Mount Carmel Health Partners Clinical Guidelines Chronic Pain Management | Page 2

Clinical Guideline: Chronic Non-Cancer Pain Management
Four Categories of Chronic Pain
• Neuropathic
• Musculoskeletal
• Inflammatory
• Visceral/Pelvic/Urologic
Assess for prior evaluation and treatment for pain; obtain
records with patient’s permission.
Patient Perceptions and Psychological Factors:
• Assess for maladaptive behavioral patterns that may influence
the course of treatment (anxiety or substance abuse)
• Determine the patient’s expectations for treatment and counsel
on how realistic expectations are
History
Pain assessment should be a routine part of any medical
encounter and has been referred to as the 5th vital sign.
Symptom Factors:
• Pain location
• Radiation
• Intensity
• Characteristics/quality
• Temporal aspects: duration, onset, and changes since onset
• Constancy or intermittency
• Characteristics of any breakthrough pain
• Exacerbating/triggering factors
• Palliative/relieving factors
Associated Symptoms:
• Restriction of range of motion, stiffness, or swelling
• Muscle aches, cramps, or spasms
• Color or temperature changes
• Changes in sweating
• Changes in skin, hair, or nail growth
• Changes in muscle strength
• Changes in sensation
Pain Impact:
Question the patient regarding the impact of pain on function
and quality of life.
• Social and recreational functioning
• Mood, affect, and anxiety
• Relationships
• Occupation
• Sleep
• Exercise
Activities of Daily Living:
Address whether patient is able to bathe, dress, feed, and live
independently.
Pain intensity scales are reliable to compare the intensity of one
patient’s pain at different times allowing clinicians and patients
to judge whether the pain is increasing or decreasing with
treatment.
Physical Examination
Complete a physical examination, including a detailed neurologic
assessment, regardless of the patient’s area of complaint.
Diagnostic Testing
• Blood Tests—Routine studies are not indicated unless specific
causes (infectious) are identified
• Imaging—patients with chronic pain typically have already had
imaging; review past studies. Consider imaging if not performed
in the past
• Neurophysiologic testing, nerve conduction studies, and
electromyography are used in suspected disorders of the
peripheral nervous system.
Referral to a Pain Specialist
Reasons to refer:
• Symptoms are debilitating
• Symptoms are at multiple sites
• Symptoms do not respond to initial therapies
• Escalating need for pain medication
Psychiatric Comorbidity
• Depression and anxiety are common in patie nts with chronic
pain and complicate the patient’s condition
Classifications of Pain
• Pain location—low back pain
• Pain duration— acute, chronic
• Pain origin—nociceptive, neuropathic
• Diagnosis—cancer
• Body system—rheumatic
• Pain severity—mild, moderate, severe
• Pain mechanism—peripheral sensitization
• Treatment responsiveness—opioid-responsive pain
Box 1: First, Second, and Third Line Drug Therapies
First Line
OTC pain medications;
NSAIDs or acetaminophen if no
contraindications
Second Line
antidepressants: tricyclic antidepressants, e.g., nortriptyline or
desipramine, SSRI; antiepileptics: gabapentin (Neurontin),
lamotrigine (Lamictal) 5% lidocaine patch; consider using ad-
junctive therapy: capsaicin cream (Zostrix), mexiletine (Mexitil)
Chronic Non-Cancer Pain Management - 2
Third Line
tramadol, opioid analgesics;
tens unit stimulation, nerve
block