDI to another measure of depression, the CES-D, Geisser et al.27 found that both the BDI and the CES-D discriminated significantly between chronic pain patients who were depressed versus those who were not. One of the...

Minnesota Multiphasic Personality Inventory

The Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2),29 one of the most widely used and researched tests of all time, is used quite extensively with chronic pain patients. Figure 10.1 shows that the use of the MMPI for pain is quite extensive, as evidenced by citations in the literature on the use of MMPI with pain patients, with the most recent decade of data indicating that 12 percent of all MMPI citations are pain related. The MMPI is a 566-question, true-false test that evaluates the presence of psychopathology through three validity scales (the degree to which respondents may be trying to distort their true persona), and clinical scales, ten of which are most commonly used hypochondriasis, depression, hysteria, psychopathic deviance (history of antisocial behavior and nonconformance), paranoia, psychasthenia (obsessive-compulsive tendencies as well as anxiety), schizophrenia, hypomania, masculinity-femininity, and social introversion. Two additional scales used with...

The Pain Patient With A Suspected Substance Abuse Problem

Among the most difficult to manage and treat populations of chronic pain patients are the patients who present with a current or past history of addiction to illicit sub stances, alcohol, or prescription drugs.43 Pain patients who are perceived to have addictive disorders are often undertreated. The unwarranted fear of addiction is a misunderstood concept in pain management that can lead to the undertreatment of pain. The increasingly accepted management of chronic nonmalignant pain with opioid therapy underscores the importance of understanding the nature of opioid addiction. As important as the psychological assessment of the chronic pain patient is in gen of the chronic pain patient with suspected abuse. This score was developed at the request of the Minnesota Board of Medical Practice (www.state.mn.us portal mn jsp home.do agency BMP), which has information about the management of chronic pain and prescribing rules.

Clinical pain measures

An increasing number of clinical trials include measures of quality of life in the evaluation of the treatment of chronic pain. These measures have become an important indicator of treatment success. Among the measures of quality of life, the Sickness Impact Profile (SIP), the SIP Roland, the West Haven-Yale Multidimensional Pain Inventory, the Nottingham Health Profile, and the SF-36 have been validated (for further details of pain measures,

Extending the evidence base

So, overall, the evidence base appears to be very strong and in general supportive of CBT for chronic pain. This has been an active field of clinical research. The tools and techniques of CBT, both in isolation and in a programmatic multidisciplinary form, have been subject to evaluation with randomized controlled trials for the last 30 years. If we stand back to admire this picture it will all appear relatively well constructed and attractive. Closer examination, however, reveals some problems.

Surveys Of Pain In The Community

There have been a number of recent market research studies of chronic pain. These employ telephone surveys administered to people in the community prescreened for chronic pain. The largest of these was the Survey of Chronic Pain in Europe funded by Mundipharma Inter-national.24 This study included interviews with 4839 individuals with chronic pain, about 300 per country, from 15 European countries and Israel. The purpose of the study was to estimate the prevalence of chronic pain, explore underlying features and correlations with demographic issues, to examine impact on quality of life and daily functioning, and understand individual attitudes. Overall they estimated that 19 percent of all those screened (N 46,394) had chronic pain for at least six months, including the last month, at least twice a week, and rated at least five out of ten on a numerical rating scale of pain severity. The median duration of pain was seven years. Selected findings from the more than 36 tables and...

Assessment Methods For Emotional Distress

For assessment of emotional distress in chronic pain, depression is a key target. The Beck Depression Inventory (BDI) has long been a standard and is a very good measure. It is very useful clinically, as its content is comprehensive, and in research where it appears sensitive to psychological differences.31 As each of the 21 items of the BDI potentially includes four statements to read, it may be too long for some applications. The BDI has been well studied in chronic pain samples.50,51 Concerns about the somatic item content of the BDI can be confusing. There is sometimes an assumption that these will contaminate or inflate judgments about the degree of depression present in an individual or sample.50 It seems likely, however, that these can be managed with an examination of endorsed item content in clinical contexts, testing of effects of content in research contexts, and a flexible use of standard cut-off scores. Results from extensive factor analysis of the BDI in patients with...

To determine the outcome of pain conditions

For example, patients with back pain who are female, have had long or frequent previous episodes of pain, who exercise less, and who have had a poor initial response to treatment are more likely to be disabled by their pain five years later.1 Studies such as this illustrate the large number of factors that must be controlled in research involving chronic pain. The stakeholders of outcome measurement are summarized in Table 14.1.

As a guide to treatment

Very many treatments have been used in patients with chronic pain. Published studies describe techniques varying from the drug treatment of phantom limb pain with anticonvulsants,2 II to heating vertebral disks to treat back pain,3 II and from the physical exercise of yoga4 II to spiritual healing.5 II It is hardly surprising that interpretation of the results of these individual treatments is difficult for the clinician, even without the added complications of several sequential or concurrent treatments, some of which may be unknown to the treating clinician. Patients naturally demand the best, but many factors are involved in determining what is best. For example, whether the simplicity, safety, and availability of transcutaneous electrical nerve stimulation (TENS) outweighs the precise stimulation localization, but inevitable risk of complications with spinal cord stimulation (SCS) cannot be reduced to yes or no. A great deal will depend on the patient and their attitudes to risk...

To determine specific treatments

Procedures for treating chronic pain sometimes involve either major surgery or the selective destruction of tissues with significant risks of complications. Preliminary evidence that these invasive procedures will be beneficial is therefore helpful. For example, the use of local anesthetic nerve blocks is able to identify patients who may respond to subsequent heat lesions of the nerves supplying the cervical facet joints 7 II indeed, in this study, preliminary nerve blocks were used first to identify patients who were eligible for a later trial of the effects of the heat lesions. Similarly, patients who respond to provocative discography (where dye is injected into an intervertebral disk in order to provoke their pain symptoms) have been offered spinal fusion surgery in order to immobilize the affected segment, although the positive predictive value of this particular test in one study appears to be low at 50 to 60 percent.8 The toss of a coin is almost as good.

Challenging populations

There are relatively few studies of treatment of chronic pain in children, but assessment methodology has been reviewed.30 Adolescents present particular challenges and a suitable compact measure has been developed.31 The elderly are often excluded from studies of chronic pain and so treatments cannot be based on sound evidence. Weiner32 sets an agenda for the improvement of analgesia in the elderly to include the improvement of

Number needed to treat

Conceived as a basic tool of evidence-based medicine,94,95 it has been refined for chronic pain studies and found to be suitable as a common currency of treatment effect81 for both medication and intervention96 studies. It is calculated as the inverse of the absolute risk reduction between groups and is most usefully expressed with confidence intervals.97 Figure 14.2 illustrates a simple example. Figure 14.2 NNT an example of a simple clinical trial. Eight patients with identical chronic pains receive treatment with medication, of whom four receive placebo and four receive an anticonvulsant. Thirty percent pain relief is considered to be a success. One of the placebo group and two of the anticonvulsant group gets 30 percent relief. It can be seen that for every four patients treated, one (one-quarter) will respond with anticonvulsant that would not have responded with placebo. Thus the NNT is 4 - and the anticonvulsant can be considered to be a moderately effective treatment for...

Administration and dosage

The proper use of paracetamol is crucial to optimizing its effectiveness and achieving pain relief. Patients may conclude that paracetamol is ineffective after taking only one or two tablets a day for short periods of time and subsequently terminate treatment. This is an inadequate trial period for chronic pain conditions, which require up to 4g day in divided doses for at least a week.95 The oral route is preferable with suspensions and dispersible preparations being available. Rectal and parenteral preparations are also available (in some countries). Paracetamol is available in combination with several opioids such as codeine, dihydrocodeine, dextropropoxyphene, and tra-madol, as well as other compounds such as caffeine and NSAIDs. The rationale behind such combinations is the theoretical enhancement of efficacy by combining two analgesics with different modes of action. Extended release paracetamol preparations are also available.

Natural history of nonspecific neck pain and whiplash with factors associated with chronic disability

Nonspecific neck pain usually resolves within days or weeks, but can recur or become chronic. Once pain becomes persistent, outcome is more unpredictable, and there is little consistency in the literature regarding the duration of symptoms and factors that influence outcome. A systematic review of the clinical course and prognostic factors in nonspecific neck pain found little consensus as to outcome or relevant prognostic factors, although this was based on poor-quality studies 19 . The systematic review found evidence that in patients with chronic pain treated in secondary care or an occupational setting, 20-78 (median 54 ) of patients remained symptomatic, irrespective of the therapy given. Six of the included studies documented prognostic factors, and the severity of pain at presentation was the best predictor of a poor outcome, although previous episodes of neck pain were also important. Three subsequent studies also considered the factors at presentation which might influence...

Evidence For Efficacy

Chronic pain with only one modality of treatment is likely to get poor and variable results. When the cause of the pain is not clear as in many chronic pain states, the failure rate of single modality opioid therapy will be even worse. Patients with chronic pain present with a complex paradigm. Many, if not all, have significant biological pain generators, but this may not be the predominant factor

Types Of Cam Therapies

Chronic pain is one of the primary reasons that patients try CAM therapies. Patients look for ways to relieve not only the daily pain but the anxiety and uncertainty that the pain produces. Many of the techniques are minimally invasive, such as acupuncture, or noninvasive, such as the energy therapies of Reiki or therapeutic touch (TT). Because many patients are attracted to this type of therapy, incorporating it into the plan of care can help track outcomes and determine benefit. Because the use of these therapeutics is controversial and research is limited, it is helpful to monitor the benefit of these therapies when they are added to a plan of care. For patients with chronic pain, this technique may be less useful during exacerbation of musculoskeletal pain, however, it may provide some added relief. Relaxation techniques have been effective for decreasing pain (Cole & Brunk, 1999). These techniques result in the reduction of physical tension, muscle relaxation, and the promotion...

Experimental Pain Studies And Depression

Consistent with epidemiologic studies which have identified a direct association between chronic pain and depression, experimental studies have demonstrated that patients with depression have altered pain thresholds and tolerances.6 In a recent study, 30 patients diagnosed with major depressive disorder, using DSM-IV criteria, were matched with 30 nondepressed control subjects.7 Pain thresholds and tolerances were assessed bilaterally in These differences in pain thresholds and tolerances suggest patients with depression may experience a differential analgesic response to opioid medications compared to patients without depression. In a randomized, cross-over, double-blind, placebo-controlled study, 60 patients with chronic low back pain were stratified into three groups based on the severity of depressive, anxiety, and neurotic symptoms.9 Subjects in each of the three groups were administered 4-6 mg of morphine intravenously and pain severity was assessed over three hours. The total...

Functional Imaging Pain And Depression

Activation of brain structures by acute pain stimuli is different among individuals with chronic pain. In general, the primary and secondary somatosensory, anterior cin-gulate, insula, and thalamus are activated significantly less compared to normal subjects. In the aforementioned meta-analysis, the average incidence of activation of these brain regions in normal controls was 82 percent compared to 42 percent for individuals with chronic pain.14 Alternatively, among adults with chronic pain, the incidence of prefrontal cortex activation was 81 percent compared to 55 percent in normal subjects.14 The observation that activity in brain structures associated with the affective-motivational dimension of pain are accentuated in patients with chronic pain is consistent with clinical observations that these patients experience more pain-related emotions and affective distress. This postulate is also consistent with neuroimaging findings from patients with comorbid depression and chronic...

Pharmacology and adverse effects including suicide

One of the most important controversies related to use of SSRIs is the potential increased risk of suicide, particularly among adolescents with depression.109,110,111 However, further research is needed to firmly establish the overall risks and benefits of antidepressant therapy on both attempted and completed suicide.112,113114 Knowledge of the potential association between SSRIs and suicide is particularly important for pain medicine specialists given the high incidence of depression among patients with chronic pain. In the context of this ongoing controversy, physicians who prescribe antidepressant medications should be vigilant in accounting for the potential risk of this uncommon, but devastating, adverse event.

Antiepileptic Drugs Carbamazepine and oxcarbazepine

Both have been shown to block tetrodotoxin-resistant Na1 channels in brain tissue.1 Neuronal hyper-excitability, linked to accumulation of sodium channels in injured peripheral axons and cell bodies, is reduced by carbamazepine, as is similar excitability in dorsal horn neurons2, 3 and possibly elsewhere in the central nervous system (CNS) where sodium channel may be up-regulated.4 The selectivity of Na1 channel blockade remains to be determined, but interaction with a low activation state of Nav1.8 channels may be one of the key mechanisms of carbamazepine.5 In addition, both car-bamazepine and oxcarbazepine appear to antagonize the A1 adenosine receptor, increase dopaminergic transmission, and potentiate voltage-gated potassium channels, all potentially useful properties in chronic pain.1 Both drugs inhibit L-type voltage-gated calcium channels and presyn-aptic glutamate release, although it is uncertain whether this happens in sufficient concentrations in clinical...

Other Antiepileptic Drugs

Used in various chronic pain conditions, usually neuropathic pain and or headache. The results are mostly disappointing and the few that claim efficacy are far from convincing. Some clearly negative results from large trials involving antiepileptic drugs remain unpublished. The clinician should therefore resist the temptation to try just another drug from this class when others have failed many old and new AEDs require good understanding of their pharmacological properties and attention to detail if they are to be used safely.

Behavioral Experiments The Example Of Exposure And Response Prevention

Behavioral experiments are an integral part of mainstream cognitive therapy27 and seen as a significant vehicle for producing cognitive and behavioral change. Behavioral experiments are developed to test individual's beliefs about the consequences (emotional, behavioral, and cognitive) of either engaging or not engaging in particular behaviors. Behavioral experiments can be used to help with many of the problems that are experienced by patients with chronic pain. The clearest example of the use of behavioral experimentation has emerged in the therapeutic application of the fear-avoidance model.28,29 III This model proposes that a proportion of chronic pain patients are inactive because they fear that movement will produce physical damage to their bodies, i.e. their behavior is negatively reinforced by the avoidance and reduction of anxiety. Treatment comprises analyses of the patient's avoidance behavior and the development of a hierarchy of feared situations. Patients' predictions...

Critical evaluation of a metaanalysis of CBT

In preparing this study,3 we made a number of a priori assumptions and exclusions. First, chronic pain was accepted as a label for a heterogeneous group of pain problems in which diagnosis, site of pain, or medical findings were not apparent major sources of variance in any of the targets of treatment. This probably reflects the assumptions made in many PMPs in clinical settings. Second, we excluded studies of psychological treatments of headache because the episodic nature of chronic headache is markedly different from nonheadache. Third, we also excluded trials reporting the effectiveness of psychological treatments for children with chronic pain, see Ref. 48 I . The study was designed to answer two questions. 1. Absolute efficacy - is CBT an effective treatment for chronic pain, i.e. is it better than no treatment

Why Do Pain Patients Seek

Pain management is an excellent example of where the biomedical model falls short. First, pain management is, by definition, an experience that is subjective1 and cannot be measured directly. Second, the pathophysiologic processes that produce clinical pain problems are still incompletely understood. We can only infer what the pathology is in broad generalities - for example, inflammatory, neuropathic, or mechanical. Complex social and psychological factors play such an important role in chronic pain problems that attempts to treat chronic pain exclusively using scientific principles are doomed to fail under our current state of scientific knowledge. Pain has a motivational component, i.e. it is accompanied by a drive to eliminate it. The result is that patients continually seek alternative treatments to eliminate their pain. All of these conditions lead patients to seek CAM for pain incomplete pathophysiologic characterization, lack of scientifically derived treatments, inability of...

Legalities Of Opioid Prescribing

The fear of increased regulatory oversight also colors the way a prescriber provides opioid medications for pain. If prescribers has a high fear level, they can be tempted to use less effective medications to treat pain in their patients. Findings from a survey with 963,385 registered physicians found that when adequate documentation exists in the medical records, the risk of action against any physician who prescribes opioids for chronic pain is very small.

Universal Precautions

Standardized guidelines have been suggested to manage all patients with chronic pain. By utilizing this approach, clinicians can lower the risks associated with opioid administration. These guidelines have been termed universal precautions in pain management, borrowing the concept of universal precautions from the infectious disease model, suggesting that it not possible for clinicians to assess all risks associated with opioid therapy (Gourlay, Heit, & Almahrezi, 2005). Therefore, it is appropriate to apply the minimum level of precaution to all patients utilizing this treatment. A more complete description of these precautionary steps is provided in this and other chapters of this book. The following steps from these guidelines are as follows

The nature of the disease

Parkinsonism provides a useful second model of a neurologic disorder in which chronic pain is both common and underestimated.26'27 The etiology very probably involves both genetic and environmental factors various toxic environmental chemicals have been implicated in the disease, as well as familial clustering of cases consistent with autosomal dominant inheritance. Concerning the pathology, degeneration of dopaminergic neurons of the substantia nigra is the hallmark of the idiopathic disease. The prevalence in the USA is in the order of

Systemic Sodium Channel Blockers

A systematic review has been undertaken of systemic local anesthetic-type drugs in chronic pain.50 I The findings can be summarized as follows the most convincing evidence for benefit is seen in neuropathic pain of peripheral nerve injury or peripheral neuropathy, with no evidence of benefit in dysesthesia from spinal cord injury or painful neuropathy (including plexopathy) in malignant disease. However, one recent publication supports their use in MS.51 V

Psychologic treatment

The application of psychology-based treatment to chronic pain is extensively covered in Chapter 13, Self-regulation skills training for adults, including relaxation Chapter 14, Biofeedback Chapter 15, Contextual cognitive-behavioral therapy and Chapter 16, Graded exposure in vivo for pain-related fear in the Practice and Procedures volume of this series. In principle, the management approach is as appropriate to chronic pain sufferers with neurologic disease as to other groups, with perhaps two qualifications.

Authors recommendations

Patients with chronic idiopathic pain need to be carefully assessed which includes eliciting their treatment goals and beliefs about treatments. In line with other chronic pain, unnecessary investigations and treatments make pain intractable and results in depressed patients. Clinicians often feel less optimistic about their ability to successfully manage these patients. A biopsychosocial approach to treatment is needed and CBT should be used alongside drug therapy in those who are found to have a high index of disability. The selective serotonin reuptake inhibitors (SSRI), especially fluoxetine and escitalopram or others such

Risks Of Chronic Opioid Therapy

Determining the true incidence of addiction in primary care patients who take long-term opioids is difficult, and more data are needed to make a definitive finding. However, there are some studies that address this question. In one study of 800 patients seen in primary care practices for chronic pain and taking opioids, the rate of addiction was roughly 4 (Flemming, Balousek, Klessig, Mundt, & Brown, 2007). In another study, the incidence of addiction in primary care patients was found to be 0.97 in opioid naive patients and 4.37 in those patients who had used opioids previously (D'Arcy, 2009b Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2008).

Commonly used interventions currently unproven

Mechanical exercises are often prescribed as it is thought that patients with pain are often reluctant to use the body part that is causing pain. Use of occlu-sal appliances is common as these are easy for dental surgeons to construct and they are more familiar with this method of treatment rather than systemic drugs. Patients with TMD pain can be divided into three treatment groups based on their response to the Graded Chronic Pain Scale minimal contact approach (one or two sessions with or without the help of a psychologist), integrated approach (with appliances, biofeedback and stress management led by hygienist) and a structured behavioral programme (psychologist led for six sessions) 45 .

Discussion of evidence

From the current evidence, it is clear that as with other chronic pain, a biopsychosocial approach is necessary as behavior and attitudes need to change and patients need to self-manage their condition. Turner et al. 32 and Gatchel et al. 33 have shown that changing TMD patients' beliefs and pain-coping strategies through the use of CBT can have a modest effect on future pain and functioning. Combining CBT with biofeedback may yield even better results as the latter has a more immediate effect and appears to be more physiologically orientated. There is some evidence that NSAIDs may be of some benefit but the side effects of these medications need to be taken into account. Benzodiazepines may be useful but they should not be used except in the short term due to dependency. As with other chronic pain, there is some evidence that tricyclic antidepres-sants as well as the newer SSRI may be of benefit. It is highly likely that dental treatment is not the way forward and the American Dental...

Evaluate and Manage Depression

Many patients with LBP are depressed. It is a common occurrence and should be treated aggressively to avoid serious repercussions. Concomitant depression can be almost as disabling as LBP. In a study of 416 patients using a depressions scale (CES-CD), 18.3 of patients with chronic pain scored as clearly depressed, and 57 of the chronic pain patients studied had a major depressive episode in their lifetime. Coping with LBP as well as a major depression can be overwhelming for the patient. The nurse practitioner should be aware of the high incidence of depression with chronic pain and screen patients with chronic pain for depression so that both the depression and pain can be adequately treated. Thie rate of suicide in patients with chronic pain is twice the rate of patients without pain (Tang & Crane, 2006). Patients need to be informed that depression is common with chronic pain and that antidepressant therapy can help the patients cope with the continuing pain. In order to make this...

Other Indicators of Functionality

Although numeric pain ratings are helpful to determine if pain medication is effective, they are not meant to be the entire method for assessing pain in patients with chronic LBP. Functionality and increases in quality of life may be more important measurement for improvement. If the patient can walk further, shop independently, and attend church, these are all goals that have true meaning for maintaining the quality of life for patients with chronic pain. Continued tracking of numeric ratings may do more harm than good if pain intensities fail to improve. Keeping an open mind about all treatment options is beneficial for patients. Encourage patients to look beyond medication management and seek opportunities to try additional types of pain relief. Medications for chronic pain should never be seen as the only option for pain relief. Using multimodal pain management will in the end produce the best outcomes for the patient and increase the potential for optimal pain relief.

Psychological Interventions

CRPS shares with all chronic pain states the problems inherent in a condition that adversely affects the individual's own psyche and self-image, role in the family, work status, financial status, and involvement in the legal system. It is apparent that CRPS does not have any predictable psychological precursor,66 but equally apparent is that it produces severe psychological adverse effects. These are not only distressing for the patient and family, but also produce secondary adverse physiological and functional changes. It is therefore not surprising that cognitive behavioral treatments are reported to be effective in the management of chronic pain states, including CRPS.68 I There are, of course, no randomized controlled studies of these methods in CRPS, but the published reports, as usual, are supportive (reviewed by Bruehl67).

General points and assumptions

More recent incidence and prevalence studies have attempted to identify pain subtypes (neuropathic, noci-ceptive, visceral) in their analysis. Many older studies did not specify whether the chronic pain associated with a central neurologic process was neuropathic or not.

Pathophysiology of chronic pelvic and perineal pain in women

This is exemplified by endometriosis, a condition affecting women predominantly in the reproductive age group and characterized by the presence of endometrial glands and stroma outside the endome-trial cavity. The condition is thought to arise mainly by i mplantation of endometrial tissue following retrograde menstruation via the fallopian tubes 1 . It presents a clinical spectrum, with endometriotic deposits sometimes observed at laparoscopy in the absence of symptoms or tissue damage, through sub-fertility apparently associated with endometriosis but in the absence of pain, to chronic pain associated with disabling pain symptoms and often gross damage to the pelvic organs through abnormal invasion of endometriotic deposits into the pelvic tissues, neo-vascularization and adhesion formation. In a series of asymptomatic multiparous patients undergoing sterilization, the prevalence was 26 3384 (3.7 ) 2 . There is a relationship between the depth of invasion of endometriosis and the...

Psychological and environmental aspects

The person with SCI undergoes a huge adjustment in relationships, lifestyle, vocation, and self-image that need to be addressed and people with a severe SCI often have significant psychological distress, particularly in the acute post injury period.103 V The presence of chronic pain may be an additional factor that prevents expected rehabilitation and return to employment and function in domestic life.5'6'22'104 V Anxiety and depression are both normal responses to injury and often improve with time and the implementation of the person's inherent coping skills. In these people, formal intervention may not be required. However, for the minority who experience severe or chronic mood dysfunction that is having an impact on their ability to function and contributing to pain, intervention should be offered.

Problem Of Definition

These time scales are all arbitrary and in practice it may not be possible to be exact. As the mechanisms of the changes that occur after injury and surgery become better understood, details of definition, such as the time scale, will become less important. To illustrate this point, if a patient has an operation for varicose veins and the saphenous nerve is injured, then they will probably have pain immediately after the operation. This may persist from the time of the operation and possibly be permanent, as it is a neuropathic pain. When does it become chronic In chronic pain after surgery, the difficulty is compounded because pain may have been one of the symptoms that the patient was complaining of prior to surgery, and in fact may have been the main reason for seeking medical help. For example, in patients who have had a cholecystectomy for right upper quadrant pain, the preexisting pain will confuse the issue and complicate understanding the process of development. Is the pain...

Mechanisms Of Chronic Postsurgical Pain

Most people expect to have some pain after an operation. This represents the same process within the organism as pain after any injury. The pain caused by an injury does not bear a simple relationship to the severity or size of the injury and in the same way the size of the operation does not neatly correlate to the severity of the chronic pain that follows. An example would be to compare vasectomy with total hip replacement or sternotomy. Vasectomy is an operation carried out for social rather than medical reasons, on fit men, and is minimally traumatic. However, in a proportion of men, the pain suffered after surgery can be severe and cause considerable disability. The prevalence of chronic pain after vasectomy varies between studies from 516 to 15 percent.17,18 In contrast, total hip replacement is a major operation on patients who have normally long-standing and painful pathology. This is a lengthy procedure that involves cutting and reaming bone, injury to muscles and other soft...

Evolutionary Perspective

As described above, the nervous system changes following injury. The injured part becomes painful and sensitive because the peripheral receptor thresholds are decreased and central amplification occurs, making any signals louder. This hypersensitivity following injury probably confers an evolutionary benefit by encouraging rest, preventing further damage, and allowing healing. The abnormal settings of the nervous system should return to normal after the injury has healed. Failure to return to normal would leave the nervous system in a sensitized state and this is probably one of the causes of chronic pain after surgery. Why the nervous system does not readjust is unknown, but animal work suggests that there is a genetic component to the development of neuropathic pain after injury.32, 33 There are many similarities between memory and chronic pain long-term potentia-tion (LTP) is a mechanism common to both.34,35 In many ways, chronic pain represents a failure to forget.

Postsurgical Pain Syndromes

As stated earlier, there are several different types of pain syndromes which may develop after surgery. Most studies of chronic pain after surgery focus on patient cohorts undergoing one surgical procedure, such as mastectomy or chest surgery, rather than assessment of large, diverse surgical populations. In this chapter, it is not possible to review all the literature on postsurgical conditions. We will review the pain syndromes associated with three types of surgery, amputation, hernia surgery, and breast surgery. These are the three areas that have received the most attention and in which there are sufficient good quality publications to draw valid conclusions. The review articles mentioned in the Introduction above cover pain syndromes after some other types of surgery, but it has to be emphasized that for many types of surgery there is little or no published evidence and often the studies are of poor quality.

Implications Of The Complexity Of Mechanisms

Understanding the scale of the changes to the nervous system and the mechanisms that predispose to chronic pain after surgery is important for many reasons. It can change the climate of blame that exists when patients have pain after an operation. Because people expect the pain after injury or an operation to resolve as the injury heals, it is natural that they should imagine that something must have gone wrong with the operation if the pain persists. It is not possible to perform surgery without some damage to tissues, and therefore a hyperalgesic state will be induced after any operation, regardless of how it is done. Usually this will revert to normal as healing occurs, but not always. Whether a patient experiences chronic pain after surgery or not is therefore more likely to depend on the set of their nervous system than on precisely what the surgeon did. For patients who have chronic pain after surgery, it is inappropriate to assume that the surgeon has necessarily done anything...

Background to perinealpelvic pain syndromes in males

Evidence-Based Chronic Pain Management. Edited by C. Stannard, E. Kalso and J. Ballantyne. 2010 Blackwell Publishing. are being used to explain the mechanisms for the pain syndrome in other cases chronic pain mechanisms are being invoked. Some of the pain syndromes will thus be recategorized, with time, into the well-defined pathology group.

Intrathecal baclofen therapy

When general or regional spasticity is severe and cannot be managed by physical or oral pharmacological means, continuous delivery of intrathecal medication should be considered. Intrathecal baclofen (ITB) therapy follows the same principles as intrathecal therapy for chronic pain as discussed elsewhere in this volume. Baclofen does not easily cross the blood-brain barrier.36 Administering this medication directly into the subarachnoid space means that very low doses of medication can be delivered directly to the spinal cord at high local concentrations. This results in good clinical effects with very low systemic absorption and hence a low incidence of side effects. A typical dose of oral baclofen is 60-80 mg day in divided doses. A typical intrathecal baclofen dose is 350 mg day (1 2000th of the oral dose) as a continuous infusion. Some patients like a bolus dose in the early hours of the morning to assist them when getting out of bed.

Magnetic resonance imaging

In patients with acute neck pain, but with no clinical indicators of any serious cause, magnetic resonance imaging (MRI) offers little prospect of a positive diagnosis. The only indication for MRI is as a screening test for rare and clinically occult disorders in patients with persistent or chronic neck pain. Yet even in that context, the use of MRI is questionable. By definition, rare conditions are unlikely to be evident, and in the absence of clinical indicators they are even more unlikely. The cardinal indicators are a past history of cancer, risk factors for infection, or signs of systemic illness. In patients with risk factors for aneurysm (see Chapter 12, Diagnostic procedures in chronic pain), magnetic resonance angiography is indicated.

Box 153 Pain treatment options chronic pancreatitis [3745

The current evidence indicates that endoscopic ultrasound-guided celiac plexus blocks are safe and well tolerated with excellent temporary results in some patients. Unfortunately, reliable predictors of success are lacking. In the absence of long-term studies in patients with chronic pancreatitis, the role of endo-scopic ultrasound-guided celiac plexus blocks should be limited to treating flares of chronic pain in patients with otherwise limited therapeutic options.

Box 154 Pain treatment options urolithiasis [4851

Eventually the disorder leads to kidney failure. Renal stone formation and liver cyst formation are both common co-morbidities. Therapeutic regimens have been proposed which suggest a general progression from nonpharmacologic methods to non-narcotic analgesics and minimally invasive procedures to progressively more invasive procedures and the use of opioids 54 . Procedures unique to polycystic kidney disease include surgical or percutaneous drainage of the cysts to decompress the lesions, sometimes followed by marsupialization to avoid fluid reaccumulation. In a study by Brown et al. 55 , 50 of patients were pain free 12-28 months after laparoscopic marsupialization. More recently, Casale and colleagues 56 reported treating 12 patients aged 8-19 years (mean age 12.4) with laparoscopic renal denervation and nephropexy. All these patients had autosomal dominant polycystic kidney disease with chronic pain that was refractory to narcotic use. All patients were reportedly pain...

Goals of the initial assessment

The initial assessment of patients with CLBP needs to be thorough and systematic. The goals of the initial evaluation are as listed in Box 37.2. Part of the initial evaluation should include a screen for risk factors for chronicity.11 These so-called yellow flags'' are psychosocial factors that increase the risk of developing or maintaining chronic pain and disability, and include Identify patients with an evolving chronic pain

Dont be fooled by these patient populations

The chronic low back pain patient, who has presented on numerous occasions, can subsequently develop a life-threatening reason for their pain. They may only complain of worsening symptoms over time or an additional area of pain, when indeed they are harboring a new cancer, infection, or fracture. The patient with psychological overlay or the possibility of chronic pain syndrome similarly can have a serious underlying reason for their pain.

Definition and timing of postsurgical pain

Pain is nearly universal following any surgical procedure, and this postoperative pain is assumed to resolve over a relatively short period measured in days or weeks. It is usually assumed that acute postoperative pain is primarily the result of nociceptive and inflammatory input from the surgical injury, although in some surgical models, nerve injury may be a significant component even during the acute phase. It is also reasonable to assume, on the basis of clinical presentation as well as investigational data, that most persistent postsurgical pain, at least after nonpain-related surgery, is predominantly neuropathic 3, 4 . Chronic pain has traditionally been defined as pain lasting more than 3 or 6 months 5 yet given the complexity of mechanisms of persistent postinjury pain, and the variations in recovery times for each component, chronic pain * Most common syndromes of persistent or chronic pain, surgery was not undertaken for pain relief, pain is usually neuropathic Pain severe...

Inguinal hernia repair

Intentional sectioning of the ilio-inguinal and iliohypogastric nerves did not alter the probability of persistent pain following hernia repair at 6 months (21 prevalence of pain for nerve sectioning and 23 prevalence for nerve preservation). An early systematic review comparing open hernia repair to laparoscopic repair 56 noted that few studies reported the prevalence of chronic pain, and there were no significant differences. Two more recent reviews of the same topic 57, 58 found a significant decrease in risk of chronic pain with laparoscopic repair (8 prevalence) compared to open mesh repair (13 prevalence). A review of open hernia repair using mesh versus not using mesh found a lower prevalence of persistent pain and a lower hernia recurrence rate with mesh repairs 59 . These findings are similar to the findings from a Cochrane Database Review 60 in which cumulative data revealed a prevalence of 6 for chronic pain following mesh repairs and 10 for open repairs. There...

Box 406 Diagnostic criteria for irritable bowel syndrome

As in any chronic pain disorder, an important (but not particularly testable) component to the management of IBS is a stable, trusting patient-physician relationship. Life-threatening pathology may be simply ruled out without an exhaustive investigation and the patient needs to be assured that their symptoms are believed. Therapeutic options for IBS are listed in Box 40.7. As part of a diagnostic therapeutic trial, patients are generally advised to engage in dietary modifications such as avoiding milk products, avoiding excessive legume consumption (associated with gas production), increasing fiber and bran in those with constipation,86, 93 avoiding caffeine- or sorbitol-containing foods, and establishing a stable dietary pattern in the hope of establishing a stable evacuation routine. Anticholinergics antidiarrheals have been extensively employed clinically and extensively studied. Reviews of the efficacy of these agents have concluded that their benefit is unproven.93 Traditional...

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