Pain management
Encyclopedia
Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life
of those living with pain
. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapist
s, and nurse practitioner
s. Pain sometimes resolves promptly once the underlying trauma
or pathology
has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain
, however, frequently requires the coordinated efforts of the management team.
Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering
during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic
measures, such as analgesics, tricyclic antidepressant
s and anticonvulsant
s, interventional procedures, physical therapy, physical exercise
, application of ice and/or heat, and psychological measures, such as biofeedback
and cognitive behavioral therapy.
, physiatrists or psychiatrists
. Palliative care
doctors are also specialists in pain management. Some practitioners have not been fellowship
trained and have opted for certification by the American Board of Pain Medicine which is not recognized by the American Board of Medical Specialties and does not indicate fellowship training. However, the American Board of Anesthesiology and the American Board of Physical Medicine and Rehabilitation have a subspecialty in pain management which is recognized by the American Board of Medical Specialties and does indicate fellowship training. Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain. Interventional procedures - typically used for chronic back pain
- include: epidural steroid injections
, facet joint
injections, neurolytic blocks
, spinal cord stimulator
s and intrathecal
drug delivery system implants. Over the last several years the number of interventional procedures done for pain has grown.
As well as medical practitioners, the area of pain management may often benefit from the input of physiotherapists, chiropractor
s, clinical psychologists and occupational therapist
s, amongst others. Together the multidisciplinary team can help create a package of care suitable to the patient.
Because of the fast growth in the field of pain medicine many practitioners have entered the field, with many of these practitioners being not board certified or being certified by unrecognized boards.
(WHO) recommends a pain ladder
for managing analgesia. It was first described for use in cancer pain
, but it can be used by medical professionals as a general principle when dealing with analgesia for any type of pain. In the treatment of chronic pain, whether due to malignant or benign processes, the three-step WHO Analgesic Ladder provides guidelines for selecting the kind and stepping up the amount of analgesia. The exact medications recommended will vary with the country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.
(acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen
.
such as hydrocodone
, may provide greater relief than their separate use.
or to treat post-operative pain
. Chronic pain
medication is for alleviating long-lasting, ongoing pain.
Morphine
is the gold standard
to which all narcotic
s are compared. Fentanyl has the benefit of less histamine
release and thus fewer side effect
s. It can also be administered via transdermal patch
which is convenient for chronic pain management. Oxycodone
is used across the Americas and Europe for relief of serious chronic pain; its main slow-release formula is known as OxyContin, and short-acting tablets, capsules, syrups and ampules are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, methadone
and buprenorphine
are used less frequently. Pethidine
, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pentazocine
, dextromoramide
and dipipanone
are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. Amitriptyline
is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiate
s are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose
.
medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long-acting or extended release medication is often prescribed in conjunction with a shorter-acting medication for breakthrough pain, or exacerbations.
Most opioid treatment is oral (tablet
, capsule or liquid), but suppositories
and skin patches can be prescribed. An opioid injection
is rarely needed for patients with chronic pain.
Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion
and addiction
may occur.
Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction; a personal or family history of substance abuse is the strongest predictor of aberrant drug-taking behavior. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.
s (NSAID). Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen
and piroxicam
, have limited benefit in chronic pain disorders and with long-term use is associated with significant adverse effect
s. The use of selective NSAIDs designated as selective COX-2 inhibitors
have significant cardiovascular and cerebrovascular risks which have limited their utilization.
and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome
. Drugs such as gabapentin
have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure
.
, the vast majority of which is used off-label for this purpose, orphenadrine
, cyclobenzaprine
, trazodone
and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxant
s and are therefore particularly useful in painful musculoskeletal conditions. Clonidine
has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.
, neuromodulation
, direct introduction of medication and nerve ablation
may be used to target either the tissue structures and organ/systems responsible for persistent nociception
or the nociceptors from the structures implicated as the source of chronic pain.
An intrathecal pump
used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour
and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.
A spinal cord stimulator
is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia
("tingling") sensation that alters the perception of pain by the patient.
(physiatry/physiotherapy) employs diverse physical techniques such as thermal agents and electrotherapy
, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.
has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy
.
involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. In 2003, the World Health Organization
published an article synthesizing the scientific research (controlled trials) of the time, and concluded acupuncture is helpful for the treatment of pain in some cases of acute pain in the epigastric area, facial pain
, headache
, knee pain, low back pain, neck pain, pain in dentistry
, postoperative pain, renal colic
, and sciatica
. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed. This review has been criticized for giving too much weight to low-quality clinical trial
s, and including a large number of trials originating in China
. The latter issue is considered problematic because trials originating in the West
include a mixture of positive, negative and neutral results while all trials in China are positive (attributed to publication bias
rather than fraud). An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal
, concluded there was little difference in the effect of real, sham
and no acupuncture. There is general agreement that acupuncture is of no use even when administered by well-trained practitioners using sterile needles, although further research is appropriate.
concluded low level laser therapy
may be effective in reducing inflammation
and pain, while a 2008 Cochrane collaboration
review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.
, the use of stress reduction and relaxation
, has been found to reduce chronic pain in some patients.
Applied behavior analysis
views chronic pain as a consequence of both respondent
and operant conditioning
, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976. The behavioral model has shown effectiveness in reducing pain responses though operant based interventions.
Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.
based on behavioral principles has shown some success for chronic pain, demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.
in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283)
to the frail elderly. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS
patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.
In the United States, Hispanic and African Americans are more likely to suffer needlessly in the hands of a physician than whites; and women's pain is more likely to be undertreated than men's. It is often recognized that a great number of patients suffering from chronic pain are being under-treated because physicians fail to provide comprehensive pain treatment. This failure may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz
), despite the relative rarity of prosecutions (147 cases across USA in 2006), or physicians' poor understanding of the health risks attached to opioid prescription. As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse, the North American medical and health care communities appear to be undergoing a shift in perspective. The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.
Strategies currently applied for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.
Quality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...
of those living with pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapist
Occupational therapist
An occupational therapist is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of "purposeful activity or interventions designed to achieve functional...
s, and nurse practitioner
Nurse practitioner
A Nurse Practitioner is an Advanced practice registered nurse who has completed graduate-level education . Additional APRN roles include the Certified Registered Nurse Anesthetist s, CNMs, and CNSs...
s. Pain sometimes resolves promptly once the underlying trauma
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
or pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
has healed, and is treated by one practitioner, with drugs such as analgesics and (occasionally) anxiolytics. Effective management of long term pain
Chronic pain
Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and...
, however, frequently requires the coordinated efforts of the management team.
Medicine treats injury and pathology to support and speed healing; and treats distressing symptoms such as pain to relieve suffering
Suffering
Suffering, or pain in a broad sense, is an individual's basic affective experience of unpleasantness and aversion associated with harm or threat of harm. Suffering may be qualified as physical or mental. It may come in all degrees of intensity, from mild to intolerable. Factors of duration and...
during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Treatment approaches to long term pain include pharmacologic
Pharmacology
Pharmacology is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function...
measures, such as analgesics, tricyclic antidepressant
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
s and anticonvulsant
Anticonvulsant
The anticonvulsants are a diverse group of pharmaceuticals used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many seem to act as mood stabilizers, and in the treatment of neuropathic pain. The goal of an...
s, interventional procedures, physical therapy, physical exercise
Physical exercise
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness. It is performed for various reasons including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, as well as for the purpose of...
, application of ice and/or heat, and psychological measures, such as biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
and cognitive behavioral therapy.
Medical specialties
Pain management practitioners come from all fields of medicine. Most often, pain fellowship trained physicians are anesthesiologists, neurologistsNeurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
, physiatrists or psychiatrists
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
. Palliative care
Palliative care
Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients...
doctors are also specialists in pain management. Some practitioners have not been fellowship
Fellowship
Fellowship may refer to:* An academic position: see fellow* A merit-based scholarship, or form of academic financial aid* Fellowship , a period of medical training after a residency...
trained and have opted for certification by the American Board of Pain Medicine which is not recognized by the American Board of Medical Specialties and does not indicate fellowship training. However, the American Board of Anesthesiology and the American Board of Physical Medicine and Rehabilitation have a subspecialty in pain management which is recognized by the American Board of Medical Specialties and does indicate fellowship training. Some practitioners focus more on the pharmacologic management of the patient, while others are very proficient at the interventional management of pain. Interventional procedures - typically used for chronic back pain
Back pain
Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.The pain can often be divided into neck pain, upper back pain, lower back pain or tailbone pain...
- include: epidural steroid injections
Epidural
The term epidural is often short for epidural analgesia, a form of regional analgesia involving injection of drugs through a catheter placed into the epidural space...
, facet joint
Zygapophysial joint
A zygapophysial joint is a synovial joint between the superior articular process of one vertebra and the inferior articular process of the vertebra directly above it...
injections, neurolytic blocks
Cordotomy
Cordotomy is a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature perception. This procedure is commonly performed on patients experiencing severe pain due to cancer or other diseases for which there is currently no...
, spinal cord stimulator
Spinal Cord Stimulator
A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic pain. Spinal cord stimulation , in the simplest form, consists of stimulating electrodes, implanted in the epidural space, an electrical pulse generator, implanted in the lower...
s and intrathecal
Intrathecal
Intrathecal is an adjective that refers to something introduced into or occurring in the space under the arachnoid membrane of the brain or spinal cord...
drug delivery system implants. Over the last several years the number of interventional procedures done for pain has grown.
As well as medical practitioners, the area of pain management may often benefit from the input of physiotherapists, chiropractor
Chiropractor
A Chiropractor, according to the Association of Chiropractic Colleges , "focuses on the relationship between the body's main structures – the skeleton, the muscles and the nerves – and the patient's health. Chiropractors believe that health can be improved and preserved by making adjustments to...
s, clinical psychologists and occupational therapist
Occupational therapist
An occupational therapist is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of "purposeful activity or interventions designed to achieve functional...
s, amongst others. Together the multidisciplinary team can help create a package of care suitable to the patient.
Because of the fast growth in the field of pain medicine many practitioners have entered the field, with many of these practitioners being not board certified or being certified by unrecognized boards.
Medications
The World Health OrganizationWorld Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO) recommends a pain ladder
Pain ladder
The pain ladder is a term originally coined by the World Health Organization to describe a method of controlling pain. It was originally described for the management of cancer pain, but is now widely used by medical professionals for the management of all types of pain.The general principle in...
for managing analgesia. It was first described for use in cancer pain
Cancer pain
Pain is a symptom frequently associated with cancer. Cancer can cause pain by irritating or damaging nerves, by stimulating nociceptors , or by releasing chemicals that make nociceptors respond to normally non-painful stimuli. Cancer pain may be caused by the tumor itself or by medical...
, but it can be used by medical professionals as a general principle when dealing with analgesia for any type of pain. In the treatment of chronic pain, whether due to malignant or benign processes, the three-step WHO Analgesic Ladder provides guidelines for selecting the kind and stepping up the amount of analgesia. The exact medications recommended will vary with the country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step.
Mild pain
ParacetamolParacetamol
Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
(acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen
Ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....
.
Mild to moderate pain
Paracetamol, an NSAID and/or paracetamol in a combination product with a weak opioidOpioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
such as hydrocodone
Hydrocodone
Hydrocodone or dihydrocodeinone is a semi-synthetic opioid derived from either of two naturally occurring opiates: codeine and thebaine. It is an orally active narcotic analgesic and antitussive...
, may provide greater relief than their separate use.
Moderate to severe pain
When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted traumaTrauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
or to treat post-operative pain
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
. Chronic pain
Chronic pain
Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and...
medication is for alleviating long-lasting, ongoing pain.
Morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
is the gold standard
Gold standard
The gold standard is a monetary system in which the standard economic unit of account is a fixed mass of gold. There are distinct kinds of gold standard...
to which all narcotic
Narcotic
The term narcotic originally referred medically to any psychoactive compound with any sleep-inducing properties. In the United States of America it has since become associated with opioids, commonly morphine and heroin and their derivatives, such as hydrocodone. The term is, today, imprecisely...
s are compared. Fentanyl has the benefit of less histamine
Histamine
Histamine is an organic nitrogen compound involved in local immune responses as well as regulating physiological function in the gut and acting as a neurotransmitter. Histamine triggers the inflammatory response. As part of an immune response to foreign pathogens, histamine is produced by...
release and thus fewer side effect
Side effect
In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequences of the use of a drug.Occasionally, drugs are...
s. It can also be administered via transdermal patch
Transdermal patch
A transdermal patch is a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream. Often, this promotes healing to an injured area of the body. An advantage of a transdermal drug delivery route over other types of...
which is convenient for chronic pain management. Oxycodone
Oxycodone
Oxycodone is an opioid analgesic medication synthesized from opium-derived thebaine. It was developed in 1916 in Germany, as one of several new semi-synthetic opioids in an attempt to improve on the existing opioids: morphine, diacetylmorphine , and codeine.Oxycodone oral medications are generally...
is used across the Americas and Europe for relief of serious chronic pain; its main slow-release formula is known as OxyContin, and short-acting tablets, capsules, syrups and ampules are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, methadone
Methadone
Methadone is a synthetic opioid, used medically as an analgesic and a maintenance anti-addictive for use in patients with opioid dependency. It was developed in Germany in 1937...
and buprenorphine
Buprenorphine
Buprenorphine is a semi-synthetic opioid that is used...
are used less frequently. Pethidine
Pethidine
Pethidine or meperidine Pethidine (INN) or meperidine (USAN) Pethidine (INN) or meperidine (USAN) (commonly referred to as Demerol but also referred to as: isonipecaine; lidol; pethanol; piridosal; Algil; Alodan; Centralgin; Dispadol; Dolantin; Mialgin (in Indonesia); Petidin Dolargan (in Poland);...
, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pentazocine
Pentazocine
Pentazocine is a synthetically prepared prototypical mixed agonist-antagonist narcotic drug of the benzomorphan class of opioids used to treat moderate to moderately severe pain...
, dextromoramide
Dextromoramide
Dextromoramide is a powerful opioid analgesic approximately three times more potent than morphine but shorter acting. It is subject to drug prohibition regimes, both internationally through UN treaties, and by the criminal law of individual states...
and dipipanone
Dipipanone
Dipipanone is a strong opioid analgesic drug, used for very severe pain in cases where other analgesics are unsuitable, for instance where morphine is indicated but cannot be used due to the patient being allergic to morphine.-Dosage forms:...
are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. Amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiate
Opiate
In medicine, the term opiate describes any of the narcotic opioid alkaloids found as natural products in the opium poppy plant.-Overview:Opiates are so named because they are constituents or derivatives of constituents found in opium, which is processed from the latex sap of the opium poppy,...
s are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose
Opioid overdose
An opioid overdose is due to excessive use of narcotics.It should not be confused with opioid dependency.-Symptoms:Opiate overdose symptoms and signs include: decreased level of consciousness and pinpoint pupil except with meperidine where one sees dilated pupils.-Treatment:Naloxone is very...
.
Opioids
OpioidOpioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long-acting or extended release medication is often prescribed in conjunction with a shorter-acting medication for breakthrough pain, or exacerbations.
Most opioid treatment is oral (tablet
Tablet
A tablet is a pharmaceutical dosage form. It comprises a mixture of active substances and excipients, usually in powder form, pressed or compacted from a powder into a solid dose...
, capsule or liquid), but suppositories
Suppository
A suppository is a drug delivery system that is inserted into the rectum , vagina or urethra , where it dissolves.They are used to deliver both systemically-acting and locally-acting medications....
and skin patches can be prescribed. An opioid injection
Injection (medicine)
An injection is an infusion method of putting fluid into the body, usually with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body...
is rarely needed for patients with chronic pain.
Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion
Drug diversion
In the terminology of the United States Drug Enforcement Administration, diversion is the use of prescription drugs for recreational purposes. The term comes from the "diverting" of the drugs from their original purposes...
and addiction
Substance use disorder
Substance use disorders include substance abuse and substance dependence. In DSM-IV, the conditions are formally diagnosed as one or the other, but it has been proposed that DSM-5 combine the two into a single condition called "Substance-use disorder"....
may occur.
Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction; a personal or family history of substance abuse is the strongest predictor of aberrant drug-taking behavior. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.
Non-steroidal anti-inflammatory drugs
The other major group of analgesics are non-steroidal anti-inflammatory drugNon-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
s (NSAID). Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen
Ketoprofen
Ketoprofen, 2--propionic acid is one of the propionic acid class of non-steroidal anti-inflammatory drug with analgesic and antipyretic effects...
and piroxicam
Piroxicam
Piroxicam is a non-steroidal anti-inflammatory drug of the oxicam class used to relieve the symptoms of rheumatoid and osteoarthritis, primary dysmenorrhoea, postoperative pain; and act as an analgesic, especially where there is an inflammatory component...
, have limited benefit in chronic pain disorders and with long-term use is associated with significant adverse effect
Adverse effect
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
s. The use of selective NSAIDs designated as selective COX-2 inhibitors
COX-2 inhibitor
COX-2 selective inhibitor is a form of non-steroidal anti-inflammatory drug that directly targets COX-2, an enzyme responsible for inflammation and pain. Targeting selectivity for COX-2 reduces the risk of peptic ulceration, and is the main feature of celecoxib, rofecoxib and other members of this...
have significant cardiovascular and cerebrovascular risks which have limited their utilization.
Antidepressants and antiepileptic drugs
Some antidepressantAntidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome
Complex regional pain syndrome
Complex regional pain syndrome is a chronic progressive disease characterized by severe pain, swelling and changes in the skin. It often affects an arm or a leg and may spread to another part of the body.Though treatment is often unsatisfactory, early multimodal therapy can cause dramatic...
. Drugs such as gabapentin
Gabapentin
Gabapentin is a pharmaceutical drug, specifically a GABA analogue. It was originally developed for the treatment of epilepsy, and currently is also used to relieve neuropathic pain...
have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure
Seizure
An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...
.
Other analgesics
Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentinGabapentin
Gabapentin is a pharmaceutical drug, specifically a GABA analogue. It was originally developed for the treatment of epilepsy, and currently is also used to relieve neuropathic pain...
, the vast majority of which is used off-label for this purpose, orphenadrine
Orphenadrine
Orphenadrine is an anticholinergic drug of the ethanolamine antihistamine class with prominent CNS and peripheral actions used to treat painful muscle spasms, other similar conditions, as well as the treatment...
, cyclobenzaprine
Cyclobenzaprine
Cyclobenzaprine is a muscle relaxant medication used to relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions. It is the most well-studied drug for this application, and it also has been used off-label for fibromyalgia treatment.- Mechanism of action :The mechanism...
, trazodone
Trazodone
Trazodone is an antidepressant of the serotonin antagonist and reuptake inhibitor class. It is a phenylpiperazine compound...
and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxant
Muscle relaxant
A muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics...
s and are therefore particularly useful in painful musculoskeletal conditions. Clonidine
Clonidine
Clonidine is a sympatholytic medication used to treat medical conditions, such as high blood pressure, some pain conditions, ADHD and anxiety/panic disorder...
has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.
Procedures
Pulsed radiofrequencyPulsed radiofrequency
Pulsed radiofrequency is the technique where by radio frequency oscillations are gated at a rate of pulses per second . Radio frequency energies occupy 1.0 X 104Hz to 3.0 X 1011HZ of the electromagnetic spectrum...
, neuromodulation
Neuromodulation
In Neuromodulation several classes of neurotransmitters regulate diverse populations of central nervous system neurons...
, direct introduction of medication and nerve ablation
Ablation
Ablation is removal of material from the surface of an object by vaporization, chipping, or other erosive processes. This occurs in spaceflight during ascent and atmospheric reentry, glaciology, medicine, and passive fire protection.-Spaceflight:...
may be used to target either the tissue structures and organ/systems responsible for persistent nociception
Nociception
Nociception is defined as "the neural processes of encoding and processing noxious stimuli." It is the afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue...
or the nociceptors from the structures implicated as the source of chronic pain.
An intrathecal pump
Intrathecal pump
An intrathecal pump is a medical device used to deliver very small quantities of medications directly to the spinal fluid of a human being. Medications such as baclofen, morphine, or ziconotide may be delivered in this manner to minimize the side effects often associated with the higher dosages...
used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.
A spinal cord stimulator
Spinal Cord Stimulator
A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic pain. Spinal cord stimulation , in the simplest form, consists of stimulating electrodes, implanted in the epidural space, an electrical pulse generator, implanted in the lower...
is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
("tingling") sensation that alters the perception of pain by the patient.
Physiatry
Physical medicine and rehabilitationPhysical medicine and rehabilitation
Physical medicine and rehabilitation , physiatry or rehabilitation medicine, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. A physician having completed training in this field is referred to as a...
(physiatry/physiotherapy) employs diverse physical techniques such as thermal agents and electrotherapy
Electrotherapy
Electrotherapy is the use of electrical energy as a medical treatment In medicine, the term electrotherapy can apply to a variety of treatments, including the use of electrical devices such as deep brain stimulators for neurological disease. The term has also been applied specifically to the use of...
, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.
TENS
Transcutaneous electrical nerve stimulationTranscutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes...
has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy
Diabetic neuropathy
Diabetic neuropathies are neuropathic disorders that are associated with diabetes mellitus. These conditions are thought to result from diabetic microvascular injury involving small blood vessels that supply nerves in addition to macrovascular conditions that can culminate in diabetic neuropathy...
.
Acupuncture
AcupunctureAcupuncture
Acupuncture is a type of alternative medicine that treats patients by insertion and manipulation of solid, generally thin needles in the body....
involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. In 2003, the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
published an article synthesizing the scientific research (controlled trials) of the time, and concluded acupuncture is helpful for the treatment of pain in some cases of acute pain in the epigastric area, facial pain
Face
The face is a central sense organ complex, for those animals that have one, normally on the ventral surface of the head, and can, depending on the definition in the human case, include the hair, forehead, eyebrow, eyelashes, eyes, nose, ears, cheeks, mouth, lips, philtrum, temple, teeth, skin, and...
, headache
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
, knee pain, low back pain, neck pain, pain in dentistry
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
, postoperative pain, renal colic
Renal colic
Renal colic is a type of abdominal pain commonly caused by kidney stones.-Presentation:The pain typically begins in the abdomen and often radiates to the hypochondrium or the groin. The pain is often colicky due to ureteric peristalsis, but may be constant...
, and sciatica
Sciatica
Sciatica is a set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, or...
. The authors also concluded acupuncture has demonstrated effectiveness in other conditions for which further proof is needed. This review has been criticized for giving too much weight to low-quality clinical trial
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
s, and including a large number of trials originating in China
China
Chinese civilization may refer to:* China for more general discussion of the country.* Chinese culture* Greater China, the transnational community of ethnic Chinese.* History of China* Sinosphere, the area historically affected by Chinese culture...
. The latter issue is considered problematic because trials originating in the West
Western culture
Western culture, sometimes equated with Western civilization or European civilization, refers to cultures of European origin and is used very broadly to refer to a heritage of social norms, ethical values, traditional customs, religious beliefs, political systems, and specific artifacts and...
include a mixture of positive, negative and neutral results while all trials in China are positive (attributed to publication bias
Publication bias
Publication bias is the tendency of researchers, editors, and pharmaceutical companies to handle the reporting of experimental results that are positive differently from results that are negative or inconclusive, leading to bias in the overall published literature...
rather than fraud). An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal
British Medical Journal
BMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...
, concluded there was little difference in the effect of real, sham
Sham surgery
Sham surgery is a faked operative intervention that omits the step thought to be therapeutically necessary. In controlled studies sham surgery is performed in the control population to assess the effect of the intervention under study by neutralizing the placebo effect and reducing bias...
and no acupuncture. There is general agreement that acupuncture is of no use even when administered by well-trained practitioners using sterile needles, although further research is appropriate.
LLLT
A 2007 reviewSystematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
concluded low level laser therapy
Low level laser therapy
Low-level laser therapy is a medical and veterinary treatment that uses low-level lasers or light-emitting diodes to alter cellular function...
may be effective in reducing inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
and pain, while a 2008 Cochrane collaboration
Cochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.
Cognitive and behavioral therapy
Mindfulness-based cognitive therapyMindfulness-based Cognitive Therapy
Mindfulness-based cognitive therapy is psychological therapy which blends features of cognitive therapy with mindfulness techniques of Buddhism. MBCT involves accepting thoughts and feelings without judgement rather than trying to push them out of consciousness, with a goal of correcting...
, the use of stress reduction and relaxation
Relaxation technique
A relaxation technique is any method, process, procedure, or activity that helps a person to relax; to attain a state of increased calmness; or otherwise reduce levels of anxiety, stress or anger...
, has been found to reduce chronic pain in some patients.
Applied behavior analysis
Applied Behavior Analysis
Applied behavior analysis is a science that involves using modern behavioral learning theory to modify behaviors. Behavior analysts reject the use of hypothetical constructs and focus on the observable relationship of behavior to the environment...
views chronic pain as a consequence of both respondent
Classical conditioning
Classical conditioning is a form of conditioning that was first demonstrated by Ivan Pavlov...
and operant conditioning
Operant conditioning
Operant conditioning is a form of psychological learning during which an individual modifies the occurrence and form of its own behavior due to the association of the behavior with a stimulus...
, where a patient learns to display pain behavior in the presence of specific environmental antecedents and consequences. The model was first proposed by Fordyce in 1976. The behavioral model has shown effectiveness in reducing pain responses though operant based interventions.
Though cognitive-behavioral intervention can be an effective and economical means of treating chronic pain, the effects are rather modest and a substantial portion of patients gain no benefit.
Biofeedback
BiofeedbackBiofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
based on behavioral principles has shown some success for chronic pain, demonstrating greater improvement in one study than peers undergoing cognitive-behavioral therapy and conservative medical treatment, though a different study showed improvements over wait-list controls but no difference between biofeedback and cognitive-behavioral therapy.
Hypnosis
A 2007 review of 13 studies found evidence for the efficacy of hypnosisHypnosis
Hypnosis is "a trance state characterized by extreme suggestibility, relaxation and heightened imagination."It is a mental state or imaginative role-enactment . It is usually induced by a procedure known as a hypnotic induction, which is commonly composed of a long series of preliminary...
in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283)
Under-treatment
Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care. This neglect is extended to all ages, from neonatesPain in babies
Pain in babies, and whether babies feel pain, has been the subject of debate within the medical profession for centuries. Prior to the late nineteenth century it was generally considered that babies hurt more easily than adults...
to the frail elderly. In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS
AIDS
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...
patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.
In the United States, Hispanic and African Americans are more likely to suffer needlessly in the hands of a physician than whites; and women's pain is more likely to be undertreated than men's. It is often recognized that a great number of patients suffering from chronic pain are being under-treated because physicians fail to provide comprehensive pain treatment. This failure may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz
William Hurwitz
William E. Hurwitz, M.D., is a Virginia based pain management physician who was aggressively prosecuted and convicted by the United States Government in 2004 for excessively prescribing pain medication to patients, some of whom subsequently abused and redistributed it on the black market. Before...
), despite the relative rarity of prosecutions (147 cases across USA in 2006), or physicians' poor understanding of the health risks attached to opioid prescription. As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse, the North American medical and health care communities appear to be undergoing a shift in perspective. The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.
Strategies currently applied for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.