Use of Opioids in Latin America: The Need of an Evidence-Based Change

Abstract

Objective

The subject of this publication has been focused on local considerations for facilitating regional best practice, including identifying and uniformly adopting the most relevant international guidelines on opioid use (OU) in chronic pain management.

Design and Setting

The Change Pain Latin America (CPLA) Advisory Panel conducted a comprehensive, robust, and critical analysis of published national and international reviews and guidelines of OU, considering those most appropriate for Latin America.

Methods

A PubMed search was conducted using the terms “opioid,” “chronic,” and “pain” and then refined using the filters “practice guidelines” and “within the last 5 years” (2007–2012). Once the publications were identified, they were selected using five key criteria: “Evidence based,” “Comprehensive,” “From a well-recognized source,” “Current publications,” and “Based on best practice” and then critically analyzed considering 10 key criteria for determining the most relevant guidelines to be applied in Latin America.

Results

The initial PubMed search identified 177 reviews and guidelines, which was reduced to 16 articles using the five preliminary criteria. After a secondary analysis according to the 10 key criteria specific to OU in Latin America, 10 publications were selected for critical review and discussion.

Conclusions

The CPLA advisory panel considered the “Safe and effective use of opioids for chronic non-cancer pain” (published in 2010 by the NOUGG of Canada) to be valid, relevant to Latin America, practical, evidence-based, concise, unambiguous, and sufficiently educational to provide clear instruction on OU and pain management and, thus, recommended for uniform adoption across the Latin America region.

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Chronic Pain in Irish Prison Officers: Profile and Predictors of Pain-Related Disability and Depression

Abstract

Objective

International research has consistently found increased risk for physical health and psychological difficulties among prison officers including elevated risk of assault resulting in acute pain. This study represented an exploratory examination of the experience of chronic pain conditions among Irish prison officers with particular reference to the psychosocial predictors of pain severity, pain interference, and depression.

Design

A questionnaire battery was completed by 152 Irish prison officers. The questionnaires measured pain severity and interference, anxiety, depression, social support, coping strategies, and resilience.

Results

Results showed that 48% of participants reported chronic pain based on the International Association for the Study of Pain definition. Psychological distress was high among respondents reporting chronic pain, with 38% of participants meeting the criteria for “probable depression” while 51% met the criteria for “probable anxiety disorder.” In regression analyses, depression emerged as a significant predictor of both pain severity and pain interference while anxiety and pain interference emerged as significant predictors of depression.

Conclusion

Chronic pain appears to be prevalent in prison officers and is associated with both physical and psychological impairment. Health care staff in correctional facilities should be aware that these health difficulties are prevalent in the prison work environment.

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Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study

Abstract

Background

Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety.

Objective

To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines.

Methods

Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events.

Results

There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event.

Conclusions

Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

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Consensus Recommendations on Initiating Prescription Therapies for Opioid-Induced Constipation

Abstract

Objective

Aims of this consensus panel were to determine (1) an optimal symptom-based method for assessing opioid-induced constipation in clinical practice and (2) a threshold of symptom severity to prompt consideration of prescription therapy.

Methods

A multidisciplinary panel of 10 experts with extensive knowledge/experience with opioid-associated adverse events convened to discuss the literature on assessment methods used for opioid-induced constipation and reach consensus on each objective using the nominal group technique.

Results

Five validated assessment tools were evaluated: the Patient Assessment of Constipation–Symptoms (PAC-SYM), Patient Assessment of Constipation–Quality of Life (PAC-QOL), Stool Symptom Screener (SSS), Bowel Function Index (BFI), and Bowel Function Diary (BF-Diary). The 3-item BFI and 4-item SSS, both clinician administered, are the shortest tools. In published trials, the BFI and 12-item PAC-SYM are most commonly used. The 11-item BF-Diary is highly relevant in opioid-induced constipation and was developed and validated in accordance with US Food and Drug Administration guidelines. However, the panel believes that the complex scoring for this tool and the SSS, PAC-SYM, and 28-item PAC-QOL may be unfeasible for clinical practice. The BFI is psychometrically validated and responsive to changes in symptom severity; scores range from 0 to 100, with higher scores indicating greater severity and scores >28.8 points indicating constipation.

Conclusions

The BFI is a simple assessment tool with a validated threshold of clinically significant constipation. Prescription treatments for opioid-induced constipation should be considered for patients who have a BFI score of ≥30 points and an inadequate response to first-line interventions.

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Outcome of Cervical Radiculopathy Treated with Periradicular/Epidural Corticosteroid Injections

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Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

Abstract

Objective

To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression.

Methods

The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice.

Results

We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP.

Conclusions

Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

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Differential Rates of Inadvertent Intravascular Injection during Lumbar Transforaminal Epidural Injections Using Blunt-Tip, Pencil-Point, and Catheter-Extension Needles

Abstract

Objective

To quantify the incidence of inadvertent vascular penetration during lumbosacral transforaminal epidural injections using blunt-tip, pencil-point, and catheter-extension needles.

Study Design/Setting

This is a prospective, observational, consecutive cohort study.

Subjects

Two hundred consecutive patients undergoing lumbosacral transforaminal epidural injections at an academic outpatient spine center.

Methods

Four hundred seventy-five fluoroscopically guided lumbosacral transforaminal epidural injections were performed on consecutively consenting patients by one interventional spine physician, using three different needle types. The presence or absence of vascular uptake was determined during contrast injection under live fluoroscopy.

Results

Vascular uptake of contrast was observed in 58 of the total 475 injections, for an overall incidence of 12.2%. By needle type, the incidence of inadvertent vascular uptake was 16.6% (26/157) in the pencil-point group, 15.6% (24/154) in the blunt-tip group, and 4.9% (8/164) in the catheter-extension group. The difference in rates is statistically significant between the catheter-extension needle group and both the pencil-point group (P = 0.0009) and blunt-tip group (P = 0.0024). A secondary analysis was performed to quantify the incidence of functional pitfalls between needle groups, with a significantly lower incidence in the pencil-point group compared to both the catheter-extension (P = 0.0148) and blunt-tip needle (P = 0.0288) groups.

Conclusions

Blunt-tip and pencil-point needles have comparable risk of inadvertent vascular injection during lumbosacral transforaminal injections. Catheter-extension needles demonstrated a reduce incidence of vascular uptake, but also result in a significantly higher rate of functional pitfalls that limits their usefulness in routine practice.

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Primary care summits

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Editor's note:

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Cognitive-Motivational Influences on Health Behavior Change in Adults with Chronic Pain

Abstract

Objective

The primary aim was to assess the psychological factors that influence engagement in health behaviors in individuals with chronic pain using a new measure, the Behavioral Engagement Test for Chronic Pain (BET-CP). A secondary aim was to determine preliminary psychometric properties of the BET-CP.

Subjects

Participants were 86 adults with chronic musculoskeletal pain recruited from University of Florida pain clinics and the community.

Methods

Participants completed a battery of self-report instruments online, including the BET-CP and measures of related constructs. Items on the BET-CP assessed motivation, self-efficacy, outcome expectations, and the symptom benefit required to engage across four health behaviors: exercise, diet, sleep, and pain self-management (e.g., relaxation and activity pacing).

Results

Participants reported modest expectations of pain-related symptom improvement if they practiced the health behaviors (22–26% improvement), but they required twice that (47–54% improvement) to make it worth their while to commit to practicing them. Participants expected to get the most symptom relief from relaxation and activity pacing, but they were most confident and motivated to eat a healthy diet. In a subsample of participants who provided data for psychometric analysis, the BET-CP demonstrated strong test-retest reliability across 7 days and adequate convergent validity.

Conclusion

While patients with musculoskeletal pain have outcome expectancies that are nearly in line with research on behavioral pain treatments, their stringent requirements for symptom benefit may impede engagement in the health behaviors recommended for their pain-related symptoms. Additional psychometric study with larger sample sizes is needed to further validate the BET-CP.

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Cancer Recurrence and Regional Anesthesia: The theories, the data, and the future in outcomes

Abstract

Objective

More than one million people each year in the United States are diagnosed with cancer. Surgery is considered curative, but the perioperative phase represents a vulnerable period for residual disease to spread. Regional anesthesia has been proposed to reduce the incidence of recurrence by attenuating the sympathetic nervous system's response during surgery, reducing opioid requirements thus diminishing their immunosuppressant effects, and providing antitumor and anti-inflammatory effects directly through systemic local anesthetic action. In this article, we present a description of the perioperative period, a summary of the proposed hypotheses and available literature on the effects of regional anesthesia on cancer recurrence, and put regional anesthesia in context in regard to its potential role in reducing cancer recurrence during the perioperative period.

Methods

A literature review was conducted through PubMed by examining the following topics: effects of surgery on tumor progression, roles of multiple perioperative variables (analgesics, hypothermia, blood transfusion, beta-blockade) in cancer recurrence, and available in vitro, animal, and human studies regarding the effects of regional anesthesia on cancer recurrence.

Results

In vitro, animal and human retrospective studies suppport the hypothesis that in certain types of cancer, regional anesthesia may be associated with lower recurrence rates. A few well-planned human randomized clinical trials are currently under way that may provide more solid evidence to substantiate or refute the benefits of regional anesthesia in reducing cancer recurrence.

Conclusions

The benefits of regional anesthesia in reducing cancer recurrence have a sound theoretical basis and, in certain cancers, are supported by the existing body of literature. This article outlines the current state of our knowledge on the relationship between cancer progression and regional analgesia.

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Effect of Deep Intramuscular Stimulation and Transcranial Magnetic Stimulation on Neurophysiological Biomarkers in Chronic Myofascial Pain Syndrome

Abstract

Objective

The aim was to assess the neuromodulation techniques effects (repetitive transcranial magnetic stimulation [rTMS] and deep intramuscular stimulation therapy [DIMST]) on pain intensity, peripheral, and neurophysiological biomarkers chronic myofascial pain syndrome (MPS) patients.

Design

Randomized, double blind, factorial design, and controlled placebo-sham clinical trial.

Setting

Clinical trial in the Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (NCT02381171).

Subjects

We recruited women aged between 19- and 75-year old, with MPS diagnosis.

Methods

Patients were randomized into four groups: rTMS + DIMST, rTMS + sham-DIMST, sham-rTMS + DIMST, sham-rTMS + sham-DIMST; and received 10 sessions for 20 minutes each one (rTMS and DIMST). Pain was assessed by visual analogue scale (VAS); neurophysiological parameters were assessed by transcranial magnetic stimulation; biochemical parameters were: BDNF, S100β, lactate dehydrogenase, inflammatory (TNF-α, IL6, and IL10), and oxidative stress parameters.

Results

We observed the pain relief assessed by VAS immediately assessed before and after the intervention (P < 0.05, F_(1,3)= 3.494 and F_(1,3)= 4.656, respectively); in the sham-rTMS + DIMST group and both three active groups in relation to sham-rTMS + sham-DIMST group, respectively. There was an increase in the MEP after rTMS + sham-DIMST (P < 0.05). However, there was no change in all-peripheral parameters analyzed across the treatment (P > 0.05).

Conclusion

Our findings add additional evidence about rTMS and DIMST in relieving pain in MPS patients without synergistic effect. No peripheral biomarkers reflected the analgesic effect of both techniques; including those related to cellular damage. Additionally, one neurophysiological parameter (increased MEP amplitude) needs to be investigated.

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Cervical transforaminal with low-dose local anesthetic is not a safeguard for neurological complications

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Multisociety Letter to the Agency for Healthcare Research and Quality: Serious Methodological Flaws Plague Technology Assessment on Pain Management Injection Therapies for Low Back Pain

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Preventive Analgesia with Pregabalin in Neuropathic Pain from “Failed Back Surgery Syndrome”: Assessment of Sleep Quality and Disability

Abstract

Objective

Pregabalin group (PGB) is an antiepileptic used to treat neuropathic pain. We evaluated analgesic efficacy and safety for postoperative/chronic pain, disability, and sleep quality in patients who underwent spine surgery administered with PGB, or not, during the presurgical and postsurgical periods.

Design

Retrospective cohort study of 60 patients (two groups with 30 patients) with full information on 50 (29 with PGB and 21 without PGB). Ten patients were dismissed as information was lacking. The PGB group (P) (29 patients) received 75 mg/12 hours before surgery, 150 mg 10 hours after surgery, and 150 mg/12 hours 3 days after surgery. The control group (C; 21 patients) took no PGB.

Methods

Neuropathic pain was assessed before surgery, and 2 and 6 months later using visual analog scales (VAS), DN4, disability (Oswestry), and sleep quality. No serious adverse events occurred with PGB.

Results

The median VAS pain score at rest was lower in the PGB group at 2 months postsurgery (1 vs 2, P = 0.032), as was the median DN4 score (0 vs 3, P = 0.032) and the median Oswestry disability index (ODI: 12 vs 18, P = 0.001). At 6 months postsurgery, pain scores were also lower in the PGB group for VAS (0 vs 4, P = 0.001), DN4 score (0 vs 4, P = 0.001) and the ODI (10 vs 24, P = 0.001). Improvement in the functionality and sleep quality of the PGB group was noteworthy (P = 0.018).

Conclusions

PGB has analgesic/antihyperalgesic effects on postoperative neuropathic pain after surgery for lumbar disc hernia. Our findings show that this benefit increases with time.

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Profiles of Urine Drug Test in Clinical Pain Patients vs Pain Research Study Subjects

Abstract

Objective

To examine similarities and differences in urine drug test (UDT) results in clinical pain patients and pain subjects participating in pain research studies.

Design

An observational study with retrospective chart review and data analysis.

Methods

We analyzed 1,874 UDT results obtained from 1) clinical pain patients (Clinical Group; n = 1,529) and 2) pain subjects consented to participate in pain research studies (Research Group; n = 345). Since several medications such as opioids used in pain management are drugs of abuse (DOA) and can result in a positive UDT, we specifically identified those cases of positive UDT due to nonprescribed DOA and designated these cases as positive UDT with DOA (PUD).

Results

We found that 1) there was a higher rate of PUD in clinical pain patients (41.3%) than in pain research study subjects (14.8%); 2) although subjects in the Research Group were informed ahead of time that UDT will be conducted as a screening test, a substantial number (14.8%) of pain research study subjects still showed PUD; 3) there were different types of DOA between clinical pain patients (cannabinoids as the top DOA) and research study subjects (cocaine as the top DOA); and 4) a common factor associated with PUD was opioid therapy in both Clinical Group and Research Group.

Conclusion

These results support previous findings that PUD is a common finding in clinical pain patients, particularly in those prescribed opioid therapy, and we suggest that UDT be used as routine screening testing in pain research studies.

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Reply to: Is it not Important that we ask the Right Question, the Right Way, on an Appropriate Sample of Patients?

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Gabapentin in Headache Disorders: What Is the Evidence?

Abstract

Objective

Gabapentin (GBP), originally an antiepileptic drug, is more commonly used in the treatment of pain, including headache disorders. Off-label GBP is used in headache disorders with some success, some failure, and much debate. Due to this ambiguity, a clinical evidence literature review was performed investigating GBP's efficacy in headache disorders.

Methods

Bibliographic reference searches for GBP use in headache disorders were performed in PUBMED and OVID Medline search engines from January 1, 1983 to August 31, 2014. Based on abstracts read by two reviewers, references were excluded if: GBP was not a study compound or headache symptoms were not studied. The resulting references were then read, reviewed, and analyzed.

Results

Fifty-six articles pertinent to GBP use in headache disorders were retained. Eight headache clinical trials were quality of evidence Class 2 or higher based on American Academy of Neurology criteria. Seven of the eight clinical trials showed statistically significant clinical benefit from GBP in various headache syndromes (though modest affects at times). One study, Mathew et al., had concerns about intention-treat analysis breaches and primary outcomes.

Conclusion

Despite the conflicting evidence surrounding select studies, a significant amount of evidence shows that GBP has benefit for a majority of primary headache syndromes, including chronic daily headaches. GBP has some efficacy in migraine headache, but not sufficient evidence to suggest primary therapy. When primary headache treatments fail, a GBP trial may be considered in the individual patient.

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Progress of Perioperative Pain Management, but Still Far from Perfect

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Erratum

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