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To diminish these inequities surrounding pain management, providers should attempt to remove as much individual discretion from decision making as feasible. When possible, providers should utilize resources such as: checklist, guidelines, or system protocols to avoid the influences of implicit biases on their management. Providers need also recognize access limitations faced by patients and ensure any treatment regimen or follow-up planning is readily accessible.

The prevalence of chronic pain in the US is difficult to estimate, but its impact is profound. Fifty to eighty million Americans experience daily pain symptoms. The cost of pain management is approximately $90 billion annually.

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The differing pathophysiology for acute pain and chronic pain requires different approaches to their diagnosis and treatment. Effective acute pain management has been shown to improve both patient satisfaction and treatment outcomes, and reduce the risk of developing chronic pain.

A chronic secondary pain syndrome initially manifests as a symptom of another disease and then continues after successful treatment of the disease.15

Plan for treatment of reinjury or exacerbation during the subacute pain phase. Often subacute pain occurs with increase in activity before tissue is completely restored to health.

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NSAIDs may also increase risk for exacerbations of hypertension, heart failure, and chronic kidney disease. NSAID use in patients with heart disease or its risk factors increases the overall risk of heart attack or stroke.

Chronic pain – pain that lasts or recurs for longer than 3 months – is not merely acute pain that does not resolve. Increasingly, chronic pain is recognized as a disease entity in and of itself, rather than as a symptom of another disease. Historically, pain has been viewed in a biomedical model, with a focus on identifying a specific pathologic cause of pain which can be treated through pharmacologic or interventional means.

Special safety hazard and unique advantages. Methadone is unique among opioids, with both increased safety concerns and advantages in long-term therapy. The safe use of methadone requires knowledge of its particular pharmacologic properties. Methadone’s duration of adverse effects far exceeds its analgesic half-life, making it dangerous when combined inappropriately with other controlled substances.

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Some evidence exists for methadone use in this population as well. However, it is less promising than buprenorphine.

Adhere to recommended guidelines and carefully document medical decision-making when prescribing opioids.

Doses required for pain treatment are lower than for mood disorders. The lower doses generally avoid problems such as QT prolongation. For patients with sleep initiation problems, taking a TCA at dinnertime rather than bedtime may reduce problems with sleep initiation and with morning fatigue.