Association of low-dose naltrexone and transcranial direct current stimulation in fibromyalgia: a randomized, double-blinded, parallel clinical trial

Abstract Introduction Fibromyalgia is a complex, generalized, and diffuse chronic musculoskeletal pain. Pharmacological approaches are widely used to relieve pain and increase quality of life. Low-Dose Naltrexone (LDN) was shown to increase the nociceptive threshold in patients with fibromyalgia. Transcranial Direct Current Stimulation (tDCS) is effective for pain management. Objective The purpose of this study was to evaluate the analgesic and neuromodulatory effects of a combination of LDN and tDCS in patients with fibromyalgia. Methods This was a randomized, double-blinded, parallel, placebo/sham-controlled trial (NCT04502251; RBR-7HK8N) in which 86 women with fibromyalgia were included, and written informed consent was obtained from them. The patients were allocated into four groups: LDN + tDCS (n = 21), LDN + tDCS Sham (n = 22), placebo + tDCS (n = 22), and placebo+tDCS Sham (n = 21). The LDN or placebo (p.o.) intervention lasted 26 days; in the last five sessions, tDCS was applied (sham or active, 20 min, 2 mA). The following categories were assessed: sociodemographic, Visual Analog Pain Scale (VAS), Pain Catastrophizing Scale (PCS), State-Trait Anxiety Inventory (STAI), Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI-II), Profile of Chronic Pain Scale (PCP:S), Pain Pressure Threshold (PPT), and Conditioned Pain Modulation (CPM). Blood samples were collected to analyze BDNF serum levels. Results At baseline, no significant difference was found regarding all measurements. VAS pain was significantly reduced in the LDN + tDCS (p = 0.010), LDN + tDCS Sham (p= 0.001), and placebo+tDCS Sham (p= 0.009) groups. In the PCP:S, the LDN+tDCS group showed reduced pain frequency and intensity (p= 0.001), effect of pain on activities (p= 0.014) and emotions (p= 0.008). Depressive symptoms reduced after all active interventions (p > 0.001). Conclusion Combined LDN+tDCS has possible benefits in reducing pain frequency and intensity; however, a placebo effect was observed in pain using VAS, and further studies should be performed to analyze the possible association.

Chronic non-cancer pain in adolescents: a narrative review

Abstract Introduction Chronic pain is defined as a pain lasting more than 3-6 months. It is estimated that 25% of the pediatric population may experience some kind of pain in this context. Adolescence, corresponding to a particular period of development, seems to present the ideal territory for the appearance of maladaptive mechanisms that can trigger episodes of persistent or recurrent pain. Methods A narrative review, in the PubMed/Medline database, in order to synthetize the available evidence in the approach to chronic pain in adolescents, highlighting its etiology, pathophysiology, diagnosis, and treatment. Results Pain is seen as a result from the interaction of biological, psychological, individual, social, and environmental factors. Headache, abdominal pain, and musculoskeletal pain are frequent causes of chronic pain in adolescents. Pain not only has implications on adolescents, but also on family, society, and how they interact. It has implications on daily activities, physical capacity, school performance, and sleep, and is associated with psychiatric comorbidities, such as anxiety and depression. The therapeutic approach of pain must be multimodal and multidisciplinary, involving adolescents, their families, and environment, using pharmacological and non-pharmacological strategies. Discussion and conclusion The acknowledgment, prevention, diagnosis, and treatment of chronic pain in adolescent patients seem not to be ideal. The development of evidence-based forms of treatment, and the training of health professionals at all levels of care are essential for the diagnosis, treatment, and early referral of these patients.

Administración prolongada de morfina intratecal por bomba de infusión implantada, en un caso de dolor crónico no oncológico / Prolonged administration of intratecal morphine by infusion pump implanted in a case of non-oncological chronic pain / Administração prolongada de morfina intratecal por bomba de infusão implantada, em caso de dor crônica não oncológica

Introducción: Se describe la evolución de un paciente que recibe morfina intratecal mediante una bomba de infusión, que le fuera implantada hace 14 años para tratamiento de su dolor lumbar crónico post-laminectomía. Material y método: Requería la administración de 60 mg/día de morfina subcutánea que le provocaban efectos secundarios que no toleraba, y múltiples internaciones para control del dolor. Se le implantó una bomba de infusión continua (Isomed) conectada a un catéter subaracnoideo, que libera 1 ml/día, y requiere ser llenada cada 60 días. Resultados: Se observó una disminución del dolor promedio de 50% al año, y de 75% a los 6 y 14 años. Requirió un aumento progresivo de las dosis de llenado, que pasaron de 30 mg de morfina (0.5 mg/día) al inicio, a 40 mg de morfina (0.66 mg /día) al año, a 70 mg de morfina (1.16 mg/día) a los 6 años, a 140 mg (2.33 mg/día) a los 14 años. No se registraron complicaciones médicas graves. Mantuvo constipación y sudoración durante todo el período, e instaló un hipogonadismo secundario con trastornos de la libido y de la erección que fueron corregidos con la administración de testosterona. No requirió más internaciones por dolor. No se observaron complicaciones relacionadas con el funcionamiento o llenado de la bomba, ni vinculadas al catéter. El paciente manifestó estar satisfecho con el implante. Discusión: A pesar del aumento de las dosis de llenado, expresión del desarrollo de tolerancia, las dosis de morfina/día requeridas son francamente inferiores al límite recomendado. Conclusiones: El balance del riesgo-beneficio del implante resultó positivo, considerando el mejor control del dolor logrado, las menores dosis de morfina utilizadas, así como la ausencia de complicaciones graves y de internaciones para control del dolor.

Introduction: The evolution of a patient receiving intrathecal morphine through an infusion pump that was implanted 14 years ago for the treatment of chronic post-laminectomy low back pain is described. Material and method: It required the administration of 60 mg / day of subcutaneous morphine that caused side effects that did not tolerate, and multiple hospitalizations for pain control. He was implanted with a continuous infusion pump (Isomed) connected to a subarachnoid catheter, which releases 1 ml / day, and needs to be filled every 60 days. Results: An average pain decrease of 50% per year, and 75% at 6 and 12 years was observed. It required a progressive increase in filling doses, which went from 30 mg of morphine (0.5 mg / day) at the beginning, to 40 mg of morphine (0.66 mg / day at the first year, to 70 mg of morphine (1.16 mg / day) at the sixth year, at 140 mg (2.33 mg / day) at the fourteen year. No serious medical complications were recorded, he maintained constipation and sweating throughout the period, and installed secondary hypogonadism with libido and erection disorders, that were corrected with the administration of testosterone. No further hospitalizations were required due to pain. No complications were observed related to the operation or filling of the pump or linked to the catheter. The patient stated that he was satisfied with the implant. Discussion: Despite the increase in filling doses, expression of tolerance development, the required morphine / day doses are frankly below the recommended limit. Conclusions: The risk-benefit balance of the implant was positive, considering the best pain control, the lowest doses used, the absence of serious complications, and the lack of hospitalizations for pain control.

Introdução: Descreve-se a evolução de um paciente que recebeu morfina intratecal através de uma bomba de infusão, implantada há 14 anos para o tratamento de lombalgia crônica pós-laminectomia. Material e método: Necessitou de administração de 60 mg/dia de morfina por via subcutânea, que provocou efeitos colaterais intolerantes, e múltiplas internações para controle da dor. Foi implantada uma bomba de infusão contínua (Isomed) conectada a um cateter subaracnóideo, que libera 1 ml/dia, necessitando de reenchimento a cada 60 dias. Resultados: Observou-se redução média da dor de 50% em um ano e 75% em 6 e 14 anos. Foi necessário um aumento progressivo das doses de enchimento, que passaram de 30 mg de morfina (0,5 mg/dia) no início, para 40 mg de morfina (0,66 mg/dia) por ano, para 70 mg de morfina (1,16 mg/dia) dia) aos 6 anos, para 140 mg (2,33 mg/dia) aos 14 anos. Não foram registradas complicações médicas graves. Manteve constipação e sudorese durante todo o período e desenvolveu hipogonadismo secundário com distúrbios de libido e ereção que foram corrigidos com administração de testosterona. Ele não necessitou de mais hospitalizações por dor. Não foram observadas complicações relacionadas à operação ou enchimento da bomba, ou relacionadas ao cateter. O paciente afirmou estar satisfeito com o implante. Discussão: Apesar do aumento das doses de enchimento, expressão do desenvolvimento da tolerância, as doses necessárias de morfina/dia são francamente inferiores ao limite recomendado. Conclusões: A relação risco-benefício do implante foi positiva, considerando o melhor controle da dor alcançado, as menores doses de morfina utilizadas, bem como a ausência de complicações graves e internações para controle da dor.

ANA- 12 inhibits spinal inflammation and alleviates acute and chronic pain in rats by targeted blocking of BDNF/TrkB signaling / 南方医科大学学报

OBJECTIVE@#To investigate the inhibitory effect of ANA-12 that blocks brain-derived neurotrophic factor (BDNF)/ tropomyosin receptor kinase B (TrkB) signaling on inflammatory pain in rats and explore the underlying mechanism.@*METHODS@#Forty-two adult SD rats were randomized into BDNF-induced acute pain group (n=24) and CFA-induced chronic pain group. The former group were randomly divided into 4 subgroups, including a control group, ANA-12 treatment group, BDNF treatment group, and BDNF+ANA-12 treatment group; the latter group were subgrouped into control group, CFA treatment group (CFA) and CFA + ANA-12 treatment group. The effects of ANA-12 treatment on pain behaviors of the rats with BDNF-induced acute pain and CFA-induced chronic inflammatory pain were observed. Western blotting was used to examine TrkB signaling and expressions of microglia marker protein Iba1 and TNF-α in the spinal cord of the rats.@*RESULTS@#BDNF injection into the subarachnoid space significantly increased the number of spontaneous paw withdrawal of the rats (P < 0.05), which was obviously reduced by ANA-12 treatment (P < 0.05). The rats with intraplantar injection of CFA, showed significantly increased ipsilateral mechanical stimulation sensitivity (P < 0.05), and ANA-12 treatment obviously increased the ipsilateral foot withdrawal threshold (P < 0.05). Treatment with either BDNF or CFA significantly increased the phosphorylation level of TrkB (Y705) in the spinal cord of the rats (P < 0.05), which was significantly lowered by ANA-12 treatment (P < 0.05). Treatment with BDNF and CFA both significantly up-regulated the expressions of Iba1 and TNF-α in the spinal cord (P < 0.05), but ANA-12 significantly reduced their expression levels (P < 0.05).@*CONCLUSION@#ANA-12 can reduce spinal cord inflammation and relieve acute and chronic pain in rats by targeted blocking of BDNF/TrkB signaling.

Perfil epidemiológico de pacientes atendidos en policlínico de dolor crónico no oncológico (DCNO), Hospital Hernán Henríquez Aravena (HHHA). Servicio de Salud Araucanía Sur, Región de la Araucanía / Epidemiological profile of patients served in chronic non-oncological pain polyclinic (DCNO), Hernán Henríquez Aravena Hospital (HHHA). Health Service Araucanía Sur, Region of la Araucanía

Introducción: El dolor crónico no oncológico (DCNO) es un tema de salud pública con alta prevalencia en Chile. Existe evidencia sobre la necesidad de abordaje multidisciplinario por profesionales capacitados. El año 2013 se crea el policlínico de DCNO por la especialidad de fisiatría, coordinando atención con anestesista para intervencionismo. El Objetivo de este trabajo es conocer las características clínicas de los usuarios en control en policlínico de DCNO. Material y Método: Estudio retrospectivo, descriptivo, observacional. Desde la base de datos de usuarios atendidos entre inicios del 2013 y mayo 2018 de policlínico DCNO del Servicio de Medicina Física y Rehabilitación del HHHA; se recogen variables como: sexo, edad, etnia, previsión, ruralidad, diagnóstico ingreso, intensidad dolor (según NRS), tratamiento farmacológico, entre otras. Para manejo estadístico se utiliza planilla Excel, con pruebas paramétricas (promedio, mínimo, máximo), tablas y gráficos. Resultados: Los usuarios en control en el periodo fueron 125, con un 67,2% de mujeres y una mediana de edad de 55,5 años (mínimo 12, máximo 88). El 58,4% tenía como previsión Fonasa B, 83.2% presenta domicilio urbano, 16% etnia mapuche. El mayor número de ingresos ocurrió el año 2017. Las derivaciones provienen de especialidades médicas (25,6%), quirúrgicas (29,6%), fisiatría (24,8%). Según tipo de dolor, el 49,6% es nociceptivo, 32% neuropático y 18,4% mixto. Al ingreso, la intensidad fue 90% severa y 10% moderada (según NRS). Los principales diagnósticos de ingreso fueron 44,8% patología de columna, 27,2% patología neurológica, 12,8% fibromialgia y 15,2% otras. Al ingreso mayoría de los usuarios usaba paracetamol, tramadol gotas o comprimidos; actualmente 23% recibe metadona, 8% parches buprenorfina, 20% paracetamol, 27,2% tramadol en gotas/comprimidos y 23,2% pregabalina/ gabapentina. En el 51,2% se requirió cambio de terapia; en el 79,7% por analgesia insuficiente y 20,3% por reacción adversa a medicamentos. Se realizó derivación a intervencionismo en 21 usuarios. 15 usuarios fueron dados de alta de policlínico DCNO (12%). Conclusiones: Estos datos servirán para futuras investigaciones y medir impacto de nuestras intervenciones. Se presenta como desafío aumentar recursos de la unidad, demostrar beneficio de atención interdisciplinaria y bajar costos para la institución.

Introduction: Non-oncological chronic pain (NOCP) is a public health issue with high prevalence in Chile. There is evidence of the need for a multidisciplinary approach by trained professionals. In 2013, the NOCP polyclinic was created for the specialty of physiatry, coordinating care with anesthesiologist for interventionism. The objective of this work is to know the clinical characteristics of users in control in NOCP polyclinic. Material and Methods: Retrospective, descriptive, observational study. From the database of users attended between the beginning of 2013 and May 2018, from the NOCP polyclinic of the Physical Medicine and Rehabilitation Service of the HHHA; variables such as: sex, age, ethnicity, foresight, rurality, income diagnosis, pain intensity (according to NRS), and pharmacological treatment, among others are collected. For statistical management Excel spreadsheet isused, with parametric tests (average, minimum, maximum), tables and graphs. Results: The users in control in the period were 125, with 67.2% of women, a median age of 55.5 years (minimum 12, maximum 88). 58.4% had Fonasa B as a forecast, 83.2% have an urban address, 16% Mapuche ethnicity. The highest number of admissions occurred in 2017. The referrals come from medical specialties (25.6%), surgical specialties (29.6%), and physiatry (24.8%). According to type of pain, 49.6% is nociceptive, 32% neuropathic and 18.4% mixed. At admission, the intensity was 90% severe and 10% moderate (according to NRS). The main diagnoses of admission were 44.8% spinal pathology, 27.2% neurological pathology, 12.8% fibromyalgia and 15.2% others. On admission, most users used paracetamol, tramadol drops or tablets; currently 23% receive methadone, 8% patches buprenorphine, 20% paracetamol, 27.2% tramadol in drops / tablets and 23.2% pregabalin / gabapentin. In 51.2%, therapy change was required; in 79.7% due to insufficient analgesia and 20.3% due to adverse drug reaction. A derivation to interventionism was carried out in 21 users. 15 users were discharged from polyclinic DCNO (12%). Conclusions: These data will serve for future research and measure the impact of our interventions. It is a challenge to increase the resources of the unit, demonstrate the benefit of interdisciplinary attention and lower costs for the institution.

Effect and Safety of Kangfuyan Capsules () for Relieving Chronic Pelvic Pain: A Multicenter, Randomized, Controlled, Double-Blind, Parallel-Group Clinical Trial / 中国结合医学杂志

OBJECTIVE@#To evaluate the effect and safety of Kangfuyan Capsules () for treating pelvic inflammatory disease (PID) in patients with chronic pelvic pain (CPP) in a multicenter, randomized, controlled, double-blind, parallel-group clinical trial.@*METHODS@#Totally, 240 PID patients with CPP were randomized into 2 groups using a computer generated random number at a 1:1 ratio from 10 hospitals in China between September 2014 and November 2015. Patients received either oral Kangfuyan Capsules or Gongyanping Capsules (, control); the regimen for both groups comprised 4 capsules (3 times daily) for 12 weeks, with follow-up visit 4 weeks after treatment. The visual analogue scale (VAS) scores, clinical responses, remarkable cure rates for each symptom, and quality of life scores were assessed at baseline, and after 1, 2, and 3 months. Adverse events were also recorded.@*RESULTS@#The VAS scores were significantly lower (P<0.05), whereas the clinical responses, remarkable cure rates for lower abdominal pain, uterine tenderness, adnexal mass, and adnexal tenderness, and Health-related quality of life (EQ-5D) scores were higher in the Kangfuyan group than in the control group at 3 months (P<0.05). Common treatment-related adverse events included high hepatic enzyme levels, reduced hemoglobin levels, and elevated platelet counts, although all the adverse events were either mild or moderate in severity.@*CONCLUSION@#Compared with Gongyanping therapy, Kangfuyan therapy yielded markedly better analgesia effects for CPP caused by PID, with obvious long-term efficacy and good safety. (Registration No. ChiCTR190022732).

Consideraciones en pacientes con dolor crónico sometidos a cirugía / Considerations in chronic pain patients that will undergo surgery

Resumen El dolor crónico es una condición cada vez más prevalente, que afecta aproximadamente a un 32% de la población nacional. Estos pacientes poseen características particulares que complejizan un óptimo cuidado perioperatorio, sobre todo en términos de analgesia, efectos adversos de los distintos fármacos y complicaciones postquirúrgicas. El objetivo de esta revisión es exponer el creciente problema que involucra el manejo de los pacientes con dolor crónico no oncológico sometidos a una cirugía, y destacar algunas consideraciones que se deben tener en su cuidado. Dentro de los aspectos más relevantes están una adecuada caracterización del dolor y un buen esquema analgésico a ser utilizado en el perioperatorio, prefiriendo un enfoque multimodal ajustado acorde a las necesidades del paciente. Se debe tener especial consideración en pacientes usuarios crónicos de opioides, aquellos con dolor neuropático y aquellos con fibromialgia. Un adecuado seguimiento de estos grupos permitirá ajustar los esquemas de acuerdo con sus necesidades y lograr un mejor manejo analgésico perioperatorio.

Chronic pain is an increasingly prevalent condition, estimated in approximately 32% of the Chilean population. These patients have characteristics that make optimal perioperative care more complex, especially in terms of analgesia, adverse effects of the different drugs, and post-surgical complications. The aim of this publication is to expose the growing problem involved in the management of patients with chronic pain undergoing surgery, and to highlight some considerations that must be taken. Among the most relevant aspects are an adequate characterization of pain and a good analgesic scheme to be used in the perioperative period, preferring a multimodal analgesia approach adjusted according to the patient's needs. Special consideration should be given to patients with chronic opioids use, those with neuropathic pain and those with fibromyalgia. An adequate follow-up of these groups will allow adjusting the schemes according to their needs and achieve a better perioperative analgesic management.

Experiencia en la práctica clínica real de la efectividad y la tolerabi- lidad de tapentadol de liberación prolongada para el tratamiento de dolor crónico postraumático producido por accidentes de trabajo / Real-world clinical practice experience of the effectiveness and tolerability of pro- longed-release tapentadol for the treatment of chronic post-traumatic pain caused by occupational accidents

Se llevó a cabo un estudio observacional para analizar si tapentadol de liberación prolongada (LP) puede considerarse un tratamiento de primera línea para pacientes con dolor crónico postraumático (DCPT). Métodos: Se presenta una serie de casos de la práctica clínica real de pacientes con DCPT producido por accidentes de trabajo. Antes de ingresar al estudio, todos los pacientes recibían tramadol, que se interrumpió cuando se inició la administración de tapentadol LP. Las evaluaciones de dolor incluyeron una escala de valoración numérica, el cuestionario DN4 y la escala de Impresión Global de Cambio del Paciente (PGIC, Patients' Global Impression of Change). Se recuperaron y registraron los eventos adversos. Resultados: 94 pacientes participaron en el estudio y 77 (82 %) completaron todas las visitas predefinidas. Cerca de la mitad de los pacientes informaron dolor crónico que tenía una duración de al menos 3 años; se observó un componente neuropático en el 87 % de los pacientes. El puntaje de dolor se redujo en 1,5 puntos luego del primer mes de tratamiento con tapentadol LP y en 2,48 puntos luego de 4 meses (p<0,05). También se asoció la administración de tapentadol LP con una reducción del 28,9 % de la dosis concomitante de pregabalina (p<0,01). De acuerdo con el cuestionario PGIC, el 74 % y el 77,9 % de los pacientes informó mejoría luego de uno y cuatro meses de tratamiento, respectivamente. El perfil de seguridad fue consistente con los datos actuales sobre tapentadol LP. Conclusión: El dolor osteomuscular crónico es una enfermedad prevalente que se caracteriza por tener resultados terapéuticos deficientes y se asocia a una mayor discapacidad y una mala calidad de vida. En este estudio de la práctica clínica real en pacientes que trabajan y que cuentan con un componente de dolor neuropático elevado, se observó que tapentadol LP produce efectos beneficiosos en términos del control del DCPT, y se obtuvieron índices altos de eficacia y seguridad.

An observational study was carried out to analyze whether prolonged-release (PR) tapentadol may be considered a first-line treatment for patients with chronic post-traumatic pain (PTD). Methods: A case series of cases of patients with PTFE caused by work accidents in a real clinical practice setting is described. Before entering the study, all patients were receiving tramadol, which was discontinued when PR tapentadol was started. Pain assessments included a numerical rating scale, the DN4 questionnaire, and the Patients' Global Impression of Change (PGIC) scale. Adverse events were retrieved and described. Results: 94 patients participated in the study and 77 (82%) completed all the predefined visits. About half of the patients reported chronic pain that lasted for at least 3 years. A neuropathic component was reported in 87% of patients. The pain score was reduced by 1.5 points after the first month of treatment with PR tapentadol and by 2.48 points after 4 months (p < 0.05). Administration of PR tapentadol was also associated with a concomitant reduction of pregabalin dose of 28.9% (p < 0.01). According to the PGIC questionnaire, 74% and 77.9% of patients reported improvement after one and four months of treatment, respectively. The safety profile was consistent with current data on PR tapentadol. Conclusion: Chronic musculoskeletal pain is a prevalent disease characterized by poor therapeutic results and associated with increased disability and poor quality of life. In our study in a real clinical practice setting with patients with a high neuropathic pain component, PR tapentadol produced beneficial effects in terms of DCPT control, and high efficacy and safety rates were obtained. Keywords: tapentadol, chronic pain, pain caused by work accidents, chronic post-traumatic pain, evidence from real clinical practice.

Diagnóstico de espondiloartrite axial em pacientes com fibromialgia / Axial spondyloarthritis diagnosis in fibromyalgia patients

Objetivo: Avaliar pacientes com fibromialgia e dor lombar, bus- cando características clínicas de espondiloatrites axiais. Méto- dos: Neste estudo transversal, cem pacientes com fibromialgia e idades entre 18 e 65 anos foram avaliados. A avaliação consis- tiu em um questionário baseado no braço clínico dos critérios Assessment of Spondyloarthritis International Society para diag- nóstico de espondiloatrites axiais e um questionário de impacto da fibromialgia (Revised Fibromyalgia Impact Questionnaire). Re- sultados: Quando o braço clínico da Assessment of Spondyloar- thritis International Society foi aplicado em pacientes com fibro- mialgia e dor lombar, 80% dos pacientes preencheram os critérios para diagnóstico de espondiloatrites axiais. As principais carac- terísticas de espondiloatrite axial foram dor lombar inflamatória, boa resposta a drogas anti-inflmatórias não esteroidais, artrite e entesite. Pacientes com critérios de espondiloatrites axiais posi- tivos apresentaram maiores níveis séricos de proteína C-reativa (p=0,00035). O valor médio do Revised Fibromyalgia Impact Ques- tionnaire para todos os pacientes avaliados foi 63,6, e não houve di- ferença entre os pacientes que preencheram os critérios e aqueles que não preencheram. Conclusão: Pacientes com fibromialgia e dor lombar frequentemente apresentam características clínicas de espondiloatrite axial, e aqueles que preencheram os crité- rios clínicos para espondiloatrites axiais também apresentaram maiores níveis séricos de proteína C-reativa.

Objective: To evaluate patients with fibromyalgia and back pain for clinical features of axial spondyloarthritis. Methods: In this cross-sectional study, one hundred fibromyalgia patients between 18 and 65 years old were assessed. The assessment consisted of a questionnaire based on the clinical arm ofthe Assessment of Spondyloarthritis International Society criteria for the diagnosis of axial spondyloarthritis and a questionnaire on the impact of fibromyalgia (Revised Fibromyalgia Impact Questionnaire). Re- sults: When the clinical arm of the Assessment of Spondyloarthri- tis International Society was applied in patients with fibromyal- gia and back pain, 80% of the patients met the clinical criteria for diagnosis of axial spondyloarthritis. The main features of axial spondyloarthritis in fibromyalgia patients were inflammatory back pain, good response to non-steroidal anti-inflammatory drugs (NSAIDs), arthritis, and enthesitis. Patients with positive axial spondyloarthritis criteria presented with higher C- reac- tive protein levels (p=0.00035). The mean value of the Revised Fibromyalgia Impact Questionnaire for all patients assessed was 63.6 and there was no difference between patients that met the criteria for axial spondyloarthritis and those who did not. Con- clusion: Patients with fibromyalgia and back pain often present clinical features of axial spondyloarthritis, and those who met the clinical criteria for axial spondyloarthritis also presented with higher levels of C-reactive protein.

Opioid-induced immunosuppression and carcinogenesis promotion theories create the newest trend in acute and chronic pain pharmacotherapy

Opioids are the main group of pharmacological agents used during the perioperative period and provide a sedative and analgesic component. The observations of opioid consumption in West Europe indicate that this group of drugs is widely used in chronic noncancer pain therapy. Nearly 20 years ago, the first publications indicating that opioids, as an element of perioperative pharmacotherapy in oncologic patients, increase the risk of tumor recurrence and affect further prognosis were presented. The actual publications suggest that there are multifactorial, complex mechanisms underlying the immunological impact and carcinogenesis promotion of opioids and that the intensity varies depending on the type of opioid. There are also questions about the immunosuppressive effects among patients receiving opioids in the treatment of chronic noncancer pain. The aim of the review article is to present information about the action of opioids on the immune system in carcinogenic settings and to define the clinical usefulness of this pharmacological phenomenon.

The use of analgesics and risk of self-medication in an urban population sample: cross-sectional study / Uso de analgésicos e o risco da automedicação em amostra de população urbana: estudo transversal

Abstract Background and objectives: There are few data in the literature characterizing the pattern of analgesic use in Latin American countries, including Brazil. Little is known about the undertreatment of pain and its influence on the habit of self-medication with analgesics. The aim of this study is to define the pattern of analgesic use among chronic pain patients and its potential association with self-medication with analgesics. Method: Cross-sectional observational study with an urban population sample. Chronic pain was defined as a pain lasting for at least 90 days. The study was approved by the Research Ethics Committee of the institution. Results: 416 subjects were included; 45.7 % (n = 190) had chronic pain, with females (72.3 %; p = 0.04) being the most affected. Self-medication with analgesics is practiced by 78.4% of patients with chronic pain. The most common current analgesic treatment consists of non-steroidal anti-inflammatory drugs (dipyrone and acetaminophen). Weak opioids are rarely used and only 2.6% of subjects with chronic pain were taking these analgesics. None of the subjects were taking potent opioids. Conclusions: The practice of self-medication with analgesics is frequent among patients with chronic pain, which may be due to the underprescription of more potent analgesics, such as opioids. It can also be said that, given the data presented, there is no crisis of recreational opioid use in the studied population.

Resumo Justificativa e objetivos: Há poucos dados na literatura que caracterizam o padrão de uso de analgésicos na América Latina e no Brasil. Também se sabe pouco sobre o subtratamento da dor e sua influência no hábito de automedicação analgésica. O objetivo desta pesquisa é definir o padrão de uso de analgésicos entre os portadores de dor crônica (DC) e a sua potencial associação à automedicação analgésica. Método: Estudo observacional transversal com amostra de população urbana. A dor crônica foi definida como aquela presente por pelo menos 90 dias. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa institucional. Resultados: Foram incluídos 416 indivíduos; 45,7% (n = 190) portadores de dor crônica, sendo os do sexo feminino (72,3%; p = 0,04) os mais acometidos. A automedicação analgésica é praticada por 78,4% dos portadores de dor crônica. O tratamento analgésico vigente mais frequente é composto pelos anti-inflamatórios não esteroides (AINES), dipirona e paracetamol. Os opioides fracos são pouco usados e apenas 2,6% dos indivíduos com dor crônica fazem uso desses analgésicos. Nenhum dos indivíduos estava em uso de opioides potentes. Conclusões: A prática de automedicação analgésica é frequente entre os portadores de dor crônica, o que pode ser consequência da pouca prescrição de analgésicos mais potentes, como os opioides. Pode-se também dizer que, pelos dados apresentados, não ocorre uma crise de uso recreativo de opioides na população estudada.

Calcitonin as an analgesic agent: review of mechanisms of action and clinical applications / Calcitonina como agente analgésico: revisão dos mecanismos de ação e das aplicações clínicas

Abstract Background and objectives: Calcitonin is a polypeptide hormone regulating the metabolism of calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain-ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin-mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain. Method: Many studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies. Conclusion: This study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.

Resumo Justificativa e objetivos: A calcitonina é um hormônio polipeptídico que regula o metabolismo do cálcio no organismo. Por muitos anos a calcitonina tem sido usada para manter e melhorar a densidade mineral óssea e reduzir a incidência de fraturas. Muitos estudos mostraram que a calcitonina teve efeito analgésico em várias condições físicas de dor. Esse efeito de melhoria da dor é irrelevante diante de seu efeito inibidor osteoclástico e de mecanismos, tais como a alteração do canal de Na+ e da expressão do receptor de serotonina, inclusive a hipótese do mecanismo mediado pela endorfina, que foram usados para explicar esse efeito. Neste estudo, fizemos uma revisão completa sobre o papel da calcitonina como agente analgésico em diferentes cenários e investigamos o fato de que a calcitonina pode ser uma medicação viável para aliviar a dor. Método: Muitos estudos centraram no efeito analgésico da calcitonina em várias condições de dor, inclusive dores agudas relacionadas a fraturas vertebrais, metástases, enxaqueca e distrofia simpática reflexa, bem como dores neuropáticas relacionadas a lesões medulares ou ao diabetes e dor fantasma. Além disso, a calcitonina mostrou ser um aditivo útil à anestesia local para o controle mais efecaz da dor pós-operatória ou neuralgia do trigêmeo. Porém, nos deparamos com alguns dados contraditórios em condições como estenose do canal lombar, síndrome complexa da dor regional, dor fantasma e malignidades. Conclusão: Este estudo mostrou que a calcitonina pode ser um analgésico útil em diferentes condições de dor. A calcitonina pode ser considerada um tratamento elegível para as dores agudas relacionadas a fraturas vertebrais e uma opção viável para o tratamento das dores neuropáticas agudas e crônicas em que outros medicamentos podem falhar.

Botulinum toxin type A in chronic neuropathic pain in refractory leprosy / Toxina Botulínica Tipo A em Dor Neuropática Crônica em Hanseníase

ABSTRACT Neuropathic pain is a chronic syndrome that is difficult to treat and often affects patients with leprosy. Recommended treatment includes the the use of analgesic drugs, codeine, tricyclic antidepressants, neuroleptics, anticonvulsants and thalidomide, but without consensus on uniform dose and fully satisfactory results. Objective: To analyze botulinum toxin type A (BoNT-A) effectiveness in treatment of chronic neuropathic pain in refractory leprous patients, as well as evaluate and compare the quality of life of patients before and after using the medication. Methods: We used a specific protocol including clinical, demographic, DN4 protocol, analogue scale (VAS), sensory evaluation and evaluation of the WHOQOL-BREF. Therapeutic intervention was performed with BOTOX® BTX-A 100U administered subcutaneously. Fifteen patients were evaluated on days 0, 10 and 60. Results: Patients on VAS showed pain between 5 and 10, in one case there was complete pain relief in 60 days, while others showed improvement in the first week with the return of symptoms with less intensity after this period. WHOQOL-BREF's domains Quality of Life and Physical to have a significant increase in QOL. Conclusion: BoNT-A proved to be a good therapeutic option in relieving pain with improved quality of life for these patients.

RESUMO A dor neuropática é uma síndrome crônica que é difícil de tratar e freqüentemente afeta pacientes com hanseníase. O tratamento recomendado inclui o uso de drogas analgésicas, codeína, antidepressivos tricíclicos, neurolépticos, anticonvulsivantes e talidomida, mas sem consenso sobre dose uniforme e resultados plenamente satisfatórios. Objetivo: Busca-se analisar a efetividade da toxina botulínica tipo A no tratamento da dor neuropática crônica hansênica refratária. Método: Estudo de intervenção do tipo ensaio clínico em portadores de dor neuropática crônica hansênica. Foram coletados dados epidemiológicos, protocolo DN4, escala analógica da dor (EVA), avaliação sensitiva, motora a avaliação do WHOQOL-Bref. Realizado intervenção terapêutica com toxina botulínica tipo A 100U. Os pacientes foram avaliados nos dias de 0, 10 e 60. A dor neuropática foi mais frequente no sexo masculino, na faixa etária de 40 à 49 anos. Resultados: Da forma Dimorfa, multibacilar com baciloscopia positiva e incapacidades presentes. Os escores EVA variam entre 5 e 10, todos os pacientes apresentaram alterações sensoriais. O WHOQOL-Bref apresentou melhora após o tratamento com TxBA. A TxBA foi bem tolerada o único efeito adverso notável foi dor leve. E com apenas uma única aplicação de TxBA promoveu efeitos analgésicos a longo prazo em pacientes com dor associada à alodinia, sugerindo que a analgesia observada pode ser causada por um efeito periférico da TxBA em terminações nociceptivas. Conclusão: O estudo sugere que a TxBA é uma boa opção para os casos de dor neuropática crônica hansênica, no entanto, novos estudos são necessários para confirmar estes resultados.

Évaluation de la prise en charge médicamenteuse de la douleur chronique

Introduction. Les douleurs chroniques sont fréquentes en oncologie et en rhumatologie. Elles constituent un problème de santé publique. Le traitement de la douleur comporte des thérapeutiques médicamenteuses et non médicamenteuses. L'objectif du travail était d'évaluer la prise en charge médicamenteuse des patients présentant une douleur chronique. Méthodologie. Il s'agit d'une étude longitudinale et prospective de cinq mois. Elle a été réalisée dans le service d'oncologie de l'Hôpital Général de Yaoundé et le service de rhumatologie de l'Hôpital Central de Yaoundé. Nous avons inclus tous les patients présentant un syndrome douloureux chronique et ayant donné leur consentement éclairé. Les variables étudiées étaient l'intensité de la douleur, les pathologies en cause, les protocoles antalgiques, les effets secondaires, l'observance et la satisfaction des patients. Résultats. Six cent six patients étaient recrutés avec une majorité féminine. Les pathologies les plus rencontrées en rhumatologie étaient : l'arthrose (71,2%), la hernie discale (20,1 %). En oncologie il s'agissait du cancer du sein (24,1%) et du cancer du col de l'utérus (13,8%). A la consultation initiale, l'intensité de la douleur était légère (1,5%), modérée (94,7%) et sévère (3,8%). Les antalgiques utilisés étaient dominés par le paracétamol (56,1%) et le tramadol (39,8%). Les coantalgiques utilisés étaient les antiépileptiques (43,1%) et les myorelaxants (34,5%). Au troisième rendez-vous, la douleur était légère (90,6%), l'observance au traitement était moyenne chez 426 patients (70,3%) et 97,2% des patients étaient satisfaits. Conclusion. La prise en charge de la douleur chronique est effective et adaptée. Elle fait appel aux antalgiques usuels. Les co-antalgiques occupent une place non négligeable

Dor crônica: manejo baseado nos mecanismos / Chronic pain: mechanism based management

A dor crônica (DC) é uma experiência sensorial e emocional desagradável e é definida por períodos contínuos ou persistentes de dor superior a três meses de duração. A classificação da DC, por seu mecanismo, permite um manejo mais adequado e eficiente. O presente trabalho objetiva revisar esta visão e analisar aspectos concernentes à essa questão.

Chronic pain (CP) is a multidimensional sensation with intrinsically unpleasant experiences. It is associated to uninterrupted or persistent periods of pain superior to e three months. CP is classified according to its mechanism, and this distinction is important to make the appropriate management of the condition. The goal of this assessment is to review such concept.

Acompanhamento farmacoterapêutico na dor crônica geriátrica: relato de caso / Pharmacotherapeutic follow up in the geriatric chronic pain: a case report / Seguimiento farmacoterapéutico en dolor geriátrico crónico: relatode caso

O presente trabalho relata o caso de uma paciente idosa que sofrede dor crônica, destacando-seos principais diagnósticos farmacêuticos encontrados,e as intervenções realizadas. Os resultados obtidos permitem concluir que o acompanhamento farmacoterapêutico pode contribuir de forma direta com a melhora na qualidade de vida de um/apaciente. No caso de doenças crônicas, como a dor, o acompanhamento deve ser contínuo, no sentido de garantir a adesão do paciente ao tratamento.

The present study aims to report the case of an elderly patient withchronic pain, highlighting main pharmaceutical diagnostics and interventions. The obtained results allow us to conclude that the pharmacotherapeutic monitoring can contribute directly to improving the quality of life of the patient. In the case of chronic diseases, such as pain, monitoring should be continuous in order to ensure adherence to treatment.

El presente trabajo informa el caso de un paciente anciano con dolor crónico, destacando los principales diagnósticos farmacéuticos encontrados e intervenciones realizadas. Los resultados obtenidos nos permiten concluir que el seguimiento farmacoterapéutico puede contribuir directamente a mejorar la calidad de vida del paciente. En el caso de enfermedades crónicas, como el dolor, la monitorización debe ser continua para garantizar el cumplimiento del tratamiento por parte del paciente.