Ann Acad Med Singap
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The use of opioids for the treatment of chronic non-cancer pain has become more widespread recently. Available data support the short-term use of opioids in clearly defined nociceptive and neuropathic pain states. Their use in 'pathological' pain states without a clear diagnosis, such as chronic low back pain, is more contentious. ⋯ Treatment should be initiated by a trial period with defined endpoints using slow-release or transdermal opioids. Ongoing management of the patient requires ideally a multi-disciplinary setting. Treatment should not be regarded as life-long and can be discontinued by tapering the dose.
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There is a high prevalence of chronic pain disorders in the population and the individual and societal costs are large. Antidepressants have been used in the treatment of chronic pain and the pain-relieving effects are independent of the mood-elevating properties. We reviewed randomised-controlled trials, systematic reviews and meta-analyses of antidepressants in the treatment of chronic pain disorders which were identified through searches of MEDLINE and EMBASE. ⋯ There is emerging evidence that newer dual-action antidepressants are equally efficacious. Antidepressants provide a viable option in the management of chronic pain disorders. Further research into novel antidepressants will aid the pain clinician in optimising treatment for patients.
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Fibromyalgia syndrome (FMS) is a chronic and debilitating musculoskeletal pain disorder of unknown aetiology with usual accompanying features of fatigue, sleep disturbances and stiffness. Its place in medical textbooks was controversial with rheumatologists holding the helm of its management for many years. Over the last decade, abnormalities have been identified at multiple levels in the peripheral, central, and sympathetic nervous systems as well as the hypothalomo-pituitary-adrenal axis stress response system. ⋯ The United States Food and Drug Administration (FDA) has also successively approved 3 drugs for the management of fibromyalgia--pregabalin, duloxetine and milnacipran. Non-pharmacological modalities showed aerobic exercise, patient education and cognitive behavioural therapy to be most effective. Overall, management of FMS requires a multi-disciplinary approach.
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Spinal cord stimulation (SCS) is one of the most effective modalities for management of refractory neuropathic pain unresponsive to conservative therapies. The SCS has been successful in providing analgesia, improving function, and enhancing quality of life for patients suffering from chronic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, ischaemic and phantom limb pain, and coronary artery disease. This technique has proven to be cost effective in the long term despite its high initial cost. In this review article, we discuss the history of SCS development, mechanism of action, and indications for SCS.
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Ann Acad Med Singap · Nov 2009
ReviewThe role of interventional therapies in cancer pain management.
Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. ⋯ These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.