This document discusses chronic non-cancer pain (CNCP) and barriers to its treatment. It reviews the prevalence of CNCP, affecting over 25% of the population. Current therapeutic approaches include non-pharmacological measures, analgesics like opioids and tramadol, and invasive interventions. However, barriers remain for physicians, patients, and the healthcare system. The document calls for a multidisciplinary approach and changes to improve CNCP management.
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
Abnormal mental states and behaviours in MSMS Trust
Learning outcomes:
Recognition and treatment of depression and anxiety in MS
Recognise sudden changes in emotional state (laughter, crying, anger)
Recognition of mania and psychosis in MS
Cognitive impairment
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
Abnormal mental states and behaviours in MSMS Trust
Learning outcomes:
Recognition and treatment of depression and anxiety in MS
Recognise sudden changes in emotional state (laughter, crying, anger)
Recognition of mania and psychosis in MS
Cognitive impairment
opioids in cancer pain manage, a case-based approach, covering
- opioid dosing and rotations
- pain assessment
- opioids adverse effects and managment thereof
- overcoming barriers to usage
opioids in cancer pain manage, a case-based approach, covering
- opioid dosing and rotations
- pain assessment
- opioids adverse effects and managment thereof
- overcoming barriers to usage
Pain definition, Pain pathways, pain modulation, the endorphin system, Types of Pain, current trend of Drugs used for pain management. New Drugs for pain
definition of pain - classification - categories and different clinical types of pain - assessment of pain and how to manage using pharmacological and non-pharmacological intervention
Pharmacotherapy of PAIN - Bigin Gyawali BiGs.pptxBigin Gyawali
Pharmacotherapy for pain involves the use of medications to alleviate or manage pain. The choice of pharmacological agents depends on the type, severity, and duration of pain, as well as individual patient factors such as age, comorbidities, and medication tolerances. Here is a comprehensive description of pharmacotherapy for pain, considering various classes of medications:
1. **Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):**
- NSAIDs, such as ibuprofen and naproxen, work by inhibiting the enzymes involved in inflammation and pain.
- They are effective in managing mild to moderate pain, particularly that associated with inflammation, such as arthritis or musculoskeletal injuries.
- However, long-term use may be associated with gastrointestinal side effects, so caution is advised.
2. **Acetaminophen:**
- Acetaminophen is a pain reliever and fever reducer that is generally considered safer for the stomach than NSAIDs.
- It is commonly used for mild to moderate pain and is often recommended for individuals who cannot tolerate NSAIDs.
- Excessive use, however, can lead to liver damage, so dosing recommendations should be followed carefully.
3. **Opioids:**
- Opioids, such as morphine, oxycodone, and hydrocodone, are potent analgesics that can be effective for moderate to severe pain.
- They work by binding to opioid receptors in the brain and spinal cord, altering the perception of pain.
- Due to the risk of tolerance, dependence, and addiction, opioids are typically reserved for short-term use or for chronic pain that has not responded to other treatments.
4. **Adjuvant Medications:**
- Certain medications originally developed for other purposes, such as anticonvulsants (e.g., gabapentin, pregabalin) and antidepressants (e.g., amitriptyline, duloxetine), can be used as adjuvants in pain management.
- These medications can help manage neuropathic pain and may enhance the effects of other analgesics.
5. **Corticosteroids:**
- Corticosteroids, such as prednisone, may be used for short-term relief of pain and inflammation, particularly in conditions like rheumatoid arthritis or certain inflammatory disorders.
- Prolonged use is generally avoided due to the risk of side effects.
6. **Topical Analgesics:**
- Topical formulations, including creams, patches, and gels, containing analgesic agents like NSAIDs, lidocaine, or capsaicin, can be applied directly to the affected area for localized pain relief.
7. **Muscle Relaxants:**
- Muscle relaxants, such as cyclobenzaprine or baclofen, may be prescribed to alleviate pain associated with muscle spasms or tension.
It's important for healthcare professionals to conduct a thorough assessment of the patient's pain and medical history to tailor the pharmacotherapy approach. The goal is to achieve adequate pain control while minimizing the risk of side effects and considering the overall well-being of the patient. Regular monitoring and communication.
Similar to 1 adequate therapy for chronic non cancer pain (20)
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
1. Adequate therapy for chronic non-cancer
1
pain:
Current barriers and thoughts for
the future
Dr. Yoram Shir
Alan Edwards Pain Management Unit
McGill University Health Centre
2. 2
Disclosure
The speaker cannot identify any potential conflict of
interest and has no relationships that should be
disclosed
3. Objectives
To review the prevalence of chronic non-cancer
pain (CNCP)
To review specific therapeutic approaches
To recognize the barriers for better treatment
To suggest changes in our approach to CNCP
4. 4
Pain
“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage” (IASP)
7. 7
Types of pain
Acute vs. chronic
Malignant vs. benign
Physiological vs. pathological
Nociceptive vs. visceral
Neuropathic
Idiopathic
8. 8
Acute vs. Chronic Pain
Acute
Symptom
Short-term
Warning sign
Anxiety
Responds well
Single treatment
Chronic
Disease
Long-term
False alarm
Depression
Less likely to respond
Multidisciplinary approach
9. 9
Non malignant vs. malignant pain
”…we have deliberately not used the term ‘non-malignant
pain’ because unrelieved chronic pain
associated with any disease is indeed malignant”
(Gourlay et al, 1991)
10. Definition: chronic non-cancer pain
10
“…pain that has been present for at least six
months or that has persisted longer than the
expected time for tissue healing or resolution of
the underlying disease process.” [Canadian Pain Society
Guidelines, 2002]
11. 11
Prevalence of chronic pain
> 80% of cancer patients
10-40% of the general population
> 50% following some surgeries
~ 25% in hospitalized populations
45-80% of the elderly populations
25% in Canada
12. Pain in the elderly
In the USA, 17% of the population is 60 years
or older
More than 38 million individuals in the USA
are 65 years or older
By 2030 the number of persons aged 65 years
or older in the USA will increase to an
estimated 71 million
By 2025, 1.2 billion people worldwide will be
aged 60 years or older
13. Prevalence of chronic pain in
elderly people
Difference between community dwelling
people & long term care
Prevalence 3.7%-80%
80% of old people with cancer
Could be due to central degenerative changes,
muscle weakness & slower rate of tissue
healing
14. 14
Burden of chronic pain
Became a global disease
Worldwide crisis
In the USA alone:
Half million lost workdays/annum
Healthcare costs > $150 billion/annum
Steady increase in cost (e.g., 70% 1988-1995)
15. 15
Chronic pain in Canada
2/3 of Canadian primary care practitioners
believe that moderate/severe chronic pain is
not well managed
Median waiting time for 1st appointment in
multi-disciplinary pain centers in Canada is 6
months (2-14 months)
16. 16
The chronic pain spiral
PPaaiinn
CCeenntteerreedd
LLiiffee
INJURY
ILLNESS
TISSUE DAMAGE
PERSISTING PAIN
LIMITS ACTIVITIES
WEAK TIGHT
MUSCLES
DECONDITIONING
HURT VS. HARM
SURGERY
STIGMA
LOSS OF CONTROL
DECREASED PHYSICAL
& SOCIAL
FUNCTIONING
DEPRESSION
Jovey RD. Pain focus. 2007;1.
19. Barriers to effective pain management
The physician:
Believing patients always tell when having pain
Lack of training/knowledge
Fear of regulatory scrutiny
Concerns about addiction and side effects
Time consuming
Pain management is secondary to disease management
Believing pain is a symptom, not a disease
Failure to define goals and expectations
19
22. Barriers to effective pain management
The patient:
22
Misconception that pain is normal
Unwillingness to report pain
Fear of side effects and addiction
Believing that therapy may prevent control of
more severe pain in the future
Cognitive impairment in elderly
Depression
Passive coping strategies
23. Barriers to effective pain management
The system:
Lack of resources
Wrongful use/investments of the existing limited
resources
Lack of basic education
Permissive compensatory system
23
24. The reality of CNCP
Once developed, our ability to effectively treat
CNCP is restricted
Nevertheless, most traditional basic research efforts
& clinical pain-relieving approaches focus on pain
palliation rather than prevention
40. 40
Anticonvulsants
Commonly used in chronic pain
Possible analgesic mechanisms:
increasing GABA inhibition
modulating sodium and calcium channels
inhibiting excitatory amino acids
decreasing abnormal neuronal hyperexcitability
41. 41
Carbamazepine
Traditionally regarded as the gold-standard
Effective in trigeminal neuralgia & diabetic neuropathy
Side effect profile opened the way for gabapentin
No clinical studies comparing it to gabapentin &
pregabalin
42. 42
Gabapentin
Acts through increased synaptic GABA
& calcium blockade at the CNS
Proven effects:
Post traumatic neuropathic pain
Peripheral neuropathy
PHN
Preemptive analgesia for PO pain
Neuropathic pain due to cancer
43. 43
Gabapentin – in what dose?
Effective dose: 900-1,800mg/day
Dose range seen at the clinic: 100-9,600mg/day
Suggested dose:
Start with 100mg T.I.D.
Stop at 2,800/day
45. 45
Pregabalin
Beneficial in:
PO pain
Diabetic peripheral neuropathy
PHN
Fibromyalgia
Recommended dose: 75-600mg/day
Almost as popular as Tylenol among chronic pain
patients
Mostly used in Quebec off-label
46. Cannabinoids
Anonymous cross-sectional survey of 209 Canadians with
chronic pain1:
35% reported using cannabis
15% reported using cannabis for pain relief
Mainly young people, post trauma/surgery
A wide range of amounts and frequency of cannabis use
Pain, sleep & mood were all subjectively improved
1Ware MA et al, Pain 102;211-6:2003
48. 48
Chronic pain palliation –
Does it work?
Switching from pathogenetic treatment with alpha-lipoic
acid to gabapentin and other analgesics in
painful diabetic neuropathy: a real-world study in
outpatients1
1Ruessmann HJ et al, J Diabetes Complications 23;174:2009
49. 49
443 chronic DM patients treated with lipoic acid
(600mg/d) for a mean period of 5 years
Switched to gabapentin (600-2400mg/d) or D/C
therapy
In the untreated group 73% developed pain within 2
weeks
In the gabapentin group:
45% developed side effects and stopped treatment
55% of patients tolerating gabapentin did not
respond to a dose of 2400mg/g
51. 1Bansal D et al, Diabetic Medicine 26;1019-26:2009
52. Outcome of chronic pain therapy
4-year community study1:
Increased prevalence (45.5 to 53.8%)
79% still reported pain after 4 years
Retrospective study of patients with CRPS2:
None had recovered
In most- only modest symptom improvement
Improvement not necessarily associated with
therapy
1Elliott AM et al, Pain 99;299-307:2002; 2Schwartzman RJ et al, Clin J Pain 25;273-
80:2009
53. 53
Limitations of injection therapy
for LBP
LBP will be experienced by most humans during
their life
1/5 will consult her/his GP
Specific diagnosis is lacking in ~ 85%
The scientific evidence for many of the
interventions is lacking
54. 54
Outcome of injection therapy
Epidural steroids injection:
Short term relief: NNT of 7
Long term relief: NNT of 13
The best study to date – no short or long-term
effect
55. 55
Outcome of injection therapy
Facet joint injections:
Not effective
Trigger point injections:
Hardly effective
56. Multiple reviews of injection outcome in
patients with LBP lasting for more than 1
month:
Treatment with facet, epidural or local
injections was not beneficial immediately
or late after the intervention
56
57. Summary – therapies for chronic pain
The prognosis of chronic pain is frequently poor
despite advanced knowledge and novel therapeutic
tools
Most resources are invested in palliation and not
prevention
We, therefore, could focus more on:
57
Prevention
The environment
Complementary & alternative medicine (CAM)
58. A call for change – prevention
rather than palliation
Learn from other major diseases like cancer:
1971: President Nixon declares ‘War on Cancer’1
Cancer Act approved by Congress
Massive funding of cancer therapy but not cancer
prevention
Cancer mortality has not decreased as expected
(10% in 2005, lower than the expected 50%)
1Sporn MB, Lancet 347;1377–81:1996
59. The cancer model – palliation vs.
prevention
While treatment is effective for certain cancers, it
ranks behind both early detection and risk-factor
modification in its potential to reduce cancer
mortality1
Calls to view cancer not only as a curable illness but
primarily a preventable one2
1Danaei G et al, Lancet 366;1784 –93:2005; 2Bailar JC 3rd et al, N Engl J Med
336;1569–74 :1997
60. Preventing CNCP
Identify patients
at risk
Environmental
contribution
Preventive analgesia;
Multimodal analgesia; Immunization;
Other, yet to be found measures
Prevention of CNCP
61. Identifying high risk patients
The selective tendency to develop CNCP is
still poorly understood
The concept of “high risk pain patient”
should be recognized similar to high risk
cardiac or pulmonary patients
Probably depends on genetic and phenotypic
characteristics
62. Genetic markers for CNCP
The tendency to develop chronic pain in rats is 30-
70% genetic1
Strong indications in humans:
Haplotypes of the gene encoding catecholamine-O-methyltransferase
(COMT) could distinguish between
patients that will have low, moderate or high experimental
pain levels2
1Mogil JS, et al., Pain 80;67:1999; 2Diatchenko L, et al., Hum Mol Genet 14;135:2005
63. Phenotypic markers
Previous exposure to painful stimuli
Early life adversities
Basic sensitivity to painful stimuli1
1Granot M, et al., Anesthesiology 98;1422:2003
64. The environment
Social conditions:
Living in a socially compromised housing area
was significantly associated with increased
chronic musculoskeletal pain1
1Bergman-S, et al., J Rheumatol 28;1368:2001
67. Supplementing rats with soy protein-rich diet
before, but not after surgical nerve injury prevents
the development of chronic neuropathic pain-like
syndrome1
1Shir Y, et al., Anesthesiology 95;1238:2001
68. Practical approach to prevent
some types of CNCP?
Be familiar with possible predictors (personal &
family history, cultural, ethnical & social
background, psychological risk factors)
Categorize level of risk
Consider suitable preemptive (preventive) therapy
Listen to your patients
69. 69
Immunization against
(neuropathic) pain?
A study done in the USA1:
In almost 40,000 older adults
Early herpes zoster vaccination resulted in:
Reduced incidence of acute shingles (51%)
Reduced incidence of chronic shingles pain
(66%)
1Oxman MN et al. N Engl J Med 352;2271-84:2005
70. Post herpetic neuralgia
• 1 million new cases/year in the USA
• 15% will develop PHN
• In patients > 70 years old the chances for PHN are
up to 70% (52)
• Refractory to most common therapies
71. Controlling the brain
Following training humans can control activation
of specific brain regions involved with
nociception, resulting in significant pain relief1
1deCharms RC, et al, Proc Natl Acad Sci U S A 102;18626-31:2005
72. When to refer patients with CNCP to a
72
pain specialist?
Uncontrolled pain
Significant disability
A comorbid psychiatric disorder
Diagnostic evaluation for unknown etiology
Consultation for treatment recommendations
Need for treatment modalities that the PCP cannot
provide
The key points to cover in this slide are:
The awakening of silent nociceptors in the skin, joints and muscles by the local release of chemical mediators in response to tissue damage.
The function of the “gate” mechanism in the dorsal horn of the spinal cord which allows three options for an incoming pain signal:
a) To suppress the pain signal (stress-induced analgesia)
b) To allow the pain signal to pass through to the brain unchanged
c) to augment the intensity of the pain signal sent to the brain (central sensitization)
Which of these three options occurs depends on the local balance of excitatory and inhibitory neurotransmitters It is option (c) that seems to occur in more severe, neuropathic pain syndromes.
The importance of the excitatory amino acids, especially glutamate, acting on the NMDA receptors to maintain and, in fact, augment pain signals at the dorsal horn of the spinal cord.
The function of the CNS descending inhibitory systems on pain signal transmission in the dorsal horn of the spinal cord.
The main message of this slide is to demonstrate the importance of treating a patient with pain as early as possible.
PQRST =
Provocative (identify pain triggers)
Quality of pain
Region of pain (location)
Severity (numeric pain scale, 0-10)
Temporal (onset, course, fluctuations)
SISAP Questions Caution with
How many drinks in a typical day? ______________ Women > 3 drinks/day or 12/week
How many drinks in a typical week? _____________ Men > 4 drinks/day or 16/week
Marijuana or hashish in the past year? ____________ Any recreational marijuana or hashish use
Ever smoked cigarettes? ___________Age ________ Any smoker under the age of 40
A consensus meeting was convened by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to provide recommendations for interpreting clinical importance of treatment outcomes in clinical trials of the efficacy and effectiveness of chronic pain treatments. A group of 40 participants from universities, governmental agencies, a patient self-help organization, and the pharmaceutical industry considered methodologic issues and research results relevant to determining the clinical importance of changes in the specific outcome measures previously recommended by IMMPACT for 4 core chronic pain outcome domains, including pain intensity assessed by a 0 to 10 numerical rating scale.
Dworkin RH, et al. J Pain. 2007; Article in press.
In deciding on a particular course of treatment for a patient’s CNCP, we need to think realistically about the goals. Ideally, we are trying to reduce pain and improve function with minimal side effects. However, in some patients with severe chronic pain of long duration, we may not be able to improve function to a significant degree due to severe disuse muscle atrophy or the side effects of our treatment. Sometimes we are not able to provide the ideal treatment for a given patient due to cost or lack of availability in our community.