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"There are among us those who haply please to think our business is to treat disease. And all unknowingly lack this lesson still 'tis not the body, but the man is ill.'" S. Weir Mitchell (cited in Turk, Meichenbaum, and Genest, 1983).

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Pain is a common symptom of an underlying disease process or injury. Acute pain arises from a known disease or injury, while chronic pain arises from a known disease or injury or from unknown etiology. Pain is modulated, increased, or decreased, by arousal (central nervous system [CNS] activity) caused by physical movement, psychological status (such as depression and anxiety), environmental factors (such as stressors or reinforcers), and conditioning history.

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Although a number of pain scales exist, pain is not measurable directly like blood pressure or body temperature; instead the clinician must rely on pain behavior (verbal and nonverbal patient expressions; see Table 32–1) together with known modulating variables, to assess the level of pain. Acute pain is primarily a symptom of a pathologic process or injury, and treating the illness or injury often will reduce or eliminate the pain symptoms. Pain medications are often used for comfort during the healing process. Chronic pain is pain that has usually not responded to the treatment for acute pain, and the modulating variables mentioned above can become the primary etiologies of the pain complaint. Comorbid psychiatric conditions can and often do occur with both acute and chronic pain. The goal of treatment, both acute and chronic, is to improve function and return the patient to as normal a lifestyle as possible, which in many cases includes return to work. Pain relief alone typically will not achieve this goal.

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Table 32–1. Pain behaviors.
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The objectives of this chapter are:

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  • To provide practical strategies for assessment of pain.
  • To provide information about treatment strategies and patient education.
  • To provide for safe and ethical pain management practice.

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Gregory T. Smith and Douglas Beers were authors of the first and second editions of this chapter.

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Establishing a good clinician–patient relationship is the key to treating pain. The effectiveness of this relationship is defined largely by the clinician's ability to acknowledge the patient's problem, address the patient's goals, and establish a collaborative approach on which both clinician and patient can agree. Because the primary concerns of clinician and patient can differ, there is potential for miscommunication.

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Patients who are in pain come to medical ...

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