The Informed Neuropathy Patient

Today's post from neuropathy.org (see link below) is a short but very important piece of advice from the Neuropathy Association. Basically, it suggests ways of becoming an informed patient regarding your neuropathy and arming yourself with information before and after you go to the doctor with your symptoms. Forearmed is forewarned they say and this is especially true when it comes to neuropathy. It's a disease with endless possibilities and an equal number of uncertainties, so the more you're aware of your situation, the less time will be wasted by your doctor or specialist having to try to explain all the complexities simply. Doing your own research will help you see your problem for what it is and make it less of a fearful mystery.
 

Dealing with nerve diseases - 10 Steps to Becoming an Informed Patient  
The Neuropathy Association 2014


Becoming an informed patient means embarking on a path of continuous learning when it comes to matters concerning your health and well-being. It also means meeting the challenge of adopting a healthy lifestyle. While there is no "best way" to become better informed about nerve diseases, there are a number of steps everyone should take as part of the process:

Prepare for visits with your doctor

Learn as much as you can about your medical diagnosis

Keep a copy of your medical records

Understand and commit to your treatment plan

Read the fine print of your health insurance plan and understand your policy 

Listen to your body and respect it

Seek a healthy work-life balance

Deal with stress and keep it at a minimum

Accept neuropathy as a part of you

Have a supportive and compassionate "go-to" buddy 

You have to become an active partner in managing your healthcare and take a positive stance regarding your neuropathy. When living with a chronic illness like neuropathy or other nerve diseases, it is important to develop a healthy doctor-patient relationship and a supportive network of friends and family. Just as important is listening to what your body tells you via your symptoms and address the situation when you recognize it. By acknowledging your symptoms and seeking an early diagnosis and treatment, you are taking a proactive approach to dealing with neuropathy and halting its progression. Ultimately, think of becoming an informed patient as an exercise in building your communications skills: we hope you continuously listen, learn, and share your knowledge with others! 

http://www.neuropathy.org/site/PageServer?pagename=Living_TenSteps

Treating The Patient As An Individual Essential For Neuropathy Treatment Success

Today's post from practicalpainmanagement.com (see link below) is written mainly for the benefit of pain professionals who are currently scratching their heads at the difficulties and complexities posed by pain treatment anno 2017. The message is that the best way of treating pain is by treating the individual and tailoring courses of treatment to that individual. Blindly following model pain behaviours has failed and results in wasted opportunities but at the moment, the medical community has little else to offer (hence the ridiculously vague, pain-testing modules). Everybody in the medical community accepts that individualised treatment has to be the answer but turning the theory into practice is mind-numbingly complex in terms of how that should be done. Nobody understands this better than the neuropathy patient who knows that his/her symptoms are unique to him/herself but is forced to follow outdated treatment models based on failing drug therapies. It strikes me that time is the problem. The average doctor or neurologist frankly does not have the time to develop individual treatment courses based on a holistic overview, for every patient. Yet this is the only answer that will bring quicker results and result in the patient swallowing less harmful medications along the way. In the end, the patient is going to have to be respected enough to form a partnership with the doctor to develop the best possible treatment outcomes. Definitely worth a read.

Distinguishing Neuropathic, Non-Neuropathic, and Mixed Pain By Charles E. Argoff, MD Last updated on: February 14, 2017 First published on: February 10, 2017
 
Given the complexity of chronic pain management, clinicians are challenged to move toward more rigorous assessment and individualized treatment to improve quality of life for all patients.

In the pain management community, we are all too familiar with the statistic estimating that there are 100 million adults suffering from chronic pain in the United States.1 However, with all of the recent negative attention on pain management, insufficient energy and attention have been focused on perhaps one of the more daunting aspects of chronic pain—the actual assessment and treatment of the person in pain. Therefore, it is reasonable to acknowledge that managing chronic pain in today’s healthcare system, as we come to understand more and more the complexity of pain, is challenging, but also quite rewarding.

It has become increasingly clear that chronic pain does not refer to one disorder or underlying mechanism and cannot be assessed or treated with a one-size-fits-all approach. Advances in our understanding have led to new, more effective patient assessment and treatment strategies.2,3 We expect that practitioner adoption of these types of tools may better guide and inform optimal chronic pain management, leading to better quality of life for patients. However, considerably more work needs to be done to implement truly individualized approaches to patient care with regard to pain management.

Among the most difficult aspects of treating a person in pain is identifying the type(s) and mechanism(s) of pain. Our patients often present to us experiencing more than 1 type of chronic pain, with more than 1 mechanism underlying their complaints. Assessing which mechanisms of pain a person is experiencing—in other words, assessing a patient’s pain profile—is not simple, but it is vital.

There are at least 2 important components of assessing the pain complaint(s):
 
Intensity, quality, and change over time
Differentiation among the mechanisms of ongoing pain, including those resulting in neuropathic and/or non-neuropathic pain.

To most accurately and effectively identify and understand the type of pain a person is experiencing, a multidimensional assessment covering both these components is imperative.

However, differentiation among pain types, as well as the root causes of the pain, can be difficult to ascertain using in-office tests. It is unlikely that functional magnetic resonance imaging (fMRI), or other similar tests, in the absence of detailed history-taking, would be sufficient to fully assess pain appropriately. Although there are many tests available, they seldom result in a specific diagnosis of a patient’s pain and may provide confounding results.

New resources are being developed to assist in the assessment of pain, including screening tools, such as the painDETECT questionnaire,4 which has been validated to detect neuropathic components of lower back pain. In the absence of specific tests, however, practitioners can still assess a patient by asking how he/she would describe the way the pain feels. For example, asking if there is any of the following symptoms: numbness, burning, tingling, or feelings of electric shock, which can provide useful insights. Notably, distinguishing between neuropathic and nonneuropathic pain types, and understanding if a person has features of both, can better allow for a more tailored treatment.

The Best Pain Management Comes From a Thorough Pain Assessment

When conducting a pain assessment, the evaluation should be as in-depth as possible to plan the most appropriate management course. When a patient with an established pain diagnosis(es) presents for chronic pain treatment, it is important to begin by assessing the patient’s functional impairment, expectations, and psychosocial needs, as well as to evaluate for any medical red flags, such as the risk of medication misuse or abuse.

Questions to consider asking include:
 
Has the patient been treated for cancer, or is he/she being treated for some potentially unrelated condition that may contribute to the pain?
What other medical/interventional/non-medical treatment is the patient receiving?
What treatments have been unsuccessful in the past?
What is the intensity and duration of the pain?
Is the patient experiencing distress or impairments associated with chronic pain?

When considering the responses to determine a course of treatment, be mindful that multimodal therapy may be required for optimal care. Since there are various potential origins for the pain that present with similar symptom profiles and distinct mechanisms that drive pain, devising a personalized treatment may be hard to come by, but still must be our ultimate goal.

Ideally, the selection of appropriate medication to address chronic pain complaints should follow the same principle as choosing an antibiotic treatment regimen, although the complexity of chronic pain and our current knowledge do not allow for this approach in all instances. For example, there are dozens of antibiotics that can be prescribed to treat a bacterial infection. Rather than a trial-and-error approach, treatment for a bacterial infection is specifically tailored to the illness based on the culture of the bacteria and the specific manifestation of the disease. Selecting the appropriate pain medication should be treated in the same manner, whenever possible.

Consider Pain Mechanisms in Prescribing Medications

Besides analgesia and depending on severity, chronic pain can be managed in many ways, including appropriate physical therapy, cognitive-behavioral approaches, neurostimulation, acupuncture, functional medicine, and other noninvasive approaches, nonanalgesic medications, and other modalities.

Medications may include commonly used analgesics, such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs); for more severe pain, opioids may be more effective. So-called adjuvant analgesics (eg, anticonvulsants or antidepressants) may also be considered.

However, there may be individual differences in response to these drugs, depending on the patient’s neuropathic and non-neuropathic pain profile. Nociceptive pain, a type of non-neuropathic pain, is generally more responsive to anti-inflammatory agents and classical opioids, while neuropathic pain may be less responsive to traditional pain management. In some cases, pharmacologic agents that address more than 1 type of pain may be more effective for some patients, and many newer medicines are designed to target both types of pain in a single pill.

As we continue to gain insight into pain mechanisms and subtypes and begin to develop increasingly sophisticated evaluation tools, the need for both a thorough assessment and individualized treatment has become more evident. Preferably, pain management will begin with a rigorous evaluation, using the latest available tools, followed by evidence-based, individualized treatment with multimodal therapy where appropriate. Bringing these crucial pieces together to improve management of chronic pain will ultimately help improve patients’ lives, which is, of course, our end goal.

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https://www.practicalpainmanagement.com/pain/distinguishing-neuropathic-non-neuropathic-mixed-pain

What A Neuropathy Patient Deserves From His Her Doctor

Today's very good post from blog.aapainmanage.org (see link below) written by a doctor, contains advice for both doctor and patient when it comes to chronic pain conditions like neuropathy. The doctor needs to look at far more than the current symptoms the patient presents and the patient can read this article and reasonably expect that the doctor carries through with most of the suggestions here, in order to come to the best possible diagnosis. It's not rocket science but you'd be amazed at how many stories emerge of doctors who diagnose and prescribe drugs, based on their ten minute time slot with the patient and nothing else. Neuropathy (nerve damage) needs a far more structured approach than this and the patient who has often been in pain and discomfort for months and even years already deserves a proper holistic approach. There is no cure for neuropathy and the current treatments and drugs leave a lot to be desired in terms of success. Most often it's a case of 'suck it and see' but given the huge numbers of people with neuropathy across the world, patients deserve better. This article goes some way to addressing the problem and is well worth a read.

Strategies for Evaluating the Patient with Chronic Pain
Written by W. Clay Jackson, MD, DipTh, Vice President of the Board, Aug 16, 2016, 

A comprehensive evaluation of the patient with chronic pain is rarely straightforward, and it begins with the recognition that a complete cure is unlikely. The patient’s pain experience may be complicated by numerous factors, including lack of an obvious pathological cause, concomitant anxiety and depression, and a downward spiral of inactivity and lowered self-esteem. Often, medications used to treat the pain may themselves cause side effects that contribute to the patient’s reduced function.

The skillful clinician will work with the patient, incorporating time-efficient tools to determine a treatment plan that combines a variety of modalities and may or may not include the use of opioids. With chronic pain patients, the evaluation is key: Failure to identify all the factors that contribute to the pain can lead to ineffective treatment, further deterioration, and mutual frustration, not to mention legal and regulatory consequences. A seasoned clinician listens carefully to validate the patient’s pain without allowing elaborate descriptions to derail the timing and purpose of the visit. For most patients with persistent pain, the goal of treatment is not the complete relief of pain, but rather improvements in the patient’s physical and mental functioning that result in an improved quality of life as he or she takes increasing responsibility in his or her own therapy. Patient and clinician may be a traveling a long and bumpy road, but the outcome can be meaningful and beneficial for both.

The Assessment Process

There are numerous guidelines for managing the patient with chronic pain (1-4). Having a routine for the evaluation ensures that relevant data are captured. The clinician should evaluate and document the patient’s pain history including the nature, location, intensity, and duration of the pain; current and prior pharmacological and nonpharmacological treatments; factors that worsen or improve the pain; underlying or coexisting conditions; and (importantly) the effect of the pain on the patient’s life. An assessment of function should include the impact of the pain on the patient’s family and social life, employment, and sleep, and provide a baseline for follow-up evaluations. The clinician should also be alert to signs that the patient is minimizing or maximizing the subjective reports of the pain or, in cases of cognitive impairment, lacks the proper resources to describe it (3).

As the noted clinician Sir William Osler stated, it is more important to consider what kind of patient has the disease, rather than what kind of disease the patient has. The treatment of the patient with chronic pain proves time and again the truth of of his aphorism. Thus, I include questions about depression, anxiety, posttraumatic stress disorder, and other factors that might impact pain, including stress levels at home or at work. I consider the patient’s capacity for chemical coping, or the likelihood of using pain medication to cope with life’s stresses. And, of course, any evaluation that may lead to a trial of opioids should include an assessment of the patient’s risk for opioid misuse, but it also should include a qualitative assessment of the patient’s goals. What are the patient’s functional goals? How does the patient define functionality? What are simple, concrete things the patient wants to do in the next 30 days? How can treatment help the patient reach her goals?

When reviewing the pharmacological history, I attempt to ascertainwhether the pain is a part of the history or consumes the history. I ask which medications has the patient tried: nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin norepinephrine reuptake inhibitors (SNRIs), nerve cell membrane stabilizers (anticonvulsants), and/or opioids. I like to think of these as the four pharmacologic pillars of pain relief, which often yield salutary results when used in combination. Is the patient equally balanced on all four pillars, or is he leaning on just one?

A comprehensive evaluation may take some time, but several strategies can be used to work within the time constraints of the office visit, especially in primary care practice. A comprehensive questionnaire can be filled out by the patient before the initial appointment, providing key historical information even before the patient enters the exam room. Self-reporting pain scales and screeners, such as the Brief Pain Inventory (BPI) (5), also can help consolidate information and maximize the time before the visit. I often bring the patient back in a week or two, or see the patient more frequently in the beginning of the treatment plan, to continue the initial evaluation. When dealing with a pain patient who may be considered difficult because he has lost the ability to cope with life, it is tempting to try to rush the evaluation. But most such patients have complex issues and histories that require a commitment on the clinician’s part to take the time to unravel them.

The clinician should perform a focused physical examination based on the patient’s history and carry out appropriate diagnostic testing. Quantitative measurements of the patient’s capacity for successful opioid treatment can be obtained from urine drug screens, electronic databases, and standard tools for risk stratification, such as the Opioid Risk Tool (6) and the revised version of the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) (7). In addition, the Sheehan Disability Scale (8) and the WHO-5 (9) are very helpful to assess functionality and wellness (a predictor of resiliency). The PHQ-9 (10) is a useful scale for depression, which often co-exists with chronic pain and will impact the patient’s care.

Treatment Considerations

The patient-clinician relationship is best viewed as a collaborative partnership; whereas patient demand should not determine the choice of a therapy, it should inform the choice. Many patients want to combine complementary and alternative medicine options with pharmacological therapy, and the assessment will help determine which therapy will provide greatest benefit. If the patient has issues with gait and balance, for example, physical therapy can improve functionality and decrease the potential for falls. We would also recommend other strategies such as fall-proofing the home, and learning ‘tricks’ for safe and less painful walking. For patients with localized neuropathic pain, dry needling techniques may be effective. Massage, either alone or combined with topical treatments such as NSAID-based gel, may ease musculoskeletal and soft tissue pain.

Most complex pain patients will be taking multiple medications, so I try to maximize their effectiveness during treatment. For example, switching a patient who is already taking a selective serotonin reuptake inhibitor (SSRI) to an SNRI will often provide additional analgesia. I try to prescribe treatments that will ‘multitask;– give multiple therapeutic effects from one molecule. Another example: if lack of sleep is an issue, I usually give gabapentinoids at night. Of course, opioids may also be required, if the risk/benefit ratio is appropriate, and non-opioid therapies alone have failed.

Treating patients with chronic pain can be challenging, but I have developed strategies for dealing with some of the frustrations. I talk with my colleagues, keep up to date with legislation and CME, and, most importantly, I trust my clinical judgment–especially when I am confident that my evaluation has been comprehensive and has involved collaborating with the patient. I am comfortable treating my patients with chronic pain, even when they become angry and disagree with the treatment decision. Because I have laid the proper groundwork, I view this not as a treatment failure, but as an opportunity to strengthen the therapeutic relationship.

References 
 
Irving G, Squire P. Medical evaluation of the chronic pain patient. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th Baltimore, MD: Lippincott Williams & Wilkins; 2010:208-223.
Fishman SM. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences; 2007:13-29.
American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–1346.
Chou R, Fanciullo GJ, Fine PG, et al., for the American Pain Society- American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med. 1994;23(2):129-138.
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–442.
Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360–372.
Leon AC, Olfson M, Portera L, Farber L, Sheehan DV.. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27(2):93-105.
Bech P. Measuring the dimensions of psychological general well-being by the WHO-5. QoL Newsletter. 2004;32:15-16.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

This story originally appeared in The Pain Practitioner, Spring 2014.

http://blog.aapainmanage.org/strategies-evaluating-patient-chronic-pain/