Management of Chronic Visceral Pain

Recommendations for the Management of Chronic Visceral Pain – Cindy Lampner –  July 05, 2016

The subjective experience of visceral pain and the neurobiological mechanisms that underlie it are substantially different from those of somatic pain, yet pain management strategies do not traditionally differ in their approaches.

As a result, the treatment of visceral pain frequently results in suboptimal outcomes and adverse effects on the GI tract.

Frequently diffuse, poorly localized and associated with autonomic and emotional reactions and alterations in visceral function, visceral pain is common across a range of clinical populations. 

While visceral pain is often found in the presence of structural, biochemical or inflammatory abnormalities such as kidney stones, pancreatitis and colitis, it frequently occurs without evidence of tissue insult, leading to the diagnosis of functional disorders such irritable bowel syndrome, non-ulcer dyspepsia or bladder pain syndrome

Many patients with visceral pain have been through multiple rounds of diagnostic procedures with multiple specialists. Providers should acknowledge the reality of the patient’s symptoms even in the absence of a definitive diagnosis in order to build confidence and a strong therapeutic relationship.

This sounds like “providers” are not expected to believe the patient’s pain, but should pretend to believe it to manipulate the patient’s trust.

The writers of the review recommend the use of the World Health Organization’s “analgesic ladder” for patients with visceral pain, but include the caveat that strong opioids be reserved for patients with organic as opposed to functional visceral disorders.

Originally developed for use in cancer pain, the ladder comprises 3 steps. The first step on the ladder involves the use of non-opioid analgesics. If pain increases or persists, clinicians initiate 2\

Unconventional pharmacological treatments such as ketamine, NGF antagonists, TRPV2 antagonists and linaclotide may eventually prove to be of benefit in visceral pain, but are yet to be validated with clinical trials

Nonpharmacological treatments including acupuncture or transcranial magnetic stimulation may also be considered, although data remain preliminary for both

References

Olesen AE, Farmer AD, Olesen SS, Aziz Q, Drewes AM. Management of chronic visceral pain. Pain Manag. June 2016.

Schwartz ES, Gebhart GF. Visceral Pain. I: Taylor BK, Finn DP, eds. Behavioral Neurobiology of Chronic Pain. Vol 20. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014:171-197. http://link.springer.com/10.1007/7854_2014_315. Accessed June 30, 2016.

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