Saturday, February 7, 2009

Chronic Pain (stats and appropriate management)

Chronic Pain

by JP Saleeby, MD

Chronic pain conditions remain one of the most common reasons for clinical visits to the primary care office and the emergency room. Data from the 1999-2002 National Health & Nutrition Examination Survey (NHANES) shows a prevalence of chronic back pain at 10.1% with other conditions such as leg and feet pain (7.1%), arms and hands (4.1%) and headache (3.1%) as reported by the respondents. There were differences of reported chronic pain by sex, where women were more likely to report headache, abdominal pain and chronic widespread pain than were men. It also crossed ethnic boundaries where the fewest reported complaints of pain came from Mexican-Americans. In a similar Canadian study reports that older adults in institutions (nursing homes) reported pain 38% of the time versus those in community-dwelling homes (private homes) only reporting 27%. Once again the Canadian study reported more women than men complained of chronic pain. Associated symptoms with chronic pain include difficulty with sleep, depression and difficulties with daily activities. Additionally chronic pain suffers tend to report that their medical care was poor.

Interestingly in a survey of over 300 physicians in Michigan, most respondents reported that they treat chronic pain, but were not confident or satisfied in their ability to treat it well. From their own perspectives they felt they fell short on accepted standards and did not choose the appropriate analgesics. There was also a general reluctance to prescribe opioids. Several overwhelming reasons for the lack of prescribing opioid analgesics were the potential for drug dependence and abuse, the untoward effects of those drugs (such as constipation, risk of withdrawal symptoms) and the potential for them finding their way to the streets (as illicit drugs).

While a review of some 60 studies looked into the abuse potential of opioid users it found a rather small percentage of those at risk in those patients who had no history of drug or alcohol abuse. However, with those patients with prior history of substance abuse and addictive personality disorders there was much risk for addiction associated with long-term opioid therapy. One of the most feared side effects of long-term opioid therapy is constipation with incidence as high as 40%. As a consequence of this additional medication would need to be prescribed to combat this condition.

The most appropriate place for chronic pain management is in the primary care setting. Emergency room visits should be limited to those suffering from acute pain episodes, not for those who are having pain for more than 2-weeks or longer. Medical management by a primary care physician or a pain management specialist offers a broader treatment plan than just pain medication. This often includes physical and/or occupational therapy, biofeedback, psychiatric counseling, adjunct therapy such as TENS, acupuncture, therapeutic massage, joint and/or muscle trigger point injections to name a few. A sole provider should be at the helm of treating chronic pain patients to insure proper prescription of medications, avoiding the possibility of drug-drug reactions from multiple prescribers and the risk of polypharmacy. From a medico-legal standpoint, only one physician should be prescribing scheduled or controlled drugs (opioid analgesics) to avoid issues of abuse or the illegal distribution of narcotics by either the prescriber or the recipient. Should your local PCP be unable to adequately control pain issues, a referral to a pain management specialist is in order and will often times be very helpful.

- JP Saleeby, MD is the medical director of the emergency department at Marlboro Park Hospital, Bennettsville, SC. He maintains a health and wellness blog at

Charles P. Vega, MD, FAAFP WebMD CME programs

Nadstawek J, Leyendecker P, Hopp M, et al. Patient assessment of a novel therapeutic approach for the treatment of severe, chronic pain. Int J Clin Pract. 2008;62:1159-1167.

(c) 2009

No comments: