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KEY POINTS

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KEY POINTS

  1. Comprehensive pain management focuses on improving patient functionality and quality of life by integrating pharmacologic treatment, interventional modalities, physical therapy, and cognitive-behavioral modification. Among them, pharmacological therapy remains the mainstay of treatment.

  2. Finding appropriate pharmacological treatments through a mechanism-based approach offers the best chance for a rational selection of proper therapies.

  3. Optimal use of medications requires a thorough understanding of their pharmacology as well as the ability to compare their effects through standardized study including meta-analysis and measures such as number needed to treat analysis.

  4. Opioid therapy presents unique challenges to the prescriber including pharmacologic tolerance, side effect, dependence, abuse, drug diversion, and medicolegal issues. Continuous monitoring and attention to the physician-patient relationship is vital.

  5. The future of pain practice involves combination therapy because a solo agent is rarely sufficient to manage pain.

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OVERVIEW

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Comprehensive pain management focuses on improving patient functionality and quality of life by integrating pharmacologic treatment, interventional modalities, physical therapy, and cognitive-behavioral modification. Among them, pharmacological therapy remains the mainstay of treatment. Pharmacology has evolved over the past few decades with the advent of new agents and insight into their action mechanisms. Likewise, the pain management field has changed over the past several decades as new discoveries about the pathophysiology of pain enable the physician to target specific sites. Additionally, outcome research continues to provide more insight into efficacy and adverse effects of current therapies. These scientific advances pave the way for evidence-based clinical practice of pharmacological pain management. Studies have shown treating chronic pain with modalities that are useful for acute pain (rest, immobilization, nonsteroidal anti-inflammatory agents (NSAIDs), and opioids) can be detrimental for the chronic pain patient. While acute pain is often associated with self-limited tissue injury of brief duration, chronic pain often requires extended multimodal treatment and complete recovery is not necessarily expected (Figure 88-1). Since pharmacologic therapy is the mainstay of pain treatment, the long-term implications and adverse effects of commonly prescribed drugs for treatment of acute pain, such as opioids and NSAIDs, must be considered. This is especially relevant for patients with chronic medical conditions who could be more vulnerable to toxicities from long-term use of these medications, such as opioid-induced cognitive and endocrine abnormalities and NSAID induced gastrointestinal side effects. In general, there is little evidence of long-term efficacy (ie, >2 years) of medications historically used for short-term analgesia.1 There is a great need for more research to determine long-term efficacy of medications used in the management of chronic pain.

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FIGURE 88-1.

Top: In acute pain, tissue damage leads to a predominantly sen- sory phenomenon of pain, with some superimposed cognitive, affective response. Bottom: In chronic pain, tissue damage may not be apparent, and symptom mag- nification, affective distress, and illness behavior may be the primary identifiable manifestation of pain. [Reproduced with permission from Waddell G, Newton M, Henderson I, et al. A fearavoidance beliefs ...

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