Pharmacologic Management of Acute and Chronic Pain: Focus on Drug Interactions and Patient-Specific Pharmacotherapeutic Selection

Robert L. Barkin, MBA, PharmD, Diana Barkin, Departments of Anesthesiology, Family Medicine, Pharmacology, and Psychiatry, Rush Medical College and The Rush Pain Center at Rush Presbyterian St. Luke's Medical Center, Chicago, Ill; and The Pain Center of Rush North Shore, Skokie, Ill

South Med J. 2001;94(8) 

In This Article

Introduction

Pain is among the most common reasons patients seek medical care. Acute and chronic pain is debilitating. Recovery is slow, interference with daily activities occurs, and pain manifests as a decremental change in the patient's quality of life. This is compounded by societal costs.[1,2,3,4,5]

Acute pain is often associated with an identifiable injury or trauma as a known antecedent, responds to therapeutic options, and resolves in less than 1 to 3 months. Chronic pain is more of a treatment challenge because the pathogenesis may be unclear, with less opportunity to predict the course of recovery. For patients already under great psychologic and financial stress, such an ambiguous prognosis is devastating. The goal of the clinician is to provide an opportunity for patients to regain some sense of control over their lives by providing the most effective pain treatment regimen possible.[1,2,3,4,5]

Pain usually defined as chronic lasts longer than 1 to 3 months or exceeds the typical recovery time for an initial injury. Chronic pain may be continuous or episodic or a combination of both. Overall, chronic pain is commonly accompanied by emotional stress, increased irritability, depression, social withdrawal, financial distress, loss of libido, disturbed sleep patterns, diminished appetite, and/or weight loss. Chronic pain can have a wide-ranging impact; its management must therefore focus on multiple aspects of a patient's life. A multidisciplinary, comprehensive treatment plan is optimal, including (1) individual psychosocial counseling in conjunction with patient/family education; (2) noninvasive or minimally invasive procedures, such as massage therapy, physical therapy, transdermal or transcutaneous electrical nerve stimulation (TENS), or acupuncture; (3) up-to-date pharmacologic and/or anesthetic therapies; and (4) if necessary, surgical intervention and physical medicine with rehabilitation focused to enhance the patient's functional status. Health care practitioners must consider uniting these various options in tailoring a patient-specific treatment plan, addressing both physiologic and psychologic symptoms.[1,2,3,4,5,6,7,8]

A pharmacotherapeutic plan begins with a thorough pain and pain medication history to identify the nature of the patient's pain (eg, acute versus chronic, acute and chronic, nociceptive versus neuropathic). The patient interview should focus on patient-reported pain descriptors (eg, exacerbation/modulation of pain; pain quality and intensity; pain sites as local, disseminated, or regional; characteristics and temporal relationships of pain), current pharmacotherapies (prescription, over-the-counter, phytopharmaceutical, and/or social/recreational agents), and past treatments (including successes and/or failures, adverse effects, and allergic reactions). A complete blood chemistry profile should be considered to determine if dosage changes are warranted. Health care practitioners should familiarize themselves with the pharmacodynamics, pharmacokinetics, and potential drug-drug or drug-food interactions and contraindications of any pharmacotherapy used by the patient.[1,2,3,7,9]

Decisions about a polypharmaceutical or other complex regimen may be made jointly. Depending on the nature of the specific pain in a given patient, combinations of antidepressants, anxiolytics, anticonvulsants, sedative/hypnotics, centrally acting agents, opiates/opioids, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), or other analgesics may be considered. Health care practitioners should also consider any factors that affect the likelihood of compliance (eg, patient age, frequency and/or complexity of the regimen, route of administration, tolerance of the regimen).[1,2,3,9]

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