Urgent Pain Problems

Chapter 15 addresses conditions that require prompt evaluation but are not generally in the group of conditions that are true emergencies. Included in this chapter are acute migraine, other severe nonemergent headaches, facial pain, severe low back pain, acute severe neuropathies such as shingles and diabetic amyotrophy, abdominal pain, and acutely painful muscle conditions requiring prompt attention, such as myositis and rhabdomyolysis. The differential diagnosis of headache with visual impairment is reviewed, as is the differential diagnosis of facial pain. Strategies for the evaluation, diagnosis, and treatment of atypical focal pains that can represent unusual presentations of common problems as well as uncommon conditions are discussed.

Pain Emergencies and Complications of Pain Treatments

Chapter 13 reviews some common pain-associated emergencies and also discusses some complications of pain treatments that require immediate attention. Pain is a common occurrence in emergent illness, and some complications of pain treatments require emergent management. Chest pain is an excellent example of clinical decision-making following a process of organized, rapid pain assessment and then diagnostic and treatment reasoning based on the findings and observations of the clinical assessment. Providers assessing patients for acute chest pain elicit basic pain characteristics of region, quality, severity, and timing as well as usually associated factors and then pursue testing and treatment for elements in the differential diagnosis accordingly. The chapter illustrates this same process applied to conditions of acute abdominal, limb, headache, and spine emergencies. In the second part of the chapter, emergencies arising in the context of pain treatments are discussed, including overdose and withdrawal from opioids, benzodiazepines, and other pain-active medications as well as pump and device complications.

Diagnostic Reasoning in the Pain-Focused Encounter

Chapter 7 addresses the processes and pitfalls of evaluating, reasoning about, and attending to the needs of patients with pain. This chapter builds on Chapter 6, which addressed clinical assessment, explaining in detail the process of extracting and abstracting information from the pain narrative (clinical history or interview) to lay the foundation for a problem list and differential diagnosis. The problem list and differential diagnosis are described and contrasted so that clinicians will be comfortable with both. A clinical model explains the need for patient-centered approaches to be omnipresent but balanced with an appropriate disease-centered knowledge base that is likewise informed by understanding the patient’s healthcare-related values and motivations. A balanced approach is emphasized. The process of planning for diagnostic testing, including imaging, laboratory testing, provocative maneuvers, and targeted referrals, is described. The last section of the chapter addresses the impact and nature of cognitive and affective biases that can mitigate the effectiveness of diagnostic reasoning. A coordinated strategy to limit the negative impact of diagnostic reasoning biases is presented in a memorable way. Finally, the ethics of errors and error disclosure are discussed as well as the process of error disclosure.

Opioid Misuse and Addiction Among Patients With Chronic Pain

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.

Standard Systemic Analgesic Agents

Chapter 9 addresses drugs used for pain management. These drugs are categorized as standard systemic analgesic agents, including nonopioid and opioid analgesics, and other, neuromodulating, agents that are addressed in subsequent chapters. There is significant variability in individual response to standard systemic analgesics, and choice of therapy should foremost include patient-specific considerations balancing efficacy with tolerability. Acetaminophen is widely recommended for various acute and chronic pain syndromes and is generally considered safe when taken within therapeutic doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are versatile analgesics and are commonly utilized for general mild to moderate pain. NSAIDs are the most widely used analgesics today. Opioids are effective for severe pain, such as pain from acute trauma, postsurgical pain, and cancer pain, but require intense monitoring for side effects. All opioids cause sedation, constipation, nausea, and somnolence and can cause respiratory depression, physical dependence, and death. Opioids are available in both short-acting and extended-release or long-acting formulations. Like NSAIDs, opioids should be used at the lowest dose for the shortest duration of time when possible.

Acute Pain

Chapter 14 covers the essentials of acute pain care in the hospital and procedural setting. The chapter begins with an overview of the negative physiologic impacts of uncontrolled acute pain. Based on a foundational understanding of pain pathways and nociceptive signaling, it is possible to construct an acute pain management plan incorporating nonpharmacologic, systemic, and focal pharmacologic elements for an effective multimodal treatment plan. Acute opioid management, including analgesic equivalence, is discussed in detail. Benefits, precautions, side effects, and toxicities of opioids are addressed. Naloxone administration is described in detail. Obstetric, regional, nerve blockade, and multimodal analgesia are described. Adjustments to therapy for patients with substance use disorder are addressed in detail.

Rehabilitation Approaches to Pain and Applications in Outpatient Practice

Chapter 12 introduces a broad range of considerations, alternatives, and coordination of nonpharmacologic pain management. Rehabilitation approaches to pain include somatic, biopsychosocial, and changes in neurochemical pathways in response to exercise, psychological interventions, and other therapeutic aspects. Rehabilitation occurs after injury, trauma, disease, or dysfunction leads to pain and the need for functional restoration. Prehabilitation is now being used in anticipation of planned procedures to reduce the impact of decreased activity in the operative setting and to increase the likelihood of successful return to function. Complementary and alternative therapies are often incorporated into rehabilitative pain management plans. In the process of providing clinical care for patients with persistent or disabling pain-associated conditions, questions of impairment, disability, and pending legal action may arise, and these are discussed. Applications in outpatient pain care address the coordination of pharmacologic and nonpharmacologic approaches and the challenges of planning and organizing effective evidence-based pain self-management plans in the outpatient setting.

Interventional Techniques and Surgical Management of Pain

Chapter 11 describes many of the most common interventional and surgical procedures performed in the field of chronic pain medicine. They are discussed in a cranial to caudal pattern, and this is done not only for logical arrangement but also to highlight the breadth of procedures that are utilized in practice. Interventional and surgical pain management techniques using image or landmark guidance may provide diagnostic and therapeutic relief for patients suffering from pain. Performed by formally trained and experienced proceduralists, interventions, in conjunction with other multimodal strategies such as medications, physical therapy, and behavioral therapies, can be useful techniques for helping patients achieve improved function and pain relief. Benefits may be short or longer term, depending on the interventional strategy utilized. Indications, evidence, and risks must be considered when choosing the most appropriate interventional options for a patient.

Neuromodulating Agents

Chapter 10 explores the variety and mechanisms of medications used for chronic and neuropathic pain. In patients with chronic and neuropathic pain, these medications can and do serve as the primary medication with efficacy. To call these agents “adjuvant” is, therefore, incorrect, despite longstanding custom. The neuromodulating medications discussed here include pain-active anticonvulsants, including gabapentinoids, pain-active antidepressants, local anesthetics, and other neuroactive agents. The medications are divided based on drug class and mechanism in order to facilitate rational combination of medications from different classes when treating patients with neuropathic or chronic pain that does not respond sufficiently to a single agent.

Clinical Assessment of Pain

Chapter 6 addresses the clinical assessment of patients with pain, including the pain-focused clinical interview (history of present illness), the patient’s illness narrative, boundary issues and precautions in examining patients with pain, and details of the basic pain-focused examination. Additionally, specific maneuvers for evaluation of common pain-associated conditions are described, including palpating for trigger points, palpation of the spine, straight leg raise testing, evaluations for radiculopathy, sacroiliac dysfunction, peripheral neuropathy, neuromas, and headache. The chapter applies the principles of patient-centered medicine, the structured clinical interview, the therapeutic alliance, and trauma-informed care to provide the health professions trainee with a useful introduction to the pain-focused clinical interview and examination.