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1.
Pain Physician ; 24(2): 175-184, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33740353

RESUMO

BACKGROUND: Insulin resistance (IR) is a pathological condition in which cells fail to respond normally to insulin. IR has been associated with multiple conditions, including chronic pain. Fibromyalgia (FM) is one of the common generalized chronic painful conditions with an incidence rate affecting 3% to 6% of the population. Substantial interest and investigation into FM continue to generate  many hypotheses.The relationship between IR and FM has not been explored. IR is known to cause abnormalities in the cerebral microvasculature, leading to focal hypoperfusion. IR also has been shown to cause cognitive impairment in FM patients, as in parkinsonism. As demonstrated by advanced imaging methods, similar brain perfusion abnormalities occur in the brain of patients with FM as with IR. OBJECTIVES: To determine the potential association between FM and IR. SETTING: Subspecialty pain medicine clinics. STUDY DESIGN: Observational cross-sectional study. METHODS: Laboratory data was extracted through a retrospective review of medical records from patients who had met the American College of Rheumatology (ACR) criteria for FM. The Hemoglobin A1c (HbA1c) values from 33 patients with FM were compared with the means of the glycated HbA1c levels of 2 control populations. In addition, established indices of IR [Quantitative Insulin Sensitivity Check Index (QUICKI) and the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR)] were calculated in a subgroup of patients in whom the analytes necessary for these calculations were available. To assess for confounding factors, the associations between HbA1c, QUICKI, HOMA-IR, fasting insulin levels, and glucose, after controlling for age, were explored by multiple analyses of variance with relation to gender and ethnicity. RESULTS: We found an association between IR and FM that was independent of age, gender, and ethnicity. We found that patients with FM belong to a distinct population that can be segregated from the control groups by their HbA1c levels, a surrogate marker of IR. This was demonstrated by analyzing the data after introducing an age correction into a linear regression model. This strategy showed significant differences between patients with FM and control subjects (P < 0.0001 and P  = 0.0002, for 2 separate control populations, respectively). A subgroup analysis using the QUICKI and HOMA-IR showed that all patients with FM in this subgroup (100%) exhibited laboratory abnormalities pointing to IR. LIMITATIONS: Small observational cross-sectional study. There are also intrinsic limitations that are attributed to cross-sectional studies. CONCLUSION: The association demonstrated in this study warrant further investigation, including the pursuit of randomized, double-blind clinical trials to determine the effect of improving insulin sensitivity in FM related pain scores. Such studies could unveil a potential pathogenetic relationship between FM, central pain, and IR. Based on these initial findings, we present the hypothesis that IR may underlie pathological mechanisms leading to central pain. If confirmed, this may lead to a paradigm shift in the management of central pain.

2.
Pain Physician ; 24(S1): S27-S208, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33492918

RESUMO

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and  recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.

3.
Korean J Anesthesiol ; 73(2): 163-168, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31475505

RESUMO

BACKGROUND: Acute post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration measured in multiple weeks. CASE: We report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy. Across all postoperative days and all three patients, the mean pain score on the numeric rating scale was 0 for each day. Similarly, no patient required any supplemental opioid analgesics during the entire postoperative period; and, no patient reported insomnia or awakenings due to pain at any time point. This was a significant improvement over historic cohorts. CONCLUSIONS: Ultrasound-guided percutaneous cryoanalgesia is a potential novel analgesic modality for acute pain management which has a duration that better-matches mastectomy than other currently-described techniques. Appropriately powered randomized, controlled clinical trials are required to demonstrate and quantify both potential benefits and risks.

4.
PLoS One ; 14(5): e0216079, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31059525

RESUMO

Fibromyalgia (FM) is one of the most frequent generalized pain disorders with poorly understood neurobiological mechanisms. This condition accounts for an enormous proportion of healthcare costs. Despite extensive research, the etiology of FM is unknown and thus, there is no disease modifying therapy available for this condition. We show that most (if not all) patients with FM belong to a distinct population that can be segregated from a control group by their glycated hemoglobin A1c (HbA1c) levels, a surrogate marker of insulin resistance (IR). This was demonstrated by analyzing the data after introducing an age stratification correction into a linear regression model. This strategy showed highly significant differences between FM patients and control subjects (p < 0.0001 and p = 0.0002, for two separate control populations, respectively). A subgroup of patients meeting criteria for pre-diabetes or diabetes (patients with HbA1c values of 5.7% or greater) who had undergone treatment with metformin showed dramatic improvements of their widespread myofascial pain, as shown by their scores using a pre and post-treatment numerical pain rating scale (NPRS) for evaluation. Although preliminary, these findings suggest a pathogenetic relationship between FM and IR, which may lead to a radical paradigm shift in the management of this disorder.

5.
Pain Physician ; 22(1S): S1-S74, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30717500

RESUMO

BACKGROUND: Regenerative medicine is a medical subspecialty that seeks to recruit and enhance the body's own inherent healing armamentarium in the treatment of patient pathology. This therapy's intention is to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous or allogenic biologics. This field is rising like a Phoenix from the ashes of underperforming conventional therapy midst the hopes and high expectations of patients and medical personnel alike. But, because this is a relatively new area of medicine that has yet to substantiate its outcomes, care must be taken in its public presentation and promises as well as in its use. OBJECTIVE: To provide guidance for the responsible, safe, and effective use of biologic therapy in the lumbar spine. To present a template on which to build standardized therapies using biologics. To ground potential administrators of biologics in the knowledge of the current outcome statistics and to stimulate those interested in providing biologic therapy to participate in high quality research that will ultimately promote and further advance this area of medicine. METHODS: The methodology used has included the development of objectives and key questions. A panel of experts from various medical specialties and subspecialties as well as differing regions collaborated in the formation of these guidelines and submitted (if any) their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these guidelines. The literature pertaining to regenerative medicine, its effectiveness, and adverse consequences was thoroughly reviewed using a best evidence synthesis of the available literature. The grading for recommendation was provided as described by the Agency for Healthcare Research and Quality (AHRQ). SUMMARY OF EVIDENCE: Lumbar Disc Injections: Based on the available evidence regarding the use of platelet-rich plasma (PRP), including one high-quality randomized controlled trial (RCT), multiple moderate-quality observational studies, a single-arm meta-analysis and evidence from a systematic review, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best-evidence synthesis. Based on the available evidence regarding the use of medicinal signaling/ mesenchymal stem cell (MSCs) with a high-quality RCT, multiple moderate-quality observational studies, a single-arm meta-analysis, and 2 systematic reviews, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Epidural Injections Based on one high-quality RCT, multiple relevant moderate-quality observational studies and a single-arm meta-analysis, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Facet Joint Injections Based on one high-quality RCT and 2 moderate-quality observational studies, the qualitative evidence for facet joint injections with PRP has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Sacroiliac Joint Injection Based on one high-quality RCT, one moderate-quality observational study, and one low-quality case report, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. CONCLUSION: Based on the evidence synthesis summarized above, there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient's needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient's medical history. Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy. Multiple guidelines from the Food and Drug Administration (FDA), potential limitations in the use of biologic therapy and the appropriate requirements for compliance with the FDA have been detailed in these guidelines. KEY WORDS: Regenerative medicine, platelet-rich plasma, medicinal signaling cells, mesenchymal stem cells, stromal vascular fraction, bone marrow concentrate, chronic low back pain, discogenic pain, facet joint pain, Food and Drug Administration, minimal manipulation, evidence synthesis.


Assuntos
Produtos Biológicos/uso terapêutico , Dor Lombar/terapia , Manejo da Dor/métodos , Manejo da Dor/normas , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medicina Regenerativa/métodos , Medicina Regenerativa/normas
6.
Pain Physician ; 22(1): E15-E36, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30700076

RESUMO

BACKGROUND: Temple headaches are common, yet the anatomic etiology of headaches in this region is often confusing. One possible cause of temple headaches is dysfunction of the auriculotemporal nerve (ATN), a branch of the third division of the trigeminal nerve. However, the site of pain is often anterior to the described path of the ATN, and corresponds more closely to a portion of the path of a small branch of the second division of the trigeminal nerve called the zygomaticotemporal nerve (ZTN). OBJECTIVES: We present the anatomic and clinical differences between these 2 nerves and describe treatment approaches. Diagnosis is made by physical examination of the temporal fossa and the temporomandibular joint, and injection of local anesthetic over the tenderest nerve. RESULTS: In general, treatments of headaches that generated from the peripheral nerve attempt to neutralize the pain origin using surgical or interventional pain techniques to reduce nerve irritation and subsequently deactivate stimulated migraine centers. CONCLUSIONS: Treatment of temporal nerve entrapment includes medications, nerve injections, dental appliances, cryoneuroablation, chemical neurolysis, neuromodulation, and surgical decompression. KEY WORDS: Headache, migraine, trigeminal nerve, Frey's syndrome, zygomaticotemporal nerve, auriculotemporal nerve, temple pain, jaw pain, ear pain, tooth pain.


Assuntos
Cefaleia/etiologia , Síndromes de Compressão Nervosa/complicações , Nervo Trigêmeo/patologia , Humanos , Masculino
7.
A A Pract ; 12(7): 231-234, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30234513

RESUMO

Pain after limb amputation is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration. Furthermore, uncontrolled pain in the immediate postoperative period is associated with persistent postsurgical pain, and frequently phantom limb pain. Cryoneurolysis is an alternative regional analgesic method to local anesthesia-based techniques. We report 3 cases in which ultrasound-guided percutaneous cryoneurolysis was performed in the perioperative period of limb amputation. All reported profound analgesia in the postoperative period without persistent postsurgical residual limb or phantom pain in the following months. No adverse events associated with the cryoneurolysis procedure occurred.


Assuntos
Crioterapia/instrumentação , Bloqueio Nervoso/métodos , Manejo da Dor/instrumentação , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Membro Fantasma/terapia , Ultrassonografia/instrumentação , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade
8.
Korean J Anesthesiol ; 70(5): 567-570, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29046778

RESUMO

Cryoneurolysis entails using low temperatures to reversibly ablate nerves, with a subsequent analgesia duration measured in weeks or months. Previously, clinical applications for acute pain were limited because treatment originally required exposing the target nerve surgically. However, three developments have now made it possible to provide prolonged postoperative analgesia by cryoneurolysis: 1) new portable, hand-held cryoneurolysis devices, 2) ultrasound machine proliferation, and, 3) anesthesiologists trained in ultrasound-guided peripheral nerve block administration. This report is the first to describe the use of a single preoperative administration of ultrasound-guided percutaneous cryoneurolysis to provide multiple weeks of analgesia following shoulder rotator cuff repair and total knee arthroplasty. Considering the significant benefits of cryoanalgesia relative to continuous peripheral nerve blocks (e.g., lack of catheter/pump care, extremely long duration), this analgesic modality may be a practical alternative for the treatment of prolonged post-surgical pain in a select group of surgical patients.

9.
A A Case Rep ; 9(5): 129-132, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28509777

RESUMO

We report 3 different cases in which ultrasound-guided percutaneous cryoneurolysis was performed to treat acute pain: 1 patient with refractory incisional pain after percutaneous nephrolithotomy; 1 patient with burns to the foot; and 1 patient with pain from iliac crest grafting. Acute pain associated with surgery or injury is a challenge to treat with local anesthetic-based regional anesthesia techniques when the anticipated pain duration exceeds a few days. Cryoneurolysis is an alternative analgesic method that utilizes extremely cold temperatures to reversibly ablate peripheral nerves and is potentially a novel method for acute pain management.


Assuntos
Dor Aguda/terapia , Criocirurgia/instrumentação , Bloqueio Nervoso/métodos , Dor Aguda/etiologia , Temperatura Baixa , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/instrumentação , Resultado do Tratamento , Ultrassonografia
10.
Pain Physician ; 20(2): E221-E231, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28158159

RESUMO

BACKGROUND: Minimally invasive surgery (MIS) technique is becoming the standard tissue sparing approach for decompression of lumbar central and lateral recess stenosis, intervertebral disc herniation, or any situation that would have required extensive open decompression laminectomy. Full-endoscopic or arthroscopic assisted surgery is arguably the "ultra-MIS" approach to lumbar spinal pathology. Age and body mass index (BMI) are significant risk factors to be considered in full-endoscopic assisted ultra-MIS. With limited medical literature published on complication rates for MIS, reports on the ultra-MIS approach are even scarcer for free-standing, outpatient ambulatory settings. OBJECTIVES: The primary goal of this study is to compare outcomes for full-endoscopic assisted ultra-MIS lumbar decompression surgical techniques, performed in a free-standing, outpatient ambulatory facility, with other spine surgery techniques. STUDY DESIGN: This is a Western Institutional Review Board (WIRB)-approved retrospective review of prospectively collected patient demographic and outcomes data for full-endoscopic assisted interlaminar and transforaminal lumbar decompressive surgery. SETTING: Free-standing, outpatient ambulatory surgery facility. METHODS: A population of 178 patients, whose age ranged between 16 and 90 years old (mean 45.5 years), with a variety of clinical presentation of symptoms underwent lumbar decompressive surgery using an interlaminar or transforaminal full-endoscopic assisted approach between January 2011 and December 2015. Operative (OR) time, complication rates, estimated blood loss, preoperative and postoperative leg and back VAS, and patient satisfaction ratings at 6, 9, and 12 months post operation are reported. RESULTS: Age is a significant predictor of OR time; older patients generally have longer surgeries. BMI does not have statistically significant effect on OR time; heavier patients have similar OR time as other cohorts. There were no reportable intra-operative complications in this series of 178 patients. There were 3 major (1.69%) and three 3 (1.69%) postoperative complications. The 3 major complications were all incidences of early postoperative reherniation that resulted in re-operation. The minor complications included 2 cases of sympathetically mediated pain syndrome and one case of postanesthetic transient urinary retention. About 95% of patients had less than 5 mL of blood loss. No patients lost more than 35 mL of blood during surgery. Visual analog scale (VAS) score dropped from 7 to 3, on a scale of 0 to 10 with 10 being the worst pain imaginable, within 2 months postoperative. On average, 70% to 80% of patients were satisfied or greatly satisfied with the surgery, and 85% to 92% of patients would recommend this type of surgery. LIMITATIONS: Retrospective study. CONCLUSIONS: Full-endoscopic assisted ultra-MIS technique is a viable option for lumbar decompressive surgery in a free-standing, outpatient ambulatory facility. The patient population in this study demonstrates its safety, efficacy, and effectiveness for treatment of various lumbar pathologies. It is particularly relevant that age and obesity are not contra-indications.Key words: Full-endoscopic, minimally invasive spine surgery, postoperative complications, lumbar discectomy, lumbar decompression, lumbar disc herniation, spinal stenosis, endoscopic discectomy, ultra-MIS, arthroscopic.


Assuntos
Descompressão Cirúrgica , Vértebras Lombares , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Pacientes Ambulatoriais , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
11.
Pain Physician ; 20(2S): S3-S92, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28226332

RESUMO

BACKGROUND: Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use. OBJECTIVES: To provide guidance for the prescription of opioids for the management of chronic non-cancer pain, to develop a consistent philosophy among the many diverse groups with an interest in opioid use as to how appropriately prescribe opioids, to improve the treatment of chronic non-cancer pain and to reduce the likelihood of drug abuse and diversion. These guidelines are intended to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique. METHODS: The methodology utilized included the development of objectives and key questions. The methodology also utilized trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various specialties and groups. The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed, with a best evidence synthesis of the available literature, and utilized grading for recommendation as described by the Agency for Healthcare Research and Quality (AHRQ).Summary of Recommendations:i. Initial Steps of Opioid Therapy 1. Comprehensive assessment and documentation. (Evidence: Level I; Strength of Recommendation: Strong) 2. Screening for opioid abuse to identify opioid abusers. (Evidence: Level II-III; Strength of Recommendation: Moderate) 3. Utilization of prescription drug monitoring programs (PDMPs). (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 4. Utilization of urine drug testing (UDT). (Evidence: Level II; Strength of Recommendation: Moderate) 5. Establish appropriate physical diagnosis and psychological diagnosis if available. (Evidence: Level I; Strength of Recommendation: Strong) 6. Consider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints. (Evidence: Level III; Strength of Recommendation: Moderate) 7. Establish medical necessity based on average moderate to severe (≥ 4 on a scale of 0 - 10) pain and/or disability. (Evidence: Level II; Strength of Recommendation: Moderate) 8. Stratify patients based on risk. (Evidence: Level I-II; Strength of Recommendation: Moderate) 9. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: Level I-II; Strength of Recommendation: Moderate) 10. Obtain a robust opioid agreement, which is followed by all parties. (Evidence: Level III; Strength of Recommendation: Moderate)ii. Assessment of Effectiveness of Long-Term Opioid Therapy 11. Initiate opioid therapy with low dose, short-acting drugs, with appropriate monitoring. (Evidence: Level II; Strength of Recommendation: Moderate) 12. Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME as a moderate dose, and greater than 91 MME as high dose. (Evidence: Level II; Strength of Recommendation: Moderate) 13. Avoid long-acting opioids for the initiation of opioid therapy. (Evidence: Level I; Strength of Recommendation: Strong) 14. Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses, within FDA recommended doses. (Evidence: Level I; Strength of Recommendation: Strong) 15. Understand and educate the patients of the effectiveness and adverse consequences. (Evidence: Level I; Strength of Recommendation: Strong) 16. Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids. (Evidence: Level I-II; Strength of recommendation: Moderate to strong) 17. Periodically assess pain relief and/or functional status improvement of ≥ 30% without adverse consequences. (Evidence: Level II; Strength of recommendation: Moderate) 18. Recommend long-acting or high dose opioids only in specific circumstances with severe intractable pain. (Evidence: Level I; Strength of Recommendation: Strong)iii. Monitoring for Adherence and Side Effects 19. Monitor for adherence, abuse, and noncompliance by UDT and PDMPs. (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 20. Monitor patients on methadone with an electrocardiogram periodically. (Evidence: Level I; Strength of Recommendation: Strong). 21. Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated. (Evidence: Level I; Strength of Recommendation: Strong)iv. Final Phase 22. May continue with monitoring with continued medical necessity, with appropriate outcomes. (Evidence: Level I-II; Strength of Recommendation: Moderate) 23. Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation. (Evidence: Level III; Strength of Recommendation: Moderate) CONCLUSIONS: These guidelines were developed based on comprehensive review of the literature, consensus among the panelists, in consonance with patient preferences, shared decision-making, and practice patterns with limited evidence, based on randomized controlled trials (RCTs) to improve pain and function in chronic non-cancer pain on a long-term basis. Consequently, chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events.Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversionDisclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Prescrições de Medicamentos , Dor/tratamento farmacológico , Dor Crônica/psicologia , Prescrições de Medicamentos/normas , Humanos , Dor/psicologia , Qualidade de Vida , Estados Unidos
12.
Expert Rev Med Devices ; 13(8): 713-25, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27333989

RESUMO

INTRODUCTION: Cryoneurolysis is the direct application of low temperatures to reversibly ablate peripheral nerves to provide pain relief. Recent development of a handheld cryoneurolysis device with small gauge probes and an integrated skin warmer broadens the clinical applications to include treatment of superficial nerves, further enabling treatments for pre-operative pain, post-surgical pain, chronic pain, and muscle movement disorders. AREAS COVERED: Cryoneurolysis is the direct application of cold temperatures to a peripheral nerve, resulting in reversible ablation due to Wallerian degeneration and nerve regeneration. Use over the last 50 years attests to a very low incidence of complications and adverse effects. Cryoprobes have traditionally been applied through a surgical incision; but, recent technical advances allow percutaneous administration. A new hand-held device is now approved for use within the United States. Cryoneurolysis has been used to treat postoperative and chronic pain states as well as spasticity. Expert commentary: Changes in the US healthcare system such as a push for the reduction of opioid use and the incorporation of Diagnostic Related Group codes, as well as recent technological advances including a handheld unit that allows for treatment of superficial nerves while protecting the skin from damage, may contribute to the resurgence of cryoneurolysis for the treatment of peripheral nerves.


Assuntos
Criocirurgia/instrumentação , Neurônios Motores/patologia , Nervos Periféricos/patologia , Células Receptoras Sensoriais/patologia , Animais , Ensaios Clínicos como Assunto , Criocirurgia/efeitos adversos , Humanos , Reprodutibilidade dos Testes
13.
Pain Physician ; 18(3): E307-22, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26000678

RESUMO

BACKGROUND: Available data have shown steady increases of drug overdose deaths between 1992 and 2011. We review evidenced-based recommendations provided by a few prominent North American pain societies and suggest ways on how health providers might help reduce opioid analgesic deaths by implementing these practices. OBJECTIVE: To identify health care providers' roles in reducing opioid analgesic deaths. STUDY DESIGN: A comprehensive review of current literature. METHODS: The review included relevant literature identified through searches of MEDLINE, Cochran reviews, and Google Scholar, PubMed and EMBASE from January 1998 to January 2014. The level of evidence was classified as I (good), II (fair), and III (limited) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). RESULTS: Several practices such as too high doses overall, giving too high doses to opioid naive patients, too fast opioid titration, insufficient use and knowledge of urine drug testing, not updating knowledge of drug metabolism/interactions, and inadequate patient monitoring are associated with higher risks of opioid analgesic deaths. Suboptimal risk stratification of patients, rotation practices, and use of opioids analgesics in chronic noncancer pain are also associated factors. LIMITATIONS: There were a paucity of good evidence studies which show recommendations reduce death. CONCLUSION: Providers should be aware of all associated factors with opiate analgesic deaths and apply the available evidence in reducing opioid analgesic deaths.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Dor Crônica/mortalidade , Overdose de Drogas/mortalidade , Pessoal de Saúde , Analgésicos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/prevenção & controle , Pessoal de Saúde/normas , Humanos , Dor/tratamento farmacológico , Dor/mortalidade , Detecção do Abuso de Substâncias/métodos , Detecção do Abuso de Substâncias/mortalidade , Detecção do Abuso de Substâncias/normas , Estados Unidos/epidemiologia
14.
Pain Physician ; 17(5): 425-45, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25247900

RESUMO

BACKGROUND: Pain clinicians have always been challenged by the variability of response to pain treatment. Differences in the degree of pain stimulation and pain sensitivity, weight and age differences, prior opioid use and tolerance, as well as the differences in bioavailability of various opioid formulations have been cited as causes for the wide variability in analgesia seen with opioids. Genetics may explain the variability of responses and help to predict more effective (or less dangerous) medication choices and doses. Genetics may also help to predict the response to specific opioids and antidepressants. OBJECTIVES: In this review article, we discuss the genetic influence of nociception, analgesia, and hyoanalgesia. The CYP450 enzymes involved in the metabolism and activity of opioids and adjuvant analgesics are genetically controlled, as are the opioid receptors and a variety of brain chemistries. METHODS: This article discusses the specific pain implications of genetic variations in CYP1A2, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP3A4, CYP3A7, OPRM1, OPRK1, OPRD1, COMT, GABA, UGT, MC1R, GCH1, ABCB1, P-glycoprotein, 5HTR1A, 5HTR2A, MTHFR, CACNA2D2, and 5-HTTLPR. RESULTS: Recent research findings suggest the relationship between genetic predisposition and clinical behavior, including the risk of opioid misuse and addiction. While urine drug testing may hint at genetic issues regarding opioid metabolism, cheek swab DNA testing has become economically viable, and we review the current and future genetic pain issues that may influence the decisions that pain clinicians make every day. CONCLUSION: Genetic testing may explain and predict many of the clinical responses seen with opioids and adjuvant medications, and may help the clinician identify those patients at genetic risk of opioid misuse and addiction.


Assuntos
Analgésicos Opioides/metabolismo , Testes Genéticos/normas , Transtornos Relacionados ao Uso de Opioides/genética , Manejo da Dor/normas , Dor/genética , Humanos
16.
Pain Physician ; 17(4): E509-24, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25054401

RESUMO

BACKGROUND: The superiority of transforaminal epidural steroid injections (TFESI) vs. interlaminar epidural steroid injections (ILESI) for treating unilateral lumbosacral radicular pain (LSRP) is unproven. OBJECTIVE: To assess studies comparing TFESI to ILESI for unilateral LSRP for pain relief and functional improvement. STUDY DESIGN: Systematic review of comparative studies. METHODS: A systematic literature search was conducted using the Cochrane Central Register of Controlled Trials, PubMed, and Scopus databases for trials reported in English. Studies meeting the Cochrane Review criteria for randomized trials and the AHCQ criteria for observational studies were included. Evidence was graded using the USPSTF classification. RESULTS: Five (prospective) and 3 (retrospective) studies were included assessing 506 patients. Statistical analysis was calculated only utilizing the 5 prospective studies and consisted of 249 patients with an average of 3.2 months follow-up. In the short-term (2 weeks), there was a 15% difference favoring TFESI vs. ILESI for pain relief. There was no efficacy difference at one or 6 months. Combined pain improvements in all 5 prospective studies revealed < 20% difference between TFESI and ILESI (54.1% vs. 42.7%). There was slightly better functional improvement in ILESI groups (56.4%) vs. TFESI groups (49.4%) at 2 weeks. Combined data showed slight differences (TFESI 40.1% and ILESI 44.8%). LIMITATIONS: The limitations of this systematic review include the relative paucity of comparative studies. CONCLUSIONS: The findings show that both TFESI and ILESI are effective in reducing pain and improving functional scores in unilateral LSRP. In the treatment of pain, TFESI demonstrated non-clinically significant superiority to ILESI only at the 2-week follow-up. Based on 2 studies, ILESI demonstrated non-clinically significant superiority to TFESI in functional improvement.


Assuntos
Glucocorticoides/administração & dosagem , Injeções Epidurais/métodos , Dor Lombar/tratamento farmacológico , Radiculopatia/tratamento farmacológico , Humanos , Região Lombossacral
17.
Best Pract Res Clin Anaesthesiol ; 28(2): 153-66, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24993436

RESUMO

The wide range of patient responses to surgical pain, opioids, and anesthetic agents has puzzled anesthesiologists for many years. Much of the variation has been attributed to differences in patient size, technique, or prior drug use. However, recent genetic testing has revealed exciting clues into the basis for these variances, allowing us to start to predict which patients may have difficulties and start to select medications more rationally. In this manuscript, we discuss genetics and pain perception, genetic predisposition to pain, drug metabolism interactions, ethnogenetics, opioid metabolism, opioid receptors, genetic-related peri-anesthetic toxicity, as well as a clinical approach and a discussion regarding the future of genetic testing and anesthesia.


Assuntos
Analgesia/métodos , Analgésicos/uso terapêutico , Genética , Analgésicos/farmacocinética , Analgésicos/farmacologia , Analgésicos Opioides/metabolismo , Anestesia/efeitos adversos , Humanos , Dor/genética
18.
Pain Pract ; 14(1): 52-6, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23279331

RESUMO

The pathophysiology of phantom limb pain (PLP) is multifactorial. It probably starts in the periphery and is amplified and modified in the central nervous system. A small group of patients with PLP were questioned as to the portion of the phantom limb affected by pain (e.g., "great toe," "thumb"). In the stump, the corresponding amputated nerve was located with a nerve stimulator. With correct placement and stimulation, the PLP could then be reproduced or exacerbated. A small dose of local anesthesia was then injected, resulting in the disappearance of the PLP. If a peripheral nerve injection gave temporary relief, our final treatment was cryoanalgesia at this location. Evaluation of 5 patients, followed for at least 2.5 years, yielded the following results: 3 patients had excellent results (100%, 95%, and 90% decrease in complaints, respectively), 1 patient had an acceptable result (40% decrease), and 1 patient had only a 20% decrease in pain. Although both central and peripheral components are likely involved in PLP, treatment of a peripheral pain locus with cryoanalgesia should be considered. We propose the identification of a peripheral etiology may help match patients to an appropriate therapy, and cryoanalgesia may result in long-term relief of PLP.


Assuntos
Cotos de Amputação/inervação , Cotos de Amputação/cirurgia , Criocirurgia/métodos , Medição da Dor/métodos , Membro Fantasma/diagnóstico , Membro Fantasma/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
20.
Pain Physician ; 16(3): E315-24, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23703431

RESUMO

Persistent anterior knee pain, especially after surgery, can be very frustrating for the patient and the clinician. Injury to the infrapatellar branch of the saphenous nerve (IPS) is not uncommon after knee surgeries and trauma, yet the diagnosis and treatment of IPS neuralgia is not usually taught in pain training programs. In this case report, we describe the anatomy of the saphenous nerve and specifically the infrapatellar saphenous nerve branch; we also discuss the types of surgical trauma, the clinical presentation, the diagnostic modalities, the diagnostic injection technique, and the treatment options. As early as 1945, surgeons were cautioned regarding the potential surgical trauma to the IPS. Although many authors dismissed the nerve damage as unavoidable, the IPS is now recognized as a potential cause of persistent anterior and anteriomedial knee pain. Even more concerning, damage to peripheral nerves such as the IPS has been identified as the cause and potential perpetuating factor for conditions such as complex regional pain syndromes (CRPS). Because the clinical presentation may be vague, it has often been misdiagnosed and underdiagnosed. There is a documented vasomotor instability, but, unfortunately, sympathetic blocks will not address the underlying pathology, and therefore patients often will not respond to this modality, although the correct diagnosis can lead to rapid and gratifying resolution of the pathology. An entity unknown to the clinician is never diagnosed, and so it is important to familiarize pain physicians with IPS neuropathy so that they may be able to offer assistance when this painful condition arises.


Assuntos
Articulação do Joelho/patologia , Neuralgia/diagnóstico , Neuralgia/cirurgia , Nervos Periféricos/patologia , Idoso , Humanos , Masculino
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