Chronic pain: the burden of disease and treatment innovations

Effect of transcutaneous neuromodulation on normalization of dermal body temperature and pain in a tender scar in the presence of low back pain: An update and case report

Low back pain affects over 20% of individuals during their lifetime, and in some patients, it may be associated with scar tissue formation after surgery. Small-fiber neuropathy and scar tissue dysfunction can lead to localized pain by affecting signals to the thalamus. Transcutaneous neuromodulation using Tape with Magnetic Particles shows promise in relieving perceived pain, modulating vascularization and the autonomic nervous system, and reducing dermal temperature. In the present case, a 24-year-old woman with L5-S1 disk herniation experienced low back pain and leg pressure. The surgical intervention provided temporary relief, but scar restrictions caused pain recurrence. Tape with Magnetic Particles application initially induced scar hypothermia and pressure tolerance during posteroanterior tests on lumbar spinous processes increased, reducing pain perception for at least 12 h. Transcutaneous neuromodulation with Tape with Magnetic Particles modulated dermal temperature immediately and for 12 h, reducing perceived pain and sustaining improvement thereafter. This highlights the potential of Tape with Magnetic Particles in managing chronic low back pain associated with scar tissue.

Management of Chronic Low Back Pain and the Impact on Patients’ Personal and Professional Lives: Results From an International Patient Survey

Objective

Methods

Results

Conclusion

Cost-Effectiveness Analysis of Tapentadol Versus Oxycodone/Naloxone in both Branded and Generic Formulations in Patients with Musculoskeletal Pain

BACKGROUND AND OBJECTIVES

Current evidence shows that tapentadol hydrochloride prolonged-release is more cost effective than other opioids. However, the introduction into the market of generic formulations of traditional comparators, leading to potential savings due to their lower price, creates space for further research. The objective of this study is to evaluate and compare the efficacy of tapentadol versus oxycodone/naloxone and the economic impact of the two alternatives in both branded and generic formulations.

METHODS

A cost-effectiveness analysis was performed using the third-payer perspective (TPP), with specific reference to the Italian National Health Service. A Markov model was implemented to simulate transitions between states, comparing two arms: The first arm simulated the administration of tapentadol, while the second simulated the administration of oxycodone/naloxone, both branded and generic. The results were reported in terms of net monetary benefit (NMB). The willingness to pay (WPT) was estimated at €35,000/quality-adjusted life year.

RESULTS

Tapentadol was dominant in all scenarios, assuming a population of 1000 individuals over a 1-year time horizon. In all cases, although the prices of oxycodone/naloxone generic formulations were lower, the costs associated with treatment discontinuation were always higher than those associated with tapentadol. The comparison with the branded formulation of oxycodone/naloxone was associated with the highest savings of €431.77 per patient, and with the highest NMB of €1943.77 per patient.

CONCLUSION

The results of this pharmacoeconomic evaluation promote the use of tapentadol in comparison with oxycodone/naloxone, confirming the results obtained in previous studies with reference to the generic formulations.

Tai Chi for Improving Chronic Primary Musculoskeletal Pain: Protocol for a Systematic Review

Background. Chronic primary musculoskeletal pain (CPMP) is a major health problem that has physical and psychological impacts as well as an associated economic burden. Currently, pharmacological treatment remains unsatisfactory because of side effects and potential misuse. Therefore, nonpharmacological approaches for pain are being actively explored, and Tai Chi has attracted increased attention as a therapy for pain. Although clinical trials have shown that Tai Chi may be effective in treating CPMP, no systematic review has clarified its effectiveness and safety. The objective of this systematic review is to assess the effect and safety of Tai Chi for patients suffering from CPMP. Methods and Analysis. We will search relevant electronic databases from inception to May 31, 2021: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, the Wanfang database, the Chongqing VIP database, and China Biology Medicine Disc. Studies comparing the use of Tai Chi with other managements for CPMP patients will be included. Our review will include studies that measured change in pain intensity as the primary outcome using patient-reported ratings (visual analog scale or numerical rating scale). Hospital Anxiety and Depression Scale scores, SF-36 Health Survey scores, Pittsburgh Sleep Quality Index scores, and adverse effects will be explored as secondary outcomes. The risk of bias and the reporting quality of included studies will be evaluated using the Cochrane Collaboration risk-of-bias assessment method. The data will be analyzed using RevMan v5.3 software. Study Registration. This study protocol was registered on PROSPERO. The registration number for this protocol is CRD42020165048.

Ultrasound-guided thermal radiofrequency ablation to treat refractory knee and hip pain: Outcomes of a case series

A number of options are currently available to treat symptomatic knee and hip pain. Among them, there is the use of thermal radiofrequency ablation. It is a more recent technique and we still have a lack regarding safety and effectiveness. In this report, we briefly present a case series of patients with refractory knee and hip pain, treated with thermal radiofrequency ablation, where we discuss the results in safety and effectiveness, concerning not only the pain control, but also the return to participation in activities.

Chronic Noncancer Pain and Opioid Addiction: Diagnostic and Management Challenges

Chronic pain is associated with higher rates of psychiatric comorbidity, including substance use disorders. Patients with chronic pain often require opioids for their pain relief. Often, clinicians are reluctant to prescribe opioids to patients with chronic pain due to fear of patients becoming dependent on opioids. Diagnosing opioid addiction in chronic pain with comorbid prescription opioid use is challenging, as some of the symptoms of addiction overlap with those of physical dependence. A 28-year-old female presented with a history of recurrent abdominal pain beginning at the age of 16 years. The patient was diagnosed with chronic pancreatitis and was prescribed tramadol orally or injections for pain. The patient started experiencing craving with repeated administration of tramadol. She started using it daily and increased her dose to about 6–7 ampoules per day. She also developed complications due to injections. She was not able to work due to her pain, as well as injection use. She would go to multiple chemist shops for getting herself injected with tramadol injections. She also developed depressive symptoms in this period. Due to abdominal pain, the patient was admitted in the gastroenterology ward, from where she was shifted to the psychiatry ward for the management of opioid misuse and depressive symptoms. The patient was diagnosed to be suffering from opioid dependence syndrome with depressive episodes, for which she was provided tablet buprenorphine 14 mg/day dose along with tablet sertraline 150 mg/day. The case demonstrates several challenges in the diagnosis and management of opioid dependence and chronic pain when they occur simultaneously.

The role of carbon monoxide, heme oxygenase 1, and the Nrf2 transcription factor in the modulation of chronic pain and their interactions with opioids and cannabinoids

Chronic pain and its associated comorbidities are difficult to treat, even when the most potent analgesic compounds are used. Thus, research on new strategies to effectively relieve nociceptive and/or emotional disorders accompanying chronic pain is essential. Several studies have demonstrated the anti-inflammatory and antinociceptive effects of different carbon monoxide-releasing molecules (CO-RMs), inducible heme oxygenase 1 (HO-1), and nuclear factor-2 erythroid factor-2 (Nrf2) transcription factor activators in several models of acute and chronic pain caused by inflammation, nerve injury or diabetes. More recently, the antidepressant and/or anxiolytic effects of several Nrf2 transcription factor inducers were demonstrated in a model of chronic neuropathic pain. These effects are mainly produced by inhibition of oxidative stress, inflammation, glial activation, mitogen-activated protein kinases and/or phosphoinositide 3-kinase/phospho-protein kinase B phosphorylation in the peripheral and/or central nervous system. Other studies also demonstrated that the analgesic effects of opioids and cannabinoids are improved when these drugs are coadministered with CO-RMs, HO-1 or Nrf2 activators in different preclinical pain models and that these improvements are generally mediated by upregulation or prevention of the downregulation of µ-opioid receptors, δ-opioid receptors and/or cannabinoid 2 receptors in the setting of chronic pain. We reviewed all these studies as well as studies on the mechanisms of action underlying the effects of CO-RMs, HO-1, and Nrf2 activators in chronic pain. In summary, activation of the Nrf2/HO-1/carbon monoxide signaling pathway alone and/or in combination with the administration of specific analgesics is a valid strategy for the treatment of chronic pain and some associated emotional disorders.

Insomnia-related Memory Impairment in Individuals With Very Complex Chronic Pain

OBJECTIVE

To investigate the specific effect of insomnia on neuropsychological functioning in patients with very complex chronic pain.

BACKGROUND

Individuals with insomnia disorder or chronic pain often experience cognitive deficits, with both conditions appearing to correlate with impairments in neuropsychological functions. As insomnia often occurs comorbid with chronic pain, distinguishing the differential effects of these two syndromes on an individual's neuropsychological functioning can be challenging. Comorbid depressive symptoms in these individuals, which may also affect cognitive function, may further obscure the associations between chronic pain, insomnia, and the neuropsychological profile.

METHODS

The neuropsychological function of 22 individuals with very complex chronic pain was assessed using specialized tests examining aspects of memory and executive functioning. The severity of insomnia, depression, and anxiety was measured using questionnaires, and pain levels were assessed using a visual analog scale. Pain medications were transformed to the morphine-equivalent daily dose.

RESULTS

Insomnia severity was found to predict memory function, accounting for 32.4% of the variance: A 1 SD increase in insomnia severity decreased memory function by 0.57 SD. The negative correlation between insomnia and memory was significant even after controlling for pain level, morphine-equivalent daily dose, and comorbid levels of anxiety and depression.

CONCLUSIONS

Insomnia severity independently predicted memory function in patients with very complex chronic pain, even after controlling for other factors known to impair cognitive function. Insomnia may possibly explain some of the cognitive impairments related to chronic pain; thus, screening for, and treating, sleep disturbances may be a central aspect of chronic pain rehabilitation.

Efficacy and tolerability of a fixed dose combination of cortex phospholipid liposomes and cyanocobalamin for intramuscular use in peripheral neuropathies

Peripheral neuropathies are frequently encountered in clinical practice and are associated with a major impairment in quality of life. However, their management remains poor, and current therapies are often burdened with major side effects and can present poor efficacy on pain and functionality. Therefore, it has been suggested that the combination of two or more different drugs may improve analgesic efficacy and reduce side effects. Tricortin® 1000 is formulated with 12 mg of Brain cortex phospholipid liposomes + 1000 µg of Cyanocobalamin injectable solution (PL+CNCbl) for intramuscular use and is indicated in the treatment of poly-algo-neuropathic syndromes. This combination exerts a marked neurotrophic action by promoting the synthesis of endogenous phospholipids; moreover, the peculiar formulation optimizes the delivery of CNCbl which has analgesic and neurotrophic action. This paper discusses the pharmacotherapy of peripheral neuropathies, including low-back pain, neck pain, postherpetic neuropathy (PHN) and focuses on the fixed dose combination PL+CNCbl clinical efficacy in association with other treatments or in monotherapy.

Tapentadol: an effective option for the treatment of back pain

Back pain, including low back pain and neck pain, is the leading cause of disability worldwide. This type of pain is challenging to treat, since it presents both a nociceptive and a neuropathic component. The latter also contributes to the evolution of pain toward chronification. Treatment selection should therefore consider the ability to prevent this event. Tapentadol is characterized by a unique and innovative peculiar mechanism of action that makes it the first representative of a new class of central strong analgesics referred to as MOR-NRI. This molecule acts both on the nociceptive and neuropathic components of pain, and it can therefore be effective in the treatment of a mixed pain condition such as back pain. This narrative review discusses the rationale for the use of tapentadol in both low back pain and neck pain and presents available clinical data. Overall, data show that tapentadol prolonged release is a well-grounded treatment for chronic back pain, sustained by a strong mechanistic rationale and robust evidence. Given also the availability of long-term efficacy and safety data, we believe that this molecule should be considered as an elective therapy for chronic back pain.

Treatment With the Delta Opioid Agonist UFP-512 Alleviates Chronic Inflammatory and Neuropathic Pain: Mechanisms Implicated

We investigated whether administration of the δ-opioid receptor (DOR) agonist H-Dmt-Tic-NH-CH(CH2-COOH)-Bid (UFP-512), which also activates nuclear factor erythroid 2-related factor 2 (Nrf2), alleviated chronic inflammatory and/or neuropathic pain and inhibited the depressive-like behaviors associated with persistent neuropathic pain. The possible mechanisms implicated were also assessed. We evaluated the following effects in male C57BL/6J mice with inflammatory pain induced by complete Freund's adjuvant or neuropathic pain caused by the chronic constriction of sciatic nerve: (1) the antinociceptive effects of UFP-512; (2) the effects of UFP-512 on the expression of Nrf2, heme oxygenase 1 (HO-1), NAD(P)H quinone oxidoreductase 1, phosphoinositide 3-kinase (PI3K), protein kinase B (Akt), inducible nitric oxide synthase, DOR, and mitogen-activated protein kinases (MAPK) in the spinal cord of animals with inflammatory or neuropathic pain; (3) the antinociceptive effects of the coadministration of UFP-512 with the Nrf2 activator sulforaphane (SFN); and (4) the antidepressant effects of UFP-512 in animals with depressive-like behaviors associated with neuropathic pain. Our results demonstrated that the intraperitoneal administration of UFP-512 inhibited chronic inflammatory and neuropathic pain and reduced the depressive-like behaviors associated with persistent neuropathic pain. The antiallodynic effects of UFP-512 were significantly augmented when it was coadministered with SFN in both types of chronic pain. The administration of UFP-512 increased/reestablished the spinal cord protein levels of Nrf2 and HO-1 in mice with inflammatory or neuropathic pain. However, while during inflammatory pain UFP-512 inhibited spinal c-Jun N-terminal kinase (JNK) and extracellular signal regulated kinase 1/2 (ERK1/2) phosphorylation induced by peripheral inflammation. This DOR agonist blocked the spinal activated PI3K/Akt signaling pathway under chronic neuropathic pain conditions, but it did not alter the enhanced protein levels of p-JNK or p-ERK1/2 induced by sciatic nerve injury. These results revealed the antinociceptive and antidepressant effects of UFP-512 in animals with chronic pain and the different mechanism of action of this DOR agonist in the presence of inflammatory or neuropathic pain. Our data also suggest the administration of UFP-512 as an alternative for the treatment of chronic pain and the depressive-like behaviors associated with neuropathic pain.

Oh Schmerz lass nach – ein kurzer Report der ersten Ergebnisse unserer interdisziplinären, integrativen, gynäkologischen Schmerzsprechstunde

<b><i>Einleitung:</i></b> Trotz immer besserer medizinischer und operativer Therapiemaßnahmen bleibt eine adäquate Schmerztherapie für viele gynäkologische Krankheitsbilder eine He­rausforderung. Neue patientenfokussierte Testsysteme können dabei zur Verlaufsbeurteilung und Therapieoptimierung beitragen. Ziel war es, die Pilot-Ergebnisse unserer, in Deutschland einmaligen, interdisziplinären, universitär geführten, integrativen Schmerzsprechstunde anhand neu­ester patientenfokussierter Testsysteme auszuwerten und zur weitergehenden interkollegialen Diskussion vorzustellen. <b><i>Materialien und Methoden:</i></b> Retrospektive, monozentrische Analyse der Behandlungsverläufe von Patientinnen einer neuen integrativen und interdisziplinären, gynäkologischen Schmerzsprechstunde mittels patientenfokussiertem Testsystem (PROMIS-29). <b><i>Ergebnisse:</i></b> Insgesamt konn­ten die Ergebnisse von 18 Patientinnen analysiert werden. Zur Nachuntersuchung zeigten sich signifikante Verbesserungen in allen Domänen des PROMIS-29. <b><i>Schlussfolgerung:</i></b> Die vorgestellte interdisziplinäre, integrative Schmerz­sprechstunde unter Zuhilfenahme patientenfokussierter Testsysteme kann relevante Schmerzdomänen erfassen und erfolgreich therapieren. Weitere Untersuchungen müssen diese neue Art der Verlaufsbeobachtung und gynäkologisch fokussierter Schmerzbehandlung nun mit längeren Nach­sorgeintervallen bestätigen.

A cross-sectional study of factors associated with the number of anatomical pain sites in an actual elderly general population: results from the PainS65+ cohort

BACKGROUND

Several studies have illustrated that multisite pain is more frequent than single pain site, and it is associated with an array of negative consequences. However, there is limited knowledge available about the potential factors associated with multisite pain in the elderly general population.

OBJECTIVE

This cross-sectional study examines whether the number of anatomical pain sites (APSs) is related to sociodemographic and health-related factors in older adults including oldest-old ages using a new method (APSs) to assess the location of pain on the body.

MATERIALS AND METHODS

The sample came from the PainS65+ cohort, which included 6,611 older individuals (mean age = 76.0 years; standard deviation [SD] = 7.4) residing in southeastern Sweden. All the participants completed and returned a postal survey that measured sociodemographic data, total annual income, pain intensity and frequency, general well-being, and quality of life. The number of pain sites (NPS) was marked on a body manikin of 45 sections, and a total of 23 APSs were then calculated. Univariable and multivariable models of regression analysis were performed.

RESULTS

Approximately 39% of the respondents had at least two painful sites. The results of the regression analysis showed an independent association between the APSs and the age group of 75-79 years, women, married, high pain intensity and frequency, and low well-being and quality of life, after adjustments for consumption of analgesics and comorbidities. The strongest association was observed for the higher frequency of pain.

CONCLUSION

Our results suggest that APSs are highly prevalent with strong relationships with various sociodemographic and health-related factors and concur well with the notion that multisite pain is a potential indicator of increased pain severity and impaired quality of life in the elderly. Our comprehensive method of calculating the number of sites could be an essential part of the clinical presentation, assessment, and treatment of multisite pain.

Considering tapentadol as a first-line analgesic: 14 questions

Tapentadol is the newest centrally acting analgesic to be approved by the US FDA and regulatory bodies in other countries. It has been called the first-in-class of a novel-acting analgesic mechanism of action that combines µ-opioid receptor agonist activity with neuronal norepinephrine-reuptake inhibition in a single molecule. This duality of action should combine inhibition of ascending (afferent) pain-transmitting signals with activation of descending (efferent) pain-attenuating systems (e.g., diffuse noxious inhibitory controls). However, not all novel mechanisms of action impart the characteristics needed for an analgesic to be considered for first-line therapy. These key questions may help inform clinical decision making.