Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5200_Библиотеки_им_академика_М_И_Перельмана
.pdf
records(EHRs).EHRsaredigitalversionsofpatient-centeredmedicalrecords,whichcanbeupdatedin
realtime(HealthIT, 2019). In2009,theAmericanRecoveryandReinvestmentAct(ARRA)authorized
CMS to offer financial incentives to providers and hospitals that exhibit meaningful use of EHR
technology(AMA,2015).Withtherecentadvancesintechnology,manyprovidershavealreadyadopted
the software necessary to maintain EHRs. However, these systems can impart challenges to smaller
practicesbecauseofthesignificantcosttoupgradetechnologyandtheoperationalchangesneededtouse
the system. Aside from the large costs associated with the purchase of EHR software, the universal
implementationofEHRrepresentsanopportunityforenhancedinteroperability, improvedcontinuityof
care,andmedicalerrorreduction.
The terms telemedicine and telehealth are sometimes used interchangeably; however, the term
telehealthreferstoabroadervarietyofdigitalhealthservicesthantelemedicine(NEJMCatalyst,2018).
Telemedicine is the delivery of remote clinical services, which may include the remote diagnosis,
treatment, and monitoring of patients through telecommunication (Center for ConnectedHealth Policy,
2019;NEJMCatalyst,2018). Thetermtelehealthreferstothe deliveryandfacilitationofhealthcare
(includingdiagnosisandmanagementofconditions),education,information,andrelatedservicesthrough
digitalcommunicationtechnologies (CenterforConnectedHealthPolicy,2019;NEJMCatalyst,2018).
ManyMCOsarebeginningtoadoptandencouragetheuseoftelehealthasithasthepotentialtoreduce
costs andwait times, improve access to care,andenhance overall health caredelivery. For example,
somehealthplansencouragememberstoutilizetelehealthservicesfortheirnon-life-threateningurgent
care needs.Byseekingcarethroughthetelehealthsystem, patients maybe ableto skipthevisittothe
urgentcareofficeortheunnecessaryandcostlyemergencydepartmentvisit,whichcanhelpsavetimeand
moneyforboththepatientandthehealthplan.Telehealthservicescanalsoimprovepatients’accesstoa
broadernetworkofspecialists.Inatraditionalhealthcaresetting,patientsaresometimesrequiredtovisit
theirprimarycareproviderinordertoreceiveareferraltoaspecialist.Withtelehealth,patientsmaybe
abletobeseenbythespecialistthroughavirtualvisit,duringwhichtheirhealthrecords,includingtest
resultsandimages,arereviewedandanevaluation,diagnosis,andtreatmentplancanbemade.
CURRENTISSUESINMANAGEDCARE
In March 2010, the U.S. Congress passed the Affordable Care Act, commonly known as either the
HealthcareReformBillorObamacare.TheobjectivefortheactwastoensureaccountabilityofMCOs,
lowerhealthcarecosts,improvequalityofcare,andprovideimprovedconsumerchoiceforhealthcare
services(U.S.DepartmentofHealth&HumanServices,2010).ComponentsoftheAffordableCareAct
include provisions requiring insurers to provide coverage for individuals with preexisting conditions,
provisions allowing individuals under the ageof26 years toremain ona parent’s insurance plan, an
eliminationoflifetimeandannualdollarlimitsforessentialhealthbenefits,andrequirementsforspecific
preventive services (e.g., colorectal cancer screeningforadultsover50, breastcancer mammography
screening for women over 40, vision screening for children) without having to pay a copayment or
coinsurance when delivered by a network provider (U.S. Department of Health & Human Services,
2019).Amandatewrittenintotheactrequiresindividualsnotcoveredbyanemployer-sponsoredhealth
planora public insurance planto obtainanapprovedprivate insurancepolicyor paya penalty. This
individual mandate provision of the act was upheld by the U.S. Supreme Court in June 2012 as a
constitutionalactionunderCongress’staxationpowers(NationalFederationofIndependentBusinesses
vs.Sebelius,2012).In2018,ataxbillthatrepealedtheAffordableCareAct’staxpenaltywassigned,
andthefederalindividualmandatepenaltywaseliminatedinmoststatesin2019;however,thepenalty
stillexistsinsomestatetaxcodessuchasMassachusetts’s(Norris,2019).WhiletheAffordableCareAct
has increased consumerchoice andimproved qualityofcare, it hasnotbeen as effective inlowering
healthcarecosts,asevidencedbythecontinuedincreasestothecostofinsurancepremiums.Theaverage
family’sannualpremiumcostswerenearly$20,600in2019,withcoveredworkerspaying29%ofthe
premium(KaiserFamilyFoundation,2019).Theactcontinuestofacelegalandlegislativechallengesin
its funding and implementation, and the regulations and provisions noted here may be modified or
eliminatedinthefuture.
Dueto the escalationinprescriptioncopaymentexpensesthatconsumersare expectedtopay,some
pharmaceutical manufacturers have begunto issue copayment cards, which are designed to reduce or
eliminate a customer’s out-of-pocket spending for prescriptions. These copay cards are available to
individualswithcommercialorprivatehealthinsurance;copaycardscannotbeutilizedforprescriptions
paidfor(inpartorinwhole)byMedicareorMedicaid.Consumersapplyforcopaycardsthroughpatient
assistance programs (PAPs) operated by manufacturers; these PAPs are often need based and place
householdincomecaps(oftensetat400% ofthefederal povertylimit)onenrollees.Ifapprovedfora
copaycard,thecardisvalidforprescriptionscoveredbythePAP,withbenefitsoftenlimitedtoasingle
medicationorlineofproductsfromthemanufacturersponsoringthePAP.Consumersredeemthesecopay
cardsattheprescriptionpointofsale;thepharmacywouldthenreceivethecopaydirectlyfromthePAP
and not the consumer. Copay cards are thought to improve patient adherence and persistence with
prescription therapy, as lower copayment levels are associated with higher rates of prescription
adherenceandimprovedhealthoutcomes(Aminetal.,2017;Gourzoulidisetal.,2017).MCOsgenerally
oppose PAPs because they undermine prescription cost-sharing requirements and benefit designs that
incentivizecost-effectiveprescribingpractices(Linehan,2019).MCOshaverespondedbyimplementing
copayaccumulatorprograms.Undera copayaccumulatorprogram,thehealthplandoes notcountPAP
paymentstowardthecustomer’sannualdeductibleorannualout-of-pocketmaximum,whichmayresultin
apatientbeingunabletocontinuetoaffordtheprescriptionifthecopaycardhasbeenexhaustedofvalue.
Despitecriticismfrompatients,prescribers,andconsumeradvocatesthatcopayaccumulatorprograms
areharmfultopublichealth,theseprogramsarebeingadoptedbyanincreasingnumberofMCOstoshift
upfrontcoststoconsumers(Silverman,2018).
Despiteitscriticsandshortcomings,managedcareislikelytoremaintheleadingmanneroffinancing
anddeliveringhealthcareintheUnitedStates.Throughmoreeffectivecommunicationandcooperation,
practitionersandMCOsmaysomedayresolve their conflictingissues.Itis imperative forpractitioners
andMCOstounderstandeachother’sroleinhealthcare.AlthoughpractitionersandMCOshavequite
differentresponsibilities inhealthcare,bothgroupsshareacommongoal:thedeliveryofhigh-quality
caretopatients.
Bibliography
*Starredreferencesarecitedinthetext.
AcademyofManagedCarePharmacy.(2019).AMCPformatforformularysubmissions,version4.1.Alexandria,VA:Author.
Agarwal,R.,Mazurenko,O.,&Menachemi,N.(2017).High-deductiblehealthplansreducehealthcare costandutilization,includinguse of
neededpreventiveservices.HealthAffairs,36(10),1762–1768.
AgencyforHealthcareResearchandQuality.(2019).Electronichealthrecords.Retrievedfromhttp://psnet.ahrq.gov/primer/electronic-health-
recordsonMarch11,2020.
American Academy of Family Physicians. (2020). What’s the difference between telemedicine and telehealth? Retrieved from
http://www.aafp.org/media-center/kits/telemedicine-and-telehealth.htmlonMarch11,2020.
American Academy of Pediatrics. (2020). What is telehealth? Retrieved from http://www.aap.org/en-us/professional-resources/practice-
transformation/telehealth/Pages/What-is-Telehealth.aspxonMarch11,2020.
*AmericanMedicalAssociation.(1994).AMApolicyondrugformulariesandtherapeuticinterchangeininpatientandambulatorypatientcare
settings.AmericanJournalofHospitalPharmacy,51,1808–1810.
*American Medical Association. (2015). Meaningful use: Electronic health record (EHR) incentive programs. Retrieved from
https://www.amaassn.org/practice-management/medicare/meaningful-use-electronic-health-record-ehr-incentive-programs on February 10,
2020.
*Amin, K., Farley, J. F., Maciejewski, M. L., et al. (2017). Effect of Medicaid policychanges on medication adherence:Differences by
baselineadherence.JournalofManagedCareandSpecialtyPharmacy,23(3),337–345.
*Association for Accessible Medicines. (2019). The case for competition: 2019 generic drug & biosimilars access & savings inthe U.S.
report. Retrieved from http://accessiblemeds.org/sites/default/files/2019-09/AAM-2019-Generic-Biosimilars-Access-and-Savings-US-
Report-WEB.pdfonFebruary9,2020.
*Bendix,J.(2013).Curingthepriorauthorizationheadache. MedicalEconomics. Retrieved fromhttp://medicaleconomics.modernmedicine.
com/medical-economics/content/tags/americas-health-insurance-plans/curing-prior-authorization-headache?page=fullonMay10,2015.
*California MedicalAssociation.(2020). CMS delays enforcementofe-prescribing requirement for controlledsubstances. Retrieved from
http://www.cmadocs.org/newsroom/news/view/ArticleId/49150/CMS-delays-enforcement-of-e-prescribing-requirement-for-controlledsubstancesonJanuary14,2021.
*TheCenterforConnectedHealthPolicy.(2019).Abouttelehealth.Retrievedfromhttp://www.cchpca.org/about/about-telehealthonJanuary
29,2020.
*CentersforMedicare&MedicaidServices.(2014).Electronicprescribing(eRx)incentiveprogram.Baltimore,MD:Author.Retrievedfrom
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlonFebruary10,2020.
*CentersforMedicare&MedicaidServices.(2019a).OfficeoftheActuary,NationalHealthStatisticsGroup.Nationalhealthexpenditures
factsheet.Washington,DC:Author.
*CentersforMedicare&MedicaidServices.(2019b).OfficeoftheActuary,NationalHealthStatisticsGroup.Nationalhealthexpenditures
accounts:historicaldata[Table16]Washington,DC:Author.
*Centers for Medicare & Medicaid Services. (2019c). E-prescribing. Baltimore, MD: Author. Retrieved from
https://www.cms.gov/Medicare/E-Health/Eprescribing/index.html?redirect=/eprescribingonFebruary10,2020.
Cohen,J.P.,ElKhoury,C.,Milne,C.,etal.(2018).Risingdrugcost drivesthegrowthofpharmacybenefitmanagersexclusionlists:Are
exclusiondecisionsvalue-based?HealthServicesResearch,53(S1),2758–2769.
*Edlin,M.(2015).Closedformulariesholdthelineoncosts:Oneofanumberofstrategiesinuse.ManagedHealthcareExecutive,25(3),48.
Enthoven,A.C.,&Baker,L.C.(2018).WithrootsinCalifornia,managedcompetitionstillaimstoreformhealthcare.HealthAffairs,37(9),
1425–1430.
*Food and Drug Administration. (2018). Electronic Orange Book preface 39th edition.
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ucm079068.htm.AccessedFebruary10,2020.
Fullerton,D.S.,&Atherly,D.S.(2004).Formularies,therapeutics,andoutcomes:Newopportunities.MedicalCare,42(4Suppl.),39–44.
*Gourzoulidis, G., Kourlaba, G., Stafylas, P., et al. (2017). Association between copayment, medication adherence, and outcomes in the
managementofpatientswithdiabetesandheartfailure.HealthPolicy,121(4),363–377.
*Health Resources and Services Administration. (2015). How does e-prescribing work?
http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/ElectronicPrescribing/epreswork.html.AccessedMay30,2015.
*HealthIT.gov.(2019).Whatisanelectronichealthrecord(EHR)?https://www.healthit.gov/faq/what-electronic-health-record-ehr.Accessed
January12,2020.
*Hodgin,S.(2018).Capitationvs.feeforservice.http://www.insight-txcin.org/post/capitation-vs-fee-for-service.AccessedJanuary14,2020.
*Holmes, D. R., Becker, J. A., Granger, C. B., et al. (2011). ACCF/AHA 2011 health policy statement on therapeutic interchange and
substitution.Circulation,124,1290–1310.
Howard, J. N., Harris, I., Frank, G., et al. (2018). Influencers of generic drug utilization: Asystematic review. Research in Social and
AdministrativePharmacy,14(7),619–627.
*Hunter,R.M.,Baio,G.,Butt,S.,etal.(2015).Aneducationalreviewofthestatisticalissuesinanalysingutilitydataforcostutilityanalysis.
Pharmacoeconomics,33,355–366.
*InstituteforClinicalandEconomicReview.(2018).TheQALY:Rewardingthecarethatmostimprovespatients’lives.WhitePaper.Boston,
MA:Author.
James,B.C.,&Poulsen,G.P.(2016).Thecaseforcapitation.HarvardBusinessReview,July/August,61,87–94.
Johnson,T.L.,Rinehart,D.J.,Durfee,J.,etal.(2015).Formanypatientswhouselargeamountsofhealthcareservices,theneedisintense
yettemporary.HealthAffairs,34(8),1312–1319.
*KaiserFamilyFoundationandHealthResearchEducationalTrust.(2019).Employerhealthbenefits2019annualsurvey.SanFrancisco,CA:
Author.
Kaufman,B.G.,Spivack,B.S.,Stearns,S.C.,etal.(2019).Impactofaccountablecareorganizationsonutilization,care,andoutcomes:A
systematicreview.MedicalCareResearchandReview,76(3),255–290.
*Kaushal,R.,Kern,L.M.,Barron,Y.,etal.(2010).Electronicprescribingimprovesmedicationsafetyincommunity-basedofficepractices.
JournalofGeneralInternalMedicine,6,530–536.
*Linehan,J.S.(2019).Assessingthelegalandpracticalimplicationsofcopayaccumulatorandmaximizerprograms.ManagedCare,28(2),
42–44.
*National Conference of State Legislatures. (2018). State Pharmaceutical Assistance Programs 2010. Retrieved from
http://www.ncsl.org/default.aspx?tabid=14334.Denver,CO:Author.
*NationalFederationofIndependentBusinessesvs.Sebelius,567.U.S.2012,132S.Ct2566.June28,2012.
*Navarro,R.P.,Dillon,M.J.,& Grzegorczyk,J.E.(2009).Roleofdrugformulariesinmanagedcareorganizations.InR.P.Navarro(Ed.),
Managedcarepharmacypractice(2nded.,pp.233–252).Sudbury,MA:JonesandBartlettPublishers.
*NEJMCatalyst.(2018).Whatistelehealth?Retrievedfromhttp://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268onJanuary29,2020.
*Norris, L. (2019). Chapter Six: What is the Obamacare penalty? Retrieved from http://www.healthinsurance.org/obamacare-enrollment-
guide/what-is-the-obamacare-penalty/onFebruary9,2020.
Penna,P.M.(2002).AMCPformatforformularysubmissions:Whoisusingthem,whowillbeevaluatingthem,andwhatregulatoryconcerns
dotheyraise?InternationalSocietyforPharmacoeconomicsandOutcomesResearchSeventhInternationalMeeting,Arlington,VA.
Seeley, E., &Kesselheim, A.S. (2019). Pharmacy benefit managers: Practices,controversies,andwhatlies ahead. CommonwealthFund
[issuebrief],March,pp.1–11.
*Silverman,E.(2018).Backlashagainstcopayaccumulators.ManagedCare,27(9),15.
*Sonnedecker,G.(1976).Kremer’sandUrdang’shistoryofpharmacy.Madison,WI:AmericanInstituteoftheHistoryofPharmacy.
*Starr,P.(1982).ThesocialtransformationofAmericanmedicine.NewYork:BasicBooks.Sweet,B.T.,Wilson,M.W.,Waugh,W.J.,et
al.(2002).Buildingtheoutcomes-basedformulary.DiseaseManagementandHealthOutcomes,10,525–530.
*TakedaPharmaceuticals.(2018).2018Trendsindrugbenefitdesignreport.Plano,TX:PharmacyBenefitManagementInstitute.
*Uhrig, P. (2019). It’s official: Half of all states will soon require E-prescribing to combat the opioid epidemic. Retrieved from
http://surescripts.com/news-center/intelligence-in-action/opioids/it-s-official-half-of-all-states-will-soon-require-e-prescribing-to-combat-the-
opioid-epidemic/onFebruary9,2020.
*U.S. Department of Health & Human Services. (2010). Understanding the affordable care act: About the law. Retrieved from
http://www.hhs.gov/healthcare/rights/index.htmlonApril27,2015.
*U.S. Department of Health & Human Services. (2019). About the Affordable Care Act. Retrieved from
https://www.hhs.gov/healthcare/about-the-aca/index.htmlonFebruary10,2020.
U.S.Food&DrugAdministration.(2018).FYs2013-2017RegulatoryScienceReport:AnalysisofGenericDrugUtilizationandSubstitution.
Retrieved from http://www.fda.gov/drugs/generic-drugs/fys-2013-2017-regulatory-science-report-analysis-generic-drug-utilization-and-
substitutiononMarch11,2020.
UNIT
2
PrinciplesofPainManagement
9
PharmacotherapyofPainManagement
MariaC.Foy
LearningObjectives
1.Explainpainpathophysiologyandtheneurotransmittersinvolvedinthefacilitationofpain.
2.Classifypainbasedonsourceandchronicity.
3.Selectfirst-linetreatmentsforapatientwithacuteorchronicpain.
4.Compareandcontrastthecurrentmedicationoptionsforthetreatmentofacuteandchronicpain.
INTRODUCTION
Oneofthemostwidelyencounteredclinicalsituationsisapatientinpain.Treatmentofpainisoneofthe
mostdifficultaspectsofpatientcare.PainisdefinedbytheInternationalAssociationfortheStudyofPain
as“anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,or
described in terms of such damage” (Merskey & Bogduk, 2012, p. 210). Pain is subjective, and its
intensity varies from patient to patient, day to day. The clinician has a large array of medications
available withwhichto assist patients inrelievingtheir pain.Theprinciplesofmanagingthevarious
typesofpainaredescribedinthischapter,whichintroducesthepracticingnursetothemanytypesand
classesofdrugsavailablefortherapeuticmanagement.
Analgesics representoneof themostfrequentlyprescribedandadministered classes ofmedications
usedinpainmanagement.Managingpainintheacutelyor chronicallyill patientrequiresbotha sound
comprehension of the clinical pharmacology of analgesics and a clear understanding of how pain is
perceived.Clinicianscaringforchronicallyill patientsnotonlyfindthemselvesassistingthepatientin
dealing with the physical component of pain but often are confronted by the patient’s psychological,
spiritual,andsocialperceptionsofpainandpainmedications.
In2000,inanefforttodealwiththeinadequatetreatmentofpain,TheJointCommissiondevelopeda
standard recommendation that pain be considered “the Fifth Vital Sign” (Phillips, 2000). However,
education on the appropriate assessment and treatment of various conditions did not follow and
prescribers were pressured to utilize opioids as their main analgesic option. Unfortunately,
overprescribing occurred when the main focus on pain control moved away from a multidisciplinary
approach to aggressive treatmentwith opi-oids. Prior to the release ofthe standards in 2001, opioid
prescribingpatternswereontherise,butamorerapidescalationoccurredafter2001,withprescriptions
peaking around 2011. Subsequently, unintended residual harm occurred with an increase in opioid
overdosesandrelateddeaths.Despiteeffortstocontroloverprescribing,deathscontinuedtorise.When
theopioid“supply” was taken away, sometimes inappropriately, many would obtain opioids fromthe
streets.
Priortostartingopioidtherapy,apatient’sriskforopioidabuseormisusemustbeassessed.Various
assessmenttoolsareavailabletodeterminetheriskofopioidusedisorder(OUD)whicharediscussedin
Chapter10.
Additional assessments are needed in order to determine the most appropriate approach to pain
management. Renal and liver dysfunction will affect the choice and dosing of analgesic agents.
Respiratorycomorbiditiescanincreasetheriskofopioid-inducedrespiratorydepression.Ageisanother
majorconsiderationinassessingpainandappropriatetherapies.Ingeneral,olderpatientsarelesslikely
tocomplainaboutpain,aremoresensitivetomedications,andrequestfeweranalgesicstoalleviatepain,
oftensecondarytoincorrectbeliefsandbiases.Acorollaryexistsinpediatricpatients,whoseinabilityto
adequatelyexpress sufferingleads somecliniciansto believethatchildrencannotfeel pain,whichwe
knownowisuntrue.Becauseoftheidentifiedcommunicationbarrier,cliniciansneedtoevaluateachild
byutilizingspecialpainassessmenttoolsdeveloped forchildren.Similarassessmenttoolsare utilized
foradultswhomaynotbeabletoverballycommunicatetheirpain.
TYPESOFPAIN
Paincanbecategorizedasnociceptive,neuropathic,or“other”basedonthepresumedunderlyingcause.
Nociceptive pain occurs as a resultof nerve receptorstimulationfollowinga mechanical,thermal, or
chemical insult. Nociceptive pain is purposeful, because the pain tells you to stop doing whatever is
causing discomfort. Nociceptive pain can be further classified as somatic or visceral. Somatic pain
associated withmuscle, skin, or bone injury is often well localized. Pain affecting internal organs is
referredtoasvisceralpain.Inflammatorypainisanothersubtypeofnociceptivepain,whichresultsfrom
thereleaseofproinflammatorycytokinesatthesiteoftissueinjury.Inflammatorypainmaybepresentin
acutepainfrombruisesorinfectionandchronicallyfromrheumatoidarthritisorosteoarthritis.
Neuropathicpainiscausedbyabnormalsignalprocessesinthecentralnervoussystem (CNS).Pain
can be peripheral or central in origin and is no longer protective in nature. Peripheral neuropathies
includepainfromdiabetesandpostherpeticneuralgia.Examplesofcentral neuropathicpainsyndromes
includepainfrommultiplesclerosis,spinalcordinjuries,migraine,andpoststrokesyndrome.Descriptors
ofneuropathicpain,suchaselectric-like,burning,tingling,stabbing,orshootingpain,candifferentiate
nervepainfromnociceptivepainandhelpdetermineappropriatetreatment.
Morethanonetypeofpainmayoccursimultaneously.Failedbacksurgerysyndrome,cancerpain,and
chronic regional pain syndrome(CRPS) may have characteristics of a mixed nociceptive–neuropathic
picture.
Newevidenceisnowdirectedtowardtheconsiderationthatmanychronicpainconditionsshouldbe
viewed as a biopsychosocial disease with pain facilitated by the combination of biological,
psychological, and environmental factors. Noxious pain precipitants are no longer present and no
pathologyexiststhatwould explainthesymptomology.This other paincategoryisoftenreferred to as
dysfunctionalpain,causedbychangesintheanalgesicpathway.Structuralchangesconsistofincreasesin
nerve endings and receptive fields and a decreased threshold for nerve activation. Sensitized pain
resulting from nervous system changes and cortical reorganization is referred to as neuroplasticity.
Patientswithpsychologicalcomorbidities,suchasanxiety,depression,poorsleeppatterns,andahistory
ofbothphysicalandpsychologicaltrauma,arepredisposedtothedevelopmentofchronicsensitizedpain
conditions(Ru-Rongetal.,2018).Thefearandthelackoftheabilitytocopecanbeunderlyingfactorsin
the development of chronic sensitized pain. Some examples of sensitized conditions include CRPS,
fibromyalgia,andmigraines(Ru-Rongetal.,2018).
CLASSIFICATIONOFPAIN
Paincanbeclassifiedintotwocategories—acuteandchronic—whichhelpidentifythederivationofthe
painandprovideaframeworkfortreatment.Paincansubsequentlybecategorizedandtreatedbasedon
theexpectedchronicityofthepainandonwhetheritisnociceptive,neuropathic,ormixedinorigin.
AcutePain
Acute pain has a sudden onset, usually subsides quickly, and is characterized by sharp, localized
sensationswith anidentifiablecause. Acutepain is a naturalphysiologic response to injury, useful in
warning individuals of disease or harmful situations. Inflammation seen in acute pain influences pain
perception andprovides a protective role by removing the painful stimuli, restoring tissue health and
facilitatinghealing.Thisprocessisoftenseenasasignalthatthebodyisinvokingcriticalimmunologic
and physiologic responses to cellular or tissue damage. Concomitant physiologic responses include
excessive sympathetic nervous system activity, such as tachycardia, diaphoresis, and increased blood
pressure and respiratoryrate. Acute pain is somewhatinstructive and purposeful bysignaling danger.
Painis usually brief andresolves within a few monthsof onset.Surgical interventionandtrauma are
commonsourcesofacutepain.
When acute pain responses become unremitting, constant, or undertreated, the biologic responses
outlivetheirusefulnessandcanlead tochronicpain.Patientswithchronicpainbecometoleranttothe
physiologicresponseseeninacutepain.Inaddition,thesepatientsoftendo notappeartobesuffering.
Thebodybecomestoleranttotheautonomicindicators,whereheartrate,bloodpressure,andrespiratory
rate normalize as pain persists. Undesired consequences, such as anxiety and depression, are often
associatedwithconstant,long-termpain.Thegoalofacutepainmanagementistoavoidprogressiontoa
chronicpainstate.Earlypaincontrolwilloftenpreventthedevelopmentofchronicpain.
ChronicPain
Chronicpain is defined by the Institute of Clinical SystemsImprovement as“pain without biological
valuethathaspersistedbeyondthenormaltimeanddespitetheusualcustomaryeffortstodiagnoseand
treat the original condition and injury” (Hooten et al., 2013, p. 7). Chronic pain may be nociceptive,
neuropathic,ormixedinorigin.Paincanbeeitherthemaincomplaint,wherenoevidenceofstructuralor
nerve damage is present to explain the discomfort, or secondary to an underlying disease. Some
conditionsmayhaveaverifiablesource,asinpatientswitharthritis,diabeticperipheralneuropathy,or
postherpeticneuralgia.Insomepatients,however,paincanbereferredtoaschronicprimarypain,when
noapparentevidenceofstructuralornervedamageexists(Treedetal.,2019).Inthesepatients,thepain
is most likely from neuroplastic changes resulting in peripheral and central sensitization of the
nociceptivepathways,explainedlaterinthischapter.
Identifying and differentiating pain through careful examination of the history, location, quality,
chronicity, and presence of psychological comorbidities is important because treatment choices are
dictatedbythecauseandtypeofpain.Patientswithpainasthemaincomplaintareespeciallydifficultto
treat,andamultimodalapproachtotreatmentisneeded.Cognitivefactorssuchaspaincatastrophizing
andanxietyhaveastrongcorrelationtopainanddisability.Thecurrentbiomedicalapproachfocusing
onlyontissue andtissueinjuryasthe causehas oftenbeenineffectiveinpeople withsensitizedpain.
Casesareoftencomplicated,andpatientsneedanindividualizedapproachtotherapy.
Painmayrespondtomosttraditionalanalgesicapproaches,includingopioidtherapy.However,higher
dosesofopioidsmayberequiredtocontrolchronicandsensitizedpain.Overtime,opioidtherapyoften
becomeslesseffectiveandfailstoimprovefunction,especiallywhenit’stheonlymodalityofanalgesia
offeredtothepatient.Withchronicpain,thegoalsoftherapyaretodecreasethepaintoatolerablelevel
andimprovefunctionusingacombinationofvarioustypesoftherapiestoultimatelyenhancequalityof
life. The patient must have realistic expectations and agree that the goal of pain control is to reduce
discomforttoatolerablelevelandthatthepainmaynevertotallyresolve.Activeversuspassivepatient
involvementisnecessary.ExamplesoftypesofchronicpainareshowninBox9.1.
Box9.1 ClassificationofChronicPain
NOCICEPTIVEPAIN
Arthropathies(e.g.,rheumatoidarthritis,osteoarthritis,gout)
Ischemicdisorders
Mechanicallowbackpain
Myalgia(e.g.,myofascialpainsyndromes)
Nonarticularinflammatorydisorders(e.g.,polymyalgiarheumatica)
Postoperativepain
Skinandmucosalulcerations
Superficialpain(sunburn,thermalburns,skincuts)
Visceralpain(appendicitis,pancreatitis)
NEUROPATHICPAIN
Alcoholicneuropathy
Cancer-relatedpainandsomecancertreatments
ChronicregionalpainsyndromeDiabeticperipheralneuropathy
Humanimmunodeficiencyvirus(HlV)–relatedpainandsomeHIVtreatments
Multiplesclerosis–relatedpain
Phantomlimbpain
Postherpeticneuralgia
Poststrokepain
Trigeminalneuralgia
VitaminB12deficiency
MIXEDORUNDETERMINEDPATHOPHYSIOLOGY
Carpaltunnelsyndrome
Chronicrecurrentheadaches
Lowbackpainwithradiculopathy
Painfulvasculitis
OpioidUseinChronicPain
Opioiduseforchronicpainiscontroversial.Inanefforttoaddressthe“paincrisis”duetoreportsofa
substantialnumberofpatientssufferingfrompain,afocuswasplacedontreatmentbasedonsubjective
patientself-reports alone.Inthe late 1990s, opioids were advocated as a safeandeffective analgesic
withminimalriskofabusewhenusedinpersistentnoncancerpain,leadingtoanincreaseinprescribing
by health care providers. In addition, providers were not given adequate training in the appropriate
assessment and management of pain and regarding where opioids fit in the treatment plan. By 2012,
enough prescriptions were written to give virtually every American a bottle of opioid medications
(Paulozzietal.,2014).Amarkedincreaseinopioid-relatedSUDanddeathsresulted.Between1999and
2014, more than 165,000 deaths due to opioids were reported (Centers for Disease Control and
Prevention[CDC],2014).
Overprescribingof opioids withsubsequentincreases inopioid-relatedmorbidityandmortality has
ledtothedevelopmentofguidelinesin2016bytheCDC.Theguidelinesproviderecommendationsfor
theuse of opioids in the treatment of chronic noncancer pain(CNCP), focusingon multiple analgesic
options.Guidancetoprimarycarephysiciansonwhentoinitiateorcontinueopioids,choice/durationof
treatment, and risk assessment of harm and SUD in patients prescribed opioids for chronic pain is
provided. However, methods on how to accomplish the recommendations are not outlined within the
guidelines.Inthesubsequentyearssinceimplementation,variouschallengeshavebeenidentifiedthatcan
potentially cause residual harmto patients.Ina report in Pain Medicine in 2019, a multidisciplinary
CDCpanelhighlightedseveralissues,whichincludedinflexibleapplicationofrecommendations,abrupt
discontinuation of long-term opioid therapies without proper tapering, failure to involve patients in
decisionsregardingtheiropioidtherapy,lackofaccesstopainspecialists,andbarrierstoprovisionfor
treatmentofopioidusedisorder(OUD)(Kroenkeetal.,2019).Lackofinsurancecoverageforanalgesic
alternativesremainsasignificantbarriertorecommendedtreatmentoptions.Somepatients,whohavehad
abrupttaperingordiscontinuationofopioids,haveturnedtothestreetsforsupplyinordertotreatpain
and/orpreventwithdrawalfromestablishedtolerancetoopioidtherapy. Infact,despitelevelingoffof
opioidprescriptions,deathscontinuetoriseatanalarmingrateduetoincreaseintheuseofheroinand
illicitfentanyl.Abalancebetweenappropriateandsafeoptionsforpaincontrolandrisksandharmsfrom
opioid therapy is needed. Clinicians must provide individualized treatment plans based on patientspecific factors, and risks and policies should allow flexibility in individualization with coverage
availableforoptionsbesidesmedications.Educationisneededonvariouspainmanagementmodalities
andassessmentofapatient’sriskofabusebeforeinitiatingopioidtherapies.Inaddition,wenowknow
that titrationto high-dose opioid therapy is nolonger recommended, especially when improvement of
functionisnotseen.
Соседние файлы в папке Библиотека им академика М.И. Перельмана