Chronic Pain Syndrome
Objectives: Upon completion of this course, the
participant will be able to:
- Summarize the latest trends and topical issues in the diagnosis
and treatment of chronic pain syndrome.
- Evaluate diagnostic and/or therapeutic strategies as they relate
to CPS.
- Review current concepts , treatments and diagnostic techniques..
INTRODUCTION
Background: Chronic
pain syndrome (CPS) is a common problem that presents a major challenge to
healthcare providers because of its complex natural history, unclear
etiology, and poor response to therapy. CPS is a poorly defined condition.
Most authors consider ongoing pain lasting longer than 6 months as
diagnostic, and others have used 3 months as the minimum criterion. In
chronic pain, the duration parameter is used arbitrarily. Some authors
suggest that any pain that persists longer than the reasonable expected
healing time for the involved tissues should be considered chronic pain.
CPS is a constellation of syndromes that usually do not respond to the
medical model of care. This condition is managed best with a
multidisciplinary approach, requiring good integration and knowledge of
multiple organ systems.
Pathophysiology: The pathophysiology of CPS is
multifactorial and complex and still is poorly understood. Some authors
have suggested that CPS might be a learned behavioral syndrome that begins
with a noxious stimulus that causes pain. This pain behavior then is
rewarded externally or internally. Thus, this pain behavior is reinforced,
and then it occurs without any noxious stimulus. Internal reinforcers are
relief from personal factors associated with many emotions (eg, guilt,
fear of work, sex, responsibilities). External reinforcers include such
factors as attention from family members and friends, socialization with
the physician, medications, compensation, and time off from work.
Patients with several psychological syndromes (eg, major depression,
somatization disorder, hypochondriasis, conversion disorder) are prone to
developing CPS.
Frequency:
- In the US: Pain is the most common complaint that
leads patients to
seek medical care. Chronic pain is not
uncommon. Approximately 35% of Americans have some element of chronic
pain, and approximately 50 million Americans are disabled partially or
totally due to chronic pain.
Mortality/Morbidity: CPS can affect patients in
various ways. Major effects in the patient's life are depressed mood,
fatigue, reduced activity and libido, excessive use of drugs and alcohol,
dependent behavior, and disability out of proportion to impairment.
Race: No known predilection of CPS for any racial
group has been described in the literature.
Sex: Chronic pain is reported more commonly in women.
CLINICAL
History: Because of the
complex etiology and the frequent presence of associated disorders, a
general and open-minded approach to the assessment of the patient is
needed. Obtaining the history of patients whose symptoms suggest CPS is
important. A thorough history is necessary for the physician to direct
further evaluation and appropriate consultations and avoid repeating
invasive and expensive procedures. A detailed review of the
musculoskeletal, reproductive, gastrointestinal, urologic, and
neuropsychological systems must be obtained. As needed, specific questions
should be asked of particular patients, depending on their associated
disorders.
- Focus the history on a characterization of the patient's pain.
Obtaining the characteristics of the pain helps establish appropriate
diagnostic and therapeutic plans.
- Pain location: The location of pain is an important part of the
history. Ask the patient to describe the type of pain and the location
on a pain diagram (anterior/posterior and lateral view of human
picture).
- Precipitating factors: Ask questions about factors that provoke or
intensify pain. This information may provide clues for possible
etiologies or associated disorders.
- Alleviating factors: Ask the patient if any factors help alleviate
the pain. For example, rest may decrease pain of musculoskeletal
origin.
- Quality of pain: Ask the patient to describe the quality of pain.
Various terms can be used to describe quality of pain, including
throbbing, pounding, shooting, pricking, boring, stabbing,
lancinating, sharp, cutting, lacerating, pressing, cramping, crushing,
pulling, pinching, stinging, burning, splitting, penetrating,
piercing, squeezing, and dull aching.
- Radiation of pain: Ask the patient if the pain spreads or
radiates. Spreading or radiating pain is a characteristic of
neuropathic pain.
- Severity or intensity of pain: Use some type of rating system to
evaluate pain severity or intensity with a degree of objectivity and
reproducibility. Different types of pain scales may be used. Numerical
scales are more useful and reliable. The visual analog scale (VAS) is
one of the commonly used numerical scales.
- Obtain history specific to different systems and disorders.
- Gynecologic and obstetric
- Psychological: A good psychosocial or psychosexual history is
needed when organic diseases are excluded or coexisting psychiatric
disorders are suggested. Obtain sufficient history to evaluate
depression; anxiety disorder; somatization; physical or sexual abuse;
drug abuse/dependence; and family, marital, or sexual problems.
Somatization is a common associated psychologic disorder in women with
chronic pain. Somatization scales can be used for
evaluation.
- Sternbach's 6 D's of CPS are as follows:
- Dramatization of complaints
- Drug misuse
- Dysfunction/disuse
- Dependency
- Depression
- Disability
Physical: Good rapport, tolerance, and an open-minded
approach are important when evaluating any patient with chronic pain. A
good thorough systematic examination usually leads to an appropriate
diagnosis and therapy. Patients often have Waddell signs. The disability
is usually out of proportion to the impairment and the objective findings.
Detailed examination of the musculoskeletal system is important.
Examination of various other systems (eg, gastrointestinal, urologic,
neurologic) also should be performed.
Causes: Various neuromuscular, reproductive,
gastrointestinal, and urologic disorders may cause or contribute to
chronic pain. Sometimes multiple contributing factors may be present in a
single patient.
- Musculoskeletal disorders
- Osteoarthritis/degenerative joint disease (DJD)/spondylosis
- Rheumatoid arthritis
- Lyme disease
- Reiter syndrome
- Disk herniation/facet osteoarthropathy
- Fractures/compression fracture of lumbar vertebrae
- Faulty or poor posture
- Fibromyalgia
- Polymyalgia rheumatica
- Mechanical low back pain
- Chronic coccygeal pain
- Muscular strains and sprains
- Pelvic floor myalgia (levator ani spasm)
- Piriformis syndrome
- Rectus tendon strain
- Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian,
perineal, umbilical)
- Abdominal wall myofascial pain (trigger points)
- Chronic overuse syndromes (eg, tendinitis,
bursitis)
- Neurological disorders
- Brachial plexus traction injury
- Cervical radiculopathy
- Thoracic outlet syndrome
- Spinal stenosis
- Arachnoiditis
- Metabolic deficiency myalgias
- Polymyositis
- Neoplasia of spinal cord or sacral nerve
- Cutaneous nerve entrapment in surgical scar
- Postherpetic neuralgia (shingles)
- Neuralgia (eg, iliohypogastric, ilioinguinal, or genitofemoral
nerves)
- Polyneuropathies
- Polyradiculoneuropathies
- Mononeuritis multiplex
- Chronic daily headaches
- Muscle tension headaches
- Migraine headaches
- Temporomandibular joint (TMJ) dysfunction
- Temporalis tendonitis
- Sinusitis
- Atypical facial pain
- Trigeminal neuralgia
- Glossopharyngeal neuralgia
- Nervus intermedius neuralgia
- Sphenopalatine neuralgia
- Referred dental or TMJ pain
- Abdominal epilepsy
- Abdominal migraine
- Urologic disorders
- Bladder neoplasm
- Chronic urinary tract infection
- Interstitial cystitis
- Radiation cystitis
- Recurrent cystitis
- Recurrent urethritis
- Urolithiasis
- Uninhibited bladder contractions (detrusor-sphincter dyssynergia)
- Urethral diverticulum
- Chronic urethral syndrome
- Urethral carbuncle
- Prostatitis
- Urethral stricture
- Testicular torsion
- Peyronie disease
- Gastrointestinal disorders
- Chronic visceral pain syndrome
- Gastroesophageal reflux
- Peptic ulcer disease
- Pancreatitis
- Chronic intermittent bowel obstruction
- Colitis
- Chronic constipation
- Diverticular disease
- Inflammatory bowel disease
- Irritable bowel syndrome
- Reproductive disorders (extrauterine)
- Endometriosis
- Adhesions
- Adnexal cysts
- Chronic ectopic pregnancy
- Chlamydial endometritis or salpingitis
- Endosalpingiosis
- Ovarian retention syndrome (residual ovary syndrome)
- Ovarian remnant syndrome
- Ovarian dystrophy or ovulatory pain
- Pelvic congestion syndrome
- Postoperative peritoneal cysts
- Residual accessory ovary
- Subacute salpingo-oophoritis
- Tuberculous salpingitis
- Reproductive disorders (uterine)
- Adenomyosis
- Chronic endometritis
- Atypical dysmenorrhea or ovulatory pain
- Cervical stenosis
- Endometrial or cervical polyps
- Leiomyomata
- Symptomatic pelvic relaxation (genital prolapse)
- Intrauterine contraceptive device
- Bipolar personality disorders
- Depression
- Porphyria
- Sleep disturbances
- Cardiovascular disease (eg, angina)
- Peripheral vascular disease
- Chemotherapeutic, radiation, or surgical
complications
DIFFERENTIALS
Other Problems to be Considered:
Adhesive Capsulitis
Brachial Neuritis
Carpal Tunnel Syndrome
Cervical Disc Disease
Cervical Myofascial Pain
Cervical Spondylosis
Cervical Sprain and Strain
Complex Regional Pain Syndromes
Fibromyalgia
Lateral Epicondylitis
Lumbar Degenerative Disc Disease
Lumbar Facet Arthropathy
Lumbar Spondylolysis and Spondylolisthesis
Mechanical Low Back Pain
Medial Epicondylitis
Meralgia Paresthetica
Mononeuritis Multiplex
Morton Neuroma
Myofascial Pain
Neoplastic Brachial Plexopathy
Neoplastic Lumbosacral Plexopathy
Osteoarthritis
Osteoporosis and Spinal Cord Injury
Piriformis Syndrome
Plantar Fasciitis
Radiation-Induced Brachial Plexopathy
Radiation-Induced Lumbosacral Plexopathy
Rotator Cuff Disease
Spasticity
Thoracic Outlet Syndrome
Traumatic Brachial Plexopathy
Trochanteric Bursitis
Hernias (eg, obturator, sciatic, inguinal, femoral, perineal,
spigelian, umbilical)
Neoplasia of the spinal cord or sacral
nerves
Mononeuropathy and nerve entrapment
Abdominal
epilepsy
Abdominal migraines
Pelvic floor pain syndrome
Rectus
abdominis pain
Faulty posture and chronic pelvic pain
Bipolar
disorders and depression
Chronic visceral pain syndrome
Chronic
fatigue syndrome
Substance abuse
Reproductive
system
Adenomyosis
Adhesions
Adnexal cysts
Cervical
stenosis
Dyspareunia
Endocervical and endometrial
polyps
Endometriosis and endosalpingiosis
Uterine
leiomyomas
Ovarian retention syndrome
Ovarian remnant
syndrome
Pelvic varicosities and pelvic congestion
syndrome
Vulvodynia
Pelvic floor relaxation disorders
Accessory
and supernumerary ovaries
Urinary system
Chronic and
recurrent urinary tract infections
Urolithiasis
Pelvic floor
dysfunction
Urethral diverticulum
Chronic urethral
syndrome
Gastrointestinal system
Chronic intermittent
bowel obstruction
Colitis
Chronic constipation
Diverticular
disease
Inflammatory bowel disease
Irritable bowel
syndrome
Peritoneal cysts
WORKUP
Lab Studies:
- The decision to perform any laboratory or imaging evaluations is
based on the need to confirm the diagnosis and to rule out other
potentially life-threatening illnesses. Sometimes certain investigations
are needed to provide appropriate and safe medical or surgical
treatment. The recommended treatment should be based on clinical
findings or changes in examination findings.
- Extreme care should be undertaken during diagnostic testing for CPS.
Carefully review prior testing to eliminate unnecessary
repetition.
- Routine complete blood count (CBC), urinalysis, and selected tests
for suspected disease are important. Urine or blood toxicology is
important for drug detoxification, as well as opioid therapy.
Imaging Studies:
- Several imaging studies (eg, radiographic studies, MRI, CT scan) are
important tools for the workup of a patient with CPS.
TREATMENT
Rehabilitation Program:
- Physical Therapy: Physical therapy (PT), in
association with occupational therapy (OT), has an important role in
functional restoration for patients with CPS. The goal of a PT program
is to increase strength and flexibility gradually beginning with gentle
gliding exercises. Patients usually are reluctant to participate in PT
because of intense pain.
A self-directed or therapist-directed PT program is important and
should be individualized to each patient's needs and goals.
PT techniques include hot or cold applications, positioning,
stretching exercises, traction, massage, ultrasound therapy,
transcutaneous electrical nerve stimulation (TENS), and manipulations.
Heat, massage, and stretching can be used to alleviate excess muscle
contraction and pain. Other intervention should be offered to enable
greater confidence and comfort when patients do not progress in a
reasonable amount of time.
- Occupational Therapy: OT is very important for
initiating gentle active measurements and preliminary desensitization
techniques with patients who have chronic pain, especially regional CPS.
- Recreational Therapy: Recreational therapy can help
the patient with chronic pain take part in pleasurable activities that
help decrease pain. The patient finds enjoyment and socialization in
previously lost or new recreational activities. Usually, patients with
chronic pain are depressed because of intense pain. Recreational
therapists may play an important role in the treatment process as they
help enable the patient to become active.
Medical
Issues/Complications: Management of chronic pain in patients with
multiple problems is complex, usually requiring specific treatment,
simultaneous psychological treatment, and PT. A good relationship between
the physician and patient should be established.
Treatment of CPS must be tailored for each individual patient. The
treatment should be aimed at interruption of reinforcement of the pain
behavior and modulation of the pain response. The goals of treatment must
be realistic and should be focused on restoration of normal function
(minimal disability), better quality of life, reduction of use of
medication, and prevention of relapse of chronic symptoms.
Surgical Intervention:
- Nerve blocks are used for diagnostic, prognostic, and therapeutic
procedures.
- Sympathetic blocks are more effective therapeutic tools for
chronic pain.
- Sympathetic blocks including stellate ganglion and lumbar
sympathetic blocks commonly are used.
- Spinal cord stimulation commonly is used to treat neuropathic pain
refractory to other forms of treatment. Spinal cord stimulation also is
used for patients with a failed back syndrome with radicular pain.
Careful evaluation is recommended before patient selection.
- Intrathecal morphine pumps, either fully implantable pumps or
external pumps, are used to treat chronic pain. This method of treatment
should be considered very carefully for pain of nonmalignant
origin.
Consultations: Consultation with a psychologist, a
urologist, a neurologist, an obstetrician-gynecologist, a gastrointestinal
specialist, or other appropriate specialists is very important, especially
before considering invasive or aggressive management.
- As in other chronic pain, the high incidence of personality
pathology, as noted by Monti, may represent an exaggeration of
maladaptive personality traits and coping styles as a result of a
chronic intense pain.
- A psychological evaluation should be performed to identify the
stressor and to obtain information about the distress of the patient.
The evaluation should consist of a structural clinical interview and a
personality measure (eg, Minnesota Multiphasic Personality Scale,
Hopelessness Index).
Other Treatment (injection, manipulation, etc.):
- Application of heat and cold: Use of these modalities is encouraged
for treatment of CPS. Use of cold in neuropathic pain is
controversial.
- TENS: This method of treatment has significant benefit in the
treatment of rheumatoid arthritis and osteoarthritis. According to a
recent double-blind study, exercise groups have significant benefit over
TENS. Electrodes should be applied over or near the area of pain with
the dipole parallel to major nerve trunks. TENS application should be
avoided near the carotid sinus, during pregnancy, and in patients with
demand-type pacemakers. The most common adverse effect of TENS is skin
hypersensitivity.
- Psychophysiological therapy
- This type of therapy consists of reassurance, counseling,
relaxation therapy, stress management programs, and biofeedback
techniques. With these modalities of treatment, both frequency and
severity of chronic pain may be reduced.
- Biofeedback may be helpful in some patients when combined with
medications. Myofascial and sympathetically mediated pain syndromes
have been treated successfully using behavioral techniques. Relaxation
training, including autogenic training and progressive muscle
relaxation, commonly is used. This approach is as effective as
biofeedback.
- Vocational therapy should be recommended and initiated early for all
appropriate patients. Each patient is evaluated to determine work
history, educational background, vocational skills and abilities, and
motivation level to return to work. The patient should get help from a
vocational counselor for legal rights and obligations in each state (eg,
workman's compensation). Each patient needs to set realistic goals.
Vocational therapy can provide work capacities and targeted work
hardening so that the patient may return to gainful employment, the
ultimate functional restoration.
- Psychological interventions, in conjunction with medical
intervention, PT, and OT, increase the effectiveness of the treatment
program. Family members are involved in the evaluation and treatment
processes.
MEDICATION
Pharmacotherapy consists of symptomatic
abortive therapy (to stop or reduce the severity of the acute
exacerbations) and long-term therapy for chronic pain. Initially, pain may
respond to simple over-the-counter (OTC) analgesics, such as paracetamol,
ibuprofen, aspirin, or naproxen. If treatment is unsatisfactory, the
addition of other modalities or the use of prescription drugs is
recommended. If possible, avoid barbiturate or opiate agonists. Also
discourage long-term and excessive use of all symptomatic analgesics
because of the risk of dependence and abuse.
Tizanidine may improve the inhibitory function in the CNS and can
provide pain relief. Amitriptyline (Elavil) and nortriptyline (Pamelor)
are the tricyclic antidepressants (TCAs) most frequently used to treat
chronic pain. The selective serotonin reuptake inhibitors (SSRIs)
fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are
commonly prescribed by many physicians. Other antidepressants such as
doxepin, desipramine protriptyline, and buspirone also can be used.
Drug Category: Antidepressants -- These
drugs increase the synaptic concentration of serotonin and/or
norepinephrine in the CNS by inhibiting their reuptake by the presynaptic
neuronal membrane.
Drug Name
|
Amitriptyline (Elavil) -- Analgesic
for certain chronic and neuropathic pain.
|
| Adult Dose |
25-100 mg/d mg PO hs; not to exceed
150 mg /d
|
| Pediatric Dose |
Children: 0.1 mg/kg PO hs;
increase, as tolerated, over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d initially; increase gradually to 100
mg/d in divided doses
| Contraindications |
Documented hypersensitivity;
patient has taken MAO inhibitors in past 14 d; has history of
seizures, cardiac arrhythmias, glaucoma, and urinary retention
|
| Interactions |
Phenobarbital may decrease effects;
coadministration with CYP2D6 enzyme system inhibitors (eg,
cimetidine, quinidine) may increase amitriptyline levels;
amitriptyline inhibits hypotensive effects of guanethidine; may
interact with thyroid medications, alcohol, CNS depressants,
barbiturates, and disulfiram
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Caution in cardiac conduction
disturbances, history of hyperthyroidism, or history of renal or
hepatic impairment; avoid using in the elderly | |
Drug Name
|
Nortriptyline (Pamelor) -- Has
demonstrated effectiveness in the treatment of chronic pain. By
inhibiting the reuptake of serotonin and/or norepinephrine by the
presynaptic neuronal membrane, this drug increases the synaptic
concentration of these neurotransmitters in the CNS. Pharmacodynamic
effects such as the desensitization of adenyl cyclase and
down-regulation of beta-adrenergic receptors and serotonin receptors
also appear to play a role in its mechanisms of action.
|
| Adult Dose |
25-100 mg hs; not to exceed 200
mg/d
|
| Pediatric Dose |
Children: 0.1 mg/kg PO hs;
increase, as tolerated, up to 0.5-2 mg/d hs
Adolescents:
25-50 mg/d; gradually increase to 100 mg/d
| Contraindications |
Documented hypersensitivity;
narrow-angle glaucoma; do not administer to patients who have taken
MAO inhibitors in past 14 days
|
| Interactions |
Cimetidine may increase
nortriptyline levels when used concurrently; nortriptyline may
increase prothrombin time in patients stabilized with warfarin
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Caution in cardiac conduction
disturbances, history of hyperthyroidism, and history of renal or
hepatic impairment; due to pronounced effects in cardiovascular
system, best to avoid in elderly | | Drug
Category: Selective serotonin reuptake inhibitors -- May
be considered as an alternative to TCAs.
Drug Name
|
Fluoxetine (Prozac) -- An atypical
non-TCA with potent specific 5HT-uptake inhibition and fewer
anticholinergic and cardiovascular adverse effects than TCAs.
|
| Adult Dose |
10 mg on waking; can be increased
q2wk; not to exceed 60 mg/d
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity;
pregnancy and breastfeeding; severe renal or hepatic disease
|
| Interactions |
Increases toxicity of diazepam and
trazodone by decreasing clearance; also increases toxicity of MAO
inhibitors and highly protein-bound drugs; serotonin syndrome (ie,
myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic
instability, coma, eventual death) occurs with simultaneous use of
other serotonergic agents (eg, anorectic agents, tramadol,
buspirone, trazodone, clomipramine, nefazodone, tryptophan);
discontinue other serotonergic agents at least 2 wk prior to SSRIs
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in hepatic impairment and
history of seizures; MAO inhibitors should be discontinued at least
14 d before initiating fluoxetine therapy; anxiety, insomnia or
drowsiness, tremor, anorexia, anorgasmia, and other sexual
dysfunctions have been reported; nausea, flulike symptoms, and
agitation that resolve within 1-2 wk also have been
noted |
Drug Name
|
Sertraline (Zoloft) -- An atypical
non-TCA with potent specific 5HT-uptake inhibition and fewer
anticholinergic and cardiovascular adverse effects than TCAs.
|
| Adult Dose |
50 mg/d PO initially; increase at
weekly intervals after several weeks; not to exceed 200 mg/d
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity;
pregnancy and breastfeeding; severe renal or hepatic disease
|
| Interactions |
Serious potentially fatal reactions
such as autonomic instability may occur with concurrent use of
MAOIs; other antidepressants, phenothiazines, group IC
antiarrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and
warfarin
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in preexisting seizure
disorders, recent myocardial infarction, unstable heart diseases,
and hepatic or renal impairment; anxiety, insomnia or drowsiness,
tremor, anorexia, anorgasmia, and other sexual dysfunctions have
been reported; nausea, flulike symptoms, and agitation that resolve
within 1-2 wk also have been noted |
Drug Name
|
Paroxetine (Paxil) -- An atypical
non-TCA with potent specific 5HT-uptake inhibition and fewer
anticholinergic and cardiovascular adverse effects than TCAs.
|
| Adult Dose |
10 mg/d PO initially, then titrate
upward; not to exceed 50 mg/d
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity;
pregnancy and breastfeeding; severe renal or hepatic disease
|
| Interactions |
Serious potentially fatal reactions
such as autonomic instability may occur with concurrent use of
MAOIs; other antidepressants, phenothiazines, group IC
antiarrhythmics, cimetidine, phenytoin, phenobarbital, digoxin, and
warfarin
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Anxiety, insomnia or drowsiness,
tremor, anorexia, anorgasmia, and other sexual dysfunctions have
been reported; nausea, flulike symptoms, and agitation that resolve
within 1-2 wk also have been noted | Drug
Category: Opioids -- Used commonly for many pain
syndromes.
Drug Name
|
Oxycodone (OxyContin, OxyIR,
Roxicodone) -- Long-acting opioids may be used in patients with CPS.
Start with small dose, and, if appropriate, gradually increase.
|
| Adult Dose |
10-160 mg PO q12h
|
| Pediatric Dose |
<12 years: Not
established
>12 years: Administer as in adults
| Contraindications |
Documented hypersensitivity;
presence of intracranial lesion associated with impaired
intracranial pressure (hydromorphone); patients receiving MAOIs or
those who have recently used MAOIs; poor respiratory function (eg,
COPD, cor pulmonale, emphysema, status asthmaticus, kyphoscoliosis)
|
| Interactions |
Phenothiazines may antagonize
analgesic effects; MAOIs, general anesthesia, CNS depressants, and
TCAs may increase toxicity
|
| Pregnancy |
B - Usually safe but benefits must
outweigh the risks.
|
| Precautions |
Pregnancy category D if used for
prolonged periods or in high doses; caution in COPD, emphysema, and
renal insufficiency | |
Drug Name
|
Fentanyl (Duragesic) -- Potent
narcotic analgesic with much shorter half-life than morphine
sulfate. DOC for conscious sedation analgesia. Ideal for analgesic
action of short duration during anesthesia and during immediate
postoperative period. Excellent choice for pain management and
sedation with short duration (30-60 min). Easy to titrate. Easily
and quickly reversed by naloxone. When using transdermal dosage
form, most patients achieve pain control with 72-h dosing intervals;
however, some patients require dosing intervals of 48 h.
|
| Adult Dose |
25-100 mcg/h system q2-3d
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity;
hypotension or potentially compromised airway that would cause
difficulty in establishing rapid airway control
|
| Interactions |
Phenothiazines may antagonize
analgesic effects of opiate agonists; TCAs may potentiate adverse
effects of fentanyl when both drugs are used concurrently
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in hypotension, respiratory
depression, constipation, nausea, emesis, and urinary retention;
idiosyncratic reaction, known as chest wall rigidity syndrome, may
require neuromuscular blockade in order to increase
ventilation | Drug Category:
Anticonvulsants -- Certain antiepileptic drugs (eg, the
GABA analogue gabapentin) have proven helpful in some cases of neuropathic
pain. Other anticonvulsant agents (eg, clonazepam, topiramate, lamotrigine,
zonisamide, tiagabine) also have been tried in CPS.
Drug Name
|
Gabapentin (Neurontin) -- Has
anticonvulsant properties and antineuralgic effects; however, exact
mechanism of action is unknown. Structurally related to GABA but
does not interact with GABA receptors.
|
| Adult Dose |
100-1200 mg PO tid
|
| Pediatric Dose |
<12 years: Not
recommended
>12 years: Administer as in adults
| Contraindications |
Documented hypersensitivity
|
| Interactions |
Antacids may significantly reduce
bioavailability of gabapentin (administer at least 2 h following
antacids); may increase norethindrone levels significantly
|
| Pregnancy |
C - Safety for use during pregnancy
has not been established.
|
| Precautions |
Caution in severe renal disease;
abrupt withdrawal may precipitate seizures | | Drug Category: Analgesics -- Pain control is
essential to quality patient care. Analgesics ensure patient comfort,
promote pulmonary toilet, and have sedating properties, which are
beneficial for patients who have sustained traumatic injuries.
Drug Name
|
Acetaminophen (Tylenol, Feverall,
Aspirin Free Anacin) -- DOC for pain in patients with documented
hypersensitivity to aspirin or NSAIDs, with upper GI disease, who
are pregnant, or who are taking oral anticoagulants.
|
| Adult Dose |
650-1000 mg PO, initially; may
repeat after 6h if necessary
|
| Pediatric Dose |
3-6 years: 10 mg/kg PO; not to
exceed 720 mg/d
6-12 years: 10 mg/kg PO; not to exceed 2.6
g/d
| Contraindications |
Documented hypersensitivity; known
G-6-PD deficiency
|
| Interactions |
Rifampin can reduce analgesic
effects of acetaminophen; coadministration with barbiturates,
carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
|
| Pregnancy |
B - Usually safe but benefits must
outweigh the risks.
|
| Precautions |
Hepatotoxicity possible following
various dose levels in those with chronic alcoholism; severe or
recurrent pain or high or continued fever may indicate a serious
illness; APAP is contained in many OTC products, and combined use
with these products may result in cumulative APAP doses exceeding
recommended maximum dose | | Drug Category:
Nonsteroidal anti-inflammatory drugs (NSAIDS) -- Have
analgesic, anti-inflammatory, and antipyretic activities. Their mechanism
of action is not known, but they may inhibit cyclo-oxygenase activity and
prostaglandin synthesis. Other mechanisms may exist as well, such as
inhibition of leukotriene synthesis, lysosomal enzyme release,
lipoxygenase activity, neutrophil aggregation, and various cell membrane
functions.
Drug Name
|
Ibuprofen (Motrin, Advil, Ibuprin)
-- DOC for patients with mild to moderate pain. Inhibits
inflammatory reactions and pain by decreasing prostaglandin
synthesis.
|
| Adult Dose |
400-800 mg PO q8h; not to exceed
3.2 g/d
|
| Pediatric Dose |
6 months to 12 years: 4-10
mg/kg/dose PO tid/qid
>12 years: Administer as in adults
| Contraindications |
Documented hypersensitivity; peptic
ulcer disease, recent GI bleeding or perforation, renal
insufficiency, or high risk of bleeding
|
| Interactions |
Coadministration with aspirin
increases risk of inducing serious NSAID-related side effects;
probenecid may increase concentrations and, possibly, toxicity of
NSAIDs; may decrease effect of hydralazine, captopril, and
beta-blockers; may decrease diuretic effects of furosemide and
thiazides; may increase PT when taking anticoagulants (instruct
patients to watch for signs of bleeding); may increase risk of
methotrexate toxicity; phenytoin levels may be increased when
administered concurrently
|
| Pregnancy |
B - Usually safe but benefits must
outweigh the risks.
|
| Precautions |
Category D in third trimester of
pregnancy; caution in congestive heart failure, hypertension, and
decreased renal and hepatic function; caution in coagulation
abnormalities or during anticoagulant therapy | |
Drug Name
|
Naproxen sodium (Anaprox, Naprelan,
Naprosyn, Anaprox) -- For relief of mild to moderate pain. Inhibits
inflammatory reactions and pain by decreasing activity of
cyclo-oxygenase, which results in a decrease of prostaglandin
synthesis.
|
| Adult Dose |
275 mg PO tid or 550 mg PO bid
|
| Pediatric Dose |
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
| Contraindications |
Documented hypersensitivity; peptic
ulcer disease; recent GI bleeding or perforation; renal
insufficiency
|
| Interactions |
Coadministration with aspirin
increases risk of inducing serious NSAID-related side effects;
probenecid may increase concentrations and, possibly, toxicity of
NSAIDs; may decrease effect of hydralazine, captopril, and
beta-blockers; may decrease diuretic effects of furosemide and
thiazides; may increase PT when taking anticoagulants (instruct
patients to watch for signs of bleeding); may increase risk of
methotrexate toxicity; phenytoin levels may be increased when
administered concurrently
|
| Pregnancy |
B - Usually safe but benefits must
outweigh the risks.
|
| Precautions |
Category D in third trimester of
pregnancy; acute renal insufficiency, interstitial nephritis,
hyperkalemia, hyponatremia, and renal papillary necrosis may occur;
patients with preexisting renal disease or compromised renal
perfusion risk acute renal failure; leukopenia occurs rarely, is
transient, and usually returns to normal during therapy; persistent
leukopenia, granulocytopenia, or thrombocytopenia warrants further
evaluation and may require discontinuation of drug | |
FOLLOW-UP
Further Inpatient Care:
- Hospitalization usually is not required for patients with CPS, but
it depends on how invasive the treatment choice is for pain control and
the severity of the case.
Further Outpatient Care:
- Patients with CPS generally are treated on an outpatient basis and
require a variety of health care professionals to manage their condition
optimally.
Complications:
- Chronic pain may lead to prolonged physical suffering, marital or
family problems, loss of employment, disability, and various adverse
medical reactions from long-term therapy.
Patient Education:
- The patient and family should have a good understanding about the
multifactorial nature of chronic pain and the benefits of a
multidisciplinary comprehensive management plan.
- Avoid uncomfortable stressful positions and bad
posture.
Regular exercise, good sleeping habits, and balanced
meals are helpful in maintaining good health.
- The patient may benefit from instruction in biofeedback and
relaxation techniques.
MISCELLANEOUS
Medical/Legal Pitfalls:
- Good rapport, tolerance, and an open-minded approach are important
when evaluating any patient with chronic pain.
- A patient with CPS may exhibit exaggerated pain behavior. Sensations
may seem to be hysterical or appear nonanatomic or nonphysiologic, but
these patients always should be taken seriously and appropriate
conservative steps should be taken.
- Obtaining a thorough past history is important to avoid repeating
invasive and expensive procedures.
- Consultation with a neurologist, obstetrician-gynecologist,
urologist, psychologist, gastrointestinal specialist, or other
appropriate specialists is very important, especially before considering
invasive or aggressive management.
Special Concerns:
- Appropriate caution must be taken during treatment of patients who
exhibit any of the following behaviors:
- Poor response to prior appropriate management
- Unusual unexpected response to prior specific treatment
- Avoiding school, work, or other social responsibility
- Noncompliance with treatment in the past
- Drug abuse or dependence
- Family, marital, or sexual problems
- History of physical or sexual abuse
BIBLIOGRAPHY
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