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This issue of Medical Clinics of North America, Guest Edited by Charles Argoff, MD is devoted to Chronic Pain Management. Dr. Argoff has assembled a group of expert authors to review the following topics: Chronic Pain Management: An Overview of Taxonomy, Conditions Commonly Encountered, and Assessment; The Acute to Chronic Pain Transition:  Can Chronic Pain Be Prevented?; What Do We Know About the Pathophysiology of Chronic Pain?  Implications for Treatment Considerations; An Overview of Pharmacologic Management of Chronic Pain; An Overview of Nonmedical Treatment of Chronic Pain; Managing Chronic Headache Disorders; Managing Osteoarthritis and Other Chronic Musculoskeletal Pain Disorders; Managing Neuropathic Pain; Managing Low Back and Other Spinal Pain Disorders; Exploring the Use of Chronic Opioid Therapy for Chronic Pain:  When, How and for Whom?; The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain; Multimodal Management of Chronic Pain: What is the Evidence?; Managing Chronic Pain in Special Populations; and The Future of Pain Management as a Subspecialty:  Meeting the Needs of the Patients We Care For.



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Managing Chronic Pain
Medical Clinics of North America
Charles E. Argoff, MD
Department of Neurology, Albany Medical College, Comprehensive Pain Center, Albany
Medical Center, Albany, NY, USA
Douglas S. Paauw
Edward R. Bollard

Clinics Review Articles


January 2016 • Volume 100 • Number 1Table of Contents
Cover image
Title page
Forthcoming Issues
Forthcoming Issues
Recent Issues
Consulting Editors
Foreword. The Management of Chronic Pain: What Do We Know, What Do We Do,
and How Should We Redesign Our Comprehensive Assessment and Treatment in
order to Provide for More Patient-Centered Care?
Preface. Yes, You Can Manage Chronic Pain
Chronic Pain Management: An Overview of Taxonomy, Conditions Commonly
Encountered, and Assessment
Key points
The experience of pain
The biology of chronic pain
Pain taxonomy
Pain categories based on organ system or region
Assessment of painPain assessment instruments
Qualitative scales, disability scales, and discriminative instruments
Category-specific pain assessment instruments
Assessing risk and benefit of opioid therapy
Assessments of psychological state and trait in pain management
Putting it all together: a sample pain management consultation
The Acute to Chronic Pain Transition: Can Chronic Pain Be Prevented?
Key points
Risk factors for development of chronic postsurgical pain
Prediction of postoperative pain
Proposed mechanisms of chronic postsurgical pain
The “ideal” acute to persistent pain study
Future considerations/Summary
What Do We Know About the Pathophysiology of Chronic Pain?: Implications for
Treatment Considerations
Key points
Pain signal transmissions
Inhibitory pathways
Nociceptive pain
Neuropathic pain
Neuropathic pain transmission
Challenges in chronic neuropathic pain
Peripheral nerve injury
Wind-up pain
Central sensitizationPathophysiology of central sensitization
Central sensitization and clinical pain phenotype
Blocking nerve conduction in perioperative periods: preemptive strikes?
Psychological factors
Medication management of neuropathic pain, current recommendations
Chronic Pain Treatment Approaches
Biopsychosocial Approach to Assessing and Managing Patients with Chronic Pain
Key points
Current approach to pain treatment
Chronic pain care in the primary care setting
Biopsychosocial approach to pain
Initial encounter with patient with chronic pain
Biopsychosocial diagnostic evaluation/interview
Biopsychosocial treatment program
Future considerations/summary
Multimodal Treatment of Chronic Pain
Key points
Pharmacologic treatment
Theory behind combined pharmacologic treatment
Studied combinations of analgesic medications in common pain conditions
Psychological approaches
InterventionsInterdisciplinary pain rehabilitation programs
Complementary and alternative medicine and self-management
An Overview of Pharmacologic Management of Chronic Pain
Key points
Overview of the pharmacologic management of chronic pain
Classes of medications
Topical agents
Botulinum toxin
Intrathecal drug therapy
Exploring the Use of Chronic Opioid Therapy for Chronic Pain: When, How, and for
Key points
Initial evaluation and assessment
Treatment initiation, titration, and maintenance
Reassessment and follow-up
Monitoring parameters
High-risk patients and special populations
ReferencesThe Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain
Key points
Procedure 1: corticosteroid injections
Procedure 2: epidural steroid injections
Procedure 3: nerve root blocks
Procedure 4: sympathetic nerve blocks
Stellate ganglion block
Celiac plexus block
Procedure 5: radiofrequency ablation
Part II: spinal cord stimulation, intrathecal drug delivery, and peripheral nerve
Procedure 7: intrathecal pumps (intrathecal drug delivery)
Common Chronic Pain Conditions
Managing Chronic Headache Disorders
Key points
Initial evaluation of headaches
Four common secondary headache disorders
Migraine management
Acute treatment
Interventional treatment
Peripheral nerve stimulation for the treatment of primary headaches
Complementary therapy
Management of menstrual migrainesManagement of migraines during pregnancy and lactation
Emergency treatment
Tension-type headache
Cluster headache
Inpatient treatment of migraine, tension headache, and cluster and other
autonomic cephalgias
Managing Osteoarthritis and Other Chronic Musculoskeletal Pain Disorders
Key points
Etiology of osteoarthritis
Treatment options
Pharmacologic options
Managing Neuropathic Pain
Key points
Assessment of neuropathic pain
Acute and Chronic Low Back Pain
Key points
Magnitude of the problem
Risk and prognostic factors
Physical examinationImaging
Managing Chronic Pain in Special Populations with Emphasis on Pediatric, Geriatric,
and Drug Abuser Populations
Key points
Pediatric chronic pain
Geriatric chronic pain
Substance abusers: a special population
Genetics as a fundamental vulnerability across the lifespan
Emerging Treatment
Is Platelet-Rich Plasma a Future Therapy in Pain Management?
Key points
What is platelet-rich plasma and how is it created?
How platelet-rich plasma can help to relieve neuropathic pain
Intervertebral disc degeneration and the role of platelet-rich plasma as a
therapeutic option
Information for physicians using platelet-rich plasma therapy
Future consideration/summary
IndexC o p y r i g h t
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Forthcoming Issues
March 2016
Travel and Adventure Medicine
Paul S. Pottinger and Christopher A. Sanford, Editors
May 2016
Medical Care for Kidney and Liver Transplant Recipients
David A. Sass and Alden M. Doyle, Editors
July 2016
Pharmacologic Therapy
Douglas S. Paauw and Kim O'Connor, Editors
Recent Issues
November 2015
Roy M. Colven, Editor
September 2015
Comprehensive Care of the Patient with Chronic Illness
Douglas S. Paauw, Editor
July 2015
Management of Cardiovascular Disease
Deborah L. Wolbrette, Editor
Related Interest
Physical Medicine and Rehabilitation Clinics of North America May 2015 (Vol. 26, No.
Chronic Pain
James P. Robinson and Virtaj Singh, Editors
Consulting Editors
DOUGLAS S. PAAUW, MD, MACP, Professor of Medicine, Division of General
Internal Medicine, Rathmann Family Foundation Endowed Chair for Patient-Centered
Clinical Education; Medicine Student Programs, Professor of Medicine, University of
Washington School of Medicine, Seattle, Washington
EDWARD R. BOLLARD, MD, DDS, FACP, Professor of Medicine, Associate Dean
of Graduate Medical Education, Designated Institutional Official, Department of
Medicine, Penn State–Hershey Medical Center, Penn State University College of
Medicine, Hershey, Pennsylvania
CHARLES E. ARGOFF, MD, Professor of Neurology, Albany Medical College,
Director, Comprehensive Pain Center, Albany Medical Center, Albany, New York
GERALD M. ARONOFF, MD, Diplomate, American Board of Psychiatry and
Neurology; Diplomate, American Board of Pain Medicine; Medical Director, Carolina
Pain Associates, PA, Charlotte, North Carolina
MIROSLAV BACKONJA, MD, Emeritus Professor, Department of Neurology,
University of Wisconsin-Madison, Madison, Wisconsin
JAIME L. BARATTA, MD, Department of Anesthesiology, Thomas Jefferson
University, Philadelphia, Pennsylvania
KYLE M. BAUMBAUER, PhD, School of Nursing, The Center for Advancing
Management of Pain, University of Connecticut, Storrs, Connecticut; Department of
Neuroscience, University of Connecticut Health Center, Farmington, Connecticut;
Institute for Systems Genomics, University of Connecticut Health Center, Farmington,
BENJAMIN R. BEAL, MD, Assistant Professor, Division of Pain Medicine,
Department of Anesthesiology, University of California, San Diego, San Diego,
DAVID BEAUSANG, MD, Department of Anesthesiology, Thomas Jefferson
University, Philadelphia, Pennsylvania
ABIGAIL BROOKS, PharmD, BCPS, Clinical Pharmacy Specialist, Pain
Management, Minneapolis VA Health Care System, Minneapolis, Minnesota
KENNETH D. CANDIDO, MD, Chairman, Clinical Professor, Department of
Anesthesiology, Advocate Illinois Masonic Medical Center, University of Illinois,