Psychological evaluations Recommended. Psychological evaluations are generally accepted, well-established diagnostic procedures not only with selected use in pain problems, but also with more widespread use in subacute and chronic pain populations. Diagnostic evaluations should distinguish between conditions that are preexisting, aggravated by the current injury or work related. Psychosocial evaluations should determine if further psychosocial interventions are indicated. The interpretations of the evaluation should provide clinicians with a better understanding of the patient in their social environment, thus allowing for more effective rehabilitation. (Main-BMJ, 2002) (Colorado, 2002) (Gatchel, 1995) (Gatchel, 1999) (Gatchel, 2004) (Gatchel, 2005) For the evaluation and prediction of patients who have a high likelihood of developing chronic pain, a study of patients who were administered a standard battery psychological assessment test found that there is a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (Gatchel, 1999) Childhood abuse and other past traumatic events were also found to be predictors of chronic pain patients. (Goldberg, 1999) Another trial found that it appears to be feasible to identify patients with high levels of risk of chronic pain and to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem. (Linton, 2002) Other studies and reviews support these theories. (Perez, 2001) (Pulliam, 2001) (Severeijns, 2001) (Sommer, 1998) In a large RCT the benefits of improved depression care (antidepressant medications and/or psychotherapy) extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status. (Lin-JAMA, 2003) See "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients" from the Colorado Division of Workers’ Compensation, which describes and evaluates the following 26 tests: (1) BHI -Battery for Health Improvement, (2) MBHI - Millon Behavioral Health Inventory, (3) MBMD - Millon Behavioral Medical Diagnostic, (4) PAB - Pain Assessment Battery, (5) MCMI-111 - Millon Clinical Multiaxial Inventory, (6) MMPI-2 - Minnesota Inventory, (7) PAI - Personality Assessment Inventory, (8) BBHI 2 - Brief Battery for Health Improvement, (9) MPI - Multidimensional Pain Inventory, (10) P-3 - Pain Patient Profile, (11) Pain Presentation Inventory, (12) PRIME-MD - Primary Care Evaluation for Mental Disorders, (13) PHQ - Patient Health Questionnaire, (14) SF 36, (15) SIP - Sickness Impact Profile, (16) BSI - Brief Symptom Inventory, (17) BSI 18 - Brief Symptom Inventory, (18) SCL-90 - Symptom Checklist, (19) BDI–II - Beck Depression Inventory, (20) CES-D - Center for Epidemiological Studies Depression Scale, (21) PDS - Post Traumatic Stress Diagnostic Scale, (22) Zung Depression Inventory, (23) MPQ - McGill Pain Questionnaire, (24) MPQ-SF - McGill Pain Questionnaire Short Form, (25) Oswestry Disability Questionnaire, (26) Visual Analogue Pain Scale – VAS. (Bruns, 2001) See also Comorbid psychiatric disorders.
Psychological evaluations, IDDS & SCS (intrathecal drug delivery systems & spinal cord stimulators) Recommended pre-intrathecal drug delivery systems (IDDS) and spinal cord stimulator (SCS) trial.
Psychological treatment Recommended for appropriately identified patients during treatment for chronic pain. Psychological intervention for chronic pain includes setting goals, determining appropriateness of treatment, conceptualizing a patient’s pain beliefs and coping styles, assessing psychological and cognitive function, and addressing co-morbid mood disorders (such as depression, anxiety, panic disorder, and posttraumatic stress disorder). Cognitive behavioral therapy and self-regulatory treatments have been found to be particularly effective. Psychological treatment incorporated into pain treatment has been found to have a positive short-term effect on pain interference and long-term effect on return to work. The following “stepped-care” approach to pain management that involves psychological intervention has been suggested:
Step 1: Identify and address specific concerns about pain and enhance interventions that emphasize self-management. The role of the psychologist at this point includes education and training of pain care providers in how to screen for patients that may need early psychological intervention.
Step 2: Identify patients who continue to experience pain and disability after the usual time of recovery. At this point a consultation with a psychologist allows for screening, assessment of goals, and further treatment options, including brief individual or group therapy.
Step 3: Pain is sustained in spite of continued therapy (including the above psychological care). Intensive care may be required from mental health professions allowing for a multidisciplinary treatment approach. See also Multi-disciplinary pain programs. (Otis, 2006) (Townsend, 2006) (Kerns, 2005) (Flor, 1992) (Morley, 1999) (Ostelo, 2005)
Pulsed radiofrequency treatment (PRF) Not recommended. Pulsed radiofrequency treatment (PRF) has been investigated as a potentially less harmful alternative to radiofrequency (RF) thermal neurolytic destruction (thermocoagulation) in the management of certain chronic pain syndromes such as facet joint pain and trigeminal neuralgia. Pulsed radiofrequency treatment is considered investigational/not medically necessary for the treatment of chronic pain syndromes. (BlueCross, 2005) A decrease in pain was observed in patients with herniated disc and spinal stenosis, but not in those with failed back surgery syndrome. However, this option does not appear to be an ideal modality of treatment for lumbar radicular pain because neurodestructive methods for the treatment of neuropathic pain are in principle generally considered inappropriate. (Abejón, 2007)
Pumps, implantable See Implantable drug-delivery systems (IDDSs).
Pycnogenol (maritime pine bark) [DWC] Pycnogenol (maritime pine bark) is not recommended for chronic pain.
Rapid detox Not recommended. Gradual weaning is recommended for long-term opioid users because opioids cannot be abruptly discontinued without probable risk of withdrawal symptoms. The data supporting the safety and effectiveness of opioid antagonist agent detoxification under sedation or general anesthesia is limited, and adequate safety has not been established. Given that the adverse events are potentially life threatening, the value of antagonist-induced withdrawal under heavy sedation or anesthesia is not supported. The high cost of anesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued. (McCabe, 2000) (Gowing-Cochrane, 2006) The American Society of Addiction Medicine (ASAM) issued a revised public policy statement (2005) regarding rapid and ultra-rapid opioid detoxification. The policy recommendations state that opioid detoxification should be part of an integrated continuum of services that promotes ongoing recovery from addiction. Additional policy recommendations state that ultra-rapid detoxification is a procedure with uncertain risks and benefits, and its use in the clinical setting is not supported. (ASAM, 2005) This treatment is not generally covered in the group health arena. (Aetna, 2006) (Blue Cross/Blue Shield, 2006) (CIGNA, 2006)
Return to work Recommended. Expedited return-to-work has been shown to be more useful in improving function and decreasing pain than extended disability. (Bernacki, 2000) (Boseman, 2001) (Colorado, 2002) (Melhorn, 2000) Lost productive time from common pain conditions among active workers costs an estimated 61.2 billion dollars per year. The majority (76.6%) of the lost productive time was explained by reduced performance while at work and not work absence. (Stewart, 2003) Chronic pain is independently related to low self-rated health in the general population. (Mantyselka-JAMA, 2003) Significant pain improvement is seen in groups that are prescribed light activity over groups that receive only medical treatment, especially in cases involving back pain. Extended bed rest is not recommended. (van Lankveld, 2000)
RS-4i sequential stimulator [DWC] See Transcutaneous Electrotherapy [DWC]
Salicylate topicals [DWC] Recommended. Topical salicylate (e.g., Ben-Gay, methyl salicylate) is significantly better than placebo in acute and chronic pain. (Mason-BMJ, 2004) See also Topical analgesics and Topical Analgesics – Compounded [DWC]
Sclerotherapy (prolotherapy) Not recommended. Sclerotherapy/prolotherapy has no proven value via well-controlled, double blind studies and may have harmful effects. (Chronic Pain, 1998)
SNRIs (serotonin noradrenaline reuptake inhibitors) See Antidepressants for neuropathic pain. See also venlafaxine (Effexor) and duloxetine (Cymbalta).
Spinal cord stimulators (SCS) Recommended only for selected patients in cases when less invasive procedures have failed or are contraindicated, for specific conditions indicated below, and following a successful temporary trial. Although there is limited evidence in favor of Spinal Cord Stimulators (SCS) for Failed Back Surgery Syndrome (FBSS) and Complex Regional Pain Syndrome (CRPS) Type I, more trials are needed to confirm whether SCS is an effective treatment for certain types of chronic pain. (Mailis-Gagnon-Cochrane, 2004) (BlueCross BlueShield, 2004) See indications list below. See Complete list of SCS_References. This supporting evidence is significantly supplemented and enhanced when combined with the individually based observational evidence gained through an individual trial prior to implant. This individually based observational evidence should be used to demonstrate effectiveness and to determine appropriate subsequent treatment. (Sundaraj, 2005) Spinal Cord Stimulation is a treatment that has been used for more than 30 years, but only in the past five years has it met with widespread acceptance and recognition by the medical community. In the first decade after its introduction, SCS was extensively practiced and applied to a wide spectrum of pain diagnoses, probably indiscriminately. The results at follow-up were poor and the method soon fell in disrepute. In the last decade there has been growing awareness that SCS is a reasonably effective therapy for many patients suffering from neuropathic pain for which there is no alternative therapy. There are several reasons for this development, the principal one being that the indications have been more clearly identified. The enhanced design of electrodes, leads, and receivers/stimulators has substantially decreased the incidence of re-operations for device failure. Further, the introduction of the percutaneous electrode implantation has enabled trial stimulation, which is now commonly recognized as an indispensable step in assessing whether the treatment is appropriate for individual patients. (Furlan-Cochrane, 2004) These implantable devices have a very high initial cost relative to conventional medical management (CMM); however, over the lifetime of the carefully selected patient, SCS may lead to cost-saving and more health gain relative to CMM for FBSS and CRPS. (Taylor, 2005) (Taylor, 2006) SCS for treatment of chronic nonmalignant pain, including FBSS, has demonstrated a 74% long-term success rate (Kumar, 2006). SCS for treatment of FBSS reported better effectiveness compared to reoperation (North, 2005). CRPS patients implanted with SCS reported pain relief of at least 50% over a median follow-up period of 33 months. SCS appears to be an effective therapy in the management of patients with CRPS. (Kemler, 2000) Permanent pain relief in CRPS-I can be attained under long-term SCS therapy combined with physical therapy. (Harke, 2005) Neuromodulation may be successfully applied in the treatment of visceral pain, a common form of pain when internal organs are damaged or injured, if more traditional analgesic treatments have been unsuccessful. (Kapural, 2006) (Prager, 2007) A recent RCT of 100 failed back surgery syndrome patients randomized to receive spinal cord stimulation plus conventional medical management (SCS group) or conventional medical management alone (CMM group), found that 48% of SCS patients versus 9% of CMM patients achieved the primary outcome of 50% or more pain relief at 6 months. (Kumar, 2007) According to the European Federation of Neurological Societies (EFNS), spinal cord stimulation (SCS) is efficacious in failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) type I (level B recommendation). (Cruccu, 2007) See also Psychological evaluations (SCS) in the Stress & Other Mental Conditions Chapter.
Indications for stimulator implantation:
• Failed back syndrome (persistent pain in patients who have undergone at least one previous back operation), more helpful for lower extremity than low back pain, although both stand to benefit, 40-60% success rate 5 years after surgery. It works best for neuropathic pain. Neurostimulation is generally considered to be ineffective in treating nociceptive pain. The procedure should be employed with more caution in the cervical region than in the thoracic or lumbar.
• Complex Regional Pain Syndrome (CRPS)/Reflex sympathetic dystrophy (RSD), 70-90% success rate, at 14 to 41 months after surgery. (Note: This is a controversial diagnosis.)
• Post amputation pain (phantom limb pain), 68% success rate
• Post herpetic neuralgia, 90% success rate
• Spinal cord injury dysesthesias (pain in lower extremities associated with spinal cord injury)
• Pain associated with multiple sclerosis
• Peripheral vascular disease (insufficient blood flow to the lower extremity, causing pain and placing it at risk for amputation), 80% success at avoiding the need for amputation when the initial implant trial was successful. The data is also very strong for angina.
Spinal cord stimulators, psychological evaluations See Psychological evaluations, SCS (spinal cord stimulators).
SSRIs (selective serotonin reuptake inhibitors) See Antidepressants for neuropathic pain and Antidepressants for non-neuropathic pain.
Stellate ganglion block Recommended as indicated below. For diagnosis and treatment of sympathetic pain involving the face, head, neck, and upper extremities secondary to CRPS-I and II, and shingles. This block is commonly used for differential diagnosis and is the preferred treatment of CRPS-I pain involving the upper extremity. For diagnostic testing, one should be sufficient. For a positive response, pain relief should be 50% or greater for the duration of the local anesthetic and pain relief should be associated with functional improvement. One to three blocks may be given therapeutically as an adjunct to functional exercise. (Colorado, 2002) (Price, 1998)
Substance abuse (tolerance, dependence, addiction) The American Pain Society, American Academy of Pain Medicine, and American Society of Addiction Medicine have jointly defined the following (AAPM3, 2001):
1) Tolerance: “A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time.” This is characterized by the need for higher doses of the medication to achieve the same pain effect and/or a diminished pain relief effect with continued use of the medication. In terms of opioids, most patients develop their plateau dose of opioids within about 2 months. (VA/DoD, 2003) One option to consider besides increasing the dose is to switch to another opioid.
2) Physical dependence: “A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” Abrupt cessation causes physiologic withdrawal. This can be expected with the use of opioids. This is not synonymous with addiction. Tolerance and withdrawal are 2 different conditions.
3) Addiction: “A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.”
DSM-IV Criteria for substance dependence (a more serious condition than substance abuse):
1) Tolerance, 2) Withdrawal, 3) The substance is taken in amounts that are greater than intended or for a longer duration, 4) The patient is unable to cut down or quit the substance and/or desires to cut down or quit, 5) A great deal of time is spent obtaining the substance (for example, going to multiple doctors), and a great deal of time is spent in recovering from the effects of the substance, 6) Functioning is affected, including social, occupational and recreational activities, 7) The substance is causing physical or psychological problems and the patient is aware of this, but use is continued. (APA, 1994)
DSM-IV Criteria for substance abuse
1) Failure to fulfill major role obligations at work, school or home, 2) Recurrent substance abuse in situations in which it is physically hazardous, 3) Recurrent legal problems associated with substance abuse, 4) Continued use despite persistent or recurrent social or interpersonal problems related to use.
Red flags for patients that may potentially abuse opioids:
(a) History of alcohol or substance abuse, (b) Active alcohol or substance abuse, (c) Borderline personality disorder, (d) Mood disorders (depression) or psychotic disorders, (e) Non-return to work for >6 months, (f) Poor response to opioids in the past (Washington, 2002)
Red flags of addiction:
1) Adverse consequences: (a) Decreased functioning, (b) Observed intoxication, (c) Negative affective state
2) Impaired control over medication use: (a) Failure to bring in unused medications, (b) Dose escalation without approval of the prescribing doctor, (c) Requests for early prescription refills, (d) Reports of lost or stolen prescriptions, (e) Unscheduled clinic appointments in “distress”, (f) Frequent visits to the ED, (g) Family reports of overuse or intoxication
3) Craving and preoccupation: (a) Non-compliance with other treatment modalities, (b) Failure to keep appointments, (c) No interest in rehabilitation, only in symptom control, (d) No relief of pain or improved function with opioid therapy, (e) Medications are provided by multiple providers. (Wisconsin, 2004)
Sympathectomy See CRPS, symathectomy.
Sympathetic therapy [DWC] See Transcutaneous Electrotherapy [DWC]
TENS (Transcutaneous electrical nerve stimulation) [DWC] See Transcutaneous Electrotherapy [DWC]
TENS, post operative pain (transcutaneous electrical nerve stimulation) [DWC] See Transcutaneous Electrotherapy [DWC]
Testosterone replacement for hypogonadism (related to opioids) [DWC] Recommended in limited circumstances for patients taking high-dose long-term opioids with documented low testosterone levels. Hypogonadism has been noted in patients receiving intrathecal opioids and long term high dose opioids. Routine testing of testosterone levels in men taking opioids is not recommended. However, an endocrine evaluation and/or testosterone levels should be considered in men who are taking long term, high dose oral opioids or intrathecal opioids and who exhibit symptoms or signs of hypogonadism, such as gynecomastia. If needed, testosterone replacement should be done by a physician with special knowledge in this field given the potential side effects such as hepatomas. There are multiple delivery mechanisms for testosterone Hypogonadism secondary to opiates appears to be central, although the exact mechanism has not been determined.
THC (tetrahydrocannabinol) See Cannabinoids.
Tiagabine (Gabitril®) See Anti-epilepsy drugs (AEDs) for general guidelines, as well as specific Tiagabine listing.
Topical Analgesics Recommended as an option as indicated below. Largely experimental in use with few randomized controlled trials to determine efficacy or safety. Primarily recommended for neuropathic pain when trials of antidepressants and anticonvulsants have failed. (Namaka, 2004) These agents are applied locally to painful areas with advantages that include lack of systemic side effects, absence of drug interactions, and no need to titrate. (Colombo, 2006) Many agents are compounded as monotherapy or in combination for pain control (including NSAIDs, opioids, capsaicin, local anesthetics, antidepressants, glutamate receptor antagonists, α-adrenergic receptor agonist, adenosine, cannabinoids, cholinergic receptor agonists, γ agonists, prostanoids, bradykinin, adenosine triphosphate, biogenic amines, and nerve growth factor). (Argoff, 2006) There is little to no research to support the use of many these agents. The use of these compounded agents requires knowledge of the specific analgesic effect of each agent and how it will be useful for the specific therapeutic goal required.
Neuropathic pain. Lidocaine: Recommended for localized peripheral pain after there has been evidence of a trial of first-line therapy (tri-cyclic or SNRI anti-depressants or an AED such as gabapentin or Lyrica). This is not a first-line treatment and is only FDA approved for post-herpetic neuralgia. Further research is needed to recommend this treatment for chronic neuropathic pain disorders other than post-herpetic neuralgia.. Formulations that do not involve a dermal-patch system are generally indicated as local anesthetics and anti-pruritics. (Argoff, 2006) (Dworkin, 2007) (Khaliq, 2007) (Knotkova, 2007)
Capsaicin: Recommended only as an option in patients who have not responded or are intolerant to other treatments. See also Capsaicin.
Other agents: Topical ketamine has only been studied for use in non-controlled studies for CRPS I and post-herpetic neuralgia, and both studies showed encouraging results. Topical clonidine has published reports in animal studies only. Topical gabapentin has no published reports.
Non-neuropathic pain (soft tissue injury and osteoarthritis). NSAIDS: The efficacy in clinical trials for this treatment modality have been inconsistent and most studies are small and of short duration. Topical NSAIDs have been shown in meta-analysis to be superior to placebo during the first 2 weeks of treatment for osteoarthritis, but either not afterward, or with a diminishing effect over another 2-week period. (Lin, 2004) (Bjordal, 2007) (Mason, 2004) When investigated specifically for osteoarthritis of the knee, topical NSAIDs have been shown to be superior to placebo for 4 to 12 weeks. In this study the effect appeared to diminish over time and it was stated that further research was required to determine if results were similar for all preparations. (Biswal, 2006) These medications may be useful for chronic musculoskeletal pain, but there are no long-term studies of their effectiveness or safety. Ketoprofen is under study in a patch formulation for treatment of ankle strain and for tendonitis/bursitis of the elbow, shoulder and knee in phase II clinical trials in Europe.
Capsaicin: Recommended only as an option in patients who have not responded or are intolerant to other treatments. See also Capsaicin.
Lidocaine: There are no randomized controlled trials evaluating the use of topical lidocaine for treatment of low back pain or osteoarthritis, and treatment with this modality is not currently recommended.
Other agents: Topical glucosamine, chondroitin and camphor showed significant pain relief for osteoarthritis of the knee after 8 weeks compared to placebo. (Cohen, 2003) See also Glucosamine (and Chondroitin Sulfate). For non-neuropathic low back and myofascial pain there are few published studies. (Argoff, 2006)