Download 5, PAIN TREATMENTS

TREATING PAIN
A MAGIC PEN?
www.euromedical.co.uk/ Living/paingonepen.html
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 1
Do you think that how we conceptualize pain
--PATHWAY vs DYNAMIC DISTRIBUTED SYSTEMS-influences how we treat pain and the success of those
treatments?
PAIN PATHWAY
Pain Seminar, Lecture #5, PAIN TREATMENTS, p.2
Let’s see…
PAIN
?
Pain Seminar, Lecture #45, PAIN TREATMENTS, p. 3
HOW CAN WE ALLEVIATE PAIN?
DRUGS
SOMATIC
SITUATIONAL
Primary analgesics
Simple
Clinician
NSAIDS
acetaminophen
opioids
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Other analgesics
-2 agonists
 adrenergic antag.
antidepressants
anticonvulsants
antiarrhythmics
Ca++ channel blockers
cannabinoids
corticosteroids
Cox 2 inhibitors
GABAB agonists
serotonin agonists
Adjuvants
antihistamines
laxatives
neuroleptics
phenothiazines
Routes
topical, oral
buccal, sublingual
intranasal
vaginal, rectal
transdermal
i.v., i.m., i.p.
epidural, intrathecal
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
Self
education
meditation
diet, herbals
art, music, poetry
theatre, virtual reality
sports, humor
gardening
aroma therapy
religion
pets
Invasive
surgery
radiation treatment
dorsal column stim.
nerve blocks
neurectomy
local ganglion blks
sympathectomy
rhizotomy
DREZ lesions
punctate myelotomy
limited myelotomy
commissural myel.
cordotomy
brain stimulation
brain lesions
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 4
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
DRUGS
(1) All drugs have “side effects”
(i.e., multiple actions)
(2) When should drugs be taken?
(a) before…
(b) Regular intervals or on
demand? PCAs
(3) How should dose/drugs be
adjusted when pain changes?
(4) What are barriers to the use of
opiates? (for patients, caregivers,
family, pharmaceutical industry,
healthcare workers)
(a) fear of side effects
(respiratory-children; deathcancer);
(b) fear of addiction;
(c) fear of prosecution
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 5
DRUGS
(1) The World Health Organization Ladder
(2) Changing drugs: Galer BS, Coyle N, Pasternak GW,
Portenoy RK. Individual variability in the response to different
opioids: report of five cases. Pain 1992;49:87-91.
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 6
DRUGS
Barrier issues
CONSENSUS - April 2001
American Academy of Pain Medicine
American Pain Society
American Society of Addiction Medicine
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 7
DRUGS
OXYCONTIN (“Hillbilly Heroin”)
New Painkiller Sparks Debate; Manufacturer Mounts Defense
Hurwitz Case Goes To Jury
The federal criminal prosecution of northern Virginia physician Dr. William Hurwitz went to the
jury in early December, 2004. As reported by the Richmond Times-Dispatch on Dec. 9, 2004 , "A
federal jury was asked yesterday to decide between two widely disparate descriptions of a prominent
Northern Virginia doctor accused of fueling a black market in potent prescription drugs. Did Dr.
William E. Hurwitz, as prosecutors alleged in closing arguments, look the other way when he learned
some of his patients were selling and abusing the medications he prescribed for them? Or, as defense
lawyers contended, is Hurwitz a caring, courageous physician who was duped by a small number of
patients enrolled in a practice that helped hundreds of other people deal with their chronic pain? After
a six-week trial and hearing from more than 75 witnesses, the jury is to begin deliberations this
morning on a 62-count indictment against Hurwitz. If convicted of the most serious charges, the
McLean doctor could be sentenced to life in prison."
The Times-Dispatch noted that "The charges against Hurwitz stem from a two-year federal investigation into doctors,
pharmacists and patients who allegedly marketed in potent prescription drugs, primarily OxyContin, a widely abused and
highly addictive painkiller."
In a story published Dec. 7, 2004, the Times-Dispatch reported that "William E. Hurwitz, on trial in U.S. District Court,
acknowledged that he prescribed massive amounts of opiates for some of his patients but said he always had a medical
reason for doing so. Hurwitz testified that he knew some of his patients were drug abusers who were illegally taking
cocaine or abusing his prescriptions. But he said he felt compelled to continue treating them with drugs such as OxyContin
- or at the very least to refrain from abruptly canceling their prescriptions - because of the withdrawal they would suffer
after taking such high doses. 'Abrupt termination of these medicines is tantamount to torture,' Hurwitz testified.
According to the Times-Dispatch, "Some of Hurwitz's patients were using the prescriptions they received to deal drugs;
many have struck plea bargains and testified against him at trial. Prosecutors have played audiotapes to the jury that they
say are proof that Hurwitz knew these patients were dealing drugs and that he turned a blind eye. Hurwitz testified that he
did not know any of his patients were dealing drugs. Expert witnesses have testified for both prosecutors and the defense,
differing on whether Hurwitz's prescriptions were medically justified. Among the doctors to testify on Hurwitz's behalf
was Russell Portenoy, chairman of the pain management department at Beth Israel Medical Center in New York and
considered one of the world's leading experts on pain management.
In addition, as the Times-Dispatch reported in a Dec. 8, 2004 story, "They also charge that two patients who came to
him seeking legitimate pain treatment were prescribed such massive amounts of drugs that he is to blame for their overdose
deaths. Hurwitz's lawyers contend those patients died of other causes. They acknowledge that at times Hurwitz prescribed
massive amounts of opiates to the patients enrolled in his clinic, but say it was part of an emerging medical trend that
encourages high-dosage opiate treatment for pain management."
The case has repercussions in the policy world as well. The Washington Post reported on Oct. 21, 2004 that "Advocates
for aggressive pain management said the DEA's decision appears to have been triggered when defense lawyers tried to
introduce the guidelines in the upcoming drug-trafficking trial of William Hurwitz, a McLean physician. In late September,
Hurwitz's defense team sought to introduce them as evidence. Several weeks later, the DEA took the document off its Web
site and said it was not official policy. Twelve days after that, U.S. Attorney Paul J. McNulty, who is prosecuting Hurwitz,
filed a motion in the case asking that the guidelines be excluded as evidence, again saying that they do 'not have the force
and effect of law.' 'It seems pretty clear that they felt they had to try to get rid of the guidelines because they supported so
many parts of our case,' said Hurwitz's defense attorney, Patrick Hallinan. 'If the Justice Department followed the
guidelines, there would be no reason to arrest and charge Dr. Hurwitz.'"
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 8
DRUGS
OXYCONTIN (continued)
December 17, 2004
Pain Doctor William Hurwitz Found Guilty
“If it wasn't so before, it is now essentially professional suicide to provide painmanagement services to one's patients -- a fact that will needlessly cost the lives of many of
society's most sick and vulnerable,” said Baylen Linnekin on DrugPolicy.org.
Dr. Hurwitz, a prominent pain management caregiver, was charged with over-prescribing
medications such as OxyContin to patients around the country, many of whom suffered from
cancer, chronic back pain, arthritis, or diabetes. While pain medications can be abused in this
way, many pain treatment specialists believe that the arrest of Dr. Hurwitz and others is
unwarranted. Data shows that the under-treatment of pain is causing an epidemic of undue
suffering and pain. As the nation’s largest health problem, an estimated 50-75 million suffer
from pain each day, resulting in more lost days from work than heart disease and cancer
combined.
Under-treatment of pain largely stems from heavy-handed Drug Enforcement
Administration (DEA) monitoring of prescriptions. Those considered to over-prescribe are
arrested, leaving many physicians afraid to appropriately treat their patients with strong pain
medications. The DEA has “an unprecedented amount of control over the behavior of
physicians” says Siobhan Reynolds, Executive Director of the Pain Relief Network. As a
result they “control a doctor’s ability to make a living.”
There has been an 800% increase in physician prosecutions over the past three years.
Recently, the DEA has aggressively focused on the pain killer OxyContin – an opioid
analgesic that is among the safest and most effective treatments for pain. Doctors now fear
arrest and are prescribing the medication less often and in smaller doses – what Reynolds
calls “tapering the patient down”.
Concerns about the number of people left under-treated or even untreated have led pain
management groups to call for a moratorium on arrests and Congressional investigations into
the validity of the DEA’s crackdown. In a blow to the DEA’s campaign to control pain
management, a Food and Drug Administration (FDA) panel [last year] voted down a DEA
proposal to further restrict patient access to OxyContin.
Content courtesy of the Drug Policy Alliance (www.drugpolicy.org).
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 9
Public service ad launched in 2005:
http://www.csdp.org/
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 10
cs
rs
SOMATIC
SOMATIC
SITUATIONAL
Simple
Clinician
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
(1) The more invasive, the more
Self helpful?
education
(2) Placebo (chptr 9 in Wall, 1999)
meditation
diet
(3)music,
Barriers?
art,
poetry
theatre
(a)
fear of permanency (invasive)?
sports,
humor
gardening
scepticism (simple/minimal)?
aroma(b)
therapy
religion
pets
Invasive
surgery
Interactive
Nathan biofeedback
PW. Success in surgery may
radiation treatment hypnosis,
not require
dorsal column stim. support
groupscutting the tracts. Pain
nerve blocks
advocacy
groups
19985;22:317-319.
neurectomy
networking
Two patients
are described in whom surgical
local ganglion blks
self-help
groups
intervention was terminated prior to lesioning of
sympathectomy
any pathways relevant to pain and yet the
rhizotomy
Structured
settings
surgery relieved the chronic severe pain.
DREZ lesions
group therapy
punctate myelotomy family counseling
limited myelotomy
job counseling
commissural myel.
cog / behav. therapy
cordotomy
psychotherapy
brain stimulation
multidisipl. clinic
brain lesions
hospice
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 11
SOMATIC
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 12
SOMATIC
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 13
SOMATIC
Monday, December 20, 2004 [National Center for Complementary and Alternative
Medicine301-496-7790
Acupuncture Relieves Pain and Improves Function in Knee Osteoarthritis
Acupuncture provides pain relief and improves function for people with osteoarthritis of the knee
and serves as an effective complement to standard care. This landmark study was funded by the
National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute
of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), both components of the National
Institutes of Health. The findings of the study the longest and largest randomized, controlled phase
III clinical trial of acupuncture ever conducted were published in the December 21, 2004, issue of the
Annals of Internal Medicine *.
The multi-site study team, including rheumatologists and licensed acupuncturists, enrolled 570 patients, aged 50 or
older with osteoarthritis of the knee. Participants had significant pain in their knee the month before joining the study, but
had never experienced acupuncture, had not had knee surgery in the previous 6 months, and had not used steroid or
similar injections. Participants were randomly assigned to receive one of three treatments: acupuncture, sham
acupuncture, or participation in a control group that followed the Arthritis Foundation's self-help course for managing
their condition. Patients continued to receive standard medical care from their primary physicians, including antiinflammatory medications, such as COX-2 selective inhibitors, non-steroidal anti-inflammatory drugs, and opioid pain
relievers.
"For the first time, a clinical trial with sufficient rigor, size, and duration has shown that acupuncture reduces the pain
and functional impairment of osteoarthritis of the knee," said Stephen E. Straus, M.D., NCCAM Director. "These results
also indicate that acupuncture can serve as an effective addition to a standard regimen of care and improve quality of life
for knee osteoarthritis sufferers. NCCAM has been building a portfolio of basic and clinical research that is now
revealing the power and promise of applying stringent research methods to ancient practices like acupuncture."
"More than 20 million Americans have osteoarthritis. This disease is one of the most frequent causes of physical
disability among adults," said Stephen I. Katz, M.D., Ph.D., NIAMS Director. "Thus, seeking an effective means of
decreasing osteoarthritis pain and increasing function is of critical importance."
During the course of the study, led by Brian M. Berman, M.D., Director of the Center for Integrative Medicine and
Professor of Family Medicine at the Univ. Maryland School of Medicine, Baltimore, MD, 190 patients received true
acupuncture and 191 patients received sham acupuncture for 24 treatment sessions over 26 weeks. Sham acupuncture is a
procedure designed to prevent patients from being able to detect if needles are actually inserted at treatment points. In
both the sham and true acupuncture procedures, a screen prevented patients from seeing the knee treatment area and
learning which treatment they received. In the education control group, 189 participants attended six, 2-hour group
sessions over 12 weeks based on the Arthritis Foundation's Arthritis Self-Help Course a proven, effective model.
On joining the study, patients' pain and knee function were assessed using standard arthritis research survey
instruments and measurement tools, such as the Western Ontario McMasters Osteoarthritis Index (WOMAC). Patients'
progress was assessed at 4, 8, 14, and 26 weeks. By week 8, participants receiving acupuncture were showing a
significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control
groups. These results, shown by declining scores on the WOMAC index, held through week 26. Overall, those who
received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function compared to
baseline assessments.
"This trial, which builds upon our previous NCCAM-funded research, establishes that acupuncture is an effective
complement to conventional arthritis treatment and can be successfully employed as part of a multidisciplinary approach
to treating the symptoms of osteoarthritis," said Dr. Berman.
Acupuncture the practice of inserting thin needles into specific body points to improve health and well-being
originated in China more than 2,000 years ago. In 2002, acupuncture was used by an estimated 2.1 million U.S. adults,
according to the Centers for Disease Control and Prevention's 2002 National Health Interview Survey. The acupuncture
technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are
manipulated by the hands or by electrical stimulation. In recent years, scientific inquiry has begun to shed more light on
acupuncture's possible mechanisms and potential benefits, especially in treating painful conditions such as arthritis.
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 14
SITUATIONAL
SITUATIONAL
Clinician
education
attitude
clinic arrangement
Self
education
meditation
diet
art, music, poetry
theatre
sports, humor
gardening
aroma therapy
religion
pets
s.
(2) “locus of control”
(3) Context important
(a) clinician
(b) patient/individual
Interactive
ent
im.
ks
(1) Deliberate use of placebo
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
omy family counseling
my
job counseling
el.
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 15
t
m.
SITUATIONAL
SITUATIONAL
Clinician
education
attitude
clinic arrangement
Self
education
meditation
diet
art, music, poetry
theatre
sports, humor
gardening
aroma therapy
religion
pets
(1) Deliberate use of placebo
(2) “locus of control”
(3) Context important
(a) clinician
(b) patient/individual
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
my family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 16
SITUATIONAL
(1) Deliberate use of placebo
(2) “locus of control”
(3) Context important
(a) clinician
(b) patient/individual
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 17
.
nt
m.
s
SITUATIONAL
SITUATIONAL
Clinician
(1) Deliberate use of placebo
education
attitude
clinic arrangement
(2) “locus of control”
Self
education
meditation
diet
art, music, poetry
theatre
sports, humor
gardening
aroma therapy
religion
pets
(3) Context important
(a) clinician
(b) patient/individual
“You can turn a pelvic pain patient into
an acute abdomen by the first question
you ask her when she enters the
clinic,” said John Slocum, MD, Chair
ObGYN, Univ of Colorado, Boulder.
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
my family counseling
y
job counseling
l.
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 18
SITUATIONAL
SITUATIONAL
(1) Deliberate use of placebo
Clinician
(2) “locus of control”
education
attitude
clinic arrangement
Self
education
meditation
diet
art, music, poetry
theatre
sports, humor
gardening
aroma therapy
religion
pets
(3) Context important
(a) clinician
(b) patient/individual
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
y family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 19
SO: How shall we make use of this table?
DRUGS
SOMATIC
SITUATIONAL
Primary analgesics
Simple
Clinician
NSAIDS
acetaminophen
opioids
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Other analgesics
-2 agonists
 adrenergic antag.
antidepressants
anticonvulsants
antiarrhythmics
Ca++ channel blockers
cannabinoids
corticosteroids
Cox 2 inhibitors
GABAB agonists
serotonin agonists
Adjuvants
antihistamines
laxatives
neuroleptics
phenothiazines
Routes
topical, oral
buccal, sublingual
intranasal
vaginal, rectal
transdermal
i.v., i.m., i.p.
epidural, intrathecal
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
Self
education
meditation
diet
art, music, poetry
theatre, virtual reality
sports, humor
gardening
aroma therapy
religion
pets
Invasive
surgery
radiation treatment
dorsal column stim.
nerve blocks
neurectomy
local ganglion blks
sympathectomy
rhizotomy
DREZ lesions
punctate myelotomy
limited myelotomy
commissural myel.
cordotomy
brain stimulation
brain lesions
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 20
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Neural Mechanisms of Pain
PAIN PATHWAY
Pain enters
here…
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 21
???--Strategy #1: If one treatment doesn’t work, try
another.
DRUGS
SOMATIC
SITUATIONAL
Primary analgesics
Simple
Clinician
NSAIDS
acetaminophen
opioids
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Other analgesics
-2 agonists
 adrenergic antag.
antidepressants
anticonvulsants
antiarrhythmics
Ca++ channel blockers
cannabinoids
corticosteroids
Cox 2 inhibitors
GABAB agonists
serotonin agonists
Adjuvants
antihistamines
laxatives
neuroleptics
phenothiazines
Routes
topical, oral
buccal, sublingual
intranasal
vaginal, rectal
transdermal
i.v., i.m., i.p.
epidural, intrathecal
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
Self
education
meditation
diet
art, music, poetry
theatre, virtual reality
sports, humor
gardening
aroma therapy
religion
pets
Invasive
surgery
radiation treatment
dorsal column stim.
nerve blocks
neurectomy
local ganglion blks
sympathectomy
rhizotomy
DREZ lesions
punctate myelotomy
limited myelotomy
commissural myel.
cordotomy
brain stimulation
brain lesions
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 22
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
???-OR, possibly: Strategy #2: “All you need is a needle and
a bunch of psychologists.” – Tallahassee doctor, 2003.
DRUGS
SOMATIC
SITUATIONAL
Primary analgesics
Simple
Clinician
NSAIDS
acetaminophen
opioids
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Other analgesics
-2 agonists
 adrenergic antag.
antidepressants
anticonvulsants
antiarrhythmics
Ca++ channel blockers
cannabinoids
corticosteroids
Cox 2 inhibitors
GABAB agonists
serotonin agonists
Adjuvants
antihistamines
laxatives
neuroleptics
phenothiazines
Routes
topical, oral
buccal, sublingual
intranasal
vaginal, rectal
transdermal
i.v., i.m., i.p.
epidural, intrathecal
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
Self
education
meditation
diet
art, music, poetry
theatre, virtual reality
sports, humor
gardening
aroma therapy
religion
pets
Invasive
surgery
radiation treatment
dorsal column stim.
nerve blocks
neurectomy
local ganglion blks
sympathectomy
rhizotomy
DREZ lesions
punctate myelotomy
limited myelotomy
commissural myel.
cordotomy
brain stimulation
brain lesions
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 23
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
Neural Mechanisms of Pain
PAIN
?
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 24
???--Strategy #3: DELIBERATE COMBINATIONS
(A Chinese Menu!)
(partnership between patient and clinician)
DRUGS
SOMATIC
SITUATIONAL
Primary analgesics
Simple
Clinician
NSAIDS
acetaminophen
opioids
heat/cold
exercise
massage
vibration
relaxation
education
attitude
clinic arrangement
Other analgesics
-2 agonists
 adrenergic antag.
antidepressants
anticonvulsants
antiarrhythmics
Ca++ channel blockers
cannabinoids
corticosteroids
Cox 2 inhibitors
GABAB agonists
serotonin agonists
Adjuvants
antihistamines
laxatives
neuroleptics
phenothiazines
Routes
topical, oral
buccal, sublingual
intranasal
vaginal, rectal
transdermal
i.v., i.m., i.p.
epidural, intrathecal
Minimally invas.
physical therapy
traction
manipulation
ultrasound
TENS
acupuncture
local anesthetics
Self
education
meditation
diet
art, music, poetry
theatre, virtual reality
sports, humor
gardening
aroma therapy
religion
pets
Invasive
surgery
radiation treatment
dorsal column stim.
nerve blocks
neurectomy
local ganglion blks
sympathectomy
rhizotomy
DREZ lesions
punctate myelotomy
limited myelotomy
commissural myel.
cordotomy
brain stimulation
brain lesions
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 25
Interactive
hypnosis, biofeedback
support groups
advocacy groups
networking
self-help groups
Structured settings
group therapy
family counseling
job counseling
cog / behav. therapy
psychotherapy
multidisipl. clinic
hospice
AN AFTERWORD……………………
Pain Seminar, Lecture # 5, PAIN TREATMENTS, p. 26