The Clinical journal of pain
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Review
Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.
Clinical experience supports the notion that opioids can be used successfully to treat many chronic pain conditions. Unfortunately, few controlled trials have assessed which individuals benefit from long-term opioid therapy, and there is concern about the use of long-term opioid therapy in individuals with a substance-abuse history. This article contains three sections relevant to the assessment of individuals with chronic pain and a substance-abuse history who are receiving long-term opioid therapy. ⋯ The third reviews areas critical in assessing treatment efficacy and substance abuse in patients with chronic pain, both in terms of documentation of past behaviors and as a measure of outcome of opioid therapy. Potential guidelines for use of opioids in patients with chronic noncancer pain are outlined. Finally, questions are posed for future investigations of the efficacy of opioid therapy for patients with chronic pain and a substance-abuse history.
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Patients may present to physicians with complaints of acute or chronic pain. Some of these patients will have a history of addiction to drugs or alcohol, and a few will have active addiction. Controlled-substance prescriptions, especially opioid pain medications, can be very beneficial for treatment of pain in patients. ⋯ General guidelines can improve physicians' comfort level in prescribing opioids for patients with chronic pain, even those with a history of addiction. These include using a medication agreement or contract, setting appropriate goals with the patient, giving appropriate amounts of pain medication, monitoring with drug screens and pill counts, and documenting the case carefully. Even patients with a history of addiction can benefit from opioid pain medications if the patients are monitored appropriately.
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Undertreatment of pain is likely to occur among patients with active addiction or those who have a history of addiction. One of the factors that can contribute to the inadequate treatment of pain in this patient population is the presence of laws and regulations that, when implemented, could impede effective pain management. ⋯ Three types of policy barriers are discussed: (1) those that can affect pain management in any patient, (2) those that can lead to patients in pain being classified as "addicts," and (3) those that relate specifically to patients with a high risk of addiction. Also presented are recent policy initiatives that can improve the use of controlled substances to treat pain and, thus, ultimately enhance pain relief for patients with an addictive disease.
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The authors sought to determine the usefulness of long-term continuous trigeminal nerve block with local anesthetics using an indwelling catheter in a patient with trigeminal neuralgia. ⋯ The authors controlled trigeminal neuralgia pain by blocking the mandibular nerve with local anesthetics administered through an indwelling catheter. Because the continuous nerve block with local anesthetics is reversible and only mildly toxic, this method is beneficial for pain control in patients with trigeminal neuralgia scheduled to undergo microvascular decompression.
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Postherpetic neuralgia remains a difficult problem to treat. A number of therapies have been shown to be effective, but some patients have intractable pain. ⋯ The patient was successfully treated with topical peppermint oil. During 2 months of follow-up she has had only a minor side effect, with continuing analgesia. The authors believe this is the first evidence of peppermint oil (or menthol) having a strong analgesic effect on neuropathic pain. The possible mechanisms of action of peppermint oil are discussed.