Pain management

Pain management involves relief of pain-pain relief, analgesia, pain control in its various dimensions, from acute and simple to chronic and challenging.

Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain.

Relief of pain in general is often an acute process, whereas managing chronic pain requires additional measures. 

The pain management team includes: medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, massage therapists, and dentists.

Pain may resolve quickly once the underlying trauma or pathology has healed, and is treated with drugs such as pain relievers and occasionally also anxiolytics. 

Chronic pain frequently requires the coordinated efforts of a pain management team.

Effective pain management often means achieving adequate quality of life in the presence of pain, through a combination of lessening the pain and/or better understanding how  to live with it.

Medicine treats distressing symptoms such as pain to relieve suffering during treatment, healing, and dying. 

Medical management is to relieve pain and suffering under three circumstances. 

When a painful injury or pathology is resistant to treatment and persists. 

When pain persists after the injury or pathology has healed. 

When the cause of pain cannot be identified.

Treatment approaches to chronic pain include: pharmacological measures, such as analgesics, antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy.

Pain management communication between the health care giver and the person experiencing pain is challenging:  patients may have difficulty recognizing or describing their pain and its intensity.

There may be miscommunication between  health care providers and patients about how pain responds to treatments.

Some treatments for pain can be harmful if overused.

A goal of pain management is to identify the amount of treatment needed to address the pain without going beyond that limit.

Physical medicine and rehabilitation uses a range of physical techniques such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy. 

Physical therapy and exercise can be prescribed as a positive alternative to opioids for decreasing one’s pain in multiple injuries, illnesses, or diseases.

This can include chronic low back pain, osteoarthritis of the hip and knee, or fibromyalgia.

Exercise, with other rehabilitation disciplines can have a positive effect on reducing pain.

Exercise can also improve one’s well-being and general health.

Manipulative and mobilization therapy are likely reduce pain for patients with chronic low back pain. 

Education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short term relief of disability of chronic low back pain.

Physical activity interventions: tai chi, yoga and Pilates, promote harmony of the mind and body through total body awareness.

They incorporate breathing techniques, meditation and a wide variety of movements, while training the body to perform functionally by increasing strength, flexibility, and range of motion.

Physical activity and exercise may improve chronic pain and overall quality of life, while minimizing the need for pain medications.

Walking has been effective in improving pain management in chronic low back pain.


Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and create chronic pain via electrical impulses.

Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain. 

However, it might help with diabetic neuropathy.

Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions.

Transcranial direct current stimulation (tDCS)involves the application of low-intensity constant direct current to the scalp through electrodes in order to modulate excitability of large cortical areas.

Transcranial direct current stimulation may have a role in pain assessment by distinguishing between somatic and affective aspects of pain experience.

Daily tDCS sessions results in subjective report of pain to decrease when compared to a sham condition.

Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas.

tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases: the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group.

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. 

An analysis of the 13 highest quality studies of pain treatment with acupuncture, was unable to quantify the difference in the effect on pain of real, sham and no acupuncture.

A systematic review in 2019 reported that acupuncture injection therapy was an effective treatment for patients with nonspecific chronic low back pain, and is widely used in Southeast Asian countries.

There i no evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain.

Audioanalgesia and music therapy using auditory stimuli to manage pain or other distress are not sufficient when used alone, but helpful adjuncts to other forms of therapy.

Interventional radiology procedures for pain control, typically used for chronic back pain: epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants.

The use of pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception as the source of chronic pain.

Radiofrequency treatment improves pain in patients for facet joint low back pain, and continuous radiofrequency is more effective in managing pain than pulsed radiofrequency.

An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid, intrathecally rather than epidurally, and the pump can be fully implanted under the skin.

A spinal cord stimulator can be implanted creating electric impulses and applied near the dorsal surface of the spinal cord provides a paresthesia/tingling sensation that alters the perception of pain by the patient.

Intra-articular ozone therapy can alleviate chronic pain in patients with knee osteoarthritis.

Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that focuses on behavior change rather than symptom change.

ACT alters the context around psychological experiences rather than to alter the makeup of the experiences, and emphasizes the use of experiential behavior change methods.

ACT uses psychological flexibility, acceptance, awareness, a present-oriented quality in interacting with experiences, an ability to persist or change behavior, and an ability to be guided by one’s values.

ACT is successful to treat chronic pain in older adults.

ACT significant increases pain acceptance, and mindfulness, improves levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain.

Cognitive behavioral therapy (CBT) helps patients with pain to understand the relationship between their pain, thoughts, emotions, and behaviors. 

A main goal in treatment of cognitive behavioral therapy is thinking, reasoning or remembering, restructuring to encourage helpful thought patterns.

Cognitive behavioral therapy (CBT) targets healthy activities such as regular exercise, lifestyle changes, improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques of relaxation, diaphragmatic breathing, and even biofeedback.

Cognitive behavioral therapy is beneficial  in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability.

CBT is significantly more effective than standard care in treatment of people with body-wide pain (fibromyalgia). 

A systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain found no evidence that behaviour therapy (BT) is effective for reducing this type of pain, however it may be useful for improving a persons mood immediately after treatment. 

This improvement appears to be small, and is short term in duration.

CBT may have a small positive short-term effect on pain immediately following treatment. 

CBT may also have a small effect on reducing disability associated with adult chronic pain. 

CBT may improve the mood of an adult who experiences chronic pain, which could possibility be maintained for longer periods of time.

For children and adolescents, psychological treatments are effective in reducing pain when people under 18 years old have headaches and other types of pain.

There is evidence for the efficacy of

The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.

A meta-analysis concluded, that mindfulness-based interventions can decrease the intensity of pain for chronic pain patients, but a review of studies of brief mindfulness-based interventions is not recommended as a first-line treatment and could not confirm their efficacy in managing chronic or acute pain.

Mindfulness-based pain management provides specific applications for people living with chronic pain and illness.

The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. 

The three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine: 

Headache-acetaminophen, NSAIDs

migraine paracetamol, NSAIDs triptans are used when the others do not work, or when migraines are frequent or severe

menstrual cramps NSAIDs

minor trauma, such as a bruise, abrasions, sprain-paracetamol, NSAIDs,and opioids not recommended

severe trauma, such as a wound, burn, bone fracture, or severe sprain opioids

strain or pulled muscle NSAIDs, muscle relaxants-if inflammation is involved, NSAIDs may work better; short-term use only

minor pain after surgery paracetamol, NSAIDs-opioids rarely needed

severe pain after surgery opioids-combinations of opioids may be prescribed if pain is severe

muscle ache paracetamol, NSAIDs-if inflammation involved, NSAIDs may work better.

toothache or pain from dental procedures-paracetamol, NSAIDs this should be short term use; opioids may be necessary for severe pain

kidney stone pain paracetamol, NSAIDs, opioids-opioids usually needed if pain is severe.

pain due to heartburn or gastroesophageal reflux disease-antacid, H2 antagonist, proton-pump inhibitor

heartburn lasting more than a week requires medical attention; aspirin and NSAIDs should be avoided

chronic back pain paracetamol, NSAIDs-opioids may be necessary if other drugs do not control pain and pain is persistent

osteoarthritis pain paracetamol, NSAIDs

fibromyalgia antidepressant, anticonvulsan-evidence suggests that opioids are not effective in treating fibromyalgia

Mild pain-Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain.

Mild to moderate pain

Paracetamol, an NSAID or paracetamol in a combination product with a weak opioid such as tramadol, may provide greater relief than their separate use. 

A combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco.

Moderate to severe pain

Morphine is the gold standard to which all narcotics are compared. 

Semi-synthetic derivatives of morphine such as hydromorphone (Dilaudid), oxymorphone (Numorphan, Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as duration of action, side effect profile and potency. 

Fentanyl has the benefit of less histamine release and thus fewer side effects. 

Fentanyl can also be administered via transdermal patch which is convenient for chronic pain management. 

Oxycodone is used for relief of serious chronic pain. 

Transdermal buprenorphine is effective at reducing chronic pain.

For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are used, with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (less commonly).

Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back with an opiate, or sometimes without it or with an NSAID.

While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.

Properly managed medical use of opioid analgesic compounds taken exactly as prescribed, is safe, can manage pain effectively, and rarely causes addiction.

Opioid medications can provide short, intermediate or long acting analgesia depending upon the specific formulation.

Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. 

In chronic pain conditions that are opioid responsive, a combination of a long-acting or extended release medication is often prescribed along with a shorter-acting medication for breakthrough pain, or exacerbations.

Opioids are strong analgesics, but do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. 

Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management.

When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion and addiction may occur.

Clinical guidelines for prescribing opioids for chronic pain: assessing the patient for the risk of substance abuse, misuse, or addiction. 

Factors correlated with an elevated risk of opioid misuse include a history of substance use disorder, younger age, major depression, and the use of psychotropic medications.

Guidelines recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. 

Suspicious of abuse occurs when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.

Commonly used opioid analgesics which have long-acting formulations: 

Oxycodone (OxyContin)

Hydromorphone (Exalgo, Hydromorph Contin)

Morphine (M-Eslon, MS Contin)

Oxymorphone (Opana ER)

Fentanyl, transdermal (Duragesic)

Buprenorphine*, transdermal (Butrans)

Tramadol (Ultram ER)

Tapentadol (Nucynta ER)

Methadone* (Metadol, Methadose)

Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER)

Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics.

Nonsteroidal anti-inflammatory drugs:

The other major group of analgesics are work by inhibiting the release of prostaglandins, which cause inflammatory pain. 

The use of selective NSAIDs, COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.

Common NSAIDs include aspirin, ibuprofen, and naproxen. 

Wide use of non-opioid analgesics can reduce opioid-induced side-effects.

Some antidepressant and antiepileptic drugs are used in chronic pain management.

 Antidepressant and antiepileptic drugs and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. 

Antidepressant and antiepileptic drugs are used to treat injured brain nerves.

These agents can be used to treat neuropathy.

These drugs also reduce pain from viruses such as shingles, phantom limb pain and post-stroke pain.

Cannabinoids can have a substantial analgesic effect.

Cannabinoids exhibit comparable effectiveness to opioids in acute pain and even greater effectiveness in chronic pain.

It is mainly the THC strain of medical marijuana that provide analgesic benefits, as opposed to the CBD strain.

Ketamine is a safe, effective alternative to opioids in the treatment of acute pain in the ED. 

Ketamine probably reduces pain more than opioids and with less nausea and vomiting.

Gabapentin, an anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates.

Drugs with anticholinergic activity, such as cyclobenzaprine, and trazodone, are given in conjunction with opioids for neuropathic pain. 

Orphenadrine and cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal conditions. 

Clonidine, an alpha-2 receptor agonist, has found use as an analgesic adjuvant.

S tudies about gender biases have concluded that female pain patients  are often over looked when it comes to the perception of their pain. 

Women participants in the studies were still perceived to be in less pain than they actually were. 

Men participants on the other hand were offered pain relief while their self reporting indicated that their pain levels didn’t necessarily warrant treatment. 

Prescribers under prescribing treatment to individuals based on them being male or female.

Non-white individuals pain perception has affected their pain treatment. 

Acute pain in children and adolescents is commonly due to injury, illness, or necessary medical procedures.

Chronic pain is present in approximately 15–25% of children and adolescents. 

Chronic pain in children and adolescents may be caused by an underlying disease, such as sickle cell anemia, cystic fibrosis, rheumatoid arthritis, cancer or functional disorders such as migraines, fibromyalgia, and complex regional pain could also cause chronic pain in children.

Pain assessment in children is challenging due to limitations in developmental level, cognitive ability, or their previous pain experiences. 

Self-report is the most accurate measure of pain. 

Acetaminophen, nonsteroidal anti-inflammatory agents, and opioid analgesics are commonly used to treat acute or chronic pain symptoms in children and adolescents. 

Physical interventions to ease pain in infants include swaddling, rocking, or a pacifier. 

Cognitive behavioral therapy (CBT) aims to reduce the emotional distress and improve the daily functioning of school-aged children and adolescents with pain.

Integrated interventions in CBT include relaxation technique, mindfulness, biofeedback, and acceptance.

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