PDF Chronic Pain Management: Guidelines for Multidisciplinary Program Development

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However, there was increased recognition that many terminal patients lived out their last days in agonizing pain. Specialists in palliative care, such as Kathleen Foley and her fellow, Russell Portenoy, at Memorial Sloan Kettering recognized the relief that opioids brought to dying cancer patients through extensive clinical experience in the s and 80 s Foley, ; Portenoy and Foley, Concurrently, the World Health Organization developed cancer pain treatment guidelines that included opioids for the first time and recognized the treatment of pain as a universal right World Health Organization, ; Lohman et al.

Although opioids were described as just one possible treatment option, the initiative did advocate a change in philosophy around use of opioids for chronic pain. Opioids were promoted as a way to improve quality at end of life. By the late s, it was generally accepted that all patients are entitled to the assessment and treatment of pain, resulting in influential regulatory bodies such as the Joint Commission on the Accreditation of Healthcare Organizations JCAHO mandating pain assessment and treatment of all patients in accredited health care settings by in order to receive federal health care dollars Manchikanti et al.

The Federation of State Medical Boards made a clear statement in that physicians would not receive excessive regulatory scrutiny if prescribing notable amounts of opioids — a fear that had previously reduced the willingness of physicians to prescribe opioids for chronic pain Joranson et al. Although the APS campaign led to increases in pain research, education, and an important focus on pain relief, there have been unintended consequences resulting in an overreliance on opioids to treat chronic non-malignant pain.

Health care providers accredited by the JCAHO were mandated to implement adequate pain assessment and treatment methods for all patients in a relatively short period of time 2 years. Although specific analgesic treatments non-pharmacologic and pharmacologic were left up to the individual physician or provider, these health care facilities developed policies that liberalized the use of opioids in an attempt to meet JCAHO standards.

In addition, as patient satisfaction including pain relief became an increasingly valued health care outcome, clinicians in these facilities were further encouraged to use opioids to control pain quickly and as completely as possible. Although higher opioid use remains a theoretical risk of rewarding patient satisfaction scores Zgierska et al. During the s and early s, provider and patient fears of addiction to prescribed opioids were minimized due to an overemphasis on the findings of two small retrospective studies which suggested that patients rarely develop opioid use disorder when opioids were prescribed for the treatment of pain Porter and Jick, ; Portenoy and Foley, The first was a letter that suggested very low 0.

The second reported on 38 patients from one practice prescribed opioids for chronic non-malignant pain Portenoy and Foley, , and showed only 2 patients 5. These reports became heavily cited in peer-reviewed and non-peer reviewed literature Fig.

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However, these early claims of low addiction risk when generalized to chronic pain management were based upon insufficient evidence as history has shown. A letter published in by Porter and Jick that dealt with opioids for acute pain as well as a report by Portenoy and Foley in on 38 cases of persons treated with opioids for chronic non-malignant pain were used hundreds of times as evidence to demonstrate that opioids had low risk for addiction. Cumulative citations for each article were obtained from Google Scholar.

Related to the historical shifts outlined above, the treatment of chronic non-cancer pain became a new and growing indication for an opioid prescription. This resulted in an exponential increase in the number of Oxycontin prescriptions from , in to about 6. As with Oxycontin, prescriptions for all opioids increased dramatically throughout the late s and s. Opioid prescriptions were frequently written by practitioners without specialty training including dentists , and in a few rare cases, by providers who focused on writing opioid prescriptions for profit. At present, there is no conclusive answer to the above question.

A systematic review was completed in preparation for the CDC guidelines on the use of opioids for the treatment of chronic non-malignant pain in primary care. As a result, no controlled studies on opioid effectiveness met inclusion criteria but 19 studies mostly uncontrolled studies using claims databases were included that examined harms. The review concluded that there were no well-controlled long-term studies indicating that opioid treatment for pain beyond twelve weeks effectively relieves pain or improves function Chou et al.

These clinical trials focused mainly on pain relief and did not typically report on other pain related outcomes, including quality of life, reduction in disability, or return to work.

current and ideal practice

Given the discrepancy between systematic reviews of controlled studies and clinical consensus, there is no clear answer on whether chronic opioid therapy can improve pain level, pain-related disability, or quality of life in patients. In addition, it is important to include in a balanced perspective that chronic opioid therapy is associated with overdose death, development of substance use disorder, fractures, and sexual dysfunction Chou et al. An unfortunate consequence of the recent focus on prescription opioids to treat chronic pain has been a lack of research on, and clinical attention to the efficacy of a wide variety of non-opioid chronic pain management strategies.

The primary goals of chronic pain management are discovering a cause, alleviating suffering, and restoring function. Biologic, psychological, and social factors all play a role in the perception and chronification of pain and each should be assessed and managed as needed.

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Therefore, the following section outlines various treatment approaches to better assist the reader in understanding the wide array of other chronic pain treatment options. Included are opioid and non-opioid pharmacotherapies, physical therapy, psychological and behavioral therapies, complementary and alternative medicine strategies, peripheral procedures, spinal procedures, and surgery Table 1.

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  7. These strategies are not mutually exclusive and can be combined as directed by a health care provider. Unfortunately, little information is known about the comparative effectiveness of these strategies. There are numerous medications used to treat chronic non-malignant pain that target the mechanisms of peripheral and central sensitization, the proposed mechanisms contributing to pain chronification, e. NSAIDs are more effective in the treatment of chronic musculoskeletal pain e. In addition, naproxen has been FDA approved for pain associated with ankylosing spondylitis, an inflammatory autoimmune disorder that causes the vertebrae of the spine to fuse together.

    Long-term use is not recommended unless under the care of a physician or other prescriber. Antidepressants and anticonvulsants are frequently used in the treatment of chronic neuropathic pain McCleane, ; Attal and Bouhassira, ; Finnerup et al. The analgesic effects of antidepressants are thought to be independent of their antidepressant effects, as persons without current major depressive disorder receive significant analgesic benefit Lynch and Watson, Duloxetine is the only antidepressant to have FDA approval for the treatment of chronic pain diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain , although antidepressants with dual serotonin and norepinephrine reuptake inhibition are used off-label to provide pain relief Table 1.

    Anticonvulsants reduce pain by inhibiting excessive neuronal firing, including nociceptors.

    Multidisciplinary team approach in chronic pain management - Pergolizzi

    First and second generation anticonvulsants e. As with anti-depressants, patients should be counseled that pain relief may take 4—6 weeks to occur and monitored for the development of new-onset suicidal ideation, sedation leading to falls, hypoglycemia, and acute renal insufficiency Table 1. There is also increasing evidence that patients may misuse or abuse gabapentin Chiappini and Schifano, ; Smith et al.

    Reductions in pain related to medications and invasive procedures can enable patients to fully participate with PT, which has an important role in pain relief and restoration of function in chronic pain patients Krismer et al. PT should strongly be considered for the management of chronic pain to gradually increase flexibility and strength, for example in knee osteoarthritis where there is demonstrated benefit Fransen et al.

    A referral from a physiatrist, primary care physician or nurse practitioner is often required before initiating PT. Although initially therapist-directed, PT can become self-directed over time. A course of PT usually requires an intake assessment and 8—12 PT sessions over the course of 4—6 weeks. Techniques include stretching exercises, manipulations, hot or cold applications, traction, transcutaneous electrical nerve stimulation TENS , and massage. Risks of PT include myocardial infarction leading to sudden death, as well as worsening pain especially at beginning of treatment.

    Many psychological and behavioral therapies have been used in the treatment of pain and its associated disability and distress — irrespective of the presence or absence of mental illness Eccleston et al. Cognitive-behavioral therapy CBT is an effective approach based on the theory that beliefs, attitudes, and expectations affect emotional and behavioral reactions to life experiences, including pain. Patients are taught to be active participants in the management of their pain with the goals of increasing activity, independence, and resourcefulness.

    Persons with high levels of pain catastrophizing may especially benefit from psychological and behavioral therapies Smeets et al. CBT usually requires 12 weeks of treatment to see maximum benefit, with hour-long weekly individual sessions with a therapist and homework to be completed outside of sessions. A referral is often needed, and the availability of pain-informed CBT therapists is a problem for many patients. Unfortunately, a systematic review found that pain relief that occurred after CBT does not persist long-term Williams et al.

    A recent randomized clinical trial has also shown the promise of mindfulness based stress reduction MBSR as a treatment for chronic pain Cherkin et al. MBSR is usually provided in group sessions lasting 2 h weekly for up to 8 weeks. Patients are also asked to practice MBSR techniques at home in between sessions. Pain relief tends to be short-term but improvements in physical functioning have been maintained up to 26 weeks of follow-up Cherkin et al. However, specialized training is required, and insurance does not typically cover MBSR. Increasingly, patients are turning to pain interventions that are not commonly taught in medical training and are less often covered by insurance payers.

    CAM treatments include acupuncture, manipulation, vitamins and supplements fish oil, capsaicin, glucosamine , yoga, music therapy, biofeedback, and hypnosis. Other than acupuncture and spinal manipulation, these strategies have been less rigorously studied in clinical trials and little is known about the long-term benefits or harms Murthy et al.

    Acupuncture is a part of traditional Chinese Medicine that involves the stimulation of specific parts of the body through the use of needles. Acupuncture has been used for pain management for two thousand years in China. Recently, electrical currents have been added to further stimulate the needles in electroacupuncture, although manual acupuncture without electrical current is the most commonly used method. The exact analgesic mechanism for acupuncture is not known, although growing evidence points towards acupuncture needles stimulating mechanoreceptors, which triggers a release of endorphins and increased activity of the descending inhibitory pain pathways Leung, Although acupuncture has been used to treat a wide variety of pain syndromes e.

    In patients with osteoarthritis, acupuncture can improve physical functioning that is maintained over follow-up but does not provide significantly greater pain relief compared to sham acupuncture in long-term follow-up Lin et al.

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    In addition, no long-term follow up studies have demonstrated that acupuncture provides greater pain relief for chronic neck pain or chronic nonspecific low back pain compared to sham acupuncture but short-term pain relief is superior comparing active to sham acupuncture Yuan et al. Liu et al. Typically, chiropractors perform spinal manipulations although doctors of osteopathic medicine are also trained in these treatments.

    There is no consensus on the exact procedure for spinal manipulation, and insurance does not often cover them. In a recent meta-analysis of sham controlled RCTs, there was evidence that spinal manipulation improved pain ratings post-treatment and in 1 month follow-up compared to sham in patients with chronic non-specific low back pain Ruddock et al. However, there have been no well-controlled long-term follow-up studies to demonstrate if these improvements are lasting. In addition, adverse events are not always reported in RCTs of spinal manipulation, so weighing risks versus benefits is challenging Gorrell et al.

    Invasive treatments that are used for the management of chronic pain include injections of local anesthetics and steroids, peripheral procedures, electrical stimulation, and surgery Manchikanti et al. The growth of interventional pain medicine as described in Section 3 has shown dramatic growth in utilization of invasive pain management interventions. Manchikanti et al. Peripheral procedures include trigger point injections and intraarticular injections.

    Trigger point injections involve dry needling into the muscle tissue to induce a localized twitch response and subsequent ending of contracture Gerwin et al. A recent systematic review showed that dry needling decreases pain immediately post-treatment compared to sham, and may result in pain relief lasting 3—6 months Boyles et al. Injection of lidocaine or corticosteroid is also performed in some trigger point injections, although medication injection is not thought to improve upon dry needling Cummings and White, ; Boyles et al.

    Chronic Pain Management Guidelines for Multidisciplinary Program

    For arthritic pain related to cartilage loss, intra-articular injections are performed with either a corticosteroid to reduce inflammation or sodium hyaluronate to form a viscoelastic solution that serves as a protective buffer between joints. Despite the lack of evidence from systematic reviews Arrich et al. Systematic reviews have not shown significant benefit of epidural steroid injections over standard treatment in chronic low back pain from any cause Staal et al. Nerve blocks involving epidural injections of lidocaine without steroids , however, do provide significant pain relief for lumbar radicular pain or pain from spinal stenosis compared to steroid injections Manchikanti et al.

    Radiofrequency ablation uses electrical heat to produce a lesion in a pain-transmitting nerve, thereby blocking pain transmission and providing pain relief Shealy, Systematic reviews have not demonstrated significant long-term pain relief with ablation compared to sham treatments, but may provide short-term pain relief for facet joint related pain Maas et al.