A Multimodal Approach to Pain Management

Approximately 100 million adults in the United States experience chronic pain, and it is the number one cause of unemployment.1

“Pain is the leading reason people seek medical attention, costing the nation $625 billion annually — more than heart disease, cancer, and diabetes combined,” said Theresa Mallick-Searle, MS, RN-BC, ANP-BC, a nurse practitioner at the Stanford University Pain Management Center in Redwood City, California.

Using a series of interactive case studies, Ms. Mallick-Searle guided audience members through a hands-on discussion exploring the pathophysiology of pain and multimodal pain management approaches, touching on concepts including pain pathways, neuroplasticity, central sensitization, and pain modulation.

When providing pain management, healthcare practitioners should seek to identify and address the causes of their patients’ pain by understanding what the pain means to them, according to Ms. Mallick-Searle.

Goals of treatment vary depending on whether the pain is acute, requiring aggressive treatment, or chronic, in which the objective should be prevention, she stated. In both scenarios, the outcome is the same: improving quality of life and decreasing suffering.

“In addition to current therapies, new methods of managing pain are on the horizon that may help personalize pain management,” Ms. Mallick-Searle said. “Opioids are being reformulated to have less potential for addiction. Additionally, scientists are using the human genome to determine how individual patients will react to specific medications, which has positive implications for patient-centered treatment.”

Types of Treatment

During her session, Ms. Mallick-Searle provided an overview of various types of pain management approaches including medications, interventions, behavioral modification, and complementary and alternative treatments.

For acute pain relief, opioid analgesics are the current “gold standard,” offering numerous routes of administration, immediate and extended-release formulations, and options for targeting 5 opioid receptors (mu, kappa, sigma, delta, and epsilon) to modify pain signals and diminish pain perception. However, chronic use can lead to adverse effects including tolerance, dependence, and addiction.

Opioid withdrawal can lead to adverse effects such as psychomotor arousal in the form of irritability, restlessness, pacing, and sleeplessness; and autonomic arousal as indicated by mydriasis, yawning, sweating, diarrhea, lacrimation, rhinorrhea, mild tachycardia, and hypertension. Individuals undergoing opioid withdrawal may also experience muscle aching, joint pain, and stomach cramping.

For peripheral/central pain, anticonvulsants work by slowing down “overly excited” nerve impulses via sodium and calcium channel modulators. Currently approved anticonvulsant medications include gabapentin (900 mg to 1200 mg twice or three times daily), pregabalin (150 mg to 300 mg twice daily), topiramate (100 mg to 150 mg twice daily), and oxcarbazepine (350 mg to 1200 mg twice daily).

Tricyclic and serotonin-norepinephrine reuptake inhibitor antidepressants modify the combination of serotonin and norepinephrine to decrease the amount of pain a patient perceives. Options approved by the US Food and Drug Administration include venlafaxine (150 mg to 225 mg daily), duloxetine (60 mg to 120 mg daily), milnacipran (150 mg to 300 mg twice daily), desipramine (100 mg to 150 mg daily), and nortriptyline (100 mg to 150 mg daily).

Typically used nonopioid analgesic options are acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and tramadol, as well as sedatives, sleep aids, and muscle relaxants.

Interventional Pain Management Techniques

The basis of interventional pain management is to block the production and/or transmission of pain signals to the brain through methods including neurologic procedures, nerve blocks, spinal cord stimulation, drug-delivery system implants, or injection of an anesthetic.

Goals of these interventional techniques include pain reduction, improving and maintaining mobility, and minimizing medication use.  The administration strategies enable pain management specialists to selectively target injured and painful body regions while minimizing complications such as infection, bleeding, further injury, and sympathetic crisis.

Behavioral/Psychological and Complementary Approaches

Emerging behavioral and psychological approaches for addressing pain focus on the mind-body relationship and consist of techniques including relaxation and stress reduction training, cognitive behavioral therapy (CBT), communication skills, and flare management.

Complementary therapies include passive modalities such as acupuncture/accupressure, hypnosis, occupational and physical therapy, massage, and transcutaneous electrical nerve stimulation; and active modalities such as relaxation, biofeedback, deep breathing, guided imagery, distraction, and visualization.

“New research continues to shed light on both the treatment and understanding of pain. But even with these strides, involving patients in care is the key to determining the best course of treatment,” Mallick-Searle concluded.

Disclosure: Theresa Mallick-Searle is a member of speaker’s bureaus for Allergan and Depomed.


  1.  Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011. Available at: http://books.nap.edu/openbook.php?record_id=13172&page=1. Accessed August 14, 2015.

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