Category Archives: Pain Management

Work-Enabling Opioid Management

Work-Enabling Opioid Management. – PubMed – NCBI – Aug 2017

OBJECTIVE: This study describes the relationship between opioid prescribing and ability to work.

METHODS: The opioid prescription patterns of 4994 claimants were studied.

This group is certainly large enough to draw conclusions from – and the scientifically proven conclusion is what we pain patients already know…   Continue reading

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Tapentadol for Some Kinds of Severe Chronic Pain

Tapentadol Extended Release in the Treatment of Severe Chronic Low Back Pain and Osteoarthritis Pain – Pain Ther. Jun 2018 – free full-text /PMC5993688/

Tapentadol is a novel pain reliever with apparently synergistic dual mechanisms of action, capable of addressing both nociceptive and neuropathic components of chronic pain.

From Wikipedia: Tapentadol (brand names: Nucynta, Palexia and Tapal) is a centrally acting opioid analgesic of the benzenoid class with a dual mode of action as an agonist of the μ-opioid receptor and as a norepinephrine reuptake inhibitor (NRI). Analgesia occurs within 32 minutes of oral administration, and lasts for 4–6 hours

As an effective analgesic with good tolerability, tapentadol may be appropriate for patients suffering from severe chronic pain associated with low back pain (LBP) or osteoarthritis (OA).   Continue reading

How Marijuana Affects Your Body and Mind – Links

Cannabis doesn’t give me pain relief as much as it gives me “mind relief”, but I know of some people who find it almost as effective as opioids. Below are a few articles explaining how this drug works and what side effects it may have:

 

Divide in Pain Mgmt Guidelines for Cancer Patients

Bridging the Critical Divide in Pain Management Guidelines From the CDC, NCCN, and ASCO for Cancer Survivors – May 31, 2018 – JAMA Oncol. – Salimah H. Meghani, PhD, MBE; Neha Vapiwala, MD

One of the most conspicuous omissions in clinical oncology is the failure to generate accumulated empirical evidence about long-term opioid therapy in patients with persistent cancer or treatment-related pain.

In response to the Centers for Disease Control and Prevention (CDC) opioid guideline for chronic pain, the American Society of Clinical Oncology (ASCO) noted that, despite the existence of multiple guidelines for pain management, evidence is lacking in many aspects of opioid use and studies on long-term opioid therapy in patients with cancer are sorely lacking.
Continue reading

Cancer vs Noncancer Pain: Shed the Distinction

Cancer vs Noncancer Pain: Time to Shed the Distinction? – Charles E. Argoff, MD – July 23, 2013

What exactly is the difference between chronic cancer-related pain and chronic non-cancer-related pain?

None: NO DIFFERENCE between cancer and non-cancer pain

are we helping ourselves by making a clear dichotomy when the dichotomy may not exist in a chronic setting? Let’s talk about acute pain related to cancer.  Continue reading

Without New Proteins, Chronic Pain Cannot Take Off

Lost in Translation: Without New Proteins, Chronic Pain Cannot Take Off – Pain Research Forum – by Nathan Fried – Feb 2018

A first-in-class RNA decoy blocks PABP from attaching to messenger RNA, preventing translation and pain sensitization.

Pain sensitivity after an injury, such as damage to a nerve or an inflammatory insult, involves the synthesis of new proteins in pain neurons.

This process is thought to play a role in the transition from acute to chronic pain, suggesting that blocking it may prevent chronic pain from developing in the first place. Now, a new paper reports a novel strategy to inhibit protein synthesis and stop pain in mice.   Continue reading

Opioid Antagonists in Chronic Pain Management

A Fresh Look at Opioid Antagonists in Chronic Pain Management – October 16, 2017 – By Dmitry M. Arbuck, MD

The article explains how these drugs are *not* effective for the pain from physical damage but are able to reduce the pain from neurological “central pain sensitization”.

As clinicians reduce their reliance on opioids for the treatment of pain, they are turning to a wider array of pharmacological tools and approaches to help overcome deficiencies of opioids, such as treatment-limiting side effects, and as aids in relieving difficult-to-treat pain conditions.

One such approach is the use of opioid antagonists. The use of opioid antagonists—in particular, naltrexone and naloxone—in chronic pain management is not new, but it deserves more recognition and acceptance than it enjoys presently.   Continue reading

Intractable Pain and a Lifetime of Pain Management

Intractable Pain – By Forest Tennant, MD, DrPH, John Liu, MD and Laura Hermann, RN, FNP – June 2018

Protocols for a lifetime of pain management for patients suffering constant, incurable, excrutiating, unrelenting pain.

The current thrust to humanely identify and treat pain is uncovering a group of patients with severe, chronic intractable pain (IP).

While epidemiologic surveys indicate that over 40% of the adult population has chronic, recurrent pain, mainly due to musculo-skeletal degenerative conditions, there is a sub-group of tragic individuals who suffer constant, excruciating, unrelenting pain.

Since IP patients always have an underlying, incurable disease or condition causing IP, their clinical management is complex and may require a specialized clinical setting.

Just as renal failure or insulin-dependent diabetes require lifetime care by a cadre of specialized medical personnel, IP likewise requires similar lifetime care due to its incurable nature.

Who Is the IP Patient?

The authors define IP as

“pain that is excruciating, constant, incurable, and of such severity that it dominates virtually every conscious moment, produces mental and physical debilitation and may produce a desire to commit suicide for the sole purpose of stopping the pain.”

In the authors’ clinical experience, bonafide IP patients suffer profusely and are fundamentally bed- or house-bound in the absence of intense medical management.

A variety of traumatic and medical conditions may be the underlying cause of IP (see Table 2). Note that over half of them involve spine degeneration.

Common Characteristics of the IP Patient

Underlying Causes of Intractable Pain in 100 Consecutive Patients

IP patients become identified as they systematically fail the usual treatments for acute and chronic pain including

  • anti-inflammatory,
  • mild opioid and non-opioid analgesics,
  • antidepressants,
  • muscle relaxants, and
  • anti-seizure medications.

They also don’t respond well to corticosteroid injections in and around the spinal column or peripheral nerves.

Physical therapy, exercise, and psychological interventions have usually been to little or no avail because the pain is so profoundly uncontrolled that participation in these therapies is not possible.

Potent opioid lifetime therapy is the only treatment to date that has proved to consistently control pain in these individuals. This treatment should be regarded as an end-stage or last resort due to its expense and inherent complications.

Obligation Of Documentation

This obligation rests on the patient and/or caretaker as well.

The physician and ancillary clinical staff must carefully document the presence of IP on the patient’s chart.

Not only do most states require documentation for legal purposes, medical management of IP is a lifetime treatment that utilizes potent medication having potentially deleterious complications.

At a minimum, the documentation must include medical records that reveal the presence of an incurable, painful condition and unsuccessful treatment attempts with the usual therapies for chronic, recurrent pain.

Patients, together with family members or caretakers who are required to accompany them to their appointments, need to provide a detailed history of the onset of IP and subsequent failed treatment attempts.

A physical examination is directed toward identifying physical evidence of the cause of pain and neuro-muscular abnormalities that are fixed, incurable, and irremovable.

IP, in an uncontrolled state, will invariably demonstrate physiologic or laboratory abnormalities, since IP causes over-excitation of the cardiovascular, autonomic, and hypothalamic-pituitary-adrenal systems.

Common physical signs and symptoms include tachycardia, hypertension, mydriasis, hyperreflexia, anxiety, and depression.

Goals Of Treatment

Once the diagnosis of IP is established, both immediate and short-term treatment goals should be quickly established.

Often, the undiagnosed or under-treated IP patient is so ill and bed-or chair-bound that diet, ambulation, and hygiene have been severely neglected.

Some uncontrolled IP patients make frequent visits to an emergency room just to obtain a modicum of relief.

Physicians should initially attempt to determine one opioid that family and patient report to be effective and prescribe this opioid in a dosage and frequency adequate enough to stop emergency room visits and allow the patient to ambulate, begin a proper diet, and attempt to return to normal activities of daily living.

Physiologic abnormalities such as tachycardia, hypertension, and altered adrenal hormone concentrations should be identified and serve as biologic markers to gauge treatment effectiveness

The long-term goals are to help the IP patient become ambulatory and be able to leave home to shop, socialize, and possibly work.

Psychiatric conditions, particularly depression and suicidal tendency should be treated.

A good quality of life, to the extent possible with medication, is the goal — rather than an impractical one, such as withdrawal from all medication or seeking a “miracle” treatment or the elusive cure. Life extension and improved quality of life is clearly possible if IP is controlled

Baseline pain is the constant, ever-present pain that is consciously perceived be the IP patient. A long-acting opioid is used to suppress baseline pain.

I thank God my EDS hasn’t progressed to the point that my pain is absolutely constant. Instead it usually “only” only hurts when I move my literally falling apart body (EDS means all my tissues are loose and fragile) and/or subject it to gravity’s force.

Occasionally and for days on end, something gets torn or twisted in my abdomen and then the resulting visceral pain becomes constant until the situation eventually resolves itself.

The following medications are available for this task: methadone, sustained-release morphine and oxycodone preparations, and transdermal fentanyl

My variety of pain locations and causes lead me to need mostly immediate-release opioid medication, but often just the downward pull of gravity causes nerves to be pinched between some bodily structures, like vertebrae, and that pain lasts as long as I’m upright.

Once entrapped like this, the nerve will continue sending nociceptive signals even when I lie down because the surrounding muscles have been alerted and stimulated to contract in order to “protect” the painful area.

Despite the administration of a long-acting opioid, there may be breakthrough pain, which is temporary and has excruciating intensity above the baseline pain.

Breakthrough pain is treated with a short-acting opioid such as hydromorphone, hydrocodone, meperidine, or oral transmucosal fentanyl (see Table 3)

The MEDD myth: pseudoscience in guidelines

The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development – free full-text /PMC4809343/ – J Pain Res – Mar 2016 – Jeffrey Fudin, Jacqueline Pratt Cleary, and Michael E Schatman

The authors point out that the concept of MEDD is flawed and call into question not only guidelines based thereon but also the many research studies that rely on such bogus numbers.

…the professional literature ubiquitously employs morphine-equivalent daily dose (MEDD) and other comparable acronyms to attribute escalating risks based on overall daily opioid dose.   Continue reading

Analysis of Pain Mgmt Tx from Cochrane Reviews

The user “Seshet” on the Inspire.com support forum has compiled this list of scientific evaluation of various non-opioid pain management treatments that are highly recommended by our government these days (as of June 2018):

An Analysis of Pain Management using Cochrane Reviews

The Cochrane organization (http://www.cochrane.org/about-us) provides meta-analyses and reviews of basic questions in clinical medicine.   Continue reading