<=
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Pain Control
Professor June L. Dahl
The University of Wisconsin School of
Medicine and Public Health
jldahl@wisc.edu
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Pain Control
Pain is an unpleasant sensory
and emotional experience
arising from actual or potential
tissue damage or described in
terms of such damage
IASP,
1979
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Pain Control
•<=
/font> Acute
–<=
/font> Pin
prick, strains, sprains, fractures, strep
throat,
postoperative pain, headache
•<=
/font> Chronic
–<=
/font> Recurrent
acute – migraines, sickle cell pain
–<=
/font> Cancer
–<=
/font> Non-cancer
pain – rheumatoid and
osteoarthritis,
peripheral neuropathies, low
back
pain, phantom limb pain
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Pain Control
•<=
/font> Nociceptive
–<=
/font> Dull,
aching, well localized OR referred to
distant
sites
•<=
/font> Neuropathic
–<=
/font> Sharp,
shooting, stabbling, burning,
numbness
or tingling
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Pain Control
Pain is often inadequately
treated
•<=
/font> Acute
pain
•<=
/font> Cancer
pain
•<=
/font> Chronic
non-cancer
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Pain Control
Impediments to effective
pain
control
•<=
/font> Deficits
in knowledge
•<=
/font> Inappropriate
attitudes
•<=
/font> Problems
in the health care and
regulatory
systems
•<=
/font> Lack
of access, inadequate
reimbursement
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Pain Control
•<=
/font> Pharmacologic
therapies
•<=
/font> Behavior
methods
•<=
/font> Physical
methods
•<=
/font> Expert
treatment of psychological
problems
•<=
/font> Interventional
techniques
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Pain Control
•<=
/font> Non-opioids
(non-narcotics)
–<=
/font> Aspirin,
ibuprofen, celecoxib
–<=
/font> Acetaminophen
•<=
/font> Opioids
–<=
/font> Morphine
is the “prototype”
•<=
/font> Drugs
for special pain problems
–<=
/font> Antidepressants,
anticonvulsants, local
anesthetics
for neuropathic pain
–<=
/font> Steroids
and others
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Pain Control
•<=
/font> Analgesic,
antiinflammatory and
antipyretic
•<=
/font> Two
classes
–<=
/font> Older
non-selective drugs
•<=
/font> Many
adverse effects, especially on stomach
–<=
/font> COX-2
inhibitors –Celebrex
•<=
/font> Less
effect on the stomach unless take in
combination
with low-dose aspirin
•<=
/font> Recent
concerns about increased risk of heart attack
and
stroke
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Pain Control
•<=
/font> Analgesic,
antipyretic
•<=
/font> Doesn’t
affect the stomach, kidneys,
platelets
as do NSAIDs
•<=
/font> Toxic
to the liver at high dose
•<=
/font> Don’t
take more than 4 g in 24 hours
•<=
/font> Often
found in combination drugs
with
opioids
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Pain Control
•<=
/font> Most
are excellent pain relievers
•<=
/font> Don’t
damage organs even with long
term
use
•<=
/font> Many
possible side effects
–<=
/font> Constipation,
sedation, dizziness, itching,
respiratory
depression in overdose
•<=
/font> Lots
of myths about these drugs
–<=
/font> Tolerance
and addiction
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Pain Control
•<=
/font> Codeine
•<=
/font> Hydrocodone
because of
acetaminophen
•<=
/font> Propoxyphene
(Darvocet)
•<=
/font> Meperidine
(Demerol)
•<=
/font> Mixed
agonist-antagonist drugs
–<=
/font> Talwin,
Nubain, Stadol
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Pain Control
•<=
/font> First-line
treatments have been
identified
•<=
/font> Current
practice: trial and error <=
/font>
•<=
/font> There
may be advantages to
combining
two first-line drugs
•<=
/font> May
take “awhile” to get a response
•<=
/font> Relief
may only be partial
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Pain Control
First-Line Drugs for
Neuropathic
Pain
Not
in order of preference
•<=
/font> Systemic
analgesics
–<=
/font> Opioids
and tramadol
•<=
/font> Topical
analgesics – 5% lidocaine patch
•<=
/font> Antidepressants
–<=
/font> Tricyclics
–<=
/font> Venlafaxine
(Effexor) and duloxetine (Cymbalta)
•<=
/font> Certain
anticonvulsants
–<=
/font> Gabapentin
(Neurontin) and pregabalin (Lyrica)
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Pain Control
•<=
/font> Steroids-many
routes of administration
•<=
/font> Muscle
Relaxants
–<=
/font> Limited
usefulness
•<=
/font> Topical
Agents
–<=
/font> Menthol
based: Tiger Balm, Deep Heat
–<=
/font> Capsaicin
- from chili peppers – don’t get in
your
eyes
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Pain Control
•<=
/font> A
thorough understanding of your pain is
essential
to any decision about treatment
•<=
/font> The
severity and type of pain will guide
the
choice of treatment
•<=
/font> The
doses of a medication and the interval
between
doses is based on the properties
of
the medication
•<=
/font> You
may need to have more than one type
of
pain medicine
•<=
/font> Some
medicines take time to work so you
may
need to have considerable patience
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Pain Control
•<=
/font> If
you are in pain more than half of
the
time, you need to be taking your
medicine
regularly
•<=
/font> Addition
of non-drug therapies may
result
in better pain relief and fewer
side
effects
•<=
/font> Purpose
of treatment is to relieve
pain
and improve function.
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Pain Control
Pain Management
Professor June L. Dahl
The University of Wisconsin Sch=
ool of
Medicine
and Public Health
jldahl@wisc.edu
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Pain Control
Pain is an unpleasant sensory and emotional experience <=
/span>=
arising
from actual or potential tissue damage or described in terms
of such damage IASP, 1979
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Pain Control
Types of Pain
• =
– Pin prick, strains, sprains,
fractures, strep throat, postoperative pain, headache
=
• =
– Recurrent acute – migraines,
sickle cell pain
– Cancer
– Non-cancer pain – rheumatoid=
and
osteoarthritis, peripheral neuropathies, low back
pain, phantom limb pain
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Pain Control
Types of Pain
•
–Dull,
aching, well localized OR referred to distant sites
=
•
– Sharp,
shooting, stabbling, burning, numbness or tingling
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Pain Control
Pain is often inadequately =
treated
•
•
•
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Pain Control
Impediments to effective
pain control
• knowledge
•
• regulatory systems
• reimbursement
•
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Pain Control
Pain Management
•
•
•
• problems
•
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Pain Control
Drugs for Pain
• Non-opioids (non-narcotics)
– Aspirin,
ibuprofen, celecoxib
– Acetami=
nophen
• Opioids
– Morphin=
e is
the “prototype”
• Drugs for special pain problems
– Antidepressants, anticonvulsants, local anesthetics for neuropathic pain
– Steroid=
s and
others
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Pain Control
NSAIDs
• Analgesic,
antiinflammatory and antipyr=
etic
• Two classes
=
– =
Older non-selective drugs
• Many adverse eff=
ects,
especially on stomach
– =
COX-2 inhibitors –Celebrex
• Less effect on t=
he
stomach unless take in combination
with low-dose aspirin
• Recent concerns =
about
increased risk of heart attack and
stroke
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Pain Control
Acetaminophen
•
• platelets as do NSAIDs
•
•
• with
opioids
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Pain Control
Opioids
• =
• term use
• =
– Constipation, sedation,
dizziness, itching, respiratory depression in overdose&#=
13;
• =
– Tolerance and addiction
=
;
–
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Pain Control
Opioids with Limitations
•
• acetaminophen
•
•
•
–=
Talwin,
Nubain, Stadol
•
•
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Pain Control
Neuropathic Pain
• identified
<=
span
style=3D'font-weight:normal'>• Current
practice: trial and error
• combining two first-line drugs
<=
/span>
<=
span
style=3D'font-weight:normal'>• May
take “awhile” to get a response
•
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Pain Control
First-Line Drugs for Neuropathic
Pain
• Not in order of
preference
• Systemic analges=
ics
– =
Opioids and tramadol
• Topical analgesi=
cs –
5% lidocaine patch
• Antidepressants&=
#13;
– =
Tricyclics
– =
Venlafaxine (Effexor) and duloxetine (Cymbalta)=
3;
• Certain
anticonvulsants
– =
Gabapentin (Neurontin) and pregabalin (Lyrica)
=
;
•
–
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Pain Control
Many Other Agents
•
•
–=
Limited
usefulness
•
–=
Menthol
based: Tiger Balm, Deep Heat
– Capsaicin
- from chili peppers – don’t get in your eyes
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Pain Control
Use of Pain Medicines
• A thorough
understanding of your pain is essential
to any decision about treatment
• The severity and =
type
of pain will guide the cho=
ice of
treatment
• The doses of a
medication and the interval between
doses is based on the properties of
the medication
• You may need to =
have
more than one type of pain
medicine
• Some medicines t=
ake
time to work so you may ne=
ed to
have considerable patience
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Pain Control
Use of Pain Medicines
• the time, you need to be
taking your medicine regularly
• result in better pain relief and fe=
wer side
effects
• pain and improve function.
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<=
/div>
<=
/div>
<=
/div>
<=
/div>
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
<=
/div>
<=
/div>
<=
/div>
<=
/div>
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------=_NextPart_01C698B4.35CC8950
Content-Location: file:///C:/6718E6F2/Dahl2006v2_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="windows-1252"
function LoadSld()
{
var sld=3DGetObj("SlideObj")
if( !g_supportsPPTHTML ) { =09
sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
=09
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
document.all("NSPlay").autoStart =3D false;
if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
1000 );
else
document.body.start();
}
}
function MakeSldVis()=20
{
var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )=09
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()=09
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()=20
{
if( !IsNts() ) return false=20
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {=20
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
{
if(SldHasTrans())
SlideObj.onfilterchange=3DAutoAdv
else
AutoAdv()
}
function AutoAdv()
{
if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
if( (sld.mAdvDelay>0) && !parent.IsFramesMode() )
setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
}
function GetObj(id)
{
if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
}
function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId()=20
{
var regExp =3D /file:\/\/\//i
var pos =3D location.href.search(regExp)
if (MHTMLPrefix !=3D "" && pos !=3D -1)
sId =3D location.href.substring(pos)
else
{
sId =3D RemoveFilePrefixFromHref(location.href);
var regExp =3D /\//
var fixedHref =3D sId
var pos =3D -1
=09
pos =3D fixedHref.search(regExp)
while (pos !=3D -1)
{
fixedHref =3D fixedHref.replace(regExp, "\\")
pos =3D fixedHref.search(regExp)
}
=09
if (g_fBaseHyperlink =3D=3D true)
sId =3D "file:///" + fixedHref;
else
sId =3D fixedHref.substring(fixedHref.lastIndexOf('\\') + 1)
}
=09
return sId
}
function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl=
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function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
&& navigator.appVersion.indexOf("Windows")>0 ) }
function SupportsPPTHTML()
{
var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
if( msie >=3D 0 )
ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) )
else
ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}
function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) ||
(event && (event.keyCode=3D=3D32) ) )
parent.GoToNextSld();
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D17, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var g_fBaseHyperlink =3D false;
var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(=
"slide0111.htm",1,-1,1),new hrefList("slide0121.htm",1,-1,1),new hrefList("=
slide0122.htm",1,-1,1),new hrefList("slide0123.htm",1,-1,1),new hrefList("s=
lide0124.htm",1,-1,1),new hrefList("slide0125.htm",1,-1,1),new hrefList("sl=
ide0126.htm",1,-1,1),new hrefList("slide0127.htm",1,-1,1),new hrefList("sli=
de0128.htm",1,-1,1),new hrefList("slide0129.htm",1,-1,1),new hrefList("slid=
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0131.htm",1,-1,1),new hrefList("slide0133.htm",1,-1,1),new hrefList("slide0=
134.htm",1,-1,1),new hrefList("slide0135.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function RemoveFilePrefixFromHref(href)
{
var regExp =3D /^file:\/\/\//i;
return href.replace(regExp, "")
}
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if (MHTMLPrefix !=3D "")
href =3D RemoveFilePrefixFromHref(href)
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
=09
if (MHTMLPrefix !=3D "")
PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(obj.mSldHref=
))
else
PPTSld.location.replace(obj.mSldHref)
=09
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
if (MHTMLPrefix !=3D "")
PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(href))
else
PPTSld.location.replace(href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln('' + ENDSHOW_MESG + '
0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
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Pain Control
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No=
tes
1
Professor June L. Dahl
The University of Wisconsin School of Medicine and Public Health
jldahl@wisc.edu
2
3
Acute
Pin prick, strains, sprains, fractures, strep throat, postoperative
pain, headache
Chronic
Recurrent acute – migraines, sickle cell pain
Cancer
Non-cancer pain – rheumatoid and osteoarthritis, peripheral
neuropathies, low back pain, phantom limb pain
4
Nociceptive
Dull, aching, well localized OR referred to distant sites
Neuropathic
Sharp, shooting, stabbling, burning, numbness or tingling
5
Acute pain
Cancer pain
Chronic non-cancer
6
Deficits in knowledge
Inappropriate attitudes
Problems in the health care and regulatory systems
Lack of access, inadequate reimbursement
7
Pharmacologic therapies
Behavior methods
Physical methods
Expert treatment of psychological problems
Interventional techniques
8
Non-opioids (non-narcotics)
Aspirin, ibuprofen, celecoxib
Acetaminophen
Opioids
Morphine is the “prototype”
Drugs for special pain problems
Antidepressants, anticonvulsants, local anesthetics for neuropathic
pain
Steroids and others
9
Analgesic, antiinflammatory and antipyretic
Two classes
Older non-selective drugs
Many adverse effects, especially on stomach
COX-2 inhibitors –Celebrex
Less effect on the stomach unless take in combination with low-dose
aspirin
Recent concerns about increased risk of heart attack and stroke
10
Analgesic, antipyretic
Doesn’t affect the stomach, kidneys, platelets as do NSAIDs
Toxic to the liver at high dose
Don’t take more than 4 g in 24 hours
Often found in combination drugs with opioids
11
Most are excellent pain relievers
Don’t damage organs even with long term use
Many possible side effects
Constipation, sedation, dizziness, itching, respiratory depression =
in
overdose
Lots of myths about these drugs
12
Codeine
Hydrocodone because of acetaminophen
Propoxyphene (Darvocet)
Meperidine (Demerol)
Mixed agonist-antagonist drugs
13
First-line treatments have been identified
Current practice: trial and=
error
There may be advantages to combining two first-line drugs
May take “awhile” to get a response
Relief may only be partial
14
Not in order of preference
Systemic analgesics
Topical analgesics – 5% lidocaine patch
Antidepressants
Tricyclics
Venlafaxine (Effexor) and duloxetine (Cymbalta)
Certain anticonvulsants
Gabapentin (Neurontin) and pregabalin (Lyrica)
15
Steroids-many routes of administration
Muscle Relaxants
Topical Agents
Menthol based: Tiger Balm, Deep Heat
Capsaicin - from chili peppers – don’t get in your eyes
16
A thorough understanding of your pain is essential to any decision a=
bout
treatment
The severity and type of pain will guide the choice of treatment
The doses of a medication and the interval between doses is based on=
the
properties of the medication
You may need to have more than one type of pain medicine
Some medicines take time to work so you may need to have considerable
patience
17
If you are in pain more than half of the time, you need to be taking
your medicine regularly
Addition of non-drug therapies may result in better pain relief and
fewer side effects
Purpose of treatment is to relieve pain and improve function.
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