Approaches to Pain Management
Approaches to the management of pain vary according to the individual patient. They also vary according to the training and experience of the clinician. The overall goal is to improve function—enabling individuals to work, attend school, and participate in other day-to-day activities.
To guide clinicians, the Michigan Pain Management and Palliative Care program developed the Pain Toolkit for Healthcare Professionals. The toolkit outlines nine essential principles for managing pain appropriately, safely, and effectively:
- Use evidence-based and consensus guidelines for best practice outcomes.
- Distinguish the underlying and distinct mechanisms of acute, acute recurring, and chronic pain.
- Understand the origins of pain and methods for treating the origin.
- Address and manage chronic pain effectively.
- Use opioids appropriately and safely.
- Know your definitions regarding opioid use in pain patients.
- Use Michigan’s electronic prescription monitoring program (MAPS).
- Improve patient safety.
- Prevent and reduce the misuse, abuse, and diversion of pain medications, and address proper storage and disposal. (LARA, 2013c)
Self-management of pain describes strategies used by a patient to manage or minimize the impact of a chronic condition on everyday life. The basic tenets of self-management include:
- Active participation by the patient
- Treatment of the whole person, not just the disease
- Empowerment of the patient (NIH, 2013)
Although some people seek professional help immediately, most try to self-manage their pain. This can include talking to friends, searching the internet, or attending group classes or programs intended to educate a person about pain management. Self-management also includes exercise, ice, heat, positioning, limiting activity, over-the-counter (OTC) medications, and education. In many cases, self-management is highly successful.
The Pain Medicine Model
The Institute of Medicine (2011) described a continuum of care referred to as the Pain Medicine Model. It begins with:
- People attempting to manage pain on their own. If this fails,
- They often seek guidance from a primary care practitioner, and if their pain continues, they turn to
- Specialty care.
The Pain Medicine Model, though it includes primary and specialty care, possesses a relatively weak basis for efficacy—particularly for chronic pain care—and often fails to involve patients as integral, active participants in their own care. Although the Pain Medicine model has low demonstrated efficacy, it is widely used because of a strong business model, industry support, and professional training in healthcare (NIH, 2013).
Seeking treatment from a primary care provider is a mainstay of the Pain Medicine Model. Primary care involves several management strategies, ideally coordinated by a general medicine specialist. Primary care clinicians often provide the initial assessment or diagnosis and serve as a starting point for specialty services; primary care may include prescription medications, referrals to other practitioners, imaging, and surgical and interventional techniques (minimally invasive procedures with placement of drugs in targeted areas or ablation of targeted nerves). Primary care physicians are responsible for the majority of prescription pain medications.
Once the primary care clinician has completed an initial assessment, medical management ideally involves a multi-disciplinary team that develops a comprehensive treatment plan that includes appropriate pharmacologic and non-pharmacologic interventions. Treatments should be regularly re-evaluated for effectiveness, adjusted as needed, and side effects quickly addressed (PPSG, 2013b).
The National Institutes of Health (NIH) Pain Consortium conducts a symposium each year that focuses on pain management research and methods. One of the presentations at the 2017 consortium, “Self-Management Strategies as Part of an Integrated Approach for Pain Management,” emphasized a blended approach to pain management with concrete suggestions for making it successful. This was just one of many presentations in 2017, and previous years, to emphasize such multi-disciplinary approaches (Friction, 2017; NIH, 2017).
The opioid crisis that came to worldwide attention in 2017 led to an examination on multiple fronts to find ways to limit opioid prescribing and to support those who became addicted to pain killers (see Module 7).
Integrative Pain Management
It is not surprising that healthcare providers, along with those dealing with the effects of pain, have sought ways to combine the strengths of the self-management model with those of the Pain Medicine Model. The combination of these two approaches is increasingly referred to as integrative pain management. A wide range of techniques, medications, and practices are included in the integrative model; they include physical and occupational therapy, chiropractic, acupuncture, complementary and alternative medicine, and a variety of other techniques and practices that are only now gaining acceptance in Western medicine.
Integrative techniques and practices are of particular importance because many chronic pain patients become resistant to conventional medical treatments or suffer adverse effects from widely used prescription medications with high addictive potential. For these reasons, patients with chronic pain frequently seek to integrate complementary therapies, often without the knowledge of their primary care provider (Abrams et al., 2013).
Perhaps the most attractive aspect of integrative medicine is its focus on patient-centered care, which at its most effective addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health. Integrative care considers the patient’s unique conditions, needs, and circumstances and uses the most appropriate interventions from an array of disciplines to heal illness and help people regain and maintain optimal health. Integrative medicine is a “whole systems” approach and, not surprisingly, chronic pain is one of the main reasons patients seek care at integrative medicine clinics (Abrams et al., 2013).
Complementary and Alternative Therapies
According to the National Center for Complementary and Integrative Health (NCCIH) many Americans—more than 30% of adults and about 12% of children—use healthcare approaches developed outside of mainstream Western, or conventional, medicine. When describing these approaches, people often use alternative and complementary interchangeably, but the two terms refer to different concepts:
- If a non-mainstream practice is used together with conventional medicine, it’s considered “complementary.”
- If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.”
True alternative medicine is uncommon. Most people who use non-mainstream approaches use them along with conventional treatments (NCCIH, 2017).
There are many definitions of integrative health are, but all involve bringing conventional and complementary approaches together in a coordinated way. The use of integrative approaches to health and wellness has grown within care settings across the United States. Researchers are currently exploring the potential benefits of integrative health in a variety of situations, including pain management for military personnel and veterans, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors (NCCIH, 2017).
A great deal more information is available at the NCCIH website (https://nccih.nih.gov/).
Rehabilitation Therapies and Chiropractic
Although rehabilitation therapists and chiropractors receive extensive training within the traditional medical model, they are uniquely positioned to combine elements from the self-management model, the medical model, and some techniques from complementary and alternative medicine. Physical and occupational therapists are trained to treat patients following many common surgeries, particularly orthopedic surgeries. Often, these therapists receive additional education and training in the treatment of neck, back, and joint injuries. Treatment modalities are aimed at reducing or eliminating pain, restoring function, and improving quality of life.
Pain Management in Special Populations
The extremes of age provide special challenges to pain care. Pediatric patients and geriatric patients have little in common physiologically, but they share a propensity toward under-medication for pain. There is some evidence that the under-treatment of pain in those at the extremes of age is improving, but acute-care clinicians should pay particular attention to pain assessment and care in these patients (Thomas, 2013).
Pain Management at the End of Life
When a person is living with an advanced illness and coming to the end of life, preventing and relieving pain is a high priority. Pain is among the most debilitating and feared symptoms that patients and families face, and effective pain management is a palliative focus for many conditions.
The Michigan Administrative Code (R 325.13302) establishes a responsibility for hospices to ensure that pain management is an essential part of patient care. Medical care is expected to prevent and control pain and other distressing symptoms (LARA, 2017; PPRG, 2013b).
Under-treatment and inequitable access to pain treatment, particularly among cancer patients presenting with pain, have been described in the literature. The reported prevalence of moderate to severe pain in advanced cancer is approximately 64%, with a sharp increase to as high as 80% to 90% at the end of life (Gao et al., 2014).
Although palliative care has, in the past, focused on cancer, it has expanded to include other conditions, including musculoskeletal pain at the end of life. Population-based studies indicate that musculoskeletal pain is such a common and significant issue at the end of life that musculoskeletal disease may have as much, if not more, effect on whether a person dies in pain than the condition that is the cause of death (Lillie et al., 2013).
Pain Management in Older Adults
It is believed that the majority of older adults experience pain on a regular basis and that the incidence of pain increases after the age of 60. Pain is the number one complaint of older adults, and 1 in 5 takes a painkiller regularly (Lillie et al., 2013).
The American Geriatrics Society and the British Geriatrics Society have issued guidelines for the management of pain in older adults. Management begins with an accurate assessment, which includes the impact of pain on the patient’s daily activities. Analgesic treatment and pain-modulating drugs are a part of the pharmacologic treatment of pain in older adults, although co-morbidities and other risk factors must be carefully considered. When prescribing medications, the least invasive method of administration should be used, and in most cases the oral route is preferred (Age and Ageing, 2013).
Older adults with low income, those without adequate prescription drug coverage, and those using high-cost medications are likely to stretch out their medication supply by skipping doses or extending the intervals between doses.
Age-related changes in physiology can render an older adult more sensitive to medications, making polypharmacy a major issue associated with adverse drug events and increased hospitalizations. Older adults also have an increased pain threshold, a decreased tolerance for pain, and recover more slowly after an injury. Decline in organ function, particularly the renal and hepatic functions, which are critical in the clearance of ingested medications, dictates the pharmacokinetic properties* of many drugs. Aging patients may experience changes in body fat and water composition. These changes alter the tissue and plasma distributions of many lipophilic and hydrophilic drugs in ways that predispose patients to adverse effects (Taylor et al., 2012).
*Pharmacokinetics: the study of the absorption, distribution, metabolism, and excretion (ADME) of drugs. Changes associated with aging affect the pharmacokinetics of medications.
Patient and family education is a central part of acute and chronic pain management in older adults. Healthcare providers play a key role in helping family members understand that preventing and controlling pain is an important issue. Patients and family members should understand the interventions available to manage pain. If opioids are part of the plan of care, fear related to side effects and risk of addiction should be addressed. Patients and family members should understand that side effects can be managed effectively with medication and the risk of addiction when using opioids to control acute pain is extremely low.
Patients and their family members have a responsibility to tell healthcare providers when the patient is experiencing pain or when the nature or level of pain changes. Although complete pain relief may not be possible, healthcare providers can assure patients and family members that they will work to keep pain at a level that allows patients to engage in activities necessary to recover and return home.
Pain Management in Children and Adolescents
It is estimated that 15% to 30% of children and adolescents experience chronic pain, with prevalence increasing with age and occurring slightly more commonly in girls than boys. The most commonly reported locations of pain in children and adolescents are the head, stomach, arms, and legs. The most common chronic pain conditions in children include migraine, recurrent abdominal pain, and general musculoskeletal pain (Carter & Threlkeld, 2012).
Effective pain management in the pediatric population requires special attention to the developmental stage of the child. Current research does not adequately address the effectiveness of tools and measurements used to assess pain in children at various ages. Knowledge of the experience of pain and its associated copying strategies has not been adequately related to developmental stages. In spite of its frequency, pain in infants, children, and adolescents is often underestimated and under-treated. Infants and children who experience pain in early life have shown long-term changes in terms of pain perception and related behaviors (Srouji et al., 2010).
Clinicians need to be able to distinguish the signs of pain by age group and determine whether symptoms are caused by pain or other factors. Barriers to pain management in children are numerous, as reflected in statements like “Children do not feel pain the way adults do,” fears regarding the use of pharmacologic agents, and deficits in knowledge of methods of pain assessment. These and other factors, such as personal values and beliefs, prevent adequate identification and alleviation of pain for all children (Srouji et al., 2010).
Understanding medication dosing, interactions, and side effects is critical in children. Dosing is different for children but the goal is to reach an analgesic level of pain control. Safe pediatric prescribing requires accurate weight, proper conversion of pounds to kilograms, and the choice of an appropriate preparation and concentration.
Children with chronic pain experience significant interference with developmental functioning, showing increased levels of emotional distress and impairment. In an effort to find treatment for chronic pain, patients must often negotiate appointments with multiple providers, primary and secondary. Consequences of searching for treatment often include missed school for the child, missed work for parents, and expenditure of emotional and financial resources (Gorodzinsky et al., 2012).