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Mercadante S, Schiavello A. Radiofrequency ablation for cancer pain with inadequate opioid response. BMJ Support Palliat Care 2024:spcare-2024-004795. [PMID: 38658050 DOI: 10.1136/spcare-2024-004795] [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: 01/18/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
Data on the use of radiofrequency (RT) to ablate a tumor mass-causing pain have not been reported. A male in his 50s, diagnosed with a pelvic relapse of rectal cancer, was admitted for pain from the left groin to the perineum. The principal findings of contrast-enhanced computed tomography (CT) revealed the presence in the pelvic area of large solid tissue infiltrating the internal obturator muscle and eroding the vertebral column of the acetabulum. Also involving the gluteal muscles.He was poorly responsive to multiple opioids. He was treated with RT under CT guidance to ablate the pelvic mass. Pain relief was immediate as it was possible to reduce methadone doses since the afternoon of the operation day. Very selected patients who are not responsive to optimisation of opioid therapy, could be candidates to RF of the tumor mass, that may offer an efficient method to provide fast pain relief and allowing opioid dose reduction.
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2
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Mercadante S. Refractory Cancer Pain and Intrathecal Therapy: Critical Review of a Systematic Review. Pain Ther 2023; 12:645-654. [PMID: 37055698 PMCID: PMC10199986 DOI: 10.1007/s40122-023-00507-z] [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: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
This critical review assessed the advantages of invasive procedures that were recently included in systematic reviews, to evaluate whether the definition of refractory pain condition was correctly followed to select patients for invasive interventions and to analyze how data were positively interpreted. A total of 21 studies were selected for the purpose of this review. Three were randomized controlled studies, ten were prospective studies, and eight were retrospective studies. Analysis of these studies showed evident lack of proper assessment before implantation for different reasons. These included an optimistic interpretation regarding the outcomes, poor consideration of complications, and inclusion of patients with short survival. Moreover, the indication of intrathecal therapy as a condition in which a patient has failed to respond to multiple therapies provided by a pain or palliative care physician or at sufficient doses for adequate durations, as suggested by a recent research group, has been disregarded. Regretfully, this can discourage the use of intrathecal therapy in patients who are unresponsive to multiple opioid strategies subtrahend a potent means to be used in a very selective population.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90100, Palermo, Italy.
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3
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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4
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Eldabe S, Obara I, Panwar C, Caraway D. Biomarkers for Chronic Pain: Significance and Summary of Recent Advances. Pain Res Manag 2022; 2022:1940906. [PMID: 36385904 PMCID: PMC9663208 DOI: 10.1155/2022/1940906] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 01/13/2024]
Abstract
Chronic pain can be difficult to predict and a challenge to treat. Biomarkers for chronic pain signal an opportunity for advancements in both management and prevention, and through their research and development offer new insights into the complex processes at play. This review considers the latest research in chronic pain biomarker development and considers how close we are to bringing these from bench to bedside. While some headway has been made that offers efficiencies in patient selection, it is unlikely that a single test will encompass the variety of chronic pain phenotypes. We offer some insights for the near future in biomarker development and areas of continued unmet need.
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Affiliation(s)
- Sam Eldabe
- The James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - Ilona Obara
- School of Pharmacy and Translational and Clinical Research Institute, The Faculty of Medical Sciences, Newcastle University, Newcastle NE1 7RU, UK
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5
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Pirvulescu I, Biskis A, Candido KD, Knezevic NN. Overcoming clinical challenges of refractory neuropathic pain. Expert Rev Neurother 2022; 22:595-622. [PMID: 35866187 DOI: 10.1080/14737175.2022.2105206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Refractory neuropathic pain (ReNP), and its definition, is widely disputed amongst clinicians due in part to unclear categorical diagnosing guidelines, overall time duration of neuropathic pain, and the exhaustiveness of treatment options. Usually ReNP is defined as chronic, intractable, and unresponsive neuropathic pain that have otherwise been untreatable. AREAS COVERED : In this narrative review, we discuss and summarize the effectiveness of prospective ReNP research conducted over the past 10 years. This research looks at pharmacological and interventional therapies in clinical trial settings. The pharmacological therapies discussed include the use of adjuvant treatments to improve the safety and efficacy of conventional approaches. Different modalities of administration, such as injection therapy and intrathecal drug delivery systems, provide targeted drug delivery. Interventional therapies such as neuromodulation, pulse radiofrequency, and nerve lesioning are more invasive, however, they are increasingly utilized in the field, as reflected in ongoing clinical trials. EXPERT OPINION : Based on the current data from RCTs and systematic reviews, it is clear that single drug therapy cannot be effective and has significant limitations. Transitioning to interventional modalities that showed more promising results sooner rather than later may be even more cost-efficient than attempting different conservative treatments with a high failure rate.
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Affiliation(s)
- Iulia Pirvulescu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Alexandras Biskis
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Advocate Aurora Research Institute, Chicago, IL, USA.,College of Aviation, Science and Technology, Lewis University, Romeoville, IL, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
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6
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De la Torre Canales G, Poluha RL, Pinzón NA, Da Silva BR, Almeida AM, Ernberg M, Manso AC, Bonjardim LR, Rizzatti-Barbosa CM. Efficacy of Botulinum Toxin Type-A I in the Improvement of Mandibular Motion and Muscle Sensibility in Myofascial Pain TMD Subjects: A Randomized Controlled Trial. Toxins (Basel) 2022; 14:toxins14070441. [PMID: 35878179 PMCID: PMC9323061 DOI: 10.3390/toxins14070441] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 12/20/2022] Open
Abstract
This study assessed the effects of botulinum toxin type A (BoNT-A) in mandibular range of motion and muscle tenderness to palpation in persistent myofascial pain (MFP) patients (ReBEC RBR-2d4vvv). Eighty consecutive female subjects with persistent MFP, were randomly divided into four groups (n = 20): three BoNT-A groups with different doses and a saline solution group (placebo control group). Treatments were injected bilaterally in the masseter and anterior temporalis muscle in a single session. Clinical measurements of mandibular movements included: pain-free opening, maximum unassisted and assisted opening, and right and left lateral excursions. Palpation tests were performed bilaterally in the masseter and temporalis muscle. Follow-up occurred 28 and 180 days after treatment. For the statistical analysis the Mann–Whitney U-test with Bonferroni correction was used for groups comparisons. Regardless of dose, all parameters of mandibular range of motion significantly improved after 180 days in all BoNT-A groups, compared with the control group. Palpation pain over the masseter and temporalis muscles were significantly reduced in all BoNT-A groups regardless of dose, compared with the control group, after 28 and 180 days of treatment. Independent of doses, BoNT-A improved mandibular range of motion and muscle tenderness to palpation in persistent MFP patients.
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Affiliation(s)
- Giancarlo De la Torre Canales
- Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, CRL, Quinta da Granja, Monte de Caparica, 2829-511 Caparica, Portugal; (A.M.A.); (A.C.M.)
- Ingá University Center, Uningá, Maringa 87020-900, Brazil;
- Correspondence:
| | | | - Natalia Alvarez Pinzón
- Institución Universitaria Colegios de Colombia-Centro de Investigación del Colegio Odontológico (CICO) 20, Bogotá 111611, Colombia;
| | | | - Andre Mariz Almeida
- Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, CRL, Quinta da Granja, Monte de Caparica, 2829-511 Caparica, Portugal; (A.M.A.); (A.C.M.)
| | - Malin Ernberg
- Department of Dental Medicine, Karolinska Institutet, and the Scandinavian Center for Orofacial Neurosciences (SCON), 141 52 Huddinge, Sweden;
| | - Ana Cristina Manso
- Clinical Research Unit (CRU), Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz—Cooperativa de Ensino Superior, CRL, Quinta da Granja, Monte de Caparica, 2829-511 Caparica, Portugal; (A.M.A.); (A.C.M.)
| | - Leonardo Rigoldi Bonjardim
- Bauru Orofacial Pain Group, Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Sao Paulo 17012-900, Brazil;
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7
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D'Souza RS, Barman R, Joseph A, Abd-Elsayed A. Evidence-Based Treatment of Painful Diabetic Neuropathy: a Systematic Review. Curr Pain Headache Rep 2022; 26:583-594. [PMID: 35716275 DOI: 10.1007/s11916-022-01061-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Painful diabetic neuropathy (PDN) manifests with pain typically in the distal lower extremities and can be challenging to treat. The authors appraised the literature for evidence on conservative, pharmacological, and neuromodulation treatment options for PDN. RECENT FINDINGS Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy compared to patients who receive conventional insulin therapy. First-line pharmacologic therapy for PDN includes gabapentinoids (pregabalin and gabapentin) and duloxetine. Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch, although studies have revealed modest treatment effects from these modalities. There is level I evidence on the use of dorsal column spinal cord stimulation (SCS) for treatment of PDN, delivering either a 10-kHz waveform or tonic waveform. In summary, this review provides an overview of treatment options for PDN. Furthermore, it provides updates on the level of evidence for SCS therapy in cases of PDN refractory to conventional medical therapy.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross Barman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amira Joseph
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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8
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Potter ST, Welch S, Tata F, Probert S, Nagpal A. Dorsal Root Ganglion Stimulation. Phys Med Rehabil Clin N Am 2022; 33:359-378. [DOI: 10.1016/j.pmr.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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Staudt MD, Prabhala T, Sheldon BL, Quaranta N, Zakher M, Bhullar R, Pilitsis JG, Argoff CE. Current Strategies for the Management of Painful Diabetic Neuropathy. J Diabetes Sci Technol 2022; 16:341-352. [PMID: 32856490 PMCID: PMC8861791 DOI: 10.1177/1932296820951829] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The development of painful diabetic neuropathy (PDN) is a common complication of chronic diabetes that can be associated with significant disability and healthcare costs. Prompt symptom identification and aggressive glycemic control is essential in controlling the development of neuropathic complications; however, adequate pain relief remains challenging and there are considerable unmet needs in this patient population. Although guidelines have been established regarding the pharmacological management of PDN, pain control is inadequate or refractory in a high proportion of patients. Pharmacotherapy with anticonvulsants (pregabalin, gabapentin) and antidepressants (duloxetine) are common first-line agents. The use of oral opioids is associated with considerable morbidity and mortality and can also lead to opioid-induced hyperalgesia. Their use is therefore discouraged. There is an emerging role for neuromodulation treatment modalities including intrathecal drug delivery, spinal cord stimulation, and dorsal root ganglion stimulation. Furthermore, consideration of holistic alternative therapies such as yoga and acupuncture may augment a multidisciplinary treatment approach. This aim of this review is to focus on the current management strategies for the treatment of PDN, with a discussion of treatment rationale and practical considerations for their implementation.
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Affiliation(s)
- Michael D Staudt
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Tarun Prabhala
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany NY, USA
| | - Breanna L Sheldon
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany NY, USA
| | - Nicholas Quaranta
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Michael Zakher
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Ravneet Bhullar
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany NY, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York, USA
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10
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Deer TR, Falowski S, Arle JE, Vesper J, Pilitsis J, Slavin KV, Hancu M, Grider JS, Mogilner AY. A Systematic Literature Review of Brain Neurostimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2021; 21:1415-1420. [PMID: 32034418 DOI: 10.1093/pm/pnz371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To conduct a systematic literature review of brain neurostimulation for pain. DESIGN Grade the evidence for deep brain neurostimulation (DBS). METHODS An international, interdisciplinary work group conducted a literature search for brain stimulation. Abstracts were reviewed to select studies for grading. Randomized controlled trials (RCTs) meeting inclusion/exclusion criteria were graded by two independent reviewers. General inclusion criteria were prospective trials (RCTs and observational) that were not part of a larger or previously reported group. Excluded studies were retrospective or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the United States Preventative Services Task Force level-of-evidence criteria. RESULTS Two high-quality RCTs and three observational trials supported DBS, resulting in Level II (moderate) evidence. CONCLUSION Moderate evidence supports DBS to treat chronic pain. Additional Level I RCTs are needed to further the strength of the evidence in this important area of medicine, but the current evidence suggests that DBS should be considered as an option in treating complex pain cases.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | - Jeff E Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich Heine University, Dusseldorf, Germany
| | - Julie Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Maria Hancu
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Alon Y Mogilner
- Department Neurosurgery, NYU Langone Medical Center, New York, New York, USA
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11
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Patel N, Calodney A, Kapural L, Province‐Azalde R, Lad SP, Pilitsis J, Wu C, Cherry T, Subbaroyan J, Gliner B, Caraway D. High-Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Nonsurgical Refractory Back Pain: Design of a Pragmatic, Multicenter, Randomized Controlled Trial. Pain Pract 2021; 21:171-183. [PMID: 33463027 PMCID: PMC7891432 DOI: 10.1111/papr.12945] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) has been shown to provide pain relief for chronic back and leg pain due to failed back surgery syndrome. But many patients with chronic back pain have not had major back surgery or are not good candidates for surgery, and conventional medical management (CMM) provides limited relief. We have termed this condition nonsurgical refractory back pain (NSRBP). Level 1 evidence does not yet exist showing the therapeutic benefit of SCS for NSRBP. OBJECTIVE To compare 10-kHz SCS plus CMM (10-kHz SCS + CMM) to CMM alone for treatment of NSRBP in terms of clinical and cost effectiveness. STUDY DESIGN Multicenter, randomized controlled trial (RCT), with subjects randomized 1:1 to either 10-kHz SCS + CMM or CMM alone. Optional crossover occurs at 6 months if treatment does not achieve ≥50% pain relief. METHODS Patients with NSRBP as defined above may be enrolled if they are ineligible for surgery based on surgical consultation. Subjects randomized to 10-kHz SCS + CMM will receive a permanent implant if sufficient pain relief is achieved in a temporary trial. Both groups will receive CMM per standard of care and will undergo assessments at baseline and at follow-ups to 12 months. Self-report outcomes include pain, disability, sleep, mental health, satisfaction, healthcare utilization, and quality of life. RESULTS Enrollment was initiated on September 10, 2018. Prespecified independent interim analysis at 40% of the enrollment target indicated the sample size was sufficient to show superiority of treatment at the primary endpoint; therefore, enrollment was stopped at 211. CONCLUSIONS This large multicenter RCT will provide valuable evidence to guide clinical decisions in NSRBP.
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Affiliation(s)
| | | | - Leonardo Kapural
- Carolina’s Pain InstituteWinston‐SalemNorth CarolinaU.S.A.
- School of MedicineWake Forest UniversityWinston‐SalemNorth CarolinaU.S.A.
| | | | | | | | - Chengyuan Wu
- Thomas Jefferson UniversityPhiladelphiaPennsylvaniaU.S.A.
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12
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Fernandes M, Schelotto M, Doldi PM, Milani G, Ariza Manzano AA, Perera Valdivia D, Winter Matos AM, Hamdy Abdelrahim Y, Hamad Bek SA, Benitez BK, Romanelli Tavares VL, Basendwah AM, Albuquerque Sousa LH, Xavier NF, Zertuche Maldonado T, Toyomi de Oliveira S, Chaker M, Menon Miyake M, Uygur Kucukseymen E, Waqar K, Alkhozondar OMJ, Bernardo da Silva R, Droppelmann G, Vaz de Macedo A, Nakamura R, Fregni F. IMPORTANCE trial: a provisional study-design of a single-center, phase II, double-blinded, placebo-controlled, randomized, 4-week study to compare the efficacy and safety of intranasal esketamine in chronic opioid refractory pain. F1000Res 2021; 10:42. [PMID: 33732434 PMCID: PMC7885290 DOI: 10.12688/f1000research.27809.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Cancer is the second leading cause of death globally. Up to 86% of advanced cancer patients experience significant pain, while 10-20% live in chronic pain. Besides, increasing prescription of opioids resulted in 33,000 deaths in the US in 2015. Both reduce patients’ functional status and quality of life. While cancer survival rates are increasing, therapeutic options for chronic opioid refractory pain are still limited. Esketamine is the s-enantiomer of ketamine, with superior analgesic effect and less psychotomimetic side effects. Intranasal esketamine was approved by the FDA for treatment-resistant depression. However, its use in chronic cancer pain has never been tested. Therefore, we propose a phase II, randomized, placebo-controlled trial to evaluate the efficacy and safety of intranasal esketamine in chronic opioid refractory cancer pain. Methods and analysis: We will recruit 120 subjects with chronic opioid refractory pain, defined as pain lasting more than 3 months despite optimal therapy with high dose opioids (>60 mg morphine equivalent dose/day) and optimal adjuvant therapy. Subjects will be randomized into two groups: intranasal esketamine (56mg) and placebo. Treatment will be administered twice a week for four consecutive weeks. The primary outcome is defined as reduction in the Numeric Pain Rating Scale (NPRS) after first application. Secondary outcomes include NPRS reduction after four weeks, the number of daily morphine rescue doses, functional status and satisfaction, and depression. Conclusion: This study may extend therapeutic options in patients with chronic pain, thus improving their quality of life and reducing opioid use. Trial registration: Clinical Trials.gov,
NCT04666623. Registered on 14 December 2020
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Affiliation(s)
| | | | - Philipp Maximilian Doldi
- Dresden International University, Dresden, Germany.,Universitätsklinikum München Campus Großhadern, München, Germany
| | | | | | | | | | | | | | - Benito K Benitez
- Department of Oral and Craniomaxillofacial Surgery, Basel, Switzerland
| | | | - Abdulrahim M Basendwah
- Oncology Division, Internal Medicine Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | | | | | | | - Melisa Chaker
- Department of Pediatric Cardiology, Hospital Nacional de Pediatría Juan Pedro Garrahan, Buenos Aires, Argentina
| | | | - Elif Uygur Kucukseymen
- Neuromodulation Center and Center for Clinical Research Learning. Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Boston, USA
| | - Kinza Waqar
- National University of Sciences and Technology, Islamabad, Pakistan
| | - Ola M J Alkhozondar
- Department of Pharmacy Clinical Informatics, Hamad Medical Corporation, Doha, Qatar
| | - Ricardo Bernardo da Silva
- Department of Vascular and Endovascular Surgery, Pontifical Catholic University of Paraná, Londrina, Brazil
| | | | | | - Rui Nakamura
- PPCR Program, ECPE, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Felipe Fregni
- PPCR Program, ECPE, Harvard T.H. Chan School of Public Health, Boston, USA
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Disease Burden and Costs in Moderate-to-Severe Chronic Osteoarthritis Pain Refractory to Standard of Care: Ancillary Analysis of the OPIOIDS Real-World Study. Rheumatol Ther 2021; 8:303-326. [PMID: 33411324 PMCID: PMC7991059 DOI: 10.1007/s40744-020-00271-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction To determine the disease burden and costs in moderate-to-severe chronic osteoarthritis (OA) pain refractory to standard-of-care treatment in the Spanish National Health System (NHS). Methods Ancillary analysis of the OPIOIDS real-world, non-interventional, retrospective, 4-year longitudinal study including patients aged at least 18 years with moderate-to-severe chronic OA pain refractory to standard-of-care with sequential NSAIDs plus opioids. Burden assessment included measurement of analgesia, cognitive functioning, basic activities of daily living, severity and frequency of comorbidities, and all-cause mortality. Costs accounted for healthcare resource utilization and related costs (year 2018). Results Records of 13,317 patients were analyzed; 68.9 (14.7) years old, 71.3% (70.5–72.1%) women, 58.1% refractory to NSAID plus weak opioid and 41.9% to NSAID plus strong opioid, accounting for 10.7% (10.5–10.8%) of patients with chronic OA pain. Mean number of comorbidities was 2.9 (1.8) and its severity was 1.8 (1.7). Pain decreased by 0.9 points (12.2%) and cognitive declined by 2.3 points (9.1%, with 4.3% more patients with cognitive deficit) and dependency worsened by 0.4 points (0.5%, with 2.3% more patients with severe-to-total dependence) over a mean treatment period of 188.6 (185.4–191.8) days on NSAIDs followed by 400.6 (393.7–407.5) days on opioids. The adjusted mortality rate was higher in patients with OA taking NSAID plus strong opioids; hazard ratio 1.44 (1.26–1.65; p < 0.001). The 4-year healthcare cost was €7350/patient (€7193–7507 or €1838/year) and was higher in those taking strong versus weak opioids; €9886 (€9608–10,164, €2472/year) vs. €5519 (€5349–5689, €1380/year), p < 0.001. Analgesia cost (16.0% of total cost, 70.2% opioids) was higher with strong versus weak opioids, 19.6% vs. 11.3%, p < 0.001. Conclusions In routine clinical practice in Spain, patients with moderate-to-severe chronic OA pain refractory to standard analgesic treatment with NSAIDs plus opioids reported modest reductions in pain, while presenting a considerable burden of comorbidities, cognitive impairment, and dependency. Healthcare costs significantly increased for the NHS particularly with NSAIDs plus strong opioids. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-020-00271-y.
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Capozza MA, Triarico S, Mastrangelo S, Attinà G, Maurizi P, Ruggiero A. Narrative review of intrathecal drug delivery (IDD): indications, devices and potential complications. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:186. [PMID: 33569488 PMCID: PMC7867880 DOI: 10.21037/atm-20-3814] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of chronic refractory pain (non-neoplastic and cancer-related pain) remains a therapeutic challenge. The continuous intrathecal (IT) administration of drugs may play an important role in the possible management options. Intrathecal drug delivery devices (IDDDs) may be effective for patients with refractory chronic pain. Therefore, they may be adopted for non-oncologic pain in patients with compression fractures, spondylolisthesis, spondylosis, back surgery failure syndrome and spinal stenosis. Oncologic patients can benefit from these treatments in a variable way according to tumor characteristics, prognosis, periprocedural imaging and risk of disease progression. In this review, we describe the most commonly used drugs (opioids and non-opioids), their pharmacokinetic and pharmacodynamic features and indications of use. The most used drugs are morphine, hydromorphone, fentanyl, methadone, bupivacaine, clonidine, and ketamine. Patient evaluation before the device implantation should be based on clinical examination, medical records assessment and psychometric evaluation. The infusion pumps available on the market are both non-programmable (with continuous IT deliver of drugs) and programmable (with variable deliver of drugs according to their flow rate). Moreover, we describe the procedure of implantation and the potential complications of IT drug delivery (such as bleeding, infection, loss of cerebrospinal fluid, wound seroma, loss of catheter pump propellant).
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Affiliation(s)
- Michele Antonio Capozza
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Silvia Triarico
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Stefano Mastrangelo
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Maurizi
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Ruggiero
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
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15
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Deer TR, Esposito MF, McRoberts WP, Grider JS, Sayed D, Verrills P, Lamer TJ, Hunter CW, Slavin KV, Shah JM, Hagedorn JM, Simopoulos T, Gonzalez DA, Amirdelfan K, Jain S, Yang A, Aiyer R, Antony A, Azeem N, Levy RM, Mekhail N. A Systematic Literature Review of Peripheral Nerve Stimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2020; 21:1590-1603. [DOI: 10.1093/pm/pnaa030] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractObjectiveTo conduct a systematic literature review of peripheral nerve stimulation (PNS) for pain.DesignGrade the evidence for PNS.MethodsAn international interdisciplinary work group conducted a literature search for PNS. Abstracts were reviewed to select studies for grading. Inclusion/exclusion criteria included prospective randomized controlled trials (RCTs) with meaningful clinical outcomes that were not part of a larger or previously reported group. Excluded studies were retrospective, had less than two months of follow-up, or existed only as abstracts. Full studies were graded by two independent reviewers using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsPeripheral nerve stimulation was studied in 14 RCTs for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS to treat pain.ConclusionPeripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | | | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, New Jersey
| | | | - Tom Simopoulos
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, Arkansas
| | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System, Detroit, Michigan
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Nomen Azeem
- Florida Spine & Pain Specialists, Bradenton, Florida
| | - Robert M Levy
- Director of Neurosurgical Services, Director of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida
| | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Deer TR, Hunter CW, Mehta P, Sayed D, Grider JS, Lamer TJ, Pope JE, Falowski S, Provenzano DA, Esposito MF, Slavin KV, Baranidharan G, Russo M, Jassal NS, Mogilner AY, Kapural L, Verrills P, Amirdelfan K, McRoberts WP, Harned ME, Chapman KB, Liem L, Carlson JD, Yang A, Aiyer R, Antony A, Fishman MA, Al-Kaisy AA, Christelis N, Levy RM, Mekhail N. A Systematic Literature Review of Dorsal Root Ganglion Neurostimulation for the Treatment of Pain. PAIN MEDICINE 2020; 21:1581-1589. [DOI: 10.1093/pm/pnaa005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AbstractObjectiveTo conduct a systematic literature review of dorsal root ganglion (DRG) stimulation for pain.DesignGrade the evidence for DRG stimulation.MethodsAn international, interdisciplinary work group conducted a literature search for DRG stimulation. Abstracts were reviewed to select studies for grading. General inclusion criteria were prospective trials (randomized controlled trials and observational studies) that were not part of a larger or previously reported group. Excluded studies were retrospective, too small, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsDRG stimulation has Level II evidence (moderate) based upon one high-quality pivotal randomized controlled trial and two lower-quality studies.ConclusionsModerate-level evidence supports DRG stimulation for treating chronic focal neuropathic pain and complex regional pain syndrome.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | | | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Jason E Pope
- Evolve Restorative Center, Santa Rosa, California
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | | | | | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, NSW, Australia
| | - Navdeep S Jassal
- Department of Neurology/Pain, University of South Florida, Spine & Pain Institute of Florida, Lakeland, Florida
| | - Alon Y Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Leo Kapural
- Carolina Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | | | | | - Michael E Harned
- Department of Anesthesiology, University of Kentucky, Lexington, Kentucky
| | | | - Liong Liem
- St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System Detroit, Michigan
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Michael A Fishman
- Center for Interventional Pain and Spine, Bryn Mawr, Pennsylvania, USA
| | - Adnan A Al-Kaisy
- Pain Management and Neuromodulation Centre at Guy’s and St. Thomas’ NHS Trust, London, UK
| | - Nick Christelis
- Pain Specialists Australia, Monash University, Richmond, Victoria, Australia
| | - Robert M Levy
- Neurosurgical Services and of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida
| | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Billot M, Naiditch N, Brandet C, Lorgeoux B, Baron S, Ounajim A, Roulaud M, Roy-Moreau A, de Montgazon G, Charrier E, Misbert L, Maillard B, Vendeuvre T, Rigoard P. Comparison of conventional, burst and high-frequency spinal cord stimulation on pain relief in refractory failed back surgery syndrome patients: study protocol for a prospective randomized double-blinded cross-over trial (MULTIWAVE study). Trials 2020; 21:696. [PMID: 32746899 PMCID: PMC7397663 DOI: 10.1186/s13063-020-04587-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
Background While the evolution of technology provides new opportunities to manage chronic refractory pain using different waveform modalities of spinal cord stimulation in failed back surgery syndrome (FBSS), there is no randomized controlled trial available to compare the efficacy of these different stimulations waveforms to date. MULTIWAVE is a prospective, randomized, double-blinded, crossover trial study designed to compare the clinical efficacy of tonic conventional stimulation (TCS), burst stimulation (BURST) and high-frequency stimulation (HF) in FBSS patients over a 15-month period in SCS implanted patients. Methods/design Twenty-eight patients will be recruited in the Poitiers University Hospital, in Niort and La Rochelle Hospitals in France. Eligible patients with post-operative low back and leg pain with an average visual analog scale (VAS) score ≥ 5 for low back pain are implanted and randomly assigned to one of the six arms (in a 1:1:1:1:1:1 ratio), where they receive a 3-month combination of TCS, BURST and HF including one treatment modality per month and varying the order of the modality received within the six possible combinations. Patients receiving intrathecal drug delivery, peripheral nerve stimulation and back resurgery related to the original back pain complaint and experimental therapies are excluded from this study. Patients included in the spinal cord stimulation group undergo trial stimulation, and they all receive a TCS treatment for 2 months, as the gold standard modality. Thereafter, patients are randomly assigned to one of the six arms for the total duration of 3-month crossover period. Then, patients choose their preferred stimulation modality (TCS, BURST, or HF) for the follow-up period of 12 months. Outcome assessments are performed at baseline (first implant), before randomization (2 months after baseline) and at 1, 2, 3, 6, 9 and 15 months post-randomization. Our primary outcome is the average global VAS of pain over 5-day pain diary period between baseline and after each period of stimulation. Additional outcomes include changes in leg and back pain intensity, functional disability, quality of life, psychological state, paraesthesia intensity perception, patient satisfaction and the number of adverse events. Discussion Recruitment began in February 2017 and will continue through 2019. Trial registration Clinicaltrials.gov NCT03014583. Registered on 9 January 2017.
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Affiliation(s)
- Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Nicolas Naiditch
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Claire Brandet
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | | | | | - Elodie Charrier
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | - Lorraine Misbert
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | - Benjamin Maillard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Tanguy Vendeuvre
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France.,Spine and Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France.,Institut Pprime UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Poitiers, France.,Department of Orthopaedic Surgery and Traumatology, Poitiers University Hospital, Poitiers, France.,ABS Lab, University of Poitiers, Poitiers, France
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France. .,Spine and Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France. .,Institut Pprime UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Poitiers, France.
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18
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Deer TR, Grider JS, Lamer TJ, Pope JE, Falowski S, Hunter CW, Provenzano DA, Slavin KV, Russo M, Carayannopoulos A, Shah JM, Harned ME, Hagedorn JM, Bolash RB, Arle JE, Kapural L, Amirdelfan K, Jain S, Liem L, Carlson JD, Malinowski MN, Bendel M, Yang A, Aiyer R, Valimahomed A, Antony A, Craig J, Fishman MA, Al-Kaisy AA, Christelis N, Rosenquist RW, Levy RM, Mekhail N. A Systematic Literature Review of Spine Neurostimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2020; 21:1421-1432. [DOI: 10.1093/pm/pnz353] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Abstract
Objective
To conduct a systematic literature review of spinal cord stimulation (SCS) for pain.
Design
Grade the evidence for SCS.
Methods
An international, interdisciplinary work group conducted literature searches, reviewed abstracts, and selected studies for grading. Inclusion/exclusion criteria included randomized controlled trials (RCTs) of patients with intractable pain of greater than one year’s duration. Full studies were graded by two independent reviewers. Excluded studies were retrospective, had small numbers of subjects, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.
Results
SCS has Level 1 evidence (strong) for axial back/lumbar radiculopathy or neuralgia (five high-quality RCTs) and complex regional pain syndrome (one high-quality RCT).
Conclusions
High-level evidence supports SCS for treating chronic pain and complex regional pain syndrome. For patients with failed back surgery syndrome, SCS was more effective than reoperation or medical management. New stimulation waveforms and frequencies may provide a greater likelihood of pain relief compared with conventional SCS for patients with axial back pain, with or without radicular pain.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Jason E Pope
- Evolve Restorative Center, Santa Rosa, California
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | | | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, NSW, Australia
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Providence, Rhode Island
- Department of Neurosurgery, Brown Medical School, Providence, Rhode Island
| | - Jay M Shah
- New York Presbyterian Hospital, Memorial Sloan Kettering Cancer Center, Hospital for Special Surgery, New York, New York
| | - Michael E Harned
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Robert B Bolash
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
| | - Jeff E Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leo Kapural
- Carolina Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | | | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, Arkansas
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Markus Bendel
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System, Detroit, Michigan
| | - Ali Valimahomed
- Advanced Orthopedics and Sports Medicine Institute, Freehold, New Jersey
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Justin Craig
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Michael A Fishman
- Center for Interventional Pain and Spine, Bryn Mawr, Pennsylvania, USA
| | - Adnan A Al-Kaisy
- Pain Management and Neuromodulation Centre at Guy’s and St. Thomas’ NHS Trust, London, UK
| | - Nick Christelis
- Pain Specialists Australia, Richmond, Monash University, Victoria, Australia
| | - Richard W Rosenquist
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida, USA
| | - Nagy Mekhail
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
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19
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Jain S, Malinowski M, Chopra P, Varshney V, Deer TR. Intrathecal drug delivery for pain management: recent advances and future developments. Expert Opin Drug Deliv 2019; 16:815-822. [PMID: 31305165 DOI: 10.1080/17425247.2019.1642870] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Chronic pain conditions of malignant and non-malignant etiology afflict a large group of the population and pose a vast economic burden on society. Intrathecal drug therapy is a viable treatment option in such patients who have failed conservative medical measures and less invasive pain management procedures. However, the clinical growth of intrathecal therapy in managing intractable chronic pain conditions continues to face many challenges and is likely underutilized secondary to its high-complexity and lack of understanding. Areas covered: This review will briefly discuss the history of intrathecal drug delivery systems (IDDS), cerebrospinal fluid (CSF) flow dynamics, types of IDDS, indications and patient profile suitable for this therapy, and risks and complications related to IDDS. We will also discuss challenges faced by physicians utilizing this therapy and the future changes that are needed for making this treatment modality more efficacious. Expert opinion: IDDS offer an effective therapy for pain control in patients suffering from chronic intractable pain conditions. These devices provide a safer alternative to oral opioid medications with reduced systemic side effects. Adherence to best practices and continued clinical and basic science research is important to ensure continuing success of this therapy.
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Affiliation(s)
- Sameer Jain
- a Pain Treatment Centers of America , Little Rock , AR , USA
| | - Mark Malinowski
- b Ohio University - HCOM , OH , USA.,c Adena Spine Center , Chillicothe , OH , USA
| | - Pooja Chopra
- d Department of Physical Medicine and Rehabilitation, University of Kentucky , Lexington , KY , USA
| | - Vishal Varshney
- e Division of Pain Medicine, Department of Anesthesiology, University of Calgary , Calgary , AB , Canada
| | - Timothy R Deer
- f Spine and Nerve Center of the Virginias , Charleston , WV , USA
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20
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Bates D, Schultheis BC, Hanes MC, Jolly SM, Chakravarthy KV, Deer TR, Levy RM, Hunter CW. A Comprehensive Algorithm for Management of Neuropathic Pain. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:S2-S12. [PMID: 31152178 PMCID: PMC6544553 DOI: 10.1093/pm/pnz075] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy. METHODS Available literature was identified through a search of the US National Library of Medicine's Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations. RESULTS The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain. CONCLUSIONS The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.
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Affiliation(s)
| | - B Carsten Schultheis
- Muskuloskelettales Zentrum - Interventionelle Schmerztherapie, Krankenhaus Neuwerk “Maria von den Aposteln,” Mönchengladbach, Germany
| | | | - Suneil M Jolly
- Louisiana Pain Specialists, New Orleans, Louisiana
- New Orleans East Hospital, New Orleans, Louisiana
| | - Krishnan V Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, La Jolla, California
- Veterans Administration San Diego Healthcare System, San Diego, California
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | | | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York, USA
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Courade M, Bertrand A, Guerrini-Rousseau L, Pagnier A, Levy D, Lervat C, Cojean N, Ribrault A, Dugue S, Thouvenin S, Piguet C, Schmitt C, Marec-Berard P. Low-dose ketamine adjuvant treatment for refractory pain in children, adolescents and young adults with cancer: a pilot study. BMJ Support Palliat Care 2019; 12:e656-e663. [PMID: 31151954 DOI: 10.1136/bmjspcare-2018-001739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/11/2019] [Accepted: 05/01/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Ketamine, an N-methyl-D-aspartate receptor antagonist, is effective at relieving adult cancer pain, although there have been very few reports to date regarding its use in children and in adolescents and young adults (AYA). This study assessed the efficacy, safety and opioid-sparing effects of low doses of ketamine added to opioid analgesics to alleviate persistent cancer pain. METHODS This prospective, multicentre, observational trial collected data regarding demographics, pain characteristics, pain score assessment within the first 48 hours of ketamine administration, tolerance and satisfaction from 38 patients aged 2-24 years prescribed with ketamine as an adjuvant antalgic for refractory cancer pain in 10 French paediatric oncology centres. RESULTS The mean visual analogue scale pain score decreased from 6.7 to 4.3 out of 10 (n=39, p<0.001) from day 1 to day 3 and by at least 2 points in 56% of the patients (n=22) 48 hours after initiation of ketamine. Nine patients experienced poor tolerance (≥2 side effects), all with infusion rates lower than 0.05 mg/kg/hour. None had limiting toxicities. An opioid-sparing effect was highlighted in four patients. Fifty-four per cent of the prescribers and 47% of the patients found the addition of ketamine 'very helpful'. CONCLUSIONS Low doses of ketamine as an adjuvant to opioids significantly reduced the intensity of pain in half of the study population. A tendency towards better pain control is shown, although a lack of statistical power somewhat limits our conclusions, especially in children. Nevertheless, ketamine may be a useful option for improving the treatment of refractory pain in children and AYA with cancer.
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Affiliation(s)
- Magali Courade
- Unité de Traitement de la Douleur de l' Enfant, Centre Leon Berard, Lyon, France
| | | | | | - Anne Pagnier
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | | | - Cyril Lervat
- Oncologie pédiatrique, Centre Oscar Lambret, Lille, France
| | | | | | - Sophie Dugue
- Oncologie pédiatrique, Hopital Universitaire Robert-Debre, Paris, France
| | - Sandrine Thouvenin
- Oncologie pédiatrique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | | | - Claudine Schmitt
- Hématologie Oncologie et Centre de la Douleur pédiatrique, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Perrine Marec-Berard
- Unité de Traitement de la Douleur de l' Enfant, Centre Leon Berard, Lyon, France
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Pollard EM, Lamer TJ, Moeschler SM, Gazelka HM, Hooten WM, Bendel MA, Warner NS, Murad MH. The effect of spinal cord stimulation on pain medication reduction in intractable spine and limb pain: a systematic review of randomized controlled trials and meta-analysis. J Pain Res 2019; 12:1311-1324. [PMID: 31118751 PMCID: PMC6502439 DOI: 10.2147/jpr.s186662] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/27/2019] [Indexed: 12/16/2022] Open
Abstract
Objective: To synthesize the evidence regarding the effect of spinal cord stimulation (SCS) on opioid and pain medication reduction in patients with intractable spine or limb pain. Methods: A comprehensive literature search was conducted to identify RCTs of patients with chronic back and/or limb pain of greater than one year duration. Only comparative studies were included (ie, conventional SCS vs medical therapy, conventional SCS vs high-frequency SCS) and were required to have a minimum follow-up period of 3 months. Random effect meta-an alysis was used to compare the three interventions. Results were expressed as odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals (CI). Results: We identified five trials enrolling 489 patients. Three of the trials reported the results as a number of patients who were able to reduce or eliminate opioid consumption in the SCS vs medical therapy group. The odds of reducing opioid consumption were significantly increased in the SCS group compared to medical therapy (OR 8.60, CI {1.93–38.30}). Two of the trials reported the results as mean medication dose reduction as measured by the Medication Quantification Scale (MQS) in the SCS group vs medical therapy group. MQS score significantly decreased in the SCS group and not in the medical group (WMD –1.97, 95% CI {–3.67, –0.27}). One trial reported a number of patients in high-frequency SCS who were able to reduce opioids vs number of patients in conventional SCS group who were able to reduce opioids. Thirty-four percent of the patients in the high-frequency group and 26% of the patients in the conventional SCS group were able to reduce opioid consumption; however, there was not a significant difference between groups (OR 1.43, 95% CI {0.74, 2.78}). This trial also quantified the opioid reduction in morphine equivalent dosage (MED). In the high-frequency SCS group, average MED decreased by 24.8 mg vs average MED decrease of 7.3 mg in the conventional SCS group. Again, the difference between groups did not reach statistical significance (–17.50, CI {–66.27, 31.27}). Conclusions: In patients with intractable spine/limb pain, SCS was associated with increased odds of reducing pain medication consumption. However, results should be treated with caution as available data were limited, and clinical significance of these findings requires further study.
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Affiliation(s)
- E Morgan Pollard
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Susan M Moeschler
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Michael Hooten
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nafisseh S Warner
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Preventive, Occupational, and Aerospace Medicine, Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Burdge G, Leach H, Walsh K. Ziconotide-induced psychosis: A case report and literature review. Ment Health Clin 2018; 8:242-246. [PMID: 30206508 PMCID: PMC6125118 DOI: 10.9740/mhc.2018.09.242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Ziconotide is an intrathecally administered medication indicated for the treatment of severe chronic pain in patients who are intolerant of or refractory to other treatment options. A black box warning is included in the packaging and states ziconotide is contraindicated in patients with a preexisting history of psychosis. Patients taking ziconotide should be monitored for evidence of cognitive impairment, hallucinations, or changes in mood, and ziconotide should be discontinued if neurological or psychiatric signs and symptoms appear. We present a case of a 49-year-old white male with no previous neuropsychiatric history who received ziconotide for several years before he developed command auditory hallucinations within 24 hours of a dose increase. Upon admission to the emergency room, the patient's pain management physician was contacted and the ziconotide dose was decreased and eventually discontinued. Because of a continuation of symptoms, the patient was transferred from the emergency room to an acute care psychiatric hospital where he was started on risperidone 1 mg orally at bedtime. At discharge, the patient was noted to be in good behavioral control without any hallucinations. The patient was encouraged to follow up with his pain management physician to determine if ziconotide should be reconsidered.
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Affiliation(s)
- Gary Burdge
- (Corresponding author) PGY1 Pharmacy Resident, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey,
| | - Henry Leach
- Clinical Coordinator, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey
| | - Kim Walsh
- Director of Pharmacy, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey
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McDowell GC, Winchell J. Role of primary care physicians in intrathecal pain management: a narrative review of the literature. Postgrad Med 2018. [PMID: 29542370 DOI: 10.1080/00325481.2018.1448207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan. METHODS The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors' clinical and research expertise. RESULTS IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a µ-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist. CONCLUSIONS Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.
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25
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Intrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain. Curr Pain Headache Rep 2018; 22:11. [DOI: 10.1007/s11916-018-0662-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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26
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Fam BN, El-Sayed GGED, Reyad RM, Mansour I. Efficacy and safety of pulsed radiofrequency and steroid injection for intercostobrachial neuralgia in postmastectomy pain syndrome - A clinical trial. Saudi J Anaesth 2018; 12:227-234. [PMID: 29628832 PMCID: PMC5875210 DOI: 10.4103/sja.sja_576_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Breast cancer is a common neoplastic tumor in women, and the postmastectomy pain syndrome has been reported frequently after surgical treatment. The injury of the intercostobrachial nerve is considered the major cause of this type of pain. Purpose: Evaluation of efficacy and safety of pulsed radiofrequency (PRF) and steroid injection on the 2nd and 3rd thoracic (T2 and T3) dorsal root ganglions (DRGs) for intercostobrachial neuralgia (ICBN) postmastectomy. Patients and Methods: This study was conducted on 100 patients with ICBN postmastectomy. The PRF waves were applied for 120 s twice on T2 and T3 DRGs then 1 ml of 4 mg dexamethasone and 1 ml of bupivacaine 0.25% were injected at each level then the technique was repeated three times 1 week apart for each patient. Results: After 6 months from the latest intervention, the mean of visual analog scale dropped from 7.48 to 4.7 (P = 0.005712) and the mean of the quality of life scale improved to 6.88 after being 4.66 (P < 0.00001) before the intervention and 64.68% of the patients decided that they would certainly repeat the procedure if they could go back in time and 66.64% would certainly recommend the same procedure to a family member. The analgesics consumption decreased mainly in the 1st month but increased again after 6 months (not significant). No serious complications were recorded. Conclusions: PRF and steroid injection on T2 and T3 DRGs assumed an effective and safe method for ICBN postmastectomy treatment.
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Affiliation(s)
- Beshoy Nabil Fam
- Department of Anesthesiology and Pain Management, Nasser Institute for Research and Treatment, Cairo, Egypt
| | | | - Raafat Mahfouz Reyad
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ikramy Mansour
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
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Abstract
Objective Physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) provide professional services on pain management teams. This review provides an overview of the practical management of chronic pain with intrathecal (IT) therapy using an interprofessional approach (eg, physicians and other health care professionals), with a focus on the contributions of PAs, NPs, and RNs. Methods Narrative review based on literature searches of the Medline database and treatment guidelines on the use of IT therapy in the management of patients with chronic pain. Results The specific roles and responsibilities of PAs, NPs, and RNs in the management of patients receiving IT therapy vary by practice. In many pain treatment centers, PAs, NPs, and RNs are responsible for patient education, postimplant maintenance, and ongoing supportive care of patients receiving IT therapy. Topics that we address include patient selection, patient expectations and goal setting, medication selection, outcome assessment, and treatment adjustment. Currently, morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker) are the only agents approved by the US Food and Drug Administration for IT analgesia. We provide relevant information on the dosing, titration, and adverse effect management of these medications for PAs, NPs, and RNs responsible for administering IT therapy. Conclusion PAs, NPs, and RNs are valuable members of IT pain management teams. Treatment success requires ongoing monitoring of efficacy and adverse effects, with corresponding adjustments to medication selection and dosing, in addition to good communication among the health care professionals involved in patient care.
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Affiliation(s)
| | - Neona M Lotz
- Cypress Ambulatory Surgery Center, Santa Maria, CA, USA
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28
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Deer TR, Pope JE, Hayek SM, Bux A, Buchser E, Eldabe S, De Andrés JA, Erdek M, Patin D, Grider JS, Doleys DM, Jacobs MS, Yaksh TL, Poree L, Wallace MS, Prager J, Rauck R, DeLeon O, Diwan S, Falowski SM, Gazelka HM, Kim P, Leong M, Levy RM, McDowell II G, McRoberts P, Naidu R, Narouze S, Perruchoud C, Rosen SM, Rosenberg WS, Saulino M, Staats P, Stearns LJ, Willis D, Krames E, Huntoon M, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation 2017; 20:96-132. [DOI: 10.1111/ner.12538] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Anjum Bux
- Anesthesia and Chronic Pain Management; Ephraim McDowell Regional Medical Center; Danville KY USA
| | - Eric Buchser
- Anaesthesia and Pain Management Department; EHC Hosptial, Morges, and CHUV University Hospital; Lausanne Switzerland
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Jose A. De Andrés
- Valencia School of Medicine; Hospital General Universitario; Valencia Spain
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- University of Kentucky College of Medicine, UK HealthCare Pain Services; Lexington KY USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology; University of California; San Diego CA USA
| | - Lawrence Poree
- Pain Clinic of Monterey Bay, University of California at San Francisco; San Francisco CA USA
| | | | - Joshua Prager
- Center for the Rehabilitation Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | - Richard Rauck
- Carolina Pain Institute, Wake Forest Baptist Health; Winston-Salem NC USA
| | - Oscar DeLeon
- Roswell Park Cancer Institute, SUNY; Buffalo NY USA
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine; Lenox Hill Hospital; New York NY USA
| | | | | | - Philip Kim
- Bryn Mawr Hospital; Bryn Mawr PA, USA
- Christiana Hospital; Newark DE USA
| | | | | | | | | | - Ramana Naidu
- San Francisco Medical Center, University of California; San Francisco CA USA
| | - Samir Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | - Peter Staats
- Premier Pain Management Centers; Shrewsbury NJ, USA
- Johns Hopkins University; Baltimore MD USA
| | | | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.); San Francisco CA USA
| | - Marc Huntoon
- Vanderbilt University Medical Center; Nashville TN USA
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30
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Deer TR, Hayek SM, Pope JE, Lamer TJ, Hamza M, Grider JS, Rosen SM, Narouze S, Perruchoud C, Thomson S, Russo M, Grigsby E, Doleys DM, Jacobs MS, Saulino M, Christo P, Kim P, Huntoon EM, Krames E, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy. Neuromodulation 2017; 20:133-154. [PMID: 28042906 DOI: 10.1111/ner.12543] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intrathecal (IT) drug infusion is an appropriate and necessary tool in the algorithm to treat refractory cancer and noncancer pain. The decision-making steps/methodology for selecting appropriate patients for implanted targeted drug delivery systems is controversial and complicated. Therefore, a consensus on best practices for determining appropriate use of IT drug infusion may involve testing/trialing this therapy before implantation. METHODS This current Polyanalgesic Consensus Conference (PACC) update was designed to address the deficiencies and emerging innovations since the previous PACC convened in 2012. A literature search identified publications available since the previous PACC publications in 2014, and relevant sources were contributed by the PACC members. After reviewing the literature, the panel determined the evidence levels and degrees of recommendations. The developed consensus was ranked as strong (>80%), moderate (50-79%), or weak (<49%). RESULTS The trialing for IT drug delivery systems (IDDS) remains an area of continued controversy. The PACC recommendations for trialing are presented in 34 consensus points and cover trialing for morphine, ziconotide, and medication admixtures; starting doses and titration practices; measurements of success; trial settings and monitoring; management of systemic opioids during trialing; and the role of psychological evaluation. Finally, the PACC describes clinical scenarios in which IT trialing is required or not required. CONCLUSION The PACC provides consensus guidance on best practices of trialing for IDDS implants. In addition, the PACC recommends that no trial may be required in certain patient populations.
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Affiliation(s)
| | - Salim M Hayek
- Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Maged Hamza
- Virginia Commonwealth University Spine Center, Richmond, VA, USA
| | - Jay S Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Steven M Rosen
- Delaware Valley Pain & Spine Institute, Chalfront, PA, USA
| | | | | | - Simon Thomson
- Basildon and Thurrock University Hospitals FHT, Essex, UK
| | - Marc Russo
- Hunter Pain Clinic, Newcastle, NSW, Australia
| | | | | | | | | | | | - Philip Kim
- Bryn Mawr Hospital, Bryn Mawr, PA, USA.,Christiana Hospital, Newark, DE, USA
| | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.), San Francisco, CA, USA
| | - Nagy Mekhail
- Cleveland Clinic, Evidence-Based Pain Management Research, Cleveland, OH, USA
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Abstract
Objective. The increasing incidence of cancer survivorship has shifted treatment of cancer-related pain from short-term analgesia to long-term chronic pain management. As a result, alternatives to oral analgesics, such as intrathecal therapy, may be beneficial for patients with cancer-related pain. The authors review the use of intrathecal therapy in the management of cancer-related pain. Methods. The Medline database was searched for English-language articles that included “ziconotide” or “morphine” AND (“cancer” OR “malignant”) AND “intrathecal” in title or abstract. Available abstracts from scientific congresses in the areas of neuromodulation and oncology were also reviewed. Results. Intrathecal therapy provides pain relief with reduced systemic concerns in patients with cancer-related pain. Patients should undergo multidisciplinary evaluation and, in most cases, drug trialing before intrathecal pump implantation. Morphine, an opioid (µ-opioid receptor antagonist), and ziconotide, a nonopioid (selective N-type calcium channel inhibitor), are both approved for intrathecal analgesia; however, tolerance and safety concerns may deter the use of intrathecal morphine. Ziconotide has also shown efficacy for reduction of cancer-related pain; however, proper dosing and titration must be used to prevent adverse events. There is little information available on use of intrathecal therapies specifically in cancer survivors. Conclusions. Treatment of cancer-related pain has shifted toward chronic pain management strategies, especially among cancer survivors. Intrathecal therapy provides an alternate route of administration of chronic pain medications (e.g., morphine and ziconotide) for cancer patients with and without active disease, although additional research is needed to support effectiveness in cancer survivors.
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Affiliation(s)
- Brian M Bruel
- *University of Texas, MD Anderson Cancer Center, Houston, Texas
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Pope JE, Deer TR, Bruel BM, Falowski S. Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm. Pain Pract 2016; 16:1092-1106. [PMID: 26914961 DOI: 10.1111/papr.12438] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/17/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S. Food and Drug Administration for intrathecal analgesia: preservative-free morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker). We describe the appropriate use of intrathecal therapy in the management of severe chronic pain, based on current best practices. Topics addressed here include patient selection, trialing, dosing and titration, adverse event profiles, long-term management, intrathecal therapy for cancer-related pain, and the placement of intrathecal therapy in the pain care algorithm. In appropriately selected patients with chronic pain, intrathecal therapy can provide substantial pain relief with improved functioning and quality of life. Successful long-term management requires ongoing patient monitoring for changes in efficacy and the occurrence of adverse events, with subsequent changes in intrathecal dosing and titration, the addition of adjuvant intrathecal agents, and the use of concomitant oral medications to address side effects, as needed. Based on an infrequent but clinically concerning risk of overdose, granuloma, and other opioid-induced complications, nonopioid therapy with ziconotide may be preferred as a first-line intrathecal therapy in patients without a history of psychosis or allergy.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, Santa Rosa, California, U.S.A
| | - Timothy R Deer
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Brian M Bruel
- University of Texas, M.D. Anderson Cancer Center, Houston, Texas, U.S.A
| | - Steven Falowski
- St. Luke's Neurosurgical Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, U.S.A
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McDowell GC, Pope JE. Intrathecal Ziconotide: Dosing and Administration Strategies in Patients With Refractory Chronic Pain. Neuromodulation 2016; 19:522-32. [PMID: 26856969 PMCID: PMC5067570 DOI: 10.1111/ner.12392] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/10/2015] [Indexed: 11/30/2022]
Abstract
Introduction Ziconotide is a non‐opioid analgesic for intrathecal (IT) administration. The aim of this review is to provide a comprehensive and clinically relevant summary of the literature on dosing and administration with IT ziconotide in the management of refractory chronic pain, and to describe novel dosing strategies intended to improve clinical outcomes. Materials and Methods A Medline search was conducted for “ziconotide,” supplemented by manual searching of published bibliographies and abstracts from conferences. Results Early experience with IT ziconotide in clinical trials combined with improved understanding of drug pharmacokinetics in the cerebrospinal fluid have led to a reappraisal of approaches to trialing and initiation of continuous‐infusion therapy in an effort to improve tolerability. The traditional paradigm of trialing by inpatient continuous infusion may be shifting toward outpatient trialing by IT bolus, although definitions of success and specific protocols remain to be agreed upon. Expert consensus on IT continuous infusion with ziconotide suggests a starting dose of 0.5 to 1.2 mcg/day followed by dose titration of ≤0.5 mcg/day on a no more than weekly basis, according to individual patients’ pain reductions and regimen tolerability. Discussion Newer modalities that include patient‐controlled analgesia and nocturnal flex dosing have been shown to hold promise of further improvements in ziconotide efficacy and tolerability. Conclusions Clinical trials and experience confirm the feasibility and usefulness of IT ziconotide in the management of refractory chronic pain. Emerging evidence suggests that additional IT delivery options may further expand the usefulness and benefits of ziconotide.
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Abstract
Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation. As these therapies evolve, so too will their placement within the pain care algorithm grounded by a foundation of evidence to improve patient safety and management of patients with difficult neuropathic pain.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, 392 Tesconi Court, Santa Rosa, CA 95401, USA.
| | - David Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA 15143, USA
| | | | - Timothy Deer
- Center for Pain Relief, Charleston, WV 25304, USA
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Pope JE, Deer TR, McRoberts WP. Intrathecal Therapy: The Burden of Being Positioned as a Salvage Therapy. PAIN MEDICINE 2015; 16:2036-8. [DOI: 10.1111/pme.12782] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/08/2015] [Accepted: 03/29/2015] [Indexed: 02/06/2023]
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Deer TR, Pope JE. Factors to consider in the choice of intrathecal drug in the treatment of neuropathic pain. Expert Rev Clin Pharmacol 2015; 8:507-10. [DOI: 10.1586/17512433.2015.1060577] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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