Page 372 Guide to Pain Management in Low-Resource Settings

360 Andreas Kopf

Acupuncture that diverge from the expected. “Odynia” is derived from
Acupuncture is a procedure involving the stimulation or the Greek word “odune” or “odyne,” which is used in
inhibition of anatomical locations on or in the skin by a “pleurodynia” and “coccydynia” and is similar in mean-
variety of techniques. A number of eff ects on pain phys- ing to the root from which we derive words with “algia”
iology have been identifi ed, the most important being or “algesia” in them. It is important to recognize that al-
the activation of the endogenous opioid system and the lodynia involves a change in the quality of a sensation,
spinal modulation of pain signalling through activation whether tactile, thermal, or of any other sort. Th e origi-
of touch fi bers (Aβ fi bers). Th ere are a number of dif- nal modality is normally nonpainful, but the response
ferent approaches to diagnosis and treatment in modern is painful. Th ere is thus a loss of specifi city of a sensory
acupuncture that incorporate medical traditions from modality. By contrast, hyperalgesia represents an aug-
China, Japan, Korea, and other countries. Acupuncture mented response in a specifi c mode. With other cuta-
was originally part of traditional Chinese medicine. In neous modalities, hyperesthesia is the term that cor-
the 1950s, French military physicians from Vietnam responds to hyperalgesia, and as with hyperalgesia, the
“exported” the technique to Europe, where it was used quality is not altered. In allodynia the stimulus mode
mostly as a complementary treatment to mainstream and the response mode diff er, unlike the situation with
medicine. A few indications in pain medicine, such as hyperalgesia. Th is distinction should not be confused by
certain types of joint pain, back pain, and headache syn- the fact that allodynia and hyperalgesia can be plotted
dromes may benefi t from acupuncture. with overlap along the same continuum of physical in-
tensity in certain circumstances, for example, with pres-
Addiction
sure or temperature. Allodynia might be provoked by
Addiction is a chronic relapsing condition character- the touch of clothes, such as in patients with posther-
ized by compulsive drug-seeking and drug abuse and by petic neuralgia. Its management may be diffi cult. Apart
long-lasting chemical changes in the brain. Addiction from coanalgesics, local treatment with local anesthetics
is the same irrespective of whether the drug is alcohol, and/or capsaicin might be of help.
amphetamines, cocaine, heroin, marijuana, or nicotine.
Anesthesia dolorosa
Every addictive substance induces pleasant states or re-
lieves distress. Continued use of the addictive substance Pain in an area or region that is anesthetic. Th erefore,
induces adaptive changes in the brain that lead to toler- neurodestructive techniques in pain management
ance, physical dependence, uncontrollable craving, and, should be limited to the few indications where anesthe-
all too often, relapse. Th e genetic factors predisposing sia dolorosa has not been observed.
to addiction are not yet fully understood. Addiction has
Analgesia
to be separated from dependence. For example, in long-
Absence of pain in response to stimulation that would
term opioid therapy, dependence is a normal result, and
the only clinical implication is that dose reduction has normally be painful. As with allodynia, the stimulus is
defi ned by its usual subjective eff ects. Analgesics are
to be stepwise. Addiction to opioids is very rare in pain
patients without preexisting addiction problems. Th ere- used in both acute and chronic pain. Whereas acute
(e.g., postoperative, post-traumatic) pain is generally
fore, asking the patient about alcohol, opioid, and ben-
zodiazepine consumption is a prerequisite before start- amenable to drug therapy, chronic pain is a complex
disease in its own right and needs to be diff erentiated
ing an opioid medication.
into malignant (cancer-related) and nonmalignant (e.g.,
Allodynia musculoskeletal, neuropathic, or infl ammatory) pain.
Allodynia is pain due to a stimulus that does not nor- Acute and cancer-related pain are commonly treat-
mally provoke pain. Th e term “allodynia” was originally able with opioids, NSAIDs, and/or local anesthetic
introduced to distinguish such pain from hyperalgesia blocks. Chronic nonmalignant pain requires a multi-
and hyperesthesia, the conditions seen in patients with disciplinary approach encompassing various pharma-
lesions of the nervous system where touch, light pres- cological and nonpharmacological (e.g., psychological,
sure, or moderate cold or warmth evoke pain when ap- physiotherapeutic) treatment strategies. Various routes
plied to apparently normal skin. “Allo-” means “other” of drug administration (e.g., oral, intravenous, subcuta-
in Greek and is a common prefi x for medical conditions neous, intrathecal, epidural, topical, intra-articular, and