Minerals such as selenium and zinc can also help reduce oxidative stress and support liver enzymes, Cherkaoui says, while choline aids fat transport. Dr. Williams says choline is the “unsung hero” in the liver health story.

Cognitive and affective responses may be influenced by spouses or other family members. Spirituality is often overlooked during pain assessment.

Expected functional benefits of opioid use should be clear, with the continuation of opioid therapy dependent on achieving them. While improved sleep and mood are somewhat subjective and should be noted, seek more objective evidence of benefit in order to prescribe and continue opioid therapy.

“You’re still going through the motion of putting something in your mouth but without the harmful risks of smoking,” notes Dr. Solanki.

Chronic pain has little in common with acute pain and should be considered as a separate medical condition. Some differences are:

Assess factors that indicate whether opioids may be beneficial. Based on pain assessment, characterize the patient’s pain based on:

Neonatal pain assessment Scoring systems for acute and postoperative pain in infants evaluate physiological parameters , behavioral changes , and/or contextual factors.

Pain location. Pain drawings are frequently used for patients to identify the location of pain. A drawing on an anatomical outline can provide a quick impression of the breadth and character of the presenting pain complaint.

Chronic peripheral pain disorders can be a significant driver to the sensitization of central nociceptive neurons Usually continues even after the initial injury has healed

Peripheral sensitization Injury, inflammation, or repetitive stimulation of the peripheral nociceptive neurons → local release of chemical mediators (e.g., cytokines, nerve growth factors, histamine)→ repeated or prolonged exposure to chemical mediators upregulates the ion channels in the nociceptors → increases sensitivity and/or reduces threshold to chemical mediators even further → increased action potentials → abnormal pain perception

The mechanism is very similar to website that which regulates the central heating in a house where there is a thermostat in, say, the living room, which is set to a particular temperature and which activates the gas- or oil-fired furnace, or boiler that heats the hot water.

Urine drug testing. Obtain a urine drug screen (UDS) for all patients on chronic opioid therapy at least once per year, and any time there is a concern for inappropriate use, use of other substances, or diversion.99

Chronic primary pain syndromes. These syndromes represent a disease itself. A chronic primary pain syndrome is defined as pain in one or more anatomical regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or functional disability (interference with activities of daily life and participation in social roles) and that cannot be better accounted for by another chronic pain condition.17

Doses required for pain treatment are lower than for mood disorders. The lower doses generally avoid problems such as QT prolongation. For patients with sleep initiation problems, taking a TCA at dinnertime rather than bedtime may reduce problems with sleep initiation and with morning fatigue.