Self-Assessment Quiz Question #1 Which of the following is NOT part of the SOCRATES acronym that can be used to gather more information to characterize a patient’s pain? a. Site: Where exactly is the pain? b. Character: What is the pain like? c. Relatives: Who else in your family has this pain? d. Exacerbating and relieving factors: Does anything make it better or worse?
NON-PHARMACOLOGIC PAIN TREATMENT
When evaluating the options available to a particular patient for the treatment of pain, providers should maximize nonphar- macologic therapies before considering the use of medications. Nonpharmacologic therapies can be grouped into several cate- gories: exercise therapy, psychoeducational interventions, mind- body therapies, and physical interventions such as chiropractic manipulation, acupuncture, and massage. Combining therapies may be more effective for maintaining long-term relief than any single treatment. The choice of therapy is based on a number of patient-specific factors, such as the type of pain, preference, cost, access, and patient values (Tauben & Stacey, 2020). Maximizing the use of nonpharmacologic treatment options, and combining their use when appropriate, can improve pain control and reduce the reliance on opioids (Dowell et al., 2016). Useful in both acute and chronic pain conditions, physical ther- apy helps patients work towards the goal of improved physical function. It involves working with a physical therapist to develop patient-specific exercises that allow patients to feel safe while be - ing physically active, encouraging patients to increase daily activ- ity levels. Physical therapy can also address deconditioning and fear-avoidance seen in chronic pain patients. It has been shown to demonstrate moderate effects on disability and pain, while im- proving quality of life, anxiety, and depression (Tauben & Stacey, 2020). Therapeutic exercise is low impact exercise programs, such as aquatic exercise, yoga, or tai chi. Studies show that exercise thera- py for chronic pain can reduce pain and improve function with few adverse effects. The American College of Physicians recommend structured exercise, yoga, and tai chi among their other first-line therapies for chronic pain (Tauben & Stacey, 2020). Psychological therapies are recommended for patients who have pain that impacts their mood, quality of life, sleep, or relationships with others. The most commonly recommended and best stud- ied psychological therapy for chronic pain is cognitive-behavioral therapy. It addresses the way that a patient’s thoughts interact with their actions, targeting maladaptive behavioral and cogni- tive responses to pain. Patients are taught to increase awareness of thoughts in order to reduce the severity of painful symptoms
using a range of strategies to modify their interactions with their environment (Tauben & Stacey, 2020). Mind-body therapies describe a broad range of treatments that address a patient’s thoughts, emotions, movement, behaviors, and body awareness. It includes mindfulness-based stress reduc- tion, deep breathing, relaxation, and meditation. Evidence sup- porting mind-body therapies is of poor quality, often due to the difficulty in studying these therapies, but suggests some benefit. A 2020 meta-analysis found the use of mind- body therapies lead to moderate improvements in pain and small reductions in opioid dose in both acute and chronic pain patients treated with opioids (Tauben & Stacey, 2020). Acupuncture, originating from traditional Chinese medicine, is one of the oldest healing practices in the world. Acupuncture stimulates specific points in the body, usually by inserting thin needles through the skin. According to the traditional Chinese medicine theory, this regulates the flow of vital energy (called qi) along pathways called meridians. In spite of the objective proof of efficacy, some success has been observed in cases where acupuncture is used alone or in combination with conventional treatment approaches. It is recommended by the American Col- lege of Physicians to include acupuncture among the first line non-pharmacological treatments for chronic low back pain. It may be appropriate to consider acupuncture in some cases of pain management (National Institutes of Health-National Center for Complementary and Alternative Medicine, 2016). Chiropractic manipulation is a form of manual therapy that in- volves correcting the alignment of a joint. A meta-analysis of over 6000 patients across 26 trials found that spinal manipulation in patients with chronic low back pain resulted in small short term re- ductions in pain, as well as improved functional status when com- pared with a variety of other interventions including medications and physical therapy. Massage can also be used in the treatment of pain, and while there is limited evidence to support its use, the harms from massage appear to be minimal, and some patients report symptomatic relief, making it a reasonable adjunctive treat- ment (Chou, 2021).
PHARMACOLOGIC TREATMENT OF PAIN
Just like the causes of pain, available treatments are also diverse. Pharmacologic treatment options run the gamut from over-the- counter pain relievers to controlled substances, with many alter- natives in between. Because of the many different pathologies, it is critical that if one approach fails, another is tried. When it comes to pain management, no single treatment is guaranteed to work as intended. Further, relief may be found using a combi- Acetaminophen Acetaminophen is a common choice for treating fevers as well as easing pain. Its mechanism of action in analgesia is unclear, but it is thought to reduce the synthesis of prostaglandins in the central nervous system. Acetaminophen does not exhibit anti-in- flammatory effects in the peripheral nervous system and is typ - ically reserved for pain without inflammation. Even though it is commonly used, there is only limited evidence of its efficacy in treating chronic pain. However, it is known to provide analgesic effects for some patients, and it is reasonable to consider using
nation treatment approach (National Institutes of Health-National Institute of Neurological Disorders and Stroke, 2017). Once non- pharmacologic therapies have been maximized, pharmacologic treatment can be considered. Milder pain episodes can often be treated using over-the-counter medications including acetamino- phen and non-steroidal anti-inflammatory agents (NSAIDs) (Free - born, 2021). acetaminophen as an adjunct for mild to moderate musculoskele- tal pain (Gerriets et al, 2021; Tauben & Stacey, 2021b). Typical doses of acetaminophen are 325-650mg every 4 to 6 hours, or 1000mg up to three times daily (Solomon, 2021a). Acet- aminophen is associated with hepatotoxicity when taken in high doses, particularly in cases of acute or chronic overdose; there- fore, the maximum daily dose should be limited. There is some debate over the maximum daily dose of acetaminophen. The Food and Drug Administration recommends a maximum dose of
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