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Initial evaluation; Pain condition; Medication dosing; Pain management; Clinical opioid; Bio-psychosocial approach

Introduction

Rehabilitation has been shown to be effective in improving pain in patients with Breast Cancer. From this review, it was noted that several features such as manual therapy, stretching and muscle strengthening exercise, upper limb mobility, lymphatic drainage, and Pilates exercises bring notable benefits for women with Breast cancer. In pain management, a critical part of providing comprehensive care is a thorough initial evaluation, including assessment of both the medical and the probable bio-psychosocial factors causing or contributing to a pain condition. A second critical step is to develop a treatment plan to address the causes of pain and to manage pain that persists despite treatment [1]. Quality pain diagnosis and management can alter opioid prescribing both by offering alternatives to opioids and by clearly stating when they may be appropriate. Several recent clinical practice guidelines for best practices for chronic pain management agree on specific recommendations for mitigating opioid-related risk through risk assessment, including screening for risks prior to initiating opioids; medication dosing thresholds; consideration of drug-drug interactions, with specific medications and drug-disease interactions; risk assessment and mitigation; drug screening/testing; prescription drug monitoring programs; and access to non-pharmacologic treatments [2]. Clinical practice guidelines for best practices that only promote and prioritize minimizing opioid administration run the risk of undertreating pain, especially when the cause of the pain is uncertain or cannot be reduced through non-opioid approaches.

Discussion

To continue improving quality of pain care in the current environment of opioid-related risks, experts have noted several key challenges associated with clinical best practices. First, there is the need to increase the use of CPGs, as indicated in specific patient groups delineated by their underlying diagnosis or cause of pain, comorbidities, psychosocial characteristics, demographics, and settings. Second, access to effective pain management treatments must be improved through adoption of clinical best practices in medical and dental practice and clinical health systems [3]. Third, clinical best practices for pain management should be better incorporated into the routine training of clinicians, with special attention to residency training to meet the needs of patients treated in each specialty. Finally, quality care must be adequately reimbursed. Pain management experts have also identified specific research gaps that are impeding the improvement of pain management best practices, including synthesizing and tailoring recommendations across guidelines, diagnoses, and populations. In addition, gaps and inconsistencies exist within and between pain management and opioid prescribing guidelines. This finding is also the result of demographic and other variances, because CBPs are developed in different regions of the country. A recent review of clinical opioid prescribing guidelines by Barth needs including the development of postoperative pain management guidelines for different surgical procedures, with the understanding of patient variability in physiology, drug metabolism, and underlying disease processes. This research further emphasizes the need for an individualized, patient-centred approach focused on achieving improved function, activities of daily living (ADLs), and QOL as well as pain control [4]. In light of these gaps, pain management providers should consider potential limitations to evidence-based clinical recommendations. A systematic review of CPGs for neuropathic pain identified shortcomings across four evaluation domains: stakeholder involvement i.e., the extent to which the guideline was developed by the appropriate stakeholders and represents the views of its intended users; The rigor of development i.e., the process used to gather and synthesize the evidence and the methods used to formulate the recommendations; Applicability i.e., likely barriers and facilitators to implementation of the guideline, strategies to improve its uptake, and resource implications of applying it; and Editorial independence i.e., bias in the formulation of the recommendations, not to mention the knowledge and skill set of the clinician [5]. Identified inconsistencies across guidelines for some painful conditions, such as fibromyalgia, have demonstrated a need for consensus in guideline development. A review of state level guidelines for opioid prescriptions found that a minority of states had guidelines specific to ED’s. Pain guidelines from the World Health Organization (WHO) are facing a lack of adoption, potentially because they lack incorporation of contemporary pain management practices. A multimodal approach to pain management consists of using treatments from one or more clinical disciplines incorporated into an overall treatment plan. This plan allows for different approaches to address the pain condition, often enabling a synergistic approach that addresses the different aspects of the pain condition, including functionality. Multidisciplinary approaches address different aspects of chronic pain conditions, including bio-psychosocial effects of the medical condition on the patient. The efficacy of such a coordinated, integrated approach has been documented to reduce pain severity, improve mood and overall QOL, and increase function [6]. Recent clinical practice guidelines developed by the VA and DoD adopt the bio-psychosocial model of pain. In this endeavour, they emphasize a collaborative, stepped care model. The bio-psychosocial approach is applied clinically across pain experiences, including chronic pain, and specifically to musculoskeletal pain, low-back pain, and HIVrelated pain. The development of a treatment plan should be preceded by a history and physical examination that aids in proper diagnosis. When clinically indicated, clinicians should consider an integrative and collaborative approach to care. Specialty interdisciplinary pain medicine team consultation, collaborative care, and mental health and addiction services should be readily available in the course of treatment of pain to help ensure the best patient outcomes [7]. Medical organizations and advocacy groups are encouraged to be involved in the development of clinical practice guidelines for the treatment of particular pain conditions. When clinically indicated, these CPGs can be used within the context of the multimodal and multidisciplinary approach to pain care. Acute pain is a ubiquitous human experience, a physiologic response to noxious stimuli that is sudden in onset and time limited. Acute pain can occur after a burn or trauma or following surgery in the perioperative period. Acute pain and chronic pain are often interlinked, with most cases of chronic pain beginning as acute pain. Acute pain flares may recur periodically in chronic medical problems, including arthritis, neuropathies, spinal conditions, lowback pain, sickle cell disease, migraine, multiple sclerosis, Trigeminal pain or neuralgia, and complex regional pain syndrome. As with acute pain flares in these and other conditions, it is important to perform a thorough evaluation that leads to a presumed diagnosis or differential diagnosis [8]. The goal is to facilitate diagnostic accuracy and effective therapeutic plans, including a continuum of care plans into the nonacute care setting. It is vital to consider a risk-benefit analysis to provide the best possible patient-centred outcome while mitigating unnecessary opioid exposure. To avoid the side effects associated with prescription opioids, it is important to exploit the benefits of multimodal, nonopioid approaches in acute pain management in conjunction with possible opioid therapy. Re-evaluation of patients is critical in this setting because the use of medications to control acute pain should be for the shortest time necessary while also ensuring that the patient is able to mobilize and restore function. Opioids are effective in treating acute pain, but patients can be at risk of becoming new chronic opioid users in the postsurgical setting. As one large study illustrated, among a population of opioid-naive patients who were given a course of opioids to treat pain following surgery, about 6% became new chronic users [9]. Patients who were at higher risk for becoming chronic opioid users were those with a history of tobacco use, alcohol and substance abuse disorders, anxiety, depression, other pain disorders, and comorbid conditions. This finding further underscores the value and importance of initial clinician-patient time together as well as appropriate followup to better assess risk and provide appropriate treatment for these complex pain conditions. To reflect multidisciplinary approaches and the bio-psychosocial model of acute and chronic pain management, the following sections are organized by five major approaches to pain management: medication, restorative therapies, interventional procedures, behavioural health approaches, and complementary and integrative health. Perioperative pain management in patients with chronic pain presents unique challenges, particularly for patients with opioid tolerance or those vulnerable to opioid-associated risks [10]. It can be more challenging to manage patients on long-term opioid therapy in the perioperative period compared with patients who are opioid naive. Considerations for managing these patients include the use of multimodal approaches as well as preoperative consultation and planning.

Conclusion

In addition, behavioural interventions show promise for use in the pre- and perioperative periods for the management of postsurgical pain. Other experts have suggested use of perioperative surgical homes for this patient population. Patients with chronic pain whose pain is managed by a pain management clinician should have this clinician consulted and involved in the planning of their pain control during and after surgeries.

Acknowledgement

None

Conflict of Interest

None

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