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Thursday, March 27, 2025

Tardive dyskinesia

From Wikipedia, the free encyclopedia
Tardive dyskinesia
Other namesLinguofacial dyskinesia, tardive dystonia, tardive oral dyskinesia
Tardive dyskinesia is believed to involve the neurotransmitter dopamine.
Pronunciation
SpecialtyNeurology, psychiatry
SymptomsInvoluntary, repetitive body movements
CausesNeuroleptic medications (antipsychotics), metoclopramide
Diagnostic methodBased on symptoms after ruling out other potential causes
Differential diagnosisHuntington's disease, cerebral palsy, Tourette syndrome, dystonia
PreventionUsing lowest possible dose of neuroleptic medication
TreatmentStopping neuroleptic medication if possible, switching to clozapine
MedicationValbenazine, tetrabenazine, botulinum toxin
PrognosisVariable
Frequency20% (atypical antipsychotics)
30% (typical antipsychotics)

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.

In the TV series The Good Wife and The Good Fight, Michael J. Fox, who suffers from Parkinson's disease, plays the lawyer Louis Canning, who has tardive dyskinesia.

Pain management

From Wikipedia, the free encyclopedia
Pain Medicine Physician
Occupation
NamesPhysician
Occupation type
Specialty
Activity sectors
Medicine
Description
Education required
Fields of
employment
Hospitals, clinics
Active and inactive μ-opioid receptors
Image of visual pain

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.

A typical multidisciplinary pain management team may include: medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists. The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics.

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

Defining pain

Pain level scale

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.

TENS

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.

Transcutaneous electrical nerve stimulation is ineffective for lower back pain. However, it might help with diabetic neuropathy as well as other illnesses.

tDCS

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

Acupuncture can sometimes help to relieve pain

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.

Sound therapy

Audioanalgesia and music therapy are both examples of using auditory stimuli to manage pain or other distress. They are generally viewed as insufficient when used alone but also as helpful adjuncts to other forms of therapy.

Interventional procedures

Interventional radiology procedures for pain control, typically used for chronic back pain, include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants.

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.

Psychological approach

Acceptance and commitment therapy

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

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.

Common types of pain and typical drug management
Pain type typical initial drug treatment comments
headache paracetamol/acetaminophen, NSAIDs 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
migraine paracetamol, NSAIDs triptans are used when the others do not work, or when migraines are frequent or severe
menstrual cramps NSAIDs some NSAIDs are marketed for cramps, but any NSAID would work
minor trauma, such as a bruise, abrasions, sprain paracetamol, NSAIDs opioids not recommended
severe trauma, such as a wound, burn, bone fracture, or severe sprain opioids more than two weeks of pain requiring opioid treatment is unusual
strain or pulled muscle NSAIDs, muscle relaxants if inflammation is involved, NSAIDs may work better; short-term use only
minor pain after surgery paracetamol, NSAIDs opioids rarely needed
severe pain after surgery opioids combinations of opioids may be prescribed if pain is severe
muscle ache paracetamol, NSAIDs if inflammation involved, NSAIDs may work better.
toothache or pain from dental procedures paracetamol, NSAIDs this should be short term use; opioids may be necessary for severe pain
kidney stone pain paracetamol, NSAIDs, opioids opioids usually needed if pain is severe.
pain due to heartburn or gastroesophageal reflux disease antacid, H2 antagonist, proton-pump inhibitor heartburn lasting more than a week requires medical attention; aspirin and NSAIDs should be avoided
chronic back pain paracetamol, NSAIDs opioids may be necessary if other drugs do not control pain and pain is persistent
osteoarthritis pain paracetamol, NSAIDs medical attention is recommended if pain persists.
fibromyalgia antidepressant, anticonvulsant evidence suggests that opioids are not effective in treating fibromyalgia

Mild pain

Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain.

Mild to moderate pain

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.

For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are used, with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (less commonly).

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.

*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-dCas9 epigenome editing method for repressing Nav1.7 gene 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

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]

In children

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.

Pain medicine in the United States

Pain physicians are often fellowship-trained board-certified anesthesiologists, neurologists, physiatrists, emergency physicians, or psychiatrists. Palliative care doctors are also specialists in pain management. The American Society of Interventional Pain Physicians, the American Board of Anesthesiology, the American Osteopathic Board of Anesthesiology (recognized by the AOABOS), the American Board of Physical Medicine and Rehabilitation, the American Board of Emergency Medicine and the American Board of Psychiatry and Neurology each provide certification for a subspecialty in pain management following fellowship training. The fellowship training is recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS). As the field of pain medicine has grown rapidly, many practitioners have entered the field, some non-ACGME board-certified.

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