Initially, when a patient presents with complaints of acute or chronic pain, the ideal goal of the physician is to provide a diagnosis, and identify the cause of the pain. This is often difficult; pain may be a symptom of virtually any condition or injury, and is not always physically identifiable with radiology and scanning technology. However, there are plenty of conditions or injuries with which sources of pain may be identified; such as spinal mutations, rheumatic and connective tissue conditions (arthritis), fractures, herniations, and inflammation etc. In many of these cases, a curative treatment may be possible, including surgical procedures, permanent nerve blocks, short term drug regimens (antibiotics, corticosteroids, NSAIDS, analgesics) and physical techniques such as osteopathic manipulative treatment, excersize and occupational therapy.
During the interventional treatment phase of a painful condition, a good physician will manage the suffering, i.e. painful symptoms, caused by the condition - This is approached pharmacologically, with any one of a variety of medications including NSAIDs, acetaminophen, tricyclic antidepressants, anticonvulsants, local anaesthetics and opioid analgesics. Opioids offer superior relief from the emotional and physical manifestations of pain through both their antinociceptive properties, and their ability to alter the brain's interpretation of pain. Managing the suffering caused by injury or illness promotes a higher spirit, better function, and faster healing.
It is unfortunate that pain, depending on the pathology, may or may not resolve whether or not the original cause has been treated.
Additionally, many conditions such as spinal stenosis, severe arthritis, types of neuralgia or neuropathies, are recurring, life long conditions which can not be 'cured' with interventional approaches.
In a perfect world, the physiological and emotional elements of pain could perhaps be 'managed' with strength and will power alone. "Pain builds character" according to some, of traditional values. Unfortunately our world is far from perfect, and even more unfortunately, living and simply coping with pain alone, only works to a limited degree, a very limited degree. There comes a point where rather than building character, the suffering experienced due to pain will systematically diminish one's character, leading to long term depression, physical disability, and worse, neurological 'hypersensitivity' (central sensitization), caused by an over-excitation of nerve signals which communicate pain, the process of nociception. Long term excess nociceptive activity can cause severe depression, an inhibition of dopaminergic activity within the nucleus accumbens leading to anhedonia, and severe hyperalgesia.
When interventional approaches such as surgery and other aggressive treatments have failed to resolve the pain, and when a chronic condition which is not 'cureable' is the source of continuous suffering, management of the distressing effects of the pain, and relate symptoms, is often the only approach left from a medical standpoint, and in many cases, may be only way to provide such a patient with a decent quality of life. Everyone has the right to freedom from pain; whether mild, moderate, or severe, the psychological & emotional effects of chronic, untreated pain are extremely serious. When pain has made such an impact on a subjects life that sleep, emotions, and basic functions have been effected, then often the concept of a long-term dependence to opioids is a preferable alternative, and at worst, a necessarry evil.
Once it has been established that the pain is not 'curable' and must simply be managed; and that medical treatment should emphasize a supportive or palliative approach, focusing on treating the physical and emotional devastation induced by chronic refractory pain...
Clinical management of pain takes on a multidisciplinary approach, applying a wide range of possible specialists, depending on the goals of the patient and the medical team.
The American Board of Medical Specialties now includes a number of specialist fields with an optional subspecialty in 'pain medicine', which is acquired through a comprehensive fellowship training. Boards with a pain medicine subspecialty include: Anaesthesiology, Palliative Care & Hospice, Physical Medicine & Rehabilitation (i.e. Physiatry), Neurology, and Psychiatry, both of which are certified by the same specialty board.
There also exists a newer group known as the American Board of Pain Medicine. The legitimacy of this particular board is ambiguous, as it is currently not endorsed by the American Board of Medical Specialties, the primary board which oversees the specialty boards. The emergence of this board of Pain Medicine comes with a growing notion within the medical field in which pain, classically known as a symptom, may in itself be considered a disease in its own right. This philosophy is controversial, however, there are currently known illnesses marked by hyperactivity of the nervous system, in which this philosophy may hold ground. Fibromyalgia is one such condition, marked by chronic widespread pain believed to be of neuropathic origin, yet with no identifiable pathology. The pain of these conditions may be of somatic, or psychosomatic origin, yet there is little doubt that such pain is genuine, whether psychosomatic, somatic, pathologically visible or non.
A pain management plan may include physical, behavioral & cognitive therapy, often provided through Psychiatrists, therapists, or Physiatrists. Addressing chronic pain from a behavioral and psychological component may be of benefit to the overall function, self image, and attitude of the patient. A neurologist or psychiatrist may address elements of depression, psychological manifestations of the pain, or the pain itself, through a pharmacological approach, while an anaesthesiologist or palliative care specialist may provide a more aggressive approach of the pain through the pharmacological approach. Any medical specialist with a fellowship training and subspecialty of pain medicine, may provide supporitve treatment for those suffering chronic pain.
A primary care physician or family doctor may play a role in a pain care plan, often the centerpiece of treatment, by maintaining a patients overall health. Family physicians are also qualified to provide pharmacological support for pain, including a regular regimen of opioids, etc. Many family or primary care physicians are comfortable and willing to provide this type of care, as the pharmacological properties of opioids are quite straightforward, and widely understood, from centuries of use as one of the world's most fundemental tools in medicine. With complex issues however, and with advancing states of pain and tolerance requiring large doses of schedule II opioids, many family physicians will prefer to consult with specialists, often handing over the analgesic component of care to a comprehensively trained pain specialist.
The ideal approach will include all of the elements previously mentioned, A balance of psychiatric, behavioral, pharmacological, dietary & lifestyle measures aimed at providing the best possible quality of life for those suffering intractable chronic pain.
Chronic pain is often continuous, lasting around the clock, or may appear intermittently at an unexpected time. Pain may be mild, moderate, moderately severe, or severe. Pain may come on rapidly, or gradually, and may be experienced as dull, sharp, throbbing, deep, aching, tingling, burning, stabbing, itching, or electric-like; these words are often used to describe the quality of the pain, and serve as a valuable diagnostic tool in determining the origin and nature of the pain, such as neuropathic, musculoskeletal, rheumatic, vascular, visceral, etc, thus allowing a specific targeted pharmacological approach.
An opioid is selected based on several elements of the pain, such as frequency, intensity, severity, onset rate, duration, anatomical area, and physical/biological characteristics of the patient. Opiates, opiate derivatives, and opioid drugs, all work in a similar manner and target the brain and spinal cord. They relieve pain by acting on opioid receptor sites, which when activated by an opioid, decrease the flow of pain signals to the brain, and blunting the the brain's emotional/physiological response to the pain, thereby altering the way in which the pain is interpreted. Opioids induce a slight sense of well being and increased mood, by promoting the release of dopamine within the nucleus accumbens, the brain's 'pleasure centers'. This contributes the drug's ability to alter pain perception.