Multidisciplinary pain management

Pain management

Interdisciplinary and multimodal pain management

The treatments indicated for the management of chronic pain consist of standardised analgesic, pharmacological and interventional regimens tailored to each patient.

Lidocaine infusion
Lidocaine is a drug with various applications, such as local anaesthesia and the treatment of ventricular cardiac arrhythmias. Precisely because of its effect in reducing nervous excitability, it is used for the treatment of neuropathic pain via the bloodstream.

Treatment with morphine

Will taking morphine lead to addiction?

The terms dependence, addiction, and tolerance should not be confused. Tolerance implies the need for progressively higher doses to achieve the same therapeutic effect. This happens with morphine, but it does not usually cause problems because, firstly, there is no ceiling, in other words, every time we increase the dose, the desired effect increases. Secondly, tolerance to side effects also develops, meaning that over time, side effects such as nausea or sedation disappear. Physical dependence means that if we abruptly stop treatment, a set of unpleasant symptoms may appear, which we call ‘withdrawal syndrome’ and which can be resolved by resuming medication or administering tranquillisers. Psychological dependence is what is commonly referred to as addiction. It only happens when morphine is used to achieve a psychological state that is different from normal. Among people with chronic cancer-related or non-cancer-related pain, the frequency of addiction is less than 0.2%.

Why do I need more and more morphine?
This may be due to a tolerance phenomenon specific to morphine, but it may also be because the progression of the disease involves an increase in requirements.

If I start taking morphine, will I never be able to stop?
In the same way that pain treatment begins by following a ladder of increasingly potent medications, it is possible to move down the ladder and withdraw morphine if the disease progresses favourably and the causes of the pain disappear. They gave me morphine and it made me very nauseous.

Does that mean I cannot take any type of opiate?
The response to different opioids (morphine, methadone, fentanyl, buprenorphine, oxycodone, tramadol, codeine) is individual and depends on the number and type of receptors we have for them. Therefore, a bad experience with one should not discourage us from trying another if we believe that the patient may benefit.

Are there other opiates besides morphine?
As mentioned above, there are other opium-derived or synthetic drugs that interact with the Mu and Kappa opioid receptors. Among them, the most commonly used are fentanyl, buprenorphine, methadone, tramadol and codeine. At present, we have options for oral, transcutaneous, oral transmucosal, intravenous, and epidural treatment. There are fast-acting, slow-acting and long-lasting (up to 72 hours) types. A long-acting medication for continuous pain is usually combined with a fast-acting medication for pain crises.

Transcutaneous electrical nerve stimulation (TENS)
Transcutaneous Electrical Nerve Stimulation (electrical stimulation through the skin) or TENS is a way of controlling pain based on the gate control theory, whereby selective stimulation of certain nerve fibres could divert the transmission of pain impulses. To do this, an electrical current supplied by an external electrical device or generator is applied, which, through skin electrodes, emits low-frequency, low-intensity pulses to the selected painful area.
Transcutaneous or percutaneous neurostimulation for the relief or blocking of chronic or acute pain is virtually free of adverse side effects.
The stimulation via TENS is perceived by the patient as a more pleasant sensation than the pain they are experiencing.

Trigger point infiltration
Trigger Point Infiltration (TPI) involves injecting anaesthetics or anti-inflammatories (cortisone derivatives) into the areas that are particularly painful for each patient. It is usually necessary to inject more than one trigger point over several sessions to achieve pain relief. It is usually necessary to inject more than one trigger point over several sessions to achieve pain relief.

Denervation using botulinum toxin

DenervaciónDenervation: One of the most painful problems is muscle pain. Muscle spasms can become chronic and eventually manifest as muscle stiffness, muscle shortening, and pain that can be mistaken for nerve or bone pain. As a result, that muscle or muscle group loses or reduces its function. An important advance has been the use of a toxin from a bacterium (Clostridium botulinum) synthesised artificially to block and thus relax contracted muscles, taking advantage of its natural effects. It is highly effective and its effects can last for several months.

Therapeutic blocks of peripheral nerves, central nerves and the autonomic nervous system
bloqueos terapeúticos

Therapeutic blocks interrupt nerve impulses and the concomitant sympathetic and motor reflexes, causing temporary analgesia, reflex interruption, and pain relief for a longer period than the local anaesthetic itself. All of this means that repeated nerve blocks constitute a treatment for chronic pain. They are performed under fluoroscopy, using electrostimulation and contrast medium to verify the exact nerve to be blocked.

A lumbar sympathetic nerve block is a procedure used to diagnose, reduce or eliminate pain caused by autonomic nerves that are affected by trauma, surgery or vascular disease.

Continuous blocks of peripheral nerves, central nerves and the autonomic nervous system (rehabilitation and neuromodulation)
In some cases, continuous blocks or interruptions of the affected nerves or system are beneficial. Adequate pain control is an important requirement for the implementation of a rehabilitation programme, and this will be observed later in functionality. The continuous interruption of the pain signal and its consequent elimination allow us to observe a regularisation or neuromodulation process that was previously altered. Therefore, continuous nerve blocks should be performed when the diagnostic nerve block has been successful or when it lasts longer than expected.

Continuous infusion pumps. Epidural and transforaminal therapeutic blocks
Bombas perfusiónEpidural infiltration involves the administration of medication into the epidural space. This space is the one between two thin layers that protect the spinal cord. Cortisone and local anaesthetics are usually administered. Its usefulness lies in the fact that the medication is closer to the problem (next to the painful nerve root) and such high doses of medication do not need to be administered. This is an outpatient procedure, so it is performed during the day and then the patient goes home. It tends to have greater effectiveness when repeated several times (2-3).

Radiofrequency thermal denervation (rhizolysis)
It consists of altering the transmission of pain to the brain by a peripheral nerve through the application of heat. To do this, a needle with a special tip that generates heat is used. Depending on the amount of heat and the frequency with which it is applied (continuous or pulsed), the phenomenon caused will be the destruction of the nerve (neurolysis) or a change in its signal (neuromodulation).

Denervacion radiofrecuencia

Joint infiltrations (facet and large joints)

Inflammation and progressive deterioration of the joints in the spine and large joints (arthritis and osteoarthritis) can cause pain. Facet joint injections and injections into the posterior medial branches that conduct pain stimuli consist of injecting medications based on local anaesthetics and cortisone into these joints or blocking the nerve that conducts pain from them.

Steroids reduce inflammation and relieve pain.

The key to this treatment is to inject at the specific point using a proven technique, which requires the use of fluoroscopy.

Infiltraciones articulares

Epiduroplasty
Epiduroplasty involves inserting a special catheter into the spine, under fluoroscopic guidance and in real time, in order to separate the fibrotic tissue surrounding the nerves, allowing us to inject an anti-inflammatory drug through it.

Epiduroplastia