Practical Management of Pain

Cover
Practical Management of Pain
Practical Management of Pain
Copyright
Dedication
Contributors
Preface
Contents
Part 1 General Considerations
1 History Is a Distillation of Rumor
2 Classification of Acute Pain and Chronic Pain Syndromes
3 Organizing an Inpatient Acute Pain Service
4 Interdisciplinary Pain Management
5 The Healthcare Policy of Pain Management
6 Quality Assessment, Improvement, and Patient Safety in Pain Management
7 Education, Training, and Certification in Pain Medicine
Part 2 Basic Considerations
8 Neurophysiology of Pain: Peripheral, Spinal, Ascending, and Descending Pathways
9 Neurochemistry of Nociception
10 Neuroimaging Techniques
11 Individual Differences in Experience and Treatment of Pain: Race, Ethnicity, and Sex
12 Communication and Clinician Relationships to Improve Care for Patients With Chronic Pain
13 Pharmacogenetics in Pain Management
14 Psychosocial and Psychiatric Aspects of Chronic Pain
15 Comprehensive Approach to Evaluating Patients With Chronic Pain
16 Mechanism-Based Treatment and Precision Medicine
17 Placebo and Nocebo Effects in Clinical Trials and Clinical Practice
Part 3 Clinical Evaluation and Assessment
18 History and Physical Examination of the Patient With Pain
19 Electromyography and Evoked Potentials
20 Radiologic Assessment of Patient With Spine Pain
21 Biomarkers of Pain: Quantitative Sensory Testing, Conditioned Pain Modulation, Punch Skin Biopsy
22 Psychological and Behavioral Assessment
23 Disability Assessment
Part 4 Clinical Conditions: Evaluation and Treatment
24 Chronic Post-surgical Pain Syndromes: Prediction and Preventive Analgesia
25 Evaluation and Pharmacologic Treatment of Postoperative Pain
26 Regional and Multimodal Treatments of Perioperative Pain
27 Evaluation and Treatment of Postoperative Pain in Patients With Opioid Use Disorder
28 Evaluation and Treatment of Acute Pain in Children
29 Low Back Pain Disorders
30 Buttock and Sciatica Pain
31 Facet Pain: Pathogenesis, Diagnosis, and Treatment
32 Neurosurgical Approaches to Pain Management
33 Evaluation and Treatment of Cancer-Related Pain
34 Evaluation and Treatment of Neuropathic Pain Syndromes
35 Evaluation and Treatment of Complex Regional Pain Syndrome
36 Evaluation and Treatment of Pain in Selected Neurologic Disorders
37 Chronic Widespread Pain
38 Headache Management
39 Cervicogenic Headache, Post-meningeal Puncture Headache, and Spontaneous Intracranial Hypotension
40 Orofacial Pain
41 Visceral Pain
42 Pelvic Pain
43 Pediatric Chronic Pain Management
44 Geriatric Pain Management
45 Managing Pain During Pregnancy and Lactation
46 Rheumatologic Conditions
47 Pain Management in Patients With Comorbidities
Part 5 Pharmacologic, Psychologic, and Physical Medicine Treatments and Associated Issues
48 Major Opioids and Chronic Opioid Therapy
49 Minor Analgesics: Non-Opioid and Opioid Formulations
50 The U.S. Opioid Crisis and the Legal and Legislative Implications
51 Evaluation for Opioid Management: Opioid Misuse Assessment Tools and Drug Testing in Pain Management
52 Pain and Addictive Disorders: Challenge and Opportunity
53 Anti-depressants
54 Adjunct Medications for Pain Management
55 Skeletal Muscle Relaxants
56 Cannabinoids for Pain Management
57 Topical Analgesics
58 Psychological Approaches in Pain Management
59 Evidence-Based Rehabilitation Approaches to Acute and Chronic Pain Management
60 Physical Rehabilitation for Patients With Chronic Pain
60 - Physical Rehabilitation for Patients With Chronic Pain
Key Points
Patient Evaluation
Patient Interview
Physical Examination
Therapy for Chronic Pain
Collaboration Between the Rehabilitation Professional and Patient
Personalized Rehabilitation Plan
Education on the Nature of the Problem
Resolution of Treatable Barriers Related to Functional Goal Attainment
Exercise Therapy
Cognitive Behavior Approach
Self-Management Techniques
Instruction in Methods to Prevent Future Problems
Monitoring of Outcome (Achievement of Patient Goals)
In the past week, were you able to walk a mile?
Monitoring of Adherence to Treatment
Planned Follow Up
Conclusion
References
Suggested Readings
61 The Integrative Approach to Pain Management
61 - The Integrative Approach to Pain Management
Integrative Medicine: Overview
Multidimensional Perception of Pain
Integrative Medicine Modalities and Pain
Acupuncture and Traditional Chinese Medicine (TCM)
Mind-Body Medicine
Progressive Muscle Relaxation
Meditation
Guided Imagery
Hypnosis
Yoga
Tai Chi and Qi Gong
Virtual Reality
Therapeutic Art and Music
Energy Medicine
Manual Therapy
Adverse Effects From Manual Therapy
Massage
Chiropractic Manipulation
Osteopathic Manipulation
Orthopedic Manual Physical Therapy
Manual Medicine and the Biopsychosocial Model
Homeopathy
Biologically Based Products: Herbs, Nutraceuticals, and Nutritional  Supplements
Capsaicin
Boswellia Serrata
Glucosamine and Chondroitin
S-adenosyl-methionine (SAM-e)
Omega-3 Fatty Acids
Summary
Key Points
Suggested Readings
Appendix A
References
62 Patient Education and Self-Management
62 - Patient Education and Self-Management
.
Pain Self-Management: Definition and Components
Definition
Components of Pain Self-Management
The Patient-Clinician Relationship
Intrapersonal Skills
Lifestyle Management
Self-Monitoring
Social Support
Evidence Supporting Pain SMPs
Finding the Relevant Comparator
Review of the Evidence
Pain Self-Management in the Context of Primary Care
Reengineering the Point-of-Care
Explaining Self-management to Patients
How to ERASE SPACE
Reimbursement
Digital SMPs
Digital Pain Self-Management: Pros and Cons
Future Directions
Key Points
Suggested Readings
References
Part 6 Neural Block and Interventional Techniques
63 Neurolytic Agents, Neuraxial Neurolysis, and Neurolysis of Sympathetic Axis for Cancer Pain
63 - Neurolytic Agents, Neuraxial Neurolysis, and Neurolysis of Sympathetic Axis for Cancer Pain
Neurolytic Agents
Alcohol
Phenol
Glycerol
Neurolytic Blocks
Head and Neck
Gasserian Ganglion Neurolysis
Other Neurolytic Blocks of the Head and Neck
Paravertebral Sympathetic Neurolysis
Stellate Ganglion Block and Neurolysis
Clinically Relevant Anatomy
Indications
Available Techniques
Complications
Lumbar Sympathetic Neurolysis
Neurolytic Blocks of the Trunk and Extremities
Intercostal Neurolysis
Ilioinguinal and Iliohypogastric Neurolysis
Neurolysis of Other Peripheral Nerves
Neurolysis for Myofascial Pain and Spasticity
Neuraxial Neurolysis
Intrathecal Alcohol
Intrathecal Phenol
Epidural Neurolytic Block
Other Complications Associated With Intrathecal and Epidural Neurolysis
Neurolysis of the Sympathetic Axis for Cancer Pain Management
Celiac Plexus Block
Clinically Relevant Anatomy
Indications
Evidence for Celiac Plexus Block
Available Techniques
Drugs and Dosing
Complications
Efficacy
Superior Hypogastric Plexus Block
Clinically Relevant Anatomy
Available Techniques and Approaches
Indications
Complications
Efficacy
Ganglion Impar Block
Clinically Relevant Anatomy
Indications
Available Techniques and Approaches
Technique of Ultrasound Guided Ganglion Impar Block
Efficacy
Complications
Conclusion
Key Points
Suggested Readings
References
64 Head and Neck Blocks
64 - Head and Neck Blocks
Atlanto-Axial Joint Blockade
Technique of Atlanto-Axial Nerve Blockade
Third Occipital Nerve Blockade
Anatomical Considerations
The Third Occipital Nerve and Headache Pain
Rationale for Blocking the Third Occipital Nerve
Technique for Third Occipital Nerve Block
Radiofrequency Neurotomy
Technique of Blocking the Greater and Lesser Occipital Nerves
Ultrasound Guided Proximal Approach for the Greater and Lesser Occipital Nerve Block
Facial Pain Nerve Blockades
Supraorbital, Infraorbital, Mental Nerve Blocks
Inferior Alveolar (Mental) Nerve Block
Sphenopalatine Ganglion Blockade
Nerve Block Techniques
Trigeminal Nerve Blockade
Pterygopalatine Fossa Injection/Maxillary Nerve Block Technique
Ultrasound Techniques
Infrazygomatic Approach
Posterior to Anterior Approach
Anterior to Posterior Approach
Suprazygomatic Approach
Fluoroscopic Techniques
Maxillary and Mandibular Nerve Blocks
Glossopharyngeal Nerve Block
Ultrasound-guided Glossopharyngeal Nerve Blockade
Summary and Conclusions
Key Points
Suggested Readings
References
65 Interlaminar and Transforaminal Therapeutic Epidural Injections
65 - Interlaminar and Transforaminal Therapeutic Epidural Injections
.
History
Pathophysiology
Epidural Injection Techniques
Cervical Transforaminal Epidural
Lumbar Transforaminal Epidural
Cervical Interlaminar Epidural
Lumbar Interlaminar Epidural
Caudal Epidural
Pharmacology
Corticosteroid Alternatives
Evidence-Based Medicine for Corticosteroid Epidural Injections
Contrast Media Use in Epidural Steroid Injections
Complications of Epidural Steroid Injections
Postdural Puncture Headaches
Vascular Injury
Solvent Toxicity
Injectate Contamination
Epidural Abscess
Disease-Modifying Anti-rheumatic Drug Complications
Hematoma
Endocrine Complications
Neurologic Complications
Summary
Key Points
Suggested Readings
References
66 Radiofrequency Treatment
66 - Radiofrequency Treatment
Radiofrequency Generator System
Theoretical Aspects of Radiofrequency Treatment
Continuous Radiofrequency Treatment
Pulsed Radiofrequency Treatment
Practical Considerations
Cooled RF
Indications for Radiofrequency Treatment
Radiofrequency Treatment Procedures On The Head
Radiofrequency Treatment of the Gasserian Ganglion
Trigeminal Neuralgia
Treatment
Evidence
Procedure
Adverse Events and Complications
Radiofrequency Treatment of the Pterygopalatine (Sphenopalatine) Ganglion
Cluster Headache
Treatment and Evidence
Persistent Idiopathic Facial Pain
Procedure
Adverse Events and Complications
Radiofrequency Treatment Procedures on the Cervical Spine
Cervical Facet (Zygapophyseal) Joint Pain
Evidence
Procedure
Adverse Events and Complications
Radiofrequency Treatment of the Cervical DRG
Cervical Radicular Pain
Evidence for Radiofrequency Treatment Adjacent to the Cervical DRG
Evidence for Pulsed Radiofrequency Treatment Adjacent to the Cervical DRG
Procedure
Adverse Events and Complications
Pulsed Radiofrequency Treatment of the Occipital Nerve
Occipital Neuralgia
Evidence for Pulsed Radiofrequency Treatment of the Occipital Nerve
Technique for Pulsed Radiofrequency Treatment of the Occipital Nerve
Radiofrequency Treatment of the Lumbar DRG
Lumbosacral Radicular Pain
Procedure for Radiofrequency Treatment of the DRG
Evidence for Radiofrequency Treatment of the DRG
Evidence for Pulsed Radiofrequency Treatment of the Lumbar DRG
Procedure
Radiofrequency Procedures on the Knee
Radiofrequency Treatment of the Genicular Nerves
Chronic Anterior Knee Pain
Evidence
Procedure
Superomedial genicular nerve
Inferomedial genicular nerve
Superolateral genicular nerve
RF procedure
Adverse Events and Complications
Conclusions
Key Points
Suggested Readings
References
67 Pain Interventions for the Knee, Hip, and Shoulder
67 - Pain Interventions for the Knee, Hip, and Shoulder
Introduction
Pharmacology of Agents Utilized for Joint Injections
Local Anesthetics
Indications and Mechanism of Action
Adverse Effects and Complications Associated With Local Anesthetic Injection
Corticosteroids
Indications and Mechanism of Action
Corticosteroid Selection (Structure and Function)
Corticosteroid Dosing and Post-injection Protocols
Adverse Effects and Complications Associated With Corticosteroid Injection
Viscosupplementation
Indications and Mechanism of Action
Viscosupplementation Agent Selection (Structure and Function)
Dosing and Post-injection Protocols
Adverse Effects and Complications Associated With Viscosupplementation Injection
Joint Injection Techniques
Shoulder
Anatomy
Subacromial/Subdeltoid Bursa Injections
Indications and Musculoskeletal Pathophysiology
Palpation Guided Anatomic Injection Technique
Fluoroscopy Guided Injection Technique
Ultrasound Guided Injection Technique
Glenohumeral Joint Injections
Indications and Musculoskeletal Pathology
Fluoroscopy Guided Injection Technique
Ultrasound Guided Injection Technique
Acromioclavicular Joint Injection
Indications and Musculoskeletal Pathology
Fluoroscopy Guided Injection Technique
Ultrasound Guided Injection Technique
Efficacy of Shoulder Injections
Efficacy of Subacromial/Subdeltoid Bursa Injections
Efficacy of Glenohumeral Joint Injections
Efficacy of Acromioclavicular Joint Injections
Hip
Anatomy
Indications and Musculoskeletal Pathology
Palpation Guided Anatomic Injection Technique
Fluoroscopy Guided Intraarticular Hip Joint Injection Techniques
Anterior Approach
Lateral Approach
Ultrasound Guided Intra-articular Hip Injection Techniques
Efficacy of Intra-articular Hip Injections
Accuracy and Efficacy for Injection Technique Comparisons
Knee
Anatomy
Indications and Musculoskeletal Pathology
Injection Techniques
Palpation Guided Anatomic Knee Injection Techniques
Fluoroscopy Guided Knee Injection Techniques
Ultrasound Guided Injection Techniques
Efficacy and Safety of Intra-articular Knee Injections
Radiofrequency Ablation
Radiofrequency Ablation of the Knee Joint
Fluoroscopy Guided Technique
Ultrasound Guided Technique
Safety and Effectiveness of Radiofrequency Ablation of the Knee Joint
Radiofrequency Ablation of the Hip Joint
Fluoroscopy Guided Technique
Safety and Effectiveness of Radiofrequency Ablation of the Hip Joint
Radiofrequency Ablation of the Shoulder Joint
Fluoroscopy Guided Technique
Safety and Effectiveness of Radiofrequency Ablation of the Shoulder
Conclusion
Key Points
Suggested Readings
References
68 Myofascial Injections and Fascial Plane Blocks for Perioperative and Chronic Pain Management
68 - Myofascial Injections and Fascial Plane Blocks for Perioperative and Chronic Pain Management
Overview and Pathophysiology of Myofascial Pain Syndromes
Clinical Presentation and Diagnosis of Myofascial Pain Syndromes
Treatment of Trigger Points
Trigger Point Injection Technique and Follow Up
Ultrasound Guided Trigger Point Injection Techniques
Piriformis Injections
Combined Fluoroscopic Nerve Stimulator Guided Technique
Ultrasound Guided Piriformis Muscle Injection Technique
Injectate for Piriformis Target
Steroid
Local Anesthetic
Botulinum Toxin
Clonidine
Results of Treatment
Iliopsoas Injection
Relevant Anatomy
Imaging
Technique
Basic Considerations
Fluoroscopic Technique
Ultrasound Guided Technique
Lateral Approach
Posterior Approach
Results of Treatment
Steroid and Local Anesthetic Injections
Botulinum Toxin Injection
Truncal Blocks
Introduction
Quadratus Lumborum Block
Pecs I Block
Pec II Block
Erector Spinae Plane Block
Serratus Anterior Plane Block
Scalene Muscle Injections for Neurogenic Thoracic Outlet Syndrome
Overview of Thoracic Outlet Syndrome
Clinical Presentation and Diagnosis of TOS
Relevant Anatomy
Imaging
Injection Technique
Ultrasound Guided Technique
Summary
Key Points
Suggested Readings
References
69 Minimally Invasive Procedures for Vertebral Compression Fractures
69 - Minimally Invasive Procedures for Vertebral Compression Fractures
Conservative Medical Therapy
Technical Aspects
Sedation
Patient Positioning
Antibiotic Prophylaxis and Skin Preparation
Needle Placement
Additional Steps For Kyphoplasty
Cement Placement
Vertebroplasty
Kyphoplasty
Controversies and Special Topics
Bipedicular Versus Unipedicular Approach
Volume of Cement Injection
Vertebra Plana
Fractures With Intraosseous Vacuum Phenomenon (Kummel Disease)
Malignant Fractures With Posterior Wall Osteolysis or Epidural Tumor Extension
Safety of Multilevel Treatment
Outcomes
Mortality Benefit
Complications
Post-procedure and Follow Up Care
Summary and Conclusions
Key Points
Suggested Readings
References
70 Biopsychosocial Pre-screening for Spinal Cord and Peripheral Nerve Stimulation Devices
70 - Biopsychosocial Pre-screening for Spinal Cord and Peripheral Nerve Stimulation Devices
Overview
The Biopsychosocial Approach to Assessment
The Biopsychosocial Pre-screening Process
Clinical Framework for Biopsychosocial Pre-screening
Intake Survey
General Assessment: Pain Intensity, Disability, and Medication Use
Emotional Factors: Assessment of Mood
Personality Factors
Cognitive and Behavioral Assessment
Foundational Work on the Pre-screening Process for Spine Surgery
Advancement of Pre-screening Research and Use for SCS
Future Directions for Patient Screening
Summary and Conclusions
Key Points
Suggested Readings
References
71 Spinal Cord Stimulation, Peripheral Nerve Stimulation, Restorative Neurostimulation, Deep Brain Stimulation, and Motor Cortex Stimulation
71 - Spinal Cord Stimulation, Peripheral Nerve Stimulation, Restorative Neurostimulation, Deep Brain Stimulation, and Moto ...
Introduction
SCS Mechanisms of Action
Spinal Cord Stimulator Trial Technique
Spinal Cord Stimulator Permanent Implant
Complications
Clinical Outcomes
Peripheral Nerve Stimulation (PNS)
Motor Cortex and Deep Brain Stimulation
Summary
Key Points
Suggested Readings
References
72 Intrathecal Drug Delivery
72 - Intrathecal Drug Delivery
##
Patient Selection, Trialing, and Implantation
Intraspinal Drug Delivery Techniques
Externalized Systems
Partially Externalized Systems
Implanted Intrathecal Infusion Pumps
Intrathecal Pump Magnetic Resonance Imaging (MRI) Compatibility
Patient Selection
Pain Type
Patient Comorbidities
Diabetes Mellitus
Anticoagulant Therapy
Infections
Pulmonary Disease
Psychological Screening
Trialing
Implantation
Location of Pump Placement
Anesthesia for Pump Implantation
Patient Positioning
Surgical Technique
Sterile Technique
Posterior Incision, Catheter Placement, and Anchoring
Pump Pocket
Tunneling
Closure
Complications
Perioperative Complications
Bleeding
Infection
Cerebrospinal Fluid Leaks
Catheter Complications
Granuloma Formation
II Intrathecal Medications
Opioids
Calcium Channel Antagonists
g-Aminobutyric Acid Agonists
Local Anesthetics
Adrenergic Agonists
Conclusion
Key Points
Suggested Readings
References
73 Radiation Safety and Radiographic Contrast Agents
73 - Radiation Safety and Radiographic Contrast Agents
Key Points
Overview of Radiation Safety
Basic Radiation Physics
Minimizing Patient Radiation Exposure
Minimize Dose and Time
Optimize the Position of the X-ray Tube
Employ Shielding Whenever Possible
Employ Collimation
Minimizing Practitioner Exposure
Employ Proper Shielding
Practitioner Position
Optimizing Image Quality
Radiation From Interventional Pain Procedures
Overview of Radiographic Contrast Medium
Pharmacology of RCM
Adverse Reactions to RCM
Nonidiosyncratic Reactions
Hypersensitivity Reactions
Recognition and Treatment of Reactions to RCM
Prevention of Reactions to RCM
Use of Gadolinium as an Alternative to Iodinated RCM
Nephrogenic Systemic Fibrosis
Brain Deposition/Retention
Encephalopathy After Unintentional Intrathecal Gadolinium Injection
Differences Between Interventional Pain Procedures and Diagnostic MRIs and CT
Concluding Statements
Acknowledgments
Suggested Readings
References
74 Infection and Anticoagulation Considerations in Pain Procedures
74 - Infection and Anticoagulation Considerations in Pain Procedures
Section 1 Risk of infection in interventional pain procedures
Introduction
Definition of SSIs
Pathogens Associated With SSIs
Scope of Interventional Pain Procedures and Risk of Infection
Infection Rates
Preoperative Risk Reduction
Patient Risk Factors
Staphylococcus Aureus Carriers
Antibiotic Prophylaxis
Surgical Hand Washing
Appropriate Hair Removal
Intra-procedural Risk Reduction
Patient Skin Preparation in the Operating Room
Draping
Surgical Attire
Surgical Technique and Procedural Efficiency
Wound Irrigation
Topical Antimicrobials
Operating Room Environment
Wound Closure
Needle Contamination
Ultrasound Guided Regional Anesthesia and Pain Procedures
Medication Vials
Postoperative Risk Reduction
Wound Dressings
Patient Education and Postoperative Wound Surveillance
Infection Management
Conclusion
Key Points
Risk of Infection in Interventional Pain Procedures
Anticoagulation Considerations in Interventional Pain Procedures
Suggested Readings
Section 2 Anticoagulation Considerations in Interventional Pain Procedures
Introduction
Stratification of Risks
Aspirin and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
P2Y12 Inhibitors
Vitamin K Antagonists
Heparin and LMWH
Fibrinolytic Agents
Fondaparinux and the Direct Oral Anticoagulants (DOACs)
Laboratory Tests, Reversal, and Management of Direct Oral Anticoagulants Before Emergency Surgery
Anti-depressants
Herbal Medications
New Anticoagulants Targeting CF XI
COVID-19 Induced Coagulopathy
Summary and Concluding Statements
References
Risk of Infection in Interventional Pain Procedures
Anticoagulation Considerations in Interventional Pain Procedures
Part 7 Pain Management in Special Situations and Special Topics
75 Pain Management in Primary Care
75 - Pain Management in Primary Care
Background and Introduction
Is Pain a Diagnosis or a Symptom?
Definitions and Types of Pain
Pain Assessment
Diagnostic Assessment
Model of Pain in Primary Care: Low Back Pain
Timing and Description of Low Back Pain
History/Physical Exam and Provocative Maneuvers
Differential Diagnosis and Indications for Consultation
Shared Decision Making
Management of Chronic Low Back Pain
Pharmacologic Therapy for Low Back Pain
General Precautions for Non-opioid Pharmacologic Therapy
Summary of Treatment Recommendations for Low Back Pain
Musculoskeletal Pain in Adults
Multimodal Therapy and Nonpharmacologic Options for Managing Pain
Pharmacologic Approach to Pain and Opioid Use
CDC Guideline for Prescribing Opioids for Chronic Pain
Decision to Refer Patients for Pain Management
Primary Care Goals for Pain Management
Key Points
Suggested Readings
References
76 Pain Management in the Emergency Department
76 - Pain Management in the Emergency Department
~
Prevalence and Assessment of Pain in the ED
The Problem of Balancing Undertreatment of Pain and the Risk of Addiction
Pain Treatment
Specific Treatment Modalities
Non-opioids
Sub-dissociative ketamine
IV Lidocaine
Opioids
Patient-Controlled Analgesia
Adjunctive therapies and nonpharmacologic treatments
Medication Assisted Therapy (MAT) in the ED
Conclusion
Key Points
Suggested Readings
References
77 Management of Pain in Sickle Cell Disease
77 - Management of Pain in Sickle Cell Disease
~
Epidemiology of Vaso-occlusive Pain
Other Pain Etiologies in Sickle Cell Disease
Sickle Cell Disease Pain Management
Education Is the Foundation
Home Management: “It Takes a Village”
Management of Sickle Cell Disease Pain in the Acute Care Setting
Sickle Cell Disease Pain Management in the Inpatient Setting
Management of Perioperative Pain in Sickle Cell Disease
Management of Chronic Pain in Sickle Cell Disease: Largely Uncharted Territory
Summary
Key Points
Suggested Readings
References
78 Burn Pain
78 - Burn Pain
Introduction
Epidemiology
Pathophysiology
Phases of Burn Recovery
Types of Pain in Burn Patients
Pain Management Options
Pharmacologic Analgesia
Opioids
NMDA Receptor Antagonists
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
α2δ Agonists
Na+-channel Blockers—Local Anesthetics
α2-Adrenergic Agonists
Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
Nonpharmacologic Analgesia
Virtual Reality
Music Therapy
Relaxation Techniques
Summary
Key Points
Suggested Readings
References
79 Pain Evaluation and Management in Patients With Limited Ability to Communicate Because of Dementia
79 - Pain Evaluation and Management in Patients With Limited Ability to Communicate Because of Dementia
Key Points
Pain Assessment Using Self-Report
Pain Assessment Using Observational Assessment Tools
Other Dimensions of the Pain Experience
A Clinical Approach to Assessment of the Older Adult With Limited Ability to Communicate Because of Dementia
Nonpharmacologic Pain Management
Pharmacologic Pain Management
Thermal and Topical Therapies
Acetaminophen
Oral Non-steroidal Antiinflammatory Drugs
Opioids
Adjuvant Therapies
General Limitations
Conclusions
Suggested Readings
References
80 Disparities in Pain Care: Descriptive Epidemiology-Potential for Primary Prevention
80 - Disparities in Pain Care: Descriptive Epidemiology-Potential for Primary Prevention
Background to this Chapter
Part I: Introduction
Part I: Epidemiology of Disparities in Pain Care
Definition of Disparities and Indicators of “Suboptimal” Pain Care
Population Groups at Risk of Disparities in Pain Care
Disparities in Pain Care: Summary of Recent Evidence
Acute Pain Care: Emergency Department, Primary Care Settings
Pre- and Post-Op and Postpartum Acute Pain Care to Ethnic/Racial Minorities
Chronic Non-cancer Pain
Ethnic/racial disparities in Cancer Pain Care
Consequences/Outcomes of Suboptimal Pain Care
Transition From Acute to Chronic Pain and Post Surgery Chronic Pain
Part II: Factors Contributing to the Occurrence of Disparities in Pain Care
Societal Issues: Systemic Racism
Systemic Racism-Contributions of the Healthcare System in the United States
Systemic Racism-Segregated Residential Neighborhoods
Provider Contributions to Disparities in Pain Care
Limited Education
False Beliefs Held by Physicians and Other Healthcare Providers
Personally, Mediated Racism: Provider Explicit and Implicit Racial Biases
Patient Characteristics That Contribute to Disparities in Their Care
Mistrust and Miscommunication between provider and patient
PART III: Potential for the Primary Prevention of Disparities in Pain Care
Actions to be Taken by Individual Pain Care Providers
Actions to Develop and/or Refine Structured Multi-session Educational Programs
Educational Programs to Develop Cultural Competence
Educational Programs for Addressing Implicit Bias
Actions to be Undertaken in Conjunction With Professional Organizations of Pain Providers
Conclusions
Key Points
Suggested Readings
References
81 Pain Management in the Critically Ill Patient
81 - Pain Management in the Critically Ill Patient
Introduction
Prevalence of Pain in the Intensive Care Unit (ICU)
Barriers to Pain Assessment in the ICU
Barriers to Pain Treatment in the ICU
Benefits of Assessing and Treating Pain in the ICU
Methods of Pain Control in the ICU
Neuraxial Analgesia and Regional Anesthesia in the ICU
Sedation in the ICU
Conclusion
Key Points
Suggested Readings
References
82 Pain Management at the End of Life and Home Care for the Terminally Ill Patient
82 - Pain Management at the End of Life and Home Care for the Terminally Ill Patient
Introduction
Prevalence and Causes of Pain at the End of Life
Assessing Pain and Suffering at the End of Life
Caregivers on the Front Line at the End of Life
The Role of Caregivers
Case 1: Caregiver’s Role
Misconceptions, Challenges, and Barriers to Pain Management in the Home
Effects of Unrelieved Pain on the Patient and Caregiver
Recommendations for Positive Outcomes
Planning for Home Pain Management
Transition From Hospital to Home
Case 2: Transition From Home to Hospital
The Decision for Long Term Care Facility or Hospice Care
Discharge to Suspected Drug Diverting Environments
Communication: The Cornerstone of Good Pain Management in the Home
Foundation of Communication
Tools of Communication
Case 3: Telemedicine as a Tool of Communication
Pain Management Therapies at the End of Life
How to Approach Pain Management at the End of Life
Nonpharmacologic Approaches to Pain Management in Palliative Care
Rehabilitation and Physical Therapy
Massage Therapy
Electrophysical Modalities
Psychotherapy
Acupuncture
Music Therapy
Pharmacologic Approaches to Pain Management in Palliative Care
Non-opioid Analgesics
Acetaminophen
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Naltrexone
Opioid Analgesics
Morphine
Oxycodone
Hydromorphone
Fentanyl
Methadone
Buprenorphine
Tapentadol
Routes of Administration of Opioids
Adjuvant Therapies
Anti-depressants
Anti-convulsants
Corticosteroids
Local Anesthetics
Bisphosphonates
Palliative Chemotherapy and Radiation Therapy
Therapy for Intractable Pain
Cannabis for End of Life Therapy
Beginning Therapy, Adding or Changing Drugs, and Breakthrough Pain
Minimizing and Managing Adverse Effects
Constipation
Sedation
Respiratory Depression
Nausea and Vomiting
Myoclonus
Pruritus
Hyperalgesia
Conclusion
Key Points
Suggested readings
References
Part 8 Research, Ethics, Healthcare Policy, and Future Directions in Pain Management
83 Clinical Trial Design Methodology and Data Analytic Strategies for Pain Outcome Studies
83 - Clinical Trial Design Methodology and Data Analytic Strategies for Pain Outcome Studies
~
Evidence-Based Medicine
The Spectrum of Outcomes Research
Experimental Versus Observational Study Designs
Case Report and Case Series
Cross-Sectional Study
Case-Control Study
Nested Case-Control Study
Cohort Study
Non-Randomized Controlled Trial
Randomized Controlled Trial
Cluster Randomized Controlled Trial
Meta-Analysis
Healthcare Economic Evaluation
Standards for Reporting Study Design and Findings
Standardization of Pain-Related Outcome Measures
Assessing and Addressing Bias and Confounding in Clinical Research
Statistical Concepts and Methods for Pain Outcome Studies
Basic Statistical Concepts and Terminology
Descriptive Statistics
Inferential Statistics
Hypothesis Testing
Effect Sizes
Commonly Used Inferential Statistical Methods in Pain Research
Statistical Methods for Continuous Outcomes
Statistical Methods for Count Data and Ordinal Data
Statistical Methods for Categorical Outcomes
Statistical Methods for Time-to-Event (Survival) Data
Statistical Methods to Assess for Agreement
Meta-Analysis
Important Statistical Considerations and Common Pitfalls
The Visual Analog Scale Controversy: Ordinal or Ratio Scale?
Sample Size Calculation
Multiplicity Adjustments
Distinguishing Between Statistical and Clinical Significance
Equivalence and Non-Inferiority Trials
Multiple Related Outcomes and Joint Hypothesis Testing
Association Versus Causation—Confounding in Observational Research
Concluding Statements
Key Points
Suggested Readings
References
84 Outcome Domains and Measures in Acute and Chronic Pain Clinical Trials
84 - Outcome Domains and Measures in Acute and Chronic Pain Clinical Trials
~
Selecting Outcome Measures  for Use in Clinical Trials
Clinical Significance vs. Statistical Significance
Outcome Domains and Measures  in Adult Acute Pain Trials
Outcome Domains for Adult Chronic Pain Clinical Trials
Pain
Neuropathic Pain Measures
Physical Functioning
Emotional Functioning
Patients’ Beliefs, Expectations, and Coping
Measures in the Elderly and Patients  With Cognitive Impairment
Domains and Measures in Acute and Chronic Pediatric Pain Clinical Trials
Patient Satisfaction
Summary and Conclusions
Key Points
Suggested Readings
References
85 Ethical Issues in Pain Research
85 - Ethical Issues in Pain Research
Brief Historical Overview
Ethical Issues Specific to Pain Research
Ethics of Placebos
The Ethics of Laboratory Induced Pain in Humans
Clinical Trials in Minors
Ethical Issues in Genomic Approaches to Understanding Pain
Conclusion
Key Points
Suggested Readings
References
86 Treatment Development: Directions and Areas in Need of Investigation
86 - Treatment Development: Directions and Areas in Need of Investigation
Introduction
Perioperative Pain Management
Enhanced Recovery Pathways
Chronic Post-surgical Pain
Preoperative Considerations
Preoperative Opioid Optimization
Intraoperative Considerations
Analgesia in Patients With Obstructive Sleep Apnea
Pharmacologic Chronic Pain Management
Acetaminophen
Nonsteroidal Anti-inflammatory Drugs
Opioids
Tramadol and Tapentadol
Anti-depressants (Tricyclic Anti-depressant, Selective Serotonin Reuptake Inhibitor, and Serotonin and Norepinephrine Reup ...
Anti-convulsants
Topical Treatments
Monoclonal Antibodies
Newer Pharmacologic Options
Cannabinoids
Nectar 181 (NKTR181) or Oxycodegol
Oliceridine (TRV130)
Kapa (kKOR) Opioid Family of Agonists
Bisphosphates
Immune Signaling
Lipid Mediators
Sodium Channel Blockers
N-Methyl-d-aspartate Antagonists
Neurokinin
Gene Therapy
Non-pharmacologic Chronic Pain Management
Interventional Pain Management
Obstacles
Comparative and Cost Effectiveness
Predictive Modeling
Biomarkers
Regenerative Medicine
Non-interventional Chronic Pain Management
The Value of Identifying Types of Pain and Underlying Processes
The Value of Identifying the Chronic Overlapping Pain Conditions
The Value of Understanding Central Sensitization
Digital Pain Management Resources
Expanding the Value of Symptom Tracking: Personalized Medicine Using N-of-1 Trials
Conclusions
Key Points
Suggested Readings
References
Index