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Chronic pain 53
rest, immobilization, compression, and elevation are cornerstones of the
treatment of acute injury, these interventions tend to exacerbate chronic
pain and associated disability. In fact, patients with chronic pain can benefit
from an active progressive exercise program. This principle is illustrated by
considering low-back pain, for which “chronic” but not “acute” sufferers reap
benefit from exercise. 1
With variable prevalence, long-standing pain is accompanied by a wide
range of psychosocial issues that either precede or result from the chronic
pain condition. Examples of such issues include depression, dependence,
dysfunction, disability, dramatization, drug addiction, and doctor-shopping.
These conditions render the acute evaluation job a difficult one for the ED
care provider. To optimize the care of this patient population, emergency
physicians should collect a chronic pain history that includes chronic pain
conditions, a detailed listing of medication use and effectiveness, and any
suspicious allergy listings. The patient should be directly queried, without
taking a pejorative tone, about substance abuse problems. The chronic pain
history is frequently aided by consultation of prior records when this information
is available.
While the underlying diagnosis is typically in hand when a patient with
chronic pain presents to the ED, the chronic pain history should include
assessment for any changes associated with the current presentation, compared
with previous episodes. This component of the history is critical, in
order to minimize chances of missing a new life- or limb-threatening process
(e.g. a cauda equina syndrome that has developed in a patient with chronic
back pain).
If an emergent or urgent condition is not present, the next concern should
be in selecting a treatment that does not exacerbate the presenting condition.
When used inappropriately in chronic pain, some agents that are useful for
acute conditions are not only ineffective but also associated with increased
frequency of undesired effects.
Ultimately, the patient with chronic pain needs a regular doctor (and
perhaps a pain specialist) to facilitate optimal management. Such longitudinal
care is essential when certain medications (e.g. opioids) are used over
an extended period. If the patient fails to follow through with longitudinal