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The role of medication in the treatment of Chronic Pain

The role of medication in the treatment of Chronic Pain. Lori Montgomery MD CCFP Medical Director, AHS (Calgary) Chronic Pain Centre Clinical Lecturer, Dept of Family Medicine and Dept of Anesthesia, U of C. Disclosures. Grants/Research Support: None Speakers Bureau/Honoraria: None

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The role of medication in the treatment of Chronic Pain

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  1. The role of medication in the treatment of Chronic Pain Lori Montgomery MD CCFP Medical Director, AHS (Calgary) Chronic Pain Centre Clinical Lecturer, Dept of Family Medicine and Dept of Anesthesia, U of C

  2. Disclosures Grants/Research Support: NoneSpeakers Bureau/Honoraria: None Consulting Fees: None

  3. Treatment options Medications

  4. Medical Management • Generally passive • Focus on medication changes • Best response rate for analgesics is 30% reduction in pain • Not all pain is opioid-responsive • Most important part of medication plan is managing expectations

  5. Background: WHO ladder http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Clinical_Updates&TEMPLATE=/CM/ContentDisplay.cfm&SECTION=Clinical_Updates&CONTENTID=7582

  6. The Chemistry of Pain Attention Expectation Affect Descending Excitation /Inhibition Dynorphin A / CCK 5HT / NE / GABA Neuronal Plasticity Tissue damage Inflammation Nerve compression 5-HT, Bradykinin, Cytokines, Histamine, Prostaglandins EAAs  NMDA receptors SubP / NGF / NK1 / CGRP / NO Peripheral Sensitization Central

  7. Acetaminophen NSAIDs COXIBs Buprenorphine Tramadol Codeine Morphine Oxycodone Hydromorphone Fentanyl Methadone Antidepressants Anticonvulsants Cannabinoids Montgomery 2013, Adapted from Twycross R, et al. Palliative Care Formulary. Radcliffe Medical Press, Oxford; 1998:86

  8. References and Further Reading Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C, Multidisciplinary rehabilitation for chronic low back pain: systematic review, BMJ 2001; 322:1516–20 Cunningham JL, Rome JD, Kerkvliet JL, and Townsend CO, Reduction in Medication Costs for Patients with Chronic Nonmalignant Pain Completing a Pain Rehabilitation Program: A Prospective Analysis of Admission, Discharge, and 6-Month Follow-Up Medication Costs, Pain Med 2009; 10 (5):787-796, Turk DC and Burwinkle TM, Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers, Professional Psychology: Research and Practice, 2005; 36(6):602–610 Chou R, Huffman LH, Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline, Ann Int Med147 (7): 492–504, 2007 http://www.topalbertadoctors.org/informed_practice/clinical_practice_guidelines/complete%20set/Low%20Back%20Pain/backpain_guideline.pdf

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