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| {{Chronic pain}} | | {{Chronic pain}} |
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| ==Overview== | | =Cognitive Behavioral Therapy= |
| It is rare to completely achieve absolute and sustained relief of pain. Thus, the clinical goal is pain management. Pain management is often multidisciplinary in nature. A recent journal article by Gatchell and Okifuji recognizes the importance of comprehensive pain programs(CPPs) in the management of chronic pain. They summarize their findings as follows: "CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment." <ref name="Henningsen P, Zipfel S.">{{cite journal |author=Henningsen P, Zipfel S, Herzog W |title=Management of functional somatic syndromes |journal=Lancet |volume=369 |issue=9565 |pages=946-55 |year=2007 |pmid=17368156}}</ref><ref name="Stanos S, Houle TT.">{{cite journal |author=Stanos S, Houle TT |title=Multidisciplinary and interdisciplinary management of chronic pain |journal=Physical medicine and rehabilitation clinics of North America |volume=17 |issue=2 |pages=435-50, vii |year=2006 |pmid=16616276}}</ref>
| | A [[randomized controlled trial]] found a reduction in pain and disability although no reduction in opioid use<ref name="pmid34724405">{{cite journal| author=DeBar L, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR | display-authors=etal| title=A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial. | journal=Ann Intern Med | year= 2021 | volume= | issue= | pages= | pmid=34724405 | doi=10.7326/M21-1436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34724405 }} </ref>. The intervention includes [https://www.acpjournals.org/doi/suppl/10.7326/M21-1436/suppl_file/M21-1436_Supplement.pdf 12 modules of learning coping skills]. The modules include: |
| | # Understanding pain/pain education and role of pain coping skills |
| | # Applying progressive muscle relaxation (PMR) and adaptation model. |
| | # Activity-rest cycle |
| | # Pleasant activity scheduling |
| | # Relaxation mini-practices |
| | # Pleasant imagery |
| | # Emotional regulation: leaning in |
| | # Emotional regulation: leaning out |
| | # Cognitive restructuring |
| | # Use of calming self-statements |
| | # Problem-solving/reinforcing the application of learned skills |
| | # Relapse prevention and maintenance enhancement training |
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| ==Medical Therapy==
| | =Rehabilitation= |
| ===Opioids for Chronic Pain===
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| [[Opioid]] medications provide short, intermediate and long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectal, transdermal, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long acting or extended release medication is often prescribed in conjunction with a shorter acting medication for break through pain (exacerbations).
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| Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective nonmalignant pain management. However, there are variable associated adverse effects, especially during the commencement or change in dosing and administration. When [[opioids]] are used for prolonged periods [[drug tolerance]], [[chemical dependency]] and (rarely) [[addiction]] may occur. [[Chemical dependency]] is ubiquitous among [[opioid]] therapy after continuous administration; however, [[drug tolerance]] is not well studied in patients on long term opioid therapy. [[ Addiction]] rarely occurs as a result of opioid prescription, but they are abused by some individuals, which can cause concern to health care providers. Diversion of opioid medications is another concern for health care providers.
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| Opioids are effective for short term use (1-16 weeks).<ref name="pmid17909211">{{cite journal| author=Chou R, Huffman LH, American Pain Society. American College of Physicians| title=Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. | journal=Ann Intern Med | year= 2007 | volume= 147 | issue= 7 | pages= 505-14 | pmid=17909211 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17909211 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18364420 Review in: Evid Based Nurs. 2008 Apr;11(2):50] </ref><ref name="pmid15561393">{{cite journal |author=Kalso E, Edwards JE, Moore RA, McQuay HJ |title=Opioids in chronic non-cancer pain: systematic review of efficacy and safety |journal=Pain |volume=112 |issue=3 |pages=372–80 |year=2004 |pmid=15561393 |doi=10.1016/j.pain.2004.09.019 |url=http://linkinghub.elsevier.com/retrieve/pii/S0304-3959(04)00447-6}}</ref><ref name="pmid17227935">{{cite journal| author=Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR et al.| title=Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. | journal=Ann Intern Med | year= 2007 | volume= 146 | issue= 2 | pages= 116-27 | pmid=17227935 | url=http://www.annals.org/content/146/2/116.full}} </ref><ref name="pmid16717269">{{cite journal |author=Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E |title=Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects |journal=CMAJ |volume=174 |issue=11 |pages=1589–94 |year=2006 |pmid=16717269 |doi=10.1503/cmaj.051528 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=16717269}}</ref>
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| * One [[systematic review]] found that trials of short term opioids did not improve functional status compared to placebo in chronic pain.<ref name="pmid15561393">{{cite journal |author=Kalso E, Edwards JE, Moore RA, McQuay HJ |title=Opioids in chronic non-cancer pain: systematic review of efficacy and safety |journal=Pain |volume=112 |issue=3 |pages=372–80 |year=2004 |pmid=15561393 |doi=10.1016/j.pain.2004.09.019 |url=http://linkinghub.elsevier.com/retrieve/pii/S0304-3959(04)00447-6}}</ref> However, a second [[systematic review]], found that opioids improved functional status compared to placebo, but not compared to other drugs.<ref name="pmid16717269">{{cite journal |author=Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E |title=Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects |journal=CMAJ |volume=174 |issue=11 |pages=1589–94 |year=2006 |pmid=16717269 |doi=10.1503/cmaj.051528 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=16717269}}</ref>
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| * According to some [[randomized controlled trial]]s, opioids reduced pain in the short term, but did not improve function in comparison to an cholinergic antagonist placebo<ref name="pmid8544547">{{cite journal| author=Moulin DE, Iezzi A, Amireh R, Sharpe WK, Boyd D, Merskey H| title=Randomised trial of oral morphine for chronic non-cancer pain. | journal=Lancet | year= 1996 | volume= 347 | issue= 8995 | pages= 143-7 | pmid=8544547 }} </ref> or [[tricyclic antidepressant]].<ref name="pmid12370455">{{cite journal| author=Raja SN, Haythornthwaite JA, Pappagallo M, Clark MR, Travison TG, Sabeen S et al.| title=Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial. | journal=Neurology | year= 2002 | volume= 59 | issue= 7 | pages= 1015-21 | pmid=12370455 | doi= | pmc= | url= }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12841962 Review in: J Fam Pract. 2003 Jul;52(7):517-8] </ref>
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| The role of ''long term treatment'' of chronic non-cancer pain is not clear.
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| * A [[systematic review]] by the [[Cochrane Collaboration]] found "weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive."<ref name="pmid20091598">{{cite journal| author=Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C et al.| title=Long-term opioid management for chronic noncancer pain. | journal=Cochrane Database Syst Rev | year= 2010 | volume= | issue= 1 | pages= CD006605 | pmid=20091598 | doi=10.1002/14651858.CD006605.pub2 }} </ref>
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| * A [[systematic review]] by the [[Agency for Healthcare Research and Quality]] found that "evidence on long-term opioid therapy for chronic pain is very limited but suggests an increased risk of serious harms that appears to be dose-dependent".<ref> Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014. [http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1988 The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain]. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014.</ref>
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| Most trials are funded by industry.<ref name="pmid16717269">{{cite journal |author=Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E |title=Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects |journal=CMAJ |volume=174 |issue=11 |pages=1589–94 |year=2006 |pmid=16717269 |doi=10.1503/cmaj.051528 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=16717269}}</ref>
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| ====Opioid Treatment Contracts====
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| Written treatment agreements (in addition to informed consent) may "help to reduce aberrant use and improve physicians’ willingness to prescribe opioids” according to a review of [[clinical practice guideline]]s.<ref name="pmid24217469">{{cite journal| author=Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P et al.| title=Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. | journal=Ann Intern Med | year= 2014 | volume= 160 | issue= 1 | pages= 38-47 | pmid=24217469 | doi=10.7326/0003-4819-160-1-201401070-00732 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24217469 }} </ref> A prior [[systematic review]]<ref name="pmid20513829">{{cite journal| author=Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ| title=Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 11 | pages= 712-20 | pmid=20513829 | doi=10.7326/0003-4819-152-11-201006010-00004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20513829 }} </ref> cited 4 controlled, although non-randomized, studies. In one study that isolated the effect of a treatment agreement, opioid misuse dropped by 21%.<ref>Goldberg KC, Simel DL, Oddone EZ. [http://nfyilma.turner-white.com/pdf/jcom_dec05_opioid.pdf Effect of an opioid management system on opioid prescribing and unscheduled visits in a large primary care clinic]. J Clin Outcomes Management. 2005; 12:621-28</ref>
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| ====Monitoring====
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| * State-wide prescription monitoring programs is associated with a reduction of possible opioid diversion by 85%.<ref name="pmid24677496">{{cite journal| author=Surratt HL, O'Grady C, Kurtz SP, Stivers Y, Cicero TJ, Dart RC et al.| title=Reductions in prescription opioid diversion following recent legislative interventions in Florida. | journal=Pharmacoepidemiol Drug Saf | year= 2014 | volume= 23 | issue= 3 | pages= 314-20 | pmid=24677496 | doi=10.1002/pds.3553 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24677496 }} </ref> An ecological study in the state of Florida from that the rate of new investigations of possible diversion of oxycodone reported to the Drug Diversion program of the [http://www.radars.org/ Researched Abuse Diversion and Addiction-Related Surveillance System] dropped from 49.81/100,000 to 7.6/100,000 of the general population.<ref name="pmid24677496"/>
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| * Urine drug testing is frequently recommended by [[clinical practice guideline]]s<ref name="pmid24217469">{{cite journal| author=Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P et al.| title=Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. | journal=Ann Intern Med | year= 2014 | volume= 160 | issue= 1 | pages= 38-47 | pmid=24217469 | doi=10.7326/0003-4819-160-1-201401070-00732 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24217469 }} </ref> and may help reduce aberrant use of prescribed opioids<ref name="pmid11173169">{{cite journal| author=Chutuape MA, Silverman K, Stitzer ML| title=Effects of urine testing frequency on outcome in a methadone take-home contingency program. | journal=Drug Alcohol Depend | year= 2001 | volume= 62 | issue= 1 | pages= 69-76 | pmid=11173169 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11173169 }} </ref>. About 30% of urine samples will be abnormal, usually for the lack of opioids or the presence of [[cannabinoids]].<ref name="pmid25217208">{{cite journal| author=Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE et al.| title=Chronic Opioid Therapy Urine Drug Testing in Primary Care: Prevalence and Predictors of Aberrant Results. | journal=J Gen Intern Med | year= 2014 | volume= | issue= | pages= | pmid=25217208 | doi=10.1007/s11606-014-3010-y | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25217208 }} </ref> Abnormal urine results are more common among patients on higher daily morphine-equivalent doses.<ref name="pmid25217208"/>
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| * The Graded Chronic Pain Scale<ref name="pmid1408309">{{cite journal| author=Von Korff M, Ormel J, Keefe FJ, Dworkin SF| title=Grading the severity of chronic pain. | journal=Pain | year= 1992 | volume= 50 | issue= 2 | pages= 133-49 | pmid=1408309 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1408309 }} </ref> is recommended by [[clinical practice guideline]]s by the Washington State Agency Medical Directors' Group.<ref>Washington State Agency Medical Directors' Group. [http://www.agencymeddirectors.wa.gov/opioiddosing.aspInteragency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid treatment]. Olympia (WA): Washington State Department of Labor and Industries; 2010. [http://www.guideline.gov/content.aspx?id=23792 Summary] at the [http://www.guideline.gov/c National Guidelines Clearinghouse]</ref>
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| ===Non-Steroidal Anti-Inflammatory Drugs===
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| The other major group of analgesics are [[Non-steroidal anti-inflammatory drug]]s ([[NSAID]]). This class of medications includes acetaminophen which may be administered as a single medication or in combination with other analgesics. The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.<ref name="Munir MA, Enany N.">{{cite journal |author=Munir MA, Enany N, Zhang JM |title=Nonopioid analgesics |journal=Med. Clin. North Am. |volume=91 |issue=1 |pages=97-111 |year=2007 |pmid=17164106}}</ref><ref name="Ballantyne JC.">{{cite journal |author=Ballantyne JC |title=Opioids for chronic nonterminal pain |journal=South. Med. J. |volume=99 |issue=11 |pages=1245-55 |year=2006 |pmid=17195420}}</ref>
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| ===Antidepressants and Antiepileptic Drugs===
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| Some [[antidepressant]] and [[antiepileptic]] drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in [[neuropathy|neuropathic]] pain disorders as well as [[complex regional pain syndrome]].<ref name="Jackson KC 2nd.">{{cite journal |author=Jackson KC |title=Pharmacotherapy for neuropathic pain |journal=Pain practice : the official journal of World Institute of Pain |volume=6 |issue=1 |pages=27-33 |year=2006 |pmid=17309706}}</ref> Drugs such as [[Gabapentin]] have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of [[seizure]].
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| ===Interventional Therapy===
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| [[Injection]]s, [[Neuromodulation]] and neuroablative therapy may be used to target either the tissue structures and organ/systems responsible for persistent [[nociception]] or the nerves conveying nociception from the structures implicated as the source of chronic pain.<ref name="Varrassi G, Paladini A">{{cite journal |author=Varrassi G, Paladini A, Marinangeli F, Racz G |title=Neural modulation by blocks and infusions |journal=Pain practice : the official journal of World Institute of Pain |volume=6 |issue=1 |pages=34-8 |year=2006 |pmid=17309707}}</ref><ref name="Meglio M.">{{cite journal |author=Meglio M |title=Spinal cord stimulation in chronic pain management |journal=Neurosurg. Clin. N. Am. |volume=15 |issue=3 |pages=297-306 |year=2004 |pmid=15246338}}</ref><ref>{{cite journal |author=Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM |title=Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience |journal=Pain |volume=121 |issue=1-2 |pages=43-52 |year=2006 |pmid=16480828}}</ref><ref name="Boswell MV, Trescott AM">{{cite journal |author=Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L |title=Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain |journal=Pain physician |volume=10 |issue=1 |pages=7-111 |year=2007 |pmid=17256025|url=http://www.painphysicianjournal.com/2007/january/2007;10;7-111.pdf?PHPSESSID=ea188711febadee5420f1c9061ebd249 |format=PDF}}</ref><ref name="Romanelli P, Esposito V">{{cite journal |author=Romanelli P, Esposito V, Adler J |title=Ablative procedures for chronic pain |journal=Neurosurg. Clin. N. Am. |volume=15 |issue=3 |pages=335-42 |year=2004 |pmid=15246341}}</ref>
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| ===Rehabilitation===
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| {{see|Physical medicine and rehabilitation}} | | {{see|Physical medicine and rehabilitation}} |
| As alluded to earlier there are other modalities used in the treatment of chronic pain. These include: physical modalities such as thermal agents and [[electrotherapy]]. Complementary and alternative medicine, therapeutic exercise and behavioral therapy are also utilized autonomously or in tandem with interventional techniques and conventional pharmacotherapy. This is most often structured in a multidisciplinary or interdisciplinary program.<ref name="Geertzen JH, Van Wilgen CP.">{{cite journal |author=Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU |title=Chronic pain in rehabilitation medicine |journal=Disability and rehabilitation |volume=28 |issue=6 |pages=363-7 |year=2006 |pmid=16492632}}</ref> | | As alluded to earlier there are other modalities used in the treatment of chronic pain. These include: physical modalities such as thermal agents and [[electrotherapy]]. Complementary and alternative medicine, therapeutic exercise and behavioral therapy are also utilized autonomously or in tandem with interventional techniques and conventional pharmacotherapy. This is most often structured in a multidisciplinary or interdisciplinary program.<ref name="Geertzen JH, Van Wilgen CP.">{{cite journal |author=Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU |title=Chronic pain in rehabilitation medicine |journal=Disability and rehabilitation |volume=28 |issue=6 |pages=363-7 |year=2006 |pmid=16492632}}</ref> |