Introduction
- A proportion of patients suffer debilitating physical pain that persist after an initial insult
- Despite extensive investigation including imaging, no reversible cause can be identified
- The pathophysiology is complex and multifactorial and beyond the scope of this article
- The treatments usually fall under the realm of the chronic pain specialist
- Various pharmacological and non-pharmacological techniques are used to modify the transmission of pain signals
- The symptoms can be frustrating for patient and the treating physician. Depression is common.
- An empathic and clear approach should be taken
The Clinical Approach
- Acknowledge that the symptoms that the patient is suffering is real. Do not dismiss their experiences
- Ensure that all reasonable investigations have been exhausted to find a reversible cause
- Redirect the discussion towards elimination of symptoms but the management of symptoms and maximising function
- Be realistic about the uncertainty of prognosis or ultimate ‘cure’
- Don’t give patient’s false hope that a certain intervention will guarantee them benefit particularly if they are highly invasive or risky. Sometimes they can make symptoms worse
- Have measured discussions about the pros and cons of treatment
- Discuss the dangers of long term use of opiate analgesia in terms of patient’s function and its limited benefit
- Ensure that there is continuity of care particularly if short-term opiates are prescribed
- Engage other professionals including physical therapists to maximise function and psychologists to provide psychological strength
- Non-opioid medications may be prescribed such as amitriptiline, carbamazepine and pregabilin
- Advise against having multiple practitioners that results in fragmented care and advice. Referral should be co-ordinated through one clinician.