Chapter 12
Introduction to management

Mary E. Lynch

Department of Anesthesia, Pain Management and Perioperative Medicine, Department of Psychiatry, Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada

Overview

All pain management should take place within the context of a biopsychosocial approach where the role of the clinician is to assist the patient in becoming an active participant in their own healthcare. The following chapters address in detail pain management from different biological, psychological and social perspectives, with the interest in this chapter focusing on integration of the approaches so as to assure all facets of care are addressed. The principles of healthful living and therapeutic exercise should be a part of every patient’s care. In addition, most people living with pain will benefit from strategies for relaxation along with cognitive approaches to deal with the pain day to day. Details of treatment approaches are presented in the following chapters. This chapter provides an overview of the four steps needed in the management of pain (Table 12.1).

Start with the basics

Step 1: Listen

Pain management begins the minute you start to listen

The importance of facilitating the patient’s narrative was reviewed in Chapter 8. This is a therapeutic way to collect information as there “is the need of ill people to tell their stories, in order to construct new maps and new perceptions of their relationship to the world” [1]. The Stone Center Study Group on Women with Chronic Illness and Disability state that “Giving voice to one’s experience with illness is courageous” and note that courage can inspire growth [2]. In this way the pain management begins the minute you start to listen.

Step 2: Communicate the diagnosis clearly

Establish and communicate the diagnosis

In determining optimal pain management, one must first establish the diagnosis as far as possible. As presented in more detail in previous chapters, chronic pain may or may not have a definitive explanation in tissue pathology. In the former case, the pain and related disability may result from a sustained sensory abnormality occurring as a result of ongoing peripheral pathology, such as chronic inflammation. It may also be autonomous and independent of the trigger that initiated it as in post‐traumatic or postsurgical neuropathic pain. Thus, patients may present with nociceptive pain (pain due to tissue damage), neuropathic pain (pain due to pathology in neural systems) or a combination. When there is no identifiable medical or biological explanation, the biopsychosocial model encourages a stronger emphasis on psychophysiological and social explanations of functional symptoms [3]. In addressing management, it is important to consider both disease‐based (e.g. diabetic neuropathy, lumbar radiculopathy, cervical sprain) and mechanistic (e.g. nociceptive, inflammatory, neuropathic) aspects of the pain. It is also important to reassure the patient as to the reality of their experience even when there is not an identifiable etiology. One must also consider comorbidities (e.g. medical, psychiatric or substance use disorders), as well as additional aspects relating to the consequences of pain and disability and the state of the patient’s overall health (e.g. psychosocial issues, metabolic and circadian factors, deconditioning) all of which will influence the experience of pain. For this reason, all management should take place within a holistic active participatory context.

Table 12.1 The four steps of good pain management.

Step 1: Listen

Narrative or telling one’s story of pain is therapeutic: pain management begins the minute you start to listen

Step 2: Communicate the diagnosis clearly

In order to come to terms with a chronic pain diagnosis, understanding regarding the cause along with an active plan for management is essential

Step 3: Review healthful living

Proper nutrition

Quit smoking

Balance of activities and rest

Good sleep hygiene

Exercise program within pain tolerance

Step 4: Consider pain reduction treatment options in biological, psychological and social domains

Medical

Pharmacotherapy

Neuromodulation

Surgery

Psychological: assure psychosocial issues are identified and addressed in management

Physical and rehabilitation

You must communicate the diagnosis to the patient in clear unambiguous terms. In most cases the pain will have come on in the context of illness or injury and will have persisted beyond the time where healing should have taken place. The presence of allodynia or hyperalgesia may support a diagnosis of a neuropathic pain. In this case it is appropriate to explain that the nerves that convey pain‐related information are alive and can be changed after injury such that they become sensitized or “stuck in the on” position like a light switch that cannot be turned off. The patient may have been previously diagnosed with Crohn’s disease or recurrent renal stones and suffering from pain in the absence of a documented Crohn’s exacerbation or presenting with pain that persists between renal stones. In this case it is important to explain to the patient that they are probably suffering from visceral hyperalgesia [4]

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