Chronic pain treatment

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Chronic pain treatment

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Although the degree of physical disease contributing to the patient's disability should be identified and reevaluated periodically when the disease is not static, primary therapy must be directed at maintaining and improving function and at treating the psychologic disorder. These interventions may also be very important in patients with other pain syndromes, including those with clearly defined organic pathology. Analgesics can be used but are ineffective if used alone.

Although psychologic consultation is often needed, the nonspecialist can organize a behavioral program that improves patient function, even without reducing pain. Patients should keep a diary of daily activities to pinpoint areas amenable to change. The physician should make specific recommendations for gradually increasing physical activity and social engagement. Activities should be prescribed in gradually increasing units of time; pain should not, if at all possible, be allowed to abort the commitment to greater function. When activities are increased in this way, pain complaints often decrease.

Various cognitive techniques of pain control (eg, relaxation training, distraction techniques, hypnosis, biofeedback) may be useful. Patients may be taught to use distraction by guided imagery (organized fantasy evoking calm and comfort; eg, imagining resting on a beach or lying in a hammock). Other cognitive-behavioral approaches (eg, self-hypnosis) may require training by specialists. Behavior of family members or fellow workers that reinforces pain behavior (eg, constant inquiries about the patient's health or insistence that the patient perform no chores) should be discouraged. The physician should avoid reinforcing pain behavior, disapprove of maladaptive behaviors, applaud progress, and provide pain treatment while emphasizing return of function.

Nondrug therapies should be considered, including TENS and counterirritation, trigger point injection, spray and stretch, and physical therapy.

Drugs, such as NSAIDs and tricyclic antidepressants, are sometimes useful. Doses of antidepressants may be increased if depression coexists. Responsible patients occasionally benefit from opioids, although their use is controversial

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