La Revue du praticien
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The chronic pain management structures were identified by the French health authorities regarding two levels: consultation (with a pluri-professional organization and proximity missions) and the center (with a multidisciplinary organization and expertise). Access to these structures is facilitated by guidelines published in 2008 by the Haute Autorité de santé.
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In 2007, the Plan for the improvement of the quality of life of people with chronic diseases stressed that support for pain was the first expectations of patient associations. And pain support is primarily the field of competence of the treating physician. It is in this context, that (HAS) recommendations were developed to promote the implementation of care tailored for people expressing a chronic pain. They advocate the support procedure: the identification and evaluation of the chronic pain in ambulatory (history, etiologic assessment, tests), the establishment of treatment or application with a specialized structure, diagnostic or therapeutic advice.
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La Revue du praticien · Jun 2013
Review[Pharmacological treatment of neuropathic pain in primary care].
Neuropathic pain is difficult to treat. First line treatment includes tricyclic antidepressants (notably amitriptyline), mixed serotonin and norepinephrine reuptake inhibitors (duloxetine for diabetic peripheral neuropathic pain), antiepileptics (gabapentin and pregabalin) and topical agents (lidocaine plasters for postherpetic neuralgia). These drugs can be subsequently associated in case of partial response to monotherapy. Opioids and tramadol are only considered second/third line, alone or in combination with first line drugs.
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La Revue du praticien · Jun 2013
Review[Pathophysiology of chronic pain. Classification of three subtypes of pain].
Pain is a physiological sensation which aim is to alert for an upcoming danger that may threaten the individual. This system includes peripheral nociceptors that initiate the nociceptive message. Then, the information is conveyed to the brain through the spinothalamic tract that projects to the thalamus, insula, SII and other areas. ⋯ This is the neuropathic pain. Case 3: between the two former cases, there is no evidence for a lesion in the nociceptive system, and there are no evidences for lesion at the peripheral level, but there are evidences of dysregulation(s). These are the cases of dysfunctional pain.
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Neurosurgical treatment of pain is based on 3 concepts: 1) lesional techniques interrupt the transmission of nociceptive neural input by lesionning the nociceptive pathways (cordotomy, radicotomy...), they are indicated to treat morphine-resistant cancer pain; 2) neuromodulation techniques try to decrease pain by reinforcing inhibitory mechanisms, using chronic electrical stimulation of the nervous system (peripheral nerve stimulation, spinal cord stimulation, motor cortex stimulation...) to treat chronic neuropathic pain; 3) intrathecal infusion of analgesics (morphine, ziconotide), using implantable pumps, allows to increase their efficacy and to reduce their side effects. These techniques can improve, sometimes dramatically, patients with severe and chronic pain, refractory to all other treatments.