Tardive dyskinesia (TD) is an iatrogenic
disorder that results in involuntary repetitive body movements, which
may include grimacing, sticking out the tongue or smacking the lips, which occurs following treatment with medication. Additional motor symptoms include chorea or athetosis. In about 20% of people with TD, the disorder interferes with daily functioning.
If TD is present in the setting of a long-term drug therapy,
reversibility can be determined primarily by severity of symptoms and
how long symptoms have been present before the long-term drug has been
stopped.
Tardive dyskinesia occurs as a result of long-term use of dopamine-receptor-blocking medications such as antipsychotics and metoclopramide. These medications are usually used for mental illness but may also be given for gastrointestinal or neurological problems. The condition typically develops only after months to years of use. The diagnosis is based on the symptoms after ruling out other potential causes.
Efforts to prevent the condition include either using the lowest possible dose or discontinuing use of Antipsychotics.
Treatment includes stopping the antipsychotic medication if possible
(although this may temporarily worsen symptoms) or switching to clozapine. Other medications such as valbenazine, tetrabenazine, or botulinum toxin may be used to lessen the symptoms. With treatment, some see a resolution of symptoms, while others do not.
Rates in those on atypical antipsychotics are about 20%, while those on typical antipsychotics have rates of about 30%. The risk of acquiring the condition is greater in older people, for women, as well as patients with mood disorders and/or medical diagnoses receiving antipsychotic medications. The term tardive dyskinesia first came into use in 1964.
Signs and symptoms
Tardive
dyskinesia is characterized by repetitive, involuntary movements, which
occurs following treatment with medication (hence the term tardive). Some examples of these types of involuntary movements include:
Grimacing
Tongue movements
Lip smacking
Lip puckering
Pursing of the lips
Excessive eye blinking
Rapid, involuntary movements of the limbs, torso, and fingers may also occur.
In some cases, an individual's legs can be so affected that walking becomes difficult or impossible. These symptoms are the opposite of people who are diagnosed with Parkinson's disease. People with Parkinson's have difficulty moving, whereas people with tardive dyskinesia have difficulty not moving.
Respiratory irregularity, such as grunting and difficulty
breathing, is another symptom associated with tardive dyskinesia,
although studies have shown that the rate of people affected is
relatively low.
Tardive dyskinesia is often misdiagnosed as a mental illness rather than a neurological disorder, and as a result, people are prescribed Antipsychotic
drugs, which increase the probability that the person will develop a
severe and disabling case, and shortening the typical survival period.
Other closely related neurological disorders have been recognized as variants of tardive dyskinesia. Tardive dystonia is similar to standard dystonia but permanent. Tardive akathisia
involves painful feelings of inner tension and anxiety and a compulsive
drive to move the body. In some extreme cases, afflicted individuals
experience so much internal tension that they lose their ability to sit
still. Tardive tourettism is a tic disorder featuring the same symptoms as Tourette syndrome.
The two disorders are extremely close in nature and often can only be
differentiated by the details of their respective onsets. Tardive myoclonus, a rare disorder, presents as brief jerks of muscles in the face, neck, trunk, and extremities.
"AIMS Examination": This test is used when psychotropic
medications have been prescribed because people sometimes develop
tardive dyskinesia due to prolonged use of antipsychotic medications.
The Abnormal Involuntary Movement Scale (AIMS) examination is a test
used to identify the symptoms of tardive dyskinesia (TD). The test is
not meant to tell whether there is an absence or presence of tardive
dyskinesia. It just scales to the level of symptoms indicated by the
actions observed. The levels range from none to severe. The AIMS
examination was constructed in the 1970s to measure involuntary facial,
trunk, and limb movements. It is best to do this test before and after
the administration of the psychotropic drugs. Taking the AIMS
consistently can help to track severity of TD over time.
Causes
Tardive dyskinesia was first described in the 1950s shortly after the introduction of chlorpromazine and other antipsychotic drugs.
However, the exact mechanism of the disorder remains uncertain. One
line of evidence suggests that tardive dyskinesia may result primarily
from antipsychotic dopamine supersensitivity in the nigrostriatal pathway,
with the D2 dopamine receptor being most affected. Antipsychotics act
primarily on this dopamine system, and older antipsychotics, which have
greater affinity for the D2 binding site, are associated with high risk
for tardive dyskinesia. The D2 hypersensitivity hypothesis is also supported by evidence of a dose–response relationship, withdrawal effects, studies on D2 agonists and antagonists, animal studies, and genetic polymorphism research.
However, the time-course of tardive dyskinesia and its increased
prevalence in older populations and drug and alcohol users suggest that
dopamine supersensitivity is not a complete explanation. Oxidative
stress is another causal explanation that accounts for the deficits in
the dopamine supersensitivity hypothesis.
Given similar doses of the same antipsychotic, differences among
individuals still exist in the likelihood of developing tardive
dyskinesia. Such individual differences may be due to genetic
polymorphisms, which code for D2 receptor binding site affinity, or
prior exposure to environmental toxins. Decreased functional reserve or
cognitive dysfunction, associated with aging, intellectual disability,
alcohol and drug use, or traumatic head injuries, has also been shown to
increase risk of developing the disorder among those treated with
antipsychotics.
Antipsychotic drugs can sometimes camouflage the signs of tardive
dyskinesia from occurring in the early stages; this can happen from the
individual having an increased dose of an antipsychotic drug. Often the
symptoms of tardive dyskinesia are not apparent until the individual
comes off of the antipsychotic drugs; however, when tardive dyskinesia
worsens, the signs become visible.
Other dopamine antagonists and antiemetics can cause tardive dyskinesia, such as metoclopramide and promethazine, used to treat gastrointestinal disorders. Atypical antipsychotics
are considered lower-risk for causing TD than their typical
counterparts, with incidence rates of 13.1% and 32.4% respectively in
short-term trials primarily utilising Haloperidol as the typical antipsychotic. Quetiapine and clozapine are considered the lowest risk agents for precipitating TD. From 2008, there have been reported cases of the anti-psychotic medication aripiprazole, a partial agonist at D2 receptors, leading to tardive dyskinesia.
As of 2013, reports of tardive dyskinesia in aripiprazole have grown in number.
The available research seems to suggest that the concurrent prophylactic
use of an antipsychotic and an antiparkinsonian drug is useless to
avoid early extrapyramidal
side-effects and may render the person more sensitive to tardive
dyskinesia. Since 1973 the use of these drugs has been found to be
associated with the development of tardive dyskinesia.
Risk factors
An increased risk of tardive dyskinesia has been associated with smoking in some studies, although a negative study does exist. There seems to be a cigarette smoke-exposure-dependent risk for TD in people who are antipsychotic-treated. Elderly people are also at a heightened risk for developing TD,
as are females and those with organic brain injuries or diabetes
mellitus and those with the negative symptoms of schizophrenia. TD is also more common in those that experience acute neurological side effects from antipsychotic drug treatment.
Racial discrepancies in TD rate also exist, with Africans and African
Americans having higher rates of TD after exposure to antipsychotics. Certain genetic risk factors for TD have been identified including polymorphisms in the genes encoding the D3, 5-HT2A and 5-HT2C receptors.
Diagnosis
Diagnosis
is most commonly done by observing the patient's face. The criteria in
which a diagnosis is made is usually followed in a step by step process.
Prevention
Prevention of tardive dyskinesia is achieved by using the lowest effective dose of a Antipsychotic
for the shortest time. However, with diseases of chronic psychosis such
as schizophrenia, this strategy must be balanced with the fact that
increased dosages of antipsychotics are more beneficial in preventing
recurrence of psychosis. If tardive dyskinesia is diagnosed, the
causative drug should be discontinued. Tardive dyskinesia may persist
after withdrawal of the drug for months, years or even permanently. Some studies suggest that practitioners should consider using atypical antipsychotics as a substitute to typical antipsychotics
for people requiring medication. These agents are associated with fewer
neuromotor side effects and a lower risk of developing tardive
dyskinesia.
Studies have tested the use of melatonin, high dosage vitamins, and different antioxidants in concurrence with antipsychotic drugs (often used to treat schizophrenia)
as a way of preventing and treating tardive dyskinesia. Although
further research is needed, studies reported a much lower percentage of
individuals developing tardive dyskinesia than the current rate of
people for those taking antipsychotic drugs. Tentative evidence supports the use of vitamin E for prevention.
Treatment
Valbenazine was approved by the FDA for tardive dyskinesia in April 2017. Tetrabenazine,
which is a dopamine depleting drug, is sometimes used to treat tardive
dyskinesia and other movement disorders (e.g. Huntington's chorea). Deutetrabenazine, an isotopic isomer of tetrabenazine, was approved by the FDA for tardive dyskinesia in August 2017. Vitamin B6 has been reported to be an effective treatment for TD in two randomised double-blind placebo-controlled trials, but the overall evidence for its effectiveness is considered "weak." Clonidine may also be useful in the treatment of TD, although dose-limiting hypotension and sedation may hinder its usage. Botox injections are used for minor focal dystonia, but not in more advanced tardive dyskinesia. As of 2018, evidence is insufficient to support the use of benzodiazepines, baclofen, progabide, sodium valproate, gaboxadol, or calcium channel blockers (e.g. diltiazem).
Epidemiology
Tardive dyskinesia most commonly occurs in people with psychiatric conditions who are treated with antipsychotic
medications for many years. The average rate of people affected has
been estimated to be around 30% for individuals taking antipsychotic
medication, such as that used to treat schizophrenia.
A study being conducted at the Yale University School of Medicine has
estimated that "32% of people develop persistent tics after 5 years on
major tranquilizers, 57% by 15 years, and 68% by 25 years."
More drastic data was found during a longitudinal study conducted on
individuals 45 years of age and older who were taking antipsychotic
drugs. According to this research study, 26% of people developed tardive
dyskinesia after just one year on the medication. Another 60% of this
at-risk group developed the disorder after 3 years, and 23% developed severe cases of tardive dyskinesia within 3 years.
According to these estimates, the majority of people will eventually
develop the disorder if they remain on the drugs long enough.
Elderly people are more prone to develop tardive dyskinesia, and
elderly women are more at-risk than elderly men. The risk is much lower
for younger men and women, and also more equal across the sexes.
Several studies have recently been conducted comparing the number of
people affected of tardive dyskinesia with second generation, or more
modern, antipsychotic drugs to that of first generation drugs. The newer
antipsychotics appear to have a substantially reduced potential for
causing tardive dyskinesia. However, some studies express concern that
the number of people affected has decreased far less than expected,
cautioning against the overestimation of the safety of modern
antipsychotics.
A practitioner can evaluate and diagnose a person with tardive
dyskinesia by conducting a systematic examination. The practitioner
should ask the person to relax, and look for symptoms like facial
grimacing, eye or lip movements, tics, respiratory irregularities, and
tongue movements. In some cases, people experience nutritional problems,
so a practitioner can also look for a gain or loss in weight.
Apart from the underlying psychiatric disorder, tardive
dyskinesia may lead to the social isolation of people with the
condition. It also increases the risk of body dysmorphic disorder
(BDD) and can even lead to suicide. Emotional or physical stress can
increase the severity of dyskinetic movements, whereas relaxation and
sedation have the opposite effect.
Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals
provide some pain control in the normal course of their practice, and
for the more complex instances of pain, they also call on additional
help from a specific medical specialty devoted to pain, which is called pain medicine.
Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain, whether acute pain or chronic pain. Relief of pain in general (analgesia) is often an acute affair, whereas managing chronic pain requires additional dimensions.
Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team.
Effective pain management does not always mean total eradication of
all pain. Rather, it often means achieving adequate quality of life in
the presence of pain, through any combination of lessening the pain
and/or better understanding it and being able to live happily despite
it. Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain and discomfort to reduce any suffering during treatment, healing, and dying.
The task of medicine is to relieve suffering under three
circumstances. The first is when a painful injury or pathology is
resistant to treatment and persists. The second is when pain persists
after the injury or pathology has healed. Finally, the third
circumstance is when medical science cannot identify the cause of pain.
Treatment approaches to chronic pain include pharmacological measures, such as analgesics (pain killer drugs), antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy.
In the nursing profession, one common definition of pain is any
problem that is "whatever the experiencing person says it is, existing
whenever the experiencing person says it does".
Pain management includes patient and communication about the pain problem. To define the pain problem, a health care provider will likely ask questions such as:
How intense is the pain?
How does the pain feel?
Where is the pain?
What, if anything, makes the pain lessen?
What, if anything, makes the pain increase?
When did the pain start?
After asking such questions, the health care provider will have a description of the pain. Pain management will then be used to address that pain.
Adverse effects
There are many types of pain management. Each have their own benefits, drawbacks, and limits.
A common challenge in pain management is communication between the health care provider and the person experiencing pain. People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is. Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments.
There is a risk in many types of pain management for the patient to
take treatment that is less effective than needed or which causes other
difficulties and side effects. Some treatments for pain can be harmful if overused.
A goal of pain management for the patient and their health care
provider is to identify the amount of treatment needed to address the
pain without going beyond that limit.
Another problem with pain management is that pain is the body's natural way of communicating a problem. Pain is supposed to resolve as the body heals itself with time and pain management. Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem.
Physical approach
Physical medicine and rehabilitation
Physical medicine and rehabilitation (PM&R), a medical specialty, uses a range of physical techniques, such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy in the management of pain.
PM&R techniques are usually part of an interdisciplinary or
multidisciplinary program that might also include pharmaceuticals. Spa therapy has showed positive effects in reducing pain among patients with chronic low back pain, but its evidence base is limited. Studies have shown that kinesiotape can be used to reduce chronic low back pain. The US Centers for Disease Control recommended that physical therapy and exercise be prescribed as first-line treatments (rather than opioids) for multiple causes of chronic pain in 2016 guidelines. Applicable disorders include chronic low back pain, osteoarthritis of the hip and knee, and fibromyalgia.
Exercise alone or with other rehabilitation disciplines (including
psychotherapeutic approaches) can have a positive effects on pain. Besides improving the experience of pain itself, exercise can also improve individuals' well-being and general health.
Manipulative and mobilization
therapies are considered safe interventions for low back pain, with
manipulation potentially offering a larger therapeutic effect.
Specifically in chronic low back pain, education about the way
the brain processes pain in conjunction with routine physiotherapy
interventions may provide short-term relief of disability and pain.
Exercise interventions
Aerobic exercise can help when it comes to pain management
Physical activity interventions, such as tai chi, yoga, and Pilates,
promote harmony of the mind and body through total body awareness.
These practices incorporate breathing techniques, meditation, and a wide
variety of movements while training the body to perform functionally by
increasing strength, flexibility, and range of motion. Physical activity can also benefit chronic sufferers by reducing inflammation and sensitivity and boosting overall energy. Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks), and overall quality of life, while minimizing the need for pain medications. More specifically, walking has been effective in improving pain management in chronic low back pain.
Transcutaneous electrical nerve stimulation (TENS) is a self-operated
portable device intended to help regulate and control chronic pain via
electrical impulses.
Limited research has explored the effectiveness of TENS in relation to
pain management of multiple sclerosis (MS). MS is a chronic autoimmune
neurological disorder, which consists of the demyelination of the nerve
axons and the disruption of nerve conduction velocity and efficiency.
In one study, electrodes were placed over the lumbar spine, and
participants received treatment twice a day and at any time when they
experienced a painful episode. This study found that TENS would benefit MS patients with localized or limited symptoms in one limb. The research is mixed with whether or not TENS helps manage pain in MS patients.
Transcranial direct current stimulation (tDCS) is a non-invasive
technique of brain stimulation that can modulate activity in specific
brain cortex regions, and it involves the application of low-intensity
(up to 2 mA) constant direct current to the scalp through electrodes in
order to modulate the excitability of large cortical areas.
tDCS may have a role in pain assessment by contributing to efforts in
distinguishing between somatic and affective aspects of pain experience.
Zaghi and colleagues (2011) found that the motor cortex, when
stimulated with tDCS, increases the threshold for both the perception of
non-painful and painful stimuli.
Although there is a greater need for research examining the mechanism
of electrical stimulation in pain treatment, one theory suggests that
the changes in thalamic activity may be due to the influence of motor
cortex stimulation on the decrease in pain sensations.
Concerning MS, a study found that daily tDCS sessions resulted in
an individual's subjective report of pain decreased when compared to a
sham condition. In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session.
Fibromyalgia is a disorder in which an individual experiences
dysfunctional brain activity, musculoskeletal pain, fatigue, and
tenderness in localized areas. Research examining tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases.
Specifically, the stimulation of the primary motor cortex resulted in
significantly greater pain improvement in comparison to the control
group (e.g., sham stimulation, stimulation of the DLPFC).
However, this effect decreased after treatment ended, but remained
significant for three weeks following the extinction of treatment.[20]
Acupuncture involves the insertion and manipulation of needles into
specific points on the body to relieve pain or for therapeutic purposes.
An analysis of the 13 highest quality studies of pain treatment with
acupuncture, published in January 2009 in the British Medical Journal, was unable to quantify the difference in the effect on pain of real, sham and no acupuncture.
A systematic review in 2019 reported that acupuncture injection therapy
was an effective treatment for patients with nonspecific chronic low
back pain, and is widely used in Southeast Asian countries.
Light therapy
Research has found evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain.
Instead of thermal therapy, where reactant energy is originated
through heat, Low-Level Light Therapy (LLLT) utilizes photochemical
reactions requiring light to function. Photochemical reactions need light in order to function. Photons,
the energy created from light, from these photochemical reactions
provide the reactants with energy to embed in muscles, thus managing
pain.
One study conducted by Stausholm et al. showed that at certain
wavelengths, LLLT reduced pain in participants with knee osteoarthritis. LLLT stimulates a variety of cell types, which in turn can help treat tendonitis, arthritis, and pain relating to muscles.
Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.Radiofrequency treatment has been seen to improve pain in patients with
facet joint low back pain. However, continuous radiofrequency is more
effective in managing pain than pulsed radiofrequency.
An intrathecal pump
is sometimes used to deliver very small quantities of medications
directly to the spinal fluid. This is similar to epidural infusions used
in labour
and postoperatively. The major differences are that it is much more
common for the drug to be delivered into the spinal fluid (intrathecal)
rather than epidurally, and the pump can be fully implanted under the
skin.
A spinal cord stimulator
is an implantable medical device that creates electric impulses and
applies them near the dorsal surface of the spinal cord, providing a paresthesia ("tingling") sensation that alters the perception of pain by the patient.
Intra-articular ozone therapy
Intra-articular ozone therapy has been seen to alleviate chronic pain in patients with knee osteoarthritis efficiently.
Acceptance and Commitment Therapy (ACT) is a form of cognitive
behavioral therapy that focuses on behavior change rather than symptom
change, includes methods designed to alter the context around
psychological experiences rather than to alter the makeup of the
experiences, and emphasizes the use of experiential behavior change
methods.
The central process in ACT revolves around psychological flexibility,
which in turn includes processes of acceptance, awareness, a
present-oriented quality in interacting with experiences, an ability to
persist or change behavior, and an ability to be guided by one's values. ACT has an increased evidence base for range of health and behavior problems, including chronic pain.
ACT influences patients to adopt a tandem process to acceptance and
change, which allows for a greater flexibility in the focus of
treatment.
Recent research has applied ACT successfully to chronic pain in
older adults due to in part of its direction from individual values and
being highly customizable to any stage of life.
In line with the therapeutic model of ACT, significant increases in
process variables, pain acceptance, and mindfulness were also observed
in a study applying ACT to chronic pain in older adults.
In addition, these primary results suggested that an ACT based
treatment may significantly improve levels of physical disability,
psychosocial disability, and depression post-treatment and at a
three-month follow-up for older adults with chronic pain.
Cognitive behavioral therapy (CBT) helps patients with pain to
understand the relationship between their pain, thoughts, emotions, and
behaviors. A main goal in treatment is cognitive (thinking, reasoning or
remembering) restructuring to encourage helpful thought patterns.
This will target healthy activities such as regular exercise and
pacing. Lifestyle changes are also trained to improve sleep patterns and
to develop better coping skills for pain and other stressors using
various techniques (e.g., relaxation, diaphragmatic breathing, and even
biofeedback).
Studies have demonstrated the usefulness of cognitive behavioral
therapy in the management of chronic low back pain, producing
significant decreases in physical and psychosocial disability.
CBT is significantly more effective than standard care in treatment of
people with body-wide pain, like fibromyalgia. Evidence for the
usefulness of CBT in the management of adult chronic pain is generally
poorly understood, due partly to the proliferation of techniques of
doubtful quality, and the poor quality of reporting in clinical trials. The crucial content of individual interventions has not been isolated
and the important contextual elements, such as therapist training and
development of treatment manuals, have not been determined. The widely
varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult.
In 2020, a systematic review of randomized controlled trials
(RCTs) evaluated the clinical effectiveness of psychological therapies
for the management of adult chronic pain (excluding headaches). There is
no evidence that behaviour therapy
(BT) is effective for reducing this type of pain, however BT may be
useful for improving a person's mood immediately after treatment. This
improvement appears to be small, and is short term in duration.
CBT may have a small positive short-term effect on pain immediately
following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy.
CBT may contribute towards improving the mood of an adult who
experiences chronic pain, which could possibility be maintained for
longer periods of time.
For children and adolescents, a review of RCTs evaluating the
effectiveness of psychological therapy for the management of chronic and
recurrent pain found that psychological treatments are effective in
reducing pain when people under 18 years old have headaches. This beneficial effect may be maintained for at least three months following the therapy.
Psychological treatments may also improve pain control for children or
adolescents who experience pain not related to headaches. It is not
known if psychological therapy improves a child or adolescents mood and
the potential for disability related to their chronic pain.
Hypnosis
A 2007 review of 13 studies found evidence for the efficacy of hypnosis
in the reduction of pain in some conditions. However the studies had
some limitations like small study sizes, bringing up issues of power to
detect group differences, and lacking credible controls for placebo or
expectation. The authors concluded that "although the findings provide
support for the general applicability of hypnosis in the treatment of
chronic pain, considerably more research will be needed to fully
determine the effects of hypnosis for different chronic-pain
conditions."
Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents.
In clinical trials addressing other patient groups, it has
significantly reduced pain compared to no treatment or some other
non-hypnotic interventions. The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation.
A 2019 systematic review of 85 studies showed it to be
significantly effective at reducing pain for people with high and medium
levels of suggestibility, but of minimal effectiveness for people with
low suggestibility. However, high quality clinical data is needed to
generalize to the whole chronic pain population.
Mindfulness meditation
A 2013 meta-analysis of studies that used techniques centered around the concept of mindfulness, concluded, "that MBIs [mindfulness-based interventions] decrease the intensity of pain for chronic pain patients."
A 2019 review of studies of brief mindfulness-based interventions
(BMBI) concluded that BMBI are not recommended as a first-line treatment
and could not confirm their efficacy in managing chronic or acute pain.
Mindfulness-based pain management
Mindfulness-based pain management
(MBPM) is a mindfulness-based intervention (MBI) providing specific
applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness.
Medications
The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain.In the treatment of chronic pain, the three-step WHO Analgesic Ladder
provides guidelines for selecting the appropriate medicine. The exact
medications recommended will vary by country and the individual
treatment center, but the following gives an example of the WHO approach
to treating chronic pain with medications. If, at any point, treatment
fails to provide adequate pain relief, then the doctor and patient move
onto the next step.
doctor consultation is appropriate if headaches are severe,
persistent, accompanied by fever, vomiting, or speech or balance
problems; self-medication should be limited to two weeks
Paracetamol, an NSAID or paracetamol in a combination product with a weak opioid such as tramadol, may provide greater relief than their separate use. A combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco.
Moderate to severe pain
When
treating moderate to severe pain, the type of the pain, acute or
chronic, needs to be considered. The type of pain can result in
different medications being prescribed. Certain medications may work
better for acute pain, others for chronic pain, and some may work
equally well on both. Acute pain medication is for rapid onset of pain
such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.
Morphine is the gold standard to which all narcotics are compared. Semi-synthetic derivatives of morphine such as hydromorphone (Dilaudid), oxymorphone (Numorphan, Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as duration of action, side effect profile and milligramme potency. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch
which is convenient for chronic pain management. In addition to the
transdermal patch and injectable fentanyl formulations, the FDA (Food
and Drug Administration) has approved various immediate release fentanyl
products for breakthrough cancer pain
(Actiq/OTFC/Fentora/Onsolis/Subsys/Lazanda/Abstral). Oxycodone is used across the Americas and Europe for relief of serious chronic pain. Its main slow-release formula is known as OxyContin. Short-acting tablets, capsules, syrups and ampules which contain oxycodone are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, and methadone are used less frequently. Clinical studies have shown that transdermal buprenorphine is effective at reducing chronic pain. Pethidine, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use.Pentazocine, dextromoramide and dipipanone
are also not recommended in new patients except for acute pain where
other analgesics are not tolerated or are inappropriate, for
pharmacological and misuse-related reasons. In some countries potent
synthetics such as piritramide and ketobemidone are used for severe pain. Tapentadol is a newer agent introduced in the last decade.
Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline
is prescribed for chronic muscular pain in the arms, legs, neck and
lower back with an opiate, or sometimes without it or with an NSAID.
While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.
Opioids
In 2009, the Food and Drug Administration stated: "According to the National Institutes of Health,
studies have shown that properly managed medical use of opioid
analgesic compounds (taken exactly as prescribed) is safe, can manage
pain effectively, and rarely causes addiction." In 2013, the FDA stated that "abuse and misuse of these products have created a serious and growing public health problem".
Opioid
medications can provide short, intermediate or long acting analgesia
depending upon the specific properties of the medication and whether it
is formulated as an extended release drug. Opioid medications may be
administered orally, by injection, via nasal mucosa or oral mucosa,
rectally, transdermally, intravenously, epidurally and intrathecally. In
chronic pain conditions that are opioid responsive, a combination of a
long-acting (OxyContin, MS Contin, Opana ER, Exalgo and Methadone) or extended release
medication is often prescribed along with a shorter-acting medication
(oxycodone, morphine or hydromorphone) for breakthrough pain, or
exacerbations.
Most opioid treatment used by patients outside of healthcare settings is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain.
Although opioids are strong analgesics, they do not provide
complete analgesia regardless of whether the pain is acute or chronic in
origin. Opioids are effective analgesics in chronic malignant pain and
modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance will occur. Other risks can include chemical dependency, diversion and addiction.
Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society
and the American Academy of Pain Medicine. Included in these guidelines
is the importance of assessing the patient for the risk of substance
abuse, misuse, or addiction. Factors correlated with an elevated risk of
opioid misuse include a history of substance use disorder, younger age,
major depression, and the use of psychotropic medications.
Physicians who prescribe opioids should integrate this treatment with
any psychotherapeutic intervention the patient may be receiving. The
guidelines also recommend monitoring not only the pain but also the
level of functioning and the achievement of therapeutic goals. The
prescribing physician should be suspicious of abuse when a patient
reports a reduction in pain but has no accompanying improvement in
function or progress in achieving identified goals.
The list below consists of commonly used opioid analgesics which
have long-acting formulations. Common brand names for the extended
release formulation are in parentheses.
Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER)
*Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics
Nonsteroidal anti-inflammatory drugs
The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID). They work by inhibiting the release of prostaglandins, which cause inflammatory pain. Acetaminophen/paracetamol
is not always included in this class of medications. However,
acetaminophen may be administered as a single medication or in
combination with other analgesics (both NSAIDs and opioids). The
alternatively prescribed NSAIDs such as ketoprofen and piroxicam have limited benefit in chronic pain disorders and with long-term use are associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization. Common NSAIDs include aspirin, ibuprofen, and naproxen.
There are many NSAIDs such as parecoxib (selective COX-2 inhibitor)
with proven effectiveness after different surgical procedures. Wide use
of non-opioid analgesics can reduce opioid-induced side-effects.
Antidepressants and antiepileptic drugs
Some antidepressant and antiepileptic
drugs are used in chronic pain management and act primarily within the
pain pathways of the central nervous system, though peripheral
mechanisms have been attributed as well. They are generally used to
treat nerve brain that results from injury to the nervous system. Neuropathy can be due to chronic high blood sugar levels (diabetic neuropathy). These drugs also reduce pain from viruses such as shingles, phantom limb pain and post-stroke pain. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. A common anti-epileptic drug is gabapentin, and an example of an antidepressant would be amitriptyline.
Cannabinoids
Evidence of medical marijuana's effect on reducing pain is generally conclusive. Detailed in a 1999 report by the Institute of Medicine, "the available evidence from animal and human studies indicates that cannabinoids can have a substantial analgesic effect". In a 2013 review study published in Fundamental & Clinical Pharmacology,
various studies were cited in demonstrating that cannabinoids exhibit
comparable effectiveness to opioids in models of acute pain and even
greater effectiveness in models of chronic pain. It is mainly the THC strain of medical marijuana that provide analgesic benefits, as opposed to the CBD strain.
Ketamine
Low-dose ketamine is sometimes used as an alternative to opioids for the treatment of acute pain in hospital emergency departments. Ketamine probably? reduces pain more than opioids and with less nausea and vomiting.
Other analgesics
Other drugs which can potentiate conventional analgesics or have analgesic properties in certain circumstances are called analgesic adjuvant medications. Gabapentin, an anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates. Drugs with anticholinergic activity, such as orphenadrine and cyclobenzaprine, are given in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal conditions. Clonidine, an alpha-2 receptor agonist, is another drug that has found use as an analgesic adjuvant. In 2021, researchers described a novel type of pain therapy — a CRISPR-dCas9epigenome editing method for repressing Nav1.7gene expression which showed therapeutic potential in three mouse models of chronic pain.
Self-management
Self-management of chronic pain has been described as the individual's ability to manage various aspects of their chronic pain. Self-management can include building self-efficacy,
monitoring one's own symptoms, goal setting and action planning. It
also includes patient-physician shared decision-making, among others.
The benefits of self-management vary depending on self-management
techniques used. They only have marginal benefits in management of
chronic musculoskeletal pain.
Some research has shown that self-management of pain can use different
approaches. Those approaches can range from different therapies such as
yoga, acupuncture, exercise and other relaxation techniques. Patients
could also take a more natural approach by taking different minerals,
vitamins or herbs. However, research has shown there is a difference
between rural patients and non-rural patients having more access to
different self-management approaches. Physicians in these areas may be
readily prescribing more pain medication in these rural cities due to
being less experienced with pain management. Simply put, it is sometimes
easier for rural patients to get a prescription that insurance pays for
instead of natural approaches that cost more money than they can afford
to spend on their pain management. Self-management may be a more
expensive alternative.
Society and culture
The medical treatment of pain as practiced in Greece and Turkey is called algology (from the Greek άλγος, algos, "pain"). The Hellenic Society of Algology and the Turkish Algology-Pain Society are the relevant local bodies affiliated to the International Association for the Study of Pain (IASP).
Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.
Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish guidelines to determine the treatment for pain which health care providers ought to offer. For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain. Health care providers may not provide the treatment which authorities recommend.
Some studies about gender biases have concluded that female pain
recipients are often overlooked when it comes to the perception of their
pain. Whether they appeared to be in high levels of pain didn't make a
difference for their observers. The women participants in the studies
were still perceived to be in less pain than they actually were.
Men participants on the other hand were offered pain relief while their
self reporting indicated that their pain levels didn't necessarily
warrant treatment. Biases exist when it comes to gender. Prescribers
have been seen over and under prescribing treatment to individuals based
on them being male or female. There
are other prevalent reasons that undertreatment of pain occurs. Gender
is a factor as well as race. When it comes to prescribers treating
patients racial disparities has become a real factor. Research has shown
that non-white individuals pain perception has affected their pain
treatment. The African-American
community has been shown to suffer significantly when it comes to
trusting the medical community to treat them. Oftentimes medication
although available to be prescribed is dispensed in less quantities due
to their pain being perceived on a smaller scale. The black community
could be undermined by physicians thinking they are not in as much pain
as they are reporting. Another occurrence may be physicians simply
making the choice not to treat the patient accordingly in spite of the
self-reported pain level. Racial disparity is definitely a real issue in
the world of pain management.[93]
Acute pain is common in children and adolescents as a result of injury, illness, or necessary medical procedures. Chronic pain is present in approximately 15–25% of children and adolescents. It may be caused by an underlying disease, such as sickle cell anemia, cystic fibrosis, rheumatoid arthritis. Cancer or functional disorders such as migraines, fibromyalgia, and complex regional pain could also cause chronic pain in children.
Young children can indicate their level of pain by pointing to the appropriate face on a children's pain scale.
Pain assessment in children is often challenging due to limitations
in developmental level, cognitive ability, or their previous pain
experiences. Clinicians must observe physiological and behavioral cues
exhibited by the child to make an assessment. Self-report, if possible,
is the most accurate measure of pain. Self-report pain scales involve
younger kids matching their pain intensity to photographs of other
children's faces, such as the Oucher Scale, pointing to schematics of
faces showing different pain levels, or pointing out the location of
pain on a body outline.
Questionnaires for older children and adolescents include the
Varni-Thompson Pediatric Pain Questionnaire (PPQ) and the Children's
Comprehensive Pain Questionnaire. They are often utilized for
individuals with chronic or persistent pain.
Acetaminophen, nonsteroidal anti-inflammatory agents, and opioid analgesics
are commonly used to treat acute or chronic pain symptoms in children
and adolescents. However a pediatrician should be consulted before
administering any medication.
Caregivers may provide nonpharmacological treatment for children
and adolescents because it carries minimal risk and is cost effective
compared to pharmacological treatment. Nonpharmacologic interventions
vary by age and developmental factors. Physical interventions to ease
pain in infants include swaddling, rocking, or sucrose via a pacifier.
For children and adolescents physical interventions include hot or cold
application, massage, or acupuncture. Cognitive behavioral therapy
(CBT) aims to reduce the emotional distress and improve the daily
functioning of school-aged children and adolescents with pain by
changing the relationship between their thoughts and emotions. In
addition this therapy teaches them adaptive coping strategies. Integrated interventions in CBT include relaxation technique, mindfulness, biofeedback, and acceptance (in the case of chronic pain). Many therapists will hold sessions for caregivers to provide them with effective management strategies.
In red-haired individuals
In recent studies, it has been noted that people who have
red-hair through the MC1R receptor gene may react to opioids and
perceive pain differently than the rest of the population.
The studies on this developing topic have only become notable in the
past few years with researchers looking into how red-haired individuals
may experience a different threshold in pain and react to pain
management differently than others. Most studies find that redheads with
this gene have a higher pain tolerance and can also react more
sensitively to opiates but require more anesthesia.
Professional certification
Pain
management practitioners come from all fields of medicine. In addition
to medical practitioners, a pain management team may often benefit from
the input of pharmacists, physiotherapists, clinical psychologists and occupational therapists, among others. Together the multidisciplinary team can help create a package of care suitable to the patient.