Pain management

This article is about pain management across medicine. For cancer-related pain management specifically, see Cancer pain.

Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine.

Active and inactive μ-opioid receptors^[1]

Pain Medicine Physician

Occupation
Names	Physician
Occupation type	Specialty
Activity sectors	Medicine
Description
Education required	Doctor of Medicine (M.D.) Doctor of Osteopathic medicine (D.O.) Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.) Bachelor of Medicine, Bachelor of Surgery (MBChB)
Fields of employment	Hospitals, clinics

Image of visual pain

Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain,^[2] whether acute pain or chronic pain. Relief of pain in general (analgesia) is often an acute affair, whereas managing chronic pain requires additional dimensions.

A typical multidisciplinary pain management team may include: medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists.^[3] The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics.

Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team.^[4] Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it. Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain and discomfort to reduce any suffering during treatment, healing, and dying.

The task of medicine is to relieve suffering under three circumstances. The first is when a painful injury or pathology is resistant to treatment and persists. The second is when pain persists after the injury or pathology has healed. Finally, the third circumstance is when medical science cannot identify the cause of pain. Treatment approaches to chronic pain include pharmacological measures, such as analgesics (pain killer drugs), antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy.

Defining pain

See also: Threshold of pain and Pain tolerance

 

Commonly used^{[citation needed]} scale to depict pain levels

In the nursing profession, one common definition of pain is any problem that is "whatever the experiencing person says it is, existing whenever the experiencing person says it does".^[5]

Pain management includes patient and communication about the pain problem.^[6] To define the pain problem, a health care provider will likely ask questions such as:^[6]

• How intense is the pain?
• How does the pain feel?
• Where is the pain?
• What, if anything, makes the pain lessen?
• What, if anything, makes the pain increase?
• When did the pain start?

After asking such questions, the health care provider will have a description of the pain.^[6] Pain management will then be used to address that pain.^[6]

Adverse effects

There are many types of pain management. Each have their own benefits, drawbacks, and limits.^[6]

A common challenge in pain management is communication between the health care provider and the person experiencing pain.^[6] People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is.^[6] Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments.^[6] There is a risk in many types of pain management for the patient to take treatment that is less effective than needed or which causes other difficulties and side effects.^[6] Some treatments for pain can be harmful if overused.^[6] A goal of pain management for the patient and their health care provider is to identify the amount of treatment needed to address the pain without going beyond that limit.^[6]

Another problem with pain management is that pain is the body's natural way of communicating a problem.^[6] Pain is supposed to resolve as the body heals itself with time and pain management.^[6] Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem.^[6]

Physical approach

Physical medicine and rehabilitation

Physical medicine and rehabilitation uses a range of physical techniques such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy. These techniques are usually part of an interdisciplinary or multidisciplinary program that might also include pharmaceutical medicines.^[7] Spa therapy has showed positive effects in reducing pain among patients with chronic low back pain. However, there are limited studies looking at this approach.^[8] Studies have shown that kinesiotape could be used on individuals with chronic low back pain to reduce pain.^[9] The Center for Disease Control recommends that physical therapy and exercise can be prescribed as a positive alternative to opioids for decreasing one's pain in multiple injuries, illnesses, or diseases.^[10] This can include chronic low back pain, osteoarthritis of the hip and knee, or fibromyalgia.^[10] Exercise alone or with other rehabilitation disciplines (such as psychologically based approaches) can have a positive effect on reducing pain.^[10] In addition to improving pain, exercise also can improve one's well-being and general health.^[10]

Manipulative and mobilization therapy are safe interventions that likely reduce pain for patients with chronic low back pain. However, manipulation produces a larger effect than mobilization.^[11]

Specifically in chronic low back pain, education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short term relief of disability and pain.^[12]

Exercise interventions

 

Aerobic exercise can help when it comes to pain management

Physical activity interventions, such as tai chi, yoga and Pilates, promote harmony of the mind and body through total body awareness. These practices incorporate breathing techniques, meditation and a wide variety of movements, while training the body to perform functionally by increasing strength, flexibility, and range of motion.^[13] Physical activity can also benefit chronic sufferers by reducing inflammation and sensitivity, and boosting overall energy.^[14] Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks),^[15] and overall quality of life, while minimizing the need for pain medications.^[13] More specifically, walking has been effective in improving pain management in chronic low back pain.^[16]

TENS

Main article: Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and control chronic pain via electrical impulses.^[17] Limited research has explored the effectiveness of TENS in relation to pain management of multiple sclerosis (MS). MS is a chronic autoimmune neurological disorder, which consists of the demyelination of the nerve axons and disruption of nerve conduction velocity and efficiency.^[17] In one study, electrodes were placed over the lumbar spine and participants received treatment twice a day and at any time when they experienced a painful episode.^[17] This study found that TENS would be beneficial to MS patients who reported localized or limited symptoms to one limb.^[17] The research is mixed with whether or not TENS helps manage pain in MS patients.

Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain. However, it might help with diabetic neuropathy^[18] as well as other illnesses.

tDCS

Main article: Transcranial direct-current stimulation

Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions, and it involves the application of low-intensity (up to 2 mA) constant direct current to the scalp through electrodes in order to modulate excitability of large cortical areas.^[19] tDCS may have a role in pain assessment by contributing to efforts in distinguishing between somatic and affective aspects of pain experience.^[19] Zaghi and colleagues (2011) found that the motor cortex, when stimulated with tDCS, increases the threshold for both the perception of non-painful and painful stimuli.^[19] Although there is a greater need for research examining the mechanism of electrical stimulation in relation to pain treatment, one theory suggests that the changes in thalamic activity may be due the influence of motor cortex stimulation on the decrease in pain sensations.^[19]

In relation to MS, a study found that after daily tDCS sessions resulted in an individual's subjective report of pain to decrease when compared to a sham condition.^[17] In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session.^[17]

Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas.^[20] Research examining tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases.^[20] Specifically, the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group (e.g., sham stimulation, stimulation of the DLPFC).^[20] However, this effect decreased after treatment ended, but remained significant for three weeks following the extinction of treatment.^[20]

Acupuncture

 

Acupuncture can sometimes help to relieve pain

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, was unable to quantify the difference in the effect on pain of real, sham and no acupuncture.^[21] A systematic review in 2019 reported that acupuncture injection therapy was an effective treatment for patients with nonspecific chronic low back pain, and is widely used in Southeast Asian countries.^[22]

Light therapy

Research has found evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain.^[23][24] Instead of thermal therapy, where reactant energy is originated through heat, Low Level Light Therapy (LLLT) utilizes photochemical reactions requiring light to function.^{[citation needed]} Photochemical reactions need light in order to function. Photons, energy created from light, from these photochemical reactions provide the reactants with energy provide the reactants with energy to embed in muscles, thus managing pain.^[25] One study conducted by Stausholm et al. showed that at certain wavelengths, LLLT reduced pain in participants with knee osteoarthritis.^[26] LLLT stimulates a variety oof cell types, which in turn can help treat tendonitis, arthritis, and pain relating to muscles.^[27]

Sound therapy

Main articles: Audioanalgesia and Music therapy

Audioanalgesia and music therapy are both examples of using auditory stimuli to manage pain or other distress. They are generally viewed as insufficient when used alone, but also as helpful adjuncts to other forms of therapy.

Interventional procedures

Main article: Interventional pain management

Interventional radiology procedures for pain control, typically used for chronic back pain, include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants.

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.^{[28][29][30][31][32]} Radiofrequency treatment has been seen to improve pain in patients for facet joint low back pain. However, continuous radiofrequency is more effective in managing pain than pulsed radiofrequency.^[33]

An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. ^{[medical citation needed]}

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.^{[medical citation needed]}

Intra-articular ozone therapy

Intra-articular ozone therapy has been seen to efficiently alleviate chronic pain in patients with knee osteoarthritis.^[34]

Psychological approach

Acceptance and commitment therapy

Main article: Acceptance and commitment therapy

Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that focuses on behavior change rather than symptom change, includes methods designed to alter the context around psychological experiences rather than to alter the makeup of the experiences, and emphasizes the use of experiential behavior change methods.^[35] The central process in ACT revolves around psychological flexibility, which in turn includes processes of acceptance, awareness, a present-oriented quality in interacting with experiences, an ability to persist or change behavior, and an ability to be guided by one's values.^[35] ACT has an increased evidence base for range of health and behavior problems, including chronic pain.^[35] ACT influences patients to adopt a tandem process to acceptance and change, which allows for a greater flexibility in the focus of treatment.^[35]

Recent research has applied ACT successfully to chronic pain in older adults due to in part of its direction from individual values and being highly customizable to any stage of life.^[35] In line with the therapeutic model of ACT, significant increases in process variables, pain acceptance, and mindfulness were also observed in a study applying ACT to chronic pain in older adults.^[35] In addition, these primary results suggested that an ACT based treatment may significantly improve levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain.^[35]

Cognitive behavioral therapy

Main article: Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) helps patients with pain to understand the relationship between their pain, thoughts, emotions, and behaviors. A main goal in treatment is cognitive (thinking, reasoning or remembering) restructuring to encourage helpful thought patterns.^[36] This will target healthy activities such as regular exercise and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques (e.g., relaxation, diaphragmatic breathing, and even biofeedback).

Studies have demonstrated the usefulness of cognitive behavioral therapy in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability.^[37] CBT is significantly more effective than standard care in treatment of people with body-wide pain, like fibromyalgia. Evidence for the usefulness of CBT in the management of adult chronic pain is generally poorly understood, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials.^{[citation needed]} The crucial content of individual interventions has not been isolated and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult.^[38]

In 2020, a systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain (excluding headaches). There is no evidence that behaviour therapy (BT) is effective for reducing this type of pain, however BT may be useful for improving a person's mood immediately after treatment. This improvement appears to be small, and is short term in duration.^[39] CBT may have a small positive short-term effect on pain immediately following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy.^[39] CBT may contribute towards improving the mood of an adult who experiences chronic pain, which could possibility be maintained for longer periods of time.^[39]

For children and adolescents, a review of RCTs evaluating the effectiveness of psychological therapy for the management of chronic and recurrent pain found that psychological treatments are effective in reducing pain when people under 18 years old have headaches.^[40] This beneficial effect may be maintained for at least three months following the therapy.^[41] Psychological treatments may also improve pain control for children or adolescents who experience pain not related to headaches. It is not known if psychological therapy improves a child or adolescents mood and the potential for disability related to their chronic pain.^[41]

Hypnosis

A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions. However the studies had some limitations like small study sizes, bringing up issues of power to detect group differences, and lacking credible controls for placebo or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions."^[42]: 283

Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents.^[43] In clinical trials addressing other patient groups, it has significantly reduced pain compared to no treatment or some other non-hypnotic interventions.^[44] The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.^[45]

Hypnosis with analgesic (painkiller) has been seen to relieve chronic pain for most people and may be a safe and effective alternative to medications. However, high quality clinical data is needed to generalize to the whole chronic pain population.^[46]

Mindfulness meditation

A 2013 meta-analysis of studies that used techniques centered around the concept of mindfulness, concluded, "that MBIs [mindfulness-based interventions] decrease the intensity of pain for chronic pain patients."^[47] A 2019 review of studies of brief mindfulness-based interventions (BMBI) concluded that BMBI are not recommended as a first-line treatment and could not confirm their efficacy in managing chronic or acute pain.^[48]

Mindfulness-based pain management

Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness.^[49][50] Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism.^[49][51] It was developed by Vidyamala Burch and is delivered through the programs of Breathworks.^[49][50] It has been subject to a range of clinical studies demonstrating its effectiveness.^{[52][53][54][55][56][57][58][49]}

Medications

The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain.^[59][60] In the treatment of chronic pain, the three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine. The exact medications recommended will vary by country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.

Common types of pain and typical drug management
Pain type	typical initial drug treatment	comments
headache	paracetamol/acetaminophen, NSAIDs^[61]	doctor consultation is appropriate if headaches are severe, persistent, accompanied by fever, vomiting, or speech or balance problems;^[61] self-medication should be limited to two weeks^[61]
migraine	paracetamol, NSAIDs^[61]	triptans are used when the others do not work, or when migraines are frequent or severe^[61]
menstrual cramps	NSAIDs^[61]	some NSAIDs are marketed for cramps, but any NSAID would work^[61]
minor trauma, such as a bruise, abrasions, sprain	paracetamol, NSAIDs^[61]	opioids not recommended^[61]
severe trauma, such as a wound, burn, bone fracture, or severe sprain	opioids^[61]	more than two weeks of pain requiring opioid treatment is unusual^[61]
strain or pulled muscle	NSAIDs, muscle relaxants^[61]	if inflammation is involved, NSAIDs may work better; short-term use only^[61]
minor pain after surgery	paracetamol, NSAIDs^[61]	opioids rarely needed^[61]
severe pain after surgery	opioids^[61]	combinations of opioids may be prescribed if pain is severe^[61]
muscle ache	paracetamol, NSAIDs^[61]	if inflammation involved, NSAIDs may work better.^[61]
toothache or pain from dental procedures	paracetamol, NSAIDs^[61]	this should be short term use; opioids may be necessary for severe pain^[61]
kidney stone pain	paracetamol, NSAIDs, opioids^[61]	opioids usually needed if pain is severe.^[61]
pain due to heartburn or gastroesophageal reflux disease	antacid, H2 antagonist, proton-pump inhibitor^[61]	heartburn lasting more than a week requires medical attention; aspirin and NSAIDs should be avoided^[61]
chronic back pain	paracetamol, NSAIDs^[61]	opioids may be necessary if other drugs do not control pain and pain is persistent^[61]
osteoarthritis pain	paracetamol, NSAIDs^[61]	medical attention is recommended if pain persists.^[61]
fibromyalgia	antidepressant, anticonvulsant^[61]	evidence suggests that opioids are not effective in treating fibromyalgia^[61]

Mild pain

Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain.^{[62] [citation needed]}

Mild to moderate pain

Paracetamol, an NSAID or paracetamol in a combination product with a weak opioid such as tramadol, may provide greater relief than their separate use. A combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco. ^{[citation needed]}

Moderate to severe pain

When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.

Morphine is the gold standard to which all narcotics are compared. Semi-synthetic derivatives of morphine such as hydromorphone (Dilaudid), oxymorphone (Numorphan, Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as duration of action, side effect profile and milligramme potency. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch which is convenient for chronic pain management. In addition to the intrathecal patch and injectable fentanyl formulations, the FDA (Food and Drug Administration) has approved various immediate release fentanyl products for breakthrough cancer pain (Actiq/OTFC/Fentora/Onsolis/Subsys/Lazanda/Abstral). Oxycodone is used across the Americas and Europe for relief of serious chronic pain. Its main slow-release formula is known as OxyContin. Short-acting tablets, capsules, syrups and ampules which contain oxycodone are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, and methadone are used less frequently.^{[citation needed]} Clinical studies have shown that transdermal buprenorphine is effective at reducing chronic pain.^[63] Pethidine, known in North America as meperidine, is not recommended ^{[by whom?]} for pain management due to its low potency, short duration of action, and toxicity associated with repeated use.^{[citation needed]} Pentazocine, dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. In some countries potent synthetics such as piritramide and ketobemidone are used for severe pain. Tapentadol is a newer agent introduced in the last decade.

For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are used, with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (less commonly).

Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back with an opiate, or sometimes without it or with an NSAID.

While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.^[64]

Opioids

In 2009, the Food and Drug Administration stated: "According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction."^[65] In 2013, the FDA stated that "abuse and misuse of these products have created a serious and growing public health problem".^[66]

Opioid medications can provide short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive, a combination of a long-acting (OxyContin, MS Contin, Opana ER, Exalgo and Methadone) or extended release medication is often prescribed along with a shorter-acting medication (oxycodone, morphine or hydromorphone) for breakthrough pain, or exacerbations.

Most opioid treatment used by patients outside of healthcare settings is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain.

Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management.^[67] However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance will occur. Other risks can include chemical dependency, diversion and addiction.^[68][69]

Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction. Factors correlated with an elevated risk of opioid misuse include a history of substance use disorder, younger age, major depression, and the use of psychotropic medications.^[70] Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.^[71]

The list below consists of commonly used opioid analgesics which have long-acting formulations. Common brand names for the extended release formulation are in parentheses.

• Oxycodone (OxyContin)
• Hydromorphone (Exalgo, Hydromorph Contin)
• Morphine (M-Eslon, MS Contin)
• Oxymorphone (Opana ER)
• Fentanyl, transdermal (Duragesic)
• Buprenorphine*, transdermal (Butrans)
• Tramadol (Ultram ER)
• Tapentadol (Nucynta ER)
• Methadone* (Metadol, Methadose)
• Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER)

*Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics

Nonsteroidal anti-inflammatory drugs

The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID). They work by inhibiting the release of prostaglandins, which cause inflammatory pain. Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam have limited benefit in chronic pain disorders and with long-term use are associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.^[72][73] Common NSAIDs include aspirin, ibuprofen, and naproxen. There are many NSAIDs such as parecoxib (selective COX-2 inhibitor) with proven effectiveness after different surgical procedures. Wide use of non-opioid analgesics can reduce opioid-induced side-effects.^[74]

Antidepressants and antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. They are generally used to treat nerve brain that results from injury to the nervous system. Neuropathy can be due to chronic high blood sugar levels (diabetic neuropathy). These drugs also reduce pain from viruses such as shingles, phantom limb pain and post-stroke pain.^[75] These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome.^[76] A common anti-epileptic drug is gabapentin, and an example of an antidepressant would be amitriptyline.

Cannabinoids

Evidence of medical marijuana's effect on reducing pain is generally conclusive. Detailed in a 1999 report by the Institute of Medicine, "the available evidence from animal and human studies indicates that cannabinoids can have a substantial analgesic effect".^[77] In a 2013 review study published in Fundamental & Clinical Pharmacology, various studies were cited in demonstrating that cannabinoids exhibit comparable effectiveness to opioids in models of acute pain and even greater effectiveness in models of chronic pain.^[78] It is mainly the THC strain of medical marijuana that provide analgesic benefits, as opposed to the CBD strain.^{[medical citation needed]}

Ketamine

Low-dose ketamine is sometimes used as an alternative to opioids for the treatment of acute pain in hospital emergency departments.^[79][80] Ketamine probably^? reduces pain more than opioids and with less nausea and vomiting.^[81]

Other analgesics

Other drugs which can potentiate conventional analgesics or have analgesic properties in certain circumstances are called analgesic adjuvant medications.^[82] Gabapentin, an anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates.^[83] Drugs with anticholinergic activity, such as orphenadrine and cyclobenzaprine, are given in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal conditions. Clonidine, an alpha-2 receptor agonist, is another drug that has found use as an analgesic adjuvant.^[82] In 2021, researchers described a novel type of pain therapy — a CRISPR-dCas9 epigenome editing method for repressing Na_v1.7 gene expression which showed therapeutic potential in three mouse models of chronic pain.^[84][85]

Self-management

Self-management of chronic pain has been described as the individual's ability to manage various aspects of their chronic pain.^[86] Self-management can include building self-efficacy, monitoring one's own symptoms, goal setting and action planning. It also includes patient-physician shared decision-making, among others.^[86] The benefits of self-management vary depending on self-management techniques used. They only have marginal benefits in management of chronic musculoskeletal pain.^[87] Some research has shown that self-management of pain can use different approaches. Those approaches can range from different therapies such as yoga, acupuncture, exercise and other relaxation techniques. Patients could also take a more natural approach by taking different minerals, vitamins or herbs. However, research has shown there is a difference between rural patients and non-rural patients having more access to different self-management approaches. Physicians in these areas may be readily prescribing more pain medication in these rural cities due to being less experienced with pain management. Simply put, it is sometimes easier for rural patients to get a prescription that insurance pays for instead of natural approaches that cost more money than they can afford to spend on their pain management. Self-management may be a more expensive alternative.^[88]

Society and culture

The medical treatment of pain as practiced in Greece and Turkey is called algology (from the Greek άλγος, algos, "pain"). The Hellenic Society of Algology^[89] and the Turkish Algology-Pain Society^[90] are the relevant local bodies affiliated to the International Association for the Study of Pain (IASP).^[91]

Undertreatment

Main article: Undertreatment of pain

Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.

Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish guidelines to determine the treatment for pain which health care providers ought to offer.^[92] For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain.^[92] Health care providers may not provide the treatment which authorities recommend.^[92] Some studies about gender biases have concluded that female pain recipients are often overlooked when it comes to the perception of their pain. Whether they appeared to be in high levels of pain didn't make a difference for their observers. The women participants in the studies were still perceived to be in less pain than they actually were. Men participants on the other hand were offered pain relief while their self reporting indicated that their pain levels didn't necessarily warrant treatment. Biases exist when it comes to gender. Prescribers have been seen over and under prescribing treatment to individuals based on them being male or female ^[93].There are other prevalent reasons that undertreatment of pain occurs. Gender is a factor as well as race. When it comes to prescribers treating patients racial disparities has become a real factor. Research has shown that non-white individuals pain perception has affected their pain treatment. The African-American community has been shown to suffer significantly when it comes to trusting the medical community to treat them. Oftentimes medication although available to be prescribed is dispensed in less quantities due to their pain being perceived on a smaller scale. The black community could be undermined by physicians thinking they are not in as much pain as they are reporting. Another occurrence may be physicians simply making the choice not to treat the patient accordingly in spite of the self-reported pain level. Racial disparity is definitely a real issue in the world of pain management.^[94]

In children

Main article: Pain management in children

Acute pain is common in children and adolescents as a result of injury, illness, or necessary medical procedures.^[95] Chronic pain is present in approximately 15–25% of children and adolescents. It may be caused by an underlying disease, such as sickle cell anemia, cystic fibrosis, rheumatoid arthritis. Cancer or functional disorders such as migraines, fibromyalgia, and complex regional pain could also cause chronic pain in children.^[96]

 

Young children can indicate their level of pain by pointing to the appropriate face on a children's pain scale.

Pain assessment in children is often challenging due to limitations in developmental level, cognitive ability, or their previous pain experiences. Clinicians must observe physiological and behavioral cues exhibited by the child to make an assessment. Self-report, if possible, is the most accurate measure of pain. Self-report pain scales involve younger kids matching their pain intensity to photographs of other children's faces, such as the Oucher Scale, pointing to schematics of faces showing different pain levels, or pointing out the location of pain on a body outline.^[97] Questionnaires for older children and adolescents include the Varni-Thompson Pediatric Pain Questionnaire (PPQ) and the Children's Comprehensive Pain Questionnaire. They are often utilized for individuals with chronic or persistent pain.^[97]

Acetaminophen, nonsteroidal anti-inflammatory agents, and opioid analgesics are commonly used to treat acute or chronic pain symptoms in children and adolescents. However a pediatrician should be consulted before administering any medication.^[97]

Caregivers may provide nonpharmacological treatment for children and adolescents because it carries minimal risk and is cost effective compared to pharmacological treatment. Nonpharmacologic interventions vary by age and developmental factors. Physical interventions to ease pain in infants include swaddling, rocking, or sucrose via a pacifier. For children and adolescents physical interventions include hot or cold application, massage, or acupuncture.^[98] Cognitive behavioral therapy (CBT) aims to reduce the emotional distress and improve the daily functioning of school-aged children and adolescents with pain by changing the relationship between their thoughts and emotions. In addition this therapy teaches them adaptive coping strategies. Integrated interventions in CBT include relaxation technique, mindfulness, biofeedback, and acceptance (in the case of chronic pain).^[99] Many therapists will hold sessions for caregivers to provide them with effective management strategies.^[96]

Professional certification

Pain management practitioners come from all fields of medicine. In addition to medical practitioners, a pain management team may often benefit from the input of pharmacists, physiotherapists, clinical psychologists and occupational therapists, among others. Together the multidisciplinary team can help create a package of care suitable to the patient.

Pain medicine in the United States

Pain physicians are often fellowship-trained board-certified anesthesiologists, neurologists, physiatrists, emergency physicians, or psychiatrists. Palliative care doctors are also specialists in pain management. The American Society of Interventional Pain Physicians, the American Board of Anesthesiology, the American Osteopathic Board of Anesthesiology (recognized by the AOABOS), the American Board of Physical Medicine and Rehabilitation, the American Board of Emergency Medicine and the American Board of Psychiatry and Neurology^[100] each provide certification for a subspecialty in pain management following fellowship training. The fellowship training is recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS). As the field of pain medicine has grown rapidly, many practitioners have entered the field, some non-ACGME board-certified.^[101]

See also

• Equianalgesic
• List of investigational analgesics
• Opioid comparison, an example of an equianalgesic chart
• Pain Catastrophizing Scale
• Pain ladder
• Pain management during childbirth
• Pain psychology

References

1. Zhorov BS, Ananthanarayanan VS (March 2000). "Homology models of mu-opioid receptor with organic and inorganic cations at conserved aspartates in the second and third transmembrane domains". Archives of Biochemistry and Biophysics. 375 (1): 31–49. doi:10.1006/abbi.1999.1529. PMID 10683246.
2. Hardy PA (1997). Chronic pain management: the essentials. U.K.: Greenwich Medical Media. p. 10. ISBN 978-1-900151-85-6.
3. Main CJ, Spanswick CC (2000). Pain management: an interdisciplinary approach. Churchill Livingstone. ISBN 978-0-443-05683-3. Pain management: an interdisciplinary approach.
4. Thienhaus O, Cole BE (2002). "The classification of pain". In Weiner RS (ed.). Pain management: A practical guide for clinicians. CRC Press. p. 29. ISBN 978-0-8493-0926-7.
5. Pasero C, McCaffery M (1999). Pain: clinical manual. St. Louis: Mosby. ISBN 0-8151-5609-X.
6. Consumer Reports (April 28, 2016). "Pain Relief: What You Need to Know". Consumer Reports. Retrieved 26 May 2016.
7. Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU (March 2006). "Chronic pain in rehabilitation medicine". Disability and Rehabilitation. 28 (6): 363–367. doi:10.1080/09638280500287437. PMID 16492632. S2CID 39024642.
8. Bai R, Li C, Xiao Y, Sharma M, Zhang F, Zhao Y (September 2019). "Effectiveness of spa therapy for patients with chronic low back pain: An updated systematic review and meta-analysis". Medicine. 98 (37): e17092. doi:10.1097/MD.0000000000017092. PMC 6750337. PMID 31517832.
9. Li Y, Yin Y, Jia G, Chen H, Yu L, Wu D (April 2019). "Effects of kinesiotape on pain and disability in individuals with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials". Clinical Rehabilitation. 33 (4): 596–606. doi:10.1177/0269215518817804. PMID 30526011. S2CID 54472064.
10. Dowell D, Haegerich TM, Chou R (March 2016). "CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016". MMWR. Recommendations and Reports. 65 (1): 1–49. doi:10.15585/mmwr.rr6501e1. PMC 6390846. PMID 26987082.
11. Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, Herman PM (May 2018). "Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis". The Spine Journal. 18 (5): 866–879. doi:10.1016/j.spinee.2018.01.013. PMC 6020029. PMID 29371112.
12. Wood L, Hendrick PA (February 2019). "A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability". European Journal of Pain. 23 (2): 234–249. doi:10.1002/ejp.1314. PMID 30178503. S2CID 52148708.
13. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH, et al. (Cochrane Pain, Palliative and Supportive Care Group) (April 2017). "Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 4 (2): CD011279. doi:10.1002/14651858.CD011279.pub3. PMC 5461882. PMID 28436583.
14. University, Utah State. "Exercise and Chronic Pain". extension.usu.edu. Retrieved 2024-03-02.
15. "Chronic Pain: Symptoms, Diagnosis, & Treatment". NIH MedlinePlus the Magazine. Retrieved 2019-03-12.
16. Vanti C, Andreatta S, Borghi S, Guccione AA, Pillastrini P, Bertozzi L (March 2019). "The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials". Disability and Rehabilitation. 41 (6): 622–632. doi:10.1080/09638288.2017.1410730. PMID 29207885. S2CID 29187140.
17. Aboud T, Schuster NM (November 2019). "Pain Management in Multiple Sclerosis: a Review of Available Treatment Options". Current Treatment Options in Neurology. 21 (12): 62. doi:10.1007/s11940-019-0601-2. PMID 31773455. S2CID 208302550.
18. Dubinsky RM, Miyasaki J (January 2010). "Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology". Neurology. 74 (2): 173–176. doi:10.1212/WNL.0b013e3181c918fc. PMID 20042705.
19. Zaghi S, Thiele B, Pimentel D, Pimentel T, Fregni F (2011). "Assessment and treatment of pain with non-invasive cortical stimulation". Restorative Neurology and Neuroscience. 29 (6): 439–451. doi:10.3233/RNN-2011-0615. PMID 22124038.
20. Fregni F, Gimenes R, Valle AC, Ferreira MJ, Rocha RR, Natalle L, et al. (December 2006). "A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia". Arthritis and Rheumatism. 54 (12): 3988–3998. doi:10.1002/art.22195. PMID 17133529.
21. Madsen MV, Gøtzsche PC, Hróbjartsson A (January 2009). "Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups". BMJ. 338: a3115. doi:10.1136/bmj.a3115. PMC 2769056. PMID 19174438.
22. Liao J, Wang T, Dong W, Yang J, Zhang J, Li L, et al. (July 2019). "Acupoint injection for nonspecific chronic low back pain: A protocol of systematic review". Medicine. 98 (29): e16478. doi:10.1097/MD.0000000000016478. PMC 6709064. PMID 31335709.
23. Chou R, Huffman LH (October 2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Annals of Internal Medicine. 147 (7): 492–504. doi:10.7326/0003-4819-147-7-200710020-00007. PMID 17909210.
24. Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Pennick V, Akbari-Kamrani M, et al. (April 2008). Yousefi-Nooraie R (ed.). "Low level laser therapy for nonspecific low-back pain". The Cochrane Database of Systematic Reviews. 2011 (2): CD005107. doi:10.1002/14651858.CD005107.pub4. PMC 9044120. PMID 18425909.
25. "Photochemical Reaction: Definition, Types, Equation, Mechanisms". Testbook. Retrieved 2024-02-02.
26. Stausholm, Martin Bjørn; Naterstad, Ingvill Fjell; Joensen, Jon; Lopes-Martins, Rodrigo Álvaro Brandão; Sæbø, Humaira; Lund, Hans; Fersum, Kjartan Vibe; Bjordal, Jan Magnus (2019-10-01). "Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials". BMJ Open. 9 (10): e031142. doi:10.1136/bmjopen-2019-031142. hdl:1956/23441. ISSN 2044-6055. PMID 31662383.
27. "Low Level Laser Therapy - an overview | ScienceDirect Topics". www.sciencedirect.com. Retrieved 2024-03-02.
28. Varrassi G, Paladini A, Marinangeli F, Racz G (March 2006). "Neural modulation by blocks and infusions". Pain Practice. 6 (1): 34–38. doi:10.1111/j.1533-2500.2006.00056.x. PMID 17309707. S2CID 22767485.
29. Meglio M (July 2004). "Spinal cord stimulation in chronic pain management". Neurosurgery Clinics of North America. 15 (3): 297–306. doi:10.1016/j.nec.2004.02.012. PMID 15246338.
30. Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM (March 2006). "Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience". Pain. 121 (1–2): 43–52. doi:10.1016/j.pain.2005.12.006. PMID 16480828. S2CID 24552444.
31. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, et al. (January 2007). "Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain" (PDF). Pain Physician. 10 (1): 7–111. PMID 17256025. Archived from the original (PDF) on 2012-09-12.
32. Romanelli P, Esposito V, Adler J (July 2004). "Ablative procedures for chronic pain". Neurosurgery Clinics of North America. 15 (3): 335–342. doi:10.1016/j.nec.2004.02.009. PMID 15246341.
33. Contreras Lopez WO, Navarro PA, Vargas MD, Alape E, Camacho Lopez PA (February 2019). "Pulsed Radiofrequency Versus Continuous Radiofrequency for Facet Joint Low Back Pain: A Systematic Review". World Neurosurgery. 122: 390–396. doi:10.1016/j.wneu.2018.10.191. PMID 30404055. S2CID 53208319.
34. Noori-Zadeh A, Bakhtiyari S, Khooz R, Haghani K, Darabi S (February 2019). "Intra-articular ozone therapy efficiently attenuates pain in knee osteoarthritic subjects: A systematic review and meta-analysis". Complementary Therapies in Medicine. 42: 240–247. doi:10.1016/j.ctim.2018.11.023. PMID 30670248. S2CID 58951422.
35. McCracken LM, Jones R (July 2012). "Treatment for chronic pain for adults in the seventh and eighth decades of life: a preliminary study of Acceptance and Commitment Therapy (ACT)". Pain Medicine. 13 (7): 860–867. doi:10.1111/j.1526-4637.2012.01407.x. PMID 22680627.
36. "What Is Cognitive Behavioral Therapy?". American Psychological Association (APA). Retrieved 2020-07-14.
37. Turner JA, Clancy S (April 1988). "Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain". Journal of Consulting and Clinical Psychology. 56 (2): 261–266. doi:10.1037/0022-006x.56.2.261. PMID 2967314.
38. Eccleston C (August 2011). "Can 'ehealth' technology deliver on its promise of pain management for all?". Pain. 152 (8): 1701–1702. doi:10.1016/j.pain.2011.05.004. PMID 21612868. S2CID 10332663.
39. Williams AC, Fisher E, Hearn L, Eccleston C (August 2020). "Psychological therapies for the management of chronic pain (excluding headache) in adults". The Cochrane Database of Systematic Reviews. 8 (5): CD007407. doi:10.1002/14651858.CD007407.pub4. PMC 7437545. PMID 32794606.
40. Fisher E, Law E, Dudeney J, Eccleston C, Palermo TM (April 2019). "Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents". The Cochrane Database of Systematic Reviews. 4 (4): CD011118. doi:10.1002/14651858.cd011118.pub3. PMC 6445568. PMID 30939227.
41. Fisher E, Law E, Dudeney J, Palermo TM, Stewart G, Eccleston C (September 2018). "Psychological therapies for the management of chronic and recurrent pain in children and adolescents". The Cochrane Database of Systematic Reviews. 9 (10): CD003968. doi:10.1002/14651858.CD003968.pub5. PMC 6257251. PMID 30270423.
42. Elkins G, Jensen MP, Patterson DR (July 2007). "Hypnotherapy for the management of chronic pain". The International Journal of Clinical and Experimental Hypnosis. 55 (3): 275–287. doi:10.1080/00207140701338621. PMC 2752362. PMID 17558718.
43. Accardi MC, Milling LS (August 2009). "The effectiveness of hypnosis for reducing procedure-related pain in children and adolescents: a comprehensive methodological review". Journal of Behavioral Medicine. 32 (4): 328–339. doi:10.1007/s10865-009-9207-6. PMID 19255840. S2CID 22933756.
44. American Psychological Association (2 July 2004). "Hypnosis for the relief and control of pain". American Psychological Association. Retrieved 29 April 2013.
45. Jensen M, Patterson DR (February 2006). "Hypnotic treatment of chronic pain". Journal of Behavioral Medicine. 29 (1): 95–124. doi:10.1007/s10865-005-9031-6. PMID 16404678. S2CID 19895534.
46. Thompson T, Terhune DB, Oram C, Sharangparni J, Rouf R, Solmi M, et al. (April 2019). "The effectiveness of hypnosis for pain relief: A systematic review and meta-analysis of 85 controlled experimental trials" (PDF). Neuroscience and Biobehavioral Reviews. 99: 298–310. doi:10.1016/j.neubiorev.2019.02.013. PMID 30790634. S2CID 72334198.
47. Reiner K, Tibi L, Lipsitz JD (February 2013). "Do mindfulness-based interventions reduce pain intensity? A critical review of the literature". Pain Medicine. 14 (2): 230–242. doi:10.1111/pme.12006. PMID 23240921.
48. McClintock AS, McCarrick SM, Garland EL, Zeidan F, Zgierska AE (March 2019). "Brief Mindfulness-Based Interventions for Acute and Chronic Pain: A Systematic Review". Journal of Alternative and Complementary Medicine. 25 (3): 265–278. doi:10.1089/acm.2018.0351. PMC 6437625. PMID 30523705.
49. Cusens B, Duggan GB, Thorne K, Burch V (2010). "Evaluation of the breathworks mindfulness-based pain management programme: effects on well-being and multiple measures of mindfulness". Clinical Psychology & Psychotherapy. 17 (1): 63–78. doi:10.1002/cpp.653. PMID 19911432.
50. "What is Mindfulness based Pain Management (MBPM)?". Breathworks CIC. 22 January 2019. Retrieved 2020-05-22.
51. Pizutti LT, Carissimi A, Valdivia LJ, Ilgenfritz CA, Freitas JJ, Sopezki D, et al. (June 2019). "Evaluation of Breathworks' Mindfulness for Stress 8-week course: Effects on depressive symptoms, psychiatric symptoms, affects, self-compassion, and mindfulness facets in Brazilian health professionals". Journal of Clinical Psychology. 75 (6): 970–984. doi:10.1002/jclp.22749. PMID 30689206. S2CID 59306658.
52. Mehan S, Morris J (2018). "A literature review of Breathworks and mindfulness intervention". British Journal of Healthcare Management. 24 (5): 235–241. doi:10.12968/bjhc.2018.24.5.235. ISSN 1358-0574.
53. Lopes SA, Vannucchi BP, Demarzo M, Cunha ÂG, Nunes MD (February 2019). "Effectiveness of a Mindfulness-Based Intervention in the Management of Musculoskeletal Pain in Nursing Workers". Pain Management Nursing. 20 (1): 32–38. doi:10.1016/j.pmn.2018.02.065. PMID 29779791. S2CID 29170927.
54. Llácer LA, Ramos-Campos M (2018). "Mindfulness y Cáncer: Aplicación del programa MBPM de Respira Vida Breatworks en pacientes oncol'ógicos". Revista de Investigación y Educación en Ciencias de la Salud (in Spanish). 3 (2): 33–45. doi:10.37536/RIECS.2018.3.2.101. hdl:10017/35501. ISSN 2530-2787.
55. Agostinis A, Barrow M, Taylor C, Gray C (2017). Self-Selection all the Way: Improving Patients' Pain Experience and Outcomes on a Pilot Breathworks Mindfulness for Health Programme.
56. Long J, Briggs M, Long A, Astin F (October 2016). "Starting where I am: a grounded theory exploration of mindfulness as a facilitator of transition in living with a long-term condition" (PDF). Journal of Advanced Nursing. 72 (10): 2445–2456. doi:10.1111/jan.12998. PMID 27174075. S2CID 4917280.
57. Doran NJ (June 2014). "Experiencing Wellness Within Illness: Exploring a Mindfulness-Based Approach to Chronic Back Pain". Qualitative Health Research. 24 (6): 749–760. doi:10.1177/1049732314529662. PMID 24728110. S2CID 45682942.
58. Brown CA, Jones AK (March 2013). "Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness-based pain management program". The Clinical Journal of Pain. 29 (3): 233–244. doi:10.1097/AJP.0b013e31824c5d9f. PMID 22874090. S2CID 33688569.
59. "WHO - WHO's cancer pain ladder for adults". WHO.
60. Reynolds LA, Tansey EM, eds. (2004). Innovation in pain management : the transcript of a Witness seminar held by the Wellcome Trust Centre for the History of Medicine at UCL, London, on 12 december 2002. London: Wellcome Trust Centre for the History of Medicine at University College London. ISBN 978-0-85484-097-7.
61. Consumer Reports Health Best Buy Drugs (July 2012), "Using Opioids to Treat: Chronic Pain - Comparing Effectiveness, Safety, and Price" (PDF), Opioids, Yonkers, New York: Consumer Reports, retrieved 28 October 2013
62. "Over-the-counter pain relievers". MedlinePlus. 12 October 2018. Retrieved 11 May 2020.
63. Aiyer R, Gulati A, Gungor S, Bhatia A, Mehta N (August 2018). "Treatment of Chronic Pain With Various Buprenorphine Formulations: A Systematic Review of Clinical Studies". Anesthesia and Analgesia. 127 (2): 529–538. doi:10.1213/ANE.0000000000002718. PMID 29239947. S2CID 33903526.
64. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. (January 2010). "Opioid prescriptions for chronic pain and overdose: a cohort study". Annals of Internal Medicine. 152 (2): 85–92. doi:10.7326/0003-4819-152-2-201001190-00006. PMC 3000551. PMID 20083827.
65. FDA.gov "A Guide to Safe Use of Pain Medicine" February 23, 2009
66. "Abuse-deterrent opioids: evaluation and laveling guidance for industry". Food and Drug Administration. Retrieved 28 March 2020.
67. Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, et al. (October 2013). "Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010". Medical Care. 51 (10): 870–878. doi:10.1097/MLR.0b013e3182a95d86. PMC 3845222. PMID 24025657.
68. Carinci AJ, Mao J (February 2010). "Pain and opioid addiction: what is the connection?". Current Pain and Headache Reports. 14 (1): 17–21. doi:10.1007/s11916-009-0086-x. PMID 20425210. S2CID 17411800.
69. Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ (June 2010). "Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain". Annals of Internal Medicine. 152 (11): 712–720. doi:10.7326/0003-4819-152-11-201006010-00004. PMID 20513829. S2CID 10551876.
70. Thomas R. Frieden, Harold W. Jaffe, Joanne Cono, et al. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65 Pg. 9-10
71. King SA (2010). "Guidelines for prescribing opioids for chronic pain". Psychiatr Times. 27 (5): 20.
72. Munir MA, Enany N, Zhang JM (January 2007). "Nonopioid analgesics". The Medical Clinics of North America. 91 (1): 97–111. doi:10.1016/j.mcna.2006.10.011. PMID 17164106.
73. Ballantyne JC (November 2006). "Opioids for chronic nonterminal pain". Southern Medical Journal. 99 (11): 1245–1255. doi:10.1097/01.smj.0000223946.19256.17. PMID 17195420. S2CID 408226.
74. Mulita F, Karpetas G, Liolis E, Vailas M, Tchabashvili L, Maroulis I (February 2021). "Comparison of analgesic efficacy of acetaminophen monotherapy versus acetaminophen combinations with either pethidine or parecoxib in patients undergoing laparoscopic cholecystectomy: a randomized prospective study". Medicinski Glasnik. 18 (1): 27–32. doi:10.17392/1245-21. PMID 33155461.
75. "BrainFacts". www.brainfacts.org. Retrieved 2019-04-03.
76. Jackson KC (March 2006). "Pharmacotherapy for neuropathic pain". Pain Practice. 6 (1): 27–33. doi:10.1111/j.1533-2500.2006.00055.x. PMID 17309706. S2CID 21422222.
77. Joy JE, Watson Jr SJ, Benson Jr JA (1999). Watson SJ, Benson JA, Joy JE (eds.). Marijuana and Medicine: Assessing the Science Base. Institute of Medicine. doi:10.17226/6376. ISBN 978-0-309-07155-0. PMID 25101425. Retrieved 3 May 2013.
78. Zogopoulos P, Vasileiou I, Patsouris E, Theocharis SE (February 2013). "The role of endocannabinoids in pain modulation". Fundamental & Clinical Pharmacology. 27 (1): 64–80. doi:10.1111/fcp.12008. PMID 23278562. S2CID 38293097.
79. American College of Emergency Physicians (2017). "Optimizing the Treatment of Acute Pain in the Emergency Department". Annals of Emergency Medicine. 70 (3). Elsevier BV: 446–448. doi:10.1016/j.annemergmed.2017.06.043. ISSN 0196-0644. PMID 28844277. Subdissociative-dose ketamine (SDK) may be used either alone or as part of a multimodal approach to pain relief for traumatic and nontraumatic pain.
80. Balzer N, McLeod SL, Walsh C, Grewal K (April 2021). "Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis". Academic Emergency Medicine. 28 (4): 444–454. doi:10.1111/acem.14159. PMID 33098707. S2CID 225063965.
81. Sandberg, Mårten (2020-11-24). "Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm". BMJ Open. 10 (11): e038134. doi:10.1136/bmjopen-2020-038134. PMC 7689093. PMID 33234621. Retrieved 2022-08-07.
82. Portenoy RK (January 2000). "Current pharmacotherapy of chronic pain". Journal of Pain and Symptom Management. 19 (1 Suppl): S16–S20. doi:10.1016/s0885-3924(99)00124-4. PMID 10687334.
83. Caraceni A, Zecca E, Martini C, De Conno F (June 1999). "Gabapentin as an adjuvant to opioid analgesia for neuropathic cancer pain". Journal of Pain and Symptom Management. 17 (6): 441–445. doi:10.1016/S0885-3924(99)00033-0. hdl:2434/913025. PMID 10388250. 
84. "Unique CRISPR gene therapy offers opioid-free chronic pain treatment". New Atlas. 11 March 2021. Retrieved 18 April 2021.
85. Moreno AM, Alemán F, Catroli GF, Hunt M, Hu M, Dailamy A, et al. (March 2021). "Long-lasting analgesia via targeted in situ repression of Na_V1.7 in mice". Science Translational Medicine. 13 (584): eaay9056. doi:10.1126/scitranslmed.aay9056. PMC 8830379. PMID 33692134. S2CID 232170826.
86. Devan H, Hale L, Hempel D, Saipe B, Perry MA (May 2018). "What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis". Physical Therapy. 98 (5): 381–397. doi:10.1093/ptj/pzy029. PMID 29669089.
87. Elbers S, Wittink H, Pool JJ, Smeets RJ (October 2018). "The effectiveness of generic self-management interventions for patients with chronic musculoskeletal pain on physical function, self-efficacy, pain intensity and physical activity: A systematic review and meta-analysis". European Journal of Pain. 22 (9): 1577–1596. doi:10.1002/ejp.1253. PMC 6175326. PMID 29845678.
88. Eaton, Linda H.; Langford, Dale J.; Meins, Alexa R.; Rue, Tessa; Tauben, David J.; Doorenbos, Ardith Z. (February 2018). "Use of Self-management Interventions for Chronic Pain Management: A Comparison between Rural and Nonrural Residents". Pain Management Nursing. 19 (1): 8–13. doi:10.1016/j.pmn.2017.09.004. PMC 5807105. PMID 29153296.
89. "Αρχική Σελίδα". HPS-Pain.gr.
90. "Ana Sayfa". Algoloji - Ağrı Derneği.
91. Schiller F (1990). "The history of algology, algotherapy, and the role of inhibition". History and Philosophy of the Life Sciences. 12 (1): 27–49. JSTOR 23330469. PMID 2243924.
92. Human Rights Watch (2 June 2011), Global State of Pain Treatment: Access to Medicines and Palliative Care, Human Rights Watch, retrieved 28 July 2016
93. Samulowitz A, Gremyr I, Eriksson E, Hensing G (2018). ""Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain". Pain Research & Management. 2018: 6358624. doi:10.1155/2018/6358624. PMC 5845507. PMID 29682130.
94. Hoffman, Kelly M.; Trawalter, Sophie; Axt, Jordan R.; Oliver, M. Norman (2016-04-19). "Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites". Proceedings of the National Academy of Sciences. 113 (16): 4296–4301. Bibcode:2016PNAS..113.4296H. doi:10.1073/pnas.1516047113. ISSN 0027-8424. PMC 4843483. PMID 27044069.
95. American Academy of Pediatrics (September 2001). "The assessment and management of acute pain in infants, children, and adolescents". Pediatrics. 108 (3): 793–797. doi:10.1542/peds.108.3.793. PMID 11533354.
96. Weydert JA (2013). "The interdisciplinary management of pediatric pain: Time for more integration". Techniques in Regional Anesthesia and Pain Management. 17 (2013): 188–94. doi:10.1053/j.trap.2014.07.006.
97. (PDF). American Medical Association. Archived from the original (PDF) on June 11, 2014. Retrieved March 27, 2014.
98. Wente SJ (March 2013). "Nonpharmacologic pediatric pain management in emergency departments: a systematic review of the literature". Journal of Emergency Nursing. 39 (2): 140–150. doi:10.1016/j.jen.2012.09.011. PMID 23199786. S2CID 10884181.
99. Zagustin TK (August 2013). "The role of cognitive behavioral therapy for chronic pain in adolescents". PM & R. 5 (8): 697–704. doi:10.1016/j.pmrj.2013.05.009. PMID 23953015. S2CID 20013375.
100. "Taking a Subspecialty Exam - American Board of Psychiatry and Neurology". Retrieved 2015-09-19.
101. Mayer EK, Ihm JM, Sibell DM, Press JM, Kennedy DJ (August 2013). "ACGME sports, ACGME pain, or non-ACGME sports and spine: which is the ideal fellowship training for PM&R physicians interested in musculoskeletal medicine?". PM & R. 5 (8): 718–23, discussion 723–5. doi:10.1016/j.pmrj.2013.07.004. PMID 23953018. S2CID 39220409.

Further reading

• Diwan S, Staats P (January 2015). Atlas of Pain Medicine Procedures. McGraw Hill. ISBN 978-0-07-173876-7.
• Staats P, Wallace M (March 2015). Pain Medicine and Management: Just the Facts. McGraw Hill. ISBN 9780071817455.
• Fausett HJ, Warfield CA (2002). Manual of pain management. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 978-0-7817-2313-8.
• Bajwa ZH, Warfield CA (2004). Principles and practice of pain medicine. New York: McGraw-Hill, Medical Publishing Division. ISBN 978-0-07-144349-4.
• Waldman SD (2006). Pain Management. Philadelphia: Saunders. ISBN 978-0-7216-0334-6.
• Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, et al. (October 2013). "Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010". Medical Care. 51 (10): 870–878. doi:10.1097/MLR.0b013e3182a95d86. PMC 3845222. PMID 24025657.
• Graham SS (2015). The Politics of Pain Medicine: A Rhetorical-Ontological Inquiry. Chicago Scholarship Online. ISBN 9780226264059.
• Reynolds LA, Tansey EM (2004). Innovation in pain management : the transcript of a witness seminar held by the Wellcome Trust Centre for the History of Medicine at UCL, London, on 12 December 2002. Wellcome Trust Centre for the History of Medicine at UCL. ISBN 978-0-85484-097-7.
• Wailoo K (2014). Pain: A Political History. Johns Hopkins University Press. ISBN 978-1421413655.

External links

 

Wikimedia Commons has media related to Pain management.