Pain management

Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain,^[2] whether acute pain or chronic pain. Relieving pain (analgesia) is typically an acute process, while managing chronic pain involves additional complexities and ideally a multidisciplinary approach.

A typical multidisciplinary pain management team may include:

Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team.^[4] Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it. Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain and discomfort to reduce any suffering during treatment, healing, and dying.

The task of medicine is to relieve suffering under three circumstances. The first is when a painful injury or pathology is resistant to treatment and persists. The second is when pain persists after the injury or pathology has healed. Finally, the third circumstance is when medical science cannot identify the cause of pain. Treatment approaches to chronic pain include

In the nursing profession, one common definition of pain is any problem that is "whatever the experiencing person says it is, existing whenever the experiencing person says it does".^[5]

Pain management includes patient and communication about the pain problem.^[6] To define the pain problem, a health care provider will likely ask questions such as:^[6]

• How intense is the pain?
• How does the pain feel?
• Where is the pain?
• What, if anything, makes the pain lessen?
• What, if anything, makes the pain increase?
• When did the pain start?

After asking such questions, the health care provider will have a description of the pain.^[6] Pain is often rated on a scale from 1 to 10, known as the Numeric Rating Scale (NRS)^[7];

Rating Pain Level

• 0 No Pain
• 1 – 3 Mild Pain (nagging, annoying, interfering little with ADLs)
• 4 – 6 Moderate Pain (interferes significantly with ADLs)
• 7 – 10 Severe Pain (disabling; unable to perform ADLs)

This pain scale is based on a person reporting their pain intensity, with 0 representing no pain experienced and 10 indicating the worst possible pain.^[8] The NRS is a common tool used by clinicians and in research to understand personal pain levels and monitor changes over time.^[8] In the clinical context, pain management will then be used to address that pain.^[6]

There are many types of pain management. Each have their own benefits, drawbacks, and limits.^[6]

A common challenge in pain management is communication between the health care provider and the person experiencing pain.^[6] People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is.^[6] Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments.^[6] There is a risk in many types of pain management for the patient to take treatment that is less effective than needed or which causes other difficulties and side effects.^[6] Some treatments for pain can be harmful if overused.^[6] A goal of pain management for the patient and their health care provider is to identify the amount of treatment needed to address the pain without going beyond that limit.^[6]

Another problem with pain management is that pain is the body's natural way of communicating a problem.^[6] Pain is supposed to resolve as the body heals itself with time and pain management.^[6] Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem.^[6]

Manipulative and mobilization therapies are considered safe interventions for low back pain, with manipulation potentially offering a larger therapeutic effect.^[13]

Specifically in chronic low back pain, education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short-term relief of disability and pain.^[14]

Physical activity interventions, such as tai chi, yoga, and Pilates, promote harmony of the mind and body through total body awareness. These practices incorporate breathing techniques, meditation, and a wide variety of movements while training the body to perform functionally by increasing strength, flexibility, and range of motion.^[15] Physical activity can also benefit chronic sufferers by reducing inflammation and sensitivity and boosting overall energy.^[16] Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks),^[17] and overall quality of life, while minimizing the need for pain medications.^[15] More specifically, walking has been effective in improving pain management in chronic low back pain.^[18]

Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and control chronic pain via electrical impulses.^[19] Limited research has explored the effectiveness of TENS in relation to pain management of multiple sclerosis (MS). MS is a chronic autoimmune neurological disorder, which consists of the demyelination of the nerve axons and the disruption of nerve conduction velocity and efficiency.^[19] In one study, electrodes were placed over the lumbar spine, and participants received treatment twice a day and at any time when they experienced a painful episode.^[19] This study found that TENS would benefit MS patients with localized or limited symptoms in one limb.^[19] The research is mixed with whether or not TENS helps manage pain in MS patients.^{[citation needed]}

Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions, and it involves the application of low-intensity (up to 2 mA) constant direct current to the scalp through electrodes in order to modulate the excitability of large cortical areas.^[21] tDCS may have a role in pain assessment by contributing to efforts in distinguishing between somatic and affective aspects of pain experience.^[21] Zaghi and colleagues (2011) found that the motor cortex, when stimulated with tDCS, increases the threshold for both the perception of non-painful and painful stimuli.^[21] Although there is a greater need for research examining the mechanism of electrical stimulation in pain treatment, one theory suggests that the changes in thalamic activity may be due to the influence of motor cortex stimulation on the decrease in pain sensations.^[21]

Concerning MS, a study found that daily tDCS sessions resulted in an individual's subjective report of pain decreased when compared to a sham condition.^[19] In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session.^[19]

Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas.^[22] Research examining tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases.^[22] Specifically, the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group (e.g., sham stimulation, stimulation of the DLPFC).^[22] However, this effect decreased after treatment ended, but remained significant for three weeks following the extinction of treatment.^[22]

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.^{[29][30][31][32][33]} Radiofrequency treatment has been seen to improve pain in patients with facet joint low back pain. However, continuous radiofrequency is more effective in managing pain than pulsed radiofrequency.^[34]

An intrathecal pump is sometimes used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. ^{[medical citation needed]}

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord, providing a paresthesia ("tingling") sensation that alters the perception of pain by the patient.^{[medical citation needed]}

Intra-articular ozone therapy has been seen to alleviate chronic pain in patients with knee osteoarthritis efficiently.^[35]

Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that focuses on behavior change rather than symptom change, includes methods designed to alter the context around psychological experiences rather than to alter the makeup of the experiences, and emphasizes the use of experiential behavior change methods.^[36] The central process in ACT revolves around psychological flexibility, which in turn includes processes of acceptance, awareness, a present-oriented quality in interacting with experiences, an ability to persist or change behavior, and an ability to be guided by one's values.^[36] ACT has an increased evidence base for range of health and behavior problems, including chronic pain.^[36] ACT influences patients to adopt a tandem process to acceptance and change, which allows for a greater flexibility in the focus of treatment.^[36]

Recent research has applied ACT successfully to chronic pain in older adults due to in part of its direction from individual values and being highly customizable to any stage of life.^[36] In line with the therapeutic model of ACT, significant increases in process variables, pain acceptance, and mindfulness were also observed in a study applying ACT to chronic pain in older adults.^[36] In addition, these primary results suggested that an ACT based treatment may significantly improve levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain.^[36]

Cognitive behavioral therapy (CBT) helps patients with pain to understand the relationship between their pain, thoughts, emotions, and behaviors. A main goal in treatment is cognitive (thinking, reasoning or remembering) restructuring to encourage helpful thought patterns.^[37] This will target healthy activities such as regular exercise and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques (e.g., relaxation, diaphragmatic breathing, and even biofeedback).^{[citation needed]}

Studies have demonstrated the usefulness of cognitive behavioral therapy in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability.^[38] CBT is significantly more effective than standard care in treatment of people with body-wide pain, like fibromyalgia. Evidence for the usefulness of CBT in the management of adult chronic pain is generally poorly understood, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials.^{[citation needed]} The crucial content of individual interventions has not been isolated and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult.^[39]

In 2020, a systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain (excluding headaches). There is no evidence that behaviour therapy (BT) is effective for reducing this type of pain, however BT may be useful for improving a person's mood immediately after treatment. This improvement appears to be small, and is short term in duration.^[40] CBT may have a small positive short-term effect on pain immediately following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy.^[40] CBT may contribute towards improving the mood of an adult who experiences chronic pain, which could possibility be maintained for longer periods of time.^[40]

For children and adolescents, a review of RCTs evaluating the effectiveness of psychological therapy for the management of chronic and recurrent pain found that psychological treatments are effective in reducing pain when people under 18 years old have headaches.^[41] This beneficial effect may be maintained for at least three months following the therapy.^[42] Psychological treatments may also improve pain control for children or adolescents who experience pain not related to headaches. It is not known if psychological therapy improves a child or adolescents mood and the potential for disability related to their chronic pain.^[42]

A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions. However the studies had some limitations like small study sizes, bringing up issues of power to detect group differences, and lacking credible controls for placebo or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions."^[43]: 283

Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents.^[44] In clinical trials addressing other patient groups, it has significantly reduced pain compared to no treatment or some other non-hypnotic interventions.^[45] The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.^[46]

A 2019 systematic review of 85 studies showed it to be significantly effective at reducing pain for people with high and medium levels of suggestibility, but of minimal effectiveness for people with low suggestibility. However, high quality clinical data is needed to generalize to the whole chronic pain population.^[47]

A 2013 meta-analysis of studies that used techniques centered around the concept of

Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness.^[50][51] Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism.^[50][52] It was developed by Vidyamala Burch and is delivered through the programs of Breathworks.^[50][51] It has been subject to a range of clinical studies demonstrating its effectiveness.^{[53][54][55][56][57][58][59][50][excessive citations]}

Pain reprocessing therapy (PRT) teaches people to shift their beliefs about the causes of pain and to perceive pain signals sent to the brain as less threatening.^[60][61] PRT is sometimes seen as one component of an integrative psychological treatment for centralized pain^[62] and may also be used for other neuroplastic symptoms such as chronic dizziness.^[63][64] Therapists help participants do painful movements while helping them re-evaluate the sensations they experience. The treatment also includes training in managing emotions that may make pain feel worse.^[60] One randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) study showed large reductions in chronic back pain with effects continuing at 1-year follow-up.^[61] Interviews with patients receiving PRT reflected three themes contributing to success included relating to pain differently, establishing links between pain, emptions, and stress which led to resolving difficult emotions, and social connections with therapists and peers.^[65]

The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain.^[66][67] In the treatment of chronic pain, the three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine. The exact medications recommended will vary by country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.^{[citation needed]}

Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain.^[69]

Paracetamol, an NSAID or paracetamol in a combination product with a weak

Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back with an opiate, or sometimes without it or with an NSAID.

While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.^[71]

In 2009, the Food and Drug Administration stated: "According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction."^[72] In 2013, the FDA stated that "abuse and misuse of these products have created a serious and growing public health problem".^[73]

Most opioid treatment used by patients outside of healthcare settings is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain.

Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management.

Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction. Factors correlated with an elevated risk of opioid misuse include a history of substance use disorder, younger age, major depression, and the use of psychotropic medications.^[77] Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.^[78]

The list below consists of commonly used opioid analgesics which have long-acting formulations. Common brand names for the extended release formulation are in parentheses.

• Oxycodone (OxyContin)
• Hydromorphone (Exalgo, Hydromorph Contin)
• Morphine (M-Eslon, MS Contin)
• Oxymorphone (Opana ER)
• Fentanyl, transdermal (Duragesic)
• Buprenorphine*, transdermal (Butrans)
• Tramadol (Ultram ER)
• Tapentadol (Nucynta ER)
• Methadone* (Metadol, Methadose)
• Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER)

*Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics

The other major group of analgesics are

Low-dose ketamine is sometimes used as an alternative to opioids for the treatment of acute pain in hospital emergency departments.^[85][86] Ketamine probably^? reduces pain more than opioids and with less nausea and vomiting.^[87]

Other drugs which can potentiate conventional analgesics or have analgesic properties in certain circumstances are called

Self-management of chronic pain has been described as the individual's ability to manage various aspects of their chronic pain.[92] Self-management can include building self-efficacy, monitoring one's own symptoms, goal setting and action planning. It also includes patient-physician shared decision-making, among others.^[92] The benefits of self-management vary depending on self-management techniques used. They only have marginal benefits in management of chronic musculoskeletal pain.^[93] Some research has shown that self-management of pain can use different approaches. Those approaches can range from different therapies such as yoga, acupuncture, exercise and other relaxation techniques. Patients could also take a more natural approach by taking different minerals, vitamins or herbs. However, research has shown there is a difference between rural patients and non-rural patients having more access to different self-management approaches. Physicians in these areas may be readily prescribing more pain medication in these rural cities due to being less experienced with pain management. Simply put, it is sometimes easier for rural patients to get a prescription that insurance pays for instead of natural approaches that cost more money than they can afford to spend on their pain management. Self-management may be a more expensive alternative.^[94]

A 2023 review said that future chronic pain diagnosis and treatment would be more personalized and precision based.^[95]

The medical treatment of pain as practiced in

Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.

Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish guidelines to determine the treatment for pain which health care providers ought to offer.^[97] For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain.^[97] Health care providers may not provide the treatment which authorities recommend.^[97] Some studies about gender biases have concluded that female pain recipients are often overlooked when it comes to the perception of their pain. Whether they appeared to be in high levels of pain didn't make a difference for their observers. The women participants in the studies were still perceived to be in less pain than they actually were. Men participants on the other hand were offered pain relief while their self reporting indicated that their pain levels didn't necessarily warrant treatment. Biases exist when it comes to gender. Prescribers have been seen over and under prescribing treatment to individuals based on them being male or female ^[98].There are other prevalent reasons that undertreatment of pain occurs. Gender is a factor as well as race. When it comes to prescribers treating patients racial disparities has become a real factor. Research has shown that non-white individuals pain perception has affected their pain treatment. The African-American community has been shown to suffer significantly when it comes to trusting the medical community to treat them. Oftentimes medication although available to be prescribed is dispensed in less quantities due to their pain being perceived on a smaller scale. The black community could be undermined by physicians thinking they are not in as much pain as they are reporting. Another occurrence may be physicians simply making the choice not to treat the patient accordingly in spite of the self-reported pain level. Racial disparity is definitely a real issue in the world of pain management.^[99]

Acute pain is common in children and adolescents as a result of injury, illness, or necessary medical procedures.

Pain assessment in children is often challenging due to limitations in developmental level, cognitive ability, or their previous pain experiences. Clinicians must observe physiological and behavioral cues exhibited by the child to make an assessment. Self-report, if possible, is the most accurate measure of pain. Self-report pain scales involve younger kids matching their pain intensity to photographs of other children's faces, such as the Oucher Scale, pointing to schematics of faces showing different pain levels, or pointing out the location of pain on a body outline.^[102] Questionnaires for older children and adolescents include the Varni-Thompson Pediatric Pain Questionnaire (PPQ) and the Children's Comprehensive Pain Questionnaire. They are often utilized for individuals with chronic or persistent pain.^[102]

Acetaminophen,

In recent studies, it has been noted that people who have red-hair through the MC1R receptor gene may react to opioids and perceive pain differently than the rest of the population.[105] The studies on this developing topic have only become notable in the past few years with researchers looking into how red-haired individuals may experience a different threshold in pain and react to pain management differently than others. Most studies find that redheads with this gene have a higher pain tolerance and can also react more sensitively to opiates but require more anesthesia. ^[106]

Pain management practitioners come from all fields of medicine. In addition to medical practitioners, a pain management team may often benefit from the input of

Further reading

• Staats, Peter; Diwan, Sudhir (2014). Atlas of Pain Medicine Procedures. McGraw-Hill Education.
  ISBN 978-0-07-173876-7
  .
• Staats, Peter; Wallace, Mark S. (2015). Pain Medicine and Management: Just the Facts. McGraw-Hill Education.
  ISBN 978-0-07-181745-5
  .
• Fausett HJ, Warfield CA (2002). Manual of pain management. Hagerstwon, MD: Lippincott Williams & Wilkins.
  ISBN 978-0-7817-2313-8
  .
• Bajwa ZH, Warfield CA (2004). Principles and practice of pain medicine. New York: McGraw-Hill, Medical Publishing Division.
  ISBN 978-0-07-144349-4
  .
• Waldman SD (2006). Pain Management. Philadelphia: Saunders.
  ISBN 978-0-7216-0334-6
  .
• Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, et al. (October 2013). "Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010". Medical Care. 51 (10): 870–878.
  PMID 24025657
  .
• Graham, S. Scott (2015). The Politics of Pain Medicine: A Rhetorical-Ontological Inquiry. University of Chicago Press.
  ISBN 978-0-226-26405-9
  .
• Reynolds LA,
  ISBN 978-0-85484-097-7
  .
• Wailoo, Keith (2014). Pain: A Political History. JHU Press.
  ISBN 978-1-4214-1365-5. Project MUSE book 30085
  .

External links

Wikimedia Commons has media related to Pain management.

• World Health Organization (WHO) Treatment Guidelines on Pain