5-07: Chronic Noncancer Pain

Chronic noncancer pain may begin as acute pain that then fails to resolve and extends beyond the expected period of healing or it may be a primary disease state, rather than the symptom residual from another condition. Common examples of chronic noncancer pain include chronic low-back pain and arthralgias (often somatic in origin), chronic abdominal pain and pelvic pain (often visceral in origin), and chronic headaches, peripheral neuropathy, and postherpetic neuralgia (neuropathic origin) as well as other less common but debilitating syndromes such as chronic trigeminal neuralgia (neuropathic origin) and complex regional pain syndrome (mixed origin). Chronic noncancer pain is common, with the World Health Organization estimating a worldwide prevalence of 20%. In the United States, 11% of adults suffer from chronic noncancer pain, and the Institute of Medicine estimates that it costs $635 billion annually in treatment and lost productivity costs.

Chronic noncancer pain requires interdisciplinary management. Generally, no one therapy by itself is sufficient to manage such chronic pain. Physical or functional therapy and cognitive behavioral therapy have been shown to be the most effective for treating chronic noncancer pain, but other modalities including pharmacologic therapy, interventional modalities, and complementary/integrative approaches are useful in caring for affected patients.

Chronic low-back pain is one example of a common chronic noncancer pain. It causes more disability globally than any other condition. Chronic low-back pain includes spondylosis, spondylolisthesis, and spinal canal stenosis (Chapter 24), and the “failed back surgery syndrome,” a term used to refer to patients in whom chronic pain develops, persists after lumbar spine surgery, or both. Also referred to as the post-laminectomy pain syndrome, it can affect 10–40% of patients after lumbar spine surgery.

The importance of clinicians knowing the many causes of chronic low-back pain and, in particular, understanding how anatomic structures relate to one another and how they can cause the different types of low-back pain, has been highlighted by the epidemic of opioid abuse in the United States since the year 2000. In fact, evidence-based practice does not support the use of prolonged opioid therapy for chronic low-back pain.