PAIN MANAGEMENT, PART II

CONTENTS

Preface xiHoward S. Smith

Opioids for Persistent Noncancer Pain 177Gary McCleane and Howard S. Smith

Opioids are extensively used in the management of all types ofpain and their use is underpinned by extensive trial evidenceand an abundance of practical experience. We are still amassing in-sight into how they achieve their pain-relieving effects, however,and this understanding becomes more complex as time progressesand shows that opioids are medications with complex and diversecentral and peripheral nervous system effects. Despite the 200years that have passed since the chemical isolation of morphine,every year brings new understanding of the mode of action, pro-pensity to cause side effects, and appropriate clinical use ofopioids. This article concentrates on this ‘‘new’’ evidence as dis-closed by recent publications.

Opioid Tolerance and Hyperalgesia 199Grace Chang, Lucy Chen, and Jianren Mao

Opioids have been successfully used for the management of acuteand cancer-related pain. Concerns regarding side effects, tolerance,dependence, addiction, and hyperalgesia have limited the use ofopioids for the management of chronic nonmalignant pain. This ar-ticle will review updated information from both clinical and precli-nical studies regarding opioid-induced hyperalgesia, tolerance, anddependence. The implications of these issues in clinical opioid ther-apy also will be discussed.

Documentation and Potential Tools in Long-Term OpioidTherapy for Pain 213Howard S. Smith and Kenneth L. Kirsh

The field of pain medicine is experiencing increased pressure fromregulatory agencies and other sources regarding the continuation,

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or even initial use, of opioids in pain patients. Therefore, it is essen-tial that pain clinicians provide rationale for engaging in this mod-ality of treatment and provide ample documentation in this regard.Thus, assessment and documentation are cornerstones for bothprotecting your practice and obtaining optimal patient outcomeswhile on opioid therapy. Several potential tools and documentationstrategies are discussed that will aid clinicians in providing evi-dence for the continuation of this type of treatment for theirpatients.

Myofascial Trigger Points 229Elizabeth Demers Lavelle, William Lavelle,and Howard S. Smith

Painful conditions of the musculoskeletal system, including myo-fascial pain syndrome, constitute some of the most importantchronic problems encountered in a clinical practice. A myofascialtrigger point is a hyperirritable spot, usually within a taut bandof skeletal muscle, which is painful on compression and can giverise to characteristic referred pain, motor dysfunction, and auto-nomic phenomena. Trigger points may be relieved through nonin-vasive measures, such as spray and stretch, transcutaneouselectrical stimulation, physical therapy, and massage. Invasivetreatments for myofascial trigger points include injections with lo-cal anesthetics, corticosteroids, or botulism toxin or dry needling.The etiology, pathophysiology, and treatment of myofascial triggerpoints are addressed in this article.

Intra-Articular Injections 241William Lavelle, Elizabeth Demers Lavelle, and Lori Lavelle

Intra-articular injections are one method that physicians may use totreat joint pain. This method offers direct access to the source ofpain for the troubled patient. Substances ranging from steroids tohyaluronic acid have been injected successfully into the variousjoints of the body in an attempt to provide relief for chronic jointpain. Anesthesiologists and orthopedic surgeons have begun touse intra-articular injections of local anesthetics for postoperativeanalgesia. The history, agents, and methods of intra-articular injec-tions are reviewed.

Intrathecal Analgesia 251Steven P. Cohen and Anthony Dragovich

Since the first use of intrathecal (IT) drug infusion systems in theearly 1980s, these delivery systems have undergone numerous re-visions making them more tolerable, easier to program, and longerlasting. Concurrent with technological advances, the indications forIT pump placement have also been continuously evolving, to thepoint where the most common indication is now noncancer pain.This article provides an evidence-based review of the indications,

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efficacy, and complications of IT drug therapy for the most com-monly administered spinal analgesics.

Interventional Approaches to Pain Management 271John D. Markman and Annie Philip

This article reviews the evidence for several common interven-tional techniques for the treatment of chronic pain, including: in-traspinal delivery of analgesics, reversible blockade with localanesthetics, augmentation with spinal cord stimulation, and abla-tion with radiofrequency energy or neurolytic agents. The role ofthese techniques is defined within the framework of a multidisci-plinary approach to the neurobehavioral syndrome of chronic pain.Challenges to the study of the analgesic efficacy of procedural in-terventions are explored, as are the practical issues raised by theirclinical implementation, with the aim of helping nonspecialist phy-sicians identify the patients most likely to benefit from theseapproaches.

Invasive and Minimally Invasive Surgical Techniques for BackPain Conditions 287William Lavelle, Allen Carl,and Elizabeth Demers Lavelle

Back pain is a ubiquitous problem for developed countries. It is asource of disability for society and is a financial drain through lostwages and productivity. The treatment of spine-related pain haschanged over the years; minimally invasive approaches are now fa-vored. Despite this trend, surgeons still rely on decompressions ofcompressed neurologic structures and the fusion of painful motionsegments. The history of treatments of spine-related pain as well asmodern and minimally invasive techniques are reviewed.

Vertebroplasty and Kyphoplasty 299William Lavelle, Allen Carl, Elizabeth Demers Lavelle,and Mohammed A. Khaleel

Vertebral compression fractures occur more frequently than hipand ankle fractures combined. These fragility fractures frequentlyresult in both acute and chronic pain, but more importantly are asource of increased morbidity and possibly mortality. Percutaneousveretebral augmentation offers a minimally invasive approach forthe treatment of vertebral compression fractures. The history, tech-nique, and results of vertebroplasty and kyphoplasty are reviewed.Both methods allow for the introduction of bone cement into thefracture site with clinical results indicating substantial pain reliefin approximately 90% of patients.

Index 315

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