Chronic Pain Management

Chronic Pain: Basics & Types - The Neverending Ouch

Pain lasting >3-6 months beyond typical healing time.

• Nociceptive: Tissue damage (e.g., osteoarthritis, visceral pain from IBS).
• Neuropathic: Nerve damage (e.g., diabetic neuropathy, post-herpetic neuralgia). Often burning/shooting.
• Nociplastic: Altered pain processing (e.g., fibromyalgia, CRPS Type I).

  ⭐ Nociplastic pain (e.g., fibromyalgia, complex regional pain syndrome type I) is characterized by altered nociception without clear evidence of actual or threatened tissue damage or lesion of the somatosensory system.

Biopsychosocial Pain: Mind Matters - Brain's Pain Game

Chronic pain is best understood via the Biopsychosocial model, integrating biological, psychological, and social factors.

• Psychological Factors: Crucial in pain perception & disability.
  • Catastrophizing (exaggerated negative orientation to pain)
  • Kinesiophobia (fear of movement leading to avoidance)
  • Fear-avoidance beliefs (pain will worsen with activity)
  • Maladaptive coping styles (e.g., passive coping)
• Psychiatric Comorbidities: Common & worsen prognosis. 📌 'SAD Pain'
  • Substance use disorders
  • Anxiety disorders (e.g., GAD, Panic)
  • Depression (Major Depressive Disorder)
  • PTSD
• Impact: Significantly ↓ quality of life, daily functioning, and social engagement.

⭐ The Fear-Avoidance Model is crucial in understanding how pain can lead to chronic disability, where fear of pain leads to avoidance of activity, deconditioning, and increased pain perception.

Pain Evaluation: C-L Approach - Sizing Up Suffering

• History: 📌 PQRST (Provocation, Quality, Region, Severity, Timing) or SOCRATES.
• Intensity Scales:
  • NRS (0-10), VAS (100mm), Faces Pain Scale.
  • 
• Qualitative: McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI).
• Psychological Screen: PHQ-9 (>10 mod. depression), GAD-7 (>10 mod. anxiety), PCL-5.
• Functional: ADLs.
• C-L Focus: Biopsychosocial formulation, coping, comorbidities.

⭐ The McGill Pain Questionnaire (MPQ) is a multidimensional tool that assesses sensory, affective, and evaluative aspects of pain, providing a more comprehensive understanding than simple intensity scales.

C-L Pain Tx: Holistics - The C-L Comfort Kit

Core: Multimodal approach. C-L psychiatrist integrates care.

• Pharmacological (Adapted WHO Ladder):

  • Non-opioids: Paracetamol, NSAIDs (monitor GI/renal risks).
  • Adjuvant Analgesics:
    • Antidepressants: TCAs (Amitriptyline: start 10-25mg hs), SNRIs (Duloxetine).
    • Anticonvulsants: Gabapentin, Pregabalin.
  • Opioids: ⚠️ Cautious use (risks: tolerance, dependence, OUD, hyperalgesia). Consider rotation/tapering.

• Non-Pharmacological:

  • Psychological: CBT, ACT, mindfulness, biofeedback.
  • Physical: Physiotherapy, TENS, graded exercise.
  • Lifestyle modifications.

⭐ Duloxetine, an SNRI, is FDA-approved for chronic musculoskeletal pain, diabetic peripheral neuropathic pain, and fibromyalgia, and also treats comorbid depression and anxiety.

High‑Yield Points - ⚡ Biggest Takeaways

• Chronic pain persists > 3-6 months, beyond typical healing.
• Biopsychosocial model is central: address biological, psychological, and social factors.
• Multimodal analgesia is key: combine pharmacological & non-pharmacological approaches.
• Key adjuvants: TCAs (amitriptyline), SNRIs (duloxetine), anticonvulsants (gabapentin, pregabalin).
• Non-pharmacological options: CBT, physiotherapy, mindfulness, TENS.
• Opioids for chronic non-cancer pain: high risk, use short-term, lowest dose, monitor.
• Address pain catastrophizing, kinesiophobia, and comorbid depression/anxiety for better outcomes.