Medical management of acute pain in patients with chronic pain

The relationship between psychosocial factors and reported disability: the role of pain self-efficacy

BACKGROUND

Chronic pain and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is now considered a world level crisis. Chronic non-specific low back pain (CNLBP) contributes a significant proportion to the chronic pain population. CNLBP occurs with overlapping psychosocial factors. This study was design to investigate specific psychosocial factors and their influence on reported disability in a population with CNLBP.

METHODS

The specific psychosocial factors examined included fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study investigated the mediating role between pain self-efficacy, the specific psychosocial factors, and reported disability. The study recruited 61 female and 29 male participants from physical therapy clinics. The participants were between 20-to-60 years of age and diagnosed with CNLBP. All participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index. The battery of questionnaires measured fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability. Multivariate regression and mediation analyses was used to analyse the data.

RESULTS

The principal finding was a strong inverse relationship between pain self-efficacy and reported disability with a p-value < 0.001. Further, pain self-efficacy was considered a statistical mediator with consistent p-value < 0.001 for the specific psychosocial factors investigated within this data set. Pain self-efficacy was considered to have a mediating role between reported fear of physical activity and disability, reported pain catastrophizing and disability, and reported depression and disability. Additionally, age and reported pain levels proved to be statistically significant. Adjustments for age and pain level did not alter the role of pain self-efficacy.

CONCLUSION

The results identified a mediating role for pain self-efficacy between the specific psychosocial factors (fear, catastrophizing, and depression) and reported disability. Pain self-efficacy plays a more significant role in the relationships between these specific psychosocial factors and reported disability with CNLBP than previously considered.

Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery

Objective

To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes.

Study Design

Prospective cohort.

Setting

Tertiary academic hospital.

Subjects and Methods

Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors.

Results

A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required.

Conclusion

Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.

Neuropathic insult increases the responsiveness to acetic acid in mice

Chronic neuropathic pain is a burden to millions of patients every day. Patients with neuropathic pain will also experience acute pain throughout their everyday lives adding to their nociceptive burden. Using nociceptive models in mice this study aimed to investigate the relationship between acute visceral pain and chronic neuropathic pain in spontaneous and affective behaviors. Neuropathic pain was induced by chronic constriction injury (CCI) of the sciatic nerve of C57BL/6J male mice and examined in assays of acetic acid (AA)-induced stretching or conditioned place aversion to assess nociceptive and aversive behaviors. Stretching induced by a low concentration (0.32%) of AA given intraperitoneally was significantly increased in CCI and paclitaxel-treated animals compared to control animals. A higher concentration (1.2%) of AA was able to induce stretching equally in both neuropathic and control mice. In the conditioned place aversion test, an AA concentration of 0.32% did not induce place aversion in either sham or CCI animals. However, the 1.2% concentration of AA-induced higher place aversion scores in CCI mice compared to sham mice. No difference in place conditioning was observed between paclitaxel and vehicle-treated mice. Overall, our results show that peripheral nerve injury and paclitaxel treatment induces hypersensitivity to AA-induced nociception and place aversion.

Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic

Prescription opioid misuse is an ongoing and escalating epidemic. Although these pharmacological agents are highly effective analgesics prescribed for different types of pain, opioids also induce euphoria, leading to increasing diversion and misuse. Opioid use and related mortalities have developed in spite of initial claims that OxyContin, one of the first opioids prescribed in the USA, was not addictive in the presence of pain. These claims allayed the fears of clinicians and contributed to an increase in the number of prescriptions, quantity of drugs manufactured, and the unforeseen diversion of these drugs for non-medical uses. Understanding the history of opioid drug development, the widespread marketing campaign for opioids, the immense financial incentive behind the treatment of pain, and vulnerable socioeconomic and physical demographics for opioid misuse give perspective on the current epidemic as an American-born problem that has expanded to global significance. In light of the current worldwide opioid epidemic, it is imperative that novel opioids are developed to treat pain without inducing the euphoria that fosters physical dependence and addiction. We describe insights from preclinical findings on the properties of opioid drugs that offer insights into improving abuse-deterrent formulations. One finding is that the ability of some agonists to activate one pathway over another, or agonist bias, can predict whether several novel opioid compounds bear promise in treating pain without causing reward among other off-target effects. In addition, we outline how the pharmacokinetic profile of each opioid contributes to their potential for misuse and discuss the emergence of mixed agonists as a promising pipeline of opioid-based analgesics. These insights from preclinical findings can be used to more effectively identify opioids that treat pain without causing physical dependence and subsequent opioid abuse.

Prevention of chronic post-surgical pain: the importance of early identification of risk factors

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.

Perioperative management in children with chronic pain

Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.

Economical synthesis of 13C-labeled opiates, cocaine derivatives and selected urinary metabolites by derivatization of the natural products

The illegal use of opiates and cocaine is a challenge world-wide, but some derivatives are also valuable pharmaceuticals. Reference samples of the active ingredients and their metabolites are needed both for controlling administration in the clinic and to detect drugs of abuse. Especially, ¹³C-labeled compounds are useful for identification and quantification purposes by mass spectroscopic techniques, potentially increasing accuracy by minimizing ion alteration/suppression effects. Thus, the synthesis of [acetyl-¹³C₄]heroin, [acetyl-¹³C₄-methyl-¹³C]heroin, [acetyl-¹³C₂-methyl-¹³C]6-acetylmorphine, [N-methyl-¹³C-O-metyl-¹³C]codeine and phenyl-¹³C₆-labeled derivatives of cocaine, benzoylecgonine, norcocaine and cocaethylene was undertaken to provide such reference materials. The synthetic work has focused on identifying ¹³C atom-efficient routes towards these derivatives. Therefore, the ¹³C-labeled opiates and cocaine derivatives were made from the corresponding natural products.

Less is more: limiting narcotic prescription quantities for common orthopedic procedures

BACKGROUND

Clinicians are now appreciating that the perception of pain is a multifaceted, biopsychosocial construct. Expectation of postsurgical pain is part of this construct and should be considered preoperatively. It is our belief that by establishing reasonable expectations with preoperative teaching, we can minimize narcotic use and lessen untoward issues that can potentially follow. With this goal in mind, we have been using a comprehensive pre- and postoperative program for our outpatient orthopedic surgery patients for the last 5 years, which includes physical, pharmacologic, and simple sport psychological techniques.

MATERIALS AND METHODS

We reviewed postoperative prescription narcotic purchases in 133 consecutive surgical patients during the last year (2013). All patients were given a prescription postoperatively for 10 hydrocodone 5-mg/acetaminophen 500-mg tablets, with 1 refill. We then contacted the patients' pharmacies to assess the actual amount purchased.

RESULTS

Data were available for 100 patients. Of these, 62 patients had undergone "simple" arthroscopies and 38 had had "open" procedures, including 25 anterior cruciate ligament reconstructions, 4 tibial tubercle osteotomies, and various other surgeries. Of the 62 arthroscopies, 24 patients (39%) refilled their prescriptions, with 4 patients (6%) needing > 1 refill. Of the 38 open procedures, 16 patients (42%) refilled their medications, 2 (5%), more than once. Thus, 89% of patients required ≤ 20 narcotic tablets after undergoing common orthopedic operations. No patient needed chronic narcotic medication.

DISCUSSION

Pain is a complex issue and patient expectation of postoperative pain is one aspect that can potentially affect the amount of narcotics used. By preparing the patient both physically and psychologically, we believe the amount of narcotics used postoperatively can be decreased without affecting pain control. As a result, the multiple possible detriments of having more narcotics available than actually necessary would be lessened. By limiting the overall number of narcotic tablets prescribed, decreased use by the patient when such a medication may no longer be appropriate, and minimized use by others in the household who might have access to it would decrease.