CBT and CFT for Chronic Pain.

PURPOSE OF REVIEW: Chronic pain is a widespread public and physical health crisis, as it is one of the most common reasons adults seek medical care and accounts for the largest medical reason for disability in the USA (Glombiewski et al., J Consult Clin Psychol. 86(6):533-545, 2018; Schemer et al., Eur J Pain. 23(3):526-538, 2019). Chronic pain is associated with decreased functional status, opioid dependence and substance abuse disorders, mental health crises, and overall lower perceived quality of life (Korff et al., J Pain. 17(10):1068-1080, 2016). For example, the leading cause of chronic pain and the leading cause of long-term disability is low back pain (LBP) (Bjorck-van Dijken et al. J Rehabil Med. 40:864-9, 2008). Evidence suggests that persistent low back pain (pLBP) is a multidimensional biopsychosocial problem with various contributing factors (Cherkin et al., JAMA. 315(12):1240-1249, 2016). Emotional distress, pain-related fear, and protective movement behaviors are all unhelpful lifestyle factors that previously were more likely to go unaddressed when assessing and treating patient discomfort (Pincus et al., Spine. 38:2118-23, 2013). Those that are not properly assisted with these psychosocial issues are often unlikely to benefit from treatment in the primary care setting and thus are referred to multidisciplinary pain rehabilitation physicians. This itself increases healthcare costs, and treatments can be invasive and have risks of their own. Therefore, less expensive and more accessible management strategies targeting these psychosocial issues should be started to facilitate improvement early. As a biopsychosocial disorder, chronic pain is influenced by a range of factors including lifestyle, mental health status, familial culture, and socioeconomic status. Physicians have moved toward multi-modal pain approaches in order to combat this public health dilemma, ranging from medications with several different mechanisms of action, lifestyle changes, procedural pain control, and psychological interventions (Fashler et al., Pain Res Manag. 2016:5960987, 2016). Part of the rehabilitation process now more and more commonly includes cognitive behavioral and cognitive functional therapy. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior. RECENT FINDINGS: CFT differs from CBT functionally, as instead of improving managing/coping mechanisms of pain control from a solely mental approach, CFT directly points out maladaptive behaviors and actively challenges the patient to change them in a cognitively integrated, progressive overloading functional manner (Bjorck-van Dijken et al. J Rehabil Med. 40:864-9, 2008). This allows CFT to be targeted to each individual patient, with the goal of personalized reconceptualization of the pain response. The end goal is to overcome the barriers that prevent functional status improvement, a healthy lifestyle, and reaching their personal goals. Chronic pain is a major public health issue. Cognitive functional therapy (CFT) and cognitive behavioral therapy (CBT) are both multidimensional psychological approaches to combat the mental portion of difficult pain control. While these therapies are quite different in their approach, they lend to the idea that chronic pain can and should be targeted using coping mechanisms, helping patients understand the pathophysiological process of pain, and altering behavior.

Pharmacogenomics, concepts for the future of perioperative medicine and pain management: A review.

Pharmacogenomics is the study of how genetic differences between individuals affect pharmacokinetics and pharmacodynamics. These differences are apparent to clinicians when taking into account the wide range of responses to medications given in clinical practice. A review of literature involving pharmacogenomics and pain management was performed. The implementation of preoperative pharmacogenomics will allow us to better care for our patients by delivering personalized, safer medicine. This review describes the current state of pharmacogenomics as it relates to many aspects of clinical practice and how clinicians can use these tools to improve patient outcomes.

Upper extremity regional anesthesia techniques: A comprehensive review for clinical anesthesiologists.

Surgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular, and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound-guided techniques, whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords, and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.

The Role of Exparel Plus Meloxicam for Postoperative Pain Management.

PURPOSE OF REVIEW: Acute postoperative pain reduction is a major target against the opioid crisis. While opioids have traditionally been the mainstay for postoperative analgesia, current practice has focused on a multimodal approach to pain control, including ultrasound-guided blocks with longer acting local anesthetic agents. RECENT FINDINGS: Non-steroidal anti-inflammatory drugs (NSAIDs), such as meloxicam, are an important class of medications utilized to manage pain in the perioperative period. An additional treatment used in perioperative or postoperative pain relief is Exparel, a bupivacaine (sodium channel blocker) liposomal injectable suspension with a 3-4-day duration of action. The long-acting mechanism and formulation of Exparel consistently has demonstrated decreased opioid use and pain scores in patients undergoing many different surgical procedures. A concern is that pH negatively alters the efficacy of bupivacaine, as in cases of inflamed tissue and acidic fluid pH. For this reason, a combination medication with both meloxicam and bupivacaine has been developed, which normalizes pH and has anti-inflammatory and anti-pain conduction properties. Clinical studies demonstrate that this combination agent can be extremely beneficial in treating postoperative pain. This manuscript summarizes the newest developments with regard to liposomal bupivacaine and the non-steroidal meloxicam, their roles in effective treatment of postoperative pain, contraindications, special considerations of using these medications, and future considerations. HTX-011 pairs up a new extended-release formulation of the local anesthetic bupivacaine with meloxicam, a well-established non-steroidal anti-inflammatory drug (NSAID).

Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review.

Alternative and non-opioid options for pain management are necessary in perioperative patient care. Opioids are no longer touted as cure-all medications, and furthermore, there have been tremendous advances in alternative therapies such as in interventional pain, physical therapy, exercise, and nutritional counseling that have proven benefits to combat pain. The center for disease control now strongly recommends the use of multimodal analgesia and multidisciplinary approaches based on the individual needs of patients: personalized medicine. In this manuscript, the specifics of non-opioid pharmacological and non-pharmacological analgesic approaches will be discussed as well as their possible indications and uses to reduce the need for excessive use of opioids for adequate pain control.

Fascia iliaca block, history, technique, and efficacy in clinical practice.

The facsia iliaca block (FIB) is a relatively new regional technique where local anesthetic is delivered within the fascia iliaca region. Indications for a FIB include surgical anesthesia to the lower extremity after knee, femoral shaft, hip surgery, management of cancer pain or pain secondary to inflammatory conditions of the lumbar plexus, as well as treatment of acute pain in the setting of trauma, fracture, or burns. The FIB may be performed using either a loss of resistance technique or an ultrasound (US)-guided technique; however, the use of US has become commonplace and resulted in improved femoral nerve and obturator nerve motor blocks. The main targets of the FIB are the predominant nerves contained in the fascia iliaca compartment (FIC), namely the femoral nerve and the lateral femoral cutaneous nerve. The FIB US guided technique is beneficial to patients and the possibility to perform FIB should be discussed and coordinated with surgical staff appropriately, considering its superiority to general or epidural anesthesia.

Truncal regional nerve blocks in clinical anesthesia practice.

Regional anesthetic techniques are important components of successful multimodal analgesic strategies. When used successfully, truncal nerve blocks of the chest wall, abdomen, and, paraneuraxial nerves, in combination with other analgesic modalities, may offer similar analgesic efficacy as neuraxial techniques, which are associated with a greater risk profile. Moreover, in comparison to neuraxial techniques, truncal nerve blocks are relatively simple to perform and technically straightforward to learn. The transversus abdominus plane (TAP) block is often incorporated into the multimodal analgesia regimen for surgical patients undergoing various abdominal and gynecological procedures. Rectus sheath blocks (RSB) were originally introduced to help relax the anterior abdominal wall during surgery and as an adjunct pain therapy. With the advancement of technology and the development of ultrasound guided techniques, RSB now have a more ubiquitous role and have been shown to decrease postoperative pain and opioid consumption. Different variations of the quadratus lumborum block may provide visceral and sensory analgesic coverage. Moreover, truncal blocks, including ilioinguinal, iliohypogastric, pectoralis nerve (PECS) blocks, serratus anterior, intercostal, and erector spinae plane blocks, have gained routine clinical use for various surgeries. In this review, we discuss the techniques, anatomy, indications, complications, and benefits of truncal nerve blocks commonly used in clinical practice.

Potential opioid-related adverse events following spine surgery in elderly patients.

OBJECTIVE: Understanding the clinical and economic impact of opioid-related adverse drug events (ORADEs) within spine surgery may guide both the clinician's and hospital administration's approach to treating perioperative pain, thus improving patient care and reducing hospital costs. The objective of this analysis is to understand how potential ORADEs after spine surgery in elderly patients affect length of stay, hospital revenue and their association with comorbid conditions. PATIENTS AND METHODS: We conducted a retrospective study utilizing the Center for Medicare/Medicaid Services Administrative Database to analyze Medicare discharges between April 2016 and March 2017 involving 14 spine surgery DRGs for major spine procedures in order to identify potential ORADEs. An analysis was conducted using this database to identify the incidence of potential ORADEs as well as their impact on mean hospital length of stay and hospital revenue. RESULTS: There were 177,432 discharges during the study period. The ORADE rate in patients undergoing spine surgery was 13.9% (24,642/177,432). The mean length of stay (LOS) for discharges with an ORADE was 3.13 days longer than without an ORADE (6.29 days with an ORADE vs 3.16 days without an ORADE). The adverse post-operative outcomes most strongly associated with potential ORADEs included shock, pneumonia, and septicemia. The mean hospital revenue per day with an ORADE was $3,076 less than without an ORADE ($7,263 with an ORADE vs $10,339 without an ORADE). CONCLUSION: Potential ORADEs in spine surgery in elderly patients are common and are associated with longer hospitalizations and decreased hospital revenue. Perioperative pain management strategies that reduce ORADEs may improve patient care and increase hospital revenue.

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.

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.

Regional Catheters for Outpatient Surgery-a Comprehensive Review.

PURPOSE OF REVIEW: This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS: Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.

The Role of Complementary and Alternative Medicine Treatments in Fibromyalgia: a Comprehensive Review.

PURPOSE OF REVIEW: Fibromyalgia is a complex chronic pain syndrome that can have debilitating consequences for affected patients. When compared to the general population, patients with fibromyalgia experience lowered mechanical and thermal pain thresholds, altered temporal summation of painful stimuli, and higher than normal pain ratings for known noxious stimuli. RECENT FINDINGS: There is no definitive cure for fibromyalgia and treatment primarily focuses on both symptom management and improving patient quality of life. This treatment strategy involves a comprehensive multidisciplinary approach consisting of lifestyle modifications, pharmacologic measures, and other complementary approaches including but not limited to acupuncture, yoga, tai chi, and meditation. This manuscript will discuss the diagnosis and treatment of fibromyalgia, as well as complementary and alternative therapies that should be considered by healthcare providers.

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines.

BACKGROUND: Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. STUDY DESIGN: Best evidence synthesis. OBJECTIVE: To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. METHODS: A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. RESULTS: 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors.2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety.5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae.6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure.7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant.8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma.9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy.11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed.12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas.13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. LIMITATIONS: The continued paucity of the literature with discordant recommendations. CONCLUSION: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. KEY WORDS: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain.

New benzodiazepines for sedation.

There are currently new drugs being developed that have benzodiazepine properties. This review will examine remimazolam, 3-hydroxyphenazapam, adinazolam, clonazolam, and deschloroetizolam as well as other novel agents. All benzodiazepines are protein bound and only moderately lipid soluble. In addition to their baseline properties, they can be enzymatically broken down into active metabolites. The mechanism of action of these medications is related to polysynaptic pathway inhibition via direct interaction with GABA and modifiable chloride channels. The main neurological areas of involvement are primarily the amygdala and reticular activating system. Benzodiazepines are used for sedation and for adjuvants to general anesthetics and not as primary induction agents. We describe the characteristics of newer drugs being developed, including their pharmacologic profile, side effects and efficacy, as well as the most recent clinical trials and future directions in benzodiazepine development.

Opioid addiction, diversion, and abuse in chronic and cancer pain.

PURPOSE OF REVIEW: The primary cause of overdose death in the United States is related to pharmaceutical opioids. A few particular populations that struggle with adverse outcomes related to opioid abuse are those in palliative care, those with chronic pain, and those receiving pain treatments secondary to cancer or chemotherapy. RECENT FINDINGS: There have been massive efforts to decrease the use of opioid abuse in patient care in a gestalt manner, but palliative care provides unique challenges in applying these reduction tactics used by other specialties. SUMMARY: We explore behavioral interventions, provider education, alternative pain management techniques, postmarketing surveillance, and abuse-deterrent formulas as emerging methods to counteract opioid abuse in these populations.

Macrolide and fluoroquinolone mediated cardiac arrhythmias: clinical considerations and comprehensive review.

While there is evidence for cardiac arrhythmias associated with macrolide and fluoroquinolone antibiotics, there is still debate among health care providers as to whether this risk of arrhythmia is overstated. A joint panel of the US Food and Drug Administration suggested that macrolide and fluoroquinolone labels need much stronger warnings regarding the possible serious adverse cardiac effects associated with these antibiotics, especially since they are so widely prescribed. And while health care providers may differ on the pertinence of the cardiac risks associated with antibiotic use, they can undoubtedly minimize the cardiac effects that are associated with these antibiotics by paying attention to the cardiac risk factors and drug history associated with the patient. Relevant studies for our review were identified from a PubMed search using keywords and combined word searches involving macrolides, fluoroquinolones, and cardiac arrhythmias. We attempted to include as many recent (>2015) articles as possible. We included case reports, randomized, controlled trials, observational studies, case-control studies, systematic reviews, and retrospective studies. Underlying cardiac issues can predispose patients to harmful cardiac side effects that can be exacerbated in the presence of antibiotics. The health care provider should rule out any risk factor associated with antibiotic-induced cardiac arrhythmia in the event that a patient does need a macrolide or fluoroquinolone antibiotic. Rigorous patient evaluation and a detailed patient history, including short and long term medication use, is the likely key to reducing any risk of cardiac arrhythmias associated with macrolides and fluoroquinolones. Clinicians should be cautious when prescribing macrolide and fluoroquinolone medications to patients with risk factors that may lead to antibiotic-induced cardiac arrhythmias, including a slow heart rate and those that are taking medications to treat arrhythmias.

Pharmacology of Antiemetics: Update and Current Considerations in Anesthesia Practice.

Postoperative nausea and vomiting (PONV) is associated with delayed recovery and dissatisfaction after surgical procedures. A key component to management is identifying risk factors and high-risk populations. Advances in pharmacologic therapeutics have resulted in agents targeting different pathways associated with the mediation of nausea and vomiting. This review focuses on these agents and the clinical aspects of their use in patients postoperatively. Combination therapies are reviewed, and studies demonstrate that when 2 or more antiemetic agents acting on different receptors are used, an overall improved efficacy is demonstrated when compared with a single agent alone in patients.