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Pain, Chronic; Assessment and Management of

Guideline Summary

Revision Date: November 2013
Sixth Edition

Scope and Target Population

The guideline will address the management of chronic pain for adults. It can be applied to pediatric populations where noted. It is not intended for the treatment of migraine headaches, cancer pain, advanced cancer pain, or in the context of palliative care or end-of-life management. Topics of addiction, withdrawal, tapering or methadone are not inclusively addressed within the context of this guideline.

Definitions
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain).

Acute pain states can be brief, lasting moments or hours, or they can be persistent, lasting weeks or several months until the disease or injury. The condition has a predictable beginning, middle and end.

Chronic pain The work group has defined chronic pain as "pain without biological value that has persisted beyond the normal time and despite the usual customary efforts to diagnose and treat the original condition and injury." If a patient's pain has persisted for six weeks (or longer than the anticipated healing time), a thorough evaluation for the course of the chronic pain is warranted.

Chronic pain syndrome – is at the end of the spectrum of chronic pain. The work group defines this as a constellation of behaviors related to persistent pain that represents significant life role disruption.

Aims

  1. Improve the function of patients age 18 years and older with chronic pain.
  2. Improve the assessment and reassessment of patients age 18 years and older with chronic pain diagnosis utilizing the biopsychosocial model.
  3. Improve the appropriate use of Level I and Level II treatment approaches for patients age 18 years and older with chronic pain.
  4. Improve the effective use of non-opioid medications in the treatment of patients age 18 years and older with chronic pain.
  5. Improve the effective use of opioid medications in the treatment of patients age 18 years and older with chronic pain.

Clinical Highlights

  • Chronic pain assessment should include determining the mechanisms of pain through documentation of pain location, intensity, quality and onset/duration; functional ability and goals; and psychological/social factors such as depression or substance abuse.
  • The goal of treatment is an emphasis on improving function through the development of long-term self-management skills including fitness and a healthy lifestyle in the face of pain that may persist.
  • A patient-centered, multifactorial, comprehensive care plan is necessary, one that includes addressing biopsychosocial factors. Addressing spiritual and cultural issues is also important. It is important to have a interdisciplinary team approach coordinated with the primary care physician to lead a team including specialty areas of psychology and physical rehabilitation.
  • Level I treatment approaches should be implemented as first steps toward rehabilitation before Level II treatments are considered.
  • Medications are not the sole focus of treatment in managing pain and should be used when needed to meet overall goals of therapy in conjunction with other treatment modalities.
  • Careful patient selection and close monitoring of all non-malignant pain patients on chronic opioids is necessary to assess the effectiveness and watch for signs of misuse or aberrant behavior.