Transcript New techniques in chronic pain management

Jennifer Crook
Advisor: Dr. Hadley
04/10/08
What is Chronic Nonmalignant Pain?
 Guideline definition:
1. Enduring or recurring nature
2. Persisting longer than usual for condition/ associated with
chronic disease process
3. Refractory to treatment
4. Associated with functional impairment
5. Possibly comorbid with a psychological disorder
(Sanders et al. 2005)
 Examples:
 Low back pain
 Trigeminal neuralgia
Chemical mediators and receptors
implicated in CNMP mechanisms
 IL-6  PGE2
 IL-1β  COX-2
 TNF-α  COX-2
 Nerve Growth Factor (NGF)
 Down-regulation of GABAB receptors
 Up-regulation of Substance P receptors
 Up-regulation of P2X7
Diagnosis and Assessment of
CNMP
 Believe the patient!
 Assessment tools:
 NIH
 Institute for Clinical Systems Improvement
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www.icsi.org
Current treatment guidelines
Pain assessment tools
 Brief Pain Inventory Scale
 Functional Ability Questionnaire
 Video
Treatment of CNMP
 Challenging for the practitioner …
 Deficit of resources
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Clear guidelines
Algorithms
 Time constraints
 Treatment necessitates continual reassessment of the patient
and frequent communication
 Multifaceted nature of treatment
 Pharmacologic
 Non-pharmacologic
 The opioid issue …
Opioids in the Treatment of CNMP
 “Current guidelines do not recommend the use of opioid
medications with CPS [CNMP] patients.”
(Sanders et al. 2005)
 Disadvantages:
 Opioid-induced Hyperalgesia (OIH)
 Debilitation of immune response
 Conclusion:
 Appropriate for subset of CNMP population
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DIRE screening tool
Opioid contracts
Video
Multidisciplinary Pain Centers
 Who?
 Functionally impaired patients
 CNMP is refractory to treatment
 What?
 Treatment goals
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Improved physical function
Improvement of general functional status
Increase in self management
Improvement of vocational/ disability status
Reduction or D/C of opiates and sedative- hypnotic medications
Reduction in health care utilization
(Sanders et al. 2005)
Multidisciplinary Pain Centers
 Where?
 Outpatient treatment centers
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40 hours per week
< 20 days
 When?
 Onset of significant disability
 Learn to recognize the development of:
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Pain behaviors
Maladaptive coping mechanisms
Multidisciplinary Pain Centers
 How?
 Pharmacologic treatment
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Non-opioid, non-sedative
“Adjunctive”
 Non-pharmacologic treatment
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Fitness/ exercise
Pain coping
Relaxation
CAM
 Internal locus of control
References
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