Acute on chronic pain management

Specialties > Palliative care & EoL care

Background knowledge 🧠

Definition

Acute on chronic pain refers to the exacerbation of pain in a patient who already experiences chronic pain.
It represents a sudden increase in pain intensity, often triggered by a new injury, illness, or procedure.
Can involve any chronic pain condition, including musculoskeletal, neuropathic, or visceral pain.

Epidemiology

Common in populations with chronic conditions such as osteoarthritis, cancer, or fibromyalgia.
Affects a significant portion of the adult population, particularly those over 50 years old.
Increased prevalence in those with multiple comorbidities.
Often underreported and undertreated.

Aetiology and pathophysiology

Acute exacerbation can be due to injury, infection, surgery, or disease progression.
Chronic pain may result from central sensitization, where the nervous system becomes more sensitive to stimuli.
Neuroplastic changes in the brain and spinal cord contribute to the persistence and exacerbation of pain.
Inflammatory processes can heighten pain perception.

Types

Nociceptive pain: typically from tissue damage or inflammation.
Neuropathic pain: arises from nerve damage or dysfunction.
Visceral pain: associated with internal organs, often difficult to localize.
Mixed pain: involves components of nociceptive and neuropathic pain.

Clinical Features 🌡️

Symptoms

Increased intensity of existing pain.
May include sharp, stabbing, or burning sensations depending on the type of pain.
Possible radiation of pain beyond the original site.
Associated symptoms like swelling, redness, or heat in the affected area.
Psychological effects: anxiety, depression, or fear related to pain exacerbation.

Signs

Visible discomfort or distress in the patient.
Possible physical signs depending on the cause (e.g., swelling, bruising).
Increased heart rate, blood pressure, or respiratory rate during episodes.
Guarding or protective behavior to avoid worsening pain.
Altered gait or posture in cases of musculoskeletal pain.

Investigations 🧪

Tests

Thorough history and examination to assess pain characteristics and triggers.
Imaging (e.g., X-ray, MRI) to identify structural causes or new injuries.
Blood tests to rule out infection or inflammatory causes.
Nerve conduction studies if neuropathic pain is suspected.
Pain assessment scales (e.g., Visual Analog Scale) for quantifying pain severity.

Management 🥼

Management

Multimodal approach: pharmacological and non-pharmacological interventions.
Pharmacological: opioids for acute pain, non-opioid analgesics, adjuvant medications (e.g., antidepressants, anticonvulsants).
Non-pharmacological: physiotherapy, cognitive-behavioral therapy, acupuncture.
Consider referral to pain management specialists for complex cases.
Patient education on pain management strategies and realistic expectations.
Regular review and adjustment of the pain management plan.

Complications

Opioid dependence or addiction due to prolonged use.
Chronic disability or reduced quality of life.
Psychological impact: depression, anxiety, or social isolation.
Adverse effects from medications (e.g., gastrointestinal issues, sedation).
Potential for overdose if opioids are misused.

Prognosis

Varies depending on underlying chronic condition and response to treatment.
Early and effective management can prevent chronicity of acute pain episodes.
Long-term outcomes are generally better with a multidisciplinary approach.
Regular follow-up is essential to adjust treatment plans and address emerging issues.

Key points

Acute on chronic pain is a common but complex condition requiring a tailored approach.
Management involves a combination of pharmacological and non-pharmacological therapies.
Regular review and patient education are crucial for effective pain management.
Multidisciplinary involvement improves patient outcomes.
Opioid stewardship is critical to prevent dependence and misuse.

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