Chronic Pain After Surgery Molecules

Mick Serpell Senior Lecturer Post-op Pain & Molecules ,[object Object],[object Object],[object Object],[object Object],[object Object]

Combination Pain ,[object Object],[object Object],[object Object],[object Object]

Drug Developments ,[object Object],[object Object],[object Object],[object Object]

WHO ladder - Nociceptive Pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neuropathic analgesics ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

NNT 0 2 4 6 8 10 12 Topiramate* Antidepressants, SSRI Capsaicin NMDA antagonists* Mexiletine* Antidepressants, SNRI Gabapentin/pregabalin Tramadol Opioids Carbamazepine/lamotrigine/ phenytoin Valproate Tricyclic antidepressants 397 109 83 389 120 420 1057 149 81 466 150 214 Peripheral neuropathic pain drugs: NNT Adapted from Finnerup et al. Pain 118 (2005) 289–305 Lidocaine plaster NNT to achieve pain relief >50%

Peripheral neuropathic pain drugs: NNH (withdrawal of Rx)‏ NNH 0 5 10 15 20 Antidepressants, SSRI Valproate Mexiletine Carbamazepine/lamotrigine/ phenytoin Gabapentin/pregabalin Opioids Antidepressants, SNRI Tricyclic antidepressants NMDA antagonists Capsaicin Tramadol Topiramate ns Finnerup et al. Pain 118 (2005) 289–305 Lidocaine plaster

Algorithm for neuropathic pain treatment: an evidence based proposal Lidocaine patch* TCA (SNRI)‏ Gabapentin/ Pregabalin Gabapentin/ Pregabalin Postherpetic neuralgia and focal neuropathy Peripheral neuropathic pain yes TCA (SNRI)‏ yes Tramadol, Oxycodone TCA contraindication no yes TCA contra-indication no no Finnerup et al. Pain 118 (2005) 289–305

2 nd Line Rx Beyond 2 nd line Rx single RCT, variable multi RCT Dworkin. Arch Neurol 2003:60:1524-34. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Multi-modal Rx ,[object Object],[object Object],[object Object],[object Object],[object Object]

Combining drugs Neuropathic vs. Nociceptive Drugs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Gabapentin & morphine for acute pain after mastectomy Dirks Anesthesiology 2002; 97: 560-564. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Acute Post-op Pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Additive or synergistic? Isobolographs Fletcher D. Anesthesiology 1997;87:317-326. Synergy Diclofenac & Morphine Additive Propacetamol & Morphine

Morphine vs GBP vs Combination for NP Gilron. NEJM 2005; 352: 1324-34. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Morphine vs GBP vs both for NeuP Gilron. NEJM 2005; 352: 1324-34. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

GBP+Oxycontin vs GBP+PBO for NP Hanna M. Poster EFIC 2006. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(33%)‏ ↓ VAS 2.1 vs PBO 1.5

GBP+Oxycontin vs GBP+PBO for NP Hanna M. Poster EFIC 2006. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Pre-emptive analgesia?? Patrick Wall

Pre-emptive preoperative analgesia P Wall. Pain 1988; 33:289-90. ,[object Object],[object Object]

[object Object],longer inflammatory phase (2 o )‏ Pre-emptive analgesia ,[object Object],[object Object],[object Object],[object Object],[object Object]

Incisional (post-op) Pain Brennan TJ. Anesthesiology 2002, 97: 535-537 ,[object Object],[object Object],[object Object],[object Object]

Prophylaxis of PHN Bowsher. J Pain Symp Manage 1997;13:327-31 . ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

? Prophylaxis of PHN Berry JD. Neurology 2005;65:444-7. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Post-op Pain … what outcomes? Wu C. Anesthesiology 2002; 97: 533-534. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cannabinoids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Sativex in NeuP + Allodynia: a 5/52 RCT DB Trial Nurmikko, Serpell et al. Pain (in press)‏ ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

7.5 7.0 6.5 6.0 5.5 5.0 4.5 0 Baseline Wk 2 Wk 3 Wk4 Wk 5 Pain Baseline Titration Wk 1 Wk 2 Wk 3 Wk 4 Sleep disturbance * P<0.05 4 3 2 1 0 ## P<0.001 CBM Placebo Wk 1 ** # P<0.01 ## ## ## ## # ** P<0.01 ** ** * Sativex in NeuP + Allodynia: a 5/52 RCT DB Trial Nurmikko, Serpell et al. Pain (in press)‏ -0.52 -1.48 ,[object Object],[object Object],[object Object],[object Object]

Short term adverse effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Canada & Cannabis www.torontohemp.com

Lidocaine Plaster: A new treatment option ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Post-op Pain & Molecules ,[object Object],[object Object],[object Object],[object Object],[object Object],[email_address]

Chronic Pain After Surgery Molecules

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Chronic Pain After Surgery Molecules