Emergency physicians must avoid labeling patients with pain as either drug seekers or legitimate patients deserving narcotics for pain relief. With these labels, emergency physicians may exacerbate the problem and promote the learned pain response, where patients believe that they must come to the ED for pain relief. Chronic pain patients often request narcotics, although the lure of going to the ED can be just as strong without receiving narcotics. Any drug that alters sensorium can exacerbate the learned pain response. The external rewards of visiting the ED for medication or evaluation are many: attention and comforting from family and nursing staff, status as a special patient who must go the ED for pain control, avoiding responsibilities at work and at home, potential money if litigation is involved, and potential income if a disability claim is pending.
Treatment with opiates frequently contributes to the psychopathologic aspects of the disease. Chronic pain and disability lead to distress and increased stress in the life of the patient. The potentiated psychological stress heightens physiologic arousal, which increases pain sensations. Elevated pain sensations exacerbate the patient's disability. Opiate use only temporarily relieves the pain sensations, but the side effects frequently increase the disability associated with chronic pain, therefore exacerbating the psychological stress and the syndrome. Furthermore, a new problem is created as the patient becomes preoccupied with seeking pain relief from opiates. Another essential consideration is that many types of chronic pain are poorly controlled by opiates, and yet the side effects remain. It is interesting to note that the presence of objective evidence of pain does little to influence a physician's administration of narcotics. Physicians' opiate-prescribing habits are most commonly prompted by observed pain behaviors, such as facial grimacing, audible expressions of distress, or patients' avoidance of activity regardless of the physical findings.15
With the exception of cancer-related pain, the use of opioids in the treatment of chronic pain is controversial. Many pain specialists feel that they should not be used. There are two essential points that affect the use of opioids in the ED on which there is agreement: (1) opioids should only be used in chronic pain if they enhance function at home and at work, and (2) a single practitioner should be the sole prescriber of narcotics or should be aware of their administration by others. Finally, a previous narcotic addiction is a relative contraindication to the use of opioids in chronic pain. In contrast to the concerns listed above, narcotics are both recommended and effective treatment for cancer pain. Long-acting narcotics such as methadone or transdermal fentanyl may be more effective than the short-acting agents.
The management of chronic pain conditions is listed in Table..34-3. The medications listed under "Primary ED Treatment" are familiar to emergency physicians. While NSAIDs are most helpful in conditions where there is ongoing tissue injury, such as chronic inflammatory arthritis or cancer-related nerve or bone damage, they are also helpful in many cases of chronic pain where no evidence of tissue damage or inflammation is evident. Nonsteroidal anti-inflammatory drugs have been shown to be more helpful in acute than in chronic pain.16 However, the need for long-standing treatment of chronic pain conditions may limit the safety of the NSAIDs. Standard dosing procedures may be followed except in the elderly (see following section).
Antidepressants and, most commonly, the tricyclic antidepressant drugs, are the most frequently used drugs for the management of chronic pain. Often, effective pain control can be achieved at doses lower than typically required for relief of depression. 3 Tricyclic antidepressants appear to enhance endogenous pain inhibitory mechanisms.17 When antidepressants are prescribed in the ED, a follow-up plan should be in place. Discussion with a pain specialist is often beneficial. The most common drug and dose is amitriptyline 10 to 25 mg, 2 h prior to bedtime.
Anticonvulsants are used for several pain disorders, especially neuropathic pain. Anticonvulsants prevent bursts of action potentials, which may prevent the severe lancinating pain of certain neuropathic syndromes. Carbamazepine (start 100 to 200 mg bid), valproic acid (start 15 mg/kg/d divided bid), and clonazepam (start 0.5 mg tid) are the most frequently used.
Muscle relaxants, such as cyclobenzaprine 10 mg every 8 h, have been useful for chronic pain patients. Their sedating effects may limit their success.
Tramadol is an atypical centrally active analgesic. It has less respiratory depression, less tolerance, and less abuse potential than do opiates. Tramadol has been used with success in patients with fibromyalgia, migraine headaches, low back pain, and neuropathic pain. The dose of tramadol is 50 to 100 mg every 4 to 6 h by mouth.
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