Opioid-Based Multimodal Care of Patients with Chronic Pain: Improving Effectiveness and Mitigating Risks

Abstract

Chronic pain, pain that persists beyond the normal tissue healing time, is a complex neurobiologic condition requiring multimodal treatment [1]. By definition a subjectively unpleasant experience, pain is an untestable hypothesis that requires predefined functional goals against which to objectively measure progress and treatment success [2,3]. Comprehensive assessment of chronic pain is necessarily multidimensional, requiring attention across multiple biological, psychological, and social domains [4,5]. First, characterizing patient complaints and functional impairment helps define realistic treatment goals. Second, identifying objective signs, patient-reported symptoms, and phenomenology of the syndrome, from which pathophysiology may be inferred, can shape mechanism-based therapies. Third, examining psychosocial and medical comorbidities can further optimize individualized therapy. Although pain may be initiated by acute tissue damage and adaptive nociceptive signaling, it is deep in the cortical areas of the brain where chronic and maladaptive pain signals are interpreted, assigned affective meaning, and ultimately perceived [6]. Treatment, especially with opioids, requires a vigilant and transparent relationship between clinician and patient, so that each understands the challenges and responsibilities inherent in treating a complex and often debilitating condition [7]. Only by integrating this information may we, as clinicians, tailor therapy consistent with the pain profile, goals of therapy, and with the level of risk. In this series of articles, clinicians across the continuum of care—pain specialists, primary care clinicians, nurse practitioners, pharmacists, and psychologists—share their best practices and contribute important insights into pain management. Together, we hope they provide a practical framework within which clinicians may improve their diagnostic skills and opioid-based multimodal treatment of chronic pain syndromes. It is generally accepted that chronic pain is not a unitary phenomenon; rather, clinical and laboratory studies have shown that the pain experience is governed by multiple pathophysiologic mechanisms. Normal sensation requires an appropriate balance among inhibitory and …