Guide to Pain Management in Low-Resource Settings
part of CRPS, but is no prerequisite for diagnosis. Diag-
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- Somatoform disorders
- Spinal stenosis
- Spondylolisthesis
- Withdrawal syndrome
- Trigeminal neuralgia
- World Health Organization
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part of CRPS, but is no prerequisite for diagnosis. Diag-
nosis and treatment are diffi cult and should be left to a specialist. Advanced CRPS may leave the patient with a permanently unusable extremity. Rheumatoid arthritis An autoimmune disease that causes chronic infl amma- tion of the joints and the tissue around the joints, as well as other organs in the body. Autoimmune diseases occur when the body tissues are mistakenly attacked by the body’s own immune system. Th e immune system is a complex organization of cells and antibodies designed to “seek and destroy” invaders of the body, particularly infections. Patients with autoimmune diseases have an- tibodies in their blood that target their own body tis- sues, where they can be associated with infl ammation. Because it can aff ect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness (meaning it can last for years), patients may experience long periods without symptoms. Pain management includes NSAIDs and opioids. Pain control should not be attempted with- out controlling the infl ammation, otherwise joint de- struction will continue. Sciatica Pain resulting from irritation of the sciatic nerve, typically felt from the low back to behind the thigh and radiating down below the knee. While sciatica can result from a herniated disk directly pressing on the nerve, any cause of irritation or inflammation of this nerve can reproduce the painful symptoms of sciatica. Diagnosis is by observation of symptoms, physical and nerve testing, and sometimes by X-ray or MRI if a herniated disk is suspected. Very often, physical examination and careful taking of the history will reveal that the pain is not radiating along typical dermatomes. Therefore, other pain etiologies than radicular compression have to be taken into account, such as facet-joint pain, sacroiliacal joint irritation, or myofascial pain. Somatoform disorders Th e somatoform disorders are a group of psychiat- ric disorders that cause unexplained physical symp- toms (somatoform disorder, hypochondriasis, pain disorder,and conversion disorder). Th e pathophysiol- ogy of these complaints still remains unclear. A com- mon main symptom of these disorders is that physical symptoms cannot be completely explained by means of a physiological process. Somatic disorders can be accompanied by defi ned physical illnesses, but they may not be adequately explained by these illnesses. Patients who suff er pain without an organic cause are often unable to cope with emotional stress; this is converted into physical stress factors. Th ese diff use stress factors can no longer be understood as a physi- cal expression of an intrapsychic confl ict, but are non- specifi c, vegetative stress factors (e.g., with agitation, shaking, and pain) as a result of emotional pressure experienced primarily physically. Various physical dis- orders can result. Th e standard medical treatment is often limited. Th ese disorders should be considered early on in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Th e identifi cation of a life event that is impor- tant enough to be taken as a cause of this disorder may prove helpful to “solve” the stress of this life event with behavioral interventions. Consequently, the somato- form pain may diminish over time. Spinal stenosis Narrowing of the spaces in the spine, resulting in com- pression of the nerve roots or spinal cord by bony spurs or soft tissues, such as disks, in the spinal canal. Stenosis occurs most often in the lumbar spine (in the low back) in patients older than 60 years, but it also occurs in the cervical spine (in the neck) and less often in the thoracic spine (in the upper back). Th e typical symptoms to ask when suspecting spinal stenosis are claudication (pain increases after a certain time of exercise without evi- dence of peripheral artery disease) and pain relief with bending forward. If surgery is not possible, a few thera- peutic options are left for analgesia, including epidural steroids, physiotherapy, opioids and NSAIDs, and fl ex- ion-orthostasis. Appendix: Glossary 371 Spondylolisthesis Forward movement of one of the vertebrae of the spine in relation to an adjacent vertebra, most often at the level of L5/S1. Simple “functional” X-ray (lateral view in full extension and full fl exion of the spine) may dem- onstrate spondylolisthesis. Only a major forward move- ment (>25–50% of the vertebral length) is an indication for surgery. Substance P Substance P is a member of the tachykinin family of neuropeptides that is expressed in sensory neurons. It works as a stimulatory neurotransmitter or neuro- modulator when it is released centrally, and as a proin- fl ammatory mediator when it is released peripherally. It activates the neurokinin-1 receptor, a major factor in central sensitization. Withdrawal syndrome Th e abrupt cessation of a repeatedly or continuously ad- ministered opioid agonist, or the administration of an antagonist, typically results in withdrawal syndrome. Signs and symptoms include sweating, tachycardia, hy- pertension, diarrhea, hyperventilation, and hyperrefl ex- ia. See also the entry on “Dependence”. Tolerance Tolerance is the need for progressively increasing doses of an agonist to maintain the same eff ect (e.g., analge- sia). In chronic pain, the need for increasing doses of opioids can be due to alterations in receptor functioning (e.g., coupling to G proteins, second messengers) and/ or to increasing painful stimulation (e.g., by a growing tumor), among other reasons. Tolerance is fortunately not common in patients who have opioid-sensitive pain. In patients seeking opioid treatment for mood stabiliza- tion, tolerance is frequent. Th erefore, in patients with nonmalignant pain and nonprogressing disease, the re- peated need for dose escalation (typically every 4 to 8 weeks, when tolerance to the sedating and euphoric eff ects of opioids develops) should be a warning sign for “inadequate” opioid use, and the opioid medication should be gradually discontinued. Trigeminal neuralgia A disorder of the trigeminal nerve in its root area (e.g., secondary trigeminal neuralgia due to malignant masses in the cerebellar region) or due to pulsatile compres- sion by the cerebellar artery that causes brief attacks of severe pain in the lips, cheeks, gums, or chin on one side of the face. Only a symptom complex including attack-like pain of less than 2 minutes, no neurological defi cits, absent or minor chronic pain, and typical trig- ger factors should be diagnosed as trigeminal neural- gia. Carbamazepine is still considered to be the drug of fi rst choice. If drug therapy fails, trigeminal neuralgia is one of the few pain syndromes where surgery is in- dicated (Janetta surgery). World Health Organization An agency of the United Nations established in 1948 to further international cooperation in improving health conditions. Although the World Health Or- ganization (WHO) inherited specifi c tasks relating to epidemic control, quarantine measures, and drug standardization from the Health Organization of the League of Nations (which was set up in 1923) and from the International Offi ce of Public Health at Par- is (established in 1909), the WHO was given a broad mandate under its constitution to promote the attain- ment of “the highest possible level of health” by all people. WHO defi nes health positively as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infi rmity.” Th e cancer pain management recommendations of the WHO (the analgesic ladder) have had a major eff ect on the rate of opioid prescriptions to patients with cancer and HIV-related pain, mainly in countries belonging to the Organization for Economic Co-operation and De- velopment (OECD). Unfortunately, Eastern European countries and many low-resource countries continue to have only very restricted opioid delivery rates to cancer patients, which should be considered a health emergency. Th e Pain and Policy Study Group of the WHO is investing a lot of eff ort to infl uence this situ- ation by advising government authorities and health care workers on legislative, educational, and treat- ment changes necessary to be able to provide adequate amounts of opioids to patients in need. For further in- formation see their website for a lot of relevant facts regarding opioids in most countries of the world. Document Outline
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