Pharmacotherapy For Pain Management Research Articles

Chronic pain healthcare workers’ challenges in pain management and receptiveness towards VR as an adjunct management tool: a qualitative study

Abstract Background Chronic pain is often a debilitating condition that affects individuals physically and mentally. Reliance on pharmacotherapy for pain management comes with risks of analgesic misuse and dependence. Hence, non-pharmacologic treatment plays a crucial role in pain management. Virtual reality is a novel method in chronic pain management. However, there is little understanding about healthcare providers’ perspectives on the use of virtual reality technology in managing chronic pain. This study aims to explore the current management challenges faced by chronic pain healthcare providers and their perspectives on using virtual reality as adjunctive therapy in managing chronic pain. Method Individual semi-structured interviews were conducted among all chronic pain healthcare providers in a tertiary hospital. The interviews were analysed using qualitative thematic analysis. Results Eight chronic pain healthcare providers participated in this study. Financial issues were cited as one of the biggest barriers to utilisation of non-pharmacological treatment. Participants highlighted the importance of psychosocial support from family and healthcare providers. Challenges identified included absence of patient engagement and lack of awareness about pain management among healthcare providers as well as the lack of an integrated multidisciplinary approach in our healthcare system. Participants were receptive towards the use of virtual reality in chronic pain management and offered ample opinions and suggestions for its application in chronic pain management. Conclusions A multilevel, multifaceted approach is needed to improve chronic pain management. Virtual reality technology could be considered as an adjunct therapy to address some of the challenges and limitations identified in this study.

Effectiveness of Transcranial Direct Current Stimulation and Pharmacotherapy in Pain Management in Patients with Chronic Pain

Background: A variety of pharmacological and nonpharmacological methods are used to treat chronic pain. Transcranial direct current stimulation (tDCS) through stimulating the central and peripheral nerves is a different and promising method for the treatment of chronic pain. Objectives: The present study aimed to investigate the effectiveness of tDCS and pharmacotherapy in pain management in patients with chronic pain in Tehran, Iran. Methods: The present study followed a clinical trial design. The statistical population comprised all patients with chronic pain who were referred to Pardis Multidisciplinary Pain Clinic in Tehran within 2020 - 21. A total of 60 patients willing to participate in the study were selected using convenience sampling. The participants were randomly divided into three groups, including pharmacotherapy (treatment by gabapentin with a dosage of 600 mg twice per day), tDCS, and control (n = 20 per group). The research instrument included the McGill Pain Questionnaire. The data were analyzed using repeated-measures analysis of variance with SPSS software (version 24.0). Results: The results showed that both pharmacotherapy and tDCS interventions led to a reduction in the mean scores of pain management components, compared to the control group (P < 0.001). Furthermore, there was no significant difference between the effects of the two experimental groups on pain management components. Conclusions: The tDCS and pharmacotherapy were both shown to be effective in pain management in patients with chronic pain. Therefore, in addition to pharmacotherapy, tDCS is also recommended for the treatment of chronic pain.

Effectiveness of Transcranial Direct Current Stimulation and Pharmacotherapy in Pain Management in Patients with Chronic Pain

Background: A variety of pharmacological and nonpharmacological methods are used to treat chronic pain. Transcranial direct current stimulation (tDCS) through stimulating the central and peripheral nerves is a different and promising method for the treatment of chronic pain. Objectives: The present study aimed to investigate the effectiveness of tDCS and pharmacotherapy in pain management in patients with chronic pain in Tehran, Iran. Methods: The present study followed a clinical trial design. The statistical population comprised all patients with chronic pain who were referred to Pardis Multidisciplinary Pain Clinic in Tehran within 2020 - 21. A total of 60 patients willing to participate in the study were selected using convenience sampling. The participants were randomly divided into three groups, including pharmacotherapy (treatment by gabapentin with a dosage of 600 mg twice per day), tDCS, and control (n = 20 per group). The research instrument included the McGill Pain Questionnaire. The data were analyzed using repeated-measures analysis of variance with SPSS software (version 24.0). Results: The results showed that both pharmacotherapy and tDCS interventions led to a reduction in the mean scores of pain management components, compared to the control group (P < 0.001). Furthermore, there was no significant difference between the effects of the two experimental groups on pain management components. Conclusions: The tDCS and pharmacotherapy were both shown to be effective in pain management in patients with chronic pain. Therefore, in addition to pharmacotherapy, tDCS is also recommended for the treatment of chronic pain.

Developing Improved Translational Models of Pain: A Role for the Behavioral Scientist.

The effective management of pain is a longstanding public health concern. Although opioids have been frontline analgesics for decades, they also have well-known undesirable effects that limit their clinical utility, such as abuse liability and respiratory depression. The failure to develop better analgesics has, in some ways, contributed to the escalating opioid epidemic that has claimed tens of thousands of lives and has cost hundreds of billions of dollars in health-care expenses. A paradigm shift is needed in the pharmacotherapy of pain management that will require extensive efforts throughout biomedical science. The purpose of the present review is to highlight the critical role of the behavioral scientist to devise improved translational models of pain for drug development. Despite high heterogeneity of painful conditions that involve cortical-dependent pain processing, current models often feature an overreliance on simple reflex-based measures and an emphasis on the absence, rather than presence, of behavior as evidence of analgesic efficacy. Novel approaches should focus on the restoration of operant and other CNS-mediated behavior under painful conditions.

Fundamental Considerations for GeneticallyGuided Pain Management with Opioids Based on CYP2D6 and OPRM1 Polymorphisms

Background: A major challenge for effective pharmacotherapy in pain management is to provide the drug best suited to the patient’s innate characteristics. Objective: The article illustrates pharmacogenetic principles to optimize treatments for patients and increase the likelihood of pain relief without dependence. Genetic variances are particularly relevant to opioid drugs used in pain control, and can now be harvested for predictive clinical decision support. Study Design: Clinically actionable polymorphisms in CYP2D6 (cytochrome p450 2D6) and OPRM1 (μ1 opioid receptor), the most important gene coding, respectively, for a metabolizing enzyme and receptor for opioids are reviewed, and functional effects described. Methods: Risk of dysfunction is calculated from the frequency of the alleles with null function for CYP2D6, and from the low function polymorphism for OPRM1. Integration of genetic variability was performed for 9 combinatorial scenarios for CYP2D6 and OPRM1. Each combination was quantified in frequency and classified for clinical impact. A rational and pharmacological basis for personalized pain management based on pharmacokinetic and pharmacodynamic modeling is extracted from the frequency of the combinations. Results: Patients can be classified in 3 broad risk categories for opioid side effects and dependence. Patients at high-risk with dysfunctional CYP2D6 or OPRM1 account for ~14% of the population and are best managed with non-opioids. Patients at medium risk with subnormal CYP2D6 or OPRM1 account for ~48% of the population and can be managed with dose monitoring. Patients at low risk with functional CYP2D6 and OPRM1 account for ~38% of the population and should be availed to opioid therapy. Limitations: Heuristic clinical decision support considerations are not validated yet by deployment in large clinical practices. Environmental modifiers such as other drugs and dietary supplements interact with innate characteristics to modify the genetic predictions. Conclusion: Through clinical decision support interpreting the genotyping data, drug choices and doses can then be tailored to provide safe and effective therapy for individual patients. This precision affords personalized medicine to be practiced in pain treatment. Genetic factors could help determine why some patients seem more vulnerable than others to opioid side effects and dependence. Key words: Pain management, opioids, CYP2D6, OPRM1, clinical decision support, pharmacokinetics, pharmacodynamics, pharmacogenetics, combinatorial genotypes

Pharmacogenetics in Pain Treatment.

Pain is an unpleasant feeling usually resulting from tissue damage that can persist along weeks, months, or even years after the injury, turning into pathological chronic pain, the leading cause of disability. Currently, pharmacology interventions are usually the first-line therapy but there is a highly variable analgesic drug response. Pharmacogenetics (PGx) offers a means to identify genetic biomarkers that can predict individual analgesic response opening doors to precision medicine. PGx analyze the way in which the presence of variations in the DNA sequence (single-nucleotide polymorphisms, SNPs) could be responsible for portions of the population reaching different levels of pain relief (phenotype) due to gene interference in the drug mechanism of action (pharmacodynamics) and/or its concentration at the place of action (pharmacokinetics). SNPs in the cytochrome P450 enzymes genes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone, and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Additional candidate genes encode for opioid receptors, transporters, and other molecules important for pharmacotherapy in pain management. However, PGx studies are often contradictory, slowing the uptake of this information. This is likely due, in large part, to a lack of robust evidence demonstrating clinical utility and to its polygenic response modulated by other exogenous or epigenetics factors. Novel therapies, including targeting of epigenetic changes and gene therapy-based approaches, broaden future options to improve understanding of pain and the treatment of people who suffer it.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management.

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5units on a 0-10pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Pharmacogenetics in palliative care

Response to analgesics, anticancer pharmacotherapy and pharmacotherapy of other cancer related symptoms vary broadly between individuals. Age, disease, comorbidities, concomitant medication, organ function and patients’ compliance may partly explain the differences. However, the focus of ongoing research has shifted towards genomic variants of phase I and II drug metabolizing enzymes with one important goal being an individual dose adjustment according to a patient's genotype. Polymorphisms of the cytochrome P 450 2D6 influence the metabolism of many drugs including the analgesics codeine, tramadol, hydrocodone and oxycodone, as well as the metabolism of tricyclic antidepressants and the anticancer drug tamoxifen. Other candidate genes such as (opioid)-receptors, transporters and other molecules important for pharmacotherapy in pain management are discussed. Although pharmacogenetics as a diagnostic tool has the potential to improve patient therapy, study results are often equivocal and limited by small sample sizes and often by their retrospective design. Well designed studies are needed to demonstrate superiority of pharmoacogenetics to conventional dosing regimes.

Personalized Therapy in Pain Management: Where Do We Stand?

Genomic variations influencing response to pharmacotherapy of pain are currently under investigation. Drug-metabolizing enzymes represent a major target of ongoing research in order to identify associations between an individual's drug response and genetic profile. Polymorphisms of the cytochrome P450 enzymes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Genomic variants of these genes associate well with NSAIDs' side effect profile. Other candidate genes, such as those encoding (opioid) receptors, transporters and other molecules important for pharmacotherapy in pain management, are discussed; however, study results are often equivocal. Besides genetic variants, further variables, for example, age, disease, comorbidity, concomitant medication, organ function as well as patients' compliance, may have an impact on pharmacotherapy and need to be addressed when pain therapists prescribe medication. Although pharmacogenetics as a diagnostic tool has the potential to improve patient therapy, well-designed studies are needed to demonstrate superiority to conventional dosing regimes.