Pain management

• ANATOMY OR SYSTEM AFFECTED: All

DEFINITION: Any treatment or management technique to lessen or eliminate pain or make it more tolerable.

Indications and Procedures

Pain is experienced as an unpleasant reaction to either an external stimulus, such as a burn, or an internal process, such as a disease. The initial evaluation of pain is aimed at determining the cause. A good description by the patient helps obtain a diagnosis. The person experiencing the pain must be able to communicate the intensity, location, pattern (e.g., throbbing, steady, or intermittent), and type (e.g., crushing, burning, sharp, or dull). In addition, factors that make the pain better or worse must be known and communicated. Duration is important; recent onset is termed “acute” pain, while long-standing pain or pain that returns periodically is termed “chronic.”

Generally, the best way to treat pain is to prevent its occurrence. Failing that, a number of different interventions should be used together. Whatever treatment is used, the therapy must be tailored to the patient and to the nature and severity of the pain. When medications are used, a review of some important principles is essential, such as the pharmacology, duration of effectiveness, and optimal dose of a certain medication. Even the route of administration must be considered in every case.

Treatment may include combinations of simple analgesics, narcotics, and other treatments. Combinations take advantage of the additive pain relief while sparing the patient potential side effects. When choosing pain medications, a step-wise approach is often used. It starts with the simple analgesics: aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are generally well tolerated, although aspirin and NSAIDs can produce gastrointestinal distress ranging from mild heartburn to bleeding ulcers. Additionally, adjuncts to these types of medications might be icing or heat, depending on the nature of the problem.

For more severe pain, the second step often includes a narcotic analgesic with or without the simple analgesics. Narcotics are very potent and have the potential for addiction. Furthermore, they may produce problems such as confusion, nausea and vomiting, constipation, and drowsiness. If the pain has a significant inflammation component that does not resolve easily with milder analgesic approaches or with narcotics, then corticosteroids may be used to alleviate the pain. This approach does not lend itself well to longer-term pain management, however, because of side effects such as fluid retention, stomach irritation, thrush, muscle weakness, weight gain, bone loss, suppressed adrenal function, and increased risk of infections, among others.

The third step in pain control involves alternative methods of pain control. Treatments here include physical therapy, nerve-blocking injections, transcutaneous electrical nerve stimulation (TENS), and behavioral approaches. The latter method seeks to identify the causes of preventable pain (physical or mental) and take steps to minimize pain.

Medical research led to interesting discoveries about the management of pain in the twenty-first century. In 2002, researchers announced that they had identified a key protein called "downstream regulatory element antagonist modulator," or DREAM for short, that controls severe pain, a discovery that could lead to better pain management for patients who suffer from chronic pain or pain associated with terminal cancer. The DREAM protein protects the neural reflex critical to survival, allowing individuals to feel pain and quickly pull away from its source, but over time, DREAM seems to help sharp pain fade as the protein becomes disabled. Moreover, while there are many types of pain, disabling the DREAM protein appears to reduce the severity of all of them, though it appears especially helpful in the treatment of pain due to arthritis. The next step in research will be to examine ways to disable the protein, a task that scientists deem difficult because of its location deep within individual cells. Additional research in this area recognizes that pain has different causes and that it may be more productive to examine the mechanisms of pain rather than taking a disease-based approach.

Pain management became a popular topic in public discourse in the twenty-first century due to the opioid crisis in the United States. The opioid crisis in America was characterized by the widespread misuse and addiction to opioid medications, which were often overprescribed by doctors and related to the dubious practices of pharmaceutical companies. The overprescribing of opioids by healthcare professionals, particularly for pain management, led to a surge in opioid dependency and addiction. In the first decades of the twenty-first century, due to the increased awareness of the risks associated with long-term opioid use and a concerted effort to find safer and more effective ways to manage pain, many doctors began to reconsider the widespread prescription of opioid and other narcotic medications for pain. At the same time, the distribution of these types of medications became highly regulated.

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