How Good Is Methadone For Neuropathic Pain

Today's post from mypcnow.org (see link below) takes a look at methadone as an alternative to other opioids for controlling neuropathic pain. Methadone has had an extremely bad rap over the years, mainly because of its association with withdrawal from drug addiction programmes. However, it is an extremely cheap and effective drug for nerve pain and because only low doses are needed, the risks of side effects and addiction are much less than for instance morphine or oxycodone. That said, it is a powerful drug and once you begin, you need to be very careful when and if you want to taper off. Never go cold turkey with methadone - it will react almost instantly. Many doctors are reluctant to issue methadone prescriptions but that's often based on lack of experience rather than factual dangers. If a patient discovers over time that nothing else works, then methadone can be very effective in controlling nerve pain. Remember, all drugs for neuropathy have side effects, so don't be put off by what you may have heard - it all boils down to careful monitoring by your doctor. Discuss it with him or her if you find that almost nothing works for you in reducing the pain of neuropathy.

METHADONE FOR NEUROPATHIC PAIN
David E Weissman MD FAST FACTS AND CONCEPTS #171

Background Prescriptions for methadone have greatly increased in the past decade (1). The reason for this increase is likely related to two factors: reduced cost relative to other potent opioids and basic science data suggesting that methadone may be particularly useful in treating neuropathic pain. Two previous Fast Facts (#75, 86) reviewed methadone’s pharmacological properties. This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.

Historical Context

Prior to 1985, when long-acting morphine preparations were introduced, methadone was commonly prescribed for cancer-related pain as it had a longer duration of action than morphine. However, it was well appreciated that methadone had a higher risk of respiratory depression due to drug accumulation with chronic dosing – an effect not associated with other opioids, for which there is no drug accumulation in the setting of normal renal function.

Prior to 1990 there was a widespread belief that opioids were relatively ineffective in treating neuropathic pain. Since then, there been a much greater understanding that opioids are an effective part of neuropathic pain treatment.

Basic science data Methadone inhibits reuptake of norepinephrine and serotonin in a similar manner to newer anti-depressants, some of which are effective against neuropathic pain (e.g. duloxetine, venlafaxine). Also, methadone binds to the NMDA receptor, a known modulator of neuropathic pain. Finally, methadone has demonstrated efficacy in animal models of neuropathic pain (2).

Patient data Small non-controlled case series and two small randomized study (methadone vs. placebo) have demonstrated that methadone can reduce neuropathic pain in both cancer and non-cancer patients (3-6). There is no data, for or against the proposition, that methadone is superior to other opioids for neuropathic pain. A 2007 Cochrane Collaborative review found, “there is no trial evidence to support the proposal that methadone has a particular role in neuropathic pain of malignant origin” (7). Furthermore, the review cautioned clinicians about the danger of methadone-induced respiratory depression due to its long terminal half-life.

Methadone deaths There is a growing awareness that the increased prescription of methadone is being paralleled by a similar increase in methadone-related deaths. Methadone has been implicated in 30% to 40% of opioid related deaths in the US, even though methadone remains a small minority of opioids prescribed (8). The US Department of Health and Human Services convened an expert panel in 2003 to investigate the rise in methadone deaths and concluded that the rise was largely due to the increasing use of methadone as an analgesic (9). The Center for Disease Control published a report detailing data from Utah in 2005, suggesting that part of the problem was due to increased prescribing (10). The current data seem to suggest that the general increased supply of methadone, via legitimate prescribing, is leading to deaths due to accidental overdose through improper prescribing or illicit diversion/recreational use. In addition to concern about respiratory depression, there has been an observation that methadone, unlike morphine or hydromorphone, can prolong the QTc interval and lead to serious cardiac conduction abnormalities especially when coadministered with antiretrovirals in HIV patients (11). Note: the overall number of opioid-related deaths has increased, not just from methadone. Note: there are no data on untimely deaths related to methadone prescribing in hospice/palliative care patients.

Summary The renewed interest in an old drug holds exciting promise of benefit for the many patients with neuropathic pain. However, clinical research has yet to confirm or deny a unique clinical role for methadone compared to other opioids. The risk of respiratory depression should give clinicians pause before prescribing methadone based solely on the theory that it is a superior opioid in neuropathic pain. Coadministration of methadone with antiretrovirals may pose a particular risk for cardiac arrhythmias and therefore should be avoided if at all possible., Given that diversion of legitimate opioid prescriptions to the illicit market can occur, even in the practice of hospice and palliative care, physicians and hospice agencies need to recognize they also have a larger social responsibility to the public welfare, and prescribe methadone with care and caution.

References

Warner M, Chen LH, et al. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief. 2011; 1-8.

Foley KM. Opioids and chronic neuropathic pain. NEJM 2003; 348:1279-1281.

Morley JS, et al. Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial. Pall Med. 2003; 17:576-587.

Altier N, et al. Management of chronic neuropathic pain with methadone: a review of 13 cases. Clin J Pain. 2005; 21:364-369.

Gagnon B, et al. Methadone in the treatment of neuropathic pain. Pain Res Manage. 2003; 8:149-154.

Moulin DE, et al. Methadone in the management of intractable neuropathic non cancer pain. Can J Neuro Sci. 2005; 32:340-343.

Nicholson, AB. Methadone for cancer pain. Cochrane Database Syst Rev 2007; 4.4.

Centers for Disease Control and Prevention (CDC). Vital signs: risk for overdose from methadone used for pain relief – United States, 1999-2010, Morb Mortal Wkly Rep 2012; 61:493-497.

Increase in poisoning deaths caused by non-illicit drugs--Utah, 1991-2003. MMWR Weekly. 2005; 54:33-36.

US Department of Health and Human Services – Division on Pharmacologic Therapies. Report on Methadone Mortality (http://dpt.samhsa.gov/reports/methodone_mortality-05.htm - no longer publicly available). Updated Report available at: http://www.dpt.samhsa.gov/pdf/MethadoneBackgroundPaper_72007_2_.pdf.

Kao D, Bartelson BB, et al. Trends in reporting methadone-associated cardiac arrhythmia, 1997-2011. Ann of Int Med 2013;158: 735-740.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in December 2006. Version copy-edited in April 2009: web-links updated. Revised again in July 2015 by Sean Marks MD: references and epidemiological data updated.

Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

Copyright: All Fast Facts and Concepts are published under a Creative Commons Attribution-NonCommercial 4.0 International Copyright (http://creativecommons.org/licenses/by-nc/4.0/). Fast Facts can only be copied and distributed for non-commercial, educational purposes. If you adapt or distribute a Fast Fact, let us know!

Disclaimer: Fast Facts and Concepts provide educational information for health care professionals. This information is not medical advice. Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Health care providers should always exercise their own independent clinical judgment and consult other relevant and up-to-date experts and resources. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

http://www.mypcnow.org/blank-ari0c

How Effective Is Carbamazepine For Neuropathy Pain

Today's post from onlinelibrary.wiley.com (see link below) is an objective assessment of the effects of carbamazepine on neuropathic pain and as such is always useful for neuropathy patients looking for confirmation that what they're being prescribed is what the doctor says it is. Carbamazepine has become increasingly popular recently, as an alternative to other anti-epilepsy drugs such as Lyrica, which has a possibly deserved bad press. However, does the research show that it works? This article suggests that it does...for some people but with caveats. Pretty much the same as all other drugs used to treat neuropathic pain then! Worth a read if you're on Carbamazepine, or likely to encounter it in the course of your treatment options.

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults 
Philip J Wiffen1,*, Sheena Derry1, R Andrew Moore1,Eija A Kalso2,3
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 10 APR 2014
Assessed as up-to-date: 7 FEB 2014

DOI: 10.1002/14651858.CD005451.pub3

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The Cochrane Library
Read a clinical summary of this review on

Abstract

Background

This is an update of a Cochrane review entitled 'Carbamazepine for acute and chronic pain in adults' published in Issue 1, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review considers the treatment of chronic neuropathic pain and fibromyalgia only, and adds no new studies. The update uses higher standards of evidence than the earlier review, which results in the exclusion of five studies that were previously included.

Objectives

To assess the analgesic efficacy of carbamazepine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse events reported in the studies.

Search methods

We searched for relevant studies in MEDLINE, EMBASE and CENTRAL up to February 2014. Additional studies were sought from clinical trials databases, and the reference list of retrieved articles and reviews.

Selection criteria

Randomised, double blind, active or placebo controlled trials (RCTs) investigating the use of carbamazepine (any dose, by any route, and for at least two weeks' duration) for the treatment of chronic neuropathic pain or fibromyalgia, with at least 10 participants per treatment group. Participants were adults aged 18 and over.

Data collection and analysis

Two study authors independently extracted data on efficacy, adverse events, and withdrawals, and examined issues of study quality. Numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) with 95% confidence intervals (CIs) were calculated from dichotomous data.

We performed analysis using three tiers of evidence. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for dropouts, at least 200 participants in the comparison, at least 8 weeks' duration, parallel design), second tier from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison, and third tier from data involving small numbers of participants that was considered very likely to be biased or used outcomes of limited clinical utility, or both.

Main results

Ten included studies (11 publications) enrolled 480 participants with trigeminal neuralgia, diabetic neuropathy, and post stroke pain. Nine studies used a cross-over design, and one a parallel group design. Most of the studies were of short duration, lasting four weeks or less.

No study provided first or second tier evidence for an efficacy outcome. Using third tier evidence, carbamazepine generally provided better pain relief than placebo in the three conditions studied, with some indication of pain improvement over mainly the short term, but with poorly defined outcomes, incomplete reporting, and in small numbers of participants. There were too few data in studies comparing carbamazepine with active comparators to draw any conclusions.

In four studies 65% (113/173) of participants experienced at least one adverse event with carbamazepine, and 27% (47/173) with placebo; for every five participants treated, two experienced an adverse event who would not have done so with placebo. In eight studies 3% (8/268) of participants withdrew due to adverse events with carbamazepine, and none (0/255) with placebo. Serious adverse events were not reported consistently; rashes were associated with carbamazepine. Four deaths occurred in patients on carbamazepine, with no obvious drug association.

Authors' conclusions

Carbamazepine is probably effective in some people with chronic neuropathic pain, but with caveats. No trial was longer than four weeks, had good reporting quality, nor used outcomes equivalent to substantial clinical benefit. In these circumstances, caution is needed in interpretation, and meaningful comparison with other interventions is not possible.

Plain language summary

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults

Neuropathic pain is pain coming from damaged nerves. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain.

Carbamazepine was developed to treat epilepsy, but it is now used to treat various forms of chronic pain. We performed searches (up to February 2014) to look for clinical trials where carbamazepine was used to treat neuropathic pain or fibromyalgia. We found 10 studies involving 418 people involved in testing carbamazepine. Studies were not generally of very good quality. Most were very small, as well as of short duration. Studies lasting only one or two weeks are unhelpful when pain can last for years.

There was not enough good quality evidence to say how well carbamazepine worked in any neuropathic pain condition. Pooling four small studies showed that it was better than placebo, but the result cannot be relied upon. There was not enough information from these studies to make any reliable comment on adverse events or harm.

Carbamazepine is probably helpful for some people with chronic neuropathic pain. It is not possible to know beforehand who will benefit and who will not. 


http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005451.pub3/abstract

Is Methadone An Option For Neuropathic Pain

Today's post from eperc.mcw.edu/ (see link below) was last revised in 2009 but nevertheless sums up current thinking regarding the use of methadone to control neuropathic symptoms. If you Google the subject you will come up with many other articles, including studies, about using methadone as a specific opioid to control nerve pain but this one is relatively easy to understand and sums up the dilemmas that doctors and specialists face in the current climate, where opioid prescription is coming under both social and legal scrutiny, especially in North America. Methadone's efficiency as an analgesic is somewhat clouded by its reputation, as a substitute for morphine, heroine and other opiate-acting drugs but that may be unfair. It seems however, that more and more people are finding that relatively low-dose methadone use can bring relief from their neuropathic pain and it may be worth discussing the possibility with your specialist or doctor, especially if all else seems to have failed. Methadone may well be a good alternative to Tramadol and Oxycodone but it is essential that the decision to take it is taken in complete agreement with your doctor. Just as with all other opioids and strong painkillers, ensuring that your progress will be monitored is also essential to avoid overdose and addiction potential. This article is not the full story but provides useful background information to help with your decision making.
Never attempt to self-medicate with Methadone or other opioids.

Methadone for Neuropathic Pain
Author(s): David E Weissman MD FAST FACTS AND CONCEPTS #171 PDF

Background Prescriptions for methadone have greatly increased in the past six years (1). The reason for this increase is likely related to two factors: reduced cost relative to other potent opioids and basic science data suggesting that methadone may be particularly useful in treating neuropathic pain. Two previous Fast Facts #75, 86) reviewed methadone’s pharmacological properties. This Fast Fact examines the research base regarding methadone and neuropathic pain and reviews the rise in methadone-related deaths.

Historical Context
 
Prior to 1985, when long-acting morphine preparations were introduced, methadone was commonly prescribed for cancer-related pain as it had a longer duration of action than morphine. However, it was well appreciated that methadone had a higher risk of respiratory depression due to drug accumulation with chronic dosing – an effect not associated with other opioids, for which there is no drug accumulation in the setting of normal renal function.

Prior to 1990 there was a widespread belief that opioids were relatively ineffective in treating neuropathic pain. Since then, there been a much greater understanding that opioids are an effective part of neuropathic pain treatment.

Basic science data Methadone inhibits reuptake of norepinephrine and serotonin in a similar manner to newer anti-depressants, some of which are effective against neuropathic pain (e.g. venlafaxine). Also, methadone binds to the NMDA receptor, a known modulator of neuropathic pain. Finally, methadone has demonstrated efficacy in animal models of neuropathic pain (1).

Patient data Small non-controlled case series and at least one small randomized study (methadone vs. placebo) have demonstrated that methadone can reduce neuropathic pain in both cancer and non-cancer patients (2-5). There is no data, for or against the proposition, that methadone is superior to other opioids for neuropathic pain. A 2004 Cochrane Collaborative review found, “there is no trial evidence to support the proposal that methadone has a particular role in neuropathic pain of malignant origin” (6). Furthermore, the review cautioned clinicians about the danger of methadone-induced respiratory depression due to its long terminal half-life.

Methadone deaths There is a growing awareness that the increased prescription of methadone is being paralleled by a similar increase in methadone-related deaths. Florida, Utah, North Carolina, Oregon, Indiana, Maryland, Alabama and West Virginia have all reported a spike in deaths related to methadone since 2000 (7,8). The US Department of Health and Human Services convened an expert panel in 2003 to investigate the rise in methadone deaths and concluded that the rise was largely due to the increasing use of methadone as an analgesic (9). The Center for Disease Control published a report detailing data from Utah in 2005, suggesting that part of the problem was due to increased prescribing (10). The current data seem to suggest that the general increased supply of methadone, via legitimate prescribing, is leading to deaths due to accidental overdose through improper prescribing or illicit diversion/recreational use. In addition to concern about respiratory depression, there has been a relatively recent observation that methadone, unlike morphine or hydromorphone, can prolong the QTc interval and lead to serious cardiac conduction abnormalities. Note: the overall number of opioid-related deaths has increased, not just from methadone. Note: there are no data on untimely deaths related to methadone prescribing in hospice/palliative care patients.

Summary The renewed interest in an old drug based on new science holds exciting promise of benefit for the many patients with neuropathic pain. However, clinical research has yet to confirm or deny a unique clinical role for methadone compared to other opioids. The risk of respiratory depression should give clinicians pause before prescribing methadone based solely on the theory that it is a superior opioid in neuropathic pain. Furthermore, given that diversion of legitimate opioid prescriptions to the illicit market can occur, even in the practice of hospice and palliative care, physicians and hospice agencies need to recognize they also have a larger social responsibility to the public welfare, and prescribe methadone with care and caution.

References
Foley KM. Opioids and chronic neuropathic pain. NEJM. 2003; 348:1279-1281.
Morley JS, et al. Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial. Pall Med. 2003; 17:576-587.
Altier N, et al. Management of chronic neuropathic pain with methadone: a review of 13 cases. Clin J Pain. 2005; 21:364-369.
Gagnon B, et al. Methadone in the treatment of neuropathic pain. Pain Res Manage. 2003; 8:149-154.
Moulin DE, et al. Methadone in the management of intractable neuropathic non cancer pain. Can J Neuro Sci. 2005; 32:340-343.
Nichloson AB. Methadone for cancer pain: Review. Cochrane Database of systematic reviews. 2004;2:CD003971.
Google Search: ‘Methadone deaths.’ December 2007.
Finn S, Tuckwiller S. Feds act on methadone deaths. West Virginia Gazette. July 23 2006.
Increase in poisoning deaths caused by non-illicit drugs--Utah, 1991-2003. MMWR Weekly. 2005; 54:33-36.
US Department of Health and Human Services – Division on Pharmacologic Therapies. Report on Methadone Mortality (http://dpt.samhsa.gov/reports/methodone_mortality-05.htm - no longer publicly available). Updated Report available at: http://www.dpt.samhsa.gov/pdf/MethadoneBackgroundPaper_72007_2_.pdf.
Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in December 2006. Current version re-copy-edited in April 2009; web-links updated.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE. Methadone for Neuropathic Pain. Fast Facts and Concepts. December 2006; 171. Available at: http://www.eperc.mcw.edu/FastFactsIndex/ff_171.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_171.htm

How Is Restless Leg Syndrome Different To Neuropathy

 Today's post comes from breathesleeplivewell.com (see link below) and talks about something which confuses many people with either peripheral neuropathy or restless leg syndrome ie: what's the difference? Because they are both neurological disorders, some doctors will tell you that your restless leg syndrome is another version of neuropathy and some of the treatments are also the same for both conditions but there are significant differences and these are highlighted here. The fact that people can have both problems at the same time, confuses the issue even further but it is important for you to see both conditions as being different, while at the same time hopefully taking the same medication for both (the less pills you have to swallow the better!)  
 

Restless legs or neuropathy, which is it?
November 11, 2012  David Ostransky, DO, DABSM

Restless Legs Syndrome, Peripheral Neuropathy, or Both?

Restless Legs Syndrome (RLS) is one of the most important causes of insomnia to recognize – because it is so common (5-15% of the general population), and it responds so well to treatment. It is often related to heredity factors (40%), but other causes include anemia, iron deficiency, neuropathies, kidney failure, and the use of certain medications. It is important to differentiate this condition from peripheral neuropathy, because of the symptoms are so similar, sometimes RLS and peripheral neuropathy occur together in some patients, and the use of some of the same medications for these conditions. Patients and primary care providers often have a difficult time differentiating between the two conditions.

Peripheral neuropathy may be caused by many different conditions including the following:

Diabetes Mellitus
Shingles
Vitamin Deficiency, especially B12 and folate
Alcohol
Auto immune disorders including lupus, rheumatoid arthritis, vasculitis, amyloidosis, or Guillain Barre
HIV infection, and its complications
Inherited disorders, Charcot Marie Tooth
Exposure to toxins, heavy metals, gold, lead, arsenic, mercury, and pesticides
Medications, including chemotherapy drugs, antibiotics, & isoniazid
Peripheral vascular disease

RLS is described by patients as the experience of vague or unpleasant sensations involving usually the lower extremities, but sometimes the upper extremities. This discomfort appears primarily during periods of inactivity, particularly during the transition from wake to sleep, or during the day, sitting on a plane, lone car rides, or sitting in a movie theater. RLS patients often have difficulty describing the sensations, rarely using conventional terms of discomfort such as “numbness, tingling, or pain,” but rather bizarre terms such as “pulling, searing, drawing, creepy, crawly, fluttering, shimmering, butterflies, or boring sensations,” with the sensations often causing anxiety. Distinct from sensory neuropathy patients, these unpleasant sensations are typically relieved by movement or counter stimulation (rubbing, massaging, hot water) of the affected part. Although, these manoeuvers are effective while being performed, the discomfort returns as soon as the individual becomes inactive or tries to return to bed. The International RLS Study Group has developed diagnostic criteria:

Minimal Criteria-IRLS Group

1. Desire to move the limbs usually associated with paresthesias/dysesthesias

2. Motor restlessness

3. Symptoms are worse or exclusively present at rest with at least partial or temporary relief by activity

4. Symptoms worse in evening/night

Supportive Criteria- IRLS Group

1. Positive response to dopaminergic treatment

2. Periodic limb movements (leg movements after sleep)

3. Positive family history( 40%)

Important differences between RLS and peripheral neuropathy(PN) are as follows:

1. Peripheral neuropathy occurs as a consequence of damage to the peripheral nervous system, whereas RLS occurs as a consequence of an imbalance of chemicals that control movement in the basal ganglia of the brain. Because there are different types of nerve fibers, motor, sensory, and autonomic, PN is a much more heterogeneous condition (more than 100 types) with a lot more variability of symptoms compared to RLS.

2. Though, the symptoms of PN and RLS may be somewhat similar, such as numbness, tingling, and prickly sensations, PN patients do not report the relief that occurs with movement that RLS patients report. PN patients often focused on the discomfort that they experience, RLS patients seem to focus on the anxiety that they experience as a consequence of the discomfort.

3. The diagnosis of PN is typically based on electromyography and nerve conduction velocity (yes, the sticking of needles into your muscles) whereas the diagnosis of RLS is based on history, specifically meeting the International RLS criteria. Sometimes, we draw a serum ferritin level (iron studies) and blood count

4. Treatment considerations for RLS include agents used to treatment Parkinson’s disease like ropirinole, pramipexole, sinemet, neupro, gabapentin (Neurotin), and horizont, benzodiazepines, opiates, and anticonvulsants, whereas PN sometimes are given medications such as gabapentin (Neurotin), lyrica, and antidepressants to manage the pain.

5. Many conditions may result in with patients having both PN and RLS, such as chronic renal failure with dialysis, neurological conditions such as multiple sclerosis, spinal cord insults and diabetic neuropathy .

http://breathesleeplivewell.com/2012/11/11/restless-legs-or-neuropathy-which-is-itb/

Neuropathy Knowledge What Is Myelin

Today's post from sciencedaily.com (see link below) is the third part of a series from the same source providing readers with explanations and information about many of the medical terms they hear when researching neuropathy, or sitting in the doctor's surgery and talking about it. Today it explains the word 'Myelin' and gives related definitions of other words associated with the workings of myelin. When the myelin sheath is damaged that can be one of the main causes of neuropathy and your pain. Worth following the links if you have the time. Other posts about myelin can be found to the right of this blog.

Myelin
Science Daily via Wikipedia

Myelin is an electrically insulating phospholipid layer that surrounds the axons of many neurons.

It is an outgrowth of glial cells: Schwann cells supply the myelin for peripheral neurons while oligodendrocytes supply it to those of the central nervous system.

The main consequence of a myelin layer (or sheath) is an increase in the speed at which impulses propagate along the myelinated fiber.

For more information about the topic Myelin, read the full article at Wikipedia.org, or see the following related articles:

Axon — An axon, or nerve fiber, is a long slender projection of a nerve cell, or neuron, that conducts electrical impulses away from the neuron's cell body ... read more

Neuron — Neurons (also known as neurones, nerve cells and nerve fibers) are electrically excitable cells in the nervous system that function to process and ... read more

Action potential — An action potential is a wave of electrical discharge that travels along the membrane of a cell. Action potentials are an essential feature of animal ...  read more

Sympathetic nervous system — The sympathetic nervous system (SNS) is part of the autonomic nervous system (ANS), which also includes the parasympathetic nervous system (PNS). The ...  read more

Nervous system — The nervous system of an animal coordinates the activity of the muscles, monitors the organs, constructs and also stops input from the senses, and ... read more

Gate control theory of pain — The gate control theory of pain, put forward by Ron Melzack and Patrick Wall in 1962, is the idea that physical pain is not a direct result of ...  read more

Sensory neuron — Sensory neurons are nerve cells within the nervous system responsible for converting external stimuli from the organism's environment into internal ...  read more

Multiple sclerosis — Multiple sclerosis (abbreviated MS, also known as disseminated sclerosis) is a chronic, inflammatory disease that affects the central nervous system ...  read more

Stem cell treatments — Medical researchers believe that stem cell treatments have the potential to change the face of human disease and alleviate suffering. A number of ... read more

Brain — In animals, the brain, or encephalon, is the control center of the central nervous system. In most animals, the brain is located in the head, ...  read more

http://www.sciencedaily.com/articles/m/myelin.htm

N Is For Neuropathy A Personal Story

Today's post from http://frecklesandapinktiara.wordpress.com (see link below) is a personal account of having neuropathy as a result of lupus. There will be things in this article which will strike a cord with most neuropathy sufferers and it always helps to read about how other people are dealing with the problem. If you're experiencing the same symptoms, you should talk to your doctor about the possibility of having neuropathy alongside your original illness. 

“N” IS FOR NEUROPATHY, PERIPHERAL NEUROPATHY
April 16, 2013 · by Monique  in Blogging from A-Z April 2013 Challenge,


Last night while PJ and I were putting everything away so we could settle into bed, I irritated the crap out him. In the process of trying to move my pill cups, I dropped them, sending my meds into a hundred different directions. Then I tried to grab one of my cups, which are the acrylic cups with lids and acrylic straws that don’t fall out for this very reason, and dropped it too. Since it’s essentially a sippy cup for grown ups, only a few drops came out. Since I have some mobility issues, I have a Winnie the Pooh crib organizer hanging on my wall next to the bed. I keep things like my hair brush, lotion, deodorant, facial moisturizer, headbands…things like that in it. Well, as I was trying to put my brush up I missed the pocket and dropped it onto the night stand right where Prince Charming had just put the laptop, and he told me to stop helping. lol

Now, from the outside looking in, you’d think my name was Grace. That’s the problem with an invisible illness though, nothing is what it seems from the outside looking in. Because even though I have been touched with klutz stick, what was going on was Peripheral Neuropathy.

A few years back, I started getting this really odd feeling in my hands and feet. It was almost like they fell asleep, but it also felt like my hands and feet had swollen to the point of stretching my skin. They felt very slick to me. I chalked it up to another attempt by Lupus to try and make me look completely crazy. Over the course of the next year or so, those sensations would happen more and more. After a while, the tingling sensation started to precede these very strange feelings that I can only describe as an electric like buzzing bolt that would shoot down my arms. The first time it happened, it happened in my left arm only, about 6 months after a heart attack {oddly enough that was 3 years and; 2 days ago…seems like a lifetime ago though} and I was terrified that I was having another one. After a visit to the E.R, I had yet one more new medical diagnosis to add to my collection, Peripheral Neuropathy.

Peripheral Neuropathy is a condition resulting from damage or disease to the peripheral nerves-the motor, sensory and autonomic nerves-that connect to the spinal cord to muscles, skin and internal organs. The causes can range from Diabetes, an unbalanced diet, heredity, and you guessed it…autoimmune diseases, especially systemic ones.

As it has progressed, the sensations have evolved. I don’t get the tingling as often anymore, but the recurrence of my hands feeling slick has increased. It got harder and harder to turn a door knob, or open things when it required grip. And about 6 months ago I started dropping things a lot, and even though I was using my walker I started falling again. I couldn’t understand it. It was like the air was tripping me and gravity went into hyper mode to pull things out of my hands.

And then I found out that if your sensory nerves become damaged that slick feeling in your hands and feet prevent you from being able to tell that you don’t have your feet firmly planted or that you don’t have a good grip on things you’re holding even if you feel like you do. Which meant that neither the air or gravity had it out for me.

Since Peripheral Neuropathy is unique to each person, and the sensations are so odd, it’s easy to over look the signs and even easier for people to look at you like you grew a second head right there in front of them when you’re trying to describe the symptoms. But because there are some treatment options that might be available to you, you need to talk to your doctor as soon as you start to experience any of the symptoms to help prevent any further damage or possibly a cure.

If you have a Facebook account, tomorrow The Neuropathy Association is hosting a Facebook chat, “Advances in Chemotherapy-Induced Peripheral Neuropathy Research” on their Facebook Page, starting at 7 pm Eastern time.

http://frecklesandapinktiara.wordpress.com/2013/04/16/n-is-for-neuropathy-peripheral-neuropathy/comment-page-1/

Is Antidepressant Milnacipran Any Good For Neuropathy

Today's post from cochrane.org (see link below) looks at Milnacipran, an antidepressant and asks whether it's effective in reducing neuropathic pain. Due to antidepressants and especially SNRI (serotonin–norepinephrine reuptake inhibitor) antidepressants, being standard treatment for neuropathic pain, that doesn't mean to say that every antidepressant in the range is effective. Cochrane has looked at the drug and concludes that there is no evidence to suggest Milnacipran is of any help in taming nerve pain. Forewarned is forearmed as they say, so if your doctor suggests taking Milnacripan, it may be worth presenting this evidence to him or her.

Milnacipran for neuropathic pain in adults
Authors: Derry S, Phillips T, Moore R, Wiffen PJ Published: 6 July 2015
 
Neuropathic pain is pain coming from damaged nerves. It is different from pain messages that are carried along healthy nerves from damaged tissue (for example, a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines to those used for pain from damaged tissue. Medicines such as paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain.

Milnacipran is an antidepressant, and antidepressants are widely recommended for treating neuropathic pain; milnacipran may also be useful in these painful conditions.

This is an update of a review of milnacipran for neuropathic pain and fibromyalgia, first published in 2012. That review has been split so that this one looked only at neuropathic pain, and a separate review looks at fibromyalgia.

In February 2015 we performed searches to look for clinical trials where milnacipran was used to treat neuropathic pain in adults.

We found only a single, small study of 40 participants who had chronic low back pain with a neuropathic component. Milnacipran was no different from placebo in terms of pain or adverse events (very low quality evidence).

There was no evidence to support use of milnacipran to treat neuropathic pain conditions.

Authors' conclusions:

There was no evidence to support the use of milnacipran to treat neuropathic pain conditions. 

Background:

Milnacipran is a serotonin–norepinephrine reuptake inhibitor (SNRI) that is sometimes used to treat chronic neuropathic pain and fibromyalgia. This is an update of an earlier review of milnacipran for neuropathic pain and fibromyalgia in adults originally published in The Cochrane Library Issue 3, 2012. We split that review so that this one looked only at neuropathic pain, and a separate review looks at fibromyalgia. 

Objectives:

To assess the analgesic efficacy and associated adverse events of milnacipran for chronic neuropathic pain in adults. 

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE to 23 February 2015, together with reference lists of retrieved papers and reviews. 

Selection criteria:

We included randomised, double-blind studies of eight weeks' duration or longer, comparing milnacipran with placebo or another active treatment in chronic neuropathic pain. 

Data collection and analysis:

Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality. We did not carry out any analysis. 

Main results:



We included a single study of 40 participants with chronic low back pain with a neuropathic component. It found no difference in pain scores between milnacipran 100 mg to 200 mg daily or placebo after six weeks (very low quality evidence). Adverse event rates were similar between treatments, with too few data to draw conclusions (very low quality evidence).

http://www.cochrane.org/CD011789/SYMPT_milnacipran-neuropathic-pain-adults

What Pain Is PART 1

I very seldom recommend an article, or advise people strongly to read it. I generally let the reader make up his or her mind if the subject interests them or not. However, today's and tomorrow's two-part post from the National Institute of Neurological Disorders and Stroke (see link below) seems to me to be extremely useful for most people living with HIV and/or Neuropathy. It was written in 2001 but as you will see, very little has changed since then.
Sooner or later, it is possible that you will experience some HIV-related complaint which gives you pain. If it's not HIV-related then it's very helpful to be able to identify exactly what it is. HIV-patients are constantly excluding possiblities before getting to the source of their problem. That applies even more to people with neuropathy. It is so complex; with so many causes and forms, that getting to the root of your pain problem is liking walking through a minefield.
This article provides a sort of easily-understandable breakdown of the various forms of pain and how they're treated (including 'alternative' treatments). It's long (had to be split up over two days) but absolutely worth reading, even if you're not in pain yourself. It will help to calm the inbuilt hypochondria that people with HIV acquire through experience and enable them to rule out many of their worries. It may also give you a starting point for discussions with your doctor.

Pain: Hope Through Research
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Introduction: The Universal Disorder

You know it at once. It may be the fiery sensation of a burn moments after your finger touches the stove. Or it's a dull ache above your brow after a day of stress and tension. Or you may recognize it as a sharp pierce in your back after you lift something heavy.

It is pain. In its most benign form, it warns us that something isn't quite right, that we should take medicine or see a doctor. At its worst, however, pain robs us of our productivity, our well-being, and, for many of us suffering from extended illness, our very lives. Pain is a complex perception that differs enormously among individual patients, even those who appear to have identical injuries or illnesses.

In 1931, the French medical missionary Dr. Albert Schweitzer wrote, "Pain is a more terrible lord of mankind than even death itself." Today, pain has become the universal disorder, a serious and costly public health issue, and a challenge for family, friends, and health care providers who must give support to the individual suffering from the physical as well as the emotional consequences of pain.

A Brief History of Pain

Ancient civilizations recorded on stone tablets accounts of pain and the treatments used: pressure, heat, water, and sun. Early humans related pain to evil, magic, and demons. Relief of pain was the responsibility of sorcerers, shamans, priests, and priestesses, who used herbs, rites, and ceremonies as their treatments.

The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system have a role in producing the perception of pain. But it was not until the Middle Ages and well into the Renaissance-the 1400s and 1500s-that evidence began to accumulate in support of these theories. Leonardo da Vinci and his contemporaries came to believe that the brain was the central organ responsible for sensation. Da Vinci also developed the idea that the spinal cord transmits sensations to the brain.

In the 17th and 18th centuries, the study of the body-and the senses-continued to be a source of wonder for the world's philosophers. In 1664, the French philosopher René Descartes described what to this day is still called a "pain pathway." Descartes illustrated how particles of fire, in contact with the foot, travel to the brain and he compared pain sensation to the ringing of a bell.

In the 19th century, pain came to dwell under a new domain-science-paving the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. These drugs led to the development of aspirin, to this day the most commonly used pain reliever. Before long, anesthesia-both general and regional-was refined and applied during surgery.

"It has no future but itself," wrote the 19th century American poet Emily Dickinson, speaking about pain. As the 21st century unfolds, however, advances in pain research are creating a less grim future than that portrayed in Dickinson’s verse, a future that includes a better understanding of pain, along with greatly improved treatments to keep it in check.

The Two Faces of Pain: Acute and Chronic

What is pain? The International Association for the Study of Pain defines it as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

It is useful to distinguish between two basic types of pain, acute and chronic, and they differ greatly.

Acute pain, for the most part, results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly, for example, after trauma or surgery, and may be accompanied by anxiety or emotional distress. The cause of acute pain can usually be diagnosed and treated, and the pain is self-limiting, that is, it is confined to a given period of time and severity. In some rare instances, it can become chronic.
Chronic pain is widely believed to represent disease itself. It can be made much worse by environmental and psychological factors. Chronic pain persists over a longer period of time than acute pain and is resistant to most medical treatments. It can—and often does—cause severe problems for patients. A person may have two or more co-existing chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.

The A to Z of Pain

Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pin prick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows amputation of a limb. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically.

Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. A number of causes, including infection or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain.

Arthritis. Millions of Americans suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body's soft tissues, including tendonitis and bursitis.

Back pain has become the high price paid by our modern lifestyle and is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a very common condition (see below). Another common type of back pain is associated with the discs of the spine, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and may sometimes rupture. Spondylolisthesis is a back condition that occurs when one vertebra extends over another, causing pressure on nerves and therefore pain. Also, damage to nerve roots (see Spine Basics in the Appendix) is a serious condition, called radiculopathy, that can be extremely painful. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids; exercise or rest, depending on the patient's condition; adequate support, such as a brace or better mattress and physical therapy. In some cases, surgery may be required to remove the damaged portion of the disc and return it to its previous condition, especially when it is pressing a nerve root. Surgical procedures include discectomy, laminectomy, or spinal fusion (see section on surgery in How is Pain Treated? for more information on these treatments).

Burn pain can be profound and poses an extreme challenge to the medical community. First-degree burns are the least severe; with third-degree burns, the skin is lost. Depending on the injury, pain accompanying burns can be excruciating, and even after the wound has healed patients may have chronic pain at the burn site.

Central pain syndrome-see "Trauma" below.

Cancer pain can accompany the growth of a tumor, the treatment of cancer, or chronic problems related to cancer's permanent effects on the body. Fortunately, most cancer pain can be treated to help minimize discomfort and stress to the patient.

Headaches affect millions of Americans. The three most common types of chronic headache are migraines, cluster headaches, and tension headaches. Each comes with its own telltale brand of pain.

Migraines are characterized by throbbing pain and sometimes by other symptoms, such as nausea and visual disturbances. Migraines are more frequent in women than men. Stress can trigger a migraine headache, and migraines can also put the sufferer at risk for stroke.
Cluster headaches are characterized by excruciating, piercing pain on one side of the head; they occur more frequently in men than women.
Tension headaches are often described as a tight band around the head.
Head and facial pain can be agonizing, whether it results from dental problems or from disorders such as cranial neuralgia, in which one of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest of the cranial nerves (see The Nervous Systems in the Appendix) and is characterized by a stabbing, shooting pain.

Muscle pain can range from an aching muscle, spasm, or strain, to the severe spasticity that accompanies paralysis. Another disabling syndrome is fibromyalgia, a disorder characterized by fatigue, stiffness, joint tenderness, and widespread muscle pain. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis.

Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body's muscles. Myofascial pain syndromes are sometimes misdiagnosed and can be debilitating. Fibromyalgia is a type of myofascial pain syndrome.

Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system (see The Nervous Systems in the Appendix). Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); reflex sympathetic dystrophy syndrome (see below), which can follow injury; phantom limb and post-amputation pain (see Phantom Pain in the Appendix), which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; and central pain syndrome, which can result from trauma to the brain or spinal cord.

Reflex sympathetic dystrophy syndrome, or RSDS, is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, RSDS causes the skin of the affected area to become characteristically shiny. In recent years, RSDS has come to be called complex regional pain syndrome (CRPS); in the past it was often called causalgia.

Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include:

Writer's cramp, which affects musicians and writers and others,
compression or entrapment neuropathies, including carpal tunnel syndrome, caused by chronic overextension of the wrist and
tendonitis or tenosynovitis, affecting one or more tendons.
Sciatica is a painful condition caused by pressure on the sciatic nerve, the main nerve that branches off the spinal cord and continues down into the thighs, legs, ankles, and feet. Sciatica is characterized by pain in the buttocks and can be caused by a number of factors. Exertion, obesity, and poor posture can all cause pressure on the sciatic nerve. One common cause of sciatica is a herniated disc (see Spine Basics in the Appendix).

Shingles and other painful disorders affect the skin. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most vexing neurological disorders is shingles or herpes zoster, an infection that often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is important to arrest the infection, which if prolonged can result in an associated condition known as postherpetic neuralgia. Other painful disorders affecting the skin include:

Vasculitis, or inflammation of blood vessels;
other infections, including herpes simplex;
skin tumors and cysts, and
tumors associated with neurofibromatosis, a neurogenetic disorder.

Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well-known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability.

Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs and leg pain usually felt while the person is standing up and often relieved by sitting down.

Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring of the patient during and after the procedure.

Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged and/or the muscles used for chewing and talking become stressed, causing pain. The condition may be the result of a number of factors, such as an injury to the jaw or joint misalignment, and may give rise to a variety of symptoms, most commonly pain in the jaw, face, and/or neck muscles. Physicians reach a diagnosis by listening to the patient's description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint.

Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain. Some patients who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such patients are sensitive to hot and cold temperatures and touch. For these individuals, a touch can be perceived as intense burning, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome or, if the damage is in the thalamus (the brain's center for processing bodily sensations), thalamic pain syndrome. It affects as many as 100,000 Americans with multiple sclerosis, Parkinson's disease, amputated limbs, spinal cord injuries, and stroke. Their pain is severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, anticonvulsants, and electrical stimulation, are options available to central pain patients.

Vascular disease or injury-such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems-all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels, as well as a condition called ischemia in which blood supply to organs, tissues, or limbs is cut off, can also result in pain.

How is Pain Diagnosed?

There is no way to tell how much pain a person has. No test can measure the intensity of pain, no imaging device can show pain, and no instrument can locate pain precisely. Sometimes, as in the case of headaches, physicians find that the best aid to diagnosis is the patient's own description of the type, duration, and location of pain. Defining pain as sharp or dull, constant or intermittent, burning or aching may give the best clues to the cause of pain. These descriptions are part of what is called the pain history, taken by the physician during the preliminary examination of a patient with pain.

Physicians, however, do have a number of technologies they use to find the cause of pain. Primarily these include:

Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. Information from EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain. Thin needles are inserted in muscles and a physician can see or listen to electrical signals displayed on an EMG machine. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock that stimulates the nerve that runs to that muscle. The second set of electrodes is used to make a recording of the nerve's electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes-one set for stimulating a nerve (these electrodes are attached to a limb) and another set on the scalp for recording the speed of nerve signal transmission to the brain.
Imaging, especially magnetic resonance imaging or MRI, provides physicians with pictures of the body's structures and tissues. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.
A neurological examination in which the physician tests movement, reflexes, sensation, balance, and coordination.
X-rays produce pictures of the body's structures, such as bones and joints.

How is Pain Treated?

The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable. The following treatments are among the most common.

Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).

Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators.

Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.

Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.

Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs.

Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.

Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness.

Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.

Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams (see Chili Peppers, Capsaicin, and Pain in the Appendix).

Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc (see Spine Basics in the Appendix) in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure's use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain.

Chiropractic care may ease back pain, neck pain, headaches, and musculoskeletal conditions. It involves "hands-on" therapy designed to adjust the relationship between the body's structure (mainly the spine) and its functioning. Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and adjacent tissues. Such care may also involve therapeutic and rehabilitative exercises.

Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.

Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.

COX-2 inhibitors may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins, which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs.

In 1999, the Food and Drug Administration approved a COX-2 inhibitor-celecoxib-for use in cases of chronic pain. The long-term effects of all COX-2 inhibitors are still being evaluated, especially in light of new information suggesting that these drugs may increase the risk of heart attack and stroke. Patients taking any of the COX-2 inhibitors should review their drug treatment with their doctors.

Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:

TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.
Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.
Spinal cord stimulation uses electrodes surgically inserted within the epidural space of the spinal cord. The patient is able to deliver a pulse of electricity to the spinal cord using a small box-like receiver and an antenna taped to the skin.
Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including severe pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains.

Exercise has come to be a prescribed part of some doctors' treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, that patients carefully follow the routine laid out by their physicians.

Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.

Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.

Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.

Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.

Narcotics (see Opioids, below).

Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade (see Nerve Blocks in the Appendix).

Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.

Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting.

Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery.

Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain's own analgesics and setting the body's self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value.

R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.

Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient's pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.
......................
See Part 2 tomorrow

http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm

Neuropathy Knowledge What Is Chronic Pain

Today's post from sciencedaily.com (see link below) is the second part of a series from the same source providing readers with explanations and information about many of the medical terms they hear when researching neuropathy, or sitting in the doctor's surgery and talking about it. Today it explains the term 'chronic pain' and gives related definitions of other words associated with this level of pain. People are often confused by the term chronic pain and aren't sure of the difference between that and ordinary or severe pain, especially in relation to neuropathy. Worth following the links if you have the time.

Chronic pain
Science Daily via Wikipedia

Chronic pain was originally defined as pain that has lasted 6 months or longer.

It is now defined as pain that persists longer than the normal course of time associated with a particular type of injury.

Chronic pain is essentially caused by the bombardment of the central nervous system (CNS) with nociceptive impulses, which causes changes in the neural response.

The pain subsequently provokes changes in the behavior of the patient, and the development of fear-avoidance strategies.

As a result, the patient may also become physically atrophied and deconditioned.

However, it is important to remember that chronic pain is multifactorial, with the underlying biological changes affecting physical and psychosocial factors.

For more information about the topic Chronic pain, read the full article at Wikipedia.org, or see the following related articles:


Fatigue (physical) — Fatigue is a state, following a period of mental or physical activity, characterized by a lessened capacity for work and reduced efficiency of ...  read more


Laryngitis — Laryngitis is an inflammation of the larynx. It causes hoarse voice or the complete loss of the voice because of irritation to the vocal folds (vocal ... read more


Multi-infarct dementia — Multi-infarct dementia, also known as vascular dementia, is a form of dementia resulting from brain damage caused by stroke or transient ischemic ...  read more


Cluster headache — Cluster headaches are rare, extremely painful and debilitating headaches that occur in groups or clusters. Cluster headache sufferers typically ...  read more


Pain — Pain's an unpleasant sensation which may be associated with actual or potential tissue damage and which may have physical and emotional components. ... read more


Tension headache — Tension headaches, which were recently renamed tension type headaches by the International Headache Society, are the most common type of headaches. ... read more


Drug addiction — Drug addiction, or substance dependence is the compulsive use of psychoactive drugs, to the point where the user has no effective choice but to ... read more


Back pain — Back pain (also known as "dorsopathy") is pain felt in the human back that may come from the spine, muscles, nerves, or other structures in the back. ...  read more


Analgesic — An analgesic (colloquially known as painkillers) is any member of the diverse group of drugs used to relieve pain and to achieve analgesia. This ... read more


Blister — A blister or bulla is a defense mechanism of the human body. It consists of a pool of lymph and other bodily fluids beneath the upper layers of the ...  read more

http://www.sciencedaily.com/articles/c/chronic_pain.htm

For Which Neuropathies Is Lyrica Really Suitable

Today's post is a Pfizer Press release (see link below) concerning Lyrica being prescribed for a specific form of neuropathy. The American FDA has approved its use for neuropathy associated with spinal cord injuries (for which there was no approved treatment before). It's a Pfizer press release, so it positively glows with pride at the achievement, yet they have withdrawn the drug for treatment of HIV-related and other neuropathies. It doesn't make sense. The pain receptors that Lyrica targets are much the same for most forms of neuropathy, yet some are considered suitable for Lyrica treatment and others not. It is still widely prescribed for HIV-related neuropathy across the world, as different medical authorities try to decide what to do about it and what the truth is. Considering the court cases Pfizer have had to face concerning the side effects of Lyrica, it would be advisable to talk carefully with your doctor before starting a course of this drug - the possible side effects shouldn't be underestimated (more articles about this subject in the list on the right of the blog). Maybe Pfizer should consider explaining the situation in simple terms to the patients themselves?

FDA Approves Lyrica For The Management Of Neuropathic Pain Associated With Spinal Cord Injury Based On Priority Review

June 21, 2012

First and Only Treatment Option Approved in the U.S. for Pain Condition Affecting 40 Percent of Spinal Cord Injury Patients

NEW YORK--(BUSINESS WIRE)--Pfizer Inc. (NYSE: PFE) announced today that the U.S. Food and Drug Administration (FDA) approved the use of Lyrica^® (pregabalin) capsules CV for the management of neuropathic pain associated with spinal cord injury. Lyrica received a priority review designation for this new indication from the FDA. More than 100,000 patients – approximately 40 percent of the 270,000 patients with spinal cord injury in the United States - suffer from this chronic, complex pain condition. Neuropathic pain associated with spinal cord injury can be severely debilitating and may significantly hinder rehabilitation and the ability to regain function.
  
“This milestone represents an important opportunity for physicians to more effectively manage the debilitating neuropathic pain that often accompanies spinal cord injury,” said clinical study investigator Diana Cardenas, MD, MHA, professor and chair, department of rehabilitation medicine, University of Miami Miller School of Medicine and chief of service for rehabilitation medicine and medical director of Jackson Rehabilitation Hospital, Miami, Florida. “Given the clinical challenges of investigating neuropathic pain in this patient population, any advancements in treatment are welcome by physicians and patients alike.”
  
An estimated 12,000 new spinal cord injury patients are diagnosed in the U.S. each year. There are a wide variety of causes for spinal cord injury, including traumatic and non-traumatic causes. Traumatic causes may include motor vehicle accidents, violence, falls and sports injuries. In these instances, a spinal cord injury typically begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae. The damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue. Non-traumatic causes may involve congenital and developmental abnormalities, genetics and metabolism, infections and inflammation, removal of a benign spinal tumor and spinal cord ischemic stroke.
  
Neuropathic pain can be experienced above, at or below the level of the spinal cord injury, and is typically not confined to one area in the body. Approximately one-third of spinal cord injury patients report below-level neuropathic pain that is severe or excruciating. Patients may experience neuropathic pain associated with spinal cord injury as early as two weeks after injury and it may persist for up to 25 years.
  
“Until now, no FDA approved treatment options were available in the U.S. for people with neuropathic pain associated with spinal cord injury, a condition which can be extremely disabling,” said Steven J. Romano, MD, senior vice president and head, medicines development group, Global Primary Care Business Unit, Pfizer. “The approval of Lyrica for this indication is a significant milestone, exemplifying Pfizer’s commitment to pursue scientific advancements that address unmet medical needs.”
  
About Lyrica Phase 3 Clinical Studies
The FDA approval is based on two randomized, double-blind, flexibly dosed (150–600 mg/day), placebo-controlled Phase 3 trials, which enrolled 357 patients. Among other medications, patients were allowed to continue taking other pain medications, including NSAIDs, opioids and non-opioids. The population of one study consisted of traumatic spinal cord injury patients. The population of the other study consisted of traumatic spinal cord injury patients and patients who had injury to the spinal cord from non-traumatic causes: e.g., removal of a benign spinal tumor or spinal cord ischemic stroke (five percent of patients).
  
The primary finding in these studies was that Lyrica significantly reduced neuropathic pain associated with spinal cord injury from baseline throughout the duration of the studies (12 weeks and 16 weeks, respectively), compared to placebo. In addition, more patients receiving Lyrica showed a 30 percent and 50 percent reduction in pain than did patients receiving placebo. In some patients, the reduction in pain with Lyrica was significant as early as week one and continued throughout the duration of the trials.
  
The most common adverse events in these trials in patients receiving Lyrica were somnolence, dizziness, dry mouth, fatigue and peripheral edema.
  
About Lyrica
Lyrica is currently approved for various indications in 120 countries and regions globally. In the United States, Lyrica is indicated for diabetic nerve pain, post herpetic neuralgia (pain after shingles), fibromyalgia, neuropathic pain associated with spinal cord injury and partial onset seizures in adults with epilepsy who take one or more drugs for seizures. Antiepileptic drugs (AEDs) including Lyrica increase the risk of suicidal thoughts or behavior in patients taking AEDs for any indication.
There have been post-marketing reports of angioedema and hypersensitivity with Lyrica. Treatment with Lyrica may cause dizziness, somnolence, dry mouth, edema and blurred vision. Other most common adverse reactions include weight gain, constipation, euphoric mood, balance disorder, increased appetite and thinking abnormal (primarily difficulty with concentration/attention).
For Lyrica prescribing information, please visit www.lyrica.com.
  
Pfizer Inc.: Working together for a healthier world^®
At Pfizer, we apply science and our global resources to improve health and well-being at every stage of life. We strive to set the standard for quality, safety and value in the discovery, development and manufacturing of medicines for people and animals. Our diversified global health care portfolio includes human and animal biologic and small molecule medicines and vaccines, as well as nutritional products and many of the world’s best-known consumer products. Every day, Pfizer colleagues work across developed and emerging markets to advance wellness, prevention, treatments and cures that challenge the most feared diseases of our time. Consistent with our responsibility as the world’s leading biopharmaceutical company, we also collaborate with health care providers, governments and local communities to support and expand access to reliable, affordable health care around the world. For more than 150 years, Pfizer has worked to make a difference for all who rely on us. To learn more about our commitments, please visit us at www.pfizer.com.

http://www.pfizer.com/news/press_releases/pfizer_press_release.jsp?guid=20120621005572en