Treatment of Chronic Non-Cancer Pain

Ross Bryan

Mercer University MS III

August 2012

INTRODUCTIONINTRODUCTION

Chronic Non-Cancer Pain Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology

Development Develops as a result of persistent stimulation of or changes to nociceptors following injury.

Treatment Options Pharmacological Interventional Psychological

Pharmacological

Pharmacological

OPIOIDS(hydrocodone,

tramadol)

OPIOIDS(hydrocodone,

tramadol) Mechanism Bind MOR in brain and SC

Indication Neuropathy

Efficacy Less pain, less function

Adverse Effects Hyperalgesia; Abuse Nausea, constipation, somnolence

SS (with tramadol)

NSAIDsNSAIDs

Mechanism Inhibits COX-1 and/or COX-2

Indications OA; RA; back pain

Efficacy Not for neuropathy or FM

Adverse Effects Gastrointestinal for COX-1 Cardiovascular for selective COX-2

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TCAs and SNRIs

(amytriptyline and

duloxetine)

TCAs and SNRIs

(amytriptyline and

duloxetine) Mechanism

Increase 5-HT and NE @ Synapse

Indications Neuropathy, fibromyalgia, low-back pain, and headaches.

Adverse Effects TCAs --> cardiovascular events

Anticonvulsants

(gabapentin and

carbamazepine)

Anticonvulsants

(gabapentin and

carbamazepine) Mechanism

Enhance GABA inhibitory system

Indication Neuropathic pain

Adverse Effects Somnolence, fatigue Dizziness

Topical Agents(Capsaicin)

Topical Agents(Capsaicin)

Mechanism Depletes substance P from primary afferent neurons

Indications Neuropathy and OA

Adverse Effects Limited

CorticosteroidsCorticosteroids Mechanism

Blocks PLA2 and IL-2

Indications Rediculopathy Facet joint pain

Adverse Effects Infection Paraplegia

SurgerySurgery

Lumbar Fusion Non-radicular degenerative changes

Discectomy Radiculopathy w/herniated disc

Decompressive Laminectomy Spinal stenosis

*many are associated with worsened quality of life after 4-5 years.

Intrathecal Implants

(morphine)

Intrathecal Implants

(morphine)

Mechanism MOR agonists

Indications Chronic refractory pain

Adverse Effects Tolerance

Interdisciplinary Pain Reduction

Programs (IPRPs)

Interdisciplinary Pain Reduction

Programs (IPRPs)

GOALS: Physical therapy Exercise Cognitive restructuring

Drug management

CommentsComments

Data on efficacy is limited by: Subjective outcomes Inconsistent diagnostic criteria

Even the most effective treatments averaged a 30% reduction of pain in only half of the patients

Even with pain reduction, there is often not concomitant improvement in emotional and physical functioning

CitationCitation

Turk, Dennis, PhD, Wilson, Hilary. Treatment of Chronic Non-cancer Pain. The Lancet, 2011 vol 377: 2226-2235.