American journal of physical medicine & rehabilitation
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Neuropathic pain results from a variety of medical conditions encountered in physiatric practice, including infection, trauma, metabolic abnormalities, and nerve compression. Unlike pain resulting from nociceptive or inflammatory processes, neuropathic pain is associated with primary lesion or dysfunction of the nervous system itself and is often difficult to treat. Existing treatment options include drug therapy (e.g., anticonvulsants, the lidocaine patch 5%, antidepressants, opioids, tramadol) or interventional treatments (e.g., peripheral or neuraxial nerve blockade, implanted spinal cord stimulators, implanted intrathecal catheters). The following article presents an overview of the cellular mechanisms associated with neuropathic pain, summarizes the results of randomized, controlled trials with the major classes of available drugs, and discusses treatment options that provide a rational basis for pharmacotherapy.
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Complex regional pain syndrome has both nociceptive/inflammatory and neuropathic elements and is always (by definition) associated with abnormal activity of the sympathetic nervous system. There is good evidence that complex regional pain syndrome, as currently conceptualized, ultimately includes central sensitization and has motor abnormalities. ⋯ The following article presents an overview of available data regarding drug and interventional treatment options for complex regional pain syndrome and of those relevant pharmacotherapies we can derive from the neuropathy literature. As with most chronic pain syndromes, pharmacotherapy coupled with functional restoration and an interdisciplinary approach to treatment are essential to a successful outcome.
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Although a universal consensus has evolved concerning the utility of opioids in cancer pain, the use of opioids for the treatment of chronic nonmalignant pain syndromes is much debated in the medical literature. Although for clinical, regulatory, and medicolegal reasons, many clinicians disagree with their use, others find them helpful, with little prevalence of abuse behaviors or intolerable adverse effects. ⋯ As a clinically distinct population among chronic pain sufferers, patients with arthritis-associated pain (including rheumatoid and osteoarthritis) are discussed separately. Particularly important issues with regard to prescribing decisions, including divergent goals and expectations, and factors associated with avoidance of withdrawal and addiction, are also evaluated to ensure that management of patients with nonmalignant chronic pain is optimized when opioids are considered.