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Chapter 66. Treatment of Chronic Pain Syndromes

Kurt Kroenke, M.D.; Erin E. Krebs, M.D., M.P.H.; Matthew J. Bair, M.D., M.S.
DOI: 10.1176/appi.books.9781585623860.438949

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Excerpt

Pain is the most common symptom reported in both the general population and the general medical setting (Kroenke 2003b; Sternbach 1986; Verhaak et al. 1998). Pain complaints account for more than 40% of all symptom-related outpatient visits, or over 100 million ambulatory encounters in the United States alone each year (Schappert 1992). Pain costs the United States more than $100 billion each year in health care and lost productivity (Stewart et al. 2003). Pain medications are the second most commonly prescribed class of drugs (after cardiac-renal drugs), accounting for 12% of all medications prescribed during ambulatory office visits in the United States (Turk 2002). Yet nonopioid analgesics fail to provide adequate relief in many patients (Curatolo and Bogduk 2001), and physicians' concerns about regulatory restrictions as well as risks of tolerance or addiction constrain the prescribing of opioid analgesics for noncancer pain (Joranson et al. 2002). Moreover, opioids themselves may produce only moderate reductions in chronic pain (Furlan et al. 2006; Martell et al. 2007; Turk 2002) and may fail to improve (or may even worsen) psychological outcomes (e.g., depression) or functional status even when they do alleviate the pain (Moulin et al. 1996). At the same time, clinicians are being pressured to respond to pain as the "fifth vital sign" (Joint Commission on Accreditation of Healthcare Organizations 2000). In House Resolution 1863, the National Pain Care Policy Act of 2003, Congress declared this the "Decade of Pain Control and Research." Indeed, persistent pain is a major international health problem (Gureje et al. 1998), prompting the World Health Organization to endorse a global campaign against pain (Breivik 2002). Persistent pain may lead to excessive surgery or other expensive or invasive procedures and is the leading reason for use of complementary and alternative medicine (CAM) (Astin 1998). Pain is also among the most common reasons for temporary as well as permanent work disability (B. H. Smith et al. 2001). Many pain treatment recommendations are based principally on expert consensus rather than on clinical trial results (Bair et al. 2005) and have yet to influence primary care practice (Chodosh et al. 2001).

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FIGURE 66–1. Analgesic algorithm for chronic pain.Algorithm for an evidence-based approach to treatment selection in the management of chronic pain. Nonpharmacological treatments can be considered at any step; ones that have proven effective in several types of pain conditions include exercise, cognitive-behavioral therapy, pain self-management, and acupuncture. CrCl = creatinine clearance; FDA = U.S. Food and Drug Administration; max = maximum; NSAID = nonsteroidal anti-inflammatory drug; SNRI = serotonin–norepinephrine reuptake inhibitor; SR = sustained release; SSRI = selective serotonin reuptake inhibitor; TCAs = tricyclic antidepressants.

FIGURE 66–2. Pain numeric rating scale (NRS).Interviewer-administered (verbal) and self-administered (visual) versions of the single-item NRS for pain, also referred to "the fifth vital sign."

FIGURE 66–3. PEG three-item pain scale.The PEG three-item pain scale—an ultrabrief measure for assessing and monitoring pain—is based on three items from the Brief Pain Inventory: average Pain severity, interference with Enjoyment of life, and interference with General activities.Source. Krebs EE, Bair MJ, Damush TM, Sutherland JM. Used with the authors' permission.
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TABLE 66–1. Oral and transdermal opioid analgesic equivalence
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TABLE 66–2. Key principles for initiating and maintaining exercise for chronic pain
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TABLE 66–3. Acupuncture and magnets for painful disorders: summary of systematic reviews
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TABLE 66–4. First-line drugs for neuropathic pain
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TABLE 66–5. Efficacy of SNRI antidepressants and anticonvulsants in fibromyalgia: summary of randomized, placebo-controlled clinical trials
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TABLE 66–6. Key aspects of evaluation and management of low back pain
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TABLE 66–7. Glucosamine, chondroitin, and hyaluronic acid for osteoarthritis (OA): summary of systematic reviews

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Sample questions:
1.
Fibromyalgia is classified as what type of pain?
2.
You read a recent journal on pain that reports that a new medication improved symptoms in 60% of the patients entered into the treatment trial, in comparison with 35% who improved on placebo. Using these results, how many patients would you need to treat to achieve a therapeutic benefit versus placebo?
3.
In prescribing opioid treatment for a patient’s chronic pain, the psychiatrist should keep in mind which of the following principles?
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