Nonmalignant Pain Prevention - An Overview

Introduction

Pain is an uncomfortable sensation. The primary reason is tissue damage. Chronic pain lasts for months or years. It can interfere with daily activities. Nonmalignant pain is the type of pain unassociated with cancer. It may or may not be linked to a disease or illness. Further, it is a poorly understood disease state. Moreover, it continues beyond the disease course.

What Is the Underlying Mechanism of Nonmalignant Pain?

The nociceptive system contains the pain receptors that carry stimuli to the brain. Nonmalignant pain results due to the incoordination of the nociceptive system and neural remodeling. Neural remodeling is the essential restructuring of the nervous system. It is essential for the nervous system's function and maturation.

How Is Nonmalignant Pain Evaluated?

Evaluating a patient with nonmalignant pain mandates a systematic approach. The first step is history. A thorough social and psychological history is important. Assessment of points such as substance abuse, depression, anxiety, and mood disorders is paramount. Different assessment techniques are required in a non-verbal patient. For the evaluation and prevention of nonmalignant pain, physicians should determine the pain mechanism. It requires a complete understanding of the cause.

1. Musculoskeletal: It involves the muscles and bones. The pain leads to an ache, soreness, and stiffness.

2. Neuropathic: It pertains to the nerves. The pain is typically stabbing, burning, or shooting.

3. Inflammatory: Swelling, aches, redness, and heat accompany an inflammatory pain.

4. Mechanical Compression: It may cause lower back pain, and tendon, or ligament tear injury.

What Are the Preventive Measures for Nonmalignant Pain?

Physicians should ensure efforts to prevent or limit tissue damage. It encompasses the primary and secondary prevention of pain. Primary prevention means preventing acute pain. It includes preemptive analgesia. Analgesia is the use of pain-relieving medication. Preemptive analgesia means the analgesic medications are started before surgery to reduce pain sensitization. However, secondary prevention refers to the early diagnosis and treatment of acute pain disorder. Prevention is done with nonpharmacological or pharmacological modalities. Non-pharmacological modalities can improve concomitant conditions such as depression, anxiety, and sleep disturbances. The nonpharmacological modalities include:

1. Lifestyle Modifications: Substance use disorder (SUD) is a form of drug addiction. Some patients have SUD. It becomes a challenge to physicians as SUDs are often seen in nonmalignant pain patients. The cessation of tobacco and illicit drugs is very important. Studies show that smokers have worse pain, sleep disorders, psychological disturbances, and mood disorders as compared to non-smokers. Obesity is another factor. Weight loss is an essential preventive measure for nonmalignant pain. Obese patients with nonmalignant pain should stop eating processed foods, incorporate an antioxidant-rich diet, and drink lots of water.

2. Physical: Aerobic exercise is beneficial for musculoskeletal pain conditions such as fibromyalgia. Yoga and stretching help with arthritis, lower back pain, migraine, and fibromyalgia. Other physical therapies are

• Nerve Blocks: Nerve blocks utilize local anesthetics (Lidocaine) to alleviate chronic pain. The injection can also contain anti-inflammatory medication.

• Trigger Point Injections: Trigger points are muscle knots that produce pain at rest or during manipulation. Injections of Lidocaine into the trigger points can help relieve pain. Steroids are also sometimes given to relieve inflammation. Trigger point injections are useful for the neck, shoulder, arms, legs, and back.

• Transcutaneous Electric Nerve Stimulation (TENS): TENS is used for chronic muscle conditions. It uses low-voltage currents to reduce pain.

3. Psychological:

• Biofeedback: Biofeedback helps the patient identify the pain source. It employs the placement of various sensors on the patient’s body. Electromyography (EMG) measures muscle tone. Electroencephalography (EEG) evaluates neural feedback and brain activity. Finally, thermal biofeedback measures skin temperature.

• Cognitive Behavioral Therapy: It is a very beneficial form of psychotherapy. It is effective in decreasing the frequency and intensity of chronic headaches in children and adolescents. CBT works on the patient’s thoughts, feelings, and behaviors.

• Hypnosis: Hypnotherapy is used for the treatment of persistent pain. It decreases pain and improves the patient’s quality of life (QOL). It also helps cope with stress, anxiety, and fear.

• Relaxation: Deep breathing, meditation, massage, and music therapy are well-known relaxation techniques. Studies reveal that listening to music lowers pain intensity levels and medication requirements.

Pharmacological prevention can be done in combination with non-pharmacological modalities. However, physicians should choose non-pharmacological modalities. Pharmacological prevention depends upon the disease mechanism. Multimodal analgesia is the combination of different medication groups to reduce pain. Multimodal analgesia works as a preventive strategy. It enhances the efficacy of medicines, reduces side effects, and improves patients’ QOL.

1. Opioid Analgesics: Opioids are also called narcotics. Physicians use them for persistent and severe pain. Opioids provide short-term relief. However, there is limited data for evaluating the long-term benefits. Long-term use also leads to addiction and adverse effects. Codeine, Fentanyl, and Tramadol are some examples.

2. Non-opioid Analgesics: These include non-steroidal anti-inflammatory drugs (NSAIDs). The most frequently used NSAIDs for nonmalignant chronic pain are Aspirin, Ibuprofen, and Naproxen.

3. Anticonvulsants: Anticonvulsants primarily work against seizures. However, they are also called adjuvant analgesics as they provided added pain relief. These work for chronic neuropathic pain. Carbamazepine, Gabapentin, Lamotrigine, and Clonazepam are the frequently prescribed anticonvulsants for nonmalignant pain.

4. Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the two categories of prescribed antidepressants. SSRIs regulate serotonin levels. Studies show that serotonin influences mood, sleep, and emotions. TCAs increase norepinephrine and serotonin levels. SSRIs and TCAs are used in many chronic nonmalignant pain conditions such as headaches, back pain, nerve disorders, and arthritis. Escitalopram is a common SSRI for chronic pain. Amitriptyline and Nortriptyline are the widely used TCAs.

What Are the Management Options for Chronic Non-malignant Pain?

Physicians should consider some important points in managing chronic nonmalignant pain. Nonmalignant pain is never an emergency. The physician and patient should develop a working relationship. Hence, a series of visits is required for a comprehensive treatment approach. It is different from cancer pain. It is because nonmalignant pain is a slow and advancing process. The physician should diagnose the pain and generate a management plan. The patient’s functional status should also be improved. A nonmalignant pain patient has tried various therapies. Hence, it is helpful to record previous treatment and their clinical response.

Conclusion

Chronic nonmalignant pain prevention and management is a daunting task. The challenges include a lack of corrective therapy and measures indicating patient improvement and the presence of complex concomitant disorders. Physicians should exercise patience in managing these challenges. Further, a goal-oriented and exhaustive care plan is recommended.