Major controversies in chronic pain

ABSTRACT

Pain medicine is a relatively new speciality in clinical medicine. While it is widely accepted and recognized, there are some areas of controversy which makes this speciality interesting and open to diverse kinds of research opportunities and clinical innovations. In this presentation, several controversial areas have been selected for discussion because of their scientific merit, clinical applicability, and evolving status in the physician's armamentarium. EPIDURAL STEROIDS FOR LOW PAIN Epidural steroid injections remain one of many modalities for managing chronic low back pain. The frequency, dose, kind of steroids used and management of complications are still open to discussion. Meta-analysis of the applicability of epidural steroids for low back pain leaves a lot to be desired. More importantly, the criteria for epidural steroid injection have not yet been clearly delineated. REFLEX SYMPATHETIC DYSTROPHY (RSD) AND NEUROPATHIC PAIN Most clinicians propose that RSD has become a "legal phenomenon" rather than a medical one. This observation indicates the adversarial focus that the injured patient possesses as far as his recovery and rehabilitation are concerned. The different diagnosis techniques and the corresponding diverse therapeutic modalities available for treating RSD are still controversial. CANCER PAIN MANAGEMENT Cancer pain management is very important in the overall management of the cancer patient, especially when dying and death appear inevitable. A proposed fourth step of the World Health Organization three-step ladder for pain management and its implication will be discussed. MORPHINE AS ANTI-ANALGESIC AGENT Review of the pharmacological activity of morphine metabolities will be undertaken. A re-evaluation of morphine-3-glucuronide and its analgesic activity may help to explain some interesting physiological phenomena observed during morphine administration. PAIN EDUCATION AND PAIN CERTIFICATION In the United States of America the education of medical and nursing students regarding pain therapy has been largely ignored. The situation is unfortunate since most young health care professionals have to deal with chronic pain problems as soon as they commence their practices. As pain medicine develops, it is important to have adequate credentialing.(AU)