Chapter 23 - Management Strategies for Chronic Pain

Abstract

This chapter focuses on some of the management strategies used in the context of chronic pain. Effective pain management requires knowledge of several domains such as the phenomenology of each chronically painful condition and pain disease, the mechanisms of action of each treatment, and the evidence basis for the effectiveness of each treatment for each clinical condition. Effective pain management also requires the application of clinical skills in the clinical encounter, acquired through training and experience, such as the ability to identify the pain generators that activate or perpetuate pain, differentiate types of pain associated with pain generators, and identify salient biopsychosocial factors contributing to the activation and perpetuation of pain. The clinical system that can identify and remediate the pathologies generating pain and mitigate the negative effects of co-morbidities and other contributing factors most completely are likely to obtain the best treatment results. The challenge for clinicians treating chronic pain is to formulate, for each patient, to the degree feasible in a particular clinical setting, the interaction of biopsychosocial factors and neural processes that activate and perpetuate pain, and to devise a treatment program that has the best chance of remediating the most salient factors. Pharmacotherapy has a central role in integrated treatment planning for chronic pain. Analgesic medications can act both peripherally and centrally through a variety of mechanisms to modulate nociception, pain perception, and, ultimately, pain behavior. Medications are provided through several routes such as oral, topical patches and gels, intramuscular and intrafascial, intravenous, transdermal, subcutaneous, transmucosal (nasal, buccal, rectal), epidural, and intrathecal.