MSK- Management of Chronic Pain

Somatic Nociceptive Pain
-well localized
-Character: sharp, dull, achy
-responds well to opiods and non-opiods
Visceral Nociceptive Pain
– Usually poorly localized
-responds well to opiods and non opiods
Neuropathic Pain
– Secondary to nerve injury
-Character- Burning or Electric
-Opiod Analgesics often ineffective
Ex: Post Herpetic Neuralgia
Diabetic Neuro
Acute Pain
Pain that occurs in the short term following noxious stimulus. It is a vital protective mechanism allowing us to live in an environment filled with potential dangers
Chronic Pain
Pain that persists beyond the usual course of an acute disease or a reasonable time for and injury to heal. It is associated with pathologic processes that cause continuous pain or pain at intervals for months or years. Not amendable to routine pain control mechanisms
Tolerance
A state of adaptation in which exposure to a drug induce changes that result in a diminution of that drug effect. With continued use more and more of a drug is needed to produce the same effect
Dependence
An Adaptive physiological state that can occur with regular drug use and results in withdrawal when drug use is discontinued.
Dependence vs addiction
Dependence has a lack of compulsive drug seeking behavior
Addiction
A chronic, relapsing DISEASE characterized by compulsive drug seeking behavior and drug use despite harmful consequences and by the molecular changes in the brain. This is a BRAIN DISORDER that is manifested by Abnormal behavior
Characteristics of Addiction : 4 C’s
loss of Control
Craving
Compulsive behavior
Continued use despite consequences
Contrast Enhancement Recommended for:
1. Tumor
2. Infection
3. Scar Tissue (Prior Spine Surgery)
Anti-Convulsants: Indications
1. Neuropathic Pain
2. Migraine prevention
Anti-Convulsants: Most Commonly Rx
1. Gabapentin
2. Pregabalin
Anti-Convulsants: Mech
Bind to sodium and calcium receptors on nerve cells
-stabilize the membrane inhibit transmission of pain signal
Duloxitene
An Antidepressant
-recently indicated for chronic MSK pain
(effects reuptake of epi/NE/serotonin
DEA Classification: Schedule I
No legitimate medical use
-Heroin, LSD, Mescaline, Peyote, Marajuana
DEA Classification: Schedule II
Risk of High Abuse: Written Rx Only, No Refills
-Codeine(Plain), Fentanyl, Methadone, Morphine, Oxycodone, Oxymorphone
DEA Classification: Schedule III
Intermediate Risk of Abuse: Telephone Rx, No refills via phone
-Hydrocodone Combinations, Codeine Combinations
DEA Classification: Schedule IV
Lower Risk
-Benzodiazapines, Fioricet, Soma
DEA Classification: Schedule V
Very Low Risk of Abuse
-Lyrica, Buprenorphine
Opiods- Routes of Administration
Oral
Transdermal
Parenteral
Intranasal
Buccal
Rectal
Spinal
Multimodal Therapy
Common Combos:
-Opiod + NSAID
-Opiod + AED
-Opiod + AED +TCA(SNRI)
(Opiod sparing effect with Co- Analgesic Drugs)
Why does a disc herniation hurt: Mech Factors
-nerve root compression
-clinical signs and symptoms not always present in patients with a disc herniation
Why does a disc herniation hurt: Chemical
-swollen inflamed nerve roots noted at surgery
-high levels of PHOSPHOLIPASE A2 (PLA2) in disc extracts
PLA2 Function
precursor to prostaglandin syn
Epidural Steroids
– Reduction of inflammation by inhibiting PLA2
-block transmission of (pain carrying) nociceptive C Fiber input
***INHIBITS (WBC) PMN MIGRATION
Facet Mediated Pain
Older Pts: 40% of chronic LBP is facet mediated
Working Age Pts: 10% of chronic LBP is facet mediated
Whiplash: most common cause of neck pain