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OBJECTIVES

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  • Describe the disproportionate burden of chronic pain in medically vulnerable populations.

  • Describe comorbidities that can present challenges in the management of chronic pain.

  • Describe a general approach to the evaluation and management of chronic pain.

  • Review common treatments, with a special focus on the role of opioids in the management of chronic pain.

  • Suggest practical tools to improve the provision and documentation of safe and effective care for chronic pain.

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INTRODUCTION

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Chronic pain usually serves little or no physiologic role and, in contrast to acute pain, it is perhaps best viewed as a disease state, not a symptom. An estimated 100 million American adults are afflicted with chronic pain, which is more than the number affected by heart disease, cancer, and diabetes combined.1 Globally, 10% of the world’s population or 60 million people suffer with chronic pain, and the World Health Organization (WHO) estimates that 1 in 10 adults are newly diagnosed with chronic pain each year.2 In Europe, one in five adults report chronic pain.3 Chronic pain affects both physical and mental health and leads people to rate their health as poor4; hence, its social and economic costs are considerable. Pain-related problems, particularly chronic pain management, are among the most challenging clinical problems confronted by clinicians.5 This chapter reviews general principles of chronic pain management, emphasizing special circumstances confronted by clinicians caring for medically vulnerable populations. The aim is for clinicians to feel empowered to provide empathic and comprehensive evidence-based care for their patients.

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DISPROPORTIONATE BURDEN OF PAIN IN VULNERABLE POPULATIONS

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JP has a history of an alcohol use disorder, major depression, and chronic low back pain following a workplace injury. He is unemployed due to his pain and is at risk of losing his housing due to lack of income. He has no history of fevers, weight loss, cancer, or other “red flag” symptoms. He fears this pain will only get worse and he will eventually need a wheelchair. He pleads for help because his pain is “absolutely out of control.”

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The burden of moderate to severe chronic pain is highest among the poor, the uninsured, and those belonging to ethnic minorities.6 Poor individuals are subject to hazardous and physically demanding work or living conditions that lead to physical injury. Chronic pain itself creates economic or social disparities by causing disability or loss of health insurance1 and treatments that could reduce or manage symptoms are often unattainable. Pain sufferers who are poor or uninsured may have difficulty navigating the health-care system to obtain proper treatment. Further, mental health conditions such as depression and anxiety are more prevalent among underserved medical populations and may impede appropriate management of pain.6 Finally, personal interaction styles, discordant cultural beliefs, and stereotypes held by both clinicians and patients may undermine communication leading to effective pain treatment.

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