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| The following needs assessment in the area
of chronic pain is derived from various sources, including guidelines and
standards for care developed by the American Pain Society, the American
Association of Pain Medicine, the Joint Commission on the Accreditation of
Healthcare Organizations, and the National Comprehensive Cancer Network.
The recommendations and guidelines are supported by clinical implications
gleaned from scientific articles and expert opinion. Prepared by the staff
at the National Pain Education Council. |
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Background
Persistent pain is a major health problem in the United States and is the
most common reason that prompts people to seek medical care. For these
reasons, the management of pain is becoming a higher priority in the
United States. In the last several years, health-policymakers, health
professionals, regulators, and the public have become increasingly
interested in the provision of better pain therapies. New consensus
statements have been developed by medical specialty societies for the
treatment of chronic pain not due to cancer, which state that opioids,
sometimes called "narcotic analgesics," are an essential part of a pain
management plan.
Definition
Chronic pain constitutes "pain of any origin that persists beyond normal
tissue healing time, which is assumed to be 3 months."
Statistics
Overview. Regardless of its cause, chronic pain can be controlled
by relatively simple means in 80% to 90% of patients.1,2 Despite the
potential for adequate pain control, chronic pain is notoriously
undertreated, as described by organizations such as the World Health
Organization,2 the American Academy of Pain Medicine and the American Pain
Society, 3,4 and the US Department of Health and Human Services.1 Reasons
for undertreatment of chronic pain include inadequate knowledge among
health care professionals about appropriate assessment and management of
pain.1
Prevalence. Up to 45% of people in the United States seek care for
persistent pain at some point in their lives. Over 75 million of Americans
are totally or partially disabled by serious pain, and more than 50
million suffer from chronic nonmalignant pain.4
Incidence. Approximately 25 million people each year experience
acute pain as a result of injuries or surgeries. Back pain alone produces
chronic disability in approximately 1% of the U.S. population, and another
1% are temporarily disabled by it;5 cancer is diagnosed in over 1 million
Americans each year.1
Impact of pain. Like many illnesses that at one time were not well
understood, pain and its many manifestations may be both poorly treated
and seriously underestimated. Unrelieved pain causes unnecessary
suffering, seriously compromising patients’ quality of life and increasing
the risk of lost livelihood and social integration.6 Because it diminishes
activity, appetite, and sleep, pain can further weaken patients who are
already debilitated. Severe chronic pain can increase suffering by
worsening helplessness, anxiety, and depression and also complicates
medical evaluation and treatment. Pain relief has been shown to increase
activity and improve mood and overall health status.7
Economics. Chronic pain is the second leading cause of medically
related work absenteeism. The Nuprin Pain Report8 specifically notes that
4 billion work days are lost each year that result in a financial loss to
the economy in the amount of $79 billion per year. The economic impact of
pain as the leading cause of disability in the working-age population has
exerted a significant effect on both private disability plans and the
Social Security system.9,10 Patients with chronic pain use health services
up to five times more frequently than the rest of the population. Despite
these substantial economic and social costs of chronic pain, the majority
of chronic pain patients is being treated inadequately.7
Etiology
Chronic pain is not a single entity but varies in etiology and
presentation. The common disorders that result in or are caused by acute
or chronic pain include head pain, joint pain, back pain, neck pain,
burning arm or leg pain, nerve pain, chest pain, abdominal pain, cancer
pain, and burn pain.1 In some cases, symptoms and signs may be evident
within a few weeks to a few months after the occurrence of an injury or
the onset of disease. The cause of pain is not always known or apparent.
For many patients, initial medical evaluation and treatment effectively
relieve pain that might otherwise become chronic. Many more pain patients
could achieve pain relief and a return to greater functionality and a
higher quality of life with improved pain management.
Clinical and Pathophysiologic Characteristics
Chronic pain may be classified by etiology as nociceptive, which relates
to pathologic injury to body tissues, or as neuropathic, which relates to
neural damage. Nociceptive pain is generally considered more receptive to
standard opioid therapies. It may also be categorized by severity,
predictability, pathophysiology, precipitating event, location, or
temporal characteristics.
Diagnosis
Evaluation of chronic pain includes a pain history and assessment of the
impact of pain on the patient, a directed physical examination, a review
of previous diagnostic studies, a review of previous interventions, a drug
history, and an assessment of coexisting diseases or conditions.
Conventional Treatment
The management of chronic pain is a complex process requiring intensive,
comprehensive, and interdisciplinary services for optimum treatment
outcomes. The principal treatment goal is return to functionality.
Pharmacologic management varies with severity of pain.2 Patients are
typically treated first with nonopioid agents including aspirin,
acetaminophen, and nonsteroidal anti-inflammatory agents, with or without
adjuvant therapies to ameliorate side effects. Adjuvant drugs, such as
short-acting opioids, may be used to enhance analgesic efficacy. For
patients whose pain cannot be controlled by such agents, long-acting
opioids are the major analgesic class.11 Side effects of opioids include
constipation, nausea, urinary retention, confusion, sedation, and
respiratory depression.1 If a trial of opioids is selected, patients and
caregivers should be informed of the risks and benefits of opioid use and
the conditions under which opioids will be prescribed.
Typically, patients with moderate-to-severe chronic nonmalignant pain
receive both short-acting, regularly scheduled analgesics plus long-acting
agents that provide around-the-clock pain relief for up to 72 hours.12
Treatment recommendations revolve around a regimen customized for the
individual patient. These recommendations favor simple dosage schedules
and less invasive routes of analgesia administration along with
appropriate management of side effects.
Therapeutic Advancements
Trends toward longer dose intervals (e.g., 12 hours for some morphine
preparations and 72 hours for a fentanyl transdermal patch) have
characterized the treatment of chronic baseline pain. Transdermal
fentanyl, approved for the treatment of chronic pain, provides
around-the-clock relief of pain for up to 72 hours. Making analgesia
easier, lasting, and available to patients in more varied environments
(such as home health care and hospice care) is important in light of
changing health care practice.13,14
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