The patient with chronic non-cancer pain.

Maybe the most difficult patient to treat. It’s important to obtain a well detailed history and physical examination to make sure all systems work well. You will always find yourself in a position where nothing is specific to a certain pathology. It will be hard to connect symptoms and the lack of objective findings. Bloodwork, ECG, radiology, etc may be unremarkable, in a patient who was intense, long lasting pain causing disability, progressively more and more.

These patients are at risk of receiving excessive radiation from exams based on little suspicion or weak proof of a specific disease. They are also at risk of receiving too much medication and even worse, benzos and opioids, therefore causing more harm than benefit. If there’s an inflammatory problem, use meds for inflamation. If there’s a neuropathic problem, use anti-convulsivants or anti-depressants. If there is no clear origin of pain and you are sure there’s no organic injury, and you think there’s an emotional-personality-affection component, try anti-depressantes. Use PPI ONLY WHEN NECESSARY and dyspepsia alone is not only a good reason. Do not use opioids chronically in non cancer pain:

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The answer to these issues may be in non pharmacological treatment.  When all examination is normal, when there’s no evidence of organic damage, chronic pain may be linked to high health expectations, little tolerance to pain, and other non organic, emocional, behavioural and functional issues. This is what we must tackle: Emphasise the importance of non pharmacological treatment like meditation, mindfulness, yoga, exercise, leisure activities.

These patients’ disability will have them inside their house doing nothing because it just hurts too much. Encourage them to set a small goal, to do something even though it may hurt, and to praise and reward themselves for that. Slowly, encourage them to do more and more. Help them function again, encourage them to find a way to return to a functional role in the family. Pain may still be there, but will not be as important. It’s not easy, it’s a long process, but it’s our job to help them.

-The Plague Doctor


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