Pain is a commonly encountered physical symptom that can be seen in any age group. However, it is more common among older individuals and in females. This debilitating condition is associated with loss of functionality and increased emotional, psychological, and economic burden. In this blog, we are going to discuss various etiologies of chronic pain, and the role of a healthcare professional in the evaluation and treatment of chronic pain for improving the quality of life of the patients.

Causes and types of pain

As far as the etiology is concerned, there are numerous conditions that can manifest as chronic pain. So, based on the organ system involvement, we are giving a brief description of the frequently encountered clinical conditions which result in chronic pain.

Neuropathic pain

The pain due to injury or compression of peripheral nerves. Shingles and burning and tingling sensations in the limbs of diabetic patients are classic examples of peripheral neuropathic pain. Moreover, some patients develop neuropathic pain after a stroke event.

Nociceptive pain

This type of pain results from tissue injury, e.g. pain due to burns or lacerations.

Musculoskeletal pain

• Lower back pain
• Osteoarthritis
• Vertebral column deformities, poor body posturing
• Osteoporosis resulting in compression of vertebral bodies, nerve foramina stenosis
• Gout and pseudogout

Inflammatory pain

Autoimmune disorders such as:

• Systemic lupus erythematosus
• Rheumatoid arthritis
• Ankylosing spondylitis
• Polymyalgia rheumatic.

Some patients may develop pain symptoms after an episode of urinary and gastrointestinal tract infections (reactive arthritis).

Psychogenic pain

Pain may also result from psychological issues. Hence patients suffering chronic psychiatric ailments such as major depressive disorder and somatoform disorder usually complain of various bodily pains such as headaches, abdominal pain, and joint pain.

Mechanical pain

Moreover, the cancerous growth of solid organs can also present as a chronic pain condition.

Evaluation and work-up of chronic pain conditions

Diagnosing the exact cause of chronic pain is the cornerstone in the optimum management of the condition. It is observed that primary care physicians or general practitioners may miss the underlying etiology of the chronic pain. Hence, they end up giving false assurances to the patients that there is nothing to worry about. In addition to it, physicians can misdiagnose or underdiagnose some neuropathies as there is no widely accepted gold standard diagnostic test. Consequently, these factors result not only in delay in embarking on standardized management, moreover it also adds to the complications of the underlying disease. Therefore, an optimal evaluation of chronic pain requires expertise in the field of pain medicine. Depending upon the findings of the history and physical examination, a trained healthcare professional will order blood panel and imaging studies to identify a specific cause. The choice of investigations to be performed varies from case to case.

MANAGEMENT OF CHRONIC PAIN

What is an optimal treatment plan for chronic pain?

Management of chronic pain is quite complex and multifaceted. After the healthcare provider has evaluated the exact underlying cause of the pain, the treatment is aimed at curing the underlying etiology. However, it also involves physical therapy and psychological interventions to alleviate the suffering of the patient.

Non-pharmacological techniques for pain control

It is best to utilize non-pharmacological interventions as an initial strategy to cope with pain. Many non-pharmacological options are available to help in pain control. Some of these treatment options include:

• Heat or cold (ice) packs
• Physical therapy e.g. stretching, strengthening, endurance development and aerobic exercises may help to reduce pain symptoms and also improves mobility.
• Massage is a short-term therapy in acute pain settings involving the muscles, ligaments, and tendons.
• Mind relaxation and stress relieving techniques e.g. meditation and yoga.
• Psychotherapy such as cognitive behavioral therapy
• Acupuncture, a method used in traditional medicine to control pain. But analysis of recent medical literature reveals that its efficacy in pain management is quite non-conclusive.
• Transcutaneous electrical nerve stimulation (TENS) can be helpful in some refractory cases of chronic pain especially in diabetic neuropathies.

Pharmacological approach towards pain management

If the frequency and severity of the pain episodes are not manageable by adopting non-pharmacological methods, a physician may consider the use of pain medicines. The pain medicines can be classified into two broader categories

• Opioids drugs
• Non-opioids drugs

Non-opioid drugs include:

• Paracetamol/acetaminophen – recommended for short-term and milder pain.
• Non-steroidal anti-inflammatory drugs (NSAIDs) – these types of drugs are indicated for moderate to severe pain.
• Local anesthetics
• Tricyclic antidepressants (TCAs) such as Amitriptyline; and serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine are preferred for the treatment of fibromyalgia and neuropathic pain.
• Anti-seizure drugs- gabapentin and pregabalin are also used to treat peripheral neuropathic pain.

Opioid medications

Certain opioid drugs are indicated for the control of severe intractable pain. These opioid medicines work by modulating chemical neurotransmitters release within the brain and spinal cord. This class of drugs includes:

• Morphine
• Codeine
• Oxycodone

The opioid drugs are very strong pain killers, therefore helpful in the control of severe pain conditions like cancer pain. However, these drugs have high addictive potential, so prescribed cautiously to prevent addiction and subsequent drug abuse.

Adverse effects associated with various pain medicines

Following are the commonly encountered adverse effects of the various classes of pain killers:

Paracetamol – safe at the recommended dose but hepatotoxic at larger doses.

Non-steroidal anti-inflammatory drugs (NSAIDs) – can cause abdominal distress, stomach ulcer, and upper gastrointestinal bleeding. These drugs should be used cautiously in patients with heart or kidney diseases.

Opioids – these drugs can result in:

• Drowsiness
• Confusion
• Constipation
• Lack of coordination in movement and imbalance leading to falls
• Opioids addiction
• A very high dose can cause cardiovascular and respiratory collapse.

 

Role of surgical interventions in chronic pain management

Surgical interventions are considered as a last resort for pain management. As it is suggested to use non-surgical methods e.g. pain medicines and physiotherapy before undergoing surgery. However, if non-surgical modalities of pain management fail to achieve optimal pain control, surgical interventions can be considered. Interestingly, over the years, neurosurgical techniques for pain control have evolved tremendously. Now, highly refined and sophisticated surgical interventions are available for effective and long-lasting pain control. Furthermore, they carry a very low risk for adverse events and complications.

Neurosurgical interventions for pain management

Different pain pathways are resected by using these interventions. These surgical techniques are minimally invasive, performed under radiological guidance (CT guided), and include:

• Percutaneous cordotomy
• Trigeminal tractotomy-nucleotomy
• Extralemniscal myelotomy
• Dorsal rhizotomy
• Spinothalamic cordotomy
• Medial thalamotomy
• Anterior cingulectomy

Factors involved in the selection of an optimal pain therapy

The selection of an appropriate pain medicine depends upon various factors such as:

• Location
• Intensity
• Duration
• Type of pain
• Comorbid conditions e.g. diabetes, hypertension

Therefore, a patient should provide all this valuable information to the healthcare professional for the right drug selection and optimal pain control. Usually, a combination of two or more modalities of pain management is recommended for effective ad rapid pain control.

What are the precautions to be observed for effective pain therapy?

Many studies have shown that successful therapy depends upon the patient’s participation and adherence to the treatment plan. Hence it is recommended that a patient should be educated about disease course, available treatment options, drug-drug interactions, therapeutic outcome, and complications associated with the various pain medicines.

Therefore, for safe and effective pain therapy, the patient should:

• Follow the directions of the physician
• Do not self-medicate
• Don’t increase or decrease the dosage or timing of medicines on their own
• If pain medicine results in side effects, immediately inform the physician
• Adopt a healthy and active lifestyle
• Optimize your daily physical activities to avoid pain trigger
• Try to adjust your daily life activities, rather than focusing on the complete stoppage of pain.
• Try to develop a social sport system around you, family and friends can play and pivotal role in it.
• Consult psychotherapist to learn new coping strategies.
• In case of pregnancy, inform your physician about it, as some pain medicines are potentially dangerous for the developing fetus.

By observing the above-mentioned measures, an optimal level of pain control can be achieved by reducing the frequency and intensity of pain episodes. Furthermore, it can also help to shorten the duration of pain therapy and minimize the adverse effects of drugs.