Dealing with pain Continued

Procedures

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.
An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively.

The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.

Physical approach

Physiatry

Physical medicine and rehabilitation (physiatry) employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.

TENS

Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy.

Acupuncture

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. In 2003, the World Health Organization published an article synthesizing the scientific research (controlled trials) of the time, and concluded acupuncture is helpful for the treatment of pain in some cases of acute pain in the epigastric area, facial pain, headache, knee pain, low back pain, neck pain, pain in dentistry, postoperative pain, renal colic, and sciatica. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed.

This review has been criticized for giving too much weight to low-quality clinical trials, and including a large number of trials originating in China. The latter issue is considered problematic because trials originating in the West include a mixture of positive, negative and neutral results while all trials in China are positive (attributed to publication bias rather than fraud).
An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there was little difference in the effect of real, sham and no acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is appropriate.

LLLT

A 2007 review concluded low level laser therapy may be effective in reducing inflammation and pain, while a 2008 Cochrane collaboration review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.

Psychological approach

Cognitive and behavioral therapy
Mindfulness-based cognitive therapy, the use of stress reduction and relaxation, has been found to reduce chronic pain in some patients. Applied behavior analysis views chronic pain as a consequence of both respondent and operant conditioning, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976. The behavioral model has shown effectiveness in reducing pain responses though operant based interventions. Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.

Biofeedback

Biofeedback based on behavioral principles has shown some success for chronic pain,demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.

Hypnosis

A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283)

Under-treatment

Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care. This neglect is extended to all ages, from neonates to the frail elderly. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.

Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.

In the United States, Hispanic and African Americans are more likely to suffer needlessly in the hands of a physician than whites; and women's pain is more likely to be undertreated than men's.

It is often recognized that a great number of patients suffering from chronic pain are being under-treated because physicians fail to provide comprehensive pain treatment. This failure may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz), despite the relative rarity of prosecutions (147 cases across USA in 2006), or physicians' poor understanding of the health risks attached to opioid prescription.

As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse, the North American medical and health care communities appear to be undergoing a shift in perspective.

The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.

Strategies currently applied for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.