CHRONIC PAIN APPROACH,

ANALYSIS AND MANAGEMENT

Nikitas P. Rodríguez MS4

UCC SoM
Ambulatory Medicine and Research Clerkship
 INTRODUCTION: WHAT IS PAIN?

OUTLINE

1. Definition of Pain
• Acute Pain
• Chronic Pain
2. Importance of the topic of pain
3. Epidemiology
4. Pathophysiology, Neurobiology, and Symptoms
5. Guidelines and Recommendations
• The opioid epidemic and pain
6. Management and Education of the patient with CP
• Public Health and the Biopsychosocial approach
7. Current Research
• Neuroglial deregulation in CP
• Neuroimmunological aspects of CP
• COVID-19 and CP
8. Bibliography
 THE DEFINITION OF PAIN

• Fundamentally, pain is a protective mechanism by which the body alerts our nervous
system that something in our physiology is either damaged or potentially hurt.
• From an evolutionary perspective, pain is beneficial to the organism and its capacity to
withdraw from danger.
• As with any other primitive selected feature of evolution, pain has a complex, dynamic,
and crucially multifactorial quality, making it a phenomenon that must be approached as
a continuum rather than in an absolute quantitative manner.
• In conclusion, pain serves a vital physiologic and psychologic function as a warning
sign of injury or infection. Still, once its warning role is over, constant pain is
maladaptive and can transform into a disease by itself which is termed chronic pain (CP)
 ACUTE PAIN VS CHRONIC PAIN

• Acute pain (AP) happens quickly as a reflex reaction to injury. Notably, the
pain response extinguishes when the threat is over or the damage is healed.
• Chronic pain (CP) is a non-adaptive reaction lasting longer than six months
that characteristically continues even when the injury or illness has been
resolved.
• CP involves a series of neurobiological and psychological changes that persist
and feedback one another until it becomes a disease itself.
 EPIDEMIOLOGY OF PAIN

• At least 116 million U.S. adults suffer from chronic pain conditions. More than
the number affected by heart disease, diabetes, and cancer combined.
• Some population groups have a much higher risk of experiencing pain and
receiving inadequate treatment.
• Pain is one of the most frequent reasons for physician visits, among the most
common reasons for taking medications, and a significant cause of work
disability.
• This implies a significant financial burden on affected individuals, their
families, their communities, and the nation as a whole.
• The annual economic cost of chronic pain, including health care expenses and
lost productivity is between $530 and $630 BILLION annually. That’s half a
TRILLION dollars!
 THE PAIN CONTINUUM:
PATHOPHYSIOLOGY AND SYMPTOMS

• Interestingly, pain can have various origins and manifestations that can be physiologic or psychologic.
• Physical pain
• Emotional pain
• Perceived pain
• Anticipated pain
• Pain threshold
• Pain tolerance
• Pain aversion
• Interestingly, Durso et al. (2015) demonstrated that “treating patients with acetaminophen, an effective and popular over-the-counter
pain reliever, has recently been shown to blunt individuals’ reactivity to a range of negative stimuli in addition to physical pain.”
• Emotional vs. Physical pain. Is there a difference?
• On the other hand, pain can be devastating and debilitating but not necessarily indicative of any pathologic process. Instead, it can
transform into a maladaptive neurobehavioral feedback loop that has a similar neurobiological profile as long-term learning and
addiction.
 PAIN AS A SOCIOBIOLOGICAL AND
SOCIOCULTURAL PHENOMENON

• In its book “Stabbed in the Back” N. Hadler M.D. explains how the very concept
of pain is a “multivariate phenomenon affected by age, socioeconomic status,
education, BMI and emotional disturbances.”
• Chronic pain must be considered in the context of the biopsychosocial model,
which views symptoms as the result of a complex and dynamic interaction
between biological, psychological, and social factors
• Pain is a normal part of our lives and nature. In most cases, it indicates no actual
pathology or disease; instead, it is a fluctuating subjective feeling that mirrors
the physiological adaptations that happen every second in our bodies to maintain
homeostasis.
• On the other hand, it can indicate a devastating pathologic process like cancer or
vascular accidents.
• So, how should we address a patient with a chief complaint of pain?
• How should we educate patients about their pain?
 PAIN VS PAIN

• Pain is an individual, subjective, and individual state. Any person complaining

of pain should be listened to and evaluated for that pain without undermining
the complaint or assuming the pain level.
• All people are at risk of chronic pain, and it comes about with age, genetic
predisposition, chronic disease, as a result of surgery, or accidents and injuries.
• Although pain can be “benign” and not reflect an actual life-threatening
pathology, chronic pain can be a disease in itself, causing changes throughout
the CNS that can worsen or persist long-term and cause significant
psychological and cognitive disturbances that could transform into separate
disease entity by itself.
• In conclusion understanding chronic pain as a disease means that it requires
direct treatment, rather than being sidelined while clinicians attempt to identify
some underlying condition that may have caused it.
 USPFTF GUIDELINES AND RECOMMENDATIONS:
THE OPIOID EPIDEMIC AND TREATMENT OF PAIN

• Although there is no specific recommended guideline for treating pain (by its
subjective and multivariate causes and presentations) the main concern in the
last decade has been the misuse of opioids for treating pain, leading to a
devastating epidemic of opioid addiction.
• For example, in 2012, health care providers wrote 259 million prescriptions for opioid
pain medication, enough for every adult in the United States to have a bottle of pills.
• “Rates of opioid prescribing vary greatly across states in ways that cannot be
explained by the underlying health status of the population, highlighting the lack of
consensus among clinicians on how to use opioid pain medication.”
• For this reason the USPFTF CDC conducted a clinical systematic review of the
scientific evidence to identify the effectiveness, benefits, and harms of long-
term opioid therapy for chronic pain, consistent with the GRADE approach
 USPFTF GUIDELINES AND
RECOMMENDATIONS

• In summary, evidence on long-term opioid therapy for chronic pain outside of

end-of-life care remains limited, with insufficient evidence to determine long-
term benefits versus no opioid therapy, though evidence suggests risk for
serious harms that appears to be dose-dependent.
• Based on randomized trials predominantly ≤12 weeks in duration, opioids were
found to be moderately effective for pain relief, with small benefits for
functional outcomes; although estimates vary, based on uncontrolled studies, a
high percentage of patients discontinued long-term opioid use because of lack
of efficacy and because of adverse events
 DETERMINING WHEN TO INITIATE OR
CONTINUE OPIOIDS FOR CHRONIC PAIN

• 1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
• 2. Clinicians should establish treatment goals with all patients, including realistic goals for pain
and function.
• 3. Clinicians should discuss with patients known risks and practical benefits of opioid therapy and
patient and clinician responsibilities for managing treatment.
• 4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting (ER/LA) opioids.
• 5. When opioids are started, clinicians should prescribe the lowest effective dosage.
• 6. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of
immediate-release opioids and define no greater quantity than needed for the expected duration of
pain.
 DETERMINING WHEN TO INITIATE OR
CONTINUE OPIOIDS FOR CHRONIC PAIN

• 7. Clinicians should evaluate the benefits and harms with patients within 1 to 4 weeks of starting opioid therapy
or of dose escalation.
• 8. Clinicians should consider offering naloxone when factors that increase the risk for opioid overdoses, such as
the history of overdose, history of a substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent
benzodiazepine use, are present.
• 9. Clinicians should evaluate other controlled substance prescriptions using state prescription drug monitoring
program (PDMP) data to determine whether patients are receiving opioid dosages or dangerous combinations that
put them at high risk for overdose.
• 10. Clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least
annually to assess for prescribed medications and other controlled prescription drugs and illicit drugs.
• 11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever
possible.
• 12. Clinicians should offer or arrange evidence-based treatment for patients with opioid use disorder.
 MANAGEMENT OF PAIN

• Just as the etiology of pain is multivariate, the management must include a multidisciplinary
and comprehensive approach.
• The initial step should always be prevention and the patient’s education so that an initial
episode of pain does not transform into a chronic state of distress.
• Role of the physician in pain management
• The effectiveness of pain treatment depends significantly on the strength of the clinician-patient
relationship.
• Value of a public health and community-based approach
• Many features of the pain problem reside in the public health domain: the large number of people
affected, disparities in occurrence and treatment, prevention strategies, and resources allocation are
some examples.
 MANAGEMENT OF PAIN:
SOCIOCULTURAL TRANSFORMATIONS

• Recently, the opioid crisis has significantly impacted pain treatment.

• Costly procedures are often performed when other actions should be considered, such as
prevention, counseling, and facilitation of lifestyle choices education.
• Psychological disturbances are a common side-effect of acute or chronic pain and should be
addressed.
• Anxiety, depression, anger, and worthlessness are examples
• Treatment can be affected by conscious and unconscious biases
• Social stigma, the subjective nature of pain, and unsuccessful treatments are examples.
• In conclusion, the healthcare system needs to remediate the mismatch between current knowledge
and its application, and this will require a sociocultural transformation in the way clinicians and
the public view pain and its treatment.
CURRENT RESEARCH
 C UR RENT RES EARCH: CONS IDERING THE
POT ENTIAL FOR AN INCRE AS E IN CHRONIC
PAIN AFTE R THE C OVID- 19 PANDE MI C

• The toll of this pandemic extends beyond physical illness, with important
psychosocial stressors that include prolonged periods of limited interpersonal
contact, isolation, fear of illness, future uncertainty, and financial strain.
• Examine the potential health consequences of COVID-19 germane to CP,
which might be nociplastic, neuropathic, or nociceptive. Specific possibilities
might include: (1) CP as part of a post-viral syndrome or the result of viral-
associated organ damage; (2) worsening of CP due to exacerbation of
preexisting pain physical or mental complaints; and (3) CP newly triggered in
individuals not infected with COVID by exacerbation of risk factors (poor
sleep, inactivity, fear, anxiety, and depression).
 C UR RENT RES EARCH: CONS IDERING THE
POT ENTIAL FOR AN INCRE AS E IN CHRONIC
PAIN AFTE R THE C OVID- 19 PANDE MI C

• Infections as a trigger for chronic pain: a chronic post-SARS syndrome consisting of fatigue, diffuse myalgia,
depression, and nonrestorative sleep (Long Covid Syndrome). A stereotypical chronic syndrome occurred at remarkably
similar rates and was not predicted by demographic, psychological/psychiatric measures or microbiological factors.
• The presence and severity of somatic symptoms during acute infection were closely correlated with the subsequent
development of chronic fatigue and pain.
• Theoretically, the diminished immune response system observed in CP patients could be even further suppressed by
factors such as depression, poor sleep, and opioid use, with the potential to increase susceptibility to SARS-CoV2.
• Mental health is also frequently affected by severe illness. Between 41% and 65% of Covid-19 survivors have
experienced persistent psychological symptoms.
• Routine clinics may be less accessible or closed, healthcare professionals may be diverted to COVID-19-related
activities, and waiting times may be prolonged, especially for medical illnesses such as CP that many consider
nonurgent.
• These numerous and persistent stressors may exacerbate pain, even in the absence of viral illness.
 BIBLIOGRAPHY

• 1. Becker, S., Navratilova, E., Nees, F., & Van Damme, S. (2018). Emotional and motivational pain processing: Current State of
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https://doi.org/10.1155/2018/5457870 Clauw, D. J., Häuser, W., Cohen, S. P., & Fitzcharles, M.-A. (2020).
• 2. Considering the potential for an increase in chronic pain after the covid-19 pandemic. Pain, 161(8), 1694–1697.
https://doi.org/10.1097/j.pain.0000000000001950 Cordier, L. S., & Kingery, H. (2019).
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• 5. Microglial optogenetics triggers chronic pain in mice. Nature Reviews Neurology, 17(5), 262–262.
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