O ROPHIC LATERAL SCLER OSIS SOCIETY OF CAN OPHIC LATERAL SCLER OSIS SOCIETY OF CAN SOCIÉTÉ CANADIENNE DE LA SCLÉR SOCIÉTÉ CAN OSE LATÉRALE AMY ADIENNE DE LA SCLÉR OSE LATÉRALE AMY T O ROPHIQUE 3000 Steeles Av 3000 Steeles A en ue East, Suite 200, Mar kham, Ontario L3R 4T9 Tel. 905-248-2052 el. 905-248-2052 F • ax: 905-248-2019 ax: 905-248-2019 T • oll Free:1 800 267-4257 oll Free:1 800 267-4257 www PAIN MANAGEMENT | Fact Sheet
Pain is one of the least acknowledged symptoms of
Pain management depends on identifying (as closely as
people living with ALS. More than 60 per cent of people
possible) the source of pain so that treatments will be
living with ALS will admit to experiencing significant pain,
effective. Non-pharmacological treatments include prop-
varying in terms of intensity and etiology.
erly fitted wheelchairs, reasonable exercise such as tai chior cycling, acupuncture and use of massage. These treat-
• Neuropathic pain: arising as a direct consequence of a
ments help patients maintain their quality of life, increas-
lesion or disease affecting the somatosensory system,
resulting in tingling, burning, numbness or shooting pains.
There are a variety of different medications used to treat
• Nociceptive pain: deep-seated pain, localized to a point
pain, including antidepressants, anticonvulsants and anti-
of injury, resulting in aching, throbbing or stiffness.
epileptics, serotonin/noradrenaline reuptake inhibitorsand opioids among others. It is important to understand
Types of pain for people living with ALS vary, and
both the positive and adverse effects of medications, as
treatments need to be tailored to the underlying source of
well as the other factors that may influence someone to
• A common source of pain originates from the loss of
subcutaneous tissue (both fat and muscle), which is the
deepest layer of skin that insulates the body and
• Although originally developed for depression, they have
protects organs and bones. This can cause significant
been known to manage neuropathic pain for many years.
pain in the bone or due to pinched nerves from
Drugs such as Amitriptyline are used in low doses to
combat hyper-salivation, a common side effect for
• Immobility commonly results in deep aching pains,
people living with ALS, as well as to treat frozen
• Spasticity in people living with ALS can cause
• Antidepressants may have adverse side effects such as
clenched-muscle and straight-muscle spasms, creating
constipation and causing confusion or encephalopathy.
• Fasciculations, or muscle twitches, common in ALS, are
usually painful as well as distressing to patients.
• Drugs such as gabapentin (Neurontin) and Pregabalin
• Joint pain by stiffness and scarring is created by
(Lyrica) work to manage the pain from immobility and
capsulitis, commonly referred to as frozen shoulder
syndrome. This throbbing pain can affect sleep and
• These drugs help with anxiety in some people, though
limit mobility and activity in patients. It should be
adverse effects include sleepiness, weight gain and in
treated early and aggressively with range of motion
rare cases papilledema and blurred vision, so it’s best to
exercises before enlisting in medications such as steroid
• Other types of pain may be secondary to the illness or
related to medications needed to battle ALS. ALS. Three letters that change people’s lives. FOREVER. AMYOTROPHIC LATERAL SCLEROSIS SOCIETY OF CANADA SOCIÉTÉ CANADIENNE DE LA SCLÉROSE LATÉRALE AMYOTROPHIQUE 3000 Steeles Avenue East, Suite 200, Markham, Ontario L3R 4T9 Tel. 905-248-2052 • Fax: 905-248-2019 • Toll Free:1 800 267-4257 • www.als.ca | Fact Sheet
Serotonin/Noradrenaline reuptake inhibitors:
• Cannabinoids, or marijuana-based drugs, include Sativex,
• These are a class of antidepressants, including the drugs
a drug which mimics the plant, encompassing THC and
Venlafaxine, also known as Effexor, and Duloxetine,
This drug is effective, but currently under conditional
• Effexor is good at controlling the highs and lows that
approval in Canada for the treatment of multiple
people living with ALS experience from changes in their
sclerosis, not ALS. People living with ALS can use
actual marijuana to treat a lack of appetite or nausea, as
• Cymbalta is good at controlling depression and
well as both neuropathic and nociceptive pain. There
are many different methods of using this type of
• These drugs are processed in the liver, which is a careful
treatment which can be chosen based on the patient’s
consideration when prescribing. They can also affect
intimacy and sexual function, which makes many
• The largest side effect of cannabinoids is the cognitive
effect, which can make it more difficult for regular day-to-day functioning.
Opioids:• These are widely used in palliative care because they are
Pain in ALS is frequent, but is one of the most
useful for deep, bony pain which occurs when patients
under-recognized symptoms. Patients do not often
have unusual pressure points or frozen shoulder
volunteer information about their pain if they are not
asked about it specifically, but it is necessary to treat their
• They are great for controlling pain but have many
pain, as it interferes with the patients’ health, affecting
adverse effects, including nausea, vomiting, dizziness
their sleep, appetite and overall quality of life.
• A Fentanyl transdermal patch, while strong, can be used
This fact sheet is reporting on current research and is meant for
by bulbar patients and can help them avoid constipation. informational purposes only. ALS Canada does not assume
• A new Buprenorphine patch, called BuTrans, is a mild
responsibility for the information contained within, nor does it
opioid and a once a week patch, which has less side
endorse any specific medication. Please seek the advice of a
effects and may be very effective for bone pain.
health-care professional for more information.
• Morphine is another form of opioid, which can be used
to treat pain, as well as the feeling of not getting
Information provided by: Angela Genge, MD, director, Clinical Research Unit at
enough air. Methadone may be used if Morphine is
Montreal Neurological Institute and assistant professor, Department ofNeurology, McGill University.
Other medications:• Tramadol works well for neuropathic and nociceptive
pain, as well as mixed pain and can be taken by patients that are still mobile and only need it once in a while.
• A new lidocaine patch coming out soon will be useful
in focal pain such as shoulder pain. ALS. Three letters that change people’s lives. FOREVER.
Sample Preparation for the Detection of Synthetic Analogues of Insulin in Human Serum Australian Sports Drug Testing Laboratory National Measurement Institute, Pymble NSW, Australia Introduction The detection of the abuse of synthetic insulins by doping laboratories is likely to become a routine requirement. The World Anti-Doping Authority (WADA) code normally requires the use of
Gyeonggi Suwon International School Entrance Health Form School APID#______________ Student’s Name; Date of Birth Entering Grade Permission for giving medication for minor complaints Acetaminophen (Tylenol) (for minor aches, menstrual cramps or headache etc…) Pepto Bismol ( for nausea, diarrhea, stomachache or heartburn etc…) I give permission for my child to be giv