treatment of chronic non-cancer pain ross bryan mercer university ms iii august 2012
TRANSCRIPT
INTRODUCTIONINTRODUCTION
Chronic Non-Cancer Pain Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology
Development Develops as a result of persistent stimulation of or changes to nociceptors following injury.
Treatment Options Pharmacological Interventional Psychological
OPIOIDS(hydrocodone,
tramadol)
OPIOIDS(hydrocodone,
tramadol) Mechanism Bind MOR in brain and SC
Indication Neuropathy
Efficacy Less pain, less function
Adverse Effects Hyperalgesia; Abuse Nausea, constipation, somnolence
SS (with tramadol)
NSAIDsNSAIDs
Mechanism Inhibits COX-1 and/or COX-2
Indications OA; RA; back pain
Efficacy Not for neuropathy or FM
Adverse Effects Gastrointestinal for COX-1 Cardiovascular for selective COX-2
QuickTime™ and a decompressor
are needed to see this picture.
TCAs and SNRIs
(amytriptyline and
duloxetine)
TCAs and SNRIs
(amytriptyline and
duloxetine) Mechanism
Increase 5-HT and NE @ Synapse
Indications Neuropathy, fibromyalgia, low-back pain, and headaches.
Adverse Effects TCAs --> cardiovascular events
Anticonvulsants
(gabapentin and
carbamazepine)
Anticonvulsants
(gabapentin and
carbamazepine) Mechanism
Enhance GABA inhibitory system
Indication Neuropathic pain
Adverse Effects Somnolence, fatigue Dizziness
Topical Agents(Capsaicin)
Topical Agents(Capsaicin)
Mechanism Depletes substance P from primary afferent neurons
Indications Neuropathy and OA
Adverse Effects Limited
CorticosteroidsCorticosteroids Mechanism
Blocks PLA2 and IL-2
Indications Rediculopathy Facet joint pain
Adverse Effects Infection Paraplegia
SurgerySurgery
Lumbar Fusion Non-radicular degenerative changes
Discectomy Radiculopathy w/herniated disc
Decompressive Laminectomy Spinal stenosis
*many are associated with worsened quality of life after 4-5 years.
Intrathecal Implants
(morphine)
Intrathecal Implants
(morphine)
Mechanism MOR agonists
Indications Chronic refractory pain
Adverse Effects Tolerance
Interdisciplinary Pain Reduction
Programs (IPRPs)
Interdisciplinary Pain Reduction
Programs (IPRPs)
GOALS: Physical therapy Exercise Cognitive restructuring
Drug management
CommentsComments
Data on efficacy is limited by: Subjective outcomes Inconsistent diagnostic criteria
Even the most effective treatments averaged a 30% reduction of pain in only half of the patients
Even with pain reduction, there is often not concomitant improvement in emotional and physical functioning