Emerging Novel Pharmacological Non-opioid Therapies in Headache Management: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic headache is a significant worldwide problem despite advances in treatment options. Chronic headaches can have significant a detrimental impact on the activities of daily living. RECENT FINDINGS: Patients who do not obtain relief from chronic head and neck pain from conservative treatments are commonly being managed with interventional treatments. These interventional treatment options include botulinum toxin A, injections, local occipital nerve anesthetic and corticosteroid infiltration, occipital nerve subcutaneous stimulation and occipital nerve pulsed radiofrequency (PRF), sphenopalatine ganglion block, and radiofrequency techniques. Recently, evidence has emerged to support non-opioid-based drug and interventional approaches. Overall, more research is necessary to clarify the safety and efficacy of interventional treatments and to better understand the pathogenesis of chronic headache pain.

A Comprehensive Review of Trigeminal Neuralgia.

PURPOSE OF REVIEW: Trigeminal neuralgia (TN) is characterized by recurrent attacks of lancinating facial pain in the dermatomal distribution of the trigeminal nerve. TN is rare, affecting 4 to 13 people per 100,000. RECENT FINDINGS: Although there remains a debate surrounding the pathogenesis of TN, neurovascular compromise is the most currently accepted theory. Minimal stimulation caused by light touch, talking, or chewing can lead to debilitating pain and incapacitation of the patient. Pain may occur sporadically, though is primarily unilateral in onset. The diagnosis is typically determined clinically. Treatment options include medications, surgery, and complementary approaches. Anti-epileptic and tricyclic antidepressant medications are first-line treatments. Surgical management of patients with TN may be indicated in those who have either failed medical treatment with at least three medications, suffer from intolerable side-effects, or have non-remitting symptoms. Surgical treatment is categorized as either destructive or non-destructive. Deep brain and motor cortex neuro-modulatory stimulation are off label emerging techniques which may offer relief to TN that is otherwise refractory to pharmacological management and surgery. Still, sufficient data has yet to be obtained and more studies are needed.

Government Legislation in Response to the Opioid Epidemic.

PURPOSE OF REVIEW: Opioid misuse and abuse in the USA has evolved into an epidemic of tragic pain and suffering, resulting in the estimated death of over 64,000 people in 2016. Governmental regulation has escalated alongside growing awareness of the epidemic's severity, both on the state and federal levels. RECENT FINDINGS: This article reviews the timeline of government interventions from the late 1990s to today, including the declaration of the opioid crisis as a national public health emergency and the resultant changes in funding and policy across myriad agencies. Aspects of the cultural climate that fuel the epidemic, and foundational change that may promote sustained success against it, are detailed within as well. As a consequence of misuse and abuse of opioids, governmental regulation has attempted to safeguard society, and clinicians should appreciate changes and expectations of prescribers.

Consensus Perioperative Management Best Practices for Patients on Transdermal Fentanyl Patches Undergoing Surgery.

PURPOSE OF REVIEW: The administration of a transdermal fentanyl patch can be complicated with different pharmacokinetics than other fentanyl preparations. RECENT FINDINGS: The medical condition and baseline opioid requirements must all be carefully considered when dosing a fentanyl patch. An advantage of the fentanyl patch is its ability to bypass the gastrointestinal tract and in many patients, provide effective analgesia with minimal side effects. Fentanyl patches must be carefully administered since morbidity and/or mortality can result from the following: Giving higher doses than a patient needs, combining the medication with potent sedatives, or heating a fentanyl patch. The use of a transdermal fentanyl patch for the treatment of acute postoperative pain is not recommended and any patient undergoing a surgical procedure should have the fentanyl patch removed preoperatively. The current manuscript discusses the history of fentanyl and the fentanyl patch, as well as perioperative considerations, contraindications, current clinical efficacy, and clinical adversities related to the transdermal fentanyl patch. Regarding the heating of a transdermal fentanyl patch, which significantly increases blood levels of fentanyl, it is of the utmost importance that the patch be removed prior to surgery.

Spinal Cord Stimulation, MILD Procedure, and Regenerative Medicine, Novel Interventional Nonopioid Therapies in Chronic Pain.

PURPOSE OF REVIEW: Chronic pain is a highly prevalent condition affecting millions of individuals. RECENT FINDINGS: In recent years, newer treatments have emerged that are changing the way clinicians treat pain pathogenesis, including novel nonopioid strategies. In this regard, spinal cord stimulation, the MILD procedure, and regenerative medicine have shown promise. This review summarizes recent literature on these three emerging treatment strategies. The results of this review suggest that under certain conditions, spinal cord stimulation, the MILD procedure, and regenerative medicine can be effective treatment modalities.

Atypical Facial Pain: a Comprehensive, Evidence-Based Review.

PURPOSE OF REVIEW: The purpose of this article is to focus on an excruciating disorder of the face, named atypical facial pain or persistent idiopathic facial pain (PIFP). It is considered an underdiagnosed condition with limited treatment options. Facial pain can be a debilitating disorder that affects patients' quality of life. Up to 26% of the general population has suffered from facial pain at some point in their lives. It is important to highlight the different types of facial pain to be able to properly manage this condition accordingly. RECENT FINDINGS: Newer interventional modalities such as pulsed radiofrequency ablation (PFR) of the sphenopalatine ganglion, peripheral nerve field stimulators (PNFS), and botulinum toxin injections have promising results. In summary, more prospective studies such as randomized controlled trials are necessary to explore the possibility of their more widespread use as viable procedures for the treatment of PIFP. In this review article, we describe the workup and diagnosis of PIFP and highlight recent literature regarding the pathophysiology and treatment of PIFP. PIFP is an excruciating disorder of the face often misdiagnosed as trigeminal neuralgia (TN) However, unlike TN symptoms, the pain is persistent rather than intermittent, usually unilateral, and without autonomic signs or symptoms. When a clinician encounters a patient with neuropathic facial pain whose symptoms are incongruent with the more common etiologies, the diagnosis of atypical facial pain must be entertained. Treatment of PIFP is multidisciplinary. Unfortunately, few randomized controlled trials for the treatment of PIFP exist. However, there are a select number of pharmacological, non-pharmacological, and interventional treatment options that have proven to be moderately effective.

Pain in the Elderly.

Pain management in the elderly has increasingly become problematic in the USA as the aged population grows. The proportion of the population over 65 continues to climb and may eclipse 20 % in the next decade. In order to effectively diagnosis and treat these patients, a proper history and physical exam remain essential; pain assessment scales such as the Verbal Descriptor Scales (VDS), the Numerical Rating Scales (NRS), and the Visual Analogue Scales (VAS) often but not always prove beneficial. The conditions most frequently afflicting this population include osteoarthritis, diabetic neuropathy, post-herpetic neuralgia, and lower back pain which include spondylosis and radiculopathies. While the normal aging process does not necessarily guarantee symptoms of chronic pain, elderly individuals are far more likely to develop these painful conditions than their younger counterparts. There are many effective treatment modalities available as potential therapeutic interventions for elderly patients, including but not limited to analgesics such as NSAIDs and opioids, as well as multiple interventional pain techniques. This review will discuss chronic pain in the elderly population, including epidemiology, diagnostic tools, the multitude of co-morbidities, and common treatment modalities currently available to physicians.

Novel improvements in perioperative sterility.

Operative sterility is a critical factor with regard to infection in the postoperative period. In recent years, techniques and devices have been developed to reduce the potential for exposure to pathogens. This brief review details the SteriCup, a unique product that has the potential to reduce the risk of healthcare-acquired infections. The SteriCup provides a designated sterile area to store suction catheters and removed endotracheal tubes and allows for their simple and safe disposal. Devices such as the SteriCup have the potential to improve operating room systems and minimize potential for operative infection.

Ultrasound practice for chronic pain procedures: A comprehensive review.

Chronic pain management techniques have evolved in recent years. With regard to this, ultrasound (US) technology has become a standard for most acute pain procedures and essential for postsurgical pain relief and enhanced recovery after surgery protocols. This manuscript summarizes clinical studies evaluating US use for chronic pain management and compares efficacy with standard techniques including fluoroscopy (FL). US possesses several unique benefits when compared with FL, including elimination of radiation exposure while providing similar clinical outcomes. In summary, US use for chronic pain procedures is emerging as a viable, safe, and effective modality. Additional studies are needed to best appreciate US and its role in chronic pain management.

Pharmacologic Considerations of Anesthetic Agents in Pediatric Patients: A Comprehensive Review.

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.