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Pain and Pain Management Modalities
The anatomy, physiology, and pharmacology of pain and analgesia have been studied extensively. A major advance has been the finding that neural pathways that arise in the brain stem descend to the spinal cord and modulate activity in spinal nociceptive pathways.153 These descending pathways, as well as related pain pathways within and above the spinal cord, respond to opioids and other analgesic drugs as well as physiologic and experimental stimuli, including stress,308 to produce analgesia. It has been speculated that the activation of this descending control system by the action of indigenous opioids such as B-endorphins and enkephalins may account for the phenomenon of placebo analgesia and the apparent analgesic effect of acupuncture in some clinical circumstances.
Pain may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."224 Although the mechanisms of pain and pain pathways are becoming better understood, it should be emphasized that an individual's perception of pain and appreciation of its meaning are complex phenomena that involve psychological and emotional processes in addition to activation of nociceptive pathways.315 Pain intensity is not proportional to the type or extent of tissue damage but may be influenced at many sites within the nervous system. The perception of pain depends on the complex interactions between nociceptive and non-nociceptive impulses in ascending pathways, in relation to the activation of descending pain-inhibitory systems. This framework provides the basis for a comprehensive, multimodal approach to the assessment and treatment of patients with pain and fits with the clinical observation that there is no single approach to effective pain management. Instead, individualized pain management should take into account the stage of disease, concurrent medical conditions, characteristics of pain, and psychological and cultural characteristics of the patient. It also requires ongoing reassessment of the pain and treatment effectiveness.
The best choice of modality often changes as the patient's condition and the characteristics of the pain change. It is important that the effectiveness of analgesic modalities used separately or in combination be carefully assessed. The flowchart indicates the complexity of both the sources of pain and the types of modalities available for managing it. This guideline elaborates on the modalities, making recommendations about their appropriate use. Whenever pain is present, clinicians should provide optimal pain relief by routinely assessing pain and treating it with one or more of the modalities described here.
The WHO ladder portrays a progression in the doses and types of analgesic drugs for effective pain management. When this noninvasive approach is ineffective, alternative modalities include other routes of drug administration, nerve blocks, and ablative neurosurgery. Patients receiving treatments of varying degrees of invasiveness may also benefit from other modalities; the number of patients receiving these modalities either separately or in combination has not been well documented. There is a need for research to determine the effectiveness of many of these modalities used alone or in combination for different patient populations in various settings.
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