The role of interfascial plane blocks in chronic pain treatment: A brief report of three cases.

Opioids for the treatment of acute pain and the pain of malignancy have been strongly encouraged for more than 25 years.1 In the past 2 decades, the treatment of chronic noncancer pain using long-term opioid therapy has become more common. However, recent studies have revealed the astonishing rapidi

HT9For this discussion, we were honored to hold this timely conversation with two renowned individuals who understand the opioid epidemic well.

Exercise as a Treatment for Chronic Pain

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Recent advances in the treatment of chronic pain with non-invasive brain stimulation techniques

Issues in Long-term Opioid Therapy: Unmet Needs, Risks, and Solutions

Dorsal column stimulation (DCS) was used in the treatment of chronic intractable pain in 51 patients. Twenty-five of the patients had back and leg pain secondary to the treatment of intervertebral disc disease; 11 had postoperative pain after general or thoracic surgical procedures. The remainder suffered pain related to multiple sclerosis, spinal cord injury, carcinoma, and peripheral vascular disease. Pain had been present for a mean of 24 months. Thirty-seven patients underwent DCS electrode placement by open laminectomy, and 11 had percutaneous epidural DCS electrode placement. Three patients first underwent epidural DCS electrode implantation and subsequently had DCS electrode implantation by laminectomy. No major complications were noted, although multiple lesser complications required 33 additional operative procedures for correction. Follow-up periods ranged from 12 to 67 months, with a mean of 38 months. Immediately after implantation. 47% of the patients reported that they had essentially complete pain relief, but 3 years later this had decreased to 8%. No patient followed for 4 years or longer reported complete pain relief. Thirty-three per cent of the patients discontinued the regular use of narcotics for pain relief after DCS electrode implantation. Unfortunately, only 16% were able to return to gainful employment or full physical activity after DCS. Based on these data and a review of the literature, the following conclusions are made: (a) assessment of success in the treatment of chronic pain is strongly dependent on the criteria used for patient evaluation: (b) with the criteria of this report, DCS is a relatively ineffective treatment for chronic pain; (c) epidural percutaneous DCS systems are no more effective than are those placed by laminectomy, and, because of technical problems with epidural systems (mainly lead breakage and migration), the latter may actually be less effective; and (d) at present DCS seems to play a minor role in the treatment of chronic intractable pain.

‘The Role of Opioids in the Treatment of Chronic Pain’ was the title of a recent workshop (September 29–30, 2014) supported by the National Institutes of Health (NIH) Office of Disease Prevention that highlights the relevance and urgency of the topic. High‐quality research presently does not exist to definitively answer questions about opioid safety, efficacy and abuse potential with long‐term use 1. However, prescriptions for opioids increased from 76 million in 1991 to 207 million in 2013, which were associated with parallel increases in opioid‐related morbidity and mortality 2. Currently, in the U.S., close to 100 million Americans suffer from chronic pain and may be given prescription opioids, along with close to two million Americans who abuse opioid analgesics 3, with over 16 000 overdose deaths attributed to prescription opioids 4. This situation reflects both the challenge to effectively treat the complex condition of chronic pain and the lack of understanding about opioid abuse potential and the risk of addiction in healthcare settings.

Anterior cingulotomy for chronic pain aims to modulate patients' attention or emotional reaction to pain rather than to modulate pain intensity. To evaluate the clinical efficacy, both short- and long-term, of anterior cingulotomy in the treatment of chronic pain. Systematic review. This systematic review assessed studies reporting anterior cingulotomy for the treatment of chronic pain. A systematic search of Web of Science, Scopus, PubMed, and PsychINFO was performed using both key words and controlled vocabulary. Articles included in this review included peer-reviewed articles describing clinical outcomes or efficacy of cingulotomy in the treatment of chronic pain with minimum follow-up of 3 months for non-malignant and 2 weeks for malignant pain. Articles reporting cingulectomies or cingulotomy only as combined with other ablative procedures were excluded, as were individual case reports. A total of 11 articles encompassing 224 patients are included in the review, with age ranging 22 to 85 (mean: 56) years at the time of the operation, 59% of which were men. Greater than 60% of patients across all studies were reported to have significant pain relief post-operatively as well as at one year after surgery. Common transient adverse effects included urinary incontinence and confusion/disorientation, subsiding within days postoperatively. Serious/permanent adverse effects included seizure in less than 5%, hemiparesis in less than 1%, and personality change in less than 1% of operations reported across all studies, all of which occurred primarily in operations where magnetic resonance (MR)-guidance was not used. The limitations of this systematic review include the lack of studies other than observational reports and the inevitable heterogeneity between included studies. Despite decreased utilization in recent years, anterior cingulotomy is an effective neurosurgical intervention in the treatment of pain and carries little risk of permanent or serious adverse effects.Key words: Anterior cingulotomy, chronic pain, stereotaxis, systematic review, pain, cingulate gyrus, cingulotomy, intractable pain.

Problem: Worldwide, at least one in four adults do not exercise sufficiently. Inactivity is associated with an increase in disease burden and mortality, whereas exercise can contribute to a longer, healthier life. Chronic musculoskeletal pain is a significant public health concern; in Germany, approximately 15% of the adult population suffers from chronic low back pain. Based on the diagnoses of chronic back pain, chronic joint pain, and chronic widespread pain or fibromyalgia syndrome, this study will evaluate the importance of exercise in the treatment of chronic pain. Methods: Narrative review based on current treatment guidelines and scientific publications. Results: Exercise and physical activity are both preventively and therapeutically effective in the treatment of chronic musculoskeletal pain. Individualized, supervised exercise programs that take patients’ preferences and goals into account appear to be particularly effective, regardless of pain location. There is evidence that the positive biopsychosocial effects of movement are more important than the specific form of exercise. Discussion: In the treatment of chronic pain, exercise and activity should be considered primary therapeutic measures and be prescribed accordingly. Supervision and adaptation of exercise programs to patient needs are critical factors of success, regardless of the type of sport or form of exercise. Even a small dose of physical activity achieves health benefits in patients with chronic pain and contributes to symptom relief.

Background The prevalence of chronic pain in children and adolescents is high. In some patients, it can be severe and refractory to conventional treatment options. There is increasing interest in the use of cannabinoids for therapeutic purposes in children and adolescents. Nabilone, a synthetic cannabinoid, is approved in Canada for the treatment of nausea and vomiting associated with chemotherapy. It can also be used off label for treatment of chronic pain. Aims This study aims to characterize the use of nabilone for severe chronic pain in a pediatric population. Methods This is a retrospective cohort study of patients 18 years or younger who were prescribed nabilone for chronic pain in a tertiary multidisciplinary pediatric chronic pain clinic between July 1, 2013 and June 30, 2017. Results During the four-year study period, we screened the charts of 507 patients and identified a total of 28 patients (5.5%) who were treated with nabilone as part of their chronic pain treatment. Common indications for nabilone treatment include mixed neuropathic/nociceptive pain, abdominal pain, neuropathic pain, and spasticity. In all patients, nabilone was prescribed as an adjunctive treatment. 7 patients (25%) reported a slight improvement in pain symptoms. Side effects were reported by 21.4% of patients. The most common reported side effects were sedation and cognitive slowing. Conclusions Adjunctive treatment with nabilone may improve pain symptoms in a subset of pediatric chronic pain patients. Further research investigating the long-term safety and efficacy of nabilone in the treatment of chronic pain in children is needed.

Management of Adolescent Chronic Pelvic Pain from Endometriosis: A Pain Center Perspective

In the treatment of chronic malignant and non-malignant pain, opioids are used as strong analgesics. Frail elderly patients often have multiple comorbidities and use multiple medicines, leading to an increased risk of clinically relevant drug-drug and drug-disease interactions. Age-related changes and increased frailty may lead to a less predictable drug response, increased drug sensitivity, and potential harmful drug effects. As a result, physicians face a complex task in prescribing medication to elderly patients. In this review, the appropriateness of the strong-acting opioids buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone and tapentadol is determined for use in elderly patients. Evidence-based recommendations for prescribing strong opioids to the frail elderly are presented. A literature search was performed for all individual drugs, using a validated and published set of 23 criteria concerning effectiveness, safety, pharmacokinetics and pharmacodynamics, experience, and convenience in elderly patients. First, information on the criteria was obtained from pharmaceutical reference books and a MEDLINE search. The information obtained on the individual drugs in the class of opioids was compared with the reference drug morphine. Evidence-based recommendations were formulated on the basis of the pros and cons for the frail elderly. Using the set of 23 criteria, no differentiation can be made between the appropriateness of buprenorphine, fentanyl, hydromorphone, morphine and oxycodone for use in elderly patients. Methadone has strong negative considerations in the treatment of chronic pain in the frail elderly. Methadone has a high drug-drug interaction potential and is associated with prolongation of the QT interval and a potential risk of accumulation due to a long elimination half-life. In addition, methadone is difficult to titrate because of its large inter-individual variability in pharmacokinetics, particularly in the frail elderly. Because of a lack of empiric knowledge, the use of tapentadol is not recommended in frail elderly persons. Nevertheless, tapentadol may prove to be a useful analgesic for the treatment of chronic pain in frail elderly persons because of its possible better gastrointestinal tolerability. In the treatment of chronic pain in the frail elderly, the opioids of first choice are buprenorphine, fentanyl, hydromorphone, morphine and oxycodone. In order to improve the convenience for elderly patients, the controlled-release oral dosage forms and transdermal formulations are preferred.

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

The association between vitamin D deficiency or insufficiency and pain in the musculoskeletal system, especially in the neck and/or back regions, and/or muscle spasm is not well studied. The results of the limited studies have been mixed. The goal of this report is to examine the association between vitamin D deficiency and insufficiency and chronic neck and back pain and muscle spasm and the role of correction of vitamin D deficiency and insufficiency in the treatment of chronic pain and muscle spasm, especially in the neck and back regions. This case series reviewed medical records to identify patients with chronic pain (lasting from 6 months to 1 year) in the neck and back regions that improved significantly through the correction of the vitamin D deficiency or insufficiency. Patients were referred to the spine clinic of a tertiary hospital in a major metropolitan area in the Northwest by their primary care physicians after physical therapy and after first-tier pain medications, including nonsteroidal anti-inflammatory drugs, had failed. Some of the patients had epidural steroid injections without significant relief. The blood vitamin D level was tested at the clinical laboratory, and patients were given 50,000 IU of oral vitamin D once a week for 12 weeks. The main outcome measures were patient self-reported visual analog scale score and degree of muscle spasm. The 4 patients included in this series all had more than 70% improvement in their symptoms after taking 50,000 IU of vitamin D once a week for 12 weeks. Vitamin D deficiency and insufficiency can cause or worsen neck and back pain and muscle spasm. The correction of vitamin D deficiency and insufficiency plays an important role in the treatment of chronic neck and back pain and muscle spasm among patients having concurrent vitamin D deficiency and insufficiency because it can be prevented and treated easily.Given the high health care expenditure on the treatment of chronic neck and back pain, prompt and accurate diagnosis and treatment of vitamin D deficiency and insufficiency not only increase the quality of care but also reduce the cost.