Pain Assessment and Management

  • Christina L. VaughanEmail author
  • Alan C. Carver


Skilled and compassionate pain assessment and management is a central component of the palliative care approach. While we are in need of new drugs with more manageable side effect profiles, and more research to help guide us as to what other “alternative” approaches may be helpful to our patients, the most pressing need of our patients is a partnership with their clinician and the assurance that they are being cared for by skilled clinicians. This chapter provides a set of important skills including (1) adequate pain assessment; (2) a basic understanding of various pain mechanisms; (3) targeted pain management including management of neuropathic pain; (4) opioid principles and management of opioid side effects; and (5) a discussion of the public health challenges of prescription drug abuse and the under-treatment of pain. Pain is often overlooked in neurologic conditions, but appropriate evaluation of pain combined with judicious selection of analgesic interventions can improve pain dramatically in our patients.


Pain Neuropathic Opioids 


  1. 1.
    Borsook D. Neurological diseases and pain. Brain. 2012;135(Pt 2):320–44.PubMedGoogle Scholar
  2. 2.
    Hansson PT, et al. Toward a definition of pharmacoresistant neuropathic pain. Eur J Pain. 2009;13(5):439–40.PubMedGoogle Scholar
  3. 3.
    Eisenstein M. Neuropathy: a name for their pain. Nature. 2016;535(7611):S10–1.PubMedGoogle Scholar
  4. 4.
    Truini A, Garcia-Larrea L, Cruccu G. Reappraising neuropathic pain in humans – how symptoms help disclose mechanisms. Nat Rev Neurol. 2013;9(10):572–82.PubMedGoogle Scholar
  5. 5.
    van Hecke O, et al. Neuropathic pain in the general population: a systematic review of epidemiological studies. Pain. 2014;155(4):654–62.PubMedGoogle Scholar
  6. 6.
    Beiske AG, et al. Pain in Parkinson’s disease: prevalence and characteristics. Pain. 2009;141(1–2):173–7.PubMedGoogle Scholar
  7. 7.
    Broen MP, et al. Prevalence of pain in Parkinson’s disease: a systematic review using the modified QUADAS tool. Mov Disord. 2012;27(4):480–4.PubMedGoogle Scholar
  8. 8.
    Valkovic P, et al. Pain in Parkinson’s disease: a cross-sectional study of its prevalence, types, and relationship to depression and quality of life. PLoS One. 2015;10(8):e0136541.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Buhmann C, et al. Pain in Parkinson disease: a cross-sectional survey of its prevalence, specifics, and therapy. J Neurol. 2017;264(4):758–69.PubMedGoogle Scholar
  10. 10.
    Lee MA, et al. A survey of pain in idiopathic Parkinson’s disease. J Pain Symptom Manag. 2006;32(5):462–9.Google Scholar
  11. 11.
    Wasner G, Deuschl G. Pains in Parkinson disease – many syndromes under one umbrella. Nat Rev Neurol. 2012;8(5):284–94.PubMedGoogle Scholar
  12. 12.
    Ford B. Pain in Parkinson’s disease. Clin Neurosci. 1998;5(2):63–72.PubMedGoogle Scholar
  13. 13.
    Blanchet PJ, Brefel-Courbon C. Chronic pain and pain processing in Parkinson’s disease. Prog Neuropsychopharmacol Biol Psychiatry. 2017.Google Scholar
  14. 14.
    de Tommaso M, et al. Pain in neurodegenerative disease: current knowledge and future perspectives. Behav Neurol. 2016;2016:7576292.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Ford B. Pain in Parkinson’s disease. Mov Disord. 2010;25(Suppl 1):S98–103.PubMedGoogle Scholar
  16. 16.
    Helme RD. Chronic pain management in older people. Eur J Pain. 2001;5(Suppl A):31–6.PubMedGoogle Scholar
  17. 17.
    Scherder E, et al. Pain in dementia. Pain. 2009;145(3):276–8.PubMedGoogle Scholar
  18. 18.
    Zwakhalen SM, et al. The prevalence of pain in nursing home residents with dementia measured using an observational pain scale. Eur J Pain. 2009;13(1):89–93.PubMedGoogle Scholar
  19. 19.
    van t’Hof CE, Zwakhalen SM, Hamers JP. Interventions after diagnosing pain in nursing home residents with dementia: the pilot implementation of an observational pain scale (PACSLAC-D). Tijdschr Gerontol Geriatr. 2011;42(2):67–78.Google Scholar
  20. 20.
    Grimby C, et al. Musculoskeletal pain and analgesic therapy in a very old population. Arch Gerontol Geriatr. 1999;29(1):29–43.PubMedGoogle Scholar
  21. 21.
    Horn SD, et al. Description of the National Pressure Ulcer Long-Term Care Study. J Am Geriatr Soc. 2002;50(11):1816–25.PubMedGoogle Scholar
  22. 22.
    Black BS, et al. Health problems and correlates of pain in nursing home residents with advanced dementia. Alzheimer Dis Assoc Disord. 2006;20(4):283–90.PubMedGoogle Scholar
  23. 23.
    Barry HE, et al. Exploring the prevalence of and factors associated with pain: a cross-sectional study of community-dwelling people with dementia. Health Soc Care Community. 2016;24(3):270–82.PubMedGoogle Scholar
  24. 24.
    Hunt LJ, et al. Pain in community-dwelling older adults with dementia: results from the National Health and Aging Trends Study. J Am Geriatr Soc. 2015;63(8):1503–11.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Werner P, et al. Pain in participants of adult day care centers: assessment by different raters. J Pain Symptom Manag. 1998;15(1):8–17.Google Scholar
  26. 26.
    Mantyselka P, et al. Effects of dementia on perceived daily pain in home-dwelling elderly people: a population-based study. Age Ageing. 2004;33(5):496–9.PubMedGoogle Scholar
  27. 27.
    Shega JW, et al. Pain in community-dwelling persons with dementia: frequency, intensity, and congruence between patient and caregiver report. J Pain Symptom Manag. 2004;28(6):585–92.Google Scholar
  28. 28.
    Calvert M, et al. Health-related quality of life and supportive care in patients with rare long-term neurological conditions. Qual Life Res. 2013;22(6):1231–8.PubMedGoogle Scholar
  29. 29.
    Scherder E, Statema M. Huntington's disease. Lancet. 2010;376(9751):1464.PubMedGoogle Scholar
  30. 30.
    De Tommaso M, et al. Nociceptive inputs transmission in Huntington’s disease: a study by laser evoked potentials. Acta Neurol Belg. 2011;111(1):33–40.PubMedGoogle Scholar
  31. 31.
    Underwood M, Bonas S, Dale MD, REGISTRY Investigators of the European Huntington’s Disease Network. Huntington’s disease: prevalence and psychological indicators of pain. Mov Disord Clin Pract. 2017;4(2):198–204.PubMedGoogle Scholar
  32. 32.
    Johnson MO, et al. Utilization of hospice services in a population of patients with Huntington’s Disease. J Pain Symptom Manag. 2018;55(2):440–3.PubMedGoogle Scholar
  33. 33.
    Borsook D, et al. A key role of the basal ganglia in pain and analgesia – insights gained through human functional imaging. Mol Pain. 2010;6:27.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Koyama T, Kato K, Mikami A. During pain-avoidance neurons activated in the macaque anterior cingulate and caudate. Neurosci Lett. 2000;283(1):17–20.PubMedGoogle Scholar
  35. 35.
    de Castro-Costa CM, et al. Amyotrophic lateral sclerosis. Clinical analysis of 78 cases from Fortaleza (Northeastern Brazil). Arq Neuropsiquiatr. 1999;57(3B):761–74.PubMedGoogle Scholar
  36. 36.
    Jensen MP, et al. Chronic pain in persons with neuromuscular disease. Arch Phys Med Rehabil. 2005;86(6):1155–63.PubMedGoogle Scholar
  37. 37.
    Wallace VC, et al. The evaluation of pain in amyotrophic lateral sclerosis: a case controlled observational study. Amyotroph Lateral Scler Frontotemporal Degener. 2014;15(7–8):520–7.PubMedGoogle Scholar
  38. 38.
    Moisset X, et al. Is there pain with neuropathic characteristics in patients with amyotrophic lateral sclerosis? A cross-sectional study. Palliat Med. 2016;30(5):486–94.PubMedGoogle Scholar
  39. 39.
    Lopes LCG, et al. Beyond weakness: characterization of pain, sensory profile and conditioned pain modulation in patients with motor neuron disease: a controlled study. Eur J Pain. 2018;22(1):72–83PubMedGoogle Scholar
  40. 40.
    Ganzini L, Johnston WS, Hoffman WF. Correlates of suffering in amyotrophic lateral sclerosis. Neurology. 1999;52(7):1434–40.PubMedGoogle Scholar
  41. 41.
    Ceruti S. What role does multiple sclerosis play in the development of untreatable painful conditions? Pain Manag. 2018;8(1):37–44.PubMedGoogle Scholar
  42. 42.
    Benson C, Kerr BJ. Pain and cognition in multiple sclerosis. Curr Top Behav Neurosci. 2014;20:201–15.PubMedGoogle Scholar
  43. 43.
    Drulovic J, et al. The prevalence of pain in adults with multiple sclerosis: a multicenter cross-sectional survey. Pain Med. 2015;16(8):1597–602.PubMedGoogle Scholar
  44. 44.
    Khan F, Pallant J. Chronic pain in multiple sclerosis: prevalence, characteristics, and impact on quality of life in an Australian community cohort. J Pain. 2007;8(8):614–23.PubMedGoogle Scholar
  45. 45.
    Brola W, Mitosek-Szewczyk K, Opara J. Symptomatology and pathogenesis of different types of pain in multiple sclerosis. Neurol Neurochir Pol. 2014;48(4):272–9.PubMedGoogle Scholar
  46. 46.
    O'Connor AB, et al. Pain associated with multiple sclerosis: systematic review and proposed classification. Pain. 2008;137(1):96–111.PubMedGoogle Scholar
  47. 47.
    Grau-Lopez L, et al. Analysis of the pain in multiple sclerosis patients. Neurologia. 2011;26(4):208–13.PubMedGoogle Scholar
  48. 48.
    Silva JV, et al. Increased multiple sclerosis relapses related to lower prevalence of pain. Arq Neuropsiquiatr. 2015;73(7):593–600.PubMedGoogle Scholar
  49. 49.
    Paolucci S, et al. Assessing and treating pain associated with stroke, multiple sclerosis, cerebral palsy, spinal cord injury and spasticity. Evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation. Eur J Phys Rehabil Med. 2016;52(6):827–40.PubMedGoogle Scholar
  50. 50.
    Bowsher D, Leijon G, Thuomas KA. Central poststroke pain: correlation of MRI with clinical pain characteristics and sensory abnormalities. Neurology. 1998;51(5):1352–8.PubMedGoogle Scholar
  51. 51.
    Headache Classification Committee of the International Headache, S. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.Google Scholar
  52. 52.
    Headache Classification Subcommittee of the International Headache, S. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9–160.Google Scholar
  53. 53.
    Richmond C. Dame Cicely Saunders. Br Med J. 2005;331(7510):238.Google Scholar
  54. 54.
    Payne R. Principles of palliative medicine and pain management in neurological illness. Continuum. 2005;11(6):13–32.Google Scholar
  55. 55.
    Daut RL, Cleeland CS, Flanery RC. Development of the Wisconsin brief pain questionnaire to assess pain in cancer and other diseases. Pain. 1983;17(2):197–210.PubMedGoogle Scholar
  56. 56.
    Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain. 1975;1(3):277–99.PubMedGoogle Scholar
  57. 57.
    Fishman B, et al. The memorial pain assessment card. A valid instrument for the evaluation of cancer pain. Cancer. 1987;60(5):1151–8.PubMedGoogle Scholar
  58. 58.
    Portenoy RK, et al. The memorial symptom assessment scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer. 1994;30A(9):1326–36.PubMedGoogle Scholar
  59. 59.
    Lichtner V, et al. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr. 2014;14:138.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Baker D. The joint commission's pain standards: origins and evolution. The Joint Commission. 2017.Google Scholar
  61. 61.
    Baker DW. History of the joint commission’s pain standards: lessons for today’s prescription opioid epidemic. JAMA. 2017;317(11):1117–8.PubMedGoogle Scholar
  62. 62.
    Bodtke S, Ligon K. Hospice and palliative medicine handbook: a clinical guide. 2016.Google Scholar
  63. 63.
    Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8(2):163–90.PubMedGoogle Scholar
  64. 64.
    Majeed MH, Ali AA, Sudak DM. Mindfulness-based interventions for chronic pain: evidence and applications. Asian J Psychiatr. 2017;32:79–83.PubMedGoogle Scholar
  65. 65.
    Elkins G, Johnson A, Fisher W. Cognitive hypnotherapy for pain management. Am J Clin Hypn. 2012;54(4):294–310.PubMedGoogle Scholar
  66. 66.
    Cherkin DC, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240–9.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Twycross R. Factors involved in difficult-to-manage pain. Indian J Palliat Care. 2004;10(2):67–8.Google Scholar
  68. 68.
    Dunlop DD, et al. Relation of physical activity time to incident disability in community dwelling adults with or at risk of knee arthritis: prospective cohort study. BMJ. 2014;348:g2472.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Jacox A, Carr DB, Payne R. New clinical-practice guidelines for the management of pain in patients with cancer. N Engl J Med. 1994;330(9):651–5.PubMedGoogle Scholar
  70. 70.
    WHO. Report of the WHO expert committee on cancer pain and relief and active supportive care: cancer pain relief with a guide to opioid availability. Technical Report Series. 1986;2(804).Google Scholar
  71. 71.
    Society AP, Principles of analgesic use in the treatment of acute pain and cancer pain. 4 ed. 1999.Google Scholar
  72. 72.
    Woolf CJ, P. American College of, S. American Physiological. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140(6):441–51.PubMedGoogle Scholar
  73. 73.
    Cruccu G, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol. 2010;17(8):1010–8.PubMedGoogle Scholar
  74. 74.
    Baron R. Neuropathic pain: a clinical perspective. Handb Exp Pharmacol. 2009;194:3–30.Google Scholar
  75. 75.
    Cruccu G, Truini A. A review of neuropathic pain: from guidelines to clinical practice. Pain Ther. 2017;6(Suppl 1):35–42.PubMedPubMedCentralGoogle Scholar
  76. 76.
    Sills GJ. The mechanisms of action of gabapentin and pregabalin. Curr Opin Pharmacol. 2006;6(1):108–13.PubMedGoogle Scholar
  77. 77.
    Finnerup NB, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162–73.PubMedPubMedCentralGoogle Scholar
  78. 78.
    Gronseth G, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008;71(15):1183–90.PubMedGoogle Scholar
  79. 79.
    Mick G, Correa-Illanes G. Topical pain management with the 5% lidocaine medicated plaster – a review. Curr Med Res Opin. 2012;28(6):937–51.PubMedGoogle Scholar
  80. 80.
    Derry S, Moore RA. Topical capsaicin (low concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2012;9:CD010111.Google Scholar
  81. 81.
    Cruccu G, et al. Superiority of capsaicin 8% patch versus oral pregabalin on dynamic mechanical allodynia in patients with peripheral neuropathic pain. Eur J Pain. 2018;22(4):700–6.PubMedGoogle Scholar
  82. 82.
    Abramowicz M. Tramadol – a new oral analgesic. Med Lett Drugs Ther. 1993;37:59–62.Google Scholar
  83. 83.
    Bonn-Miller MO, et al. Self-reported cannabis use characteristics, patterns and helpfulness among medical cannabis users. Am J Drug Alcohol Abuse. 2014;40(1):23–30.PubMedGoogle Scholar
  84. 84.
    Ilgen MA, et al. Characteristics of adults seeking medical marijuana certification. Drug Alcohol Depend. 2013;132(3):654–9.PubMedGoogle Scholar
  85. 85.
    Nugent SM, et al. The effects of Cannabis among adults with chronic pain and an overview of general harms: a systematic review. Ann Intern Med. 2017;167(5):319–31.PubMedGoogle Scholar
  86. 86.
    Whiting PF, Wolff RF, Deshpande S. Cannabinoids for medical use: a systematic review and meta-analysis (vol 313, pg 2456, 2015). JAMA-J Am Med Assoc. 2015;314(8):837.Google Scholar
  87. 87.
    Holbech JV, et al. Combination treatment of neuropathic pain: Danish expert recommendations based on a Delphi process. J Pain Res. 2017;10:1467–75.PubMedPubMedCentralGoogle Scholar
  88. 88.
    Payne R, Portenoy RK. Appropriate opioid pharmacotherapy for chronic pain management. Monograph 1: optimizing treatment of chronic pain with opioid therapy. National Pain Education Council. 2002.Google Scholar
  89. 89.
    Reuben SS, Connelly NR, Maciolek H. Postoperative analgesia with controlled-release oxycodone for outpatient anterior cruciate ligament surgery. Anesth Analg. 1999;88(6):1286–91.PubMedGoogle Scholar
  90. 90.
    Swanwick M, Haworth M, Lennard RF. The prevalence of episodic pain in cancer: a survey of hospice patients on admission. Palliat Med. 2001;15(1):9–18.PubMedGoogle Scholar
  91. 91.
    Fortner BV, Okon TA, Portenoy RK. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain. 2002;3(1):38–44.PubMedGoogle Scholar
  92. 92.
    Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990;41(3):273–81.PubMedGoogle Scholar
  93. 93.
    Zeppetella G, O’Doherty CA, Collins S. Prevalence and characteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice. Palliat Med. 2001;15(3):243–6.PubMedGoogle Scholar
  94. 94.
    Caraceni A, Portenoy RK. An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain. Pain. 1999;82(3):263–74.PubMedGoogle Scholar
  95. 95.
    Foley K. Changing concepts of tolerance to opioids: what the cancer ptient has taught us. In: Chapman CR, Foley KM, editors. Current and emerging issues in cancer pain: research and practice. New York: Raven Press; 1993. p. 331–50.Google Scholar
  96. 96.
    Carver AC, Foley KM. Symptom assessment and management. Neurol Clin. 2001;19(4):921–47.PubMedGoogle Scholar
  97. 97.
    Weissman DE, Haddox JD. Opioid pseudoaddiction – an iatrogenic syndrome. Pain. 1989;36(3):363–6.PubMedGoogle Scholar
  98. 98.
    Jamison RN, Serraillier J, Michna E. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. Pain Res Treat. 2011;2011:941808.PubMedPubMedCentralGoogle Scholar
  99. 99.
    Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–42.PubMedGoogle Scholar
  100. 100.
    Bell TJ, et al. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Med. 2009;10(1):35–42.PubMedGoogle Scholar
  101. 101.
    Murphy JA, Sheridan EA. Evidence Based Review of Pharmacotherapy for Opioid-Induced Constipation in Noncancer Pain. Ann Pharmacother. 2018;52(4):370–9.PubMedGoogle Scholar
  102. 102.
    Larkin PJ, et al. The management of constipation in palliative care: clinical practice recommendations. Palliat Med. 2008;22(7):796–807.PubMedGoogle Scholar
  103. 103.
    Mercadante S. Pathophysiology and treatment of opioid-related myoclonus in cancer patients. Pain. 1998;74(1):5–9.PubMedGoogle Scholar
  104. 104.
    Verhamme KM, et al. Drug-induced urinary retention: incidence, management and prevention. Drug Saf. 2008;31(5):373–88.PubMedGoogle Scholar
  105. 105.
    Maher DP, Chen L, Mao J. Intravenous ketamine infusions for neuropathic pain management: a promising therapy in need of optimization. Anesth Analg. 2017;124(2):661–74.PubMedGoogle Scholar
  106. 106.
    Kandil E, Melikman E, Adinoff B. Lidocaine infusion: a promising therapeutic approach for chronic pain. J Anesth Clin Res. 2017;8(1).Google Scholar
  107. 107.
    Lee B. Interventional pain management techniques for palliative care in cancer patients. J Pain Symptom Manag. 2010;39(2):352–3.Google Scholar
  108. 108.
    Khalifeh M, et al. Botulinum toxin type A for the treatment of head and neck chronic myofascial pain syndrome: a systematic review and meta-analysis. J Am Dent Assoc. 2016;147(12):959–73. e1.PubMedGoogle Scholar
  109. 109.
    Chiang CC, Starling AJ. OnabotulinumtoxinA in the treatment of patients with chronic migraine: clinical evidence and experience. Ther Adv Neurol Disord. 2017;10(12):397–406.PubMedPubMedCentralGoogle Scholar
  110. 110.
    Park J, Park HJ. Botulinum toxin for the treatment of neuropathic pain. Toxins (Basel). 2017;9(9).PubMedCentralGoogle Scholar
  111. 111.
    Dressler D, et al. Botulinum toxin therapy for treatment of spasticity in multiple sclerosis: review and recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders task force. J Neurol. 2017;264(1):112–20.PubMedGoogle Scholar
  112. 112.
    Rosales R. Botulinum toxin therapy as an early intervention for post-stroke spasticity: beyond a functional viewpoint. J Neurol Sci. 2017;382:187–8.PubMedGoogle Scholar
  113. 113.
    Hanlan A, et al. Interdisciplinary spasticity management clinic outcomes using the goal attainment scale: a retrospective chart review. J Rehabil Med. 2017;49(5):423–30.PubMedGoogle Scholar
  114. 114.
    Dressler D. Botulinum toxin for treatment of dystonia. Eur J Neurol. 2010;17(Suppl 1):88–96.PubMedGoogle Scholar
  115. 115.
    Argoff CE. A focused review on the use of botulinum toxins for neuropathic pain. Clin J Pain. 2002;18(6 Suppl):S177–81.PubMedGoogle Scholar
  116. 116.
    Rawicki B, et al. Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement. Eur J Neurol. 2010;17(Suppl 2):122–34.PubMedGoogle Scholar
  117. 117.
    Ranoux D, et al. Botulinum toxin type A induces direct analgesic effects in chronic neuropathic pain. Ann Neurol. 2008;64(3):274–83.PubMedGoogle Scholar
  118. 118.
    Bach-Rojecky L, Lackovic Z. Central origin of the antinociceptive action of botulinum toxin type A. Pharmacol Biochem Behav. 2009;94(2):234–8.PubMedGoogle Scholar
  119. 119.
    Favre-Guilmard C, Auguet M, Chabrier PE. Different antinociceptive effects of botulinum toxin type A in inflammatory and peripheral polyneuropathic rat models. Eur J Pharmacol. 2009;617(1–3):48–53.PubMedGoogle Scholar
  120. 120.
    Costigan M, Woolf CJ. Pain: molecular mechanisms. J Pain. 2000;1(3 Suppl):35–44.PubMedGoogle Scholar
  121. 121.
    Buonocore M, et al. Effect of botulinum toxin on disabling neuropathic pain: a case presentation suggesting a new therapeutic strategy. PM R. 2017;9(2):200–3.PubMedGoogle Scholar
  122. 122.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA. 2016;315(15):1624–45.PubMedGoogle Scholar
  123. 123.
    WHO. Traitement de la douleur cancéreuse. 1987.Google Scholar
  124. 124.
    Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician. 2010;56(6):514–7. e202–5.PubMedPubMedCentralGoogle Scholar
  125. 125.
    Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-specialist Settings. London; 2013.Google Scholar

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© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Colorado, Anschutz Medical CampusAuroraUSA
  2. 2.Department of NeurologyMemorial Sloan Kettering Cancer CenterNew YorkUSA

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