Current Pharmacotherapy of Chronic Pain
|
|
- Della Norma Thomas
- 6 years ago
- Views:
Transcription
1 S16 Journal of Pain and Symptom Management Vol. 19 No. 1(Suppl.) January 2000 Proceedings Supplement NMDA-Receptor Antagonists: Evolving Role in Analgesia Current Pharmacotherapy of Chronic Pain Russell K. Portenoy, MD Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York, USA Abstract Advances in basic and clinical research have greatly expanded the options for analgesic pharmacotherapy. There are three broad categories of analgesic medications: (1) nonopioid analgesics, which includes the nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, dipyrone, and others; (2) a diverse group of drugs known as the adjuvant analgesics, which are defined as drugs that have primary indications other than pain but may be analgesic in selected circumstances; and (3) opioid analgesics. The advent of highly selective COX-2 inhibitors has generated excitement because of the possibility that these new NSAIDs will be much safer than previous COX inhibitors. However, the cost benefit of using these relatively more expensive drugs versus other NSAIDs plus gastroprotective therapies needs to be determined. Adjuvant analgesics can be grouped into four major classes according to their use: multipurpose, neuropathic pain, musculoskeletal pain, and cancer pain. There has been a dramatic increase in the number of these drugs during the past two decades and they now play an important role in the management of chronic pain. Pain specialists are now using opioids for chronic nonmalignant pain in addition to the traditional use for acute and cancer pain. This change in practice evolved from recognition that selected patients with chronic noncancer-related pain can experience sustained analgesia and function better with these drugs, without developing an addictive disorder. The combination of opioids and other drugs, such as an N-methyl-D-aspartate-receptor antagonist, may improve the balance between analgesia and adverse effects. J Pain Symptom Manage 2000;19:S16 S20. U.S. Cancer Pain Relief Committee, Introduction Rapid advances in basic and clinical research have greatly expanded the options for analgesic pharmacotherapy. This has been most important for the extremely large and diverse population with chronic pain. For some patients with chronic pain, such as those with cancer pain, analgesic drug therapy is the Address reprint requests to: Russell K. Portenoy, MD, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York, 10003, USA. Accepted for publication: September 17, mainstay approach and may be appropriately used as a single strategy. In other types of patients, drug therapy is one element in a multimodality strategy. Regardless, the optimal use of analgesic drugs is now an essential goal of pain management. Pharmacotherapy involves three broad categories of analgesic medications. The nonopioid analgesics include the nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and others that are not available in the United States. A very broad and diverse group of drugs is known as the adjuvant analgesics. These drugs have primary indications other than pain, but may be analgesic in selected circum- U.S. Cancer Pain Relief Committee, /00/$ see front matter Published by Elsevier, New York, New York PII S (99)
2 Vol. 19 No. 1(Suppl.) January 2000 Current Analgesic Pharmacotherapy S17 stances. The third category includes opioid analgesics. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) The mechanism of the NSAIDs is to inhibit both peripheral and central cyclooxygenase. There are two main forms of cyclooxygenase: COX-1, which is constitutive (that is, the compounds produced by the activity of this enzyme are necessary for normal physiologic function of stomach, kidney, and platelets), and COX-2, which is inducible and involved in inflammation. It has long been recognized that the possibility of selectively inhibiting COX-2, while leaving COX-1 uninhibited, may produce an NSAID with a greater therapeutic index. Nonselective COX inhibitors have been available for many years and now include numerous drugs in diverse classes: salicylates, propionic acids, acetic acids, oxicams, naphthylalkalones, and fenamates. The relative selectivity between COX-1 and COX-2 varies across these agents, and drug-specific differences in toxicity are in part based on this relative selectivity. The advent of highly-selective COX-2 inhibitors, such as celecoxib (Celebrex) and rofecoxib (Vioxx), has generated great excitement because of the possibility that these highly-selective COX-2 inhibitors will actually be much safer than nonselective COX inhibitors, even those that are more selective for COX-2 than for COX-1. NSAIDs have dose-dependent effects. The ceiling dose for analgesic and anti-inflammatory effects has been evaluated in broad terms in dose-ranging studies, but, in any individual patient, the minimum effective dose and ceiling dose are unknown. This suggests the value of dose titration. All these drugs are nonspecific analgesics and can be effective for a variety of pain syndromes. They produce no physical dependence or tolerance. There is marked individual variation in analgesic efficacy and side effects, and the concept of sequential drug trials or drug rotation has been accepted for a long time. Despite considerable knowledge about the basic mechanisms of NSAIDs and information from numerous clinical studies, guidelines regarding NSAID selection and dosing are empirical, based on best clinical judgment. It is generally better to titrate from a low dose, particularly among patients who are relatively predisposed to toxicity. As the dose is increased, there is the need to recognize the ceiling effect. The potential for adverse effects must be recognized. Unfortunately, most of the toxicities with these drugs are actually occult. For example, the risk of massive GI hemorrhage increases with dose, but one cannot predict that risk; the first sign is frequently when the patient presents with a life-threatening hemorrhage. To reduce the risks associated with these drugs, clinicians must recognize the high-risk patients (e.g., the elderly; those receiving corticosteroids or anticoagulants; those who have previously experienced NSAID toxicity; etc.), use the safest agents possible, and try to identify the minimal effective dose. It is important to recognize improvements in gastroprotective therapy that have been evaluated with the nonselective COX drugs. Prostaglandin analogues (e.g., misoprostol), proton pump inhibitors (e.g., omeprazole), and H2 blockers (e.g., famotidine) have been shown to be effective. The advent of the selective COX-2 inhibitors offers great clinical potential. However, the cost benefit of using these relatively more expensive drugs compared to nonselective NSAIDs with gastroprotective therapies is unknown. In populations not at high risk for GI hemorrhage, for example, it may be just as beneficial to use ibuprofen and an inexpensive H2 blocker, rather than a COX-2 selective inhibitor, which incurs a higher cost for the patient. This kind of information needs to be determined and made available. Adjuvant Analgesics Advances in NSAID therapy pale in comparison to the enormous advances that have occurred in the area of adjuvant analgesics over the past 20 years. 1 It has been astounding to see the development of data supporting the use of a broad array of drugs that were hitherto thought to be nonanalgesic. Adjuvant analgesics can be grouped into four major classes according to their use. For example, drugs that can potentially work for any kind of pain are classified as multipurpose analgesics. Some drugs are used for neuropathic pain, some are used predominantly for
3 S18 Portenoy Vol. 19 No. 1(Suppl.) January 2000 Table 1 Adjuvant Analgesics: Major Classes Multipurpose analgesics Neuropathic pain Musculoskeletal pain Cancer pain Antidepressants 2 -adrenergic agonists Corticosteroids Local anesthetics Anticonvulsants GABA agonists Neuroleptics Topical analgesics Calcitonin Sympatholytics Muscle relaxants Some benzodiazepines Osteoclast inhibitors Radiopharmaceuticals Anticholinergics Octreotide musculoskeletal pain, and some are used predominantly or exclusively in the cancer pain population (Table 1). Multipurpose Analgesics Among the multipurpose analgesics are antidepressants, 2 -adrenergic agonists, and corticosteroids. The importance of antidepressant analgesia has been recognized for decades. These widely used drugs can potentially help chronic pain of any type, as indicated by controlled clinical trials in a variety of diverse pain syndromes. If used for neuropathic pain, they have traditionally been preferred for continuous dysesthesia, and are second-line for lancinating dysesthesia. Most of the data supporting these drugs as analgesics were evaluated for the tricyclic antidepressants. Some studies have compared the relatively more toxic, tertiary amine drugs, such as amitriptyline, against the secondary amine drugs like desipramine. However, there are few studies that have compared those drugs against the even safer compounds, the serotonin selective reuptake inhibitors (SSRIs) and the atypical antidepressants, e.g., venlafaxine (Effexor ). Because there is little information, the selection of drugs at this point is in the realm of good clinical judgment. Drug selection must be based on a careful evaluation of the patient, which may suggest a specific drug or give the clinician a sense of whether the patient will be able to tolerate a tricyclic versus a selective serotonin reuptake inhibitor. Considerably more information is needed to be able to select a specific antidepressant on the basis of predicted efficacy or tolerability. The 2 -adrenergic agonists also are multipurpose analgesics. In the United States, there are now two drugs available, clonidine (Catapres ) and tizanidine (Zanaflex ). Tizanidine, which has been on the market for a relatively short period of time, may be better tolerated than clonidine. These drugs can potentially be used for patients with syndromes as diverse as headache, lower back pain, neuropathic pain, and cancer pain. Drugs for Neuropathic Pain For the treatment of neuropathic pain, the antidepressants and 2 -adrenergic agonists can be used. In addition, a large number of drugs have been targeted specifically for neuropathic pain. One could speculate that these drugs actually might be multipurpose analgesics, but the data do not allow a recommendation for use in any type of pain syndrome other than neuropathic pain. The most popular drug by far is gabapentin (Neurontin ), an anticonvulsant. In the last year or so, two placebo-controlled randomized trials have demonstrated the analgesic efficacy of gabapentin in postherpetic neuralgia and diabetic painful polyneuropathy. In these trials, the dose was titrated as high as 3600 mg. To maximize the benefits of this drug, gradual dose escalation to this level, and sometimes even higher, may be needed. Other anticonvulsants have been used for pain for many years, but in general, studies have established analgesic efficacy only for patients with lancinating or paroxysmal dysesthesia. Empirically, however, some patients with continuous dysesthesias who have been treated with anticonvulsant therapy have done extremely well. Carbamazepine (Tegretol ), phenytoin (Dilantin ), valproate (Depakote ), clonazepam (Klonopin ), as well as newer drugs, such as lamotrigine (Lamictal ), topiramate (Topamax ), and tiagabine (Gabatril ) are on the list of anticonvulsant drugs that are tried, sometimes sequentially, in patients with refractory neuropathic pain. This is a remarkable demonstration of how quickly the area of adjuvant analgesics is evolving. Oral local anesthetics, such as mexiletine (Mexitil ), flecainide (Tambocor ), or tocainide (Tonocarel ), are also used for chronic neu-
4 Vol. 19 No. 1(Suppl.) January 2000 Current Analgesic Pharmacotherapy S19 ropathic pain of any type. In the United States, mexiletine is generally preferred. Neuropathic pain and other types of pain syndromes also can be treated with topical analgesics. Local anesthetics typically do not penetrate the epidermis and produce cutaneous anesthesia, but EMLA cream, a eutectic mixture of local anesthetics (i.e., 1:1 mixture of prilocaine and lidocaine), does penetrate epidermis and can produce anesthesia. The Food and Drug Administration has just approved a new topical local anesthetic, lidocaine (Lidoderm ), a patch for use in postherpetic neuralgia that may be a useful addition to local anesthetic therapies. The analgesic efficacy of topical capsaicin continues to be controversial. The best studies seem to be those in patients with painful, small joint osteoarthropathy, and not neuropathic pain syndromes. This drug is relatively safe and is often tried. Topical NSAIDs are effective analgesics in some patients. In the United States, topical NSAIDs, other than topical salicylates, have not made it to the marketplace, but some pharmacies will compound these products for clinicians. This may be another way of approaching different types of pain, including neuropathic pain. N-methyl-d-aspartate (NMDA)-receptor antagonists reflect a new approach in the broad category of adjuvant analgesics. Preclinical studies have established that this receptor is involved both in the development of neuropathic pain and in the appearance of opioid tolerance. Studies in experimental pain and clinical pain have confirmed the potential for analgesics from NMDA-receptor blockers. New data also confirm the capacity for analgesic potentiation when such a drug is added to morphine. The broad utility of NMDA-receptor antagonists as single-entity analgesics and as analgesics in combination with other drugs, such as the opioids, is discussed elsewhere in this supplement. Drugs for Musculoskeletal Pain There is very little evidence that the most popular muscle relaxant drugs, such as orphenadrine (Norflex ), methocarbamol (Robaxin ), carisoprodol (Soma ), chlorzoxazone (Parafon Forte ), cyclobenzaprine (Flexeril ), or metaxalone (Skelaxin ) actually relax skeletal muscle. Nonetheless, when these drugs are studied in acute dosing paradigms in patients with musculoskeletal pain, they are effective analgesics. Their sedative and anticholinergic side effects are usually well tolerated, particularly with acute doses, and they are commonly used for acute musculoskeletal pain. Opioids There has been a dramatic change in the way pain specialists view the use of opioid drugs for the management of chronic, noncancer-related pain. 2 It has been accepted for decades that opioid analgesics are the mainstay approach for acute pain and chronic cancer pain. Their role in chronic nonmalignant pain is rapidly evolving. The traditional view is that opioids should not be used for chronic nonmalignant pain because of side effects, tolerance, and addiction. Data generated from multidisciplinary pain management programs about 10 years ago suggested that opioid use was associated with more pain, more disability, more distress, less effective therapy, and substance abuse behavior. These data, however, cannot be generalized to the entire pain population. The strong referral bias and observer bias that exist in multidisciplinary pain management programs do not reflect the reality of clinical practice. There is growing recognition that selected patients with chronic noncancer-related pain can be provided opioid drugs for prolonged periods without overt evidence of tolerance and without intolerable toxicity. Many patients function better with these drugs. These observations have led to the development of consensus statements in support of cautious opioid use in carefully selected and well-monitored patients. These consensus statements have now been published by the American Pain Society, American Academy of Pain Medicine, American Society of Addiction Medicine, and the Canadian Pain Society. This evolving view of opioid therapy is supported by data from surveys and controlled studies. The latest controlled study, 3 a randomized, long-term comparison of two opioid regimens and naproxen in patients with low back pain, demonstrated less pain and less emotional distress among opioid-treated patients. Patients with diverse pain states could potentially benefit from opioid therapy. Serious adverse effects are rare, and doses generally re-
5 S20 Portenoy Vol. 19 No. 1(Suppl.) January 2000 main stable, if the pain syndrome is stable. Addiction (defined as loss of control over the drug, compulsive drug use, and continued use of the drug despite harm) is rare, particularly if there is no history of chemical dependency. A therapeutic opioid trial may be warranted in selected patients. Future research needs to provide more information about the clinical use of these drugs: how to select patients; how to select the right drug; how to titrate the drug; how to manage side effects; how to appropriately monitor the outcomes in chronic nonmalignant pain, including outcomes related to chemical dependency; and finally, how to add drugs to the opioids to maximize benefit and minimize risk by improving the balance between analgesia and adverse effects. The goal is to improve maximal efficacy and the ease of therapy. References 1. Portenoy RK. Adjuvant analgesics. In: Doyle D, Hanks GW, MacDonald RN, eds. Oxford textbook of palliative medicine, 2nd ed. Oxford, UK: Oxford University Press, 1998: Portenoy RK. Opioid therapy for nonmalignant pain: a clinician s perspective. J Law Med Ethics 1996;24: Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic noncancer back pain: a randomized prospective study. Spine 1998;23:
Pharmacotherapy of Pain SUPHAT SUBONGKOT, PHARM.D. BCOP, BCOP CLINICAL PHARMACY DIVISION KHON KAEN UNIVERSITY, THAILAND
Pharmacotherapy of Pain SUPHAT SUBONGKOT, PHARM.D. BCOP, BCOP CLINICAL PHARMACY DIVISION KHON KAEN UNIVERSITY, THAILAND Therapeutic Strategies for Pain and Disability Pharmacotherapy Rehabilitative approaches
More informationAvailable Strengths. Cost per Rx 325 mg tablet - $ mg tablet - $ mg ER tablet - $ mg capsule - $ mg chewable tablet
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY Non-Opioids LAST REVIEW 5/9/2017 THERAPEUTIC CLASS Pain REVIEW HISTORY 2/16, 5/15 LOB AFFECTED Medi-Cal (MONTH/YEAR) This
More information3/1/2018. Disclosures. Objectives. Clinical advisory board member- Daiichi Sankyo
Adjuvant pain medications in geriatrics Thomas B. Gregory, Pharm.D., BCPS, CPE, FASPE Clinical Pharmacy Specialist Pain Management CoxHealth Springfield, MO Disclosures Clinical advisory board member-
More informationInterprofessional Webinar Series
Interprofessional Webinar Series Drug Therapy for Neuropathic Pain in the Medically Ill Russell K. Portenoy, MD Executive Director, MJHS Institute for Innovation in Palliative Care Chief Medical Officer,
More informationNon-opioid and adjuvant pain management
Non-opioid and adjuvant pain management ALLISON JORDAN, MD, HMDC MEDICAL DIRECTOR OF PALLIATIVE CARE SERVICES CHRISTIAN AND ALTON MEMORIAL HOSPITALS ASSOCIATE MEDICAL DIRECTOR, BJC HOSPICE ASSISTANT PROFESSOR
More informationCHAPTER 4 PAIN AND ITS MANAGEMENT
CHAPTER 4 PAIN AND ITS MANAGEMENT Pain Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Types of Pain
More informationPractical Pain Management Leah Centanni, MSN, FNP-C, Asst. Clinical Professor CANP Conference March 22, 2014
Practical Pain Management Leah Centanni, MSN, FNP-C, Asst. Clinical Professor CANP Conference March 22, 2014 Overview Types of Pain Physical Examination of Pain Pharmacologic Approach in Pain Management
More informationNATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Neuropathic pain pharmacological management: the pharmacological management of neuropathic pain in adults in non-specialist
More informationIF I M NOT TREATING WITH OPIOIDS, THEN WHAT AM I SUPPOSED TO USE?
NON-OPIOID TREATMENT OPTIONS FOR CHRONIC PAIN Alison Knutson, PharmD, BCACP Medication Management Pharmacist Park Nicollet Creekside Clinic Dr. Knutson indicated no potential conflict of interest to this
More informationPain Management in the
Pain Management in the Elderly Meri Hix, PharmD, CGP, BCPS Associate Professor of Pharmacy Practice Midwestern University Chicago College of Pharmacy No conflicts of interest to declare Objectives Discuss
More informationNon-Opioid Drugs to Treat Neuropathic Pain. March 2018
Non-Opioid Drugs to Treat Neuropathic Pain Final Report March 2018 This report is intended only for state employees in states participating in the Drug Effectiveness Review Project (DERP). Do not distribute
More informationNocioceptive Pain. Inflammatory Pain. Nociceptive Pain. Inflammatory Pain. Neuropathic Pain
Nocioceptive Pain Pathophysiology of Pain Larry Levine, MD Alaska Spine Institute Ex: Acute Postoperative Pain Noxious peripheral Stimuli Heat/Cold Mechanical Force Chemical Irritants Nociceptive Pain
More informationNo Pain, No Gain Pharmacy Patient Pain Counseling Competition
No Pain, No Gain Pharmacy Patient Pain Counseling Competition Offered by the Maine Pharmacy Association as part of the 2010 MPA Fall Conference Sponsored by an educational grant by NASPA and Purdue Pharma,
More informationSUMMARY OF ARIZONA OPIOID PRESCRIBING GUIDELINES FOR THE TREATMENT OF CHRONIC NON-TERMINAL PAIN (CNTP)
9 SUMMARY OF ARIZONA OPIOID PRESCRIBING GUIDELINES FOR THE TREATMENT OF CHRONIC NON-TERMINAL PAIN (CNTP) SUMMARY OF ARIZONA OPIOID PRESCRIBING GUIDELINES FOR THE TREATMENT OF ACUTE PAIN NONOPIOID TREATMENTS
More informationRational Polypharmacy
Rational Polypharmacy Thomas B. Gregory, PharmD, BCPS, CPE, FASPE Disclosures Clinical advisory board: Daiichi Sankyo 1 Introduction Cox Health Ambulatory Pain Clinic Pharmacy Specialist Learning Objectives
More informationPain Management: Overview of A Practical Approach
Pain Management: Overview of A Practical Approach Michael B. Potter, M.D. Department of Family and Community Medicine University of California, San Francisco What is Pain? An unpleasant sensory and emotional
More informationPain control in Cancer patients. Dr Ali Shoeibi, Assistant Professor of Neurology
Pain control in Cancer patients Dr Ali Shoeibi, Assistant Professor of Neurology More than two thirds of patients with advanced cancer experience cancer pain Almost all pain can be controlled to some extent
More informationPain Signaling Neuropathic Pain Distinctly different from nociceptive pain Sustained by abnormal processing of sensory input by the peripheral or cent
Objectives Pharmacologic Management of Neuropathic Pain Joseph R. Ineck, Pharm.D.,., CPE Pharmacist: St. Luke s Health System At the conclusion of this presentation, pharmacists will be able to: 1. Differentiate
More informationCHAPTER 4 PAIN AND ITS MANAGEMENT
CHAPTER 4 PAIN AND ITS MANAGEMENT Pain Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Types of Pain
More informationIf Not Opioids then LEAH EDMONDS CSHP OCTOBER 26, 2017
If Not Opioids then what LEAH EDMONDS CSHP OCTOBER 26, 2017 Disclosure Nothing to disclose Objectives Identify various non-opioid options for the treatment of chronic non cancer pain Choose appropriate
More informationPAIN MANAGEMENT STRATEGIES: ALTERNATIVES TO OPIOIDS
PAIN MANAGEMENT STRATEGIES: ALTERNATIVES TO OPIOIDS SATURDAY/2:00-3:00PM ACPE UAN: 0107-9999-17-239-L01-P 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacists: Upon completion
More informationPain. November 1, 2006 Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine
Pain November 1, 2006 Dr. Jana Pilkey MD, FRCP(C) Internal Medicine, Palliative Medicine Objectives To be able to define pain To be able to evaluate pain To be able to classify types of pain To learn appropriate
More informationDisclosures. Management of Chronic, Non- Terminal Pain. Learning Objectives. Outline. Drug Schedules. Applicable State Laws
Disclosures Management of Chronic, Non- Terminal Pain No financial disclosures or conflicts of interest to report Michael A. Smith, PharmD, BCPS Clinical Assistant Professor, University of Michigan College
More informationCancer patients at End-of-Life: Multidimensional Pain Requiring Multimodal Therapy
Cancer patients at End-of-Life: Multidimensional Pain Requiring Multimodal Therapy Presented by: Marsha Farrell BSN, RN-BC, CHPN Pathways to Success Conference by the Bay November 12, 2014 Conflict of
More informationAnalgesics and Adjuvants for Pain Therapy
Topics to be covered Analgesics and Adjuvants for Pain Therapy Chuthamanee C. Suthisisang BPharm, PhD Department of Pharmacology Faculty of Pharmacy Mahidol University Neurochemistry of pain Early pain
More informationMedications for Persistent Pain
Medications for Persistent Pain An Older Adult s Guide to Safe Use of Pain Medications THE AGS FOUNDATION FOR HEALTH IN AGING What is persistent pain? Introduction Persistent, or chronic pain, is pain
More informationPAIN. TREATMENT TABLES Analgesics. NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose
NON-OPIOID SHORT-ACTING LONG-ACTING **** O PAIN TREATMENT TABLES Analgesics NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose Tramadol 50 mg Ultram Every 4 hours 1-2 tabs,
More informationManaging the Chronic Pain Patient. (and some stuff about opioids)
Managing the Chronic Pain Patient. (and some stuff about opioids) C. Patrick Carroll, M.D. Assistant Professor Johns Hopkins University School of Medicine Department of Psychiatry and Behavioral Sciences
More informationOverview of Neuropathic pain
Overview of Neuropathic pain Kongkiat Kulkantrakorn,M.D. Neurology division Thammasat University 1 Contents Overview of pain New concepts and mechanism Treatment options New data in management 2 3 Breaking
More informationBaclofen is a GABA-agonist, although its exact mechanism of action remains uncertain. It is known to reduce release of excitatory neurotransmitters.
Muscle relaxants may be needed, including benzodiazepines such as diazepam (Valium). For increased muscle tone (spasticity) Baclofen (Lioresal?) is a useful drug. Baclofen is a GABA-agonist, although its
More informationADJUVANT PAIN MANAGEMENT
ADJUVANT PAIN MANAGEMENT Bruce H. Chamberlain, MD FACP FAAHPM Palliative Consulting Orem, UT AAHPM Intensive Board Review Course Using Adjuvant Treatments for Chronic Pain Bruce H. Chamberlain, MD FACP
More informationCancer Pain Management: An Update
Cancer Pain Management: An Update Presented By Dr. Marcelo Garcia Palliative Care Consultant Physician Winnipeg Regional Health Authority Topics Pain-what is it? Assessment of cancer pain Types of pain
More informationAchieving Optimal Therapeutic Outcomes in Pain Management from a Pharmacist's Perspective
Achieving Optimal Therapeutic Outcomes in Pain Management from a Pharmacist s Perspective Chris Herndon, PharmD, BCPS, CPE Assistant Professor Southern Illinois University Edwardsville Clinical Pharmacy
More informationIndex. Surg Clin N Am 85 (2005) Note: Page numbers of article titles are in boldface type.
Surg Clin N Am 85 (2005) 393 398 Index Note: Page numbers of article titles are in boldface type. A Acetaminophen, for chronic pain, in surgical patients, 219 a2 Adrenergic agonists, for neuropathic pain,
More informationPharmacological treatment of Pain
Pharmacological treatment of Pain None Disclosures and Conflict of Interest Dr John F. Flannery Medical Director MSK and Multisystem Rehab Program PMR - FRCPC Objectives At the end of this presentation
More informationNEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES
NEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES GENERAL PRINCIPLES Neuropathic pain may be relieved in the majority of patients by multimodal management A careful history and examination are essential.
More informationNeuropathic pain, which is caused by nerve injury. Topical Ketamine Gel: Possible Role in Treating Neuropathic Pain
PAIN MEDICINE Volume 1 Number 1 2000 Topical Ketamine Gel: Possible Role in Treating Neuropathic Pain Arnold Gammaitoni, PharmD,* Rollin M. Gallagher, MD, MPH,* and Maripat Welz-Bosna, RN* *Pain Medicine
More informationPain: Current Understanding of Assessment, Management, and Treatments. Sponsored by the American Pain Sciety
Pain: Current Understanding of Assessment, Management, and Treatments Sponsored by the American Pain Sciety This program is supported by an unrestricted educational grant from NPC. For permission to reprint
More informationA Patient s Guide to Pain Management Medications
A Patient s Guide to Pain Management Medications 228 West Main, Suite C Missoula, MT 59802 Phone: info@spineuniversity.com DISCLAIMER: The information in this booklet is compiled from a variety of sources.
More information9/30/2017. Case Study: Complete Pain Assessment and Multimodal Approach to Pain Management. Program Objectives. Impact of Poorly Managed Pain
Case Study: Complete Pain Assessment and Multimodal Approach to Pain Management MARY BETH PARTYKA MSN ADULT NURSE PRACTITIONER ADVOCATE CHRIST MEDICAL CENTER ADULT PAIN SERVICE Program Objectives Identify
More informationAmber D. Hartman, PharmD Specialty Practice Pharmacist James Cancer Center & Solove Research Institute Ohio State University Medical Center
Pharmacologic Management of Pain Amber D. Hartman, PharmD Specialty Practice Pharmacist James Cancer Center & Solove Research Institute Ohio State University Medical Center Objectives Identify types of
More informationALTERNATIVES TO OPIOIDS FOR CHRONIC PAIN & OPIOID TAPERING
ALTERNATIVES TO OPIOIDS FOR CHRONIC PAIN & OPIOID TAPERING Karen Hulbert, MD Associate Professor Department of Family & Community Medicine Medical College of Wisconsin Winter Refresher January 31, 2018
More informationOptimizing Neuropathic Pain Medications. Dermot More-O Ferrall, MD
Optimizing Neuropathic Pain Medications Dermot More-O Ferrall, MD PAIN MANAGEMENT OPIOID DISPENSING Objectives Understand: Definition and subtypes of pain Pathophysiology of neuropathic pain Pharmacologic
More informationNeuropathic Pain in Palliative Care
Neuropathic Pain in Palliative Care Neuropathic Pain in Advanced Cancer Affects 40% of patients Multiple concurrent pains are common Often complex pathophysiology with mixed components Nocioceptive Neuropathic
More informationDisclosures. Objectives 9/8/2015
The Aftermath of the Decade of Pain: Alternatives to Opioids in Chronic Pain Management Julie Cunningham, PharmD, BCPP Disclosures No relevant financial disclosures I will discuss off-label uses of antiepileptics,
More informationMiPCT Care Management Webinar
MiPCT Care Management Webinar The Use of Multimodal Therapies in the Management of Pain 2-25-15 MiPCT CM Webinar: The Use of Multimodal Therapies in the Management of Pain Guest Presenter: Peg Nelson,
More informationGUIDELINES ON PAIN MANAGEMENT IN UROLOGY
GUIDELINES ON PAIN MANAGEMENT IN UROLOGY F. Francesca (chairman), P. Bader, D. Echtle, F. Giunta, J. Williams Eur Urol 2003; 44(4):383-389 Introduction Pain is defined as an unpleasant sensory and emotional
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Lyrica) Reference Number: ERX.NPA.10 Effective Date: 06.01.15 Last Review Date: 08.17 Line of Business: Commercial [Prescription Drug Plan] Revision Log See Important Reminder at the
More information21 st June BDS BASHD Therapeutics Pain and Analgesia. BASHD Therapeutics Analgesics and Pain Management. Links to other BASHD content
Volume of Prescribing by Dentists 2011 ( a reminder) BASHD Therapeutics Analgesics and Pain Management Analgesics account for 1 in 80 dental prescriptions made A lot more analgesics will be suggested for
More informationTreatment of Neuropathic Pain: What Does the Evidence Say? or Just the Facts Ma am
Treatment of Neuropathic Pain: What Does the Evidence Say? or Just the Facts Ma am Tim R Brown, PharmD, BCACP, FASHP Director of Clinical Pharmacotherapy Cleveland Clinic Akron General Center for Family
More informationPAIN TERMINOLOGY TABLE
PAIN TERMINOLOGY TABLE TERM DEFINITION HOW TO USE CLINICALLY Acute Pain Pain that is usually temporary and results from something specific, such as a surgery, an injury, or an infection Addiction A chronic
More informationSkeletal Muscle Relaxants Drug Class Prior Authorization Protocol
Line of Business: Medi-Cal Effective Date: June 1, 2016 Renewal Date: August 16, 2017 Skeletal Muscle Relaxants Drug Class Prior Authorization Protocol This policy has been developed through review of
More informationPain Management: Pharmacological
Pain Resource Nurse Pain Management: Pharmacological Pain Resource Nurse Program Module 3 The Resource Center of the Alliance of State Pain Initiatives University of Wisconsin Board of Regents, 2011 Classes
More informationKnock Out Opioid Abuse in New Jersey:
Knock Out Opioid Abuse in New Jersey: A Resource for Safer Prescribing GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN IMPROVING PRACTICE THROUGH RECOMMENDATIONS CDC s Guideline for Prescribing Opioids
More informationPain is one of the most frequent clinical problems
Easing the Ouch: Relieving Short-Term Pain By Brian Goldman, MD, MCFP(EM) As presented at the Family Medicine Forum, Montreal, Quebec (November 8, 2002) Pain is one of the most frequent clinical problems
More informationCOMPOUNDING PHARMACY SOLUTIONS PRESCRIPTION COMPOUNDING FOR PAIN MANAGEMENT
JANUARY 2012 COMPOUNDING PHARMACY SOLUTIONS PRESCRIPTION COMPOUNDING WWW.CPSRXS. COM We customize individual prescriptions for the specific needs of our patients. INSIDE THIS ISSUE: Osteoarthritis Pain
More informationMyofascial and Neuropathic Pain The Role of Long Acting Opioids
Myofascial and Neuropathic Pain The Role of Long Acting Opioids Physical Medicine Rehabilitation Update The Canyons, Park City Utah January 19, 2015 Arthur G. Lipman, PharmD, FASHP Professor emeritus of
More informationGateshead Pain Guidelines for Chronic Conditions
Gateshead Pain Guidelines for Chronic Conditions Effective Date: 13.2.2013 Review Date: 13.2.2015 Gateshead Pain Guidelines: Contents PAIN GUIDELINES Chronic Non-Malignant Pain 5 Musculoskeletal Pain 6
More informationAmbulatory Pain Management. Richard T. Jermyn D.O., F.A.A.P.M.R. Associate Professor: UMDNJ:SOM Acting Chair: Department of PM&R Director: NMI
Ambulatory Pain Management Richard T. Jermyn D.O., F.A.A.P.M.R. Associate Professor: UMDNJ:SOM Acting Chair: Department of PM&R Director: NMI Disclosure Richard Jermyn, DO Company Consultant and Speaker
More informationDiabetic Peripheral Neuropathic Pain: Evaluating Treatment Options
Diabetic Peripheral Neuropathic Pain: Evaluating Treatment Options Ramon L. Cuevas-Trisan, MD Disclosures Speakers Bureau/Honoraria: Allergan, Ipsen 1 Learning Objectives Discuss practical approaches to
More informationPAIN MANAGEMENT IN UROLOGY
24 PAIN MANAGEMENT IN UROLOGY F. Francesca (chairman), P. Bader, D. Echtle, F. Giunta, J. Williams Eur Urol 2003; 44(4):383-389 Introduction Pain is defined as an unpleasant sensory and emotional experience
More informationManaging Pain after Transplant Denice Economou, RN,MN,CHPN,AOCN
Managing Pain after Transplant Denice Economou, RN,MN,CHPN,AOCN Oncology Clinical Nurse Specialist, Senior Research Specialist City of Hope Definition of Pain Pain is an unpleasant sensory and emotional
More informationSteven Richeimer, M.D.
Steven Richeimer, M.D. Associate Professor of Anesthesiology & Psychiatry Chief, Division of Pain Medicine Keck School of Medicine, USC Los Angeles, CA 323-442-6202 www.helpforpain.com Pain Light touch
More informationKatee Kindler, PharmD, BCACP
Speaker Introduction Katee Kindler, PharmD, BCACP Current Practice: Clinical Pharmacy Specialist Ambulatory Care, St. Vincent Indianapolis Assistant Professor of Pharmacy Practice, Manchester University,
More informationCancer Pain. Suresh K Reddy, MD,FFARCS The University of Texas MD Anderson Cancer Center
Cancer Pain Suresh K Reddy, MD,FFARCS The University of Texas MD Anderson Cancer Center Prevalence of the Most Common Symptoms in Advanced Cancer (1000 Adults) Symptom % Symptom % Pain 82 Lack of Energy
More informationMontana Utilization and Treatment Guidelines
Montana Utilization and Treatment Guidelines F7. Medications - Chronic Pain Disorder F.7 Medications There is no single formula for pharmacological treatment of patients with chronic nonmalignant pain.
More informationA Patient s Guide to The Medication Approach to Chronic Pain
A Patient s Guide to The Medication Approach to Chronic Pain 651 Old Country Road Plainview, NY 11803 Phone: 5166818822 Fax: 5166813332 p.lettieri@aol.com DISCLAIMER: The information in this booklet is
More informationOpioid Analgesic Treatment Worksheet
Opioid Analgesic Treatment Worksheet Aetna Better Health of Louisiana Fax: 1 844 699 2889 www.aetnabetterhealth.com/louisiana/providers/pharmacy LA Legacy Fee for Service (FFS) Medicaid Fax: 1 866 797
More informationAssociate Professor Supranee Niruthisard Department of Anesthesiology Faculty of Medicine Chulalongkorn University January 21, 2008
Associate Professor Supranee Niruthisard Department of Anesthesiology Faculty of Medicine Chulalongkorn University January 21, 2008 PAIN MECHANISMS Somatic Nociceptive Visceral Inflammatory response sensitizes
More informationTreating Pain and Depression
Treating Pain and Depression Without Getting Depressed Joseph P, Arpaia, MD www.jparpaiamd.com More than 50% of patients with chronic pain also have clinically significant depression. Interestingly that
More informationMonte H. Moore, MD. Idaho Physical Medicine and Rehabilitation. Meridian, ID
Monte H. Moore, MD Idaho Physical Medicine and Rehabilitation Meridian, ID Chronic pain brief review Opiates important things to know Factors in determining whether to use an opiate What to watch for if
More informationNociceptive Pain. Pathophysiologic Pain. Types of Pain. At Presentation. At Presentation. Nonpharmacologic Therapy. Modulation
Learning Objectives Effective, Safe Analgesia An Approach to Appropriate Outpatient Chronic Pain Treatment By the end of this presentation, participants will be able to: Identify multiple factors that
More informationChoose a category. You will be given the answer. You must give the correct question. Click to begin.
Instructions for using this template. Remember this is Jeopardy, so where I have written Answer this is the prompt the students will see, and where I have Question should be the student s response. To
More informationOpioid Analgesic Treatment Worksheet
Opioid Analgesic Treatment Worksheet Aetna Better Health of Louisiana Fax: 1 844 699 2889 www.aetnabetterhealth.com/louisiana/providers/pharmacy LA Legacy Fee for Service (FFS) Medicaid Fax: 1 866 797
More information10/1/2018. Treating Acute Pain in Patients Being Treated for Opioid Use Disorder Michael McNett, MD Medical Director for Chronic Pain Aurora GMS
Treating Acute Pain in Patients Being Treated for Opioid Use Disorder Michael McNett, MD Medical Director for Chronic Pain Aurora GMS Some Background In 2015, the incidence of opioid use disorder (OUD)
More informationTreating Acute Pain in Patients Being Treated for Opioid Use Disorder
Treating Acute Pain in Patients Being Treated for Opioid Use Disorder Michael McNett, MD Medical Director for Chronic Pain Aurora GMS Some Background In 2015, the incidence of opioid use disorder (OUD)
More informationSalicylates: Interactions 10/14/2009. Salicylates DRUGS USED IN THE MANAGEMENT OF MUSCULOSKELETAL DISORDERS. Chapters 17, 18, 34 & Pages 577 &
DRUGS USED IN THE MANAGEMENT OF MUSCULOSKELETAL DISORDERS Chapters 17, 18, 34 & Pages 577 & 579-586 Salicylates aspirin Have analgesic, antipyretic, and anti-inflammatory effects. Inhibits the production
More informationNew Guidelines for Prescribing Opioids for Chronic Pain
New Guidelines for Prescribing Opioids for Chronic Pain Andrew Lowe, Pharm.D. CAPA Meeting October 6, 2016 THE EPIDEMIC Chronic Pain and Prescription Opioids 11% of Americans experience daily (chronic)
More informationPain Pathways Made Simple
Pain Pathways Made Simple David M Glick, DC, DAAPM, CPE Disclosures! Nothing to Disclose! Learning Objectives!Differentiate between nociceptive and neuropathic pain! Describe the process of pain transmission!identify
More informationIndex. Note: Page numbers of article titles are in boldface type.
Note: Page numbers of article titles are in boldface type. A Acetaminophen in chronic pain management, 225 Acupuncture in chronic pain management, 251, 338 339 Ajurvedic medicine in chronic pain management,
More informationPharmacological and Nonpharmacological Approaches
Pharmacological and Nonpharmacological Approaches NAS Workshop December 4, 2018 Kurt Kroenke, MD, MACP Indiana University School of Medicine Regenstrief Institute, Inc. Balanced Treatment Options Medications
More informationPractical Management Of Osteoporosis
Practical Management Of Osteoporosis CONFERENCE 2012 Education Centre, Bournemouth.19 November The following companies have given funding towards the cost of this meeting but have no input into the agenda
More informationRational Polypharmacy in Pain Management
Rational Polypharmacy in Pain Management Charles Argoff, MD Disclosures: Charles Argoff Financial Disclosure: Consultant: Teva, Daiichi Sakyo, Pfizer, Nektar, Purdue, Depomed, Arbor, Novartis, Quest, Gruenenthal,
More informationPAIN. (Review article for physicians) Method of Alexander Mauskop, MD New York Headache Center, New York, NY. From Connâs Current Therapy, 1996
PAIN (Review article for physicians) Method of Alexander Mauskop, MD New York Headache Center, New York, NY. From Connâs Current Therapy, 1996 PHARMACOTHERAPY Major advances are being made in the development
More informationPain management in older patients. David Lussier, MD, FRCPC November 27, 2018
Pain management in older patients David Lussier, MD, FRCPC November 27, 2018 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms
More information2009 Workers' Compensation Drug Trend Report. An analysis of trend and a forecast for the future
2009 Workers' Compensation Drug Trend Report An analysis of trend and a forecast for the future Published April 2010 LEAD AUTHORS Emily Cox, PhD, RPh Yakov Svirnovskiy Jennifer Kaburick, RN Ruth Martinez,
More informationAnalgesics: Management of Pain In the Elderly Handout Package
Analgesics: Management of Pain In the Elderly Handout Package Analgesics: Management of Pain in the Elderly Each patient or resident and their pain problem is unique. A complete assessment should be performed
More informationModule 2 Pain Management. Handouts. Pain Is... Please click the links button under the video. You can print and/or save the handouts.
E L N E C End-of-Life Nursing Education Consortium SuperCore Curriculum Module 2 Pain Management Handouts Please click the links button under the video. You can print and/or save the handouts. Pain Is...
More informationsolutions MEDICATION MIS MANAGEMENT and Chronic Pain 10/4/2016 Opioid Abuse: Current Data Opioid Abuse: Current Data
MEDICATION MIS MANAGEMENT and Chronic Pain solutions Opioid Abuse: Current Data Americans consume 80% of the global supply of opioids This includes 99% of the world s hydrocodone and 2/3s of the world
More informationI s s u e 1,
I s s u e 1, 2 0 1 4 Guidelines for the Pharmacological Treatment of Peripheral Neuropathic Pain: Expert Panel Recommendations for the Middle East Region EFNS guidelines on the pharmacological treatment
More informationPalliative Care: Treatment at the End of Life
Page 1 Palliative Care: Treatment at the End of Life This webcast has been supported by an educational grant from Purdue Pharma L.P. Mary Lynn McPherson, Pharm.D., BCPS, CDE Professor, University of Maryland
More informationMAT for Opioid Dependence. MAT and Pain Management. Epidemiology. Epidemiology. Factors Impacting Pain Perception 9/23/2014
MAT for Opioid Dependence Methadone maintenance treatment (MMT) Buprenorphine/naloxone (suboxone) Buprenorhine/naloxone (BupNX) Buprenorphine SL Parenteral naltrexone (P-ntx) Oral naltrexone (ntx) MAT
More informationNeuropathic Pain. Griffith Research Online. Author. Published. Journal Title. Copyright Statement. Downloaded from. Link to published version
Griffith Research Online https://research-repository.griffith.edu.au Neuropathic Pain Author Hall, Tony Published 2010 Journal Title Australian Journal of Pharmacy Copyright Statement Copyright 2010 Australian
More informationAlternative Treatments for Chronic Pain
Alternative Treatments for Chronic Pain MICIS Workshop Speakers: Peter Michaud, RN, JD Elisabeth Fowlie Mock, MD, MPH Gordon Smith, JD Disclosures MICIS does not accept any money from pharmaceutical companies
More informationFran Pulver, MD - PM&R Laurie Bell, PT - Physical Therapy Steven Severyn, MD, MBA, MSS Anesthesia Gregg Weidner, MD - Anesthesia
Fran Pulver, MD - PM&R Laurie Bell, PT - Physical Therapy Steven Severyn, MD, MBA, MSS Anesthesia Gregg Weidner, MD - Anesthesia Case Presentation-Lumbar Sprain/Strain Patient is 42 years old Had sudden
More informationNeuropathic Pain and Pain Management Options. Mihnea Dumitrescu, MD
Neuropathic Pain and Pain Management Options Mihnea Dumitrescu, MD www.austinppc.com International Association for the Study of Pain (IASP): Definition of Pain Pain is an unpleasant sensory and emotional
More informationManaging Pain in Long Term Care
Troubleshooting Managing Pain in Long Term Care presented by Melanie Simpson, PhD, RN-BC, OCN, CHPN Click to View Webinar All handouts for this webinar are included in this document. You may access the
More informationLumbar Fusion. Reference Guide for PACU CLINICAL PATHWAY. All patient variances to the pathway are to be circled and addressed in the progress notes.
Reference Guide for PACU Lumbar Fusion CLINICAL PATHWAY All patient variances to the pathway are to be circled and addressed in the progress notes. This Clinical Pathway is intended to assist in clinical
More information