Treatment Planning

Treatment Principles and Methods

  • Combine multiple modalities/disciplines: medications, appropriate invasive interventions (e.g., injections or surgery), rehabilitation, integrative medicine, as well as psychological, spiritual, and vocational/occupational interventions. Treatment should be rational, balanced and multimodal. There are very few situations when a multimodal approach (combination of pharmacologic and nonpharmacologic strategies) is not appropriate or necessary.
  • Educate and communicate with patients and caregivers: Patients engaged in collaborative care, shared decision-making with their providers, and chronic disease self-management have improved health outcomes. Share evidence with patients and families in a comprehensible manner that is appropriate to their circumstances. This approach enables them to make better decisions and anticipate their needs. For example, provide information about available pain control options, how to utilize the options chosen, and how to achieve realistic goals and outcomes.

Analgesics

  • Be familiar with the indications and contraindications for several drugs from each of the 3 categories: non-opioids (acetaminophen and the non-steroidal anti-inflammatory drugs), opioids, and adjuvant analgesics. (Table 5).
  • Remember the "5 Rs":
    1. Right analgesic(s) - based on type and severity of pain and co-morbidities. Consider patient and drug characteristics including, but not limited to: type and intensity of pain, duration of pain, patient age, past exposure and prior response to analgesics (both pain relief and side effects), comorbidities, end organ function, concomitant administration of other drugs, and pharmacokinetics of the analgesic(s) to be ordered.
    2. Right route - when possible the oral route is preferred unless rapid titration is needed or the oral route is unavailable.
    3. Right dose - understand there is great inter-patient variability. Provide a dosage range large enough to permit appropriate and safe dose titration. The maximum dose within an opioid PRN range should not be greater than four times the minimum dose. The dosing interval should be appropriate for the drug and route of administration; take into account the usual absorption and distribution characteristics, time to onset, time to peak effect, and duration of action. Open ended orders such as "titrate to comfort" are not acceptable.
    4. Right dosing interval (scheduled dosing vs PRN dosing) - when pain is constant, scheduled dosing is preferred, preferably with long-acting drugs.
    5. Right message with nondrug interventions - patients should be instructed about the limitations of pharmacologic approaches and the importance of using nondrug strategies to enhance and complement the effect of medications.

Nonpharmacologic Interventions (cognitive-behavioral and physical modalities)

  • Cognitive-behavioral approaches include such techniques as passive relaxation with mental imagery, distraction, progressive relaxation, biofeedback, hypnosis, and music therapy. Cognitive-behavioral strategies can help patients understand more about their pain, alter their pain behavior and coping skills, and change their perception of pain.
  • Physical techniques include applications of heat and cold, massage, exercise, and transcutaneous nerve stimulation. The goal of these techniques is to reduce pain by altering the physiologic response and providing the patient with some sense of control over the pain.

Interventional Pain Management (IPM)

  • What and When (indications): Injection procedures and minimally invasive surgical procedures are often used in combination with medications, rehabilitation and psychological treatments to treat or evaluate patients with acute and chronic, non-cancer and cancer pain.
    • Diagnostic injections to selectively target potential sources of pain and differentiate the nociceptive pain generating structure when the cause or source of pain is not obvious, e.g., non-radiating neck or back pain.
    • Treatments such as epidural steroid injections (for radiating limb pain from herniated disc or spinal stenosis), and vertebroplasty (for trunk pain in patients with vertebral compression fractures).
    • Intrathecal drug delivery via implanted pump in certain situations when systemic analgesia is not tolerated
    • Spinal cord stimulation to relieve pain and/or spasticity in patients who are refractory to systemic medication and have exhausted other treatments.
    • Neurolysis by radiofrequency or surgery to destroy nerve structures; reserved for patients with a limited life expectancy.
  • How: Use image guidance (real time fluoroscopy, CT, MRI, ultrasound) and a percutaneous technique to place specially designed needles precisely at a select structure (e.g., a spinal or peripheral nerve, spinal or peripheral joint) or in an epidural or sub-arachnoid space. Confirm precise needle placement, and then deliver local anesthetics, corticosteroids or other agents/drugs to the selected target to decrease pain.
  • Contraindications: any patient with an uncorrected bleeding disorder/coagulopathy, or taking platelet inhibiting drugs or anticoagulants; patients with active local or systemic infections, uncontrolled diabetes or other unstable medical condition. These patients will need stabilization of the medical condition, and normalization of labs prior to a procedure.
  • Possible adverse effects: bleeding, infection, sepsis, drug or contrast-related allergy, transient increase in pain, nerve injury, spinal cord injury, pneumothorax have been reported.