Management of Chronic Pain in Adults

Acute and chronic pain negatively impacts the psychosocial and physical health condition of an individual. It also affects an individual’s daily function, heath-related quality of life and participation in daily life activities. The management of pain across various settings is also associated with financial, resource and personal costs. To alleviate the management of pain, various bodies and organization develop clinical practice guideline indicating how pain should be managed at various stages. These guidelines are based on evidence-based practice. Examples of two clinical guidelines managing pain in clinical settings include the Management of Chronic Pain, A National Clinical Guideline proposed by the Scottish Intercollegiate Guidelines and Network and Assessment and Management of Chronic Pain Guideline developed by the Institute for Clinical System Development (ISCI), a Canadian based healthcare organization.  The Management of Chronic Pain, A National Clinical Guideline proposes the use of both pharmacological and non-pharmacological methods in the management and assessment of pain in patients within clinical settings. The guideline also supports the combinational methods of pain treatment as well as the use of behavioral methods as well as other complementary methods of pain management while Assessment and Management of Chronic Pain Guideline specifically focus on the management of chronic pain among patients. The guideline provides both an assessment and management algorithms which are used to determine the best form of treatment for patients.  Pain management methods are classified into two with the first level specifically dealing with the pharmacological methods of pain management. The second method requires the use of a multidisciplinary method in reducing pain levels among patients.

Discussion

Critique

            Scope and Purpose

            The overall scope and purpose of the Management of Chronic Pain, A National Clinical Guideline is defined as dealing with the management of chronic pain presented within a clinical setting within the first 12 weeks (Scottish Intercollegiate Guidelines Network 2013).  The guideline category includes counseling, management, and treatment of pain. The intended users and the clinical specialty is also adequately described. Furthermore, the general objective of the guideline is elucidated as the provision of recommendations based on current evidence for best practices in the management of pain in adults specifically with chronic but non-malignant pain in clinical settings (Scottish Intercollegiate Guidelines Network 2013). The guideline also specifies other essential areas excluded including the treatment of headaches, underlying conditions and interventions applied in secondary care.

            The ISCI guideline assesses and manages chronic pain in adults and other physiologically mature adolescents aged between 16 to 18 years of age (Institute of Clinical Systems Improvement 2017). It also assesses, diagnoses and treats acute, subacute pain within the ambulatory system. It only deals with non-cancer pain. Furthermore, it does not cover patients with migraines, those receiving pain in hospice care or active cancer pain (Institute of Clinical Systems Improvement 2017). Visceral pain is also excluded from the guideline.

            Stakeholder’s Involvement

            The ISCI provides information on all stakeholders involved in the treatment process. It also outlines the need to use the family members and members of the multidisciplinary team in pain management. The guideline takes into account views of different patients during the treatment process. The Management of Chronic Pain, A National Clinical Guideline indicates the need for patient education in pain management. No furthermore information is provided on other stakeholders.

            Rigor of Development

            A rigorous and systematic search was used to search for all of the relevant information in both the two guidelines.  The systematic criteria used to search for information in both guidelines was also stated.  The types of designs which were searched across different databases were also well elucidated.  However, the two guidelines did not  adequately provide any information relating to the strength and limitations of quality of evidence utilized although there was a definitive framework used in making the final recommendations in either of the two guidelines. The Management of chronic pain A national clinical guideline provided  more information relating to benefits associated with health risks and benefits. All the two guidelines contained relevant information on the link between the evidence collected and provided recommendations. Lastly, both guidelines provided information quality was assessed before being published. An elaborate methodology for updating the guideline was also provided. 

            Clarity of Presentation

             ISCI recommendations are more clearly defined and unambiguous. The guideline provides various levels of assessing pain before applying the relevant management method (Institute of Clinical Systems Improvement 2017). It also defined which level of pain management to be applied in case one methods. The other guideline provides general information on specific methods of pain management to be applied as well as the drug dosage in some cases. It also defines the specific type of pain management method whether pharmacological or non-pharmacological to be provided to different types of pain within the body (Scottish Intercollegiate Guidelines Network 2013). Recommendations for the ISCI guideline were provided in tabular form making it a more clearly presented guideline compared to the other guideline.

            Applicability

            The ISCI guideline provides information regarding some likely patient barriers in the application of the guideline. Patient resources and work and disability issues are clearly expounded as some of the barriers affecting the application of the above guideline. It also provides relevant information on resources to be utilized in implementing the guideline as well as other essential issues including patient engagement and shared decision making. The other guideline provides less information relating to the applicability of the guideline with respect to resource applications. Both guidelines provide information on funding bodies.

            Editorial Independence

             Both the two guidelines indicate no conflicting interests in the recommendations provided in the management and treatment of pain.

Clinical Guideline Comparison

            The guideline developed by ISCI has better protocols and procedures towards the management of pain compared to the Management of Chronic Pain, A National Clinical Guideline. First, the ISCI guideline identifies a framework that requires clinicians to assess the type of pain in a patient before applying a specific management practice. It utilizes specific information relating to the patient’s history as well as the use of validated pain assessment tools before making a final conclusion on the specific method to be used in the pain management process (Institute of Clinical Systems Improvement 2017). The other guideline fails to specifically mention any instance of assessing the patient’s pain and does not provide any information on the use of validated tools in making a final decision.

            Secondly, the Management of Chronic Pain, A National Clinical Guideline provides specific pain management practices for each type of pain experienced by the patient. For example, it defines the type of pharmacological treatment which should be applied for lower back pain as well as musculoskeletal pain (Scottish Intercollegiate Guidelines Network 2013). Although the methods defined are elaborate and specific and would aid in the proper treatment of the patient, the guideline defines a wide range of pain management methods to be used which may affect the applicability of some of the measures. ISCI formulated guideline shortens the above approach by classifying the different types of common pain which are more likely to occur within a clinical setting. Under each method, other associated conditions are identified. For example, the guideline identifies neuropathic pain, muscle, inflammatory and mechanical pain as the major classes of pain likely to occur within a clinical setting and goes further to list all the available forms of pains in each of the section (Institute of Clinical Systems Improvement 2017). Various disorders associated with different types of pain are also identified and appropriate information classified under the identified method.       

The ISCI developed guideline goes further to define whether the pain felt by the patient is chronic or acute before taking any appropriate measure, an essential component which lacks in the Management of Chronic Pain, A National Clinical Guideline. In case, it is established that the pain felt by the patient is acute,the clinician is required to follow the ISCI guideline. Without the implementation of an effective follow-up approach the Management of Chronic Pain, A National Clinical Guideline risks treating some of the patients with acute pain using chronic methods identified in the guideline. This could be detrimental to the patient considering that some of the methods identified in the guideline require the use of opioids which are associated with increased incidences of addiction. The assessment and follow up approach ensures that the patient is provided with the appropriate diagnosis at all times. The ISCI guideline also goes further in identifying whether there is a correctable approach to the pain felt by the patient before opting for pain management. During this phase, other causes of pain including work-related issues, contributing barriers, and psychological issues are taken into account (Institute of Clinical Systems Improvement 2017). In essence, the guideline provides for remedial measures in each of the steps before applying any pain management practices.

The final unique feature of the ISCI developed guideline to the other guideline is the managing pain in two levels with the second approach coming into effect after the failure of the first management practice. The Management of Chronic Pain, A National Clinical Guideline can be considered only to have one level of pain management which is defined for every type of pain. For example, the guideline only clearly defines the type of pain management methods to be applied to a specific condition without the use of a follow-up measure. In essence, if the first mode of treatment proposed by the clinical guideline fails, there are not alternative measures clearly identified which could act to manage the condition.  The ISCI guideline has two levels of managing pain. The first method specifically addresses the common pharmacological and non-pharmacological methods used in pain management as well as the different complementary measures highlighted in the other guideline (Institute of Clinical Systems Improvement 2017). However, it goes further to allow for the development of multidisciplinary teams in managing pain in case the first level of pain management fails to attain the required objectives. It also provides for patients pain management measures to be assessed after the appropriate educational measures have been implemented. Due to the aforementioned methods, the ISCI develop guideline is considered to a better guideline compared to the Management of Chronic Pain, A National Clinical Guideline.

Differences in Clinical Guidelines

            The differences in the clinical guideline measure between the two methods could primarily arise due to varying amount of resources required in pain management. The ISCI methods seem to advocate for the use of more resources in the management of pain compared to the Management of Chronic Pain, A National Clinical Guideline. Furthermore, the two guideline were developed in different countries, and as a result, the difference in the application could also be a pointer on how healthcare resources are distributed within the country. The ISCI developed guideline requires more resources due to the increased number of steps in pain management methods. For example, the guideline requires a specific team of individuals to assess the level of pain management in the patient. The team is then supposed to recommend whether alternative measures could be used in pain management. If such a scenario occurs then it results in the use of more resources. The need for more resources may also set in cases where the multidisciplinary team has to intervene in the pain management process. The Management of Chronic Pain, A National Clinical Guideline only focuses on pain management without the use of different levels, and as a result, fewer resources may be utilized.

Conclusion

            Clinical guidelines provide various measures which could be used to manage chronic pain among patients. Various methods of managing chronic pain associated with different disease conditions include pharmacological, non-pharmacological and behavioral therapy methods. The development of clinical guidelines takes into consideration a host of issues covering the scope and objective of the guideline as well as the applicability and scientific evidence. As a result, various guidelines tend to differ in the addressing aspects such as pain management. Assessment of clinical guidelines with the latest evidence through approaches such as AGREE II serves to provide information on why specific guidelines could be selected over others. Although most scientific guidelines provide relevant information towards the management of a specific condition, individual differences exist due to the amount of resources used in the development of the guideline as well as the effectiveness of addressing a health issue with the available resources in a country’s healthcare system.

References

Institute of Clinical Systems Improvement (2017) Pain: Assessment, Non-Opioid Treatment       Approaches and Opioid Management. Available at: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guideline            catalog_neurological_guidelines/pain/ (Accessed: 8 November 2018).

Scottish Intercollegiate Guidelines Network (2013) Management of chronic pain A national          clinical guideline Clinical Practice Guidelines. Available at:            https://www.guidelinecentral.com/summaries/management-of-chronic-pain-a-national           clinical-guideline/#section-420 (Accessed: 8 November 2018).