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CHRONIC PAIN MANAGEMENT

Learning objectives
By the end of this educational module you should be able to:
1. understand the importance of addressing patients' physical functionality in pain management
2. recognise and assess different types of pain
3. interpret patients’ individual needs in pain management
4. understand the holistic approach to chronic pain management and the role your specialty can play
5. know how to address the needs of patients with chronic pain during the COVID-19 pandemic

Management of chronic pain

  • CHALLENGES IN CHRONIC PAIN MANAGEMENT

    In a large-scale (N=46,394) computer-assisted telephone survey that was undertaken with people aged >18 years to explore the prevalence, severity, treatment and impact of chronic pain in 15 European countries and Israel, the results showed:18

    PAIN SEVERELY REDUCED PATIENTS' QUALITY OF LIFE.
    OF THE RESPONDENTS:

    • 65% had problems sleeping
    • 54% were less able or unable to do household chores
    • 30% had difficulty maintaining an independent lifestyle
    • 27% had relationship difficulties

    RESPONDENTS STATED THEY OFTEN FOUND THEIR CURRENT PAIN MANAGEMENT INADEQUATE:

    • 40% of respondents were not satisfied with the management of their pain
    • 64% said there are times when their pain medicines are not adequate

    PARTICIPANTS VOICED CONSERNS ABOUT PAIN MEDICATIONS:

    • 63% of patients were worried about drug side effects
    • 38% of patients were worried about addiction

  • NON-PHARMACOLOGICAL TREATMENTS FOR NON-CANCER CHRONIC PAIN

    A range of non-pharmacological interventions that are effective in reducing symptoms and disability in some people with non-cancer chronic pain are available:11

    SELF-MANAGEMENT
     

    • examples: occupational therapy, patient education, exercise12,19
    • may be an effective complement to other therapies12

    COGNITIVE BEHAVIOURAL THERAPY

    • used as part of a comprehensive pain management programme19
    • may reduce pain intensity and depression and improve measures of disability and quality of life12

  • PHARMACOLOGICAL TREATMENT OPTIONS FOR PAIN

    Pharmacological agents available for the management of chronic pain include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antidepressants, anti-epileptics, topical treatments and others such as muscle relaxants.20,22

    Paracetamol, NSAIDs and cyclo-oxygenase-2 inhibitors target the nociceptive component of chronic pain, whereas antidepressants and anti-epileptics target the neuropathic component.22 Commonly used antidepressants include tricyclic antidepressants, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.20

    Topical local anaesthetic preparations are recommended for management of localised peripheral neuropathic pain such as post-herpetic neuralgia and diabetic polyneuropathy.22 Topical capsaicin is recommended for use in treatment of neuropathic pain for suitable patients who wish to avoid, or cannot tolerate oral treatments.20

    Some of the pharmacological agents available are used in treatment of mixed pain.10,22 Corticosteroid injections vary in their clinical presentation and underlying pathophysiology but are commonly used to manage many chronic non-cancer pain conditions.23

    There is little evidence that opioids are helpful for chronic pain. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and use is intermittent, but it is difficult to identify these people at the start of treatment.11

    2019 guidance from NICE states cannabis-based medicinal products nabilone, dronabinol, THC (delta-9-tetrahydrocannabinol) or a combination of cannabidiol (CBD) with THC should not be offered to manage chronic pain in adults. CBD can be offered to manage chronic pain in adults if it is part of a clinical trial.24

    NICE: National Institute for Health and Care Excellence.

    Targeting the different mechanisms of pain by combining agents with different mechanisms of action is a rational approach to management of chronic pain.10,22

  • HOLISTIC APPROACH TO TREATMENT AND COMMUNITY CARE

    The management of chronic pain requires a holistic approach, addressing the physical, psychological and social aspects of pain.12,25,26

    Following diagnosis and initiation of treatment, regular reviews should be carried out to assess and monitor the effectiveness of treatment.20,27 Clinical guidance from the NICE recommends to carry out regular clinical reviews that should include assessment of:20

    • pain control
    • impact on lifestyle, daily activities (including sleep disturbance) and participation
    • physical and psychological wellbeing
    • adverse effects
    • continued need for treatment

    If necessary, a change in treatment, referral to a specialist, or both should be considered.27


    Most patients can be well-managed in the community or at local hospitals by trained members of interdisciplinary pain management services.28,29 Intense pain, or pain that causes significant distress and impact on functioning and substantial comorbidities, requires specialised pain management services involving multidisciplinary, interdisciplinary and multi-specialty teams.28,30

    The following pathway can be used in management of chronic pain:28-30

     

    CCG: clinical commissioning group; LHB: local health board.

  • WHEN SHOULD YOU REFER PATIENTS?

    GUIDELINE RECOMMENDATIONS

    NICE guidance provides recommendations for referral of patients with neuropathic pain that present in non-specialist settings:20

    • Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews if:
      • they have severe pain, or
      • their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation, or
      • their underlying health condition has deteriorated

    Guidelines from the Faculty of Pain Medicine provide recommendations on referral of patients with chronic pain to pain management services. People who should be referred according to the guidance are:28

    • patients with persistent or recurrent pain not adequately managed in primary care
    • patients where referral is recommended by national guidelines
    • patients whose pain is causing significant distress or functional impairment
    • patients with analgesic misuse problems or who are taking recreational drugs/ alcohol for pain relief
    • patients with pain-related psychological and psychosocial problems that complicate their pain symptoms or rehabilitation
    • patients requiring specific procedures as part of a pain management plan aimed at improving function and quality of life
    • young people (aged <18 years) with significant pain require referral to nationally recognised specialised services
    • patients with cancer who may benefit from joint management with palliative care
    • 'cancer survivors', ie patients with cancer who have undergone treatment (eg surgery, chemotherapy or radiotherapy) but who have persistent pain
    • patients not responding to specialist pain service input should be considered for onward referral to a specialised pain management centre

REFERENCES
  1. Cole B E. Pain management: classifying, understanding, and treating pain. Hosp Physician 2002:23-30
  2. Gangadhar M, Kumar Mishra R et al. Future directions in the treatment of neuropathic pain: a review on various therapeutic targets. CNS Neurol Disord-Drug Targets 2014;13(1):63-81
  3. Nicholson B. Differential diagnosis: nociceptive and neuropathic pain. Am J Manag Care 2006;12(9 Suppl):S256-262
  4. Ryan C G, Vijayaraman A et al. The association between baseline persistent pain and weight change in patients attending a specialist weight management service. PLoS One 2017;12(6):e0179227
  5. Baird A, Sheffield D. The relationship between pain beliefs and physical and mental health outcome measures in chronic low back pain: direct and indirect effects. Healthcare (Basel) 2016;4(3)
  6. Surah A, Baranidharan G, Morley S. Chronic pain and depression. Contin Educ Anaesth Crit Care Pain 2014;14:85-89
  7. Patel A S, Farquharson R et al. The impact and burden of chronic pain in the workplace: a qualitative systematic review. Pain Pract 2012;12(7):578-589
  8. Sloan G, Shillo P et al. A new look at painful diabetic neuropathy. Diabetes Res Clin Pr 2018;144:177-191
  9. International Association for the Study of Pain. IASP Terminology. Available at: www.iasp-pain.org. Accessed December 2020
  10. Freynhagen R, Parada H A et al. Current understanding of the mixed pain concept: a brief narrative review. Curr Med Res Opin 2019;35(6):1011-1018
  11. National Institute for Health and Care Excellence (NICE). Key therapeutic topic (KTT)21. Medicines optimisation in chronic pain. Available at: www.nice.org.uk. Accessed December 2020
  12. Mills S, Torrance N, Smith B H. Identification and management of chronic pain in primary care: a review. Curr Psychiatry Rep 2016;18(2):22-22
  13. Grimmer-Somers K, Kumar S et al. Primary care assessment instruments for patients at risk of, or with, persistent pain: opportunistic findings from a systematic literature review. Int J Gen Med 2009;2:121-128
  14. Jennings A A, Linehan M, Foley T. The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia. BMC Fam Pract 2018;19(1):166
  15. Hill J C, Dunn K M et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632-641
  16. Versus arthritis. Musculoskeletal health questionnaire (MSK-HQ). Available at: www.versusarthritis.org. Accessed December 2020
  17. Pain Concern. My pain concerns form. Available at: painconcern.org.uk. Accessed December 2020
  18. Breivik H, Collett B et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10(4):287-333
  19. National Institute for Health and Care Excellence (NICE). NICE guideline (NG)59. Low back pain and sciatica in over 16s: assessment and management. Available at: www.nice.org.uk. Accessed December 2020
  20. National Institute for Health and Care Excellence (NICE). Clinical guideline (CG)173. Neuropathic pain in adults: pharmacological management in non-specialist settings. Available at: www.nice.org.uk. Accessed December 2020
  21. Geneen L J, Martin D J et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev 2015;4:132
  22. Morlion B. Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components. Curr Med Res Opin 2011;27(1):11-33
  23. Shanthanna H, Busse J W et al. Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2016;5:18-18
  24. National Institute for Health and Care Excellence (NICE). NICE guideline (NG)144. Cannabis-based medicinal products. Available at: www.nice.org.uk. Accessed December 2020
  25. Yasaei R, Saadabadi A. Chronic pain syndrome. Available at: www.ncbi.nlm.nih.gov. Accessed December 2020
  26. Henry S G, Bell R A et al. Goals of chronic pain management: do patients and primary care physicians agree and does it matter? Clin J Pain 2017;33(11):955-961
  27. Price C, Lee J et al. Initial assessment and management of pain: a pathway for care developed by the British Pain Society. Br J Anaesth 2014;112(5):816-823
  28. Faculty of Pain Medicine of the Royal College of Anaesthetists. Core standards for pain management services in the UK. 2015. Available at: fpm.ac.uk. Accessed December 2020
  29. NHS England. Adult specialised pain service specification. Available at: www.england.nhs.uk. Accessed December 2020
  30. Faculty of Pain Medicine of the Royal College of Anaesthetists. Local commissioning of specialist services for pain. 2013. Available at: www.salg.ac.uk. Accessed December 2020
  31. Shanthanna H, Strand N H et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia 2020;75(7):935-944
  32. Eccleston C, Blyth F M et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain 2020;161(5):889-893
  33. British Pain Society. Pain management during COVID-19 viral infection. Available at: www.britishpainsociety.org. Accessed December 2020
© NICE 2017. Medicines optimisation in chronic pain. Available from: www.nice.org.uk/advice/ktt21. All rights reserved. Subject to Notice of rights
© NICE 2016. Low back pain and sciatica in over 16s: assessment and management. Available from: www.nice.org.uk/guidance/ng59. All rights reserved. Subject to Notice of rights
© NICE 2013. Neuropathic pain in adults: pharmacological management in non-specialist settings. Available from: www.nice.org.uk/guidance/cg173. All rights reserved. Subject to Notice of rights
© NICE 2019. Cannabis-based medicinal products. Available from www.nice.org.uk/guidance/ng144. All rights reserved. Subject to Notice of rights
 

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