Volume 102, Issue s9

The multidisciplinary pain management team is the optimal method for delivery of comprehensive treatment to patients in pain. The biopsychosocial model of pain considers multiple factors for assessment, diagnosis, and treatment of pain. A structured approach to nonpharmacologic pain management includes medical and psychological interventions to educate and to empower patients to manage pain. Relaxation training, biofeedback, hypnosis, imagery, and cognitive-behavioral therapy are nonpharmacologic treatment modalities recommended by multidisciplinary pain management teams for effective pain control.

Osteopathic manipulative treatment (OMT) is an important aspect of pain management and disease prevention. Advantages of OMT administered postoperatively include easy implementation and cost-effectiveness in terms of shortened hospital stays resulting from effective relief of acute pain. Patients who receive morphine preoperatively and OMT postoperatively tend to have less postoperative pain and require less intravenously administered morphine. In addition, OMT and relief of pain lead to decreased postoperative morbidity and mortality and increased patient satisfaction. Also, soft tissue manipulative techniques and thoracic pump techniques help to promote early ambulation and body movement.

This review of interventional treatment of the spine emphasizes the need for aggressive pain control as a means of preventing persistent pain. The use and application of lumbar epidural injections, facet blocks/denervation, lysis of epidural adhesions, thermal annuloplasty, radiofrequency neurotomy, and nucleoplasty are the treatment options described. These descriptions are not all-inclusive of advanced treatment options for patients with spine pain.

Barriers to appropriate prescribing of opioids include the deficit in educating medical students in core curricula. Other barriers include physicians' lack of knowledge of pain management, failure to educate their patients or include them in treatment options, and failure to take adequate medical histories and obtain records of their patients' previous treatment. In addition, physicians often lack the ability to distinguish the patient who is suffering pain from the addict. Patients, too, may fear that opioid therapy may cause addiction. This article provides an overview of guidelines and federal regulations for prescribing opioids, along with some caveats, in the hope that physicians and patients alike will appreciate that pain management is an integral part of treatment. And, that treatment is aimed at decreasing or eradicating pain and maintaining patients' function to the greatest possible degree while monitoring and treating side effects.

Administration of opioids to alleviate moderate to severe acute pain and chronic cancer pain is an established management process. However, advancements in clinical pharmacologic research have shown that opioids are also effective in chronic noncancerous pain. Many patients properly treated for prolonged periods with opioids develop tolerance and subsequently, physical dependence. This process is not necessarily harmful to the patient and will not cause the patient to develop an addiction (properly defined as psychologic dependence). For many patients who have been on opioid therapy for months or years, analgesic effectiveness tragically becomes less. In addition, opioid-induced constipation can be severe and cause pain; patients do not develop tolerance to this adverse reaction. Therefore, such issues become a management problem and require additional intervention. Currently, many different classes of drugs can serve as effective adjuncts to opioids for treatment of pain. Adding adjunctive medication to opioid therapy improves pain management primarily by nonopioid mechanisms of action. Clinical outcomes of such combinations include greater analgesia and attenuation of opioid-induced adverse reactions such as nausea and vomiting, constipation, sedation, and respiratory depression. Adjuncts include acetaminophen, antiarrhythmics, anticonvulsants, antidepressants, antipsychotics, baclofen, benzodiazepines, capsaicin, calcium channel blockers, clonidine hydrochloride, central nervous system stimulants, corticosteroids, local anesthetics, N-methyl-D-aspartate receptor antagonists, nonsteroidal antiinflammatory drugs, pentoxifylline, and scopolamine. Some adjuncts (eg, acetaminophen) are routinely used today, whereas others (eg, nifedipine [calcium channel blocker]) are used on a limited basis but have great potential for more widespread application. All professionals (eg, nurses, pharmacists, physicians, physicians' assistants, social workers, members of the clergy) involved in treating patients with unresolved pain recognize this to be an extraordinary and delicate time. It is when patients are likely to request physicians to provide some method to accelerate their death. Thus, inadequate analgesia can become a suicidogen, ie, any factor that causes a patient to want to commit suicide. Incorporation of adjuncts to opioid therapy can serve to lessen pain and improve quality of life for a suffering patient.

Pain is associated with myriad medical conditions and affects millions of Americans. Chronic pain is one of the most common reasons prompting visits to healthcare providers; collectively, it possibly disables more people annually than heart disease and cancer combined. Primary goals of treating patients with chronic pain are to reduce pain as much as possible and facilitate functional restoration. When chronic pain becomes a disease state, it can be controlled, but, at present, it cannot be cured. Better understanding of the pathophysiology of acute and chronic pain has led to numerous advances in pharmacologic management of painful disorders, including low back pain, migraine headache, fibromyalgia, postherpetic neuralgia, osteoarthritis, rheumatoid arthritis, and cancer-related neuropathic pain. This presentation reviews the available agents and how to use them rationally, either singly or in combination, so practitioners can treat patients with chronic pain as effectively as possible.

In the grieving process, patient, family, and health professionals have the same needs-rest, relaxation, nourishment, a sense of security, trust, hope in the future, and humor among them. Grief, defined as a shared, universal, and natural neuropsychobiologic expression in response to loss, is distinct from mourning, a practice that varies in expression across diverse cultures. To aid in an understanding of grief and its effects, the author looks at the models for grief proposed by Kubler-Ross, Bowlby, Parkes, Worden, and Wolfelt. Addressing patients' concerns requires physicians be empathic, attentive, and respective and have willingness to take time, be present, and listen.