Treatment%20Strategies%20for%20Chronic%20Nonmalignant%20Pain

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Treatment Strategies for Chronic Nonmalignant Pain

• Jennifer Crook
• Advisor Dr. Hadley
• 04/10/08

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What is Chronic Nonmalignant Pain?

• Guideline definition
• 1. Enduring or recurring nature
• 2. Persisting longer than usual for condition/
  associated with chronic disease process
• 3. Refractory to treatment
• 4. Associated with functional impairment
• 5. Possibly comorbid with a psychological
  disorder
• 
  (Sanders et al. 2005)
• Examples
• Low back pain
• Trigeminal neuralgia

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Chemical mediators and receptors implicated in
CNMP mechanisms

• IL-6 ? PGE2
• IL-1ß ? COX-2
• TNF-a ? COX-2
• Nerve Growth Factor (NGF)
• Down-regulation of GABAB receptors
• Up-regulation of Substance P receptors
• Up-regulation of P2X7

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Diagnosis and Assessment of CNMP

• Believe the patient!
• Assessment tools
• NIH
• Institute for Clinical Systems Improvement
• www.icsi.org
• Current treatment guidelines
• Pain assessment tools
• Brief Pain Inventory Scale
• Functional Ability Questionnaire
• Video

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Treatment of CNMP

• Challenging for the practitioner
• Deficit of resources
• Clear guidelines
• Algorithms
• Time constraints
• Treatment necessitates continual reassessment of
  the patient and frequent communication
• Multifaceted nature of treatment
• Pharmacologic
• Non-pharmacologic
• The opioid issue

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Opioids in the Treatment of CNMP

• Current guidelines do not recommend the use of
  opioid medications with CPS CNMP patients.
• 
  (Sanders et al. 2005)
• Disadvantages
• Opioid-induced Hyperalgesia (OIH)
• Debilitation of immune response
• Conclusion
• Appropriate for subset of CNMP population
• DIRE screening tool
• Opioid contracts
• Video

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Multidisciplinary Pain Centers

• Who?
• Functionally impaired patients
• CNMP is refractory to treatment
• What?
• Treatment goals
• Improved physical function
• Improvement of general functional status
• Increase in self management
• Improvement of vocational/ disability status
• Reduction or D/C of opiates and sedative-
  hypnotic medications
• Reduction in health care utilization
• (Sanders et al. 2005)

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Multidisciplinary Pain Centers

• Where?
• Outpatient treatment centers
• 40 hours per week
• lt 20 days
• When?
• Onset of significant disability
• Learn to recognize the development of
• Pain behaviors
• Maladaptive coping mechanisms

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Multidisciplinary Pain Centers

• How?
• Pharmacologic treatment
• Non-opioid, non-sedative
• Adjunctive
• Non-pharmacologic treatment
• Fitness/ exercise
• Pain coping
• Relaxation
• CAM
• Internal locus of control

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References

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• Castro AR, Pinto M, Lima D, Tavares I (2006)
  Secondary hyperalgesia in the monoarthritic rat
  is mediated by GABAB and NK1 receptors of spinal
  dorsal horn neurons a behavior and c-fos study.
  Neuroscience 141 2087-2095
• Célèrier E, Laulin J-P, Corcuff J-B, Le Moal M,
  Simonnet G (2001) Progressive enhancement of
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• Ciccone DS, Just N, Bandilla EB, Reimer E,
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• summary.aspx?doc_id10724nbr005586stringchroni
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• Accessed 02/29/08
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