Pain Management

Today's massive denial of pain medication is a consequence of the social, regulatory and law enforcement climate created by the War on Drugs. Doctors can suffer loss of license or even incarceration when the inevitable mistake of providing medicine to a dishonest patient who may be misusing or diverting medication occurs. The climate has led to a situation in which most physicians are incorrectly trained in pain management and under- or non-treatment of pain is the norm.

Because of the feeling of helplessness many patients have when trying to relieve chronic pain, patients are in danger of assuming what is called a "sick role." After countless doctors office visits and a myriad of diagnostic tests, some patients will become the victim of their pain symptoms. This sick role can cause significant isolation and feelings of worthlessness. Learning to manage the pain can be just as important as treating the pain. By not falling victim to chronic pain, patients maintain control of their health and the potential for curing their symptoms. Here are some suggestions for managing chronic pain and avoiding the sick role:
• Stay Active
Chronic pain has been shown to improve only when a patient't level of activity increases. While many patients will feel bound to a sedentary lifestyle because of their pain, there are always exercises and rehabilitation no matter how difficult the situation. Physical therapy should focus on reconditioning, stretching, and pain reduction modalities (e.g. ice, heat, ultrasound, etc.).
• Focus on Others
Be active in your community, stay in touch with friends and family, and look for volunteer activities. By keeping active with friends and family you will feel less isolated, and by maintaining active in your community you will pay more attention to others?problems and less to your own.
• Accept Your Pain
Don't deny or exaggerate your symptoms, and perform your daily functions accordingly. If there are things you need help with, don't be afraid to ask. If you are avoiding things you can do, make an effort to do those activities.
• Stay Healthy
Abnormal weight and sleep disturbance have both been shown to adversely affect pain treatment. Get a good night of sleep on a regular schedule and eat a healthy diet. Harmful habits such as tobacco, alcohol, and drug use all make pain more difficult to treat. Specifically, nicotine is associated with increased pain levels, and may decrease the effectiveness of treatment medications by altering their blood levels.

Acute pain can be defined as pain that lasts less than 6 weeks, or pain that is directly related to tissue damage. The pain that is experienced from a paper cut or from standing on a tack is acute pain. Pain that is felt after an operation is acute pain; it is severe, but we expect it to go away.

The difference between acute pain and chronic pain is very dramatic. Chronic pain patients expect to have daily pain, are often depressed, have neural plasticity, and are physiologically different from patients who do not have chronic persistent pain. Chronic pain patients also have limitations on functionality that affect their daily lives. Acute pain, on the other hand, is a pain that patients know is self-limiting. They expect to get better from their surgery or injury and will take pain medication to help maintain as close to normal functioning as possible. Treating acute pain is extremely important. If acute pain is not adequately treated, it may lead to the development of harder-to-treat chronic pain conditions, such as complex regional pain syndrome.

A complicating factor in the treatment of acute pain is the fact that most patients who are being treated for acute pain in the hospital setting are unknown to the staff caring for the patient. Healthcare professionals may be apprehensive about prescribing opioids for patients who they do not know. Therefore, in the acute setting pain, assessment, and medication choices are particularly important.
For acute pain, the most relevant method of pain assessment is the 0-10 Likert-type Numeric Pain Intensity (NPI) scale, in which 0 is "no pain" and 10 is the "worst pain possible" The real measure that this pain intensity rating captures is the efficacy of the pain medication or modality being used to treat the pain. However, the simple numeric rating does not capture the true essence of the total pain experience. Most patients who rate their pain at a level of 3 out of 10 or lower can participate in daily activities. A decrease of 3 points on the numeric intensity scale is considered to be clinically significant, and in many cases it is the best outcome possible.

The real problem with pain assessment is the difficulty that healthcare professionals have in believing the patient's report of pain. If the patient in the hospital or clinic reports a high pain intensity of 7/10, severe pain, but can ambulate or participate in therapy, the assumption is made that the patient's self-report is not credible and the pain is not that intense. This reliance on physical performance does not account for underlying chronic pain conditions, high pain tolerance, a coping style that is stoic, or even a simple misunderstanding of how to use the pain rating scale. For acute pain, when the patient provides a numeric pain rating, providing a medication that will treat the pain and reassessing for efficacy are the best options.
Medication choices for pain should reflect the reported intensity of the pain and any confounding factors, such as comorbidities and other medications being used concurrently, such as sedatives, sleeping pills, and antiemetics -- which can have a contributory sedating effect when used with opioids.

Today we have many more options for relieving acute pain than our predecessors. In a similar evolution, surgical anesthesia has advanced well beyond ether to combinations of paralytics, pain medications, intrathecal routes, or epidural catheters; treating acute pain has progressed into advanced techniques, new medications, and delivery systems that improve pain relief. By overcoming the barriers to effective pain relief and by using multimodal pain regimens, pain management can provide patients with adequate pain relief for the majority of acute pain conditions.

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