Projeto ARTICULADOR: protocolo de atendimento psicoeducativo em manejo de dor baseado em hipnose ericksoniana e visualização guiada / ARTICULATOR Project: protocol of psychoeducational care in pain management based on ericksonian hypnosis and visualization guided

Introdução: A dor é uma experiência essencialmente subjetiva e multifatorial cujo manejo e o tratamento devem considerar os aspectos afetivos, sensoriais, autonômicos e comportamentais associados. Nessa perspectiva, a Área de Controle e Tratamento da Dor (ARDOR) do Instituto Nacional de Traumatologia e Ortopedia Jamil Andrade (INTO) identificou a necessidade de atualizar seu modus operandi mediante ao esgotamento do modelo assistencial vigente frente aos desafios da contemporaneidade. No rastro dessa mudança, os psicólogos atuantes na ARDOR são convidados a reinventar seu próprio modo de intervenção, articulando novas técnicas, processos e ações. Objetivos: O objetivo desta pesquisa é propor um novo protocolo assistencial em Saúde Mental na Clínica da Dor baseado na hipnose ericksoniana e na visualização guiada, associadas a práticas grupais e ações estratégicas de gerenciamento. O novo protocolo de atendimento está centrado em grupos psicoeducativos fechados, focais e breves, orientados para o manejo e enfrentamento da dor. Método: Buscou-se averiguar as evidências de eficácia da hipnose quanto ao manejo de dor através da elaboração de uma revisão sistemática da literatura e análise dos resultados obtidos de um estudo piloto com pacientes da clínica da dor. Ambos os estudos ­ teórico e prático ­ corroboraram para a elaboração do protocolo. Resultados: As evidências obtidas tanto na revisão sistemática quanto análise dos resultados do ensaio piloto apontaram a hipnose como sendo eficaz em pelo menos um aspecto no manejo da dor (redução da interferência, qualidade ou intensidade da dor). A catastrofização mostrou-se uma variável interveniente com um expressivo viés em alguns resultados, por isso foi incluída no protocolo. Conclusão: Enquanto práticas integrativas, a hipnose e a visualização guiada são técnicas eficazes no manejo da dor, sendo de fácil aplicação, podendo ser aprendida e transmitida adiante pelos pacientes. Este protocolo é passível de ser reproduzido em outras instituições. Recomenda-se que seja utilizado por profissional de saúde treinado e com experiência no trabalho com práticas integrativas

Introduction: Pain is an essentially subjective and multifactorial experience whose management and treatment must consider the associated affective, sensory, autonomic and behavioral aspects. In this perspective, the Pain Control and Treatment Area (ARDOR) of National Institute of Traumatology and Orthopedics Jamil Andrade (INTO) identified the need to update its modus operandi by exhausting the current care model in the face of contemporary challenges. In the wake of this change, the psychologists working at ARDOR are invited to reinvent their own way of intervention, articulating new techniques, processes and actions. Objectives: The objective of this research is to propose a new mental health care protocol at Clínica da Dor based on Ericksonian hypnosis and guided visualization, associated with group practices and strategic management actions. The new care protocol is centered on closed, focal and brief psychoeducational groups, oriented to the management and coping of pain. Method: We sought to investigate the evidence of the effectiveness of hypnosis in pain management through the development of a systematic review of the literature and analysis of the results obtained from a pilot study with patients in the pain clinic. Both studies - theoretical and practical - supported the preparation of the protocol. Results: The evidence obtained both in the systematic review and analysis of the results of the pilot project pointed out hypnosis as being effective in at least one aspect in pain management (reduction of interference, quality or intensity of pain). Catastrophization proved to be an intervening variable with a significant bias in some results, so it was included in the protocol. Conclusion: As an integrative practice, hypnosis and guided visualization are effective techniques for pain management, being easy to apply and can be learned and transmitted by patients. This protocol is capable of being reproduced in other institutions. it is recommended to be used by a trained health professional with experience working with integrative practices

Cannabidiol for Pain Treatment: Focus on Pharmacology and Mechanism of Action.

Cannabis has a long history of medical use. Although there are many cannabinoids present in cannabis, Δ9tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) are the two components found in the highest concentrations. CBD itself does not produce typical behavioral cannabimimetic effects and was thought not to be responsible for psychotropic effects of cannabis. Numerous anecdotal findings testify to the therapeutic effects of CBD, which in some cases were further supported by research findings. However, data regarding CBD's mechanism of action and therapeutic potential are abundant and omnifarious. Therefore, we review the basic research regarding molecular mechanism of CBD's action with particular focus on its analgesic potential. Moreover, this article describes the detailed analgesic and anti-inflammatory effects of CBD in various models, including neuropathic pain, inflammatory pain, osteoarthritis and others. The dose and route of the administration-dependent effect of CBD, on the reduction in pain, hyperalgesia or allodynia, as well as the production of pro and anti-inflammatory cytokines, were described depending on the disease model. The clinical applications of CBD-containing drugs are also mentioned. The data presented herein unravel what is known about CBD's pharmacodynamics and analgesic effects to provide the reader with current state-of-art knowledge regarding CBD's action and future perspectives for research.

Cannabis for Symptom Management in Older Adults.

The purpose of this article is to present evidence on the efficacy and safety of medical cannabis as a therapy for symptom management in palliative care. This article provides an overview of the evidence on the risks and benefits of using medical cannabis for the indications of chronic pain, cancer-related pain, cancer cachexia, dementia, and Alzheimer's disease. Currently, there is insufficient evidence to determine the effectiveness and safety of cannabinoids for most reviewed indications, with the exception of chronic pain. Future research is required before palliative care clinicians can make evidence-based decisions on the integration of medical cannabis as adjunct therapies.

Therapeutic potential of opioid/cannabinoid combinations in humans: Review of the evidence.

The endogenous opioid and cannabinoid receptor systems are widely distributed and co-localized throughout central and peripheral nervous system regions. A large body of preclinical evidence suggests that there are functional interactions between these two systems that may be leveraged to address various health conditions. Numerous animal studies have shown that cannabinoid agonists (e.g., delta-9-tetrahydrocannabinol [Δ9-THC]) enhance the analgesic effects of µ-opioid analgesics as evidenced by decreasing the opioid dose required for analgesia (i.e., opioid sparing) and extending the duration of the opioid analgesia. In contrast, controlled human laboratory studies and clinical trials have not demonstrated robust analgesic or opioid-sparing effects from opioid-cannabinoid combinations. Meta-analyses of the literature (clinical trials, controlled laboratory studies; some non-controlled studies/case reports) have examined the effects of cannabis/cannabinoids for pain relief in those taking a wide variety of analgesics, including prescription opioid medications. These data do not strongly support the use of cannabinoids for chronic pain nor do prospective studies demonstrate significant cannabinoid-mediated opioid-sparing effects. Preclinical studies have also suggested a role for cannabinoids for the treatment of opioid withdrawal. Controlled laboratory and clinical studies suggest that there may be a modest signal for Δ9-THC to suppress some opioid signs and symptoms but they are not completely ameliorated and there may also be concerns around safety of Δ9-THC administration in a state of heightened autonomic arousal as occurs with opioid withdrawal. Despite anecdotal and correlational reports suggesting a benefit of cannabis on reducing opioid overdose, there is no strong data supporting this contention and emerging reports have conflicting results. In summary, there is a groundswell of public advocacy supporting the use of cannabis and cannabinoids to replace opioid analgesics or to reduce opioid use; however, the extant controlled clinical data do not support the role of cannabinoids for opioid replacement or opioid-sparing effects when treating opioid use disorder or chronic pain.

The Role of Cannabidiol (CBD) in Chronic Pain Management: An Assessment of Current Evidence.

PURPOSE OF REVIEW: Given the growing challenges in chronic pain management coupled with the ongoing consequences of the opioid epidemic, pain management practitioners are looking into more effective, innovative, and safer alternatives to treat pain. Cannabis-based medicine had been described for hundreds of years but only recently have we seen the more scientific, evidence-based approach to its use, and ongoing investigations continue to explore its potential medical benefits. While historically more attention has been paid to the psychoactive component of the cannabis plant Δ9-tetrahydrocannabinol (THC), there have been fewer scientific studies on the medical use of the cannabidiol (CBD) - a non-psychoactive component of the cannabis plant. RECENT FINDINGS: By examining recent literature, we investigated the use of CBD and its potential role in pain management. Since there are currently no approved pharmaceutical products that contain CBD alone for the management of pain, this review focused on nabiximols (which is a combined product of THC/CBD in a 1:1 ratio) as the only pharmaceutical product available that contains CBD and is being used for the management of pain. It is difficult to definitely attribute the therapeutic properties to CBD alone since it is always administered with THC. Based on the available literature, it is difficult to make a recommendation for the use of CBD in chronic pain management. It is also important to note that there are many CBD products currently available as supplements, but these products are non-pharmaceuticals and lack the appropriate clinical studies to support their efficacy claims.

Challenges and Opportunities in Preclinical Research of Synthetic Cannabinoids for Pain Therapy.

Cannabis has been used in pain management since 2900 BC. In the 20th century, synthetic cannabinoids began to emerge, thus opening the way for improved efficacy. The search for new forms of synthetic cannabinoids continues and, as such, the aim of this review is to provide a comprehensive tool for the research and development of this promising class of drugs. Methods for the in vitro assessment of cytotoxic, mutagenic or developmental effects are presented, followed by the main in vivo pain models used in cannabis research and the results yielded by different types of administration (systemic versus intrathecal versus inhalation). Animal models designed for assessing side-effects and long-term uses are also discussed. In the second part of this review, pharmacokinetic and pharmacodynamic studies of synthetic cannabinoid biodistribution, together with liquid chromatography-mass spectrometric identification of synthetic cannabinoids in biological fluids from rodents to humans are presented. Last, but not least, different strategies for improving the solubility and physicochemical stability of synthetic cannabinoids and their potential impact on pain management are discussed. In conclusion, synthetic cannabinoids are one of the most promising classes of drugs in pain medicine, and preclinical research should focus on identifying new and improved alternatives for a better clinical and preclinical outcome.

Review of Opioid Prescribing in the Osteopathic and Ambulatory Setting.

The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven by the medical-pharmaceutical complex, and fueled by campaigns representing the most prestigious health care organizations and advocacy groups. Comprehensive guidelines for proper prescribing have been released in addition to state-sponsored prescription drug-monitoring programs (PDMPs) in response to overprescribing habits. When considering opioid treatment for a patient, physicians should document a thorough history of pain, give an appropriate physical examination, and complete a risk assessment using the proper diagnostic tools. Considering the osteopathic philosophy and approach to chronic pain, physicians should account for an integrative treatment approach for improved patient outcomes when considering applying the osteopathic philosophy to chronic pain management. A successful treatment plan can integrate cognitive behavioral therapy and promote self-healing by treating somatic dysfunctions with osteopathic manipulative treatment. This literature review discusses how to treat patients with chronic pain and how to properly use and prescribe opioids. The researchers analyzed the history and current status of the opioid epidemic, examined opioid management in the outpatient setting, reviewed the current domestic and international opioid prescribing guidelines, and discussed the incorporation of the osteopathic philosophy to manage chronic pain.

Frequency of cannabis and illicit opioid use among people who use drugs and report chronic pain: A longitudinal analysis.

BACKGROUND: Ecological research suggests that increased access to cannabis may facilitate reductions in opioid use and harms, and medical cannabis patients describe the substitution of opioids with cannabis for pain management. However, there is a lack of research using individual-level data to explore this question. We aimed to investigate the longitudinal association between frequency of cannabis use and illicit opioid use among people who use drugs (PWUD) experiencing chronic pain. METHODS AND FINDINGS: This study included data from people in 2 prospective cohorts of PWUD in Vancouver, Canada, who reported major or persistent pain from June 1, 2014, to December 1, 2017 (n = 1,152). We used descriptive statistics to examine reasons for cannabis use and a multivariable generalized linear mixed-effects model to estimate the relationship between daily (once or more per day) cannabis use and daily illicit opioid use. There were 424 (36.8%) women in the study, and the median age at baseline was 49.3 years (IQR 42.3-54.9). In total, 455 (40%) reported daily illicit opioid use, and 410 (36%) reported daily cannabis use during at least one 6-month follow-up period. The most commonly reported therapeutic reasons for cannabis use were pain (36%), sleep (35%), stress (31%), and nausea (30%). After adjusting for demographic characteristics, substance use, and health-related factors, daily cannabis use was associated with significantly lower odds of daily illicit opioid use (adjusted odds ratio 0.50, 95% CI 0.34-0.74, p < 0.001). Limitations of the study included self-reported measures of substance use and chronic pain, and a lack of data for cannabis preparations, dosages, and modes of administration. CONCLUSIONS: We observed an independent negative association between frequent cannabis use and frequent illicit opioid use among PWUD with chronic pain. These findings provide longitudinal observational evidence that cannabis may serve as an adjunct to or substitute for illicit opioid use among PWUD with chronic pain.

Recent advances in pain treatment for children with serious illness.

Pain is a common distressing symptom in children receiving pediatric palliative care. Both in children with cancer, but especially in children with progressive neurodegenerative and chromosomal conditions with CNS impairment pain is common, and often under-recognized and undertreated. Multimodal analgesia for children with serious illness acts synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. Successful pain treatment and prevention usually include integrative 'nonpharmacological' therapies, rehabilitation, psychology and spirituality in addition to pharmacology and regional anesthesia. This review article will address these effective components of multimodal pediatric analgesia and present starting doses of basic analgesia, opioids and adjuvants analgesia in infants, children and adolescents with serious illness.

Substitution of marijuana for opioids in a national survey of US adults.

Opioid prescriptions for chronic pain and subsequent opioid-related complications have risen dramatically in the US. Recent data suggest that medical marijuana laws have been associated with lower state-level opioid overdose mortality. In a national survey, we examined the prevalence of substitution of marijuana for opioids among US adults taking opioids for pain.Using GfK's KnowledgePanel, we conducted an Internet-based survey of a nationally representative sample of 16,280 adults in 2017 about individual perceptions and use of marijuana. We developed questions designed to assess the extent and reasons for substitution of marijuana for opioids. We examined opioid substitution among respondents with a history of ever using marijuana who used opioids in the past 12 months. There were 9,003 respondents, corresponding to a 55.3% response rate. The mean age was 48 years. Among the 5% (n = 486) who reported ever using marijuana and using opioids in the past year, 43% used opioids daily, and 23% reported current (past 30 day) marijuana use. Forty-one percent reported a decrease or cessation of opioid use due to marijuana use; 46% reported no change in opioid use; and 8% reported an increase in opioid use. We found that a substantial number of US adults reported that they substituted marijuana for opioids.

A comparison of effects of scalp nerve block and local anesthetic infiltration on inflammatory response, hemodynamic response, and postoperative pain in patients undergoing craniotomy for cerebral aneurysms: a randomized controlled trial.

BACKGROUND: The purpose of this study was to compare the effects of scalp nerve block (SNB) and local anesthetic infiltration (LA) with 0.75% ropivacaine on postoperative inflammatory response, intraoperative hemodynamic response, and postoperative pain control in patients undergoing craniotomy. METHODS: Fifty-seven patients were admitted for elective craniotomy for surgical clipping of a cerebral aneurysm. They were randomly divided into three groups: Group S (SNB with 15 mL of 0.75% ropivacaine), group I (LA with 15 mL of 0.75% ropivacaine) and group C (that only received routine intravenous analgesia). Pro-inflammatory cytokine levels in plasma for 72 h postoperatively, hemodynamic response to skin incision, and postoperative pain intensity were measured. RESULTS: The SNB with 0.75% ropivacaine not only decreased IL-6 levels in plasma 6 h after craniotomy but also decreased plasma CRP levels and increased plasma IL-10 levels 12 and 24 h after surgery compared to LA and routine analgesia. There were significant increases in mean arterial pressure 2 and 5 mins after the incision and during dura opening in Groups I and C compared with Group S. Group S had lower postoperative pain intensity, longer duration before the first dose of oxycodone, less consumption of oxycodone and lower incidence of PONV through 48 h postoperatively than Groups I and C. CONCLUSION: Preoperative SNB attenuated inflammatory response to craniotomy for cerebral aneurysms, blunted the hemodynamic response to scalp incision, and controlled postoperative pain better than LA or routine analgesia. TRIAL REGISTRATION: Clinicaltrials.gov NCT03073889 (PI:Xi Yang; date of registration:08/03/2017).

How Theory Can Help Facilitate Implementing Relaxation as a Complementary Pain Management Approach.

Complementary therapies provide cancer survivors and clinicians with options for managing chronic pain. Recent published clinical guidelines and research findings support the use of relaxation therapy for managing chronic pain in cancer survivors. However, translating research findings into clinical practice remains a challenge. Using theory to guide implementation of a new practice can increase the likelihood of successful adoption. This article uses relaxation therapy for cancer survivors to describe how clinicians could use Rogers' Diffusion of Innovation Theory and the related Collaborative Research Utilization Model to implement a complementary therapy and ensure that it becomes standard practice.

Traditional and Novel Migraine Therapy in the Aging Population.

Migraine is a common disabling disorder that affects 36 million Americans. The clinical features of migraine are less typical in the people above age 60, making the diagnosis and treatment difficult in this group. In this review, we will discuss migraine-specific drugs and their use in populations about age 60 who suffer from migraine. This discussion will include an overview of traditional treatments for the acute and preventive treatment of migraine, and considerations for their use in patient populations above age 60. In addition, we will discuss newer agents that show a more promising safety profile.

Treating pain in primary care: Optimizing an integrated psychological intervention based on perspectives of psychologists, primary care providers, and patients.

INTRODUCTION: Although behavioral health treatment can improve distress and pain functioning for patients with chronic pain, few who are referred by their primary care physician will see a behavioral health specialist. Given the benefits of integrating behavioral health into primary care, this may be an avenue for delivering a psychological intervention for chronic pain. The purpose of this study was to optimize a psychological intervention for patients with chronic pain to be delivered in primary care, utilizing the perspectives of providers and patients. METHOD: Psychologists (n = 9), primary care providers (n = 9), and patients with chronic pain (n = 9) participated in separate focus groups. Participants reviewed the proposed 4-session intervention, provided feedback prompted by a set of open-ended questions, and completed a survey. RESULTS: Statements from focus groups were transcribed and coded into 2 thematic categories: (a) content of the intervention and (b) logistics and design. Participants believed that offering a brief, behavioral intervention for chronic pain in a primary care clinic was feasible and useful. All providers (100%) agreed or strongly agreed that they would refer a patient to this intervention, and 100% of patients agreed or strongly agreed that they would participate. DISCUSSION: Feedback solicited from the focus groups led to alterations to the treatment manual, such as adding a fifth session, using different psychological strategies, and logistical changes in delivery (i.e., meeting biweekly and intervisit contacts). The modified version of this intervention will be evaluated with a pilot randomized controlled clinical trial. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cannabinoids in Pain Treatment: An Overview.

The current landscape contains conflicting reports regarding the use of medical marijuana, creating fields of misinformation and lack of understanding by health care providers about cannabinoids. In this article we provide a dispassionate look at medical marijuana, while providing a clinical overview focusing on pain management. We examine the mechanisms of the endocannabinoid system, along with the pharmacology of cannabinoids. Current research on the use of marijuana for the treatment of pain is reviewed. Finally, recommendations for pain management nurses on integrating research, clinical practice, and U.S. drug policy are made.