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Saputra T, Sutiyono D, Istanto Nurcahyo W. The Effectiveness and Safety of Rhomboid Intercostal Block for Postoperative Pain Management in Thoracic and Breast Surgical Procedures: A Meta-analysis. Anesth Pain Med 2024; 14. [DOI: 10.5812/aapm-150753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/20/2024] [Accepted: 08/31/2024] [Indexed: 01/04/2025] Open
Abstract
Background: The rhomboid intercostal block (RIB) is an emerging regional anesthesia (RA) technique used for pain control following thoracic and breast surgery. However, comprehensive documentation on its effectiveness and safety profile remains limited. This study aims to assess the effectiveness and safety of RIB in thoracic and breast surgical procedures. Methods: A study search was conducted following PRISMA 2020 guidelines in PubMed, Cochrane Library, Embase, Scopus, and ProQuest from 2016 to 2023 to identify randomized controlled trials (RCTs) evaluating the effectiveness and safety of RIB in thoracic and breast surgeries. The primary outcome was patient pain scores at rest, recorded at one, six, 12, and 24 hours post-surgery. Secondary outcomes included 24-hour opioid consumption and rates of postoperative nausea and vomiting (PONV). Results: This meta-analysis included five RCTs with a total of 368 patients. Rhomboid intercostal block led to a significant reduction in NRS scores one hour post-surgery (SMD = -1.33; 95% CI = -1.74 to -0.91; P < 0.00001, I² = 18%, P = 0.27), 12 hours post-surgery (SMD = -0.74; 95% CI = -0.99 to -0.48; P < 0.00001, I² = 36%, P = 0.21), and 24 hours post-surgery (SMD = -1.62; 95% CI = -2.56 to -0.69; P = 0.0006, I² = 91%, P < 0.00001). Regarding secondary outcomes, the RIB group showed a significant reduction in 24-hour opioid consumption (SMD = -4.49; 95% CI = -6.09 to -2.90; P < 0.00001, I² = 95%, P < 0.00001) and PONV rates (RR = 0.29; 95% CI = 0.18 to 0.47; P < 0.00001, I² = 0%, P = 0.88). Conclusions: Rhomboid intercostal block provides effective pain reduction and lowers opioid consumption within 24 hours post-surgery, while also minimizing PONV rates.
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Vitin AA, Egan TD. Remifentanil-induced hyperalgesia: the current state of affairs. Curr Opin Anaesthesiol 2024; 37:371-378. [PMID: 38841986 DOI: 10.1097/aco.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Remifentanil-induced hyperalgesia (RIH) is a part of a general opioid-induced hyperalgesia (OIH) syndrome, seemingly resulting from abrupt cessation of continuous remifentanil infusion at rates equal or exceeding 0.3 mcg/kg/min. The intricate mechanisms of its development are still not completely understood. However, hyperactivation of the N -methyl d -aspartate receptor system, descending spinal facilitation and increased concentration of dynorphin (a κ-opioid ligand) are commonly proposed as possible mechanisms. Several ways of prevention and management have been suggested, such as slow withdrawal of remifentanil infusion, the addition of propofol, pretreatment with or concomitant administration of ketamine, buprenorphine, cyclooxygenase-2 inhibitors (NSAIDs), methadone, dexmedetomidine. In clinical and animal studies, these strategies exhibited varying success, and many are still being investigated.
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Affiliation(s)
| | - Talmage D Egan
- Department of Anesthesiology, Perioperative & Pain Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Bhat V, Sheehan VA. Can we use biomarkers to identify those at risk of acute pain from sickle cell disease? Expert Rev Hematol 2024; 17:411-418. [PMID: 38949576 DOI: 10.1080/17474086.2024.2372322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Acute pain episodes, also known as vaso-occlusive crises (VOC), are a major symptom of sickle cell disease (SCD) and lead to frequent hospitalizations. The diagnosis of VOC can be challenging, particularly in adults with SCD, 50% of whom have chronic pain. Several potential biomarkers have been proposed for identifying individuals with VOC, including elevation above the baseline of various vascular growth factors, cytokines, and other markers of inflammation. However, none have been validated to date. AREAS COVERED We summarize prospective biomarkers for the diagnosis of acute pain in SCD, and how they may be involved in the pathophysiology of a VOC. Previous and current strategies for biomarker discovery, including the use of omics techniques, are discussed. EXPERT OPINION Implementing a multi-omics-based approach will facilitate the discovery of objective and validated biomarkers for acute pain.
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Affiliation(s)
- Varsha Bhat
- Center for Integrative Genomics, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Vivien A Sheehan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Reddy D, Wickman JR, Ajit SK. Epigenetic regulation in opioid induced hyperalgesia. NEUROBIOLOGY OF PAIN (CAMBRIDGE, MASS.) 2023; 14:100146. [PMID: 38099284 PMCID: PMC10719581 DOI: 10.1016/j.ynpai.2023.100146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/14/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
About 25 million American adults experience pain daily and one of the most commonly prescribed drugs to treat pain are opioids. Prolonged opioid usage and dose escalations can cause a paradoxical response where patients experience enhanced pain sensitivity. This opioid induced hyperalgesia (OIH) is a major hurdle when treating pain in the clinic because its underlying mechanisms are still not fully understood. OIH is also commonly overlooked and lacks guidelines to prevent its onset. Research on pain disorders and opioid usage have recognized potential epigenetic drivers of disease including DNA methylation, histone modifications, miRNA regulation, but their involvement in OIH has not been well studied. This article discusses epigenetic changes that may contribute to pathogenesis, with an emphasis on miRNA alterations in OIH. There is a crucial gap in knowledge including how multiple epigenetic modulators contribute to OIH. Elucidating the epigenetic changes underlying OIH and the crosstalk among these mechanisms could lead to the development of novel targets for the prevention and treatment of this painful phenomena.
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Affiliation(s)
- Deepa Reddy
- Department of Pharmacology & Physiology, Drexel University College of Medicine, 245 North 15th Street, Philadelphia, PA 19102, USA
| | - Jason R. Wickman
- Department of Pharmacology & Physiology, Drexel University College of Medicine, 245 North 15th Street, Philadelphia, PA 19102, USA
| | - Seena K. Ajit
- Department of Pharmacology & Physiology, Drexel University College of Medicine, 245 North 15th Street, Philadelphia, PA 19102, USA
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Ramírez-Paesano C, Rodiera Clarens C, Sharp Segovia A, Coila Bustinza A, Rodiera Olive J, Juanola Galceran A. Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation. Orphanet J Rare Dis 2023; 18:214. [PMID: 37491286 PMCID: PMC10369693 DOI: 10.1186/s13023-023-02829-9] [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: 04/27/2022] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.
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Affiliation(s)
- Carlos Ramírez-Paesano
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain.
| | - Claudia Rodiera Clarens
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Allan Sharp Segovia
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Alan Coila Bustinza
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Josep Rodiera Olive
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Albert Juanola Galceran
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
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Delorme J, Kerckhove N, Authier N, Pereira B, Bertin C, Chenaf C. Systematic Review and Meta-Analysis of the Prevalence of Chronic Pain Among Patients With Opioid Use Disorder and Receiving Opioid Substitution Therapy. THE JOURNAL OF PAIN 2023; 24:192-203. [PMID: 36220483 DOI: 10.1016/j.jpain.2022.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/08/2022]
Abstract
To assess studies examining the prevalence of chronic pain (CP) in patients treated with Opioid Substitution Treatment (OST - buprenorphine or methadone) for Opioid Used Disorder (OUD), we conducted a systematic review and meta-analysis of the literature between the years 2000 and 2020. We searched EMBASE, PsycINFO, Cochrane, and MEDLINE databases and included studies assessing the prevalence of CP in OUD adults treated with OST. The studies were assessed for risk of bias and overall quality and the results were pooled using a random-effects model. Subgroup analyses and meta-regressions were used to identify possible factors associated with CP. Twenty-three studies reported data on the prevalence of CP in patients treated with OST were evaluated. The prevalence obtained was 45.3% (CI95% [38.7; 52.1]). Overall, 78.3% of the studies had a low risk of bias. Subgroup analysis estimates did not vary according to gender, OST, and CP duration. However, it appeared that the clinical settings was associated with a lower CP prevalence when assessed in primary care sites. Our study provided an estimate regarding the prevalence of CP among OST patients. These patients deserve specific attention from health professionals and health authorities. Thus, the real challenge in OST patients is the implementation of a multidisciplinary approach to manage CP. PERSPECTIVE: Our meta-analysis provided an estimate of CP prevalence, reaching almost 50% of OUD patients with OST. Thus, the urgent challenge in OST patients is to pay systematic attention to chronic pain diagnosis, along with the implementation of a multidisciplinary patient-focused approach for an appropriate management of CP. REGISTRATION: PROSPERO (CRD42021284790).
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Affiliation(s)
- Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicolas Kerckhove
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France.
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, Secteur Biométrie et Médico-économie, Clermont-Ferrand, France
| | - Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French monitoring centre for analgesic drugs, Université Clermont Auvergne - CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Analgesia, Faculté de Médecine, Clermont-Ferrand, France
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Wang Z, Yao Y, Tao Y, Fan P, Yu Y, Xie K, Wang G. Spinal microRNA-134-5p targets glutamate receptor ionotropic kainate 3 to modulate opioid induced hyperalgesia in mice. Mol Pain 2023; 19:17448069231178271. [PMID: 37247385 DOI: 10.1177/17448069231178271] [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: 05/31/2023] Open
Abstract
Background: Fentanyl and its analogs are extensively used for pain relief. However, their paradoxically pronociceptive effects often lead to increased opioids consumption and risk of chronic pain. Compared to other synthetic opioids, remifentanil has been strongly linked to acute opioid hyperalgesia after exposure [remifentanil-induced hyperalgesia (RIH)]. The epigenetic regulation of microRNAs (miRNAs) on targeted mRNAs has emerged as an important pathogenesis in pain. The current research aimed at exploring the significance and contributions of miR-134-5p to the development of RIH. Methods: Both the antinociceptive and pronociceptive effects of two commonly used opioids were assessed, and miRNA expression profiles in the spinal dorsal horn (SDH) of mice acutely exposed to remifentanil and remifentanil equianalgesic dose (RED) sufentanil were screened. Next, the candidate miRNA level, cellular distribution, and function were examined by qPCR, fluorescent in situ hybridization (FISH) and Argonaute-2 immunoprecipitation. Furthermore, bioinformatics analysis, luciferase assays, miRNA overexpression, behavioral tests, golgi staining, electron microscopy, whole-cell patch-clamp recording, and immunoblotting were employed to investigate the potential targets and mechanisms underlying RIH. Results: Remifentanil induced significant pronociceptive effects and a distinct miRNA-profile from sufentanil when compared to saline controls. Among top 30 differentially expressed miRNAs spectrum, spinal miR-134-5p was dramatically downregulated in RIH mice but remained comparative in mice subjected to sufentanil. Moreover, Glutamate Receptor Ionotropic Kainate 3 (Grik3) was a target of miR-134-5p. The overexpression of miR-134-5p attenuated the hyperalgesic phenotype, excessive dendritic spine remodeling, excitatory synaptic structural plasticity, and Kainate receptor-mediated miniature excitatory postsynaptic currents (mEPSCs) in SDH resulting from remifentanil exposure. Besides, intrathecal injection of selective KA-R antagonist was able to reverse the GRIK3 membrane trafficking and relieved RIH. Conclusion: The miR-134-5p contributes to remifentanil-induced pronociceptive features via directly targeting Grik3 to modulate dendritic spine morphology and synaptic plasticity in spinal neurons.
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Affiliation(s)
- Zhen Wang
- Department of Anesthesiology, Tianjin Research Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yao Yao
- Department of Anesthesiology, Tianjin Research Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuzhu Tao
- Department of Anesthesiology, Tianjin Huanhu Hospital, Tianjin, China
| | - Peixin Fan
- Department of Animal and Dairy Science, Mississippi State University, Starkville, MS, USA
- Institute for Genomics, Biocomputing & Biotechnology, Mississippi State University, Starkville, MS, USA
| | - Yonghao Yu
- Department of Anesthesiology, Tianjin Research Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Keliang Xie
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Guolin Wang
- Department of Anesthesiology, Tianjin Research Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
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Intravenous diclofenac and orphenadrine for the treatment of postoperative pain after remifentanil-based anesthesia : A double-blinded, randomized, placebo-controlled study. Wien Klin Wochenschr 2023; 135:67-74. [PMID: 36576555 PMCID: PMC9938044 DOI: 10.1007/s00508-022-02131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/14/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative intravenous diclofenac reduces patient opioid demand and is commonly used in surgical units. Orphenadrine is mainly used in combination with diclofenac for musculoskeletal injuries and postoperative pain control. The objective of this study was to compare the analgesic efficacy of diclofenac-orphenadrine, diclofenac alone and saline. METHODS We performed a double-blind, randomized, placebo-controlled, parallel-group, single-center clinical study investigating the opioid-sparing effect of a combination of diclofenac and orphenadrine versus diclofenac alone versus isotonic saline solution. Initially 72 patients were included and received total intravenous anesthesia during cruciate ligament surgery. All patients were postoperatively treated with a patient-controlled analgesia (PCA) device containing hydromorphone. Pharmacological safety was assessed by laboratory parameters, vital signs, and delirium detection scores. RESULTS There was no significant difference between the groups in cumulative dose of PCA analgesics required after 24 h postsurgery, with 5.90 mg (SD ± 2.90 mg) in the placebo group, 5.73 mg (SD ± 4.75 mg) in the diclofenac group, and 4.13 mg (SD ± 2.57 mg) in the diclofenac-orphenadrine group. Furthermore, there was no significant difference between the groups in cumulative dose of PCA analgesics required 2 h postsurgery (n = 65). Mean dose of hydromorphone required after 2 h was 1.54 mg (SD ± 0.57 mg) in the placebo group, 1.56 mg (SD ± 1.19 mg) in the diclofenac-only group, and 1.37 mg (SD ± 0.78 mg) in the diclofenac-orphenadrine group. However, when comparing the diclofenac-orphenadrine group and the diclofenac group combined to placebo there was a significant reduction in PCA usage in the first 24 h postsurgery. In total, there were 25 adverse events reported, none of which were rated as severe. CONCLUSION Orphenadrine-diclofenac failed to significantly reduce postoperative opioid requirements. However, in an exploratory post hoc analysis the diclofenac-orphenadrine and the diclofenac group combined versus placebo showed a tendency to reduce opioid demand in postoperative pain control. Further research is required to determine the value of orphenadrine as an adjuvant in a multimodal approach for postoperative pain management.
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Sampaio-Cunha TJ, Martins I. Knowing the Enemy Is Halfway towards Victory: A Scoping Review on Opioid-Induced Hyperalgesia. J Clin Med 2022; 11:jcm11206161. [PMID: 36294488 PMCID: PMC9604911 DOI: 10.3390/jcm11206161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/26/2022] Open
Abstract
Opioid-induced hyperalgesia (OIH) is a paradoxical effect of opioids that is not consensually recognized in clinical settings. We conducted a revision of clinical and preclinical studies and discuss them side by side to provide an updated and renewed view on OIH. We critically analyze data on the human manifestations of OIH in the context of chronic and post-operative pain. We also discuss how, in the context of cancer pain, though there are no direct evidence of OIH, several inherent conditions to the tumor and chemotherapy provide a substrate for the development of OIH. The review of the clinical data, namely in what concerns the strategies to counter OIH, emphasizes how much OIH rely mechanistically on the existence of µ-opioid receptor (MOR) signaling through opposite, inhibitory/antinociceptive and excitatory/pronociceptive, pathways. The rationale for the maladaptive excitatory signaling of opioids is provided by the emerging growing information on the functional role of alternative splicing and heteromerization of MOR. The crossroads between opioids and neuroinflammation also play a major role in OIH. The latest pre-clinical data in this field brings new insights to new and promising therapeutic targets to address OIH. In conclusion, although OIH remains insufficiently recognized in clinical practice, the appropriate diagnosis can turn it into a treatable pain disorder. Therefore, in times of scarce alternatives to opioids to treat pain, mainly unmanageable chronic pain, increased knowledge and recognition of OIH, likely represent the first steps towards safer and efficient use of opioids as analgesics.
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Affiliation(s)
- Tiago J. Sampaio-Cunha
- Department of Biomedicine, Unit of Experimental Biology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
- i3S–Institute for Research & Innovation in Health, University of Porto, 4200-135 Porto, Portugal
- IBMC-Institute for Molecular and Cell Biology, University of Porto, 4200-135 Porto, Portugal
| | - Isabel Martins
- Department of Biomedicine, Unit of Experimental Biology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
- i3S–Institute for Research & Innovation in Health, University of Porto, 4200-135 Porto, Portugal
- IBMC-Institute for Molecular and Cell Biology, University of Porto, 4200-135 Porto, Portugal
- Correspondence: ; Tel.: +351-22-0426780; Fax: +351-22-5513655
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Dieterle M, Zurbriggen L, Mauermann E, Mercer-Chalmers-Bender K, Frei P, Ruppen W, Schneider T. Pain response to cannabidiol in opioid-induced hyperalgesia, acute nociceptive pain, and allodynia using a model mimicking acute pain in healthy adults in a randomized trial (CANAB II). Pain 2022; 163:1919-1928. [PMID: 35239547 PMCID: PMC9982727 DOI: 10.1097/j.pain.0000000000002591] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/25/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
ABSTRACT Opioids in general and remifentanil in particular can induce hyperalgesia. Preclinical data suggest that cannabidiol might have the capacity to reduce opioid-induced hyperalgesia (OIH). Thus, we investigated the effect of oral cannabidiol on OIH in healthy volunteers using an established pain model. Twenty-four healthy participants were included in this randomized, double-blinded, crossover study and received either a 1600-mg single-dose oral cannabidiol or placebo. Hyperalgesia, allodynia, and pain were induced by intracutaneous electrical stimulation. To provoke OIH, participants recieved an infusion of 0.1 µg/kg/min remifentanil over a time frame of 30 minutes, starting 100 minutes after oral cannabidiol ingestion. The primary outcome was the area of hyperalgesia (in square centimetres) up to 60 minutes after remifentanil administration. The area of allodynia (in square centimetres) and pain (numeric rating scale) were also assessed.Cannabidiol had no significant effect on hyperalgesia, allodynia, or pain at any time point of measurement compared with placebo. The area of hyperalgesia after remifentanil administration significantly increased compared with baseline (17.0 cm 2 [8.1-28.7] vs 25.3 cm 2 [15.1-39.6]; P = 0.013). Mean cannabidiol blood levels were 4.1 ± 3.0 µg/L (mean ± SD) at 130 minutes after ingestion and were 8.2 μg/L ± 6.9 µg/L (mean ± SD) at 200 minutes. Cannabidiol was well tolerated. We conclude that a high single-oral dose of 1600-mg cannabidiol is not effective in reducing OIH. Before excluding an effect of cannabidiol on OIH, research should focus on drug formulations enabling higher cannabidiol concentrations.
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Affiliation(s)
- Markus Dieterle
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Laura Zurbriggen
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | | | - Priska Frei
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Wilhelm Ruppen
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Tobias Schneider
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
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11
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Anosike UG, Ouko I, Mwaura AW, Ongidi I, Mbonu CC. Phenotypes and Genotypes in Postherpetic Neuralgia Drug Therapy: A Narrative Mini-review. Clin J Pain 2022; 38:536-540. [PMID: 35703453 DOI: 10.1097/ajp.0000000000001045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
Abstract
Neuropathic pain is a debilitating symptom reported by patients presenting with postherpetic neuralgia (PHN). Efforts to alleviate this pain have been projected to lie in individualization of pharmacological treatment through pain phenotyping and subsequent investigations into the genetic basis of PHN therapy. Understanding the various mechanisms related to these phenotypes can aid in improvement of available treatment options and discovery of new ones. Knowledge and application of genetic variations in PHN, structural proteins, and genes can aid in ascertaining risk, susceptibility to, severity of, and protection from PHN. This review summarizes the most recent information that has been published on phenotypes and genotypes with possible clinical applications and directions for future research.
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Affiliation(s)
- Udochukwu G Anosike
- Faculty of Medicine, Nnamdi Azikiwe University College of Health Sciences, Awka, Nigeria
| | - Innocent Ouko
- Department of Human Anatomy, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Anita W Mwaura
- Department of Human Anatomy, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Ibsen Ongidi
- Department of Human Anatomy, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Chijioke C Mbonu
- Faculty of Medicine, Nnamdi Azikiwe University College of Health Sciences, Awka, Nigeria
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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13
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Testosterone Improved Hyperalgesia in a Patient Under Methadone Maintenance Treatment. ARCHIVES OF NEUROSCIENCE 2022. [DOI: 10.5812/ans.121361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Long-term use of narcotics causes hyperalgesia in some patients with an unknown mechanism known as opioid-induced hyperalgesia (OIH). Case Presentation: Testosterone was prescribed to a 43-year-old man suffering from the effects of OIH syndrome due to long-term use of methadone. Testosterone prescription significantly reduced the hyperalgesia. Conclusions: Testosterone may have a therapeutic value in OIH.
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Hino C, Ran-Castillo D, Akhtari M, Cao H, Silvestre J. Role of Ketamine and Opioid Rotation in the Management of Opioid Induced Hyperalgesia in a Patient With Acute Promyelocytic Leukemia. J Oncol Pharm Pract 2022:10781552221074285. [DOI: 10.1177/10781552221074285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Opioid analgesics are commonly used to manage moderate to severe cancer related pain. However long-term use of opioids has been known to lead to several unintended side effects, including opioid induced hyperalgesia (OIH) which is defined as the paradoxical increase in pain sensitization to pain stimulus following opioid exposure. Currently there are limited reports on the association between patients with cancer and OIH, and this phenomenon is rarely described in patients with leukemia or lymphoma. Here we report a patient with acute promyelocytic leukemia who developed opioid induced hyperalgesia following rapid escalation of opioids. Case report A 36-year-old female being treated for acute promyelocytic leukemia presented with rapidly worsening acute on chronic hip pain requiring increasing opioid requriements. Given the rapid escalation of opioid dose with minimal response and physical exam findings consistent with allodynia/hyperalgesia a diagnosis of opioid induced hyperalgesia was made. Management and outcome Following recognition of opioid induced hyperalgesia, the patient was managed with opioid rotation and ketamine, which resulted in prompt alleviation of pain. Discussion Opioid induced hyperalgesia is likely an underrecognized phenomenon in patients with cancer-related pain. A high index of clinical suspicion are necessary for diagnosis and proper management of this disease entity.
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Affiliation(s)
- Christopher Hino
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Dan Ran-Castillo
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Mojtaba Akhtari
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Huynh Cao
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Julio Silvestre
- Department of Palliative care, Loma Linda University, Loma Linda, California, USA
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Park S, Choi SH, Song YK, Kwon JW. Comparison of Online Patient Reviews and National Pharmacovigilance Data for Tramadol-Related Adverse Events: Comparative Observational Study. JMIR Public Health Surveill 2022; 8:e33311. [PMID: 34982723 PMCID: PMC8767477 DOI: 10.2196/33311] [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: 09/01/2021] [Revised: 11/08/2021] [Accepted: 11/27/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tramadol is known to cause fewer adverse events (AEs) than other opioids. However, recent research has raised concerns about various safety issues. OBJECTIVE We aimed to explore these new AEs related to tramadol using social media and conventional pharmacovigilance data. METHODS This study used 2 data sets, 1 from patients' drug reviews on WebMD (January 2007 to January 2021) and 1 from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS; January 2016 to December 2020). We analyzed 2062 and 29,350 patient reports from WebMD and FAERS, respectively. Patient posts on WebMD were manually assigned the preferred terms of the Medical Dictionary for Regulatory Activities. To analyze AEs from FAERS, a disproportionality analysis was performed with 3 measures: proportional reporting ratio, reporting odds ratio, and information component. RESULTS From the 869 AEs reported, we identified 125 new signals related to tramadol use not listed on the drug label that satisfied all 3 signal detection criteria. In addition, 20 serious AEs were selected from new signals. Among new serious AEs, vascular disorders had the largest signal detection criteria value. Based on the disproportionality analysis and patients' symptom descriptions, tramadol-induced pain might also be an unexpected AE. CONCLUSIONS This study detected several novel signals related to tramadol use, suggesting newly identified possible AEs. Additionally, this study indicates that unexpected AEs can be detected using social media analysis alongside traditional pharmacovigilance data.
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Affiliation(s)
- Susan Park
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Republic of Korea
| | - So Hyun Choi
- Department of Statistics, Kyungpook National University, Daegu, Republic of Korea
| | - Yun-Kyoung Song
- College of Pharmacy, Daegu Catholic University, Gyeongsan-si, Gyeongbuk, Republic of Korea
| | - Jin-Won Kwon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Republic of Korea
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16
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:479-483. [DOI: 10.1093/ijpp/riac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 03/23/2022] [Indexed: 11/14/2022]
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Faghih M, Phillips AE, Kuhlmann L, Afghani E, Drewes AM, Yadav D, Singh VK, Olesen SS. Pancreatic QST Differentiates Chronic Pancreatitis Patients into Distinct Pain Phenotypes Independent of Psychiatric Comorbidities. Clin Gastroenterol Hepatol 2022; 20:153-161.e2. [PMID: 34108130 PMCID: PMC8629107 DOI: 10.1016/j.cgh.2020.10.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quantitative sensory testing (QST) has been previously used to study pain in chronic pancreatitis (CP) but included methods that are not suitable for clinical purposes. The aims of this study were to determine if pancreatic QST (P-QST) can differentiate patients into distinct pain phenotypes and to determine the association of these with their clinical pain and psychiatric comorbidities. METHODS A multicenter cross-sectional study was conducted where patients completed validated questionnaires assessing quality of life (QoL), depression and anxiety scores as well as clinical pain symptoms followed by P-QST which included a cold pressor test, repetitive pinprick stimuli and pressure stimulation of the upper abdominal (T10) and control dermatomes. P-QST categorized patients into pain phenotypes based on a previously established nomogram. QoL, clinical pain and psychiatric assessment scores were compared across these groups. RESULTS A total of 179 patients were enrolled with a mean age of 54.1±13.6 years among whom 59% were males and 42% had an alcoholic etiology. P-QST showed no hyperalgesia in 91 (51%), segmental hyperalgesia in 50 (28%) and widespread hyperalgesia in 38 (21%) patients. Patients with widespread hyperalgesia had significantly higher pain intensity scores (P = .03) and rates of constant pain (P = .002) as well as decreased QoL (P < .001) and physical functioning (P =.03) in comparison with the other two pain phenotypes. In contrast, psychiatric comorbidities were similar across all groups. CONCLUSIONS P-QST may serve as a novel unbiased pain assessment tool in CP as it categorizes patients into distinct pain phenotypes independent of their psychiatric comorbidities.
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Affiliation(s)
- Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anna E Phillips
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Yadav
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia. Pain Manag 2021; 11:405-417. [PMID: 33779215 DOI: 10.2217/pmt-2020-0105] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.
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Affiliation(s)
- Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kevin M Hellman
- Department of Obstetrics & Gynecology, NorthShore University Health System & Pritzker School of Medicine at the University of Chicago, Evanston, IL 60201, USA
| | - Dominika James
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Adam C Adler
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
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