Rheumatology Book

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Chronic Pain Management

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  1. See Also
    1. Chronic Pain
    2. Chronic Pain Evaluation
    3. Diffuse Musculoskeletal Pain Causes
    4. Chronic Pain Resources
  2. Protocol
    1. Complete thorough Pain Evaluation that is updated at each visit
    2. Consider referral to pain management specialists
    3. Periodic repeat review of treatment plan and outcomes (Mnemonic: 6 As)
      1. Analgesia: Pain relief
      2. Affect: Mood?
      3. Activities: Quality of Life and Activities of Daily Living
      4. Adjuncts: Nonpharmacologic and non-Opioid medications
      5. Adverse Effects: Medication side effects
      6. Aberrant behavior: Increasing tolerance, drug dependence, addiction
    4. Medical records should reflect systematic process of evaluation and treatment
      1. Document Pain Evaluation, treatment plan, consultation, informed consent and contracts
      2. Document medication history
      3. Document high risk behaviors (e.g. drug seeking)
    5. Follow a written treatment plan
      1. Include both non-pharmacologic (e.g. lifestyle) and medications
      2. Establish realistic objectives of successful treatment
      3. Address future diagnostic testing if needed
    6. Obtain informed consent
      1. Risks and benefits are discussed
      2. Pain contract should be a part of the normal process
      3. Discuss reasons for cessation of treatment (breaking contract)
      4. Consider urine drug screening
  3. Management: General
    1. Treat specific conditions as each condition has specific guidelines for pain management
    2. Set realistic goals (complete elimination of pain is not realistic)
      1. Decrease physical limitations and improve occupational functioning
      2. Improve social, psychological and interpersonal functioning
      3. Improve quality of life by increasing pleasurable activities
    3. Lifestyle changes
      1. Tobacco Cessation
      2. Weight loss
      3. Exercise
      4. Stretching and Yoga
    4. Treat Myofascial Pain
      1. Fibromyalgia
      2. Myofascial Pain Syndrome
    5. Consider physical rehabilitation methods
      1. Transcutaneous electrical nerve stimulation (TENS)
      2. Acupuncture
      3. Massage
      4. Stretch and Spray
      5. Trigger Point Injection
      6. Nerve blocks
    6. Approach is similar to treatment of Somatization
      1. Non-Pharmacologic Management is critical
      2. See Somatization Management
      3. See Somatoform Disorder Management Pitfalls
  4. Management: Pharmacologic
    1. Medications augment non-pharmacologic management
    2. Analgesics
      1. NSAIDs or COX-2 Inhibitors
      2. Acetaminophen
    3. Tricyclic Antidepressants
      1. Nighttime only use (Tertiary amines)
        1. Amitriptyline (Elavil)
        2. Imipramine (Tofranil)
        3. Doxepin (Sinequan)
      2. Daytime and nighttime use (Secondary amines)
        1. Nortriptyline (Pamelor)
        2. Desipramine (Norpramin)
    4. Novel Antidepressants with efficacy in Chronic Pain
      1. Venlafaxine (Effexor)
      2. Duloxetine (Cymbalta)
      3. Bupropion (Wellbutrin)
    5. Anticonvulsants
      1. Indicated for sharp, lancinating, intermittent pain
      2. Potential Agents
        1. Gabapentin (Neurontin)
          1. Most studied anticonvulsant for neuropathic pain
          2. Titrate to effective doses (2400 to 3600 mg/day)
          3. Indications
            1. Diabetic Neuropathy
            2. Postherpetic Neuralgia
        2. Carbamazepine (Tegretol)
          1. Primary indication: Trigeminal Neuralgia
          2. Other indications with modest efficacy
            1. Diabetic Neuropathy
            2. Postherpetic Neuralgia
        3. Pregablin (Lyrica)
          1. New agent pending FDA approval in 2005
          2. Indications
            1. Diabetic Neuropathy
            2. Postherpetic Neuralgia
            3. Fibromyalgia
        4. Phenytoin (Dilantin)
        5. Valproic Acid (Depakote)
        6. Lamotrigine (Lamictal)
        7. Topiramate (Topamax)
    6. Adjunctive agents
      1. Caffeine 65 to 200 mg
        1. Enhances Analgesic effect
        2. Use in combination with Analgesic
          1. Acetaminophen
          2. Aspirin
          3. Ibuprofen
      2. Hydroxyzine (Atarax, Vistaril)
        1. Enhances Opioid Analgesic effect
        2. Reduces Opioid associated Nausea and Vomiting
    7. Avoid Narcotics if possible
      1. See Chronic Narcotic Guidelines
    8. Avoid Benzodiazepines
    9. Experimental protocols: Cannabinoids
      1. CT-3 appears to reduce neuropathic pain
      2. Karst (2003) JAMA 290:1757
  5. References
    1. Ansari (2000) Harv Rev Psychiatry 7:257
    2. Barkin (2000) Am J Ther 7:31
    3. Bajwa (1999) Neurology 52:1917
    4. Dellemijn (1999) Pain 80:453
    5. Jackman (2008) Am Fam Physician 78(10):1155
    6. Kingery (1997) Pain 73:123
    7. Laird (2000) Ann Pharmacother 34:802
    8. Maizels (2005) Am Fam Physician 71(3):483
    9. McQuay (1995) BMJ 311:1047
    10. Sindrup (1999) Pain 83:389
    11. (2000) Med Lett Drugs Ther 42(1085):73

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