Pain physician
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The ability of opioids to effectively and safely control acute and cancer pain has been one of several arguments used to support extending opioid treatment to patients with chronic pain, against a backdrop of considerable caution that has been based upon fears of addiction. Of course, opioids may cause addiction, but the "principle of balance" may justify that "...efforts to address abuse should not interfere with legitimate medical practice and patient care." Yet, situations are increasingly encountered in which opioid-maintained patients are refractory to analgesia during periods of pain, or even during the course of chronic treatment. The real question is whether analgesic efficacy of opioids can be maintained over time. ⋯ Still, side effects can negatively affect the outcomes and continuity of therapy. This paper addresses 1) what evidence supports the long-term utility of opioids for chronic pain; 2) how side effects may alter quality of life; 3) the nature of addiction and why it is different in pain patients, and 4) on what grounds could pain medication be denied? These questions are discussed in light of patients' rights, and warrant balancing particular responsibilities with risks. These are framed within the Hippocratic tradition of "producing good for the patient and protecting from harm," so as to enable 1) more informed clinical decision making, and 2) progress towards right use and utility of opioid treatment for chronic pain.
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Clinical Trial
Using peripheral stimulation to reduce the pain of C2-mediated occipital headaches: a preliminary report.
Peripheral nerve stimulation (PNS) is an accepted treatment for neuropathic pain. Recent studies have focused on its potential for relieving headache pain. ⋯ PNS reduced headache pain, headache frequency and medication use.
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Case Reports
A case of spinal cord stimulation in Raynaud's Phenomenon: can subthreshold sensory stimulation have an effect?
Spinal cord stimulation is currently used to treat a variety of chronic intractable painful conditions. We report a case of severe Raynaud's phenomenon in the hands refractory to conservative treatment and responsive to diagnostic stellate ganglion block that was effectively treated with a spinal cord stimulator placed in the cervical epidural space. After capturing the affected areas with paresthesias, blood flow in the left hand and fingers significantly improved as evidenced by an increase in skin temperature, a change from cyanotic to pink appearance and concomitant reduction in pain. ⋯ Thus it seems, at least in the overnight period, paresthesias were not required to maintain pain relief. This case presents a potential divergence between a requirement for paresthesias and pain relief in spinal cord stimulation therapy for the treatment of Raynaud's phenomenon. The possible role of the sympathetic nervous system in this relationship is also discussed.
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Lumbar selective nerve root blocks have been performed to establish the origin of lumbar radiculopathy in clinically difficult cases. The diagnostic ability of selective nerve root blocks remains controversial because of concern over potential spread of an injectate onto adjacent structures. ⋯ Injection of 1 ml of contrast under fluoroscopic guidance does not guarantee selective spread of the contrast around L4 or L5 nerve roots only. There is also spread toward the more medial nerve root in the same spinal segment during L4 and L5 nerve root infiltration. These findings suggest that it is possible to differentiate between L4 and L5 nerve root pathology using a sequential nerve root blocks under fluoroscopic guidance.