Treating Acute Pain in Light of the Chronification of Pain

The Efficacy and Feasibility of an Interoceptive Exposure Technique for Preventing the Transition From Subacute to Chronic Back Pain by Altering the Emotional Response to Pain: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Psychological factors such as stress, anxiety, mood, emotions, cognitive functioning, and pain behavior are relevant to the onset of pain and its continuation in the transition to chronic conditions. Subacute low back pain (LBP), a precursor to chronic LBP, is particularly poorly understood, and its relationships with psychological factors are understudied.

OBJECTIVE

We will conduct a study aiming to prevent the chronicity of subacute LBP by altering the emotional response to pain using an interoceptive exposure technique (IET). Considering the recent increase in knowledge about psychological risk factors, as well as recent findings in cognitive neuroscience regarding emotional and cognitive background factors in the LBP chronicity process, efforts should be made to discover effective preventive methods.

METHODS

We present a novel method aiming to prevent the transition from subacute to chronic back pain by altering the emotional response to pain using an IET. In this pilot randomized controlled trial, participants who are at a higher risk of LBP chronification due to the presence of a biomarker (ie, functional connectivity between the medial prefrontal cortex and nucleus accumbens) will be randomly assigned to the IET intervention group or control group A (treatment as usual). Participants who do not present with the biomarker will be assigned to control group B (treatment as usual) to assess how well this biomarker predicts the chronification of subacute LBP in this study population. Questionnaires measuring the pain experience and psychological distress will be used before the intervention, after the intervention (at 3 months), and at the 12-month follow-up.

RESULTS

This research project will combine 2 novel methods: a biomarker as the inclusion criterion and an IET as the intervention. The comparative study design enables evaluation of the efficacy of the IET, as well as replication of the biomarker's validity as a possible clinical screening method.

CONCLUSIONS

If found to be useful, the IET would offer a cost-effective and reasonable way to develop treatment for acute and subacute back pain conditions. Potential benefits include increased pain management and quality of life for the individual patient with the addition of a potentially useful functional pain management method at the societal level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05450263; https://clinicaltrials.gov/ct2/show/NCT05450263.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45701.

Functional versus dysfunctional coping with physical pain: An experimental comparison of acceptance vs. avoidance coping

This study compared acceptance vs. avoidance coping with acute physical pain, in a pain-induction experiment and examined both between and within-group differences, multi-methodically and multi-dimensionally using behavioral, physiological and self-report measures. The sample consisted of 88 University students (76.1% females; Mage = 21.33 years). Participants were randomly assigned to four instructed groups and participated twice in the Cold Pressor Task: (a) Acceptance followed by avoidance; (b) Avoidance followed by acceptance; (c) No instructions (control) followed by acceptance, and (d) No instructions (control) followed by avoidance. All analyses were conducted using repeated-measures ANOVAs. Randomized techniques analyses showed that participants receiving no instructions followed by acceptance reported significantly greater changes in physiological and behavioral measures across time. Low adherence to acceptance instructions was found, especially during the first phase. Exploratory analyses on actual techniques used (as opposed to taught technique) showed that participants using avoidance followed by acceptance exhibited significantly greater changes in physiological and behavioral measures across time. No significant differences were found for the self-report of negative affect outcome. Overall, our findings provide support to ACT theory, as participants might have to use firstly ineffective coping to understand what works best to cope with pain. This is the first study examining acceptance vs. avoidance coping both between and within individuals in physical pain, multi-methodically and multi-dimensionally.

Anxiety, pain intensity, and decision regret of living liver donors during postoperative period

AIM

The aim of this study was to explore and examine the relationship between anxiety, acute pain intensity, and decision regret of living liver donors in the postoperative stage.

METHODS

This is a prospective correlational study. Data were collected consecutively for one year (from September 2017 to September 2018) at a medical center in northern Taiwan. Information about anxiety and acute pain intensity was collected preoperatively and on postoperative day (POD) 3 and POD 7. Satisfaction with pain management and decision regret was inquired about on POD 7.

RESULTS

Data of 57 consecutive living liver donors (56.1 % male, mean age 34.12 ± 9.92 years) were analyzed. Living liver donors experienced moderate anxiety and acute pain levels in the postoperative period. The mean score of decision regret was 12.63 (range 0-60), indicating a low level of regret. The acute pain intensity decreased significantly between POD 3 and POD 7 (p < .001); however, the anxiety level slightly increased (p = .031). Older and married living liver donors had higher anxiety levels. The satisfaction level of pain management was negatively correlated with the POD 7 acute pain intensity (r = -0.26, p = .049) and decision regret (r = -0.37, p = .005), but it was positively correlated with POD 7 anxiety (r = 0.38, p = .004).

CONCLUSIONS

The postoperative period was hard for living liver donors as they would experience moderate acute pain and anxiety. Although the decision regret was low, the satisfaction level of pain management would negatively affect it. Therefore, the effectiveness of pain management and anxiety management should be continually ensured in the postoperative period.

Morphine-induced changes in the function of microglia and macrophages after acute spinal cord injury

Background

Opioids are among the most effective and commonly prescribed analgesics for the treatment of acute pain after spinal cord injury (SCI). However, morphine administration in the early phase of SCI undermines locomotor recovery, increases cell death, and decreases overall health in a rodent contusion model. Based on our previous studies we hypothesize that morphine acts on classic opioid receptors to alter the immune response. Indeed, we found that a single dose of intrathecal morphine increases the expression of activated microglia and macrophages at the injury site. Whether similar effects of morphine would be seen with repeated intravenous administration, more closely simulating clinical treatment, is not known.

Methods

To address this, we used flow cytometry to examine changes in the temporal expression of microglia and macrophages after SCI and intravenous morphine. Next, we explored whether morphine changed the function of these cells through the engagement of cell-signaling pathways linked to neurotoxicity using Western blot analysis.

Results

Our flow cytometry studies showed that 3 consecutive days of morphine administration after an SCI significantly increased the number of microglia and macrophages around the lesion. Using Western blot analysis, we also found that repeated administration of morphine increases β-arrestin, ERK-1 and dynorphin (an endogenous kappa opioid receptor agonist) production by microglia and macrophages.

Conclusions

These results suggest that morphine administered immediately after an SCI changes the innate immune response by increasing the number of immune cells and altering neuropeptide synthesis by these cells.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12868-022-00739-3.

A Role for Global DNA Methylation Level and IL2 Expression in the Transition From Acute to Chronic Low Back Pain

Objectives: The transition from acute low back pain (aLBP) to chronic LBP (cLBP) results from a variety of factors, including epigenetic modifications of DNA. The aim of this study was to (1) compare global DNA (gDNA) methylation and histone acetylation at LBP onset between the aLBP and cLBP participants, (2) compare mRNA expression of genes with known roles in the transduction, maintenance, and/or modulation of pain between the aLBP and cLBP participants, (3) compare somatosensory function and pain ratings in our participants, and (4) determine if the aforementioned measurements were associated.

Methods: A total of 220 participants were recruited for this prospective observational study following recent onset of an episode of LBP. We retained 45 individuals whose gDNA was of sufficient quality for analysis. The final sample included 14 participants whose pain resolved within 6 weeks of onset (aLBP),15 participants that reported pain for 6 months (cLBP), and 16 healthy controls. Participants were subjected to quantitative sensory testing (QST), blood was drawn via venipuncture, gDNA isolated, and global DNA methylation and histone acetylation, as well as mRNA expression of 84 candidate genes, were measured.

Results: Individuals that develop cLBP display multimodal somatosensory hypersensitivity relative to aLBP participants. cLBP participants also had significantly lower global DNA methylation, which was negatively correlated with interleukin-2 (IL2) mRNA expression.

Discussion: cLBP is characterized by somatosensory hypersensitivity, lower global DNA methylation, and higher IL2 expression level compared to those whose pain will resolve quickly (aLBP). These results suggest potential diagnostic and therapeutic relevance for global DNA methylation and IL2 expression in the pathology underlying the transition from acute to chronic LBP.

The role of deficient pain modulatory systems in the development of persistent post-traumatic headaches following mild traumatic brain injury: an exploratory longitudinal study

BACKGROUND

Post-traumatic headache (PTH) is one of the most common and long-lasting symptoms following mild traumatic brain injury (TBI). However, the pathological mechanisms underlying the development of persistent PTH remain poorly understood. The primary purpose of this prospective pilot study was to evaluate whether early pain modulatory profiles (sensitization and endogenous pain inhibitory capacity) and psychological factors after mild TBI predict the development of persistent PTH in mild TBI patients.

METHODS

Adult mild TBI patients recruited from Level I Emergency Department Trauma Centers completed study sessions at 1-2 weeks, 1-month, and 4-months post mild TBI. Participants completed the following outcome measures during each session: conditioned pain modulation to measure endogenous pain inhibitory capacity, temporal summation of pain and pressure pain thresholds of the head to measure sensitization of the head, Pain Catastrophizing Scale, Center for Epidemiological Studies - Depression Scale, and a standardized headache survey. Participants were classified into persistent PTH (PPTH) and no-PPTH groups based on the 4-month data.

RESULTS

The results revealed that mild TBI patients developing persistent PTH exhibited significantly diminished pain inhibitory capacity, and greater depression and pain catastrophizing following injury compared to those who do not develop persistent PTH. Furthermore, logistic regression indicated that headache pain intensity at 1-2 weeks and pain inhibitory capacity on the conditioned pain modulation test at 1-2 weeks predicted persistent PTH classification at 4 months post injury.

CONCLUSIONS

Overall, the results suggested that persistent PTH is characterized by dysfunctional alterations in endogenous pain modulatory function and psychological processes in the early stages following mild TBI, which likely exacerbate risk for the maintenance of PTH.

An Evaluation of Navy En Route Care Training Using a High-Fidelity Medical Simulation Scenario of Interfacility Patient Transport

INTRODUCTION

Military prehospital and en route care (ERC) directly impacts patient morbidity and mortality. Provider knowledge and skills are critical variables in the effectiveness of ERC. No Navy doctrine defines provider choice for patient transport or requires standardized provider training. Frequently, Search and Rescue Medical Technicians (SMTs) and Navy Nurses (ERC RNs) are tasked with this mission though physicians have also been used. Navy ERC provider training varies greatly by professional role. Historically, evaluations of ERC and patient outcomes have been based on retrospective analyses of incomplete data sets that provide limited insight on ERC practices. Little evidence exists to determine if current training is adequate to care for the most common injuries seen in combat trauma patients.

MATERIALS AND METHODS

Simulation technology facilitates a standardized patient encounter to enable complete, prospective data collection while studying provider type as the independent variable. Information acquired through skill performance observation can be used to make evidence-based recommendations to improve ERC training. This IRB approved multi-center study funded through a Congressionally Directed Medical Research Program grant from the Combat Casualty Care Intramural Research Joint En Route Care portfolio evaluated Navy ERC providers. The study evaluated 84 SMT, ERC RN, and physician participants in the performance of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an interfacility transfer. Simulation evaluators with military ERC expertise, blinded to participant training and background, graded each participant's performance. Inter-rater reliability was calculated using Cohen's Kappa to evaluate concordance between evaluator assessments. Categorical data were reported as frequencies and percentages. Performance attempt and accuracy rates were compared with likelihood ratio chi-square or Fisher's exact test where appropriate. Tests were two-tailed and we considered results significant, that is, a difference not likely due to chance exists between groups, if p < 0.05. Confidence intervals were used to present overlap in performance between provider types.

RESULTS

Critical and secondary actions were assessed. A majority of providers completed at least one of the critical life-saving actions; only one participant completed all critical actions. Evaluation of critical actions demonstrated that a tourniquet was applied by 64% of providers, blood products administered by 46%, needle decompression performed by 51%, and a complete handoff report performed by 48%. Assessment of secondary actions demonstrated analgesic was accurately administered by 24% of all providers, and 44% reinforced the "hemorrhaging amputation site dressing."

CONCLUSION

Over 98% of participants failed to properly perform all critical actions during the interfacility transfer scenario, which in a real-life combat casualty transport scenario could result in a preventable death. Study results demonstrate serious skill deficits among all types of Navy ERC providers. These data can be used to improve the training of Navy ERC providers, ultimately improving care to injured soldiers, sailors, airmen, and marines.

Frequency, nature and management of patient-reported severe acute pain episodes in the over-the-counter setting: results of an online survey

Aim: Understand the frequency, nature and over-the-counter (OTC) self-management of patient-reported severe acute pain occasions. Patients & methods: A consumer-based survey of adults experiencing acute pain in Australia, Russia and the UK. Participants recorded pain type, frequency and intensity plus action taken to address pain. Results: A total of 2994 participants completed the survey; 1366 provided ≥1 diary entry (total 6527 pain occasions). Of these, 744 (11%) were reported as severe, and 72% were treated with OTC medication. Participants were somewhat satisfied/very satisfied with the action taken for 87% of pain occasions overall, and for 83% of severe pain episodes; however, participants with severe pain were somewhat/very dissatisfied with treatment in 9% of cases. Conclusion: Acute pain episodes described as 'severe' are not uncommon in the self-management setting; most can be managed successfully with self-medication. Individuals seeking strong OTC pain relief should be supported to consider self-management strategies first, before considering prescription medication.

Photobiomodulation therapy reduces acute pain and inflammation in mice

Photobiomodulation (PBM) is a therapy suggested for the treatment of pain and inflammation. Different mechanisms have been proposed to explain the analgesic and inflammatory effects of photobiomodulation, but there are still gaps on the mechanisms underlying. The objective was to investigate the analgesic and anti-inflammatory effect of red LED, as well as to investigate the possible mechanism of action in acute nociception models. Radiation was applied with red LED (660 nm, 215 mW, 84.64 mW/cm², 2.531 J/cm² (30s); 5.07 J/cm² (60s) 7.61 J/cm² (90s) and 10.15 J/cm² (120 s)). The red LED applied 60 s before the experiments, promoted reduction of the nociceptive neurogenic (1st phase) and inflammatory pain (2nd phase) induced by intraplantar (i.pl.) injection of formalin. This effect duration in the second phase was 180 min after pretreatment of the LED. Red LED also reduced nociception induced by intraperitoneal injection of acetic acid. Furthermore, red LED prevented nociception induced by i.pl. injection of cinnamaldehyde, capsaicin, menthol and acidified saline. It was demonstrate the involvement of glutamatergic system with the reduction the nociception induced by glutamate. The red LED was able to prevent nociception induced by intracellular signaling cascades activators, phorbol 12-myristate 13-acetate (PMA), bradykinin, forskolin and prostaglandin. In addition, red LED, respectively, from 30 to 90s demonstrated an antiedematogenic effect on ear edema and reduction the migration of inflammatory cells induced by single application of croton oil. Thus, the new findings in this study support some underlying mechanism by which red LED phototherapy reduces acute pain. However, need further clarification regarding analgesic and anti-inflammatory effect of the photobiomodulation in preclinical studies.

Tapentadol: an analgesic that differs from classic opioids due to its noradrenergic mechanism of action

Chronic pain treatment represents one of the most complex clinical challenges and even though opioids exhibit particular efficacy on nociceptive pain, their use must be controlled to avoid the risk of adverse reactions. A useful approach, aimed at maintaining analgesia and mitigating side effects, is represented by the use of a new class of analgesics endowed of µ-opioid (MOR) receptor agonism and noradrenaline reuptake inhibition (NRI) mechanisms. Tapentadol is the progenitor of this new class of drugs called MOP-NRI. A literature review has been conducted to gain information about the efficacy and the tolerability profile of tapentadol shifting from MOR agonism (acute pain) to NRI activity (chronic pain). The tolerability and therapeutic safety of tapentadol in neuropathic pain models, as well as in clinical settings, has been analyzed showing a good gastrointestinal tolerability profile, a moderate effect on hormone levels (in healthy volunteers and in patients) and on cognitive performance, a lack of significant alteration of the electrocardiogram recording and no changes of the QT/QTc interval, a minimal effect on serotonin reuptake in vivo with a low risk of serotonin syndrome, a longer time for the onset of analgesic tolerance and a less occurrence of abuse liability compared to formulations containing other comparator compounds. Tapentadol represents a great innovation in chronic pain therapy with a unique analgesic profile different form classical opioids, therefore, thanks to its synergistic MOR-NRI action, it may be a good option for the treatment of chronic, neuropathic and mixed pain.

Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting

OBJECTIVE

Acute postoperative pain is experienced by the majority of hospitalized patients undergoing surgical procedures, with many reporting inadequate pain relief and/or high levels of dissatisfaction with their pain management. Patient-controlled analgesia (PCA) ensures patient involvement in acute pain control, a key component for implementing a quality management system. This narrative article overviews the clinical evidence for conventional PCA and briefly discusses new, non-invasive PCA systems, namely the sufentanil sublingual tablet system (SSTS) and the fentanyl iontophoretic transdermal system (FITS).

METHODS

A Medline literature search ("patient-controlled analgesia" and "acute postoperative pain") was conducted to 1 April 2017; results from the main clinical trials are discussed. Additional literature was identified from the reference lists of cited publications.

RESULTS

Moderate to low quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain. However, despite the benefits of PCA, conventional intravenous PCA is limited by system-, drug- and human-related issues. The non-invasive SSTS and FITS have demonstrated good efficacy and safety in placebo- and intravenous morphine PCA-controlled trials, and are associated with high patient/healthcare practitioner satisfaction/ease of care ratings and offer early patient mobilization.

CONCLUSIONS

Evidence-based guidelines for acute postoperative pain management support the use of multimodal regimens in many situations. As effective and safe alternatives to conventional PCA, and with the added benefits of being non-invasive, easy to use and allowing early patient mobilization, the newer PCA systems may complement multimodal approaches, or potentially replace certain regimens, in hospitalized patients with acute postoperative pain.

Pain chronification: what should a non-pain medicine specialist know?

OBJECTIVE

Pain is one of the most common reasons for an individual to consult their primary care physician, with most chronic pain being treated in the primary care setting. However, many primary care physicians/non-pain medicine specialists lack enough awareness, education and skills to manage pain patients appropriately, and there is currently no clear, common consensus/formal definition of "pain chronification".

METHODS

This article, based on an international Change Pain Chronic Advisory Board meeting which was held in Wiesbaden, Germany, in October 2016, provides primary care physicians/non-pain medicine specialists with a narrative overview of pain chronification, including underlying physiological and psychosocial processes, predictive factors for pain chronification, a brief summary of preventive strategies, and the role of primary care physicians and non-pain medicine specialists in the holistic management of pain chronification.

RESULTS

Based on currently available evidence, we propose the following consensus-based definition of pain chronification which provides a common framework to raise awareness among non-pain medicine specialists: "Pain chronification describes the process of transient pain progressing into persistent pain; pain processing changes as a result of an imbalance between pain amplification and pain inhibition; genetic, environmental and biopsychosocial factors determine the risk, the degree, and time-course of chronification."

CONCLUSIONS

Early intervention plays an important role in preventing pain chronification and, as key influencers in the management of patients with acute pain, it is critical that primary care physicians are equipped with the necessary awareness, education and skills to manage pain patients appropriately.

Comorbid mild traumatic brain injury increases pain symptoms in patients suffering from an isolated limb fracture

OBJECTIVES

This study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group).

PATIENTS AND METHODS

All subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed.

RESULTS

A total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49days, SD: 34.9), compared to the control group (p<0.0001; mean difference 2.8, 95% confidence interval 1.8-4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation.

CONCLUSIONS

Results suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.

The effects of food on opioid-induced nausea and vomiting and pharmacological parameters: a systematic review

Opioids remain the standard of care for treating moderate to severe pain resulting from surgery or injury in cases of acute pain, and are recommended for patients who have not responded to nonopioid analgesics. Effective management of pain has an impact on clinical course and often depends on achieving an acceptable balance between opioid efficacy, safety, and tolerability. Common opioid-related adverse events such as nausea and vomiting are associated with an overall lower achievement of effective pain management and patient satisfaction. However, in practice, clinicians employ various strategies to maximize efficacy, minimize these adverse effects, and ensure the careful, judicious, and evidence-based use of opioids for patients who require them. Typical strategies for management and minimization of these types of adverse events include dose reduction, dose titration, opioid rotation, prescription for an antiemetic, and recommending the patient take opioids with food. Overall, the most straightforward approach that clinicians tend to employ that does not require additional visits or adjustment of prescriptions, is to recommend patients take opioids with food. However, given the current climate with opioids, it is critical and imperative that decisions for use of opioids be grounded in a solid and thorough evidence-base. In fact, several opioids are recommended to be taken explicitly with or without food because of interactions with abuse-deterrent technologies that can cause increased adverse events or inadequate analgesia. Therefore, we sought to review, synthesize, and summarize the literature for randomized, controlled trials and other studies to support the hypothesis that taking opioids with food reduces opioid-related events such as nausea and vomiting. Based on the current evidence we surveyed, the recommendation to take opioids with food does not appear to consistently and unequivocally reduce nausea and vomiting and, in many cases, increases the frequency of these adverse events in the studies we examined.

Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms

Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.

DIAGNOSIS

Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.

CONCLUSIONS

This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.

The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review

Morphine and other opioids are widely used to manage moderate to severe acute pain syndromes, such as pain associated with trauma or postoperative pain, and they have been used to manage chronic pain, even chronic nonmalignant pain. However, recent years have seen a renewed recognition of the potential for overuse, misuse, and abuse of opioids. Therefore, prescribing opioids is challenging for healthcare providers in that clinical effectiveness must be balanced against negative outcomes-with the possibility that neither are achieved perfectly. The current discourse about the dual 'epidemics' of under-treatment of legitimate pain and the over-prescription of opioids is clouded by inadequate or inaccurate understanding of opioid drugs and the endogenous pain pathways with which they interact. An understanding of the basic pharmacology of opioids helps inform the clinician and other stakeholders about these simultaneously under- and over-used agents.

Evidence and consensus recommendations for the pharmacological management of pain in India

Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events - particularly with opioids and surgical methods of analgesia - are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case-control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making.

Assessing and Managing Acute Pain: A Call to Action

: Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic.

The prevalence of chronic pain in orchestra musicians

Background: The study investigated the incidence of chronic pain as well as causes and mechanisms of pain chronification in orchestra musicians. Aims: Chronic pain is a serious problem in the study group due to very specific playing techniques and body positions while playing, with a high impact on professional and private life. Methods: 8,645 professional musicians from 132 German cultural orchestras were contacted and asked about chronic pain via an online questionnaire. The study group comprised orchestra musicians suffering from pain. The control group consisted of musicians playing the same type of instruments (same working conditions) who reported to be free of pain. Results: The response rate was 8.6% (740 musicians). 66.2% (n=490) out of 740 musicians who completed the questionnaire reported chronic pain. The most frequently reported localizations of pain were the body parts which are mostly involved in instrumental playing such as back (70%), shoulders (67.8%), neck (64.1%), hands and wrists (39.8%). 27.4% of the investigated musicians suffered from pain with a high degree of impairment. Conclusions: These results appear conclusive and indicate a need to continue research into chronic pain in musicians.

T4 syndrome - A distinct theoretical concept or elusive clinical entity? A case report

T4 syndrome has existed as a clinical concept for more than three decades and it has been identified as a source of upper extremity (UE) symptoms. This case report explores the clinical reasoning in the diagnoses and management of a patient with symptoms consistent with T4-type syndrome and critically discusses the concept of T4 syndrome using recent research to help explain the clinical presentation. Manual therapy treatment focused on stimulation of the sympathetic ganglia, decreasing local upper thoracic pain and UE referral pattern noted during passive examination. The successful outcomes included immediate and lasting symptom relief after upper thoracic spinal manipulation. Although treatment has been based on the theory that mechanical thoracic dysfunction can produce sympathetic nervous system (SNS) referred pain, the role the sympathetic reflexes potentially plays on the referral symptoms to the UE presently remains unclear.

Economic and clinical burden of opioid-induced nausea and vomiting

Opioids are the standard of care for treating moderate-to-severe pain; however, their efficacy can be limited by adverse events (AEs), including nausea and vomiting. Opioid-induced nausea and vomiting (OINV) is an inherent adverse effect of opioid treatment, exerting effects centrally and peripherally. Opioid-related AEs can impact treatment adherence and discontinuation, which can result in inadequate pain management. OINV may persist long-term, negatively affecting patient functional outcomes, physical and mental health, patient satisfaction, and overall costs of treatment. Multiple factors may contribute to OINV, including activation of opioid receptors in the chemoreceptor trigger zone, vestibular apparatus, and gastrointestinal tract. Prophylactic or early treatment with antiemetics may be appropriate for patients who are at high risk for OINV.

Health Care Utilization and Costs Associated with Nausea and Vomiting in Patients Receiving Oral Immediate-Release Opioids for Outpatient Acute Pain Management

Introduction

Nausea and vomiting (NV) are common side effects of opioid use and limiting factors in pain management. This study sought to quantify the frequency of antiemetic prescribing and the impact of NV on health care resource utilization and costs in outpatients prescribed opioids for acute pain. The perspective was that of a commercial health plan.

Methods

Medical and pharmacy claims from IMS PharMetrics Plus were used to identify patients initiating opioid therapy with a prescription for an oxycodone-, hydrocodone- or codeine-containing immediate-release product for acute use (≤15-day supply) between October 1, 2013 and September 30, 2014. Patients with a medical claim for NV (International Classification of Diseases, Ninth Revision, Clinical Modification codes 787.0x), with or without an antiemetic prescription fill, were compared with patients with no NV claim or antiemetic prescription fill to assess differences in all-cause health care utilization and costs over 1 month. Propensity score matching (PSM) was used to adjust for between-group differences in baseline patient characteristics.

Results

The co-prescribing of opioids with antiemetic agents was 10.2%. After PSM (n = 45,790 per group), patients with NV claims had significantly more hospitalizations (11.5% vs 4.2%), emergency department visits (65.0% vs 12.1%), and physician office visits (85.2% vs 64.5%) compared with patients with no NV claims (all P < 0.0001). Mean total health care costs were higher among patients with a NV claim versus those without evidence of the side effect ($6290 vs $2309; P < 0.0001). Among patients with a recent hospitalization, patients with NV claims had higher rates of 30-day rehospitalization than those with no NV claims (24.4% vs 3.0%; P < 0.0001).

Conclusions

Among outpatients prescribed opioids for management of acute pain, co-prescribing with antiemetics was low, and the economic burden associated with NV was high. Efforts to prevent NV in patients receiving opioid therapy may improve patient outcomes and provide cost savings to the health care system.

Funding

Daiichi Sankyo, Inc.

Electronic supplementary material

The online version of this article (doi:10.1007/s40122-016-0057-y) contains supplementary material, which is available to authorized users.

Improving the management of post-operative acute pain: priorities for change

Poor management of post-operative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. It is therefore important that all patients undergoing surgery should receive adequate pain management. However, evidence suggests this is not currently the case; between 10% and 50% of patients develop chronic pain after various common operations, and one recent US study recorded >80% of patients experiencing post-operative pain. At the first meeting of the acute chapter of the Change Pain Advisory Board, key priorities for improving post-operative pain management were identified in four different areas. Firstly, patients should be more involved in decisions regarding their own treatment, particularly when fateful alternatives are being considered. For this to be meaningful, relevant information should be provided so they are well informed about the various options available. Good physician/patient communication is also essential. Secondly, better professional education and training of the various members of the multidisciplinary pain management team would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain at different points along pain pathways, more widespread adoption of patient-controlled analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational change could provide similar benefits; introducing acute pain services and increasing their availability towards the 24 hours/day ideal, greater adherence to protocols, increased use of patient-reported outcomes, and greater receptivity to technological advances would all help to enhance performance and increase patient satisfaction. It must be acknowledged that implementing these recommendations would incur a considerable cost that purchasers of healthcare may be unwilling or unable to finance. Nevertheless, change is under way and the political will exists for it to continue.

Acute Pain Medicine in the United States: A Status Report

BACKGROUND

Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs.

METHODS

A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education.

RESULTS

The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM.

CONCLUSION

This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.