Chronic Pain

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Etiology 3 Complications 4 Management 5 More General Terms 6 References

More Specific Terms

• chronic abdominal pain
• chronic daily headache
• chronic musculoskeletal pain
• chronic pelvic pain syndrome (CPPS)
• neuropathic pain

Etiology

• somatic pain

• arthritis
• bone pain
• muscle spasm
• peripheral neuropathy
• arterial insufficiency, atherosclerosis
• reflex sympathetic dystrophy (also a neuropathy)
• headache

• migraine
• cluster headache
• sinusitis
• trigeminal neuralgia ( peripheral neuropathy)

• fibromyalgia
• cancer pain

• visceral pain

• chronic pancreatitis
• chronic active hepatitis
• diabetic neuropathy

• secondary factors perpetuating pain after resolution of a disease process

• damaged sensory nerves
• sympathetic efferent activity
• painful muscle contraction

• psychologic conditions can perpetuate or cause pain

• emotional trauma
• physical or sexual abuse
• substance abuse

Complications

• depression is common
• suicide risk ( hazzard ratio 1.4-3.0)

Management

• acetaminophen: up to 1000 mg QID (4000 mg/day)
• non-steroidal anti-inflammatory drugs ( NSAIDs)
• antidepressants for neuropathic pain

• tricyclic antidepressants

• doxepin 75-400 mg/day
• amitriptyline 25-300 mg/day
• imipramine 75-400 mg/day
• nortriptyline 40-150 mg/day
• desipramine 50-300 mg/day

• venlafaxine
• duloxetine [4,5]

• anticonvulsants for neuropathic pain

• phenytoin ( Dilantin) 300 mg QHS
• carbamazepine ( Tegretol) 200-300 mg every 6 hours
• clonazepam ( Klonopin)
• gabapentin ( Neurontin):

• start 300 mg QHS
• increase to 300-600 mg TID

• mexiletine 150-300 mg every 6-12 hours
• opiates

• use in combination with other analgesics
• start short-acting opiate PRN

• titrate as needed
• switch to long-acting opiate when PRN dose is stable adverse effects are tolerable [8]

• prevention & treatment of constipation

• scheduled dose of stool softener
• laxative scheduled or PRN

• 40% of deaths from unintentional drug overdose are caused by prescription opioids [7]
• opioid use increases risk falls & fractures, hospitalization & doubles mortality [7]

• cognitive behavior therapy
• physical therapy
• aerobic exercise

More General Terms

• pain [odyn-]
• chronic disease

References

1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 56-58
2. Trescot AM et al, Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) guidelines. Pain Phys 2008 Mar-Apr;11(2S):S5-62. PMID: &dopt=Abstract
3. Veterans Administration Memorandum Dec 24, 2009 Recent VHA Findings regarding chronic pain conditions and suicide risk
4. Medical Knowledge Self Assessment Program (MKSAP) 15, American College of Physicians, Philadelphia 2009
5. FDA News release, Nov. 4, 2010 FDA clears Cymbalta to treat chronic musculoskeletal pain [1]
6. Prescriber's Letter 17(12): 2010 COMMENTARY: Opioids for Chronic Non-Cancer Pain CHART: Equianalgesic Dosing of Opioids for Pain Management Detail-Document#: [2] (subscription needed) [3]
7. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med 2010 Nov 18; 363:1981 PMID: [4]
   - Campbell CI et al. Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Public Health 2010 Dec; 100:2541. PMID: [5]
   - Solomon DH et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med 2010 Dec 13/27; 170:1968. PMID: [6]
   - Solomon DH et al. The comparative safety of opioids for nonmalignant pain in older adults. Arch Intern Med 2010 Dec 13/27; 170:1979. PMID: [7]
   - Graf J. Analgesic use in the elderly: The "pain" and simple truth. Arch Intern Med 2010 Dec 13/27; 170:1976. PMID: [8]
   - Becker WC and O'Connor PG. The safety of opioid analgesics in the elderly: New data raise new concerns. Arch Intern Med 2010 Dec 13/27; 170:1986. PMID: [9]
   - Katz MH. Long-term opioid treatment of nonmalignant pain: A believer loses his faith. Arch Intern Med 2010 Sep 13; 170:1422. PMID: [10]
8. Becker WC, O'Connor PG. The safety of opioid analgesics in the elderly: New data raise new concerns: Comment on "The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults". Arch Intern Med 2010; 170(22):1986-1988. PMID: [11]
   - Papaleontiou M, Henderson CR, Turner BJ, et al. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 2010; 58(7):1353-1369. Epub 2010 Jun 1. PMID: [12]
9. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
10. Chronic pain [13]
11. VA/DoD Clinical Practice Guidelines Management of Opioid Therapy (OT) for Chronic Pain [14]
12. National Guideline Clearinghouse
    - VA/DoD clinical practice guideline for the management of opioid therapy for chronic pain ngc-guideline: [15]
    - Assessment and management of chronic pain. (Institute for Clinical Systems Improvement) ngc-guideline: [16]
    - Antiepileptic drugs guideline for chronic pain. Washington State Department of Labor and Industries ngc-guideline: [17]
    - Persistent pain management. (University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core) ngc-guideline: [18]
    - Pain (chronic). (Work Loss Data Institute) ngc-guideline: [19]
    - Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) guidelines. ngc-guideline: [20]
    - Managing chronic non-terminal pain including prescribing controlled substances. University of Michigan Health System ngc-guideline: [21]
    - Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. American Pain Society ngc-guideline: [22]
    - Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. ngc-guideline: [23]
    - Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid therapy. Washington State Agency Medical Directors' Group ngc-guideline: [24]

chronic pain