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Head and Neck Blocks

Head and neck blocks consist of blockade of the atlanto-axial joint, third occipital nerve, occipital nerve, sphenopalatine ganglion, trigeminal nerve, and glossopharyngeal nerve. This chapter will discuss the rationale for these blocks, the relevant anatomy, and the technique in performing the blocks. There has been tremendous progress in the performance of these blocks, mirroring the progress of other peripheral nerve blocks: from landmark technique to use…

Neurolytic Agents, Neuraxial Neurolysis, and Neurolysis of Sympathetic Axis for Cancer Pain

Neurolytic therapy, for the appropriate patient, may result in significant improvement of quality of life and possibly improved function. Few other interventional pain therapies have such extreme risk/benefit profiles requiring targeted patient selection and meticulous procedural technique. Evaluating neurolysis as a therapeutic option is usually reserved for end-stage therapy, primarily for patients with refractory cancer pain resulting from the possibility of severe side effects. For instance,…

Patient Education and Self-Management

The 2011 report from the United States Institute of Medicine concluded that pain care should be tailored to each person’s experience and that self-management should be promoted as a central strategy to improve care. The importance of self-management was again emphasized in the National Pain Strategy (NPS), a blueprint for delivering optimal pain care, and in the Centers for Disease Control Guidelines for Prescribing Opioids for…

The Integrative Approach to Pain Management

Integrative Medicine: Overview Integrative Medicine is a philosophy of care that integrates conventional allopathic medical therapies with modalities not typically included in conventional care and addresses the physical, emotional, and spiritual needs of the patient. This field of medicine is sometimes referred to as complementary medicine or complementary and alternative medicine. However, these terms refer more precisely to modalities, such as acupuncture, meditation, nutritional supplements, and…

Physical Rehabilitation for Patients With Chronic Pain

Key Points Interdisciplinary care of patients with chronic pain has proven to be of significant value. A collaborative relationship between patients and rehabilitation professionals is essential to enhance successful outcomes. The pain management treatment plan must be tailored to the individual patient. Establishing treatment goals, patient education, therapeutic exercise, and behavioral techniques are at the core of rehabilitation management. Active involvement of patients and treatment adherence…

Evidence-Based Rehabilitation Approaches to Acute and Chronic Pain Management

~ A rehabilitation approach utilizes a combination of person-centered, non-pharmacologic, and pharmacologic strategies for pain management. A number of different healthcare practitioners participate and can provide rehabilitation to the patient, including physicians who specialize in physical medicine and rehabilitation, pain medicine, sports medicine, and clinicians in physical therapy, occupational therapy, and integrative health. Rehabilitation for a person with pain is used to provide treatment during the…

Psychological Approaches in Pain Management

Psychological interventions for managing individuals experiencing chronic pain include a wide range of approaches and therapeutic targets. They are based on several theoretical perspectives. This chapter will first provide an overview of the basic principles and backgrounds on which psychological approaches to chronic pain are predicated and then provide reviews of the evidence-based approaches that have demonstrated the greatest empirical support. From a psychosocial perspective in…

Topical Analgesics

In contrast to the use of a systemic analgesic, the use of a topical analgesic may result in pain relief without the requirement for notable systemic absorption. In certain situations, and with specific agents (i.e. nitroglycerine, fentanyl, clonidine), transdermal application results in systemic uptake. In these cases, absorption through the skin while achieving a certain therapeutic blood concentration is responsible for the effects of the drug.…

Cannabinoids for Pain Management

Key Points The endocannabinoid system is a complex biologic system composed of endogenous CBR and their respective agonists. It is involved in the regulation of multiple physiologic and cognitive processes in the human body to maintain homeostasis. Endocannabinoids are endogenous fatty acid neurotransmitters that are responsible for intercellular signaling. Seven endocannabinoids have been identified to date, but the most studied are AEA and 2-AG. CBR are…

Skeletal Muscle Relaxants

Key Points There are three broad classes of muscle relaxants: antispasmodic, antispasticity, and combination agents. Muscle relaxants may treat muscle spasticity in two manners. First, they can modify the stretch reflex arc, either by reducing the excitatory signals or by augmenting the inhibitory interneurons. This decreases activation of the alpha motor neuron. Second, they can disrupt the excitation-contraction coupling that produces muscle contraction. Cyclobenzaprine is a…

Adjunct Medications for Pain Management

Treatment of chronic pain involves understanding the delicate interplay of nociceptive, neuropathic, and nociplastic mechanisms involved in any given pain syndrome’s pathophysiology. Research into the underlying pathways for chronic pain has provided the mechanistic basis to utilize numerous non-opioid medications to treat chronic pain disorders. Non-opioid medications, often referred to as adjuvant medications, can take the form of amine reuptake inhibitors, such as the serotonin-norepinephrine reuptake…

Anti-depressants

Key Points Anti-depressants can be effective for treating neuropathic pain independently of their actions on comorbid depression. The analgesic effects tend to occur more rapidly and at lower doses than those used for treating depression. The primary mechanism of action is through a block of monoamine reuptake in descending modulatory pathways. However, many TCAs have an additional affinity for monoaminergic receptors, which can contribute to their…

Pain and Addictive Disorders: Challenge and Opportunity

Introduction The treatment of pain in patients with comorbid addiction or substance use disorders (SUDs) is complex. 1 The terms substance use disorders and addiction are used interchangeably in this chapter. Traditionally, chronic pain and SUDs have been treated by separate providers in different clinical settings. Until recently, pain researchers routinely excluded individuals with SUDs from clinical trials of treatments for chronic pain. Since chronic pain…

Evaluation for Opioid Management: Opioid Misuse Assessment Tools and Drug Testing in Pain Management

Key Points Chronic pain inflicts an enormous human toll of suffering and disability and is often associated with psychiatric comorbidities such as emotional distress, negative affect, depression, and anxiety. There is a corresponding relationship between mood disorder and opioid misuse, abuse, and/or diversion. Because of suboptimal opioid prescribing practices in the past, there has been an opioid epidemic, and the future of opioid prescribing calls for…

The U.S. Opioid Crisis and the Legal and Legislative Implications

Key Points Opioids are an essential tool in a physician’s toolbox, but their addictive nature and lethality have also plagued humanity throughout history. The development of OxyContin in 1996, combined with an advertising campaign and sponsorship of more than 20,000 educational programs, led to an acceleration in opioid prescription. The first wave of the opioid epidemic began in 1999, with a large increase in prescription opioid…

Minor Analgesics: Non-Opioid and Opioid Formulations

The use of naturally occurring plant material for the relief of pain dates back to early times. Advances in antipyretic and analgesic medications began in the late 1800s with the development of salicylic acid, antipyrine, phenacetin, and acetaminophen (APAP). These basic medications are still used today to various degrees in both over-the-counter (OTC) and prescription preparations—the minor analgesics salicylic acid and APAP are widely marketed and…

Major Opioids and Chronic Opioid Therapy

General Considerations of Opioid Administration Derivatives from the opium plant have been described as analgesics and used for pain control since 3500 bc . It was not until 1806 that a pure opioid substance was isolated. This substance was called “morphine,” named after the Greek god Morpheus. Since then, the opium plant has yielded other byproducts, and synthetic analogs of morphine have been produced for medicinal…

Pain Management in Patients With Comorbidities

Introduction Pain is defined by the International Association of Pain (IASP) as “an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage.” Given that pain is not only a symptom but also an independent disease, it is highly likely that patients with chronic pain may also have other medical comorbidities and disorders that will influence the scope of…

Rheumatologic Conditions

Introduction Rheumatology is the study of rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments. , Rheumatologic conditions are highly prevalent. Nearly one-fifth of the United Kingdom population reports a chronic musculoskeletal system condition. Rheumatologic conditions commonly begin during working life, with the peak incidence of gout and rheumatoid arthritis in late working life, although many people are afflicted by inflammatory arthritis in early…

Managing Pain During Pregnancy and Lactation

Use of Medications During Pregnancy Medical management of the pregnant patient should begin with attempts to minimize the use of all medications and use non-pharmacologic therapies whenever possible. When opting for drug therapy, the clinician must consider any potential for harm to the mother or the fetus and the course of the physiologic state of pregnancy itself. The degree of protein binding and lipid solubility of…