**2.4 Tissue injury, organ failure, comorbidities, and pain**

Soft tissue or bone in the elderly have more issues like arthritis, tissue injury and healing can be poor giving rise to the pain. Acute or Chronic kidney disease (AKI or CKD) with comorbidities require pain management and most opioids are excreted through kidney and opioid toxicity is common. Diabetes is associated with neuropathy, likely microvascular insufficiency [12] (**Figure 2**)**.**

#### **2.5 Taxonomy**

Nociceptive pain, neuropathic pain and nociplastic pain have been approved by IASP in 2019 and International Classification of Diseases (ICD-11), which the

#### **Figure 3.**

*Taxonomy change in 2019, IASP added "Nociplastic Pain" relating to neuroplasticity and future application of research.*

**7**

**3.1 Education**

**Figure 4.**

online [19].

*What Do We Need to Consider for Pain Management? DOI: http://dx.doi.org/10.5772/intechopen.93640*

epigenetic effects can be generational [16–17].

**3. Principles of pain management**

opioid therapy [18].

World Health Organization adopted in the same year. These combined efforts have

Neuroplasticity is the change in neuronal pathways and synapses that occurs due to certain factors: behavior, environment, and neural process. Chronic pain has been related to central excitation, wind-up theory and IASP approved Neuroplastic pain; as the brain learning or neuroplasticity and alteration in the function of

Epigenetic effects, including major depression in an individual related to negative experience associated with poor coping and neuroplasticity secondary to changes in gene–environment, psychosocial environment leading to lower levels of neurotrophic factors altering structural and functional aspects of brain. Such

Pain management should include biopsychosocial assessment, pain severity, pain descriptors and planning physical, psychological, spiritual rehabilitation, invasive therapies, and pharmacological interventions for patients with acute, chronic, neuropathic and nociplastic pain. Patients in pain crisis and agitated often require pharmacotherapy initially to manage pain and following that nonpharmacological

Acute pain may require anti-inflammatory medications, steroids and opioids, depending upon the extent of injury for a short period, which could be hours to

Chronic pain is associated with goal setting. If patient's opioid use disorder risk is high by using "opioid Risk Tool" questionnaire, before opioids are being used requires boundary setting, along with written patient agreement document, for

Patients with life expectancy few hours, days or weeks may need more pharmacological interventions, as other interventions non-pharmacological to improve

Individuals with chronic pain, and suffering may benefit with explanation of their pain, which is a subjective symptom along with interventional plan which should include in such education. Such education either individual, or group education, depending upon the choice of the patient. Education can be verbal, written or

*Pain management includes variety of approaches, which require to improve patient's suffering.*

potential benefits for both research and patient care [13] (**Figure 3**).

anatomy for future research an appropriate term [14, 15].

interventions have a value and can reduce or stop medications.

days, which needs to be explained to the patient and family.

symptoms, may need longer time to respond (**Figure 4**).

*What Do We Need to Consider for Pain Management? DOI: http://dx.doi.org/10.5772/intechopen.93640*

*Pain Management - Practices, Novel Therapies and Bioactives*

**2.4 Tissue injury, organ failure, comorbidities, and pain**

*Pain classification: acute, chronic, and acute on chronic pain.*

ropathy, likely microvascular insufficiency [12] (**Figure 2**)**.**

Soft tissue or bone in the elderly have more issues like arthritis, tissue injury and healing can be poor giving rise to the pain. Acute or Chronic kidney disease (AKI or CKD) with comorbidities require pain management and most opioids are excreted through kidney and opioid toxicity is common. Diabetes is associated with neu-

Nociceptive pain, neuropathic pain and nociplastic pain have been approved by IASP in 2019 and International Classification of Diseases (ICD-11), which the

*Taxonomy change in 2019, IASP added "Nociplastic Pain" relating to neuroplasticity and future application of* 

**6**

**Figure 3.**

*research.*

**2.5 Taxonomy**

**Figure 2.**

World Health Organization adopted in the same year. These combined efforts have potential benefits for both research and patient care [13] (**Figure 3**).

Neuroplasticity is the change in neuronal pathways and synapses that occurs due to certain factors: behavior, environment, and neural process. Chronic pain has been related to central excitation, wind-up theory and IASP approved Neuroplastic pain; as the brain learning or neuroplasticity and alteration in the function of anatomy for future research an appropriate term [14, 15].

Epigenetic effects, including major depression in an individual related to negative experience associated with poor coping and neuroplasticity secondary to changes in gene–environment, psychosocial environment leading to lower levels of neurotrophic factors altering structural and functional aspects of brain. Such epigenetic effects can be generational [16–17].

### **3. Principles of pain management**

Pain management should include biopsychosocial assessment, pain severity, pain descriptors and planning physical, psychological, spiritual rehabilitation, invasive therapies, and pharmacological interventions for patients with acute, chronic, neuropathic and nociplastic pain. Patients in pain crisis and agitated often require pharmacotherapy initially to manage pain and following that nonpharmacological interventions have a value and can reduce or stop medications.

Acute pain may require anti-inflammatory medications, steroids and opioids, depending upon the extent of injury for a short period, which could be hours to days, which needs to be explained to the patient and family.

Chronic pain is associated with goal setting. If patient's opioid use disorder risk is high by using "opioid Risk Tool" questionnaire, before opioids are being used requires boundary setting, along with written patient agreement document, for opioid therapy [18].

Patients with life expectancy few hours, days or weeks may need more pharmacological interventions, as other interventions non-pharmacological to improve symptoms, may need longer time to respond (**Figure 4**).

**Figure 4.**

*Pain management includes variety of approaches, which require to improve patient's suffering.*

#### **3.1 Education**

Individuals with chronic pain, and suffering may benefit with explanation of their pain, which is a subjective symptom along with interventional plan which should include in such education. Such education either individual, or group education, depending upon the choice of the patient. Education can be verbal, written or online [19].

#### **3.2 Physical medicine approach**

Somatic, myofascial nociceptive pain can respond to exercise, passive physical modalities (TENS, laser, ultrasound, and massage) along with stretching has value in chronic back, neck and shoulder pain. Elderly, chronic pain, neuropathic, psychosocial and cancer pain patients/individuals may require interprofessional management [20, 21].

#### **3.3 Psychosocial approach**

Chronic pain in some patients is associated with alteration in the function and anatomy of limbic system in the brain and prefrontal system is not comfortable.

Cognitive-behavioral therapy (CBT) for chronic pain management has been used widely. Dennis Turk first described in 1983 education, skill acquisition, cognitive and behavioral rehearsal, generalization, and maintenance, and in review 2008 CBT, self-management skills and other suggestions [22].

Vulnerable populations with pain require social and financial rehabilitation along with multidisciplinary engagement.

#### **3.4 Spiritual approach**

Spiritual awakening as non-medical approach: meditation seems to benefit self-management skills, emotional improvement, and empowerment. Physical pain and discomfort in an individual may improve, whether neurotransmitters alter to benefit emotions.

#### **3.5 Interventional approaches**

#### *3.5.1 Surgery*

For patients with a reversible pain diagnosis due to fracture, obstruction, perforation and other causes, surgical intervention is possible and beneficial. Chronic pain improves with deep brain or spinal stimulation, which requires surgery [23].

#### *3.5.2 Radiation therapy*

Primary cancer and metastasis either curative or palliative- the intention is to reduce acute or chronic pain. It is a local therapy and initial fractions may increase pain due to inflammation. Systemic injection of radionuclide was used few decades ago for bone metastasis, but at present it is used for thyroid cancer as a primary therapy only [24].

#### *3.5.3 Chemo and immune therapy*

Patients with cancer pain receiving chemotherapy, initially the pain may increase due to necrotic tumor and inflammation. After two or three cycles of chemotherapy the tumor may reduce in size and pain may improve along with other symptoms.

#### *3.5.4 Interventional radiology (IR)*

Lately nerve mapping is better and anatomically using local anesthetic, steroids or other medications can reduce or stop pain for a few weeks. IR can be used for

**9**

**Table 1.**

*follow-up.*

*What Do We Need to Consider for Pain Management? DOI: http://dx.doi.org/10.5772/intechopen.93640*

ceuticals to control pain is available [26].

**3.6 Adjuvants, co-analgesics: systemic and topical**

symptoms.

*3.5.5 Neuraxial therapy*

*3.5.6 Pharmacological*

and not harmful.

*3.6.1 Opioid analgesics*

Restful sleep at night

Pain reduction by >30% Improved activity and function Physical, psychological rehabilitation

**Goal setting—Chronic pain—opioids**

Plan for reduction of opioids—if pain improved

Brain activity sharp in the daytime Affect, being better than neutral

[18] (**Table 1**).

palliative bone/musculoskeletal and neuropathic pain in the form of cryoablation, microwave thermal ablation, plasma medicated radiofrequency ablation. Vertebroplasty and kyphoplasty along with stent therapy is possible [25].

Sympathetic blockade, stellate ganglion, coeliac and splanchnic plexus, and lumbar plexus block is possible to reduce sympathetically medicated pain and

Palliative and end of life care when the pain is not manageable epidural and spinal analgesia using local anesthetic, opioid, alpha-2 agonist, and other pharma-

Non-opioid analgesics such as anti-inflammatory; acetaminophen, NSAIDs and Cox-2 inhibitors are used for acute pain but less effective with chronic pain including neuropathic or nociplastic pain. Such medications are associated with adverse effects and a therapeutic trial is useful in an individual and testing appropriate dose is useful

Antidepressants and anticonvulsants have been used as systemic adjuvants for chronic pain and neuropathic pain. Number needed to treat (NNT) and number needed to harm (NNH) was adapted from Finnerup et al. in 2005 and 2007. Topical adjuvants include lidocaine patch and capsaicin and ointment and topical formulation with certain local anesthetic, amitriptyline, ketamine, gabapentin, and clonidine have been reported as beneficial for localized pain which is neuropathic in nature [27, 28].

Chronic pain management requires opioids, we need to consider pain diagnosis, risk/benefit of use of opioid in an individual, mental health and behavior. Opioid risk tool has been useful to note the risk and if it is high, consider goals and boundaries, verbal or written signed documents to encourage patient's better behavior

*Opioid use requires goal setting and needs to be shared with the patient, the first time and reminded on* 

#### *What Do We Need to Consider for Pain Management? DOI: http://dx.doi.org/10.5772/intechopen.93640*

palliative bone/musculoskeletal and neuropathic pain in the form of cryoablation, microwave thermal ablation, plasma medicated radiofrequency ablation. Vertebroplasty and kyphoplasty along with stent therapy is possible [25].

Sympathetic blockade, stellate ganglion, coeliac and splanchnic plexus, and lumbar plexus block is possible to reduce sympathetically medicated pain and symptoms.

#### *3.5.5 Neuraxial therapy*

*Pain Management - Practices, Novel Therapies and Bioactives*

CBT, self-management skills and other suggestions [22].

along with multidisciplinary engagement.

Somatic, myofascial nociceptive pain can respond to exercise, passive physical modalities (TENS, laser, ultrasound, and massage) along with stretching has value in chronic back, neck and shoulder pain. Elderly, chronic pain, neuropathic, psychosocial and cancer pain patients/individuals may require interprofessional

Chronic pain in some patients is associated with alteration in the function and anatomy of limbic system in the brain and prefrontal system is not comfortable. Cognitive-behavioral therapy (CBT) for chronic pain management has been used widely. Dennis Turk first described in 1983 education, skill acquisition, cognitive and behavioral rehearsal, generalization, and maintenance, and in review 2008

Vulnerable populations with pain require social and financial rehabilitation

Spiritual awakening as non-medical approach: meditation seems to benefit self-management skills, emotional improvement, and empowerment. Physical pain and discomfort in an individual may improve, whether neurotransmitters alter to

For patients with a reversible pain diagnosis due to fracture, obstruction, perforation and other causes, surgical intervention is possible and beneficial. Chronic pain improves with deep brain or spinal stimulation, which requires surgery [23].

Primary cancer and metastasis either curative or palliative- the intention is to reduce acute or chronic pain. It is a local therapy and initial fractions may increase pain due to inflammation. Systemic injection of radionuclide was used few decades ago for bone metastasis, but at present it is used for thyroid cancer as a primary

Patients with cancer pain receiving chemotherapy, initially the pain may increase due to necrotic tumor and inflammation. After two or three cycles of chemotherapy the tumor may reduce in size and pain may improve along with other symptoms.

Lately nerve mapping is better and anatomically using local anesthetic, steroids or other medications can reduce or stop pain for a few weeks. IR can be used for

**3.2 Physical medicine approach**

management [20, 21].

**3.4 Spiritual approach**

**3.5 Interventional approaches**

benefit emotions.

*3.5.2 Radiation therapy*

therapy only [24].

*3.5.3 Chemo and immune therapy*

*3.5.4 Interventional radiology (IR)*

*3.5.1 Surgery*

**3.3 Psychosocial approach**

**8**

Palliative and end of life care when the pain is not manageable epidural and spinal analgesia using local anesthetic, opioid, alpha-2 agonist, and other pharmaceuticals to control pain is available [26].
