Treatment Of Nonmalignant Pain Research Articles

SAFE AND EFFECTIVE PAIN CONTROL FOR GERIATRIC PATIENTS: A MULTIDISCIPLINARY APPROACH DURING THE OPIOID EPIDEMIC

Opioid use is at a crisis level. According to the CDC, an estimated 20 % of patients presenting to physician offices with non-cancer pain receive an opioid prescription (1). According to the Administration on Aging and Substance Abuse and Mental Health Services Administration, the population of older adults who misuse opioids is expected to double by 2020. Today’s mandate to reduce opioid use and to manage patients safely with adjuvant medications comes with many challenges in geriatrics. Many patients have comorbidities which limit the use of adjuvant pain medications. A careful balance must be achieved, in order to provide good pain management and improve quality of life in this patient population. This symposium will explore multidisciplinary approaches to managing pain in geriatrics to reduce opioid use and manage safe opioid use where necessary. Pharmacological strategies for adjusting dosing and managing compliance will be discussed. Cooperative education to improve prescribing practices along with patient education to improve safe use, are important elements. Adjunct use of physical therapy and integrative medicine are also discussed as viable and effective adjuncts or alternatives to traditional pain management. You will learn how to use medications safely, utilize physical therapy to its maximum potential and learn more about innovative integrative medicine techniques, all of which decrease pain and improve function and most importantly quality of life. (1) Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 200-2010. Med Care 2013; 51:870-8

PSY92 - Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000–2010

PSY92 - Ambulatory diagnosis and treatment of non-malignant pain in the United States, 2000–2010

Hyper-Acute Toxic Delirium In A Patient Using Transdermal Fentanyl

The unpredictable, recurrent, intense, and frequently persistent nature of pain associated with sickle cell disease poses a difficult challenge in terms of management. The long-term treatment of non-malignant pain with opioids has traditionally been a matter of debate globally due to the perceived fears of addiction, toxicity and tolerance [1]. In the past decade, opioid analgesics have been advocated by some medical professionals for the treatment of refractory non-malignant pain. For patients with SCD and chronic pain, the pain differs from other forms of chronic pain (e.g., cancer pain) in that sickle cell pain is typically associated with episodic and chaotic waxing and waning acute pain on top of chronic pain. There is also likely to be a larger component of neuropathic pain, peripheral and central sensitization to pain, and opioid hyperalgesia in patients with SCD. In addition, unlike individuals with cancer who have pain, patients with SCD live with this pain for decades? Transdermal fentanyl (Duragesic) is indicated for patients who require continuous opioid administration for the treatment of chronic pain that cannot be managed with other medications such as short-acting opioids on an as-needed basis or non-opioid analgesics. Pain should be under relatively stable control prior to the initiation of transdermal fentanyl, since meaningful pain relief is not obtained until 12-16 hours after application.We describe here the case of a fifty-year-old woman with sickle cell/beta thalassemia complicated by multiple painfull crisis admissions and suspected opioid abuse, who manifested unusual psycho-mimetic reactions after the first-time application of transdermal fentanyl.

Radiofrequency and cryoablation for cancer pain

Prevalence of pain in patients with cancer is high and is a feared and burdensome symptom. There has been a paradigm shift away from the World Health Organization ladder with adoption of interventional treatments early on in the treatment of cancer pain. Intentional destruction of nerves (neurolysis) with chemical (alcohol or phenol), heat (radiofrequency), or cold (cryo) are treatment modalities used to treat cancer pain. These management modalities have become both mainstays of cancer pain therapy and adjuvants to medical management. Chemical neurolysis with phenol or alcohol are commonly used for sympathetic neurolysis. Radiofrequency ablation (conventional and pulsed) and cryoablation are widely used in the treatment of nonmalignant pain. The published data on the use of theses modalities in the cancer population consist mainly of case reports. At the University of Texas MD Anderson Cancer Care Center, neuroablative techniques are frequently used to control refractory cancer pain. The evolution, histologic effect of radiofrequency and cryoablation, and their application are reviewed herein. Common clinical applications and specific techniques conducted at MD Anderson Cancer Care Center are used as examples of how these techniques can be applied to treat cancer related pain.

Poster 37: Long-Term Effectiveness of Sustained-Release Opioids in the Treatment of Nonmalignant Pain

Poster 37: Long-Term Effectiveness of Sustained-Release Opioids in the Treatment of Nonmalignant Pain

10-year follow-up of chronic non-malignant pain patients: Opioid use, health related quality of life and health care utilization

Background In Denmark, opioids have been used liberally for many years in the treatment of non-malignant pain, but long-term consequences as tolerance and influence on health related quality of life remain unknown. Aim Adherence to medical treatment, opioid dose escalation, health related quality of life, anxiety, depression, coping strategies and health care utilization were evaluated in chronic pain patients 10 years after treatment in a multidisciplinary pain centre. Methods Information was gathered from medical records, postal questionnaires and a central hospital register. Results Opioid dose escalation occurred in only a few patients. Increase and decrease in opioid dose were almost equally frequent. Sixty percent of those discharged on long acting opioids were still on that treatment at follow-up. Twenty-eight percent of the patients initiated opioid treatment after discharge from the pain centre. Occupational status was identified as a determining factor for future opioid use. Opioid users had a lower health related quality of life, higher occurrence of depression and more frequent use of coping strategies like ‘Catastrophizing’ and ‘Hoping and Praying’. Adjuvant analgesics were highly discontinued. Multidisciplinary pain treatment reduced the number of hospital admissions and in-hospital days. Conclusion We recommend that future research on opioid treatment does not only focus on biological issues. The effect of opioids needs to be viewed in a much more complex context where consequences like health related quality of life, depression and the role of various coping strategies are included.

Pain management in the ED.

Recent regulatory and legal scrutiny has raised concerns about the over- and undertreatment of pain in the hospital. This debate stems from either the overly aggressive approach to the management of pain with opioids or, alternatively, to the barriers preventing the appropriate prescribing of these medications. The media attention on diversion of controlled substances for illicit purposes has intensified this debate, highlighting the possible overuse of these medications in the treatment of nonmalignant pain. Because pain is a highly common presenting complaint in the ED, EPs are pivotal players in these controversies. Accordingly, they must apprise themselves of pain management skills and continue to help those in need of appropriate medications while thwarting inappropriate prescribing. This review offers a synopsis of the pitfalls associated with ED pain management and provides recommendations for selected conditions.

Opioid therapy in chronic non-malignant pain

In long-term treatment opioids seem to have only minimal side-effects compared with other analgesics and co-analgesics.Nevertheless, some risks have to be considered. While immunosuppression, neurotoxicity, teratogenity, tolerance and addiction are clinically not relevant or very rare, cognitive impairment, sedation and obstipation may have a clinical impact.However, these symptoms can usually be managed by adjuvant medication and patient education. Treatment of non-malignant pain with opioids can only be considered on an individual basis. Scientific evidence for general treatment with opioids, treatment of specific pain syndromes or treatment with certain opioids is not available. In conclusion, only recommendations regarding opioid treatment for certain chronic pain syndromes can be made. In only a minority of patients can a long-term analgesic effect be expected.Therefore, careful evaluation of alternative options of pain management is necessary before opioid therapy is started. With standardized documentation responders may be distinguished from non-responders. For clinical practice of long-term opioid therapy in non-malignant pain a specialized knowledge in pain management is a prerequisite. Future studies with more sophisticated methodology will be necessary to advocate more precise guidelines.However, the therapeutic recommendations from the DGSS consensus conference allow a safer,well structured and validated use of opioids for chronic non-malignant pain.

Pain Management in a Long-Term Care Facility

An analysis of the treatment of nonmalignant pain in the elderly at a long-term facility was conducted to allow development of a pain management program that complies with both JCAHO guidelines for pain management and with the Tennessee Medicaid (TennCare) reimbursement schedule, and to determine if tramadol can meet the standards of pain management under these new guidelines. Inclusion criteria were residence in our long-term care facility; a pain intensity score > 4 on a modified Wong Baker Pain Scale; the patient having prescription orders for one or more of the following drugs: propoxyphene, meperidine, or high dosages of acetaminophen (approaching 4 g/day); suspected neuropathic or mixed nociceptive/neuropathic pain; and/or a diagnosis of diabetes, osteoarthritis, or degenerative joint disease. Exclusion criteria were history of seizures, history of opioid or alcohol abuse, and demonstrated hypersensitivity to tramadol or opioids. Tramadol administration began at a dose of 25 mg/day titrated up to a maximum of 300 mg/day over a 16-day period. Data were collected from computer records, dispensing reports, medication administration reports (MARs), current federal minimum data set (MDS) data, and weekly care plan meetings. Data were tabulated at baseline and 4–6 weeks after a stable dose of tramadol had been established. Fourteen residents (mean age 85 years, 1 male, 13 female) met the criteria and received tramadol up to 300 mg/day (qid). Tramadol reduced the residents' pain scores from an average of 6 to 2 using the Modified Wong Baker Pain Scale, reduced the percentage of residents taking propoxyphene from 50% to 14%, and reduced those taking high doses of APAP or APAP products from 43% to 14%. Tramadol reduced the percentage of residents falling, losing weight, showing no change or decline in activities in daily living (ADLs), displaying inappropriate behavioral symptoms, suffering depression, and/or taking psychotropic medications. In the state of Tennessee, new reimbursement schedules by TennCare have allowed our hospital to comply with the JCAHO standards of “optimal achievable care” for the treatment of pain by allowing the hospital staff to treat patients with newer, safer, more effective analgesics such as tramadol. Early results from this ongoing study have shown that tramadol can provide a safe and effective treatment on non-malignant pain in a long-term care facility and improve adherence to JCAHO and TennCare standards for proper pain management.

Treatment of non-malignant pain in the Dutch GP population: an analysis of treatment standards, prescription habits and basic attitudes.

The aim of this study was to evaluate whether dexibuprofen meets the basic requirements of Dutch General Practitioners (GPs) for acceptance as an analgesic in mild to moderate pain. The available GP treatment standards for mild to moderate pain were analysed. If no treatment standard was available, results from two semistructured round table group sessions were used. The available treatment standards are either diagnosis oriented (e.g. otitis media) or symptom oriented (e.g. lower backache). Prescription data (1988-2000) show that GPs usually prescribe the medication suggested by the standards. Paracetamol, diclofenac, ibuprofen and naproxen, all over 25 years old, have a combined marketshare greater than 84%. Most new drugs have been short-lived and/or little prescribed. Round tables show three basic dimensions to pain treatment: objective, subjective, and the action taken to relieve the pain. The objective dimension relates to anamnesis and physical examination to rule out serious causes. The subjective dimension relates to the doctor's assessment of the pain threshold of the patient, expectations towards the doctor, and previous action taken by the patient. The pain relief dimension relates to acceptance of the pain by the patient, the solution proposed by the doctor and the way this is presented. Medication prescribed should be exclusive for doctors. The GP must also have faith in the medication, and so previous experience is a dominant factor in the choice made. GPs are relatively insensitive to new products, as there are few unmet needs. As a new NSAID dexibuprofen meets two basic requirements. First, it is only available to doctors. Secondly, because it is a pure form of ibuprofen, doctors can relate to extensive previous experience when prescribing it. This might ensure its rapid acceptance compared to other new NSAIDs.

Neuraxial infusion in patients with chronic intractable cancer and noncancer pain.

Ever since the application in 1980 of morphine for spinal analgesia in patients with refractory cancer pain, spinal infusion therapy has become one of the cornerstones for the management of chronic, medically intractable pain. Initially, spinal infusion therapy was indicated only for patients with cancer pain that could not be adequately controlled with systemic narcotics. However, over the past decade, there has been a significant increase in the number of pumps implanted for the treatment of nonmalignant pain. Indeed, "benign" pain syndromes, particularly failed back surgery syndrome, are the most common indication for intrathecal opiates. As we have gained more experience with this therapy, it has become apparent that even intrathecal opiates, when administered in the long term, can be associated with problems such as tolerance, hyperalgesia, and other side effects. Consequently, long-term efficacy has not been as significant as had been hoped. Because of the difficulties associated with long-term intrathecal opiate therapy, much of the research, both basic and clinical, has focused on developing alternative nonopioid agents to be used either alone or in combination with opiates. Clinical trials have been and continue to be conducted to evaluate drugs such as clonidine, SNX-111, local anesthetics, baclofen, and many other less common agents to determine their efficacy and potential toxicity for intrathecal therapy. This article reviews the agents developed as alternatives to intrathecal opiates.

Long-Term Efficacy of Intrathecal Morphine in the Treatment of Nonmalignant Pain: A Retrospective Study

Long-Term Efficacy of Intrathecal Morphine in the Treatment of Nonmalignant Pain: A Retrospective Study

Pain management: Establishing a role for implantable technologies

Pain due to terminal illness such as AIDS and cancer-related pain should be managed according to the guidelines set forth by the World Health Organization. These guidelines suggest a pharmacologic tailoring approach to the level and intensity of the patient's pain. These guidelines obey the KISS principal (keep it simple) suggesting the use of less potent analgesic agents before utilizing more potent agents. Likewise, the treatment of non-malignant pain should be based on the same KISS principal utilizing least costly and least invasive therapies either in series or in parallel until the patient's pain is well managed. Interventional strategies and certainly implantable technologies for pain control have a place as 'tools' for the management of cancer, AIDS, and non-malignant-related pain syndromes. Since these therapies are costly and invasive, they should be used only after the failure of more conservative, less invasive and less costly therapies. This paper outlines a rational place for the use of implantable modalities for the treatment of cancer, AIDS and non-malignant pain.

Proposed Initial Guidelines for Selection and Use of Opioids in the Treatment of Non-Malignant Pain

Proposed Initial Guidelines for Selection and Use of Opioids in the Treatment of Non-Malignant Pain

Interruption of nerve pathways in the treatment of nonmalignant pain.

Interruption of nerve pathways in the treatment of nonmalignant pain.