Difficult-to-treat chronic pain syndromes

Neuropathy includes pain sensation caused by neuromatous or ganglion-cell sources.
Neuropathy includes pain sensation caused by neuromatous or ganglion-cell sources.
Pain is one of the most common reasons patients seek medical care, so it is inevitable that primary-care clinicians will be dealing with  difficult-to-treat pain syndromes. Some of these syndromes include low back pain (LBP); fibromyalgia; and such neuropathic conditions as postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome (CRPS), and oncology-related syndromes (e.g., postmastectomy pain). Effective treatment of chronic pain requires a multimodal approach that includes pain medication, adjunct medications, and other forms of therapy (e.g., exercise and relaxation).

The impact of chronic pain

Pain that lasts beyond the normal healing period or longer than three to six months is considered chronic. It can be persistent or appear periodically. Some patients have more pain during the day, while others experience higher levels at night. No matter what the cause or pattern of the pain, its chronicity causes physiologic and psychological stress that wears on the patient physically and emotionally.  

Chronic pain also takes a toll on public health, robbing communities of productive work time, billions of dollars, and most important, overall quality of life. It can affect anyone and can lead to depression, sleep disturbances, and anxiety. Clinicians who treat pain need a comprehensive long-term plan to return their patients to a reasonable level of functionality. Such treatment requires skill at pain assessment as well as medication selection and titration. The clinician must also incorporate nonpharmacologic therapies and provide adequate patient education.

Older patients can have special needs related to pain management and may experience many of the difficult-to-treat pain syndromes. An estimated 80% of patients in long-term-care facilities experience chronic daily pain, and 25%-50% of community-dwelling elders have chronic daily pain that impacts their ability to function.1 Many older patients do not like to take pain medications because of side effects (e.g., constipation, mental confusion). This creates a situation in which pain is present but the means to control it are viewed as unacceptable. The high incidence of chronic pain in the older patient and the limited ability to manage it makes effective treatment difficult.

Assessing pain

When pain is the primary complaint, an integral part of the history and physical is a comprehensive assessment that includes intensity, location, duration, quality, alleviating and aggravating factors, and functionality. For acute pain, a simple numeric rating in which 0 equals no pain and 10 is the worst possible pain is sufficient. For chronic pain, however, a multidimensional assessment tool is a better option to obtain all salient information.

Several tools for assessing chronic pain are commonly used, such as the Brief Pain Inventory and the McGill Pain Questionnaire, but the Brief Pain Impact Questionnaire (BPIQ) (see sidebar) is much easier to use clinically and provides a template for the patient interview. Using the BPIQ to structure the patient interview around the pertinent questions on functionality, ability for self-care, exercise, sleep, depression, and pain medication provides a baseline for comparison during future appointments.

Choosing the appropriate medication

The physical exam should be focused on the complaint of pain as well. A thorough neurologic assessment is key, and palpating painful areas can help detect any radiation or radicular aspects of the pain. A simple test for LBP is the straight-leg raise. Using von Frey's filaments to determine sensitivity is helpful in locating and detecting the spread of neuropathic pain.

Once the history and physical are complete, choosing the appropriate intervention is crucial. Many clinicians are reluctant to start opioid medications. Fear of federal drug enforcement oversight and addiction can drive prescribers away from opioids. Lack of knowledge on how to dose and combine opioids can also limit their use. Oftentimes clinicians opt to begin treatment with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) instead. Depending on the source and intensity of the pain, this may lead to undertreatment, which could exacerbate the problem.
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