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INTRODUCTION

Most pain is acute and short lived. Acute pain is primarily a symptom of a pathological process or injury. Typically treating the illness or injury will reduce or eliminate acute pain symptoms. Analgesic medications are often used in this setting for comfort during the healing process. For the most part, treatment of the underlying pathology or injury and medication management are effective in the treatment of acute pain. Many resources exist for assisting clinicians with acute pain management strategies.

Despite even the best efforts, acute pain evolves into chronic pain in approximately one out of five patients. The management of chronic pain is complex and often involves both pharmacological and nonpharmacological interventions. Because chronic pain is also modulated by psychological status (e.g., depression and anxiety), environmental consequences (e.g., stressors or reinforcers), and prior conditioning history, a comprehensive, multidisciplinary approach to management of this condition is of critical importance.

Management of patients with chronic pain is often challenging and can lead to complex patient–physician relationships. Often these relationships engender strong reactions from primary care providers. This chapter focuses on helpful strategies for the management of chronic pain and approaches for facing the particular challenges of caring for patients with chronic pain.

CHRONIC PAIN PREVALENCE/BACKGROUND DATA

The International Association for the Study of Pain (IASP) defines pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage.” The transition from acute to chronic pain is defined by duration. Acute pain may last up to 3 months at most, whereas chronic pain is any pain that lasts more than 3 months. Although pain from untreatable malignancies often lasts many months and is ­progressive, the terminal nature of the underlying condition leads most to consider cancer-related pain separately from chronic noncancer pain. Roughly 20% of the patients with acute pain will eventually seek treatment each year for chronic noncancer pain. Of these, 62% will report having pain for longer than 1 year; 57% report that their pain is episodic (e.g., migraine, neuropathy), whereas 43% will report having constant pain.

Chronic noncancer pain accounts for more than 70 million office visits per year in the United States, with annual direct medical costs of $125 billion. The cost of treating low back pain alone averages almost $86 billion annually. Although the diagnosis of low back pain represents only 5–10% of all disability claims, these claims account for 80–85% of the costs of disability.

Figure 35-1.

Harvested Poppy Capsules, Afghanistan.

CLINICIAN–PATIENT RELATIONSHIP/GOALS OF THERAPY

Taking care of patients with chronic noncancer pain can be problematic for the primary care provider. Even the most experienced practitioners occasionally find the clinical relationship with a patient with chronic pain to be challenging and frustrating. Some patients with chronic pain are engaged in living ...

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