Herbal Medicine for Pain Management: Efficacy and Drug Interactions.

Complementary and alternative medicines such as herbal medicines are not currently part of the conventional medical system. As the popularity of and global market for herbal medicine grows among all age groups, with supporting scientific data and clinical trials, specific alternative treatments such as herbal medicine can be reclassified as a practice of conventional medicine. One of the most common conditions for which adults use herbal medicine is pain. However, herbal medicines carry safety concerns and may impact the efficacy of conventional therapies. Unfortunately, mechanisms of action are poorly understood, and their use is unregulated and often underreported to medical professionals. This review aims to compile common and available herbal medicines which can be used as an alternative to or in combination with conventional pain management approaches. Efficacy and safety are assessed through clinical studies on pain relief. Ensuing herb-drug interactions such as cytochrome modulation, additive and synergistic effects, and contraindications are discussed. While self-management has been recognized as part of the overall treatment strategy for patients suffering from chronic pain, it is important for practitioners to be able to also optimize and integrate herbal medicine and, if warranted, other complementary and alternative medicines into their care.

The use of alternative therapies in conjunction with opioids for cancer pain.

Introduction: There is a growing recognition of the role of interventional techniques (IT) for the management of cancer pain (CP). However, there are many controversies on how and when to use such techniques. Areas covered: Patients who are unresponsive to systemic opioid analgesics or patients unable to tolerate systemic opioids may benefit from different IT for which the successful use depends on the selection of the right therapy for the right patient. The evidence regarding these techniques is often anecdotal and the potential risks, benefits, alternatives, and complications should be balanced to take a decision. Expert opinion: The successful use of IT depends on many factors, including a careful assessment of previous treatments, patient's characteristics, and the logistics. Risks, benefits, alternatives, and complications should be balanced to take a decision. Although IT have been described as effective in patients with CP, the evidence is still limited, unless for celiac plexus block, which has a high benefit-risk ratio. The intrathecal therapy should be chosen in patients who were poorly responding to opioid therapy, after an appropriate trial with different opioids. A careful selection of patients and techniques, a large experience in performing the procedures, sufficient logistics and staff skills, appropriate indications, and assessment of benefits and risks may help to achieve the best benefit for patients in individual cases.

Transcutaneous Electrical Nerve Stimulation in Treatment of Occipital Neuralgia: A Case Report.

Occipital neuralgia is the third most common headache syndrome after migraine and tension type headaches. There is no well-established treatment regimen for a reliable cure. The current case presents a 39-year-old woman, diagnosed with occipital neuralgia of idiopathic cause. The condition was difficult to control by conservative or interventional approaches. The patient was started on conventional transcutaneous electrical nerve stimulation, 3 sessions per week. After the procedure, the patient achieved significant pain relief: 1-2/10 on the numeric rating scale, pain initially being 10/10. With maintenance therapy consisting of physical therapy, deep tissue massage, and muscle relaxants, 12 months after starting transcutaneous electrical nerve stimulation therapy, she is pain free.

Repeated Quantitative Urine Toxicology Analysis May Improve Chronic Pain Patient Compliance with Opioid Therapy.

BACKGROUND: Even though serious efforts have been undertaken by different medical societies to reduce opioid use for treating chronic benign pain, many Americans continue to seek pain relief through opioid consumption. Assuring compliance of these patients may be a difficult aspect of proper management even with regular behavioral monitoring. OBJECTIVE: The purpose of this study was to accurately assess the compliance of chronic opioid-consuming patients in an outpatient setting and evaluate if utilizing repeated urine drug testing (UDT) could improve compliance. STUDY DESIGN: Retrospective analysis of prospectively collected data. SETTING: Outpatient pain management clinic. METHODS: After Institutional Review Board (IRB) approval, a retrospective analysis of data for 500 patients was conducted. We included patients who were aged 18 years and older who were treated with opioid analgesic medication for chronic pain. Patients were asked to provide supervised urine toxicology specimens during their regular clinic visits, and were asked to do so without prior notification. The specimens were sent to an external laboratory for quantitative testing using liquid chromatography-tandem mass spectrometry. RESULTS: Three hundred and eighty-six (77.2%) patients were compliant with prescribed medications and did not use any illicit drugs or undeclared medications. Forty-one (8.2%) patients tested positive for opioid medication(s) that were not prescribed in our clinic; 8 (1.6%) of the patients were positive for medication that was not prescribed by any physician and was not present in the Illinois Prescription Monitoring Program; 5 (1%) patients tested negative for prescribed opioids; and 60 (12%) patients were positive for illicit drugs (8.6% marijuana, 3.2% cocaine, 0.2% heroin). Repeated UDTs following education and disclosure, showed 49 of the 77 patients (63.6%) had improved compliance. LIMITATIONS: This was a single-site study and we normalized concentrations of opioids in urine with creatinine levels while specific gravity normalization was not used. CONCLUSIONS: Our results showed that repeated UDT can improve compliance of patients on opioid medications and can improve overall pain management. We believe UDT testing should be used as an important adjunctive tool to help guide clinical decision-making regarding opioid therapy, potentially increasing future quality of care.Key words: Urine toxicology analysis, chronic pain, opioids, compliance, pain management, urine drug testing, urine drug screening.

Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery.

BACKGROUND: Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. However, some studies have shown minimal benefit, and have raised concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore, there is a paucity of studies wherein control (IV) dexamethasone was considered. OBJECTIVE: The purpose of this meta-analysis was to evaluate the effectiveness of different concentrations of perineural dexamethasone injection on postoperative analgesia, as well as complications from its use for brachial plexus blocks. METHODS: A systematic literature search was conducted using the Cochrane Central Registry of Controlled Trials, PubMed, and Scopus. Trials comparing control and local dexamethasone-treated groups, and those which reported duration of analgesia and/or pain scores/opioid consumptions were selected. Meta-analysis was performed using the Review Manager (RevMan) software 5.1. RESULTS: Fourteen studies consisting of a total of 1,022 patients were included. Perineural dexamethasone significantly prolonged the duration of postoperative analgesia in patients receiving both low-dose (4 - 5 mg) [SMD 2.41 (95% CI: 1.47, 3.35 P = 0<0.00001) I² = 82%], and higher-doses (8 - 10 mg) [SMD 4.46 (95% CI 3.54, 5.38 P < 0.00001) I² = 94%]. However, the duration of motor block was also prolonged [SMD 2.52 (95% CI: 1.06, 3.98 P = 0.0007) I² = 97%] and dexamethasone delayed latency of onset of sensory [SMD -0.49 (95% CI: -0.89, -0.09 P = 0.02) I² = 76%] and motor [SMD -0.56 (95% CI: -1.13, 0.00 P = 0.05) I² = 87%] blocks. Postoperative pain scores were improved at both 24 hours [SMD -1.46 (95% CI: -2.43, -0.50 P = 0.003) I² = 95%] and 48 hours [SMD -1.20 (95% CI: -2.26, -0.13 P = 0.03) I² = 95%] in dexamethasone-treated groups, whereas opioid consumption was reduced only at 48 hours [SMD -2.97 (95% CI: -4.17, -1.76 P < 0.00001) I² = 88%]. Complications were comparable between control and dexamethasone-adjuvant groups, except for the excessively prolonged nerve block that was observed predominantly in the dexamethasone-adjuvant group. LIMITATIONS: The limitations include different definitions used for the measurements of certain parameters such as the duration of analgesia and duration of motor block, number of studies assessing certain parameters having high heterogeneity, and varying types of local anesthetics used in various studies. CONCLUSIONS: Perineural dexamethasone addition to local anesthetic solutions significantly improved postoperative pain in brachial plexus block without increasing complications. However, perineural adjuvant dexamethasone delayed the onset of sensory and motor block, and prolonged the duration of motor block. Smaller doses of dexamethasone (4 - 5 mg) were as effective as higher doses (8 - 10 mg).

Cervical epidural steroid injections for the treatment of cervical spinal (neck) pain.

Cervical epidural steroid injections (CESI) are an accepted treatment for neck pain with a radicular component, and may be accomplished by using either transforaminal (CTFESI) or interlaminar (CILESI) approaches. CESIs are routinely performed using real-time fluoroscopic-guidance in conjunction with the injection of water soluble, iodine-based contrast media to enhance visualization of intravascular injections. Digital subtraction angiography (DSA) imaging is an adjuvant to fluoroscopic methods for visualizing blood vessels while performing spinal injections. However, as with any neuraxial procedure, various complications associated with CESIs have been reported. Complications are directly associated with the technical procedures of CESIs. Particulate steroids may have a prolonged duration of action but non-particulate steroids are safer for CESIs. Blunt-beveled needles are less likely than sharp-beveled needles to penetrate blood vessels to cause bleeding complications during CTFESI procedures. Small doses of local anesthetics appear to be safe and assist in identifying intravascular injections previously overlooked by conventional techniques.