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ISBN 10: 1496347773
ISBN 13: 9781496347770
Author:  Gary Brenner, James Rathmell
Offering expert guidance from seasoned clinicians at Massachusetts General Hospital, this bestselling handbook provides accurate, clinically essential information in a portable, quick-reference format. Broad-based, multidisciplinary coverage draws from the disciplines of anesthesiology, neurology, behavioral medicine, nursing, psychiatry, and physical therapy to provide practical, evidence-based information for sound therapeutic choices. Now in full color for the first time, The Massachusetts General Hospital Handbook of Pain Management, Fourth Edition, contains numerous new chapters, new illustrations, and other features that keep you up to date with today’s latest approaches to pain management.
 

The Massachusetts General Hospital Handbook of Pain Management 4th Table of contents:

SECTION I: GENERAL CONSIDERATIONS

1 Neurophysiologic Basis of Pain

I. PRIMARY SOMATOSENSORY NEURONS

A. Definitions

B. Nerve Fiber Types

C. Nociceptors

D. Peripheral Sensitization

II. SPINAL CORD AND DORSAL HORN SYNAPTIC TRANSMISSION

A. Dorsal Horn Laminar Organization

B. Dorsal Horn Neurotransmission

C. Central Sensitization

III. SUPRASPINAL PAIN PROCESSING

A. Ascending Nociceptive Tracts

B. Brain Centers

IV. DESCENDING PROJECTIONS

A. Descending Systems

B. Neurotransmitters Involved in Descending Modulation

V. CONCLUSION

2 Pain Mechanisms and Their Importance in Clinical Practice and Research

I. CANONICAL NOCICEPTION PATHWAY

II. PAIN ONTOLOGY AND PATIENT SYMPTOMOLOGY

III. MECHANISMS OF PATHOLOGICAL PAIN

A. Peripheral Sensitization

B. Peripheral Respecification

C. Synaptic Potentiation

D. Synaptic Sprouting

E. Opening the Gate

1. Inhibitory Interneuron Death

2. Modification of Chloride Gradient

F. Descending Pain Control

G. Encoding Pain in the Brain

IV. TOWARD MECHANISM-BASED DIAGNOSIS AND THERAPY

A. Genetics of Pain Mechanisms

V. IMPLICATIONS FOR EVALUATION OF NEW THERAPIES

VI. CONCLUSION

3 Ethics of Pain Management

I. ETHICAL FRAMEWORKS

A. Four Principles

1. Nonmaleficence

2. Beneficence

3. Autonomy

4. Justice

B. Four-Quadrant Approach

1. Indications for Medical Intervention

2. Patient Preferences

3. Quality of Life

4. Contextual Features

C. CARE

1. Core Beliefs: Interior Individual

2. Actions: Exterior Individual

3. Reasons: Interior Collective

4. Experience: Exterior Collective

D. Microethics

1. Respecting and Constructing Patient Values and Preferences

2. Self-awareness and Management of Clinician Values and Biases

3. Managing Medical Information

II. EXAMPLES OF ETHICAL APPLICATIONS IN PAIN MEDICINE

A. Nonopioid Pharmacologic Options

1. Case

2. Discussion

B. Opioids and Interventions

1. Case

2. Discussion

III. CONCLUSIONS

SECTION II: DIAGNOSIS OF PAIN

4 The History and Clinical Examination

I. PATIENT INTERVIEW

A. Pain History

1. Development and Timing

2. Intensity

3. Character

4. Evolution

5. Associated Symptoms

6. Aggravating and Relieving Factors

7. Previous Treatment

B. Medical History

1. Review of Systems

2. Past Medical History

3. Past Surgical History

C. Drug History

1. Current Medications

2. Allergies

D. Social History

1. General Social History

2. Family History

3. Occupational History

II. PATIENT EXAMINATION

A. General Examination

1. Constitutional Factors

2. Pain Behavior

3. Skin

B. System Examination

1. Cardiovascular System

2. Lungs

3. Musculoskeletal System

C. Specific Tests

1. Straight Leg Raising (SLR, Lasègue)

2. Basic Sacroiliac Tests

3. Spinal Flexibility

4. Adson Test

5. Neurologic Examination

6. Mental Status Examination

III. INCONSISTENCIES IN THE HISTORY AND PHYSICAL EXAMINATION

IV. CONCLUSION

5 Assessment of Pain

I. PAIN HISTORY

A. Pain Assessment Tools

1. Unidimensional Self-report Scales

2. Multiple Dimension Instruments

3. Pain Diaries

B. Pain Location

C. Pain Etiology

1. Types of Pain

II. PHYSICAL EXAMINATION

A. General Physical Examination

B. Specific Pain Evaluation

C. Neurologic Examination

D. Sensory Testing

E. Musculoskeletal System Examination

F. Assessment of Psychological Factors

III. DIAGNOSTIC STUDIES

IV. CONCLUSION

6 Psychological Assessment of Pain and Headache

I. THE BIOPSYCHOSOCIAL MODEL OF PAIN ASSESSMENT

II. PSYCHOLOGICAL RISK SCREENING VS COMPREHENSIVE PSYCHOSOCIAL ASSESSMENT

III. THE PROGRESSION FROM ACUTE TO CHRONIC PAIN CONDITIONS

IV. COMMON PSYCHOLOGICAL COMORBIDITIES WITH CHRONIC PAIN

V. PAIN BEHAVIORS

VI. STANDARDIZED MEASURES

VII. SELF-REPORT MEASURES

VIII. OBSERVATIONAL MEASURES

IX. BEHAVIORAL ASSESSMENT FOR EFFECTIVE GOAL SETTING

X. BARRIERS AND STIGMA ASSOCIATED WITH PSYCHOLOGICAL ASSESSMENT

XI. SPECIAL CONSIDERATIONS FOR INDIVIDUALS RECEIVING CHRONIC OPIOID THERAPY

XII. SPECIAL CONSIDERATIONS FOR WORK-INJURED POPULATIONS

XIII. KEY POINTS

7 Diagnostic Imaging and Pain Management

I. OVERVIEW

II. IMAGING TECHNIQUES AND STUDIES

A. Plain Films

B. Fluoroscopy

C. Computed Tomography

D. Magnetic Resonance Imaging

E. Myelography

F. Bone Scans and Nuclear Medicine

G. Discography

H. Positron Emission Tomography

I. Functional Magnetic Resonance Imaging

III. HEADACHE

A. Primary Headache

B. Secondary Headache

IV. CRANIOFACIAL PAIN SYNDROMES

A. Trigeminal Neuralgia

B. Glossopharyngeal Neuralgia

V. CENTRAL PAIN SYNDROMES

VI. THALAMIC PAIN SYNDROMES

VII. SPINAL CORD INJURY

A. Axial Low Back Pain

B. Plain X-ray Evaluation of Low Back Pain

C. MRI and Low Back Pain

D. Pain After Lumbar Surgery

E. Arachnoiditis

VIII. METASTATIC DISEASE OF THE SPINE

IX. INFECTIOUS PROCESSES OF THE VERTEBRAL SPINE

X. CONCLUSION

8 Neurophysiologic Testing in Pain Management

I. INTRODUCTION

II. ELECTRODIAGNOSTIC TESTING

A. Nerve Conduction Studies

B. Needle Electrode Examination

C. Localizing a Nerve Injury

D. Aiding in Diagnosis

E. Clinical Applications

III. QUANTITATIVE SENSORY TESTING

A. Thermal Stimuli

B. Vibration Stimuli

C. Mechanical Stimuli

D. Electrical Stimuli

IV. EVOKED POTENTIALS

A. Somatosensory Evoked Potentials

B. Laser Evoked Potentials

V. AUTONOMIC TESTING

VI. CONCLUSION

9 Disability Assessment

I. BURDEN OF DISABILITY ASSOCIATED WITH PAIN

II. WHY PROVIDERS ARE ASKED TO ASSESS DISABILITY

III. KEY INSIGHTS ON ASSESSING DISABILITY

IV. HOW TO ASSESS DISABILITY

A. Preparation

B. Face-to-Face Interview

C. Functional Assessment

D. Document Observations, Answer Specific Questions, and Develop Report

V. PITFALLS OF FORMAL FUNCTIONAL CAPACITY EVALUATIONS

VI. MALINGERING AND NONMEDICAL INFORMATION

VII. CONCLUSION

SECTION III: THERAPEUTIC OPTIONS: PHARMACOLOGIC APPROACHES

10 Neuropathic Pain Medications

I. ANTIDEPRESSANTS

II. TRICYCLIC ANTIDEPRESSANTS

A. Mechanism of Action

B. Pharmacology

C. Dosing and Monitoring

D. Adverse Side Effects

E. Indications and Evidence

III. SELECTIVE SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS

A. Mechanism of Action

B. Pharmacology

C. Dosing and Monitoring

D. Adverse Side Effects

E. Indications and Evidence

IV. SELECTIVE SEROTONIN REUPTAKE INHIBITORS

A. Mechanism of Action

B. Pharmacology

C. Dosing and Monitoring

D. Adverse Side Effects

E. Indications and Evidence

V. OTHER MEDICATIONS

A. Trazodone

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

B. Mirtazapine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

C. Bupropion

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

D. Ketamine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

VI. CALCIUM CHANNEL BLOCKERS

A. Gabapentin

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

B. Pregabalin

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

C. Ziconotide

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

D. Zonisamide

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

VII. ANTICONVULSANTS

A. Carbamazepine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

B. Oxcarbazepine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

C. Lamotrigine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

D. Topiramate

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

E. Lithium

F. Phenytoin

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

VIII. LOCAL ANESTHETICS

A. Lidocaine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

B. Mexiletine

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

IX. NEUROLEPTICS

A. Typical

1. Mechanism of Action

2. Pharmacology

3. Adverse Side Effects

4. Indications and Evidence

B. Atypical

1. Mechanism of Action

2. Pharmacology

3. Adverse Side Effects

4. Indications and Evidence

C. Capsaicin

1. Mechanism of Action

2. Pharmacology

3. Dosing and Monitoring

4. Adverse Side Effects

5. Indications and Evidence

11 Opioids

I. DEFINITIONS

A. Addiction

B. Physical Dependence

C. Tolerance

D. Opium

E. Opioid

F. Opiate

G. Narcotic

H. Opioid-Induced Hyperalgesia

II. HISTORY

III. OPIOID CRISIS

IV. MECHANISM OF ACTION

V. DURATION OF TREATMENT

VI. OPIOID RISK STRATIFICATION

VII. COMMON OUTPATIENT OPIOIDS

A. Buprenorphine

B. Codeine

C. Fentanyl

D. Hydrocodone

E. Hydromorphone

F. Morphine

G. Oxycodone

H. Methadone

I. Tramadol

VIII. DIALYSIS-DEPENDENT PATIENTS

IX. SIDE EFFECTS

A. Endocrine Effects

B. Falls Risks

X. FUTURE OF OPIOIDS

12 Nonsteroidal Anti-inflammatory Medications

I. MECHANISM OF ACTION

II. PHARMACOKINETICS

III. ADVERSE EFFECTS

A. Gastrointestinal Side Effects

B. Cardiovascular Side Effects

C. Hematologic Side Effects

D. Renal and Hepatic Side Effects

E. Miscellaneous Side Effects

IV. SPECIFIC MEDICATIONS

A. Acetaminophen

13 Psychopharmacology for the Pain Specialist

I. ANTIDEPRESSANTS

A. Tricyclic Antidepressants

1. Indications

2. Mechanisms

3. Adverse Effects

4. Dosages and Monitoring

B. Selective Serotonin Reuptake Inhibitors

1. Indications

2. Mechanisms

3. Adverse Reactions

4. Dosages and Monitoring

C. Serotonin-NE Reuptake Inhibitors

1. Indications

2. Mechanisms

3. Adverse Reactions

4. Dosages and Monitoring

D. Atypical Antidepressants

1. Indications

2. Mechanisms

3. Adverse Reactions

4. Dosages and Monitoring

II. ANTIEPILEPTIC AGENTS (ANTICONVULSANTS)/MOOD STABILIZERS

A. Indications

B. Mechanisms

C. Adverse Reactions

D. Dosages and Monitoring (Table 13.6)

III. ANXIOLYTICS

A. Indications

B. Mechanisms

C. Adverse Reactions

1. Dosages and Monitoring

IV. ANTIPSYCHOTICS

A. Indications

B. Mechanisms

C. Adverse Reactions

D. Dosages and Monitoring

V. PSYCHOSTIMULANTS

A. Indications

B. Mechanisms

C. Adverse Reactions

D. Dosages and Monitoring

VI. CONCLUSIONS

SECTION IV: THERAPEUTIC OPTIONS: INTERVENTIONAL APPROACHES

14 Epidural Steroid Injection

I. EFFICACY

A. Evidence of Efficacy

B. Mechanisms of Efficacy

II. GENERAL PRINCIPLES

A. Choice of Injectate

1. Corticosteroids

2. Local Anesthetic

B. Physiologic Effects of Corticosteroids and Epidural Steroid Injections

1. Immunosuppression

2. Elevation of Blood Glucose

3. Suppression of the Hypothalamic-Pituitary-Adrenal Axis

4. Bone Demineralization

C. Complications

III. PROCEDURAL CONSIDERATIONS

A. Preprocedure Management

B. Contrast Media

C. Postprocedure Management

D. Lumbar and Cervical Interlaminar Approach

E. Lumbar Transforaminal Approach

F. Posterior S1 Foramen Approach

G. Caudal Approach

15 Radiofrequency Procedures for Chronic Pain

I. TYPES OF RFA

II. FACET JOINTS

III. SACROILIAC JOINT

IV. DORSAL ROOT GANGLIA

V. HIP

VI. KNEE

VII. OCCIPITAL NERVES

VIII. TRIGEMINAL NERVE

IX. SYMPATHETIC GANGLIA

X. CONCLUSIONS

16 Sympathetic Blocks

I. LUMBAR SYMPATHETIC BLOCK

A. Anatomy

B. Indications

C. Technique

D. Complications

II. STELLATE GANGLION BLOCK

A. Anatomy

B. Indications

C. Technique

D. Complications

III. CELIAC PLEXUS BLOCK

A. Anatomy

B. Indications

C. Technique

D. Complications

IV. SUPERIOR HYPOGASTRIC BLOCK

A. Anatomy

B. Indications

C. Techniques

D. Complications

V. GANGLION IMPAR BLOCK

A. Anatomy

B. Indications

C. Technique

D. Complications

17 Lumbar Diskography and Intradiscal Treatments

I. PROVOCATION DISKOGRAPHY/DISK STIMULATION

A. Definitions

B. Patient Selection

C. Contraindications

D. Procedure

E. Level Determination

F. Needle Positioning

G. Disk Stimulation

II. INTRADISCAL INTERVENTION PROCEDURES

III. PERCUTANEOUS DISK DECOMPRESSION

A. Intradiscal Electrothermal Therapy

B. Nucleoplasty

C. Biacuplasty

18 Spinal Cord Stimulation

I. MECHANISM OF ACTION

II. INDICATIONS AND EVIDENCE

III. TECHNICAL CONSIDERATIONS

IV. COMPLICATIONS

V. FUTURE DIRECTIONS

19 Peripheral Nerve Blocks

I. OCCIPITAL NERVE BLOCK

A. Indications

B. Equipment and Position

C. Technique

D. Complications

E. Considerations

II. TRIGEMINAL NERVE BRANCH BLOCKS

A. Indications

B. Equipment and Position

C. Technique

1. Pain in Ophthalmic (V1) Division

2. Pain in Maxillary (V2) and Mandibular (V3) Divisions

D. Complications

E. Considerations

III. SPHENOPALATINE GANGLION BLOCK

A. Indications

B. Equipment

C. Technique

D. Complications

E. Considerations

IV. SUPRASCAPULAR NERVE BLOCK

A. Indications

B. Equipment

C. Techniques

1. Landmark Technique

2. Fluoroscopically Guided Technique

3. Ultrasound Guided Technique

D. Complications

E. Considerations

V. INTERCOSTAL NERVE BLOCK

A. Indications

B. Equipment and Position

C. Technique

1. Landmark Technique

2. Fluoroscopy Guided Technique

3. Ultrasound Guided Technique

D. Specific Complications

E. Considerations

VI. ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE BLOCK

A. Indications

B. Equipment

C. Technique

1. Landmark Technique

2. Ultrasound Guided Technique

D. Complications

E. Considerations

VII. PUDENDAL NERVE BLOCK

A. Indications

B. Equipment

C. Technique

D. Specific Complications

E. Considerations

VIII. LATERAL FEMORAL CUTANEOUS NERVE BLOCK

A. Indications

B. Equipment

C. Technique

1. Landmark Technique

2. Ultrasound Guided Technique

D. Complications

E. Considerations

IX. GENICULAR NERVE BLOCK

A. Indications

B. Equipment

C. Technique

D. Complications

E. Considerations

20 Implanted Spinal Drug Delivery Systems

I. MECHANISM OF ACTION

II. OVERVIEW OF IT PHARMACOLOGY

A. Morphine

B. Hydromorphone

C. Fentanyl and Sufentanil

D. Bupivacaine

E. Clonidine

F. Ziconotide

III. PATIENT SELECTION

IV. NONPHARMACOLOGICAL COMPLICATIONS

V. CONCLUSIONS

21 Infusion Therapies

I. LIDOCAINE AND MEXILETINE

A. Mechanism of Action and Pharmacology

B. Uses in Specific Populations

C. Dosing

D. Routes of Administration

E. Adverse Effects

II. KETAMINE INFUSION

A. Mechanism of Action and Pharmacology

B. Uses in Specific Populations

C. Dosing

D. Routes of Administration

E. Adverse Effects

III. DEXMEDETOMIDINE INFUSION

A. Mechanism of Action and Pharmacology

B. Uses in Specific Populations

C. Dosing

D. Routes of Administration

E. Adverse Effects

IV. BISPHOSPHONATE INFUSION

A. Mechanism of Action and Pharmacology

B. Uses in Specific Populations

C. Dosing

D. Routes of Administration

E. Adverse Effects

V. PHENTOLAMINE

A. Mechanism of Action and Pharmacology

B. Uses in Specific Populations

C. Dosing

D. Routes of Administration

E. Adverse Effects

22 Neurosurgical Interventions for Pain

I. GENERAL CONSIDERATIONS

A. Timing and Patient Selection

B. Treatment Modalities

II. TRIGEMINAL NEURALGIA

A. Diagnostic Considerations

B. Microvascular Decompression

C. Percutaneous Treatments

D. Radiosurgery

III. SPINAL INTERVENTIONS FOR NEUROPATHIC PAIN

A. Dorsal Root Entry Zone Lesioning

B. Spinal Cord Stimulation

IV. CANCER PAIN

A. Cordotomy

B. Implantable Drug Delivery Pumps

V. AFFECTIVE PAIN

A. Cingulotomy

VI. NEUROMODULATION FOR PAIN

A. Deep Brain Stimulation

B. Motor Cortex Stimulation

VII. CONCLUSIONS

23 Complications Associated With Interventional Pain Treatment

I. OVERVIEW

II. COMPLICATIONS ASSOCIATED WITH EPIDURAL, FACET JOINT, AND SACROILIAC INJECTION

A. Neurotoxicity

B. Neurologic Injury

III. PHARMACOLOGIC EFFECTS OF CORTICOSTEROIDS

IV. BLEEDING COMPLICATIONS

V. INFECTIOUS COMPLICATIONS

VI. COMPLICATIONS ASSOCIATED WITH TRANSFORAMINAL INJECTIONS

VII. COMPLICATIONS ASSOCIATED WITH IMPLANTABLE DEVICES

24 Fluoroscopy and Radiation Safety

I. OVERVIEW

II. BASIC RADIATION PHYSICS

III. MINIMIZING PATIENT RADIATION EXPOSURE

A. Minimize Dose and Time

B. Optimize the Position of the X-ray Tube

C. Employ Shielding Whenever Possible

D. Employ Collimation

IV. MINIMIZING PRACTITIONER EXPOSURE

A. Employ Proper Shielding

B. Practitioner Position

C. Optimizing Image Quality

25 Outcome Data and Interventional Pain Medicine

I. INTRODUCTION

II. TYPES OF OUTCOME DATA

III. CHARACTERISTICS OF OUTCOME DATA

IV. BIAS IN OUTCOME DATA

V. SPECIAL FEATURES OF OUTCOME DATA IN PAIN MEDICINE

VI. OUTCOME MEASUREMENT IN SPECIAL POPULATIONS

VII. OUTCOME DATA FOR PAIN

VIII. CONCLUSIONS

SECTION V: THERAPEUTIC OPTIONS: NONPHARMACOLOGIC/NONINTERVENTIONAL APPROACHES

26 Behavioral Treatments for Chronic Pain

I. INTRODUCTION

II. HISTORY

A. Operant Behavioral

B. Cognitive-Behavioral Therapy

C. Mindfulness- and Acceptance-Based Treatments

III. DSM-5 CHANGES: SOMATIC SYMPTOM DISORDER

IV. PSYCHOLOGICAL FACTORS THAT IMPACT PAIN AND FUNCTION

V. BEHAVIORAL HEALTH INTERVENTION FOR PATIENTS UTILIZING OPIOID MEDICATIONS

VI. OPERANT BEHAVIORAL THERAPY

VII. COGNITIVE-BEHAVIORAL THERAPY

VIII. MINDFULNESS MEDITATION

IX. ACCEPTANCE AND COMMITMENT THERAPY

X. MOTIVATIONAL INTERVIEWING

XI. CONCLUSIONS AND FUTURE DIRECTIONS

27 Physical Therapy

I. PHYSICAL THERAPY EVALUATION

II. PHYSICAL THERAPY INTERVENTION/PAIN MANAGEMENT

C. Education and Self-management

D. Therapeutic Exercise

E. Passive Modalities

F. Coordination With Care Team

III. CONCLUSION

28 Myofascial Pain Syndrome and Fibromyalgia: Evaluation and Treatment

I. OVERVIEW

A. Myofascial Pain Syndrome

B. Fibromyalgia

II. EVALUATING THE PATIENT WITH CHRONIC WIDESPREAD PAIN

A. Myofascial Pain Syndrome

1. Clinical Presentation

2. Diagnostic Criteria

B. Fibromyalgia

1. Clinical Presentation

2. Diagnostic Criteria

III. TREATMENT PRINCIPLES

A. Myofascial Pain Syndrome

1. Pharmacologic Management

2. Interventional Treatments/Trigger Point Injections

3. Rehabilitation Approaches

4. Psychological Therapies

B. Fibromyalgia

1. Pharmacologic Management

2. Interventional Treatments

3. Rehabilitation Approaches

4. Psychological Therapies

IV. CONCLUSION

29 Acupuncture

I. INTRODUCTION

II. THE THEORY OF ACUPUNCTURE TREATMENT

III. COMPLICATIONS AND SIDE EFFECTS

IV. SCIENTIFIC BASIS

A. Central Nervous System

B. Peripheral Nerve System

C. Endogenous Opioid Peptides

D. Neurotransmitters

E. Nitric Oxide

F. Functional Magnetic Resonance Imaging

V. CLINICAL EVIDENCE

A. Treatment Effect Categories From WHO

B. Back Pain

C. Neck and Shoulder Pain

D. Headache

E. Acupuncture for Other Pain

F. Acupuncture for Other Medical Conditions

VI. CHALLENGES OF ACUPUNCTURE TREATMENT

VII. CONCLUSION

SECTION VI: ACUTE PAIN

30 Adult Postoperative Pain

I. INTRODUCTION

II. PRINCIPLES OF POSTOPERATIVE PAIN MANAGEMENT

A. Preoperative Planning and Setting Expectations

1. Physical Prehabilitation

2. Psychological Prehabilitation

III. METHODS OF POSTOPERATIVE ANALGESIA

A. Pharmacology

1. Opioids

2. Nonsteroidal Anti-inflammatory Drugs

3. Anticonvulsants

4. Antidepressants

5. N-Methyl-D-Aspartate (NMDA) Receptor Antagonists

6. α2 Agonists

7. Local Anesthetics

B. Regional Anesthesia

1. Epidural Analgesia

2. Postoperative Pain Indications

3. Management Principles

4. Drug Choices

5. Management of Inadequate Analgesia

6. Patient-Controlled Epidural Analgesia

7. Side Effects

8. Complications

9. Anticoagulation and Epidurals

10. Single-Shot Neuraxial Morphine

11. Peripheral Nerve Blockade

12. Intraoperative Neural Blockade

C. Nonpharmacologic Treatments

1. Education

2. Behavioral Therapy

3. Physical Therapy

IV. SPECIAL SUBPOPULATIONS

A. The Elderly

B. The Mentally and Physically Disabled

C. Substance Use Disorder

D. Intensive Care Patients

E. Patients With Chronic Pain

V. CONCLUSION

31 Postoperative Pain in Children

I. HISTORY

II. PLANNING FOR POSTOPERATIVE ANALGESIA

A. Multimodal Pain Therapy

B. Communication

III. ASSESSING ACUTE PAIN IN INFANTS AND CHILDREN

A. Neonates, Infants, and Children Aged 4 Years and Younger

B. Children Aged 4-8 Years

C. Children Older Than 7 Years

D. Children With Cognitive Impairment

E. New Emerging Techniques to Assess for Pain

IV. TREATMENT CHOICES

A. Acetaminophen and Nonsteroidal Anti-inflammatory Drugs

B. Opioids

C. Emerging Coanalgesic Therapies

D. Neuraxial and Regional Anesthesia and Analgesia

E. Epidural Placement in Children

F. Single-Shot Epidural and Caudal Analgesia

G. Managing Epidural Infusions

H. Treatment of Side Effects and Complications

I. Spinals

J. Peripheral Nerve Blocks

K. Topical Analgesia

L. Nonpharmacologic Techniques

M. Cognitive Approaches

N. Cutaneous Stimulation

O. Acupuncture

V. ANALGESIA FOR PEDIATRIC AMBULATORY SURGERY

VI. ANALGESIA FOR NEONATES

VII. CONCLUSION

32 Care of Burn Patients

I. EPIDEMIOLOGY

II. ANATOMY AND PHYSIOLOGY

A. Classification

B. Mechanism of Burn Pain

III. CLINICAL FEATURES

A. Patterns of Burn Pain

IV. MANAGEMENT

A. Pharmacologic

1. Opioids

2. NSAIDs and Acetaminophen

3. Anticonvulsants

4. Antidepressants

5. Alpha-2 Receptor Agonists

V. ANESTHETICS

A. Ketamine

B. Propofol

C. Regional Anesthesia

VI. NONPHARMACOLOGIC

33 Pain Management for Sickle Cell Disease

I. INTRODUCTION

II. OVERVIEW

A. Epidemiology

B. Pathophysiology

C. Complications and Organ Systems Affected

1. Hematologic

2. Neurologic

3. Cardiopulmonary

4. Gastrointestinal and Renal

5. Musculoskeletal

III. ACUTE PAIN

A. Vaso-occlusive Crisis (VOC)

1. Overview

2. Assessment of Pain

B. Treatment

C. Acute Chest Syndrome

D. Preventive Therapy

IV. CHRONIC PAIN

A. Types of Chronic Pain in SCD

B. Management

C. Curative Therapy

1. Stem Cell Transplant

2. Gene Therapy

V. PSYCHOSOCIAL CONSIDERATIONS

34 Pain Management in the Trauma Patient

I. INTRODUCTION

II. MECHANISM OF PAIN IN TRAUMA

A. Nociceptive Pain (Somatic or Visceral)

B. Inflammatory Pain

C. Neuropathic Pain

III. CONSIDERATIONS

A. Austere Settings

B. Chronicity of Trauma Pain

C. Surgery as Trauma

IV. THERAPEUTIC OPTIONS

A. Medications

B. Regional Anesthesia

V. SPECIAL POPULATIONS

A. Chronic Pain Patient

1. Opioid Dependence

2. Methadone

3. Buprenorphine

VI. CONCLUSION

SECTION VII: CHRONIC PAIN

35 Neuropathic Pain Syndromes

I. CLINICAL MANIFESTATIONS

II. SPECIFIC NEUROPATHIC PAIN SYNDROMES

A. Trigeminal Neuralgia

B. Glossopharyngeal Neuralgia

C. Occipital Neuralgia

D. Brachial Plexus Syndromes

E. Radiculopathy

F. Postherpetic Neuralgia

G. Meralgia Parethetica

H. Postamputation Stump Pain and Phantom Limb Pain

I. Complex Regional Pain Syndrome

J. Painful Diabetic Neuropathy

K. Diabetic Amyotrophy

L. Small Fiber Neuropathy

M. Erythromelalgia

N. Central Post-stroke Pain

O. Spinal Cord Injury

P. Syringomyelia and Syringobulbia

III. TREATMENT OF NEUROPATHIC PAIN

IV. CONCLUSION

36 Low Back Pain: Evaluation and Management

I. LOW BACK PAIN OVERVIEW

A. Location of Pain: Definitions

B. Epidemiology

C. Acute (<6 weeks) and Subacute (6-12 weeks) Low Back Pain

D. Yellow Flags (Risk Factors for Development of Chronicity)

E. Chronic Low Back Pain (>12 Weeks Duration)

II. PATIENT ASSESSMENT

A. History

B. Physical Exam

C. Diagnostic Testing

III. ETIOLOGY OF LOWER BACK PAIN

IV. TREATMENT FOR LOW BACK PAIN (TABLE 36.2)

A. Multidisciplinary Approach to Treatment

B. Pharmacologic Treatment

1. Acetaminophen

2. NSAIDs

3. Skeletal Muscle Relaxants

4. Tramadol and More Potent Opioids

5. Tricyclic Antidepressants (TCAs)

6. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

7. Antiepileptics

C. Psychological Treatments

D. Physical and Rehabilitation Treatments

1. Exercise Therapy

2. Multidisciplinary Functional Rehabilitation Programs

3. Other PT/Rehab Modalities Lacking RCT Support for Chronic LBP

E. Complementary and Alternative Medicine Approaches

1. Acupuncture

2. Manual Medicine/Manipulation

3. Sleep Support

F. Interventional Minimally Invasive Percutaneous Approaches for Axial Low Back Pain

1. General Principles

2. Lumbar Facet (Zygapophyseal) Joint Interventions

3. Sacroiliac Joint Interventions

4. Lumbar Radicular Pain and Spinal Stenosis Treatment with Epidural Steroid Injections (ESI)

5. Lumbar Postlaminectomy Syndrome and Spinal Cord Stimulation (SCS)

37 Complex Regional Pain Syndrome

I. HISTORY

II. BASIC MECHANISMS

III. CLINICAL PRESENTATION

IV. DIAGNOSIS

V. TREATMENT

A. Physical Therapy

B. Pharmacologic Treatments

1. Neuropathic Pain Medications

2. Nonsteroidal Anti-inflammatory Drugs

3. Opioids

4. Inhibitors of Osteoclast Activity

5. Corticosteroids

6. Others

C. Regional Anesthesia

1. Sympathetic Blockade

2. Intravenous Regional Blockade

3. Epidural Blockade

4. Brachial Plexus Blockade

D. Neuromodulation

1. Spinal Cord Stimulation

2. Peripheral Nerve Stimulation

E. Psychotherapy

VI. CONCLUSION

38 Headache

I. EPIDEMIOLOGY

II. HEADACHE HISTORY

A. Red Flags for Secondary Causes of Headache

B. Distinguishing Primary Headache Disorders

III. HEADACHE PHYSICAL EXAMINATION

IV. HEADACHE LABORATORY TESTING AND IMAGING

V. DIFFERENTIAL DIAGNOSIS

A. Secondary Headache Disorders

B. Primary Headache Disorders

C. Selected Headache Disorders In-Depth

VI. Treatments

A. Lifestyle Treatments

B. Preventive Migraine Treatments

C. Interventional Treatments

D. Acute Migraine Treatments

E. Rescue Migraine Treatments

F. Treatment of Trigeminal Autonomic Cephalgias and Selected Other Primary Headache Disorders

VII. CONCLUSIONS AND KEY POINTS

A. SNOOP Mnemonic

B. Migrainous and Autonomic Features

C. Patient Education

D. Preventative Medications

E. Rescue Treatment Plans

39 Orofacial Pain

I. DIAGNOSTIC EVALUATION

A. Chief Complaint

B. History of Present Complaint

C. Medical History

D. Physical Examination

E. Intraoral Examination

II. PAIN CAUSED BY PATHOLOGY OF THE HEAD, FACE, AND ORAL CAVITY

A. Dental Pain (Table 39.1)

B. Disorders of the Periodontium (Periodontal Disease)

C. Oral Mucous Membrane Disorders (Table 39.2)

D. Salivary Gland Disorders (Table 39.3)

E. Disorders of Maxilla and Mandible

F. Sinus Disorders

G. Disorders of Eye and Ear

H. Vascular Disorders

I. Tumors

III. TEMPOROMANDIBULAR DISORDERS (TABLE 39.7)

A. Masticatory Muscle Disorders (Table 39.8)

B. Temporomandibular Joint Disorders (Table 39.9)

IV. NEUROPATHIC PAIN DISORDERS (TABLES 39.10 AND 39.11)

A. Trigeminal Neuralgia

B. Painful Posttraumatic Trigeminal Neuropathy

C. Postherpetic Neuralgia

D. Burning Mouth Syndrome

SECTION VIII: CANCER PAIN AND PALLIATIVE CARE

40 Pain in Adults With Cancer

I. THE INCIDENCE AND IMPACT OF CANCER PAIN

II. ASSESSMENT OF CANCER PAIN: THE IMPORTANCE OF A DIAGNOSTIC APPROACH

III. TREATMENT OF CANCER PAIN

A. The WHO Stepladder and Modern Approach to Pain

B. Nonopioids

C. Acetaminophen/NSAIDs

D. Corticosteroids

E. Neuropathic Agents

F. Bisphosphonates and RANK Ligand Inhibitors

G. Cannabinoids

IV. OPIOID MANAGEMENT

A. Opioid Selection

B. Routes of Administration

C. Renal and Hepatic Dysfunction

D. Opioid Dosing and Titration

E. Opioid Rotation

F. Methadone

G. Adverse Effects

H. Addiction and Cancer Pain

V. NONPHARMACOLOGIC THERAPIES FOR CANCER PAIN

A. Radiation and Radionuclide Therapies

B. Interventional Procedures: Vertebral Augmentation, Neurolytic Blockade, Cryoablation, and Cordotomy

C. Neuraxial Drug Delivery: Epidural and Intrathecal Analgesia

VI. REFRACTORY CANCER PAIN

VII. CONCLUSION

41 Pediatric Cancer Pain

I. OVERVIEW OF PEDIATRIC CANCER

A. Epidemiology

B. Illness Trajectory

II. PEDIATRIC CANCER PAIN PRESENTATION

A. General

B. Myths About Pediatric Pain

C. Developmental Issues in the Expression of Pain

III. ASSESSMENT OF PEDIATRIC CANCER PAIN

A. Types of Pain

B. Instruments to Report Pain

IV. DISEASE AND TREATMENT-RELATED PAIN

A. Disease-Related Pain

B. Treatment-Related Pain

V. TREATMENT OF CANCER-RELATED PAIN IN CHILDREN

A. General Strategy

B. Nonpharmacologic

C. Nonopioids, Opioids, and Adjuvants

D. Regional Anesthesia and Analgesia

VI. CONCLUSION

42 Palliative Medicine

I. PALLIATIVE CARE OVERVIEW

A. Palliative Care Vs Hospice

II. CORE ELEMENTS OF PALLIATIVE CARE

A. Symptom Control

B. Patient-Centered Decision-Making

C. Common Misconceptions

D. Psychosocial and Spiritual Care

III. MODES OF PALLIATIVE CARE DELIVERY

IV. PAIN MANAGEMENT AT THE END OF LIFE

A. Overview

B. Patient Case: Pain Management at the End of Life

V. NONPAIN SYMPTOM MANAGEMENT

A. Overview

B. Depression and Anxiety

C. Constipation

D. Delirium

E. Dyspnea

F. Nausea and Vomiting

VI. SERIOUS ILLNESS COMMUNICATION WITH PATIENTS AND FAMILIES

VII. PALLIATIVE SEDATION FOR REFRACTORY SYMPTOMS AT END OF LIFE

VIII. CONCLUSION

SECTION IX: SPECIAL CONSIDERATIONS IN PAIN MEDICINE

43 Opioids in Chronic Nonterminal Pain

I. INTRODUCTION

II. RATIONALE FOR CHOOSING OPIOID THERAPY

III. AREAS OF CONCERN

A. Loss of Efficacy

B. Unacceptable Side Effects

C. Hormonal Effects

D. Immune Effects

E. Problematic Opioid Use

F. Opioid Use in Elderly Populations

IV. STRUCTURED, GOAL-ORIENTED APPROACH TO LONG-TERM TREATMENT

A. Decision Phase

B. Titration Phase

C. Stable Phase

1. Monthly Refills

2. Comprehensive Follow-Up

3. Toxicology Screening and Identifying Aberrant Behaviors

D. Dose Escalation

E. Criteria for Success and Failure

F. Discontinuation

V. CONCLUSION

44 Identifying and Mitigating the Risks of Long-Term Opioid Treatment

I. WEIGHING BENEFITS AND RISKS

A. Benefits

B. Risks

C. Individual Risk Assessment

II. RISK MITIGATION DURING LOT

A. Monitoring

B. Overdose Prevention

C. Managing a Difficult Course of Treatment

D. Discontinuation of LOT

III. CONCLUSION

45 Geriatric Pain Management

I. GERIATRIC OVERVIEW

A. Demographics and Prevalence

B. Pharmacokinetics and Pharmacodynamics Considerations

C. Changes in Pain Processing and Perception With Aging

D. Consequences of Untreated Pain in the Older Adult

E. American Geriatric Society Position on Pain Management

II. PAIN ASSESSMENT

A. General Overview

B. Addressing Misconceptions

C. Functional Pain Assessment

D. Pain Assessment in Dementia

E. Pain Assessment in Delirium

III. PAIN THERAPEUTICS

A. General Overview

B. Pharmacotherapy

1. Nonopioids

2. Opioids

C. Nonpharmacologic Interventions

IV. CONCLUSION

46 Management of Noncancer and Chronic Pain in Children With Life-Threatening Illness

I. PRESENTATION OF NONCANCER AND CHRONIC PAIN IN CHILDREN WITH LIFE-THREATENING ILLNESSES

A. Epidemiology

B. Typical Trajectories

II. GENERAL PRINCIPLES

A. Development and the Pain System

B. Maturation of the Nervous System

C. Developmental Aspects of Drug Metabolism

D. Cognitive Development

E. Relational Aspects of Pain Presentation

III. ASSESSMENT OF PAIN

A. General Principles

B. Pain Behavior and Physiologic Variables

C. Self-report

D. Conditions Presenting as Pain That Warrant Specific Attention

E. The Assessment of Pain in Nonverbal Infants and Children

IV. PAIN MANAGEMENT

A. Pain Presentations and Types of Pain

B. Pharmacologic Treatment

C. Regional Anesthesia and Analgesia

D. Other Techniques

V. CONCLUSION

47 Emergencies in Pain Medicine

I. INTRODUCTION

II. PROCEDURE-RELATED EMERGENCIES

A. Vasovagal Syncope

1. Symptoms and Signs

2. Treatment

B. Systemic Local Anesthetic Toxicity

1. Treatment (Primary Goal to Prevent Acidosis and Hypoxemia)

C. Complications of Epidural and Intrathecal Procedures

1. Epidural Hematoma

2. Epidural Abscess

3. High Spinal Anesthetics

4. Accidental Overdose via Neuraxial Pump

5. Treatment

D. Hypotension

1. Treatment

E. Hypertension

1. Treatment

F. Pneumothorax

1. Symptoms

2. Treatment

III. MEDICATION-RELATED EMERGENCIES

A. Anaphylaxis

1. Symptoms and Signs

2. Treatment

B. Opioid Overdose

1. Symptoms and Signs

2. Treatment

C. Opioid Withdrawal

1. Symptoms and Signs

2. Treatment

D. Steroid Overdose and Adrenal Insufficiency

1. Symptoms and Signs

2. Treatment

IV. CONCLUSION

Appendix I: Dermatomes and Nerve Distribution

Appendix II: Prescription Guidelines

I. CDC PRESCRIBING RECOMMENDATIONS AND ERRATA

II. FSMB PRESCRIBING GUIDELINES

Appendix III: Drug Enforcement Administration (DEA) Drug Schedules

I. DEFINITION OF CONTROLLED SUBSTANCE SCHEDULES

Appendix IV: Medications Commonly Used in Pain Practice

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