Chronic Nonmalignant Pain

Chronic Nonmalignant Pain

Pain not associated with a malignant disease and lasting >6 months or beyond the healing period is considered to be chronic nonmalignant pain. This pain also has been called chronic benign pain, an obvious misrepresentation, because pain is never benign when it causes patient suffering. Chronic nonmalignant pain is recognized as a serious health problem that affects millions of people worldwide and carries far-reaching social implications.²⁷ The development of treatment guidelines is difficult because of the heterogeneity of causes. For most types of chronic pain, initial therapy is often conservative. Failure of conservative therapy may necessitate the use of more potent analgesics. The use of opiates in this patient population is controversial; however, increasing data support opiate use in psychologically healthy patients.^28,29 Because chronic pain affects many aspects of a patient's life, a multidisciplinary approach that addresses effective drug therapy and comprehensive rehabilitation often provides greater relief to the patient than drug therapy alone.

Much of the difficulty encountered in pain management arises when clinicians are not sufficiently educated or trained in dealing with the complex pharmacologic and psychosocial

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problems associated with chronic pain. Often the clinician fails to listen to the patient or fails to recognize clues to the subtle nature of the patient's pain complaints. Drug selection often is irrational and doses are frequently inadequate. An unfortunate tragedy occurs when clinicians occasionally withhold adequate analgesia because of a misunderstood fear of addiction, or when a patient refuses medications because of a similar fear of addiction.^30,31

Table 8-1 Common Causes of Analgesic Treatment Failure

Problem Potential Impact on Pain Management Example 1. Inappropriate or unknown diagnosis Improper medication selection Using a nonsteroidal anti-inflammatory drug (NSAID) for abdominal pain that may be related to a gastrointestinal bleed 2. Misunderstanding of pharmacology or pharmacokinetics Overestimating potency or half-life Dosing an opioid less frequently than necessary to provide adequate relief 3. Inadequate management of adverse effects Patient may discontinue therapy or misuse over-the-counter remedies Patient suffers constipation from antidepressants and uses daily bisacodyl 4. Fear of addiction Physician or patient or caregiver may withhold medications Evidence of tolerance after chronic use of opioids may be mistaken for addiction 5. Unrealistic goals for therapy Patient will not be satisfied with pain management regimen and may seek other care Patient states a desire to be “pain free” following significant nerve injury 6. Irrational polypharmacy Over- or under-use of appropriate therapies Patient with neuropathic pain using three different opioids without any adjuncts in the regimen 7. Patient barriers Patient cannot understand appropriate medication use or other pain management modalities Language or comprehension deficits Cognitive deficits: patient cannot remember regimen Physical impediments to using medicines appropriately Cultural barriers (e.g., stoicism) 8. Lack of understanding of pathophysiology of pain Limitations of health care providers' ability to adequately relieve pain Drugs that show benefit in animal models are not useful for human pain conditions

Posted in: General Care,Pain and Its Management