Pain and Its Relief Without Addiction:

Text on the pharmacologic care of people in pain. For physicians and the informed lay-level reader.

Preface

xiii

(2)

Acknowledgments

xv

SECTION I: PHYSIOLOGICAL CONCEPTS OF PAIN AND DEPENDENCE

3

(90)

Chapter 1. The Anatomy of Pain

3

(26)

Introduction

3

(1)

Theories of Pain Perception

4

(2)

Current Taxonomy

6

(4)

Peripheral Neuronal Systems

10

(4)

Central Mechanisms

14

(9)

Summary

23

(6)

Chapter 2. Neuroregulators and Pain

29

(22)

Introduction

29

(4)

Endorphins and Enkephalins

33

(4)

Acetylcholine

37

(1)

Catecholamines

38

(4)

Histamine

42

(1)

Serotonin (5 Hydroxytryptamine)

42

(1)

Substance P

43

(1)

Glutamate and Gaba

44

(2)

Neuroregulators Involved in Tissue Damage

46

(1)

Other Endogenous Substances Implicated in Pain Perception

47

(1)

Summary

48

(3)

Chapter 3. Basic Concepts of Dependence, Addiction, Tolerance, and Withdrawal

51

(24)

Introduction

51

(2)

Terms Defining Drug Use

53

(3)

Dependence-Producing Drugs

56

(3)

Behavioral Aspects of Dependence

59

(5)

Biology of Dependence

64

(6)

Summary

70

(5)

Chapter 4. The Effects of Emotion on Pain

75

(18)

Introduction

75

(1)

The Immediate Response to Pain

76

(1)

Psychodynamic Constructs of Pain

76

(1)

Anxiety and Pain

77

(1)

Conditioning Effects and the Perpetuation of Pain

77

(1)

Suggestion and Pain: The Role of the Placebo

78

(3)

Demographic Characteristics of Pain

81

(1)

Psychogenic Pain

82

(4)

Summary

86

(7)

SECTION II: DRUGS USED TO RELIEVE PAIN

93

(184)

Chapter 5. Nonopioid Analgesics and Nonsteroidal Anti-Inflammatory Drugs

93

(30)

Introduction

93

(1)

The Salicylates

93

(18)

Para-Aminophenol Derivatives

111

(4)

Nonsteroidal Anti-Inflammatory Drugs

115

(3)

Summary

118

(5)

Chapter 6. Opioid (Narcotic) Analgesics I: Opioid Agonists

123

(38)

History

123

(1)

Classification

123

(1)

General Pharmacologic Properties

124

(11)

Morphine and Its Congeners

135

(2)

Morphinans

137

(1)

Phenylpiperidines

137

(2)

Phenylheptylamines

139

(3)

Narcotic Combinations

142

(2)

Other Clinical Effects Associated with Narcotic Use

144

(9)

Drug Interactions

153

(3)

Summary

156

(5)

Chapter 7. Opioid (Narcotic) Analgesics II: Opioid Agonist-Antagonists

161

(14)

Introduction

161

(1)

Classification

161

(2)

Pharmacology

163

(1)

Analgesic Effects

164

(2)

Available Analgesics

166

(6)

Summary

172

(3)

Chapter 8. The Stimulants

175

(26)

Introduction

175

(4)

Amphetamines

179

(7)

Cocaine

186

(5)

Caffeine

191

(5)

Drug Interactions

196

(1)

Summary

197

(4)

Chapter 9. Barbiturates, Nonbarbiturate Hypnotics, and Minor Tranquilizers

201

(24)

Introduction

201

(1)

Hypnotics and Sedatives

201

(8)

Benzodiazepines

209

(6)

Buspirone

215

(1)

Hydroxyzine

215

(1)

Zolpidem

216

(1)

Drug Interactions

216

(9)

Chapter 10. The Major Tranquilizers

225

(14)

Phenothiazines

225

(9)

Butyrophenones

234

(1)

Summary

235

(4)

Chapter 11. The Antidepressants

239

(20)

Introduction

239

(1)

Tricyclic Antidepressants

239

(1)

Pharmacology

239

(5)

Analgesic Activity

244

(2)

Toxicity and Overdose

246

(2)

Drug Interactions

248

(4)

Newly Developed Antidepressants

252

(1)

Tetracyclic Antidepressants

252

(1)

Inhibitors of Serotonin Uptake

253

(2)

Bupropion

255

(1)

Summary

255

(4)

Chapter 12. Marijuana

259

(18)

Introduction

259

(1)

Preparations

259

(1)

Patterns of Use

260

(1)

Pharmacology

261

(1)

Effects on Organ Systems

262

(4)

Analgesic Activity

266

(2)

Dependence, Tolerance, and Withdrawal

268

(1)

Toxicity

269

(1)

Drug Interactions

269

(2)

Summary

271

(6)

SECTION III: THE PRACTICAL MANAGEMENT OF PAIN

277

(70)

Chapter 13. General Principles of Pain Management

277

(26)

Introduction

277

(1)

Guidelines for Pain Management

277

(5)

Principles of Pharmacologic Therapy

282

(2)

Develop Appropriate Objectives

284

(16)

Summary

300

(3)

Chapter 14. Management of Acute and Chronic Pain

303

(30)

Introduction

303

(1)

Acute Pain

303

(5)

Chronic Pain

308

(1)

Conditions Associated with Chronic Pain

309

(4)

Diagnosis

313

(3)

Management

316

(6)

Adjunctive Medications in Specific Brain States

322

(5)

Psychological Support

327

(1)

Measuring Effectiveness of Therapy

328

(1)

Unrelieved Pain

329

(1)

Summary

329

(4)

Chapter 15. Unrelieved Pain: The Role of the Physician

333

(14)

Introduction

333

(1)

Federal and State Regulations: Fear of Sanctions

333

(3)

Monitoring Systems

336

(1)

Inadequate Physician Knowledge Base

337

(1)

Fear of Addiction

338

(1)

Adherence to Customary Prescribing Practices

339

(1)

Unconscious Bias

340

(1)

Cultural and Social Barriers

340

(1)

Overprescription of Analgesics

341

(1)

The Drug-Dependent Physician

341

(1)

Summary

342

(5)

SECTION IV: MANAGEMENT OF PAIN IN SPECIAL POPULATIONS

347

(48)

Chapter 16. Pain Relief in Children and the Elderly

347

(16)

Introduction

347

(1)

Children

347

(5)

The Elderly

352

(8)

Summary

360

(3)

Chapter 17. Relieving Pain in Malignant Disorders: The Acquired Immunodeficiency Syndrome and Cancer

363

(18)

The Acquired Immunodeficiency Syndrome

363

(3)

Malignant Diseases

366

(2)

Management of Pain

368

(10)

Summary

378

(3)

Chapter 18. Persons Tolerant to or Dependent upon Opioids and Pain of Undocumented Etiology

381

(14)

Introduction

381

(1)

Narcotic Dependency Associated with Underlying Medical Disorders

381

(6)

Heroin Addicts

387

(2)

Persons in Methadone Maintenance

389

(2)

Pain of Undocumented Etiology

391

(4)

Index

395

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Pain and Its Relief Without Addiction: Clinical Issues in the Use of Opioids and Other Analgesics

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