Chronic pain medical therapy
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Chronic pain medical therapy On the Web
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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." 
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.
- One systematic review found that trials of short term opioids did not improve functional status compared to placebo in chronic pain. However, a second systematic review, found that opioids improved functional status compared to placebo, but not compared to other drugs.
- According to some randomized controlled trials, opioids reduced pain in the short term, but did not improve function in comparison to an cholinergic antagonist placebo or tricyclic antidepressant.
The role of long term treatment of chronic non-cancer pain is not clear.
- 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."
- 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".
Treatment of depression may reduce the dose of opioids needed.
Most trials are funded by industry.
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. A prior systematic review cited 4 controlled, although non-randomized, studies. In one study that isolated the effect of a treatment agreement, opioid misuse dropped by 21%.
- State-wide prescription monitoring programs is associated with a reduction of possible opioid diversion by 85%. 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.
- Urine drug testing is frequently recommended by clinical practice guidelines and may help reduce aberrant use of prescribed opioids. About 30% of urine samples will be abnormal, usually for the lack of opioids or the presence of cannabinoids. Abnormal urine results are more common among patients on higher daily morphine-equivalent doses.
- The Graded Chronic Pain Scale is recommended by clinical practice guidelines by the Washington State Agency Medical Directors' Group.
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.
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. 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.
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.
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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.
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