generate barcode in c#.net Treatment of Intractable Pain in Microsoft Office

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Treatment of Intractable Pain
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Once the nature of the patient s pain and underlying disease have been determined, therapy must include some type of pain control Initially, of course, attention is directed to the underlying disease, with the idea of eliminating the source of the pain by appropriate medical, surgical, or radiotherapeutic measures When pain cannot be relieved because the primary disease is not tractable, the physician should, if time and the circumstances permit, attempt to use the milder measures for pain relief rst for example, nonnarcotic analgesics and antidepressants or anticonvulsants before resorting to narcotics and local nerve blocks before contemplating surgical approaches for pain relief Not all situations allow this graduated approach, and large doses of narcotics may be required early in the course of illness for example, to treat the pain of visceral and bone cancer The same measured strategy is appropriate in the treatment of neuropathic pain and of pain of unclear origin except that one generally stops short of permanent ablative procedures that irrevocably damage nerves The entire eld of pain relief has been changed by the introduction of analgesic procedures that block nerves, alter neural conduction, or administer conventional medications in unconventional ways These have become the province of pain clinics and hospital pain services, usually run by departments of anesthesiology In addition, a number of special procedures or unique medications are highly effective for pain relief but are unique to speci c situations These include certain forms of headache and limb pain (temporal arteritis and polymyalgia rheumatica treated with corticosteroids, or migraine relief with triptan drugs); trigeminal neuralgia, which may be relieved by microvascular decompression of a branch of the basilar artery or by controlled damage of the gasserian ganglion; painful dystonic disorders that are relieved by the injection of botulinum toxin, and so on Special procedures that have been devised to treat various forms of spinal back pain fall into the same category The following discussion provides some guidance for the physician who is asked to undertake the treatment of chronic pain or of neuropathic pain, which often falls primarily to the neurologist Use of Opioids and Opiates A useful way in which to undertake the management of chronic pain that affects several parts of the body, as in the patient with metastases, is with codeine, oxycodone, or propoxyphene taken together with aspirin, acetaminophen, or
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Rare and Unusual Disturbances of Pain Perception
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Lesions of the parieto-occipital regions of one cerebral hemisphere sometimes have peculiar effects on the patient s capacity to feel and react to pain Under the title of pain hemiagnosia, Hecaen and Ajuriaguerra described several cases of left-sided paralysis from a right parietal lesion, which, at the same time, rendered the patient hypersensitive to noxious stimuli When pinched on the affected side, the patient, after a delay, became agitated, moaned, and seemed distressed but made no effort to fend off the painful stimulus with the other hand or to withdraw from it In contrast, if the good side was pinched, the patient reacted normally and moved the normal hand at once to the site of the stimulus to remove it The motor responses seem no longer to be guided by sensory information from one side of the body There are also two varieties of rare individuals who from birth are totally indifferent to pain coupled with anhidrosis ( congenital insensitivity to pain ) or are incapable of feeling pain ( universal analgesia ) The former have been found by Indo and colleagues to have a mutation in the a neural tyrosine kinase receptor, a nerve growth factor receptor; those in the second group suffer from either
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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another nonsteroidal anti-in ammatory drug (NSAID) The analgesic effects of these two types of drugs are additive, which is not the case when narcotics are combined with diazepam or phenothiazine Antidepressants and anticonvulsants, as discussed further on, may have a bene cial effect on pain even in the absence of overt depression This is true particularly in cases of neuropathic pain (painful polyneuropathy and some types of radicular pain) Sometimes these nonnarcotic agents may in themselves or in combination with these treatment modalities be suf cient to control the patient s pain; the use of narcotics can then be kept in reserve Should the foregoing measures prove to be ineffective, one must turn to more potent narcotic agents Methadone and levorphanol are sometimes useful drugs with which to begin, because of their effectiveness by mouth and the relatively slow development of tolerance Some pain clinics prefer the use of shorter acting drugs such as oxycodone, given more frequently through the day The oral route should be utilized whenever possible, since it is more comfortable for the patient than the parenteral route Also, the oral route is associated with fewer side effects except for nausea and vomiting, which tend to be worse than with parenteral administration Should the latter become necessary, one must be aware of the ratios of oral to parenteral dosages required to produce equivalent analgesia These are indicated in Table 8-3 If oral medication fails to control the pain, the parenteral administration of codeine or more potent opioids becomes necessary One may begin with methadone, dihydromorphone (Dilaudid), or levorphanol, given at intervals of 4 to 6 h, because of their relaTable 8-3 Common drugs for the management of chronic pain
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