Makindo Medical Notes

Chronic pain persists beyond the expected healing time and can occur in the absence of ongoing tissue damage. It can significantly impair quality of life, leading to physical disability, anxiety, depression, and social isolation. Common causes of chronic pain include osteoarthritis, lower back pain, neuropathic pain, and fibromyalgia.

Assessment: requires a thorough assessment, including a biopsychosocial approach.

• History: Duration, pattern, and impact of pain on daily activities, sleep, and mood. Assess for psychological factors (e.g., depression, anxiety).
• Pain Diaries: Patients can be encouraged to keep a diary of their pain, triggers, and response to treatment.
• Screening Tools: Tools like the Pain Catastrophizing Scale or the Brief Pain Inventory can help assess the psychological impact of chronic pain.

Pharmacological Management

1. Non-Opioid Analgesics:
   • Paracetamol and NSAIDs can be used for chronic pain, though long-term use should be monitored for side effects (e.g., renal impairment, gastrointestinal issues).
2. Neuropathic Pain Agents:
   • Amitriptyline: A tricyclic antidepressant (TCA) used at low doses (10–25 mg at night) for neuropathic pain and fibromyalgia.
   • Gabapentin or Pregabalin: Commonly used for neuropathic pain (e.g., postherpetic neuralgia, diabetic neuropathy). Start low and titrate up to minimize side effects such as sedation or dizziness.
3. Opioids: While opioids may be used in the short term for severe chronic pain, long-term use is associated with dependence and tolerance. They should be used cautiously and with regular review.
4. Topical Analgesics: Capsaicin cream or topical NSAIDs can be useful in localized pain (e.g., osteoarthritis of the knee).

Non-Pharmacological Management

Non-pharmacological approaches are essential in the long-term management of chronic pain. A multidisciplinary approach is often required, involving pain specialists, physiotherapists, psychologists, and occupational therapists.

• Cognitive Behavioral Therapy (CBT): CBT can help patients cope with the psychological impact of chronic pain, addressing issues like fear-avoidance behavior, anxiety, and depression.
• Exercise Therapy: Regular, low-impact exercises such as swimming, walking, or yoga can improve mobility and reduce pain intensity.
• Mindfulness and Relaxation Techniques: Meditation, deep breathing exercises, and mindfulness-based stress reduction (MBSR) can be helpful for managing chronic pain.
• Patient Education: Encouraging patients to self-manage their condition through education about pacing activities, avoiding triggers, and realistic goal-setting.

Specialist Referral

Consider referring patients with chronic pain to a specialist pain management clinic, particularly if:

• Pain is severe and unresponsive to initial treatment.
• There are significant psychosocial factors complicating pain management (e.g., depression, substance abuse).
• Interventional procedures (e.g., nerve blocks, spinal cord stimulation) are being considered.

Conclusion

Pain management in adults, whether acute or chronic, requires a tailored approach based on the type of pain, its severity, and the impact on the patient’s quality of life. The use of both pharmacological and non-pharmacological methods is key to improving outcomes. In chronic pain, a multidisciplinary approach is often essential, with a focus on both physical and psychological management.