Lidocaine Patch Treatment in Patients with Low Back Pain: Results of an Open-Label, Nonrandomized Pilot Study

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use

INTRO

Pain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population.

METHODS

Pediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol.

RESULTS

Forty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain.

CONCLUSION

Post-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum.

LEVEL OF EVIDENCE

Level II.

Assessment and nonsurgical management of low back pain: a narrative review

Low back pain (LBP) is a common condition that affects people of all ages and income levels worldwide. The etiology of LBP may be mechanical, neuropathic, systemic, referred visceral, or secondary to other causes. Despite numerous studies, the diagnosis and management of LBP remain challenging due to the complex biomechanics of the spine and confounding factors, such as trivial degenerative imaging findings irrelevant to symptoms and psychological and emotional factors. However, it is imperative to identify the crucial signs ("red flags") indicating a serious underlying condition. While many recent guidelines emphasize non-pharmacologic management approaches, such as education, reassurance, and physical and psychological care, as the first option, LBP patients in many countries, including South Korea, are prescribed medications. Multidisciplinary rehabilitation combined with prudent use of medications is required in patients unresponsive to first-line therapy. The development of practical guidelines apposite for South Korea is needed with multidisciplinary discussion.

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

Topical Lidocaine for Chronic Pain Treatment

Topical lidocaine is widely used in current practice for a variety of pain conditions. This literature review shows that its limited absorption and relative lack of systemic adverse events are an attractive analgesic option for a number of vulnerable patients. Topical lidocaine has been approved by health authorities for the treatment of post-herpetic neuralgia in a number of countries, and studies present some degree of evidence of its efficacy and safety in postsurgical pain, diabetic peripheral neuropathy, carpal tunnel syndrome, chronic lower back pain and osteoarthritis. Topical lidocaine may be a great alternative alone or in addition to systemic drugs and non-pharmacological approaches for an optimized pain management and in multimodal analgesia.

Comparative safety review of current treatment options for chronic low back pain and unmet needs: a narrative review

Introduction: The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.Areas covered: The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological agents used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.Expert opinion: The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life, thus, affecting their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain will promote development of new therapeutic strategies.

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

BACKGROUND

Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion.

METHODS

We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay.

RESULTS

Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches (P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08).

DISCUSSION

In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients' hospital course.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

The Efficacy, Effectiveness and Safety of 5% Transdermal Lidocaine Patch for Chronic Low Back Pain: A Narrative Review

Local anesthetics, such as the 5% transdermal lidocaine patch (5LP), have been frequently used in the treatment of musculoskeletal pain, especially chronic low back pain (CLBP). This review compiles the literature available on the efficacy, effectiveness, and safety of 5LP when used for the management of CLBP. A systematic search method revealed seven articles that fit the inclusion criteria. For each study, efficacy, effectiveness, and adverse events data were extracted. We found no randomized controlled trials with substantial evidence to support the use of 5LP in CLBP, despite the presence of nonrandomized noncontrolled trials suggesting its effectiveness for relief of pain. Future randomized controlled trials with clinically useful outcomes are needed to assess the efficacy, effectiveness, and safety of 5LP for CLBP more appropriately.

Use of Lidocaine for Pain Management in the Emergency Medicine: A Systematic Review and Meta-Analysis

Background: Lidocaine is a well-known medium-acting local anesthetic with a short onset time. It is a valuable drug for managing both acute and chronic pains and is being used as a popular agent for pain control in the emergency department (ED). In this systematic review, we intended to define the effectiveness of lidocaine in pain management of the patients referring to ED. Methods: The preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement was utilized for this Systematic Review (SR). We searched the databases of PubMed, Scopus, ProQuest, and Medline (Ovid) from 1990 to August 2017 for Randomized Controlled Trials (RCTs) in which the study population was referred to the emergency department and received lidocaine. Full-texts of the studies that were published in English were reviewed for inclusion. Both authors individualistically evaluated all studies. Seven articles were eligible for the meta-analysis based on their common outcomes. Results: The total number of subjects was 671. The studies were categorized based on the type of drug and administration route. Mean pain, regardless of the drug administration method, in the placebo group was 0.69 units higher than the lidocaine group. Considering the administration route, mean pain in the placebo group was 0.35 units higher than the lidocaine group when administered topically, and it was lower in the subcutaneous method than the topical method by 1.41 units. Conclusion: Infiltration of lidocaine decreases pain of different procedures in the ED whereas the effect of topical lidocaine is controversial issue.

Local Anesthetics: Pharmacology and Special Preparations

Local anesthetics are the only class of drugs that can block transduction and transmission of nociception. Physical properties, mechanism of action, and pharmacokinetics of this class of drugs are reviewed in this article. The clinical use, such intravenous administration of lidocaine, and local and systemic toxic effects are covered. A review of current studies published in the human and veterinary literature on lidocaine patches (Lidoderm) and liposomal bupivacaine (Experal and Nocita) are discussed.

Lidocaine medicated plaster, an additional potential treatment option for localized post-surgical neuropathic pain: efficacy and safety results of a randomized, placebo-controlled trial

OBJECTIVE

To assess the efficacy and safety of lidocaine 700 mg medicated plaster (lidocaine plaster) compared to placebo in patients with moderate to severe chronic post-surgical neuropathic pain (PSNP).

METHODS

Patients (n = 363) with a diagnosis of PSNP for a minimum of 3 months to 36 months were randomized (1:1) to lidocaine plaster or placebo for a 12 week double-blind treatment period. Randomization was stratified as "plaster-only" (no concomitant medication for PSNP) or as "add-on" (stable systemic medication for PSNP). The primary efficacy endpoint was the change from baseline in 24 hour average pain intensity at Week 12, assessed by 11 point numerical rating scale (NRS). The trial was registered in ClinicalTrials.gov (NCT01752322) and EudraCT (2012-000347-28).

RESULTS

Treatment with lidocaine or placebo plaster led to a clinically relevant reduction in average pain intensity. Pain reduction (least squares mean [LS mean] standard error [SE], [95% confidence interval, CI]) with lidocaine plaster (-1.70 [0.16], [-2.03, -1.38]) was numerically higher than with placebo (-1.47 [0.16], [-1.78, -1.15]) but the difference was not statistically significant (-0.23 [0.23], [-0.69, 0.22]). Pre-specified exploratory subgroup analyses showed the largest differentiation between lidocaine and placebo in patients without concomitant pain medication, and in patients with more than 1 year between surgery and enrollment. Many secondary outcomes showed a numerically larger improvement in favor of lidocaine. The most commonly reported adverse events were administration site reactions linked to topical administration.

CONCLUSIONS

A clinically relevant pain reduction was observed with lidocaine plaster in patients with PSNP. The safety and tolerability profile is consistent with current knowledge.

Efficacy of lidocaine 5% medicated plaster (VERSATIS®) in patients with localized neuropathic pain poorly responsive to pharmacological therapy

BACKGROUND

Localized neuropathic pain (LNP) is a subgroup of neuropathic pain characterized by consistent and circumscribed area(s) of maximum pain, associated with negative or positive sensory signs and/or spontaneous symptoms characteristic of NP. Lidocaine medicated plasters (LMP) have shown to be effective in pain relief in selective LNP syndromes.

METHODS

We collected data of 130 patients in our database with LNP syndromes who used LMP.

RESULTS

Forty-one patients out of 130 patients (32%) were treated with antiepileptics, antidepressants and opioids without improvement and/or with intolerable adverse effects and are not assuming systemic therapy anymore. Globally, during the 12 months follow-up, 15% of patients reached a complete pain relief without any systemic therapy, mainly in trigeminal and post-herpetic neuralgia (P=0.009), 38% of patients reduced analgesic drug consumption with the highest reduction in radiculopathy, post-herpetic neuralgia and trigeminal neuralgia. Topical and transient adverse effects, such as itching or local erythema, were seen in 19/130 (14.6%) patients; 7 of these patients (5.4%) needed to discontinue the treatment due to the occurrence of adverse effects. The dropout rate on global population (excluding cured and lost to follow-up) was 45%, and the main cause of dropouts was the inefficacy of treatment in the first 3 months of therapy with LMP.

CONCLUSIONS

LMP treatment is safe and worth consideration also as add-on therapy in order to reduce analgesic drug consumption in selected LNP.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

The assessment and management of pain in cirrhosis

Purpose of review

The treatment of pain in patients with cirrhosis is complicated by unpredictable hepatic drug metabolism and a higher risk of adverse drug reactions. We aimed to conduct a scoping review regarding pain management in cirrhosis.

Recent findings

Despite the high prevalence of pain in patients with cirrhosis, there is little literature to guide the management of pain in this population. Complex pain syndromes and disease-specific pain etiologies exist are common in patients with cirrhosis. There are numerous contraindications and limitations when considering pharmacotherapy for analgesia in cirrhosis, specifically with non-steroidal anti-inflammatory drugs (NSAIDS) and opioid medications. Non-pharmacologic therapies for pain have not been specifically assessed in this population.

Summary

As with other populations, a multi-dimensional treatment approach to pain with a focus on physical, behavioral, procedural and pharmacologic treatment is recommended when caring for patients with cirrhosis and pain. However, more research is needed to evaluate opioid-sparing and non-pharmacologic analgesia in this population.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

Pharmacologic Treatment of Pain

Adolescents and children are frequently affected by chronic pain conditions that can lead to disability and distress. The best approach to evaluation and treatment of these conditions involves use of the biopsychosocial model, which includes use of medication management. Chronic pain conditions are treated pharmacologically with a number of different medication classes via several routes of administration as drug delivery systems have progressed. These include anti-inflammatory drugs, muscle relaxants, antiepileptic medicines, antidepressants, opioids, and local anesthetics. Most are prescribed without regulatory body approval to treat specific pain syndromes as data to support their use are sparse. Medical decision making is guided by experience, empiric evidence, extrapolation from adult studies, and matching medication classes with the theorized mechanism of the pain condition. It is not recommended that nonpain practitioners prescribe opioid medications for treatment of chronic pain conditions, and pain management practitioners should seek to minimize their use. The appropriate and commonly used medications for pain conditions are presented in this narrative review.

Neuropathic low back pain in clinical practice

Background and objective

Low back pain (LBP) is one of the most common chronic pain conditions. This paper reviews the available literature on the role of neuropathic mechanisms in chronic LBP and discusses implications for its clinical management, with a particular focus on pharmacological treatments.

Databases and data treatment

Literature searches were performed in PubMed, key pain congresses and ProQuest Dialog to identify published evidence on neuropathic back pain and its management. All titles were assessed for relevant literature.

Results

Chronic LBP comprises both nociceptive and neuropathic components, however, the neuropathic component appears under‐recognized and undertreated. Neuropathic pain (NP) is challenging to manage. Many patients with chronic LBP have pain that is refractory to existing treatments. Typically, less than half of patients experience clinically meaningful analgesia with oral pharmacotherapies; these are also associated with risks of adverse effects. Paracetamol and NSAIDs, although widely used for LBP, are unlikely to ameliorate the neuropathic component and data on the use of NP medications such as antidepressants and gabapentin/pregabalin are limited. While there is an unmet need for improved treatment options, recent data have shown tapentadol to have efficacy in the neuropathic component of LBP, and studies suggest that the capsaicin 8% patch and lidocaine 5% medicated plaster, topical analgesics available for the treatment of peripheral NP, may be a valuable additional approach for the management of neuropathic LBP.

Conclusions

Chronic LBP often has an under‐recognized neuropathic component, which can be challenging to manage, and requires improved understanding and better diagnosis and treatment.

What does this review add?

Increased recognition and improved understanding of the neuropathic component of low back pain raises the potential for the development of mechanism‐based therapies.

Open and retrospective studies suggest that agents like tapentadol and topical analgesics — such as the capsaicin 8% patch and the lidocaine 5% medicated plaster — may be effective options for the treatment of neuropathic low back pain in defined patient groups.

Is lidocaine patch as effective as intravenous lidocaine in pain and illus reduction after laparoscopic colorectal surgery? A randomized clinical trial

Objective:

To evaluate the efficacy of lidocaine patch applied around wound in laparoscopic colorectal surgery in reduction of postoperative pain and illus compared to intravenous lidocaine infusion and placebo.

Background:

Postoperative illus and pain after colorectal surgery is a challenging problem associated with increased morbidity and cost. Inflammatory response to surgery plays crucial rule in inducing postoperative illus. Systemic local anesthetics proved to have anti-inflammatory properties that may be beneficial in preventing ileus added to its analgesic actions. The lidocaine patch evaluated in many types of pain with promising results. We try to evaluate the patch in perioperative field as a more simple and safe technique than the intravenous route.

Materials and Methods:

Prospective, randomized, controlled study was conducted, comparing three groups. Group 1 (placebo) received saline infusion, group 2 received i.v. lidocaine infusion after induction of anesthesia, 2 mg/min if body weight >70 kg or 1 mg/min if body weight <70 kg, group 3 received lidocaine patch 5%, three patches each one divided into two equal parts and applied around the three wounds just before induction. Data collected were, pain scores (VAS), morphine consumption, return of bowel function, pro-inflammatory cytokines plasma levels and plasma lidocaine level.

Results:

Pain intensity (VAS) scores at rest and during coughing were significantly lower during the first 72 h postoperative in i.v. lidocaine group and patch group compared to the placebo group. Mean morphine consumption were significantly lower in the i.v. lidocaine group and patch group compared to placebo group. Return of the bowel function was significantly earlier in i.v. lidocaine group in comparison to the other groups. Proinflammatory cytokines (IL6, IL8, and C3a) were significantly lower in i.v. lidocaine group compared to the other two groups.

Conclusion:

The lidocaine patch was equal to i.v. lidocaine infusion in decreasing pain scores and morphine consumption but not in acceleration of bowel function return.

Lidocaine patch for acute pain management: a meta-analysis of prospective controlled trials

BACKGROUND

Local anesthetic is one of the cornerstones of multimodal analgesia. We investigated the efficacy of the lidocaine patch for acute pain management.

METHODS

We searched MEDLINE, CINAHL, Scopus, and the Cochrane Controlled Trials Register for published prospective controlled clinical trials that evaluated the analgesic effect of the lidocaine patch for acute or postoperative pain management (1966--2014). The outcomes were postoperative opioid consumption, pain intensity and length of hospital stay.

RESULTS

Five trials comparing the lidocaine patch with control (no treatment/placebo) for acute or postoperative pain treatment/management were included in this meta-analysis. Data was analyzed on 251 patients. Between the lidocaine patch group and the control group, no significant difference was found for all three outcomes (all p > 0.05). For postoperative opioid consumption, mean difference (MD) was -8.2 mg morphine equivalent (95% CI -28.68, 12.24). For postoperative pain intensity, MD was -9.1 mm visual analog scale or equivalent (95% CI -23.31, 5.20). For length of hospital stay, MD was -0.2 days (95% CI -0.80, 0.43).

CONCLUSION

Application of a lidocaine patch may not be an effective adjunct for acute and postoperative pain management, in terms of pain intensity, opioid consumption and length of hospital stay.

LIMITATIONS

The limitations were a small number of included studies, potential biases from some unblinded studies, clinical heterogeneity between studies, and incomplete reported data for adjunct analgesics.

Use of 5% lidocaine medicated plasters for the treatment of pain in routine hospital practice: patient reported pain, functioning and satisfaction

OBJECTIVE

5% lidocaine medicated plasters are a topical option in the treatment of peripheral neuropathic pain, as monotherapy or as an adjunct to systemic medication. This study sought to determine the impact of lidocaine plaster use on self-reported pain, functioning and patient satisfaction within a large teaching hospital.

RESEARCH DESIGN AND METHODS

Patients were selected from the pain and rheumatology outpatient departments in Cardiff, Wales (2008-9). Postal surveys were sent to patients prescribed lidocaine plaster asking whether patients currently used the plaster and, if not, reason for discontinuation. Patients were asked to record pain score before and after therapy initiation, percentage pain relief, duration of effectiveness and impact on functioning.

MAIN OUTCOME MEASURES

Pain scores, pain relief and levels of functioning before and after treatment.

RESULTS

A total of 850 surveys were dispatched; 408 (48.0%) responses received; 197 (48.3%) patients were current users at survey completion. Median pain score prior to plaster use was 8 (IQR 7-9). One month after initiation, median pain score was 6 (4-8, p < 0.001) overall and 5 (4-7, p < 0.001) for current users. Median pain relief, after initial month of plaster use, was 30% (10-60%) for all patients and 50% (30-70%) for current users, whilst pain relief at time of survey was 30% (0-60%) and 50% (30-70%), respectively. A total of 181 (93.3%) current users claimed the plasters were effective. All three measures of functioning were significantly improved in current users: sleep (63.3% versus 20.1%, p < 0.001), mood (59.2% versus 18.6%, p < 0.001) and activity level (50.0% versus 19.5%, p < 0.001). Median satisfaction was 5 (IQR 1-8) for all patients and 7 (5-9) for current plaster users.

CONCLUSIONS

The results of this study need to be considered within the context of a self-reported survey. However, pain, functioning and patient satisfaction were significantly improved in current users of 5% lidocaine medicated plasters.

Low back pain: pharmacologic management

Adequate treatment of low back pain is essential, but has been challenging for many primary care physicians. Most patients with low back pain can be treated in the primary care environment, provided the physician has enough knowledge of the medications used to treat low back pain. The main treatment goal for acute low back pain is to control the pain and maintain function. For patients with chronic back pain, the goal is continual pain management and prevention of future exacerbations. This article reviews current pharmacological options for the treatment of low back pain, and possible future innovations.

Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC.

METHODS

A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus.

RESULTS

Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations.

CONCLUSION

Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Duloxetine in the management of chronic musculoskeletal pain

Chronic musculoskeletal pain is among the most frequent painful complaints that healthcare providers address. The bulk of these complaints are chronic low back pain and chronic osteoarthritis. Osteoarthritis is the most common form of arthritis in the United States. It is a chronic degenerative disorder characterized by a loss of cartilage, and occurs most often in older persons. The management of osteoarthritis and chronic low back pain may involve both nonpharmacologic (eg, weight loss, resistive and aerobic exercise, patient education, cognitive behavioral therapy) and pharmacologic approaches. Older adults with severe osteoarthritis pain are more likely to take analgesics than those with less severe pain. The pharmacologic approaches to painful osteoarthritis remain controversial, but may include topical as well as oral nonsteroidal antiinflammatory drugs, acetaminophen, duloxetine, and opioids. The role of duloxetine for musculoskeletal conditions is still evolving.

Topical pain management with the 5% lidocaine medicated plaster--a review

BACKGROUND

The topical 5% lidocaine medicated plaster is recommended as first-line treatment for localized peripheral neuropathic pain.

SCOPE

In order to provide an overview of the efficacy and safety of the lidocaine plaster in the treatment of different neuropathic pain conditions, all efficacy and safety studies (randomized, controlled, or open-label with well described methodology), case reports, and pharmacological studies on the lidocaine plaster retrieved from a PubMed literature research (1960-March 2012) plus additional references identified from retrieved articles were included.

FINDINGS

The lidocaine plaster is efficacious in the treatment of neuropathic pain symptoms associated with previous herpes zoster infection. Results from a large open-label controlled study suggest that the lidocaine plaster could be at least as effective as systemic pregabalin in the treatment of postherpetic neuralgia and painful diabetic polyneuropathy. Open-label studies indicate efficacy in the treatment of other localized neuropathic pain conditions, such as painful idiopathic sensory polyneuropathy, complex regional pain syndrome, carpal tunnel syndrome sequelae, postsurgical and posttraumatic pain. Quality of life markedly improved in a variety of neuropathic pain conditions and long-term treatment provided sustained relief in patients with neuropathic pain who are responsive to lidocaine plaster. The lidocaine plaster is usually well tolerated. The risk of systemic adverse events and pharmacokinetic interactions with concomitant medication is minimal owing to low systemic exposure.

CONCLUSIONS

Treatment of several, primarily neuropathic and mixed-pain conditions with the 5% lidocaine medicated plaster was found efficacious and safe. Further controlled studies, in particular where only small open-label studies or case reports are available, should be considered.

Patient perceptions associated with the 5% lidocaine medicated plaster in daily practice

OBJECTIVE

To evaluate patients' perceptions of 5% lidocaine medicated plaster for treatment of chronic neuropathic pain in daily clinical practice.

RESEARCH DESIGN AND METHODS

In a prospective, multicentre, non-interventional observation, patient-reported outcome data were collected in clinical practices in Germany using the German Pain Questionnaire for pre-treatment documentation and the German Pain Diary for documentation of weekly treatment-associated changes. Questionnaires were completed by the patients without input from their physicians.

MAIN OUTCOME MEASURES

Mean changes over the 12-week treatment period in pain intensity, in impairments of daily activities (modified pain disability index, mPDI) and of quality of life (quality of life impairment by pain inventory, QLIP), in Hospital Anxiety and Depression Scale scores (HADS-A and HADS-D), and in overall burden of pain.

RESULTS

Data of 922 patients were evaluated. Mean average pain intensity over 24 h improved by 5.1 points (74%) from 6.9 ± 1.6 points at baseline. A 30% reduction in overall pain intensity was already observed within the first 2-3 weeks with continuous further reductions until end of observation. Marked improvements in anxiety and depression scores (40% and 52%, respectively), and in pain-related restrictions in daily life activities (66%) and quality of life (157%) were also noted. Burden of pain was reduced by 56.2 points (73%) from 77.5 points at baseline. Stratification by diagnosis showed a treatment effect of lidocaine plaster for all underlying conditions with highest treatment effects for diabetic polyneuropathy and postherpetic neuralgia.

CONCLUSIONS

In a patient population where 46% of individuals already suffered from chronic to markedly chronic pain, patients perceive the 5% lidocaine medicated plaster as an efficacious topical treatment of chronic neuropathic pain in daily clinical practice. Strongest pain relief as well as associated improvements in pain-related restrictions were observed within the first five treatment weeks; however, beneficial effects continued until end of observation.

Lidocaine patch (5%) is no more potent than placebo in treating chronic back pain when tested in a randomised double blind placebo controlled brain imaging study

Background

The 5% Lidocaine patch is used for treating chronic neuropathic pain conditions such as chronic back pain (CBP), diabetic neuropathy and complex regional pain syndrome, but is effective in a variable proportion of patients. Our lab has reported that this treatment reduces CBP intensity and associated brain activations when tested in an open labelled preliminary study. Notably, effectiveness of the 5% Lidocaine patch has not been tested against placebo for treating CBP. In this study, effectiveness of the 5% Lidocaine patch was compared with placebo in 30 CBP patients in a randomised double-blind study where 15 patients received 5% Lidocaine patches and the remaining patients received placebo patches. Functional MRI was used to identify brain activity for fluctuations of spontaneous pain, at baseline and at two time points after start of treatment (6 hours and 2 weeks).

Results

There was no significant difference between the treatment groups in either pain intensity, sensory and affective qualities of pain or in pain related brain activation at any time point. However, 50% patients in both the Lidocaine and placebo arms reported a greater than 50% decrease in pain suggesting a marked placebo effect. When tested against an untreated CBP group at similar time points, the patch treated subjects showed significantly greater decrease in pain compared to the untreated group (n = 15).

Conclusions

These findings suggest that although the 5% Lidocaine is not better than placebo in its effectiveness for treating pain, the patch itself induces a potent placebo effect in a significant proportion of CBP patients.

[Lidocaine patch for therapy of neuropathic and non-neuropathic pain. A clinical case series of 87 patients]

BACKGROUND

Topical lidocaine patches (LP) reduce pain in postherpetic neuralgia and other forms of focal neuropathy. The aim of this study was to determine clinical predictors of therapeutic success.

MATERIAL AND METHODS

The medical histories of 87 patients with neuropathic (NS) and non-neuropathic pain (NNS) who had received LP as an add-on to their established pain medication were retrospectively analyzed. The variables assessed were gender, age, analgesic co-medication, pain localization, adverse effects and presence of dynamic allodynia. The impact of these variables on the clinical pain-relieving effect (scored on a 5-point scale) was investigated.

RESULTS

A total of 24 out of 28 patients with manifest allodynia scored the therapy with LP as beneficial, patients without allodynia (n=59, 67.8%) profited significantly less frequently with only 39% (p<0.001). The probability of profiting from LP therapy in the presence of allodynia was found to be about tenfold higher compared to patients without allodynia (odds ratio 9.14). Of the 87 patients investigated 48 were female (55.2%). Allodynia was considerably more frequent in women (39.6%) compared to men (23.1%) but this was insignificant. Of the female patients 62.5% responded to LP treatment, compared to only 43.6% of men. In more than 60% of cases rated as very good pain relief allodynia was manifest and in non-responders only in less than 10%. The variables age, pain localization and analgesic co-medication were not related with the success of therapy.

DISCUSSION

Patients with manifest allodynia profited significantly more frequently from LP therapy and were less frequently non-responders. Female patients showed therapeutic success more often together with a higher rate of allodynia.

CONCLUSIONS

In the presence of allodynia, in especially of neuropathic origin, LP seems to be an effective and save option for add-on therapy, this being independent from pain localization and age. Gender specific effects however need more systematic investigation.

Diclofenac epolamine topical patch relieves pain associated with ankle sprain

Background:

Sports-related injuries, such as sprains and strains, commonly occur during exercise and athletic events. Current therapy includes nonsteroidal anti-inflammatory drugs (NSAIDs), which have a high incidence of upper gastrointestinal side effects. The present study assessed the efficacy and safety of the diclofenac epolamine topical patch (DETP, 1.3%), a topical NSAID for the treatment of acute minor sprains and strains.

Methods:

This multicenter, randomized, placebo-controlled clinical study enrolled adult patients (n = 134) with acute ankle pain (due to a minor sprain) occurring less than 48 hours prior to entering the study. Patients were treated with either the DETP or a placebo topical patch daily for seven days. Pain intensity was evaluated during the first six hours after application of the patch, and on treatment days 1, 2, 3, and 7.

Results:

Patients treated with the DETP experienced a significantly greater reduction in pain associated with their ankle injury compared with placebo, beginning four hours after the first patch application (P = 0.02). The DETP was well tolerated and was comparable with placebo in terms of safety.

Conclusion:

Overall, the results of this study demonstrate that the DETP is an effective analgesic for local treatment of pain in mild acute ankle sprain.

Opioid therapy for osteoarthritis and chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) and osteoarthritis (OA) of any joint are highly prevalent, occurring in > 50% of US adults aged ≥ 60 years. Opioids are prescribed more frequently for CLBP and OA than for any other noncancer pain, and the judicious use of opioids is recommended by treatment guidelines for the management of CLBP and OA pain.

OBJECTIVE

To review the appropriate role of opioid analgesics in the treatment of patients with moderate-to-severe pain due to CLBP or OA and provide recommendations for best practices when prescribing opioids.

METHODS

Articles were identified through a search of PubMed. Additional references were identified for inclusion from the reference lists of articles identified via the literature search, treatment guidelines, and Cochrane Reviews.

RESULTS

The available data suggest that opioid therapy represents a valuable treatment option in patients who do not respond to other analgesics and in whom the potential benefits of treatment outweigh the potential risks. Prescribing physicians need to perform vigilant patient screening and monitoring for signs of abuse, intervene promptly to manage or prevent adverse events and drug interactions, tailor opioid therapy to individual patients' comorbidities, and know how to switch or rotate opioids to find the best treatment option.

CONCLUSIONS

Prescribers need to understand the place of opioid therapy in a multimodal treatment program that includes patient rehabilitation to reduce pain and improve function. The analgesic benefits of opioids must be balanced against concerns about addiction and abuse, adverse events, and their potential impact on other aspects of treatment.

Outcome predictors for treatment success with 5% lidocaine medicated plaster in low back pain with neuropathic components and neuropathic pain after surgical and nonsurgical trauma

Five percent lidocaine medicated plaster has been proven efficacious for the symptomatic relief of neuropathic pain in diverse pain conditions which might be attributed to a common localized symptomatology in these indications, possibly with common predictors of treatment success. To discuss potential symptoms and other factors predicting response to treatment with lidocaine plaster for the indications of low back pain with neuropathic components and neuropathic pain after surgical and nonsurgical trauma, 44 pain specialists from 17 countries attended a two-day conference meeting in December 2009. Discussions were based on the retrospective analysis of case reports (sent in by participants in the four weeks prior to the meeting) and the practical experience of the participants. The results indicate some predictors for success with 5% lidocaine medicated plaster for the two indications. Localized pain, hyperalgesia and/or allodynia, and other positive sensory symptoms, such as dysesthesia, were considered positive predictors, whereas widespread pain and negative sensory symptoms were regarded as negative predictors. Paresthesia, diagnosis, and site of pain were considered to be of no predictive value. Common symptomatology with other neurologic pathologies suggests that treatment of localized neuropathic pain symptoms with the plaster can be considered across different neuropathic pain indications.

Topical preparations for pain relief: efficacy and patient adherence

There has been an increasing focus on development of new routes of drug administration to provide tailored treatments for patients, without decreasing efficacy of analgesia, in proportion to the progression of the knowledge of pain mechanisms. While acute pain acts as an alarm, chronic pain is a syndrome requiring meticulous selection of analgesic drugs of high bioavailability for long-term use. Such criteria are challenges that topical medications aim to overcome, allowing progressive delivery of active component, maintaining stable plasma levels, with a good safety profile. This review presents recent findings regarding topical formulations of the most widely used drugs for pain treatment, such as nonsteroidal anti-inflammatory agents, anesthetics, and capsaicin, and the role of physical agents as delivery enhancers (phonophoresis and iontophoresis). Although the number of topical agents is limited for use in peripheral conditions, increasing evidence supports the efficacy of these preparations in blocking nociceptive and neuropathic pain. Patient adherence to medical treatment is also a challenge, especially in chronic painful conditions. It is known that reduction of treatment complexity and pill burden are good strategies to increase patient compliance, as discussed here. However, the role of topical presentations, when compared to traditional routes, has not yet been fully explored and thus remains unclear.

Time to significant pain reduction following DETP application vs placebo for acute soft tissue injuries

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) provide fast and effective acute pain relief, but systemic administration has increased risk for some adverse reactions. The diclofenac epolamine 1.3% topical patch (DETP) is a topical NSAID with demonstrated safety and efficacy in treatment of acute pain from minor soft tissue injuries. Significant pain reduction has been observed in clinical trials within several hours following DETP application, suggesting rapid pain relief; however, this has not been extensively studied for topical NSAIDs in general. This retrospective post-hoc analysis examined time to onset of significant pain reduction after DETP application compared to a placebo patch for patients with mild-to-moderate acute ankle sprain, evaluating the primary efficacy endpoint from two nearly identical studies.

RESEARCH DESIGN AND METHODS

Data from two double-blind, randomized, parallel-group, placebo-controlled studies (N = 274) of safety and efficacy of the DETP applied once daily for 7 days for acute ankle sprain were evaluated post-hoc using statistical modeling to estimate time to onset of significant pain reduction following DETP application.

MAIN OUTCOME MEASURES

Pain on active movement on a 100 mm Visual Analog Scale (VAS) recorded in patient diaries; physician- and patient-assessed tolerability; and adverse events.

RESULTS

DETP treatment resulted in significant pain reduction within approximately 3 hours compared to placebo. Within-treatment post-hoc analysis based on a statistical model suggested significant pain reduction occurred as early as 1.27 hours for the DETP group. The study may have been limited by the retrospective nature of the analyses. In both studies, the DETP was well tolerated with few adverse events, limited primarily to application site skin reactions.

CONCLUSION

The DETP is an effective treatment for acute minor soft tissue injury, providing pain relief as rapidly as 1.27 hours post-treatment. Statistical modeling may be useful in estimating time to onset of pain relief for comparison of topical and oral NSAIDs.

Pain management in older people

At times providing pain relief in elderly patients can prove troublesome. Their tolerance and perception of pain can differ from that of younger patients, while the incidence of pain is above that found in those of less advanced years.

Conventional approaches to providing pain relief can be successful, but the tolerance to the side-effects of those drugs used to provide pain relief can be less. Furthermore, polypharmacy can have implications for the range of analgesic drugs that can be considered. Fortunately there are an increasing range of medicinal products with reduced potential for side-effects that can be considered when treating older patients with pain.

Acute back pain: benefits and risks of current treatments

OBJECTIVE

To review the efficacy and safety of current treatments for acute low back pain.

RESEARCH DESIGN AND METHODS

PubMed was searched for clinical trials in which the words, acute, back, and pain all appeared in the study summary. The search was from the earliest references included in this database (1949) until 1 May 2009. This resulted in retrieval of 129 papers. Review of study summaries indicated that 36 provided information about either a topical treatment or oral therapy for acute low back pain. In addition, studies included as part of the evidence base for the Evidence Review of American Pain Society/American Academy of Pain Medicine Evidence Review for Evaluation and Management of Low Back Pain were reviewed.

RESULTS

Recommended topical and systemic pharmacologic treatments for acute low back pain include application of superficial heat, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants/benzodiazepines, and opioids including tramadol. Only a small number of studies compared different approaches to treatment of acute back pain and most failed to demonstrate significant differences among treatments. Available results support the view that both NSAIDs and low-level continuous heat treatment are more effective than acetaminophen and that heat treatment is also significantly more effective than ibuprofen. A potential limitation of this study is that information from trials published in journals not included in PubMed or reported only at meetings and not yet published was not included.

CONCLUSIONS

A wide range of treatments is currently recommended for the management of patients with acute back pain and all are supported by results from controlled clinical trials.

Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre

BACKGROUND

There are few reports of the use of the lidocaine 5% patch (L5%P) for neuropathic pain (NP) in the cancer patient. Within a comprehensive cancer centre, L5%P has been prescribed by the Pain and Palliative Care Service (Peter McCallum Cancer Centre, East Melbourne, Victoria, Australia) for selected patients with NP since 2001.

OBJECTIVE

To retrospectively audit the use of L5%P within a comprehensive cancer centre.

METHODS

All L5%P prescriptions up to January 2009 were listed and patient medical records were searched to determine neuropathic pain syndromes treated, the presence of allodynia, previous analgesic medications, treatment duration and outcome.

RESULTS

L5%P was prescribed for 97 patients, most frequently for persistent postsurgical NP (n=26), postherpetic neuralgia (n=24) and cancer-related NP (n=18). Six patients had no history of cancer and two patients never applied L5%P. Reviewers classed L5%P analgesic efficacy as 'potent' in 38% of patients with postherpetic neuralgia, 35% of patients with postsurgical pain, 27% of patients with NP after other treatments for cancer and 12% of patients with NP attributed to cancer alone. Allodynia featured in at least 60% of patients. Where allodynia was present, the efficacy of L5%P was assessed as 'potent' in 38% and 'partial' in 24%, but 'ineffective' in 26%, and 'causing worse pain' in 3.4% of patients. Treatment duration extended longer than one month in 52 patients, longer than two months in 29 patients and longer than one year in 13 patients. Therapy was ceased due to skin irritation in seven patients. The outcomes in relation to other reports are discussed.

CONCLUSION

The present data support trials of L5%P for cancer patients with NP syndromes associated with allodynia.

Management of neuropathic pain after surgical and non-surgical trauma with lidocaine 5% patches: study of 40 consecutive cases

OBJECTIVE

To determine the efficacy of lidocaine 5% patches [Versatis, commercialised by Grünenthal GmbH, Aachen, Germany] in patients with PNCCP.

BACKGROUND

This study focuses on chronic pain states of a neuropathic nature, located at the scar or over a larger area of the skin around the scar. This post-operative/post-traumatic neuropathic chronic cutaneous pain (PNCCP) may be a side-effect of any incision of the skin in the context of a surgical procedure or a traumatic event.

RESEARCH DESIGN AND METHODS

A single-centre, open, non-randomised, prospective study was performed in a university hospital referral centre for patients with chronic neuropathic pain after surgical or non-surgical trauma. Forty consecutive patients with chronic PNCCP, a VAS score > or =5, a LANSS score > or =12, and a stable consumption of pain medication were prospectively evaluated. All patients were given lidocaine 5% patches, following a 12 h on/off schedule.

MAIN OUTCOME MEASURES

Visual analogue scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed pretreatment (day 0), on the 28th day (4 weeks), and after 84 days (12 weeks).

RESULTS

The mean pretreatment VAS score (VAS(0)) was 7.225 +/- 1.209, and the mean pretreatment LANSS score (LANSS(0)) was 18.60 +/- 2.610. The number of patients with a VAS score <5 at the latest follow-up (VAS(84)) was 21 (52.5%). Mean VAS(84) was 4.625 +/- 1.675. Seventeen patients (42.5%) had a LANSS score <12 at the latest follow-up. Overall mean LANSS(84) was 12.85 +/- 3.093.

CONCLUSION

Lidocaine 5% patches seem to be an effective treatment of post-surgical and post-traumatic pain. These results should be supported with randomised and placebo-controlled studies with larger sample sizes and longer follow-ups.