Management of Chronic Pain Essay Example
Management of Chronic Pain Essay Example

Management of Chronic Pain Essay Example

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  • Pages: 12 (3238 words)
  • Published: September 22, 2018
  • Type: Case Study
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The purpose of this paper is to argue that narcotics are crucial for long-term management of chronic pain (Hadler, 2003). Medication is necessary for alleviating pain and improving health conditions. The goal of contemporary medicine is to prescribe appropriate medication and remedies in the correct dosage for each patient. Managing chronic pain is complex due to psychological, social, and physical factors. Therefore, assessing and managing chronic pain requires a sustained relationship and time investment beyond what is commonly accepted for acute medicine (Hadler, 2003). This paper will discuss the individual pathophysiology of chronic pain, the properties and limitations of opioids, alternative medical treatments, and strategies for acute care practitioners to effectively treat chronic pain with long-term management in mind.

What exactly is Chronic Pain? According to the American Chronic Pain As

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sociation, chronic pain refers to pain that continues beyond the typical recovery period for an injury or illness. It may be continuous or intermittent. Another definition includes persistent or episodic pain of a duration or intensity that negatively affects the function or wellbeing of the patient, regardless of its cause. Acute injuries such as fractures usually result in intense pain lasting no longer than 14 days. When patients experience intense acute pain for 14 days or more, it may indicate the development of a chronic pain syndrome.Chronic pain is a prevalent health condition that affects a significant portion of the global population. Approximately 11% of patients in American hospitals suffer from chronic pain, and a Gallup survey shows that 89% of Americans experience pain at least twice monthly. Among those who have daily pain, individuals aged 65 and older account for 55%. It is important to

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recognize that errors in treating chronic pain can have profound implications for billions of people worldwide.

Chronic pain has unique biological considerations as it serves as an alert for individuals to protect themselves from further harm. However, some individuals may be insensitive to pain, which can lead to destructive processes like Charcot joint formation. While most people have similar thresholds for experiencing pain, research suggests that practices such as relaxation techniques, acupuncture, imagery, or hypnosis can increase their tolerance by up to 50% (Hadler, 2003). Additionally, scientific evidence supports the idea that genetic factors contribute to variations in pain tolerance among individuals.

Some individuals may find it difficult or unwilling to endure moderate levels of discomfort. The perception of pain is multifaceted and includes emotional impact, physical sensations, and the meaning attributed to the sensation (Clean, 1999).While opioids are commonly used for treating chronic pain, their use can complicate pain management. This is because they have the potential to worsen pain through the NMDA receptor and reinforce their own use (Hadler, 2003). The use of opioids for chronic pain is controversial, although they are widely utilized in cancer treatment and acute pains.

Opioids have various positive effects on respiration, blood pressure, stomach secretion, severe coughing, nausea, and vomiting. However, their primary purpose is to alleviate intense suffering-related pain. Unfortunately, the pleasurable effects of opioids have led to misuse for euphoric purposes.

Studies have shown that certain opioids like tramadol, propoxyphene,and codeine can initially improve patients' pain levels and functionality during long-term therapy. Nonetheless, these opioids exhibit a diminished analgesic efficacy over time. This implies that patients may primarily derive benefits from their euphoric side effects. However, this state of

euphoria eventually declines and addiction takes its place.

At some point, individuals may solely rely on opioids to alleviate withdrawal symptoms. Therefore it is not recommended to use opioids for managing chronic pain when accompanied by multiple sclerosis or sympathetically maintained conditions.

A two-year observation revealed that only 50% of patients who underwent prolonged intrathecal morphine injection for low back pain experienced less than 25% relief in their pain level.Patients who viewed opioids as the most effective treatment were given opioid placebos to assess their beliefs. The group that received the placebos reported no significant difference in pain relief compared to those receiving opioids, leading them to choose detoxification and rehabilitation to overcome their dependence on opioids. While some studies have shown positive reactions to opioids, a considerable portion of patients experienced minimal or no pain relief, making it difficult to differentiate between euphoric and analgesic effects. Psychological therapies like hypnosis, relaxation techniques, imagery utilization, and acupuncture have proven highly effective alternatives for managing chronic pain patients. Additionally, women who underwent Lamaze class training for childbirth techniques experienced a noticeable reduction in labor pains. Research indicates that around 90% of women can give birth without pain medication by using relaxation techniques, which not only increase pain tolerance but also reduce reliance on painkillers. This benefits both laboring women and individuals with chronic pain (Hadler, 2003). Cognitive behavioral approaches have been extensively studied and found highly effective in relieving pain and restoring physical and emotional functionality. Other psychological strategies such as relaxation training, operant conditioning, mindfulness, and meditation have also demonstrated success.The combination of cognitive strategies and multidisciplinary treatment yields the best results in achieving relief from pain

(Mannik & Gilliland, 2006). Physical therapy plays a crucial role in strengthening adaptive qualities, reducing dysfunctional pain behaviors, improving overall well-being and functionality, and decreasing opioid usage. Additionally, it assists in retraining the nervous system to establish healthy neural connections. Unfortunately, the significance of reconditioning and increasing physical activity is often underestimated when it comes to alleviating pain. Numerous studies reveal that placebo or nonspecific therapies can be equally effective as physical therapy in providing relief from discomfort. These studies demonstrate that engaging patients in any form of physical activity holds therapeutic value in reducing pain. It is imperative to prevent patients from remaining sedentary and immobile. Other physical therapies like acupuncture, manual therapy, and various exercises have also been proven effective. For example, exposure to cold water or cold temperatures can enhance pain tolerance for a duration of 10-14 hours. Many of these therapies function by suppressing pain-inhibiting systems. Acupuncture specifically stimulates the body's natural opioids for pain relief; however, there are concerns regarding the diminishing effectiveness of acupuncture and similar physical therapies due to the addictive nature of opioids over time.Multidisciplinary pain clinics emphasize the combination of physical and psychological methods for more effective treatment. Managing chronic pain often requires a comprehensive approach, including psychological counseling, physical medicine, and behavior correction. A positive physician-patient relationship is beneficial for any type of therapy. Patients are typically referred to these clinics for three to five months, depending on the development of chronic or persistent pain conditions. Even mild and intermittent chronic pain requires various therapy modalities, including a psychological evaluation for potential remedial techniques. Complex pain, which involves factors such as psychology, legal issues, family

dynamics, and medication usage, requires increased social and psychological involvement. Numerous studies have shown that combined treatment can provide relief for moderate to severe chronic pain and benefit the majority of patients. A follow-up study was conducted on patients who showed improvements but discontinued multidisciplinary therapy; instead, some individuals resorted to opioid medication at urgent care or emergency facilities, resulting in their conditions deteriorating. Research has indicated that dissatisfied patients and those who did not complete a multidisciplinary pain program were primarily individuals with significant psychological problems and strong reliance on opioids.It is ironic that individuals who need multidisciplinary therapy the most are also the ones for whom chronic opioid therapy is strictly contraindicated (Fields, 1991). Acetaminophen and Cyclooxygenase Inhibitors are commonly used drugs to manage chronic pain. Acetaminophen is a safe and effective analgesic for mild to moderate pain, but its effectiveness is often underestimated due to its widespread availability. However, many painkillers containing codeine/acetaminophen combinations derive from acetaminophen, making their efficacy highly valuable. Patients can safely use acetaminophen if they adhere to the prescribed dosage and avoid mixing it with other medications that contain acetaminophen (Rogers & Thompson, 2004).

Non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly used for pain relief. However, their analgesic effects for musculoskeletal pain only slightly exceed those of acetaminophen because conditions like tendonitis or osteoarthritis typically involve minimal or no chronic inflammation. To address gastrointestinal bleeding, using a COX-2 inhibitor (cyclooxygenase-2) is an effective remedy. Various medications can treat chronic pain even if they were not initially intended for analgesic purposes; examples include Baclophen and clonidine.Tapering doses of steroids are recommended for neurogenic back pain and complex regional pain syndromes.

Anticonvulsants and antidepressants are also used as complementary treatments in acute therapy clinics, but supervision from a personal pain physician is necessary. Carbamazepine has shown success in treating neuropathic pain by significantly improving patients' pain levels from 8.2 to 4.0 (a 51% improvement), although the reduction in depression was only about 26%. The initial dose of carbamazepine should be between 100 to 200 mg taken twice a day. Gabapentin is another effective medication for neuropathic pain, especially in post-herpetic neuralgia. The recommended dosage of gabapentin starts at 300 mg per day and can gradually increase to 1800 mg, then up to 2400 mg, and finally reaching 3600 mg per day. It is important to divide this dosage into three separate doses. Both Gabarentine and carbamazerine have side effects like dizziness and somnolence. Approximately 35% of cases experience these side effects with Gabarentine, while about 20% experience them with carbamazerine (Kodell, 2002). NMDA receptor antagonists such as dextromethorphan, ketamine, methadone, and amantadine are highly anticipated drugs for the treatment of chronic pain.
Combining morphine sulfate (MS) and dextromethorphan in equal parts reduces the required morphine dosage by half for pain relief in cancer patients and individuals with chronic pain conditions. However, an accumulation of NMDA receptors in the hippocampus and cerebral cortex can result in various psychological side effects (Schofferman, 1993). There are numerous effective methods available to alleviate chronic pain without relying on opioid drugs. These methods have the advantage of avoiding risks associated with tolerance-induced pain or dependence on opioids' euphoric properties.

Although opioid therapy may be convenient for patients, it can disrupt non-opioid management and rehabilitation therapies for chronic pain. Therefore, treatment and emergency physicians

need to educate patients about the side effects of opioid treatment and advocate for non-opioid alternatives (Kodell, 2002). The significance of urgent care and emergency physicians lies in their role in treating chronic pain patients as they are accessible round-the-clock to address acute pain while reinforcing management strategies for chronic pain. These physicians often serve as a viable alternative if patients are dissatisfied with their current treatments.

It is crucial for urgent care and emergency physicians to exercise caution by providing immediate relief rather than solely focusing on addressing the initial problem of chronic pain.Physicians have a responsibility to inform patients that there is no quick fix for their health condition and emphasize the need for active participation in therapy. It is important for physicians to show support and empathy towards chronic pain patients while being careful not to downplay or exaggerate the severity of their conditions. Studies have demonstrated that patients with minor whiplash injuries recover faster when they are informed that the physical damage is insignificant and does not cause prolonged pain.

To facilitate a prompt return to normal activities, urgent care and emergency physicians should collaborate with local pain treatment clinics and personal physicians. Failure to cooperate can negatively impact both the clinic's treatment methods and patient trust. The personal physician and pain clinic must be aware of any previous opioid use by the patient in order to develop a comprehensive treatment plan.

While analgesia and opioids can be included in the plan, it is crucial to avoid relying on opioids for an extended period as it may have irreversible negative effects on the patient's natural pain control system (Gallup, 2009). According to JCAHO standards,

acute care and emergency physicians are required to document pain levels but are not obligated to use opioids if they believe them inappropriate for alleviating patients' pain.

Documenting pain evaluation during and after treatment has been shown to increase patient satisfaction (ASA, 2004).There is concern about the excessive reliance on acute care medicine and the use of opioids, both for therapeutic purposes and addiction. It is important for personal physicians and pain clinics to exercise caution regarding the negative effects of opioids and their potential to cause tolerance in patients. Unfortunately, urgent and emergency care medical specialists are less likely to explore alternative pain therapies and often choose to prescribe opioids instead. According to a study that followed 30 opioid-addicted patients, even after being informed that they would no longer receive narcotics from clinics, 71% still managed to obtain opioids from urgent care physicians (ASA, 2004). Patient files can be useful in identifying and monitoring chronic pain patients who may be at risk of addiction or worsening of ongoing pain. These files are governed by state laws, the HIPPA Act of 1996, and the JCAHO. In Hansen's chapter on drug-seeking patients in this particular issue on drug-seeking patients (ACPA, 2001), various strategies are discussed for improving therapy for addicted chronic pain patients with legitimate needs through supervised opioid use. These strategies include tracking systems to monitor patients as well as narcotic contracts that outline obligations and responsibilities. Furthermore, a pain management committee sends letters to chronic pain patients informing them that they must provide a detailed history from their personal physicians in order to obtain narcotics.The manager of the chronic pain facility evaluates the patient's medical

history, collaborates with their doctors, and creates a comprehensive care plan that includes follow-up suggestions and referrals to multidisciplinary pain facilities or individual drug treatment programs. This plan also provides detailed information on alternative treatment options and prescribes appropriate medications for each patient's specific condition. The primary goal is to reduce the number of patients who frequently seek emergency care for chronic pain treatment. Originally designed to identify chronic pain patients reliant on emergency drugs, the program quickly became crucial in delivering suitable outpatient care as well.

Chronic pain patients who visited emergency centers ten or more times within a year for opioids treatment were closely monitored and considered for inclusion in a registry specifically for chronic pain patients. In order to be included in this registry, patients must provide contact details for their primary care medical specialist, who can be reached at any time. They must also receive treatment for their chronic pain diagnosis at the same emergency centers and undergo an evaluation by an experienced medical specialist specializing in both chronic pain diseases and drug dependence issues.

Patients who fail to meet certain requirements or choose not to participate in the registry will be denied opioids at any U.S. emergency center.When implementing this system, it is important to consider the long-term health benefits for patients and ensure compliance with standards and regulations set by local pain management facilities or personal physicians (Gallup, 2009). An effective treatment for Complex Regional Pain Syndrome (CRPS), a specific chronic pain syndrome, involves physical therapy that includes mild desensitization and other measures to improve symptoms. Research has shown that this therapy can reduce pain levels by approximately 50% over a

three-month period. Physical therapy has also demonstrated positive results in children with CRPS. These children often rely on wheelchairs and crutches and experience chronic secondary modifications due to immobility. To stimulate their senses, intensive physical therapeutic loads and energetic toweling are used, immobilizing the opposite side of the body to encourage movement in the affected side. After completing this intense therapy, 12 out of 20 children experienced complete relief from their pain syndromes while the remaining eight experienced periodic discomforting pain. All children exhibited normal functioning of their body systems and no longer required crutches or a wheelchair.A study conducted over three years (ASA, 2004) reported only one instance of relapse in Myofascial Pain Syndrome (MPS), a specific chronic pain disorder. The study found that multidisciplinary therapy, including intense physical therapy and triggering point injections, had a significant positive impact on improving the condition. It is crucial to properly treat MPS as failure to do so can lead to the development of a complex chronic pain syndrome accompanied by physiological pathologies, insomnia, and fatigue.

To ensure effective administration of triggering point injections for MPS, it is important for experienced medical specialists in acute care settings who are familiar with the technique to perform them (ACPA, 2001). In the case of fibromyalgia, another distinct chronic pain syndrome, long-term improvement can be achieved through cardiovascular fitness and aerobic exercise training. Although these exercises may initially worsen the patient's symptoms, it is imperative to prevent further detraining.

Patients with fibromyalgia may have doubts and resistance initially but complying with the treatment plan can yield positive outcomes. Acupuncture and antidepressants have shown high effectiveness for fibromyalgia and may work synergistically. Convincing

patients with fibromyalgia that they have the ability to function better and eliminating negative thoughts can greatly impact their willingness to believe in positive results (Gallup, 2009).

In cases of low back pain, intensive rehabilitation trainings on an annual basis can help prevent further damage.Regular exercise has been shown to be as effective as traditional physiotherapy for chronic low back pain in patients with limited aerobic capacity. By improving overall fitness, exercise can reduce pain and minimize damage. Combining percutaneous electrical nerve and spinal cord stimulation with increased activity can decrease pain by about 50%. Therapeutic massage has been found to alleviate discomfort by approximately 32% within four weeks in 74% of cases (ACPA, 2001). A study on multidisciplinary pain clinics for low back pain revealed that physical training resulted in a decrease in pain in 37% of cases compared to only 4% in a control group who received medication only. The study also found improvements in pain behavior, intensity, and patients' level of activity, which increased up to 65%. Some training programs had a success rate over 80%, while it was only about 40% in the control group (Fields, 1991). The key aspect of successful care for chronic low back pain is reducing patients' subjective perception of damage. This promotes mobility, activity levels, and reduces negative social behavior and seeking sympathetic attention. It is important to approach the assessment of chronic pain differently from acute pain due to differences in underlying pathophysiology and psychosocial factors.Opioids are less effective than analgesics for chronic pain treatment and can actually increase sensitivity to pain with prolonged use. The addictive nature of opioids can cause confusion, as some individuals

mistake euphoria for pain relief even when their condition worsens over time. While there are alternative treatments available, they may be complex and require significant patient commitment. Many long-term opioid users may have doubts and hesitations about trying these alternatives. To effectively manage chronic pain, a comprehensive assessment encompassing psychosocial and physical aspects is crucial. However, conducting a proper assessment can be challenging in urgent care and emergency center settings. Therefore, it's essential for urgent care and emergency medical specialists to communicate with the patient's personal pain management specialist. Implementing a special program could help identify and monitor patients who may have compromised opioid medication needs due to prolonged usage. These patients are at risk of developing psychological issues that contribute to dependence on the euphoric effects of opioids; thus, extreme caution should be exercised when using opioids, with close supervision of patients (Fields, 1991). According to wise elders' wisdom, good intentions can sometimes lead to disastrous results; hence the belief that the path to hell is paved with these good intentions.The significance of abiding by the oath "Noli nocere" for medical professionals is underscored here. "Noli nocere" translates to "Do no harm" and was established by Hippocrates during the period between 460 BC and 370 BC. It serves as a crucial reminder that administering pain-relieving drugs can potentially exacerbate patients' ailments, rendering them more perilous than their initial condition.

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