A review is presented of the meaning of neuralgia - from its introduction in 1801, to indicate an affection of one or more nerves causing pain, to its present day use. There was early dispute whether neuralgia required a lesion to be present in the nerve, and whether peripheral branches, nerve roots or the neuraxis was involved. Affections of organs were seen as a cause and the concept was extended to include links with psychological illness. In the last decades of the 19th century and throughout the 20th century, opinion on neuralgia gradually moved closer to the original meaning.

Chris N Alam

H Merskey

Neuralgia: The History of a Meaning

BACKGROUND: Many physicians are overly cautious about prescribing opioids for chronic pain because of fears of iatrogenic addiction. However, in patients with chronic pain, addiction to opioid analgesics is exceedingly rare when there is no prior history of alcohol or drug abuse.OBJECTIVE: To validate an instrument that separates possible opioid abusers from those who are at low risk.DESIGN/METHODS: The Screening Instrument for Substance Abuse Potential (SISAP) was designed to identify individuals with a possible substance abuse history quickly and accurately. It is based on the National Alcohol and Drug Use Survey (n=9915). Using the first half of the sample (n=4967), two previously validated alcohol use items were combined with three illicit drug use items. These five questions identified those with a history of alcohol and/or illicit drug use.RESULTS: Using the second half of the sample (n=4948), the validation procedure showed that the five combined items correctly classified 91% of substance abusers and had a low rate of false negatives.DISCUSSION: The SISAP is brief and resistant to misrepresentation or falsification. The SISAP is expected to improve pain management by facilitating focus on the appropriate use of opioid analgesics and therapeutic outcomes in the majority of patients who are not at risk of opioid abuse, while carefully monitoring those who may be at greater risk.

Robert B Coambs

Josée L Jarry

Anusha C Santhiapillai

Rixi V Abrahamsohn

Cristina M Atance

The SISAP: A New Screening Instrument for Identifying Potential Opioid Abusers in the Management of Chronic Nonmalignant Pain Within General Medical Practice

BACKGROUND: Multidisciplinary programs for treatment of chronic pain are generally effective, yet many patients fail to show significant improvement. The search for predictors of outcome has not explicitly considered sex.OBJECTIVE: To examine mediation and moderation pathways through which sex may predict outcome.DESIGN: Correlational outcome, exploratory, archival study.PARTICIPANTS: A total of 156 chronic pain patients.SETTING: Four-week multidisciplinary pain program.PREDICTOR AND OUTCOME MEASURES: Predictor variables of pain level, activity interference and perceived pain helplessness were culled from patient charts. Outcome was assessed with staff ratings of patient progress.RESULTS: While men responded to treatment more poorly than women, regressions suggested that the greater number of surgeries for men mediated this link. Further analyses revealed that sex acted as a moderator. Among women, perceived pain helplessness was negatively related to outcome, while married women with dissatisfying marriages responded more poorly than unmarried women and women with satisfying marriages. These variables were not significant predictors of outcome among men.CONCLUSIONS: Men and women may be differentially characterized by various risk factors for treatment failure. Moreover, relationships between pretreatment psychosocial factors and outcome may depend on sex.

John W Burns

Barbara J Johnson

Neil Mahoney

Martha Derleth

Ronald Pawl

Sex Differences in Predictors of Response to Multidisciplinary Treatment of Chronic Pain

Many chronic pain patients seem to have difficulty regulating exercise programs and require detailed, precise instructions of what exercises to do as well as their frequency and timing. This may be due to a lack of information concerning the state of the damaged tissues, which may result from inadequate feedback mechanisms for pain, stretch and position. The straight leg raising test was used as a model of this mechanism, and variance in targeting the end-point of this test was measured in patients with chronic pain and in controls. Variance about the end-point in chronic pain patients was more than three times larger than that in controls. Although chronic pain patients were older, there was no correlation between straight leg raising and age. The implications of these findings to the maintenance of the original injury and the importance of this in the maintenance and continuation of chronic pain states are discussed.

Ann Marie Hoirch

Vicky Smith

Sophie Beugnot

Joanne Turner

Richard FH Catchlove

Impaired Discriminative Function in Patients with Chronic Pain Measured by Variance in Straight Leg Raising

Although postherpetic neuralgia and trigeminal neuralgia (tic douloureux) are common causes of facial pain, they have very little in common aside from lancinating pain (other qualities of pain in each disorder are different). Each disorder affects different areas of the face and the treatment of each is quite dissimilar. The pathogenesis of these two disorders quite likely involves different mechanisms. This report reviews aspects of these two difficult pain problems, particularly with reference to the work of the late Gerhard Fromm, to whom this is dedicated.

C Peter N Watson

Comparison of Trigeminal and Postherpetic Neuralgia

That disease or dysfunction of the neck may present as headache is an idea that is not widely accepted in North American traditional medicine. This review focuses on 'cervicogenic headaches'. Topics include the mechanisms of cervicogenic headache, cervical signs to suspect that a patient's headache originates in the neck, diagnostic manoeuvres that are nonspecific and unreliable, laboratory tests that may assist in establishing a diagnosis of cervicogenic headache and treatment of this condition.

John Edmeads

Cervicogenic Headache

This article reviews recent research advances in animals that have identified critical neural elements in the brainstem receiving and transmitting craniofacial nociceptive inputs, as well as some of the mechanisms involved in the modulation and plasticity of nociceptive transmission. Nociceptive neurones in the trigeminal (V) brainstem sensory nuclear complex can be classified as nociceptive-specific (NS) or wide dynamic range (WDR). Some of these neurones respond exclusively to sensory inputs evoked by stimulation of facial skin or oral mucosa and have features suggesting that they are critical neural elements involved in the ability to localize an acute superficial pain and sense its intensity and duration. Many of the V brainstem nociceptive neurones, however, receive convergent inputs from afferents supplying deep craniofacial tissues (eg, dural vessel, muscle) and skin or mucosa. These neurones are likely involved in deep pain, including headache, because few nociceptive neurones receive inputs exclusively from afferents supplying these tissues. These extensive convergent input patterns also appear to be important factors in pain spread and referral, and in central mechanisms underlying neuroplastic changes in V neuronal properties that may occur with injury and inflammation. For example, application of the small fibre excitant and inflammatory irritant mustard oil into the temporomandibular joint, masseter or tongue musculature induces a prolonged but reversible enhancement of responses to cutaneous and deep afferent inputs of most WDR and NS neurones. These effects may be accompanied by increased electromyographic activity reflexly induced in the masticatory muscles by mustard oil, and involve endogenous N-methyl-D-aspartate and opioid neurochemical mechanisms. Such peripherally induced modulation of brainstem nociceptive neuronal properties reflects the functional plasticity of the central V system, and may be involved in the development of headache and other conditions that manifest craniofacial pain and neuromuscular dysfunction.

Barry J Sessle

Craniofacial Pain: Brainstem Mechanisms

Long term administration of an opioid drug for chronic nonmalignant pain continues to be controversial, but is no longer uniformly rejected by pain specialists. This is true despite concerns that the regulatory agencies that oversee physician prescribing of opioid drugs continue to stigmatize the practice. The changing clinical perspective has been driven, in part, by widespread acknowledgement of the remarkably favourable outcomes achieved during opioid treatment of cancer pain. These outcomes contrast starkly with popular teaching about chronic opioid therapy and affirm the potential for prolonged efficacy, tolerable side effects, enhanced function associated with improved comfort and minimal risk of aberrant drug-related behaviours consistent with addiction. A large anecdotal experience in populations with nonmalignant pain suggests that these patients are more heterogeneous and that opioid therapy will greatly benefit some and will contribute to negative outcomes for others. The few controlled clinical trials that have been performed support the safety and efficacy of opioid therapy, but have been too limited to ensure generalization to the clinical setting. A critical review of the medical literature pertaining to chronic pain, opioid pharmacology and addiction medicine can clarify misconceptions about opioid therapy and provide a foundation for patient selection and drug administration. The available data support the view that opioids are no panacea for chronic pain, but should be considered in carefully selected patients using clinically derived guidelines that stress a structured approach and ongoing monitoring of efficacy, adverse effects, functional outcomes and the occurrence of aberrant drug-related behaviours.

Russell K Portenoy

Opioid Therapy for Chronic Nonmalignant Pain

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Pain Research and Management publishes research focusing on laboratory and clinical findings in the field of pain research and the prevention and management of pain.

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Chief Editor&nbsp;Professor Valeriani specialises in clinical neurophysiology with a particular interest in pain and headaches in children and adults, and is currently a neurologist who works at the Bambi Gesu Children’s Hospital in Rome.

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Pain Research and Management - Table of contents 1996

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Pain Research and Management publishes research focusing on laboratory and clinical findings in the field of pain research and the prevention and management of pain.

Pain Research and Management