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. Management: General
    1. Treat specific rheumatic conditions
    2. Treat Myofascial Pain
      1. Fibromyalgia
      2. Myofascial Pain Syndrome
    3. Consider physical rehabilitation methods
      1. Acupuncture
      2. Massage
      3. Stretch and Spray
      4. Trigger Point Injection
    4. Approach is similar to treatment of Somatization
      1. Non-Pharmacologic Management is critical
      2. See Somatization Management
      3. See Somatoform Disorder Management Pitfalls
  3. Management
    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
  4. 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. Kingery (1997) Pain 73:123
    6. Laird (2000) Ann Pharmacother 34:802
    7. Maizels (2005) Am Fam Physician 71(3):483
    8. McQuay (1995) BMJ 311:1047
    9. Sindrup (1999) Pain 83:389
    10. (2000) Med Lett Drugs Ther 42(1085):73

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