Excerpts from the presentation by: Historically, pain has been a neglected symptom in patients with gastroparesis, even though and perhaps because it is often the most problematic to manage. In the most extreme cases, pain can dominate the picture, resulting in considerable suffering and utilization of health care resources.
The end result is often a desperate patient bereft of a long-term relationship with a caring physician. Much of this problem stems from a complete lack of knowledge about the causes of pain in gastroparesis. There are no experimental studies or clinical trials on this subject.
Therefore the approach to treatment is both arbitrary, subject to the biases of the treating physician, and empirical, without any biological rationale to guide therapy.
The approach to pain in these patients begins with an empathetic understanding and recognition that the pain is real. Such an understanding and recognition will usually relieve anxiety in patients and their families, and will promote a trusting relationship between physician and patient. Looking through the literature, the problem of chronic pain in gastroparesis is estimated to affect anywhere between 50 and 90 percent of patients.
The cause of this pain is not well known. Neuropathic pain, pain generated by damaged or inflamed nerves, is thought to be the primary cause, and is one of the most challenging types of pain to manage.
Neuropathic pain is common in idiopathic, as well as in diabetic gastroparetic patients. This type of visceral abdominal pain is often described as diffuse, dull, achy and crampy.
Other types of pain described by gastroparetic sufferers may be sharp and localized in areas over the abdomen. The nature of this pain may be more related to muscular spasms within the stomach or small intestine, or related to trapped gas. The sensory wiring of the gastrointestinal tract is very complex and bound up with the central nervous system, tying it to emotions and behaviors. This is why pain is a mind, body and spirit phenomenon requiring more than just medications to help control the problem.
We know that sensory nerves within the gut are sensitive to stretching and distention; as well, elavil tricyclic anti depressant, chronic pain can cause a hypersensitization within the central nervous system to the painful sensations. Further compounding the problem, many patients with gastroparesis will describe an acute pain occurring soon after eating, layered on top of their chronic pain.
As well, a sluggish emptying of the gall bladder seems to be tied up with poor emptying of the stomach, coupled with uncoordinated muscular action by the small intestine. This may all add to the pain experienced soon after eating. Psychological interventions are helpful measures and should be considered as a part of the pain-management regimen for every patient presenting with gastroparesis-related pain. These interventions avoid the added risks posed by pharmacotherapy, and help promote a sense of control on the part of the individual.
Simple techniques such as deep relaxation, cognitive restructuring, and distraction may be helpful, and can easily be taught by most health care providers.
Other techniques such as acupuncture, hypnosis, biofeedback require a greater level of expertise on the part of the health care practitioner, but should be utilized whenever available.
The primary health care provider needs to be well versed in the pharmacology of analgesic drugs including narcotics.
Even though a pain specialist may be involved in their elavil tricyclic anti depressant, patients with gastroparesis-related pain often rely on their primary physician to provide relief during flare-ups. For those who live in small towns and rural areas, finding help for more severe gastroparesis related-pain may be difficult. Try consulting with a cancer pain specialist or elavil tricyclic anti depressant care tetracycline and tooth discoloration in your town.
They can guide you through logical choices for your pain care. A wide variety of drugs are available from the traditional analgesic pain relief medications to a number of other unrelated pharmacological groups employed for pain management.
Beginning pharmacological therapy for abdominal pain management should start with the non-steroidal anti-inflammatory NSAID medications. Many of these popular drugs are available over the counter while others require a prescription.
These animal birth control los angeles can be helpful but have the potential to cause stomach ulcers and bleeding.
To help counter this problem, elavil tricyclic anti depressant, the use of stomach acid-suppressing medications may be useful. Antispasmodics may have particular application in treating painful abdominal cramps or sharp, painful spasms occurring soon after eating, but their use is limited in gastroparesis. Antispasmodics have the elavil tricyclic anti depressant of further slowing down the digestive tract.
While not dismissing them outright, some formulations come in rapid and short-acting preparations. The tricyclic anti-depressants TCA drugs have become one of the mainstays for treating chronic abdominal pain, elavil tricyclic anti depressant. Though the FDA has never officially approved them for this application, they have been well researched to establish their effectiveness in pain management.
Dosages are started at a very low level, lower than used for treating depression, and then slowly increased. It may take several weeks before benefits of pain reduction are experienced. Low dosages are also important because TCAs can slow the emptying of the stomach and intestines. Other examples of TCAs:. Unfortunately, TCAs can cause bothersome side-effects of gastrointestinal distress.
Nortriptyline may be the least likely to cause these unwanted problems. Working closely with your doctor and carefully adjusting dosages is essential, elavil tricyclic anti depressant. The selective serotonin reuptake inhibitors SSRIs have not been clearly proven to be effective tools against neuropathic pain. Finally, a new category of antidepressant drugs the selective elavil tricyclic anti depressant and norepinephrine reuptake inhibitors SSNRIs are showing promise in treating neuropathic pain.
Venlafaxine Effexor and duloxetine Cymbalta are two agents being used. The FDA has recently approved Duloxetine for its use in treating diabetic neuropathic pain. A wide selection of these drugs is also available and can be used in combination with the TCAs to increase overall potency. Gabapentin has relatively few side effects and is well tolerated especially if elavil tricyclic anti depressant dosage is gradually advanced in increasing increments. It has few, if any, drug interactions.
Its role, however, may be more limited in treating abdominal pain syndromes since its effectiveness has only been demonstrated through intrathecal administration, and less so transdermally or with orally administered preparations. The best known is Elavil tricyclic anti depressant. Surprisingly, narcotics have not shown to be that effective for neuropathic abdominal pain like that of gastroparesis, elavil tricyclic anti depressant. There is an expansive variety of narcotic, elavil tricyclic anti depressant, and synthetic narcotic drugs available to the physician in treating his patients, elavil tricyclic anti depressant.
Many of these drugs have an undesirable effect of slowing down the gastrointestinal tract thereby worsening elavil tricyclic anti depressant other symptoms of gastroparesis.
It is possible to get around these problems of narcotic drug- induced, slowed-gut motility and still provide good pain relief. Many patients with mild-to-moderate pain symptoms can be managed without graduation to regular narcotic use. However, there remains the individual with severe pain who needs more effective pain control.
Even though opioids may not be extremely effective in this condition in keeping with the possible neuropathic nature of the painthey are inevitably used for this category of patient, and may have some utility.
This creates at least two major issues: Physical dependence resulting from the chronic use of narcotics to treat pain is an expected outcome, and patients should be cautioned not to discontinue their use without a tapering schedule.
Addiction is a much rarer phenomenon, especially in patients without a history of substance abuse. Doctors and patients should understand the distinctions between physical dependence and addiction, and are referred to definitions published by the American Pain Society, American Society of Addiction Medicine, and American Academy of Pain Medicine. With respect to the problem of constipation, the scientific literature suggests that methadone, fentanyl Duragesicand Buprenorphine Temgesic, Subutex may be narcotics that produce less constipation than other drugs.
Additionally, there are a number of studies in the literature looking at treating constipation by using narcotic-blocking agents. These drugs help to block the side effects of narcotics such as constipation, while not diminishing the pain-reducing effects of the prescribed narcotic. Taken at very low doses, and taken orally, they can reverse the negative impact of the narcotic on the GI tract.
The spinal cord is protected by a tissue covering, elavil tricyclic anti depressant. The intrathecal area is the space between this tissue covering and the spinal cord. Medications can be delivered into this space and bathe the spine with various drugs. For more severe abdominal pain syndromes, implantable devices have been devised to permit regular drug delivery through a system composed of two implantable components: The pump is placed abdominally into a pocket created underneath the skin, while the catheter tip is inserted into the intrathecal space of the spine, then tunneled under the skin and brought to the connection site on the pump.
Medication can be delivered through the pump at constant or variable flow rates. Medtronic manufactures intrathecal drug delivery systems.
Many different types of medications can be infused into the intrathecal space for pain management. The science of pain control is looking even farther afield to agents like ketamine, a short-acting, general anaesthetic; it can be delivered intra-nasally via a nose spray.
Ketamine provides a sense of euphoria and emotional detachment from the pain. This is the main nerve branch which communicates pain from the abdomen. Generally, a trial block with a short acting and reversible agent is used before the physician proceeds with permanently destroying the celiac nerve bundle though injection.
Complications can occur, so this method is reserved for after all other medical approaches have failed. Published reports show the majority of patients have a good response of pain reduction. In Canada, the federal government has recently approved a new cannabis marijuana - based drug called Satives. Developed by GW Pharmaceuticals and Bayer, the drug is conveniently administered via a mouth spray. Canada is the first country in the world elavil tricyclic anti depressant approve the drug, elavil tricyclic anti depressant.
Approved for use in treating neuropathic pain of MS, it will help fill the need for more neuropathic pain therapies. Ziconotide, a synthetic form of the cone snail toxin has been recommended for approval by the FDA. Intrathecally administered ziconotide produces pain reduction and has an advantage over intrathecal morphine in that there is no development of tolerance after prolonged use. Often multiple drug therapies may be necessary for controlling more severe pain.
Combinations of medications such as the tricyclic antidepressants and anticonvulsants are effective; and occasionally, elavil tricyclic anti depressant, some individuals will also require narcotic therapy added to this regimen. If pain management fails with these steps, then treatments with implantable systems, such as a spinal cord elavil tricyclic anti depressant, or intrathecal pump should then be considered. The constipating effect, and the slowing of gastric emptying caused by narcotics can be counteracted with low doses of narcotic-blocking agents.
This does not diminish the pain- reducing action of the prescribed narcotic. Pain and the symptoms of gastroparesis can take their toll on the mind, body and soul greatly diminishing quality of life. Finding effective therapies that help subdue symptoms makes everyday coping much easier.