Medication Management Philosophy

Physicians have a long history of prescribing, and patients have a long history of using, inappropriate medications, and particularly narcotic medications.

Studies show that patients are usually inadequately treated for acute pain syndromes and over treated for chronic ones. In addition, some physicians mistakenly believe that giving medication on an as-needed basis rather than on a scheduled dosage results in less addiction.

Physicians also tend to incorrectly label patients who respond to a placebo as having a nonorganic type of pain. The goal of pharmacological management of a patient with chronic pain is to moderate or eliminate the use of narcotics, tranquilizers, and hypnotic medications.

This approach usually requires detoxification in an in-hospital or day program. No injectible medications are allowed and patients are switched to an oral preparation as soon as possible.

Initially, patients are usually allowed to take their oral medications on an as-needed basis but with strict record keeping. No new narcotics, tranquilizers, or hypnotic drugs should be prescribed.

Once the daily baseline requirement for the patient is obtained over a few days, a "pain cocktail" approach is used on a time-contingent basis. The pain cocktail typically consists of methadone or a similar preparation in a dose equivalent to the currently used narcotic medication.

It is mixed with a masking vehicle such as cherry syrup. The patient is fully informed in advance that the drug will gradually be withdrawn, but is not told the daily dose of the active ingredient.

The cocktail is given at the dosage and on the time schedule the patient demonstrated in the daily requirement. Gradual reduction of the active ingredient with an equal increase in masking vehicle is carried out over 3 to 6 weeks. Decrements are made slowly so as not to elicit withdrawal sign and symptoms.

Eventually the patient is receiving only the masking vehicle, and the cocktail is discontinued. This cocktail approach of gradually withdrawal can also be used for tranquilizers and hypnotics as well as for narcotic medications.

Studies show that the used of antidepressants, particularly the tricycle antidepressants, lead to a smoother treatment course for the patient with chronic pain.

Psychosocial Interventions

Recent evidence suggests that the use of psychological modalities in conjunction with medical interventions and physical therapy increases the effectiveness of the treatment program.

A wide variety of interventions are available to improve the psychological functioning of the chronic patient. Psychological treatments of chronic pain include psychoeducation, psychotherapy, biofeedback and relaxation training, and vocational counseling.

Cognitive-behavioral approaches to chronic pain rely heavily on skills training and psychoeducational interventions. Group psychotherapy has been used successfully to enhance the functioning of patients in a pain rehabilitation program.

Individual and family therapy are other interventions frequently used with chronic pain patients to treat underlying psychosocial stresses. Recently a compelling case has been made for including family members and significant others in the evaluation and treatment process.

Relaxation training and feedback are behavioral treatment methods, which have been successfully used to treat and sympathetically maintained pain syndromes. There are several relaxation techniques, which can be used for chronic pain, the two most common being autogenic training and progressive muscle relaxation.

Biofeedback is simply a system, which utilizes instrumentation to provide feedback on a variety of physiological responses such as hand temperature, muscle tension, and sweat gland activity to facilitate relaxation and enhance self-regulation of physical processes.

Repeat practice and experience by the patient with relaxation techniques is important to ensure effectiveness.