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Chronic Pain Management: an Evidence-Based Approach

Chronic Pain Management: an Evidence-Based Approach is a topic covered in the 5-Minute Clinical Consult.

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Basics

  • Chronic pain is pain persisting beyond the time of normal tissue healing, usually >3 months.
  • Over time, neuroplastic changes in the CNS transform pain into a chronic disease. Pain levels exceed pathology observed on exam or imaging.
  • Pain experience is inherently related to emotional, psychological, and cognitive factors.
  • An epidemic of undertreated pain coexists with an epidemic of prescription drug abuse in the United States.
  • Use an evidence-based, systems-based practice to safely and effectively prescribe any opioid medication, and only when indicated for chronic, nonmalignant pain.

Epidemiology

Incidence
Incidence is rising, but exact rate is unclear. The annual economic cost of chronic pain in the United States is estimated at $560 to $635 billion (1)[B].

Prevalence
In the United States, an estimated 50 million adults live with significant chronic or severe pain, according to the National Institutes of Health. People with severe pain are more likely to have worse health status, use more health care, and suffer more disability (2)[B].

ALERT
Caution: More people died from drug overdoses in 2016 than in any year on record. The majority of drug overdose deaths (more than 6 out of 10) involve an opioid. From 2000 to 2016, over half a million people died from drug overdoses (http://www.cdc.gov/drugoverdose/index.html) (3)[B].

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 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 with chronic pain.
  • Patients often have an identifiable etiology (most commonly musculoskeletal problems or headache), but pain levels are often worse than observable tissue injury. Many patients have no obvious cause of chronic pain.

Genetics
Current research suggests a genetic polymorphism in opioid receptors; may affect patient’s response and/or side effects to individual opioids

Risk Factors

  • Traumatic: motor vehicle accidents, repetitive motion injuries, sports injuries, work-related injuries, and falls
  • Postsurgical: especially back surgeries, amputations, and thoracotomies
  • Psychiatric comorbidities: substance abuse, depression, posttraumatic stress disorder (PTSD), personality disorders
  • Aging: increased incidence with age but should not be considered a “normal” part of aging

General Prevention

  • Prevent work-related injuries through the use of ergonomically correct workplace design.
  • Exercise and physical therapy to help prevent work-related low back pain.
  • 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, including diabetes, cardiovascular disease, HIV, progressive neurologic conditions, lung disease, cirrhosis, autoimmune disease, cancer, renal failure, depression, and mental illness.

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Citation

Stephens, Mark B., et al., editors. "Chronic Pain Management: an Evidence-Based Approach." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688018/all/Chronic_Pain_Management:_an_Evidence_Based_Approach.
Chronic Pain Management: an Evidence-Based Approach. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688018/all/Chronic_Pain_Management:_an_Evidence_Based_Approach. Accessed April 20, 2019.
Chronic Pain Management: an Evidence-Based Approach. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688018/all/Chronic_Pain_Management:_an_Evidence_Based_Approach
Chronic Pain Management: an Evidence-Based Approach [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 20]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688018/all/Chronic_Pain_Management:_an_Evidence_Based_Approach.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Chronic Pain Management: an Evidence-Based Approach ID - 1688018 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688018/all/Chronic_Pain_Management:_an_Evidence_Based_Approach PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -