Chronic pain medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

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." [1][2]

Medical Therapy

Opioids for Chronic Pain

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). 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.

Opioids are effective for short term use (1-16 weeks).[3][4][5][6]

The role of long term treatment of chronic non-cancer pain is not clear.[9]

Treatment of depression may reduce the dose of opioids needed.[12]

Most trials are funded by industry.[6]

Opioid Treatment Contracts

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 guidelines.[13] A prior systematic review[14] cited 4 controlled, although non-randomized, studies. In one study that isolated the effect of a treatment agreement, opioid misuse dropped by 21%.[15]

Monitoring

  • State-wide prescription monitoring programs is associated with a reduction of possible opioid diversion by 85%.[16] 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 Researched Abuse Diversion and Addiction-Related Surveillance System dropped from 49.81/100,000 to 7.6/100,000 of the general population.[16]
  • Urine drug testing is frequently recommended by clinical practice guidelines[13] and may help reduce aberrant use of prescribed opioids[17]. About 30% of urine samples will be abnormal, usually for the lack of opioids or the presence of cannabinoids.[18] Abnormal urine results are more common among patients on higher daily morphine-equivalent doses.[18]
  • The Graded Chronic Pain Scale[19] is recommended by clinical practice guidelines by the Washington State Agency Medical Directors' Group.[20]

Non-Steroidal Anti-Inflammatory Drugs

The other major group of analgesics are Non-steroidal anti-inflammatory drugs (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.[21][22]

Antidepressants and Antiepileptic Drugs

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 neuropathic pain disorders as well as complex regional pain syndrome.[23] 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.

Interventional Therapy

Injections, 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.[24][25][26][27][28]

Rehabilitation

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  • From a page move: This is a redirect from a page that has been moved (renamed). This page was kept as a redirect to avoid breaking links, both internal and external, that may have been made to the old page name.

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.[29]

References

  1. Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet. 369 (9565): 946–55. PMID 17368156.
  2. Stanos S, Houle TT (2006). "Multidisciplinary and interdisciplinary management of chronic pain". Physical medicine and rehabilitation clinics of North America. 17 (2): 435–50, vii. PMID 16616276.
  3. Chou R, Huffman LH, American Pain Society. American College of Physicians (2007). "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". Ann Intern Med. 147 (7): 505–14. PMID 17909211. Review in: Evid Based Nurs. 2008 Apr;11(2):50
  4. 4.0 4.1 Kalso E, Edwards JE, Moore RA, McQuay HJ (2004). "Opioids in chronic non-cancer pain: systematic review of efficacy and safety". Pain. 112 (3): 372–80. doi:10.1016/j.pain.2004.09.019. PMID 15561393.
  5. Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR; et al. (2007). "Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction". Ann Intern Med. 146 (2): 116–27. PMID 17227935.
  6. 6.0 6.1 6.2 Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E (2006). "Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects". CMAJ. 174 (11): 1589–94. doi:10.1503/cmaj.051528. PMID 16717269.
  7. Moulin DE, Iezzi A, Amireh R, Sharpe WK, Boyd D, Merskey H (1996). "Randomised trial of oral morphine for chronic non-cancer pain". Lancet. 347 (8995): 143–7. PMID 8544547.
  8. Raja SN, Haythornthwaite JA, Pappagallo M, Clark MR, Travison TG, Sabeen S; et al. (2002). "Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial". Neurology. 59 (7): 1015–21. PMID 12370455. Review in: J Fam Pract. 2003 Jul;52(7):517-8
  9. Von Korff M, Kolodny A, Deyo RA, Chou R (2011). "Long-term opioid therapy reconsidered". Ann Intern Med. 155 (5): 325–8. doi:10.7326/0003-4819-155-5-201109060-00011. PMC 3280085. PMID 21893626.
  10. Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C; et al. (2010). "Long-term opioid management for chronic noncancer pain". Cochrane Database Syst Rev (1): CD006605. doi:10.1002/14651858.CD006605.pub2. PMID 20091598.
  11. 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. 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.
  12. Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J; et al. (2009). "Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial". JAMA. 301 (20): 2099–110. doi:10.1001/jama.2009.723. PMC 2884224. PMID 19470987. Review in: Evid Based Ment Health. 2010 Feb;13(1):13
  13. 13.0 13.1 Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P; et al. (2014). "Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain". Ann Intern Med. 160 (1): 38–47. doi:10.7326/0003-4819-160-1-201401070-00732. PMID 24217469.
  14. Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ (2010). "Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain". Ann Intern Med. 152 (11): 712–20. doi:10.7326/0003-4819-152-11-201006010-00004. PMID 20513829.
  15. Goldberg KC, Simel DL, Oddone EZ. 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
  16. 16.0 16.1 Surratt HL, O'Grady C, Kurtz SP, Stivers Y, Cicero TJ, Dart RC; et al. (2014). "Reductions in prescription opioid diversion following recent legislative interventions in Florida". Pharmacoepidemiol Drug Saf. 23 (3): 314–20. doi:10.1002/pds.3553. PMID 24677496.
  17. Chutuape MA, Silverman K, Stitzer ML (2001). "Effects of urine testing frequency on outcome in a methadone take-home contingency program". Drug Alcohol Depend. 62 (1): 69–76. PMID 11173169.
  18. 18.0 18.1 Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE; et al. (2014). "Chronic Opioid Therapy Urine Drug Testing in Primary Care: Prevalence and Predictors of Aberrant Results". J Gen Intern Med. doi:10.1007/s11606-014-3010-y. PMID 25217208.
  19. Von Korff M, Ormel J, Keefe FJ, Dworkin SF (1992). "Grading the severity of chronic pain". Pain. 50 (2): 133–49. PMID 1408309.
  20. Washington State Agency Medical Directors' Group. 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. Summary at the National Guidelines Clearinghouse
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  22. Ballantyne JC (2006). "Opioids for chronic nonterminal pain". South. Med. J. 99 (11): 1245–55. PMID 17195420.
  23. Jackson KC (2006). "Pharmacotherapy for neuropathic pain". Pain practice : the official journal of World Institute of Pain. 6 (1): 27–33. PMID 17309706.
  24. Varrassi G, Paladini A, Marinangeli F, Racz G (2006). "Neural modulation by blocks and infusions". Pain practice : the official journal of World Institute of Pain. 6 (1): 34–8. PMID 17309707.
  25. Meglio M (2004). "Spinal cord stimulation in chronic pain management". Neurosurg. Clin. N. Am. 15 (3): 297–306. PMID 15246338.
  26. Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM (2006). "Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience". Pain. 121 (1–2): 43–52. PMID 16480828.
  27. 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 (2007). "Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain" (PDF). Pain physician. 10 (1): 7–111. PMID 17256025.
  28. Romanelli P, Esposito V, Adler J (2004). "Ablative procedures for chronic pain". Neurosurg. Clin. N. Am. 15 (3): 335–42. PMID 15246341.
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