Management of chronic pain in the acute care setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.     

Physiological measures of assessing infant pain: a literature review

Neonatal pain assessment is not standardized. Clinicians may use various parameters in the measurement of pain which can lead to different interpretations. Currently, there is no validated biological marker for assessing infant pain in any age group. However, in the non-verbal patient, the most feasible way to assess pain may be by evaluation of physiological parameters. The author conducted a systematic review of the literature using qualitative methods and seven research papers were selected for review, in which physiological measures were used in the assessment of neonatal pain. Heart rate was the most frequently used physiological pain measure in these studies. Oxygen saturation, blood pressure and respiratory rate lacked sensitivity and specificity and cannot be used independently. These measures may detect pain but cannot quantify it and are, therefore, not useful assessments of chronic pain. The multidimensional approach to pain assessment may be the most appropriate owing to the correlation between behavioural and physiological indicators of pain in the neonate.     

Chronic facial pain from psychiatric point of view - differential diagnosis and therapeutic strategies

Chronic facial pain may cause diagnostic and therapeutic difficulties, thus demanding a complete interdisciplinary consultation. As in 20 to 25% of patients with a nociceptive or primary neuropathic pain a psychiatric comorbidity is expected, it is necessary to include psychiatric and psychosomatic examinations. Every 8th male and every 4th female pain patient has the statistical risk of having a depression at the same time. Depression may develop as a consequence of pain, but may also be the primary basis for a pain syndrome. An independent coincidence is possible as well.Besides affective disorders, persistent somatoform pain syndromes, syndromes of conversion, hypochondriac or artificial disorders and pain in psychosis have to be excluded in patients presenting with chronic facial pain.In depression, persistent somatoform pain syndromes, atypical facial pain but also when dysfunctional illness beliefs and coping mechanisms are present, cognitive-behavioral therapy should be offered to the patient. Motivation to psychotherapy may be difficult, especially in patients relying exclusively on physical illness beliefs. The physician should develop and extend the physical illness beliefs together with the patient to a model that includes biological as well as psychosocial factors.Tricyclic antidepressants may be indicated not only in depression, but also in chronic pain due to the analgetic effects of these drugs. The choice of drug therapy should conform to the main complaints of depression and accompanying illnesses.Indication of antidepressants or neuroleptic drugs in somatoform pain syndromes is still unclear. Their potential slight effect may simply be due to the high comorbidity between somatoform pain syndromes and depression.     

The validity and reliability of pain measures in adults with cancer.

To be most useful, clinical trials of cancer pain treatments should use pain measures that are both reliable and valid. A great variety of measures are now available that may be used to assess cancer pain. However, there are not yet any clear guidelines for selecting one or more measures over the others. The purpose of this article is to summarize the evidence concerning the validity and reliability of cancer pain measures. One hundred sixty-four articles were identified that provided psychometric data of pain measures among patients with cancer. The results indicate that commonly used single-item ratings of pain intensity are all valid and adequately reliable as measures of pain intensity, although some scales appear to be easier for patients with cancer to understand and to use than others. Multiple-item measures of pain intensity are reliable, but evidence concerning their validity is lacking. There is a paucity of research examining the psychometric properties of measures of cancer pain interference, pain relief, pain site, the temporal aspects of pain, and pain quality. This lack of evidence limits the conclusions that may be drawn concerning the reliability and validity of these other pain measures. Composite measures that combine ratings of pain intensity and pain interference into a single score appear to be both valid and reliable for describing patient populations, although their usefulness in clinical trials may be limited because they can obscure the contributions of intensity and interference to the total score. Proxy measures of cancer pain (pain ratings made by someone other than the patient) may be useful when patients are not able to provide pain ratings, but they should not be used as replacements for patient ratings when patient self-report measures are available. The discussion includes specific recommendations for selecting from among the available pain measures, as well as recommendations for future research into the assessment of cancer pain.     

Treatment Considerations for Cancer Pain: A Global Perspective

Cancer pain is prevalent, undertreated, and feared by patients with cancer. In April 2013, a panel of pain experts convened in Singapore to address the treatment of cancer pain. They discussed the various types of cancer pain, including breakthrough pain, which is sometimes clinically confused with analgesic gaps. Reasons for undertreating cancer pain include attitudes of patients, clinicians, and factors associated with healthcare systems. The consequences of not treating cancer pain may include reduced quality of life for patients with cancer (who now live longer than ever), functional decline, and increased psychological stress. Early analgesic intervention for cancer pain may reduce the risk of central sensitization and chronification of pain. To manage pain in oncology patients, clinicians should assess pain during regular follow‐up visits using validated pain measurement tools and follow prescribing guidelines, if necessary referring patients with cancer to pain specialists. Many patients with cancer require opioids for pain relief. Pain associated with cancer may also relate to cancer treatments, such as chemotherapy‐induced peripheral neuropathy. Many patients with cancer are what might be considered “special populations,” in that they may be elderly, frail, comorbid, or have end‐stage organ failure. Specific pain therapy guidelines for those populations are reviewed. Patients with cancer with a history of or active substance abuse disorder deserve pain control but may require close medical supervision. While much “treatment inertia” exists in cancer pain control, cancer pain can be safely and effectively managed and should be carried out to alleviate suffering and improve outcomes.     

Anatomy, physiology, and neuropharmacology of cancer pain

The anatomy, physiology, and pharmacology of nociception and its modification by analgesic drugs have been studied extensively in the past decade. Although the neural mechanisms of nociceptors and the stimuli that activate them are much better understood, it must be emphasized that the perception of pain, as well as the meaning of pain to the individual, is a complex behavioral phenomenon and involves psychologic and emotional processes in addition to activation of nociceptive pathways. Pain related to malignant disease can be classified as somatic, visceral, and deafferentation in type. Somatic pain and visceral pain involve direct activation of nociceptors and are often a complication of tumor infiltration of tissues or injury of tissues as a consequence of cancer therapy. The management of this type of pain is typically accomplished by treating the tumor (with surgery, chemotherapy, and/or radiation therapy) and by using the appropriate non-narcotic, narcotic, and adjuvant analgesic agents. Neuroablative therapies may be helpful in specific circumstances. For example, cordotomy may be helpful for unilateral pain below the waist in patients with somatic and visceral pain. This procedure may also be helpful for early deafferentiation pain (i.e., lumbosacral plexopathy) in which peripheral nerves are compressed but not infiltrated or destroyed by metastatic tumor growth. Deafferentiation pain may be a complication of tumor infiltration of peripheral nerve or of cancer therapy that injures neural tissue. This type of pain is often poorly tolerated and difficult to control, particularly if not treated early and aggressively. Although incompletely understood, the pathophysiology of deafferentation pain appears to be different from that of somatic or visceral pain, and the treatment approaches may be different. Management approaches to deafferentation pain usually emphasize treatment of the pain, because injury to the nervous system may be difficult to reverse, even if one can successfully treat the underlying malignancy, and many deafferentation pain syndromes occur as a complication of cancer therapy. The role of narcotic analgesics in the management of deafferentation pain is not clear, although the published experience suggests that they are less useful than in somatic or visceral pain.     

Individual Differences in Pain Sensitivity: Measurement,Causation, and Consequences

Not only are some clinical conditions experienced as more painful than others, but the variability in pain ratings of patients with the same disease or trauma is enormous. Available evidence indicates that to a large extent these differences reflect individual differences in pain sensitivity. Pain sensitivity can be estimated only through the use of well-controlled experimental pain stimuli. Such estimates show substantial heritability but equally important environmental effects. The genetic and environmental factors that influence pain sensitivity differ across pain modalities. For example, genetic factors that influence cold pressor pain have little impact on phasic heat pain and visa versa. Individual differences in pain sensitivity can complicate diagnosis, among other reasons because low sensitivity to pain may delay self-referral. Inclusion of patients with reduced pain sensitivity can attenuate treatment effects in clinical trials, unless controlled for. Measures of pain sensitivity are predictive of acute postoperative pain, and there is preliminary evidence that heightened pain sensitivity increases risk for future chronic pain conditions. At this time, however, it is unclear which experimental pain modalities should be used as predictors for future pain conditions. Careful assessment of each individual's pain sensitivity may become invaluable for the prevention, evaluation, and treatment of pain.PerspectiveLarge individual differences in pain sensitivity can complicate diagnosis and pain treatment and can confound clinical trials. Pain sensitivity may also be of great importance for the development of clinical pain. Thus, assessment of pain sensitivity may be relevant for the prevention, evaluation, and treatment of acute and chronic pain.     

Continuous intrathecal meperidine for severe refractory cancer pain: a case report

The control of severe cancer pain may be problematic despite advances in pain management. Patients with severe intractable pain and/or intractable side effects may require aggressive interventional pain management strategies including the administration of medications by the continuous intrathecal route and/or neurosurgical procedures. Various medications, including opioids, local anesthetics, and alpha-2 agonists may be used intrathecally for the control of cancer pain. Failure of the intrathecal route may require the additional use of neurosurgical procedures such as cordotomy for pain control. We describe a case of severe cancer pain refractory to conventional intrathecal medications and cordotomy that was successfully managed by the addition of meperidine to the intrathecal regimen.     

Exposure to Contact Sports Results in Maintained Performance During Experimental Pain

During pain, motor performance tends to decline. However, athletes who engage in contact sports are able to maintain performance despite the inherent pain that accompanies participation. This may be the result of being challenged rather than threatened by pain; adaptive coping strategies; habituation to pain; or finding pain less bothersome. This study aimed to measure performance of a novel motor task both in pain and not in pain within experienced contact athletes (n = 40), novice contact athletes (n = 40), and noncontact athletes (n = 40). Challenge and threat perceptions were manipulated during the pain condition and measures of pain tolerance, perception, coping styles, and bothersomeness were taken. Results indicated that contact athletes, regardless of experience, were able to maintain their performance during painful stimulation. Noncontact athletes, conversely, performed significantly worse during pain stimulation. In addition, contact athletes tended to be more challenged and the noncontact athletes more threatened within the pain condition. Experienced contact athletes demonstrated higher levels of pain tolerance and direct coping, and reported lower levels of pain bothersomeness and intensity than the other groups. The results suggest that even relatively brief exposure to contact sports may be enough to help maintain performance in pain. Being in a challenged state appears to be an important factor during performance in pain. Moreover, pain tolerance, intensity, and bothersomeness may differentiate novice and experienced athletes.PerspectiveExposure to voluntary pain and challenge states are associated with adaptive responses to pain. Motor task performance may be maintained in individuals with more experience of sports-related pain.     

Chest pain. How serious is it?

The very thought of chest pain often brings terror to patients and health care providers. Chest pain typically invokes a "worst case" scenario of massive myocardial infarction (MI) resulting from cardiovascular disease (CD) and requiring immediate medical attention. However, chest pain is a common complaint suffered by most people at some time in their lives. People complaining of chest pain may be young, middle-aged, or elderly, and they may or may not be under a health care provider's care. Chest pain may be a symptom of a variety of disorders other than CD. Therefore it is helpful to differentiate quickly between the types of chest pain to determine whether immediate assistance is necessary.     

Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms.

Breakthrough pain or transient worsening of pain in patients with an ongoing steady pain is a well known feature in cancer pain patients, but it is also seen in non-malignant pain conditions with involvement of nerves, muscles, bones or viscera. Continuous and intermittent pain seems to be a general feature of these different pain conditions, and this raises the possibility of one or several common mechanisms underlying breakthrough pain in malignant and non-malignant disorders. Although the mechanisms of spontaneous ongoing pain and intermittent flares of pain (BTP) may be difficult to separate, we suggest that peripheral and/or central sensitization (hyperexcitability) may play a major role in many causes of BTP. Mechanical stimuli (e.g. micro-fractures) changes in chemical environments and release of tumour growth factors may initiate sensitization both peripherally and centrally. It is suggested that sensitization could be the common denominator of BTP in malignant and non-malignant pain.     

Memory of dental pain

The possibility that patients' memory for acute pain is reconstructed over time was tested by comparing the degree of pain remembered 3 months after a dental appointment with both expected and experienced pain, as reported immediately before and after the appointment. As hypothesised, there was a closer association between remembered and expected pain than between remembered and experienced pain, particularly for those patients who scored high on the Dental Anxiety Scale. These results suggest that the accuracy of patients' reports of pain experienced in the past may be suspect, and that dental anxiety may be slow to extinguish because the discrepancy between expected and experienced pain felt at one appointment may not be recalled accurately by anxious patients at their next appointment.     

Chronic pain in patients with substance abuse disorder: general guidelines and an approach to treatment

Treating pain may be difficult in patients with a coexisting substance abuse disorder. Opioids can be used successfully to control pain in such a patient population, but the physician must have a general understanding of addictive behavior and early signs of abuse. The challenge is not in treating pain, but identifying true pain from drug-seeking behaviors. Furthermore, several myths of opioid usage, such as iatrogenic addiction and risk of disciplinary action, may be unfounded. General guidelines and open communication between patient and physician may aid in controlling pain. With better understanding and a systematic treatment approach, patients with substance abuse disorders can receive adequate symptomatic pain relief.     

Chronic pain: second, do no harm

Pain may be undertreated--contributing to anguish, as reported by the World Health Organization. Pain may be overtreated--inadvertently contributing to drug addiction, drug diversion, and even death. Pain may be misunderstood-contributing to illness propagation, as reported in somatization literature. Pain words may even be presented as a tool of manipulation, where report of pain is verbiage in pursuit of utilitarian social consequence. Thus, primum non nocere--first, do no harm--is not easily achieved in the pharmacological treatment of pain, particularly in pain reported chronically. Herein, we examine the pharmacological treatment of chronic pain, and we suggest strategies for improved management that are based on solid principles derived from extensive experience which may protect against the problems derived from the vague and subjective nature of pain symptoms. Optimal treatment of chronic pain may be assisted by three paradigms: (1) an adequate model of appraisal, (2) treatment focused on pathophysiology (whether physical, psychosocial, or some combination of these), and (3) frequent reassessment of total social function. By these approaches, contribution to drug abuse, diversion, and life deterioration can be largely avoided. Whereas the emphasis here is pharmacological management, the principles may be more widely applied to other therapies of chronic pain.     

Neuromuscular Function in Painful Knee Osteoarthritis

Pain is a major cause of impaired mobility in elderly patients with chronic osteoarthritis (OA) of the knee. Central sensitization and impaired nociceptive inhibitory mechanisms have both been identified as contributing factors to heightened pain in this patient population. While central sensitization has been shown to produce enhanced pain responses and spread of pain to adjacent and remote body regions, conditioned pain modulation has also been shown to be adversely affected, and may be characteristic of those patients with chronic pain. Alterations of quantitative sensory testing measures have been demonstrated in patients with knee OA, and may serve as a clinical means of staging chronic musculoskeletal pain, including assessment of hyperalgesia and hypoesthesia. In addition, pain and altered somatosensation commonly associated with OA may be correlated with functional deficits.     

Finger pain

The local, systemic, and referred causes of finger pain are generally recognizable by historical features and physical examination findings, although radiographs and laboratory evaluation are often required to support the diagnostic impression. Most minor traumatic causes of finger pain require only conservative management, including immobilization followed by exercise. Infectious causes of finger pain include cellulitis, tendinitis, paronychia, felon, and infectious emboli, which generally require antibiotics with or without drainage. Certain patients with finger pain resulting from infection should be referred to a hand surgeon. Vascular and ischemic causes of finger pain represent true emergencies, because tissue viability is dependent on prompt intervention. Whereas any sensory neuropathy may present with finger pain, carpal tunnel syndrome is among the most common. Systemic rheumatic disease, such as rheumatoid arthritis or vasculitis, may begin with finger pain. In addition, such pain may be the first manifestation of a serious systemic illness, as in hypertrophic pulmonary osteoarthropathy. Reflex sympathetic dystrophy is an example of referred pain, presumably by way of neural mechanisms. Certain infectious, traumatic, and ischemic causes of finger pain must be diagnosed promptly to avoid significant morbidity; depending upon the cause of the symptoms, referral to a hand surgeon, rheumatologist, or neurologist may be appropriate. Symptomatic and functional improvement may also be hastened by the input of an occupational therapist.     

Douleurs chroniques et traumatismes psychiques

Chronic pain may occur at the consequence of trauma, which may be either unique or repeated (and may even be a reactivation of past trauma). The resulting pain may take numerous forms such as simple chronic pain, conversion phenomena, subjective syndromes or even posttraumatic hypochondria. Clinical or biological signs of posttraumatic stress disorder must be investigated systematically in these patients, in order to set up an appropriate treatment plan.     

Diagnosing heel pain in adults

Heel pain is a common condition in adults that may cause significant discomfort and disability. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Narrowing the differential diagnosis begins with a history and physical examination of the lower extremity to pinpoint the anatomic origin of the heel pain. The most common cause of heel pain in adults is plantar fasciitis. Patients with plantar fasciitis report increased heel pain with their first steps in the morning or when they stand up after prolonged sitting. Tenderness at the calcaneal tuberosity usually is apparent on examination and is increased with passive dorsiflexion of the toes. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain. Calcaneal stress fractures are more likely to occur in athletes who participate in sports that require running and jumping. Patients with plantar heel pain accompanied by tingling, burning, or numbness may have tarsal tunnel syndrome. Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese. Less common causes of heel pain, which should be considered when symptoms are prolonged or unexplained, include osteomyelitis, bony abnormalities (such as calcaneal stress fracture), or tumor. Heel pain rarely is a presenting symptom in patients with systemic illnesses, but the latter may be a factor in persons with bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions.     

23. Pain in Patients with Cancer

Abstract: Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients’ quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization’s pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.