Pain and Advances in Managing Pain

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Pain and Advances in Managing Pain Essay

Chronic pain and opioid misuse are significant and interrelated health care issues that are important to our patients, the medical community, and society as a whole. A core tenet of the practice of medicine is to relieve suffering, yet the undertreatment of pain has been deemed a public health crisis by the National Academy of Medicine (NAM).1 The physician community struggles with uncertainties when managing a patient’s chronic pain in the face of an epidemic of opioid misuse, as well as the morbidity and mortality associated with overdose. When a family physician sits down with a patient who is seeking help, the fundamental goals of relieving suffering and avoiding harm can come into clear opposition.Pain and Advances in Managing Pain Essay

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Sadly, our current health care system is poorly equipped to address the needs of a patient who has chronic pain and/or opioid dependence. Patients can feel abandoned in their care, such as when they are marked with the stigma of addiction, labeled as “drug seekers” by health care providers, or “fired” from medical practices for opioid misuse. No one disputes that chronic pain should be managed with a multidisciplinary approach, yet family physicians often do not have the resources or personnel to provide that approach. They must work within a fragmented health care system in which patients can obtain prescriptions from multiple sources and multiple physicians. Since family physicians treat the whole patient and not just a subset of diseases, they face the challenge of working with patients who have multiple comorbidities, which complicates both managing chronic pain and balancing competing priorities during the office visit. Furthermore, the payment structure for the system at large (and for medications in particular) often rewards a fast-track approach instead of the comprehensive and time-consuming processes required to deliver the most appropriate care to patients struggling with chronic pain and/or opioid dependence and opioid use disorder.Pain and Advances in Managing Pain Essay

Despite these challenges, family physicians must understand the history of managing chronic pain and opioid dependence, as well as the current science. They must also be prepared to be a key part of the solution. This position paper provides family physicians with critical information and calls them to action to address chronic pain and opioid dependence and opioid use disorder.

Acute Pain And Chronic Pain Nursing Essay
Management of pain is very important in the medical setting. An excellent assessment of pain is essential to identify the kind of pain and cause of the pain. It is a subjective experience and therefore there is a necessity of individualised pain management. Pain comes with an inter-relationship with the personal injury response and has physiological and internal effects on the individual. These effects can lead to a poorer final result in the individual therefore optimal pain management is important. Multi-modal pain management works well and the pathophysiology of pain helps understand the utilization of different analgesic drugs.Pain and Advances in Managing Pain Essay

Acute Pain and Chronic Pain
The International Association of the study of pain has identified pain as ‘an unpleasant sensory and psychological experience associated with real or potential tissue damage, or described in terms of such destruction’ (Merskey & Bogduk, 1994). Pain can be nociceptive pain or neuropathic pain. . Nociceptive pain could be somatic or visceral pain where somatic pain is usually described as a distinct, hot, stinging, well localised pain associated with local tenderness. Visceral pain is dreary, cramping and colicky pain that is often poorly localised (Scott & McDonald, 2008). It is important to identify the reason for pain as it will help with effective individualised pain management. Neuropathic pain is ‘pain initiated or the effect of a principal lesion or dysfunction in the anxious system’ (Loeser & Treede, 2008). These types of pain can be either severe or serious pain. Within the acute pain establishing nociceptive pain is predominant but some patients may also present with neuropathic pain (Gray, 2008). Acute pain can be defined as ‘pain of recent onset and probable limited length. It usually comes with an identifiable temporal and causal marriage to harm or disease’. Acute agony provides an important biological function.Pain and Advances in Managing Pain Essay There exists increasing research that recognizing acute agony early on and effectively will postpone or prevent the acute pain sliding into persistent pain or health issues. As opposed to acute pain, chronic pain may provide no useful purpose. Chronic pain ‘commonly persists beyond enough time of treatment of a personal injury and sometimes there might not exactly be any plainly identifiable cause’ (Ready & Edwards, 1992). It possibly could cause extreme emotional, physical monetary and social strains upon the patient, the family and modern culture.

Pathophysiology of pain
‘Nociception can be defined as the neural process that underlies the encoding and processing of noxious stimuli’ (Loeser & Treede, 2008). The somatosensory system is able to find the stimuli that are noxious and probably tissue-damaging and for that reason, provides as an important protective system. The somatosensory system will involve multiple peripheral and central mechanisms which interact.Pain and Advances in Managing Pain Essay

Pain is a subjective experience that is affected by mental health and environmental factors in each individual. The amount of pain a particular stimulus creates will depend on many factors other than the stimulus itself and then the sensation of pain is multifactorial (Eccleston, 2001).

Two major components can be distinguished in the pathological talk about of pain. They will be the peripheral nociceptors that are activated by the noxious stimulus and the central mechanisms by which the afferent insight generates a experience of pain.Pain and Advances in Managing Pain Essay

Peripheral nociceptors-
To discover a noxious stimulus the peripheral sensory organs (nociceptors) need to be activated and, transduced action potentials need to be conducted to the central stressed system. The nociceptive afferent nerve fibres can be found throughout your body, including the pores and skin, muscle, joints, viscera and meninges. Many of these afferent fibres are the non-myelinated slow conducting, small diameter, C fibres. Others are the myelinated, medium diameter A fibres which conduct quicker. The C fibre afferents react to mechanical, thermal and chemical type stimuli. A number of receptors like the transient receptor potential vanilloid receptor 1 (TRPV1) (Patapoutian et al, 2009), acid- sensing ion programs (ASICs) and potassium stations react to different noxious stimuli (Woolf & Ma, 2007). Endogenous modulators of the nociceptors include proteinases, pro-inflammatory cytokines, anti-inflammatory cytokines and chemokines. These may also become signalling molecules in the pain pathway. Illness, irritation or ischaemia triggers tissue damage leading to the release of local mediators by cell disruption, degranulation of mast skin cells or by the inflammatory cells which results in the immediate activation of the nociceptors or sensitization of the nociceptors via ligand gated ion stations or metabatropic receptors.Pain and Advances in Managing Pain Essay

Within the dorsal horn inhibitory modulation could also take place via non-nociceptive peripheral inputs, local inhibitory GABAergic and glycinergic interneurons, descending bulbospinal projections, and higher order brain function such as distraction and cognitive type. These inhibitory mechanisms exert their result through neurotransmitters such as endorphins, enkephalins, noradrenaline and serotonin.

Pain relief may be accomplished by either reducing the excitatory transmission by using brokers such as local anaesthetics and ketamine or by improving the inhibition with agents such as opioids, clonidine and antidepressants.Pain and Advances in Managing Pain Essay

Central Pathway-
There are two primary ascending nociceptive pathways present. The spinomescenphalic tracts that originate from profound in the dorsal horn and task to the medulla and brainstem and play an important role in integrating the nociceptive information as well as arousal, homeostatic and autonomic reactions. They also project to central areas which are concerned with discrimination of pain and also mediate the mental element of pain. The spinobrachial pathway which originates from the superficial dorsal horn feeds areas with the mind that are involved with the affective and motivational component of pain.

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Acute Pain and the personal injury response
Acute pain is one of the factors that mediates the activation of the complicated neurohumoral and immune system response to harm. The peripheral and central responses to injury subsequently have a major effect on the mechanisms of acute pain. Thus there is an inter-relationship between acute pain and injury of course, if the personal injury response is prolonged there can be a negative influence on the outcome.Pain and Advances in Managing Pain Essay

The response to noxious stimuli that occurs in personal injury or disease is because multiple relationships between different neural systems and mental health factors. The interactions of the sensory, motivational and cognitive techniques act on the engine systems and produce the intricate physiological behavior, and affective responses which characterize acute pain.

Generally the immediate response consists of:

An involuntary response which involves the segmental and suprasegmental reflex response that really helps to usually protect homeostasis which is manifested by the -Pain and Advances in Managing Pain Essay

Contraction or spasm of the skeletal muscles

Increased glandular, vasomotor and sudomotor activity

Changes in the cardiovascular and respiratory systems, alterations in the visceral functions and a wide-spread and general endocrine response.

A cerebral cortical response which includes the emotional connection with pain, psychodynamic replies which produce affective reactions such as anxiousness, apprehension and general responses that happen to be characteristic of acute agony.

The immediate response will also entail the release of local mediators that will lead to biochemical and metabolic changes that will reduce the threshold of the nociceptors and cause local tenderness and hyperalgesia.

Pain is finally an psychological response which requires awareness. During general anaesthesia the individual who reacts to the surgical incisions made by moving, by an increase in blood pressure and heart rate, or modifying the respiratory design is not sense the pain but is producing reflexes to the noxious stimuli. Some reflex replies to noxious stimuli (extreme excitement of the mesentery) can be only be suppressed by standard anaesthesia. Muscle relaxants are able to control the reflex muscle moves but are unable to reduce the circulatory, respiratory system and endocrine respond to damage. Regional anaesthesia is able to suppress these reflex replies by disrupting the afferent and efferent limbs of the reflexes.Pain and Advances in Managing Pain Essay

Systematic effects of pain
Experiments have shown that pain in the lack of injury is associated with a hormonal/metabolic response which included increased degrees of cortisol, catecholamines and glucagon in addition to a decrease in level of sensitivity to insulin (Greisen et al, 2001). It is believed that there is a correlation between your magnitude of pain induced by tissue damage and the activation of the sympathetic systems which include the activation of the cardiomotor neurones, vasoconstrictor neurones which innervate the level of resistance vessels, sudomotor neurones and sympathetic pre ganglionic neurons that innervate the adrenal medulla. Because of this activation of the sympathetic system there is an upsurge in the heart rate, arterial blood circulation pressure, cutaneous conductance, and levels of plasma norepinephrine or epinephrine. This assumption was derived by the actual fact that experiments have shown that graded noxious stimuli shows a graded activation of the various functional sympathetic neurons.Pain and Advances in Managing Pain Essay

The activation of the sympathetic efferent anxious systmen by pain and the subsequent increase in heart rate, inotropy and blood pressure increases the myocardial oxygen demand. There is also a decrease in the myocardial oxygen supply. This escalates the risk in cardiac ischaemia especially in patients with pre-existing cardiac disease.

The improved sympathetic activity also influences the gastrointestinal system and ends up with reducd gastrointestinal motility which contributes to post-operative ileus. The wide-spread influence on the gut and urinary tract motility may lead to create operative ileus, nausea, throwing up and urinary retention.Pain and Advances in Managing Pain Essay

Severe pain that is present after upper abs and thoracic surgery may add widespread changes in pulmonary function, and increase in abdominal muscle build and an associated decrease in diaphragmatic function. This might result in an failure to cough and clear lung secretions which may lead to lung atelectasis and pneumonia. A decrease in useful residual capacity may lead to ventilation-perfusion abnormalities and hypoxaemia.

The reaction to harm also suppresses the mobile and humoral immune system function and contributes to a hypercoagulable express following surgery. Prolonged pain can reduce physical exercise and lead to venous stasis and increased risk of deep vein thrombosis and consequent pulmonary embolism.Pain and Advances in Managing Pain Essay

Acute pain after surgery, as stated above, is said to be an activator of the sympathetic stress response but a recently available research done by Ledowski et al. , shows that as opposed to common belief the severe nature of postoperative pain will not may actually have an association with the amount of sympathetic stress response after surgery. The mean arterial pressure, heartrate, respiration rate, plasma levels of epinephrine and norepinephrine were measured and they revealed no relationship with the speed of pain. It had been therefore importantly explained that the lack of sympathetic stimulation does not guarantee that there is no pain (Ledowski et al. , 2012).

Importance of Acute Pain management
Patients at a higher risk of complications from unrelieved acute agony include very young or older patients, patients with co morbidities and the ones who are considering major surgery (Liu & Wu, 2008).Pain and Advances in Managing Pain Essay

Effective acute pain alleviation is of great importance to anyone who’s treating patients considering surgery. Pain relief should be performed specifically for humanitarian reasons and for the comfort of patient but as pain has a physiological impact pain relief has been shown to truly have a significant physiological effect. Effective pain relief means enhanced restoration which means patients recover from surgery more quickly and ends up with earlier release from clinic. Patients are able to job application their normal daily lifestyle quicker and addititionally there is reduction in the onset of persistent pain syndromes (Fawcett et al. , 2012).Pain and Advances in Managing Pain Essay

If acute agony is not relieved it can affect the patient psychologically as well. It may bring about increased anxiety, lack of ability to sleep, demoralisation, loss of control and feeling of hopelessness (Cousins et al. , 2004).

The goal of pain management is to reduce or get rid of the pain and discomfort and must look at the needs of the patient. The best determinant of enough pain relief would be the patient’s perception of pain.

Multimodal management of pain
The responsibility for recognizing and managing acute agony lies within the complete medical team. The acute pain team provides leadership, education and onward planning as well as assistance with the management of more complex problems. The responsibility for handling more easy pain conditions would lie generally with the doctors and nurses on the ward.Pain and Advances in Managing Pain Essay

Patients vulnerable to more severe acute pain are patients with pre-existing persistent pain, those taking strong opioid analgesics, people that have high degrees of anxiety and who’ve had a prior poor pain experience.

The world health organization has introduced the idea of the analgesic ladder (Body 1) in which paracetamol is employed with or without non steroidal anti inflammatory drugs (NSAIDs) in the beginning, then weaker opioids such as codeine and then strong opioids such as morphine are being used. This model is exquisite for conditions where the pain intensity gradually increases as time passes but might not be very befitting conditions where the acute agony is expected to decrease over a brief period of energy. In such situations the inverse of this approach could be utilized where a amount of different drugs are used at first and the more potent analgesics which often have more side results are tapered off and discontinued as the depth of the pain decreases (Vickers 2010).Pain and Advances in Managing Pain Essay

Figure 1: The WHO analgesic ladder
Analgesics can be split into three main communities. Paracetamol, the NSAIDs and Cyclo-oxygenase (COX) 2 inhibitors (‘Coxibs’), and the opioids. The term opioids include the naturally behaving opioids such as morphine, the man-made opioids such as fentanyl as well as the endogenous opioids like the endomorphins. The concept of multi-modal analgesia is employed when a blend of drugs which have a different device of action may be used to maximize the pain control with minimum amount amount of aspect effects. The blend of tramadol and paracetamol synergistically action together to provide a greater result. (Amount 2)Pain and Advances in Managing Pain Essay

Figure 2: The efficacy of different analgesic by itself and in combo with other analgesics
Paracetamol which can be an anti pyretic and analgesic medicine has no anti-inflammatory actions. It is known to respond via the central anxious system and has results on COX pathways, stimulates descending inhibitory pathways via serotonin and inhibits compound P. Paracetamol is usually approved either alone or in combination to all patients who have no contraindications and also have post operative pain.

NSAIDs action via inhibiting the cyclo-oxygenase enzyme which catalyses the transformation of arachidonic acid to prostaglandins. Their strong analgesic and anti-inflammatory effects as well as their relatively common adverse effects are because of this action. The NSAIDs that are most commonly used for post-operative pain in the united kingdom are ibuprofen and diclofenac.Pain and Advances in Managing Pain Essay

NSAIDs have lots of side effects such as inhibition of platelet aggregation, connection with other anticoagulants, peptic ulceration and bleeding, exacerbation of asthma and renal impairment. The inhibition of platelet aggregation ends up with an extended bleeding time but do not impact the prothrombin time or the activated partial thromboplastin time.

The influence on platelet function may complicate other anticoagulants such as warfarin or heparin. NSAIDs are able to displace warfarin bound to plasma protein further inhibiting coagulation therefore NSAIDs are approved with extreme caution to patients getting other anticoagulants. NSAIDs are prevented in patients with peptic ulcers or a past history of peptic ulcer bleeding. Roughly 5% of asthmatic patients exhibit aspirin-induced asthma and there maybe some cross-reactivity with NSAIDs therefore they are being used with extreme care in asthmatics who’ve not been prescribed NSAIDs before. Prostaglandins play role in maintaining the blood flow to the kidneys and therefore NSAIDs in healthy patients may briefly have an impact on kidney function. NSAIDs should be avoided or recommended cautiously in patients who’ve kidney dysfunction or are at risk of producing kidney dysfunction (Vickers 2010).Pain and Advances in Managing Pain Essay

The cyclo-oxygenase prevails in two varieties namely, COX1 and COX2. The constitutive form of the enzyme is COX1 which retains the standard functions of prostaglandins such as platelet aggregation, coverage of the gastric mucosa and perfusion of the kidneys. The inducible form which is COX2 is brought on by stimuli such as tissue injury which is accountable for the irritation and pain caused by prostaglandins. Selective inhibitors of COX2 were discovered and were not proven to have the medial side effects from the COX inhibitors but it was uncovered they have an increased risk of myocardial infarction or heart stroke in high risk patients.Pain and Advances in Managing Pain Essay

Codeine is the most commonly used fragile opioid. Since codeine is a prodrug of morphine and needs to be converted into the dynamic analgesic in the gut in a proportion of the populace codeine may have little if any analgesic result. Tramadol, although regarded as an opioid analgesic has only a fragile influence on the mu opioid receptors and for that reason less respiratory depression than seen with morphine. Tramadol comes with an inhibitory effect on the re-uptake of both noradrenaline and seronin therefore works more effectively in neuropathic pain when compared to 100 % pure opioids. Nausea, vomiting dizziness and drowsiness are normal side effects seen with Tramadol.

Strong opioids are used to control severe pain and morphine is usually the first choice in most of patients. Side effects of opioids include sedation, nausea, vomiting and constipation. A significant side effect of opioids is respiratory melancholy and the combination of respiratory major depression and increasing level of sedation functions as a warning sign. Morphine can be given intermittently as a part of the multimodal management of pain. Patient manipulated analgesia (PCA) has often been shown to own better treatment than the intramuscular delivery of opioids.Pain and Advances in Managing Pain Essay

Adjuncts to these major classes of analgesic drugs may be local anaesthetics, ketamine and gabapentinoids.

Conclusion
The effect of analgesic drugs vary greatly from patient to patient and the response cannot be predicted. Studies have shown that the health care team which include doctors and nurses overestimate the length of action of the medication and the effectiveness of the drug, and also have concerns over part effects, regarding opioids vomiting, sedation and dependency, therefore under-treating acute agony especially in the post-operative setting up. Improvement may be accomplished by better education for any staff worried about the delivery of postoperative treatment and by making the assessment and recording of pain levels part of the routine management of every patient.

The Role of Research
Research fuels and sustains this knowledge, and should provide the physician with an understanding of which techniques and/or technologies work, which don’t, and why.9,10 Research can take time and, while there has been some debate about whether the relative slowness of the research process incurs a negative effect on healthcare (e.g., by delaying the availability of new techniques, technologies, drugs, etc.),11 these concerns are countered by the argument that 1) research is aimed at advancing the “good” of knowledge that can prevent against particular harms (of omission and commission), 2) the research process seeks to evaluate as many variables as possible in this goal, so as to maximize benefit(s) and reduce potential risk(s), and 3) this cannot be rushed or compromised.Pain and Advances in Managing Pain Essay

Obviously, neither research nor medicine occurs in a social vacuum and so the direction and conduct of both are susceptible to particular socio-cultural and temporal values and biases.12 Given that science can never be truly “value-free,” it is incumbent upon scientists and physicians (as users and enactors of scientific knowledge) to recognize this potential for value-ladeness, and respond with self-criticism, self-revision, and self-control.Pain and Advances in Managing Pain Essay

Technological Influence
Determining which technologies to use and which to avoid can be a problem of excessive choice—especially since much of the intellectual landscape of modern medicine has been shaped by technological advances, and this has generally yielded a positive net effect. This tends to reinforce Jurgen Habermas’ claim that the use of technology can be seen as progress.13 The Industrial Revolution(s) gave rise to incentives to develop machines to ease and improve the quality of life and, by the end of the 20th century, this had led to considerable social technophilism and technocentricism.14 To be sure, we must acknowledge 1) the pervasiveness of technology in virtually all facets of modern life, 2) that analysis of health trends in third-world countries that has irrefutably demonstrated that the absence or unavailability of medical technology incurs significantly negative impact on broad aspects of the public health, and 3) the potential and actual cost-savings afforded through the prudent use of medical technology.15 Given these facts, it would be counter-intuitive, if not pragmatically and ethically unsound to ignore or refute the benefits of technology in and to medicine. But, to balance that reality, one needs only to consider the philosopher Hans Jonas’ reckoning that in modern society, technology has become “…a process” and worldview.Pain and Advances in Managing Pain Essay

Considering Another “Technological Imperative”
The rise of technology concomitantly advanced (and was fortified by) the industrial market-model, as well as the needs and desires for speed and efficiency. While incentives for time-efficiency were initially intended to ease the human condition, the pervasiveness of the market-effect wedded time- and cost-efficiency to end-goals of increasing economic gain(s) with minimal loss (of fiscal, physical, and temporal resources).17 Therefore, I opine that many of the problems of modern medicine are not due to technology, per se, but to the commodification of medicine, and the use of technology as a leveraging factor in this market ethos.Pain and Advances in Managing Pain Essay

To be sure, technology has become an important, if not frankly necessary, tool in the contemporary practice of medicine. But given Alasdair MacIntyre’s definition of a practice as “…an exchange of the good between individuals … in relationship,”18 it becomes clear that the use of technology is not sufficient for the full enactment of medicine as a practice.19 In fact, the essential, telic “good” of medicine (i.e., a right and morally sound healing) is wholly dependent upon the physician’s ability to understand inherent strengths and limitations of any therapeutic(s) in various applications, evaluate the safety, risks, and burdens of use or non-use, and determine the relative benefits that such treatments can provide for specific patients.20 In light of this, I believe that the real “imperative” is not merely to develop and use technology, but to understand how such technology works, and how it could (best) be used to achieve the good ends of medicine. The decisional process that directs this use in the treatment of individual patients is reliant both upon research to determine the practical good of a given technique or technology, and the physician’s ability to sift through this available research to direct evidence-based, patient-centered care.Pain and Advances in Managing Pain Essay

In this latter regard, medicine is both art and skill—what is referred to in classical Greek as tekne.21 As a matter of fact, the effective use of research and technology comprises much of the tekne of modern medicine.22 But technology—like any tool—is inert; it must be employed by individuals within a system that establishes paradigms and protocols that define and describe its utility and use(s).Pain and Advances in Managing Pain Essay

Influence of the Market upon Technological Research and Use
The market-model has come to define much of the use of technology in medicine according to an ethic of profit.23 Far too often, the market-model mindset, business ethic and ethos dictate what and how technologies are marketed, advanced, and utilized. This can promote an excessive and/or inappropriate use of various technologies at all levels of sophistication, ranging from surface magnets to the most advanced neuroimaging and neurostimulation devices. As a result, the value of research to define the various benefits, burdens, and harms of technologies and techniques is lessened, and certain technologies are advocated according to their “infomercial” rather than evidence-based impact. This can 1) “sidestep” the discriminative, intellectual integrity of science, 2) advance pseudoscientific findings, 3) subvert the expert knowledge of the physician, 4) compromise physicians’ ability to act in patients’ best interests, and thereby 5) denigrate the humanitarian and fiduciary aspects of medicine.Pain and Advances in Managing Pain Essay

As Valentinuzzi remarks, “…many sly people make money out of ignorance of the rest while endangering the health of innocent patients who, one way or the other, must pay…”24 Inarguably, this is in direct opposition to the probity of the medical relationship and contrary to the altruistic and caring virtues that are axiomatic to medicine as a practice and profession.25 Thus, the challenge is to recognize the limits of the market and, in so doing, clarify that while market and business forces may be operative in science and medicine, neither science nor medicine should be conducted as business. Most fundamentally, this is because the profit-oriented ends of business do not comport with the often fragile contingencies of truth in science or the beneficence of medicine.Pain and Advances in Managing Pain Essay

“Once considered for, or incorporated into use in medical contexts, technologies and techniques are means toward achieving the humanitarian ends of medicine (not business)…”
And herein lays the crux of the issue. Once considered for, or incorporated into use in medical contexts, technologies and techniques are means toward achieving the humanitarian ends of medicine (not business) and, as such, must be evaluated and employed in accordance with those ends. In this way, they become one of the instrumental “goods” that enable the primary good (i.e. a healing action) of the practice to be achieved, not merely products or commodities of the market. Therefore technologies and techniques must be studied for safety and benefit and utilized in ways that are technically correct and ethically sound and not simply marketed for economic return(s).Pain and Advances in Managing Pain Essay

Sustaining Obligations for Care
Valentinuzzi recalls the Hippocratic obligation to “…care for patients.”27 The etymology of the word care reveals notions of “…deep thought, worry, and strong regard.”28 Thus, by definition, care cannot be superficial; such care mandates good scientific studies to reveal the risks and benefits of various technologies that are relevant to clinical contexts and, as I have stated previously and reiterate here, that how such knowledge is acquired and used may be as important as what this knowledge entails.29,30 My argument is that research undergirds the telos of medicine by seeking and providing knowledge that 1) enables the physician to evaluate the risks, benefits, and value(s) of treatments and technologies, and 2) empowers patients to be informed participants in their clinical care, thereby lessening their inherent vulnerability.31 To achieve this, research must be methodologically rigorous so as to serve its intellectual and ethical good. But if we adhere to the standard that “good” must entail “right,” then it may become apparent that while controlled, double-blind protocols are effective, they are not the only approaches and may not uniformly best suited to evaluating particular variables and circumstances of real-world use.32,33 As new technologies and techniques develop, we may need to examine the methods used to test and evaluate these devices and approaches in different situations and patient populations.Pain and Advances in Managing Pain Essay This is not to infer that the randomized, controlled, double-blind study should not be used, but rather that we must recognize that our understanding of new technologies and biological organisms and systems prompts a broader, more inclusive palette of research approaches (e.g., use of Bayesian and non-Bayesian methods, attribute-treatment interaction studies, mixed methodologies, etc).34 Any effort of this type requires participation of “…physicians, biomedical engineers, …basic medical scientists,”35 and should also conjoin the perspectives of social scientists, philosophers and ethicists, so as to gain a better understanding of how science, medicine, and persons are nested within the domains and values of society and culture. If the template of medical history provides a salient object lesson, then the pattern of hundred-year change in the socio-cultural biases and conduct of medicine would suggest that we are facing a time of potential change catalyzed by the concatenation of technology, economics, politics, and worldview(s).Pain and Advances in Managing Pain Essay

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Conclusion
As technology progresses, so too do the responsibilities to study, and utilize (or not utilize) these technologies in ways that sustain medicine’s obligation(s) for good and non-harm. These responsibilities should not be subverted by the capricious forces of the market. If we are to 1) validly inform patients about the technologies and techniques that can be employed in pain management, 2) gain consent to use these treatments, and 3) morally sustain the trust of the medical relationship, then it is vital to thoroughly evaluate what approaches work, what approaches do not, and why. The deterministic impetus to “use what we’ve got” because 1) “we’ve got it”, and 2) such use dictates and is prompted by profit(s), leads to the over-use of technology and, in fact, the under-treatment (i.e., failure to render right and appropriate care) of pain. In sum, the more we know—about the brain-mind, pain, healing, as well as technology and the social forces that affect its development and use—the more there is to discover, and the more rigorous, diverse, and collaborative our approaches to discovery and practice must be.Pain and Advances in Managing Pain Essay

Dedication
This writing is dedicated to the memory of my father: an engineer, idealist, humanitarian, and teacher.

Acknowledgement
This essay was adapted from a larger work by the author “Neuroethical reconsideration of the technological imperative,” and from a paper by the author and Alessandra Valadas “On the use of biotechnology: Potential, problems, and a call for prudence.” These works were supported, in part, by a grant from the Laurance S. Rockefeller Trust, a CTNS-STARS Research Award, and funds from the Samueli Institute.Pain and Advances in Managing Pain Essay

Pain and Opioids: How Did We Get Here?
Pain is one of the oldest medical problems, with a long history in medicine, religion, and social science. Recent history demonstrates that we still do not have a full understanding of chronic pain, leading us to ineffective and counterproductive pain management strategies.2 Opioid use for pain dates back to the 1800s. The use of opioids increased due to the need to treat devastating injuries sustained in warfare; opioid use was also affected by advancements in pain physiology, the discovery of endogenous endorphins and opioid receptors, and the development of synthetic opioids.3-5 Opioid pain relievers can effectively reduce pain, as demonstrated by multiple randomized trials.6 Unfortunately, almost all of these studies have lasted less than 16 weeks, and there are few data regarding the longer term effectiveness of opioids for chronic pain.7 On the basis of limited data, the U.S. Food and Drug Administration (FDA)—using varying degrees of scrutiny—approved many of the current extended-release opioids.8 The result was a false sense of security in the physician community about the efficacy and safety of these medications to address the growing issue of chronic pain.Pain and Advances in Managing Pain Essay

Chronic pain is common, with approximately 11% of the U.S. population reporting daily pain.9 In addition, pain is often more severe and more frequently undertreated in vulnerable subpopulations, including the elderly, racial/ethnic minorities, women, and socioeconomically challenged groups.1, 10 Efforts to address the significant morbidity of chronic pain led to an increased emphasis on the recognition and treatment of chronic pain. These efforts—which were highlighted by actions of the U.S. Congress, the National Academy of Medicine (NAM), and multiple professional organizations—focused on improving care, increasing research into pain and its management, and improving training of physicians who manage pain.Pain and Advances in Managing Pain Essay

Current Issues with Opioid Misuse and Abuse
Regular opioid use, including use in an appropriate therapeutic context, is associated with both tolerance and dependence. The presence of tolerance or dependence does not necessarily mean that an individual has an opioid use disorder. Tolerance is present when an individual needs to use more of a substance in order to achieve the same desired therapeutic effect. Dependence is characterized by specific signs or symptoms when a drug is stopped. “Opioid misuse” is a broad term that covers any situation in which opioid use is outside of prescribed parameters; this can range from a simple misunderstanding of instructions, to self-medication for other symptoms, to compulsive use driven by an opioid use disorder.13 “Abuse” is also a nonspecific term that refers to use of a drug without a prescription, for a reason other than that prescribed, or to elicit certain sensory responses.Pain and Advances in Managing Pain Essay

While cause and effect is unclear, the fact that rates of opioid use increased at the same time that physicians were being criticized for their undertreatment of pain is probably not a coincidence. Efforts to improve pain control led to pain becoming the “fifth vital sign,” and physicians were encouraged to address pain aggressively. In 2012, the number of opioid prescriptions written (259 million) equaled the adult population of the United States.14 Despite the increase in opioid prescribing, similar increases have not been observed with other analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or other adjunctive nonopioid therapies, nor have we seen a concomitant change in the amount of pain that Americans report.Pain and Advances in Managing Pain Essay

Increasing rates of opioid misuse and abuse have become a prominent topic in medical, public health, and mainstream media. The reality is that this growing trend is largely related to misuse of prescription medications. Prescription opioids are second only to marijuana as the first illicit substance people try, with approximately 1.9 million new initiates per year.14 Sales of prescriptions opioids quadrupled between 1999 and 2014.17 Not surprisingly, the prescribing practices of physicians have come under scrutiny. It is estimated that one out of five patients who have noncancer pain is prescribed opioids.15 Family physicians have played a role in this rising trend; primary care providers are responsible for about half of the opioid pain relievers dispensed.Pain and Advances in Managing Pain Essay

These increased prescribing practices have clearly contributed to the growing opioid epidemic. In 2014, almost 2 million Americans abused or were dependent on prescription opioids.18 In primary care settings, one in four people who receive prescription opioids chronically for noncancer pain struggles with opioid dependence.19 Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.20 Concurrently, some of the challenges associated with obtaining prescription opioids, as well as cost issues, have led to a rise in heroin use.Pain and Advances in Managing Pain Essay

Probably the most concerning consequence is the rise in intentional and unintentional opioid overdoses, which lead to substantial morbidity and mortality. While most people who abuse opioids get them for free from a friend or relative, those at highest risk of overdose (defined as individuals who use prescription opioids nonmedically for 200 or more days a year) obtain opioids using their own prescriptions (27%), get them from friends or relatives for free (26%), buy them from friends or relatives (23%), or buy them from a drug dealer (15%).23 The ultimate source remains prescribed medications. At least half of all U.S. opioid overdose deaths involve a prescription opioid.24 Based on data from 1999 to 2014, risk factors for death from prescription opioid overdose included being between ages 25 and 54, being a non-Hispanic white, and being male.24 Other risk factors include concomitant use of multiple prescribed and illicit substances (especially benzodiazepines),25, 26 nicotine use, higher prescribed dosages, inappropriate prescribing procedures, methadone use, and having a history of substance abuse.Pain and Advances in Managing Pain Essay

Opioids and the Management of Pain
There are key differences between acute and chronic pain. Acute pain is a warning symptom that has a functional role in the immune system and resolves with tissue recovery. It is mediated by intact neural pathways and it can be, when needed, controlled with opioids.28 Chronic pain arises from a complex web of heterogeneous illnesses and injuries, and affects a patient physically, psychologically, and emotionally. Frequently, it is associated with undue social and functional consequences, leading to lost productivity, reduced quality of life, and social stigma. Not surprisingly, addressing chronic pain requires a comprehensive approach, with an emphasis on safe and compassionate patient-centered care; chronic pain usually cannot be managed by prescription therapy alone.Pain and Advances in Managing Pain Essay

Recognizing this complexity, family physicians need guidance on how to best provide patient-centered, compassionate care. While guidelines and policy statements provide some assistance, the evidence available to support such recommendations and guidance is very limited. Previous guidelines have encouraged physicians to access and use specific resources, such as opioid risk assessment screeners,30 urine drug screening, standardized pain scales, and prescription drug monitoring databases.31, 32 Using these resources often adds time to already busy patient visits, so it is not surprising that many are not routinely used by physicians prescribing opioids for chronic pain.33 It is also worth noting that a report from the 2014 National Institutes of Health (NIH) Pathways to Prevention Workshop on the role of opioids in treatment of chronic pain stated that “evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain.”Pain and Advances in Managing Pain Essay

The Federation of State Medical Boards (FSMB) developed a model policy to help state medical boards ensure the practice of both appropriate pain management and safe, appropriate opioid prescribing. This policy addresses key areas for medical boards, physicians, and patients with respect to the following: understanding of pain; patient evaluation and risk stratification; development of a treatment plan and goals; informed consent and treatment agreement; initiation of an opioid trial; ongoing monitoring and adaptation of the treatment plan; periodic drug testing; consultation and referral; discontinuation of opioid therapy; medical records; and compliance with controlled substance laws and regulations.34 Many states either have a medical board policy that is reflective of the FSMB’s model policy or are currently amending their medical board policy to reflect the model policy.Pain and Advances in Managing Pain Essay

In 2016, the Centers for Disease Control and Prevention (CDC) published the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,35 which addresses many of the elements of the FSMB’s model policy. This CDC guideline was based on an evidence review that found no studies that evaluated the effectiveness of long-term (one year or greater) opioid therapy versus placebo or nonuse with regard to pain, function, and quality of life.35 Instead, the CDC based most of its recommendations on a review of contextual evidence using inconsistent inclusion and exclusion criteria for different pain management therapies. Because of these inconsistencies in methodology, and because strong recommendations were made on the basis of low-quality or insufficient evidence, the American Academy of Family Physicians (AAFP) did not endorse the guideline. However, the guideline does provide some useful information for family physicians; therefore, it was categorized as Affirmation of Value.Pain and Advances in Managing Pain Essay

While guidelines and policies are available to physicians, there is a substantial deficit in the peer-reviewed research necessary to form a reliable evidence base. In order to fill this gap, it is imperative that family physicians actively advocate for and engage in research opportunities on appropriate pain management strategies.

Role of Family Medicine in Care of Patients with Opioid Use Disorders

Screening for Opioid Abuse and Misuse Pain and Advances in Managing Pain Essay

Most guidelines recommend screening patients to determine risks of drug misuse and abuse and to mitigate those risks as much as possible. Screening is typically based on risk factors that can be identified through a thorough patient history, the use of prescription drug monitoring programs (PDMPs), and, on occasion, drug screening. Unfortunately, there are no risk assessment tools that have been validated in multiple settings and populations. Furthermore, cited risk factors, such as sociodemographic factors, psychological comorbidity, family history, and alcohol and substance use disorders,38 may lead to discriminatory practices that affect care for vulnerable populations. As a member of the American Medical Association (AMA) Task Force to Reduce Prescription Opioid Abuse, the American Academy of Family Physicians (AAFP) encourages physicians to use their state PDMP.39 These electronic databases are used to track prescribing and dispensing of controlled prescription drugs; they can be used to obtain information on suspected abuse or diversion and to help identify patients at risk so they can benefit from early intervention.Pain and Advances in Managing Pain Essay

Naloxone

Family physicians should be aware of the utility of naloxone in a harm-reduction strategy for combating opioid overdose. The use of naloxone as a reversal agent for opioid overdose is standard therapy for advanced emergency medical service (EMS) providers and in emergency departments. Increasingly over the last two decades, naloxone has been provided to lay people for use in an opioid overdose.41 While little high-quality data is available, naloxone consistently shows benefit in the studies that are available, whether used by nonmedical first responders42 or lay people.41, 43 The Centers for Disease Control and Prevention (CDC) reports more than 26,000 opioid reversals by lay people from 1996 to 2014.41 Often, these opioid reversals are part of an overdose education and naloxone distribution (OEND) program. The Substance Abuse and Mental Health Services Administration (SAMSHA)44 and the AMA Task Force to Reduce Prescription Opioid Abuse45 are encouraging physicians to identify patients at higher risk of overdose (e.g., use of higher opioid doses, concomitant benzodiazepine use, respiratory disease) and to provide them with naloxone. Most, but not all, states provide for increased layperson access to naloxone, and many have Good Samaritan provisions for prescribers and lay people.Pain and Advances in Managing Pain Essay

Medication-Assisted Treatment

Medication-assisted treatment (MAT) of opioid and heroin dependence has existed for more than five decades46 and involves some form of opioid substitution treatment. Originally, only methadone (an opioid agonist) was available, but now clinicians have buprenorphine (a partial agonist used alone or in combination with naloxone) and naltrexone (an opioid antagonist with both oral and extended-release injectable formulations) as pharmacologic options for MAT. In addition, adjunctive medications such as clonidine, nonsteroidal anti-inflammatory medications (NSAIDs), and others are used in the treatment of specific opioid withdrawal symptoms.47 Prior to the Drug Addiction Treatment Act of 2000 (DATA 2000), medications for the treatment of substance abuse were available only via federally approved opioid treatment programs (OTPs). In these programs, personnel specifically trained in addiction medicine dispense certain Schedule II medications (methadone and levo-alpha-acetylmethadol [LAAM]) on a daily basis. With passage of DATA 2000, qualified physicians can now get a waiver to prescribe or dispense approved Schedule III, IV, or V medications for the treatment of opioid dependence outside of an OTP.Pain and Advances in Managing Pain Essay

With the increase in opioid misuse and the passage and implementation of DATA 2000, various federal and state authorities and professional organizations have produced guidelines to help providers treat opioid use disorders.47, 49-51 Since 2001, SAMHSA has provided the Federal Guidelines for Opioid Treatment Programs(store.samhsa.gov), which outlines specific recommendations for the administrative and organizational structure and function of an OTP.51 SAMHSA also published Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction(www.ncbi.nlm.nih.gov), which outlines the elements of office-based opioid treatment (OBOT) utilizing buprenorphine.49 The American Society of Addiction Medicine (ASAM) guideline(www.ncbi.nlm.nih.gov) for treatment of opioid use disorders describes a comprehensive strategy for management that encompasses elements of OTPs and OBOT.47 Similar to the SAMHSA guidelines, it details the initial assessment and evaluation of the patient who has opioid use disorder, offers recommendations for managing opioid withdrawal, and describes and contrasts all of the available pharmacologic options for treatment of opioid use disorder. It concludes with a discussion of psychosocial therapy to be used in conjunction with pharmacologic treatments, and provides guidance in the management of various special populations (e.g., pregnant women and adolescents).Pain and Advances in Managing Pain Essay