Upload
others
View
12
Download
0
Embed Size (px)
Citation preview
ChronicPainManagementDanielW.Odell,M.D.AssistantProfessor
DepartmentofAnesthesiology,UniversityofUtahSupportiveOncologyandSurvivorship,HuntsmanCancerHospital
ChronicPain
• Affectsapproximately20%ofthepopulation• Severelyimpactsqualityoflife,sociallife,workforceactivities,overallhealth• Mostcommonpainlocations:• Lowback• Headache• Neckpain• Jointpain• Generalizedpain/fibromyalgia
DiagnosticEvaluationofChronicPain
PainAssessment
• History– OPQRST• Onset• Provocation/Palliation• Quality• Region/radiation• Severity• Timecourse
• History+• Medicationtrialsandresponse
• Adequatedose?• Adequatelengthofmedicationtrial?
• Relatedconditions• Sleep• Function• Mood
• SocialHistory• Substanceabuse• Socialsituation
DiagnosticEvaluation
• Fullphysicalexam• Begentle!• Painbehaviorsandeffort• Neurologicandmusculoskeletalexam• Evaluationofgeneralizedtenderness• Generalizedpainsyndrome• Opioid-inducedhyperralgesia
• Palpationoftriggerpoints
DiagnosticEvaluation
• Characterizetypesofpain�Myofascial� Generalized� Neuropathic� Nociceptive– visceral� Nociceptive- somatic�Mostpatientswillhavemixedpaintypes
• Trytoputitalltogether�Why dotheyhavepain?
Myofascial Pain
Myofascial Pain
• Extremelyunder-recognized!• NotthesameasFibromyalgia– reallyquitetheopposite!• Painresultingfromdisorganizedmusclefibers• Triggerpoints– painradiateswithpalpation• Canmimicradicular painandbeverypainful– morethan“musclepain”• Post-surgical• Deconditioning• Alteredgaitorpositioning
Myofascial Pain
• Gluteusminimus andmedius triggerpointreferralpattern• LookslikeL5radiculitis
Characteristicreferralpatternsoftriggerpoints
SimonandTravells “MyofascialPainandDysfunction:theTriggerPointManual”
Myofascial Pain
• SternocleidomastoidandTrapeziustriggerpoints• Looksliketensionheadache• Canmimicorprovokemigraineheadache
Myofascial Pain• Verytreatable!• Physicaltherapy– morerehab-basedthanorthopedic-based• Experiencewithmyofascialrelease• Experiencewithdryneedling
• Triggerpointinjections• IncombinationwithPT
• Massage• Acupuncture• Theracane/BodyBackBuddy• “TheTriggerPointTherapyWorkbook”
Theracane /BodyBackBuddy
• $35onAmazon.com oroccasionallyatRelaxtheBackstore• Holdtriggerpointwithlight-medium pressurefor10-15sec
NeuropathicPain
• “Painarisingasdirectconsequenceofalesionordiseaseaffectingthesomatosensory system”• Affects3-8%ofpopulation• Characteristics• Burning• Shooting• Electric• Limitedbenefitfromopioids• Mayormaynotbeconfinedtoknownnerve/nerverootdistribution
NeuropathicPain
• Peripheralneuropathy• Phantomlimbpain• Post-herpeticneuralgia• Multiplesclerosispain• Post-surgicalneuropathicpain• Post-injuryneuropathicpain• Chronicradiculopathy• Complexregionalpainsyndrome
PhantomLimbPain
Painperceivedinanabsentbodypart• Variableincidence,60-80%in1st year,maydiminishovertime• ↑incidence:traumaticamputation,upperextremityamputation
Onset§ ImmediateoryearslaterDuration§ Random,recurringintervals§ Canresolvespontaneouslyorpersistforyears
Severity§ For3–10%ofamputees,phantompainischronic&severe
PreventionofPhantomLimbPain• ReferraltospecialistweekstomonthsBEFOREamputationifpossible• InterdisciplinaryTreatmentfocusedon:• Pain:Somatic,Neuropathic,Myofascial• Psychologicalsupport• Physicaltherapy• Familysupport
• MirrorTherapy?• Linksvisualandmotorpathwaystoimagerecreatebody• Reversemaladaptivememorytraces
Medical Physical Psychological Invasive
Gabapentinoids Physicaltherapy Explanation StumprevisionTCAs Mirrortherapy GuidedImagery Neuroma
resection
SNRIs Prosthesisadjustment
Relaxation Spinalcordstimulation
Anticonvulsants Stumpdesensitizing
Behavioraltherapy
Thalamic/cortexstimulation
Beta-blockers Acupuncture HypnosisKetamine Stumpmassage Biofeedback
LidocaineIV TENS Psychotherapy
TreatmentofPhantomLimbPain
Post-HerpeticNeuralgia
• Painthatpersistsaftershinglesinfection• Unilateral,dermatomal
• Increaseincidencewithage• 80%inpatients80yo
• Severeburning,shootingpain+/-skinhypersensitivity• Morecommoninimmunosuppressedpatients• Earlytreatmentassociatedwithimprovedoutcomes
Post-HerpeticNeuralgia
•Prevention• Antivirals infirst48hoursofshinglesoutbreak• Zostervaccineif>60yoorprioroutbreak
• Treatment• NeuropathicAgents
• InterventionalTherapies• Stellate Ganglionblock• Face/upperextremity
• Epiduralsteroidinjection• Thorax/abdomen
ComplexRegionalPainSyndrome• Spectrumofdiseasebutveryspecific
• Not“PainNOS,”NotReflexSympathyDystrophy(RSD)
• Continuouspain,disproportionatetoanyincitingevent• Historyofonesymptomin3categoriesandpresenceatthetimeofevaluationofsymptomsin2categories:• Sensory– hyperesthesia,allodynia• Vasomotor– temperatureasymmetry,skincolorchanges• Sudomotor/Edema– swelling,sweating• Motor/Trophic – decreasedrangeofmotion,motordysfunction,trophic changes
• Nootherdiagnosisthatbetterexplainsthesigns/symptoms
ComplexRegionalPainSyndrome
• Uncommontobepresentinmorethan1bodypart• Thereisnosuchthingas“Full-bodyCRPS”thoughCRPShassystemiceffects
• Variableprogressionovertime– overallfavorable• Returnoffunctionandreliefofpainassociatedwithearlyandaggressivecare
• Treatment• Physicaltherapywithdesensitizationfollowedbyincreasingflexibility,rangeofmotionandstrength
• Pharmacotherapywithanti-neuropathicagents• Sympatheticnerveblockstofacilitatephysicaltherapy• Moreinvasivetherapiesifneeded(spinalcordstimulator)
ComplexRegionalPainSyndrome
ComplexRegionalPainSyndrome
• Physicaltherapy• Experiencedprovider• Desensitizationtherapy• Mirrortherapy• Increasingrangeofmotionslowly
• Sympatheticnerveblocks• UsedtofacilitatePTandbreakcycleofpain
• Neuropathicmedications
GeneralizedPain
GeneralizedPainSyndromes• Widespreadpainthroughoutthebody• Notmultiplelocationsbutcontinuousinjoints,softtissue,etc
• Variablequality,usuallynoincitingevent• Diffusetendernesstopalpationthroughoutbodyonexam• Absenceofsignificanttriggerpoints
• Associatedwithdepression,poorsleep• Thoughtduetocentralsensitization
Fibromyalgia
• Specificdiagnosiswithin“GeneralizedPainStates”• Specificdiagnosticcriteria• Incorporatessleep,cognitivesymptoms,othersomaticsymptomsintodiagnosis
• NOTTHESAMEASMYOFASCIALPAIN• Affects2-4%ofthepopulation,femalepredominance• Oftenbeginsinmiddleadulthood
Fibromyalgia
GeneralizedPainStates
• Treatment• Physicalactivity!
• Startat5min/day,workupto30min/dayaerobicactivity
• Verygradual• Sleephygiene• Treatmentofconcurrentmooddisorders• Gabapentin/Pregabalin,Duloxetine,?TCA,NSAIDs,tylenol• Opioidsnotindicated!
• Noteffectiveandmaycontributetohyperalgesia
NociceptiveVisceralPain
NociceptiveVisceralPain
• Painresultingfromthoracic,abdominalorpelvicviscera• Distension,ischemia,inflammation
• Poorlylocalized• Dull,aching,pressure,squeezing• Notparticularlymovement-related
VisceralPain
• Referredtosuperficialstructures• Diaphragmà Shoulder• Anginaà Leftneck/arm
• Chronicabdominalandpelvicpain• Cancerpain
NociceptiveSomaticPain
NociceptiveSomaticPain• Arisesfromdamageorinjurytobone,joint,muscle,skinorconnectivetissue• “Mechanical”pain
• Well-localized• Intenseache,throbbing,sharp,stabbing,pinprick• Bonypain
• Metastases,fractures• Degenerativespinedisease
• Jointpain• Osteoarthritis
TreatmentApproachtoChronicPain
TreatmentAlgorithm• Conservativetreatment• Physicaltherapy,Pooltherapy• Behavioraltherapy• Complementarymedicine– acupuncture,massage,acupressure• Tylenol,NSAIDs
• Adjunctmedications• Neuropathicagents,antidepressants,topicalagents,musclerelaxants
• Injections/Procedures• InvasiveProcedures/ImplantedDevices
ConservativeTreatment
ConservativeTreatment
• PhysicalTherapy• Onesizedoesnotfitall!• Earlyinstitution• Experiencedproviders• Tailoredtreatment
• PoolTherapy
ConservativeTreatment• BehavioralMedicine• RelaxationTherapy• BehaviorModification• Education• Biofeedback• Counseling/Therapy– CBT• Hypnosis
• Beneficialforall!• Recognizetheimpactofmoodonpainandvisaversa• Centralsensitization
ConservativeTreatment
• Complementarymedicine• Acupuncture• Acupuncture• Massagetherapy• TaiChi• Mindfulnessmeditation
Acetaminophen
• Analgesicandantipyretic•Mechanismofactionpoorlyunderstood
• Blocksprostaglandinsynthetase inCNS,notperipherally• Lacksperipheralanti-inflammatoryeffects• Lacksplatelet,GI,bone,renaleffects
First-linetreatmentforpainintheelderlyMaximum3000-4000mg/day
• Beawareofothertylenol-containingproducts• 2000mg/daywithhepaticdisease
NSAIDsCOXInhibitors:Preventinflammatorycascade
NSAIDs
NSAIDsTwoisoformsofCOXenzymeCOX-1◦ Constitutive◦ “Housekeepingenzyme”◦ GItract◦ Kidneys◦ Platelets
COX-2◦ Induciblewithinflammatorystimulus
NSAIDs
• Aspirin• Ibuprofen• Ketorolac• Naproxen• Indomethacin• Diclofenac• Meloxicam• Etodolac• Celecoxib
Non-Selective,TemporaryCOX-Inhibitors
Selective,TemporaryCOX-2Inhibitors
Non-Selective,PermanentCOX-Inhibitor
NSAIDs AdverseEffects
GI- Gastritis,gastric/pepticulcersHematologic– IncreasedriskofbleedingOrthopedic– Impairedbonehealing?Renal- AcutekidneyinsufficencyCardiovascular- IncreasedriskofMI
DecreasedincidencewithCOX-2Inhibitor
NSAIDs
• ALWAYSTAKEWITHFOOD• ConsiderconcurrentPPIuse• Naproxen375- 550mgbid• Meloxicam7.5-15mgdaily
• 7.5mgdoseisCOX-2selective
• Celebrex100-200mgbid– easiestonGIsystem,saferwithanticoagulants,expensive• Ibuprofen600-800mgtid• IncreasedriskofAKI
HotOffthePress!
• “TakinganydoseofNSAIDsforoneweek,onemonth,ormorethanamonthwasassociatedwithanincreasedriskofmyocardialinfarction.”
AdjunctMedications
AdjunctMedications
•Gabapentinoids• Gabapentin• Calciumchannelblocker• 300mgqhs withtitrationtototaldailydose1800-3600mg(startwith100mgqhs withtitrationto300mgtid inelderly)
• Neuropathicpain,generalizedpain,opioid-sparing• Pregabalin• Calciumchannelblocker• 50mgqhs withtitrationtototaldailydose300-600mg• Neuropathicpain,generalizedpain,opioid-sparing
AdjunctMedications
• Antidepressants• Tricyclic antidepressants
• Amitriptyline andImipramine – tertiaryamines,moresideeffects
• Nortriptyline andDesipramine – secondaryamines,lesssideeffects• Desipramine causesleastamountofsleepiness
• Startat25mgqhs,titrateto100mgqhs astolerated(lessinelderly)
• Cautionwithotherseratonergicmedications,elderlypatients• SNRIs• Duloxetine(60-120mg/day)• Venlafaxine?• Evidenceisunderwhelming
AdjunctMedications
•Anticonvulsants• Topiramate• Sodiumchannelblocker• Poorevidenceinpainotherthanmigraineprophylaxis
• Carbamazepine/Oxcarbazepine• Sodiumchannelblockers• Trigeminalneuralgia
AdjunctMedications
•MuscleRelaxants• Workbestwithshort-termuse(10days),tolerancedevelopsquickly• Cyclobenzaprine5-10mgtid• TCA-like,cautionwithotherseratonergicmedsandintheelderly
• Tizanidine2-8mgtid• Valium,Soma(carisoprodol),Robaxin (methocarbamol),Skelaxin(metaxaolone)• CNSsedatives– notmusclerelaxants.Avoid.• SomaisadangerousCNS-depressantandimplicatedinmanymultidrugunintentionaloverdosedeaths
AdjunctMedications•TopicalAgents•Voltaren gelorFlector patch• Diclofenacpreparations– gelnowgeneric• Applytoaffectedarea• Greatforpatientsonoralanticoagulation• Worksbestwhenpainfulareaisclosetotheskin• Knees,finger/toes,etc
•Compoundedcreams• Expensiveandineffective• Exceptionmaybeketamine creamforallodynia
OpioidMedications
PainandAddiction
• Chronicpainiscommon• Occursin33%ofthepopulation,severein10%
• Opioidsarefrequentlyprescribedforpain• 16%ofpatientsinprimarycaresettingin2002
• Opioidmisuseandaddictionarecommon• Fishbain 2007
• 11.5%ofchronicpainpatientsmisuseopioids• 3.5%ofchronicpainpatientshavedevelopopioidaddiction• 14.5%ofchronicpainpatientsuseillicitdrugs
Whentoconsideropioids• Appropriatetypeofpain
• Notmyofascial pain• Notgeneralized/fibromyalgiapain
• NEVERfirstline• Conservativetreatment• Adjunctmedications• Physical,behavioral,complementarytherapies
• Failureofmultiplepasttrialsofmedication/therapies• Willitimprovefunction??
InitiationofOpioids• Documentationofpainandpriorinterventions,therapiesandmedicationtrials• Psychologicalassessment• Substanceabuseassessment
• Risk/benefitdiscussionwiththepatient• Medicationagreement• Specifywhocanprescribeopioids• Whocanprescribeothercontrolledmedications• Managementofacutepain
• Considerbaselineurinedrugscreen
InitiationofOpioids
• Trialofopioids• Lowdose(Hydrocodone 5/325bid-tid)• Mildescalationreasonable(approaching30-50mgOME?)
• Assessmentofimprovement• Pain• FUNCTION!
• Routinely assess4A’s• Analgesia• Activity• AdverseEffects• AberrantBehavior
CasualPrescribingofOpioids
• Ifyoustartopioidsyouhavebecomethatpatient’sopioidprescriber• Maybereasonableforacuteissues• Importantforpatienttohaveappropriateexpectations• Duediligence
• ControlledSubstanceDatabasereport• Knowledgeofothersedatingmedications• Healthhistory
• Donotgiveopioidsandtellapatientanotherprovider(PainSpecialist,Surgeon,Dentist)willgivethemmore
Pre-ExistingOpioids• Managementofpatientsalreadyonopioids• Sameconsiderations
• Appropriatetypeofpain• Failureofmultipletherapiesandnon-opioidmedications• Psychologicalassessment• Substanceabuseassessment• Risk/benefitdiscussionwiththepatient• Medicationagreement
• Ifnotappropriateinformthepatientanddevelopplanforopioidtaperwithinitiationofothertreatment• Youarenotbeholdentoprescribeopioidsjustbecauseanotherpractitionerhasdoneso• Howevertaperingovertimecanpromotetherapeuticrelationshipwithpatient
Preventionofopioidmisuse/abuse
•Prescriberfactors• Dose• Risksincreaseabove100mgOME,skyrocketover200mgOME
• Concurrentcontrolledsubstances• Risksincreasewithconcurrentbenzodiazepinesorhypnotics
• “Musclerelaxants”otherthantizandine/cyclobenzaprine• Sleepaids:Ambien/Lunesta/Sonata,temazepam• Onlyone?Onlytwo?
CDC.CDCgrandrounds:prescriptiondrugoverdoses-aU.S.epidemic.MMWRMorb MortalWkly Rep2012;61:10-3.
Detectionofaberrantopioid-relatedbehaviors
AberrantBehavior
• Lostopioid prescriptions• Outofopioids early• InappropriateDOPL• InappropriateUDS• Failuretoparticipateinnon-opioid treatment• Concernforopioid diversion• Overtsedation
AberrantBehavior
• Safetyofpatientandcommunityisfirstconsideration• Verifythefacts• Controlledsubstancedatabasereport• Callpatient’spharmacyorotherproviders• RequestrecordsfromED/Hospital
• Basedecisiononcontinuedprescribingonsafety,factualinformation,painissueandinformthepatient• Provideresourcesforopioidwithdrawal
Detectionofaberrantopioidbehaviors• UrineDrugScreening• Presenceofexpectedmedicationsandmetabolites• Absenceofillicitsubstancesorotheropioids• Onlyasgoodasyourtest!
• Falsepositivesandnegativesexist– knowyourpatientandtest• High-resolutiontestinEPIC• ARUPpathologistsoncalltotroubleshoot/answerquestions
• Howoften?• PRIORtoinitialprescribing• Q3-12months• Witnessed?• Orjustmakesuretheydon’ttakeanythingintothebathroom?
Detectionofaberrantopioidbehaviors
• PrescriptionDrugMonitoringPrograms(DOPL)• Everytimeyouseeapatientorrefillamedication• Hopefullyeventuallynationwide• CansetsurrogatestoaccessthisunderyourlicenseinUT
• 3RNsorMas
• PillCounts• Requirecoordinationofstaffandpatient
• Requestsforearlymedicationrefills• Reportsfromfamily/friends
• Canlistentoanyinformation,maynotdiscloseany• Finelinetowalk
ManagementofaberrantopioidrelatedbehaviorThehardstuff
Managementofaberrantbehavior• Safetyofpatientandcommunityisfirstconsideration• Verifythefacts• Controlledsubstancedatabasereport• Callpatient’spharmacyorotherproviders• RequestrecordsfromED/Hospital
• Basedecisiononcontinuedprescribingonsafety,factualinformation,painissueandinformthepatient• Provideresourcesforopioidwithdrawal
• Youmustcontinuetocareforpatientsfor30daysafterclinicdischarge– thisdoesnotimplyprescribingopioids
• Dependsonseverity• “Common”- Earlyrefills,inappropriateUDS/DOPL/PillCount
• Verifythefacts,givethepatientanopportunitytoexplain• Reasonablepractice
• Firststrikeincursawarning– documentit!• Secondstrike=nocontinuedopioidprescribing
• Concurrentillicitdruguse• Nofurtheropioidprescribing(marijuana?)
• Confirmedoverdose• Nofurtheropioidprescribing
• Confirmeddiversion• Dischargepatient
• Youmustcontinuetocareforpatientsfor30daysafterclinicdischarge– thisdoesnotimplyprescribingopioids
Managementofaberrantbehavior
InjectionProcedures
ChronicSpinePain•Mechanical• Scoliosis,arthritis,stenosis,degenerative• Facetarthropathy,sacroiliacjointarthropathy• Failedback/necksurgerysyndrome
EpiduralInjections• Epiduralinjections• Localanesthetic+steroidinjectedintoepiduralspacesurroundingnerveroots• Clearsinflammatorymediatorsandreducesinflammation/compression
• Indicatedforradicular upperextremityorlowerextremitypain• Burning,shootingpaininspecificdistributiontodistalareaoflimb• Neurologicdeficitsà radiculopathy,“just”pain– radiculitis
• Alsoindicatedforspinalstenosis andpostherpeticneuralgia• Differentapproachesdependingonnatureandlocationofpain• Relieflasts2-4monthsonaverage
FacetArthropathy• Painjustoffmidline,worsewithextension/rotation• Doesnotcauseradicular painbutpaincanradiatelocally• Candevelopduetoarthritis,misalignment• Injections:• Thermalablationofnervebranchthatinnervatesthejoint(older)• Lasts6-9months,canberepeated
• Intra-articularsteroidinjections(younger)• Lesseffective
SacroiliacJointInjection
• Jointatintersectionofspineandpelvis• Significantmovementandweightloading
• Candeveloppainduetoarthritisormisalignment
• PainoverSIjointwithradiationintobuttockandposteriorthigh• “FABER”provokespain
• flexion,abductionandexternalrotationofhip• Localanesthetic+steroid,lasts3-4months
SacroiliacJointDysfunction
PeripheralNerveInjections
• Ilioninguinal NerveBlock:• Indications:Ilioinguinalneuralgia(groinpainafteringuinalsurgery/tumor)• Steroid+localanesthetic–lastsapprox3months
PeripheralNerveInjections
nOccipitalNerveBlock:n Indications:Occipitalneuralgia(occipitalpain/HAaftersurgeryortumor)
n Steroid+localanesthetic–lastsapprox3months
PeripheralNerveInjections
•Genicular NerveBlock• Indications:Chronickneepain,notoperativecandidate• Diagnosticnerveblockwiththermalablationifsuccessful• Success50/50
PeripheralNerveInjections
IntercostalNerveBlock◦ Indications:Intercostalneuralgia,Chronicribpain(post-thoracotomy)
◦ Localanesthetic+steroid
JointInjections
•Hip,Knee,Shouldermostcommon• Painfulosteoarthritisofjoint• Dx withx-ray
• Steroid+localanesthetic– lastsapprox3months• Hyaluronate viscosupplementationforkneesmaylast6-12months• Ultrasound,fluoroscopy,“blind”
InvasiveInjectionsandImplantedDevices
SympatheticBlocks
• Diagnostic• Isthepainsympatheticallymediated?
• Therapeutic• Localanesthetic– breakthecycle• Seriesofsympatheticblocks+PTforCRPS
• Steroid– littleevidence• Chemicalneurolysis– denaturethenerves
• TerminalCancer
SympatheticBlocks
• Stellate Ganglion• Neuropathicpainoftheface,neck,shoulderorupperextremity• CRPS,PhantomLimb,PHN
LumbarSympatheticBlock• Neuropathic,suspectedsympathetically-mediatedpaininthelowerextremity• CRPS,Phantomlimbpain,Ischemicpain/vascularinsufficiency
SpinalCordStimulationNeuromodulation:providealternateinputtospinalcordto“coverup”pain• Leadsimplantedinepiduralspaceconnectedtoanimplantedbatterysource
• Patientsundergo“Trial”firstwithtemporarypercutaneousleadsfor3-7days• Multipledevicecompanies,stimulationmethods/parameters• InternationalNeuromodulation Society:http://www.neuromodulation.com/spinal-cord-stimulation
SpinalCordStimulation
• Indications:• Neuropathicpaininlimbs
• Persistentradicularpain,phantomlimbpain,postherpetic neuralgia,brachialplexusinjury
• Failedback/necksurgerysyndromeRapidlyChanging• High-frequencySCS:Effectiveforaxiallowbackorneckpain?• DorsalRootGanglionSCS:Groinpain,ilioinguinal pain,intercostalpain,radiculopathy?
• Newwaveforms/programmingtechniques:Burst,high-density,etc.
SpinalCordStimulation
•Downsides:• Invasive• Complications• Infectionrate5-10%
• Diminishedeffectovertime(5+years)• Maybelesswithnewerwaveforms
• Doesnottreatmyofascial ormechanicalpain• NotallsystemsareMRI-compatible
PeripheralNerveStimulation
• Similartospinalcordstimulation• Indicatedforspecificnerves• Occipitalneuralgia• Ilioinguinal neuralgia
• Mayhavearoleinchronicmigraine• Emergingfield• Insurancecoveragechallenging
Conclusion• Diagnosis:history,physicalexamandcharacterizationofpaintypes• Myofascial,Generalized,Neuropathic,Nociceptivevisceral,Nociceptivesomatic
• TreatmentAlgorithmtailoredtopaintypes• Conservativetreatment• Adjunctmedications• Injections/Procedures• InvasiveProcedures/ImplantedDevices
Thanksforyourattention!
Acknowledgements- JillSindt,M.D.- PerryFine,M.D.- PainManagementCenter,UniversityofUtah- SupportiveOncologyandSurvivorship,HuntsmanCancerHospital
References• JohannesCBetal.TheprevalenceofchronicpaininUnitedStatesadults:Resultsofaninternet-basedsurvey.Pain2010;11(11):1230-39.
• ClarkJD.ChronicPainPrevalenceandAnalgesicPrescribinginaGeneralMedicalPopulation.JPainSymp Manage2002;23(2):131-37
• Fishbain,DAetal.2007.Whatpercentageofchronicnonmalignantpainpatientsexposedtochronicopioid analgesictherapydevelopabuse/addictionand/oraberrantdrug-relatedbehaviors?Astructuredevidence-basedreview.PainMed.9,444–459.
• WilliamC.Beckeretal.Non-medicaluse,abuseanddependenceonprescriptionopioidsamongU.S.adults:Psychiatric,medicalandsubstanceusecorrelates.DrugAlcoholDepend2008:94:37-47.
• Okie,Susan.Afloodofopioids,arisingtideofdeath.NEngl JMed2010;363:1981-1985
ThankYou!