Page 114 Complete Your CE Test Online - Click Here These are the three steps to the WHO analgesic ladder (WHO, 1996): ● ● Step 1: Treatment with nonopioids, such as NSAIDS, with or without adjuvant pain medication. ● ● Step 2: Treatment with weak opioids, such as codeine, for mild to moderate pain with or without nonopioids or adjuvant medications. ● ● Step 3: Treatment with strong opioids, such as morphine, for moderate to severe pain with or without nonopioids or adjuvant medications. Morphine is the most effective pain reliever for moderate to severe cancer pain. Other pharmacologic treatments include hydromorphone, oxycodone, fentanyl, buprenorphine, or methadone if the patient is intolerant to morphine (Quimby, 2005). In addition, antidepressants, anticonvulsants, and corticosteroids may be used as adjuvant medication for relief from cancer pain (WHO, 1996). Central pain syndrome Central pain syndrome is a type of chronic pain resulting from a neurological condition that affects the central nervous system and occurs in people who have or have had strokes, Parkinson’s disease, multiple sclerosis, brain tumors, brain or spinal cord injuries, or limb amputations (American Chronic Pain Association [ACPA], 2016). Central pain syndrome can start months to years after injury to the CNS and includes such conditions as complex regional pain syndrome, chronic headaches, and fibromyalgia (ACPA). The pain is typically a burning or “pins and needles” pain, and there may be allodynia. Chronic back pain About 80% of adults experience back pain at some point in their life. About 20% of those with acute back pain develop chronic back pain, pain that persists for longer than 12 weeks or after the initial injury has healed (National Institute of Neurological Disorders and Stroke [NINDS], n.d.). As of 2010, low back pain was rated third in terms of poor health/mortality, surpassed only by heart disease and chronic obstructive pulmonary disease (NINDS). Condition-specific treatment for chronic back pain involves hot or cold therapy to ease symptoms, strengthening exercises, physical therapy, and medications, including these (NINDS, n.d.): ● ● NSAIDS, acetaminophen, aspirin. ● ● Anticonvulsants. ● ● Antidepressants. ● ● Topical analgesics. Complex regional pain syndrome Complex regional pain syndrome (CRPS) is a rare disorder whose hallmark symptom is chronic and severe pain. CRPS most often affects one limb, usually after an injury, and is believed to be caused by damage or malfunction of the peripheral and central nervous systems (National Institute of Neurological Disorders and Stroke [NINDS], n.d.). CRPS is more common in women than in men; has a peak onset age of 40; and is characterized by prolonged and excessive pain and changes in skin color, temperature, and swelling of the affected area (NINDS). Pain is described as burning, “pins and needles,” or a squeezing pain, often with allodynia resulting in a hypersensitive response to light touch on the affected limb (NINDS). Condition-specific treatment for CRPS involves the following: ● ● Physical therapy. ● ● Psychotherapy. ● ● Sympathetic nerve block. ● ● Spinal cord and neurostimulation. ● ● Surgical sympathectomy. ● ● Intrathecal drug pumps. ● ● Medications (NINDS, n.d.). ○ ○ Biphosphates. ○ ○ NSAIDS. ○ ○ Corticosteroids. ○ ○ Anticonvulsants. ○ ○ Botulinum toxin injections. ○ ○ Topical anesthetic creams and patches. ○ ○ Dextromethorphan and ketamine. ○ ○ Opioids. Fibromyalgia Fibromyalgia (FM) is an intractable and diffuse pain disorder that affects 2% to 3% of the population, most of whom are women (Senba, Okamoto, & Imbe, 2015). The etiology of fibromyalgia is unknown. Patients suffer pain and tenderness in various and changing locations throughout the body. There is no evidence of tissue damage or structural damage in patients with fibromyalgia, but it is thought that there is a hyperexcitability of the CNS or a dysfunction in the central inhibitory system that leads to the development of the disease (Senba, Okamoto, & Imbe). Patients with fibromyalgia also frequently have other disorders, including chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorder, headache, depression, insomnia, and urinary disturbances (Senba, Okamoto, & Imbe, 2015). Treatment of FM includes medications: pregabalin, gabapentin, milnacipran, duloxetine, and tricyclic antidepressants (CDC, 2016). The patient should be included in her pain management plan and encouraged to perform low-impact aerobic activities or pursue cognitive behavioral therapy and biofeedback (CDC). Inflammatory pain Inflammatory pain occurs in conditions where the inflammatory response has been activated, such conditions as arthritis, infection, tissue injury, and postsurgery. Inflammatory pain results from the release of inflammatory mediators that cause an increased excitability of peripheral nociceptive sensor fibers resulting in the transmission of pain signals to the brain (Linley, Rose, Ooi, & Gamper, 2010). Inflammatory pain can be acute or chronic. Condition-specific treatment for inflammatory pain aims to decrease inflammation and can include NSAIDS, corticosteroids, and other pain relievers. Ischemic pain Ischemic pain results from insufficient blood flow to tissues in the body that results in pain (Guyton & Hall, 2006). Tissue hypoxia causes the release of inflammatory and pain-producing chemicals resulting in an aching, burning, or prickling sensation (Copstead & Banasik, 2013). Ischemic pain can be acute or chronic and can result from anything that restricts blood flow, including arterial disease, peripheral vascular disease, injury, or surgical trauma. Ischemic pain in a cardiac event is visceral and is described as deep, aching, pressing, and diffuse (Copstead & Banasik). Chronic ischemic pain resulting from atherosclerosis usually develops gradually as plaque congregates in the arteries, typically in the lower extremities, resulting in a cramping type of pain (Copstead & Banasik). Ischemic neuropathy may develop in more severe cases and cause a burning, shooting type of pain (Copstead & Banasik). Condition-specific treatment includes measures to improve blood flow to the area. Chronic ischemia associated with atherosclerosis may be managed by lifestyle changes—weight loss, smoking cessation, exercise, reduction in cholesterol levels— and by bypass procedures or stent placement ( Copstead & Banasik, 2013). Migraine Migraines and severe headache are leading reasons for visits to emergency rooms (Burch, Loder, Loder, & Smitherman, 2015). The prevalence of migraine is high, affecting approximately one out of every seven Americans annually (Burch, Loder, Loder, & Smitherman). A chronic migraine headache is defined as headache that occurs on at least 50% of days of the previous three month period (Treede et al., 2015). Condition-specific treatment for headache and migraine includes preventative measures as well as medication for acute pain. Beta blockers, tricyclic antidepressants, calcium channel blockers, and antiseizure medications are used for prevention (CDC, 2016).