Chronic pain syndromes

Discuss with the patient how chronic pain affects their life, including daily activities, work, sleep, social interaction, and relationships. Be sensitive to how their socioeconomic, cultural, and ethnic background may influence the impact of pain on them and their care. Provide information about prognosis, including the likelihood of flare-ups and/or that the pain may not improve or may get worse over time.

Chronic pain is best managed using self-management techniques. After initial training with a therapist, patients should maintain regular skill practice:

• Twice daily stretching exercises

• Daily relaxation practice to be performed in the morning, throughout the day and at bedtime

• Incorporation of proper daily pacing and scheduling to avoid excessive activity schedule or excessive activity restrictions

• Daily aerobic exercise (biking, walking, or swimming)

• Proper nutrition to avoid excessive weight

• Sleep hygiene techniques.

If opioid treatment is being considered for intractable chronic pain that has not responded to nonpharmacologic and nonopioid pharmacologic therapies, discuss with the patient the realistic benefits and known risks of opioid therapy, work with them to establish treatment goals for pain and function, and explain that opioid therapy will be discontinued if benefits do not outweigh risks.[42]Dowell D, Ragan KR, Jones CM, et al. CDC Clinical practice guideline for prescribing opioids for pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71(3):1-95. https://www.doi.org/10.15585/mmwr.rr7103a1 http://www.ncbi.nlm.nih.gov/pubmed/36327391?tool=bestpractice.com

Women and girls of childbearing potential should be informed that they must follow a pregnancy prevention program while on treatment with valproate medicines. An example of one such program was launched in 2018 by the European Medicines Agency, for use across the EU, and includes the following:[94]European Medicines Agency. New measures to avoid valproate exposure in pregnancy endorsed. March 2018 [internet publication]. https://www.ema.europa.eu/en/documents/referral/valproate-article-31-referral-new-measures-avoid-valproate-exposure-pregnancy-endorsed_en.pdf

• An assessment of the patient's potential for becoming pregnant

• Pregnancy tests before starting and during treatment as needed

• Counseling about the risks of valproate treatment and the need for effective contraception throughout treatment

• A review of ongoing treatment by a specialist at least annually

• A risk acknowledgement form that patients and prescribers will go through at each such annual review to confirm that appropriate advice has been given and understood.