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Management
Beverly Pearce-Smith, MD
Clinical Assistant Professor
Department of
Anesthesiology
UPMC-McKeesport Hospital
July 2008
IASP Definition of Pain
Postherpeti
Postoperative
Arthritis c Trigeminal
pain
neuralgia neuralgia
Sickle cell Neuropathic
Mechanical crisis low back pain Central post-
low back pain
Distal stroke pain
Sports/exercise polyneuropathy
injuries (eg, diabetic, HIV)
*Complex regional pain syndrome
Possible Descriptions
of Neuropathic
Sensations
Pain
Signs/Symptoms
numbness allodynia: pain from a
tingling stimulus that does not
burning normally evoke pain
paresthetic thermal
paroxysmal mechanical
lancinating hyperalgesia:
electriclike exaggerated response
raw skin to a normally painful
shooting stimulus
deep, dull, bonelike ache
Physiology of Pain
Perception
Injury Brain
Transduction
Transmission
Modulation
Perception Descending
Pathway
Interpretation
Behavior
Dorsal
Peripheral Root
Nerve Ganglion
Ascending
Pathways
C-Fiber
Neuropathic
More Pain
than one mechanism of action likely involved
Neuropathic pain may result from abnormal
peripheral nerve function and neural processing of
impulses due to abnormal neuronal receptor and
mediator activity
Combination of medications may be needed to
manage pain: topicals, anticonvulsants, tricyclic
antidepressants, serotonin-norepinephrine reuptake
inhibitors, and opioids
In the future, ability to determine the relationship
between the pathophysiology and symptoms/signs
may help target therapy
Neuropathic Pain
Pain initiated or caused by a primary lesion
or dysfunction in the nervous system
Merskey & Bogduk 1994
Central & peripheral sites
Acute & chronic pain states
CRPS I: consequent of acute, often minor
trauma
CRPS II: consequence of nerve injury
Sympathetically maintained Pain (SMP) or
independent of the SNS
Neuropathic Pain
Burning, stabbing, paraesthesia, allodynia, hyperalgesia
Threshold for activation of injured 1o afferents is lowered
Ectopic discharges may arise from the injury site or the
DRG
2o to changes in Na+ channel expression
2o to central changes
Reduced inhibition
Functional (neurotransmitter) & anatomical (sprouting)
changes in A fibres tactile allodynia (pain induced by
light touch)
Acute Neuropathic Pain
Acute causes
iatrogenic, traumatic, inflammatory, infective
Acute neuropathic pain = 1-3%
Based on cases referred to an acute pain
service
Majority still present at 12 months
May be a risk factor for chronic pain
Prompt diagnosis & Rx may prevent
chronic pain
Examples of Acute NP
Phantom Limb Pain (PLP)
Complex Regional Pain Syndrome
(CRPS)
Spinal Cord Injury Pain
Peripheral nerve injury
Post-surgical (eg thoracotomy,
mastectomy)
NEUROPATHIC PAIN
LESION IN THE NERVOUS SYSTEM
SPONTANEOUS- CONTINOUS OR
INTERMITTENT
-Burning, Shooting, Shock-like
Topical medications
Systemic medications*
Interventional
techniques*
trigeminal neuralgia
Duloxetine
peripheral diabetic neuropathy
Gabapentin
postherpetic neuralgia
Lidocaine Patch 5%
postherpetic neuralgia
Pregabalin*
peripheral diabetic neuropathy
postherpetic neuralgia
Dorsal Central
PNS Horn Sensitization
Anticonvulsants
Opioids
NMDA-Receptor
Peripheral Local Anesthetics Antagonists
Topical Analgesics Tricyclic/SNRI
Sensitization Antidepressants
Anticonvulsants
Tricyclic
Antidepressants
Opioids
Anticonvulsant Drugs for
Neuropathic Pain Disorders
Postherpetic HIV-associated
neuralgia neuropathy
gabapentin* lamotrigine
pregabalin * Trigeminal neuralgia
Diabetic neuropathy carbamazepine*
carbamazepine lamotrigine
phenytoin oxcarbazepine
gabapentin Central poststroke
lamotrigine pain
pregabalin *
lamotrigine
Pain Disorders
FDA approved for postherpetic neuralgia
'tolerance-protective' agent
Indication: Protective analgesia, NP treatment,
opioid-tolerant patients
SE: Dysphoria, nightmares, psychedelic effects
Dose: Low doses usually well tolerated
Intra-op: 0.5mg/kg bolus then 0.25-0.5
versus
Fixed-dose regimens generally preferred over prn
regimens
Document treatment plan and outcomes
Consider use of opioid written care agreement
Opioids can be effective in neuropathic pain
Most opioid AEs controlled with appropriate specific
management (eg, prophylactic bowel regimen, use of
stimulants)
Understand distinction between addiction, tolerance,
physical dependence, and pseudoaddiction
Opioids
A select group of pain patients benefits
from opioids, with resultant pain
reduction and improved physical and
psychological functioning
They have minimal side effects & show
increased activity levels & less pain
Other patients do poorly with opioids,
experiencing tolerance and side effects,
especially with escalating doses
Distinguishing
Dependence, Tolerance,
and Addiction
Physical dependence: withdrawal syndrome
arises
if drug discontinued, dose substantially reduced,
or antagonist administered
Tolerance: greater amount of drug needed to
maintain therapeutic effect, or loss of effect over
time
Pseudoaddiction: behavior suggestive of
addiction; caused by undertreatment of pain
Addiction (psychological dependence):
psychiatric disorder characterized by continued
compulsive use of substance despite harm
Opioids
Action: NT release, cell excitability
Indications: Any NP
Oxycodone, morphine (NNT = 2.5)
Tramadol (NNT = 3.9)
SE: usual, and ?OIH
Doses: usual
? Stay below 100-200mg/d PO Morphine
equivalent (ie. 30-60mg/d IV)
? methadone & buprenorphine less
hyperalgesic
Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain
treatment: An evidence based proposal. Pain 118 (2005) 289305
Antidepressants in
Neuropathic Pain
Disorders*
Multiple mechanisms of action
64
Endorphins and Pain
Concentration of endorphins is generally less
for people suffering from chronic pain (Akil et
al., 1978)
65
Nociceptors in Skin
Epiderm
Free
is
Nerve
Endings
Dermis
Pain Pathways
Lots of effort to id neural pathways
Attention
Physical factors
Pain
Perception
Experienc
e
Emotion
Behaviour
Reinforcement contingencies
+ve reinforcement (e.g. attention / affection
for pain behaviours)
-ve reinforcement (e.g. avoid unpleasant
events such as work, school)
Recently, growth in cognitive behaviour models
Fear-Avoidance Theory
(-ve) appraisals (catastrophising) fear of
pain (illness cognitions) & re-injury
Non-anti-inflammatory non-steroid
(paracetamol)
Anti-inflammatory non-steroids (eg ibprofen)
Opioids (eg morphine)
Psychological
Behavioural initially
Treatment of Chronic Pain
Surgical procedures to block the
transmission of pain from the
peripheral nervous system to the brain.
Synovectomy Removing membranes
that become inflamed in arthritic joints.
Spinal fusion joins two or more
adjacent vertebrae to treat chronic
back pain.
Psychological Pain Control
Methods
Biofeedback provides biophysiological
feedback to patient about some bodily
process the patient is unaware of (e.g.,
forehead muscle tension).
Relaxation systematic relaxation of
the large muscle groups.
Hypnosis relaxation + suggestion +
distraction + altering the meaning of
pain.
Psychological Pain
Methods
Acupuncture not sure how it works.
Could include:
Counter-irritation may close the spinal
gating mechanism in pain perception.
Expectancy
Reduced anxiety from belief that it will work.
Distraction
Trigger release of endorphins
Phantom Limb pain
Affects the majority of amputees
For most the sensation fades, but a minority
experience lasting discomfort.
Theories
Neuroma
Psychology Pharmacy
Nursing Recommendati
on
Multidisciplinary Clinics
Comprised of 2 or more disciplines
Goal is to provide coordinated and more
comprehensive care to patients for more
complex chronic pain problems
3 general subtypes
Psychoeducational clinic (mild and motivating)
Problem-based clinic (e.g. headache, LBP, FM)
Comprehensive multidisciplinary clinic
Inpatient or outpatient
Chronic Pain Disciplines and Roles
(Core)
Mechanistic Approach To Pain
Therapy Modify Expression Increase
Anxiolytics Inhibition
TCAs, SSRIs,
Clonidine
Prevent
Decrease Centralization
Inflammatory Decrease Conduction COX 2,
Response Gabapentin, Opioids,
NSAIDs, Carbamazepine, Ketamine,
Local Anesthetics, Local Anesthetics, -2 Agonists.
Steroids Opioids
Summary
Chronic neuropathic pain is a disease, not a
symptom
Rational polypharmacy is often necessary
combining peripheral and central nervous system
agents enhances pain relief
Treatment goals include:
balancing efficacy, safety, and tolerability
reducing baseline pain and pain exacerbations
improving function and QOL
New agents and new uses for existing agents
offer additional treatment options
Further Reading
Rosenzweig et al. cover pain in the
second half of chapter eight.
Horne, S. & Munafo, M. (1997).
Pain, theory, research and
intervention. Oxford University
Press
Wall, P. & Melzack, R. (1988). The
challenge of Pain. Penguin.
REFERENCES
Review Neuropathic pain: a practical guide for
the clinician ; Ian Gilron, C. Peter N. Watson,
Catherine M. Cahill and Dwight E. Moulin
Dworkin RH, Backonja M, Rowbotham MC, et al.
Advances in neuropathic pain. Arch Neurol
2003;60:1524-34.
Gilron I, Bailey JM, Tu D, et al. Morphine,
gabapentin, or their combination for neuropathic
pain. N Engl J Med 2005;352:1324-34.
Stephen Macres, Understanding Neuropathic Pain
Eisenberg E, McNicol ED, Carr DB. Efficacy and
safety of opioid agonists in the treatment of
neuropathic pain of nonmalignant origin. JAMA
2005;293:3043-52.
The end
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