1. Treatment of Chronic Non-Cancer Pain Ross Bryan Mercer University MS III August 2012

2. INTRODUCTION  Chronic Non-Cancer Pain  Pain lasting longer than 3 months or beyond the expected period of healing of tissue pathology  Development  Develops as a result of persistent stimulation of or changes to nociceptors following injury.  Treatment Options  Pharmacological  Interventional  Psychological

3. Pharmacological

4. OPIOIDS (hydrocodone, tramadol)  Mechanism  Bind MOR in brain and SC  Indication  Neuropathy  Efficacy  Less pain, less function  Adverse Effects  Hyperalgesia; Abuse  Nausea, constipation, somnolence  SS (with tramadol)

5. NSAIDs  Mechanism  Inhibits COX-1 and/or COX-2  Indications  OA; RA; back pain  Efficacy  Not for neuropathy or FM  Adverse Effects  Gastrointestinal for COX-1  Cardiovascular for selective COX-2

6. TCAs and SNRIs (amytriptyline and duloxetine)  Mechanism  Increase 5-HT and NE @ Synapse  Indications  Neuropathy, fibromyalgia, low- back pain, and headaches.  Adverse Effects  TCAs --> cardiovascular events

7. Anticonvulsants (gabapentin and carbamazepine)  Mechanism  Enhance GABA inhibitory system  Indication  Neuropathic pain  Adverse Effects  Somnolence, fatigue  Dizziness

8. Topical Agents (Capsaicin)  Mechanism  Depletes substance P from primary afferent neurons  Indications  Neuropathy and OA  Adverse Effects  Limited

9. Corticosteroids  Mechanism  Blocks PLA2 and IL-2  Indications  Rediculopathy  Facet joint pain  Adverse Effects  Infection  Paraplegia

10. Surgery  Lumbar Fusion  Non-radicular degenerative changes  Discectomy  Radiculopathy w/herniated disc  Decompressive Laminectomy  Spinal stenosis *many are associated with worsened quality of life after 4-5 years.

11. Intrathecal Implants (morphine)  Mechanism  MOR agonists  Indications  Chronic refractory pain  Adverse Effects  Tolerance

12. Interdisciplinary Pain Reduction Programs (IPRPs)  GOALS:  Physical therapy  Exercise  Cognitive restructuring  Drug management

13. Comments  Data on efficacy is limited by:  Subjective outcomes  Inconsistent diagnostic criteria  Even the most effective treatments averaged a 30% reduction of pain in only half of the patients  Even with pain reduction, there is often not concomitant improvement in emotional and physical functioning

14. Citation  Turk, Dennis, PhD, Wilson, Hilary. Treatment of Chronic Non-cancer Pain. The Lancet, 2011 vol 377: 2226- 2235.