Therapeutic Options for Chronic Pain

Las Vegas—Treating patients with chronic pain can cause difficulties since there are both physiological components and psychological issues, which can lead to irritability or depression and make the condition even worse.

To best treat patients, physicians should use a multimodal approach that includes pharmacologic, rehabilitative, psychological, and other strategies, according to Mark Rosenberg, MD, PhD, president of BHM Healthcare Solutions, a consulting and advisory firm. Dr. Rosenberg also recommended clinicians and care managers utilize a collaborative approach.

Speaking during a session at the NAMCP meeting, Dr. Rosenberg used the International Association for the Study of Pain’s definition of pain: an unpleasant sensory and emotional experience, which we primarily associate with tissue damage, or describe in terms of such damage, or both.

Since it is difficult to assess and measure pain, some providers in the healthcare industry are skeptical of patients complaining about pain, according to Dr. Rosenberg. When patients talk about their pain, Dr. Rosenberg said physicians should take them seriously.

“You have to believe them,” Dr. Rosenberg said. “Err on the side of feeling you are not being snowed.”

Approximately 10% of people in the United States and 60% of people ≥65 years of age have had pain lasting ≥1 year, according to a report from the National Center for Health Statistics. Dr. Rosenberg said patients with chronic pain have more hospital admissions, longer hospital stays, and more unnecessary trips to the emergency department than those without chronic pain.

Dr. Rosenberg cited a 1998 report from the National Institutes of Health, which estimated the economic toll of pain in the United States at $100 billion per year. He also estimated the annual cost of pain management is now similar to diabetes ($174 billion per year), although there are no recent cost estimates for poorly controlled pain.

There are various types of pain, with acute pain not lasting longer than a few days or weeks and persistent pain lasting for a longer, unknown duration. To assess pain, Dr. Rosenberg said physicians should begin by obtaining a detailed history of previous therapies or diagnoses of pain and then conduct a physical examination. After finishing the neurological and musculoskeletal examinations, they should obtain and review past medical records and diagnostic studies before developing a treatment plan.

Dr. Rosenberg said it is important to ask patients to quantify the pain at regular intervals to measure the time frame, clinical context, and average intensity of pain.

For acute pain, the goal should be reducing the pain intensity as quickly as possible, according to Dr. Rosenberg. For persistent, cancer-related pain, the goal should be comforting pain, relieving other symptoms, and managing comorbidities. For persistent, noncancer-related pain, the goal should be decreasing pain intensity, comforting pain, managing comorbidities, and restoring function.

Common drugs used to treat pain are classified into 2 categories: (1) nonopioids and (2) opioids. Nonopioids include aspirin and other salicylates and nonsteroidal anti-inflammatory drugs such as COX-2 selective inhibitors. There are different types of opioids (short-acting, long-acting, and rapid-onset) and include morphine, hydromorphone, fentanyl, oxymorphone, and oxycodone.

Dr. Rosenberg said some clinicians are concerned that patients may become addicted to opioids and worry about the drugs’ toxicities. However, he said physicians should gain a deep understanding of opioids, including their relative potency, pharmacokinetics, pharmacodynamics, formulation differences, and potential drug interactions.

“The goal is comfort,” Dr. Rosenberg said. “The fears and worries of addiction need to take a backseat.”