We are all aware that chronic pain is common. The trick is to be aware of this and to have a plan of action.
One in five Australians will suffer from chronic pain in their lifetime. This does not include the minor aches and sprains of life; what we’re talking about persistent/chronic pain, with its significant and long-term negative health consequences.
If you consider the prevalence of diabetes, which is 5% of the population, chronic pain, which is at 20%, is setting itself to be a key driver of suffering and disability now and in the future.
Even more worrying is that 80% of chronic pain sufferers will miss out on effective treatment that could improve their health and quality of life. This number says it all: we need to do more for our pain patients.
1. Diagnose chronic pain early
Pain can be considered chronic when the pain persists for more than one month following anticipated tissue healing or if any pain continues for longer than three months.
Chronic pain is usually triggered by an acute injury, disease or process that the body has long since recovered from. Be aware of common causes of chronic pain. Some of these initial triggers can include surgeries like spinal surgery, thoracotomy, mastectomy and herniorraphy, trauma, shingles, a minor back or spine injury, a joint problem, and even arthritis. In fact, anything that can affect nerves detrimentally can cause chronic neuronal changes and dysfunction, which can then lead to persistent sensory changes and chronic pain.
The knock-on effects of chronic pain are multiple and can affect all aspects of physical and mental health.
Put yourself in a chronic pain suffers shoes for a minute.
Movement triggers pain, and people with chronic pain think that they will damage something when they move (this is a maladaptive thought), then they end up resting excessively (this is a maladaptive behavior). These maladaptive thoughts, which lead to maladaptive behaviours, can in turn, lead to deconditioning and all its dangerous consequences.
It might sound like this: “My movements hurts and will make it worse, so I must avoid those movements and rest!”
There are many maladaptive thoughts and behaviours. Another maladaptive behavior might be: “I need to take medications, which are the only way to make me feel better”, this in turn re-inforces a poor coping strategy called ‘chemical coping’, where the only way of coping is to take medications.
2. Evaluate the flags and perform psychological screening
Chronic pain can happen to anyone, including you and me. It’s when the chronic pain is not diagnosed early and not managed effectively in an allied health setting that the pain can have knock on effects.
Fig. 1 The flag system in evaluation chronic pain
3. Have a working diagnosis
Work through a differential diagnosis, which should include other causes of pain, neuropathic pain, and psychological comorbidities.
4. Treat chronic pain like a chronic disease
A chronic disease is defined as a long-lasting condition that can have persistent effects but that can be controlled but not cured. Chronic pain can, and does behave in the same way as a chronic disease and hence should be managed the same way. The key to chronic pain management is to use the correct medical treatments to reduce the pain, whether they be medications and/or interventional pain procedures, but at the same time paying attention to and focusing on the person who is in pain using your allied health team.
Another key is not to use long-term dangerous medications like opioids.
5. Show patients that you understand and have a plan for them
Chronic pain suffers need the time to be heard. They have been through a lot and have usually spent much time and money seeking answers and curative treatments.
A simple plan could be as follows: trialling combination anti-neuropathic agents, educating patients on increased physical activities and stress reduction and monitoring their coping strategies.
If you feel this plan is failing, get your patients to a pain specialist physician with the abilities to apply diagnostic and therapeutic blocks and interventions as part of a multidisciplinary management approach.
6. Use combination anti-neuropathic agents
- Trial low dose pregabalin or gabapentin with tricyclic or SNRI antidepressants. If they can tolerate the low doses, then gradually increase the doses
- Treat sleep problems with tricyclic antidepressants or gabapentinoids and not benzodiazepines
- Use NASIDS or coxibs if appropriate
- If there is associated depression use antidepressants with analgesic properties like venlafaxine or duloxetine
- Don’t forget that tramadol has anti-neuropathic properties, that can be useful, if your patients can tolerate it
7. Use a multidisciplinary team approach
If your patients are not improving with trials of anti-neuropathic agents or they are displaying poor coping/rising levels of stress, worry or anxiety, refer them to an experienced allied health pain management team, which should include a pain specialist physician who can consider interventional therapies when needed.
8. Consider interventional therapies
Interventional pain medicine uses the principles of a tiered approach to the diagnosis and therapeutic treatment of chronic pain. This tiered approach includes: blocks, radiofrequency and even neurostimulation.
Fig. 2 This is what a step-wise interventional and multidisciplinary treatment approach looks like
If the pain can be effectively reduced using medications and advanced interventional techniques, your patient is more likely to engage with the allied health team and benefit from the multidisciplinary approach.
9. If your patients are displaying refractory pain, consider whether they may be candidates for a trial of neurostimulation1
Refractory pain is where multiple evidenced-based biomedical therapies used in a clinically appropriate and acceptable fashion have failed to reach treatment goals that may include pain reduction &/or improvement in daily functioning or have resulted in intolerable adverse effects.
If patients have refractory pain are psychologically stable, they may be considered for a trial of neurostimulation where the electrodes are implanted percutaneously via needles and then connected to an external pulse generator (battery) taped to the skin temporarily. A trial lasts for about two weeks and is used to determine its effectiveness and if the pain is responsive to neurostimulation. If the pain is reduced by more than 50% during the trial, an implant of a neurostimulator could be considered at a later date.
Conditions likely to respond to neurostimulation
- Failed back surgical syndrome (FBSS) or now called Post Operative Persistent Syndrome (POPS)
- Complex regional pain syndrome (CRPS)
- Neuropathic pain secondary to peripheral nerve damage
- Refractory angina pectoris, where no further cardiac interventions are considered
Conditions that may respond to neurostimulation
- Pain associated with peripheral vascular disease, where no further surgery is considered
- Brachial plexopathy: traumatic (partial, not avulsion), post irradiation
- Pain following surgery e.g. intercostal neuralgia after thoracotomy
- Other peripheral neuropathic pain syndromes, such as those following trauma
- Axial back pain following spinal surgery
- Some forms of chronic back pain
Fig. 3 This is what a two-week trial of spinal cord stimulation looks like
10. Trial of opioids as a last resort2, 3
Despite the current liberal use of opioids for chronic pain, the evidence for this treatment is limited and the risks of opioids are significant. If you get to the point of considering a trial of opioid therapy, use principles of safe opioid prescribing which might include:
- Rationalising sedative medications; taper and stop sedating medications like benzodiazepines and muscle relaxants.
- Perform opioid risk stratification e.g. using the Opioid Risk Tool (ORT)
- Consider inform consent and written contracts
- Do a trial of opioids
- Only use slow release preparations
- Slow titration
- Have a ceiling dose of 100mg of oral morphine equivalent/day
- Do not use pethidine
- Do not use immediate release opioids
- Do not use injectable opioids
- Do not allow concomitant use of other sedatives or alcohol
- Monitor the six As
- Activities of daily living
- Adverse events
- Aberrant drug-taking behaviors
- Accurate record keeping
- Have an exit strategy
If the pain doesn’t respond to the trial or there is no increase in ADLs or if there are side effects or aberrant behaviours, wean and stop the opioids
1. Mekhail NA1, Mathews M, Nageeb F, Guirguis M, Mekhail MN, Cheng J. Retrospective review of 707 cases of spinal cord stimulation: indications and complications. Pain Pract. 2011 Mar-Apr;11(2):148-53.
2. Recommendations regarding the use of Opioid Analgesics in patients with chronic Non-Cancer Pain. Faculty of Pain Medicine, Australia and New Zealand College of Anaesthetists. PM01-2015. http://fpm.anzca.edu.au/documents/pm1-2010
3. Currow DC, Phillips J, Clark K. Using opioids in general practice for chronic non-cancer pain: an overview of current evidence Med J Aust 2016; 204 (8): 305-309
AUTHOR | Dr Nick Christelis
Dr Nick Christelis holds two specialist medical qualifications in pain medicines. He is trained in all aspects of pain medicine including advanced international techniques like nerve blocks, radiofrequency and spinal cord stimulation. View eBook on Managing Chronic Pain – a guide for GPs
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PH | 1300 798 682 WEB | www.vicpain.com.au