SELF-MANAGEMENT
- examples: occupational therapy, patient education, exercise12,19
- may be an effective complement to other therapies12
Learning objectives
By the end of this educational module you should be able to:
1. understand the importance of addressing patients' physical functionality in pain management
2. recognise and assess different types of pain
3. interpret patients’ individual needs in pain management
4. understand the holistic approach to chronic pain management and the role your specialty can play
5. know how to address the needs of patients with chronic pain during the COVID-19 pandemic
Pharmacological agents available for the management of chronic pain include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antidepressants, anti-epileptics, topical treatments and others such as muscle relaxants.20,22
Paracetamol, NSAIDs and cyclo-oxygenase-2 inhibitors target the nociceptive component of chronic pain, whereas antidepressants and anti-epileptics target the neuropathic component.22 Commonly used antidepressants include tricyclic antidepressants, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.20
Topical local anaesthetic preparations are recommended for management of localised peripheral neuropathic pain such as post-herpetic neuralgia and diabetic polyneuropathy.22 Topical capsaicin is recommended for use in treatment of neuropathic pain for suitable patients who wish to avoid, or cannot tolerate oral treatments.20
Some of the pharmacological agents available are used in treatment of mixed pain.10,22 Corticosteroid injections vary in their clinical presentation and underlying pathophysiology but are commonly used to manage many chronic non-cancer pain conditions.23
There is little evidence that opioids are helpful for chronic pain. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and use is intermittent, but it is difficult to identify these people at the start of treatment.11
2019 guidance from NICE states cannabis-based medicinal products nabilone, dronabinol, THC (delta-9-tetrahydrocannabinol) or a combination of cannabidiol (CBD) with THC should not be offered to manage chronic pain in adults. CBD can be offered to manage chronic pain in adults if it is part of a clinical trial.24
NICE: National Institute for Health and Care Excellence.
Targeting the different mechanisms of pain by combining agents with different mechanisms of action is a rational approach to management of chronic pain.10,22
The management of chronic pain requires a holistic approach, addressing the physical, psychological and social aspects of pain.12,25,26
Following diagnosis and initiation of treatment, regular reviews should be carried out to assess and monitor the effectiveness of treatment.20,27 Clinical guidance from the NICE recommends to carry out regular clinical reviews that should include assessment of:20
If necessary, a change in treatment, referral to a specialist, or both should be considered.27
Most patients can be well-managed in the community or at local hospitals by trained members of interdisciplinary pain management services.28,29 Intense pain, or pain that causes significant distress and impact on functioning and substantial comorbidities, requires specialised pain management services involving multidisciplinary, interdisciplinary and multi-specialty teams.28,30
The following pathway can be used in management of chronic pain:28-30
CCG: clinical commissioning group; LHB: local health board.
GUIDELINE RECOMMENDATIONS
NICE guidance provides recommendations for referral of patients with neuropathic pain that present in non-specialist settings:20
Guidelines from the Faculty of Pain Medicine provide recommendations on referral of patients with chronic pain to pain management services. People who should be referred according to the guidance are:28
Reporting adverse events (UK Healthcare Professionals):
Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/
Adverse events should also be reported to Grünenthal Limited
Please contact telephone 0800 254 5540 or medicalinformationuk@grunenthal.com
Reporting possible side effects (UK patients and general public):
Reporting of side effects: If you experience any side effects, talk to your doctor, pharmacist or nurse. This includes possible side effects not listed in the package leaflet. You can also report side effects directly via the Yellow Card Scheme at https://yellowcard.mhra.gov.uk/. Side effects should also be reported to Grünenthal Limited Medical Information on telephone 0800 254 5540 or medicalinformationuk@grunenthal.com. By reporting side effects, you can help provide more information on the safety of medicines.
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