Chronic Pain Management in the ED
Rahim Valani
Introduction
Chronic pain is defined by the International Association for the Study of Pain as pain without the biological value that has persisted beyond the normal healing time.
Usually defined as pain lasting for more than 6 months.
It is estimated that 35% of the US population suffer from chronic pain, which costs $40 billion per year.
Approximately 21% of people with chronic pain are dissatisfied with their current pain management.
Stages of progression from acute to chronic pain:
Stage 1 – acute phase.
Initial psychological distress that is expected – fear and anxiety.
Stage 2 – exacerbation of psychological problems.
When pain lasts over 2–4 months.
Patient’s response includes anger, distress, and somatization.
Social, financial, and environment factors play an important role in how the patient copes with this phase.
Stage 3 – acceptance of the “sick role.”
Physical deconditioning occurs in all three stages.
The most common chronic pain conditions in general practice include:
Irritable bowel syndrome.
Osteoarthritis.
Lower back pain.
Chronic pelvic pain.
Migraine headaches/tension headaches.
Fibromyalgia.
It is important to complete a thorough pain history for every patient who presents to the ED, including:
Pain characteristics – onset, location, quality, radiation, severity, temporal profile, and alleviating factors.
Effects on daily living – Can they cope with daily activities of living such as bathing, dressing themselves, doing the laundry, and cooking?
Effects on their family/friends.
Effects on their employment – Are they able to continue to work? What are the limitations? Can they be accommodated for limited duties?
Changes in recreational activities.
Psychological impact of pain – mood, sexual function, sleep, etc.
Physical examinations should include:
Inspecting for:
Signs of inflammation.
Trophic changes.
Deformities.
Range of motion of affected joints and muscles.
Palpation for tenderness, crepitus, and warmth.
Issues surrounding the adequate treatment of chronic pain:
Poor knowledge by health care professionals.
Inadequate pain assessment.
Not recognizing multidimensional cause of pain.
Poor documentation.
Misconceptions about the use of opioids.
Patient’s reluctance to report pain.
Opioid used for non-cancer and chronic pain.
Opioids continue to be one of the most prescribed medications for chronic pain.
Three largest increases over the 10 years (1997–2006) include the use of:
Methadone (1,177% increase).
Oxycodone (732%).
Fentanyl (479%).
Consider the following steps in prescribing opioids for chronic pain:
Comprehensive initial evaluation.
Establish need for opioid, either as a supplemental medication or lack of response to prior medication.
Assess risk of starting and using opioid medication.
Establish treatment goals with patient.
Obtain informed consent and agreement with patient.
Initial dose adjustment phase in first 3 months, followed by frequent reevaluation to titrate dose accordingly.
Outcomes – dose adjustments, steady state, or discontinuing medications.
Consequences of chronic pain:
Inability to perform normal activities of daily living.
Feeling of hopelessness.
Fear of activities that can exacerbate the pain.
Myofascial Pain
Estimated to affect up to 54% of individuals.
Regional painful muscle/soft tissue condition related to specific trigger points and related pain.
Also referred to as myofascial trigger point pain.
Hallmark is localized trigger points with focal tenderness.
Usually tight bands typically located in the center of the rigid muscle.
Pain on sustained compression over the tender point.
Local twitch response within the band of muscle on plucking palpation across the fibers.
Immediate response to injection of local anesthetic is characteristic.
Classified as primary or secondary.
Primary – from a specific cause with ongoing pain with continued use of that muscle.
Secondary – pain referred from a primary site due to mechanical stress or inflammation.
Common posterior myofascial trigger points are located at:
Levator scapulae.
Trapezius.Related posts:
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