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Chronic Pain

Neuropathic Pain

Pain pathway includes transduction at the peripheral receptor-conduction through pain neurons-spinal cord transmission to thalamus which is a major pain center-perception at sensory level. Neuropathic pain is caused by damage to the pathway to the thalamus.
Neuropathic pain can be peripheral or central to thalamus.

Example of neuropathic pains are:

  • Diabetic neuropathy
  • Peripheral Neuropathy
  • Post Herpetic neuralgia
  • Phantom Limb Pain
  • HIV
  • Alcoholism
  • Failed Back syndrome after spinal surgery
  • Stroke
  • Nerve compression
  • Lyme disease

Patients often experience shooting and burning pain with tingling and numb sensation.
Patients who are refractory to conventional antidepressant and anticonvulsant treatment may experience immediate relief of pain.

Complex Regional Pain Syndrome

CRPS, previously known as RSD Reflex Sympathetic Dystrophy is a progressive disease of sympathetic nervous system.

CRPS TYPE 1, formerly known as RSD can follow from minor nerve injury; CRPS TYPE2, once known as causalgia,involves definable major nerve injury.
Patients experience constant burning pain in the distal part of affected extremity. Pain can be disproportional to the inciting event and can persist when pain generator is no longer present.

Patients experince allodynia which is an extreme sensitivity evoked from simple mechanical or thermal stimulation. Autonomic abnormalities include swelling,excessive or no sweating,vasodilation or constriction and abnormal skin temperature. Affected areas can show atropy and weakness.

Patients are treated with antidepressants, anticonvulsants and often ended up with prescription opioids. Other modalities includes repeat stellate ganglion block,lumbar sympathetic block . Ketamine infusion showed clinical improvement by resetting NMDA receptor wind up phenomena.

Fibromyalgia

Patients experience widespread musculoskeletal pain accompanied with fatigue,sleep disturbance,memory and mood changes. Studies show that fibromyalgia amplifies painful sensation by affecting the way brain process the pain sensation.

Women develop fibromyalgia more often than men.
People with fibromyalgia often have tension headache, temporomandibular disorder,irritable bowel syndrome,chronic fatigue syndrome,anxiety and depression.

IV ketamine infusion is a diagnostic and therapeutic modality for a central sensitization of pain in the central nervous system.

Opioid use disorder

If you meet the diagnostic criteria as below,you may have opioid use disorder.

  1. more opioids are taken than intended
  2. unable to decrease the amount of opioid use
  3. large amounts of time are spent to obtain opioids,use opioids, or recover from taking them
  4. craving for opioids
  5. difficulty to fulfilling professional duties at work or school
  6. continue to use opioids leading to social and interpersonal consequence
  7. decreased social or recreational activity
  8. using opioids despite physically dangerous setting
  9. continued use despite opioids worsening physical or psychological health
  10. Tolerance
  11. Withdrawal

Many people taking prescription opioids for pain relief may develop opioid tolerance which requires higher dose to control pain and withdrawal symptoms when opioid are abruptly discontinued. Addiction and dependence are component of opioid use disorder. Opioid dependence can manifest as physical, psychological, or both.

Opioid induced hyperalgesia is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to painful stimuli.

Studies showed NMDA receptor is responsible for tolerance and opioids induced hyperalgesia . Since many patients with opioid use disorder have comorbidity of chronic pain,depression, PTSD and anxiety, ketamine infusion can help wean opioid use and alleviate withdrawal symptoms. After detoxification,patients must be aware of increased sensitivity to opioids effects such as sedation and respiratory depression if opioid is administered again.

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