Page 115 Complete Your CE Test Online - Click Here Biofeedback, exercise, relaxation techniques, cognitive behavioral therapy, and avoiding triggers are useful tools to prevent migraine (CDC). Medication for acute pain of migraine includes aspirin, NSAIDS (with or without caffeine), antinausea medication, and migraine-specific triptans (CDC). Neuropathic pain Neuropathic pain is a chronic type of pain that develops when there is tissue injury or dysfunction in peripheral or central nerves ( Copstead & Banasik, 2013). Nerve injury can be a result of tumor growth, surgery, metastatic cancer, radiation or chemotherapy, elevated blood glucose levels, viral infection, or trauma ( Copstead & Banasik). Other examples of neuropathy include these conditions ( Copstead & Banasik, 2013): ● ● Trigeminal neuralgia: Also known as tic douloureux, trigeminal neuralgia affects the trigeminal, or fifth, cranial nerve and causes sporadic and sudden burning and shock-like facial pain that can last from a few seconds to minutes per episode (NINDS, n.d.). An atypical type of trigeminal neuralgia can cause a constant aching and burning pain of lower intensity (NINDS). ● ● Diabetic neuropathy: This is a peripheral nerve disorder caused by diabetes or poor blood sugar control that results in numbness, pain, or tingling in the feet or legs contributing to ulcer or lesion formation as a result of decreased sensation (NINDS, n.d.). ● ● Postherpetic neuropathy: Postherpetic neuralgia is a complex chronic complication of the herpes zoster virus that increases in frequency with age and is the most common neuropathic pain resulting from infection (Johnson, 2014). It is the reactivation of the commonly known chicken pox virus that results in shingles in older adults. Pathologic damage can occur from the skin to the spinal cord and can cause pain from as long as three months to years after the onset of symptoms (Johnson, 2014). ● ● Epidural spinal compression: Compression of the spinal cord can result from various causes, including fracture, tumor, abscess, ruptured disc, or lesion-causing pain and stiffness in the back or neck. ● ● Brachial plexus injuries: These are injuries resulting from damage to a network of nerves leading from the spine to the shoulder, arm, and hand that result in a limp or paralyzed arm or lack of muscle control in the arm, hand, or wrist (NINDS, n.d.). ● ● Phantom limb pain: Pain following amputation of a limb, phantom limb pain is experienced by 60% to 80% of patients following amputation and is severe in 5% to 10% of cases (Nikolajsen & Jensen, 2000). The mechanisms behind the pain are still not thoroughly understood (Nikolajsen & Jensen). Antidepressants and anticonvulsants are the first-line therapy for the treatment of neuropathic pain (Otari, Shete, & Upasani, 2012). The efficacy of opioid therapy for those experiencing neuropathic pain has been found to be uncertain (McNicol, Midbari, & Eisenberg, 2013). Sickle cell disease Sickle cell disease (SCD) is a type of inherited red blood disorder. Abnormal hemoglobin (known as hemoglobin S, or sickle hemoglobin) that is sickle shaped and present in red blood cells causes the cells to stick to vessels resulting in blockages and lack of oxygen to tissues (National Heart, Lung, and Blood Institute [NHLBI], n.d.). Both parents must carry the abnormal hemoglobin gene in order to pass it on to their child. In the United States, African Americans are affected the most by SCD, with 1 in 13 African Americans born with the sickle cell trait, and 1 in 365 African American babies born with sickle cell disease (NHLBI). Although symptoms vary for individuals with SCD, pain is commonly reported. Vaso-occlusive crisis is acute pain experienced by the patient with SCD and is sharp, intense, and stabbing (NHLBI, n.d.). The pain typically occurs in the lower back, legs, arms, abdomen, or chest and can be induced by illness, stress, temperature changes, dehydration, or being at higher altitudes (NHLBI). Sickle cell disease can cause an array of physical complications, many of which are very painful. SCD can also cause a chronic type of pain that greatly affects quality of life for patients. Treatment for acute pain flares caused by SCD includes fluids; NSAIDS; acetaminophen; and complementary therapy, such as massage, relaxation, or heat therapy (NHLBI, n.d.). If pain becomes more severe, stronger pain medication may be indicated. Pain relief for chronic pain from SCD includes NSAIDS, duloxetine, gabapentin, amitriptyline, and opioids (NHLBI). As of July 2017, the FDA has approved the first drug in 20 years to treat SCD, known as L-glutamine, which has been shown to reduce severe complications of the disease in patients older than 5 years (FDA, 2017). Nursing consideration: An open dialogue with the patient experiencing chronic pain should include realistic and measurable goals of treatment and should be re-evaluated frequently. Different approaches to pain management may be necessary, as well as a referral to a pain specialist if available. Self-assessment question 6 The first line of therapy for neuropathic pain is: a. Opioid therapy. b. Benzodiazepines. c. Massage and physical therapy. d. Antidepressants or anticonvulsants. Treatment of chronic pain The treatment goal of chronic pain is to reduce pain to a level where it is tolerable for the patient and the patient is able to function and perform activities of daily living to the best of his ability. Chronic pain treatment should include a multimodal approach using a variety of pain relieving techniques, including pharmacological and nonpharmacological treatments. Opioid therapy may be used in chronic pain situations, but there is a risk of dependency and tolerance to medication as well as opioid-induced hyperalgesia (a form of pain sensitization related to the use of opioids). CDC (2016) recommended the following principles for treatment of chronic pain: ● ● Use nonopioid therapies to their fullest extent. ● ● Address and treat any coexisting mental health conditions, such as depression, anxiety, PTSD. ● ● Use disease-specific treatments when available. ● ● Use first-line medications, such as NSAIDS, acetaminophen, gabapentin/pregabalin, tricyclic antidepressants/ SSRIs; and topical agents, such as lidocaine and capsaicin. ● ● Use multimodal approaches. ● ● Engage patients in their pain management plan. Continuous opioid therapy in patients with chronic pain Continuous opioid therapy (COT) may be an option for patients who experience chronic pain that does not respond to other treatments. A thorough history and physical should be obtained, as well as a risk assessment of substance abuse, misuse, or addiction. A benefit to harm evaluation should be performed before COT and throughout treatment at regular intervals (Chou et al., 2009). A personal history of alcohol or drug abuse is shown to be a strong predictor of potential abuse of opioids (Ives et al., 2006). Informed consent should be sought with a thorough and continuing discussion regarding risks and goals (Chou et al.). Urine drug screens performed intermittently may be useful to evaluate the patient’s adherence to the prescribed medication treatment (Chou et al.).