Case Studies in Pain Management (Cambridge Medicine)

Cover
Half-title
Title page
Copyright information
Dedication
Table of contents
Contributors
Foreword
Section 1 Neurological Disorders
Chapter 1 Postherpetic neuralgia
Case study
1. What are the basic facts regarding postherpetic neuralgia, varicella-zoster virus, and shingles?
2. What are the basic features of postherpetic neuralgia?
3. Why are there are so many challenges with regard to postherpetic neuralgia treatment options?
4. What are the guidelines for postherpetic neuralgia management?
Criteria for recommendations varies
5. Are there any systematic reviews and meta-analysis data on postherpetic neuralgia treatments?
6. Are there any gaps in the Postherpetic Neuralgia Treatment Guidelines?
7. Are there any new clinical data on postherpetic neuralgia treatments?
High-concentration (8%) topical capsaicin patch
Gastroretentive gabapentin
Gabapentin enacarbil
Pregabalin combination therapeutic approaches
8. What are key considerations in choosing postherpetic neuralgia treatments?
Tolerability
Dosing and onset of analgesia
Are there challenging subsets of patients and guideline gaps in subpopulations of patients with postherpetic neuralgia?
The older patient
Renal/hepatic impairment
Patient with anxiety and depression
The patient with a history of substance abuse
Miscellaneous considerations
9. What are the key summarized points for treatment of postherpetic neuralgia?
References
Chapter 2 Patient with spinal cord injury pain
Case study
1. What is this patient's diagnosis?
2. How many spinal cord injury (SCI) patients are there, and how common is chronic pain in this population?
3. What are commonly experienced types and examples of pain conditions in SCI patients?
4. What types of neuropathic pain are experienced in SCI patients?
5. What form does visceral pain take in SCI patients?
6. What other painful conditions are SCI patients prone to?
7. What other conditions must the pain provider be aware of?
8. What is the relevance of heterotopic ossification?
9. What work-up might be helpful to clarify pain diagnosis in an SCI patient?
10. What are the pharmacologic treatments available for patients with SCI pain?
11. Are there interventional treatments that have been shown to be beneficial for SCI patients?
12. What are the non-pharmacologic treatments effective for SCI pain?
13. Are there particular issues or sensitivities that you need to be aware of when working with SCI patients?
Summary
References
Chapter 3 Patient with poststroke pain
Case study
1. What is the diagnosis explaining this patient's pain?
2. How common is poststroke pain?
3. What is the incidence of CPSP (epidemiology)?
4. What painful conditions are commonly seen in poststroke patients?
5. What area of the brain injury correlates with the development of central poststroke pain?
6. What is the likely mechanism of poststroke pain?
What is the likely mechanism of CPSP?
What is the likely mechanism of shoulder pain?
What is known about spasticity after stroke?
What is known about headache poststroke?
7. What is the work-up of poststroke pain?
Diagnosis of CPSP
Hemiplegic shoulder pain work-up
8. What pharmacologic treatments are available for poststroke pain?
What treatments are available for CPSP?
What are the treatments available for hemiplegic shoulder pain?
9. Are there any interventional treatments that have been tried for the treatment of patients with poststroke pain?
10. What are some special concerns in poststroke pain?
Conclusion/summary
References
Chapter 4 Patient with brachial plexopathy
Case study
1. What is brachial plexopathy?
2. Describe the anatomy of the brachial plexus
3. Clinical classification of brachial plexopathies
4. What is the epidemiology of plexopathies?
5. What are the causes and mechanisms of brachial plexopathies?
6. What happens to nerves in plexopathy?
7. Describe the clinical presentation of brachial plexopathies
8. What is the differential diagnosis?
9. How do you diagnose nerve root avulsion/brachial plexopathies?
10. What other disease processes mimic traumatic nerve root avulsion?
11. How should I treat this patient?
12. Are there any complications to worry about following treatment?
13. What is the prognosis of brachial plexopathies?
14. What are the social considerations in brachial plexopathy patients?
Conclusions
References
Chapter 5 Phantom limb pain
Case study
1. What is postamputation pain?
2. What is phantom limb pain?
3. Demographics/epidemiology of phantom pain?
4. What are the indications for amputation?
5. What are the risk factors for phantom limb pain?
6. What are the clinical symptoms and signs of phantom limb pain?
7. Describe the pathophysiology of phantom limb pain
8. How is PLP diagnosed?
9. How is phantom limb pain managed?
10. How to prevent phantom limb pain
11. How successful are these treatment modalities?
12. How does this impact a person's life?
Conclusions
References
Chapter 6 Patient with post-thoracotomy pain
Case study
1. What is the differential diagnosis?
2. What is a neuroma?
3. Describe the clinical exam and how would one evaluate the differential diagnoses?
4. How do you diagnose the conditions listed in the differential diagnosis?
5. How should one treat this condition?
6. Are there potential complications from injections?
7. What are the outcomes?
References
Chapter 7 Complex regional pain syndrome
Case study
1. What are the differential diagnoses in this case?
2. What is complex regional pain syndrome?
3. What are the classification and diagnostic criteria of CRPS?
4. How does one make the diagnosis of CRPS?
5. What is the treatment approach for CRPS?
6. What interventional methods are available to treat CRPS?
7. What is the course of CRPS?
References
Chapter 8 Diabetic neuropathy
Case study
1. How prevalent is this disease presentation? Could you explain some of the epidemiologic features of this disease? Are there any cost concerns?
2. What are some of the other conditions that could have the same presentation?
3. How would you differentiate diabetic neuropathy from some of these other disorders?
4. What diagnostic studies would you obtain?
5. How would you make a diagnosis of diabetic neuropathy?
6. What are some of the other presentations in diabetic neuropathy?
7. What are the EMG findings in diabetic neuropathy?
8. What is Seddon's and Sunderland's classification for peripheral nerve injuries?
9. What is the pathophysiology of PDPN?
10. What are some treatment modalities you would offer to this patient?
11. Disease-modifying medications
a-Lipoic acid
Protein kinase C inhibitors
Polyol pathway
Advanced glycation end products
12. Symptomatic treatment
Anticonvulsants
Antidepressants
Local anesthetics
Topical agents
Combination therapies
Interventional therapy
Spinal cord stimulation
Intrathecal medication devices
Deep brain stimulation
Surgery
Physical therapy
Psychologic treatment
Complementary and alternative medicine
New developing drugs
13. What are some of the complications from the treatment modalities?
14. The patient has been unable to return to work. How would you improve this?
15. Describe the conclusions you would draw from this case?
References
Chapter 9 Alcohol-induced neuropathy
Case study
1. What are some of the epidemiologic considerations for this disease? What is the financial burden it imposes on society?
2. What is the pathophysiology of the disease?
3. What are some other clinical conditions that may present in a similar way?
4. What are some of the clinical features of alcohol-induced neuropathy?
5. What are other tests including lab tests and imaging that may aid in your diagnostic work-up? How would you make a diagnosis of alcohol neuropathy?
6. Briefly describe the therapeutic options available to treat and manage alcohol neuropathy
Alpha-lipoic acid
Acetyl-L-carnitine
Vitamin E
Anticonvulsants
Antidepressants
Topical agents
Opioids
Physical therapy
Occupational therapy
Psychotherapy
6. Describe any treatment-related complications
7. Patient refuses to stop drinking and using marijuana. Does that impose any ethical issues?
8. What conclusions could you draw from this case?
References
Chapter 10 HIV neuropathy
Case study
1. How prevalent is this disease presentation? Could you explain some of the epidemiologic features of this disease? Are there any cost concerns?
2. What is the differential diagnosis of HIV neuropathy?
3. Describe the clinical presentations of HIV neuropathy
Distal symmetric polyneuropathy (DSP)
ARV-associated neuropathy
Progressive polyradiculopathy
Mononeuropathy multiplex
4. How would you make a diagnosis of HIV neuropathy?
Brief peripheral neuropathy screen
Total neuropathy score
5. Describe some of the laboratory tests that would aid in your diagnosis
Quantitative sensory testing
Nerve conduction studies
EMG
Nerve biopsy
Skin biopsy
Measures of small-fiber neuropathy
Utah Early Neuropathy Scale
Quantitative Sudomotor Axon Reflex Test
Autonomic function testing
6. Are there any imaging tests that would help in the diagnosis?
7. What is the pathophysiology of this disease?
8. What treatment modalities exist currently for this condition?
Pharmacologic treatment
Anticonvulsants
Antidepressants
Topical agents
Opioids
Smoked cannabis
Antiretroviral therapy
Nerve growth factor
Prosapeptide
What conclusions can be made for the treatment of HIV-associated neuropathy?
Complementary and alternative medicine
Psychotherapy/cognitive behavioral therapy
Interventional techniques
9. Are there any special concerns that you might have in the care of patients with HIV neuropathy?
10. What conclusions would you draw from this case?
References
Section 2 Spinal Disorders
Chapter 11 Cervicogenic headache
Case study
1. What is the differential diagnosis?
2. What are the differentiating features of the cervical spine pain syndromes?
3. What are some of the legal ramifications encountered with workplace and motor vehicle injuries?
4. What are the differing roles of clinical assessment between a clinical practitioner and independent medical assessment?
5. How do clinical assessments differ among practitioners in the diagnosis of cervicogenic headache?
6. What symptoms can be associated with cervicogenic headaches?
7. What are some of the different subsets in cervicogenic headache?
8. What are the available treatments for cervicogenic headache and occipital neuralgia?
References
Chapter 12 Cervical stenosis and myelopathy
Case study
1. Cervical x-rays taken 6 weeks earlier reveal
2. Assessment
3. Plan
4. MRI cervical spine following encounter reveals
5. What is the differential diagnosis?
6. What is the definition of cervical spondylotic myelopathy?
7. What is the epidemiology of CSM?
8. What are the clinical manifestations of CSM?
9. What are the physical examination findings in a patient with CSM?
10. What are the imaging studies available to evaluate for CSM?
11. What radiologic criteria are used to diagnose stenosis?
12. What additional studies may be of benefit in the evaluation of CSM?
13. What is the natural history of patients with CSM?
14. What are the risk factors associated with the development of CSM?
15. What is the pathology behind the development of CSM?
16. How is CSM managed non-operatively?
17. What are the surgical options for management of CSM?
18. How does ossification of posterior longitudinal ligament cause CSM?
19. How does rheumatoid arthritis cause CSM?
20. What is the expected neurologic outcome after decompression surgery?
Cited References
References
Chapter 13 Thoracic outlet syndrome (TOS): an enigma in pain medicine
Case study
1. What is thoracic outlet syndrome?
2. What are the types of thoracic outlet syndrome?
3. What is the epidemiology of TOS?
4. What is thoracic outlet?
5. What is the clinical classification of the brachial plexus?
6. Discuss the etiology of TOS
7. Discuss and differentiate clinical presentations by the type of TOS
8. Discuss the differential diagnosis of TOS
9. What is double crush syndrome in TOS?
10. Discuss the relevant physical examination findings in TOS
11. What are the diagnostic modalities of TOS?
12. What are the conservative management strategies of TOS?
13. Discuss surgical management strategies of TOS
14. What are the treatment outcomes for TOS?
15. What could be the impact of TOS on a person's life?
Conclusion
References
Chapter 14 Patient with cervical radiculopathy
Case description
1. Provide a differential diagnosis for the patient´s complaint
2. Who is affected by cervical radiculopathy?
3. Describe the likely anatomical causes of cervical radiculopathy and the pathophysiologic mechanisms for the observed symptoms
4. What factors from the history and physical examination support the diagnosis?
5. What is the value of diagnostic testing and imaging in evaluating a patient with cervical radiculopathy?
6. What is the efficacy of non-surgical treatment strategies?
7. Describe the benefits and risks of interventional strategies to treat cervical radiculopathy
8. Discuss the role for a surgical consultation
9. Compare the anticipated outcomes with conservative, interventional, and surgical approaches
References
Chapter 15 Patient with axial neck pain
Case study
1. What is the differential diagnosis?
2. What is the mechanism of injury in this patient?
3. Why is this condition occasionally misdiagnosed?
4. Describe the anatomy and pathophysiology of the cervical facet (zygopophysial) joints
5. How to diagnose cervical axial pain?
6. What are the treatment options for axial neck pain?
7. Procedural description
8. What are the possible complications from these procedures?
9. What are the outcomes with facet joint procedures?
10. Intradiscal procedures
11. What are the possible complications from a cervical intradiscal procedure?
References
Chapter 16 Patient with thoracic spine pain
Case study
1. What are the anatomical structures that can produce pain in the thoracic region?
2. What are the key features in the differential diagnosis of thoracic pain?
3. What is ankylosing spondylitis?
4. What is Tietze syndrome?
5. What is DISH?
6. What is Scheuermann's kyphosis? Describe the end plate changes of this disease
7. What is posterior rami syndrome (dorsal ramus syndrome, Ma
8. How would you manage patients with thoracic pain?
Conservative approaches
Interventional approaches
References
Chapter 17 Patient with lumbar disc herniation
Case study
1. What is the differential diagnosis?
2. What is a lumbar disc herniation?
3. Describe the pathogenesis of lumbar radiculopathy secondary to an LDH
4. Discuss clinical symptoms, signs, imaging, and diagnostic testing for an LDH
5. Discuss conservative treatment options
6. Discuss surgical approaches to the lumbar disc herniation
References
Chapter 18 Patient with lumbar facet-mediated pain
Case study
1. What is the differential diagnosis?
2. What is the mechanism of pain generation in this patient?
3. What is the difference between the axial back pain and radicular pain?
4. Describe the anatomy and pathophysiology of the lumbar facet (zygapophysial) joint pain?
5. How to diagnose lumbar axial pain?
6. What are the treatment options for axial low back pain due to the facets?
Conservative approaches
Interventional treatments
7. Procedural description
8. What are the possible complications from these procedures?
9. What are the outcomes with facet joint procedures?
References
Chapter 19 Discogenic pain in the setting of lumbar spondylosis
Case study
1. What is the differential diagnosis?
2. What is the anatomy of a healthy intervertebral disc?
3. What risk factors predispose patients to develop degenerative disc disease?
4. What is the pathophysiology of degenerative disc disease?
5. What is the role of radiographic imaging in discogenic pain?
6. Is there a gold standard for the diagnosis of discogenic pain?
7. Does the spread of the contrast on a discogram tell us anything?
8. What are the complications of discography?
9. What treatment modalities are available for discogenic pain?
References
Chapter 20 Unusual pain syndromes: epidural lipomatosis
Case study
1. What is the differential diagnosis?
2. What are the most common symptoms of idiopathic epidural lipomatosis?
3. What is a proper approach to these symptoms?
4. What are the findings during a physical examination in epidural lipomatosis?
5. What is the pathophysiology of idiopathic epidural lipomatosis?
6. What is the most reliable diagnostic modality?
7. How should this patient be treated?
8. What is the long-term outcome after treatment?
Summary
References
Chapter 21 Unusual pain syndromes: Bertolotti´s syndrome
Case study
1. What is Bertolotti's syndrome?
2. Describe the pathophysiology of Bertolotti's syndrome
3. What is Castellvi's classification?
4. How does Bertolotti's syndrome manifest clinically?
5. How do you diagnose a Bertolotti's syndrome?
6. How should I treat this patient?
7. What are the outcomes?
References
Chapter 22 Unusual pain syndromes: Baastrup's disease/interspinous bursitis
Case study
1. What is Baastrup's disease?
2. Describe the epidemiology of Baastrup's disease
3. Describe the anatomy and pathophysiology of Baastrup's disease
4. How to diagnose Baastrup's disease?
5. What are the differential diagnoses of Baastrup's disease?
6. How should you treat a patient with BD/ISB?
References
Chapter 23 Lumbar spinal stenosis and neurogenic claudication
Case study
1. What is spinal stenosis?
2. What is the Verbiest syndrome?
3. What is the natural history of spinal stenosis?
4. What is the anatomical basis of spinal stenosis?
5. How is lumbar spinal stenosis classified radiologically?
6. How is the diagnosis of spinal stenosis made?
7. What are the differential diagnoses of lumbar spinal stenosis?
a. Lumbosacral radicular pain secondary to nerve root impingement
b. Referred pain from adjacent anatomic structures
c. Lumbar vertebral compression fracture
d. Intermittent claudication secondary to peripheral vascular disease
e. Peripheral neuropathy
f. Visceral referred pain
g. Other differential diagnoses
8. Are conservative treatments effective in lumbar spinal stenosis?
9. What is the next step if simple conservative options are not effective?
10. Neuroplasty therapy (adhesiolysis)
11. Minimally invasive lumbar decompression
12. Interspinous spacers
13. How effective is decompression for the treatment of LSS?
14. How would you manage this patient?
References
Chapter 24 Management of the patient with postlaminectomy pain syndrome
Case study
1. What is postlaminectomy pain syndrome?
2. What is the etiology of postlaminectomy pain syndrome?
3. How is postlaminectomy pain syndrome diagnosed?
4. What interventional treatments may be utilized?
Lumbar epidural steroid injections and PLPS
Caudal epidural injection and PLPS
Facet and medial branch interventions
Adhesiolysis
Spinal cord stimulation
Pharmacologic management
Intrathecal drug delivery
Interdisciplinary management
5. Complications/Conclusions
References
Chapter 25 A patient with a lumbar compression fracture
Case study
1. What is the differential diagnosis?
2. What is the difference between a simple vertebral compression fracture and a burst fracture?
3. What is the pathogenesis and pathophysiology of a vertebral compression fracture? Is osteoporosis a factor?
4. How is vertebral compression fracture diagnosed?
5. How are vertebral compression fractures treated? Describe a conservative and an interventional treatment
6. What is the controversy surrounding vertebral augmentation?
References
Chapter 26 Sacroiliac joint pain and arthritis
Case study
1. What are the differential diagnoses in this patient?
2. What are the referred pain patterns that are important in the differential diagnosis?
3. What anatomic considerations help to explain the variable presentation of SI joint pain?
4. What are the physical exam findings that would suggest SI joint pain?
5. Does imaging play a large role in the diagnostic work-up of this patient?
6. How is the diagnosis of SI joint pain made?
7. What are the conservative management options in patients with SI joint pain?
8. When considering SI joint injection, what factors should be kept in mind?
9. Is there a long-term therapeutic solution to SI joint pain?
References
Uncited References
Chapter 27 Sacral insufficiency fracture and treatment options
Case study
1. What is the differential diagnosis?
2. What risk factors predispose patients to develop sacral insufficiency fractures?
3. Why is this condition overlooked?
4. Describe the anatomy and pathophysiology of a SIF
5. How do you diagnose a SIF?
6. Is there any other diagnostic testing that should be done?
7. How should I treat this patient?
Conservative approaches
Procedural
8. Are there any complications to worry about following sacroplasty or sacral kyphoplasty?
9. What are the outcomes?
References
Chapter 28 Skeletal metastases and treatment options
Case study
1. What is the differential diagnosis?
2. What is this?
3. How do you diagnose this?
4. Why is treatment or palliation of this lesion important?
5. The patient presented with skeletal pain shortly after being diagnosed with recurrent bronchial stump cancer. Why is this?
6. How would you treat this pain?
7. Is there a role for targeted therapy in this population?
8. What types of targeted therapy for skeletal metastases are available?
9. What is the mechanism of rapid pain relief?
10. Are there any complications to worry about following vertebroplasty or kyphoplasty?
11. What can one conclude?
References
Chapter 29 Fibromyalgia and opioid-induced hyperalgesia
Case study
1. What is the differential diagnosis?
2. What is fibromyalgia? How do you diagnose it? Are there diagnostic and/or clinical criteria?
3. How do you differentially diagnose fibromyalgia from similar problems?
4. What is the treatment for fibromyalgia? Is it ethical to prescribe opioids in the treatment of fibromyalgia?
Case follow-up
5. Does the worsening of her pain despite opioid therapy make you question your diagnosis? Are there any other diagnoses to consider at this point?
References
Section 3 Musculoskeletal Pain
Chapter 30 Patient with myofascial pain syndrome: focus on functional restoration
Case study
1. What happens when an employee files a claim through workers' compensation?
2. Why do some patients have an attorney?
3. What are the different types of disability benefits and how is candidacy for these benefits determined?
4. What are pharmacologic options for our patient going forward?
Medications
5. Are there interventional options for our patient?
6. What type of physical therapy is best?
7. Is psychologic therapy necessary for this patient?
8. What is a functional restoration program?
References
Chapter 31 Spinal manipulation, osteopathic manipulative treatment, and spasticity
Case study
1. Introduction to spinal manipulation
2. Contraindications to spinal manipulation
3. Current literature considerations
4. Introduction to spasticity
5. Spasticity management
Disclosure
References
Chapter 32 Patient with ankle pain
Case study
1. What is the differential diagnosis?
2. What risk factors predispose patients to have a chronic ankle sprain?
3. Why is this condition overlooked?
4. Describe the anatomy and pathophysiology of a chronic ankle sprain
5. How do you diagnose a chronic ankle sprain?
6. How should I treat this patient?
Conservative approaches
Procedural
Corticosteroid injections
Viscosupplementation/hyaluronic acid injections
Acupuncture
Dry-needling
Radiofrequency ablation/radiofrequency coblation
Regenerative injection procedures
Prolotherapy
Platelet-based procedures
Surgical treatment options
Open surgical repair for chronic ankle instability/hypermobility
Open surgical repair for chronic ankle pain, OA/other causes
References
Chapter 33 Patient with lateral epicondylosis or other focal tendinopathy
Case study
1. What is the differential diagnosis?
2. What risk factors predispose patients to developing sacral insufficiency fractures?
3. Describe the anatomy and pathophysiology of a lateral epicondylosis
4. How do you diagnose a lateral epicondylosis?
5. Is there any other diagnostic testing that should be done?
6. How should I treat this patient?
Conservative approaches
Procedural
References
Chapter 34 Knee osteoarthritis with emphasis on percutaneous regenerative medicine
Case study
1. What are the most common etiologies of chronic knee pain?
2. What is knee osteoarthritis and what is the pathophysiologic basis for its development?
3. What are the common causes of KOA?
4. What other type(s) of arthropathy need to be ruled out and how do they differ from OA?
5. What does a pertinent exam of the knee consist of in a patient that is suspected of having knee osteoarthritis?
6. What imaging is currently used to diagnose KOA and is it adequate?
7. Are there any labs that need to be ordered when working up a patient with knee pain?
8. What are the traditional non-surgical treatment options for early KOA?
Diet and exercise
Physical therapy
Pharmacologic intervention
Orthotics
Psychology therapy
Traditional percutaneous injections
9. What are the innovative non-surgical management options for early KOA?
10. What are the traditional surgical treatment options for early KOA?
11. What are innovative surgical treatment options for KOA?
12. Coalescence of surgery and injections
References
Section 4 Visceral Pain
Chapter 35 Patient with chronic abdominal pain from pancreatitis
Case study
1. What is the difference between acute and chronic pancreatitis?
2. What is the most common cause of chronic pancreatitis and which demographics are usually affected?
3. Describe the typical presentation of pain in chronic pancreatitis
4. What is the pathogenesis of pain in chronic pancreatitis?
5. Which other clinical manifestations may contribute to the overall pain experience of patients?
6. Which diagnostic studies are of value for diagnosis and staging of chronic pancreatitis?
7. What is the first step in treatment of pain in chronic pancreatitis?
8. Which are the initial steps in conservative management of chronic pancreatitis?
9. What are the medical treatment options available for treatment of chronic pancreatitis?
10. Can COX-2 inhibitors be given for long-term pain management in chronic pancreatitis?
11. Which are the most common adjuvants used in medical treatment of chronic pancreatitis?
12. What are the indications for the use of opioids in chronic pancreatitis?
13. What is the reasoning behind the use of antioxidants in the treatment of chronic pancreatitis?
14. When are interventional options indicated and which procedures can be used?
15. What is the evidence behind the use of radiofrequency ablation and spinal cord stimulation for treatment of pain in chronic pancreatitis?
16. What are the endoscopic and surgical treatment options available?
References
Chapter 36 Patient with chronic pelvic pain from endometrial fibrosis
Case study
1. What is chronic pelvic pain?
2. Describe the epidemiology and prevalence of endometriosis
3. What is the pathophysiology of endometriosis?
4. What is the mechanism of pain associated with endometriosis?
5. How is endometriosis presented clinically?
What is the differential diagnosis of chronic pelvic pain in females?[17]
How to establish the diagnosis of CPP due to endometriosis?
How to manage CPP due to endometriosis?
Treatment of endometriosis
Hormonal treatments
Surgical treatment
Managing CPP associated with endometriosis
Medical management
Interventional and surgical management
References
Chapter 37 Patient (male) with chronic pelvic pain from interstitial cystitis
Case study
1. What is the innervation of the male pelvis?
2. What is the differential diagnosis for a male presenting with chronic pelvic pain?
3. How are prostate syndromes classified? What is the epidemiology of chronic prostatitis?
4. How should male CPP be evaluated?
History
Physical exam
Laboratory
Additional studies
5. What non-pharmacologic treatment options are available to patients with CPPS?
6. What pharmacologic agents are used in the treatment of CPPS?
7. What interventional procedures can be performed in the treatment of CPPS?
8. How are the iliohypogastric, ilioinguinal, genitofemoral, and pudendal nerve blocks performed?
Iliohypogastric and ilioinguinal nerve block
Genitofemoral nerve block
Pudendal nerve block
Superior hypogastric plexus block
9. What other treatment options are available if pharmacotherapy and targeted nerve blocks have failed to provide adequate pain relief?
Neuromodulation
Intrathecal drug therapy
10. How do you monitor the progress of treatment in CPPS?
11. What is the treatment course in CPPS?
References
Chapter 38 Chronic rectal pain
Case study
1. What is the differential diagnosis for rectal pain?
2. Describe the neuroanatomy of the pelvic viscera including the rectum
3. What are some unique features of rectal innervation and how do they contribute to rectal pain?
4. What is the typical work-up for rectal pain?
5. What are the pathophysiology and diagnostic criteria of coccygodynia?
6. What are the pathophysiology and diagnostic criteria of proctalgia fugax?
7. What are the pathophysiology and diagnostic criteria of radiation proctitis?
8. What are some treatment modalities of rectal pain?
9. What are some topical medications used to treat rectal pain?
10. When is the ganglion impar block indicated and how is it performed?
11. When is the pudendal nerve block indicated and how is it performed?
12. When is the inferior hypogastric plexus block indicated and how is it performed?
13. How is BOTOX used to treat rectal pain?
14. How can neuromodulation be used to help manage rectal pain?
References
Chapter 39 Pain in pregnancy
Case study
1. What are the common etiologies for pain in the pregnant patient?
Low back pain and disc disease
Pelvic girdle pain
Pubic symphysis separation (pubic diastasis, symphysiolysis, osteitis pubis)
Hip pain and transient osteoporosis of the hip
Knee pain and patellofemoral disorder
Leg cramps
Abdominal wall pain
2. How does the evaluation for low back pain compare from the parturient to the non-parturient?
3. What pharmacotherapy for pain is safe to give in pregnancy?
4. What role do non-pharmacologic therapies have in treatment for pain in pregnancy?
Exercise and physical therapy
Acupuncture
Pelvic belt and pillow
Transcutaneous electronic nerve stimulation
Osteopathic manipulative treatment
5. What role do non-opioid medications have in treating pain in pregnancy?
Acetaminophen
NSAIDs
Benzodiazepines
Antidepressants
Anticonvulsants
Local anesthetics
Skeletal muscle relaxants
Steroids
6. What role do opioids have in treating pain in pregnancy? If started on opioids, what is the risk to the mother and the fetus, both in gestation and the peripartum stage?
7. What interventions are available to the parturient? What are the risks associated with pain procedures for the parturient and the fetus?
8. What would be the suggested overall therapeutic management for the parturient with lower back pain?
References
Chapter 40 Postpartum pain
Case study
1. What are common etiologies of back pain in a postpartum patient?
2. What is the correlation, if any, between neuraxial analgesia and chronic back pain?
3. What other pain syndromes are common or unique to the postpartum female?
Chronic pelvic girdle pain
Meralgia paresthetica
Chronic pelvic pain
Chronic pain after cesarean delivery
Chronic perineal pain
4. What are common risk factors for chronic postpartum pain?
Pre-delivery
During delivery
Post-delivery
5. How should a patient with postpartum pain be evaluated?
Targeted pain history
Targeted physical examination
Imaging and other diagnostic modalities
6. What non-pharmacologic treatment options for postpartum pain are available in a breastfeeding female?
Physical therapy
Pelvic belts
Acupuncture
TENS
Biofeedback and relaxation training
7. What pharmacologic agents are available for treatment of postpartum pain in a breastfeeding female?
Acetaminophen
NSAIDs
Local anesthetics
Steroids
Antidepressants
Benzodiazepines
Opioids
8. What medications should be used with caution in the breastfeeding mother?
Gabapentin
Pregabalin
Antidepressants
Lithium
9. What guidelines can a physician follow in management of postpartum pain in a breastfeeding mother?
References
Section 5 Headaches and Facial Pain
Chapter 41 Patient with migraine headaches
Case study
1. Discuss the epidemiology of migraine
2. Discuss the pathogenesis of migraine
3. Clinical assessment and associated signs
International Headache Society Diagnosis Criteria for Migraine
Migraine without aura (MO) diagnostic criteria[10]
Migraine with aura (MA) diagnostic criteria[10]
4. Counseling on long-term risks of migraine
Stroke
5. Diagnostic evaluation
6. Medications: triptans
7. Medications: other non-opioid abortive treatments
8. Medications: opioids and butalbital-containing combination pills
Beta-blockers (e.g., propranolol, atenolol, nadolol, timolol)
Anticonvulsants (e.g., valproate, topiramate, gabapentin)
Calcium channel blockers (i.e., verapamil, amlodipine)
Tricyclic antidepressants (i.e., amitriptyline, nortriptyline, desipramine)
Selective SNRIs (i.e., duloxetine, milnacipram)
Treatment of chronic migraine
9. Functional measures for outcomes: headache diary
10. Interventional approaches: BOTOX, peripheral nerve blocks, peripheral nerve stimulation (including occipital nerve stimulation and supraorbital nerve stimulation)
11. Preventive measures: physical therapy, modalities, and nutrition
12. Thoughts from an expert, e.g., overlooked areas
References
Chapter 42 Patient with cluster headache
Case study
1. What is the epidemiology and clinical presentation of cluster headache?
2. How is cluster headache diagnosed?
3. What are the diagnostic criteria for cluster headache?
4. What are the diagnostic pitfalls?
5. What is the differential diagnosis?
6. Does the specific diagnosis matter?
7. What risk factors predispose patients to develop cluster headaches?
8. Why is this condition overlooked?
9. What is the anatomy and pathophysiology of a cluster headache?
10. Is there any other diagnostic testing that should be done?
11. How is cluster headache treated?
Pharmacotherapy
Acute treatment
Preventive treatments
Procedural
Occipital nerve block
Neurostimulation
12. How should I treat this patient?
13. Are there any complications to worry about using DHE (dihydroergotamine) or triptans for acute treatment of cluster headache?
14. What are the outcomes of treatment of cluster headache patients?
References
Chapter 43 Patients with tension headaches
Case study
1. What is the differential diagnosis?
2. What is the epidemiology of these headaches?
3. Describe the clinical presentation
4. What is the pathophysiology of tension-type headache?
5. Treatment
6. Conclusion
References
Chapter 44 Pain management in trigeminal neuralgia: clinical case illustrations
Introduction
Clinical cases
1. What are the history, incidence, and epidemiology of trigeminal neuralgia?
2. What are the features of trigeminal neuralgia?
3. What is the etiology and pathophysiology of trigeminal neuralgia?
4. How is a diagnosis of TN made?
5. What are the distinct management categories for trigeminal neuralgia?
6. What is microvascular decompression for trigeminal neuralgia?
7. What are some of the advantages of microvascular decompression for TN?
8. Are there any other alternative techniques for trigeminal neuralgia?
9. What are the key points regarding trigeminal neuralgia for the clinician?
Disclosure
References
Chapter 45 Patient with chronic glossopharyngeal neuralgia/post-tonsillectomy pain
Case study
1. What is glossopharyngeal neuralgia?
2. Describe the signs and symptoms
3. Discuss the etiology and pathophysiology
4. Diagnosis
5. Treatment
References
Chapter 46 Patient with sphenopalatine neuralgia
Case study
1. What is the differential diagnosis?
2. What is Sluder neuralgia or sphenopalatine ganglion neuralgia?
3. What is the anatomy of the sphenopalatine ganglion?
4. What are the major nerve structures involved with the sphenopalatine ganglion?
5. What is the proposed etiology of sphenopalatine neuralgia?
6. What is the clinical presentation of sphenopalatine neuralgia?
7. What is the recommended work-up for suspected sphenopalatine neuralgia?
8. What is the recommended medical management of sphenopalatine neuralgia?
9. What are the interventional therapies for treatment of sphenopalatine neuralgia?
10. What are the complications of the sphenopalatine block?
Summary
References
Chapter 47 Temporomandibular joint disorders
Case study
1. What is temporomandibular joint disorder (TMD) and how does it typically present?
2. What are the relevant anatomical structures related to TMD?
3. What is the cause of pain in TMDs?
4. How common is TMD?
5. What would be included in the differential diagnosis?
6. How is TMD evaluated and diagnosed?
7. What are the potential treatments for TMD?
Conclusion
References
Section 6 Cancer Pain
Chapter 48 Cancer pain
Case study
1. What is the etiology of cancer pain?
2. Could there be other non-cancer causes for the patient's pain?
3. What is the epidemiology of cancer pain?
4. Are there any risk factors for the development of cancer pain?
5. What analgesic treatments are available to relieve this cancer pain?
6. What is the World Health Organization Analgesic Ladder for the treatment of cancer pain?
7. What analgesic medications should I use to treat this cancer pain?
Non-steroidal anti-inflammatory drugs and acetaminophen
Adjuvant analgesics
Opioids
8. What if our patient has intermittent pain in spite of regular opioid therapy?
9. My patient is unable to take oral medications. What should I now do?
10. What opioid side effects are common in the chronic treatment of cancer pain?
11. Are there any non-drug therapies for cancer pain management?
12. Would a "nerve block" be helpful for this patient?
13. What is involved with a celiac plexus neurolytic block?
Conclusions
References
Chapter 49 Patient presents with pancreatic cancer with persistent pain despite all other treatments
Case study
1. What barriers to patient care might an interventional pain physician face in cross-disciplinary care?
2. What are common sources of pain in the pancreatic cancer patient?
3. What interventional techniques may be used?
Blocks
Spinal cord stimulation
Neuraxial drug administration
4. What are the complications/contraindications to neuraxial analgesia?
References
Chapter 50 Pain management in hematological cancer: clinical case illustrations
Case studies
1. Introduction
2. Discussion
Conclusion
References
Chapter 51 Patient with metastatic breast cancer who had a mastectomy complicated by lymphedema
Case study
1. What is the prevalence of upper-body morbidity and lymphedema after breast cancer?
2. What are known risk factors for the development or exacerbation of upper-body morbidity and lymphedema after breast cancer?
3. What is the differential diagnosis for pain syndromes after breast cancer?
4. What are some clinical manifestations of lymphedema after breast cancer?
5. How is lymphedema diagnosed?
6. For patients at risk for lymphedema who do not have the condition, how should they be educated regarding preventive care?
7. What are the components of the "gold standard" treatment regimen for established lymphedema?
8. What other treatments can be considered for lymphedema?
Intermittent external pneumatic compression
Weight loss
Low-level laser therapy
Surgery
9. What rare complications of lymphedema should practitioners be aware of?
10. Conclusions - how would you treat this patient in the vignette?
References
Section 7 Special Topics
Chapter 52 A 57-year-old male with chronic pain syndrome, anxiety disorder, and hypertension is seeking mental health counseling
Why is it important to address the risk of suicide?
The patient doesn't demonstrate any suicidal thoughts, has a good support system at home, and doesn't have any concrete executable plans for self harm. You now feel comfortable discussing more conventional mental health strategies. What do you recommend?
Cognitive behavioral therapy
Relaxation training
Psychoanalysis
Psychiatric approach
During this discussion, the patient presents a newspaper article touting the benefits of biofeedback. He says that one of his friends mentioned hypnosis. Can you explain these modalities to the patient?
What is biofeedback?
What is hypnosis?
Inpatient versus outpatient psychologic therapy?
References
Chapter 53 Pediatric, infant, and fetal pain
Case study 1
1. Would this fetus require analgesia?
2. How can anesthetics/analgesics be delivered to a fetus?
Case study 2
1. How would you assess pain in this patient?
2. How would you treat this infant´s pain?
Case study 3
1. How would you assess this patient´s pain?
2. How would you manage her pain?
Case study 4
1. What is your differential diagnosis?
2. How does complex regional pain type 1 present in children?
3. How would you treat this patient?
Case study 5
1. Is this patient's presentation consistent with functional abdominal pain? Are there any concerning features in this patient's presentation?
2. What diagnostic studies are indicated in this patient?
3. How is FAP treated in children?
References
Chapter 54 Patient with hearing impairment and chronic pain
Case study
1. What should the provider be aware of when communicating with the hearing impaired?
2. Why use sign language?
3. How do you evaluate the deaf pain patient?
References
Chapter 55 Complementary and alternative medicine
Case study
1. How effective are conventional therapies for chronic low back pain?
2. What is complementary and alternative medicine, and who uses it?
3. Discuss the effectiveness of CAM therapies for low back pain
Acupuncture
Massage
Meditation
Autogenic training
Progressive muscle relaxation
Tai chi
Manipulation
Yoga
Biofield therapies
Balneotherapy
Behavioral therapies
Prolotherapy
Neuroreflexotherapy
Herbal therapy
4. What is integrative medicine?
5. What information would you discuss with this patient seeking to use complementary and alternative medicine?
References
Chapter 56 Ethical issues in the substance abusing pain patient
Case study
1. What is the scope of the public health problem related to the use of prescription opioids for pain?
2. What are the differential diagnoses of aberrant opioid-taking behaviors?
3. What are some common terminologies related to drug abuse and addiction?
4. Describe the basic neurobiologic process underlying addiction
5. What are the ethical principles that guide the use of opioids in pain control?
6. How can opioids be safely used for chronic pain?
7. Considering the complexity and risks, why not just avoid offering opioid therapy altogether?
References
Chapter 57 Approach to the patient with abnormal drug screen
Case study 1
1. Clinical assessment
What is the differential diagnosis for a patient with a positive drug screen?
What information exists regarding the epidemiology of drug abuse in the chronic pain population?
What are the clinical implications of drug misuse in this patient population?
2. Overview of drug testing
What modalities and assays are available for clinical drug testing?
What limitations should be considered when interpreting urine drug test results?
What guidelines exist regarding drug testing in the clinical setting?
3. Clinical management
How would the results of this urine drug test affect your future management of this patient?
Case study 2
1. Clinical assessement
What are this patient's risk factors for illicit substance abuse?
What is the differential interpretation of these results?
2. Illicit drug abuse and detection
What are the clinical trends and implications of substance abuse?
What is the time frame for detection of marijuana in urine drug testing? What is the time frame for detection of other drugs with abuse potential?
Would you include marijuana in your routine clinical drug screening? Why or why not?
3. Clinical management
What are the next steps in your management of this patient?
Case study 3
1. Clinical assessment
What is the differential interpretation of these findings?
What steps would you take to determine a diagnosis?
2. Clinical management
What are your next steps in management of this patient?
References
Chapter 58 Physician exposed to excessive radiation
Interventional pain physician has to go to occupational medicine office regarding radiation exposure
1. What is the reason for the state inspection?
2. What are the OSHA standards regarding ionizing radiation?
3. Who sets and enforces the medical radiation dosage standards?
4. What are the penetrating characteristics of various radiation beams?
5. What are the biologic effects of ionizing radiation?
6. What are the maximum permissible doses (MPD) of radiation?
7. What can I do to reduce my exposure to radiation while performing the fluoroscopic procedures?
8. What are the recommendations by US Environmental Protection Agency regarding radiation exposure?
Summary
References
Chapter 59 Patient becomes paralyzed following a lumbar transforaminal epidural steroid injection
Case study
1. What are the possible complications after a transforaminal epidural steroid injection?
2. What is the vascular anatomy of the blood supply to the spinal cord?
3. Where is the location of the arteries in the foramen?
4. What is the pathogenesis and mechanism of injury leading to paraplegia?
5. What changes in technique have been proposed to improve the safety of TFESI?
6. What are the pros and cons of the suggested technique modifications?
7. What is the treatment of paraplegia secondary to infarction?
8. What ethical and legal ramifications are there surrounding this procedure and the possible complications?
References
Chapter 60 Postepidural steroid injection paraplegia
Case study
1. What is the differential diagnosis?
2. Review the anatomy and vasculature of the epidural space
3. If the patient developed lower extremity paralysis immediately following the epidural steroid injection, which diagnosis would be highest on the differential?
4. If the patient underwent a transforaminal epidural steroid injection, describe the most favorable needle placement to minimize the risk of these serious postinjection symptoms?
5. Which of the following symptoms should be the most worrisome for the clinician?
6. What safety measures could the physician have taken to try to prevent such complications secondary to the epidural steroid injection?
7. What is the most reliable way to diagnose an epidural hematoma?
8. How should the clinician interpret the results, depending on when the modality was utilized following symptom onset?
9. What is the treatment for an epidural hematoma?
Acute management
Chronic management
10. What is the role of intravenous steroids in acute spinal cord injury?
References
Chapter 61 Complications: patient with dural puncture following cervical interlaminar epidural steroid injection
Case study
1. What is the differential diagnosis?
2. What are the signs and symptoms of a postdural puncture headache?
3. Describe the anatomy and pathophysiology for postdural puncture headaches
4. How is the diagnosis of a postdural puncture headache made in this patient?
5. What are the non-interventional treatments for a postdural puncture headache?
6. What are the interventional treatments for a postdural headache and how are they performed?
7. What are the factors to avoid a dural puncture?
8. What are the complications from a dural puncture?
References
Chapter 62 Complications: a patient with serotonin syndrome
Case study
What is serotonin syndrome?
Which drugs have been implicated in SS?
How is SS diagnosed?
What is the differential diagnosis?
References
Chapter 63 Office-based buprenorphine to wean patients off opioids
Case study
1. How common is opioid dependence?
2. What is the best approach to address opioid dependence in the USA?
3. What are the risk factors for opioid addiction?
4. How do you diagnose opioid dependence?
5. What are some of the features that make buprenorphine a desirable option for the treatment of opioid addiction?
6. What are the pharmacokinetics and pharmacodynamics of buprenorphine and the best form of administration?
7. Is dose adjustment required for buprenorphine in the presence of hepatic and renal disease?
8. What forms of buprenorphine are available for treatment of opioid dependence?
9. Why is buprenorphine not used via oral route?
10. How can I get certified to prescribe buprenorphine for this indication?
11. How should I start this patient on buprenorphine?
12. What is the standard induction protocol?
13. What is the safety of using buprenorphine in the treatment of opioid dependence?
14. Can you use buprenorphine for pain control?
15. What are the clinical outcomes using buprenorphine?
Summary
References
Chapter 64 Patient on chronic opioids who wants to have anesthesia-assisted detoxification
Case study
1. What are the various terms related to addiction and withdrawal?
2. What are the indications for anesthesia-assisted opiate detoxification (AAOD)?
3. What are the contraindications to anesthesia-assisted opiate detoxification?
Contraindications include:
4. What pre-assessment is needed for anesthesia-assisted detoxification?
Pre-anesthetic testing
4. What is the actual methodology to perform AAOD?
Premedication
Monitoring
Induction and maintenance
4. How do you know when the detoxification is complete?
What post-procedure monitoring is required?
5. What complications can occur in AAOD?
6. How does AAOD compare to traditional methods of detoxification?
7. How can the opiate-dependent patient maintain abstinent state?
8. Does AAOD actually lead to prolonged abstinence?
9. What evidence-based reviews have been conducted of AAOD?
10. Are there potential benefits of AAOD?
11. Should this procedure be conducted at all?
12. What ethical conundrums occur with AAOD?
13. What is the role of clonidine in mitigating withdrawal?
References
Chapter 65 Munchausen syndrome and pain
Case study
What is the origin and history of this condition?
How is this diagnosed?
What are the treatment options?
References
Chapter 66 Insomnia and chronic pain
Case study
1. How common are sleep disorders among chronic pain patients?
2. What type of sleep disorder is this patient struggling with?
3. What information is needed to assist in the diagnosis and treatment of this sleep problem?
Interview
Polysomnography
Sleep diary
Psychometric tools
4. Are there any drugs that may be contributing to his sleep problem?
5. What are some initial recommendations you might make to address sleep difficulties?
6. Are there any medications you might consider to assist with his sleep?
Prescription
Non-prescription
7. What other non-pharmacologic treatments are available?
8. Conclusions
References
Chapter 67 Opioid-induced constipation
Case study
1. What is the differential diagnosis?
2. What is the prevalence of opioid-induced constipation?
3. Describe the relevant anatomy of the bowel as it relates to opioid-induced constipation
4. Describe the opioid receptors in the bowel and its relation to the physiology of the bowel
5. Describe the clinical presentation of opioid-induced constipation
6. What is the role of the patient´s history in determining constipation caused by opioid use?
7. What is the benefit of the physical examination in a patient with opioid-induced constipation?
8. Is there a role for imaging in evaluating opioid-induced constipation?
9. How important is fluid intake for treatment of opioid-induced constipation?
10. What is the roll of diet and fiber?
11. Are fiber-based laxatives safe for patient´s with fecal impaction?
12. Is exercise effective?
13. Why are stimulants effective in opioid-induced constipation?
14. What is the mechanism of action of docusate and is it effective for opiate-induced constipation?
15. What is the mechanism of action of osmotic laxatives such as lactulose and sorbitol?
16. What is the mechanism of action of magnesium sulfate?
17. Should suppositories and enemas be considered as first-line treatment modalities?
18. Is there a role for opioid receptor antagonists in the treatment of opioid-induced constipation?
19. What is opioid rotation?
Conclusion
References
Chapter 68 Complications: vasovagal response during pain procedures
Case study
1. What is the differential diagnosis?
2. What is a vasovagal response?
3. How does a vasovagal response occur?
4. What are the risk factors/causative factors for a vasovagal response during pain procedures?
5. What is the association of vasovagal response with pain procedures?
6. In which type of pain procedures are vasovagal responses more common?
7. How do you diagnose a vasovagal response?
8. How would you treat a patient for a vasovagal response during a pain procedure?
References
Chapter 69 Acute pain management: patient-controlled analgesia
Case study
1. What is patient-controlled analgesia?
2. How does an IV PCA work?
3. Why is an IV PCA beneficial?
4. What are some patient selection criteria for appropriate use of an IV PCA?
5. When would a continuous infusion on an IV PCA be appropriate?
6. What is the ideal opioid for an IV PCA?
7. How do I initially program a PCA in my opioid-naive patients?
8. How do patient characteristics such as age and weight affect IV PCA use?
9. What if the patient continues to have pain while on the PCA?
10. What are the side effects of an IV PCA?
11. How safe is an IV PCA?
12. What are the limitations of an IV PCA?
13. Are there ways to improve the efficacy of IV PCA use?
14. Can a PCA mask postoperative complications?
15. How does the cost of IV PCA compare to conventional dosing?
References
Chapter 70 Acute pain management: PCEA/continuous epidural catheters
Case study
1. What are the indications for placing an epidural catheter for postoperative analgesia?
2. What postoperative pain treatment options are available for patients undergoing thoracotomy?
3. What are the benefits of a thoracic epidural patient-controlled analgesia as an analgesic technique?
4. How should an epidural catheter be placed? What techniques can be used for assistance with a difficult placement?
5. What are some risks of an epidural placement?
6. What are some medications used for epidural analgesia?
7. What are the options for infusion strategies?
8. What special considerations exist for the use of neuraxial analgesia in patients with multiple sclerosis?
9. For what other procedures might epidural analgesia be beneficial?
10. What are the contraindications for placing an epidural catheter?
Reference
Chapter 71 New vistas: continuous peripheral catheters/regional anesthesia in postoperative pain management
Case study
1. What are some of the important epidemiologic considerations in TKA?
2. What is the rationale for standardizing the perioperative pain management pathway for TKA patients?
3. What is a multimodal analgesic protocol?
4. What are potential components of an effective multimodal analgesic protocol?
Local anesthetics
Opioid analgesics
Non-opioid systemic analgesics
5. What are some special considerations for patients with chronic pain and chronic opioid therapy?
6. How does the diagnosis of obstructive sleep apnea (OSA) influence the analgesic protocol?
Conflict of interest
References
Chapter 72 Methadone and treatment of chronic pain
Case study
1. What are the clinical uses of methadone?
2. What about using methadone in the chronically ill patient with HIV?
3. How does her history of substance abuse change methadone prescribing?
4. What is the cost of methadone?
5. How common is accidental overdose in methadone use?
6. What are other risks of methadone use?
7. What are drugdrug interactions of methadone?
8. What is the role of genetic testing?
9. What is the metabolism and mechanism of methadone?
10. What are the advantages of methadone in this patient?
11. What are the risks of methadone in this patient?
12. What are the ethical considerations?
13. What should be the initial approach to this patient?
References
Chapter 73 Drug testing
Case study
1. Why is it important to do drug testing in patients with chronic pain managed with opioids?
2. What methods are available for urine drug testing?
3. How accurate are the urine drug tests?
4. How long will a urine drug test remain positive for opioids, benzodiazepines, and barbiturates?
5. How long will a urine drug test remain positive for drugs of abuse?
6. This patient tells you he ran out of his medication and last took his oxycodone 2 days ago. Would you expect his urine drug test to be positive or negative?
7. Can urine drug testing tell you how much of a given drug the patient is currently taking?
8. What medications and substances can trigger a false positive urine drug test result?
9. How reliable is a physician's history or "gut instinct" in predicting aberrant drug use?
10. What are the most common inappropriate drugs found on a urine drug testing?
11. Is drug testing mandatory or required by law?
12. What would you do if the urine drug test is unexpectedly positive or unexpectedly negative?
References
Index