Chronic Pain: Avoiding Addiction, Death, Medical Malpractice

Methadone as a substitute for chronic narcotic medication can kill within the first week or two of taking it, leading necessarily to medical malpractice litigation.  Personal Injury attorneys both defense and plaintiff sooner or later will work on such a case.

Recently the American Society of Anesthesiologists Task Force on Chronic Pain Management produced, for the first time, in more than 10 years, produced new guidelines that cover a range of advances not included in the initial version published in 1997. 

Chronic pain is a common phenomenon seen in a variety of settings and is defined as pain of any cause not directly related to cancer extending in duration beyond the period of normal healing, and adversely affecting the function or well-being of the individual.  The purpose of the new guidelines is to optimize pain control, enhance functional abilities and physical and psychologic well-being, enhance quality of life, and minimize adverse outcomes such as the sudden death I describe above.


The Study highlights follow:

  • All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.
  • A pain history should include a general medical history with emphasis on the chronology and symptomatology of the presenting complaints; a history of current illness; and a review of previous diagnostic tests, results of previous therapies, and current therapies.
  • The causes as well as the effects of pain (eg, the ability to perform activities of daily living, changes in occupational status) and the impacts of previous treatment should be evaluated and documented.
  • The psychosocial evaluation should include information about the presence of psychologic symptoms (eg, anxiety, depression, or anger), psychiatric disorders, personality traits or states, history of substance or current medication use or misuse, and coping mechanisms.
  • The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation.
  • Appropriate diagnostic procedures may be conducted as part of a patient's evaluation, based on a patient's clinical presentation.
  • The choice of an interventional diagnostic procedure (eg, selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, and provocative discography) should be based on the patient's specific history and physical examination and anticipated course of treatment.
  • Multimodal interventions should be part of a treatment strategy for patients with chronic pain. Also, a long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.
  • The following single-modality interventions are often explored and are used in conjunction with multimodal interventions:
    • Ablative techniques are used; however, other treatment modalities should be attempted before consideration of these techniques.
    • Acupuncture may be considered as an adjuvant to conventional therapy in the treatment of nonspecific, noninflammatory low back pain.
    • Intraarticular facet joint injections may be used for the symptomatic relief of facet-mediated pain and sacroiliac joint injections for the symptomatic relief of sacroiliac joint pain.
    • Nerve and nerve root blocks such as celiac plexus blocks, lumbar sympathetic blocks, sympathetic nerve blocks, medial branch blocks, and peripheral somatic nerve blocks may be used.
    • Botulinum toxin may be used as an adjunct for the treatment of piriformis syndrome.
    • Neuromodulation with electrical stimulus, such as subcutaneous peripheral nerve stimulation and spinal cord stimulation, may be used. Shared decision making should include a specific discussion of potential complications associated with spinal cord stimulator placement.
    • Transcutaneous electrical nerve stimulation should be used for pain management in patients with chronic back pain and may be used for other pain conditions.
    • Epidural steroid injections with or without local anesthetics may provide pain relief in selected patients with radicular pain or radiculopathy. Transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before a therapeutic substance is injected.
    • Intrathecal neurolytic blocks should not be performed in the routine treatment of patients with noncancer pain.
    • Intrathecal preservative-free steroid injections may be used for the relief of intractable postherpetic neuralgia nonresponsive to previous therapies. Ziconotide infusion is used in the treatment of a select subset of patients with refractory chronic pain.
    • Intrathecal opioid injection or infusion may be used for patients with neuropathic pain; however, neuraxial opioid trials should be performed before permanent implantation of intrathecal drug delivery systems is considered.
  • Minimally invasive spinal procedures (eg, vertebroplasty) may be used for the treatment of pain related to vertebral compression fractures.
  • The following pharmacologic treatments can also be used for chronic pain:
    • Anticonvulsants and antidepressants should be used as part of a multimodal strategy for patients with chronic pain.
    • Extended-release oral opioids should be used for neuropathic or back pain patients, as well as transdermal, sublingual, and immediate-release oral opioids.
    • For selected patients, ionotropic N-methyl-D-aspartate receptor antagonists (eg, neuropathic pain), nonsteroidal anti-inflammatory drugs (eg, back pain), and topical agents (eg, peripheral neuropathic pain) may be used, and benzodiazepines and skeletal muscle relaxants may be considered.
    • A strategy for monitoring and managing adverse effects and compliance should be considered for all patients undergoing any long-term pharmacologic therapy.
  • Physical or restorative therapy may be used for patients with low back pain and for other chronic pain conditions.
  • Cognitive behavioral therapy, biofeedback, or relaxation training as well as supportive psychotherapy, group therapy, or counseling should be considered for patients with chronic pain conditions.



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