Chronic Pain Management

After a patient presents with complaints of Chronic pain. One needs to first find out the diagnosis. Is there a neuropathy, neuromuscular pain or is the process central. Then one needs to focus on the treatment of the particular disease process. If the cause of the neuropathy is immune mediated then proper treatment by current guidelines of this condition should take place. The most common cause of pain is Myofacial pain. Which is easily treated .

Treatment Options

When treating pain with medications there are three general categories of drug treatments:

Neuropathic  & Psychiatric Medications
Neuropathic pain is associated with damage to the nerve. Often this type of pain is associated with symptoms of burning or increased sensitivity over the painful area. Neuropathic pain is best treated by either antidepressants (e.g. Elavil, Paxil, Zoloft) or by antiepileptics (e.g. Dilantin, Tegretol). The antidepressant medications also have beneficial effects of improved mood, decreased anxiety, and improved sleep cycle. These medications are not addictive, and when appropriately managed have few side effects.

Pain Medications
Pain medications are separated into several categories:

 Local pain relief.

Local anesthetics  like Emla cream can be used over the painful area.

• Acetaminophen (Tylenol)
  Tylenol is used to treat pain, but it does not have the anti-inflammatory effects of the NSAIDs listed below. Often, however, in cases of chronic pain there is no inflammation at the site of the pain, and thus Tylenol may be an appropriate treatment choice. Tylenol is a safe medication when used appropriately, but can be very dangerous when used inappropriately. The risk of liver or kidney damage is significant when more than the recommended dose of Tylenol is used.
• NSAIDs
  These are the nonsteroidal anti-inflammatory drugs (NSAIDs). The NSAIDs (e.g. Motrin, Aleve, etc.) are most beneficial in cases of acute pain, or flare-ups in patients with chronic pain. In general these should not be used on a daily basis for the treatment of chronic pain. When used on a daily basis for a period of several years, there is a risk of damage to the kidneys that can be significant. Furthermore, there are well known risk of ulcer formation with NSAIDs. While the newer, so-called COX-2 inhibitors (Celebrex, Vioxx), were designed to avoid this complication, caution should still be used if there is a risk of ulcers or GI bleeding.
• Narcotics : These medications are to be used in acute conditions and for prn use only. Immune suppression is the biggest problem for the patient in any long term use. This can be measured by checking the IgG and IgG sub class levels. Immune suppression leads to worsening of cancer, worsening of autoimmune disease and may give rise to multiple infections. Symptoms of chronic fatigue and mental cloudiness are reported by all patients. For those who recommend these on a daily basis they are Ignorant of the above facts. There is no need to take pain medication if you are pain free. Men tend to have more Mu receptors thus they often need drugs which can act on this receptor. While women have more Kappa receptors and they benefit from Kappa agonist and antagonist. There is no need for chronic administration of Narcotics.

 Treatment of painful conditions. For treatment of pain a correct diagnosis of the specfic condition is needed. Chronic pain is a term not a diagnosis.

Myofacial pain:  Need to find out the perpetuating factors

•Sudden trauma  (muscles, ligaments, tendons, bursae,  discs )
•Repetitive motions; Excessive exercise; Muscle strain due to over activity
•Systemic conditions (eg, gall bladder inflammation, heart attack, appendicitis, stomach ulcers)
• Poor posture and body mechanics, Lack of activity 
•Nutritional deficiencies (B6 - B12 and mineral deficiency)
•Hormonal changes (eg, trigger point development during PMS or menopause)
•Stress and Depression.Impaired sleep . Exposure to chemicals.
•Chilling of the body (eg, sitting under an air conditioning duct; sleeping in front of an air conditioner)

Treatment of the perpetuating factor will take care of future development of this pain. In an acute attack the best treatment remains the Trigger point injection. Immediate pain relief is seen. We have seen this in chronic cancer patients. One elderly gentleman who had severe metastases in his spine with pain did not want narcotics. They would cause him to be drowsy. So  he was treated by one single simple lidocaine injection  with complete pain relief. Seen the same effect in Herpes Zoster pain.

Trigger points can also be inactivated by stretching , cooling and heating. Simple massage also helps them. In selecting the proper modality it worth to consider some facts.  Children do well with Florimethane  spray.

C.I.D.P.

Any patient suffering from a painful neuropathy , autonomic neuropathy with involvement of sweating or burning sensations has to be evaluated for CIDP. As this is a treatable immune neuropathy. If this is treated with narcotics this can make the condition worse.

Other neuropathic pains secondary to Herpes Zoster, AIDS, Hepatitis -C, Lymes, Syphilis  are also a immune mediated neuropathy and should be treated like CIDP.

We do not recommend sympathectomy or other invasive procedures which destroy nerve roots or spinal tracts. In time remyelination will take place or the nervous system will re route the messages through surviving fibers and this will negate the effects of these surgeries.

Antidepressants: Low-dose antidepressants (e.g., tricyclic antidepressants) may be prescribed for patients to take at bedtime, to help relieve symptoms.³⁰  Remember stimulating antidepressants should not be used only sedating antidepressants like amitrptiline should be used. 

Pain in malignant disorders is either Myofacial or neuropathic.

Reflex Sympathetic dystrophy, Complex regional pain syndrome need to be evaluated for CIDP or nutritional neuropathies.

Acute Back pain. Usually resolves within two weeks. Is usually Myofacial.

Fibromyalgia. Is a chronic pain disorder and will respond to various immune antiinflammatory meds.