Mount Carmel Health Partners Clinical Guidelines Chronic Pain Management

Chronic Non-Cancer Pain Management
Clinical Guideline
Definition: Chronic pain has been defined as pain which lasts beyond the ordinary duration of time that an insult or injury to the body
needs to heal. Duration is usually six weeks or longer.
Types of Pain: Pain mechanisms can be broadly categorized as nociceptive or neuropathic.
Nociceptive Pain: Pain that is caused by the activation of nociceptors, which are sensory neurons found throughout the body. A
nociceptor is a receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged.
Neuropathic Pain: Pain that is initiated or caused by a primary lesion or dysfunction of the nervous system. Normal nociception would
not be considered dysfunction of the nervous system.
Patient presents with chronic pain;
usual duration is more than six weeks
Ohio requires an OARRS
review of repeated
narcotic prescribing or of
narcotic prescriptions for
more than 7 days. Refer
to page 5 for additional
information.
Obtain history and perform a physical
examination including pain assessment;
determine cause of pain, if possible.
Address specific cause; consider referral to
specialist for involvement where indicated
Evaluation
Determine mechanism of pain.
Treatment
Neuropathic
(burning, stabbing, shooting)
e.g., peripheral or central
nervous system conditions;
regional pain syndrome,
Parkinson’s disease, multiple
sclerosis, myelopathies,
stroke
Musculoskeletal
(aching, soreness,
stiffness) e.g.,
fibromyalgia, myofascial
pain, trauma, low back
pain; muscle, tendon, and
ligament pain
Inflammatory
(aching, swelling,
erythema, heat)
Visceral/ Pelvic/Urologic
e.g., endometriosis, irritable
bowel syndrome, chronic
visceral pain, interstitial
cystitis, chronic pancreatitis,
chronic cholecystitis, cancer-
related pain, and
gastroparesis
Mixed
(combination
of pain
patterns)
Educate patient regarding treatment options;
obtain shared goals about outcome of therapy
Ineffective or partial
response: consider next
line of therapy
Initiate first line drug
monotherapy; consider
referral to a specialist; if
pain is controlled,
monitor every 1-3
months or as needed.
(See Box 1 for first line
drug recommendations.)
Consider non-pharmacologic treatments
• physical therapy: reconditioning, stretching exercises, massage manipulation;
trigger point injection, acupuncture
• occupational therapy: body mechanics, work simplification, pacing skills
• psychology: cognitive restructuring, relaxation therapy, stress management
• if pain is controlled, monitor every 1-3 months or as needed
Ineffective or
partial response:
consider next
line of therapy
Initiate second line drug
therapy;
consider referral to a
specialist; if pain is
controlled, monitor
every 1-3 months or
as needed. (See Box 1
for second line drug
recommendations.)
Initiate third line drug therapy;
consider referral to a specialist;
Ineffective or
partial response:
consider next line of
therapy
if pain is controlled, monitor
every 1-3 months or as
needed. (See Box 1 for third
line drug recommendations.)
( See Table C for red-flag
behaviors.)
October 2017