Chronic pain management

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  • Myelination increases the speed of transmission and so sudden, sharp pain gets transmitted to the cerebral cortex faster than dull or aching pain. This may be important for survival. The motivational and affective elements of pain appear to be influenced strongly by the C-fibers. They project onto the thalamus, hypothalamus, and amygdala.
    The A-delta fibers project onto particular areas of the thalamus and sensory areas of the cerebral cortex.
    Neurotransmitters are also involved, in particular, substance P.
  • Colored portrait picture of a white woman, shoulder length brown hair with a worried look on her face . She is on the right side of the page.
  • Studies show depression and anxiety create more pain and stronger pain. Pure psychologic pain. Poor under report pain for fear of being a burdn, mistrust of richer docs, addiction running around neighborhood. Subtle cultural diffenences – ex –
    Eastern European rate pain worse than Asians or African Amer. Gender – females tolerate visceral pain better, males – somatic. Spiritual suffering can increase pain and different religions have different meaning behind physical suffersing – “cruxifixion complex”
  • Episodes of neuralgia occur suddenly and without apparent cause. Someone with causalgia may report that it feels like my arm is pressed against a hot stove. Typically follows a traumatic injury like a gun shot wound or stabbing and occurs at the site of injury. Is experienced well after the wound has healed.
    Phantom limb pain – example might be burning sensation in your toes after the limb and foot has been amputated. Person can experience a sense of their limb moving. Can persist for months and years. Pain can be felt as shooting, burning, or cramping (e.g., feel like hand is clenched with finger nails digging into the hand).
  • Poor pain control is based on misperceptions of pain controlling medications – e.g., fear of addiction. Children, for fear of needles or lack of knowledge about pain-killer medications, may request medications less.
  • Capsaicin (Zostrix) – red hot chili pepper juice – used for centuries in S. America, burns for first few days then wears out substance P in pain receptors
    PT/chirpracter/massage/yoga/acupuncture in some studies equally effective in certain conditions like low back pain
    NSAIDs – beware of GI side effects and platelet effects, though the Salcylate class and Diflunisal have less of these effects. NSAIDs in studies shown to decrease narcotic use by up to 40% in things like wide-spread boney mets
    Relaxants – soma, flexeril, benzodiazepines
  • Biofeedback for the treatment of chronic pain appears to be no more effective than relaxation methods. Relaxation may work in two ways: 1) reducing muscle tension; and 2) helping the patient better manage stress and anxiety. Relaxation exercises are frequently used in preparing a pregnant women for the delivery of her child. Relaxation may also stimulate the release of endogenous opioids, as well as boosting immune function. Evidence suggests that its effects are modest but useful in combination with other methods.
    Mechanism by which hypnosis works for some pain conditions, particularly acute pain such as that during surgery, is not well understood. Cognitive methods of pain control appear to be as effectives as hypnosis.
  • Chronic pain management

    1. 1. Dr.P.NARASIMHA REDDY M.D D.A Professor And H.O.D Dept.Of Anesthesiology Narayana medical college hospital Nellore.
    2. 2. Good Evening
    3. 3.  Pain is defined by international association for study of pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.
    4. 4.     Pain is always a subjective experience Everyone learns the meaning of “pain” through experiences usually related to injuries in early life As an unpleasant sensation it becomes an emotional experience Pain is a significant stress physically, emotionally
    5. 5. Somatic pain:caused by the activation of pain receptors in either the cutaneous (the body surface) or deeper tissues (musculoskeletal tissues). Visceral pain: pain that is caused by activation of pain receptors from infiltration, compression, extension or stretching of the thoracic, abdominal or pelvic viscera (chest, stomach and pelvic areas). Neuropathic pain: caused by injury to the nervous system either as a result of a tumor compressing nerves or the spinal cord, or cancer actually infiltrating into the nerves or spinal cord.
    6. 6.    Mild: ?? Moderate: ?? Severe: ??  Although descriptive, does not provide correct information, perhaps these should be used to modify acute and chronic pain indications to allow patients to understand, but how do you measure what is mild, moderate, severe: ultimately it is the bias of the agency, investigators, sponsors to suggest which is which.
    7. 7.  Acute pain: short-lasting and manifesting in objective ways that can be easily described and observed. It may be clinically associated with diaphoresis and tachycardia. It can last for several days, increasing in intensity over time (subacute pain), or it can occur intermittently (episodic or intermittent pain). Usually related to a discreet event for onset: post op, post truama, fracture, etc  Chronic pain: Long-term and typically defined if it lasts for > three months. It is more subjective and not as easily clinically characterized as acute pain and is more psychological. This kind of pain usually affects a person's life, changing personality, their ability to function, and their overall lifestyle.
    8. 8. Chronic pain has a psycho-social component that must be dealt with before depression becomes a part of the clinical picture. Chronic pain should be recognized as a multi-factorial disease state requiring intervention at many levels.
    9. 9. 1. 2. Normal or Nociceptive pain – includes acute,subacute & inflammatory pain. Abnormal or pathophysiologic pain – Neuropathic and central pain.
    10. 10.   - Nociceptors : are free nerve endings, innervated by A-delta and C nerve fibers, that respond to intense ,potentially damaging stimuli that exist throughout the body. Found in skin in form of High threshold mechanoreceptors Polymodal receptors Silent receptors.
    11. 11.  Chemical mediators:
    12. 12.  Local release of prostaglandins potentiate the action of bradykinin and acts as sensitiser to nociceptors.
    13. 13.   First order neurons:Nociceptive afferent fibers terminate in spinal dorsal horn on the same side as the dorsal root ganglion where primary sensory neural cells are located. Rexed laminae:
    14. 14. Second order neurons: 1. Wide dynamic range neurons.(WDR) 2. Nociceptive specific neurons.  WDR neurons are located in laminae V of dorsal horn. 
    15. 15.    Occurs at Nociceptor, spinal cord or in supra spinal structures. It can either facilitate or inhibit pain. At the spinal level modulation is via “GATE CONTROL THEORY” by MELZACK & WALL.
    16. 16.    Described physiological mechanism by which psychological factors can affect the experience of pain. Neural gate can open and close thereby modulating pain. Gate is located in the spinal cord.
    17. 17.  Physical conditions    Emotional conditions     Extent of injury Inappropriate activity level Anxiety or worry Tension Depression Mental Conditions   Focusing on pain Boredom
    18. 18.  Physical conditions    Emotional conditions    Medications Counter stimulation (e.g., heat, message) Positive emotions Relaxation, Rest Mental conditions   Intense concentration or distraction Involvement and interest in life activities
    19. 19.   A-delta fibers – small, myelinated fibers that transmit sharp pain C-fibers – small unmyelinated nerve fibers that transmit dull or aching pain.
    20. 20.   Hypothalamus, pons and somatosensory cortex : stimulation of these areas causes analgesia Three endogenous systems involved in the inhibitory pathways for pain: (1) the opioid system, (2) the noradrenergic system, and (3) the serotonergic system
    21. 21.  Increased catabolic demands: poor wound healing, weakness, muscle breakdown.  Decreased limb movement: increased risk of DVT/PE Respiratory effects: shallow breathing, tachypnea, cough suppression increasing risk of pneumonia and atelectasis.   Increased sodium and water retention (renal) Decreased gastrointestinal mobility.  Tachycardia and elevated blood pressure 
    22. 22.    Negative emotions: anxiety, depression Sleep deprivation Existential suffering: may lead to patients seeking active end of life.
    23. 23.   Decrease natural killer cell counts Effects on other lymphocytes not yet defined.
    24. 24.    Chronic pain is pain that:  continues a month or more beyond the usual recovery period for an injury or illness or  goes on for months or years due to a chronic condition. The pain may not be constant but disrupts daily life. It also can interfere with sleep, keeping you awake a night.
    25. 25. Loneliness Hostility Social Factors TIME Anxiety Depression Psychological Factors Pathological Process Physical Factors
    26. 26.    Nociceptive,Neuropathic or both. Psychological mechanisms play a major role. Attenuated neuroendocrine stress response and have prominent sleep and affective disturbances.
    27. 27.    Neuropathic pain: Paroxysmal and lancinating,has a burning quality and is associated with hyperpathia. Deafferentation pain: neuropathic pain associated with loss of sensory input into the CNS. Sympathetically mediated pain:sympathetic system plays a major role.
    28. 28.      Psychologic factors – depression, anxiety, somatization Socioeconomic factors – cultural differences, urban poor, gender Spiritual factors – spiritual suffering, meaning of pain Physical factors – VERY complex neuroanatomy creating the pain sensation, from pain receptors to afferent nerves to spinothalamic tract, to thalamus to cortex with modulators all along the way Therefore best approach is multi-disciplinary
    29. 29. Episodic pain syndromes:  Headaches – migraine, tension, cluster…  Ischemic episodes – claudication, angina, sickle cell disease  Visceral pain – biliary colic, irritable bowel, premenstrual syndrome, renal colic  Somatic pain - gout
    30. 30. Chronic pain syndromes:  Somatic – low back pain ,degenerative and inflammatory arthitis, lumbosacral radiculopathy,Failed back surgery, vertebral compression fractures, bony metastases, Myofascial pain syndrome.  Visceral – abdominal cancers, chronic pancreatitis.  Neuropathic – CRPS,Post herpetic neuralgia,Trigeminal neuralgia,diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets,
    31. 31.    Neuralgia – an extremely painful condition consisting of recurrent episodes of intense shooting or stabbing pain along the course of the nerve. Causalgia – recurrent episodes of severe burning pain. Phantom limb pain – feelings of pain in a limb that is no longer there and has no functioning nerves.
    32. 32.       MEDICAL EVALUATION: Location,onset. Quality,radiation. Response to previous treatments. h/o past,personal,social,economic,psychological and emotional status. Plain radiographs,CT,MRI, bone scans.
    33. 33. PSYCHOLOGICAL EVALUATION: 1. Clinical interview. 2. A structured pain inventory a. Mc Gill pain questionnaire. b. Psychosocial pain inventory. c. Westhaven - Yale multidimensional pain inventory. d. Pain profile. 
    34. 34. 3. Psychometric testing: a. Minnesota multiphasic pain inventory(MMPI) b. Symptom check list-90. c. Million behavioural pain inventory. d. The beck depression inventory. e. The spielberger state-trait anxiety scale.
    35. 35.    Electromyography and Nerve conduction studies: Useful for confirming diagnosis of entrapment syndromes,neural trauma and polyneuropathies,radicular syndromes. Can distinguish b/n neurogenic and myogenic disorders.
    36. 36.   - Reliable quantitation of pain severity helps determine therapeutic interventions and evaluate the efficacy of treatments. PAIN SCALES: Numerical rating scale. Faces rating scale Visual analog scale. McGill pain questionnaire.
    37. 37. VISUAL ANALOGUE SCALE
    38. 38. McGill Pain questionnaire:  It is a checklist of words describing symptoms.  Attempts to define the pain in 3 major dimensions. 1. Sensory – discriminative. 2. Motivational – affective. 3. Cognitive – evaluative. 
    39. 39. Contains 20 sets of words that are divided into 4 groups. 1. 10 sensory. 2. 5 affective. 3. 1 evaluative. 4. 4 miscellaneous. 
    40. 40.  Low back pain:
    41. 41.     Treatment: Bed rest widely recommended but shown to impede recovery. Current consensus – maintenance of activity and work status. If beyond 4-wks – refer to multidisciplinary pain centre.
    42. 42.     General term for congenital and acquired disorders of spine. Narrowing of the bony frame surrounding the neural structures . Can affect central spinal canal or lateral intervertebral foramen. Narrowing can be caused by spondylolisthesis,osteoarthritis of spine,degenerative disk disease.
    43. 43.      Also called as post laminectomy syndrome. One of the most difficult groups of chronic pain patients. Exhibits strong nociceptive and neuropathic characteristics. Pain may be sharp and shooting ,burning,dydesthic. Iatrogenic and due to development of fibrous scarring.
    44. 44.      Soft tissue disorder that creates pain in tender areas within muscle groups. Diagnosis made on clinical trigger points . Trigger points are painful regions in a taut band of muscle that produces referenced pain with application of pressure. Painful area usually feels like a “rope”. Created by events like trauma or prolonged tension from poor posture.
    45. 45.   Local prolonged ischemia may trigger the formation of subsequent fibrosis. Therapeutic modalities – passive stretching,cold spray,compression massage,injection of 0.5% lidocaine at the trigger point,botulinum toxin injection.
    46. 46.  Common complaint.
    47. 47.     Neuropathic pain that involves upper and lower extremities. Reflex sympathetic dystrophy and causalgia are replaced by CRPS I ,CRPS II. CRPS type I: follows minor trauma. Preceeding events are trauma,surgery,sprain,fracture,dislocation.
    48. 48.  3 phases.
    49. 49.     CRPS type II: also called as causalgia. Burning pain,follows high velocity injuries to large nerves. Pain immediate in onset. Associated with allodynia,hyperpathia,vasomotor and sudomotor dysfunction.
    50. 50.     Treatment: Sympathetic blocks. Physical therapy plays major role. Cure rate is high if Rx initiated within 1month of symptoms and appears to decrease with time.
    51. 51.    Intractable pain that develops as a sequel of acute herpes zoster infection.(AHZ) Pain from AHZ resolves usually within 3-4 weeks and if pain lasts longer than 4-6wks PHN should be suspected. In AHZ large myelinated fibers are destroyed whereas in PHN pain processing by small fibers is compromised.
    52. 52.      Typically presents with unilateral pain in dermatomal distribution. Treatment: Sympathetic blockade during attack Antidepressants,anticonvulsants,opioids. TENS.
    53. 53.    TIC DOULOUREUX classically presents as a painful, unilateral affliction of the face, characterized by brief electric-shock-like pain, limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli, including washing, shaving, smoking, talking and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination may remit for varying periods.
    54. 54.     Treatment: Carbamazepine. Invasive treatment- Glycerol injection,Radiofrequency ablation of gasserian ganglion Microsurgical decompression of trigeminal nerve.
    55. 55.     Improvements in nociception, not curing. Decrease pain and suffering Increase daily activity. Instill hope
    56. 56. 1. 2. 3. 4. PHARMACOLOGICAL. PHYSICAL MEASURES/NON PHARMACOLOGICAL. PSYCHOLOGICAL MEASURES. INVASIVE TECHNIQUES.
    57. 57.    About half of hospitalized patients who have pain are under-medicated. Children are at particular risk of poor pain control methods. Medications are given as:   PRN – “as needed” As a prescribed schedule
    58. 58.       NSAIDS, COX INHIBITORS. OPIOIDS ANTI DEPRESSANTS ANTI CONVULSANTS CORTICOSTEROIDS LOCAL ANAESTHETICS – systemic administration.
    59. 59.   Traditional NSAIDs are effective in the treatment of mild to moderate pain, but their use is limited by potentially serious adverse effects ketorolac : indicated only in the management of moderately severe acute pain that requires opioid level analgesics ; no more than 5 days
    60. 60.   COX-2 selective inhibitors [celecoxib (Celebrex), rofecoxib (Vioxx) and valdecoxib (Bextra)] 200-fold to 300-fold selectivity for inhibition of COX-2 over COX-1
    61. 61.     Codeine Fentanyl Hydrocodone Hydormorphone Methadone Morphine Oxycodone Oxymorphone
    62. 62.      Individualize route, dosage, and schedule Administer analgesics regularly (not PRN) if pain is present most of day Become familiar with dose / time course of several strong opioids Give infants / children adequate opioid dose Follow patients closely, particularly when beginning or changing analgesic regimens
    63. 63.  When changing to a new opioid or different route   Use equianalgesic dosing table to estimate new dose Modify estimate based on clinical situation  Recognize and treat side effects  Be aware of potential hazards of meperidine / mixed agonist-antagonists - particularly pentazocine  Do not use placebos to assess nature of pain
    64. 64.  Watch for development of:   Tolerance - treat appropriately Physical dependence – prevent withdrawal  Do not label a patient psychologically dependent, “addicted”, if you mean physically dependent on / tolerant to opioids  Be alert to psychological side of patient .
    65. 65.       Constipation , no tolerance develops to constipation, use stimulants (Senokot, Bisocodyl, Pericolace) Nausea/vomiting – tolerance can occur in 2-5 days. Sedation – tolerance can occur in 2-3 days. Clonic jerks – usually high doses, can change drug or diazepam can help Respiratory suppression in toxic doses, never see it if have pain or use the drugs the right way. Can produce Hyperalgesia in certain individuals.
    66. 66. PHYSICAL DEPENDENCE:  Tolerance (20-40%) – up-regulate opioid receptors to need higher dose for sustained effect  Withdrawal (20-40%) – after 2 wks, withdrawing drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day. PSYCHOLOGIC DEPENDENCE:  Addiction (0.1% in CA pain) – a need to get “high” where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal.
    67. 67. PSEUDO-ADDICTION:  Physical dependence confused with psychologic dependence  Pain-relief seeking, not drug-seeking  When right dose used, patient functions better in life, whereas opposite true with the true addict  To help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts
    68. 68.  Definition  Agents which enhance analgesic efficacy, have independent analgesic activity for specific types of pain, and / or relieve concurrent symptoms which exacerbate pain
    69. 69.      Antidepressants Anticonvulsants Corticosteroids Neuroleptics Antihistamines      Analeptics Benzodiazepines Antispasmodics Muscle relaxants Systemic local anesthetics
    70. 70.     Antidepressants are effective agents in the treatment of neuropathic pain. Action due to blockade of presynaptic reuptake of serotonin,norepinephrine or both. serious side effects , include anticholinergic effects including dry mouth, confusion, and urinary retention . Ex. Amitr yptiline,Clomipramine,Doxepine,Fluox etine,Imipramine.
    71. 71.     Antiepileptic drugs have been used for many years in the treatment of neuropathic pain particularly trigeminal neuralgia and diabetic neuropathy. Blocks voltage gated sodium channels and can suppress spontaneous neuronal discharges. phenytoin, carbamazepine, and valproic acid The newer agents, gabapentin appears to be the most effective and well tolerated
    72. 72.    Useful in patients with marked agitation or psychotic symptoms. Fluphenazine,Haloperidol,Chlorpromazine and perphenazine are commonly used. Action due to blockade of dopaminergic receptors.
    73. 73.   Glucocorticoids are extensively used in pain management for their anti inflammatory and possibly analgesic actions. Can be given topically,orally,parenterally.
    74. 74.  Lidocaine Infusion   More effective in neuropathic pain but can be used for all pain syndromes. Starting dose 0.5mg-2 mg/kg per hr IV or SC. Some studies demonstrate long-lasting pain relief even after drug has been stopped. Need to decrease opioids when starting. Lidocaine Patch (Lidoderm®)   On 12hrs off 12 hours (but can leave on 24) Expensive (great indigent program however)
    75. 75.    Alpha adrenergic agonist. Action – activation of descending inhibitory pathways. Can be given epidurally,intrathecally,parenterally.
    76. 76.      N-methyl-D-aspartate receptor antagonist (NMDA) Used as an anesthetic for years Case reports show effectiveness when traditional and invasive techniques fail Starting IV dose 150mg qd (0.1-0.2mg/kg) with reduction of opioid achieved or 10-15 mg q6 increasing by 10 mg dose each day Appears to have a synergistic effect with opioids
    77. 77.       Pamidronate (Aredia) Zoledronic acid (Zometa) Strontium-89 (Metastron) Calcitonin (Calcimar) Not in cancer ? arthritis Capsaicin (Zostrix) scheduled in neuropathic pain Cannabinoid (Marinol)
    78. 78. Quality of Life Invasive treatments Proposed 4 th Step Opioid Delivery Pain persisting or increasing Step 3 Opioid for moderate to severe pain ± Nonopioid ± Adjuvant Pain persisting or increasing The WHO Ladder Step 2 Opioid for mild to moderate pain ± Nonopioid ± Adjuvant Pain persisting or increasing Step 1 ± Nonopioid ± Adjuvant Pain
    79. 79.   - - Exercises :Graded exercise program prevents joint stiffness,muscle atrophy and contractures. Superficial heating modalities: Conductive – hot packs,paraffin baths,fluido therapy. Convective Radiant.
    80. 80.  ULTRASOUND: for deep pain.
    81. 81.    ACCUPUNCTURE: Useful adjunct for patients with chronic musculoskeletal disorders and headaches. Technique – insertion of needles in discrete anatomically defined points called “MERIDIANS”.
    82. 82.   Used widely in chronic pain All available trials used TENS as an adjuvant to medication, and it’s possible the effects of TENS was masked by the analgesic effect of medication
    83. 83.        Ice packs Chiropractic/osteopathic manipulations Massage Yoga Topical agents (Ben Gay/Icy Hot – with menthol, salcylates, Capcaicin) Local injections (steroids, lidocaine) Glucosamine shown to help with osteoarthritis
    84. 84.      Herbals/supplements – glucosamine shown to be useful in osteoarthritis, certain herbs like chamomile useful for colicky pain Homeopathies/flower essences – for relaxation, visceral pain Healing touch/Reiki – using energy techniques, useful with emotional components Neuro Emotional Technique – A chiropractic technique also useful with emotional components Mind – focusing therapies: • • • Meditation, yoga, guided-imagery, hypnosis, biofeedback Art/music/humor therapy, pet therapy By distraction, found to lower HR/RR and decrease pain up to 10-20%
    85. 85. Integral part of multidisciplinary approach to pain management. 1. Self management techniques – cognitive methods,relaxation,biofeedback. 2. Operant techniques. 3. Group therapy. 
    86. 86.     Cognitive methods: Based on assumptions that a patients attitude towards pain can influence the perception of pain. Maladaptive attitudes contribute to suffering and disability. Patient is taught skills for coping with pain either individually or in group therapy.
    87. 87.    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.
    88. 88.    OPERANT / BEHAVIOUR THERAPY: Based on premise that behaviour in patients with chronic pain is determined by consequences of behaviour. Positive reinforcers aggravate the pain,negative reinforcers reduce pain behaviour.
    89. 89.   Intractable pain* Intractable side effects* *Symptoms that persists despite carefully individualized patient management
    90. 90.    SELECTION OF BLOCK: Depends on Location of pain Its presumed mechanism Skills of treating physician. L.A ‘s can be applied locally,at peripheral nerve,somatic plexus,sympathetic ganglia or nerve root, centrally in neuraxis.
    91. 91.  - Somatic nerve blocks: Trigeminal nerve blocks Cervical,thoracic,lumbar paravertebral blocks Facet blocks Trans sacral nerve blocks etc.
    92. 92.  - Sympathetic blocks: Stellate ganlion block Celiac plexus block Thoracic,lumbar sympathetic chain block etc.
    93. 93. CELIAC PLEXUS BLOCK
    94. 94. EPIDURAL INJECTIONS: - Lumbar interlaminar epidural injections - Fluoroscopic injections - Transforaminal injections - Radiofrequency rhizotomy
    95. 95.   SPINAL INJECTIONS: Therapeutic effects of spinal injections are a combination of primary physiologic changes that result from the procedure and the secondary results arising from the enhanced pain control that allow other treatments.
    96. 96.    Also called dorsal coloumn stimulation. Produces analgesia by directly stimulating large A beta fibers in dorsal coloumns of the spinal cord. Mechanism – activation of descending modulating systems and inhibition of sympathetic outflow.
    97. 97.    Indications: Sympathetically mediated pain Spinal cord lesions Phantom limb pain Failed back surgery syndrome. Technique: electrodes placed epidurally and connected to an external generator. Complications: infection,lead migration,lead breakage.
    98. 98.  - - Deep brain stimulation may be used for intractable cancer pain and rarely for intractable neuropathic pain of nonmalignant origin. Electrodes are implanted stereotactically into periaqueductal and periventricular gray areas for nociceptive pain. Complications: intracranial hemorrhage and infection.
    99. 99.       Pain is unnecessary. Effective tools are available to help doctors evaluate pain in their patients. Unrelieved pain should be treated just like any other vital sign: with aggressive measures. Effective therapies are available to treat pain. Use guidelines to develop a rational plan to relieve pain. Side effects are manageable. Anticipate side effects and treat aggressively. Addiction rarely occurs. Trust your patient when they report pain. Tolerance and physical dependence can occur. Plan and you will succeed. Take the initiative and focus on relieving pain at your hospital. Your patients depend on it.
    100. 100.      John C.Rowlingson – Chronic Pain.Miller’s Anaesthesia. Raj PP:Practical Management Of Pain . Wall PD,Melzack OC:Text book of pain. ISA Journal On pain. Gowri devi M;Chronic pain ManagementPsychological aspectsin current conceptsin pain management.CMEabstract 1998.

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