Chronic Pain: Assessment and Management

Course Content

Author: Adrianne E. Avillion, D.Ed., RN

Contact Hours: 6

Objectives:

  1. Compare acute and chronic pain
  2. Explain the pathophysiology and influencing factors of chronic pain.
  3. Appraise the ethics of pain management.
  4. Explain the impact of chronic pain.
  5. Examine the assessment and diagnosis process for chronic pain.
  6. Summarize various conditions related to chronic pain.
  7. Explain pharmacological approaches for pain management including use of opioids.
  8. Compare therapeutic options for pain management.
  9. Evaluate complementary options for pain management.
  10. Appraise special issues to consider for pain management.

Introduction

During 2021, an estimated 20.9% of U.S. adults (51.6 million persons) experienced chronic pain, and 6.9% (17.1 million people) experienced high-impact chronic pain. Chronic pain is a serious public health problem and a debilitating condition that affects the lives of millions of adults in the U.S. Compounding the problem are the disparities in the treatment of chronic pain and access to affordable and appropriate pain management care (Centers for Disease Control and Prevention (CDC), 2023). This education program addresses the pathophysiology of pain, ethical implications, types of conditions related to chronic pain, and therapeutic options for pain management.

Comparison Between Acute and Chronic Pain

The International Association for the Study of Pain (IASP) (2020) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” The IASP further expands upon this definition via six additional concepts and the etymology of the word pain. It is important that healthcare professionals’ knowledge of pain terminology and concepts include the latest information from pain experts.

  1. Pain is a personal experience influenced by biological, psychological, and social factors.
  2. Pain and nociception (central nervous system (CNS) and peripheral nervous system (PNS) processing of noxious stimuli) are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  3. Through their life experiences, individuals learn the concept of pain.
  4. A person’s report of an experience in pain should be respected.
  5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  6. Verbal description is only one of several behaviors to express pain; the inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

The IASP defines acute pain as pain that occurs suddenly, has a specific cause, and serves as a warning sign of disease or threat to the body. Acute pain is caused by issues such as injury, surgery, illness, trauma, or painful medical procedures and generally lasts from a few minutes to less than six months. Acute pain typically subsides when the underlying cause is treated or healed (IASP, n.d.).

Chronic pain is ongoing and typically lasts longer than six months. Chronic pain can continue even after the injury or illness that triggered it has healed or subsided. Pain signals remain active in the nervous system for indefinite periods of time (e.g., weeks, months, or years). Chronic pain can exist even though it is not associated with past injury or apparent body damage. This type of pain is linked to conditions such as arthritis, cancer, or fibromyalgia (Cleveland Clinic, 2020a). About 52 million people suffer from chronic pain (CDC, 2023).

A relatively new pain classification is high-impact chronic pain (HIP). HIP is pain that has lasted for at least three months, severe, worsening pain, increased mental health issues, cognitive impairment, and at least one major activity limitation such as being unable to work outside the home or perform household chores. HIP has been diagnosed in 39% (25.3 million) of chronic pain sufferers (Somnath, 2020).

The comparisons among the different categories help to assess and intervene effectively for those patients in pain, whether acute or chronic. HIP compounds the already significant problems linked to chronic pain.

Chronic Pain Alert! Chronic Pain in Children

Data related to chronic pain in children is limited. Available data indicate that between one-quarter and one-third of children may experience chronic pain. Children with chronic pain may suffer from emotional and mental health issues. Chronic pain may also interfere with children’s social development (Kuehn, 2021). The most common causes of chronic pain in children include headaches, recurrent abdominal pain, and general musculoskeletal pain (Children’s Hospital Colorado, n.d.).

Pathophysiology of Pain

The most common reason that patients seek medical care is pain. Pain has both sensory and emotional components. Acute pain is often linked to anxiety and hyperactivity of the sympathetic nervous system, which leads to tachycardia, elevated respiratory rate, hypertension, diaphoresis, and pupil dilation. Chronic pain, however, does not involve hyperactivity of the sympathetic nervous system but may be associated with vegetative signs such as fatigue, loss of libido, lack of appetite, sleep disturbances, and depression. It is important to note that pain tolerance varies significantly among people (Merck Manual Professional Version, 2023).

Chronic pain associated with ongoing tissue injury is most likely caused by ongoing activation of tissue fibers. The severity of tissue injury does not necessarily predict the severity of acute or chronic pain. Ongoing damage to or dysfunction of the peripheral or central nervous system (CNS) leads to neuropathic pain (Merck Manual Professional Version, 2023).

Chronic Pain Alert! Neuropathic Pain

Neuropathic pain is caused by damage to or dysfunction of either the peripheral or CNS. Diagnosis is made by pain that is out of proportion to tissue injury, dysesthesia, and signs of nerve injury (Watson, 2022).

The sensation of pain is dependent on complex behaviors of neural systems that extend from the affected area of the body to the brain, which involves various modulatory effects (Griffin & Brenner, 2021). The descending pain modulatory system (DPMS) is a network of extensively distributed brain regions that are essential for proper effectual modulation of sensory input to the CNS and behavioral responses to the pain sensation (Goksan et al., 2018).

Nociceptive Pain

Nociceptive pain (pain caused by tissue injury) may be somatic (of the body) or visceral (of the internal organs) (Merck Manual Professional Version, 2023). Nociception is influenced by the stimulus type, location, and intensity, the duration and timing of the pain stimulus, prior history of nociceptive pain, and prior history of injury or inflammation of affected nerves (Griffin & Brenner, 2021).

Receptors for somatic pain are found in skin, subcutaneous tissues, fascia, other connective tissues, the periosteum (outer covering of bone), endosteum (membrane that lines the inner surface of the bony wall), and joint capsules. Stimulation of these kinds of pain receptors typically causes sharp or dull localized pain. However, a burning pain also occurs if the skin or subcutaneous tissues are involved. (Merck Manual Professional Version, 2023).

Visceral pain receptors are found in most viscera (internal organs in the body’s main cavities, especially organs located in the abdomen) and surrounding connective tissues. Visceral pain caused by obstruction of a hollow organ is characterized as (Merck Manual Professional Version, 2023):

  • Poorly localized
  • Deep.
  • Occasionally cramping.
  • May be referred to remote cutaneous sites.

If there is injury of organ capsules or other types of deep connective tissues, visceral pain may be characterized as sharp and more localized (Merck Manual Professional Version, 2023).

Pain Transmission

Pain fibers enter the spinal cord at the dorsal root ganglia and synapse in the dorsal horn. At this point, fibers cross to the opposite side and move up the lateral columns to the thalamus and then to the cerebral cortex (Merck Manual Professional Version, 2023).

Sustained stimulation (e.g., chronic pain condition) of neurons can actually sensitize neurons in the dorsal horn of the spinal cord. This sensitization can mean that a lesser peripheral stimulus leads to pain. This triggering of pain by a lesser stimulus is referred to as the “wind-up phenomenon.” Practitioners should be aware that peripheral nerves and nerves located at other levels of the CNS may also become sensitized. This causes long-term synaptic changes in cortical receptive fields, which can be modified by experience or injury to sensory nerves causing changes in the field’s size and position. Ultimately the exaggerated pain perception is maintained (Merck Manual Professional Version, 2023).

“Increased sensitivity (lower thresholds) and remodeling of central nociceptive pathways and receptors is termed central sensitization and explains the occurrence of allodynia (pain response to nonpainful stimulus and hyperalgesia (excessive pain response to a normal pain stimulus” (Merck Manual Professional Version, 2023).

A variety of neurochemical mediators, including endorphins and monoamines, modulate the pain signal at multiple points in segmental and descending mediators. These mediators interact (in ways still not clearly understood) to increase, sustain, shorten, or reduce perceptions and responses to pain (Merck Manual Professional Version, 2023).

Chronic Pain Alert! Ceasing of Nociceptive signals

Nociceptive signals end with the termination of the pain stimulus, dephosphorylation (the process of removing phosphate groups from a molecule), and suppression of the receptor. Ending also occurs once the entry of calcium through the open membrane proteins causes the nociceptive nerve ending to collapse and become resistant to restimulation (Armstrong & Herr, 2023).

Psychologic and Cognitive Factors Influencing Pain

The experience of pain is highly individualized. The pain experience is significantly influenced by various psychological and cognitive factors (Heshmat, 2023). Age, gender identification, presence or lack of support systems, access to healthcare services, and disparities in healthcare delivery all influence pain perception (Pasquale & Murphy, 2022). The following factors are among the most common and most influential factors that influence the pain experience.

Attention

Pain interferes with someone’s ability to concentrate and may lead to a lack of needed attention to life’s activities. Pain actually forces people to focus on both the pain and their bodies. Focusing closely on the sensations of pain may actually increase the intensity of the pain. Human beings typically are able to concentrate only on one significant occurrence at a time. For example, this is how athletes can continue to perform despite pain and may not notice their injuries until the action stops. Attention distraction is one of the common strategies for pain management (Heshmat, 2023).

Spirituality and Religion

Religion and spirituality can influence pain “messages” from the brain and affect the way pain is transmitted in the spinal cord, thus influencing how pain is experienced. The words religion and spirituality are often used interchangeably. However, they are different. Religion is “a set of practices and beliefs and involves a relationship with a god. Spirituality is the experience of connectedness, meaning, and purpose in life, and integrating aspects of self, which may or may not involve relation with a God (or supreme being). Spirituality gives individual autonomy with one’s interpretation of the soul” (Tamirisa, n.d.). Religion can be a source of support, strength, and security. Spirituality is a personal understanding of religious principles and can help patients and healthcare professionals understand how and why pain is perceived (Tamirisa, n.d.).

Please note that the following descriptions are based on theological generalities and not used to make broad assumptions about anyone’s religion and how it is practiced (or not practiced).

Various religions and spiritual understanding view suffering and pain in different ways. For example, in the Hindu tradition, suffering and pain are viewed as a consequence of one’s inappropriate actions in this life or a previous life. Pain is not considered to be a punishment, but rather as a consequence of previous actions. Hindu traditions believe that pain is dealt with as accepting it as a consequence and understanding that suffering is not accidental. Even though the body can feel pain, the soul does not. Since the soul is not affected, pain is seen as only temporary suffering (Tamirisa, n.d.).

Buddhism teaches that there are three kinds of suffering (dukkha). The first is physical and mental pain due to inevitable stresses of life (e.g., sickness); the second is the distress felt because of impermanence and change (e.g., losing something that is highly valued); and the third kind of stress is described as existential suffering, the angst of being human and living in a conditioned existence and being subject to rebirth (TRICYCLE Buddhism for Beginners, 2023).

The basis of all types of suffering is going through life grasping or clinging to what is believed to be gratifying and avoiding what is disliked. Grasping and clinging may give momentary relief or temporary satisfaction. It is not permanent. The way to end suffering is to develop contentment and happiness that are not dependent on external objects or events, but rather from a “cultivated” state of mind that does not vary as circumstances. Buddhism teaches that the means of liberating oneself from suffering is always available (TRICYCLE Buddhism for Beginners, 2023).

Islam teaches that a knowledge of right and wrong is a fundamental component of human nature. People should know, without having to be told, which actions are evil and contribute to the suffering of others, and which actions are good and contribute to well-being. Muslims must choose between “right” (using the guidance of Allah) and “wrong” following the temptations of Shaytan (Satan/the Devil) (BBC, 2023).

Many Muslims believe that suffering is the result of selfishness and evil of human beings., which can lead to making bad decisions. They may also believe that enduring suffering and evil is a test from Allah is preparation for entering Paradise (Heaven). Additionally, Muslims may see a purpose in suffering, believing that suffering’s purpose is (BBC, 2023):

  • Allah’s way of teaching them.
  • Retribution for a wrong they have committed.
  • A test.

By responding to suffering with patience while remaining adherent to their faith, Muslims may believe that they will be increasingly rewarded in the afterlife. Thus, suffering may be viewed as a blessing (BBC, 2023).

Jewish tradition promotes the concept that both good and bad in life are God-given and have a purpose. Many Jews believe that evil originated from the first sin of Adam and Eve who ate from the Tree of Knowledge against the wishes and mandates of God. Thus, evil becomes “part” of human beings, and humans suffer because they violate God’s wishes and become separated from God. Some Jewish people believe that Satan is not a separate entity. Instead, Satan is the tendency that exists in every human to do wrong. Many, if not most, Jews believe that everything God does is ultimately for good, and whatever happens on Earth is according to God’s plan (BBC, n.d.).

Some of the Jewish responses to evil and suffering include (BBC, n.d.):

  • Hebrew scripture teaches that suffering can be a punishment for sins.
  • Hebrew scripture teaches that suffering can be a test from God to see if humans freely follow God’s commandments.
  • Suffering can bring people closer to God.
  • Suffering helps people to empathize with others and to help them when needed.
  • Suffering cannot be understood by humans, but they must do everything that they

For Christians, suffering is an expected part of life. Suffering was not part of God’s original plan of creation. Sin corrupted the world as a result of the disobedience of Adam and Eve and continues its corruption as humans make poor decisions, rebel, and behave selfishly. Sin does not only harm those who commit it, but to other people as well (Got Questions Ministries, 2023).

Christians cite several possible reasons for suffering distinct from the reasons for generalized suffering experience by all people. These include (Got Questions Ministries, n.d.):

  • Suffering may be viewed as a form of discipline. Hebrews 12:5-11 reads, “Endure hardship as discipline; God is treating you as his children. For what children are not disciplined by their father?” For example, people who spend all their time and effort at work to attain wealth and things that money can buy and ignore the needs of family and friends may lose his job. This loss may be explained by believing that God is helping them to readjust priorities and rediscover their families and the word of God.
  • Suffering helps Christians to identify with and encourage other sufferers. It may be that God is providing some people with the opportunity to use their own suffering for the good of others.
  • Suffering may help people move closer to the Lord. Suffering may force people to study scriptures and rely on God, ultimately finding peace and purpose.
  • Suffering may remind human beings that the Earth is not their true home. People who are suffering may move closer to God and focus the on the peace and joy of eternity in Heaven.

Cultural Impact

Culture is the foundation that guides human behavior. The interpretation and the expression of pain are typically influenced by cultural background. It is important, however, to realize that not all members of a culture behave according to its particular set of behaviors or beliefs. Cultural stereotyping can negatively impact the assessment and treatment of pain (Gordon, 2023).

Culture influences the way patients view pain, consider pharmacological therapy, and participate in development and implementation of the pain management regimen. It also influences the involvement of the family in the pain management process. Many family members want to be directly involved on a daily basis. In some cultures, the heads of the family (whoever that may be) is responsible for directing healthcare decisions and patients may defer to them (Givler et al., 2023).

Healthcare professionals must be aware of their own cultural values and behaviors, which can impact healthcare delivery. In order to provide culturally competent care, healthcare professionals must (Gordon, 2023):

  • Be cognizant of their own cultural backgrounds and values.
  • Be aware of their own personal biases and beliefs about people from different cultures.
  • Be aware and accept cultural differences between themselves and the patients and their colleagues.
  • Respect diversity as they work to deliver optimal patient care.

Failure to understand how culture influences pain perception and pain experience can significantly interfere with patient care delivery. For example, in some Asian cultures overt expression of pain may be considered undignified and/or inappropriate. However, just because someone is stoic when it comes to pain expression, it does not mean that there is an absence of pain. Healthcare professionals must conduct a thorough pain assessment and intervene appropriately regardless of whether or not patients are overtly expressing feelings of pain (Anthony et al., 2023).

Some cultures may encourage the overt expression of pain. Some healthcare professionals may interpret this as “overreacting to pain” or exaggerating the pain experience. Again, it is imperative that healthcare professionals understand cultural nuances, objectively assess patients’ pain experiences, and intervene appropriately (Anthony et al., 2023).

Catastrophic Thinking

Catastrophic thinking can be defined as “imagining the worst possible result that could happen” (Heshmat, 2023). This type of thinking may actually make pain worse by making the person focus on the pain and attach additional emotion to the pain experience. Catastrophic thinking may also be a coping strategy and/or a tactic to gain support and sympathy from others. If catastrophic thinking provides secondary gains (such as increased support from family and friends), it may become ongoing (Heshmat, 2023).

Anxiety

Research shows that anxiety increases pain. People who are anxious may have lower pain thresholds, and they may also avoid seeking healthcare services because they are afraid that they will receive bad news. In an effort to reduce pain and anxiety, some individuals turn to alcohol and drugs. Conversely, positive emotions and emotional states (e.g., relaxing with loved ones) typically reduce pain (Heshmat, 2023).

Depression

Pain and depression are significantly linked to one another. Depression can cause pain, and pain can cause depression. In other words, pain worsens depression, and the depression increases the pain (Mayo Clinic, 2019b).

Chronic Pain Alert! Depression and Pain

Persons dealing with ongoing pain should be screened for depression and other mental health issues. An appropriate pain management program should incorporate mental health screening and treatment (Mayo Clinic, 2019b).

Implicit Bias

Implicit bias, also known as unconscious bias, is a typically negative attitude towards a specific group of people (e.g., based on race, or socioeconomic status). The critical component of implicit bias is that the person holding this negative attitude is not consciously aware of the bias (American Psychological Association, 2022). Implicit bias contributes to healthcare inequalities and poor patient outcomes.

Research shows that racial bias and discrimination add to inequities in both the experience of pain and how it is managed. These inequities are found in the care given to Black, Indigenous, and People of Color (BIPOC) compared to White people. One of the inequities is the significant undertreatment of pain in members of minority groups (Ghoshal, 2020).

A review of the literature regarding pain management in (BIPOC) indicates that (Ghoshal, 2020):

  • Black patients receive less analgesics when being treated for fractures in emergency rooms compared to White patients (57% to 74%).
  • When dealing with metastatic or recurrent cancer BIPOC patients do not receive enough analgesics compared to White patients.
  • Historically, Black women have been underdiagnosed and undertreated for endometriosis, a condition that often causes severe pelvic pain, because of the stereotypical belief that endometriosis is more common in White women.
  • Black patients experience more burdens (e.g., functional limitations) because of many chronic, non-cancer painful conditions (e.g., arthritis) compared to White people.
  • Hispanic Americans who are dealing with chronic pain experience more monetary barriers because of a lack of health insurance and less pain treatment compared to other patients dealing with chronic pain.
  • Indigenous peoples in rural and tribal areas feel that they lack access to pain management and that healthcare providers undertreat or ignore their concerns about pain.

Ethics of Pain Management

Healthcare professionals deal with ethical issues in all facets of their professional practice. A pain management plan must be developed using an ethical framework. Biases and prejudices influence healthcare professionals’ ability to objectively and effectively help patients to manage their pain. Biases can be overt or covert (implicit). People with overt biases are aware of their biases and aware of their consequences. As previously noted, implicit biases occur automatically and unintentionally. People are not aware of implicit biases (also called unconscious bias). Whether overt or covert, bias can have significant adverse impacts on patient care (National Institutes of Health (NIH), 2022).

The American Nurses Association’s (ANA) 2018 position statement on ethical responsibilities for nurses in pain management. Its purpose is to “provide ethical guidance and support to nurses as they fulfill their responsibility to provide optimal care to persons experiencing pain.” The statement includes questions for nurses (applicable to all healthcare professionals) to help them reflect on their own experiences, backgrounds, and/or biases. These include (ANA, 2018):

  • Do I worry about causing my patients to become addicted to pain medication?
  • Do I feel that some people are more likely to use rules or laws to get what they want in in unfair way? (e.g., to gain more pain medication)
  • Do I feel anxious about discussing pain management with my colleagues?
  • Do I ever feel guilty about providing too much or too little pain relief?
  • Do I recognize that pain is whatever the person experiencing it says it is but I really feel that the patient is sometimes incorrect?
  • Do I impose my own experiences with addiction, opioid misuse, and drug-seeking behaviors on others?
  • Do I resist the idea that some patients may need more aggressive pain management than prescribed?

The following issues are also critical to the process of adhering to an ethical framework.

  • Moral disengagement: Moral disengagement is the process of distancing oneself from the normal or typical ethical standards of behavior in a given situation. Those people who morally disengage become convinced that new unethical behaviors performed in these situations are justified, often due to perceived extenuating circumstances. Research indicates that people who morally disengage do so in order to carry out unethical behavior (The OR Briefings, 2021).
  • Respect and education: As already noted, each patient’s experience of pain is unique. Pain is what the patient says it is. Persons dealing with chronic pain should be treated with respect and objectivity. Education must be delivered with respect as well. Patients should be taught about the multiple causes of pain, the impact/effects of pain, treatment options, and how to monitor treatment effectiveness of their treatment regimen. Healthcare professionals must receive ongoing education about pain management. They cannot provide adequate patient care unless they understand the process of chronic pain and its management. Education should be delivered to a multi-discipline team whose members must work in conjunction with the patient and each other (National Academy of Sciences, 2019).
  • Treatment choices: Treatment choices must be made in conjunction with patients and based on specific treatment goals. Decisions must be made in the context of patients’ personal values and beliefs. Failure to incorporate all of these factors is detrimental to desired patient outcomes and an ethical violation as well (Dinoff, 2019).

Chronic Pain Alert!

“Respect for Patient Autonomy is the foundation of ethical decision-making for most healthcare disciplines” ( Dinoff, 2019).

  • Access to treatment: A review of the literature shows that disparities in healthcare delivery affect people who have a variety of medical problems. This is particularly true for those who experience chronic pain. A recent research study showed that 50% of White medical students who were participants believed at least one false statement such as “Black people’s nerve-endings are less sensitive than white people’s nerve endings” (U.S. Pain Foundation, 2021b). Research findings pertaining to healthcare disparities include (U.S. Pain Foundation, 2021b):

    • Implicit bias has led to Black patients receiving a lower percentage of opioid prescriptions and a 36% lower mean annual dose.
    • There is a lack of diversity among the physician population. Among active physicians an estimated 56% identified as White, 17% as Asian, six percent as Hispanic, and five percent as Black or African American. This means that a diverse patient population will meet (at least 50% of the time) with a physician who is White and who probably has a different cultural and spiritual background.
    • People who are experiencing chronic pain have an estimated two times the risk of death by suicide compared to those without chronic pain. Discrimination against the LGBTQ community compounds the risk of mental health disorders, including death by suicide.
    • Among members of the LGBTQ community who are 50 years of age or older in the U.S. they are more likely than heterosexual older adults to have a weakened immune system and low back or neck pain.
    • The percentage of adults with chronic pain and high-impact chronic pain increases as their place of residence becomes more rural. This is due, in part, to the lack of pain management facilities and pain specialists. Although telemedicine can help to increase accessibility, some communities may not have adequate internet services.

Ethical Frameworks

The four principles framework provides an abstract and a theoretical foundation. Principles include (Bicket, 2021):

  • Nonmaleficence: Healthcare professionals must not cause avoidable or preventable harm to patients. Additionally, heroic interventions that cause a risk that outweighs the potential benefits to the patient should be avoided.
  • Beneficence: Healthcare professionals have an obligation to act in the best interest of the patient, regardless of self-interests in other entities such as pharmaceutical companies.
  • Autonomy: Patient autonomy regarding treatment choices and having information needed to make informed decisions.
  • Justice: Justice is the need and responsibility to eliminate disparities in treatment and to promote the equal distribution of healthcare resources.

The four-quadrant approach integrates combinations of the four principles. The four quadrants are (Bicket, 2021):

  • Indications for medical intervention: This involves assessment, treatment options and goals, and the probability of achieving those goals.
  • Patient preferences: What does the patient want? If the patient is not competent what actions are in the best interest of the patient?
  • Quality of life: What changes in the patient’s quality of life are anticipated with treatment? Are these changes going to improve quality of life?
  • Contextual features: What are the religious, cultural, legal, and societal factors that influence the patient’s decisions?

Critical Thinking Scenario # 1

Amy is a recently licensed physical therapist who works in a large pain management clinic. Amy is still orienting to her new role and responsibilities. Today she is preparing to meet a new patient. As she reads the notes from the patient’s intake interview, she finds that the patient, Mason, is a 16-year-old male student-athlete who was injured during a playoff basketball game. Eight weeks ago, Mason suffered a compound fracture of his right ankle and a severely sprained left wrist. Additionally, Mason is also dealing with nerve damage due to the fracture. Mason is still in considerable pain which is relieved only by an opioid analgesic. He is also exhibiting symptoms of depression. Mason is counting on earning a college scholarship thanks to his athletic ability, and he fears that his injuries will put an end to his basketball career. The intake interview notes mentioned that Mason is of Asian ancestry, and his parents were the first of their generation to be born in the U.S.

New to her profession, as well as new to the field of pain management, Amy makes several assumptions after reading the intake notes. First, based on his cultural background, physical fitness, and age, Amy thought that he would be more stoic and able to manage pain without a narcotic after eight weeks. She also wonders if Mason’s fears about jeopardizing his chances for a scholarship are realistic. He has two more years of high school during which he can prove his worth to college scouts. Amy hopes that she and Mason can address his fears during their therapy sessions. She is concerned about the existence of depressive symptoms. Amy looks at the ongoing progress notes to review the current pain management plan and how Mason (and his parents) feel about the progress, or lack thereof, of his pain management.

Amy’s assumptions indicate some dominant biases. She is critiquing Mason’s fears and pain experience based, in part, on his cultural background. In some Asian cultures stress stoicism and avoiding overt expressions of pain. This does not apply to all members of a given culture. Additionally, Mason and his parents were born and raised in the U.S., which may alter cultural influences. Amy cannot know the cultural impact of Mason’s pain management until she meets and assesses him in person.

Amy also needs to consider Mason’s concerns about his scholarship. She should not assume that his injuries will heal to the point that his athletic pursuits will continue, nor should Amy make assumptions based on Mason’s age and athletic ability. Amy does express concern, however, about Mason’s depression symptoms. She acknowledges that this is a serious issue and is anxious to take into consideration mental health findings and interventions.

As a new healthcare professional Amy needs to evaluate her own biases (both overt and implicit) and how her personal beliefs and values may influence care delivery. She also needs to examine how her assumptions can seriously impact patient care.

Impact of Chronic Pain

Chronic pain impacts patients, their families, and society. It also has a significant economic impact. A study conducted by Pitcher and colleagues (2019) showed that:

  • Chronic pain is linked to a significant likelihood of disability.
  • High-impact chronic pain includes both pain duration and disability.
  • The high-impact chronic pain population experiences severe pain and mental health and cognitive impairments.
  • The chronic pain population reports that they have more difficulty with self-care and a higher use of healthcare services.
  • Disability is not the result of other chronic health conditions.

Economic Impact

For most people, the medical costs of chronic pain are almost unaffordable. Some research shows that about 74% of people with high-impact chronic pain are currently unemployed. This not only interferes with the ability to afford medical care but the ability to afford basic necessities (e.g., food, shelter, transportation).

In August 2020, the U.S. Pain Foundation conducted a survey of 1,581 people with pain showed that barriers to adequate pain management include cost, insurance coverage and limits, concerns about side effects, limited or a lack of information about treatment options, geographic location, and mobility issues. Over 75% of respondents noted that cost prevented them from accessing one or more treatment options (U.S. Pain Foundation, 2020).

The American Pain Society and the IOM estimate that the total national cost of pain ranges from $560 billion to $635 billion annually in direct costs of treatment and lost productivity. Indirect costs attributed to lost productivity based on days of work missed, annual hours of work lost, and lower hourly wages range from $299 billion to $335 billion. The cost of medical expenditures ranges from $261 billion to $335 billion. Cost estimates are believed to be conservative estimates and do not include costs linked to the care of institutionalized people, military personnel, and children aged 18 years of age and less, the cost of pain to caregivers, and lost productivity of people 24 years of age and less and more than 65 years of age. Costs also do not include non-work-related activities, legal fees, and lost tax revenue (American Health & Drug Benefits, 2021).

Chronic Pain Alert! Direct Costs

Direct costs of chronic pain include medications, other treatment initiatives, and hospital and clinic-based services. Direct costs are only a portion of the financial cost of chronic pain (American Health & Drug Benefits, 2021).

Impact on Patients

Patients with chronic pain may experience a variety of adverse effects. These can include physical and mental health, and role in family, at work, and socially.

Physical Issues

Chronic pain can take a toll on both mind and body. Research suggests that chronic pain can actually alter brain structure. Chronic pain decreases the volume of gray matter, which controls learning, attention, memory, thought processes, motor control, and coordination. Alterations in these functions may lead to difficulty concentrating, remembering, memories, and problem-solving. Motor coordination may also be impaired. However, this change in gray matter is reversible. Research shows that getting effective treatment for chronic pain reverses this type of adverse effect. The important thing to remember is that the longer treatment is delayed, the more gray matter is lost, and the longer it will take to recover (D’arcy-Sharpe, 2020).

Pixabay. (n.d.). Brain anatomy. Picture in public domain. Accessed from public domain

https://pixabay.com/illustrations/brain-anatomy-human-science-health-512758/

Chronic pain can cause central sensitization, meaning that there is an “increased central neuronal responsiveness and causes hyperalgesia (abnormally heightened sensitivity to pain), allodynia (pain is caused by a stimulus that does not normally cause pain), and referred pain. These factors can cause chronic widespread pain (D’arcy-Sharpe, 2019).

Stress-related to chronic pain also has an adverse effect on the body. Stress causes chemical imbalances, which lead to more pain, and more pain causes more stress. It becomes an ongoing cycle of stress and pain. Such an ongoing cycle can cause fatigue and exhaustion since the body is not designed to deal with the prolonged emotional intensity caused by pain and stress. Blood pressure may increase, muscle aches and pains may occur, and patients may experience headaches (D’arcy-Sharpe, 2019).

An injury, even a mild injury, can act as a trigger for ongoing pain. When an injury occurs, the CNS transports signals back and forth to the brain, telling it that there is a painful injury. In some cases, even when the injury is healed, nerves are accustomed to transmitting pain signals. These signals continue to be transmitted, even though the injury has healed. These types of long-lasting changes can lead to chronic pain and insomnia (D’Arcy-Sharpe, 2019).

The potential for compromised mobility is also a possible adverse effect of chronic pain. Some people may avoid even simple exercises such as walking, for fear of aggravating pain. Failure to move/exercise as much as possible can lead to muscle and joint stiffness and atrophy and compromised gait and mobility. Patients should be taught to move and exercise in ways that benefit physical functioning and movement (D’Arcy-Sharpe, 2019).

Chronic Pain Alert!

Maintaining a healthy diet ensures that nutrients necessary for health and wellness are ingested. Although a healthy diet will not cure chronic pain, proper nutrition can help in symptom management and overall health (D’Arcy-Sharpe, 2019). Referral to a dietician may be helpful for patients dealing with chronic pain. Healthcare professionals must be alert to the benefits referrals may make to the quality of life for patients.

Mental Health Issues

The pain and mental health cycle is intertwined. Anxiety, depression, and chronic pain frequently occur in conjunction with one another. Research indicates that mental health disorders add to pain intensity and increase the risk of disability. An estimated 65% of Historically, researchers believed that the relationship between pain, anxiety, and depression was due primarily to psychological, rather than biological factors. However, current research shows that pain shares some of the same biological mechanisms as anxiety and depression (Harvard Health Publishing, 2021). The prevalence of mental health issues necessitates that mental health screenings be performed on all patients dealing with pain.

A summary of these mechanisms include (Harvard Health Publishing, 2021):

  • The somatosensory cortex (responsible for the interpretations of sensations) interacts with the amygdala, the hypothalamus, and the anterior cingulate gyrus (responsible for regulating emotions and the stress response) to trigger the mental and physical sensations of pain. These same regions contribute to anxiety and depression.
  • The neurotransmitters, serotonin and norepinephrine, that contribute to pain messaging are also associated with anxiety and depression.

Chronic Pain Alert! Prevalence of Anxiety and Depression

Research indicates that people dealing with chronic pain are four times more likely to have depression and anxiety compared to people who are pain-free (U. S. Pain Foundation, 2021a).

Chronic pain also influences the risk of death by suicide. A 2018 study reviewed data from 123,000 people who died by suicide from 2003 to 2014. Results showed that about nine percent of people who died by suicide had evidence of chronic pain (Petrosky et al., 2018). Later research findings indicate that persons with chronic pain have at least twice the risk of death by suicide than those who do not have pain (U. S. Pain Foundation, 2021a).

A large study conducted in 2021 consisted of 13,839 participants who completed online questionnaires about chronic pain, mental health symptoms, comorbidities, treatment response, and general health and wellness. The researchers found that chronic pain was associated with a higher risk of depression and an increased risk of suicidal behavior (Roughan et al., 2021).

Research findings show that the high use of tobacco, and misuse of opioids and other medications, are more common in patients with chronic pain. Research findings also show that there is an association between opioid misuse and suicidal behavior. In older adults, functional disability and chronic health conditions are linked to suicide risk (Lockett, 2022).

Chronic pain has been shown to limit a patient’s ability to participate fully in life, including problems fulfilling work and family roles and responsibilities. This inability can trigger negative feelings and decrease self-esteem. These feelings are increased when pain management care is unaffordable or unavailable (U.S. Pain Foundation, 2021a).

Chronic Pain Alert! Research shows that death by suicide risk is decreased if pain is properly managed (U.S. Department of Veterans Affairs, 2022).

Impact on Family

The impact of chronic pain can have a significant impact on the family. Patients may no longer be able to fulfill the role of caregiver (e.g., parent to children, caregiver to parent). Such role reversals can increase stress and interpersonal conflict. Members of the household may resent the patient’s inability to fulfill expected roles. If the patient is no longer able to work there may be considerable financial consequences for the household.

Intimate relationships may suffer and, depending on the patient’s condition, sexual interaction may be compromised. One of the goals for patients and their loved ones is to identify and maintain a balance between validating the patient’s pain experience and helping the patient to achieve a maximum state of wellness (Pasquale, 2022).

The caregiver and other members of the household may experience fear that they will not be able to deal with the caregiver role indefinitely or that the patient’s condition may deteriorate significantly. Caregivers and other loved ones may begin to have their own symptoms of physical or mental health illnesses This is especially true if the caregivers do not have the help and support of others as they deal with changes in family dynamics and, possibly, changes in their own health as well (Cosio, 2019).

The social consequences of chronic pain can affect the family unit and the patient’s alternative support systems if no family member is present. Examples of social consequences include (Gaudon, 2020):

  • Decreased participation in social/leisure activities.
  • Mar interpersonal functioning.
  • Prevalence of negativity, which can adversely affect decisions and increase bias among others.
  • Loss of social roles.
  • Loss of self-identify.

Impact on Employers and Careers

An estimated 40% of American workers deal with chronic pain. As the lifespan increases, and the financial need for older adults to stay in the workplace beyond retirement age, it is predicted that chronic pain will become even more prevalent in the future (Gulseren et al., 2021).

Work-related factors, such as having physically demanding jobs or high-stress jobs, can increase the severity of chronic pain. Chronic pain in the workplace is often called an “invisible” condition because employees will often take extreme actions to conceal their pain. There are times, however, when chronic pain causes absenteeism, which can lead to productivity loss and employer frustration. If patients are not able to work because of the extent of their pain, they may face severe financial consequences (Gulseren et al., 2021).

The multitude of factors related to the impact of chronic pain have far-reaching impact on the patient, family, society, and employers. Early assessment and diagnosis of chronic pain facilitates effective treatment and provides the best possible quality of life.

Critical Thinking Scenario # 2

Karen is a 42-year-old nurse whose husband Daniel is experiencing chronic pain due to injuries suffered in a car crash two years ago. He is a writer of historical biographies and earns a very good living. Karen is an oncology nurse practitioner and also earns a good living. Despite dealing with chronic pain, Daniel is able to continue writing at home, albeit not as prolifically as prior to the car accident. They are able to afford household help with cleaning and property maintenance.

Karen and Daniel’s marriage is very strong, and they support each other unconditionally. As a nurse, Karen is very aware of the impact of chronic pain. Both she and Daniel are being monitored for symptoms of depression and anxiety. They also attend psychotherapy sessions singly and as a couple. Daniel is under the supervision of a pain management clinician and participates fully in developing, updating, and evaluating the pain management plan. As an oncology nurse practitioner, Karen quite often works with patients who are dealing with chronic pain and is also part of the pain management plan development and evaluation.

Karen and Daniel have a 16-year-old female teenager, Jeannie. Jeannie is distraught over the changes in parental involvement in her life. Daniel is no longer able to attend many of Jeannie’s sports events or other school activities. Karen seldom attends due to her work schedule and spending considerable time with Daniel. The household is focused on supporting Daniel and doing everything to help him achieve and maintain his maximum state of wellness. Therapy sessions also take up a lot of her parents’ time. Jeannie does not attend therapy sessions. When she tries to tell her parents about her concerns, they tell her she is being selfish.

The impact of chronic pain affects all members of the family. What strengths have emerged in the management of Daniel’s chronic pain? What circumstances indicate weaknesses and a need for action?

On the positive side, Daniel is able to continue working. The family’s financial status has remained unchanged. Karen, as an oncology nurse practitioner, has significant experience in pain management. Both Karen and Daniel are deeply involved in developing and evaluating Daniel’s pain management plan. This type of involvement is essential to the success of any pain management program. Daniel is fortunate in that he receives substantial emotional support from his wife and help with physical limitations.

Additionally, both Karen and Daniel are participating in psychotherapy. Both of them are well aware of chronic pain’s impact on the mental health of both patients and families.

There are, however, problems with Daniel’s pain management activities. Although he and his wife are a cohesive unit, their daughter seems to have been isolated. Jeannie is struggling with changes in household roles and activities. She is concerned about her father, her family, and herself. Jeannie’s concerns have not been addressed, or if they have it is to be told that she is selfish. Additionally, Jeannie is not participating in psychotherapy. It is not known whether Jeannie has been offered the chance to participate in therapy or if she refused to participate. Based on her parents’ actions, however, it seems likely that it was not thought to include her.

What recommendations would be appropriate for this situation? Jeannie should be included as an important part of the pain management process. Each member of the family is affected when one of them is dealing with chronic pain. Jeannie may not know her father’s pain status or how the condition affects the family. Jeannie should be included in the pain management plan as appropriate and offered the opportunity to participate in psychotherapy. Her concerns need to be acknowledged and addressed. Efforts should be made to attend events that are important to Jeannie.

Chronic pain management is complex and affects all members of a family. The focus of pain management is the patient. But the impact of the condition as it affects family members should be monitored and adequate interventions implemented.

Assessment and Diagnosis

Assessment

The assessment process is multi-faceted. Recognition of risk factors for chronic pain help patients and families to take action to prevent or delay onset of this condition. Recognition of risk factors also enables healthcare professionals to assist patients to take preventive action.

Risk Factors

A wide variety of health issues or injuries can cause chronic pain. There are, however, risk factors that increase the likelihood of its development. These risk factors include (Cleveland Clinic, n.d.).

  • Genetics: Some problems that cause chronic pain (e.g., migraines) are found to be prevalent in families. Thus, there is a genetic fluence for the development of chronic pain.
  • Obesity: Obesity can exacerbate certain health problems that cause pain (e.g., arthritis).
  • Age: Older adults are more likely to develop chronic pain from conditions such as neuropathy.
  • Prior injury: Having a past traumatic injury in the past increases the likelihood of developing chronic pain in the future.
  • Working at a labor-intensive job: A physically demanding job is associated with an increased risk of developing chronic pain.
  • Dealing with stress: Research shows that chronic pain is associated with frequent stress as well as post-traumatic stress disorder (PTSD).
  • Smoking: Smoking increases the risk of developing medical issues that lead to chronic pain.

Screening Tools

Adult Screening Tools. There are a number of tools that are used in the assessment of pain. One such tool is the Numeric Pain Scale. Patients are requested to give three pain ratings that correspond to the current, best, and worst pain experienced over the past 24 hours. The average of the three ratings is used to represent the patient’s report f pain over the previous 24 hours. Pain is rated on a 10-point scale: 0-3 is mild; 4-6 is moderate; and 7-10 is severe (University of Florida, n.d.).

Numeric Pain Rating Scale

Resource: U. S. government. This scale is in the public domain. https://www.nih.gov

The Visual Analog Scale is presented as a straight line with one end indicating that the patient is feeling no pain and the other end indicating the worst pain imaginable. The patients make a mark on the line that matches the amount of pain they feel (National Cancer Institute, n.d.).

Resource: This example was developed by the author.

The Adult Non-Verbal Pain Assessment Tool uses pictures of faces whose expressions indicate how much pain they are in. If the patients are unable to understand or physically unable to point to the face that best represents their pain, the tool can be modified so that it can be scored by observation. Examples include observing (Odhner, n.d.):

  • The face: No particular expression: 0; Occasional grimace, frowning: 1; Frequent grimace frowning, tearing: +2.
  • Guarding: Lying quietly: 0; Tense, Splinting parts of the body: +1; Rigid, stiff: +2.

Other observations can include vital signs and respiratory status.

Adult Non-Verbal Pain Scale

Resource: Pain Assessment Tool. Public domain. Accessed at

https://publicdomainvectors.org/en/free-clipart/Pain-scale/50153.html

The Pain Assessment in Advanced Dementia (PAINAD) scale is a pain assessment tool for patients with advanced dementia. This reliable scale can be used in both verbal and nonverbal patients. This scale is especially useful for patients with aphasia or patients who cannot report the degree of pain (EB Medicine, 2019).

Items in the PAINAD are ranked from 0-+2 and totals range from 0 to 10. Items scored in the scale include (Warden, n.d.):

  • Breathing (independent of vocalization).
  • Negative vocalization.
  • Facial expression.
  • Body language.
  • Consolability.
Resource: Schwerin,, D. (2019). Pain Assessment in Advanced Dementia (PAINAD) Scale.
https://www.ncbi.nlm.nih.gov/books/NBK570552/figure/nurse-article-20337.image.f1/?report=objectonl.
Illustration is in the public domain via the U.S. government National Institutes of Health (NIH).

Pediatric Assessment Tools. There are also a number of assessment tools used in children of various ages. The Neonatal Infant Pain Scale (NIPS) assesses six behavioral reactions to painful procedures in preterm and full-term newborns. It has been found to be reliable and valid (Sarkania & Gruszfeld, 2022).

The six factors assessed include (University of Wisconsin, n.d.):

  1. Facial expression.
  2. Cry.
  3. Breathing patterns.
  4. Arms.
  5. Legs.
  6. State of arousal.

The Wong-Baker Scale for Children was originally developed with input from children to help them communicate the severity of their pain. It is typically used with people three years of age and older. Ratings range from no pain to hursts the worst (Wong-Baker FACES Foundation, n.d.).

The Wong-Baker Scale for Children

Resource: Physiopedia. (n.d.). Wong-Baker scale with emoji.png. Accessed at

The preceding examples are only a sampling of the many pain assessment tools available. Each healthcare organization should select the tools most appropriate for the patient population. Once the selection is made, tools should be used consistently.

Family Assessment Tools. Since chronic pain affects the whole family, it is important to assess family functioning. The Life Course Intervention Research Network (LCIRN) has identified a number of tools that can be used to assess family functioning. Some of the tools described include (LCIRN, 2023):

  • Assessment of Strategies in Families Effectiveness (ASF-E): Forty-item survey used to estimate the effectiveness of family functioning.
  • Brief Family Relationship Scale: Nineteen-item tool used to assess young people’s perception of the quality of family relationship functioning.
  • Dyadic Adjustment Scale (DAS): Thirty-two-item scale used to assess couples’ relationship satisfaction.
  • Family Functioning in Adolescents Questionnaire (FFAQ): Thirty-five-item questionnaire used to assess the psychosocial health of the family from the perspective of adolescent family members.
  • Marital Satisfaction Inventory-Revised: One-hundred-fifty-item self-report tool that is used to assess the nature and density of distress in specific areas of partners’ interaction.
  • Relational Support Inventory: Twelve-item tool used to measure perceived relational support.
  • Quality of Marriage Index: Six-item tool used to assess global satisfaction with marriage and partner.
  • Self-Report of Family Functioning (SRFF): Seventy-five-item tool used to measure attachment avoidance and anxiety.

hronic Pain Alert! Screening for Depression and Anxiety

There are a number of screening tools available for depression and anxiety. It is important to incorporate these types of tools consistently when screening for chronic pain. Examples of depression screening tools include (Pistoia, 2023):

  • Patient Health Questionnaire (PHQ)
  • Beck Depression Inventory (BDI)
  • Children’s Depression Inventory (CDI)
  • Geriatric Depression Scale (GDS)
  • Edinburgh Postnatal Depression Scale (EPDS)

Examples of anxiety screening tools include (Alston, 2023):

  • Generalized Anxiety Disorder 7 (GAD-7)
  • Generalized Anxiety Disorder Severity Scale (GADSS)
  • Beck Anxiety Inventory (BAI)
  • Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV)
  • Hamilton Anxiety Rating Scale (HARS)

History and Physical

A complete physical and mental health examination is conducted. In some cases, the cause of the pain may seem obvious. For example, the patient may have injuries or physical conditions (e.g., arthritis) that are the source of the pain. It is important to not only look at what seems to be obvious but what other underlying issues are present. All body systems are assessed and any indicated diagnostic studies are ordered. These actions help to identify sources of pain, factors that exacerbate the pain, and possible interventions. It is important that attention be given to the mental health consequences of chronic pain since anxiety and depression have been linked to the experience of chronic pain.

Pain Levels and Pain Characteristics

An important part of the diagnostic process is to gather information from the patient/family about the quality and characteristics of the pain. Using the previously described pain assessment screening tools is an important part of this process. Equally important is the way healthcare professionals ask patients/families about pain characteristics. The following tips provide guidelines for effective communication with patients/families and include (University of St. Augustine for Health Sciences, 2023):

  • Verbal communication: Remain objective and non-judgmental. Respect cultural, religious, and personal values and behaviors. Use language appropriate to the patient’s age, culture, and level of healthcare literacy. Avoid technical healthcare jargon. Ask open-ended questions rather than questions that can be answered with a yes or a no. For example, “Describe what your pain feels like.” Avoid condescending names such as honey or dear.
  • Non-verbal communication: Maintain a pleasant, interested facial expression. Maintain eye contact as appropriate. Avoid crossing your arms or standing over the patient. Avoid using excessive gesturing. Keep your hands at your sides or relaxed in front of you. Position yourself at the same level as the patient.
  • Active listening: Listen by giving your complete attention to the patient/family. Lean forward and maintain eye contact (as culturally appropriate). Nod your head and give minimal verbal reinforcement such as “go on” or “tell me more.”
  • Trust: Inspire trust by actively listening and taking all concerns seriously. Always be truthful and maintain confidentiality.

Asking specific assessment questions about pain level and its characteristics should be done in a consistent, methodical fashion to avoid missing critical details about the pain experience. Pain is a totally subjective experience, and healthcare professionals need to gather in-depth information about the pain experience.

One approach to elicit information about pain level and its characteristics is the PQRST Pain Assessment Method. The acronym stands for P: Provocation; Q: Quality/Quantity; R: Region/Radiation; S: Severity; T: Timing (Furst, 2023).

Provocation entails asking questions about what triggers the pain. Questions might include (Crozer Health, 2022):

  • What were you doing when your pain started?
  • What helps to relieve the pain? (e.g., medication, resting, massage, exercise)
  • What makes the pain worse? (e.g., stress, movement, walking)
  • How long does the pain last? (e.g., all of the time, when walking, intermittently)
  • Have you had a recent injury or surgery?

Quality/Quantity focuses on the characteristics of the pain and its quantity. Questions/comments that may be used to elicit this information include (Furst, 2023):

  • Describe your pain. Patients may need help to describe the pain and could be given options such as sharp, dull, throbbing, aching, burning, or shooting. Caution should be taken so that the healthcare professional is not putting words in patients’ mouths or influencing them to describe their pain in particular ways.
  • How often does the pain occur?

Radiation/Region focuses on the location of pain and whether or not it radiates. Sample questions include (Crozer Health, 2022; Furst, 2023):

  • What is the location of the pain?
  • Does the pain stay in one spot?
  • Does it feel as though the pain moves from one place to another in the body? (radiate)

Severity involves having the patients describe the severity of their pain. Assessing severity usually involves using one of the reliable and valid pain assessment tools. The preferred severity rating is having patients describe their personal experiences of pain. However, non-verbal and confused adults and very young babies and children may not be able to initiate conversations about severity. In these cases, one of the assessment tools is designed to meet the needs of patients under these circumstances (Crozer Health, 2022).

Timing seeks more information about the time and duration of pain. Examples of timing questions include (Crozer Health, 2022):

  • When did the pain start?
  • How long does the pain last?
  • How often does it occur? (e.g., daily weekly, constantly)
  • When does the pain usually affect you? (e.g., day, night, early morning)
  • Does the pain wake you up at night?
  • Does the pain occur before, during, or after meals?
  • Do other symptoms occur with the pain? (e.g., nausea, vomiting, dizziness)

Patients should also be asked to provide a list of prescription and over-the-counter medications being taken as well as any dietary or herbal supplements. It is also important to know if the patient has any allergies or past history of chronic pain (Furst, 2023).

Critical Thinking Scenario # 3

Asking the appropriate questions, in an effective way, is the foundation for pain assessment. The following examples of asking questions contain both appropriate and non-appropriate skills. Each should be analyzed in terms of appropriateness.

Most people say that pain caused by your type of injury feels like someone is stabbing them. Would you describe your pain as stabbing or would you describe it in another way?

This is an ineffective way of asking for a description of pain. By pointing out that most people describe the pain as stabbing the questioner is making the patient believe that their pain “should” be stabbing. The questionnaire concludes by asking a yes or no response question, which fails to elicit much information.

I see that you are concerned about not getting enough sleep and that you awaken frequently throughout the night. What is it that awakens you?

This is an effective question. The patient’s concerns are acknowledged and the question itself is open-ended. One may assume that it is pain that is the cause of sleep disturbances. However, it may be something quite different such as financial worries, conflict with loved ones, or problems at work. Asking about the cause of the sleep disturbances allows the patient to actually communicate what is believed to be the trigger of this problem.

Has your pain made it difficult to fulfill your work responsibilities?

This is an ineffective question. It is a yes or no question. Such questions make it easy for the patient to deflect the question and avoid going into detail. A better option is to ask, “How has the pain affected your job?”

Diagnosis

Healthcare providers may order a variety of imaging and lab tests to help in the diagnosis of chronic pain. The results of these tests may be used to identify, or rule out, conditions in the body that can cause chronic pain.

Lab Tests

Diagnosis of chronic pain is not made based on lab studies alone. The history and physical and pain evaluation are the foundations of diagnosis. However, lab studies may be able to help in the diagnostic process.

C-Reactive Protein (CRP) Test. CRP is a liver-produced protein that is released during an acute inflammatory process and other diseases. It is typically used to diagnose bacterial infections, infectious diseases, and inflammatory disorders such as rheumatoid arthritis. The synthesis of CRP is triggered by antigen-immune complexes, bacteria, fungi, and trauma. It is important to note that elevated CRP levels indicate the presence of, but not the cause, of disease (Pagana et al., 2022).

If the inflammation lasts for a lengthy period of time, healthy tissues can be damaged, which is referred to as chronic inflammation. Chronic inflammation can be caused by chronic infections, some autoimmune disorders (e.g., lupus, rheumatoid arthritis inflammatory bowel disease), and tissues that are repeatedly irritated from actions such as smoking or environmental chemicals (Medline Plus, 2022).

A1C. A1C measures average blood sugar levels over the past three months. It is commonly used to diagnose prediabetes and diabetes, which can lead to chronic pain conditions (e.g., peripheral neuropathy). A1C is also critical to the management of diabetes (Centers for Disease Control and Prevention (CDC), 2022a).

painHS. Researchers in Australia, led by Mark Hutchinson (a neuroscientist) are developing a new blood test called painHS that they believe will soon be an accurate assessment tool for the objective levels of chronic pain. Hutchinson says “We are literally quantifying the color of pain. We’ve now discovered that we can use the natural color of biology to predict the severity of pain. What we found is that persistent chronic pain has a different natural color in immune cells than in a situation where there isn’t persistent pain” (Aliabadi, 2021).

This test uses advanced electromagnetic spectrum analysis to show how pain changes the molecular structure of immune cells. The researchers hope that their work will eventually enable healthcare providers to measure pain levels experienced by each patient, and each patient’s personal pain tolerance. One concern about the use of this test is that patients may report that their pain is an eight on a 10-point scale, but the test shows that the pain level is a four. This might cause patients to be denied necessary pain relief. Healthcare providers must remember that no blood test can replace good communication between them and their patients (Aliabadi, 2021).

Hutchinson emphasizes that painHS, or any other blood test, does not replace patients’ description of their pain. Self-reporting and the use of screening tools for nonverbal patients are still the focus of pain. The researchers hope that the development of painHS will facilitate chronic pain diagnosis and be a helpful tool for those patients who have trouble communicating (Aliabadi, 2021).

Imaging Tests

Diagnosing chronic pain typically includes several imaging tests. Imaging studies can identify abnormalities in the bones, organs, and other soft tissues. Some of these studies include the following procedures.

X-rays. X-rays are two-dimensional images used to effectively identify anomalies in skeletal structures. “Plain” X-rays are first-line imaging choices for decreasing numbers of conditions. However, they are still excellent for the assessment of fractures and anomalies of bony structures (Rathmell, 2021).

Fluoroscopy. Fluoroscopy provides two-dimensional images via continuous X-rays that are viewed on a fluorescent screen. Fluoroscopy is important to the proper needle and catheter placement during procedures such as barium enemas, angiograms, and orthopedic surgery, inserting and manipulating catheter movement through blood vessels, bile ducts, or the urinary system, and placement of devices within the body (e.g., stents) (Food and Drug Administration (FDA), 2023).

Computed Tomography (CT) Scan. CT scans are procedures during which a computerized X-ray aims a narrow beam aimed at patients and swiftly rotates around the body producing signals that are generated as cross-sectional images (slices). A number of successive slices are gathered by the machine’s computer and stacked to produce a three-dimensional (3D) image (National Institute of Biomedical Imaging and Bioengineering (NIH), 2022). CT scans have proven to be a valuable tool for the measurement of bone density for the assessment of osteoporosis (Rathmell, 2021).

Magnetic Resonance Imaging (MRI). MRI signals are gathered when body tissues are subjected to strong magnetic fields that cause hydrogen ions to “relax” to their original structure when the magnetic fields are removed (Rathmell, 2021). MRIs are used to assess or diagnose conditions that affect soft tissue (e.g., tumors, brain disorders) (Pagana et al., 2022).

Bone Scans and Nuclear Medicine. Bone scans are nuclear medicine tests. A tiny amount of a radioactive substance (tracer) is injected into a vein. The tracer is absorbed in varying amounts that highlight specific body areas. When cells and tissues are changing structure, they absorb more of the tracer. This absorption may indicate bone damage, bone metastases, or tumors (American Society of Clinical Oncology (ASC), 2020).

Myelogram. A myelogram is typically used to diagnose disorders of the spinal cord or spinal canal. A special dye is injected into the cerebrospinal fluid (CSF), after which an MRI, CT scan, or X-ray is performed. This test is typically used to identify conditions such as bone fractures or herniated discs (Pagana et al., 2022).

Ultrasound Imaging. Ultrasound imaging uses high-frequency sound waves that bounce off the body’s tissues. This produces “real-time” images on a computer screen. Ultrasound is used in a variety of circumstances such as viewing abdominal and pelvic organs, muscles, the heart, and blood vessels (Pagana et al., 2022).

Nerve Block. During a nerve block, an injection of an anesthetic is administered at points where nerves are believed to be pain sources. Nerves are numbed to assist in the identification of the sources of pain (Ghauri, 2021).

EMG. An EMG (electromyography) measures muscle response or electrical activity in response to a nerve’s stimulation of muscle to detect abnormalities of the neuromuscular system. EMG is used to help in the identification of neuromuscular abnormalities. Electrodes are inserted into the muscle, and its electrical activity is shown on an oscilloscope. Muscle electrical activity is measured during rest, slight contraction, and forceful contraction (Johns Hopkins Medicine, n.d.b.).

Evaluation for Disability

The Social Security Administration (SSA) evaluates pain when considering disability benefit claims. SSA regulations include both medical evidence and mandatory consideration of subjective testimony when chronic pain is the cause of disability. No benefits are payable for partial disability or short-term disability. Applicants must have worked in jobs covered by Social Security and have a medical condition that meets the SSA’s strict definition of disability (SSA, n.d.).

The SSA considers that someone has a qualifying disability if all of the following are true (SSA, n.d.):

  • The person cannot do work and engage in substantial gainful activity (SGA) because of a medical condition.
  • The person cannot do work that was done previously or adjust to other work because of the medical condition.
  • The condition has lasted or is expected to last for at least one year or to result in death.

In general, monthly benefits are paid to people who are unable to work for a year or more because of a disability. There is generally a five-month waiting period and the first benefit is paid the sixth full month after the date the disability was determined to begin (SSA, n.d.).

Conditions Associated with Chronic Pain

A wide variety of conditions are associated with chronic pain. The following are some of these conditions.

Headache

Headache is the third leading cause of disability throughout the world. Patients’ concerns may be dismissed if healthcare professionals believe that (after appropriate tests to rule out serious conditions) not much treatment is needed because “it’s only a headache.” Headaches should be evaluated and treated the same as any other issue that requires pain management. Migraine is the primary type of headache disorder for which medical care is sought (Schuster & Wagner, 2021).

Fortunately, most headaches (primary headaches) are caused by conditions such as migraine or tension headaches. However, there are several identified red flags that may indicate secondary headache disorders including infections, vascular problems, and cancer. These red flags are referred to by the acronym SNOOP, which stands for (Schuster & Wagner, 2021):

  • S: Systemic signs or symptoms. These include items such as fever, chills, and night sweats.
  • N: Neurologic signs or symptoms. New focal neurological deficits are especially significant.
  • O: Onset. Onset refers to the abrupt onset of a thunderclap headache (extremely painful headache that occurs suddenly) or a severe headache that reaches maximum severity within one minute of onset.
  • O: Older. Older describes a new-onset headache beginning in persons over 50 years of age. Some sources believe that the age limit is lowered to over 40 years of age.
  • P: Positional headache. Positional headaches are described as “high-pressure headaches if present upon awakening and improving with standing up. (or) Low-pressure headache if present when standing and remitting when lying down.

Chronic Pain Alert! Triggers

Healthcare professionals should be aware of the factors that trigger headaches including (Schuster & Wagner, 2021):

  • Cough
  • Valsalva maneuver
  • Sex
  • Sleep patterns (e.g., headaches that cause someone to wake from sleep or at the same time every night.)
  • Cutaneous triggers of the face or the mouth

Back Pain

An estimated eight out of 10 Americans will experience some type of back pain during their lifetime. Of persons with back pain, about eight percent of them deals with it on a chronic basis (Health Partners, n.d.). The most common causes of back pain include the following issues.

Muscle Atrophy

Muscle atrophy, also referred to as muscle deconditioning, is among the most common causes of chronic back pain. Although some atrophy occurs with the aging process, a lack of exercise/physical activity is the major cause of atrophy. A lack of physical activity causes muscles to atrophy and weaken, which lessens the body’s ability to support ligaments and vertebrae (Health Partners, n.d.).

Improper Body Mechanics and Poor Posture

Failure to maintain proper posture and/or body mechanics places stress and strain on the soft tissues that surround the spine. If this goes on repeatedly the structural components of the spine are compromised. People who have physically demanding jobs are at higher risk for back pain, especially if proper body mechanics are not in use. People who sit for long periods of time need to stretch and move around on a regular basis. Failure to do this leads to flexion of the hips and hamstring weakening. Hunching over a desk or computer keyboard can lead to kyphosis (excessive outward curvature of the spine (Health Partners, n.d.).

Genetics and the Aging Process

Research indicates that there is a strong genetic link associated with chronic back pain caused by degenerative disc disease. Current research focuses on the identification of specific genes that influence degenerative disc disease and chronic back pain (Uribe, 2019).

Aging can contribute to the process of chronic back pain. However, symptoms such as fever, weight loss, increased pain at night, incontinence of bowel and/or bladder, pain that radiates down the legs, numbness or tingling, weakness, severe pain that fails to improve with rest, and pain associated with injuries may indicate a more serious condition such as a tumor or infection (Penn Medicine, 2023).

Repetitive Motion Activities

Common daily activities can lead to chronic back pain if they involve repetitive motion. Examples of such activities include driving or sitting for lengthy periods of time, lifting heavy objects, bending over, or exercising (Health Partners, n.d.).

Traumatic Events

High-impact injuries are especially likely to eventually cause chronic pain. Events such as car accidents, diving injuries, and falls are examples of those types of events that can lead to chronic pain. These circumstances can eventually lead to overcompensating movements in an effort to ease discomfort (Health Partners, n.d.).

Additional Common Causes

Additional causes of chronic pain include (Nava, n.d.):

  • Arthritis of the spine.
  • Spinal stenosis.
  • Herniated or bulging discs.
  • Myofascial pain syndrome.
  • Spinal cord injuries.

Neuropathic Pain Syndrome

Neuropathic pain is described as a painful condition due to neurological lesions or diseases. Possible causes include multiple sclerosis (MS), post-stroke pain, diabetic neuropathy, and spinal cord injury. It is essential that diagnosis be made as quickly and accurately as possible so that the best possible outcomes are achieved (Mitskostas et al., 2022).

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is chronic pain that typically affects an arm or a leg. It generally develops after an injury, surgery, a stroke, or a heart attack. An uncommon problem, CRPS is characterized by (Mayo Clinic, 2022):

  • Continuous burning or throbbing pain.
  • Cold or touch sensitivity.
  • Swelling of the painful area of the body.
  • Skin temperature changes ranging from warm and sweaty to cold.
  • Skin color changes that range from white to red or blue.
  • Skin texture changes.
  • Alterations in the growth of hair and nails.
  • Swelling, stiffness, and damage to the joints.
  • Muscle atrophy.
  • Decreased movement of the affected arm or leg.

The exact etiology of CRPS is not understood. Complications of the syndrome include atrophy of skin, bones, and muscles and/or muscle contractures. Treatment is most effective when it begins as quickly as possible. Early treatment can lead to improvement and, possibly, remission (Mayo Clinic, 2022).

Arthritis

There are more than 100 different types of arthritis and arthritis-related diseases. The most common types of arthritis include osteoarthritis (OA), rheumatoid arthritis (RA), psoriatic arthritis (PsA), and gout. More than 33% of adults who have arthritis say that the disease limits their leisure activities and work. Twenty-five percent of these people report that it causes severe pain, seven or higher on a scale of zero to 10 (Arthritis Foundation, n.d.).

Each of these types of arthritis can affect the body in different ways. The following descriptions provide a brief overview of the different types of arthritis.

Osteoarthritis

Osteoarthritis is a degenerative disease that affects not only the whole joint, but the protective cartilage and synovial fluid as well. As the disease progresses it makes movement of the joints both difficult and painful. If the progression continues, bone joints may actually rub directly against one another, which leads to severe, possibly debilitating, pain. The intensity of the pain caused by osteoarthritis can range from mild to moderate, to severe and debilitating (Arthritis Foundation, n.d.).

Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory, autoimmune disorder. As the immune system mistakenly “attacks” healthy cells, inflammation occurs. Rheumatoid arthritis usually affects multiple joints at the same time. In joints, the synovial lining becomes inflamed, and the tissue of the joints is damaged. This type of damage can lead to long-lasting or chronic pain, difficulty with mobility, and deformity. Rheumatoid arthritis can also affect other body tissues such as the lungs, heart, and eyes (CDC, 2020).

Chronic Pain Alert! Juvenile Idiopathic Arthritis (JIA)

The pathology of JIA is similar to that of rheumatoid arthritis. It typically affects one or more joints for at least six weeks in a child 16 years of age or younger. Unlike adult rheumatoid arthritis that is chronic, children often outgrow JIA. However, it can affect bone development in growing children (Johns Hopkins Medicine, 2023).

Psoriatic Arthritis

Psoriatic arthritis is an inflammatory autoimmune disease that especially affects the skin and the joints. The disease causes skin rashes and pain. Persons at higher risk for the disease are those who have psoriasis, another autoimmune disease that causes the production of red or silver scaly skin patches as the production of skin cells increases. The patches can be painful, itchy, dry, and cracked. The disease can affect any joint, but may also affect entheses (areas where ligaments or tendons attach to bone). Commonly affected areas are the heel, bottom of the foot, and the lower back (Arthritis Foundation, n.d.).

Gout

Gout is a type of inflammatory arthritis, but it does not cause inflammation throughout the body. Gout typically affects the large joint of the big toe, but other joints are sometimes affected. The pain can be quite extreme (Arthritis Foundation, n.d.).

Excessive levels of uric acid are the cause of gout. If the excess acid is not removed quickly enough, crystal formation in the joints occurs. Gout typically occurs abruptly and causes pain that patients call “excruciating” (Arthritis Foundation, n.d.).

Fibromyalgia

Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain. The pain occurs in conjunction with fatigue, sleep disturbances, memory problems, and mood swings. Symptoms often appear after physical trauma, surgery, infection, or significant mental health stress. For some patients, however, symptoms slowly accumulate over time without a single, identifying triggering event (Mayo Clinic, 2021).

People at higher risk for the development of fibromyalgia have the following risk factors (Mayo Clinic, 2021; National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2021).

  • Sex: Fibromyalgia is diagnosed more often in women compared to men.
  • Rheumatic diseases: Diseases such as arthritic conditions and other diseases of the joints, tendons, muscles, bones, and ligaments increase the risk for fibromyalgia.
  • Mood disorders: Mood disorders such as anxiety and depression increase the risk for fibromyalgia.
  • Irritable bowel syndrome: Having irritable syndrome increases the risk for fibromyalgia.
  • Genetics: Family history of fibromyalgia, especially history in parents or siblings, is also among risk factors for fibromyalgia.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, chronic disorder of the gastrointestinal (GI) tract. The syndrome is characterized by cramping, bloating, abdominal pain, flatulence, diarrhea and/or constipation. One of its most prominent features is chronic, visceral pain. Fortunately, IBS does alter bowel tissue or increase the risk of colorectal cancer (Mayo Clinic, 2023b).

The exact cause of IBS is unknown. It is hypothesized that dysmotility (impaired GI muscle contraction leading to problems transporting through the GI tract, visceral hypersensitivity (particularly extra-sensitive GI tract nerves, and brain-gut dysfunction (problems with communication between nerves of the brain and gut) can lead to the development of IBS. IBS is described as a functional GI disorder, which means there are problems with the way the GI tract and brain communicate with each other. This impaired communication increases the sensitivity of the GI tract and how its muscles contract. IBS can be triggered by certain foods, medication, and/or emotional stress. Triggers can be different for each patient (Cleveland Clinic, 2020b).

Cancer

Pain is one of the most feared complications of cancer. An estimated 30%-40% of patients with cancer will have to deal with pain early in their illness. This percentage increases to 70% to 90% in patients with advanced cancer. The majority of pain is due to the cancer itself, and about 25% is due to treatments related to the cancer such as surgery or chemotherapy (Leiter et al., 2021).

The multitude of cancers and their impact on patients can make pain management a challenge. Healthcare providers must be familiar with general prescribing guidelines for treating pain in patients with cancer. For example, The World Health Organization (WHO)’s stepladder is a simple guide for pain relief prescriptions. The first step or initial treatment consists of “Nonopioid +/- one Adjacent”. The next step describes recommendations for persistent pain or increasing pain. This step recommends “Opioid for mild to moderate pain, +/- Nonopioid, and +/- Adjacent.” The third step recommends “Opioid for Moderate to Severe Pain, +/- Nonopioid, and +/- Adjacent (Leiter et al., 2021).

Critical Thinking Scenario # 4

An interdisciplinary team of healthcare professionals is working with patients and their families to develop effective pain management plans. They work at a large pain management outpatient clinic in a major metropolitan area. Some of their patients include the following patients and families.

Stacey is a 10-year-old child who has just been diagnosed with juvenile Idiopathic Arthritis (JIA). Her parents are distraught. One of the parent’s grandmothers had rheumatoid arthritis and suffered from lifelong, disabling pain. They believe that their daughter is destined to suffer from a life of pain and suffering.

Steven is a 22-year-old college student who was recently diagnosed with IBS. He is majoring in chemical engineering, a demanding course of study. He has come to the clinic for help controlling the severity and resulting pain of the disease.

Tracey was hospitalized after developing sepsis following a urinary tract infection. She was hospitalized for two weeks and was discharged without complications. However, she is now experiencing fatigue, memory problems, and difficulty sleeping. Her primary healthcare provider attributes these issues to having had sepsis. Tracey has developed widespread musculoskeletal pain. Her healthcare provider, after reviewing Tracey’s health history, now makes a diagnosis of fibromyalgia.

These three situations indicate a significant need for patient/family education. What are some important factors for healthcare professionals to include in patient teaching?

Stacey’s parents are understandably concerned about their daughter. They have a basic misconception that Stacey’s diagnosis of JIA equates with life-long pain and eventual disability. Although its pathology is similar to that of rheumatoid arthritis, children generally outgrow the condition. Stacey’s parents will be relieved to hear that Stacey has a good chance of having her JIA resolved. However, she will need ongoing monitoring, especially in the area of bone development. She will also need a pain management plan as long as she is dealing with JIA pain. Providing her parents with objective information should help them deal more effectively with the diagnosis. Stacey also needs such information provided at a level that she can understand.

Steven’s diagnosis of IBS has, understandably, left him with many questions and concerns. One of his most basic concerns is pain management. He is also worried about the bouts of diarrhea he is experiencing. Although the exact cause of IBS is unknown, stress has been identified as one of its triggers. Steven’s demanding course of study is stressful. Steven would benefit from a pain management plan that also identifies his personal triggers and how to deal with them.

Tracey has certainly had a lot to deal with. Recovering from sepsis, even without complications, is not an easy task. Compounding her recovery is her diagnosis of fibromyalgia, which often appears after events such as trauma, surgery, or infection. Sepsis is likely a major contributing factor to the development of fibromyalgia. The pain management plan should include identifying risk factors and if Tracey’s health history includes issues such as mood disorders, IBS, and family history.

Pharmacological Approaches for Pain Management

There are many options for the treatment of chronic pain. Pharmacological agents are commonly used in pain management plans. When prescribing analgesia for chronic pain it is generally recommended that patients use the least addictive and smallest dose of medications that control a patient’s pain. Each patient’s experience of pain is personal, subjective, and unique. Likewise, medications that are part of the pain management plan must be prescribed based on the patient’s experience of pain and general state of health.

The CDC reports that nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if the expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks (CDC, 2022b).

Using CDC guidelines and the WHO’s Pain Ladder, it is possible to effectively incorporate pharmacological agents into patients’ pain management plans.

Acetaminophen

Acetaminophen is typically recommended as a first-line treatment for mild to moderate pain and is often used to help in the management of osteoarthritis and back pain. It may also be used in conjunction with opioids as adjuvant medication to help reduce the amount of opioids needed. Acetaminophen is not used to treat inflammation or swelling, however, and it is not used in the treatment of inflammatory conditions such as rheumatoid arthritis (Hendler, 2023; Mayo Clinic, 2023a).

Acetaminophen is usually considered to be a safer option than other pain medications. It does not cause side effects such as bleeding or GI pain. Taking more than the recommended dose or taking it with alcohol increases the risk of kidney and liver failure over time (Mayo Clinic, 2023a).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are effectively used to mitigate mild to moderate pain caused by swelling and inflammation. Commonly used for arthritic disorders, NSAIDs are also used to relieve pain due to muscle sprains and strains, back and neck injuries, and menstrual cramps (Mayo Clinic, 2023b).

NSAIDs (e.g., ibuprofen, Aleve) are generally safe when taken as directed. However, taking larger than recommended dosage can lead to nausea, GI pain, gastric bleeding, or ulcers. These problems can occur even if patients take only the recommended dosage. Large doses of NSAIDs can cause kidney problems, fluid retention, and hypertension. Risk for these complications increases as patients age or have other health conditions such as diabetes, a history of stomach ulcers or bleeding, reflux, and kidney disease (Hendler, 2023; Mayo Clinic, 2023a).

Chronic Pain Alert! NSAID Limitation

It is important to know that NSAIDs have what is referred to as a ceiling effect. This means that beyond a certain dose, no additional relief from pain is provided (Mayo Clinic, 2023a).

COX-2 Inhibitors

COX-2 inhibitors (e.g., Celebrex) are typically used for arthritis and pain caused by muscle sprains and strains, back and neck injuries, or menstrual cramps. COX-2 inhibitors are as effective as NSAIDs, but have less risk for side effects such as gastric bleeding or ulcers. However, bleeding can still occur, particularly at higher doses. Additional side effects include headaches, dizziness, hypertension, kidney issues, and hypertension. Older adults may be at greater risk for side effects. COX-2 inhibitors should be taken at the lowest effective dose for the shortest period of time that is possible (Hendler, 2023; Mayo Clinic, 2023a).

Antidepressants

A growing number of research studies are showing that suggest some neurologic pathways shared by mental health disorders such as depression and anxiety are also shared by the problem of chronic pain (Ciaramella, 2020).

Some antidepressants help to manage chronic pain caused by various conditions, especially nerve pain. Antidepressants may also have a collaborative effect in people who are dealing with depression as well as with chronic pain (Harvard Health Publishing, 2020).

Chronic Pain Alert! Suicidal Ideation

In children, teens and young adults under the age of 25, there is a risk of suicidal ideation when taking antidepressants, particularly when therapy has just started or dosage is changed. Patients must be carefully monitored for any evidence of suicidal ideation (Cleveland Clinic, 2023).

Tricyclic Antidepressants

Tricyclic antidepressants are some of the most effective antidepressants in use for pain. They are used even when depression is not a known factor. Examples of these types of antidepressants include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Pamelor). (Harvard Health Publishing, 2020; Mayo Clinic, 2019a):

Tricyclic antidepressants are prescribed for pain at lower doses than are prescribed for depression (Harvard Health Publishing, 2020). Side effects of these kinds of antidepressants include blurred vision, drowsiness, dry mouth, orthostatic hypotension, nausea, constipation, trouble thinking clearly, difficulty urinating, sexual dysfunction, and arrhythmias (Hendler, 2023; Mayo Clinic, 2019a).

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs such as duloxetine (Cymbalta) desvenlafaxine (Pristiq), milnacipran (Savella), and venlafaxine (Effexor XR). SNRIs have fewer side effects compared to tricyclic antidepressants. However, some research findings indicate that SNRIS may be less effective for chronic pain than tricyclics (Harvard Health Publishing, 2020).

The Food and Drug Administration (FDA) has approved specific SNRIs for specific types of pain including (Cleveland Clinic, 2023):

  • Milnacipran (Savella) is only FDA-approved to treat symptoms of fibromyalgia.
  • Duloxetine (Cymbalta) is FDA-approved to treat pain from diabetes-related neuropathy, fibromyalgia, and chronic musculoskeletal pain.

Each brand of SNRIs has its own side effects, so healthcare providers must be sure to teach patients and families about side effects specific to certain drugs. Generally, common side effects include nausea and vomiting, xerostomia (dry mouth), constipation, fatigue, drowsiness, dizziness, diaphoresis, and sexual dysfunction. (Cleveland Clinic, 2023).

Chronic Pain Alert! Serotonin Syndrome

Serotonin syndrome can be a complication of SNRI therapy. It occurs when there is an excess of serotonin in the body. Serotonin, a neurotransmitter, is produced by nerve cells n the brain as well as other areas of the body. Symptoms of serotonin syndrome can range form mild (e.g., diarrhea and nausea) to severe symptoms (e.g., dangerously elevated temperature or seizures). In severe cases, serotonin syndrome can be fatal unless it is recognized and treated promptly (Cleveland Clinic, 2023).

Anticonvulsants

Anticonvulsants are believed to interfere with overactive transmission of pain signals from nerves that are damaged (neuropathy) or, as in fibromyalgia, overly sensitized nerves (Mayo Clinic, 2019c).

Anticonvulsants used as therapy for chronic pain include (Mayo Clinic, 2019c):

  • Gabapetin (Gralise, Neurotin)
  • Carbamazepine (Carbatrol Tegretol)
  • Pregabalin (Lyrica)
  • Phenytoin (Dilantin)
  • Lamotrigine (Lamictal)

Side effects include hepatic damage, nausea, vomiting, diplopia (double vision), drowsiness, headache, and loss of coordination (Hendler, 2023).

Recent research, however, links gabapentinoids to some serious consequences. In 2018, the FDA increased warnings for both gabapentin and pregabalin in order to emphasize the central nervous system (CNS) side effects and the risk of respiratory depression. Respiratory depression is more likely when bagapentinoids are used in conjunction with other CNS-acting drugs (William et al., 2023).

Gabapentin and pregabalin are FDA-approved for a variety of conditions including seizures, nerve pain, and restless leg syndrome. Pregabalin is a Schedule V controlled substance, meaning it has a lower potential for abuse among the drugs scheduled by the Drug Enforcement Administration but may lead to some physical or psychological dependence. Gabapentinoids are frequently used in conjunction with CNS depressants, which increases the chances of respiratory depression. There is less evidence supporting the risk of serious respiratory compromise in healthy people taking gabapentinoids alone (FDA, 2022).

In 2022, the FDA published a number of concerns/warnings about the use of gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR. These include (FDA, 2022):

  • The FDA is requiring new warnings about the risk of respiratory depression be added to gabapentinoids prescribing information.
  • Drug manufacturers must conduct clinical trials to further assess abuse potential, especially if prescribed in conjunction with opioids. (Misuse and abuse of gabapentinoids is increasing as is the risk of respiratory depression).
  • Gabapentinoids should be prescribed at the lowest dose at the start of therapy. Patients must be monitored for signs of respiratory depression and sedation when prescribing an opioid or other CNS depressants, as this increases the risk of respiratory depression

Opioids

Opioids are the cause of the most prescription medication-related overdose deaths in the U.S. The risk of use and misuse is so significant opioids should be prescribed at the lowest possible dose for as short a period of time as possible. Opioids may be the most appropriate medication for long-term pain related to cancer and its treatments. These kinds of drugs may be used for noncancer pain if there has been no effective response to other medications (Mayo Clinic, 2023a).

Opioids mimic the brain’s naturally produced chemicals that relieve pain. Opioids reduce the intensity of pain signals that are sent throughout the body by the nervous system. They also affect other nerve cell functions resulting in slowed respiratory rate, confusion, sedation, pruritus, constipation, nausea, and vomiting. If the respiratory rate is slowed for long periods of time, hypoxia may occur, resulting in diminished oxygen flow to the brain (Hendler, 2023).

Chronic Pain Alert! Opioid Dependence

The longer opioids are used, the greater the possibility of addiction. Research findings indicate that taking opioids even for more than a few days increases this possibility. Findings also indicate that the chances of being on opioids a year after starting a short course of opioid therapy increases after only five days on the medication. Patients on opioid therapy must be carefully monitored (Mayo Clinic, 2023a).

Examples of opioids used in pain management include oxycodone (Roxicodone), fentanyl (Fentora, Actiq), codeine, and oxycodone (Roxicodone). Research findings show that the body adapts to opioids over time, and this adaptation means that the drugs bring progressively less relief of pain. In consideration of the side effects and addictive properties of opioids, opioids are considered to be a last resort for chronic noncancer pain (Mayo Clinic, 2023a).

The CDC published CDC Clinical Practice Guideline for Prescribing Opioids for Pain: United States, 2022. This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients 18 years of age and older. It also updates the CDC guidelines for prescribing opioids for chronic pain (CDC, 2022b)

The 2022 guideline consists of 12 recommendations and criteria for opioid use disorder (CDC, 2022b).

Recommendation 1

Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

Recommendation 2

Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.

Recommendation 3

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.

Recommendation 4

When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.

Recommendation 5

For patients already receiving opioid therapy, clinicians should carefully weigh the benefits and risks and exercise care when changing opioid dosage. If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If the benefits do not outweigh the risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.

Recommendation 6

When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

Recommendation 7

Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or dosage escalation. Clinicians should regularly reevaluate the benefits and risks of continued opioid therapy with patients.

Recommendation 8

Before starting and periodically during the continuation of opioid therapy, clinicians should evaluate the risk for opioid-related harms and discuss the risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.

Recommendation 9

When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.

Recommendation 10

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.

Recommendation 11

Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether the benefits outweigh the risks of concurrent prescribing of opioids and other central nervous system depressants.

Recommendation 12

Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks of resuming drug use, overdose, and overdose death.

The CDC included information about the criteria for opioid use disorder. Opioid use disorder is manifested by at least two of 11 defined criteria occurring within a year (CDC, 2022b).

  1. Opioids are often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful attempts to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving, or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following:

    1. a need for markedly increased amounts of opioids to achieve intoxication or desired effect, or
    2. a markedly diminished effect with continued use of the same amount of an opioid.
  11. Withdrawal, as manifested by either of the following:

    1. the characteristic opioid withdrawal syndrome, or
    2. opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

Criteria 10 and 11 are not considered to be met for those persons taking opioids solely under appropriate medical supervision. Severity is specified as mild (2–3 criteria), moderate (4–5 criteria), or severe (?6 criteria).

Chronic Pain Alert! Pain Management for Patients with Opioid Use Disorder

Although identification of an opioid use disorder can alter the expected benefits and risks of opioid therapy for pain, patients with co-occurring pain and substance use disorder require ongoing pain management that maximizes benefits relative to risks. Clinicians should use nonpharmacologic and nonopioid pharmacologic pain treatments as appropriate (CDC, 2022b).

Non-Pharmacologic Interventional Treatment Options (Injections)

Chronic pain treatment options include injections (interventional therapy). These types of injections typically deposit local anesthetics or cortisone into the areas around nerves or joints (Suvar, 2021).

Lumbar Epidural Steroid Injection (ESIs)

A lumbar epidural steroid injection (ESI0 involves injecting a steroid or corticosteroid into the epidural space around the spine’s nerves in the lower back (Cleveland Clinic, 2021). Performed under X-ray for accuracy, ESIs are typically performed to relieve pain affecting the back, leg, neck, or arm/hand. The leg will usually become warm immediately following the injection. Side effects include back soreness and some temporary numbness (Suvar, 2021).

Chronic Pain Alert! Dangerous Side Effects

Patients should be cautioned that if they feel sharp pains radiating down the leg or to the groin during the injection, they should immediately inform the person performing the procedures. Although there may be some temporary numbness after the injection, if numbness or weakness persists for more than eight hours healthcare providers should be contacted immediately (Suvar, 2021).

Celiac Plexus Block

Celiac plexus block is performed for the relief of pain in patients with chronic abdominal pain or malignancies in areas of the abdomen. A needle is placed in the area of the back to target abdominal sympathetic nerves. The procedure is performed under fluoroscopy. A small amount of dye is administered through the needle, and numbing medicine is transported to the celiac plexus nerves (Suvar, 2021).

For patients in chronic pain, this procedure is performed in a series of three injections. For patients with cancer, a single diagnostic injection is performed to determine whether a more permanent injection may help to ease pain (Suvar, 2021).

Lumbar Facet Joint Injection

Lumbar facet joints (zygapophysial joints or Z-joints) are responsible for spinal movement and alignment. Injections are administered to provide relief of neck or back pain. These injections are part of spinal medicine and usually used to help patients who are dealing with arthritic pain in their facet joints (Felton, 2022; Suvar, 2021).

A needle is inserted into the neck or back and advanced to the level of the affected joint under X-ray visualization and a local anesthetic is injected. Depending on the number of affected joints, more than one injection may be needed. A lumbar facet joint injection is often performed to learn about the cause of the patient’s pain. A longer-lasting injection may be necessary if significant pain relief is achieved from the original injection (Felton, 2022; Suvar, 2021).

Side effects of lumbar facet injection include (Suvar, 2021):

  • Nerve injury.
  • Infection.
  • Allergic reactions.
  • Bleeding.
  • Elevated blood glucose levels.
  • Temporary vaginal spotting.
  • Temporary flushing of the face.
  • Stomach ulcers.
  • Severe arthritis of the hip.
  • Cataracts.
  • Increased appetite.
  • Decrease in bone density.

Lumbar Sympathetic Block

A lumbar sympathetic block is typically performed to relieve leg pain thought to be caused by complex regional pain syndrome (CRPS) type I. CRPS type I (formerly known as reflex sympathetic dystrophy (RSD)) is a syndrome characterized by pain, swelling, and vasomotor dysfunction of an extremity. Its course is variable and its etiology is unknown, although it often occurs after trauma or surgery. Limb mobility may also lead to this syndrome (Nandan, 2023; Suvar, 2021)

A lumbar sympathetic block is typically performed under fluoroscopy or with ultrasound guidance. A needle is placed using X-ray guidance or with ultrasound direction just anterior to the vertebral body to the side of the affected area. After the needle(s) are accurately placed, a small amount of dye is injected to confirm placement. After confirmation, a numbing medication is injected (Suvar, 2021).

The leg is probably going to feel warm immediately after the injection. Back soreness is also a common side effect. However, if the patient feels sharp radiating pains down the leg or to the groin during injection, the patient must immediately inform the healthcare provider performing the procedure. There may be temporary numbness after the injection, but the healthcare provider should be contacted if there is persistent numbness or weakness or numbness or weakness that lasts more than eight hours (Suvar, 2021).

Trigger Point Injections

Trigger point injections are used to relieve muscle pain in the arms, legs, lower back, and neck. This procedure has also been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome that does not respond to other types of treatment. Trigger point injections target painful areas of muscle that contain trigger points (knots of muscle that form in response to muscles that do not relax because of pain (Sachdev, 2022).

During the procedure, a small needle is used to inject a local anesthetic that may include a steroid into a trigger point. Sterile salt water is sometimes injected. The injection deactivates the trigger point and pain is relieved. A brief course of treatment typically leads to sustained relief (Sachdev, 2022).

Chronic Pain Alert! Botox Injections for Migraines

Onabotulinumtoxina (Botox) can be injected to relieve chronic migraine headaches. Botox is a toxin that suppresses signals from nerves to muscles. This procedure requires multiple injections administered around the head and neck ever 12 weeks and may relieve pain for up to three months (Sachdev, 2022).

Stellate Ganglion Block

Stellate ganglion block is initiated to treat and manage CRPS of the hand, arm, or shoulder. This procedure is also used to facilitate blood flow in the hand or arm due to conditions that cause poor circulation of the hand (Suvar, 2021).

The injection is performed using fluoroscopic guidance or ultrasound imaging. An anesthetic medication is injected into a collection of nerves (the stellate ganglion). These nerves are found in the neck and both sides of the larynx. Side effects include soreness at the needle placement site, drooping eyelid on the side of the body that is injected, a stuffy nose, temporary hoarseness, or dysphagia (Suvar, 2021).

Implants

Implantable devices are typically used to help patients who are experiencing severe, sometimes intractable, pain that has not responded to more conventional treatments (Columbia University, 2923).

Spinal Cord Stimulation

A specialist inserts a small, programmable device into the spinal canal. This device produces mild electrical pulses to the spinal cord, which changes the pain signals that are sent to the brain (Columbia University, 2023).

Intrathecal Drug Delivery

Intrathecal drug delivery is used for the treatment of pain due to issues such as chronic back and neck pain, sciatica, chronic abdominal pain, failed back and neck surgery, cancer, or CRPS. Intrathecal drug delivery may be recommended to patients if other treatments have not been effective (University of California San Francisco, n.d.).

The procedure involves surgically placing a small pump under the abdominal skin. The pump delivers pain medication via a catheter to the area surrounding the spinal cord. Prior to implanting a permanent pain pump, a temporary trial procedure may be performed to determine if patients are good candidates for a permanent implant (University of California San Francisco, n.d.).

The pump is programmed to release medication gradually over a period of time. It can also be programmed to release different doses depending on the needs of the patients. The pump maintains the information about the prescription in its memory. This information is reviewed by the healthcare provider to monitor effectiveness. When the pump’s reservoir is empty, the healthcare provider refills the pump by inserting a needle through the skin and into the port on top of the reservoir. The most common side effect is pain at the insertion site (University of California San Francisco, n.d.).

Dorsal Root Ganglion Stimulation

Dorsal root ganglion (DRG) stimulation involves implanting a device into the dorsal root ganglion of the spinal cord. The DRG system consists of the following components (Penn State Health, n.d.).

  • Generator: This is a small battery-controlled device that sends out mild electrical pulses.
  • Leads: Leads are insulated wires that transport the electrical impulses from the generator to the dorsal root ganglia.
  • Patient controller: This is a handheld, remote control device that the patient uses to adjust the strength and location of stimulation. The patient may also turn the stimulation off.

Thermal Energy and Stimulation Interventions

Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) relies on the delivery of mild electrical impulses for pain relief. It is used to ease pain caused by arthritis, surgery, bursitis, tendonitis, migraines, wounds, injuries, and nerve pain. TENS sessions typically last from five to 15 minutes. Sessions can be performed as often as needed. Certain TENS units may be used at home (University of Rochester Medical Center, n.d.).

The TENS system consists of a power unit, a pair of wires, and electrode pads that are placed on the skin near the location of the pain. A healthcare professional turns on the unit, and low-voltage electrical current is transported through the body. Various stimulation frequencies and intensities are available. TENS is often implemented as part of a physical therapy regimen (University of Rochester Medical Center, n.d.).

Radiofrequency Ablation

Radiofrequency ablation is mainly used to treat arthritis or spinal joint pain. During the procedure, a pain specialist healthcare provider places specialized needles over the affected nerves. After placement, thermal energy or heat signals are sent through the needles, which temporarily disconnects the nerves. Radiofrequency ablation blocks the number of pain signals radiating from the joints. It is typically an excellent method of back pain relief (Kenevan, 2023).

Pain relief ranges from occurring immediately after the procedure to about four to six weeks later. The length of time that pain is relieved varies, but it is hoped that relief will last from nine to 12 months. Some patients have even experienced pain relief lasting for multiple years. Pain can return after regeneration of the affected nerves (Kenevan, 2023).

Therapeutic Options for Chronic Pain Treatment

Physical Therapy

Physical therapy does more than help patients cope and experience relief from chronic pain. Physical therapists can help to identify why patients are feeling particular pain sensations, and work with them to strengthen associated muscle groups to improve endurance and range of motion (Integrated Rehabilitation Services, 2021).

Physical therapists and patients work in conjunction to develop a pain management plan that takes into consideration patients’ levels of pain, age, diagnosis, and other medical conditions (Summit, 2022). Some of the important facets of physical therapy interventions for chronic pain are as follows.

Physical therapy can take the form of active or passive therapy. Active therapy includes interventions such as low-impact aerobic exercises, strengthening exercises, exercises that focus on the area or areas of the body that cause pain, and stretching as a means of warming up before exercise, and winding down or recovering from the exercise itself (Integrated Rehabilitation Services, 2021).

Passive therapy includes interventions such as dry needling. During dry needling, thin needles are inserted into or near the pain trigger points. The needles stimulate muscles causing contraction or twitching, which helps to relieve pain (Cleveland Clinic, 2023). Additional passive therapy interventions include heat and ice application, massage, pain neuroscience education (PNE), and how to move without pain (Integrated Rehabilitation Services, 2021).

Exercise

Exercise can help strengthen muscles and joints, improve mobility, and help to interfere with pain-causing brain signals. Examples of exercises that can be used to manage chronic pain include (Integrated Rehabilitation Services, 2021; Summit Health, 2022):

  • Low-impact aerobic exercises (e.g., walking): It is important that these types of exercises do not place additional stress on affected areas.
  • Strengthening exercises: These may be performed with resistance bands or weights. The patient’s own weight can also be used as part of resistance training. Strengthening exercises typically focus on the affected areas of the body and the muscles surrounding them.
  • Stretching: Stretching techniques may be used as both a warm-up activity and as a way to lengthen tight muscles.
  • Manual therapies to ease pain, relax muscles, and enhance range of motion such as massage, myofascial release, joint and soft tissue mobilization, manual traction, and taping.

Passive Therapy

Passive therapy may be used to improve the range of motion as well as pain relief. Examples of passive therapy include (Integrated Rehabilitation Services, 2021):

  • Dry needling: Dry needling is the insertion of thin needles into or near trigger points. This technique is used to stimulate muscles, causing them to contract, which helps to relieve pain and improve range of motion.
  • Application of heat and ice: Applying heat and ice is used to decrease inflammation and pain.
  • Pain Neuroscience Education (PNE): PNE is a patient education strategy that helps patients to understand why the pain is occurring the way it is and to rethink the way they view pain.
  • Movement strategies: The patients are taught how to move without pain and includes strategies for walking, sitting, standing, and lifting. They are also taught how to implement good body mechanics and improve posture.

Occupational Therapy

Occupational therapists work with patients to help them learn how to do activities of daily living differently so that pain is decreased and injury is avoided (Cleveland Clinic, n.d.).

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a type of psychological treatment that focuses on identifying, dealing with, and changing unhelpful thinking so that well-being, behaviors, and mindset improve over time (Bettino, 2021). Research indicates that CBT can help to dial down pain signals and improve quality of life (Bee, 2019).

The overall goal of CBT is to help patients adapt and alter their mindset and behaviors by reevaluating distorted thought patterns and replacing them with helpful thoughts and behaviors. Desired patient behaviors include (American Psychological Association, 2023):

  • Learn to identify their distortions in thinking that are causing problems.
  • Reevaluate thinking distortions in a reality-based framework.
  • Gain an improved comprehension of behaviors and motivations of other people.
  • Use effective problem-solving skills to cope with difficult situations.
  • Acquire a greater sense of confidence and self-esteem in their abilities.
  • Acknowledge their fears instead of avoiding them.
  • Use roleplaying to prepare for potentially problematic situations and interactions with other people.
  • Learn to calm their minds and relax their bodies.

Chronic Pain Alert! CBT Emphasis

CBT places great importance on helping patients to learn to “be their own therapists.” Patients should develop coping skills and learn to change their own thinking patterns, and emotions that are problematic, and harmful behaviors. Therapists focus on what is currently happening in patients’ lives instead of emphasizing what led to their problems (American Psychological Association, 2023).

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is described as “an action-oriented approach to psychotherapy that originates from traditional behavior therapy and cognitive behavioral therapy” (Psychology Today, n.d.).

Working in conjunction with a therapist, patients learn to “listen” to their own self-talk (the way they talk to themselves) about traumatic events, problematic relationships, physical limitations, or other difficult circumstances. After facing and accepting their current challenges, patients can make a commitment to not fight the past and associated emotions, and develop confident and optimistic behaviors that are rooted in their personal values and life goals (Psychology Today, n.d.).

Psychology Today staff (n.d.) have identified six essential patient processes to support psychological flexibility. These processes are:

  1. Acceptance: Accept thoughts and emotions rather than avoiding or denying them.
  2. Cognitive defusion: Distance themselves from the way they react to distressing thoughts, feelings, and situations in order to lessen their harmful effects.
  3. Being present: Maintain being mindful in the present moment. Assess thoughts and feelings without judgment and work to change behavior.
  4. Self as context: Become aware that they are more than their thoughts, feelings, and experiences. Expand the notion of self.
  5. Values: Choose personal values and work to live according to these values instead of acting to avoid distress or adhere to the expectations of others.
  6. Committed action: Be committed to taking specific steps to incorporate behaviors and thoughts that are in line with values and working to incorporate positive change.

Patient/Family Education

Most healthcare professionals are aware of chronic pain education topics such as mobility techniques, safe medication practices, and safe exercise. What many healthcare professionals are not aware of, however, are best practices for teaching adults. The best practices of adult education are grounded in andragogy, a set of principles, strategies, and best practices for teaching adult learners (University of San Diego, n.d.).

The theory of andragogy was initially developed by Malcolm Knowles, who believed that adult education is both a science and an art. He identified the following key principles, that have been studied, researched, and adapted by adult education specialists over the years (Knowles, 1980; University of San Diego, n.d.).

Knowles made the following assumptions/principles about adult learners (Knowles, 1980; University of San Diego, n.d.).

  • Adults learn best when their self-concepts are respected and when achieving independence in their activities of daily living.
  • Adults learn best when they learn from first-hand experiences and interactions. For example, demonstration and return demonstration of safe mobility techniques.
  • Adults learn best when there are clearly understood objectives to be achieved. For example, patients demonstrate that they know medication side effects, what to do if they occur, and how it should be taken. The objective was to take medication safely and accurately.
  • Adults learn best when the learned information can be immediately applied and are of value. For example, a patient wants to return to work. Learning how to effectively adhere to the pain management plan. This type of learning can provide pain relief and the prompt (or as soon as possible) ability to return to work.
  • Adults are motivated by internal issues rather than external issues. For example, patients would not necessarily be motivated to learn about pain relief techniques that are not applicable to their individual situations. However, learning strategies that help them to live a life of the best possible wellness are significant motivators.

Also essential to adult education is to respect learners’ viewpoints, values, and personal goals. Healthcare professionals must treat adults with respect at all times and in language appropriate to their understanding. Adults also have a wealth of life experiences, which should be considered when formulating a pain management plan (Knowles, 1980; University of San Diego, n.d.).

Chronic Pain Alert! Assessing Knowledge Acquisition

Learning must be objectively evaluated. If patients are being taught about the side effects of their medications, they should be asked to verbally respond to the healthcare professional’s request to explain the side effects and what to do about them. Yes/no questions should be avoided. It is easy to respond “yes” rather than admit they don’t know the answer. Objective measurement is essential (Knowles, 1980; University of San Diego, n.d.).

Lifestyle Changes

The Cleveland Clinic (n.d.) has identified four major lifestyle factors that can influence chronic pain and help to minimize it.

  • Stress: Stress has been identified as playing a significant role in many adverse health conditions. Chronic pain is one of those conditions. Patients need to incorporate stress reduction strategies into their daily lifestyles. CBT can help to manage stress, as can meditation, mindfulness, and deep breathing.
  • Exercise: Low-intensity exercises (e.g., walking) for about 30 minutes five times a week is recommended as tolerated. All exercise regimens should be discussed with the pain management team prior to their implementation.
  • Diet: A healthy diet enhances overall health. Sometimes an anti-inflammatory diet is recommended. Foods that cause inflammation (e.g., red meat and refined carbohydrates are eliminated.
  • Sleep: Adequate amounts of sleep is important for overall health. Insufficient sleep can lead to weight gain, which exacerbates chronic pain. The quality of sleep is also important for the management of stress. (Adults who sleep less than seven hours per night may have more adverse health issues compared to people who sleep seven or more hours a night. Sleep needs of children depend on the age of each child (National Heart, Lung, and Blood Institute, 2022).

Employer Behaviors

An estimated 40% of American workers are dealing with chronic pain. This makes chronic pain a management issue. In September 2020, Gulseren and colleagues surveyed 500 American business leaders on the topic of chronic pain. Findings showed that even though 80% of leaders recognized that chronic pain is a problem for employees, they did not know how to deal with employees who were dealing with chronic pain. Seventy-seven percent wanted to know how leaders could help employees with chronic pain (Gulseren et al., 2021).

The investigators recommend the following actions to establish an evidence-based model for the prevention of workplace factors that contribute to chronic pain and interventions and accommodations for employees affected by chronic pain (Gulseren et al., 2021).

  • Support employees with chronic pain by engaging in effective communication with them. Although employers may feel ill-prepared to talk about chronic pain and its impact, supportive conversations are a good starting point for finding effective solutions. It is important that employees know that their leadership values their health and safety.
  • Focus on preventing chronic pain that is associated with work-related activities. Education regarding proper body mechanics is important. The workplace environments should be evaluated for conditions that can contribute to chronic pain. Potential hazards should be eliminated and, if available, an occupational health and safety expert should assess the workplace to identify conditions that contribute to the development of chronic pain.
  • Design jobs to give employees autonomy and skill variety. Research indicates that by providing autonomy and encouraging employees to utilize their range of skills. For example, if employees could do certain tasks when their pain is less intense and other tasks when the pain is severe, they could use their autonomy to determine how they could fulfill their job responsibilities effectively.
  • Allow work flexibility. If jobs allow employees to work from home or to work flexible hours, their physical needs (e.g., pain management strategies) could be accommodated.
  • Increase access to chronic pain management resources in the workplace. Possible resources include providing written materials, including employees in making decisions about purchasing ergonomic furniture or establishing a pain support group.

Critical Thinking Scenario # 5

David is a 55-year-old college professor who is dealing with increasingly painful osteoarthritis. He is taking a low-dose aspirin every other day as part of his treatment regimen post-myocardial infarction. David has been taking acetaminophen (Tylenol) to help alleviate his chronic pain. Unfortunately, despite increasing the dose and frequency of the medication, his pain continues to worsen. He is reluctant to visit his doctor because, as he says, “I’m sick of doctors and sick of taking medicine.” One of his work colleagues suggests, “Start taking Aleve. It really helps me. You could combine it with the Tylenol.” David decides to follow this suggestion. Is this a good idea? Why or why not?

This is not a good idea for a number of reasons. First, adding or eliminating medications to his pain management regimen is a mistake unless the issue has been discussed with his healthcare provider(s) and approved any changes. Combining medications, even over-the-counter medications, can have serious adverse effects. Additionally, David is taking aspirin therapy after suffering a myocardial infarction. Aspirin can contribute to the development of gastric bleeding. So can another NSAID, the suggested Aleve. The cumulative effects of these medications have the potential to cause ulcers, gastric bleeding, and kidney issues.

Shirley is dealing with chronic back and neck pain after a serious injury 3 years ago. She and her family recently moved to a new city that has a large pain management clinic. She becomes a patient at that facility. She and her pain management team decided that Shirley would benefit from TENS therapy. Shirley especially likes the fact that not only does this type of therapy seem to be helping, but it can be performed at home. Shirley works as an executive assistant for the CEO of a large manufacturing plant and is eager to find a way to manage her pain at home and at work. Is TENS an effective option for Shirley?

TENS is a good treatment option for Shirley. She can perform sessions as often as needed. Another advantage is that each session lasts for only five to 15 minutes. She needs the support of her boss if she is to use the TENS unit at work since it necessitates that she take breaks as needed to use the unit. They must develop a work strategy that works for both employees and employers.

It is a busy day at the pain management clinic. Several employees have called in sick, and all members of staff are under pressure. Sylvia, a patient in her mid-70s, has come to the clinic to receive instructions about her new medication regimen. The nurse practitioner (NP) who is responsible for educating Sylvia about the new regimen is rather distracted. There are several new patients waiting to be evaluated and she is concerned that there will not be enough time for proper evaluation. Sylvia tells the NP that her daughter is a nurse. The NP is immediately relieved, believing that the daughter can help to educate Sylvia. The NP quickly goes over how and when to take the medication and some possible side effects. She asks Sylvia,”Do you understand this information about your new medication?” Sylvia senses that the NP is very busy and replies “yes” even though she does not understand most of the information given to her. What, if anything, is problematic about this situation?

It is evident that Sylvia has not received adequate instruction, nor has her knowledge been objectively evaluated. Asking a question that can be answered with a yes or a no makes it very easy for Sylvia to just say yes since she sees that the NP is very busy.

The assumption that Sylvia’s daughter will assume responsibility for educating her mother may or not be true. The NP does not ask if Sylvia has any family members who can help with the new medication regimen. The NP’s actions do not fulfill her responsibility to her patient.

Complementary Treatment Options

There are a variety of complementary treatment options that could be used as part of a pain management plan. Before adding any such options to the plan, patients must consult with their healthcare pain management team.

Acupuncture

Acupuncture, a component of ancient Traditional Chinese medicine, is the act of penetrating the skin with very thin, solid, metallic needles that are activated through gentle and specific movements of the provider’s hands or with electrical stimulation. The needles are inserted to rebalance the body’s energy or qi, which helps the body to release natural chemicals to combat illness or symptoms (e.g., pain). Some people who use acupuncture say that the procedure makes them feel stimulated, while others report that they feel relaxed (Johns Hopkins Medicine, n.d.a.).

The use of acupuncture as a complementary therapy for pain is increasing. It is typically well-tolerated and poses minimal risk. Research indicates that acupuncture may provide modest amounts of pain relief for persons with chronic pain (Kelly & Willis, 2019). Some studies report that acupuncture has the potential to relieve chronic pain by about 50% (Menezes, 2020). For patients who do not respond to, or are unable to tolerate, traditional therapies acupuncture is believed to be a reasonable treatment option (Kelly & Willis, 2019).

Chronic Pain Alert! Qualified Acupuncture Practitioners!

The FDA regulates acupuncture needles as it does other medical devices. When considering acupuncture, patients should first discuss this option with their healthcare providers, who may be able to recommend qualified acupuncture practitioners. In addition to validating a practitioner’s qualifications, potential patients should ask how the needles are sterilized if disposable needles are used, and what is the practitioner’s training, licensure, or registration. If possible, references should be obtained from people who are using, or who have used, the services of the practitioner they are considering using (Johns Hopkins Health, n.d.a.).

Aromatherapy

Aromatherapy is defined as the therapeutic use of essential oils (essences extracted naturally from plants). Research indicates that aromatherapy may affect patients not only through the mind and emotions but by having a relaxant effect on the nervous system. Most essential oils are safe and do not cause adverse effects when inhaled or diluted and used topically. There are, however, some risks for persons with hypertension, seizures, or who are taking multiple medications (Morriss, 2019).

Essential oils that have been used for their analgesic impact include (Morriss, 2019):

  • Lavender: Used as an analgesic and antispasmodic. It is also used for its calming and sedating effects.
  • Peppermint: Traditionally used as an analgesic and antispasmodic. Peppermint has been studied in clinical trials for its analgesic impact on headaches and reduction of colon spasms.
  • Ginger: Traditionally used as an analgesic and anti-inflammatory, ginger has been studied in small clinical trials for its ability to reduce knee pain and the pain of arthritis.
  • Lemongrass: When used as an analgesic, it is believed to help to reduce muscle pain.
  • Black pepper: Traditionally used as an antispasmodic and relaxant, results from clinical trials show that it has the ability to decrease arthritis pain.
  • Geranium: Geranium has been used for its antispasmodic effects and for stress-related disorders. Results from clinical trials show that it produces a significant reduction in neuropathic pain.

Biofeedback

Biofeedback is a mind-body therapy that is used to control body functions such as heart rate, breathing patterns, and muscle responses. Pain typically increases pulse and respirations, and muscles tighten. During biofeedback, a practitioner will place painless sensors on the skin. These sensors measure, in addition to pulse, respirations, muscle activity, sweating, and skin temperature. Results are shown on a screen and, with the guidance of the practitioner, patients learn to make body adjustments (e.g., slow breathing, relaxing muscles, changing posture) to relieve pain (Cleveland Clinic, n.d.).

Hypnotherapy

Hypnotherapy is achieving a heightened state of concentration and focus. With the guidance of a trained, certified hypnotherapy practitioner, patients learn to be more willing to accept suggestions to make positive changes in perceptions, emotions, thoughts, or behaviors (Cleveland Clinic, n.d.).

Music Therapy

Music affects the brain in many ways. Music therapists are nationally credentialed as board-certified (MT-BC) and provide multifaceted, individualized music experiences. Research indicates that music therapy can be a helpful strategy to improve symptoms of depression, decrease anxiety, increase activity in the reward and pleasure areas of the brain, reduce pain and disability, and improve motivation, empowerment, and social engagement (Crosse, 2021).

Mindfulness Training

Mindfulness has been described as “awareness that arises through paying attention, on purpose, in the present moment nonjudgmentally” (Mayo Clinic, 2020). Research shows that mindfulness can help people manage symptoms related to stress, anxiety, depression, and other mental health issues. Mindfulness is also used as a way to manage chronic pain (Mayo Clinic, 2020).

Research findings indicate that for some people, mindfulness participants, this strategy leads to less activation of pain sensors. Some people are even able to reduce the amount of pain medication needed. Mindfulness exercises facilitate the ability to focus both mind and body in the moment without judgment. The ability to focus on relaxing the body and becoming aware of breath and body sensations in the present moment can help mitigate negative, worrisome thoughts and reduce problematic symptoms (Mayo Clinic, 2020).

Reiki (Healing Touch)

Reiki is the Japanese name for Universal Life Force Energy. Reiki (also referred to as healing touch) is a gentle form of touch therapy during which the therapists (or patients) place their hands on various areas of the body to promote relaxation and feelings of calm. Reiki therapy treatments are administered by trained reiki Master Therapists. Master Therapists may also teach patients to perform treatments on themselves. Reiki therapy has been found to promote relaxation, reduce stress and anxiety, increase energy levels, reduce fatigue, and facilitate the development of a sense of positive well-being (Cleveland Clinic, n.d.).

Relaxation Techniques

There are many types of relaxation techniques in use. The following examples, while not all-inclusive, describe different ways of incorporating relaxation techniques into a pain management plan.

Meditation

Meditation as a form of treatment has been in use for thousands of years. There are different types of meditation used throughout the world. Meditation itself involves focusing or “clearing” the mind by using a combination of physical and mental techniques (Cleveland Clinic, n.d.).

Examples of meditation techniques include (Cleveland Clinic, n.d.):

  • Body-centered meditation: This form of meditation involves focusing on the various physical sensations felt throughout the body.
  • Contemplation: During contemplation, the person concentrates on a specific question or contradiction without letting the mind wander to other issues.
  • Emotion-centered: Emotion-centered meditation requires that focus is on a specific emotion.
  • Mantra: Mantra meditation is the process of repeating (either verbally or silently) and focusing on a sound or specific sound.
  • Meditation with movement: People meditating with movement focus on breathing, holding their breath, or engaging in specific movements of the body.

Yoga

Yoga is a mind-body exercise that helps people to relax, focus, breathe, and strengthen both body and mind. Research results show that yoga can be beneficial for those who are dealing with joint-related pain (Beaumont Health, n.d.):

  • Reducing stress
  • Improving mood and psychological well-being
  • Improving strength, stability, flexibility, and balance.
  • Improving posture.
  • Increasing energy.
  • Promoting relaxation.
  • Increasing metabolism.
  • Helping to manage weight.
  • Preventing of breakdown of cartilage and joints.

Beaumont Health (n.d.) identifies certain poses that have been shown to reduce joint pain.

  • Chronic back pain: Cat pose, dolphin, plank pose, and downward-facing dog.
  • Shoulder pain: Bow pose, eagle, cat, dolphin, half-moon, and plow.
  • Knee pain: Big toe, bound angle, bridge, and extended triangle.
  • Hip pain: Bajaradvaja’s twist, boat, big toe, child, cat, and easy.

Massage

Massage therapy is used as a pain management technique for both acute and chronic pain. Qualified massage therapists do intake interviews and assessments in order to develop an individualized massage treatment plan based on patient needs (Beaumont Health, n.d.).

Chronic pain typically requires an extended massage treatment plan that might consist of weekly sessions for months or years depending on patient needs. Massage techniques used in the treatment of chronic pain include (Beaumont Health, n.d.):

  • Mindful adjustments: Mindful adjustments focus is on a patient’s conscious effort to make musculoskeletal corrections to avoid repeat injury.
  • Trigger point therapy: Trigger point therapy is particularly helpful for chronic conditions such as joint pain. It focuses on “breaking up” muscle knots and adhesions.
  • Cross-fiber therapy: Cross-fiber therapy uses transverse friction to reduce excess tension and pain that accumulate in muscles over time.

Chronic Pain Alert! Lifestyle Changes and Massage

Patients’ lifestyles are a critical component of the success of massage therapy. A healthy lifestyle (e.g., exercise, proper nutrition, no smoking) can be “the single biggest influence on a massage treatment plan’s duration and effectiveness” (Beaumont Health, n.d.).

Guided Imagery

Guided imagery is a relaxation technique during which patients focus on a positive mental image or scene. Therapists use guided imagery but patients can also teach it to themselves. Guided imagery is also called visualization or guided imagery. It has been shown to stimulate the body’s natural ability to relax. Guided imagery may slow breathing, reduce blood pressure, and reduce heart rate, as well as serve as a distraction for someone who is in pain (West, 2022).

Herbal and Spice Supplements

A variety of herbal supplements are used to relieve inflammation and pain. Before adding herbal supplements to any pain management regimen, patients must consult with their healthcare providers.

The following descriptions are of some of the herbs and spices used to manage pain.

White Willow Bark

White willow bark has been in use for centuries as a natural remedy to reduce inflammation and pain. Researchers believe that white willow bark is effective at treating headaches, reducing muscle pain, and reducing inflammation. However, it does not seem to be effective in helping to reduce fever. White willow bark may cause gastrointestinal upset, affect kidney function, increase bleeding time, and increase bleeding risk. White willow bark is contraindicated in children (Wong, 2022).

Boswellia

Boswellia is used to relieve muscle and joint pain, reduce pain, and improve mobility that is compromised due to osteoarthritis. Results from research studies show that a cream made from the oil of Boswellia eases pain due to skin damage that is caused by cancer radiation treatment (Wong, 2022).

Devil’s Claw

Initially used to treat pain due to rheumatoid arthritis, devil’s claw is also used to relieve pain from osteoarthritis, tendonitis, and back and neck pain. Devil’s claw possesses significant pain-relieving and anti-inflammatory properties (Wong, 2022).

Bromelain

Bromelain reduces the level of prostaglandins (hormones that control inflammation) in the body. Research suggests that bromelain can help reduce pain caused by arthritis and musculoskeletal tension. It may also help to reduce accident-related inflammation or inflammation caused by physical trauma (Wong, 2022).

Turmeric

Turmeric contains curcumin, an antioxidant compound. Turmeric may help to decrease pain associated with autoimmune diseases and tendonitis (Wong, 2022).

Ginger

Findings from early research studies suggest that ginger could possibly reduce pain and inflammation as well as NSAIDs although more research is needed to verify this (Wong, 2022).

Thyme

Thyme has been found to have significant antioxidant properties as well as anti-inflammatory and anti-microbial properties. In 2018, thyme was identified as the most commonly used herbal medicine in people with rheumatoid arthritis (Iliades, 2022).

Green Tea

Green tea has been used medicinally in Asia for thousands of years. Rich in antioxidants, green tea can help to reduce inflammation and protect joints (Iliades, 2022).

Cinnamon

Cinnamon is a spice commonly used in cooking and as a flavor-enhancing agent. It also has significant antioxidant properties that inhibit free radical cell damage. It may even reduce blood sugar and cholesterol and possibly protect cognitive functioning as people age. However, overdoses of cinnamon might not be safe for women who are pregnant (Iliades, 2022).

Garlic and Black Pepper

Garlic and black pepper are commonly used to add flavor to many dishes. They also have properties that help in pain reduction. Garlic contains diallyl disulfide, which is an anti-inflammatory compound. Garlic may help to reduce inflammation and prevent cartilage destruction. Black pepper has antioxidant, antimicrobial, anti-inflammatory, and gastro-protective properties (Iliades, 2022).

Cayenne

Cayenne and other types of chili peppers contain capsaicinoids, which are natural compounds that possess anti-inflammatory properties. Cayenne is available to sprinkle on food, as a cream and ointment, and in capsule form (Iliades, 2022).

Special Issues

Reducing Risks of Opioid Therapy

It is important to evaluate the benefits and risks of opioid therapy. Opioid therapy is an effective pain therapy if prescribed appropriately (see earlier section on opioid therapy). It is important, however, to assess risks before initiating opioid therapy.

The following risk factors are associated with ineffective long-term opioid therapy and substance use disorder (Berna et al., 2021).

  • Prior or current substance use disorder with any substance.
  • Unclear or inconsistent diagnosis of pain.
  • Mental health disorder occurring in conjunction with chronic pain (e.g., depression, anxiety).
  • Breathing that is sleep-disordered.
  • Taking sedating drugs in conjunction with opioids.
  • Diseases of the hepatic and renal systems.
  • Pregnancy.
  • Family history of substance use disorder.
  • Chronic disability.
  • Work-related injury.
  • History of criminal behavior.
  • Refuses non-opioid treatment options.
  • High morphine dose equivalent (above 50 or 80 mg).
  • Continuation of high pain levels even though receiving opioid therapy.
  • Unrealistic expectations of opioid therapy.
  • Lack of trust in the healthcare pain management team.
  • Inconsistent urine toxicology or monitoring of prescriptions.

After determining that the risk-benefit ratio is favorable, an opioid treatment agreement between the patient and the pain management team is a type of informed consent and agreement to adhere to the treatment plan. This agreement must be signed before the first opioid prescription (Berna et al., 2021).

Benefits, risks, side effects, and effectiveness of treatment must be reevaluated regularly. Toxicology screening must also be part of the monitoring process as well as pill counts. Healthcare providers who provide optimum opioid therapy perform baseline assessments, follow-up risk-benefit assessments, use written agreements between team and patient, and careful toxicology monitoring are more likely to prescribe opioids less frequently and at lower doses. These safety practices make it less likely for worst-case scenarios to occur and positive outcomes to be achieved (Berna et al., 2021).

Pain Management of the Older Adult

A significant problem when managing pain in the older adult is the underreporting and treatment of chronic pain. Some reasons for this problem include the issue that diseases often present atypically in older adults. Another issue is that many older adults (and some healthcare professionals) believe that chronic pain is a “normal” part of aging. Some older adults associate pain with disease development or disease progression. They may be fearful of negative findings and/or fear of additional tests and/or medication increases (Area Agency on Aging 1-B).

When prescribing analgesic medications, providers must consider the age-associated differences in the physiology of older adults, prescribing doses appropriate for older adults, and how to monitor medication side effects, which may be more intense in older adults (Area Agency on Aging 1-B, n.d.).

Non-pharmacologic treatment strategies may be quite beneficial for older adults. Options include CBT, education regarding coping with and preventing pain, and participating in an exercise that targets chronic pain sources and prevents deconditioning. Complementary therapies such as massage and acupuncture may also be helpful (Area Agency on Aging 1-B).

Chronic Pain in Children

Research suggests that about 30% of children and adolescents have pain that lasts for three months or more. Chronic pain is most common around the age of 14 and girls are more frequently affected than boys. Children who have chronic illnesses or those who have had to have multiple pain procedures or surgeries are at higher risk for chronic pain. The most common issues related to chronic pain in children include headaches, recurrent abdominal pain, and general musculoskeletal pain. However, the most common cause of chronic pain in children is pain with no known cause (Children’s Hospital of Colorado, n.d.).

Children with chronic pain seem to benefit most from interdisciplinary programs that include CBT, physical rehabilitation, and standard pain management care. Numerous analgesics are effective for pain management in children (e.g., NSAIDs, muscle relaxants, low-dose antidepressants). Relaxation strategies that are age-appropriate have been found to be beneficial to the treatment of chronic pain in children. Opioids are rarely recommended to treat chronic pain in children. However, opioids may be beneficial in the presence of severe painful conditions (i.e., cancer) that have a clearly defined source (Children’s Hospital of Colorado, n.d.).

Chronic Pain Alert! Chronic Pain Etiology in Children

Identifying the source of chronic pain can be quite complex.

Chronic pain (in both adults and children) can often elicit other problematic conditions such as poor posture or compromised mobility. Children, like adults, may also be prone to mental health disorders in conjunction with chronic pain (Children’s Hospital of Colorado, n.d.).

Cancer Pain

Thanks to advances in the detection and treatment of cancer, it is possible to manage pain effectively in most people who are dealing with cancer. Unfortunately, cancer-related pain cannot always be completely relieved, but appropriate therapy can lessen the pain for almost all people with cancer. Patients should be encouraged to report feelings of pain since the sensation of pain can actually interfere with cancer treatment effectiveness (Memorial Sloan Kettering Cancer, n.d.).

The Memorial Sloan Kettering Cancer Center (n.d.) identifies the following approaches for dealing with cancer-related pain.

Cancer Removal or Reduction

Surgery, radiation, chemotherapy, and immune therapy are all treatment options to remove most, or a portion of the cancer. These options can offer patients significant pain reduction (Memorial Sloan Kettering Cancer Center, n.d.).

Palliative Surgery or Radiation Therapy

Strategies for palliative relief of pain include surgery and radiation. The goal is to reduce pain so that people with cancer can sustain a maximum quality of life. Surgery is also used to prevent or control complications due to cancer (e.g., bowel obstruction). Palliative approaches are typically used for people who have advanced cancer (Memorial Sloan Kettering Cancer Center, n.d.).

Pharmacological Strategies

Healthcare providers typically classify pain into three categories (Memorial Sloan Kettering Cancer Center, n.d.):

  • Mild to moderate pain: Non-opioids, such as acetaminophen and NSAIDs, can relieve the mild to moderate pain of cancer. Useful for muscle and bone pain, non-opioids can be used as adjunctive drugs in combination with opioids in order to provide greater pain relief.
  • Moderate to severe pain: Opioids are quite effective for the relief of moderate to severe pain. Some patients express fear of addiction if opioids are prescribed. If opioids are appropriately prescribed and taken as prescribed addiction is rare. Opioids may be prescribed at any stage of treatment depending on individualized patient needs.

Chronic Pain Alert! Timing of Medication

Some people are worried that if they use analgesic medications early in their treatment, stronger analgesics will not be effective if needed later in the treatment course. This is not accurate. Increasing doses of opioids can be used for years without becoming dependent or addicted as long as proper prescribing and monitoring principles are implemented. Healthcare providers will taper opioids before discontinuing them if discontinuation is appropriate (Memorial Sloan Kettering Cancer Center, n.d.).

  • Breakthrough pain: Breakthrough pain, severe pain that bursts forth while patients are already being medicated with long-acting analgesia, may be treated with a rapid-acting, potent medication (e.g., morphine). Patients can have this type of rapid-acting analgesic available to them if breakthrough pain occurs. Doses of pain medication used for breakthrough pain are referred to as “rescue doses.” Rescue doses are quick-acting and “leave” the body fairly soon. Rescue doses are typically prescribed to patients’ regularly prescribed pain medications.

    Procedures such as nerve blocks, patient-controlled analgesia (PCA), CBT, and complementary strategies may also be used to relieve cancer-related pain.

Pain Management Emergencies

There are a number of complications related to pain management treatment strategies. The following complications are classified as pain management emergencies.

Vasovagal Syncope

Vasovagal syncope is one of the most common adverse events related to procedures related to pain relief. Extremes of emotion such as fear and anxiety can lead to a vasovagal response. This causes a self-limit hypotension clinical presentation that leads to light-headedness, nausea, sweating, weakness, blurry vision, pallor, bradycardia, or tinnitus. The patient should be placed in a supine position, preferably the Trendelenburg position. Oxygen is administered, an intravenous line (IV) is inserted, vital signs are monitored, and assisted muscle tensing behaviors (Alexandre & Gilligan, 2021).

Anesthetic Toxicity

Toxicity can be secondary to excessive dosing, rapid absorption, or IV infiltration. Symptoms include dizziness, tinnitus, dysphoria, confusion, drowsiness, seizures, and symptoms of cardiac toxicity (e.g., dyspnea, hyper or hypotension, ventricular fibrillation, bradycardia, tachycardia, or asystole. Treatment includes ventilation with 100% oxygen, 20% lipid emulsion infusion, suppression of seizures, and, in cases where patients do not improve, a cardiopulmonary bypass is considered (Alexandre & Gilligan, 2021).

Complications of Injection Therapies

Some of the complications of epidural and intrathecal procedures include epidural hematoma, epidural abscess, high spinal anesthetics, and accidental overdose. Treatment involves immediate cessation of the injection, ensure airway patency, breathing, and circulation. Establish intravenous routes, and administer naloxone in cases of opioid overdose (Alexandre & Gilligan, 2021).

Hypo or Hypertension

If significant hypotension occurs, it is typically due to conditions such as vasovagal syncope, drug reactions, anaphylaxis, or pulmonary or cardiac compromise. Hypertension may be due to steroids, NSAIDs, drug interactions, or abrupt drug discontinuation. Oxygen should be administered in cases of both hypo and hypertension. With hypotension, an IV challenge is administered and the lower extremities are elevated. With hypertension, depending on the cause, treatment may include entail reinstitution of a drawn agent (e.g., restarting clonidine). Blood pressure must not be lowered too rapidly, no more than >10%-20% in the first hour (Alexandre & Gilligan, 2021).

Pneumothorax

Pneumothorax may occur secondarily to procedures such as nerve blocks. Symptoms include dyspnea, reduced breath sounds, wheezing, cyanosis, and hemodynamic instability. Pneumothorax is treated with oxygen therapy, needle aspiration, small-bore chest tube insertion, and, for unstable patients, needle decompression followed by tube thoracostomy may be attempted (Alexandre & Gilligan, 2021).

Opioid Overdose

Opioid dose presents with miotic pupils (small, constricted pupils, referred to as pinpoint pupils), respiratory depression, decreased bowel sounds, restlessness, agitation, and/or sudden onset seizures. Support of airway patency, breathing, circulation, and administration of Naloxone to reverse the consequences of an opioid overdose (Alexandre & Gilligan, 2021).

Opioid Withdrawal

Opioid withdrawal is a potentially life-threatening complication. It may begin six-12 hours after the last dose of a short-acting opioid and last for several days. Withdrawal from methadone may occur within 24-48 hours from the last dose and last up to two weeks. Symptoms of withdrawal include hypertension, nausea, vomiting, diarrhea, fever, chills, irritability, abdominal cramping, and muscle aches. Withdrawal is treated by resumption of the drug, possibly at 25%-40% of the original dose. Adjunctive nonopioid medications may be used for symptom management (Alexandre & Gilligan, 2021).

Conclusion

The management of chronic pain requires the complete involvement of all members of the pain management team as well as the patient. There are a wide variety of treatment options, each with its own benefits and risks. It is the responsibility of all healthcare professionals to remain alert to updates and advances in pain management treatment strategies. It is also their responsibility to individualize pain management plans according to the needs and values of patients. The ultimate goal of pain management is to relieve pain to the maximum extent possible and enhance each patient’s quality of life.

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