The purpose of this course is to provide an overview of pain management. It is meant to fulfill the requirements for the six-hour mandatory course in pain/pain management mandated by Oregon State Bill 885.
At the completion of this course, the learner will
Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Merskey & Bogduk, 1994). Nerve stimulation leads to the physical component of pain. Pain results from an injury and may be confined to a discrete area, or it can be generalized to conditions such as fibromyalgia. Nerve fibers transmit pain impulses to the brain where the brain can personalize the pain experience (www.Medicinenet.com, 2016).
Patients may experience acute, chronic, or cancer pain. Acute pain follows injury to the body and generally disappears as healing takes place. There is an identifiable pathology that accounts for the pain. It may arise from operative procedures or from tissue trauma associated with an inflammatory process. It may be associated with objective physical signs such as increased heart rate, increased blood pressure, and pallor (autonomic nervous system activity); making patients "look" like they are in pain.
Chronic non-malignant pain is pain that lasts for an extended period of time. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity.
Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is typically related to tumor recurrence or treatment.
Pain is a major problem in today’s society. Pain carries with it consequences across a broad range of categories including ethical, social, economic and legal arenas. This course will discuss the ethical, social, economic and legal implications of pain and pain management.
Chronic pain affects approximately 76.2 million Americans (National Centers for Health Statistics, 2006). These numbers make it easy to understand that pain is one of the most common reasons that people seek medical attention. Pain is a common problem seen in primary care with about 20% of outpatient visits being for pain issues (Alford, Liebschutz, & Chen, 2008). Chronic pain affects about one in two long-term care residents (National Guideline Clearinghouse, 2013).
Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Every year, chronic pain leads to more than 50 million lost work days in the United States and costs the American taxpayer over 100 billion dollars (Stewart, Ricci & Chee, 2003).
Chronic pain is defined as pain lasting more than 3 months and may affect any part of the body. Chronic pain is most frequently caused by back pain (10%), leg/foot pain (7%), arm/hand pain (4.1%), headache (3.5%), and widespread pain (3.6%). Many affected by chronic pain have more than one type of pain (Hardt, Jacobsen, & Goldberg, 2008).
Acute pain typically has an abrupt onset and is often described as sharp. It is often caused by events such as a broken bone, surgery, childbirth, dental pain or burns. Acute pain may last a short period of time or may last for a few months. The pain dissipates when the underlying cause has healed. When acute pain lasts longer than 3-6 months, it is then termed chronic. It is possible that acute pain that is not treated properly may lead to chronic pain.
Multiple barriers to effective pain management exist. These barriers include many individuals, family, healthcare provider, society and political barriers.
The good news is that we have the knowledge and skills to effectively manage most pain. So what is the problem? Why is unrelieved pain still so prevalent?
Knowledge is important. Clinicians, as well as patients, need to be made knowledgeable about methods of assessing and managing pain. Knowledge alone rarely changes practice. Efforts must go beyond education alone if pain treatment is to improve. Pain needs to be made visible so it will not go unnoticed by clinicians.
Pain theories help clinicians understand pain and help in the guidance of the treatment of pain. Pain theories have been around for many years. One of the first pain theories was the Intensive Theory which was created by Plato in the fourth century BCE. It defined pain as an emotion that happens when a stimulus is more intense than usual. It has been refined over the years by other scientists/philosophers. The theory suggests that repeated tactile stimulation produces pain.
The Specificity Theory of Pain suggests that certain pain receptors send out signals to the brain that creates the awareness of pain. According to the theory, pain is an independent sensation with particular peripheral sensory receptors, which act in response to damage to drive signals through the nervous system to centers in the brain.
Other theories that came to light in the 1900’s include the Pattern Theory, Central Summation Theory, the Fourth Theory of Pain and the Sensory Interaction Theory.
A more recent theory is the Gate Control Theory. Pain stimulation is transmitted by small, slow fibers that go into the dorsal horn of the spinal cord. The theory states that there is a gate in the spinal cord which controls sensory information through the spinal cord. When there is more pain stimulation, the gate blocking is less effective. When there is a lot of activity in the pain fibers, the gates open. When there is stimulation of the A-beta fibers, which provide stimulus for mild irritation such as lightly touching the skin (massage), the gates may be closed. This inhibits the perception of pain.
In addition, messages that descend from the brain – such as those in anxiety states or extreme excitement – can affect the opening or closing of the gates.
The Biopsychosocial Model of Pain suggests that pain involves not just physiological factors but also psychological and social factors. It suggests that family and culture influence the perception of pain and the individual’s response to pain involves not just physiological factors but also psychological and social factors.
Pain – “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (Merskey & Bogduk, 1994).
Acute pain – Pain that has an abrupt onset and offers a warning of a disease process or a threat to the body.
Chronic pain – Pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal. Pain without apparent biologic value that has lasted beyond the usual tissue healing time (typically at least three months). Some define chronic pain as pain that continues for at least six months (America Psychiatric Association, 2013).
Maladaptive pain – Pain that is not useful and is out of proportion to tissue damage. This type of pain tends to last long after tissue healing and is often due to changes in the central nervous system.
Adaptive pain – Pain that protects the individual from injury and aids with healing after an injury.
Allodynia — Pain from a stimulus that typically does not cause pain.
Hyperesthesia – Increased sensitivity to stimulation.
Paresthesia— An unusual sensation that is often described as burning or prickling and commonly affects the extremities.
Visceral pain – Pain from the viscera mediated by stretch receptors. This pain is commonly described as deep, dull, poorly localized and cramping.
Nociceptive pain – Pain from threatened or real tissue damage to non-neural tissue that is caused by the activation of nociceptors.
Neuropathic pain – Pain from abnormal neural activity from an injury, disease process or dysfunction of the nervous system.
Mononeuropathy - Neuropathy affecting one nerve.
Polyneuropathy – Neuropathy affecting several nerves.
Anatomy and physiology are key factors in understanding pain. Primary afferent fibers are involved in the transmission of pain. Adelta and C fibers transmit noxious stimuli from the body’s periphery to the dorsal horn of the spinal cord. The A delta fibers have a small diameter and are lightly myelinated and conduct slowly. They transmit rapid, sharp pain. C fibers are small and unmyelinated fibers that conduct slowly and respond to multiple stimuli and lead to dull, achy pain. If the pain signal is strong enough, it transmits through the dorsal horn to the spinothalamic tract and the spinoreticular tract. These are the ascending tracts to the cerebral cortex where the stimulus is recognized as pain. When the pain is identified in the cerebral cortex, it descends back to the periphery.
The neurons are involved in the transmission of pain through the release of substances and neurotransmitters. The excitatory substances that contribute to pain include substance P, glutamate, prostaglandins, and nitrous oxide. Inhibitory neurotransmitters inhibit, or partially, the transmission of pain. Common inhibitory neurotransmitters include glycine, serotonin, norepinephrine, acetylcholine, and gamma-aminobutyric acid (GABA). Medications are involved in modulating these neurotransmitters to help reduce pain.
Pain affects multiple aspects of life. Pain can lead to physiological changes and potentially to physical illness. It has the potential to lead to cognitive changes as many patients with chronic pain suffer from depression and anxiety. Pain can change the way one thinks and acts leading to behavioral changes.
Pain has to potential to affect an individual’s social life. Chronic pain may limit the patient’s desire to interact in social settings. Social consequences of unrelieved pain may include isolation, inability or reduced desire to go to work and an overall reduced quality of life. Expression and reporting of pain can vary by culture. Some cultures have a more stoic attitude to pain, while others may express more emotion to pain.
The political arena can strongly influence pain in society. The assessment of pain over the last 20 years has focused on eliminating and reducing pain at all costs. This attitude has contributed to the opioid epidemic and many problems for society. In recent years, politicians have been implementing laws to help assure that pain is adequately assessed and treated with extra caution being placed on the prevention of medication abuse.
Many regulatory issues surround pain management. Pain management will be optimized when regulatory barriers are limited. The Institute of Medicine (2011) is calling for laws to be reviewed that have the potential to prevent optimal pain management. It is a challenging venture as regulations and law must be set up to optimally manages pain, but also to deter the abuse, diversion and illegal use of controlled substances.
Society, including regulations set in the political arena, must change to help assure that the negative effects of pain and the treatment of pain do not lead to further problems in society. Substance abuse/misuse and drug diversion are major problems associated with pain management.
Substance abuse issues are a real concern in the management of pain.
Opioid misuse and abuse is a major public health problem, and it affects 34.2 million Americans over the age of 12 (SAMHSA, 2012). According to the Center for Disease Control, in the United States, 46 people die each day from an overdose of prescription painkillers. In 2012, healthcare providers wrote 259 million prescriptions for painkillers (Center for Disease Control, 2014). Two times as many painkiller prescriptions are written in the United States as in Canada.
Misuse prevalence is variable.
The number of people who sought treatment for non-heroin opioid substance abuse increased from 1.0 percent in 1995 to 8.7 percent in 2010 (Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013). Research also shows that white individuals account for 88 percent of those who reported non-heroin opioid substance abuse and the majority of these individuals lived in a rural setting. Those who live in rural settings account for 10.6 percent of cases and urban individuals accounting for 4.0 percent of non-heroin opioid abuse individuals who sought treatment (Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013).
In 2010, there were 16,650 cases of drug overdose deaths involving opioid analgesics out of approximately 38,000 overdoses (Jones, Mack, & Paulozzi, 2013). Of the overdose deaths from opioid analgesia, thirty percent also involved benzodiazepines.
Opioids have the potential to provide analgesia and improve function. These benefits must be weighed against the potential risks including: misuse, addiction, physical dependence, tolerance, overdose, abuse by others, drug-to-drug and drug-to-disease interactions.
Risk factors for opioid analgesic misuse in those who have it prescribed for chronic pain include (Liebschutz et al., 2010; Edlund, Steffick, Hudson, Harris, & Sullivan, 2007): history of substance abuse, tobacco use, family history of substance abuse, history of legal problems, white race, diagnosis of depression or posttraumatic stress disorder and being less than 40 years old.
Opioid dependence costs the United States health care system one billion dollars annually (National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction, 1998). In addition, opioid dependence costs lost work productivity, legal costs and psychological effects of the victims of the crimes caused by the opioid abuse. In addition, opioid misuse leads to other diseases such as HIV, hepatitis and sexually transmitted disease.
Prescription drug misuse is the use of prescription medication in a method or intent inconsistent with how it was prescribed. This includes using medication to get high, selling or sharing it with other (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary but not solely a sufficient criterion for a substance use disorder.
Susceptible individuals are at risk to misuse medications that stimulate the reward center of the brain which may include: opioid analgesics, stimulants, benzodiazepines or tranquilizers.
Drug abuse is when drugs are not used medically or socially appropriately. Controlled substances may lead to dependence, either physical or psychological. Physical dependence transpires when there are withdrawal symptoms such as anxiety, tachycardia, hypertension, diaphoresis, a volatile mood, or dysphoria after the rapid discontinuation of the substance. Psychological dependence is the perceived need for the substance. It makes the person feel as though they cannot function if they do not have the substance. Psychological dependence often kicks in after physical dependence wears off. It typically lasts much longer than physical dependence and often is a strong contributing factor to relapse.
Addiction is a psychological dependence and extreme behavior patterns associated with the drug. At this point, there is typically a loss of control regarding drug use. The drug is continued despite serious medical and/or social consequences. Tolerance, increasing doses of the medication needed to produce an equivalent effect, is typically seen by the time addiction is present. Physical dependence can occur without addiction. Individuals who take chronic pain medication may be dependent on the medication, but not addicted.
Addiction is a major concern in those taking opioids. When opioids are prescribed, it is important to determine who is likely to participate in aberrant drug-related behaviors. This may occur in those with major depression, psychotropic medication use, younger age or those with a family or personal history of drug or alcohol misuse (Boscarino et al., 2010). Those at high risk for addiction should likely be managed in concert with a specialist (Sehgal, Manchikanti, & Smith, 2012).
Aberrant behaviors may include abuse, misuse or addiction. Examples of aberrant drug-related behaviors include: requests for early refills, not taking medications as prescribed, failure to keep appointments, visits in distress, frequent reports of lost medication, using multiple prescribers, positive urine drug test for illicit substances, altering prescriptions, resistance to referrals, resistance to providing prior medical records, resistance to change in therapy, increasing the dose without telling the prescriber, or requests for specific drugs.
The Federal government has an important role in combating substance abuse. They have the responsibility to support states and provide tools, data and guidance to help healthcare providers prescribe safely. Increased access to mental health care and substance abuse treatment programs will reduce the risk and consequences of substance abuse. The government can also work to increase access to naloxone for first responders.
Many states, including Oregon, have prescription drug monitoring programs. Healthcare providers need to assure that they are using these drug monitoring programs to find patients who are misusing prescriptions and placing them at risk of overdose.
Multiple factors are associated with a risk of overdose death. Some factors include: using 4 or more prescribers, using four or more pharmacies and getting more than 100 morphine equivalents per day (Gwira Baumbladd et al., 2014).
In addition to opioids, other medications are associated with misuse including stimulants, sedatives, hypnotics and others. The use of stimulants has increased over recent years. Abuse is most common in those 18-25 years old. In the last year, 2-5 percent of high school students misused methylphenidate (Wilens et al., 2008). Among college students, 5-6 percent misused stimulants in the last year, and 5-43 percent misused stimulants over their life (Bogle & Smith, 2009).
Stimulants have the potential to cause tachycardia, high blood pressure, increased body temperature, reduced appetite, anxiety, reduce sleep, agitation and paranoia. An overdose of stimulants may lead to agitation, tremor, confusion, anxiety, delirium, mydriasis, hyperreflexia, aggressiveness, hallucinations, delirium, paranoia, seizures and movement disorders (Spiller, Hays, & Aleguas, 2013).
Risk factors for abuse of stimulants include (Kaye & Darke, 2012; Substance Abuse and Mental Health Services Administration, 2013): white race, past-month use of cannabis, grade point average less than 3.5, being a member of a fraternity or sorority and one episode or more of binge drinking in the last two weeks.
Of those 12 and older, there was a 0.1-0.2 percent non-medical use of sedatives and 0.7 to 0.9 percent non-medical uses of tranquilizers (Substance Abuse and Mental Health Services Administration, 2013). The combination of sedatives and hypnotics, especially with alcohol or opioids is often the cause of overdose death (Hall et al., 2008).
Risk factors for non-medical use of tranquilizers and sedatives include white race, female, panic symptoms, cigarette use, illicit drug use, alcohol abuse, unemployed and uninsured (Becker, Fiellin, & Desai, 2007).
The Joint Commission (JC) recognizes that pain control is an important part of quality health care. They acknowledge that pain is considered the fifth vital sign and should be assessed with other vital signs. According to the JC, patients have the right to assessment and treatment of pain. Other beliefs of the JC include:
The State of Oregon has multiple initiatives to assure proper pain management. The Oregon Pain Management Commission was created to enhance the management of pain. The Commission makes recommendations, provides education, and is involved in research and policy to improve pain control. In the State of Oregon, many healthcare providers (e.g., nurses, physicians, physician assistants, acupuncturists, podiatrists, chiropractors, naturopaths,psychologists, etc.) are required to take a pain management course. This course includes seven hours of pain management education, and it must include one hour that is provided by the Oregon Pain Management Commission.
The Oregon Medical Board desires effective pain control which includes the use of specialists, adequate record keeping, coordination of care, and the use of the Prescriptions Drug Monitoring Program. The Prescription Drug Monitoring Program is a database that tracks the dispensing and prescribing of controlled substances to patients. It helps healthcare providers identify patients at high risk to abuse medications
In 2009, Oregon Senate Bill 355 created a Prescription Drug Monitoring Program for all Schedules II, III and IV controlled substances dispensed to Oregon residents. Authorized healthcare providers can only access information to patients under their care.
In 2014, Senate Bill 470 went into effect in Oregon. It made multiple changes to Oregon Senate Bill 355 including: it allowed staff members of prescribers and pharmacists to access the Prescription Drug Monitoring Program, allowed prescribers in neighboring states to access the system if they are treating residents of Oregon, allowed public health officials to use de-identified data from the system and allowed prescribers to review prescriptions under their DEA number.
The Intractable Pain Treatment Act, which was passed in 1995, has a goal of improving pain control but providing immunity to prescribers for prescribing opioids to those with intractable pain. In 2008, the state of Oregon removed the term Intractable Pain from the Act, so the Act could be applied to a wider range of pain.
In 1997, Oregon implemented the Oregon Death with Dignity Act. It allows terminally ill adults to self-administer lethal doses of medications that they obtained via prescription from their physician.
In 1998, the Oregon Medical Marijuana Act was passed. This allows Oregon residents, who have a recommendation from their physician, to use, cultivate or possess marijuana. Conditions that are allowed under this act include: cancer, HIV/AIDS, severe pain, agitation secondary to Alzheimer’s disease, glaucoma, nausea, seizures, and persistent muscle spasms.
Pain and its management is surrounded by multiple ethical issues. Healthcare providers should attempt to minimize pain and suffering while maintaining a balance between adequate pain management and minimizing harm from the treatment of pain. The healthcare provider has to do no harm and must guard against overmedicating the patient. The healthcare provider has to be aware of negative consequences of pharmacotherapy including physical dependence, tolerance, and abuse.
Some think that pain management is a human right. Medical organizations do not consider pain management an explicit duty of the prescriber, except for a part of good medical care. If pain is considered a human right, it will force the government in the middle of the patient-physician relationship (Hall & Boswell, 2009).
Access to healthcare is not equitable and brings up questions of justice. Certain populations are at a disadvantage when it comes to access to pain management. Individuals who do not have insurance may lack the means to receiving medical care and pain management. Individuals who are more likely to have access to care include: those who are older, those who live in a suburb, those who have insurance or a college degree or have a high income. Those with less access to care include those with financial problems and those of Hispanic ethnicity (Nguyen, Ugarte, Fuller, Haas & Portenoy, 2005).
Ethical issues surround end of life care. The management of pain at the end of life is a moral duty of the provider caring for a terminal patient. While opioid use may suppress respiration and may even hasten death, the treatment of pain is an important part of care for intractable pain as death nears. The goal of giving pain management is to relieve suffering, not to accelerate death. The use of palliative sedation may be considered to manage refractory pain at the end of life.
The assessment of a pain patient is a critical aspect of the proper management of pain. It requires a team approach. The physician or advanced level provider relies on other support personnel such as nurses, nurses’ aides and therapists in assuring proper assessment of the patient
Complex patients require a full assessment which includes pain characteristics, the impact of pain on functional status, treatment history, past pain experiences and how it affects the patient’s psychological state including relationships.
Basic pain assessment is simple and must be performed regularly. Action needs to be planned on the basis of the patient’s report of pain.
It makes no difference whether patients are in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic or being cared for by a home care agency. No matter where patients are, the intensity of pain should be assessed and documented (1) during the initial evaluation of the patient, (2) after any known pain-producing procedure, (3) with each new report of pain, (4) at regular intervals when vital signs are taken, and (5) at suitable intervals after pharmacologic (45-60 minutes after oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.
Measuring the severity of pain is often done on scales. Pain scales are meant to compare the intensity of the patient’s pain at different points in time, not to compare one person’s pain to another. The use of pain scales assists the healthcare provider to determine the effectiveness of pain treatment.
The best scales are those that are brief, valid, require minimal training to use, and use both behavioral and descriptive measures of pain. When selecting a scale, it is important to consider which type of scale would work best for the individual patient.
A "0 to 10" numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients are asked to rate their pain from 0 to 10, with "0" equaling no pain and "10" equals the worst possible pain they can imagine.
Another scale allows the patient to rate their pain as, “no pain, mild pain, moderate pain, severe pain, or unbearable pain." Pain maps can be used for those who have a difficult time speaking. In a pain map, there is a front and rear view of the body on a piece of paper and the patient draws on the location of the pain and may rate the severity of the pain.
Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, for example, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe that they are the best judges of a person´s pain; however, many studies demonstrate that healthcare providers either over or underestimate a patient´s pain.
For patients who are NOT cognitively impaired but who cannot respond verbally and/or rate their pain numerically, faces scales with happy faces representing no pain (0), and progressively sadder faces representing increasing pain intensity may be used. The patient is asked to choose the face that best depicts how they are feeling.
Besides current pain intensity, the complete pain assessment includes the following:
|1.||Location of pain|
|2.||Pain intensity for the worst pain, the best pain gets, and the acceptable level of pain. Satisfactory pain relief is a level of pain that may be noticeable, but not bothersome.|
|3.||Character or quality of pain. The words used by the patient to describe pain may enhance the understanding of the etiology of the pain and provide usefulness in selecting interventions to manage it. For example, somatic (musculoskeletal) pain is usually localized and described as dull, achy, and sore. Visceral pain is usually poorly localized and described as cramping or squeezing. Descriptors of burning, shooting or knife-like are indicative of neuropathic (nerve) pain. (Refer to Table 1).|
|4.||Onset, duration, variations and pattern (is the pain better or worse at certain times, certain hours?)|
|5.||Alleviating factors – what makes the pain better?|
|6.||Aggravating factors – what makes the pain worse?|
|7.||Impact of pain on quality of life and daily functioning. How does the pain affect sleeping, relationships with others, mood, emotions, concentration, for examples?|
|Tumors occupying the liver, pancreas, spleen; abdominal or thoracic|
|Dull, achy, throbbing, sore||Bone metastases, musculoskeletal injury, mucositis, skin lesions|
It is also important to document the impact pain has on quality of life. Key questions to ask include:
Understanding how pain was treated in the past for the patient will help the clinician treat the current pain. A review of past medical records will help the pain management team evaluate the condition. Reviewing all previous history, diagnostic testing, treatment options and the efficacy of those treatment options will help the team make an accurate diagnosis and manage pain appropriately. Certain treatment modalities, including specific medications, are often more effective in one individual when compared to another based on individual genetic variations.
Having a full understanding of all medical and surgical conditions can be very helpful in assuring proper pain management. Chronic disease may have a strong impact on the management of pain. Chronic kidney disease, for example, can affect the way that drugs are excreted. The use of non-steroidal anti-inflammatory medications can lead to kidney failure in those with chronic kidney disease.
A mental health evaluation can help the clinician understand the best way to manage pain. Mood or cognitive disorders can affect the way the pain is managed. If mental illness is not appropriately identified and managed, chronic pain will likely never be adequately managed. A history of drug abuse is an important factor to ascertain, as this could profoundly affect how chronic pain is treated.
Personal characteristics may have a strong effect on pain management. Factors that influence pain include race, age, culture, religion, sex and/or language.
Review of the patient’s perception of the pain is important. Why does the patient believe they have persistent pain? Does the patient feel there was adequate workup done on their condition? What does the patient expect out of treatment and what are the patient’s goals? In addition, psychological factors that contribute to the pain should be assessed. This will help assess the patient’s expectations. It is important for patients to have realistic expectations about pain management.
A complete physical exam is an essential part of the management of pain. It is important to have a baseline examination so subsequent evaluations will allow the health care team to determine progress in pain management and functional capacity.
The physical exam should include a detailed neurological exam including the patient’s ability to ambulate. While exams may include general observations, exams may be focused according to the presenting condition. Observing hygiene, posture, dress and appearance is important. Those with severe pain will often have poor hygiene, unkempt dress and appear to be in pain. Observe for any splinting, which may suggest a painful part of the body. Assessing skin and joints for redness, swelling or deformities helps determine the location and etiology of pain. An abdominal exam for any tenderness or distention should be done. In addition, checking joints for range of motion is an important part of the physical exam in chronic pain. The exam should include an evaluation of functional capacity, strength, endurance and any pain related limitations
Ongoing monitoring for the efficacy and effectiveness of the implemented plan is important. Utilizing similar assessment tools, the healthcare provider can document the effectiveness of the pain management plan on the patient, which will include any improvement in quality of life.
Diagnostic testing can be helpful in evaluating painful conditions. It is important to realize that an abnormal diagnostic test does not confirm the source of the pain. Blood tests can be helpful in some conditions to determine or monitor certain causes of pain. For example, an elevated C-reactive protein or an erythrocyte sedimentation rate may be seen in those with polymyalgia rheumatica, infection or rheumatoid arthritis (which are all conditions that may cause pain).
Imaging may be necessary for some situation of chronic pain. X-rays, computed tomography and magnetic resonance imaging can help define the etiology of the pain. Caution must be utilized when using imaging as many abnormalities may be seen in imaging tests that are not the source of the pain.
An electromyogram (EMG) or nerve condition studies are often done to assess the cause of pain. The EMG measures the electrical activity of the muscle and can help find damaged muscle, nerves or neuromuscular abnormalities such as a herniated disc or myasthenia gravis. The nerve conduction study measures the ability of the nerves to send electrical signals and can help diagnose carpal tunnel syndrome or other neuropathies.
Goals of pain management are not necessarily complete pain relief. They may include a reduction in the amount of pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society and a reduction in health care utilization.
A pain management plan is more than just a prescription for pain medication. In addition to pharmacotherapy, it should include psychological and physical modalities to manage pain. It should be modified when interventions are not effective.
The patient should be provided education regarding the plan. It should include information about medications prescribed, other treatment options and methods to contact the pain management team.
When developing a treatment plan, there are many considerations. The type of pain should be considered. In addition, the effect the pain has on lifestyle including psychological, social and biological components of life should be considered.
Many factors affect the success of the treatment plan. Issues related to the patient, such as their ability to understand and apply the management plan, will help determine the success of the plan. The patient’s willingness to implement the whole plan can have a profound effect on the success of the plan. If a patient is willing to take a pill but is not willing to work on non-pharmacologic interventions (such as physical therapy or weight loss), then the plan will lose its effectiveness.
Current treatments to manage chronic pain are not very effective resulting in about a 30 percent reduction in pain (Turk, Wilson, & Cahana, 2011). The clinician has the responsibility to manage pain the best that they can because proper treatment of pain can result in a significant improvement in the quality of life.
General physicians lack training in the management of chronic pain (IOM, 2011). Referral to a pain management specialist may be indicated for those who have debilitating symptoms, those that need increased doses of pain medications, those who are non-responsive to treatments, or those with symptoms at multiple sites.
Caregiver or healthcare provider issues often affect the pain management plan. Many caregivers and healthcare providers do not have an accurate comprehension of the patient’s pain and may hold false beliefs regarding pain management. Caregivers and healthcare providers may be inhibited by fear of side effects from medications or concerns of drug addiction so may withhold giving medication to those who are in pain. In addition, caregivers/healthcare providers and patients may have discordant goals.
Controlled substances should be prescribed for a legitimate medical purpose with careful consideration of the patient’s safety, goals of therapy and efficacy of the treatment. Treatment of pain should include not only pharmacotherapy but also physical and psychological therapies.
Numerous non-pharmacologic therapies are used in the management of pain. These may include a combination of physical and psychological techniques. Some methods used other than medications include: physical therapy, exercise, massage, ultrasound therapy, heat/cold application, chiropractic manipulation, psychotherapy, biofeedback, relaxation therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), music therapy, injections, neuromodulation, spinal cord stimulation, deep brain stimulation, and radiofrequency ablation of nerve tissue.
For those with pain, a trial of physical therapy and/or occupational therapy can be helpful. With the help of a physical therapist, the use of exercises targeting a specific type of pathology can be helpful in the management of pain. Occupational therapists can be helpful in recommending devices that can assist in enhancing activities of daily living.
Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.
Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and/or anesthesia of the area stimulated.
Heat and cold therapies can assist in the management of pain. Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. The application of cold reduces muscle spasms secondary to underlying skeletal muscle spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of either one alone.
Multiple psychological techniques can aid in reducing pain. The basis for the use of these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient’s active participation.
Relaxation is a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.
Imagery/visualization involves mentally creating a picture by using one’s imagination. This may be a focus on a close person, a place of enjoyment, a past event, or anything that is thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus
Distraction from pain is the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are extremely effective means of distraction.
Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain.
Biofeedback is a technique to harness the mind’s power to allow the patient to be more aware of the sensations in the body. The exact mechanism that it works is unclear, but it promotes relaxation and helps reduce pain (Sielski, Reif, & Blombiewski, 2016).
Acupuncture is a neurostimulation technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer an explanation of how acupuncture works.
Music therapy may be used to treat pain. Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in a wide variety of health care and educational settings.
Music therapists use music to facilitate changes that are non-musical in nature. Studies done with arthritic patients demonstrated that music helps to relieve pain and anxiety, induce relaxation, promote healing, enhance mental function, improve communication, promote physical rehabilitation, and reduce stress providing positive changes in both mood and emotional state (McCaffrey & Freeman, 2003). Individuals doing music therapy listen to music created under the guidance of a specially educated and certified professional in music therapy.
It is believed that music, like relaxation and guided imagery, can strengthen the right side of the brain, which controls the body's healing processes. The theory of music therapy's effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the “pain pathway,” ultimately sending signals that provide pain relief. There are also signals that stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.
Different surgical interventions or procedures can be used in the pain management plan. Procedures may include injections, spinal cord stimulation, deep brain stimulation, neural ablative techniques, and surgical interventions. These are potential options for those in whom other methods have not controlled the pain.
Analgesic agents are often given orally as this is convenient and allows a relatively steady blood concentration of the drug. Pain medication may be administered on an as-needed basis for episodic pain, or it may be given routinely for chronic pain. The use of routine, around-the-clock medication sustains a steady state in the blood and offers better pain relief for those with persistent pain.
Classes of medications include non-opioid analgesic agents, antidepressants, muscle relaxants, antiepileptic medications, topical agents and opioids. Some get effective relief from one medication, but some get better pain relief from a combination of medications that work on different pathways. Unfortunately, research is sparse on combination medication in the management of pain.
Considering all co-morbidities is an important step in the management of pain. For example, when a patient is afflicted with chronic pain and depression some medications may help effectively manage both conditions (for example, duloxetine is approved to treat chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain in addition to depression). It is also important to establish the pathophysiology of the pain syndrome, evaluate the medication list, and consider the side effects of the medications being prescribed.
The clinician should distinguish between neuropathic pain and nociceptive pain. The etiology of neuropathic pain must be established and if the etiology is reversible, manage the underlying problem. For example, if a medication (e. g., metronidazole, nitrofurantoin, isoniazid, or many cancer agents) is the etiology of the neuropathy – stop that medication.
Medications used in the treatment of neuropathic pain include calcium channel alpha 2-delta ligands (gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine uptake inhibitors (SNRIs), the lidocaine patch and narcotic analgesics.
Nociceptive pain is typically treated with non-narcotic and opioid analgesia. Common causes of nociceptive pain include arthritis and chronic low back pain. Acetaminophen is often used as a first-line agent in the management of nociceptive pain.
Acetaminophen is associated with a risk of hepatotoxicity when doses are more than three to four grams per day. When more than four grams is consumed for more than four days, an increase in serum liver aminotransferase levels in noticed. Hepatotoxicity may occur even at therapeutic doses of acetaminophen, particularly in those who chronically use alcohol (Jalan, Williams & Bernuau, 2006).
Acetaminophen is not an anti-inflammatory agent but is a very common over the counter medication used for the management of pain. It is recommended as a primary agent in the management of hip and knee osteoarthritis (Zhang et al., 2007). Acetaminophen is commonly administered with opioid medications to reduce the amount of opioid medication needed to manage the pain. There is some evidence of renal toxicity with long-term use of high-dose acetaminophen over the years.
Acetaminophen is dosed 325 to 650 mg every four hours or 500-1000 mg every 6 hours, not to exceed 3000 to 4000 mg a day. In the pediatric population, acetaminophen is dosed at 10-15 mg/kg/dose every 4-6 hours with a maximum of 75 mg/kg/day, but no more than 4000 mg a day. The dose should be reduced in those with hepatic insufficiency or alcohol abuse. Absolute contraindication to acetaminophen is liver failure while relative contraindications include chronic alcohol abuse or hepatic insufficiency. Those who are on a statin cholesterol medication may need a lower dose of acetaminophen.
Before going to a stronger pain medication, it is important that clinicians determine that acetaminophen is given in the proper dose. The use of up to 1000 mg per dose (in adults) may be necessary to provide relief.
Even though acetaminophen is better than placebo for the relief of osteoarthritic pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are more effective than acetaminophen (Lee et al., 2004).
NSAIDs are used as alternative options to acetaminophen and are indicated for mild to moderate pain, while some are indicated for severe pain. Like acetaminophen, they act synergistically with opioids.
NSAIDs are considered an alternative to acetaminophen for mild to moderate osteoarthritis or chronic low back pain (Fendrick & Greenberg, 2009). When compared to acetaminophen, NSAIDs are considered more effective in providing relief from hip and knee pain in osteoarthritis (Fendrick & Greenberg, 2009). Because they act as an anti-inflammatory agent, they are often used for arthritis, strains, sprains, bursitis and tendonitis.
NSAIDs are associated with more side effects and are potentially more problematic, especially in older adults. In older adults, the American Geriatric Society guidelines recommend that persistent pain due to osteoarthritis not be primarily managed with non-steroidal anti-inflammatory agents. The use of topical NSAIDs is a good option for those with localized pain.
Oral cyclooxygenase-2 (COX-2) inhibitors, celecoxib (Celebrex) is the main agent on the market in this class, have equal effectiveness when compared to non-selective NSAIDs, but are associated with fewer gastrointestinal side effects (Jones & Lamdin, 2010). The majority of NSAIDs are equally effective (Roelofs, Deyo, Koes, Scholton & vanTulder, 2008), but if one agent is ineffective it may be reasonable to try a different NSAID as there is individual variation response to different medications (Table 2).
Absolute contraindications to NSAIDs include an active peptic ulcer, chronic kidney disease or heart failure. Relative contraindications include a history of peptic ulcer disease, Helicobacter pylori infection, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids.
Side effects of NSAIDs include gastrointestinal bleeding, renal insults, adverse cardiovascular effects, headaches, constipation and mental status changes. Gastrointestinal effects may include gastric ulceration and dyspepsia. Taking the medication with food or antacids may reduce the risk of dyspepsia. Those at high risk of gastric ulceration – older age, on corticosteroids, bleeding problems, or a history of gastric ulceration – should likely not use NSAIDs. The use of a proton pump inhibitor reduces the risk of gastric ulceration with the use of NSAIDs. NSAIDs have the potential to interact with many antihypertensive medications, aspirin, selective serotonin reuptake inhibitors, corticosteroids and warfarin.
The use of misoprostol or proton pump inhibitors may be considered with NSAIDs to reduce the risk of gastrointestinal ulceration. It may be reasonable to use a COX-2 inhibitor in those at high risk for gastrointestinal bleeding. In very high-risk patients a COX-2 agent along with a proton pump inhibitor can be considered. It is also important to check for and eradicate Helicobacter pylori in those when it is present to reduce the risk of NSAID-induced gastrointestinal injury.
NSAIDs have the potential to cause nephrotoxicity. NSAIDs inhibit prostaglandin synthesis which leads to vasoconstriction of the afferent arteriole in the kidney. This results in a reduction in the glomerular filtration rate. NSAIDs should be used cautiously in those with renal impairment.
NSAIDs have the potential to lead to cardiovascular complications. The use of NSAIDs interferes with the cardioprotective effect of aspirin, raises blood pressure and may exacerbate heart failure. NSAIDs also may increase the risk of clotting and should be used extremely cautiously in those with a history of venous thrombosis. For those with high cardiovascular risk, the use of NSAIDs should be limited.
NSAIDs may interfere with the antiplatelet activity of aspirin therapy (Gladding et al., 2008). Chronic NSAID use should be avoided by those who are on chronic aspirin therapy. They should also be avoided in those with thrombocytopenia (low platelet count). Patients receiving warfarin or heparin should not receive NSAIDs.
Antidepressant medications are effective for multiple types of chronic pain. They have shown effectiveness in neuropathic pain, fibromyalgia and pain associated with depression. This next section will look at some of the antidepressants used in the management of pain.
Tricyclic antidepressants (TCA) modify pain by inhibiting the uptake of norepinephrine and serotonin and block multiple channels including the sodium, adrenergic, cholinergic and histaminergic channels. Medications in this class include nortriptyline, desipramine, amitriptyline and imipramine.
Nortriptyline and desipramine (secondary amine tricyclic antidepressants) are preferred agents in this class as they are associated with a better side effect profile. These agents are often used in the management of neuropathic pain, but can also be used in chronic pain management as adjuvant agents.
In order to achieve moderate pain relief, the number needed to treat for one patient to see benefit for imipramine is 2.2, for desipramine is 2.6 and for amitriptyline is 3.1 (Saarto & Wiffen, 2007).
Tricyclic antidepressants need to be used cautiously in older adults as they have many side effects (constipation, dry mouth, mental status changes, blurred vision, urinary retention, blood pressure change, tachycardia, and heart block). They should be used very cautiously or not at all in those with cardiac or electrocardiographic abnormalities. The analgesic effect is typically noticed in a shorter period of time and at a lower dose than when treating for depression. Some patients will have a diminishing of side effects as their body adapts to the medications.
In adults, most TCAs are often started at 10 mg per day and is then titrated up to 75 mg per day. Older individuals rarely tolerate doses more than 75-100 mg per day. It may take up to 8 weeks before analgesia is appreciated, but pain relief may be noticed as soon as one week.
Serotonin-norepinephrine reuptake inhibitors are used for neuropathic pain but can be used for other types of pain. Duloxetine (Cymbalta) is indicated for diabetic neuropathy and painful chronic musculoskeletal conditions such as osteoarthritis and chronic low back pain. It is also approved for fibromyalgia. Common side effects include insomnia, drowsiness, dry mouth, fatigue, nausea and dizziness.
Duloxetine should be started at 20-30 mg per day for at least a week before increasing to 60 mg per day. It should not be used in those with severe renal insufficiency or hepatic insufficiency. When stopped it should be tapered slowly due to withdrawal symptoms.
Venlafaxine (Effexor), another SNRI, is sometimes used for neuropathic pain, but it is an unlabeled use. It is dosed between 75-225 mg per day, and it may take 1-2 weeks for relief to be noticed and may up to 6 weeks for full benefit (Grothe, Scheckner & Albano, 2004) Venlafaxine may lead to increased blood pressure. When the medications stopped, it should be tapered slowly to minimize withdrawal symptoms.
Gabapentin is approved in adults for post-herpetic neuralgia up to 3600 mg per day in divided doses. Dosage adjustment is needed in those with renal disease. It comes in an extended-release form called Gralise. Gabapentin is often used off-label for other neuropathic conditions including diabetic neuropathy, generalized neuropathic pain, anxiety, and post-operative pain.
Pregabalin (Lyrica) can be used in adults for fibromyalgia, neuropathic pain (diabetes related), neuropathic pain in those with spinal cord injury and post-herpetic neuralgia. It is started at 75-150 mg per day in divided doses. The typical effective dose is 300 mg per day in divided doses with a maximum dose is 600 mg per day. An adjustment in dose is needed in those with a creatinine clearance less than 60 mL/min. Pregabalin may interact with some angiotensin-converting enzyme inhibitors.
Topical lidocaine is used as first-line therapy for post-herpetic neuralgia. It must be applied to intact skin, and up to three patches may be applied for no more than 12 hours in a 24 hour period.
Muscle relaxants can be used in the management of acute and chronic pain. Cyclobenzaprine (Flexeril) was initially classified as a tricyclic antidepressant but was then remade as a muscle relaxer. Side effects are similar between the TCAs and the cyclobenzaprine including sedation, dry mouth, constipation, urinary retention and mental status changes.
Carisoprodol (Soma) is another commonly used muscle relaxer that has been increasingly linked to dependence. Due to the concerns of dependence, this medication is less commonly used. Older muscle relaxers include metaxalone (Skelaxin) and orphenadrine (Norflex). The most common side effect of all muscle relaxers is sedation.
Two medications, which are not FDA-approved as a muscle relaxer, are often used as muscle relaxers. Tizanidine (Zanaflex) is used to treat spasticity, but there is evidence that it works for acute and chronic pain (Argoff, 2012). Like other medications in this class, it often causes sedation. Lioresal (Baclofen) is another antispasmodic agent that is used for musculoskeletal pain.
NSAIDs are laced with risks, and some patients are unable to tolerate NSAIDs due to side effects and co-morbid conditions. The risk associated with NSAIDs is one reason many clinicians choose an opioid to manage pain. Opioid therapy is effective in the management of many chronic pain conditions including osteoarthritis, low back pain, neuropathic pain, and post-herpetic neuralgia.
In recent times opioids therapy has become more commonly used, in the past it was only used for severe acute pain and cancer pain. It is now the most common class of medications prescribed in the United States (Kuehn, 2007).
A recent position paper from the American Academy of Neurology suggested that there is evidence for good short-term pain relief with opioids, but no good evidence exists for the continuation of pain relief or improved function for extended periods of time without sustaining serious risk of dependence, overdose, or addiction (Franklin, 2014).
When non-opioid therapy is ineffective, or there is severe nociceptive pain, opioid therapy is often used. In chronic back pain, opioids do not improve pain scores any more than non-opioid therapy (Martell, O'Connor, & Kerns, 2007). Opioid therapy is often used to manage neuropathic pain but is commonly thought to be second line to antidepressants and anticonvulsants.
Opioid medications are associated with multiple side effects including constipation, nausea, vomiting, pruritus, abdominal cramping, sedation, and mental status changes. Multiple interventions are available to reduce side effects.
While there are many opioids, morphine is considered by many as a standard comparator for other drugs. Morphine can be given orally, rectally, intravenously, subcutaneously or intramuscularly.
Morphine is used for moderate to severe acute pain and chronic serious pain. It comes in multiple formulations. For acute pain, it is dosed at 10-30 mg every 4 hours for those who are opioid naïve. It is available as tablet, solution, suppository and parenteral solution. The immediate release tablet is dosed 15-30 mg every 4 hours as needed and the oral solution is dosed 10-20 mg every 4 hours as needed. It can also be given rectally and is often dosed 10-20 mg every 4 hours as needed. Morphine also comes in a controlled release form, a sustained release form and an extended release form.
Longer-acting formulations include:
Avinza: The initial dose for the opioid naïve patient is typically 30 mg a day, and 90 mg and 120 mg are only indicated for use in opioid-tolerant patients. When converting over from immediate-release morphine the first dose of Avinza may be taken with the last dose of IR formulation. The medication may be adjusted in 15-30 mg increments every 3-4 days. The maximum dose is 1600 mg a day because of the fumaric acid content.
Kadian: It is not indicated for initial opioid analgesia. For non-opioid tolerant patients, 30 mg once a day is recommended. Higher doses are indicated for opioid-tolerant patients. Titration may be done every 1- 2 days. When converting from other forms of morphine, it may be given once or twice a day.
MS Contin: is started at 15 mg every 8-12 hours with the dosage being adjusted every 1-2 days.
Side effects of morphine are similar to other opioid analgesics and include dry mouth, constipation, bradycardia, hypotension, nausea, drowsiness, dizziness, mental status changes, fever, itching, weakness, hypoxia and urinary retention.
Morphine should not be used in those with a hypersensitivity to morphine, those with toxin-mediated diarrheal disease, those with severe/acute asthma, paralytic ileus or severe respiratory depression. The extended-release form should not be used in those with GI obstruction.
The extended-release forms of morphine are not interchangeable. Changing from one medication to another should be done only by those experienced in how to do this. Extreme caution should be used when using a highly concentrated solution, so overdoses do not occur.
Drug interactions commonly seen with morphine include:
Fentanyl can be given as an injection, transdermal patch (Duragesic), an oral transmucosal lozenge (Actiq), a sublingual tablet (Abstral), a sublingual spray (Subsys), a buccal tablet (Fentora), a buccal film (Onsolis) and a nasal spray (Lazanda). The transdermal patch is used in opioid-tolerant patients with moderate to severe pain and is often started at 25 mcg per hour and changed every 72 hours.
Fentanyl can be used for multiple reasons including premedication for surgery, for general anesthesia, as an adjunct to general and regional anesthesia, and chronic pain management. The transdermal patch is indicated for around the clock pain management in those with chronic severe pain. Fentanyl transmucosal and intranasal is indicated for cancer pain.
While no official dosage adjustment is recommended in those with renal or hepatic impairment, those with mild to moderate renal or hepatic impairment should likely have the dose reduced by 50 percent with the patch, and the use is not recommended in severe renal or hepatic impairment. Transmucosal and nasal spray have no specific recommendations for dose reduction in renal or hepatic impairment.
Common side effects of fentanyl include dry mouth, edema, bradycardia, dehydration, respiratory depression, shortness of breath, diaphoresis, nausea/vomiting, constipation, application site erythema (patch), weakness, muscle rigidity, mental status changes, headache, sedation, and CNS depression.
As with most opioids contraindications includes hypersensitivity, toxin-mediated diarrheal disease, and paralytic ileus. It should not be used for short-term pain, post-operative pain and should not be used for those who have a severe respiratory disease. The transmucosal and nasal form of fentanyl are typically only used by specialists for opioid-tolerant cancer patients.
The patch form should not be exposed to external heat as this may increase absorption of the medication. Exercising with the patch on has the potential to increase absorption of fentanyl. In addition, patients with a fever may also notice an increase in absorption of the medication. The patch should only be applied to intact skin, and it contains aluminum and must be removed prior to an MRI.
Like many medications, there are multiple potential interactions. Some more common interactions include:
Fentanyl is pregnancy category C. It does enter the breast milk and is not recommended in the breastfeeding mother.
Oxycodone is a schedule II controlled substance and is available in multiple forms.
-Immediate release (Roxicodone) is dosed 5-30 mg every 4-6 hours (lower range for opioid-naive patients). There is also an abuse-deterrent tablet (Oxceta) that comes as a 5 mg and 7.5 mg tablet.
-The controlled release tablet (OxyContin) is indicated for those who require around the clock pain control. It is dosed 10 mg every 12 hours to start and titrated carefully. When changing from immediate release to extended release, start the extended release at half of the daily dose of oxycodone every 12 hours. When changing from transdermal fentanyl to extended release oxycodone, substitute 10 mg of extended-release oxycodone every 12 hours for each 25 mcg/hour of fentanyl. The oxycodone should be started 18 hours after the removal of the transdermal fentanyl patch.
-It also comes as an oral concentrate and an oral solution.
-Oxycodone is often combined with other analgesic agents such as acetaminophen (e.g., Percocet, Roxicet, Tylox), aspirin (e.g., Percodan, Endodan, Oxycodan) and ibuprofen (Combunox).
Those with a creatinine clearance less than 60 mL/min should have the dose adjusted down as serum concentration of oxycodone will increase in renal insufficiency. Those with hepatic impairment should have doses reduced; with the extended-release formulation the starting dose should be lowered one-third to one-half and slowly titrated up to affect.
Side effects include drowsiness, dizziness, itching, constipation, nausea and vomiting. Less common side effects include dry mouth, headache, abnormal dreaming, blood pressure changes, diaphoresis, weakness and fever.
Oxycodone is contraindicated in those with paralytic ileus, significant respiratory depression, hypercarbia, acute or severe bronchial asthma, and GI obstruction.
Caution should be used in those with biliary tract impairment such as acute pancreatitis as it may lead to constriction of the sphincter of Oddi. It may lead to an elevation of intracranial pressure (ICP) and should be used carefully those with intracranial lesions, elevated ICP or a head injury.
Extended-release tablets may be lodged into the GI tract including the throat in those with swallowing issues. It may also lead to intestinal obstruction or diverticulitis.
Common drug interactions with oxycodone:
Oxycodone is pregnancy category B and D if used for an extended period of time or near term. It does enter breast milk and is not recommended in those who are breastfeeding.
Hydrocodone, which was classified as a Schedule II Controlled Substance in October of 2014, is available as a combination pill with non-narcotic analgesia (e.g., Lorcet, Lortab, Norco and Vicodin) and by its self in an extended release form. The combination pill has a short-acting version of hydrocodone and is dosed 2.5 to 10 mg of hydrocodone every 4-6 hours as needed for moderate to severe pain.
Hydrocodone extended-release (Zohydro ER) is typically dosed 10 mg every 12 hours in treatment-naive patients. It is used for severe pain requiring around the clock dosing of hydrocodone. The dose may be increased every 3-7 days in 10 mg increments.
Those with severe hepatic impairment should start at the lowest dose and titrate up very slowly while monitoring for side effects. Caution should be used with renal impairment as plasma concentration may rise.
Side effects include constipation, nausea, vomiting, dry mouth, drowsiness, headache, dizziness, pruritus and nausea.
Contraindications to hydrocodone include paralytic ileus, severe asthma, severe respiratory depression and hypercarbia.
Hydrocodone is pregnancy category C. The extended-release form minimally enters the breast milk and should be used with caution in breastfeeding and the combination pill has been shown to enter breast milk and its use is not recommended.
As of August 18, 2014, the DEA placed tramadol into a Schedule IV of the Controlled Substance Act. It is indicated for moderate-to-severe pain, and the immediate release form is dosed at 50-100 mg every 4-6 hours for a maximum of 400 mg a day.
Tramadol is also indicated for chronic moderate-to-severe pain. For those who do not need a rapid onset of pain relief and/or affected by side effects, it may be dosed at 25 mg/day and titrated up every 3 days to 50-100 mg every 4-6 hours to a maximum of 400 mg a day.
Tramadol also comes in an extended release form, ConZip and Ultram ER, which is dosed 100 mg once a day and may be titrated by 100 mg every five days to a maximum dose of 300 mg a day.
When prescribing tramadol to older adults use the lower end of the dosage range and titrate slowly. In those over 75 years old, 300 mg a day should not be exceeded and utilize extreme caution with the extended release form.
In those with a creatinine clearance less than 30 mL/min, only the immediate release formulation should be used with doses of 25-100 mg split every 12 hours (maximum dose of 200 mg a day). In those with severe liver impairment, the immediate release form should be given at a maximum of 50 mg every 12 hours.
Side effects include flushing, dizziness, constipation, nausea, vomiting, dyspepsia, itching, headache, somnolence, insomnia and weakness. Less common side effects include orthostatic hypotension, mental status changes, euphoria, rash, hot flashes, diarrhea, dry mouth, anorexia, joint pain, blurred vision and sweating.
Patients may experience withdrawal symptoms from tramadol that may include nausea, diarrhea, anxiety, pain, sweating, tremor and rigors. Extended use of tramadol may lead to dependence, and these medications should be tapered slowly to reduce the risk of withdrawal symptoms.
Tramadol is contraindicated in those who are hypersensitive to the agent and those with severe liver or kidney impairment. The extended-release tablet should not be used with psychotropic drugs, opioids, hypnotics, acute intoxication with alcohol or centrally acting analgesics and the extended release capsule formulation should not be used in those with severe respiratory depression, severe asthma or hypercapnia.
Tramadol has been shown to increase the risk of seizures. This risk is increased in those who take serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics, other opioids, or other drugs that lower the seizure threshold. The risk may also be increased in those who have seizures or are at risk for seizures such as those who have a CNS infection, cancer, history of head trauma or while patients are going through drug or alcohol withdrawal.
Caution should be used in those with respiratory disease as those with significant disease may be at increased risk for respiratory depression.
Tramadol is pregnancy category C. It enters the breast milk and is not recommended in lactating women.
Ms. L is a 52-year-old female with a history of bilateral knee osteoarthritis; she currently rates the pain as a 7/10 in her right knee and 6/10 in her left knee. She takes celecoxib 200 mg twice a day and uses 1000 mg of acetaminophen for breakthrough pain about 3 times a day. She has been stable with these medications for the past 6 months, but over the last month she has not been getting adequate relief from her pain and has been progressively disabled and has stopped exercising because of pain in her knees.
In addition to osteoarthritis, she has a past medical history of hypertension, dyslipidemia, depression, and obesity. She has a past surgical history of an appendectomy as a child. She is currently on atorvastatin, lisinopril, celecoxib and acetaminophen. She has no known allergies.
She has no history of alcohol, drug or substance abuse. She has a family network that is strong including a supportive husband of 25 years and 2 sons who live within twenty miles of her home. She has a past history of depression but is currently not depressed.
The physical exam shows significant crepitus in both knees and obesity (BMI of 34). She is unable to reach full extension of the right knee due to pain.
An x-ray demonstrates moderate arthritic changes in both knees. The patient is unwilling to consider surgery of her knees.
The prescriber offers tramadol immediate-release 25 mg in the morning, which is titrated every three days in 25 mg increments as distinct doses to 100 mg/day (25 mg four times a day). Pain control was still not adequate, and the dose was then increased by 25 mg every three days to 50 mg every 6 hours.
Pain control was significantly improved, and then the patient was given tramadol SR 200 mg once a day. The patient was able to function and exercise. Her quality of life was much improved.
|Drug||Initial dose (Treatment Naïve)||Duration of effect (in hours)||Notes|
|Immediate-release||10-30 mg every 3-4 hours as needed||3-6|
|Controlled-release ((MS Contin, Oramorph SR)||15 mg two times a day||8-12|
|30 mg one to two times a day||12-24|
|30 mg once a day|
|Immediate-release||2 - 4 mg every 3-4 hours as needed||3-6|
|8 mg every 24 hours||24|
|Immediate-release||5-15 mg every 4-6 hours||3-6||Often combined with acetaminophen or aspirin|
|Controlled-release (OxyContin)||10 mg two time per day||8-12|
|Extended-release (with acetaminophen) (Xartemis XR))||15 mg oxycodone with 650 mg acetaminophen every 12 hours||8-12|
|Immediate-release||5-10 mg every 6 hours||4-8||Combined with acetaminophen or ibuprofen|
|Extended-release (Zohydro ER)||10 mg every 12 hours||12|
|Fentanyl patch||25 mcg per hour changed every 72 hours|
48 to 72(12 hours after removal)
|Not for opioid naïve patients, or acute pain; onset 12-24 hours.|
|Immediate-release (Opana)||5-20 mg every 4-6 hours||4-6|
|5 mg two times a day||12|
|Methadone||2.5 mg every 8-12 hours||First dose 4-8 hours, up to 48 hours with repeated doses||High risk for overdose partly due to the long half-life; prescribed only by a trained prescriber|
|Immediate-release (Nucynta)||50 - 100 mg every 6 hours||3-6|
|Extended-release (Nucynta ER)||50 mg every 12 hours||Unsure|
|Immediate-release (tramadol)||50-100 mg every 4-6 hours||4-6||Max dose 400 mg/day|
|Extended-release (Ultram ER, ConZip)||100 mg once a day||Unsure||Max dose: 300 mg/day|
Oxymorphone, a schedule II medication, can be given intravenously, subcutaneously, intramuscularly or orally. For acute pain, the immediate-release tablet (Opana) is used at 5-20 mg every 4-6 hours as needed for opioid naïve patients. For those with chronic severe pain, the extended-release tablet is used (Opana® ER) and is started at 5 mg every 12 hours and may be titrated up at 5-10 mg increments every 12 hours every three to seven days. Caution should be used in those with a creatinine clearance less than 50 mL/minute, and the medication should not be used in moderate to severe hepatic impairment. Oxymorphone is pregnancy category C, and it is unclear if it is excreted in breast milk and should, therefore, be used cautiously.
Hydromorphone can be given orally, rectally, subcutaneously, intramuscularly or intravenously. The oral medication comes in standard and extended-release forms. The standard form is used for moderate to severe pain and is often dosed 2 to 4 mg every 4-6 hours. The oral liquid is typically dosed 2.5 to 10 mg every 3 to 6 hours. Parental and oral doses are not equivalent. The parenteral dose is five times more potent than the oral dose. The long-acting form (Exalgo) is used for opioid-tolerant patients who have chronic severe pain. It is dosed 8-64 mg once a day. Hydromorphone is pregnancy category C and is excreted in breast milk. It is not recommended for lactating women.
Methadone can be given intravenously, subcutaneously, intramuscularly or orally. The oral dose is started in the opioid naïve patient at 2.5 every 8-12 hours. Methadone is a high-risk drug to lead to overdose. It has a half-life of up to five days and may accumulate in the body. Methadone may also prolong the QT interval leading to cardiac arrhythmias especially at doses higher than 120 mg a day. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in the use of methadone. Methadone is also used in detoxification.
Tapentadol (Nucynta, Nucynta ER) is used for acute moderate to severe pain and started at 50-100 mg every six hours for the immediate-release formulation. The starting dose for the extended-release tablet is 50 mg every 12 hours. For chronic pain, it is typically dosed 50-250 mg two times a day as needed. The maximum dose is 500 mg a day. This medication is not recommended for those with severe liver or renal insufficiency. It is also indicated for diabetic peripheral neuropathy.
Propoxyphene has been taken off the US market as it has been linked with fatal cardiac arrhythmias. Meperidine is not recommended as a first-line agent for chronic pain as it is associated with high rates of central nervous system toxicity.
Many narcotics are available in liquid form for pediatric use. Acetaminophen with hydrocodone is available as an elixir. Acetaminophen with oxycodone and oxycodone alone is also available in liquid form. The dose is based on the oxycodone and is dosed at 0.05 to 0.15 mg/kg/dose every 4-6 hours to a maximum of 5 mg per dose. Morphine is available as an immediate release formulation and is dosed at 0.2 to 0.5 mg/kg every 4-6 hours to a maximum of 30 mg per dose. Hydromorphone is dosed at 0.05 mg/kg every 4-6 hours to a maximum of 5 mg per dose.
In 1970, section 812 of the Controlled Substance Act was enacted which lists substances that are controlled (Drug Enforcement Agency, 2014). The list describes basic or parent chemicals that may be classified as controlled substances. The Controlled Substance Act divides the drugs and other substances into five schedules, which is updated annually at http://www.deadiversion.usdoj.gov/21cfr/cfr/2108cfrt.htm .
Schedule I controlled substances have no accepted medical use in the United States, have a high potential for abuse and lack safety data. Substances in this class include heroin, marijuana, 3,4-methylenedioxymethamphetamine ("Ecstasy") and lysergic acid diethylamide (LSD).
Schedule II and IIN substances may potentially be abused and may lead to severe physical or psychological dependence. Schedule II narcotics includes oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Zohydro ER), fentanyl (Sublimaze, Duragesic),methadone (Dolophine), hydromorphone (Dilaudid), morphine, opium, and codeine. Examples of Schedule IIN stimulants include methylphenidate (Ritalin) and amphetamine (Dexedrine, Adderall).
Schedule III or IIIN substances have less abuse potential than those substances that are Schedule I or II. They are at high risk for psychological dependence and low to moderate risk of physical dependence. Examples of medications in this class include: buprenorphine (Suboxone) and products that have less than 90 milligrams of codeine per dosage unit such as Tylenol with Codeine. Medications that are considered Schedule IIIN include anabolic steroids such as Depo-Testosterone and ketamine.
Schedule IV controlled substances have a lower potential for abuse when compared to Schedule III controlled substances. Examples of medications in this class include: benzodiazepines, midazolam (Versed), modafinil (Provigil), tramadol (Ultram) and carisoprodol (Soma).
Schedule V controlled substances have a low abuse potential relative to Schedule IV substances. Examples of medications in this class include cough preparations that contain less than 200 milligrams of codeine per 100 milliliters or per 100 grams such as Robitussin AC, lacosamide (Vimpat), and pregabalin (Lyrica).
The Controlled Substance Act regulates five classes of medications: anabolic steroids, depressants, hallucinogens, narcotics and stimulants. Each class has different properties, and substances in each class typically produce similar effects. Most controlled substances alter mood, feeling or thought due to their effect on the central nervous system. Medications likely to produce euphoria are more likely to be abused, but medications may be abused to aid in sleep, reduce pain, reduce anxiety, reduce depression and improve energy.
When opioid therapy is prescribed, it is important to have a record of the discussion between the patient and provider. The documentation must include the diagnosis being treated and the medication that will be used to manage the diagnosis. In addition, the goals of therapy along with the anticipative results should be documented. Any alternative or additional therapies should be discussed. When discussing the medications, it is important to document significant adverse reactions, risk for addiction or withdrawal, and medication interactions.
To prevent prescription drug abuse, the clinician needs to assure:
Patients risk should be assessed, and contraindications should be immediately identified. Contraindications to opioid treatment include those who have an erratic follow-up, suffer from current untreated addiction or have poorly controlled mental illness (Chou et al., AmericanPainSociety-American Academy ofPain Medicine OpioidsGuidelinesPanel, 2009).
When taking a patient history, document the opioid currently prescribed, its dose, the frequency of use and the duration of use. It is important to query the state prescription drug monitoring program (PDMP) to confirm the patient’s report of prescription use. In addition, it is important to contact past providers to obtain medical records.
Before controlled substances are prescribed, history of illegal substances uses, alcohol use, tobacco use, prescription drugs use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network and cultural background should be assessed. History of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.
Multiple tools are available to evaluate for opioid risk. The Opioid Risk Tool is a tool that is used in primary care to screen adults for the risk of aberrant behaviors when they are prescribed opioids for chronic pain. It is a copyrighted tool, encompasses five questions and takes about one minute to use. It classifies a patient as low, moderate or high risk to abuse opioids. Those who are high risk have a high likelihood of an aberrant drug-related behavior. It is not validated in the individuals without pain. The five questions include asking about family and personal history of substance abuse (alcohol, prescription drugs or illegal drugs), age (risk is 16-45 years old), psychological disease and a history of preadolescence sexual abuse. The questions are scored with different points assigned for each question which is variable between men and women, and the total score is tallied. The patient is placed in low, moderate or high risk.
Regular follow-up is important and should occur at a minimum of every three months. When assessing the pain patient, the five A’s should be assessed: analgesia, addiction, activities of daily living, adherence and adverse effects. Part of the follow-up should be urine drug testing which can be used to detect medication adherence as well as illicit and non-prescription drug use. It is critical that the clinician adequately document any and all interactions with patients, assessments, results of testing and treatment plans.
Written treatment agreements, which should be used between prescribers and patients when controlled substances are used, help guide the conversation between patient and prescriber. It discusses expectations, the risks and the monitoring that will occur to limit the complications of controlled substances (Table 4).
Prescription monitoring programs are available in the majority of states, including Oregon. They provide an online database which lists all prescriptions of controlled substances dispensed to each patient by pharmacies. Ideally, the prescriber should check the database before prescribing controlled substances. If a patient has an undisclosed prescription for controlled substances, it is prescription drug misuse.
When abuse/misuse is detected how should the clinician respond? If it is alone, minor deviation than counseling along with more intensive monitoring may be all that is needed. Tapering controlled substance to reduce the risk of withdrawal is appropriate in more severe or persistent cases of misuse. When diversion is the cause of misuse, immediate removal of the prescription is likely the best course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.
Neonates feel pain like any other patient. Untreated or pain not treated appropriately may lead to long-term effects including altered sensitivity to pain (Kanwaljeet, 2016).
It is important to have a standard method to assess pain in neonates. It is difficult to assess pain in neonates and infants because they have limited ability to communicate. In this population, assessment is based on physiological and behavioral factors. Factors that suggest pain in the neonate and infant include vital signs, oxygen saturation, skin color, crying pattern, facial expressions, muscle tone and consolability. Scales for pain in neonates used in the neonatal intensive care unit include Neonatal Facial Coding System, Neonatal Infant Pain Scale and the Neonatal Pain Agitation and Sedation Scale. No tools are universally accepted to assess pain in infants and children. In neonates, pain assessment tools have a difficult time detecting pain in those with very low birth weight, on paralytic medications or those that have prolonged pain (Kanwaljeet, 2016).
Due to the difficulty in finding and quantifying pain in the neonate and young child, pain management should include an attempt to reduce or prevent pain in the face of potentially painful situations. It is important to limit the number of painful procedures performed on young children.
Pain in children is similar to adults. The source of the pain, along with its location and severity should be ascertained. In older children, self-reporting is a reasonable technique to assess pain. For those too young to understand self-reporting the use of scales such as the facial expression scale can be used. With the help of a caregiver, observing the child for verbal responses, motor responses or facial expressions will help the clinician determine the degree of pain in a non-verbal child.
Pain management in children should work to control, lower or prevent the pain. Pain management techniques are based on the severity, type, duration and source of pain. Non-pharmacological measures to control pain include physical/occupational therapy and cognitive/behavioral therapy.
Pharmacological agents may also be considered. Mild pain can be managed with NSAIDs or acetaminophen. When pain is not responsive to these medications, the use of stronger medications including opioids are considered. Regular assessment of pain control during treatment will help assure proper pain management. When pain is moderate to severe, providing pain medication around the clock is a reasonable option.
Adjunctive therapy can be used in children including medications to manage co-morbid depression and anxiety. The use of anticonvulsants for neuropathic pain may also be considered.
Age does not cause pain, but many conditions that cause pain are more common in older adults. In general, older adults are undertreated in regard to their pain partly because they have problems communicating pain (Feldt, Ryden, & Miles, 1998). Those with reduced vision, reduced hearing or impairments in cognition present a bigger challenge in the assessment of pain.
In individuals who are cognitively intact, self-report of pain is the most reliable method to assess pain (AGSPanel on Persistent Pain in Older Persons, 2002) For those who have cognitive impairment, simple questions and basic screening tools can often reliably identify pain. Long-term care residents are often afflicted with some degree of cognitive impairment. Residents of long-term care facilities may present with behavioral changes or some physical change as the presentation of pain.
Older adults may not report pain as readily as younger adults. Some older adults believe that pain is part of aging and therefore do not bother to discuss it with the health care team. When assessing the older adult, it is important to determine their perception of pain. Some patients perceive severe pain as a sign of a serious illness or loss of independence, or they may believe this is just a consequence of aging.
When evaluating the older adult, it is important to have an accurate medication history including herbal medication and dietary supplements. Patients should also be asked about alcohol use, drug use and tobacco use.
It is also important to determine the patient’s coping techniques. This will help the nurse understand how the patient functions and to help them deal with the pain in the most effective way. Many older adults use prayer and hope to assist in coping with pain.
Goals should be set for the patient to determine an acceptable level of pain to allow the patients to have a satisfactory quality of life. Closely monitoring for adverse drug reactions is an important part of the management of chronic pain, as many medications have many side effects. A balance should be sought between quality of life and side effects/risks of the treatment.
Older adults have some physiological changes that affect the way medications are used. There is slowing of the gastrointestinal transit time which may extend the effects of continuous release medications. Changes in gastric pH may affect absorption of some medications. Chronic liver changes may lead to changes in drug metabolism. Chronic renal insufficiency is common in older adults and may lead to reduced clearance of medications.
Since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/or unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at even greater risk for inadequate pain control.
When patients cannot self-report, other measures need to be used to detect pain. Even if they cannot speak for themselves, these patients have the right to pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are clearly needed. The American Society for Pain Management recommends the following multifaceted approach for consideration in detecting pain in this population (Herr et al., 2006).
Pregnancy is associated with many changes that have the potential to cause pain such as changing body shape, increasing weight, hormonal shifts and joint laxity. Acetaminophen is thought to be a safe option for pain control throughout pregnancy. NSAIDs should not be used in late pregnancy. NSAIDs have the potential to lead to premature closing of the ductus arteriosus if used in the third trimester.
Many different pain syndromes are commonly seen in pregnancy. Mechanical back pain due to weight distribution changes is one of the most common types of pain. Pain in the pubic symphysis is common and can be managed with position changes and the use of pelvic support devices. Leg cramps may be prevented and treated with calf stretching. Carpal tunnel syndrome is often seen during pregnancy and is likely related to fluid retention which causes compression on the nerves in the carpal tunnel. Symptoms of carpal tunnel syndrome most commonly come on in the third trimester and resolve after pregnancy, but may be prolonged by breastfeeding.
Labor is a painful period and treatment may involve a variety of techniques. The most reliable method to manage pain is with epidural and spinal analgesic techniques. The use of opioids induces sedation and thereby contributes to pain control. Unfortunately, opioids act systemically, and some effect may be transferred to the fetus leading to respiratory depression in the neonate.
Psychiatric disorders are up to three times higher in those with chronic pain when compared to the general population. Depression, anxiety and post-traumatic stress disorder are the most prevalent psychiatric disorders in patients with chronic pain (Renner, 2014). The patient with pain and psychiatric disease typically reports more intense pain than the patient without co-morbid mental illness.
Chronic pain management has multiple challenges in psychiatric patients. Optimizing treatment of the underlying psychiatric illness is an important step in order to achieve an optimal reduction in pain. It is also important to screen and treat for any substance abuse or substance-induced disorder. This will help assure appropriate and adequate treatment of pain. Medications with abuse potential should be used cautiously, as there is a high prevalence of drug use disorders in psychiatric patients. The use of exercise and cognitive behavioral therapy is an important step in the management of pain in the psychiatric patient. In addition, monitoring for compliance is an important part of the management of the psychiatric patient who suffers from chronic pain.
Many conditions lead to visceral pain. Visceral pain occurs when there is stimulation of nociceptors of the organs in the abdomen, pelvis or chest. Visceral pain is diffuse, hard to pinpoint and often referred to a remote structure. Visceral structures are aggravated by ischemia, inflammation and stretch.
Chest pain can occur from many different etiologies. There are a few life-threatening situations that must be considered including myocardial infarction, pulmonary embolism, aortic dissection, tension pneumothorax and esophageal rupture. The majority of chest pain is not life-threatening, and selected causes include chest wall pain (costochondritis, muscle strain), panic attacks, pneumonia, pleurisy, myocarditis, gastroesophageal reflux disease and pericarditis.
Abdominal pain is a common problem and most cases are not life-threatening. Like chest pain, it is important to rule out serious causes of abdominal pain immediately. Serious causes of abdominal pain are suggested by unstable vital signs, high fever, an inability to pass gas or have a bowel movement, vomiting blood or having dark/tarry stools. Common diagnoses that are potentially life-threatening include acute bowel obstruction, acute mesenteric ischemia, bowel perforation, ulcer, acute myocardial infarction and ectopic pregnancy. Other causes of abdominal pain include appendicitis, gallbladder disease, diverticulitis, constipation, kidney stones, lactose intolerance and inflammatory bowel disease.
Many patients have chronic abdominal pain, and many of these cases are benign – functional dyspepsia or irritable bowel syndrome. If no organic disease is found, then that patient should be treated symptomatically. Those individuals over the age of 50 are more likely to have a more serious cause of chronic abdominal pain, and functional abdominal pain should be made only after more serious causes have been ruled out.
Pelvic pain is a common problem in women and may represent a urologic, gynecologic, gastrointestinal, musculoskeletal, metabolic or vascular issue. Acute pelvic pain may be of visceral or somatic origin. All women who have the possibility of being pregnant, a pregnancy test should be done. Additional testing to rule out other causes of pelvic pain includes a complete blood count, sedimentation rate, chlamydia/gonorrhea testing, a serum hCG level and a urinalysis.
Diagnostic testing may include a pelvic ultrasound to rule out a mass or ectopic pregnancy, or laparoscopy can help determine if endometriosis is present. Features that suggest a serious cause of pelvic pain include peritoneal signs, brisk vaginal bleeding, high fever or unstable vital signs.
There are many potential causes for chronic pelvic pain. Diagnosing and treating chronic pelvic pain can be challenging. Determining the exact cause of the abdominal pain may include the use of extensive laboratory evaluation, imaging modalities and at times exploratory surgery. For those with chronic pelvic pain, the examination may use a pain map and identify tender areas to see if physical exam tender areas match the pain map. Ideally, the clinician should attempt to treat the underlying cause of the pelvic pain, but the use of non-specific treatment may be considered when there is no specific diagnosis.
Sickle cell crisis is a vaso-occlusive phenomenon leading to pain associated with blood cell destruction and subsequent anemia. While not the only feature of sickle cell disease, pain is a major component of the condition. Acute sickle cell disease pain is secondary to vaso-occlusion and the consequent tissue ischemia and inflammation. Over time chronic pain may result. Assessment of pain is challenging in sickle cell crisis as there are no objective findings that definitively confirm a crisis or the degree of pain.
An acute painful episode can be precipitated by multiple events such as stress, infection, weather conditions, dehydration or alcohol consumption. Pain can affect many parts of the body such as the chest, back, extremities or abdomen. Many times the pain is associated with fever, elevated breathing rate, hypertension, nausea and vomiting.
Treatment of pain in chronic disease can be challenging to manage. If mild pain is present and the patient is not on chronic opioid therapy, pain management should be started with non-opioid therapy moving to opioids when pain becomes more severe. Individuals who are on chronic opioids will require additional opioids for breakthrough pain. When treated in the emergency room, the use of intravenous morphine, hydromorphone or fentanyl can be used. If pain cannot be relieved with 2 doses, then admitting the patient to the hospital for pain management may be necessary. Many patients with sickle cell disease have chronic pain that is managed with long-acting opioids (DeBaun & Vichinsky, 2016).
Headaches are a frequent cause of recurrent pain and one of the most common diagnoses seen in health care. There are multiple types of headaches including migraine, tension, and cluster headache. Tension headache is the most common. It is important for the healthcare provider to have an understanding of red flags that suggest a serious cause of a headache. When a serious cause of a headache is suspected, urgent evaluation is necessary and may include the use of brain imaging to rule out an underlying secondary cause of a headache. Signs/symptoms that suggest a more serious cause of headache include:
Tension headaches may occur every day and have a variable presentation. Typically there are described as pressure, tightness or aching. They may feel like a band around the head, and they may be bifrontal or bitemporal or generalized. Tension headaches can be intermittent with a variable duration or constant
Migraine headaches are classically one-sided (but may generalize), are pounding or throbbing. Patients with migraines often have co-existent nausea/vomiting and/or photophobia.
An acute migraine can be managed with multiple agents. The use of acetaminophen or NSAIDs may be considered. When simple analgesics are not effective in the management of the pain, the use of migraine-specific agents (triptans or dihydroergotamine) may be considered. These agents are available in oral, rectal and injectable formulations. Oral agents are preferred by many patients, but for those with severe nausea that accompanies a migraine, a non-oral route is the best option. First line prophylactic agents for migraines include propranolol, amitriptyline, topiramate and valproic acid.
Many conditions lead to neuropathic pain including multiple sclerosis, post-stroke pain, spinal cord injury, traumatic brain injury, syringomyelia, trigeminal neuralgia, peripheral neuropathy and post-herpetic neuralgia.
Multiple sclerosis (MS) is commonly associated with pain. It is estimated that 43 percent of MS patients have at least one painful symptom (Olek, 2016). Common painful symptoms include dysesthetic pain, back pain, spasms, Lhermitte sign, visceral pain and trigeminal neuralgia.
Central post-stroke pain is experienced as unilateral head/facial pain that starts within six months of a stroke. It affects up to 8 percent of stroke victims (Garza, 2016). The pain is typically persistent but may come and go. The severity of the pain may be variable, and stress often exacerbates the pain.
Treatment of central post-stroke pain include benzodiazepines; anticonvulsants such as gabapentin, pregabalin, lamotrigine or carbamazepine; baclofen; antidepressants such as amitriptyline or a SSRIs; and clonidine. When pain is resistant to pharmacotherapy the use of neuromodulation (deep brain stimulation) and surgery may be considered.
Spinal cord injury (SCI) patients often develop chronic pain after spinal cord injury that affects the quality of life. Pain is often poorly localized and neuropathic in nature (e.g., burning, stabbing). The pain can be evoked or spontaneous. Pain can be an at-level pain (pain at the level of the SCI) that is caused by injury to the nerve roots and dorsal gray matter causing pain at the level of the injury. Pain can also be below the level of the SCI which is thought to be caused by injury to the spinothalamic tracts and/or thalamic deafferentation.
Pain may be managed with antidepressants (e.g., tricyclic antidepressants), antiepileptics (e.g., gabapentin, lamotrigine or valproate), and standard analgesic medications (opiates). When medications are not effective, the use of invasive treatments is considered. These may include deep brain stimulation, cordotomy or motor cortex stimulation.
Syringomyelia is a delayed progressive intramedullary cystic degeneration that affects a small number of patients after spinal cord injury. It is thought to occur from scarring and subsequent obstruction of cerebral spinal fluid flow and altered tissue compliance leading to the extension of the central canal which presses on the nearby cord tissue (Abrams & Wakasa, 2016).
In syringomyelia, the patient will present with progressive pain that may include sensory, motor or bowel problems. Treatment of the condition is mainly surgical.
Post-concussion syndrome can occur days or even weeks after a traumatic brain injury (TBI). This can occur with any degree of head injury from the mild to severe. It is characterized by dizziness, vertigo, headache, reduced concentration, apathy, depression, sleep disturbance, confusion, irritability, and anxiety. A headache after TBI typically occurs within seven days of the injury and is typical of the tension-type or migraine type of headache. In those with TBI, many other headache syndromes may be seen.
While post-concussive syndrome is often reported in athletes, it is more common in older adults. MRIs may be performed for patients who have symptoms that persist to rule out other problems and provide reassurance.
Treatment options for post-concussive headaches can be variable. Not a lot of research is available on the use of medications in the management of a post-concussive headache. Management involves treatment of the symptoms which includes analgesics, migraine-specific medication (e.g., tricyclic antidepressants, propranolol), psychotropic medications and counseling to manage psychosocial symptoms. Most patients have a quick recovery (within weeks), but some patients may have prolonged symptoms.
Trigeminal neuralgia results in a head/facial pain coming from one or more of the branches of the trigeminal nerve. Classically the pain is unilateral, brief, stabbing and/or lancinating that is sudden in onset.
Imaging, typically with an MRI, is sometimes done to distinguish primary from secondary trigeminal neuralgia. Primary disease has no identifiable lesion causing the symptoms. Secondary causes of trigeminal neuralgia include acoustic neuromas, multiple sclerosis, cerebral aneurysms and trigeminal neuromas. Secondary disease is more common if there is bilateral involvement; it occurs at a younger age; or if there is associated sensory loss.
Conditions that may mimic trigeminal neuralgia include dental pain, multiple sclerosis, herpes zoster or atypical headaches.
Treatment for the pain of trigeminal neuralgia includes carbamazepine and oxcarbazepine. For those who are intolerant or non-responsive to these agents baclofen or lamotrigine can be used. Surgical options are sometimes tried for refractory cases.
Peripheral neuropathy can come from many etiologies including diabetes, cancer, alcohol and HIV. Peripheral neuropathy typically presents with distal sensory loss, weakness, numbness and/or burning. The presentation may be variable.
Neuropathy due to diabetes is one of the more common types of neuropathies. Many forms of diabetic neuropathy exist including symmetric polyneuropathy, radiculopathies, autonomic neuropathy and mononeuropathies. They typically result in symptoms that begin in the lower extremities. Sensory symptoms are seen first; followed by motor symptoms. Patients complain of a gradual sensory loss, numbness, a burning sensation and pain in the feet, and mild gait abnormalities. Overtime weakness may develop and a "stocking and glove" distribution of sensory loss may occur. Physical exam findings depend on which nerve fibers are involved.
Diagnostic tests that help define a neuropathy include conduction studies such as electromyogram and/or nerve condition studies. Treatment of neuropathies includes treating the underlying disease (e.g., control blood sugar in diabetes) and medications to treat the symptoms. Medications used to manage the pain of neuropathy include tricyclic antidepressants, duloxetine, gabapentin, pregabalin, carbamazepine, topiramate, tramadol and NSAIDs.
Post-herpetic neuralgia is pain that presents after a herpes zoster infection, which is caused by the varicella zoster virus. Certain groups are at higher risk to develop pain after a herpes zoster infection. These include older individuals, those who had higher levels of acute pain during the acute infection and those with a more severe rash (Bajwa & Ortega, 2016).
Herpes zoster is an infection that starts with a sharp, burning, stabbing pain that follows a dermatome. A rash will be seen a few days later along the same dermatome. Commonly affected dermatomes include the thoracic, cervical and trigeminal nerves. After the rash abates, some individuals develop pain along the same dermatome that persists longer than four months. Pain may persist for years or even throughout life. Allodynia is often seen in those with post-herpetic neuralgia.
Post-herpetic neuralgia is commonly treated with tricyclic antidepressants, pregabalin and gabapentin. Topical capsaicin or lidocaine can be used. Opioids are sometimes used but should be used cautiously. They are considered second or third line options and are sometimes used while the TCAs, pregabalin, gabapentin take effect, then tapered. If all other options are not effective the use of intrathecal glucocorticoids may be considered.
Most cases of back pain are non-specific and will improve within a few weeks with conservative treatment, but some people develop chronic pain. Those more likely to develop chronic back pain include those with functional impairment, poor health, psychiatric co-morbid conditions, maladaptive pain coping behaviors and non-organic signs – such as pain in the low back when pressing directly on top of the head (Wheeler, Wipf, Staiger, & Deyo, 2016).
Less than one percent of patients with back pain have a serious cause of back pain, and less than ten percent have specific etiologies (Wheeler, Wipf, Staiger, & Deyo, 2016). When back pain is present, it is important to rule out any serious pathologies. Serious pathologies are suggested by certain red flags (See table 5).
A complete history and physical exam is an important part of the exam to rule out serious causes of back pain and help identify the cause of the back pain.
Certain conditions that are more urgent require immediate imaging with an MRI and referral, including those who have any red flags. Those who have not improved after 4-6 weeks of conservative therapy may be considered for imaging. Patients who have conditions that may benefit from surgery or epidural injections should have imaging. Other conditions that are helped by imaging include osteoarthritis and ankylosing spondylitis.
Back pain should not be treated with bed rest, but modifying activity slightly to account for the pain is appropriate. Oral analgesics should be used short-term to provide pain control. Re-evaluation should occur at four weeks to assure improvement, evaluate for any needed testing and reevaluate the need for pain medications.
Initial oral agents should include NSAIDs for 2-4 weeks. Those with an allergy or contraindication to NSAIDs may consider acetaminophen. When pain is not controlled with NSAIDs, the use of a muscle relaxant may be considered. For those who cannot take a muscle relaxant, the combination of an NSAID and acetaminophen is an option.
The use of opioids and tramadol should be used very judiciously in acute low back pain and only in those who are not getting pain control from other agents or contraindications to those other agents.
Physical therapy can be used for acute low back pain but is more often used for chronic low back pain. One of the most important aspects in the management of back pain is education. Patients should be educated on the causes of back pain, the expected course of back pain, its encouraging prognosis, the value of diagnostic testing, treatment options and when to contact their healthcare provider.
Specific Cases of Back Pain
Acute disc herniation with radiculopathy in the lower back (lumbosacral spine) is a common diagnosis. The five lumbar vertebral bodies are movable, while the five sacral vertebrae are fused. Below each vertebra, a pair of neural foramina (spinal nerve roots) exits that have the same number as the vertebral body. For example, the L5 nerve root exits between the L5 and S1 vertebral body.
The most common cause of lumbosacral radiculopathy is a herniated disc or degenerative arthritis leading to stenosis of the neural foramina. Other causes of radiculopathy include congenital abnormalities, infection and cancer.
Radiculopathy can occur at any nerve root, but L5 or S1 impairment is the most common. L5 radiculopathy is associated with back pain that radiates down the lateral aspect of the leg into the foot. The exam shows reduced dorsiflexion, foot inversion and eversion, and reduced toe extension. The reflexes are typically normal in L5 radiculopathy.
S1 radiculopathy presents with back pain that radiates down the posterior aspect of the leg into the foot. The exam shows reduced strength in leg extension and plantar flexion. There is reduced sensation on the lateral foot and the posterior part of the leg. The ankle reflex is reduced or absent.
It is typically not necessary to perform an emergent MRI on patients with suspected lumbar or sacral radiculopathy as long as the clinician does not suspect a serious underlying cause (e.g., cauda equina syndrome, cancer, epidural abscess) of the radiculopathy. If symptoms persist, worsen, do not respond to conservative therapy, or procedures are considered, the use of imaging with an MRI may be considered. For those with severe or unrelenting findings that have imaging results not suggestive of an underlying cause should undergo electromyography and nerve conduction studies. In some cases, a lumbar puncture is done.
Chris is a 44-year-old secretary who presents to her primary care provider with back pain for the last three weeks. The pain started after she lifted a heavy box at work. Her self-management regime included bed rest and taking acetaminophen alternating with ibuprofen for the last three weeks. She reports that the pain is not getting any better.
The pain is described as aching and diffuse along her lower back. She reports that the pain is worse with walking and prolonged standing or sitting and is relieved when lying down. She reports that the pain radiates into her right buttock, but not down the leg.
Chris is generally healthy. The only medication that she takes on a regular basis is sertraline for depression. She has never had any surgeries and has no allergies to medications.
On physical exam her vitals are stable, and she appears comfortable. She walks with a slight limp. The exam shows diffuse tenderness across her lumbar spine. There is no deformity, the straight leg raise is normal, sensation is intact to the lower extremities, and the remaining aspects of her exam shows no focal neurological finding. Recent labs demonstrated a normal blood count and normal liver and renal function.
Her primary care physician recommends that she goes to physical therapy and prescribes diclofenac 50 mg three times a day for three weeks and encourages her to use acetaminophen for breakthrough pain.
At the three week follow-up, Chris is doing better. Her primary care physician recommends continued home exercises as recommended by the physical therapist and use of as needed acetaminophen for pain; the NSAID is stopped at this time as it is likely limited, if any, inflammation is contributing to the pain.
This case is typical of back pain; it essentially resolved within six weeks. The pain was caused by an acute injury with muscle spasms causing referral of pain into the buttock. Radicular pain was not present. Radicular pain would be present if there was inflammation, compression or injury to a spinal nerve root.
The use of imaging is not indicated in this case because there were no red flags. Typically this type of back pain responds to the use of simple analgesics; the use of opioids is not necessary. Acetaminophen is preferred for analgesia, because of its relatively safe profile. The use of a NSAID may be needed because of its anti-inflammatory effect. At times, short-term use of a muscle relaxer may be helpful for muscle spasm that often contributes to this type of acute pain. Tramadol is often used in cases of mild acute pain, but due to its potential abuse should be relegated to a second or third line option. In this case, Chris is also on sertraline, and there is a potential interaction between tramadol and sertraline.
The goal, in this case, is to minimize disability and return Chris to her baseline function as soon as possible. Relative rest at first may be appropriate, but prolonged bed rest will contribute to deconditioning and stiffness and will prolong recovery. The patient with acute low back pain should have exercises to strengthen the low back, stomach and other core muscles as well as stretching the low back and legs.
Appropriate health care of back pain will get patients back to normal functioning quickly while minimizing the risk of dangerous treatment options.
Neck pain can occur from multiple pathologies including trauma, muscle strain or disc pain. The majority of cases of neck pain will resolve within three weeks. Initial treatments are conservative including oral analgesics (acetaminophen or NSAIDs for mild or moderate pain; short-term opioids for severe pain), posture modification and exercise.
Chronic neck pain has multiple treatment options. The use of a long-term cervical collar is not recommended. The use of a cervical collar to manage severe pain for less than three hours a day for a maximum of 2 weeks may be considered. Physical therapy and home exercises should be used.
Pharmacological options for chronic pain include: acetaminophen; NSAIDs; a low-dose antidepressant, especially in those who have pain that interrupts sleep; a muscle relaxant may be considered for those with muscle spasm; and rarely opioids.
Other options for pain management include trigger point injections, cervical medial branch blocks, TENS units, and radiofrequency neurotomy. Surgical evaluation may be considered in those with myelopathy or neurological symptoms associated with radiculopathy.
Cervical radiculopathy often resolves on its own. The initial treatment of those who have obvious signs/symptoms of cervical radiculopathy includes pain control, often with non-steroidal anti-inflammatory medications. At times, the use of oral corticosteroids to reduced inflammation is considered. When the pain is reasonably controlled, physical therapy is initiated.
After conservative treatment, some patients may have recurrent symptoms even if there is initial improvement. At this point, conservative treatment should again be initiated except in the cause of significant motor deficit or myelopathy.
Confirmed cervical radiculopathy with severe symptoms that have not responded to conservative therapy can be managed with epidural steroid injections under fluoroscopic guidance unless there is a progressive neurological deficit.
No firm evidence exists that surgery for cervical radiculopathy provides significant benefit. Some individuals will derive benefit from surgery, while others will not. Certain individuals should have surgical evaluation including those with cervical nerve root compression on imaging, persistent radicular pain after 6-12 weeks of conservative treatment, signs/symptoms of cervical radiculopathy or progressive motor weakness that impairs function (Robinson & Kothari, 2016).
Complex regional pain syndrome (CRPS) is broken down into type I and II. It is a disorder of the extremities illustrated by regional pain that is inconsistent in degree or time to the expected pain. The pain is localized around a certain territory.
The primary clinical manifestation is pain that is typically described as stinging, burning or tearing and is exacerbated by movement, temperature variation, stress or any contact. In addition, some individuals have allodynia or hyperalgesia. The patient may also notice differences in skin color or temperature. The affected side may be more edematous or sweat more when compared to the other side. Limb movement is typically impaired by pain, edema or contractures. The patient with CRPS may also have unilateral variations in hair or nail growth along with skin atrophy.
The progression of the condition is variable over time. The underlying pathology is not well understood but may include inflammation and changes in pain perception in the central nervous system.
CRPS I is the more common type and is diagnosed when the typical symptoms are present and there is no evidence of a peripheral nerve injury. CRPS II is less common and is present when there is evidence of a peripheral nerve injury.
CRPS is more commonly seen in women. It is often associated with some acute event that starts the syndrome. This may include some sort of trauma such as a broken bone or a crush injury. The diagnosis is made on clinical exam after other conditions are ruled out.
Treatment of CPRS should involve a multidisciplinary approach including physical and occupational therapy, physiological interventions and pharmacotherapy. Pharmacologic options include NSAIDs, tricyclic antidepressants, gabapentin, or topical treatments (lidocaine or capsaicin). Other less common options include calcitonin, glucocorticoids, alpha-adrenergic agonists/antagonist (e.g., prazosin, clonidine), ketamine, and opioids. Multiple interventional approaches may be considered including regional sympathetic nerve blocks, trigger/tenderpoint injections and spinal cord stimulation.
Phantom limb pain is aching, burning or shock-like pain where an amputated limb used to be. It is important to rule out other cause of the symptoms, such as infection or wound on the stump, ischemia or neuroma, before diagnosing phantom limb pain. The incidence of this condition is variable, and it is hypothesized that not controlling pain before and after the surgery increase the risk of phantom limb pain. Multiple agents are helpful in the management of phantom limb pain including acetaminophen, NSAIDs, TCAs, and gabapentin. In addition to medication, non-pharmacologic methods to manage pain include: TENS units, mirror therapy (which helps resolve the visual-proprioceptive disconnect), biofeedback and occasionally surgical interventions.
Pain is very prevalent in cancer. It is present in up to one-half of patients when first diagnosed with cancer and according to some estimates up to 100 percent of people with advanced cancer (Davies & D’Arcy, 2013).
Pain in cancer can be acute or chronic. Acute pain is seen during interventions such as surgery, tissue injury or radiation therapy. Acute pain can also be felt secondary to the cancer itself such as an obstructed bowel, a perforated bile duct, bleeding from liver cancer or a pathological fracture. Chronic pain during cancer is typically related to the tumor itself or as a complication of treatment.
Neuropathic pain is also seen in cancer patients. Neuropathic pain in cancer can arise from the tumor pressing on a nerve or nerve plexus. In addition, neuropathic pain can be a result of the treatment as many chemotherapeutic agents or radiation therapy have the potential to cause nerve injury. Many conditions that result in neuropathic pain - such as herpes zoster, post-herpetic neuralgia - are relatively common in cancer patients.
Management of cancer pain is typically aggressive. The use of opioids is common in chronic cancer pain, and doses should be titrated to find effective pain control. Agents commonly used include hydromorphone, morphine, oxycodone and hydromorphone. These agents are preferably given orally or transdermally. Dosing is commonly started with short-acting agents, but for those with chronic pain switching over to a long-acting formulation is preferred with the continued use of short-acting agents for break-through pain. The dose for breakthrough pain is typically about 10 percent of the basal daily opioid dose. Individuals who need rapid titration do well with the use of opioids given via infusion by the IV or SC route.
While morphine is traditionally a common agent that is used, other agents have a good effect in certain situations. For those with swallowing difficulty or poor ability to absorb from the GI tract, the use of fentanyl can be used. Hydromorphone or fentanyl is recommended for those with renal insufficiency.
Irritable bowel syndrome (IBS) has multiple presentations. The most common symptoms include abdominal pain and altered bowel habits (constipation, diarrhea or alternating constipation and diarrhea). The abdominal pain of IBS improves with bowel movements, and the onset of pain is associated with a change in stool frequency and a change in the form of the stool (Longstreth et al., 2006).
To diagnose the condition, the criteria for recurrent abdominal pain occurring at least one day a week for the last three months associated two of the following three: 1. Change in the form of the stool 2. Change in the frequency of the stool 3. Pain related to the bowel movement.
IBS is not associated with weight loss, anemia, rectal bleeding and does not wake the person from sleep. As long as no alarm features are present, endoscopic evaluation is not necessary.
For individuals with mild and intermittent symptoms, lifestyle and dietary modification may be used such as avoiding irritating foods including beans, cabbage, and onions. Other dietary changes that may be helpful include avoiding large meals, avoiding caffeine, eating on a regular basis, and limiting fat intake.
In patients with mild to moderate symptoms that do not respond to lifestyle changes or those with severe symptoms, the use of pharmacotherapy can be considered in addition to lifestyle changes. Pharmacotherapy should focus on the treatment of the predominant symptoms. Medication trials should be re-evaluated at two to four weeks.
When constipation is the predominant symptom, the use of psyllium or polyethylene glycol should be tried. Next line options for constipation predominant IBS includes linaclotide and lubiprostone.
For patients with abdominal pain, the use of antispasmodics (e.g., dicyclomine, hyoscyamine) may be used. Antidepressants can be added when abdominal pain persists when using antispasmodics. Antidepressants are helpful in those with IBS and depression.
When IBS presents with diarrhea, the use of antidiarrheal agents can be used. If these are not effective, bile acid sequestrants are added. In select cases, rifaximin is considered.
Fibromyalgia (FMS) is a condition characterized by chronic widespread musculoskeletal pain. Patients also complain of fatigue, sleep disturbances, psychiatric symptoms, cognitive disturbances and multiple other somatic complaints. The etiology and pathophysiology are unclear.
In FMS, pain is typically diffuse and persistent. It is often described as stiffness, deep aching, soreness, burning or throbbing. Patients typically report that pain is persistently present, but the intensity may vary. Poor sleep, excessive stress, and/or exposure to cold may exacerbate the pain. Generally, pain is worse in the morning and improves throughout the day. Pain commonly affects the neck, shoulders, back, arms, legs and chest wall.
The patient looks well, and no objective findings characterize the disease on exam. In addition, laboratory and radiological exams are normal in fibromyalgia.
Some have suggested that fibromyalgia is a form of central sensitization (Sarzi-Puttini, Atzeni & Mease, 2011). Likely there is a genetic predisposition to the condition. It is thought that certain stressors such as sleep disturbance, infections or trauma (emotional and physical) may lead to fibromyalgia.
Fibromyalgia is more common in women and has been shown to be six times more common when compared to men. The prevalence is about 2-3 percent in the United States. It is the most common cause of generalized musculoskeletal pain in females aged 20 to 55 (Vincent et al., 2013).
Signs and Symptoms
Physical exam findings
In 1990, the American College of Rheumatology (ACR) developed classification criteria. It identified nine pairs or 18 tender points and said that 11 of 18 of the points should be positive to diagnosis FMS.
In 2010, a new criterion to diagnosed FMS was published. It did not recommend using the tender point examination to diagnosis FMS as they are difficult to obtain and many clinicians have not been trained in their use. It uses a widespread pain index (WPI) and a symptom severity (SS) scale in the diagnosis of FMS. The WPI assesses the number of painful body regions from a list of 19 areas. The SS score assesses the amount of fatigue, cognitive symptoms, the degree of waking up feeling unrefreshed, and the number of general somatic symptoms.
Patients with FMS often complain of hurting all over or feeling as though they have the flu. It is diagnosed in those with chronic pain and no hint of muscle inflammation.
Differential diagnosis of FMS includes osteoarthritis, autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, hypothyroidism, inflammatory myopathy, systemic inflammatory arthropathies, spondyloarthritis, Ankylosing spondylitis, myositis and polymyalgia rheumatic.
The laboratory evaluation rules out other conditions and should include a complete blood count (CBC), an erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP). Other tests may be ordered on an individual basis such as a thyroid-stimulating hormone test (if hypothyroidism is suspected) or a creatine kinase (if inflammatory myopathy is suspected). Testing for other rheumatologic diseases (an antinuclear antibody test and rheumatoid factor) should be done only if clinically indicated.
Treatment of FMS is challenging at best. It typically includes a combination of non-pharmacological and pharmacological treatments implemented by a multidisciplinary team. The treatment approach must be individualized. Goals of treatment are to reduce pain and other symptoms of the disease.
Education is a critical step in the treatment of FMS. The condition must be explained to the patient including treatment approaches. Key aspects of patient education include:
Medications are often used in the management of FMS. Typically non-pharmacological methods are used first and when they are not effective the addition of medication is considered. Commonly used medications include low dose tricyclic antidepressants, selective serotonin reuptake inhibitors, pregabalin, duloxetine, cyclobenzaprine and milnacipran. When utilizing medications, the dose should be started low and built up gradually.
Amitriptyline, milnacipran and duloxetine are first line agents for fibromyalgia, but most patients do not find significant improvement (some improvement was noted with sleep and pain, but fatigue and quality of life were only minimally improved) on these medications and many have significant side effects (Häuser, Wolfe, Tölle, Uçeyler, & Sommer, 2012).
When first-line agents do not work, a combination of medications can be tried. For example, the use of duloxetine in the morning and a tricyclic antidepressant before bed is one such combination. Combinations of medications work through different mechanisms of action and focus on different symptoms.
At times the addition of analgesics or anti-inflammatory medication can be tried. The use of acetaminophen, NSAIDs or tramadol may be considered to target pain when more traditional FMS agents do not work. Generally, opioids should be avoided in FMS.
Rheumatoid arthritis (RA), a chronic destructive, sometimes deforming disease, attacks the collagen in the body, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as fatigue, fever, poor appetite, nerve damage and increased size of the spleen and lymph nodes. RA can irreversibly damage joints. Therefore early diagnosis and treatment to control inflammation can improve outcomes of the disease.
Treatment options include psychosocial care, patient education, therapy and pharmacologic treatment. A rheumatologist should be involved in the care of patients with RA as disease-modifying antirheumatic drugs (DMARD) are complex to use. If therapy is started soon, the patient will experience better outcomes. DMARD therapy is complex and requires a lot of monitoring and beyond the scope of this article.
The use of NSAIDs and glucocorticoids are also used in the management of RA. They can be used as bridging therapy to get quick control of inflammation until the DMARDs take effect and can be used for pain control.
Osteoarthritis (OA) is the most common cause of disability in the older population.
Arthritis affects twenty percent of adults and costs more than $128 billion annually in the United States. As the population ages, the burden of OA will increase (Healthy People, 2013). Managing arthritis improves mobility, decreases falls, decreases death rates and improves quality of life.
Osteoarthritis is defined as a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones - called cartilage, which normally cushion the bones - no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.
Treatment of osteoarthritis focuses on pain control and maintaining function. In the near future there may be treatments available to reverse or even cure the disease process, but at present symptom control is the only option. Treatment focuses on medications and non-medication means to control the pain and minimize disability.
Non-drug treatment is the first line management as it bypasses the negative effects drugs have on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets and patient education.
When non-drug methods do not provide adequate relief, medications are used to treat OA. Acetaminophen is recommended as first-line treatment for OA (US Department of Health and Human Services, 2011), primarily due to its lack of negative side effects when compared to non-steroidal anti-inflammatory medications. Acetaminophen is more likely to be beneficial if the arthritis is not inflammatory.
The American Academy of Orthopaedic Surgeons does not recommend for or against the use of acetaminophen. Their position paper reports that acetaminophen has no benefit over placebo, so they do not recommend this treatment. They do acknowledge that the side effect profile of acetaminophen is less toxic than non-steroidal anti-inflammatory agents (NSAIDs). NSAIDs are considered more effective in providing relief from hip and knee pain in osteoarthritis (Towheed et al., 2006). Like acetaminophen, they act synergistically with opioids.
NSAIDs, such as ibuprofen (Motrin, Advil), naproxen sodium (Aleve, Naprosyn), choline and magnesium salicylates (Trilisate), diclofenac sodium (Voltaren, Voltaren XR), celecoxib (Celebrex), meloxicam (Mobic), and nabumetone (Relafen), are recommended by the American Academy of Orthopaedic Surgeons (Towheed et al., 2006). These medications have more side effects than acetaminophen.
Another option for those with risk for gastric ulceration is the use of celecoxib. Celecoxib is the only available selective inhibitor of cyclooxygenase (COX) -2. COX-2 inhibitors are less likely to lead to gastric irritation. In those at very high risk for gastrointestinal bleeding, a COX-2 agent along with a proton pump inhibitor can be used. Monitoring for and eradication of Helicobacter pylori reduces the risk of NSAID-induced gastrointestinal injury.
Generally, NSAIDs are equally effective (Roelofs, Deyo, Koes, Scholten, & van Tulder, 2008), but if one agent is ineffective, another NSAID may be effective as there is individual variation in response to different NSAIDs.
Topical NSAIDs may be used especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution are available for the management of osteoarthritis.
Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which is involved in the transmission of pain. Capsaicin is applied three to four times a day. It takes Capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance.
Another topical agent sometimes used for treatment of localized pain is the lidoderm patch. This is not approved by the food and drug administration for use in OA but is often used. It is a small patch applied to the skin around the painful joint wore for no more than 12 hours a day.
Other options include tramadol, codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.
Intra-articular steroid injections can be used for painful joints. This involves placing a needle directly into the arthritic joint and injecting a steroid along with a numbing agent. Prior to administration of the medication, aspiration of synovial fluid may occur. These are very effective treatments, but their length of effect is variable from weeks to months. Reduction in pain may be seen as soon as one week after the injection. Corticosteroid injections have the potential to damage cartilage and no more than three injections per year should be given (Lozada, 2013).
Intra-articular hyaluronic acid is sometimes used to mimic the joint lubricant – which is often reduced in those with OA - that naturally occurs in the knee. It is classified as a medical device and not a drug. Products include Hyalgan, Supartz, Orthovisc, and Euflexxa, and Synvisc. The American Academy of Orthopaedic Surgeons does not recommend treatment (American Academy of Orthopedic Surgeons, 2008). Side effects include discomfort, swelling and pain at the injections site.
When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion.
Myofascial pain syndrome is a group of conditions that involve muscle, tendon, ligament, fascia, bursa, and/or subcutaneous tissue. Diagnoses commonly seen in myofascial pain syndrome include tendinitis, bursitis, enthesitis, fasciitis and regional myofascial pain disorder. Some are self-limiting while others are more chronic.
Tendonitis commonly occurs due to overuse and presents with local discomfort and inflammation. Bursitis is inflammation of the bursa, which are small pads that are filled with fluid. It is caused by infection, systemic disease or repetitive injury. Enthesitis is when there is inflammation where the tendon inserts on the bone. Common diagnoses in this condition include plantar fasciitis and Achilles tendonitis.
Regional myofascial pain presents with taut bands in the skeletal muscle or in the fascia. These bands are indurated and hurt when pressed on. They result from acute trauma, minor microtrauma or chronic strain.
Myofascial pain syndrome is a wide range of conditions that are typically treated symptomatically. Many of these conditions are caused by inflammation and are best treated with anti-inflammatory agents to treat not only the pain but also the inflammation.
Pain is a disagreeable sensory and emotional experience connected with actual or potential tissue damage or explained in terms of such damage. Many conditions have the potential to cause pain. Having an understanding of these conditions, how to assess them and how to treat them are a vital part of adequately managing the pain. In the current health care system, much pain is not even addressed. Many regulatory agencies have implemented guidelines within the health care system to help with addressing the pain epidemic.
It is the role of the health care team to perform a good initial pain assessment and an on-going assessment of pain. Proper pain management requires a team approach in the assessment and treatment of pain. Many options are available for the management of pain including non-pharmacological options, non-opioid medications, opioid medications, and adjunctive medications. Opioid analgesics, while very good at managing pain, have lead to many social and legal problems including overuse and diversion.
The health care team also has the responsibility to partner with the patient to properly manage the pain. Each health care team member has their role in the management of pain. If health care team members perform their role and the patient takes an active role in his/her care, the adequate treatment of pain is a very attainable goal.
Abrams GM & Wakasa M. (2016). Chronic complications of spinal cord injury and disease. Retrieved May 25, 2106 from: www.uptodate.com Geriatric Society, 50, S205.
AGS Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatric Society, 50, S205.
Alford DP, Liebschutz J & Chen IA. (2008). Update in pain medicine. Journal of General Internal Medicine. 23(6), 841-5.
American Academy of Orthopaedic Surgeons. (2008). Treatment of Osteoarthritis (OA) of the Knee. AAOS: American Academy of Orthopaedic Surgeons. Retrieved June 6, 2016 (Visit Source).
American Medical Directors Association (AMDA). (2012)Pain management in the long term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2012.
America Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-V), 5th ed., America Psychiatric Association, Washington.
Annemans L, Wessely S, Spaepen E, et al. (2008). Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheumatology, 58(3), 895-902.
Anxiety and Depression Association of America. (2013). Facts & Statistics. Retrieved October 1, 2015 (Visit Source).
Argoff CE. (2012). Using Muscle Relaxants in Chronic Pain. Retrieved June 26, 2016 (Visit Source).
Bajwa ZH & Ortega E. (2016). Post-herpetic neuralgia. Retrieved May 20, 2016 from: www.uptodate.com
Becker WC, Fiellin DA, Gallagher RM, Barth KS, Ross JT & Oslin DW. (2009). The association between chronic pain and prescription drug abuse in Veterans. Pain Medicine. 10(3), 531-6.
Becker WC, Fiellin DA & Desai RA. (2007). Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug and Alcohol Dependence. 90(2-3), 280-7.
Bogle KE & Smith BH. (2009). Illicit methylphenidate use: a review of prevalence, availability, pharmacology, and consequences. Current Drug Abuse Review. 2(2), 157-76.
Boscarino JA, Rukstalis M, Hoffman SN, Han JJ, Erlich PM, Gerhard PM Gerhard DS & Stewart WF. (2010). Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 105(10), 1776-82.
Brown ME, Swiggar WH, Dewey CM & Ghulyan MV (2012). Searching for answers: proper prescribing of controlled prescription drugs. Journal of Psychoactive Drugs. 44(1), 79-85.
Center for Disease Control. (2014). Opioid Painkiller Prescribing. Retrieved May 1, 2016 (Visit Source).
Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P,... Miaskowski C; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. Journal of Pain. 10(2),113-30.
Cloos JM & Ferreira V. (2009). Current use of benzodiazepines in anxiety disorders. Current Opinions in Psychiatry. 22(1), 90–95.
Closs SJ & Briggs M. (2002). Patients' verbal descriptions of pain and discomfort following orthopaedic surgery. International Journal of Nursing Studies. 39(5), 563-72.
Colburn JL, Jasinski DR & Rastegar DA. (2012). Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic. Journal of Opioid Management. 8(3), 153-60.
Davies PS & D’Arcy Y. (2013). Cancer Pain Management. Springer Publishing Company; New York.
DeBaun MR & Vichinsky EP. (2016). Vasoocclusive pain management in sickle cell disease. Retrieved May 15, 2016 from: www.uptodate.com
Department of Veteran Affairs and Department of Defense. Tapering and Discontinuing Opioids. Retrieved January 11, 2016 (Visit Source).
Drug Enforcement Agency. (2014). Controlled Substance List. Retrieved May 30, 2016 (Visit Source).
Dworkin RH, O'Connor AB, Backonja M, et al. (2007). Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain, 132(3), 237-51.
Edlund MJ, Steffick D, Hudson T, Harris KM & Sullivan M (2007). Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 129(3), 355-62.
Feldt KS, Ryden MB, Miles S. (1998). Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. Journal of the American Geriatric Society, 46(9), 1079-85.
Fendrick AM & Greenberg BP. (2009). A review of the benefits and risks of nonsteroidal anti-inflammatory drugs in the management of mild-to-moderate osteoarthritis. Osteopathic Medicine and Primary Care, 3, 1.
Franklin G. (2014). Opioids for chronic noncancer pain. Neurology. 83(14), 1277-1284.
Fredman S & Korn M. (2002). Anxiety Disorders and Related Conditions. Retrieved May 1, 2016 (Visit Source)
Garza I. (2016). Central neuropathic facial pain. Retrieved May 25, 2016 from: www.uptodate.com
Gladding PA, Webster MW, Farrell HB, Zing IS, Park R, & Ruijne N. (2008). The antiplatelet effect of six non-steroidal anti-inflammatory drugs and their pharmacodynamic interaction with aspirin in healthy volunteers. American Journal of Cardiology, 101, 1060–1063.
Grothe DR, Scheckner B & Albano D. (2004). Treatment of Pain Syndromes With Venlafaxine. Pharmacotherapy, 24(5), 621-29.
Gwira-Baumbladd JA, Weideman C, Dunn JR, Schaffner W, Paulozzi LJ & Jones TF. (2014). High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Internal Medicine. 174(5), 796-801.
Hall JK & Boswell MV. (2009). Ethics, law, and pain management as a patient right. Pain Physician, 12(3):499-506.
Hall AJ, Logan JE, Toblin RL, Hall AJ, Kaplan JA, Kraner JC, Bixler D, Crosby AE & Paulozzi LJ. (2008). Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 300(22), 2613-20.
Hardt J, Jacobsen C & Goldberg J. (2008). Prevalence of chronic pain in a representative sample in the United States. Pain Medicine. 9(7), 803-12.
Häuser W, Wolfe F, Tölle T, Uçeyler N, & Sommer C,(2012). The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs, 26(4), 297-307.
Healthy People 2010. DATA 2010. 2014. Retrieved May 1, 2016 (Visit Source).
Herr K, Coyne PJ, Key T, Manworren R, McCaffery M, Merkel S,…Wild L. (2006). Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44-52.
Jalan R, Williams R & Bernuau J. (2006). Paracetamol: are therapeutic doses entirely safe? Lancet, 368(9554), 2195-6.
Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Retrieved May 1, 2016 (Visit Source).
Jones P & Lamdin R. (2010). Oral cyclo-oxygenase 2 inhibitors versus other oral analgesics for acute soft tissue injury: systematic review and meta-analysis. Clinical Drug Investigation, 30(7), 419-37.
Jones CM, Mack KA & Paulozzi LJ. (2013). Pharmaceutical overdose deaths, United States, 2010. JAMA. 309(7), 657-9.
Kanwaljeet JS. (2016) Prevention and Treatment of Pain in the Neonate. Retrieved May 3, 2016 from www.uptodate.com
Kaye S & Darke S. (2012). The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care? Addiction. 107(3), 467-77.
Kuehn BM. (2007). Prescription drug abuse rises globally. Journal of the American Medical Association. 297(12), 1306.
Lee, C., Straus, W. L., Balshaw, R., Barlas, S., Vogel., & Schnitzer, TJ.(2004). A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: a meta-analysis. Arthritis & Rheumatism, 51(5), 746-54.
Lewis M, Herndon CM & Chibnall JT. (2012). Patient aberrant drug taking behaviors in a large family medicine residency program: a retrospective chart review of screening practices, incidence, and predictors. Journal of Opioid Management. 10(3),169-75.
Liebschutz JM, Saitz R, Weiss RD, Averbuch T, Schwartz S, Meltzer EC, Claggett-Bourne E, Cabral H & Samet JH. (2010). Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain. The Journal of Pain. 11(11),1047-55.
Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, & Spiller R. (2006) Functional bowel disorders. Gastroenterology 2006; 130:1480.
Lorenz KA, Sherbourne CD, & Shugarman LR (2009). How reliable is pain as the fifth vital sign? Journal of the American Board of Family Medicine. 22(3), 291-8.
Lozada CJ. (2016). Osteoarthritis Treatment & Management. Retrieved June 10, 2016 from:http://emedicine.medscape.com/article/330487-treatment#aw2aab6b6b2
Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV,… Wargo BW; American Society of Interventional Pain Physicians. (2012). American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician. 15(3 Suppl), S67-116.
Martell BA, O'Connor PG, & Kerns RD. (2007). Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of Internal Medicine. 146(2), 116-27.
McCaffrey R & Freeman E. (2003). Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing, 44(5); 517-524
MedicineNet.com. (2016). Definition of Pain. Retrieved June 4, 2016 (Visit Source).
Merikangas KR & McClair VL. (2012). Epidemiology of substance use disorders. Human Genetics. 131(6), 779-89.
Merskey H & Bogduk N. (1994). Classification of Chronic Pain, 2nd ed. IASP Press: Seattle.
National Centers for Health Statistics. (2006). Chartbook on Trends in the Health of Americans 2006. Special feature: pain. Retrieved April 22, 2016 (Visit Source).
National Clearinghouse Guidelines. (2013). Pain management in older adults. In: Evidence-based geriatric nursing protocols for best practice. Retrieved June 1, 2016 (Visit Source).
National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. (1998). Effective medical treatment of opiate addiction. JAMA. 280(22),1936-43.
Nguyen M, Ugarte C, Fuller I., Haas, G, & Portenoy RK. (2005). Access to care for chronic pain: a racial and ethnic differences. Journal of Pain. 6(5), 301-14.
Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, DiCapua P & Chou R. (2014). Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Annals of Internal Medicine. 160(1), 38-47.
O'Connor AB & Dworkin RH. (2009). Treatment of neuropathic pain: an overview of recent guidelines. American Journal of Medicine. 122(10 Suppl), S22-32.
Olek MJ. (2016). Clinical features of multiple sclerosis in adults. Retrieved May 25, 2016 from: www.uptodate.com
Otto MW & Pollack MH. (2009). Stopping Anxiety Medication. 2nd Edition. Oxford University Press: Oxford, UK
Renner JA. (2014). Managing Patients with Pain, Psychiatric Co-Morbidity & Addiction. Retrieved June 1, 2016 (Visit Source).
Robinson J & Kothari MJ. (2016). Treatment of cervical radiculopathy. Retrieved June 1, 2016 from: www.uptodate.com
Roelofs PD, Deyo RA, Koes BW, Scholton, RJ., & van Tulder, MW (2008). Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine, 33(16), 1766-74.
SAMHSA. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD.
Saarto T, & Wiffen PJ. (2007) Antidepressants for neuropathic pain. Cochrane Database Syst Rev 2007;(4):CD005454
Sarzi-Puttini P, Atzeni F, & Mease PJ. (2011). Chronic widespread pain: from peripheral to central evolution. Best Practice and Research Clinical Rheumatology 25(2),133-9
Sehgal N, Manchikanti L & Smith HS. (2012). Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 15(3 Suppl), ES67-92.
Sielski R, Reif W, & Blombiewski, JA. (2016) Efficacy of Biofeedback in Chronic back pain: a meta-analysis. International Journal of Behavioral Medicine. Retrieved June 19, 2016 (Visit Source).
Seitz DP. (2005). Screening mnemonic for generalized anxiety disorder. Canadian Family Physician. 51(10), 1340-1342.
Sofeff S. (2014). Attention Deficit Hyperactivity Disorder. Retrieved May 23, 2016 (Visit Source).
Spiller HA, Hays HL & Aleguas A Jr. (2013). Overdose of drugs for attention-deficit hyperactivity disorder: clinical presentation, mechanisms of toxicity, and management. CNS Drugs. 27(7), 531-43.
Stewart WF, Ricci JA, & Chee E. (2003). Lost productive time and cost due to common pain conditions in the US workforce. Journal of the American Medical Association. 290, 2443-54.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). The TEDS Report: 2001-2011: National Admissions to Substance Abuse Treatment Services. Retrieved May 1, 2016 (Visit Source).
Tcheremissine OV & Salazar JO. (2008). Pharmacotherapy of adult attention deficit/hyperactivity disorder: review of evidence-based practices and future directions. Expert Opinion in Pharmacotherapy. 9(8), 1299-310.
Towheed TE, Maxwell L, Judd MG, Catton, Hochberg, & Wells (2006). Acetaminophen for osteoarthritis. Cochrane Database Syst Rev, 25;(1), CD004257.
Turk DC, Wilson HD & Cahana A. (2011). Treatment of chronic non-cancer pain. Lancet. 377(9784), 2226-35.
US Department of Health and Human Services. (2011). American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Retrieved on June 6, 2016 (Visit Source).
Vincent A, Lahr BD, Wolfe F, Clauw DJ, Whipple MO, Oh TH,…St Sauver J. (2013). Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care and Research. 65(5), 786-92.
Volkow ND & Swanson JM. (2008). Does childhood treatment of ADHD with stimulant medication affect substance abuse in adulthood? American Journal of Psychiatry. 165(5), 553-5.
Webb JR, Valasek MA & North CS. (2013). Prevalence of stimulant use in a sample of US medical students. Annals of Clinical Psychiatry. 25(1), 27-32.
Wheeler SG, Wipf JE, Staiger TO, & Deyo RA. (2016). Evaluation of low back pain. Retrieved May 24, 2016 from: www.uptodate.com
Wilens TE, Adler LA, Adams J, Sgambati S, Rotrosen J, Sawtelle R, Utzinger L & Fusillo S. (2008). Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. Journal of the American Academy of Child and Adolescent Psychiatry. 47(1), 21-31.
World Health Organization. WHO's pain ladder. Retrieved June 5, 2016 from (Visit Source).
Zhang W, Moskowitz RW, Nuki G., Abramson S., Altman RD., Arden N.,…Tugwell P.(2007). OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis and Cartilage, 15(9), 981-1000.