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chronic pain

Etiology: 1) somatic pain a) inflammatory pain, arthritis b) bone pain c) muscle pain, muscle spasm d) neuropathic pain, peripheral neuropathy e) arterial insufficiency, atherosclerosis f) reflex sympathetic dystrophy (also a neuropathy) g) headache - migraine - cluster headache - sinusitis - trigeminal neuralgia (peripheral neuropathy) h) fibromyalgia i) cancer pain 2) visceral pain a) chronic pancreatitis b) chronic active hepatitis c) diabetic neuropathy 3) secondary factors perpetuating pain after resolution of a disease process a) damaged sensory nerves b) sympathetic efferent activity c) painful muscle contraction 4) psychologic conditions can perpetuate or cause pain a) emotional trauma b) physical or sexual abuse c) substance abuse Epidemiology: - disproportionately affects the elderly, minorities, & those with socioeconomic disadvantages [39] Pathology: - chronic pain may be associated with neuroinflammation, microglial activation, & neurogeneration History: - about the pain - pain onset - pain location - pain quality & intensity - relieving & exacerbating factors - functional status - effect of pain on functional status - mental health - depression - anxiety - somatization [4] - substance abuse - verbal, physical or sexual abuse Laboratory: - no specific role for diagnostic testing because abnormalities identified may not be related to the patient's pain [4] - urine drug screen for monitoring use of controlled substances - can be difficult to interpret [18] - recommended prior to initiation of opiates & yearly thereafter [26] - CSF markers - patients with chronic pain have increased CSF total tau, CSF sTREM2 & CSF TNF-alpha - CSF ptau181 increases with duration chronic pain, while CSF beta-amyloid 1-42 decreases with chronic pain [58] Radiology: - brain imaging should not be used to prove whether a patient has chronic pain [36] Complications: 1) depression is common 2) suicide risk (hazzard ratio 1.4-3.0) - cancer pain [41] - suicide risk for non cancer pain highest for - migraine (RR=1.34) - psychogenic pain (RR=1.58) 3) undertreatment - cognitive impairment, age > 95 years, black or Asian race less likely to receive opiate [9] Management: === eliminate barriers to functional improvement === - behavioral, social or systems issues - telephone-based pain management can improve symptoms in patients with chronic musculoskeletal pain [21] - mean pain score was 3.57 (out of 10) vs 4.59 - asking about pain tolerability has advantages over a 10 point scale [44] - multimodal pain management strategy [4] === non-pharmaceutical measures === 1) multimodal pain management strategy [4] 2) cognitive behavior therapy (CBT) [24,25,40] - self management strategies that reduce pain [24] - adaption for education level [39] - group-based approach may provide benefit [40] - CBT provides improvement in pain & quality of life without changing opioid use [48] 3) physical therapy, massage, chiropractic manipulation 4) ice & heat therapy 5) aerobic exercise - exercise may mitigate morbidity of chronic pain through enhancement of pain tolerance [56] 6) transcutaneous nerve stimulation (TENS) [4] 7) impantation of a spinal cord stimulator for intractable back or leg pain [43] 8) acupuncture can help alleviate chronic pain, but much of the benefit can be explained by a placebo effect [10] - not much better than sham procedure [19] 9) treatment agreements for patients on long-term controlled substances [20] a) may diminish misuse & improve safety b) required by some state medical boards [20] 10) nurse care manager [24] 11) green eyeglasses may reduce anxiety & opiate use in patients with chronic pain [49] 12) physician empathy associated with lesser pain intensity & less disability [60] 13) emotional awareness & expression therapy (EAET) may outperform CBT [61] === pharmaceutical stategies for treating chronic pain === 1) protocol-driven analgesic therapy [24] 2) multimodal strategy including acetaminophen, NSAID, gabapentenoid, antidepressant, opiate &/or possibly cannabis [4] === pharmaceuticals === 1) acetaminophen: up to 1000 mg every 8 hours (3000 mg/day) 2) non-steroidal anti-inflammatory drugs (NSAIDs) - refs [2,11] do not exclude NDSAIDs in pain ladder for 85 yo with cancer pain 3) antidepressants for neuropathic pain a) tricyclic antidepressants 1] doxepin 75-400 mg/day 2] amitriptyline 25-300 mg/day 3] imipramine 75-400 mg/day 4] nortriptyline 40-150 mg/day 5] desipramine 50-300 mg/day 6] irritable bowel syndrome, neuropathic pain, chronic tension headache (low-certainty evidence) [51] b) serotonin & norepinephrine reuptake inhibitors (SNRIs) 1] venlafaxine 2] duloxetine [4,5] only antidepressant effective for chronic pain [53] 3] chronic back pain, postoperative pain, fibromyalgia, neuropathic pain (moderate-certainty evidence) [51] 4] depression with comorbid chronic pain, knee osteoarthritis (low-certainty evidence) [51] 4) anticonvulsants for neuropathic pain a) phenytoin (Dilantin) 300 mg QHS b) carbamazepine (Tegretol) 200-300 mg every 6 hours c) clonazepam (Klonopin) d) gabapentin (Neurontin): 1] start 300 mg QHS 2] increase to 300-600 mg TID e) pregabalin 5) mexiletine 150-300 mg every 6-12 hours 6) opiates a) use in combination with other analgesics or not at all - avoid use of opiates for chronic neuropathic pain [4] b) start short-acting opiate PRN 1] titrate as needed - opioids do not have a ceiling for analgesic efficacy [4] 2] extra precautions when prescribing at or above 50 morphine mg equivalents per day [26] 3] switch to long-acting opiate when PRN dose is stable adverse effects are tolerable [8] 4] oral opiates preferred; do not use intramuscular [4] 5] sublingual or subcutaneous if oral route not feasible [4] c) prevention & treatment of constipation (all patients on chronic opioids) [4] 1] stimulant laxative (senna, bisacodyl) with or without docusate 2] osmotic agent (polyethylene glycol, sorbitol, lactulose) 3] naldemedine, naloxegol, or naltrexone 4] tolerance does NOT develop to constipating effects [4] d) prescribe doses of opiate > 80-120 mg/day morphine equivalent only for patients with meaningful pain & functional improvement with treatment, in consultation with a pain management specialist [22,26] e) discuss benefits & harms of continued opioid treatment with patients at least every 3 months f) little evidence of improved function, enhanced quality of life, or diminished pain [4,23]; overall functional status, quality of life, & pain actually worse with chronic opiates [4] g) 40% of deaths from unintentional drug overdose are caused by prescription opioids [7] h) opioid use increases risk of falls & fractures, hospitalization & doubles mortality [7] i) increased mortality (RR=1.64) relative to use of antidepressants or anticonvulsants [31] j) urine drug testing before initiation of opiates & yearly thereafter [26] k) avoid combination of opiates & benzodiazepines [26] l) coprescribing naloxone with opioids - patients taking >= 50 morphine mg equivalents per day - patients also taking benzodiazepine (if combination unavoidable) - may diminish opioid-related emergency department visits [32] m) reduction or cessation of long-term opiate therapy may improve pain, function, & quality of life [35] n) opioids no better than nonopioid drugs for chronic back pain or chronic pain related to hip osteoarthritis or knee osteoarthritis [38] o) transdermal fentanyl safest opiate in renal failure & liver failure [4] - start lower dose patch with liver failure - use only in opioid-tolerant patients [4] p) hydromorphine reasonable choice if renal failure - reduce dose with liver failure q) meperidine is not recommended due to increased risk for seizures r) tramadol has drug interactions with other serotoninergic agents s) methadone 1/2life averages 25 hours [52] 7) buprenorphine, rather than a full agonist opioid, for chronic pain, given its lower risk for overdose or misuse 8) medical marijuana when other options have failed [4,42] - may result in a decrease in use of other analgesics [50] 9) investigational - cold analgesia can block pain signaling Notes: - poor medication management most common reason for lawsuits against pain physicians [37] - few payouts, no payouts for termination of opioid prescription - systematic review assessing the effectiveness & harms of plant-based treatments for chronic pain [45] - alternative medicine increasingly used for treatment of chronic pain [59]

Interactions

disease interactions

Related

long-term opiate therapy

Specific

chronic abdominal pain chronic daily headache chronic musculoskeletal pain chronic pelvic pain syndrome (CPPS) neuropathic pain wind-up pain

General

chronic disease pain [odyn-]

References

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