Chronic Pain Management: An Evidence-Based Approach
- Chronic pain is defined as pain persisting beyond the time anticipated for normal tissue healing, usually >3 months.
- Over time, neuroplastic changes in the CNS transform pain into a chronic experience with emotional, psychological, and cognitive dimensions.
- An epidemic of undertreated pain coexists with an epidemic of prescription drug abuse in the United States.
- People of color, especially African Americans, are often undertreated.
- Opioid medications should be prescribed using an evidence/systems-based approach and only when indicated for chronic, nonmalignant pain.
- Chronic pain has been reported by as many as 20–40% of patients in primary care.
- The annual economic cost of chronic pain in the United States is estimated at $560 to $635 billion (1).
In the United States, an estimated 20% (50 million) adults reported some level of chronic pain on cross-sectional household surveys. The prevalence was higher among women and those with lower socioeconomic status (https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm).
Opioid-related overdoses are at an all-time high. Deaths have surged during the COVID-19 pandemic (https://www.cdc.gov/drugoverdose/resources/covid-drugs-QA.html).
Etiology and Pathophysiology
- With intense, repeated, or prolonged stimulation of damaged or inflamed tissues, the threshold for activating primary afferent pain fibers is lowered, the frequency of firing is higher, and there is an increased response to noxious and/or normal stimuli (peripheral and central sensitization). The amygdala, prefrontal cortex, and cortex relay emotions related to the pain experience, and these areas undergo structural and functional changes over time.
- Patients often have an identifiable etiology, but pain levels can be worse than observable tissue injury. Many patients have no obvious source of chronic pain.
A genetic polymorphism in opioid receptors may affect patient’s response to individual opioids.
- Traumatic: motor vehicle accidents, repetitive motion injuries, falls
- Postsurgical: back surgeries, amputations, thoracotomies
- Psychiatric comorbidities: substance abuse, depression, posttraumatic stress disorder (PTSD)
- Prevent work-related injuries through ergonomic workplace design.
- Varicella vaccine and rapid treatment of shingles to lower risk of postherpetic neuralgia
- Tight glycemic control for diabetic patients, prevention of alcohol abuse, smoking cessation
Commonly Associated Conditions
Any chronic disease and/or its treatment can cause chronic pain.
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