The purpose of this paper is to justify the following statement: the rule of narcotics is in the long term management of chronic pain. With the ultimate goal of moving towards the elimination of “reliance” on narcotics for treatment while utilizing the alternative approaches for the treatment of chronic pain (Hadler, 2003). The mankind needs some medication to alleviate pain and lessen sufferings from diseases. In other words, it needs something to improve the health conditions. Therefore, a primary goal of contemporary medicine is to prescribe the proper medication and, as a consequence, the right remedy in the proper dose for each patient. The management of chronic pain is complicated in any environment. Chronic pain is generally associated with a complex interplay of psychological social and physical elements. Therefore, the assessment and management of chronic pain needs a prolonged relationship and time investment far beyond the things being simply acceptable to acute the medicine (Hadler, 2003).
In this paper, the individual pathophysiology of chronic pain, the properties and restrictions of opioids, alternative forms of medical treatment and the methods according to which acute care medical practitioners could treat the chronic pain will be delineated. This means in such ways that they have a positive effect in the course of the long-term management.
What Is Chronic Pain
The American Chronic Pain Association specifies chronic pain as it “continues beyond the usual recovery period for an injury or an illness. It may be continuous or come and go” (ACPA, 2001). One more definition comprises a “persistent or episodic pain of a duration or intensity that adversely affects the function or wellbeing of the patient, attributable to any etiology” (ACPA, 2001). The intense pain from keen injuries and comprising fractures seldom stays longer than 14 days. When patients continue complaining on the intense and acute pain for a time period of 14 days, such phenomenon should be considered as a possible developing of a chronic pain syndrome (Gallup, 2009).
At the American hospitals, about 11% of patients experienced chronic pain (ACPA, 2001). A Gallup survey reported that 89% of the American population experience pain at least twice a month. People aged 65 and older consist of 55% of those experiencing pain daily (Gallup, 2009). Considering this data, chronic pain is an omnipresent health condition that affects the majority of the world population at some point. The meaning of this is that any mistakes in the chronic pain treatment fraught with far-reaching consequences for billions of people.
Special Biological Considerations in Chronic Pain
The function of ordinary pain is to effect people to protect them from a further damage. Inborn or nonheritable insensitiveness to pain can result into such destroying processes as a Charcot joint. Most people have a similar threshold of pain sensitivity. Nevertheless, it has been proved that the pain limit could be extended up to 50% for most people with practicing relaxation, acupuncture, imagery or hypnosis (Hadler, 2003). The pain tolerance also differs; and as scientifically proved it has a genetic dependence. Some people are less able or willing to handle a moderate pain. A pain level measures according to the patients’ pain sensitivity and does not measure the strength of harmful physiologic influence. The sensing of pain could be separated into three elements: affective (an emotional affect), sensory (some physical senses) and evaluative (this is what pain means) (Clean, 1999).
The Role of Opioids in Chronic Pain
Opioid medications are generally applied in the treatment of chronic pain. However, they have an ability to complicate the further management of chronic pain, probably aggravating the pain through the NMDA-receptor (N-methyl D-aspartate) advocated leniency and making a level of pain facilitation lower. In addition, opioids are inherently self-strengthening; this may be a reason of taking them obsessively even as they lead to deteriorating the patient’s conditions (Hadler, 2003). Although opioids are currently widely spread for the medicamental treatment of cancer and other acute pains, the prolonged usage of opioids for treatment of chronic pain is controversial. Opioids are morphine like, natural or synthetic preparations, which influence positively on respiration, blood pressure and stomach secretion, as well as alleviate a severe cough, nausea and vomiting. However, the primary usage of all opioids is to assuage a strong and consistent pain and apprehension which is concomitant to suffering. The sense of contentment and well-being associated with the medical effect led to misuse of those drugs with the euphoric phenomenon. A number of studies confirm that the patients’ pain and function amend during a prolonged therapy with such opioids as tamadol, proxyphene and codeine. However, considering that these opioids have the weak analgesic efficiency, which is getting worse in some time, it is possible that people primarily experience some benefits from euphoric side effects. However, these euphoric effects will be getting weaker. This will occur with the development of addiction; at some point, patients will be taking the opioids exclusively to alleviate their withdrawal symptoms. Therefore, opioids are not effective and not recommended to treat the chronic pain, especially, sympathetically maintained or accompanied with a multiple sclerosis. There has been a 2-year observation of the prolonged intrathecal morphine injection for the low back pain that demonstrated that 50% of the patients had the pain relief less than 25% (ASA, 2004)
The study was conducted with participation of patients suffering from idiopathic pain. Patients believed that opioids were the most effective remedy for their pain, so they were tricked by giving them instead opioid placebo. This experimental group of patients acknowledged that they did not feel the essential difference in pain relief between opioids and placebo. Thus, these patients agreed to be detoxified and rehabilitated in order to get rid of their opioid dependence (Hadler, 2003).
There are some studies that confirmed the positive responses to opioids of an experimental group of patients. However, still an essential percentage had little or no alleviation in their pain; it was hard to distinguish the difference between euphoric and analgesic effect among those feeling alleviation (Clean, 1999).
Non-Opioid Alternative Therapy: Psychological Treatments
There are many of substitute therapies to opioid medications, which could be highly efficient in the treatment of chronic pain patients. As mentioned above, a threshold of pain sensitivity can be extended up to 50% applying such techniques as hypnosis, relaxation, imagery and acupuncture (ASA, 2004). The women, trained in Lamaze class to individual childbirth techniques, have demonstrated a sharp pain decreasing in the active labor. As the studies have showed, approximately 90% of women gave birth to their children without any pain medication applying some relaxation techniques. These techniques can considerably extend the human’s pain threshold and decrease the reliance on pain killers not only for the women in labor but for the patients with chronic pain (Hadler, 2003).
The cognitive behavioral methods are some psychological techniques, which are successfully applied in the alleviating chronic pain. The basis of techniques is teaching patients to think in a different way about the pain. The technique also explains how patients should respond to their ache. These cognitive-behavioral methods are experimentally proved to be exceedingly helpful in alleviating the patients’ pain and restoring their physical and emotional functioning. Such psychological techniques as relaxation training, operant conditioning, mindfulness and meditation are also applied exceptionally successful. However, the cognitive approaches usually work better in the combination with a multidisciplinary treatment (Mannik & Gilliland, 2006).
The physical therapy makes stronger adaptive properties and eliminates some dysfunctional pain behaviors; it provides some improvements in the functionality, activity and well-being and facilitates reducing the opioids usage. The physical therapy also facilitates retraining the nervous system in order to renovate healthy neural connections. Pain commonly is not alleviated until patients understand the meaning of reconditioning and increasing their level of physical activity. The number of studies demonstrates that placebo or nonspecific therapies can provide an alleviating equivalent being equal to the physical therapy. These studies suggest that a therapeutic value of pain alleviating therapy in forcing patients to undertake any physical activity. What is noteworthy is not allowing patients to be sedentary and motionless. Other physical therapies such as acupuncture, manual therapy and different kinds of exercises are also found to be efficient. For example, dousing with cold water or just exposing to cold increases the threshold of pain sensitivity up to 10-14 hours (Lipman, 1996). Many of these therapies are based on the process of decreasing pain prohibitory systems. Acupuncture has the property to influence by stimulating endogenous opioids. Due to the addictive properties of opioids, such quality of acupuncture raises the concern that acupuncture and similar physical therapies may become less efficient when the tolerance to drug will be developed.
Multidisciplinary Pain Clinics
Physical and psychological therapeutic methods are much more efficient when they are combined. The management of chronic pain in most cases needs a complex multidisciplinary therapy, comprising psychological counseling, physical medicine and behavior correction. A positive relationship between a physician and a patient are particularly valuable for any kind of therapy. Patients are usually referred to as a pain multidisciplinary clinic during the period from three-four weeks to three-five months. It usually depends on the development of pain, which can be chronic or persistent. Even weak and discontinuous chronic pain needs some plethora modalities of therapy, comprising a psychological assessment of a possible remedial technique. Chronic pain can be “complex”, which means that pain interacts with some psychological, legal, family and medication aspects. Such complex pain needs an increasingly intensive social and psychological involvement. A number of studies indicate that the combined treatment provides alleviation both from the moderate consistent pain and from intense consistent pain, and such positive results peculiar to the majority of patients with chronic pain (Mogil & Sternberg, 1996).
The patients having some improvements and then quitting the multidisciplinary therapy were followed up. Regardless of the effectiveness and improvement that patients had achieved in the multidisciplinary pain clinics some of them chose not to continue with the multidisciplinary therapy. They decided instead to get the opioid medication at urgent care facilities or emergency rooms. It is reported that their conditions became worse. According to the studies, dissatisfied patients and those which did not complete a multidisciplinary pain program were mostly those having the greatest psychological pathology and strongest opioid dependence. Ironically, these patients are those that have the indispensable need in a multidisciplinary therapy, and simultaneously those to whom the chronic opioid therapy is categorically contraindicated (Fields, 1991).
Drugs for Chronic Pain: Acetaminophen and Cyclooxygenase Inhibitors
Acetaminophen is a secure and efficient analgesic that cures the mild and moderate pain. This drug has a “ceiling” of the maximal pain relief, after reaching which an increased dosage of drug will not provide bigger analgesic effect. The effectiveness of acetaminophen is often understated due to its availability. Nevertheless, almost all of pain killers provided on the basis of codeine/acetaminophen combinations came from acetominophen; therefore, their efficacy should be much more appreciated. Patients can use acetaminophen without misgive and hesitation, yet not exceeding the prescribed dose, and not mixing it with other medications including acetaminophen (Rogers & Thompson, 2004).
The NSAIDS drugs (Non-steroidal anti-inflammatory) are commonly used, but they insignificantly excel the acetaminophen’s alleviating effect for the musculoskeletal pain because in tendonitis or osteoarthritis there is the little or no chronic inflammation. In case of danger of gastrointestinal bleeding, a COX-2 inhibitor (cyclooxygenase-2) is a remarkably respectable cure (Fields, 1991).
Drugs for Chronic Pain: Non-Analgesic Drugs
There are many medications for the usage in chronic pain that were not initially utilized as analgesics. Those comprise such agonists as baclophen and clonidine. Tapering doses of steroids are recommended for a back pain of neurogenic character and a complex pain of regional syndromes. Anticonvulsants and antidepressants are utilized as a complementary treatment in the acute therapy clinics. They require the supervision of a personal pain physician. Carbamazepine is utilized successfully in the therapy of neuropathic pain. The number of studies that examined the carbamazepine application to cure depressed chronic pain patients is confirmed that the patients’ pain had alleviated from the point of 8.2 to 4.0 (the improvement consists of 51%). However, the depression alleviation was only about 26%. The initial dosage of carbamazepine has to be 100 to 200 mg. As for the medicine, it has to be taken twice a day. Gabapentin is successfully utilized for the neuropathic pain too. In the course of a post-herpetic neuralgia treatment, the dosage could be gradually augmented from 300 mg per day to the dosage of 1800, and that to 2400 mg per day; after that up to 3600 mg per day. Such dosage should be divided into three doses. Gabarentine and carbamazerine have the certain side effects, which comprise dizziness and somnolence in about 35% and 20% cases accordingly (Kodell, 2002).
The drugs for which physicians have the greatest expectations for the chronic pain treatment are the antagonists of a NMDA receptor. Those comprise dextromethorphan, ketamine, methadone and amantadine. Morphine sulfate (MS) mixed with dextromethorphan in the ratio 1:1 decreases by 50% the amount of morphine, which needed to provide a relief effect for cancer and other chronic pain. However, the NMDA receptors when they accumulated in the high concentration in the hippo campus and cerebral cortex. These receptors may result in various side effects of psychological pathology (Schofferman, 1993).
There are many efficacious methods and ways to alleviate chronic pain, which do not include opioid drugs. These methods have an advantage that they exclude the possibility of exposing the patient to the hazard of tolerance-induced pain or physical and psychological depending on euphoric properties of opioids. Patients choose the opioid therapy because it is the easiest way. As a result, the opioid drugs often interfere with the non-opioid therapies of management and rehabilitation of chronic pain patients. Therefore, the urgent treatment and emergency physicians should explain patients the side effects of opioid treatment of their chronic pain and advocate for the non-opioid treatment (Kodell, 2002).
The Role of the Urgent Care and Emergency Physician
Urgent care and emergency physicians play a leading role in the treatment of chronic pain patients. Not only because they are available 24/7 to treat acute the reinforcement of chronic pain, but because they are the first medical specialists that patients contact. In addition, they can be alternative to the pain clinic of the patient’s personal physician in cases when patients are dissatisfied with their methods of treatment. The urgent care and emergency physicians have to be extremely careful because their actions contribute to the immediate solution and not to resolving around an initial problem of chronic pain (Kodell, 2002).
The urgent care and emergency physicians have to inform chronic pain patients that there is no immediate decision for their health condition. Their chronic pain will be treated only if they actively participate in their therapy. Physicians should be supportive and sympathetic in relation to such patients. However, they have to be extremely careful not to exaggerate or diminish the seriousness or problems of their health conditions. It is known of the cases when patients experiencing minor whiplash injuries demonstrate the faster recovery if they were told that a factual physical damage is insignificant. Such damage does not result in a prolonged pain. Urgent care and emergency physicians should encourage patients to return to their normal activity as soon as possible (Cline, 1999).
Disposition and Consultation
It is essential that the acute care and emergency physicians work together with a local pain treatment clinic and a personal physician of a patient. Physicians should understand that many treatments for chronic pain need a lot of time and commitment from their patients. In the attempt to make these therapies work without united efforts of the patient and physicians, the clinic may do not achieve the necessary effect; patients may lose a trust to the method of treatment. The personal physician as well as the pain clinic has to know whether opioids have been given to a patient before. Ideally, the treatment should include a detailed plan for applying analgesia and opioids to facilitate the patients’ efforts, but the treatment should not rely on the opioids usage too long. This will help in avoiding the development of the opioids dependency, which may result in nonreversible harmful modifications in the patients’ endogenous system of pain control (Gallup, 2009).
The acute care and emergency physicians have to document pain levels pursuant to the JCAHO standards and guidelines. Nevertheless, it does not have to make medical specialists feel obliged to use opioids to alleviate the patients’ pain, especially if the physician considers that these are not appropriate. The number of studies demonstrates that the documentation of pain evaluation during and after treatment plan is accompanied with enhancing the patients’ satisfaction with the result of treatment (ASA, 2004).
Over-Reliance on the Acute Care Medicine
The difference between therapeutic opioid patients and addicted drug seekers can be defined as a level of dependency over some period of time on the treatment based on opioids. It is indispensable that the personal physicians and pain clinics maintain the policy that the usage of opioids can be harmful to patients, when the patient is developing tolerance. Unfortunately, the study shows that urgent and emergency care medical specialists are not inclined in introducing the patients to alternative pain therapies. However, they are much more inclined to simplify the problems by prescribing opioids. There has been a study in which 30 opioids-addicting patients were monitored. They were told that they would not receive any longer narcotics from the clinics. But 71% of those patients received opioids from emergency and urgent care physicians anyway (ASA, 2004).
The files of habitual patients facilitate identifying and monitoring those chronic pain patients being at danger for addiction or tolerance-induce aggravating of their continuous pain. Such files are applied according to the state law and the HIPPA Act of 1996 (the Health Insurance Portability and Accountability) as well as the JCAHO. These are reviewed in details in the chapter written by Hansen elsewhere in this issue on drug-seeking patients (ACPA, 2001).
Arrangements to Improve the Care
There are a lot of ways according to which the acute care could enhance the therapy of addicted chronic pain patients having a legitimate necessity and a supervised opioid use. Those comprise the tracking systems, which can follow patients and narcotic contracts, in which the described obligations and responsibility are described in details. Finally, these are the letters from a pain management committee sent to chronic pain patients. These letters warn patients that they will be refused in narcotics unless they provide a detailed history of their illness from their personal physicians. The manager of the chronic pain facility reviews the patient’s history and corroborates with the patients’ doctors. He makes up a detailed care plan for the patient. Such measures include the follow-up recommendations for patients and provide some referrals to the multidisciplinary pain facility or some individual drug treatment programs. They have the detailed information to patients about the alternative methods of treatment, as well as establish the permissible and appropriate drugs for the patients’ particular conditions. Such program provides a better effect and provides a more essential care for both groups at risk such as legitimate chronic pain patients are as well as drug addicted users. This may be reviwed in comparison with other similar programs. The program decreases an amount of revisits of both types of the patient to the emergency care. Initially, this system has been introduced to identify chronic pain patients, which over rely on emergency drugs. Then, it becomes the foremost contributor into appropriate outpatients’ care. The patients with chronic pain complaints addressing the emergency centers for opioids treatment ten times or more during one year were monitored and reviewed for an entry to a registry of chronic pain patients. To become a member of registry, patients have to provide the contact details of their primary care medical specialist that can be contacted 24/7. They have to go to the same emergency centers for treatment of their chronic pain diagnosis and agree to undergo through the assessment by a medical specialist with the expertise in chronic pain diseases and drug dependence problems. Those patients that do not meet the requirements of this program or refuse to be included into the registry would be refused from opioids at any emergency center throughout the U.S (Gallup, 2009).
Nevertheless, which the system is being applied, it is essential to remember about long-term benefits for the patients’ health. The system should be consistent with the standards and rules of local pain management facilities or the patients’ personal physicians.
Particular Chronic Pain Syndromes: Complex Regional Pain Syndrome
A physical therapy, comprising a mild desensitization and other improving measures, is one of the several interferences, which has been demonstrated to be efficient in the supervised studies of the CRPS. It provides approximately 50% of decreasing in the pain level during 3 months period. The physical therapy has demonstrated the efficient results in the treatment of children with the CRPS syndrome (ACPA, 2001). The majority of children, as the study shows, was using wheelchairs and crutches and had the chronic secondary modifications due to maintaining the immobile and dependent position. These children were treated exclusively with intensive physical therapeutic loads and energetic toweling to provide the intense sensory stimulation. The opposite side was immobilized in order to force the affected side of body to work. By the end of such intense therapy, 12 children out of 20 and had a full dispersal of their pain syndromes. Eight others had the periodical discomforting pain. All children had a normal functioning of their body systems; none of them need crutches or a wheel chair anymore. These results had been followed up for 3 years, and there was observed only one case of relapse (ASA, 2004).
Specific Chronic Pain Syndromes: Myofascial Pain Syndrome
A myofascial pain syndrome demonstrates the best improvement due to the multidisciplinary therapy. The therapy should comprise specific musculoskeletal methods, comprising a physical intense therapy and triggering point injections. If the myofascial pain syndrome is not treated appropriately, pain may turn into a complex chronic pain syndrome with some physiological pathologies, insomnia and fatigue. Triggering point injections can be provided in the acute care environment by medical specialists being familiar with the method (ACPA, 2001).
Specific Chronic Pain Syndromes: Fibromyalgia
Cardiovascular fitness and aerobic exercise training provide a prolonged improvement. Although cardiovascular fitness and aerobic exercise training can make the patient feel worse at the beginning of training, it is crucial to prevent the further detraining. Patients have a tendency to be skeptical and reluctant initially, so results can be achieved if patients are noncompliant. Acupuncture and antidepressants could be truly efficient in fibromyalgia and may have a synergistic effect. Removing the disaster thoughts of fibromayalgia patients and persuading them that they are capable of being more functional usually has an essential influence on their willingness to see the positive result (Gallup, 2009).
Specific Chronic Pain Syndromes: Low Back Pain
Every year, the intensive rehabilitation trainings can prevent a damage of low back pain. The nonspecific regular exercise has been proved to be as efficient as a traditional physiotherapy. Low back pain patients usually have a weak aerobic capability. Enhancing their body fitness could alleviate their pain and reduce the damage to a minimal point. The stimulation of percutaneous electrical nerve and spinal cord stimulation has been demonstrated to provide about 50% decreasing in pain with the enhanced activity. A therapeutic massage was demonstrated to alleviate discomfort approximately by 32% at a period of four weeks in 74% cases (ACPA, 2001). A monitoring of efficacy of the multidisciplinary pain clinics in relation to the low back pain has established that pain decreased in 37% of cases in comparison with only 4% case (a control group); there the patients did not have any physical training but only medication. The pain improved its behavior and intensity; and patients’ level of activity improved up to 65%. Some training programs have a success rate of over 80% in comparison with about 40% in the control group (Fields, 1991). The most essential change in a successful care of the chronic low back pain is decreasing the patients’ subjective feelings of their damage. This encourages chronic pain patients to be more mobile and active and decreases the negative unsocial behavior and their attempts to obtain the sympathetic attention.
Chronic pain needs an assessment that is different from the acute pain that needs the assessment. The pathophysiology is decidedly different. There is generally some level of psychosocial and emotional discrepancy. Opioids are less efficient in comparison with analgesics for chronic pain. They can grow the sensitivity to pain when they taken prolonged time. Because opioids are addictive, some people have confused the euphoria property of opioids with an alleviating effect. This occurs even in such cases when patients’ conditions become worse and worse in the course of time. There are a lot of efficient alternative methods of treatment to opioids, but their application is complicated and needs a lot of time and energy on the part of patients. These patients are often reluctant and skeptical to make any effort. Patients resist from these alternative methods, especially those having already been taken opioids for a long time.
An advanced psychosocial and physical assessment is a principal condition in the management of chronic pain. The proper assessment is impossible in the urgent care and emergency centers’ environment. Therefore, the urgent care and emergency medical specialists should communicate with the patients’ personal pain management specialists. A special program helps to identify and monitor those patients the need for opioids medication of which may be compromised due to a prolonged drug usage. Such patients are at risk of the psychological pathology, which causes an addiction to opioids euphoric properties. Therefore, opioids should be applied exceedingly carefully. Patients taking them should be supervised (Fields, 1991). The wise old people say that, “The road to hell is paved with good intentions”. Hence, it is crucial for medical specialists to remember their oath, “Noli nocere”. In English this means as, “Do not do harm” (Hippocrates, 460 BC – 370BC) because using drugs for pain alleviating may lead and unfortunately often leads to the conditions even more dangerous than the original patients’ state.