PAIN TREATMENT OVERVIEW
PAIN TYPES & CHRONIC PAIN CLASSIFICATION
Many pain specialists recommend that the term “chronic pain” should be described as “persistent pain” – which can be continuous or recurrent and of sufficient duration and intensity to adversely affect a person’s well-being, level of function, and quality of life. This document continues to use the term “chronic pain” given its universal acceptance.
Acute pain is distinguished as being of recent onset, transient, and usually from an identifiable cause.
Chronic or persistent pain can be described as ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3 to 6 months, and which adversely affects the individual’s well-being. A simpler definition for chronic or persistent pain is pain that continues when it should not.
Chronic pain is classified by pathophysiology (the functional changes associated with or resulting from disease or injury) as nociceptive (due to ongoing tissue injury) or neuropathic (resulting from damage to the brain, spinal cord, or peripheral nerves), with mixed or undetermined causes as well.
Central pain syndrome is a neurological condition caused by a dysfunction that specifically affects the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. The disorder occurs in people who have or who have experienced strokes, multiple sclerosis, Parkinson's disease, brain tumors, limb amputations, brain injuries, or spinal cord injuries. It may develop months or years after injury or damage to the CNS.
Tailoring selection of analgesics that target underlying pathophysiology is one of the challenges of medication management. For example, opioid analgesics are generally effective for nociceptive pain but may be less effective for neuropathic and central pain.
Continuous pain is pain that is typically present for approximately half the day or more. In most cases, this type of pain is treated with an around-the-clock approach with medications, such as regularly scheduled analgesic doses and a sustained exercise program.
Flare-up pain (the term break-through pain was coined to refer to cancer related flare-ups) can be described as a transitory increase in pain in someone who has relatively stable and adequately controlled baseline pain. It may be caused by changes in an underlying disease, including treatment, or involuntary or voluntary physical actions such as coughing or getting up from a chair. It can also be caused by emotions such as increased stress, anxiety, or worry. Flare-up pain may occur at the end of the scheduled pain medicine dose as well.
Treatment for moderate-to-severe flare-up pain can consist of medication and/or the use of non- pharmacological tools. Non-pharmacological tools are recommended and include relaxation techniques, light stretching or activity, and positive self-talk.
The treatment of flare-up pain with a short-acting opioid is common in individuals with active cancer or other types of advanced medical illness for which opioid therapy is the mainstay for the long-term management of moderate to severe pain. However, there is no agreement among healthcare professionals on how best to treat this type of pain in people with non-cancer pain. We have come to realize that the regular use of short-acting additional opioids throughout the day for increased pain may only lead to more pain flare-ups and escalating drug usage rather than true pain relief and increased function.
It is important to tell your healthcare professional if you are experiencing flare-up pain so that a treatment strategy that is right for you can be developed.
PAIN IN CHILDREN
Chronic pain (defined as persistent and recurrent pain) is a significant problem in the pediatric population, conservatively estimated to affect 20% to 40% of children and adolescents around the world. The most common chronic pain conditions are musculoskeletal pain, headaches, and abdominal pain. Children may experience physical and psychological sequelae and their families may experience emotional and social consequences as a result of pain and associated disability.
Childhood pain brings significant direct and indirect costs from healthcare utilization and lost wages due to taking time off work to care for the child. In addition, longitudinal studies provide convincing evidence to suggest that childhood chronic pain predisposes both for the continuation of pain and the development of new forms of chronic pain in adulthood (from Assessment and Management of Children with Chronic Pain, A Position Statement from the American Pain Society
- 1/4/12 www.americanpainsociety.org/uploads/pdfs/aps12-pcp.pdf.
PAIN IN OLDER PERSONS
Persistent or chronic pain is prevalent in older adults. The issue has been addressed in the American Geriatrics Society (http://www.americangeriatrics.org) Pharmacological Management of Persistent Pain in Older Persons at the following Internet Web site: http://www.americangeriatrics.org/files/documents/2009_Guideline.pdf.
In general, thirty percent of hospital admissions among the elderly may be linked to an adverse drug related event or toxic effect from opioids and sedatives. Nearly one third of all prescribed
medications are for patients over the age of 65 years. Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the patient is experiencing a medication-related problem.
Some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs.
In older persons, the dose is often started low and adjusted slowly to optimize pain relief while monitoring and managing side effects. Careful use of multiple drugs together can be seen as potentially advantageous. Combining smaller doses of more than one medication may minimize the dose-limiting adverse effects of using a particular single drug.
Beyond pharmacologic treatment, physical rehabilitation and other interventional therapies, including targeted injections and acupuncture, can be helpful to minimize side-effects and maximize physical function with pain relief.
CLINICAL TRIALS
Clinical Trials (see http://clinicaltrials.gov for more information) are health-related medical research studies in human beings that follow a pre-defined plan. Choosing to participate in a clinical trial is an important personal decision. It is often helpful to talk to a physician, family members, or friends about deciding to join a trial. The results of the clinical trial can lead to new treatments or therapies becoming available for many people coping with chronic pain.
Information about Learn About Clinical Studies can be found at:
http://clinicaltrials.gov/ct2/about-studies/learn
PAIN TREATMENT OVERVIEWPAIN TYPES & CHRONIC PAIN CLASSIFICATIONMany pain specialists recommend that the term “chronic pain” should be described as “persistent pain” – which can be continuous or recurrent and of sufficient duration and intensity to adversely affect a person’s well-being, level of function, and quality of life. This document continues to use the term “chronic pain” given its universal acceptance.Acute pain is distinguished as being of recent onset, transient, and usually from an identifiable cause.Chronic or persistent pain can be described as ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3 to 6 months, and which adversely affects the individual’s well-being. A simpler definition for chronic or persistent pain is pain that continues when it should not.Chronic pain is classified by pathophysiology (the functional changes associated with or resulting from disease or injury) as nociceptive (due to ongoing tissue injury) or neuropathic (resulting from damage to the brain, spinal cord, or peripheral nerves), with mixed or undetermined causes as well.Central pain syndrome is a neurological condition caused by a dysfunction that specifically affects the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. The disorder occurs in people who have or who have experienced strokes, multiple sclerosis, Parkinson's disease, brain tumors, limb amputations, brain injuries, or spinal cord injuries. It may develop months or years after injury or damage to the CNS.Tailoring selection of analgesics that target underlying pathophysiology is one of the challenges of medication management. For example, opioid analgesics are generally effective for nociceptive pain but may be less effective for neuropathic and central pain.Continuous pain is pain that is typically present for approximately half the day or more. In most cases, this type of pain is treated with an around-the-clock approach with medications, such as regularly scheduled analgesic doses and a sustained exercise program.Flare-up pain (the term break-through pain was coined to refer to cancer related flare-ups) can be described as a transitory increase in pain in someone who has relatively stable and adequately controlled baseline pain. It may be caused by changes in an underlying disease, including treatment, or involuntary or voluntary physical actions such as coughing or getting up from a chair. It can also be caused by emotions such as increased stress, anxiety, or worry. Flare-up pain may occur at the end of the scheduled pain medicine dose as well. Treatment for moderate-to-severe flare-up pain can consist of medication and/or the use of non- pharmacological tools. Non-pharmacological tools are recommended and include relaxation techniques, light stretching or activity, and positive self-talk.The treatment of flare-up pain with a short-acting opioid is common in individuals with active cancer or other types of advanced medical illness for which opioid therapy is the mainstay for the long-term management of moderate to severe pain. However, there is no agreement among healthcare professionals on how best to treat this type of pain in people with non-cancer pain. We have come to realize that the regular use of short-acting additional opioids throughout the day for increased pain may only lead to more pain flare-ups and escalating drug usage rather than true pain relief and increased function.It is important to tell your healthcare professional if you are experiencing flare-up pain so that a treatment strategy that is right for you can be developed.PAIN IN CHILDRENChronic pain (defined as persistent and recurrent pain) is a significant problem in the pediatric population, conservatively estimated to affect 20% to 40% of children and adolescents around the world. The most common chronic pain conditions are musculoskeletal pain, headaches, and abdominal pain. Children may experience physical and psychological sequelae and their families may experience emotional and social consequences as a result of pain and associated disability.Childhood pain brings significant direct and indirect costs from healthcare utilization and lost wages due to taking time off work to care for the child. In addition, longitudinal studies provide convincing evidence to suggest that childhood chronic pain predisposes both for the continuation of pain and the development of new forms of chronic pain in adulthood (from Assessment and Management of Children with Chronic Pain, A Position Statement from the American Pain Society- 1/4/12 www.americanpainsociety.org/uploads/pdfs/aps12-pcp.pdf.PAIN IN OLDER PERSONSPersistent or chronic pain is prevalent in older adults. The issue has been addressed in the American Geriatrics Society (http://www.americangeriatrics.org) Pharmacological Management of Persistent Pain in Older Persons at the following Internet Web site: http://www.americangeriatrics.org/files/documents/2009_Guideline.pdf.In general, thirty percent of hospital admissions among the elderly may be linked to an adverse drug related event or toxic effect from opioids and sedatives. Nearly one third of all prescribed medications are for patients over the age of 65 years. Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the patient is experiencing a medication-related problem.Some older individuals may be more sensitive to medications, more likely to experience side effects, and more likely to be using multiple drugs with the associated risk of interactions between the drugs.In older persons, the dose is often started low and adjusted slowly to optimize pain relief while monitoring and managing side effects. Careful use of multiple drugs together can be seen as potentially advantageous. Combining smaller doses of more than one medication may minimize the dose-limiting adverse effects of using a particular single drug.Beyond pharmacologic treatment, physical rehabilitation and other interventional therapies, including targeted injections and acupuncture, can be helpful to minimize side-effects and maximize physical function with pain relief.CLINICAL TRIALSClinical Trials (see http://clinicaltrials.gov for more information) are health-related medical research studies in human beings that follow a pre-defined plan. Choosing to participate in a clinical trial is an important personal decision. It is often helpful to talk to a physician, family members, or friends about deciding to join a trial. The results of the clinical trial can lead to new treatments or therapies becoming available for many people coping with chronic pain.Information about Learn About Clinical Studies can be found at:http://clinicaltrials.gov/ct2/about-studies/learn
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