Clinical Concepts

Overview - Pain Management & Treatment

Documents in this section examine pain mechanisms and diagnosis, barriers to effective management, and treatment strategies and planning. Various treatment modalities may be considered, including: pharmacologic, non-pharmacotherapies, surgery, and other interventions. In some cases, criteria for measuring successful outcomes and patient monitoring practices are presented.

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ACPA Consumer Guide to Pain Medication & Treatment - 2010

From: American Chronic Pain Association (ACPA); updated 2010; 81 pages.

 PDF available for download: http://www.theacpa.org/documents/ACPA Consumer Guide 2010 010410.pdf

Also see, video presentations of this document: http://www.theacpa.org/medsup/default.aspx

This document is revised annually to provide current information on drugs as well as their potential side effects, and other treatments. Written initially for patients, it is perhaps the most concise and comprehensive document of its kind, which also makes it an excellent reference for all healthcare providers. Beginning with the 2009 edition, the guide features expanded coverage of non-drug interventions and complementary therapy options. Basic information is provided on invasive interventions, such as spinal cord stimulation and implanted intrathecal drug delivery systems, as well as non-invasive passive interventions, like acupuncture and manipulation therapy.

Descriptions of indications and the pros and cons of non-opioid analgesics are conveniently provided in a table. A listing of commonly used opioid medications precedes an easy to understand explanation of the issues related to tolerance, physiological impairment, dependence, addiction, and withdrawal. Uses of antidepressants, anticonvulsants, sedatives, muscle relaxants, and topical analgesics in pain management are discussed. This manuscript can be printed or used online; it has many links within the text to additional Internet resources.

Reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.  Access checked February 5, 2010.

Current Treatments In the Management of Diabetic Peripheral Neuropathic Pain 2009

By: Louis Kuritzky, MD, George P. Samraj, MD, Charles E. Argoff, MD. Pain Medicine News. 2009(Aug);7(8).

PDF available at: http://painmedicinenews.com/download/DPNP_PMN0809_WM.pdf (12 pp)

Painful diabetic peripheral neuropathy (DPN) will develop in 25% to 50% of patients with diabetes during their lifetime, but remains widely misdiagnosed and undertreated. This updated educational review, including a neurologist’s commentary (CE Argoff), provides clinicians with a thorough overview of the diagnosis, treatment and management of this extremely painful condition. Topics include differential diagnosis of DPN, treatment goals, and extensive descriptions of FDA-approved and off-label therapies.

Reviewer: Stewart B. Leavitt, MA, PhD. Access checked September 11, 2009.

Which Analgesics Work Best? What Do They Cost?

From: Consumer Reports Best Buy Drugs, 2005-2008.

Selecting an appropriate analgesic can be difficult, and becomes challenging when cost is a concern. The Consumers Union -- an independent, nonprofit organization and publisher of Consumer Reports -- offers guidance via their public education project, Consumer Reports Best Buy Drugs™. Funding comes primarily from educational grants and reviews are conducted by physicians and researchers as part of the Drug Effectiveness Review Project (DERP), an initiative aimed at providing the public with safety and efficacy data for commonly used prescription drugs. Documents for each of the 4 drug classes listed below offer valuable information for healthcare providers and their patients.

Reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD. Access checked April 28, 2009.

The website page for each drug class below provides a brief summary of the pain-relieving benefits of the drugs and has a quick-reference tab for drug comparisons. A small box on the right-hand side of the description has links to...

• Full Report -- ranging 15 to 23 pages -- includes a discussion of selection considerations in choosing appropriate analgesics for each patient, provides recommendations, and explains the efficacy, dosing, safety issues, and relative costs for each drug in the class.
• 2-Page Summaries -- in English and in Spanish – that include recommendations plus listings of generic and trade names along with dosing and cost information for drug comparison purposes.
  

 > Opioid Drugs

For acute severe pain and sometimes longer-term moderate to severe pain. (2008)

See page: http://www.consumerreports.org/health/best-buy-drugs/opioids.htm

 > Anticonvulsants

For fibromyalgia, neuropathies, and herpes zoster infections. (2007)

See page: http://www.consumerreports.org/health/best-buy-drugs/anticonvulsants.htm

 > Triptans

For the treatment of migraine headaches. (2006)

See page: http://www.consumerreports.org/health/best-buy-drugs/triptan.htm

 > Nonsteroidal anti-inflammatory Drugs

Most frequently used for osteoarthritis and mild to moderate pain. (2005)

See page: http://www.consumerreports.org/health/best-buy-drugs/nsaids.htm

 > Laxatives (for drug-induced constipation)

Special edition on Constipation discusses effective, economical treatment options. (2008)

See page: http://www.consumerreports.org/health/best-buy-drugs/constipation.htm

Antidepressant Agents for the Treatment of Chronic Pain and Depression

By: Michael W. Jann, PharmD and Julian H. Slade, PharmD. Posted at Medscape, 2008 [from Pharmacotherapy. 2007;27(11):1571-1587].

HTML article available at: http://www.medscape.com/viewarticle/565763

Depression and pain can occur together in up to 54% of patients, and can have devastating effects on health, productivity, and overall quality of life. Antidepressants of various types remain fundamental therapeutic agents for depression and anxiety disorders, and the extension of their use into chronic pain, depression with physical pain, and other medical conditions are discussed in this paper.

NOTES: After publication of this paper, there were two important announcements: 1) In early 2008 pregabalin [Lyrica] was FDA-approved for the treatment of fibromyalgia, which also often involves depression; 2) A Cochrane review -- Urquhart DM, et al. Antidepressants for non-specific low back pain (Review). Cochrane Database of Systematic Reviews 2008, Issue 1 – concluded that existing studies do not provide adequate evidence for or against the use of antidepressants in nonspecific low back pain, and antidepressants should be regarded as an unproven treatment for this condition.

Reviewer: Stewart B. Leavitt, MA, PhD. Access checked April 28, 2009.

Pain Management: The Online Series

From: American Medical Association. 2007.

Monographs available at: http://www.ama-cmeonline.com/pain_mgmt/

This comprehensive 12-module program on pain management offers an opportunity to choose individual monographs of interest. These are all evidence-based and cover a diverse range of topics that would be of interest to any healthcare provider – physicians, nurses, pharmacists, and others.
-- Module 1: Pathophysiology of Pain and Pain Assessment
-- Module 2: Overview of Management Options
-- Module 3: Barriers to Pain Management and Pain in Special Populations
-- Module 4: Assessing and Treating Pain in Patients with Substance Abuse Concerns
-- Module 5: Assessing and Treating Pain in Older Adults
-- Module 6: Pediatric Pain Management
-- Module 7: Assessing & Treating Persistent Nonmalignant Pain: An Overview
-- Module 8: Assessing and Treating Persistent Nonmalignant Pain: Common Conditions
-- Module 9: Assessing and Treating Neuropathic Pain
-- Module 10: Overview and Assessment of Cancer Pain
-- Module 11: Cancer Pain: Pharmacotherapy
-- Module 12: Management of Cancer Pain: Other Analgesic Approaches and End-of-Life Care

Reviewer: Stewart B. Leavitt, MA, PhD. Access checked April 28, 2009.

Translating Science Into the Art of Acute Pain Management

By: Sharon M. Gordon, DDS, MPH, PhD. Compendium. 2007(May).

CME article available at: http://www.compendiumlive.com/toc.php?year=2007&month=05

(See item in Table of Contents, Free registration is required.)

This paper interprets the current science of pain control and makes recommendations for the use of oral analgesics to prevent, block, or attenuate pain. Its primary focus is on the control of orofacial pain associated with dental procedures. However, the author provides a very practical discussion of pain mechanisms and how various oral analgesics can improve patient comfort, facilitate the delivery of care, and decrease patient anxiety. Two very important points emerge that may apply to any outpatient medical procedure that might incur pain: 1) NSAIDs at appropriate doses may be more effective than stronger agents such as opioids; 2) administration of these prior to the procedure (pretreatment) can lessen the pain of the procedure and provide greater comfort afterward.

This paper does not address recently-noted concerns about gastrointestinal complications and heart attack or stroke potentially associated with NSAIDs. For a consideration of these concerns, see the articles at:
http://pain-topics.org/non_opioid_therapies/nsaids.php#NSAIDs

Reviewer: Stewart B. Leavitt, MA, PhD. Access checked April 28, 2009.

The PainEDU.org Manual: A Pocket Guide to Pain Management, 3rd Edition  

By: Lynette A. Menefee Pujol, PhD, Nathaniel P. Katz, MD, and Kevin L. Zacharoff, MD; from PainEDU.com; 2007; 226 pages.

PDF available for download at: http://www.painedu.com/manual.asp  (Free registration required.)

The PainEDU Manual, published by Inflexxion, Inc., is a comprehensive pain management resource for all practitioners -- physicians, nurses, pharmacists, psychologists, and others. It provides an overview of pain epidemiology, types of pain, assessment, pathophysiology, measurement tools, psychology of pain, diagnostic testing, and treatment of both acute and chronic pain. Pharmacologic therapies with opioids, non-opioids, and adjuvant agents are presented in some detail.

Reviewer: Stewart B. Leavitt, MA, PhD. Access checked April 28, 2009.

Neuropathic Pain: A Practical Guide for the Clinician

By: Gilron I, Watson CPN, Cahill CM, et al. Canadian Medical Association Journal; August 2006; 11 pages.

PDF available for download at: http://www.cmaj.ca/cgi/reprint/175/3/265 (358 KB)

This report from pain researchers and practitioners in Ontario, Canada, begins with a review of the pathophysiology of neuropathic pain and includes a guide to the signs and symptoms of common neuropathic pain syndromes. An assessment section includes the important elements of the clinical evaluation, including specific characteristics identifiable during physical examination and a list of the most essential diagnostic tests. An algorithm for the management of neuropathic pain for the primary care practitioner includes multiple drug classes. The medication table includes detailed information on dosing, drug interactions, and adverse effects.

Reviewer: Winnie Dawson, RN, BSN, MA. Access checked April 28, 2009.

PAIN: Current Understanding of Assessment, Management, and Treatments

From: American Pain Society; June 2006; 108 pages.

  PDF available here for download: http//www.pain-topics.org/pdf/Pain_APS_2006.pdf (3.2 MB)

This extensive monograph is a 2006 update of an earlier version (2001) co-sponsored by JCAHO. It offers a comprehensive examination of pain mechanisms and assessment, barriers to effective management, and treatment strategies. Clinical practice guidelines are reviewed and the classes of drugs available for pain management are explored in relationship to specific treatment goals.

Reviewer: Stewart B. Leavitt, MA, PhD.  Access checked April 28, 2009.

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