Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

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Pain remains as one of the most common reasons for visits to a doctor. Although all doctors are familiar with pain as a complaint, the majority treat pain as a symptom rather than a disease. This, however, only applies to acute pain, which resolves when injured tissues heal. On the other hand, there are a substantial group of patients with chronic pain, defined as pain that persists for more than three months, or beyond the healing period. We must first and foremost realize that chronic pain is different from acute pain, and therefore needs to be approached differently. While acute pain is a symptom, a warning signal of tissue damage, chronic pain should be seen as a disease in its own right ‘ a disease of the nervous system which should be managed independently of the underlying disease.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

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In this paper, non-pharmacological aspects of acute pain management were explored. Much of the research to date with regard to pain management, has been done, addressing the needs of chronic rather than acute pain. It is thought that misconceptions are still held by some health care professionals regarding the adequacy of pharmacology to deal totally with the problems of acute pain management, and it is of more importance to concentrate on issues associated with chronic pain. This is borne out by the relative attention paid to acute and chronic pain in the current body of research. Some aspects of non-pharmacological methods of pain management have been well researched over the last 20 to 30 years, whilst others are more recent innovations. Non-pharmacological aspects of acute pain management were examined under two headings: 1. Psychological approaches: including preoperative information giving, cognitive methods, relaxation training, distraction, guided imagery, humour, hypnosis, music and biofeedback. 2. Complementary therapies and other techniques: including both hands on and other physical therapies using equipment: massage, aromatherapy, reflex zone therapy, acupuncture, shiatsu, therapeutic touch and TENS. There is a sound body of knowledge to support the use of many of the established nonpharmacological methods in the management of acute pain. These include: appropriate preoperative information giving, preoperative relaxation, guided imagery and breathing training, cognitive reframing, distraction in both visual and auditory (music) forms, massage, acupuncture, TENS. Other methods which may be of assistance in acute pain management but are inconclusive in their effect from the current body of available research and may require further examination include: hypnosis, humour therapy, biofeedback techniques, aromatherapy, reflex zone therapy, shiatsu, Therapeutic Touch.

Pain serves to alert a person to potential or actual damage to the body. The definition for damage is quite broad: pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counterproductive. Pain can have a negative impact on a person’s quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person’s health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual’s quality of life.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Yet, the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

Ethnic and cultural values. In some cultures, tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
Age. This refers to the concept that grownups never cry.
Anxiety and stress. This is related to being in a strange, fearful place such as a hospital, and the fear of the unknown consequences of the pain and the condition causing it, which can all combined to make pain feel more severe. For patients being treated for pain, knowing the duration of activity of an analgesic leads to anxiety about the return of pain when the drug wears off. This anxiety can make the pain more severe.
Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.

The perception of pain is an individual experience. Health care providers play an important role in understanding their patients’ pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in theJournal of Advanced Nursing evaluated nurses’ perceptions of a select group of white American and Mexican-American women patients’ pain following gallbladder surgery. Objective assessments of each patient’s pain showed little difference between the perceived severities for each group. Yet, the nurses involved in the study consistently rated all patients’ pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less-educated Mexican-American women. Nurses from a northern European background were more apt to minimize the severity of pain than nurses from eastern and southern Europe or Africa. The study indicated how health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person’s pain.

In a 1990 study reported in the journal Pain, nurses were found to overestimate the severity of pain in patients with severe burns. In most other studies, nurses and physicians ascribe a lower pain severity than do patients.

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body, except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs, or those in the abdomen).Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors, which are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones such as prostaglandins may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight-or-flight response of the body). It normally resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer; persistent and degenerative conditions; and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause such as the majority of cases of low back pain may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve’s connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and non-pharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon the following three-step ladder approach:

Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor’s prescription. NSAIDs include aspirin , ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short duration) pain.
Mild to moderate pain is eased with a milder opioid medication, plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxy-codon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
Moderate to severe pain is treated with stronger opioid drugs, plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given by starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) andcarbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Because these pumps offer the patient some degree of control over the amount of analgesic administered, the system, commonly called patient controlled analgesia (PCA), reduces the level of anxiety about availability of pain medication. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain. These substances would kill the selected cells and thus stop transmission of the pain message.

NON-PHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques such as yoga and meditation are used to focus the brain elsewhere than on the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body’s natural painkillers.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease, even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Tension-type headache (TTH) is the most prevalent headache type and the one with the highest socioeconomic costs.¹ It is a complex disorder in which a range of heterogeneous mechanisms are likely to play a role.² The treatment of an acute episode in patients with infrequent TTH is often straightforward. However, in patients with frequent headaches, biological mechanisms – in particular increased sensitivity of the central nervous system³ – and psychological mechanisms often complicate treatment. It is important to consider which mechanisms may be important for the individual patient and to tailor the treatment accordingly.
The diagnostic problem most often encountered is the difficulty of discriminating between TTH and mild migraines. Measures towards attaining a correct diagnosis include keeping a headache diary⁴ over at least four weeks. The diary may also reveal triggers and medication overuse, and it will establish the baseline against which to measure the efficacy of treatments. Identification of a high intake of analgesics is essential as other treatments are largely ineffective in the presence of medication overuse.⁵ Significant co-morbidity, e.g. anxiety or depression, should be identified and treated concomitantly. It should be explained to the patient that frequent TTH can only rarely be cured, but that a meaningful improvement can be obtained with the combination of non-drug and drug treatments. These treatments are described separately in the following article, but should go hand in hand.

Non-pharmacological Management

Information, Reassurance and Identification of Trigger Factors

Non-drug management is widely used and should be considered for all patients with TTH. However, the scientific evidence for the efficacy of most treatment modalities is sparse. The fact that the physician is concerned about the problem may have a therapeutic effect, particularly if the patient is troubled about serious disease, e.g. brain tumour, and can be reassured by a thorough examination. A detailed analysis of trigger factors should be performed, since avoidance of trigger factors may have a long-lasting effect. The most frequently reported triggers for TTH are stress (mental or physical), irregular or inappropriate meals, high intake of coffee and other caffeine-containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced or inappropriate physical exercise, psychological problems, variations during the female menstrual cycle and hormonal substitution.^6,7 Most triggers are self-reported and so far none of the triggers has been systematically tested.
Information about the nature of the disease is important. It can be explained that muscle pain may lead to a disturbance of the brain’s pain-modulating mechanisms,^3,8 so that normally innocuous stimuli are perceived as painful, with secondary perpetuation of muscle pain and risk of anxiety and depression. Moreover, it should be made clear to the patient that the prognosis in the longer run is favourable, since approximately half of all individuals with frequent or chronic TTH experienced remission of their headaches in a 12-year epidemiological follow-up study.⁹

Psychological Treatments

A large number of psychological treatment strategies have been used to treat TTH. Three strategies have reached reasonable scientific support for effectiveness10 and will be described.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Relaxation Training

The goal of relaxation training is to help the patient to recognise and control tension as it arises in the course of daily activities. During the training, the patient sequentially tenses and then releases specific groups of muscles throughout the body. Advanced stages involve relaxation by recall, association of relaxation with a cue word and maintaining relaxation in muscles not needed for the activity currently engaged in.¹⁰

Electromyography Biofeedback

The aim of electromyography (EMG) biofeedback is to help the patient to recognise and control muscle tension by providing continuous feedback about muscle activity. Sessions typically include an adaptation phase, a baseline phase, a training phase – where feedback is provided – and a self-control phase – where the patient practises controlling muscle tension without the aid of feedback.¹⁰

Cognitive–Behavioural Therapy

The aim of cognitive–behavioural therapy is to teach the patient to identify thoughts and beliefs that generate stress and aggravate headaches.¹¹ These thoughts are then challenged, and alternative adaptive coping self-instructions are considered. A variety of exercises may be used to challenge thoughts and beliefs, including experimenting with the adoption of another person’s view of the situation, actively generating other possible views of a situation and devising a behavioural experiment to test the validity of a particular belief.¹⁰
Meta-analyses have concluded that the treatments described above reduce headache by 37–50%, with no significant difference among treatments.¹² However, the exact degree of effect is difficult to estimate because of methodological difficulties of designing appropriate placebo procedures. The most useful information on efficacy derives from a study by Holroyd et al.¹³demonstrating similar improvements in patients with chronic TTH by cognitive–behavioural therapy, treatment with tricyclic antidepressants and a combination of the two treatments. All three treatment strategies reduced the headache index by approximately 30% more than placebo after six months. Patients who received the combination of the two treatments were more likely to show substantial reductions in TTH than patients who received either treatment alone.
Although the psychological treatments seem to have similar efficacy in controlled trials, this is unlikely to be the case for the individual patient. Psychological treatments are relatively time-consuming, and unfortunately there are no documented guidelines about the psychological treatment(s) to choose for the individual patient. Therefore, until scientific evidence is provided, common sense must be used. Thus, it is likely that cognitive–behavioural therapy will be most beneficial for the patient in whom psychological problems or affective distress play a major role, while biofeedback or relaxation training may be preferable for the tense patient.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Physical Therapy

Physical therapy is the most used non-pharmacological treatment of TTH and includes the improvement of posture, relaxation, exercise programmes, hot and cold packs, ultrasound and electrical stimulation, but the majority of these modalities have not been properly evaluated.¹⁴Active treatment strategies are generally recommended.¹⁴ A controlled study¹⁵ combined various techniques such as massage, relaxation and home-based exercises and found a modest effect. It was recently reported that adding craniocervical training to classic physiotherapy was better than physiotherapy alone.¹⁶ A recent study found no significant long-lasting differences in efficacy between relaxation and physical training and acupuncture.¹⁷ Furthermore, spinal manipulation has no effect for the treatment of episodic TTH.¹⁸ Oromandibular treatment with occlusal splints is often recommended, but has not yet been tested in trials of reasonable quality and cannot be generally recommended.¹⁹
It can be concluded that there is a huge contrast between the widespread use of physical therapies and a lack of robust scientific evidence for the efficacy of these therapies. Further studies of improved quality are necessary to either support or refute the effectiveness of physical modalities in TTH.^20,21

Acupuncture and Nerve Block

There are conflicting results regarding the efficacy of acupuncture for the treatment of TTH. A recent large trial found acupuncture to be better than no treatment but not superior to minimal acupuncture,²² while another recent trial²³ found no significant effect of traditional Chinese acupuncture over sham puncture on the primary efficacy parameter, while secondary efficacy parameters indicated a modest effect of traditional acupuncture. Recently, laser acupuncture has been reported as effective,²⁴ while acupuncture-like electrical stimulation was not effective.²⁵ A recent study reported no effect of greater occipital nerve block in patients with chronic TTH.²⁶

Pharmacological Management

Acute drug therapy refers to the treatment of individual attacks of headache in patients with episodic and chronic TTH. Most headaches in patients with episodic TTH are mild to moderate and the patients can often self-manage by using simple analgesics. The efficacy of simple analgesics tends to decrease with increasing frequency of the headaches. In patients with chronic TTH, the headaches are often associated with stress, anxiety and depression. Simple analgesics are usually ineffective, and should be used with caution because of the risk of medication-overuse headache at a regular intake of simple analgesics (over 14 days a month), or of triptans or combination analgesics for more than nine days a month.²⁷ Other interventions such as non-drug treatments and prophylactic pharmacotherapy should be considered. The following discussion on acute drug therapy mainly addresses the treatment of patients with episodic TTH, while the discussion on prophylactic drug therapy addresses the treatment of chronic TTH.

Acute Pharmacotherapy

Simple Analgesics

Most randomised, placebo-controlled trials have demonstrated that aspirin in doses of 500 and 1,000mg²⁸ and acetaminophen 1,000mg^28,29 are effective in the acute therapy of TTH. One study found no difference in efficacy between solid and effervescent aspirin.³⁰ There is no consistent difference in efficacy between aspirin and acetaminophen. The non-steroidal anti-inflammatory drugs (NSAIDs) – ibuprofen 200–400mg, naproxen sodium 375–550mg, ketoprofen 25–50mg and diclofenac potassium 50–100mg – have all been demonstrated to be more effective than placebo in acute TTH.^31,32 Most, but not all, comparative studies report that the above-mentioned NSAIDs are more effective than acetaminophen and aspirin.^31,32 Although simple analgesics are effective in episodic TTH, the degree of efficacy has to be put in perspective. For example, the proportion of patients who were pain-free two hours after treatment with acetaminophen 1,000mg, naproxen 375mg and placebo were 37, 32 and 26%, respectively.²⁹ Thus, efficacy is modest and clearly there is room for better acute treatment of episodic TTH.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Combination Analgesics

The efficacy of simple analgesics is increased by combination with caffeine 64–200mg.^31,33 There are no comparative studies examining the efficacy of combination with codeine. Generally, combination analgesics cannot be recommended because of the increased risk of medication-overuse headache.

Triptans and Muscle Relaxants

Triptans have been reported to be effective for the treatment of interval headaches in patients with migraine,³⁴ which were most likely mild migraines,³⁵ but triptans do not have a clinically relevant effect in patients with episodic TTH.³⁶ Muscle relaxants have not been demonstrated to be effective in episodic TTH.

Conclusions

Simple analgesics are the mainstays in the acute therapy of TTH (see Table 1). Acetaminophen 1,000mg may be recommended as the drug of first choice because of a better gastric side-effect profile.³⁷ If acetaminophen is not effective, ibuprofen 400mg may be recommended because of a favourable gastrointestinal side-effect profile compared with other NSAIDs.³⁷ Physicians should be aware of the risk of developing medication-overuse headache as a result of frequent and excessive use of analgesics in acute therapy.⁵ Triptans, muscle relaxants and opioids do not have a role in the treatment of TTH.

Prophylactic Pharmacotherapy

Prophylactic pharmacotherapy should be considered in patients with headaches for more than 15 days per month, i.e. in patients with chronic TTH. For many years the tricyclic antidepressant amitriptyline has been used. Recently, other antidepressants, NSAIDs, muscle relaxants, anticonvulsants and botulinum toxin have been tested in chronic TTH.

Amitriptyline

Amitriptyline, a tricyclic antidepressant, is the only drug that has been proved to be effective in several controlled trials in TTH. Thus, five out of six placebo-controlled studies found a significant effect of amitriptyline.³⁸ The two most recent studies reported that amitriptyline 75mg/day reduced the headache index (duration x intensity) by 30% compared with placebo.^13,39 The effect was long-lasting (at least six months)¹³ and not related to the presence of depression.³⁹ It is important that patients are not only informed that this is an antidepressant agent, but also that it has an independent action on pain. Amitriptyline should be started at low dosages (10mg/day) and titrated by 10mg weekly, until the patient has either good therapeutic effect or side effects are encountered. The maintenance dose is usually 30–70mg daily administered one to two hours before bedtime to help to circumvent any sedative adverse effects. A significant effect of amitriptyline may be observed as early as the first week on the therapeutic dose.³⁹ Therefore, it is advisable to change to another prophylactic therapy if the patient does not respond after three to four weeks on maintenance dose. The side effects of amitriptyline include dry mouth, drowsiness, dizziness, obstipation and weight gain. Dry mouth was observed in 75% and drowsiness in 53% of chronic TTH patients.³⁹ Discontinuation should be attempted every six to 12 months.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Other Antidepressants

The tricyclic antidepressant clomipramine and the tetracyclic antidepressants maprotiline and mianserin have been reported to be more effective than placebo, while the selective serotonin re-uptake inhibitors (SSRIs) have not been found to be effective.³⁸ Interestingly, antidepressants with action on both serotonin and noradrenaline seem to be as effective as amitriptyline, with the advantage that they are tolerated at the doses needed for the treatment of a concomitant depression. Thus, the noradrenergic and specific serotonergic antidepressant mirtazapine 30mg/day reduced the headache index by 34% more than placebo in difficult-to-treat patients, including patients who had not responded to amitriptyline.⁴⁰ The serotonin and noradrenaline re-uptake inhibitor venlafaxine (150mg/day)⁴¹ reduced headache days from 15 to 12 per month. However, the latter study is difficult to compare with the other studies mentioned because it was a small parallel-group study performed in a mixed group of patients with either frequent episodic or chronic TTH.
A recent study demonstrated that low-dose mirtazapine 4.5mg/day alone or in combination with ibuprofen 400mg/day was not effective in treating chronic TTH. Interestingly, ibuprofen alone increased headache, indicating a possible early onset of medication-overuse headache.⁴²

Miscellaneous Agents

A recent open study reported an effect of the anticonvulsant topiramate 100mg/day.⁴³ Currently, tizanidine, botulinum toxin, propranolol or valproic acid cannot be recommended for the prophylactic treatment of TTH.³⁸

Conclusions

In general, the initial approach to prophylactic pharmacotherapy of chronic TTH is through the use of amitriptyline (see Table 1). Concomitant use of daily analgesics should be avoided. If the patient does not respond to amitriptyline, mirtazapine could be attempted. Venlafaxine or SSRIs could be considered in patients with concomitant depression if tricyclics or mirtazapine are not tolerated. The physician should keep in mind that the efficacy of preventative drug therapy in TTH is often modest, and that the efficacy should outweigh the side effects. More efficient prophylactic drugs with fewer side effects are urgently needed for the preventative treatment of TTH.
As neither non-pharmacological nor pharmacological management is highly efficient, it is usually recommended to combine multiple strategies, although proper evidence is lacking. Therefore, it is reassuring that the first study that has evaluated the efficacy of a multidisciplinary headache clinic has reported positive results.⁴⁴ Treatment results for all patients discharged within one year were evaluated. Patients with episodic TTH demonstrated a 50% reduction in frequency, a 75% reduction in intensity and a 33% absence rate, whereas chronic TTH patients responded with 32, 30 and 40% reductions, respectively.⁴⁴

TTH is a common primary headache with tremendous socioeconomic impact. The establishment of an accurate diagnosis is important before the initiation of any treatment. Non-pharmacological management is crucial. Information, reassurance and identification of trigger factors may be rewarding. Psychological treatments with scientific evidence for efficacy include relaxation training, EMG biofeedback and cognitive–behavioural therapy. Physical therapy and acupuncture are widely used, but the scientific evidence of efficacy is sparse. Simple analgesics are the mainstays for treatment of episodic TTH. Combination analgesics, triptans, muscle relaxants and opioids should not be used, and it is crucial to avoid frequent and excessive use of simple analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is the drug of first choice for the prophylactic treatment of chronic TTH. The efficacy is modest, and treatment is often hampered by side effects. Thus, treatment of frequent TTH is often difficult and multidisciplinary treatment strategies can be useful. The development of specific non-pharmacological and pharmacological managements for TTH with higher efficacy and fewer side effects is urgently needed. Future studies should also examine the relative efficacy of the various treatment modalities, e.g. psychological, physical and pharmacological treatments, and clarify how treatment programmes should be optimised to best suit the patient Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Orthodontics is the area of Dentistry dedicated to the growth, development and relationship between dentition, jaws and face. It also involves corrective treatment of teeth and jaws when they are irregular in alignment, morphology or function. Usually, orthodontic treatment is performed to improve the function and appearance of teeth. This can involve tooth movement by applying forces through fixed, removable or functional appliances [1].

Pain is a recurrent undesirable side effect in orthodontic treatment. It is a complex phenomenon influenced by factors such as age, sex, individual pain threshold and amount of applied force. To achieve orthodontic movement, forces are applied in the dentoalveolar complex, resulting in inflammation or ischemia in the periodontal ligament with subsequent release of histamine, bradykinin, prostaglandins, substance P and serotonin. These mediators stimulate local nerve endings and send pain signals to the brain [2].

Pain experience is reported by 91% to 94% of patients undergoing orthodontic treatment.[3] Perceived as discomfort, dull pain and hypersensitivity in affected teeth, it tends to reach the peak after 24 hours, with decline after the third day of use of the appliance. Pain is a major concern for professionals and patients, and may discourage them seeking, or maintaining orthodontic treatment

There is accumulating evidence that recurring pain symptoms in children are becoming a serious health concern. Children and adolescents who suffer from ongoing pain have negative outcomes not only to their physical health, but also to their emotional and spiritual health. Furthermore, recurrent pain in children may also cause a number of other negative consequences to the child, the family and society. Thus, a non-pharmacological approach to reduce the pain is vital to help children having better quality of life. Objectives: The objective of this review is to determine the best available evidence on the effectiveness of non-pharmacological pain management in relieving chronic pain for children and adolescents. Search strategy: The search strategy aimed to find published studies, between 1956 and 2008 and limited to the English or Chinese languages. Reference lists of studies that met the inclusion criteria were searched for additional studies. Types of studies: This review included any systematic reviews, randomized controlled trials and quasi-experimental design that explored the effectiveness of non-pharmacological intervention for chronic pain in children and adolescents. Types of participants: Children and adolescents with cancer pain, Juvenile chronic arthritis, sickle cell disease, burn pain, chronic or recurrent abdominal pain, headache and aged 18 years old or less and suffering with pain for at least one month. Types of interventions: The review considered studies that examined non-pharmacological interventions in relieving chronic pain for children and adolescents that included heat wrap therapy, massage, chiropractic spinal manipulative therapy, cognitive-behavioral therapy (distraction & guided imagery), meditation, progressive muscle relaxation, self-hypnosis, biofeedback, music therapy, and dance training. Types of outcome measures: The primary outcome measures included: (1) Behavioral variables, such as pain behavior, cognitive coping and appraisal, psychiatric reaction (anxiety and depression), and social activities, (2) Quality of life scores and (3) Pain scores. Types of setting: The review focuses on studies that operated either at a hospital or in a community setting. Data collection and analysis: Meta-analysis was used to pool the data from studies to determine the effectiveness of the intervention. The Comprehensive Meta Analysis V2 was used to manage the data. Results: The search process identified 43,100 studies that addressed the objectives of the review protocol. Fifty-four articles were selected for critical appraisal. Finally, 31 trials were considered to be eligible for the present review and 5 articles were excluded. Data was pooled together from eight articles using meta-analysis to examine the effectiveness of relaxation training of the pre-test and post-test of headache intensity. The findings show that the effective size was 0.323 with significant difference. Two of the articles evaluate the effectiveness of relaxation training for releasing the recurrent headaches for adolescents and the post-test data were collected over the following six months. The findings show that there is a statistically significance difference. Another two articles examined the effectiveness of a relaxation training program in reducing the sum of medication used of adolescents with recurrent headaches. The findings show that there is no statistical significance. Furthermore, the findings show that biofeedback treatment could improve the outcome of children and adolescents’ headache, especially at 6 and 12 months after the treatment. In terms of psychosocial treatment, five articles examined the effectiveness of behavioral treatment, relaxation training program, cognitive behavior therapy, and acupuncture/ hypnosis intervention to reduce anxiety of children and adolescent with chronic pain. The various outcomes measures among the five studies. Conclusions: This review has provided an evidence-based guide to future priorities for clinical practice. Relaxation programs could reduce recurrent headache and pain intensity in children and adolescents in the short term as well as lasting for three and six months. Furthermore, biofeedback treatment could reduce recurrent headache of pain intensity in children and adolescents in the short term and last for as long as six months.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

This is the group that continues to frustrate the health care provider, coming repeatedly with the same complaints of pain with only temporary relief from usual treatments for pain, including drugs and injections. In many cases these patients come back complaining of adverse reactions due to the drugs or injections. These complaints include constipation , drowsiness, cardiovascular and respiratory complications, ulcers and gastrointestinal bleeding, liver damage , kidney problems and in some cases even potential to be habit forming.

The bigger challenge in today’s medical world is however, to manage pain effectively with minimal or without any side effects. Looking from this perspective, I came up with the topic of ‘Non-drug modalities as an alternative to reduce side effects in pain management’
REVIEW OF LITERATURE

Side effects are peripheral or secondary effect, especially an undesirable secondary effect of a drug or therapeutic regimen [American Heritage Medical Dictionary, 2007].

Opioids can increase the risk of bone fractures in adults over the age of 60, especially when taken doses higher than 50 milligrams [Journal of General Internal Medicine, 2010].

Taking high doses of ibuprofen for as few as three days can cause gastrointestinal bleeding [American Gastroenterological Association, 2005].

We now have many modalities, including medication, interventional pain management techniques, along with physical therapy and alternative medicine to help reduce the pain [Dr. Sameh Yonan, MD, Hillcrest Cleveland Church].

Stimulating the nerves [Dr.Maya Nagaratnam, Fit4 life, Star. 22 December,2013]

Pain Management: Trends and Challenges [Mary Suma Cardosa, Medical Journal, June 2006]

Successful Pain Management [Dr. Syed Abdul Latiff Alsagoff, Health Today, April 2012]

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Introduction
Pain management also known as pain medicine or algiatry is a branch of medicine employing an interdisciplinary approach to easing the suffering and improving the quality of life of those living with pain. Pain Management is a relatively new field in this part of the world. In countries like United States, Europe and Australia there are medical personnel specially trained in Pain management.

In Malaysia the field of pain management is slowly emerging as an important and integral part of healthcare. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, physician assistants, nurse practitioners, and clinical nurse specialists.

The International Association for the Study of pain defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. In most cases, pain is a sign that a person has been injured,( eg, burning one’s hand on a hot kettle or stepping on a sharp object).

In these instances, pain alerts the person that something is wrong and prompts him/her to take action to protect against it. So, without the sensation of pain to raise the alarm, one may seriously injure him/herself. All pain signals travel to the brain, which in turn, sends out its own pain killer (endorphins) to reduce the pain. (refer to the picture below)

Pain can be classified as either acute or chronic. Acute pain appears suddenly and is generally in response to injury or trauma. It may also be accompanied by anxiety or emotional distress. Chronic pain is when the pain persists even when the underlying injury has healed. It can last for weeks, months or even years.

A pain scale is usually used to measure the intensity of pain on a patient. Pain scales are based on self-report, observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible. Pain scales are available for children and for adults. For children the Wong-Baker Faces Pain Rating Scale offers a more visual representation of pain. It helps the child to pin point the numbered face that best how the child feels.

As for adults, the numerical scale where patients put a number to their pain. This is a rough gauge of how much a patient may be enduring, from a scale of 0-10, with 0 representing no pain and 10 representing unbearable pain. Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Numerical scale of pain intensity for adults.

In Malaysia, the field of pain management is generally practiced by anesthesiologists aided by physiotherapists and clinical nurse specialists. There are two types of pain, acute pain, pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection. The other is chronic pain, pain that lasts beyond the term of an injury or painful stimulus. This can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause. The combined effort of these people should lead the way in changing the approach to the management of pain.

Pain can either be managed by using pharmacological or interventional procedures. Both these procedures are drug based. Drugs are designed with the intention of chemically altering the natural processes of the body in one way or another. As such, side effects are quite common. Whereas some side effects are minor and relatively rare, there are others that can be extremely serious, often leading to serious personal injury or death.

Alternative pain management in the form of non-drug modalities may be explored in an effort to reduce the side effects caused my both pharmacological or interventional procedures. Non-drug modalities includes Acupuncture, Percutaneous Electrical Nerve Stimulation (PENS) and Transcutaneous Electrical Nerve Stimulation (TENS)

Pharmocological procedures in pain management.
Depending on the patient’s acute or chronic pain condition, there may be several types of treatment available that can provide the patient with the pain relief and quality of life he/she deserve. Specifically, pharmacologic pain management focuses on the administration of prescription (Rx) or over-the-counter (OTC) medications to alleviate the pain symptoms.When someone is diagnosed with a serious, life-threatening illness, one of the first things they are likely to worry about is pain. In fact, it’s just about the most common question patients and their caregivers ask. There are effective treatments for pain, and you can put those treatment plans in place ahead of time. It’s also important to know that medications are not the only option available to treat pain in the context of palliative care. For example, radiation therapy can sometimes be helpful in treating pain from tumor growth and in easing bone pain related to cancer.

Paramedicine and the emergency medical services have been moving in the direction of advancing pharmaceutical intervention for the management of pain in both acute and chronic situations. This coincides with other areas of advanced life support and patient management strategies that have been well researched and continue to benefit from the increasing evidence. Even though paramedic practice is firmly focused on pharmacological interventions to alleviate pain, there is emerging evidence proposing a range of nonpharmacological options that can have an important role in pain management. This review highlights literature that suggests that paramedicine and emergency medical services should be considering the application of complementary and alternative therapies which can enhance current practice and reduce the use of pharmacological interventions.

Fibromyalgia (FM) is an idiopathic pain disorder which has been associated with a state of pain amplification and psychological distress [1]. A heterogeneous series of disturbances, mainly involving autonomic, neuroendocrine and neuropsychic systems, is usually present, alongside with symptoms such as sleep disturbance, fatigue, pain, daily function impairment and often stress [2]. The lack of peripheral abnormalities in this disease has led clinicians and researchers alike to question if this syndrome represents a valid entity [3]. However, Harris et al. [4] have suggested that FM is a central nervous system disorder, since FM patients have abnormalities within central brain structures that normally encode pain sensations, leading to a hypersensitivity to pain. For these authors, FM patients do not process the body’s natural pain relievers efficiently, which it may be due to a dysfunction in their analgesic (painkilling) mechanism.

Pain is a common complaint among patients cared for by paramedics [1]. Cases attended by paramedics involve patients who report pain as their chief complaint and symptom that instigated an ambulance call for assistance. In other cases, the sensation of pain will be a component of a constellation of symptoms, and the patient’s report of pain will be an important diagnostic cue that guides the clinical examination. Paramedics will also encounter patients who report persistent pain, but where the pain is unrelated to their current health crisis.

Paramedics have an important role in identifying and reducing the burden of pain. The alleviation of pain is important from a humanitarian perspective, with freedom from pain considered as a basic human right [2]. Pain is also associated with significant morbidity, and as the study of pain evolves, the relationship between poorly managed acute pain and the development of chronic pain syndromes is becoming recognized [3].Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Patients who seek medical care may understandably expect relief from pain, with a study of patients presenting to an emergency department finding a majority that expected relief from their pain, with a significant proportion expecting complete relief [4]. Regardless of the health care setting, pain is a frequently reported symptom. For paramedics, an encounter with a patient reporting pain is a common event [5].

The provision of reassurance and comfort for the relief of pain and distress has been described as a primary goal of paramedics and emergency medical services (EMS) [6]. However, reassurance alone may provide inadequate relief of pain. Prior to the introduction of advanced levels of training and clinical guidelines for the administration of analgesics, the management of pain in patients who were injured relied on techniques such as splinting fractures so that the immobilized limb was less likely to move and exacerbate tissue injury resulting in further pain. While there are still rudimentary skills used, paramedic practice has advanced and become more specialised and now includes the administration of a range of pharmacological agents to relieve or minimize pain [7, 8]. These now include opioids, nonsteroidal anti-inflammatories, paracetamol, NMDA-receptor antagonists, methoxyflurane, and local anaesthetics for nerve blocks. Morphine is commonly used for the treatment of pain, and this drug is considered the “gold standard” against which other analgesics are measured [9]. The efficacy of opioids such as morphine and fentanyl for the management of severe pain in the paramedic practice setting has been established [10].

Over the last two decades, this escalating reliance upon pharmaceuticals for pain management practice has been borne in part by the need to respond to societal expectations. In addition, pain management has been identified as a key performance indicator by some EMS. In Australia, the Council of Ambulance Authorities (CAA) has identified that the quality of pain relief is a surrogate measure of compassion and caring and has recently recommended that EMS develop and adopt clinical performance indicators that include the reduction of pain [22]. However, this is not a binding recommendation and national data relating to the adoption of pain management performance indicators by Australian EMS is not widely available.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

The acknowledgement of pain management as an important component of paramedic practice is reflected by the use of evidence-based guidelines for the relief of pain. However, these almost exclusively focus on acute pain and pharmacological interventions. References to nonpharmacological therapies in Australian clinical guidelines for paramedics are uncommon, with the exception of traditional measures such as splinting, cooling, and reassurance. References to complementary and alternative therapies such as acupuncture are rare in the paramedic literature and resources that support paramedic education [23, 24]. Although uncommon in Australian paramedic curricula, nonpharmacological therapies for pain relief feature consistently in the practice of several allied health disciplines, with cognitive-behavioral and complementary therapies included in the International Association for the Study of Pain Core Curriculum for Health Professionals [25].

Nonpharmacological interventions to alleviate pain rely on the inhibition of pain signalling. Pain arises from nociceptive transmission through small afferents to the spinal cord and then to higher brain nuclei and the cerebral cortex. Nociceptive signals are mediated by peripheral and central components that may facilitate or inhibit this input [26]. These signals are modulated by midbrain networks which exert bidirectional control over nociceptive transmission through the spinal cord. Several neurotransmitters are involved in mediating nociceptive signals including substance P which facilitates transmission and endogenous opioid-based compounds that inhibit transmission [27]. Nonpharmacological analgesia therefore involves the inhibition of nociceptive input by activating separate antinociceptive outputs. Procedures such as transcutaneous electrical nerve stimulation (TENS) and acupoint stimulation rely on inhibiting the nociceptive signal to induce an analgesic effect.

Nonpharmacological approaches to the relief of pain are more commonly associated with nonacute settings and may be classified as follows:(i)psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions),(ii)acupuncture and acupressure,(iii)transcutaneous electrical nerve stimulation,(iv)physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic).

These approaches to pain management may complement or indeed substitute pharmacological therapy in some types of pain. Chronic pain (which is also commonly encountered in paramedic practice) is one situation where a range of interventions may be used to manage complex health problems such as cancer pain, lower back pain, and specific diseases associated with pain such as endometriosis. Evidence of efficacy is variable, and this may be due to the type of pain, type of intervention, patient characteristics, skill and experience of the clinician, and heterogeneous study populations. For example, significant variability in the efficacy of acupuncture has been reported in the literature [28].

The use of these therapies to manage acute pain, such as pain arising from trauma or tissue injury associated with inflammation or ischemia, is rarely described in the literature. The role of alternatives in pharmacotherapy is acknowledged by the Australian and New Zealand College of Anaesthetists (ANZCA), albeit as adjunctive or complementary therapy [29]. When describing pain management in the emergency health setting, the ANZCA recommends “ice, elevation, and splinting for injuries” as well as reassurance as the mainstays of nonpharmacological management of pain [29].Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

This paper will appraise the current evidence of nonpharmacological interventions for pain management in the paramedic practice setting, either as complementary therapies or as alternatives to pharmacological interventions. Our review will focus upon acupuncture and acupressure, TENS, and the use of warming as all simple measures that may be implemented and would potentially complement current paramedic pain management guidelines. This contributes to the knowledge base for paramedic pain management practice and should inform future research that seeks to establish the role for nonpharmacological therapies in the relief of pain. For data sources, electronic literature searches were conducted using Medline, Embase, the Cochrane Library, and Cinahl (EBSCO). The search terms used were “paramedic” OR “CAM” OR “acupuncture” OR “acupressure” OR “TENS.”

2. Transcutaneous Electrical Nerve Stimulation (TENS)

Alternative approaches to paramedic-initiated analgesia such as TENS have been reported in the literature [30, 31]. However, research into the use of nonpharmacological interventions in paramedic practice is limited. This lack of research may reflect the developing status of paramedic practice as an allied health profession. There may also be limited impetus for research in this area if nonpharmacological interventions are deemed to be inappropriate for the management of pain associated with acute trauma or health emergencies, particularly in an environment where the time taken for each interval in the patient care process is a closely monitored performance indicator. The drive to minimize time spent with each patient is designed to improve operational effectiveness, and this may restrict the use of nonpharmacological therapies that require extended time to deliver the care compared with the intravenous titration of opioids. Furthermore, attitudes among paramedics and service providers regarding the utility of nonpharmacological interventions to relieve pain may inhibit clinical trials that compare the efficacy of these therapies.

Although TENS has been clinically used for over three decades, the mechanisms by which analgesia is produced are only recently being described [32]. Gate control theory is the most common theory used to support the effect of inhibiting pain by TENS. Gate control theory describes how a stimulus that activates nonnociceptive fibers can inhibit pain. Pain is reduced when the area is rubbed or stimulated due to activation of nonnociceptive fibers inhibiting the nociceptive response in the dorsal horn of the spinal cord [33]. In TENS, nonnociceptive fibers are selectively stimulated with electrodes in order to produce this effect and thereby inhibit pain [33].

TENS appears to produce both segmental and descending pain inhibition since inhibition remains after spinalization (removal of descending inhibition) in the animal model [34]. Adenosine also appears to play a role in TENS analgesia since caffeine (adenosine receptor antagonist) significantly reduces the analgesic effect resulting from activation of large diameter fibers [35]. Additionally, concentrations of endogenous opioids have been shown to increase in cerebrospinal fluid following TENS procedure [36].

TENS uses electric current produced by a portable device to stimulate the nerves for therapeutic purposes. Previous intervention trials investigating the effect of TENS on pain are shown in Table 1. One randomized double-blinded study investigating TENS in an EMS setting showed that TENS intervention in female patients () with acute pelvic pain (salpingitis, ovarian cyst, dysmenorrhea, vaginal infection, and vaginal trauma) reduced pain, anxiety, heart rate, nausea, and arteriolar vasoconstriction with an improvement of overall patient satisfaction compared with those () treated with sham TENS [11]. The effect of TENS producing pain relief was further supported in another study in which patients suffering from acute posttraumatic hip pain felt less pain and anxiety with TENS intervention compared with those treated with sham TENS [12]. These observations suggest that TENS could be an effective and fast-acting pain treatment with applications within paramedic practice.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Current treatments for FM include medical, self-management and alternative interventions. Although the number of published studies has risen steadily over the past decade, treatment remains inadequate to reliably resolve persistent symptoms and improve functional limitations and quality of life in most patients [5]. Pharmacotherapy (specially antidepressants), and nonpharmacologic interventions (mainly exercise, occupational therapy and psychological strategies) have shown moderate evidence for efficacy in this regard [6-8]. However, despite the fact that several alternative and complementary therapies (nonmedicinal ones) have shown little clinical benefit [6], 60%-90% of the patients with FM in the United States have reported to have used one or more complementary or alternative treatments in their disease [9] which states the need for further evaluation of this kind of interventions.

There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies.

Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability.

The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursementbarriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

The International Association for the Study of Pain¹definition of pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or described in terms of such damage. Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children². Perquin, et. al.³ analyzed a large representative sample of school children’s pain experiences and found that 25% of the children reported chronic and recurrent pain of 3 months or longer. Children and adolescents who suffer from ongoing pain have negative outcomes not only to their physical health, but also to their emotional and spiritual health. Besides the discomfort of the pain itself, recurrent pain in children may also cause a number of other negative consequences to the child, the family and society. Thus, there is accumulating evidence that recurrent pain symptoms in children are becoming a serious health concern.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Chronic pain includes persistent and recurrent pain with possible fluctuations in severity, quality, regularity and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple organ systems. Ongoing pain is associated with neurosensory changes, and persistent nociception can result in a sensitization of the peripheral and central nervous systems to produce neuroanatomical, neurochemical, and neurophysiological change. Chronic pain may include varying amounts of disability, from none to severe, independent of the amount of tissue damage. Biological, psychological, sociocultural factors are in the developmental context of pain in children.⁴ Thus, a non-pharmacological approach to reduce the pain is vital to help children having better quality of life. The IASP characterized chronic pain as time periods of less than 1 month, 1 to 6 months, and greater than 6 months.¹ Early intervention is very important and essential if it is suspected a child may be developing chronic pain, and it is inappropriate to delay the treatment of chronic pain for longer than one month. Thus, in this study, chronic pain will be defined as pain experienced for equal to or greater than one month.

There are a number of conditions that lead to children and adolescents experiencing chronic pain including chronic abdominal pain, recurrent headache, stomach-ache, backache, vasocclusive pain and cancer pain.

Chronic pain combined with the emotional state and cognitive capacity of an individual can alter the normal sensory and perceptive components of pain. The individuals’ perception of pain is influenced by the interaction of physiologic, psychological and social factors, resulting in prolonged perception of pain. Chronic pain develops when the normal impulse associated with noxious stimuli are altered. Chronic pain in children and adolescents affects their own coping strategies and of their entire family.^5–8 The persistence of pain may become the central focus for the patient and family, distracting from normal daily activities. Unrelieved pain in children may lead to a state of fear that the pain or illness may never resolve, resulting in anxiety that is as debilitating as the pain itself.

The gate control theory of pain emphasis on the modulation of inputs in the spinal dorsal horns and the dynamic role of the brain in pain processes had a clinical as well as a scientific impact. Psychological factors are an integral part of pain processing and new avenues for pain control were open Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Besides the systemic and regional pharmacological interventions, a multi-model approach of treating chronic pain in children is often seen as being effective. Based on the gate control theory, chronic pain tends to move a C-fiber pathway. Once the slow pain message reaches the brain, it takes a pathway to the hypothalamus and limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body, while the limbic system is responsible for processing emotions. The brain also controls pain messages by attaching meaning to the personal and social context in which the pain is experienced. The brain can send signals down the spinal cord to open and close the nerve gates. In times of anxiety or stress, descending messages from the brain may actually amplify the pain signal at the nerve gate as it moves up the spinal cord.

Alternatively, impulses from the brain can “close” the nerve gate, preventing the pain signal from reaching the brain and being experienced as pain. Furthermore, there are some other factors that can open or close the pain gates as messages move up and down the spinal cord. These can be roughly divided into sensory (physical being and activities), cognitive (thoughts), or emotional (feelings) areas. Most of the techniques in developing non-pharmacological treatments were based on these principles. Some of the non-pharmacological interventions that have been commonly used in the treatment of chronic pain is children and adolescents include: increasing activities, relaxation training, message, mind-body therapy (individual psychological therapy, group therapy, art and expression therapy, support therapy), hypnosis therapy, breathing technique, guided imagery, progressive muscle relaxation, biofeedback, cognitive-behavioral training, and music therapy and cognitive behavioral interventions.

A recent Cochrane systematic review identified 18 randomized controlled trails, of which 13 (12 trials of headache and one on the management of abdominal pain in children) provided data suitable for meta-analysis.¹⁰ The main findings of this review was that the number of patients needing to be treated to show benefit for psychological therapies producing more than 50% pain relief compared with control treatments. From the pooled data set the NNT was 2.32 (95% CI 1.96 to 2.88). This compares favorably with numbers needed to treat for other published treatments in chronic pain. A striking finding is the evidence was that psychological therapy for headache can be delivered with good effect at low cost, in community settings, and by trained non-psychologists. Unfortunately these trails reported only analyzable data for non-pharmacological pain relief. It remains unclear whether these treatments are also effective for other outcomes.

The context of pain experience is multidimensional. When we are discussing the parental factors and family factors affects on chronic pain experience of children, there are two dominant theoretical models in which such parent and family factors may be considered: operant-behavioral theories and family systems theories. Operant-behavioral theories are centered on the role of social reinforcement in maintaining maladaptive pain behaviors. Treatments based on operant theories attempt to shift social contingencies through operant conditioning to reinforce well behaviors.

Family systems theories emphasize individuals’ behavior within the context of their family situations, such as the child’s response to pain under the conditions of the family’s overall functioning and role assignment. Treatments stemming from family systems theories attempt to change dysfunctional patterns of relating and communicating using more traditional family therapy approaches to achieve change.^{8, 11–12} Some research investigating the effectiveness of nonpharmacological interventions to relieve children’s and adolescent’s pain include parental factors and dyad factors.¹³

This systematic review will examine the effectiveness of the non-pharmacological pain management for children and adolescents with chronic pain and associated distress and disability. The systematic literature review for study will include children and adolescents with cancer pain, Juvenile chronic arthritis, Sickle cell disease, burn pain, chronic or recurrent abdominal pain, and headache.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Non-pharmacological pain management refers to interventions that do not involve medications. Medications may serve an important part, but non-pharmacological interventions may help just as much and sometimes even more than medications. In fact, utilizing both pharmacological and non-pharmacological methods shows the most benefit for pain control.

Common non-pharmacological interventions include the use of ice, rest, and elevation. If you twist your ankle and it’s painful and swollen, applying an ice pack intermittently can help reduce the swelling and relieve pain. Combine that with rest and elevation for even better results. Staying off your ankle will aid in healing, and elevating the leg will also help with the swelling, which could relieve some of the pain associated with the injury.

Most of us can understand the pain associated with a strained muscle. The use of heat and massage can be helpful in relieving the pain of a strained neck or back muscle. Now, let’s look at some interventions that may not be as common.

The International Association for the Study of Pain (IASP) defines pain as “unpleasant sensory and emotional experience associated to real or potential tissue injury, or described in terms of such injuries. People learn how to use this term through their previous traumatic experiences…”¹. According to the Brazilian Association for the Study of Pain (SBED)²^,³, population longevity associated to increased survival with regard to trauma and chronic diseases favors, in general, the appearance of painful sequelae, fact which requires the development of strategies directing health professional actions to its correct and adequate control.

This means that human resources duly graduated and qualified to lead management processes and attention to evaluate and treat pain are critical and, for such, nurses play an important role considering their responsibilities related to sectoral management, planning of assistance of the team coordinated by them, in addition to generalist and holistic qualification which should involve their graduation.

Nurses have preponderant role on accurate pain evaluation and on promotion, maintenance and recovery of painful patients’ comfort, through the organization of assistance given by them or by the Nursing team to patients with pain⁴.

Nursing care may promote pain relief, which justifies the need for efforts that reproduce assistance patterns specifically aimed at different pain manifestations and perceptions, by using scales and other tools to translate pain intensity and quality, in addition to the use of Nursing care strategies or non-pharmacological interventions to decrease physiological reactions and promote comfort⁵^,⁶. This statement shows the imminent need to prepare Nursing professionals, since their qualification, for the development of such competence⁷.

The reference of Nursing care as additional strategy for pain relief is based on the use of techniques such as music, guided imagery, environmental noise control, touch, massage, physical therapies, in addition to communication itself, as resources to decrease distress secondary to pain, which should be discussed with professionals along their formal and ongoing education process⁸^,⁹.

This justifies this study based on the relevance of strategies which may be used by the Nursing team to contribute to pain management, considering the importance of pain as the fifth vital sign.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

This study aimed at describing Nursing interventions to be taught as strategies for pain relief, according to the perception of nursing professors.

This is a descriptive and exploratory research with qualitative focus of the theme content analysis-type. The study was carried out in a Nursing graduation course of a university located in Mogi das Cruzes. Participated in the study all nurses who have taught, during 2011, Nursing disciplines. Participants have signed the Free and Informed Consent Term (FICT). Data were collected to characterize participants, such as gender, age, graduation time and nursing teaching time, and then a semi-structured interview was carried out and recorded in audio, as from the guiding question: “According to your perception, which are the Nursing interventions to be taught as strategies for pain relief?

Then, recorded interviews were transcribed and after their accurate and thorough reading, they were classified as shown intable 1, being established Registry Units from which Understanding Cores resulted having as reference landmark the Pedagogic Module of the Brazilian Society for the Study of Pain. After analysis, a new regrouping and classification was performed, resulting in Categories. Reflexive and relational analysis of contents was based on theoretical referential, aiming at understanding the meaning of the phenomenon about Nursing graduation professors perception.

The concept of pain has been defined and explained from many dimensions. The International Association for the Study of Pain [1] defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Some studies state that pain is known as the fifth vital sign, and health professionals should monitor and manage it when caring for patients [2, 3]. There are three types of pain, based on where in the body the pain is felt, somatic, visceral, and neuropathic. As observed by previous studies [4], pain has physical harmful effects that may lead to physiologically unsafe conditions. Smeltzer et al.[5] also elaborate that inadequately treated pain has harmful effects such as sleep alterations [6]. Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia [4, 7]. Bernhofer [8] also states that undertreated pain leads to respiratory, cardiac and endocrine complications, and delay in healing and potentiates the onset of chronic pain. Despite the growing awareness on pain management, patients still suffer from unnecessary pain in many hospitals with the resultant negative effects on physical, emotional, and spiritual health and quality of life [9–11]. Pain management is an important aspect of patient care and nurses play a significant role in the acute care setting in providing pain assessment and treatment [9, 12]. The use of nonpharmacological pain relief techniques has been found to be effective with less side effects and complications associated with them (Rakel and Barr, 2010). On a global perspective, the prevailing persistent challenge in the use of nonpharmacological pain techniques has been expressed in many studies as care provider attitude and lack of knowledge [1]. Previous studies reveal that nondrug methods of pain management do the following, diminish pain perception by reducing intensity and increasing pain tolerance, reduce pain-related distress, strengthen coping abilities; and give the patient and family a sense of control over pain [6, 13]. Traditionally, pain management tends to emphasize the use of pharmacological agents. However, pain is influenced by an array of physical and psychosocial factors, and patients differ in their response to pain and to analgesics. Therefore, it is important to have a range of options, including nonpharmacological therapies available, in order to manage patients’ pain effectively. Evidence in the African context shows that pain has been under managed [14]. In Zimbabwe, previous studies do not show many discrepancies in the use of the nonpharmacological pain control methods, with knowledge and attitudes playing a critical factor in terms of practice [6, 7]. Kipkoriri [15] reveals that the majority of women in labour who used nonpharmacological techniques reported control of pain. However uptake of these complementary methods of pain management is still low by both clients and health workers in Zimbabwe [15]. This study is aimed at improving the quality of patient care, providing the nursing fraternity with bases of research areas, widening the scope of nursing practice, and adding nonpharmacological remedies to the registered nurse curriculum [2]. Furthermore, nonpharmacological pain management has not been considered as an option, such that the nursing curriculum has not enucleated it as a subject on its own [6, 7, 16]. This study will assist in improving the acceptance levels and inclusion of nonpharmacological therapies in basic nursing programmes as a topic or subject area to be studied extensively [2]. On the other hand, lack of knowledge together with other barriers to implementation of these therapies has let patients suffer inadequate pain relief [9, 17]. Overall, there has been little utilisation of nonpharmacological pain management modalities [7].Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Non-pharmacological therapies are ways to decrease pain in addition to medicine. Your healthcare provider will help you choose therapies that are right for you. Your provider will explain the advantages for each treatment and which may work best for the cause of your pain. Each person may respond to these therapies differently.

Why is pain control important?

If pain is not treated, it can decrease your appetite and make it difficult for you to sleep. You may feel that you lack energy or the ability to do things. Pain can also affect your mood and relationships with others. Non-pharmacological therapies may help decrease your pain or give you more control over your pain. This can improve your quality of life.

What therapies are used with medicine to help control pain?

Heat helps decrease pain and muscle spasms. Apply heat to the area for 20 to 30 minutes every 2 hours for as many days as directed.
Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel and place it on the area for 15 to 20 minutes every hour, or as directed.
Massage therapy may help relax tight muscles and decrease pain.
Physical therapy teaches you exercises to help improve movement and strength, and to decrease pain.
A transcutaneous electrical nerve stimulation (TENS) unit is a portable, pocket-sized, battery-powered device that attaches to your skin. It is usually placed over the area of pain. It uses mild, safe electrical signals to help control pain.
A spinal cord stimulator (SCS) is an electrode implanted near your spinal cord during a simple procedure. The electrode is connected to a stimulator (a small box). The stimulator sends mild, safe electrical signals to the electrode. The electrical signals help relax the nerves that cause your pain.

What other therapies may help control or reduce pain?

Relaxation techniques can help you relax, relieve stress, and decrease pain. Common relaxation techniques include any of the following:
- Aromatherapy is a way of using scents to relax, relieve stress, and decrease pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and trees. They may be inhaled or used during massages, facials, body wraps, and baths.
- Deep breathing can help you relax and help decrease your pain. Take a deep breath in and then release it slowly. Do this as many times as needed.
- Tense your muscles and then relax them. Start with the muscles in your feet then slowly move up your leg. Then move to the muscles of your middle body, arms, neck and head.
- Meditation and yoga may help your mind and body relax. They can also help you have an increased feeling of wellness. Meditation and yoga help you take the focus off your pain.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper
Guided imagery teaches you to imagine a picture in your mind. You learn to focus on the picture instead of your pain. It may help you learn how to change the way your body senses and responds to pain.
Music may help increase energy levels and improve your mood. It may help reduce pain by triggering your body to release endorphins. These are natural body chemicals that decrease pain. Music may be used with any of the other techniques, such as relaxation and distraction.
Biofeedback helps your body respond differently to the stress of being in pain. Healthcare providers may use a biofeedback machine to help know when your body is relaxed. You will learn what your breathing and heart rate are when you are relaxed. When you are in pain, you practice getting your breathing and heart rate to those levels. This may help you feel more control over your pain.
Self-hypnosis is a way to direct your attention to something other than your pain. For example, you might repeat a positive statement about ignoring the pain or seeing the pain in a positive way.
Acupuncture therapy uses very thin needles to balance energy channels in the body. This is thought to help reduce pain and other symptoms.

Nonpharmacological approaches to the relief of pain are more commonly associated with nonacute settings and may be classified as follows:

(i) psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions),
(ii) acupuncture and acupressure,
(iii) transcutaneous electrical nerve stimulation,
(iv) physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic).

2. Transcutaneous Electrical Nerve Stimulation (TENS)

TENS uses electric current produced by a portable device to stimulate the nerves for therapeutic purposes. Previous intervention trials investigating the effect of TENS on pain are shown in Table 1. One randomized double-blinded study investigating TENS in an EMS setting showed that TENS intervention in female patients (n = 29) with acute pelvic pain (salpingitis, ovarian cyst, dysmenorrhea, vaginal infection, and vaginal trauma) reduced pain, anxiety, heart rate, nausea, and arteriolar vasoconstriction with an improvement of overall patient satisfaction compared with those (n = 33) treated with sham TENS [11]. The effect of TENS producing pain relief was further supported in another study in which patients suffering from acute posttraumatic hip pain felt less pain and anxiety with TENS intervention compared with those treated with sham TENS [12]. These observations suggest that TENS could be an effective and fast-acting pain treatment with applications within paramedic practice.

What is non-pharmacological pain management?

Non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain. Methods of non-pharmacological pain include:Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Education and psychological conditioning

Not knowing what to expect with cancer treatment is very stressful. However, if you are prepared and can anticipate what will happen, your stress level will be much lower.

To decrease your anxiety about cancer treatment, consider the following:

Ask for an explanation of each step of a procedure in detail, utilizing simple pictures or diagrams when available.
Meet with the person who will be performing the procedure and write down answers to questions.
Tour the room where the procedure will take place.
Ask what you can expect as an outcome of the treatment.

Hypnosis

With hypnosis, a psychologist or doctor guides you into an altered state of consciousness. This helps you to focus or narrow your attention to reduce discomfort.

Methods for hypnosis include:

Imagery: Guiding you through imaginary mental images of sights, sounds, tastes, smells, and feelings can help shift attention away from the pain.
Distraction: Distraction is usually used to help children, especially babies. Using colorful, moving objects or singing songs, telling stories, or looking at books or videos can distract preschoolers. Older children and adults find watching TV or listening to music helpful. Use distraction appropriately, and not in place of an explanation of what to expect.
Relaxation/guided imagery: Guiding you through relaxation exercises such as deep breathing and stretching can often reduce discomfort

Other non-pharmacological pain management may utilize alternative therapies such as comfort therapy, physical and occupational therapy, psychosocial therapy/counseling, and neurostimulation to better manage and reduce pain. Examples of these non-pharmacological pain management techniques include the following:

Comfort therapy

Comfort therapy may involve the following:

Companionship
Exercise
Heat/cold application
Lotions/massage therapy
Meditation
Music, art, or drama therapy
Pastoral counseling
Positioning

Physical and occupational therapy

Physical and occupational therapy may involve the following:

Aquatherapy
Tone and strengthening
Desensitization

Psychosocial therapy/counseling

Psychosocial therapy/counseling may involve the following:

Individual counseling
Family counseling
Group counseling

Neurostimulation

Neurostimulation may involve the following:

Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
Acupressure

The United States is in the midst of a public health crisis. Drug overdose deaths have been on the rise over the past fifteen years with more than 64,000 drug related deaths reported in 2016 alone. Opioids play a major role in preventable drug overdose deaths, with prescription opioid related deaths claiming the lives of 19,354 Americans in 2016 according to the Center for Disease Control.1 Since leaving pain untreated is not an option, understanding the analgesic effectiveness of non-opioid modalities and medications for the management of acute and chronic pain is paramount to reducing opioid prescriptions.2 Interventions such as trigger point injection and topical analgesics are gaining interest in the management of musculoskeletal pain as they may treat underlying inflammation and spasm providing relief in lieu of prescription opioids.

This is the fourth essay in Missouri Medicine series originating from the Larry Lewis Symposium in August 2017 concerning the transdisciplinary responses to the current opioid epidemic. The vision of this series is to move beyond solely discussing the epidemic at large and to explore key innovations that can simultaneously support more responsible opioid prescribing while ensuring timely, definitive, and compassionate attention to patient’s pain or substance use disorder across a complex healthcare setting. This essay reviews two alternative treatments to opioids for pain with the goal to treat appropriate patients with non-opioid regimens in order to decrease opioid exposure. The logic is that decreased opioid exposures will be associated with a decrease in the risk of developing an opioid use disorder (OUD) with concomitant decreases in opioid overdoses and deaths.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Musculoskeletal back pain is one of the leading causes of disability among working age Americans and a common presenting complaint in the emergency department and outpatient setting.3 A grossly under recognized cause of muscular pain is Myofascial Pain Syndrome (MPS).4,5 Patients with MPS may present with musculoskeletal pain that is worse with movement, and has a component of referred or regional pain. The vague presenting symptoms can make the accurate identification of trigger point(s) difficult as these findings can mimic other musculoskeletal sources of pain such as fractures, disc herniation, and neuropathy.6 Focal areas of hyperirritable muscle spasm, called trigger points, are a hallmark of this condition. Trigger points are small localized taut bands or nodules within skeletal muscle that are exquisitely painful when palpated, and fully reproduce the reported pain. They are largely due to repetitive strain, chronic musculoskeletal disorders, or acute myofascial injury.7 There are no standardized locations in which trigger points arise. Instead, trigger points can develop in any muscle group, but are most commonly identified in the upper, mid, and low back. 7

History is paramount for diagnosing MPS. Patients presenting with MPS will describe muscular pain exacerbated with movement leading to a decreased range of motion in the affected muscle group, as well as referred pain that does not follow a dermatomal or myotomal distribution.8 The majority of MPS patients report recent acute trauma or repetitive use of the affected area due to occupational demands. The most common muscles involved include the paraspinal cervical muscles of the neck, the upper trapezius muscles, rhomboids, quadratus luborum, and levator scapulae.5 Two important distinguishing features of trigger point pain include the history of pain with movement and the presence of very localized spasm that upon palpation feels like a nodule or taut band. Trigger points are not present in specific predetermined locations but rather develop spontaneously within skeletal muscle. A unique and pathognomonic characteristic of a trigger point includes a local twitch response with application of firm pressure or the insertion of a needle into the trigger point itself Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

MPS referred pain mimics conditions such as headache, radicular back pain, torticollis, temporomandibular joint pain and non-painful conditions such as tinnitus which can complicate or delay the correct diagnosis6. Performing a thorough physical exam is vital because trigger point identification as a root cause can significantly change management.12–14 When attempting to identify trigger points within a muscle it is important to communicate with the patient regarding localized areas of severe maximal pain. Although patients may report global muscle pain and spasm in the affected muscle group, trigger points present as focal taut bands or nodules that are significantly more painful upon palpation than the surrounding tissue.11 No high quality research (randomized controlled trials, meta-analysis) exist to support the accuracy or therapeutic impact of history and physical exam to identify trigger points, nor the effectiveness of injecting these sites in comparison to placebo, non-opioid, or opioid alternatives. In addition, no laboratory or imaging options exist to identify trigger points. In the essays and textbook chapters referenced, the diagnosis of a trigger point is based solely on the history and physical exam leaving open the possibility of multiple forms of diagnostic and therapeutic bias.

Trigger point management may be used in conjunction with a variety of systemic or topical analgesics, muscle relaxants, or varying non pharmacological modalities including ethyl chloride Spray and Stretch techniques, osteopathic manipulative therapy, ultrasonography, massage, or acupuncture. Unfortunately, high-quality effectiveness research quantifying the potential risks and benefits of these techniques is currently lacking.9,15 However, the authors’ experience suggests that trigger point injection provides targeted and immediate relief via direct mechanical inactivation of severe muscle spasm. The procedure is low risk so can be performed in most inpatient and outpatient settings with minimal supplies

What is pain?

Pain is a signal in your nervous system that something may be wrong. It is an unpleasant feeling, such as a prick, tingle, sting, burn, or ache. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen, chest, pelvis, or you may feel pain all over.

There are two types of pain:

Acute pain usually comes on suddenly, because of a disease, injury, or inflammation. It can often be diagnosed and treated. It usually goes away, though sometimes it can turn into chronic pain.
Chronic pain lasts for a long time, and can cause severe problems

What are pain relievers?

Pain relievers are medicines that reduce or relieve pain. There are many different pain medicines, and each one has advantages and risks. Some are over-the-counter (OTC) medicines. Others are stronger medicines, which are available by prescription. The most powerful prescription pain relievers are opioids. They are very effective, but people who take them are at risk of addiction and overdose.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Because of the side effects and risks of pain relievers, you may want to try non-drug treatments first. And if you do need to take medicines, also doing some non-drug treatments may allow you to take a lower dose.

What are some non-drug treatments for pain?

There are many non-drug treatments that can help with pain. It is important to check with your health care provider before trying any of them:

Acupuncture involves stimulating acupuncture points. These are specific points on your body. There are different acupuncture methods. The most common one involves inserting thin needles through the skin. Others include using pressure, electrical stimulation, and heat. Acupuncture is based on the belief that qi (vital energy) flows through the body along paths, called meridians. Practitioners believe that stimulating the acupuncture points can rebalance the qi. Research suggests that acupuncture can help manage certain pain conditions.
Biofeedback techniques use electronic devices to measure body functions such as breathing and heart rate. This teaches you to be more aware of your body functions so you can learn to control them. For example, a biofeedback device may show you measurements of your muscle tension. By watching how these measurements change, you can become more aware of when your muscles are tense and learn to relax them. Biofeedback may help to control pain, including chronic headaches and back pain.
Electrical stimulation involves using a device to send a gentle electric current to your nerves or muscles. This can help treat pain by interrupting or blocking the pain signals. Types include
- Transcutaneous electrical stimulation (TENS)
- Implanted electric nerve stimulation
- Deep brain or spinal cord stimulation
Massage therapy is a treatment in which the soft tissues of the body are kneaded, rubbed, tapped, and stroked. Among other benefits, it may help people relax, and relieve stress and pain.
Meditation is a mind-body practice in which you focus your attention on something, such as an object, word, phrase, or breathing. This helps you to minimize distracting or stressful thoughts or feelings.
Physical therapy uses techniques such as heat, cold, exercise, massage, and manipulation. It can help to control pain, as well as condition muscles and restore strength.
Psychotherapy (talk therapy) uses methods such as discussion, listening, and counseling to treat mental and behavioral disorders. It can also help people who have pain, especially chronic pain, by
- Teaching them coping skills, to be able to better deal with the stress that pain can cause
- Addressing negative thoughts and emotions that can make pain worse
- Providing them with support
Relaxation therapy can help reduce muscle tension and stress, lower blood pressure, and control pain. It may involve tensing and relaxing muscles throughout the body. It may be used with guided imagery (focusing the mind on positive images) and meditation.
Surgery can sometimes be necessary to treat severe pain, especially when it is caused by back problems or serious musculoskeletal injuries. There are always risks to getting surgery, and it does not always work to treat pain. So it is important to go through all of the risks and benefits with your health care provider.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

During the evaluation period, the physician may decide whether a pharmacologic pain management plan will be effective in treating the condition and severity of the pain. If drug treatment is established, there are many types of medications from which the physician may choose to administer, prescribe, or recommend. Pharmacological Pain Management is administered in 6 ways:

(i)Hypodermically by way of a needle injection,
(ii) Intravenously with a catheter inserted into a vein,
(iii) Orally in the form of a capsule, syrup or tablet
(iv) Transdermally through a patch
(v)Topically as a cream,
(vi) Rectally via a suppository.

Narcotics (Opioids) / Analgesics
In pharmacologic pain management, narcotics (opioids) and analgesics may be prescribed to treat acute pain (severe, short-lived pain), post-operative pain, and certain types of chronic pain. Pain management physicians will help determine if pharmacologic (medical) pain management is the right course of action in helping the patient find pain relief and regain control over his/her quality of life. There are a variety of narcotics and analgesics available for pain treatment ,such as Alfentanil, Anileridine, Buprenorphine, Butorphanol, Codeine, Hydrocodone, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Nalbuphine, Oxycodone, Oxymorphone, Pentazocine, Propoxyphene, Remifentanil and Sufentanil.

Muscle Relaxants
Muscle relaxants (often called muscle relaxers or sedatives) are typically used to treat acute muscle problems due to injury, but can be used as part of a comprehensive treatment plan for the management of chronic pain conditions that involve painful muscle strains or spasms. In instances of chronic lower back pain or neck pain, muscle relaxants can reduce pain and increase mobility or range of motion. There are many categories of muscle relaxants available. Muscle relaxants work to reduce muscle tone and relax tight, tense muscles by interrupting the muscle-spasm-pain-anxiety cycle. Muscles are prone to spasm from a variety of causes, resulting in pain that can radiate throughout the body depending on location. Muscle relaxants do not produce a direct effect on the muscle, but instead produce relaxation through a depression of the central nerve pathway (or brain) for more of a total body relaxant.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are considered the most common pain relief and pain control medications. As part of a pharmacologic pain management plan, NSAIDs may be used for acute or breakthrough pain, and chronic pain, such as back or knee pain lasting for more than a few months. Most NSAIDs are taken orally and can be obtained over-the-counter or by a prescription from pain management physicians. Below are some popular over-the-counter and prescription non-steroidal anti-inflammatory drugs.
Over-the ‘counter NSAIDs : Aspirin, Ibuprofen, Ketoprofen, Naproxen Sodium.
Prescription NSAIDs : Oxaprozin, Indomethacin, Etodolac, Nabumetone

NSAIDs work by blocking the production of certain chemicals in the body that cause inflammation, which is characterized by redness, warmth, swelling, and pain. More specifically, non-steroidal anti-inflammatory drugs effectively block the effect of an enzyme called cyclooxygenase that is critical in our body’s production of prostaglandins, which cause inflammation. This enzyme interference decreases the production of prostaglandins and thus decreases pain and swelling.

Corticosteroids
Corticosteroids are a group of anti-inflammatory drugs used in pharmacologic pain management treatment. Short-term acute therapy of corticosteroid medications are often given to provide symptomatic relief of lower back pain, bursitis, cancer pain, and other conditions. Long-term chronic treatment is typically avoided due to the risk of toxicity.
Cortisol is a naturally produced hormone in our body that works to control salt and water balance, regulate metabolism of carbohydrates, fats, and proteins, and suppress inflammation, which in many conditions is the cause of swelling and pain. Corticosteroids are synthetic versions of cortisol and function similarly by blocking the production of substances in the immune system (such as prostaglandins) that trigger allergic and painful inflammatory reactions.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Selective Norepinephrine Reuptake Inhibitors (SNRIs)
Selective norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressant drugs used in pharmacologic pain management to treat chronic neuropathic pain and fibromyalgia, among others. Norepinephrine reuptake inhibitors acts as a reuptake inhibitor for the neurotransmitters norepinephrine (noradrenaline) and epinephrine (adrenaline) by blocking the action of the norepinephrine transporter. Essentially, SNRIs increase adrenaline levels by inhibiting reabsorption (reuptake) into cells in the brain for enhanced neurotransmission ‘ the sending of nerve impulses ‘ to improve and elevate alertness and energy. These medications for pain management are known to have both antidepressant and analgesic qualities.

Side Effects of Pain killers
According to the American Heritage Medical Dictionary, side effects are peripheral or secondary effect, especially an undesirable secondary effect of a drug or therapeutic regimen. Drugs are designed with the intention of chemically altering the natural processes of the body in one way or another. As such, side effects are quite common. Whereas some side effects are minor and relatively rare, there are others that can be extremely serious, often leading to serious personal injury or death. Now we will see the side effects of the various types of pharmacologic pain management we had discussed above.
Narcotics (Opioids) / Analgesics
The analgesic (painkiller) effects of opioids are due to decreased perception of pain, decreased reaction to pain as well as increased pain tolerance. The side effects of opioids include sedation, respiratory depression, constipation, and a strong sense of euphoria. Opioid dependence can develop with ongoing administration, leading to a withdrawal syndrome with abrupt discontinuation.

Opioids are not only well known for their addictive properties, but also for their ability to produce a feeling of euphoria, motivating some to use opioids recreationally.
A 2010 study by the Journal of General Internal Medicine revealed that a group of powerful prescription medications known as opioids can increase the risk of bone fractures in adults over the age of 60, especially when taken doses higher than 50 milligrams.

Muscle Relaxants
General side effects of muscle relaxants include double or blurred vision, dry mouth, nausea, sleepiness, and drowsiness, and it is recommended that these medications are not taken before driving or operating heavy machinery. As with most medications used in pharmacologic pain management, there is a risk for possible addiction or dependence. These drugs must be used with caution and under the strict direction of pain management physicians. Muscle relaxants may interact with some other medicines. It is important that the patient disclose all other medications, including over-the-counter or nonprescription medicines, to his/her doctor prior to initial use, and be sure to report any unusual side effects.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Most people who use NSAIDs do not have any serious complications; however, some people may experience gastrointestinal problems, high blood pressure, kidney damage, and allergic reactions. Less severe side effects can include stomach pain and heartburn, or headaches and dizziness. Before one start taking NSAID medications or begin an NSAID therapy, he /she should talk to the pain management physician and let him know about any other medical problems he/she have, especially hypertension, asthma, kidney, or stomach problems.

When taken in high doses, aspirin and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can cause damage to the lining of the stomach and upper intestine, resulting in an ulcer or gastrointestinal bleeding. Ulcers may induce vomiting and weight loss, or even require surgery if left untreated.
According to a 2005 study by the American Gastroenterological Association, taking high doses of ibuprofen for as few as three days can cause gastrointestinal bleeding. This can cause significant harm to the digestive system, as well as triggering stomach pain.

Corticosteroids
Typically, acute treatment with corticosteroids is well tolerated, but in some cases side effects may include hyperglycemia, fluid retention, and insomnia. However, more serious side effects, such as diabetes, osteoporosis, and decreased immune response, may occur with chronic administration or when this medication is taken over long periods of time. Before undergoing corticosteroid therapy as treatment for pain relief and control, potential risks and benefits should be discussed with a pain management physician.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Selective Norepinephrine Reuptake Inhibitors (SNRIs)
Side effects of (SNRIs) include cough and sore throat, nausea, insomnia, constipation, weight loss, sexual dysfunction, and dilated pupils. These medications for pain can cause high blood pressure as well, so pain management physicians may recommend that patients have their blood pressure monitored frequently during treatment or therapy. In some cases selective norepinephrine reuptake inhibitors may be administered as first-line therapy to reduce side effects.

Alternative Treatments in Pain Management
People are physiologically different, not all people are ‘tolerant’ to drug based pain killers. Some may be ‘tolerant’ to drug based pain killers and some may not be ‘tolerant’. Those who are ‘intolerant’ to these drugs may feel the side effects and as a result has to discontinue the drugs. There may also be cases where patients who do not want to be too dependent on drug based pain killers. As a result they may seek alternative treatments.

Whether it’s because medications are ineffective, too expensive, accompanying side ‘effects or because they don’t want to be too dependent on drugs, a growing number of people are turning to alternative medicine for pain management. Pain is a common complaint among people who seek out such alternative treatments. Pain management is a rapidly growing medical specialty that takes a multi-disciplinary approach to treating all kinds of pain.

Dr. Sameh Yonan, a pain management specialist at the Cleveland Clinic, in U.S.A. says “We now have many modalities, including medication, interventional pain management techniques (nerve blocks, spinal cord stimulators and similar treatments), along with physical therapy and alternative medicine to help reduce the pain,” This clearly indicates, drug based medicines are not the only way of treating pain. This certainly gives hope for those who have a low level of tolerance to drug based medications.

Acupuncture
Acupuncture is a component of traditional Chinese Medicine originated in China over 5,000 years ago. It is based on the belief that living beings have a vital energy, called “qi”, that circulates through twelve invisible energy lines known as meridians on the body. Each meridian is associated with a different organ system. An imbalance in the flow of qi throughout a meridian is how disease begins. Acupuncturists insert needles into specified points along meridian lines to influence the restore balance to the flow of qi. There are over 1,000 acupuncture points on the body. (please refer to pictures in reference section)

Acupuncture is an alternative treatment in pain management which carries no side effects or adverse reactions to the patient. Acupuncture is thought to decrease pain by increasing the release of endorphins, chemicals that block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins that block the message of pain from being delivered to the brain.

Acupuncture may be useful as an accompanying treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis (especially of the knee), and myofascial pain. Acupuncture also may be an acceptable alternative to or may be included as part of a comprehensive pain management program.
Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Relatively few complications from acupuncture have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs. Additionally, there are fewer adverse effects associated with acupuncture than with many standard drug treatments (such as anti-inflammatory medication and steroid injections) used to manage painful musculoskeletal conditions like fibromyalgia, myofascial pain, osteoarthritis, and tennis elbow.

Transcutaneous Electrical Nerve Stimulation (TENS)

Transcutaneous Electrical Nerve Stimulation (TENS) is a medical method of relieving pain without using drugs. TENS equipment consists of a battery operated stimulator with lead wires and 2 or more electrodes which are taped to the skin. By adjusting control knobs on the stimulator one is able to start or stop the electrical impulses and control the intensity of each impulse.
The current, which produces a mild tingling sensation, travels from the stimulator through the lead wires to the electrodes which are placed over the painful areas. The exact electrode placement may be anywhere along this path, but often 1 pair of electrodes is located either at the pain site or near the spine where the nerve pathway connects to the spinal cord.

TENS works by cutting the pain signals off at the pass, stopping them dead in their tracks before they have a chance to arrive at the brain. TENS treatment also triggers the release of the body’s natural pain-fighting endorphins.
TENS has been used to control acute and chronic pain in a wide variety of cases. These include back and neck injuries, pulled muscles, arthritis, migraine headaches, labour and delivery and post-operative recovery. The success of TENS depends in part on how easily the nerve pathway carrying the painful signals can be identified and how accessible they are for placing the electrodes.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper

Percutaneous Electrical Nerve Stimulation (PENS)
Percutaneous Electrical Nerve Stimulation (PENS) is another treatment which carries no side effects to the patients. This particular treatment has emerged in recent years and slowly gaining popularity among patients. In the past, acupuncture and Transcutaneous Electrical Nerve Stimulation (TENS) have been used to effectively treat various forms of arthritic pain. Now, PENS offers a more effective alternative to acupuncture and TENS.

According to Dr. Maya Nagaratnam, a pain specialist pioneering PENS therapy in Malaysia, PENS is similar in concept to TENS, but instead of placing the electrodes on the skin of the affected area, needles are inserted, either around or immediately adjacent to the nerves serving the painful area. The nerves are then stimulated by passing a low-voltage electrical current through the needles. PENS is generally reserved for patients whom fail to get pain relief from TENS. PENS, differs from electrical acupuncture in that the placement of needles for electrical acupuncture is based on traditional Chinese medicine theories regarding the flow of energy or qi through the body. In PENS, the needles are located based on the area of pain. Basically, PENS combines the benefits of acupuncture and TENS.

She further reiterates, in chronic pain, the affected nerves and muscles are hypersensitive and send incorrect electrical impulses. The nerves ‘ misbehave’ by sending off random electrical messages, which cumulatively gives rise to the sensation of pain, along with causing shortened, tense muscles.(refer to the picture above) The hypersensitive spot will eventually also affect the surrounding area, causing the sensation of pain.
PENS therapy causes a tingling sensation (paraesthesia) in the area of the body associated with the pain. It alters the activity of the peripheral nerve, and reduces and controls the sensation of pain. The PENS treatment does not destroy the affected nerves, but makes them less sensitive to pain.
On the workings of PENS, Dr. Maya further elaborates, a low-voltage electrical current is delivered to the fatty layer just below the surface of the skin close to either a specific nerve, or all the nerve endings situated in that area. It is purported that the electrical pulses block the transmission of pain to nerve fibers or may stimulate the release of endorphins or serotonin.
As a concluding note Dr. Maya assures that PENS is useful in treating all forms of chronic pain, including non-specific low back pain, occipital headache, post-surgical pain, post-hernia repair and cancer-related pain (from either surgery or radiotherapy) PENS is also minimally invasive, avoids the risks and expenses of surgery, well tolerated with no side effects. It should be noted though, that PENS is not meant to be used as a single treatment option, but as part of a wider pain management programme.

Conclusion
Understanding the degree of a patient’s pain can prove challenging to even the most experienced of doctors. When it comes to chronic pain ‘where there is an impact on overall function and performance as well as quality of life, correctly assessing the pain and selecting the appropriate treatment is crucial. Considering the health and well-being of the patient has to be the doctor’s first priority.
Pain management has to be tailored to the individual patient, bearing in mind a number of factors: any underlying causes, the patient’s expectations, the functional needs of the patient, and the tolerability of the side-effects that often accompany treatment. Should a patient experience any side-effects due to drug based pain management, alternative pain management should be the next line of treatment.
Accupuncture points on the body.

Accupuncture points on the body.

For this assignment, I took up this topic to explore pain management further. This field of medicine is relatively new to our country. Pain management is an integral part of health all over the world and is constantly being improved. Besides, I also wanted to find out the mechanism of pain, how we respond to it, types of pain, medications to counter it as well as alternative methods to help patients who are intolerant to pain medications.
In doing this assignment, I have a better understanding of pain, medications used in pain management and alternative methods in pain management. I have learnt about the various drug-based medication used in the field of pain management. I also learnt about the side effects that may accompany the administration of these medications. Ultimately, I have learnt about the uses of alternative medicine in pain management.Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper
In any setting, doctor-patient relationship is central to the practice of healthcare. Hence, it is essential for high quality healthcare in the diagnosis and treatment of pain. Doctor-patient relationship forms one of the foundations of contemporary medical ethics. Doctors must find one way or another to give the best medical care to patients since patient welfare is of utmost important. In doing so, doctors may look into alternative medicine if it suits the patient best.
This assignment has served as an eye- opener for me as it is the first step for me to explore the field of pain management further. While doing this assignment I have read and related articles from books, health magazines and most importantly, the internet that has provided various health journals. I also obtained a lot information and improved my knowledge on health through various internet websites. Non-Drug Modalities As An Alternative To Reduce Side Effects In Pain Management Essay Paper