The TEN Commandments of Chronic Pain Management
Listen to the patient with the aim of understanding the pain experience and to provide better medication management.
Establish the pain mechanism or working diagnosis and differential diagnosis. Starting with a good pain history is the platform for which treatment can then be planned around. Upskilling with CPD nursing courses may be necessary.
Use the a “little bit of everything” treatment approach. Otherwise also known as “multimodal” therapy.
- Rational polypharmacy is acceptable. It is important to understand how to use chronic pain medicines in this way.
Start LOW and Go SLOW
- Chronic pain medicines should be given consistently. Start a trial and titrate analgesic therapy till optimum benefit is reached.
- Start with immediate release preparations then change to slow release formulations.
- Trial period of 4-6 weeks
BUT NOT too SLOW….
- In the management of chronic non-cancer pain, it is recommended that short acting opioids are efficiently titrated to a daily sustained or controlled release formulation.
- The goal is for patients to take sustained release preparations rather than later so as to avoid the “wait for the next dose” type of behaviour.
- So certainly start LOW and go SLOW but NOT TOOOO SLOW and don’t get stuck managing chronic pain with immediate release
- Chronic pain that is left untreated efficiently may develop into neuropathic pain which is irreversible.
Rotation of Opioids to reduce harms.
An understanding of chronic pain medication management will employ strategies that monitors and switches one opioid to another in an effort to improve clinical outcomes. It just may increase therapeutic benefits, reduce dose of new opioid and reduce harms.
Adjuvant analgesics may have a part to play.
Particularly for neuropathic pain adjuvant analgesics may be effective. Tricyclic antidepressants and/or anticonvulsants may reduce pain and improve quality of life. BUT they are not magic bullets!! It is reported that only HALF of the patients get relief. MedRN’s chronic pain training course may help to improve your understanding of these medicines used to treat neuropathic pain.
Realistic goal setting.
Education and discussion with cognitively able patients or their representing family members on the goal of drug and non-drug treatment is important. This will promote compliance, set expectations on effectiveness and improve the understanding of potential side effects. Do not assume that those taking chronic pain medicines for many years truly understands how they work or understand their limitations. Talking about medication management and medication administration with specific focus on chronic pain medicines is very important for these patients.
Treating the patient as a WHOLE is important. Chronic pain is more than just a physical burden. Depression is a top risk factor. It is important to acknowledge that patients suffering chronic pain will also be living with other chronic conditions. Chronic disease management is important. The stress of having other chronic diseases together with chronic pain can amplify core symptoms and exacerbate negative emotions which can complicate treatment and interfere with a person’s quality of life.
RE-ASSESS and OPTIMISE
Once initial treatment has commenced, it is vital to review how everything is going.
Re-assess the effectiveness of the medicine prescribed or the non-drug strategy employed. Assess and review initial diagnosis, other pathologies and any side effects experienced. Also assess for risks of addictive disorders or tendencies (personal and family history).
Then, optimise treatment with a new plan or new medicine to reach optimal goal.
Optimise your own learning also by updating your knowledge with chronic pain training courses and your patient’s will gain from the knowledge you have gained.