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Treatment of Chronic Non-Cancer Pain

Treatment of Chronic Non-Cancer Pain. Ross Bryan Mercer University MS III August 2012. INTRODUCTION. Chronic Non-Cancer Pain Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology Development

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Treatment of Chronic Non-Cancer Pain

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  1. Treatment of Chronic Non-Cancer Pain Ross Bryan Mercer University MS III August 2012

  2. INTRODUCTION • 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

  3. Pharmacological

  4. 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)

  5. NSAIDs • 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

  6. 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

  7. Anticonvulsants(gabapentin and carbamazepine) • Mechanism • Enhance GABA inhibitory system • Indication • Neuropathic pain • Adverse Effects • Somnolence, fatigue • Dizziness

  8. Topical Agents(Capsaicin) • Mechanism • Depletes substance P from primary afferent neurons • Indications • Neuropathy and OA • Adverse Effects • Limited

  9. Corticosteroids • Mechanism • Blocks PLA2 and IL-2 • Indications • Rediculopathy • Facet joint pain • Adverse Effects • Infection • Paraplegia

  10. Surgery • 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.

  11. Intrathecal Implants(morphine) • Mechanism • MOR agonists • Indications • Chronic refractory pain • Adverse Effects • Tolerance

  12. Interdisciplinary Pain Reduction Programs (IPRPs) • GOALS: • Physical therapy • Exercise • Cognitive restructuring • Drug management

  13. Comments • 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

  14. Citation • Turk, Dennis, PhD, Wilson, Hilary. Treatment of Chronic Non-cancer Pain. The Lancet, 2011 vol 377: 2226-2235.

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