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Bielewicz J, Kamieniak M, Szymoniuk M, Litak J, Czyżewski W, Kamieniak P. Diagnosis and Management of Neuropathic Pain in Spine Diseases. J Clin Med 2023; 12:jcm12041380. [PMID: 36835916 PMCID: PMC9961043 DOI: 10.3390/jcm12041380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Neuropathic pain is generally defined as a non-physiological pain experience caused by damage to the nervous system. It can occur spontaneously, as a reaction to a given stimulus, or independently of its action, leading to unusual pain sensations usually referred to as firing, burning or throbbing. In the course of spine disorders, pain symptoms commonly occur. According to available epidemiological studies, a neuropathic component of pain is often present in patients with spinal diseases, with a frequency ranging from 36% to 55% of patients. Distinguishing between chronic nociceptive pain and neuropathic pain very often remains a challenge. Consequently, neuropathic pain is often underdiagnosed in patients with spinal diseases. In reference to current guidelines for the treatment of neuropathic pain, gabapentin, serotonin and norepinephrine reuptake inhibitors and tricyclic antidepressants constitute first-line therapeutic agents. However, long-term pharmacologic treatment often leads to developing tolerance and resistance to used medications. Therefore, in recent years, a plethora of therapeutic methods for neuropathic pain have been developed and investigated to improve clinical outcomes. In this review, we briefly summarized current knowledge about the pathophysiology and diagnosis of neuropathic pain. Moreover, we described the most effective treatment approaches for neuropathic pain and discussed their relevance in the treatment of spinal pain.
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Affiliation(s)
- Joanna Bielewicz
- Department of Neurology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Maciej Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Michał Szymoniuk
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Correspondence:
| | - Jakub Litak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Department of Clinical Immunology, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland
| | - Wojciech Czyżewski
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Department of Didactics and Medical Simulation, Medical University of Lublin, Chodźki 4, 20-093 Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
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Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 407] [Impact Index Per Article: 203.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
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Szikszay TM, Lévénez JLM, Adamczyk WM, Carvalho GF, Luedtke K. Offset analgesia is increased intra-orally. J Oral Rehabil 2022; 49:993-1001. [PMID: 35841379 DOI: 10.1111/joor.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/27/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Offset analgesia (OA) is commonly used to quantify endogenous pain inhibition. However, the potential role of afferent inputs and the subsequent peripheral factors from different body areas on the underlying mechanisms are still unclear. OBJECTIVES The aim of this cross-sectional study was to compare the magnitude of OA in four different body areas representing a) glabrous and non-glabrous skin, b) trigeminal and extra-trigeminal areas, and c) intra- and extra-oral tissue. METHODS OA was assessed at the oral mucosa of the lower lip, at the skin of the cheek, the forearm and the palm of the hand in 32 healthy and pain-free participants. OA testing included two trials: (1) a constant trial (30 seconds of constant heat stimulation at an individualized temperature of Pain50 (pain intensity of 50 out of 100)), and (2) an offset trial (10 seconds of individualized Pain50 , followed by 5 seconds at Pain50 +1°C and 15 seconds at Pain50 ). Participants continuously rated their pain during each trial with a computerized visual analog scale. RESULTS A significant OA response was recorded at the oral mucosa (p<0.001, d=1.24), the cheek (p<0.001, d=0.84) and the forearm (p<0.001, d=1.04), but not at the palm (p=0.19, d=0.24). Significant differences were shown for OA recorded at the cheek versus the mucosa (p=0.02), and between palm and mucosa (p=0.007), but not between the remaining areas (p>0.05). CONCLUSION This study suggests that intra-oral endogenous pain inhibition assessed with OA is enhanced and supports the role of peripheral mechanisms contributing to the OA response.
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Affiliation(s)
- T M Szikszay
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - J L M Lévénez
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - W M Adamczyk
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany.,Laboratory of Pain Research, Institute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - G F Carvalho
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - K Luedtke
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
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Barrachina J, Margarit C, Muriel J, López-Gil S, López-Gil V, Vara-González A, Planelles B, Inda MDM, Morales D, Peiró AM. Oxycodone/naloxone versus tapentadol in real-world chronic non-cancer pain management: an observational and pharmacogenetic study. Sci Rep 2022; 12:10126. [PMID: 35710811 PMCID: PMC9203709 DOI: 10.1038/s41598-022-13085-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/20/2022] [Indexed: 12/25/2022] Open
Abstract
Tapentadol (TAP) and oxycodone/naloxone (OXN) potentially offer an improved opioid tolerability. However, real-world studies in chronic non-cancer pain (CNCP) remain scarce. Our aim was to compare effectiveness and security in daily pain practice, together with the influence of pharmacogenetic markers. An observational study was developed with ambulatory test cases under TAP (n = 194) or OXN (n = 175) prescription with controls (prescribed with other opioids (control), n = 216) CNCP patients. Pain intensity and relief, quality of life, morphine equivalent daily doses (MEDD), concomitant analgesic drugs, adverse events (AEs), hospital frequentation and genetic variants of OPRM1 (rs1799971, A118G) and COMT (rs4680, G472A) genes, were analysed. Test CNCP cases evidenced a significantly higher pain relief predictable due to pain intensity and quality of life (R2 = 0.3), in front of controls. Here, OXN achieved the greatest pain relief under a 28% higher MEDD, 8–13% higher use of pregabalin and duloxetine, and 23% more prescription change due to pain, compared to TAP. Whilst, TAP yielded a better tolerability due the lower number of 4 [0–6] AEs/patient, in front of OXN. Furthermore, OXN COMT-AA homozygotes evidenced higher rates of erythema and vomiting, especially in females. CNCP real-world patients achieved higher pain relief than other traditional opioids with a better tolerability for TAP. Further research is necessary to clarify the potential influence of COMT and sex on OXN side-effects.
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Affiliation(s)
- Jordi Barrachina
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain
| | - Cesar Margarit
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.,Pain Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Javier Muriel
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.,Pain Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Santiago López-Gil
- Occupational Observatory, Miguel Hernández University of Elche, Alicante, Spain
| | - Vicente López-Gil
- Occupational Observatory, Miguel Hernández University of Elche, Alicante, Spain
| | - Amaya Vara-González
- Occupational Observatory, Miguel Hernández University of Elche, Alicante, Spain
| | - Beatriz Planelles
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.,Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernández University of Elche, Elche, Spain
| | - María-Del-Mar Inda
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain
| | - Domingo Morales
- Operations Research Centre, Miguel Hernández University of Elche, Elche, Spain
| | - Ana M Peiró
- Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain. .,Department of Pharmacology, Paediatrics and Organic Chemistry, Miguel Hernández University of Elche, Elche, Spain. .,Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain. .,Neuropharmacology on Pain (NED) Research Group, Hospital General Universitario de Alicante, C/Pintor Baeza, 12, 03010, Alicante, Spain.
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White KM, LaRowe LR, Powers JM, Paladino MB, Maisto SA, Zvolensky MJ, Glatt SJ, Ditre JW. Family History of Alcohol Use Disorder as a Predictor of Endogenous Pain Modulation Among Moderate to Heavy Drinkers. THE JOURNAL OF PAIN 2022; 23:864-875. [PMID: 34974175 PMCID: PMC9086107 DOI: 10.1016/j.jpain.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/01/2021] [Accepted: 12/13/2021] [Indexed: 05/03/2023]
Abstract
Family history of alcohol use disorder (AUD) is frequently endorsed by persons with chronic pain. Although individuals with a family history of AUD have demonstrated enhanced sensitivity to painful stimulation, previous research has not examined endogenous pain modulation in this population. The goal of this study was to test family history of AUD as a predictor of conditioned pain modulation, offset analgesia, and temporal summation among a sample of moderate and heavy drinkers. Adults with no current pain (N = 235; 58.3% male; Mage = 34.3; 91.9% non-Hispanic; 60% white) were evaluated for family history of AUD at baseline and pain modulatory outcomes were assessed via quantitative sensory testing. Participants with a family history of AUD (relative to those without) evinced a pro-nociceptive pain modulation profile in response to experimental pain. Specifically, family history of AUD was associated with deficits in pain-inhibitory processes. Approximately 4% of the variance in endogenous pain modulation was accounted for by family history, and exploratory analyses suggested these effects may be driven by paternal AUD. PERSPECTIVE: The current findings suggest individuals with a family history of AUD demonstrate pain modulatory function that may predispose them to the development of chronic pain. Clinically, these data may inform pain management approaches for individuals with a family history of AUD.
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Affiliation(s)
- Kyle M White
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Lisa R LaRowe
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Jessica M Powers
- Department of Psychology, Syracuse University, Syracuse, New York
| | | | - Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, Texas.; Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen J Glatt
- Department of Psychiatry and Behavioral Sciences, The State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, New York..
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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Abstract
Managing chronic pain remains a major unmet clinical challenge. Patients can be treated with a range of interventions, but pharmacotherapy is the most common. These include opioids, antidepressants, calcium channel modulators, sodium channel blockers, and nonsteroidal anti-inflammatory drugs. Many of these drugs target a particular mechanism; however, chronic pain in many diseases is multifactorial and induces plasticity throughout the sensory neuroaxis. Furthermore, comorbidities such as depression, anxiety, and sleep disturbances worsen quality of life. Given the complexity of mechanisms and symptoms in patients, it is unsurprising that many fail to achieve adequate pain relief from a single agent. The efforts to develop novel drug classes with better efficacy have not always proved successful; a multimodal or combination approach to analgesia is an important strategy in pain control. Many patients frequently take more than one medication, but high-quality evidence to support various combinations is often sparse. Ideally, combining drugs would produce synergistic action to maximize analgesia and reduce side effects, although sub-additive and additive analgesia is still advantageous if additive side-effects can be avoided. In this review, we discuss pain mechanisms, drug actions, and the rationale for mechanism-led treatment selection.Abbreviations: COX - cyclooxygenase, CGRP - calcitonin gene-related peptide, CPM - conditioned pain modulation, NGF - nerve growth factor, NNT - number needed to treat, NMDA - N-methyl-d-aspartate, NSAID - nonsteroidal anti-inflammatory drugs, TCA - tricyclic antidepressant, SNRI - serotonin-noradrenaline reuptake inhibitor, QST - quantitative sensory testing.
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Affiliation(s)
- Ryan Patel
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
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Pujol J, Martínez-Vilavella G, Doreste A, Blanco-Hinojo L, Ojeda F, Llorente-Onaindia J, Polino L, Deus J, Monfort J. Tapentadol effects on brain response to pain in sensitized patients with knee osteoarthritis. Rheumatology (Oxford) 2021; 61:2335-2345. [PMID: 34636838 DOI: 10.1093/rheumatology/keab761] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Pain sensitization, in the form of knee tenderness and anatomically spread hyperalgesia, is notably common in patients with knee osteoarthritis and is often refractory to conventional interventions. Tapentadol, as an opioid receptor agonist and noradrenaline reuptake inhibitor, has been proposed as a potentially effective symptomatic treatment for pain-sensitized osteoarthritis patients. We empirically tested whether tapentadol could attenuate brain response to painful stimulation on the tender knee using functional MRI. METHODS Pressure painful stimulation was applied to the articular interline and the tibial surface, a commonly sensitized site surrounding the joint. Thirty patients completed the crossover trial designed to compare prolonged release tapentadol and placebo effects administered over 14 days. RESULTS We found no effects in the direction of the prediction. Instead, patients administered with tapentadol showed stronger activation in response to pressure on the tender site in the right prefrontal cortex and somatosensory cortices. The somatosensory effect was compatible with the spread of neural activation around the knee cortical representation. Consistent with the functional MRI findings, the patients showed higher clinical ratings of pain sensitization under tapentadol and a significant positive association was identified between the number of tapentadol tablets and the evoked subjective pain. CONCLUSION The tapentadol effect paradoxically involved both the spread of the somatosensory cortex response and a stronger activation in prefrontal areas with a recognized role in the appraisal of pain sensations. Further studies are warranted to explore how osteoarthritis patients may benefit from powerful analgesic drugs without the associated risks of prolonged use. EudraCT-[2016-005082-31].
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Affiliation(s)
- Jesus Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | | | - Andrea Doreste
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain
| | - Laura Blanco-Hinojo
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | - Fabiola Ojeda
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | | | - Luciano Polino
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Joan Deus
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain
| | - Jordi Monfort
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
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Assessment of pain associated with chronic pancreatitis: An international consensus guideline. Pancreatology 2021; 21:1256-1284. [PMID: 34391675 DOI: 10.1016/j.pan.2021.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022]
Abstract
Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.
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