Pharmacological Management Of Chronic Pain Research Articles

Pharmacological Management of Chronic Pain: How to Deal with the Catch-22 Situation

Management of chronic pain is multidisciplinary, but pharmacotherapy is one of the mainstays of pain management. As applies in all medical therapies, clinicians must strive to achieve the best possible outcome for patients in terms of maximising benefit and minimizing risks, and ensure that this is conducted for each treatment and as an integral element in selecting appropriate therapies. If the balance between risk and benefits is not achieved and understood by the patient.
 Chronic pain patients may already experience a degree of stigmatisation, which can be further exacerbated by evolving socio-political pressures in respect of analgesic availability and accessibility. Hence, we have a Catch-22 situation in which patients become ensnared; they may need supervised access to legitimate analgesic medication(s) but these are not easily accessible because of concerns of the analgesic side-effects and abuse/misuse potential influencing both the individual and wider society. 
 In this paper, we review the evidence in respect of analgesic use in chronic pain. We highlight the importance of: 1) better education and awareness of the problem, 2) evaluate the balance between effect and side effects rather than focusing on pain intensity alone, and include such composite measures in clinical trials, 3) identification of responders to treatment and systematic monitoring for misuse and 4) the use of big data to guide politicians away from inappropriate regulatory restrictions. Such a strategy will improve pain treatment and due to the major costs associated with chronic pain it will also be of benefit for society.

Comprehensive engineering of the tarantula venom peptide huwentoxin-IV to inhibit the human voltage-gated sodium channel hNav1.7

Comprehensive engineering of the tarantula venom peptide huwentoxin-IV to inhibit the human voltage-gated sodium channel hNav1.7

Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice.

Inappropriate use of pain medication has serious consequences for older populations. Experts in the field have noted an increase in opioid prescriptions, and opioid-related hospitalisations and deaths among this vulnerable population. In the pursuit of educating pharmacists, physicians, allied healthcare professionals, researchers, academics and the public facing the challenges of chronic pain medication management, 'The Inaugural Monash University School of Public Health and Preventive Medicine (SPHPM) Best Practice in Chronic Pain Medication Management Day Conference' was held in December 2016 at the Alfred Medical Research and Education Precinct (Melbourne, Australia). Fifteen experts presented on aspects of chronic pain epidemiology and current analgesic use in older Australians, and discussed current practice and associated challenges. Presenters highlighted the dramatic increase in opioid prescribing, development of tolerance and withdrawal symptoms, problems with abuse and addiction, increased risk of death from overdose or suicide, potentiation of sedative effects with concurrent use of anxiolytics/hypnotics, and medication diversion. Pharmacists are very accessible to patients and are crucial members of medication management teams. They have the necessary medication expertise to review medication regimens and provide patient education. Towards addressing chronic pain medication management of older populations, pharmacists can contribute in several ways, such as being aware of relevant guidelines and completing further training, contributing to policy and guideline development, participating in multidisciplinary panels, working groups and pain management teams, collaborating on research projects, and educating the community. With regards to opioid medication management, pharmacists are in an ideal position to: monitor prescription dispensing and potential misuse, provide education about overuse, and, if appropriate, provide access to naloxone. In order to fulfil these roles and responsibilities, allied healthcare professionals should be educated and informed, and opportunities for continuing professional education should be available and utilised. Pharmacists should have the necessary knowledge and skills to optimise chronic pain management, and to both deliver and inform policies and guidelines on pharmacological management of chronic pain in older people.

Ongoing Pharmacological Management of Chronic Pain in Pregnancy.

The article discusses possible effects of the use of analgesics during pregnancy. It summarizes the pertinent literature and reports some previously unpublished data from the Swedish Medical Birth Register. Most likely the use of analgesics does not cause spontaneous abortion. Only small malformation risk increases are seen after the use of opioids and perhaps non-steroid anti-inflammatory drug (NSAID) use. If possible, the latter should be avoided during the first trimester. If exposure has occurred there is no reason to consider an interruption of the pregnancy. Continued use of analgesics may increase the risk of preeclampsia and of preterm birth, especially valid for opioids. Use of acetylsalicylic acid (ASA) in late pregnancy should be avoided because of the risk of bleeding and (valid also for NSAIDs) premature closure of the ductus arteriosus. A small risk for neonatal abstinence syndrome may exist after the use of opioids for chronic pain, notably during the third trimester and long-lasting effects on child development can possibly occur. For a woman with chronic pain, adequate use of pain killers during pregnancy is needed. It is prudent to avoid ASA and NSAIDs towards the end of the pregnancy, while acetaminophen is an acceptable option all through pregnancy. If continued use of opioids is necessary, the associated risks are low. Triptans can be used for migraine during pregnancy. If possible sumatriptan is preferable to other triptans as data for the latter are largely lacking. Ergots are preferably avoided as not enough data are available.

Approach to the pharmacological management of chronic pain in patients with an alcohol use disorder.

This paper provides an overview of research, guidelines, and clinical considerations for the use of medications for chronic pain in the management of patients with an alcohol use disorder. A review of the literature identified randomized controlled trials, epidemiological cohort studies, consensus guidelines, and one systematic review and meta-analysis. Where gaps in the literature existed, clinical experience of the authors is included. Use of nonopioid medications should be given priority and may offer a more favorable risk profile as well as benefits beyond pain management, such as improvement in anxiety, depression, or insomnia. Pregabalin and gabapentin have additional benefits to decrease alcohol cravings or time to relapse after a period of abstinence from alcohol. Drug interactions between selected analgesics and alcohol, disulfiram, or naltrexone require careful consideration.

An Overview of Pharmacologic Management of Chronic Pain.

Patients with chronic pain can be challenging to manage and historically providers have relied on opiates to treat pain. Recent studies have brought into question the safety and efficacy of chronic opiate therapy in the noncancer population. There is a vast amount of literature to support the use of nonsteroidal anti-inflammatory medications, antidepressants, anticonvulsants, topical agents, cannabinoids, and botulinum toxin either in conjunction with or in lieu of opioids. Intrathecal drug delivery systems can deliver some of these medications directly to their primary site of action while minimizing the side effects seen with systemic administration.

Nociceptin/orphanin FQ receptor and pain: Feasibility of the fourth opioid family member

The pharmacological management of chronic pain is a major therapeutic problem. The need of repeated treatments reduces the usefulness of classical analgesic drugs, like μ opioid receptor (MOP) agonists, characterized by tolerance development, side effects and abuse. Moreover, the pathological persistence of pain modifies nociceptive signals and pain-devoted structure activity weakening MOP agonists and making difficult the research of new active molecules. Nociceptine/orphanin FQ (N/OFQ) and its receptor (NOP) offers a peculiar opioid system able to interact with MOP receptors and made more sensitive by chronic pain conditions. The pain reliever efficacy of NOP agonists against persistent pain, mainly neuropathic pain, has been highlighted after intrathecal infusions in rats and non human primates (NHPs). The differences emerged between the effects of NOP stimulation in rodents and NHPs allow to hypothesize the relevance of NOP modulators in higher organisms strongly encouraging the development of compounds active by a systemic route. Possible applicative perspectives are (i) selective NOP agonists as such, (ii) NOP modulation as adjuvant of MOP-based treatments, or (iii) mixed non-selective agonists vs NOP and classical opioid receptors.

Chronic pain: what are the options when NSAID treatment is inadequate?

The focus of this article is the pharmacological management of chronic pain caused by osteoarthritis. There is no universally accepted definition of chronic pain in the veterinary literature, but a useful working definition is pain that has been ongoing for weeks or months. By definition, all pain encompasses both sensory and emotional components; however, arguably in chronic pain the emotional component predominates. This component is very poorly understood in animals, yet improving an animal's quality of life in addition to decreasing the sensory component of pain should be one of the key goals of therapy, and quality of life should be monitored alongside pain intensity. Non-steroidal anti-inflammatory drugs (NSAIDs) should form the backbone of analgesic therapy for pain caused by osteoarthritis. Tramadol, amantadine and gabapentin are the three ‘non-traditional’ analgesic adjuncts for which there is the greatest clinical data to support use in cats and dogs. It is currently impossible to make evidence-based recommendations about the order in which these drugs should be introduced into an analgesic regimen, and trial analgesic therapy, combined with close monitoring of analgesic efficacy and quality of life, is recommended.

Improving the Pharmacologic Management of Pain in Older Adults: Identifying the Research Gaps and Methods to Address Them

There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits. Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them. Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life. Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

Pharmacologic Management of Chronic Pain

Chronic pain is a multifactorial condition with both physical and psychological symptoms, and it affects around 20% of the population in the developed world. In spite of outstanding advances in pain management over the past decades, chronic pain remains a significant problem. This article provides a mechanism- and evidence-based approach to improve the outcome for pharmacologic management of chronic pain. The usual approach to treat mild to moderate pain is to start with a nonopioid analgesic. If this is inadequate, and if there is an element of sleep deprivation, then it is reasonable to add an antidepressant with analgesic qualities. If there is a component of neuropathic pain or fibromyalgia, then a trial with one of the gabapentinoids is appropriate. If these steps are inadequate, then an opioid analgesic may be added. For moderate to severe pain, one would initiate an earlier trial of a long term opioid. Skeletal muscle relaxants and topicals may also be appropriate as single agents or in combination. Meanwhile, the steps of pharmacologic treatments for neuropathic pain include (1) certain antidepressants (tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors), calcium channel α2-δ ligands (gabapentin and pregabalin) and topical lidocaine, (2) opioid analgesics and tramadol (for first-line use in selected clinical circumstances) and (3) certain other antidepressant and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists). It is essential to have a thorough understanding about the different pain mechanisms of chronic pain and evidence-based multi-mechanistic treatment. It is also essential to increase the individualization of treatment.

Current pharmacological management of chronic pain

Chronic pain is associated with disabling physical and emotional symptoms. Patients with chronic pain utilize more health services, have an impaired sense of well-being and frequently experience anxiety or depression. Unfortunately, treatment for chronic pain is not always correctly targeted, which leads to a reduced quality of life. Treatment of chronic pain involves a comprehensive approach using medication and functional rehabilitation. The usual approach for mild to moderate pain is to start with nonopioid analgesics. Also, trying antidepressant drugs for sleep loss and gabapentin for neuropathic pain or fibromyalgia is appropriate. For moderate to severe chronic pain, opioid analgesics can be used without any serious side effects if adequately used at the right dosage. It is important to provide guidance on the safe use of analgesics and other psychoactive drugs. Dosing of acetaminophen should be limited to avoid liver toxicity, and topical analgesics are preferred for focal pain. Full-dose nonsteroidal anti-inflammatory drugs should not be used for more than short periods, in order to avoid gastrointestinal, renal, and cardiovascular complications. Mechanisms of analgesia, drug selection, and recommendations for clinical usage for the management of chronic pain are reviewed in this paper.

Handbook on the pharmacological management of chronic pain

Handbook on the pharmacological management of chronic pain

Clinical management of the child with chronic pain

Clinical management of the child with chronic pain

Safety issues in the pharmacologic management of chronic pain in the elderly.

Chronic pain is commonly encountered in elderly patients. About 20-50% of community-dwelling elderly experience it, and 45-80% of nursing home residents may be affected. Selection of pharmacologic therapy for the management of chronic pain must take into consideration the increased potential for adverse effects in this population. Major classes of drugs used to treat chronic pain (nonsteroidal antiinflammatory drugs, opioids, antidepressants) have adverse effects that occur more frequently in elderly than in younger patients. Given the often prolonged duration of therapy, optimal management requires minimizing the risk of adverse reactions.

Pharmacological management of chronic pain: A clinician's perspective

Of the currently available mu agonist drugs, the following are relatively contraindicated: 1. Methadone--unpredictable duration of action [5]. 2. Pethidine--unwanted central effects, metabolised to an active metabolite and too short acting. 3. Codeine--too weak and with constipating side-effects. 4. Fentanyl--too short acting. 5. Oxycodone--too short acting although suppositories may overcome some theoretical disadvantages. 6. Dextropropoxyphene--weak agonist which is possibly metabolised to a cardiotoxic metabolite [6]. Morphine remains the drug of choice for chronic pain when administered in a sustained release preparation. MS Contin, a slow release oral formulation of morphine, is available and has a predictable duration of action lasting from 8-12 h, while improved formulations are about to be released in the near future in some countries. Prescribers need to take into account the relatively poor oral bioavailability of morphine when calculating the daily morphine dose.

Pain Syndromes in Neurology

Hiperalgesia and sensitization of primary afferent fibers, Srinivasa N.Raja, Richard A.Meyer and James N.Campbell pain and the pathophysiology of damaged nerve, Marshall Devor and Z.Harry Rappaport sympathetic nervous system influence on acute and chronic pain, William J.Roberts and Ronald C.Kramis reflex sympathetic dystrophy syndrome - diagnosis and treatment, Richard Payne pain in generalized neuropathies, Arthur K.Asbury management of nociceptive, deafferentation and central pain by surgical intervention, Ronald R. Tasker deafferentation on syndromes and dorsal root entry zone lesions, Burchiel postherpetic neurologica - clinical features and treatment, C.P.Watson diagnosis of cancer pain syndromes, Russel K.Portenoy pharmacologic management of chronic pain, Russel K. Portenoy.

The pharmacological management of chronic pain in the paraplegic patient.

(1986). The Pharmacological Management of Chronic Pain in the Paraplegic Patient. The Journal of The American Paraplegia Society: Vol. 9, No. 3-4, pp. 41-50.