extent, level, or impact of the pain. Examples of conditions that involve chronic nociplastic pain include fibromyalgia, arthritis, and irritable bowel syndrome. Clinical presentation is widespread pain that may include hyperalgesia (defined as extreme sensitivity to painful stimuli) or allodynia (defined as pain evoked by stimuli that do not usually painful, such as light pressure) (Tauben & Sta - cey, 2021a; IASP, 2021). Psychogenic pain : is pain that is predominately attributed to psy- chological factors, including fears, beliefs and strong emotions. It does not refer to other types of pain that are exacerbated by psy-
chological factors. Symptoms include headaches, stomach pain, back pain or muscle soreness. If all organic causes of pain are ruled out, the practitioner may establish a psychogenic pain diag- nosis. Often, medical practitioners will work together with mental health specialists to reach an appropriate diagnosis. Psychogen- ic pain treatment often involves psychotherapy, antidepressants with pain-relieving effects such as tricyclic antidepressants, and non-narcotic pain relievers such as NSAIDs (Portenoy & Dhingra, 2021).
EPIDEMIOLOGY OF PAIN
Chronic pain is among the most common reasons that adults seek medical care in the United States, and is associated with poor mental health, decreased quality of life, and opioid dependence. The 2019 National Health Interview Survey found that in the pre- vious 3 months, 20.4% of adults had chronic pain, and 7.4% of adults had chronic pain that limited their work or life activities,
known as high-impact chronic pain. The incidence of both chronic pain and high-impact chronic pain increased with age, with the highest prevalence in people over the age of 65. Incidence was also higher in rural areas, and among women as compared to men (Zelaya et al, 2020).
PATHOPHYSIOLOGY OF PAIN
Without question, pain is a mystery. As a result, the topic gener- ates intense interest and enthusiasm when considering treatment approaches. Although it is evident that pain exists, it may be dif- ficult to find its cause due to its subjective nature. Even in cases where a cause is found, there may be little or no correlation be- tween the extent of disease and the patient’s degree of suffering. A pathology that may bring excruciating pain to one person could be easily tolerated by another. In some cases, even if the cause is identified and removed, the suffering may continue (Tauben & Stacey, 2021a). Pain is the result of nociception, which is the nervous system’s process of interpreting noxious stimuli. The movement of pain
signals is a highly complicated process involving peripheral nerve activation, interactions with the spinal dorsal horn, and activating the circuits connecting the spinal cord to supraspinal structures. Ultimately, the nerve impulses excite nociceptive inputs at the lev- el of the spinal cord (Tauben & Stacey, 2021a). Although this appears to be part of a normal process of trans- mitting and interpreting pain, the system can undergo transfor- mations when pain is encountered over a period of time as an adaptive feedback loop. Therapies aimed at disrupting any parts of the loop may be effective at diminishing or even abolishing the pain (Tauben & Stacey, 2021a). ● R adiation: Does the pain radiate or move anywhere? ● A ssociations: Is there anything else associated with the pain such as sweating or vomiting? ● T ime course: Does it follow any time pattern? How long does it last? ● E xacerbating and relieving factors: Does anything make it bet- ter or worse? ● S everity: How severe is the pain? Consider using a visual an- alog scale (VAS) to characterize the level of pain experienced by the patient. This allows patients to rate their pain between 0 (no pain) and 10 (worst pain imaginable). All patients presenting with chronic pain should have a compre- hensive physical exam conducted to assess for abnormalities that may be related to the complaint of pain. Depending on the type and location of the pain, imaging studies and even diagnostic nerve blocks can be used to further define the pain. Patients pre - senting with complex or difficult to treat pain may require referral to a pain management specialist. Criteria for referral include (Tau- ben & Stacey, 2021a): ● Patients who continue to seek treatment for persistent, unex- plained pain. ● Patients with complex or high-risk pain treatment conditions, such as polypharmacy or those taking high dose opioids. ● Patients with persistent pain with significant impacts on quality of life, function, or mental health that have not responded to initial treatment by a primary care provider. ● Patients with persistent neuropathic pain who failed first-line therapies. ● Patients who require multidisciplinary care, such as rehabilita- tion, mental health treatment, and medical management. ● Patients who may be candidates for interventional treatment.
EVALUATION OF PAIN
Pain diagnosis can be complex because of its extremely personal and subjective nature. There is no available technology or test that can locate, characterize and measure pain with any degree of precision. As a result, healthcare professionals need to rely on the patient’s description of their discomfort as a major part of a thor- ough pain assessment. In most cases where pain is the chief com- plaint, it is appropriate to begin a conversation by asking about the pain, but then it is usually best to review the broader context and impact of that pain. Diligent prescribers look beyond the spe- cific complaint and holistically evaluate the broader mental, cul - tural, and socioeconomic contexts in which the chief complaint is embedded (Goodwin & Bajwa, 2016; OSCE Skills, 2018). Before a physical examination, a comprehensive physical, med- ical, and social history should be taken. A good medical history assessment is a test of the provider’s knowledge and communica- tion skills. Depending on the mental state and reliability of the pa- tient, a collateral history from a friend, relative, or caregiver may be required. It may be possible to gather this information before an in-person visit by using paper or online questionnaires. The history should include (Tauben & Stacey, 2021a): ● Past medical and surgical history, to determine the etiology of pain and comorbidities that may affect therapy. ● A review of systems, to evaluate the effects of pain. ● Social and family history, which helps elicit any issues pertain- ing to the development and treatment of pain. ● Reviewing psychiatric comorbidities, which may require co-treatment. ● Assessment of pain, including history, location, characteristics, severity and impact. The SOCRATES acronym is a useful tool to remember key points to be collected when assessing a complaint of pain (Goodwin & Bajwa, 2016): ● S ite: Where exactly is the pain? ● O nset: When did it start? Was it constant or intermittent? Was it gradual or sudden? ● C haracter: What is the pain like? Sharp? Burning? Tight?
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