From the Guidelines
The most effective management strategy for chronic pain in anesthesia involves a multimodal approach, prioritizing non-pharmacological interventions like cognitive behavioral therapy (CBT), yoga, physical and occupational therapy, and hypnosis, as recommended by recent guidelines 1. When considering pharmacological interventions, a stepwise approach is recommended, starting with acetaminophen and NSAIDs for mild to moderate pain, followed by gabapentinoids, duloxetine, and other SNRIs for neuropathic pain and comorbid depression. For moderate to severe pain, opioids may be considered with careful patient selection and close monitoring for adverse effects and dependency. Some key points to consider in managing chronic pain include:
- Cognitive behavioral therapy (CBT) is strongly recommended for chronic pain management as it promotes patient acceptance of responsibility for change and the development of adaptive behaviors 1.
- Yoga is recommended for the treatment of chronic neck/back pain, headache, rheumatoid arthritis, and general musculoskeletal pain as it has been shown to be effective in reducing pain and improving functional outcomes 1.
- Physical and occupational therapy are recommended for chronic pain as they can help improve functional outcomes and reduce pain 1.
- Hypnosis is recommended for neuropathic pain as it has been shown to be effective in reducing pain and improving quality of life 1.
- Interventional techniques like nerve blocks, epidural steroid injections, radiofrequency ablation, and neuromodulation can be considered for refractory cases, with careful patient selection and monitoring for adverse effects 1. It's essential to note that the level of evidence for effectiveness and risks varies by procedure, and additional research is needed to establish the clinical benefits as well as risks of specific interventional procedures for specific pain conditions compared with risks of opioid pain medications and other pharmacologic therapies 1. Therefore, clinicians should consult with a qualified pain management specialist to determine the potential appropriateness of specific interventional procedures for their patients’ indications and clinical circumstances.
From the FDA Drug Label
When managing patients taking opioid analgesics, particularly those who have been treated for a long duration and/or with high doses for chronic pain, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper A multimodal approach to pain management may optimize the treatment of chronic pain, as well as assist with the successful tapering of the opioid analgesic [see Warnings and Precautions (5.13), Drug Abuse and Dependence (9.3)] 2 Prescribers should individualize treatment using a progressive plan of pain management such as outlined by the World Health Organization, the Agency for Health Research and Quality, the Federation of State Medical Boards Model Policy, or the American Pain Society 3
The latest management strategies for chronic pain in the field of Anesthesia (pain medicine) include:
- Multimodal approach: using a combination of treatments, including mental health support, to manage chronic pain
- Individualized treatment: tailoring treatment to each patient's specific needs and circumstances
- Progressive plan: using a step-by-step approach to manage pain, as outlined by various health organizations
- Opioid tapering: gradually reducing the dose of opioid analgesics to minimize withdrawal symptoms and optimize pain management
- Patient-specific plan: creating a personalized plan to taper the dose of opioid analgesics, taking into account the patient's individual needs and circumstances 2 3
From the Research
Management Strategies for Chronic Pain
- A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care 4
- Utilization of nonopioid analgesics, such as acetaminophen and nonsteroidal antiinflammatories, can be effective in reducing pain for many chronic pain conditions 5, 6
- Regional anesthesia techniques may be superior to opioids for improved pain control, increased patient satisfaction, and decreased perioperative morbidity and mortality in patients with co-existing chronic pain 7
- A multimodal approach to perioperative care, including medication classes and anesthetic techniques, can provide effective pain management for patients with chronic pain 6
- Comprehensive preadmission assessment, complete medication history, and close follow-up management are essential for patients with pre-existing chronic pain throughout the perioperative setting 7
Considerations for Opioid Management
- Opioid analgesics may be necessary for some patients with chronic pain, but their use should be carefully considered due to the risk of tolerance, physical dependence, addiction, and opioid-induced hyperalgesia 4, 5
- A meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care 4
- At least half the chronic pain patient's daily pre-admission opioid dose should be continued daily throughout the perioperative period to avoid opioid withdrawal 7
Interdisciplinary Approach to Chronic Pain Management
- Patients with chronic pain commonly experience depression, sleep disturbance, fatigue, and decreased overall physical and mental functioning, requiring an interdisciplinary model of care 8
- Therapy may include medication, nerve blocks, active physical therapy, behavioral interventions, and assistance with vocational evaluation and training 8
- A multimodal approach to chronic pain management, including nonpharmacological and pharmacological interventions, can provide effective pain management and improve patient outcomes 5, 6