Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology.

There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.

Pain as a disease in the new International Classification of Diseases (ICD-11): Latin American expert consensus.

Aims: Pain diagnoses in the 10th version of the International Classification of Diseases (ICD-10) did not adequately support the current management of pain. Therefore, we aimed to review the new 11th revision (ICD-11) in order to analyze its usefulness for the management, coding, research and education of chronic pain from a Latin American perspective. Methods: The Latin American Federation of Associations for the Study of Pain convened a meeting of pain experts in Lima, Peru. Pain specialists from 14 Latin American countries attended the consensus meeting. Results: In ICD-11, chronic pain is defined as pain that persists or recurs longer than 3 months and is subdivided into seven categories: chronic primary pain and six types of chronic secondary pain. Chronic primary pain is now considered a disease in itself, and not a mere symptom of an underlying disease. Conclusion: The novel definition and classification of chronic pain in ICD-11 is helpful for better medical care, research and health statistics. ICD-11 will improve chronic pain management in Latin American countries, for both the pain specialist and the primary care physician.

Chronic pain is one of the most frequent reasons for medical consultation in Latin America. In the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10), chronic pain was not adequately defined and individual pain diagnoses were poorly defined. For the first time in Latin America, a meeting of pain experts analyzed and reviewed the 11th version of the International Classification of Diseases (ICD-11), when the Latin America Federation of Associations for the Study of Pain organized a meeting of experts from 14 Latin American countries. In ICD-11, chronic pain is recognized as a biopsychosocial phenomenon and defined as pain that continues or returns for more than 3 months. It is split into seven types: chronic primary pain and six types of chronic secondary pain. In ICD-11, chronic primary pain is now considered a disease in itself, not a mere manifestation of other disease. Our article is the first to address the problems, challenges and benefits of using ICD-11 from a Latin American perspective. It will help to facilitate and disseminate the use of this new classification of chronic pain. This will improve chronic pain treatment, statistics, research and development of better health strategies for pain management in Latin America.

Practical aspects of the use of medicinal cannabis in chronic pain / Aspectos práticos do uso da cannabis medicinal em dor crônica

ABSTRACT BACKGROUND AND OBJECTIVES: Evidence has revealed an important role in the use of medical cannabis, and the interaction of the endocannabinoid system with other drugs for the treatment of chronic neuropathic and nociplastic pain. The objective of this review is to bring an update on published data on doses and care with the use of cannabinoids that demonstrate the interaction in the pathophysiology of chronic pain and its treatment. CONTENTS: A research-based review was carried out in the MEDLINE, PUBMED database using the keywords "cannabis and pain", "endocannabinoid"; "neuropathic pain"; "nociplastic pain"; "drug interactions". CONCLUSION: Drug interaction with cannabinoids requires further scientific knowledge and doses are individual, which makes it difficult to create a protocol for treatment.

RESUMO JUSTIFICATIVA E OBJETIVOS: As evidências têm revelado um papel importante sobre o uso da cannabis medicinal e da interação do sistema endocanabinoide com outros fármacos para o tratamento de dor crônica neuropática e nociplástica. O objetivo deste estudo foi prover atualização sobre os dados publicados quanto a doses e cuidados com o uso dos canabinoides que mostrem interação na fisiopatologia da dor crônica e seu tratamento. CONTEÚDO: Foi realizada uma revisão baseada em pesquisa na base de dados Medline, Pubmed com uso dos unitermos "cannabis e dor", "endocannabinoid", "neuropathic pain", "nociplastic pain" e "drug interactions". CONCLUSÃO: A interação farmacológica com os canabinoides requer aprofundamento do conhecimento científico e as doses são individuais, o que dificulta a criação de um protocolo para tratamento.

Cannabinoids for the treatment of autism and childhood epilepsy / Canabinoides no tratamento do autismo e epilepsia infantil

ABSTRACT BACKGROUND AND OBJECTIVES: Epilepsy and autism spectrum disorder (ASD) are diseases with neuropsychiatric impairment, which, depending on their clinical presentation, can be treated with medical cannabis. The objective of this work is to present a brief review of the literature on the use of cannabinoids (CNB) in the management of ASD and epilepsy. CONTENTS: The elaboration of this review was made from search and selection. Searches were carried out in the following databases: LILACS, Medline via Pubmed, Scielo and Cochrane Library, published from January 2010 to December 2022. CONCLUSION: The use of CNB, both for epilepsy and for ASD, has been shown to be safe, however actual effectiveness has yet to be proven.

RESUMO JUSTIFICATIVA E OBJETIVOS: A epilepsia e o transtorno do espectro do autismo (TEA) são doenças com comprometimento neuropsiquiátrico, os quais, dependendo da sua apresentação clínica, podem ser tratados com a cannabis medicinal. O objetivo deste estudo foi apresentar uma breve revisão da literatura sobre o uso de canabinoides (CNB) no manejo do TEA e da epilepsia. CONTEÚDO: A elaboração desta revisão foi feita a partir de busca e seleção. Foram realizadas buscas nas bases de dados: LILACS, Medline via Pubmed, Scielo e Cochrane Library, publicados no período de janeiro de 2010 a dezembro de 2022. CONCLUSÃO: O uso dos CNB, tanto para epilepsia quanto para o TEA, tem se mostrado seguro, porém a real eficácia ainda não foi comprovada.

Transfusion Practices in Gastrointestinal Bleeding - a Tertiary Care Single-Centre Analysis.

Acute upper or lower Gastrointestinal bleeding (GIB) is a clinical emergency in which transfusion can be lifesaving. An individualized and restrictive transfusion strategy is recommended. This study aims to analyze and evaluate GIB transfusion practices during one year in a large tertiary hospital in Lisbon, Portugal. All patients with GIB and transfusion support during 2014 were identified and clinical data collected and statistically treated. There were 1005 GIB transfusion episodes, in a total of 494 patients. Upper GIB was more common. The median haemoglobin concentration that triggered RBC transfusion was 7,6 g/dL with a median of 2 RBC per episode. In 21,9% of episodes, RBC were used in combination with other therapies, in 70,8%, only RBC were administered and in 7,3% RBC were not used at all. In the subgroup of patients receiving FC and/or PCC there were higher median of blood products transfused: RBC (3 17 units), FFP (3 units), PC (1 unit). In a large percentage of the transfusion episodes for GIB, only RBC were used whereas only 7,3% of the GIB didn't require RBC transfusion. Patients requiring FC and/or PCC, needed more allogenic components. We observed, in accordance with the latest clinical practice guidelines and the published literature, a restrictive transfusion approach in our clinical practice.

Interventional Algorithm in Gastrointestinal Bleeding-An Expert Consensus Multimodal Approach Based on a Multidisciplinary Team.

The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.

Experimental models for the study of neuropathic pain / Modelos experimentais para o estudo da dor neuropática

ABSTRACT BACKGROUND AND OBJECTIVES: Ideal models should reproduce just sensory deficits, such as alodynia, hyperalgesia and spontaneous pain for short periods. There are different types of animal models to evaluate different neuropathic pain etiologies and manifestations. Some models study neuropathic pain peripheral mechanisms and other study its central mechanisms. This review focuses on animal models most commonly used for neuropathic pain research. CONTENTS: Animal models based on peripheral nerves ligation which are more commonly used are described. From all models described in this review, spared nerve injury is that producing more reproducible behavioral abnormalities for a longer period, while chronic sciatic nerve compression produces behavioral signs of less predictable painful neuropathies. Spinal hemisection and cytokines-induced spinal injury are the models of choice for the study of central pain mechanisms. Other specific models are used for the study of the specific etiology of pain. CONCLUSION: Since neuropathic pain is multifactorial, different neuropathic pain animal models were developed throughout the years, which have been critical for the study of neuropathic pain, since much of current knowledge comes from studies with rats and mice. Current animal models need to be further refined and more efforts should be made to determine which animal models may be more predictive, with less biases and more complex and objective analysis parameters.

RESUMO JUSTIFICATIVA E OBJETIVOS: Os modelos ideais deveriam reproduzir apenas déficits sensitivos, como alodínea, hiperalgesia e dor espontânea por curtos períodos de tempo. Existem diversos tipos de modelos animais, que avaliam as diversas etiologias e manifestações da dor neuropática. Alguns modelos estudam os mecanismos periféricos e outros estudam mecanismos centrais da dor neuropática. Esta revisão enfoca os modelos animais mais comumente utilizados para pesquisa em dor neuropática. CONTEÚDO: São descritos modelos animais baseados em ligadura de nervos periféricos que são mais comumente empregados. De todos os modelos descritos nesta revisão, a lesão poupadora de nervo é aquela que produz anormalidades comportamentais mais reprodutíveis, por um período mais longo, ao passo que a constrição crônica do ciático produz sinais comportamentais de neuropatia dolorosas menos previsíveis. Hemisecção espinhal e lesão espinhal induzida por citocinas são os modelos de escolha para estudar mecanismos de dor central. Outros modelos específicos são utilizados para estudo da etiologia específica da condição dolorosa. CONCLUSÃO: Como a dor neuropática é multifatorial, diferentes modelos animais de dor neuropática foram desenvolvidos ao longo dos anos que têm sido fundamentais para o estudo da dor neuropática, uma vez que muito do conhecimento atual provém de estudos em ratos e camundongos. São necessários maiores refinamentos nos modelos animais atualmente empregados e mais esforços para determinar quais modelos animais podem ser mais preditivos, com menos vieses e com parâmetros de análises mais complexos e objetivos.