[Appropriate use of strong opioids in medical units: Recommendations and action to be taken in daily practice]

The use of strong opioids in medical units is recurrent, mainly for analgesic purposes. The risk of occurrence of an overdose or an opioid use disorders causes very legitimate concerns for the physician, which may limit the use of opioid treatment or the adaptation of the doses necessary to relieve the patient. We provide a summary of the literature aimed at defining the indications, the adverse effects and the risks involved, the prescribing methods in order to reassure professionals and promote the safe use of these molecules.

[Optimal pain management for cancer patients with chronic renal failure]

The management of multimorphic cancer pain is a major supportive care in oncology, for which many national and international recommendations have recently been updated. Any cancer patient must benefit from access to supportive care from the diagnosis, throughout the entire care pathway. Chronic renal failure, from any etiology, requires special attention and constant attention to details from interdisciplinary caregivers' teams to propose the best analgesic therapeutic strategy, combining complementary and interventional approaches to treatments. Analgesic therapies, in particular opioids and antineuropathics, require specific precautions. A therapeutic alliance integrating clinical pharmacy as a supportive care in its own right, is a major asset allowing the optimization and securing of analgesic drug treatments, conditioning both their efficacy, their tolerance and therapeutic observance, in the goal of improving the patient's quality of life.

Neuropathic pain: Evidence based recommendations

Neuropathic pain continues to be a significant problem that lacks effective solutions for every single patient. In 2015, international guidelines (NeuPSIG) were published, while the French recommendations were updated in 2020. The purpose of this minireview is to provide an update on the process of developing evidence-based recommendations and explore potential changes to the current recommendations. Primary treatments for neuropathic pain include selective serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine, gabapentin, tricyclic antidepressants, as well as topical lidocaine and transcutaneous electrical nerve stimulation, which are specifically suggested for focal peripheral neuropathic pain. Pregabalin is a first line treatment according to international guidelines but second-line in the more recent French guidelines, due to lower efficacy seen in more recent studies and misuse risk. Additionally, tramadol, combination therapies, and psychotherapy as adjuncts are proposed second line; high-concentration capsaicin patches, and botulinum toxin A are proposed specifically for focal peripheral neuropathic pain. In cases where primary and secondary treatments prove insufficient, third-line options come into play. These include high-frequency repetitive transcranial magnetic stimulation (rTMS) targeting the motor cortex, spinal cord stimulation, and the use of strong opioids when no alternative is available. To ensure optimal management of neuropathic pain in real-life situations, it is imperative to disseminate these recommendations widely and secure the acceptance of practitioners. By doing so, we can bridge the gap between theory and practice, and enhance the overall care and treatment of individuals suffering from neuropathic pain.

[Endometriosis and pain]

Managing chronic pain in endometriosis requires multidisciplinary assessment and care. The aim is not complete disappearance of symptoms, but rehabilitation through medication, non-medication treatments and overall follow-up.

Comment on: Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

See the Reply by Candon et al.

Diabetic Neuropathic Pain and Serotonin: What Is New in the Last 15 Years?

The neurotransmitter serotonin (5-hydroxytryptamine, 5-HT) is involved in numerous physiological functions and plays a key role in pain modulation including neuropathic pain. Diabetic neuropathy is a common complication of diabetes mellitus often accompanied by chronic neuropathic pain. Animal models of diabetes offer relevant tools for studying the pathophysiological mechanisms and pharmacological sensitivity of diabetic neuropathic pain and for identifying new therapeutic targets. In this review, we report data from preclinical work published over the last 15 years on the analgesic activity of drugs acting on the serotonergic system, such as serotonin and noradrenaline reuptake inhibitor (SNRI) antidepressants, and on the involvement of certain serotonin receptors-in particular 5-HT_1A, 5-HT_2A/2c and 5-HT₆ receptors-in rodent models of painful diabetic neuropathy.

[Pain management in 2023]

Pain is a frequent symptom for healthcare professionals in the community and in hospital. Appropriate management of pain begins with a precise and comprehensive assessment, whether acute or chronic. The available therapies are summarized below, so that they can be used as closely as possible to the pathophysiology of pain. Available drug analgesics are reinforced by non-drug interventions, which are increasingly present in the algology care offering. In 2023, the authorities have announced a new ten-year national plan for pain and palliative care. Proof that this public health issue, at the heart of caregivers' concerns, is also a priority for political leaders.

[The management of multimorphic cancer pain, from diagnosis to treatment]

Cancer pain remains a major public health issue. Despite progress in pain medicine thanks to the interest shown in early and timely supportive care, more than half the patients managed for cancer are in pain. One of the key factors in high quality multidisciplinary management throughout the care pathway is to assess more than just pain: it is necessary to assess the patient as a whole. Understanding the complexity of cancer pain - or the various types of pain - through the innovative multimorphic cancer pain model, effectively opens up new perspectives for a targeted, personalised, and multimodal approach. The subsequent treatment strategies, whether drug-based with opioids, or interventional, are codified by guidelines based on scientific evidence for the healthcare professionals and, ultimately, patients.

French guidelines for neuropathic pain: An update and commentary

Neuropathic pain remains a significant unmet need. French recommendations were updated in 2020. The goal of this minireview is to provide an update on these published guidelines. Despite newer relevant studies, our proposed algorithm remains relevant. First-line treatments include serotonin-noradrenaline reuptake inhibitors (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants, topical lidocaine and transcutaneous electrical nerve stimulation being specifically proposed for focal peripheral neuropathic pain. Second-line treatments include pregabalin (such position being confirmed by newer studies), tramadol, combinations and psychotherapy as add on, high-concentration capsaicin patches and botulinum toxin A being proposed specifically for focal peripheral neuropathic pain. Third-line treatments include high-frequency repetitive transcranial magnetic stimulation of the motor cortex, spinal cord stimulation and strong opioids (in the lack of alternative). Disseminating these recommendations and ensuring that they are well accepted by French practitioners will be necessary to optimize neuropathic pain management in real life.