Primer on Pain Management

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Primer on Pain Management CME/CE

Disclosures

Charles P Vega, MD University of California - Irvine

Introduction

Pain, both acute and chronic, is 1 of the most common reasons that patients visit their family physician. Over 8 hours of continuing medical education (CME) was dedicated to this important subject at the American Academy of Family Physicians (AAFP) 2005 Scientific Assembly. The speakers enlightened the audience on some of the unique aspects of diagnosing and treating pain.
Perspectives on Chronic Pain

During their CME activity on the first day of the Assembly, Heidi Pomm, PhD, Behavioral Science Director, St. Vincent's Family Medicine Residency Program, Jacksonville, Florida, and Penny Tenzer, MD, Vice Chair and Residency Director, Department of Family Medicine and Community Health, University of Miami School of Medicine, Miami, Florida, explained that pain is now considered the "fifth vital sign" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[1] This fact implies that pain should be measured regularly in every patient. Dr. Tenzer advocated for the "HAMSTER" model as a means to assess and follow pain:

H -- History

A -- Assessment (including patient's function, psychological state, and use of medications)

M -- Mechanism of pain

S -- Social and psychological factors

T -- Treatment

E -- Education

R -- Reassessment

To follow pain over time, Dr. Tenzer recommends use of paper or verbal pain scales; numeric scales can help rate the degree or intensity of the pain; and caricature representation of the human body can be used for children or patients with developmental disabilities.
Neuropathic Pain

While nociceptive pain, defined as pain in response to noxious stimuli, is common and may result in significant morbidity, neuropathic pain is considered more frustrating for patient and physician alike. According to Dr. Tenzer, this is partly because neuropathic pain "is the symptom, not the disease." Neuropathic pain is often chronic, and the pain is caused by damage to the neurologic system itself. In addition, many patients experience windup of peripheral nerve roots (when more nerves become involved following repetitive stimuli) and central sensitization (dorsal root ganglions become more easily excited after multiple episodes of pain). Chronic neuropathic pain is difficult to treat, says Dr. Tenzer, because it is mediated by "some of the toughest receptors to treat," including the central N-methyl-D-aspartate receptor.

First-line treatment options for patients with neuropathic pain include gabapentin, lidocaine patches, tramadol, tricyclic antidepressants, and opioid analgesics. Dr. Tenzer suggested some tips for using opioid analgesics, including use of oral medications whenever possible and beginning with a low dose. When titrating these medications to achieve pain control, she recommends using the model of insulin dosing in diabetes. Thus, the physician should add up a daily total of short-acting pain medications used by a patient and then convert this total into an equivalent amount of daily long-acting opioids. While the bulk of analgesia should be delivered through long-acting agents, patients should also have short-acting medications available for breakthrough pain. Finally, the possibility of addiction to narcotics was put in context -- Dr. Pomm noted that "less than 1% of patients who need opioids for pain become addicted."

Dr. Tenzer cautioned against the routine use of meperidine because its metabolites can cause seizures. She also recommended not using propoxyphene because of lower efficacy than other opioids,[2] and discouraged the use of mixed agonist/antagonist opioid medications.
Comorbid Conditions

Depression, anxiety, and sleep disturbances commonly occur with chronic pain, mandating attention and treatment in their own right.[3] Dr. Pomm emphasized that pain is both a sensory and an emotional experience and that "you can't take one [away] from the other." She noted that psychiatric disorders actually predispose patients to chronic pain and decrease patients' functionality when they have pain.

Given the severity and frequency of mood disorders associated with such pain, she believes that "rational polypharmacy" using analgesics along with adjuvant medications is the best course of action. Tricyclic antidepressants, for example, have proven efficacy in treating multiple causes of chronic pain, including diabetic neuropathy, postherpetic neuralgia, migraine and tension headaches, and fibromyalgia.[4,5] These medications can also improve mood, although Dr. Tenzer noted that tricyclic antidepressants as prescribed for pain do not require the higher dose necessary to control depression. Dr. Tenzer recommended starting at the lowest possible dose and titrating upward every few days as tolerated by the patient. Side effects still limit the usefulness of tricyclic antidepressants for chronic pain, but splitting the dose between morning and evening may help tolerability. Desipramine and nortriptyline incur fewer side effects than amitriptyline.[6] Selective serotonin-reuptake inhibitors (SSRIs),which are associated with fewer adverse effects, have a mixed record in the treatment of chronic pain. They do, however, play a role in treating comorbid depression in patients with chronic pain.[7]
Treating Chronic Pain: Beyond Medications

Given the nature of the problem, medication alone is frequently not enough to relieve chronic pain. In a 3-hour session, Robert Bonakdar, MD, Director of Integrative Pain Services and Co-Chair, Scripps Green Hospital Pain Management Committee, Scripps Center for Integrative Medicine, La Jolla, California, and David C. Leopold, MD, Director of Integrative Medical Education and Director of the Integrative Medicine Weight Management Program, Scripps Center for Integrative Medicine, La Jolla, California, led the audience through a review of nonpharmacologic treatment of pain.[6] They noted that 40% of individuals with chronic back pain seek nonpharmacologic treatment.[8] Most of these patients desire alternative therapy because they are dissatisfied with traditional care. Drs. Bonakdar and Leopold described the most popular and effective alternative pain treatments, reviewing the evidence for their efficacy.
Manual Medicine

According to Dr. Leopold, the main goal of manual therapy, whether applied through a chiropractor, doctor of osteopathy, or massage therapist, is "to achieve maximal synchrony of form and function of the system as a holistic unit." Practitioners of manual medicine seek to relieve tendons that are inappropriately shortened and under stress secondary to chronic pain. In 2 study of 459 patients receiving osteopathic manipulative maneuvers (OMMs), OMMs were associated with improved pain and mobility, especially in women. Patient satisfaction with OMMs was high.[7]

Although not proven scientifically, Dr. Leopold reported that, in his clinical experience, manual medicine is most effective for low back pain, cervicalgia, headache, and piriformis pain. He believes that its greatest benefit lies in reducing time to heal and in decreasing medication use. However, he cautioned that patients must be involved in their own care and perform home exercises to derive the most benefit from manual medicine techniques. Regarding traditional vs manual medicine for pain, Dr. Leopold encourages physicians not to feel compelled to necessarily choose 1 over the other, explaining that he prescribes both at the same time.
Electrostimulation

Several types of treatment are categorized as electrostimulation:
Transcutaneous electrical nerve stimulation (TENS)


Neuromuscle electrical stimulators (NMES)


Interferential stimulation


Laser therapy


Electromagnetic field therapy.

While Dr. Bonakdar reports that electrostimulation is "a poor evidence-based therapy," he does recommend it as a means to treat pain from osteoarthritis, carpal tunnel syndrome, low back pain (especially with muscle spasm), and fibromyalgia. He prefers newer methods, like NMES and laser, over older methods, such as TENS. The lack of scientific evidence on these methods partially results from high heterogeneity of the research. A recent Cochrane Review, however, concluded that TENS has value for the treatment of osteoarthritis of the knee because, despite the heterogeneity of the 7 studies included in the analysis, the treatment was superior to placebo.[9]
Acupuncture

Acupuncture has been used to manage several types of pain in non-Western countries for over 2500 years. Dr. Bonakdar now feels that, compared with other "alternative" treatments for pain, acupuncture has won the greatest acceptance among Western physicians. How it works seems to involve multiple mechanisms:
Stimulation of localized electrothermal changes


Modification of the central transmission of pain signals


Enhanced release of endorphins

Dr. Bonakdar described 2 studies strongly supporting the use of acupuncture for chronic headache and osteoarthritis.[10,11]

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Exercise and Diet

Exercise is an important adjunct to other therapies in the treatment of musculoskeletal pain. Dr. Leopold cited evidence that exercise can help improve the pain of fibromyalgia, osteoarthritis, and even rheumatoid arthritis. He feels that this can partly be explained by the positive effects of exercise on weight loss and depressed mood.

According to Dr. Leopold, "It is very difficult to get someone with fibromyalgia healthy without exercise." In 1 randomized trial involving 132 patients with fibromyalgia, aerobic exercise was associated with fewer tender points, improved self-ratings of health, and a reduced number of patients meeting the criteria for fibromyalgia compared with stretching therapy alone.[12]

Patients with rheumatoid arthritis should receive medical clearance before beginning an exercise program. Low-impact exercise, such as elliptical training, yoga, and swimming, should be emphasized for these persons, and exercise duration should be increased gradually to achieve a goal of 45 minutes per day.

In addition to exercise, Dr. Leopold feels that increasing foods rich in omega-3 fatty acids (flaxseed; fish oils; green, leafy vegetables; walnuts) and decreasing foods with high amounts of omega-6 fatty acids (margarine, corn oil) and saturated fats can improve chronic inflammation and pain. He cited a study in which the Mediterranean diet for patients with rheumatoid arthritis was associated with reduced pain and joint edema.[13] Although he acknowledged that dietary change is difficult for patients, he tells patients that "one of the things I guarantee is that if you go on the anti-inflammatory diet, you will feel better."
Supplements for Pain

Dr. Bonakdar stated that there is good evidence for the efficacy of glucosamine in the treatment of osteoarthritis, although he noted that the brand used "makes a ton of difference." He stated that the Dona preparation is the most consistent formulation of glucosamine, and he recommends 1500 mg/day. It is important for patients to understand that the analgesic effects may not peak for 2-3 months after treatment with glucosamine is started or, for that matter, any supplement intended to reduce pain and inflammation. S-adenosylmethionine (SAMe) has also been shown to be as effective as celecoxib in treating osteoarthritis, although it has a slower onset of action.[14] The maximum dosage of SAMe recommended by Dr. Bonakdar is 1600 mg/day.
Conclusion

Drs. Leopold and Bonakdar closed by emphasizing that alternative therapy is not meant to replace, but rather to augment, traditional methods of pain management. Attention to the connection between mind and body improves patients' overall sense of well-being. Their talk was well-received, since combining high-tech medicine with high-touch care to serve the whole patient fits the philosophy and practice of family physicians.
References
Pomm HA, Tenzer P. Perspectives on chronic pain. Program and abstracts of the American Academy of Family Physicians Annual Scientific Assembly; September 28 -October 2, 2005; San Francisco, California. Abstract 277.
Sachs CJ. Oral analgesics for acute nonspecific pain. Am Fam Physician. 2005;71:913-918.
Fishbain DA. The association of chronic pain and suicide. Semin Clin Neuropsychiatry. 1999;4:221-227.
Richeimer SH, Bajwa ZH, Kahraman SS, Ransil BJ, Warfield CA. Utilization patterns of tricyclic antidepressants in a multidisciplinary pain clinic: a survey. Clin J Pain. 1997;13:324-329.
Greco T, Eckert G, Kroenke K. The outcome of physical symptoms with treatment of depression. J Gen Intern Med. 2004;19:893-895.
Bonakdar RA, Leopold DC. Non-pharmacological treatment of pain. Program and abstracts of the American Academy of Family Physicians Annual Scientific Assembly; September 28 -October 2, 2005; San Francisco, California. Abstract 282.
Licciardone J, Gamber R, Cardarelli K. Patient satisfaction and clinical outcomes associated with osteopathic manipulative treatment. J Am Osteopath Assoc. 2002;102:13-20.
Nayak S, Matheis RJ, Agostinelli S, Shifleft SC. The use of complementary and alternative therapies for chronic pain following spinal cord injury: a pilot survey. Spinal Cord Med. 2001;24:54-62.
Osiri M, Brosseau L, McGowan J, Robinson VA, Shea BJ, Tugwell P, Wells G. Transcutaneous electrical nerve stimulation (TENS) for knee osteoarthritis. The Cochrane Database 2005; Issue 3. Available at [Ссылки доступны только зарегистрированным пользователям ]. Accessed November 1, 2005.
Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients with tension-type headache: randomised controlled trial. BMJ. 2005; 331:376-382.
Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004;141:901-910.
Richards SC, Scott DL. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ. 2002;325:185.
Skoldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis 2003; 62: 208-214.
Najm WI, Reinsch S, Hoehler F, Tobis JS, Harvey PW. S-adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial. BMC Musculoskelet Disord. 2004;26:5-6.


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