Most chronic pain treatment involves various combinations of these modalities. Treatment Review Panels, Pain Management Teams, and Integrated Multi-disciplinary Case Reviews are extremely valuable strategies for managing patients with chronic pain syndromes. An important tool to protect against legal consequences is a comprehensive written consent form signed by the patient during registration, appointment check-in, during the provider visit, at pharmacy, or behavioral health/alcohol and other drugs of abuse counselor intake appointments. The comprehensive consent form should explicitly delineate all of the professionals that may be present during case review in order to meet the requirements of Health Insurance Portability and Accountability Act (HIPAA) of 1996, 45 CFR § 164.508(a)(2)- psychotherapy notes confidentiality, and 42 U.S.C. Part 2 (Confidentiality of Alcohol and Drugs of Abuse Patient Records). Communicate with your local, State, Federal, and Tribal legal counsel to offer further guidance on sharing of information for purposes of continuity of care. Disciplines that are recommended to be included in Review Panels and Case Review include but not limited to: medical providers, clinic nurses, community health nurses, nutritionists, physical therapists, pharmacists, mental health counselors, alcohol and other drugs of abuse counselors, and other staff that have direct patient care responsibilities both in the clinic as well as the community.
The table below outlines individual treatment modalities for managing chronic pain.
…includes: anticonvulsants (gabapentin or pregabalin for neuropathic pain); antidepressants (amitriptyline, nortriptyline, venlafaxine, or duloxetine for neuropathic pain); N-methyl-D-aspartate (NMDA) receptor antagonists; nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, indomethacin, meloxicam, naproxen, diclofenac (oral, gel, or patches); muscle relaxants such as cyclobenzaprine, baclofen, metaxalone; and topical agents such as lidocaine patches.
Opioids (such as hydrocodone, morphine, codeine, or oxycodone) should be utilized cautiously, sparingly, and last line for very short duration. Opioid medications should be utilized primarily for post-surgical and acute traumatic pain management for a very short duration (weeks to less than 3 months); chronic pain syndromes that persist beyond 3 months should not be treated with opioids due to opiate-induced hyperalgesia, tolerance and dependence, iatrogenic addiction, diversion, overdose, reduction in quality of life and functionality, and general ineffectiveness for adequate pain control.
Avoid the muscle relaxant soma (carisoprodol). Carisoprodol is a pro-drug that metabolizes into meprobamate, which is a schedule IV depressant having physical and psychological addictive properties and exhibits many barbiturate-like pharmacological effects.
Exercise extreme caution prescribing opioids concomitantly with other Central Nervous System depressants such as benzodiazepines (alprazolam, lorazepam, clonazepam, diazepam) and sleep hypnotics (zolpidem and eszopiclone). These combinations of medications are referred to as the "deadly trifecta" or "terrible triad" due to the additive respiratory depression and potential for inadvertent overdose at medically prescribed doses. Alcohol use with any of these agents also poses a morbidity and mortality risk. Avoid these medications in patients with a history or current alcohol use, including social drinking.
Benzodiazepines should not be used for symptom management of chronic pain syndromes and are contraindicated in patients with history of or current alcohol and substance abuse disorders; these are last-line agents for treatment of anxiety, in which psychotherapy and/or anti-depressants are first-line treatments.
Drugs listed above in bold are on the IHS National Core Formulary as of May 22, 2014.
|Treatment Option: Multimodal care||…includes exercise, manual therapy, dry needling, pain science education, mind body strategies, and modalities.|
|Joint blocks (via injections) and nerve or nerve root blocks||…may be useful for relief of some types of pain.|
|Epidural steroid injections||…alleviate radicular (nerve root) pain.|
|Botulin injections||… may be used as an adjunct in the treatment of piriformis syndrome, a type of sciatica.|
|Intrathecal (brain or spinal cord) drug therapies||…include neurolytic (nervous tissue) blocks and injected steroids, ziconotide, and opioids. Effectiveness of neurolytic blocks is controversial.|
|Minimally invasive spinal procedures||…alleviate pain from osteoporosis or fractures of the vertebrae.|
|Physical therapy||…strengthening of the musculoskeletal system can improve chronic pain. Exercise causes the release of the body's natural pain neurochemicals (enkaphalins, dynorphines, and endorphins or "endogenous morphine") and has been proven to reduce stress, decrease depression and anxiety, and improve sleep.|
|Psychological treatment||… includes one-on-one or group counseling, mindful cognitive behavioral therapy, biofeedback, and relaxation therapy. Therapy should focus on cognitive reframing of pain perception and development of healthy primary coping skills. Referrals for screening and treatment of underlying mental health disorders such as depression, anxiety, and post-traumatic stress disorder is essential for pain symptom management. Pain symptom perception is exacerbated by uncontrolled and untreated mental health disorders.|
|Acupuncture||…may be used in conjunction with conventional therapy to relieve non-inflammatory lower back pain.|
|Electrical nerve stimulation||… through the skin or with an implanted device can treat nerve injuries or radicular (nerve root) pain for patients who've not responded to other therapies.|
|Trigger point injections||…used to ease chronic pain in tissue surrounding muscle that does not respond to other treatment. Effectiveness is controversial.|
|Ablation (burning or abrasion)||…of nerves or nerve roots should be a last resort treatment for intractable pain non-responsive to traditional therapies.|
|Alternative Medicine Therapy||…encourage Tai Chi, Chi Quong, Zen Meditation, and/or Yoga practices as adjunctive treatment.|
“Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.” Anesthesiology 112(4) (2010): 1–24.