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1.
Membrane Stabilizer Medications in the Treatment of Chronic Neuropathic Pain: a Comprehensive Review.
Viswanath, O, Urits, I, Jones, MR, Peck, JM, Kochanski, J, Hasegawa, M, Anyama, B, Kaye, AD
Current pain and headache reports. 2019;(6):37
Abstract
PURPOSE OF REVIEW Neuropathic pain is often debilitating, severely limiting the daily lives of patients who are affected. Typically, neuropathic pain is difficult to manage and, as a result, leads to progression into a chronic condition that is, in many instances, refractory to medical management. RECENT FINDINGS Gabapentinoids, belonging to the calcium channel blocking class of drugs, have shown good efficacy in the management of chronic pain and are thus commonly utilized as first-line therapy. Various sodium channel blocking drugs, belonging to the categories of anticonvulsants and local anesthetics, have demonstrated varying degrees of efficacy in the in the treatment of neurogenic pain. Though there is limited medical literature as to efficacy of any one drug, individualized multimodal therapy can provide significant analgesia to patients with chronic neuropathic pain.
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2.
Literature review informs clinical guidelines for pain management during screening and laser photocoagulation for retinopathy of prematurity.
Pirelli, A, Savant Levet, P, Garetti, E, Ancora, G, Merazzi, D, Bellieni, CV, Lago, P, ,
Acta paediatrica (Oslo, Norway : 1992). 2019;(4):593-599
Abstract
AIM: The aim of this study was to carry out a literature review and develop clinical guidelines for pain prevention and control during screening and laser photocoagulation for retinopathy of prematurity (ROP) in neonatal intensive care units (NICUs). METHODS The Italian Society of Neonatology assessed papers published between 1986 and June 2017 and used the Grading of Recommendations, Assessment, Development and Evaluation approach, to develop new guidelines on pain and ROP. RESULTS The Society's pain experts assessed the full texts of 47 papers, including randomised or quasi-randomised controlled trials and case-control studies on nonpharmacological and pharmacological measures used in NICUs during the screening and laser photocoagulation of neonates for ROP. The literature suggested methods for reducing the stress and pain associated with ROP screening procedures. The panel concluded that the literature showed that it was feasible to provide laser photocoagulation for ROP in spontaneously breathing patients with adequate analgesia. CONCLUSION This literature review on managing pain in infants with ROP in NICUs led to the development of national guidelines, which will help physicians and nurses to reduce the stress and pain experienced by premature newborn infants during unavoidable screening and treatment for ROP.
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3.
Pain and distress management in palliative neonatal care.
Garten, L, Bührer, C
Seminars in fetal & neonatal medicine. 2019;(4):101008
Abstract
Palliative care concentrates on preventing and relieving suffering by reducing the severity of disease symptoms. Consistent treatment of pain and distress must therefore be an integral component of every palliative care concept. In this review non-pharmacological and pharmacological measures for pain and distress management in the context of palliative neonatal care are summarised. Furthermore, recommendations are given focusing on two special palliative neonatal care settings: compassionate extubation and withdrawing artificial nutrition and hydration.
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4.
Revisiting Tramadol: A Multi-Modal Agent for Pain Management.
Barakat, A
CNS drugs. 2019;(5):481-501
Abstract
Tramadol-an atypical opioid analgesic-has a unique pharmacokinetic and pharmacodynamic profile, with opioidergic, noradrenergic, and serotonergic actions. Tramadol has long been used as a well-tolerated alternative to other drugs in moderate pain because of its opioidergic and monoaminergic activities. However, cumulative evidence has been gathered over the last few years that supports other likely mechanisms and uses of tramadol in pain management. Tramadol has modulatory effects on several mediators involved in pain signaling, such as voltage-gated sodium ion channels, transient receptor potential V1 channels, glutamate receptors, α2-adrenoceptors, adenosine receptors, and mechanisms involving substance P, calcitonin gene-related peptide, prostaglandin E2, and proinflammatory cytokines. Tramadol also modifies the crosstalk between neuronal and non-neuronal cells in peripheral and central sites. Through these molecular effects, tramadol could modulate peripheral and central neuronal hyperexcitability. Given the broad spectrum of molecular targets, tramadol as a unimodal analgesic relieves a broad range of pain types, such as postoperative, low back, and neuropathic pain and that associated with labor, osteoarthritis, fibromyalgia, and cancer. Moreover, tramadol has anxiolytic, antidepressant, and anti-shivering activities that could improve pain management outcomes. The aim of this review was to address these issues in the context of maladaptive physiological and psychological processes that are associated with different pain types.
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5.
Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review.
Gemzell-Danielsson, K, Jensen, JT, Monteiro, I, Peers, T, Rodriguez, M, Di Spiezio Sardo, A, Bahamondes, L
Acta obstetricia et gynecologica Scandinavica. 2019;(12):1500-1513
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Abstract
A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure-related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement-related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement-related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.
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Consensus recommendations for managing osteoarthritic pain with topical NSAIDs in Asia-Pacific.
Rafanan, BS, Valdecañas, BF, Lim, BP, Malairungsakul, A, Tassanawipas, W, Shiyi, C, Tse, LF, Luong, TK
Pain management. 2018;(2):115-128
Abstract
Osteoarthritis prevalence is expected to increase markedly in the Asia-Pacific region due to rapid population aging. Identifying effective and safe therapeutic options to manage osteoarthritic pain is viewed as a priority. The Asia-Pacific Experts on Topical Analgesics Advisory Board developed consensus statements for use of topical NSAIDs in musculoskeletal pain. Evidence supporting these statements in osteoarthritic pain was reviewed. Best available evidence indicates that topical NSAIDs have a moderate effect on relief of osteoarthritic pain, comparable to that of oral NSAIDs but with a better risk-to-benefit ratio. International clinical practice guidelines recommend topical NSAIDs on par with or ahead of oral NSAIDs for pain management in patients with knee and hand osteoarthritis, and as the first-line choice in persons aged ≥75 years.
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A critical overview of the current myofascial pain literature - January 2018.
Dommerholt, J, Hooks, T, Chou, LW, Finnegan, M
Journal of bodywork and movement therapies. 2018;(1):184-191
Abstract
The majority of papers included in the quarterly review discuss various aspects of dry needling (DN), which continues to be of interest to researchers and clinicians. A study by Liu et al. is the first paper to examine the effects of DN of acetylcholine, esterase and receptors. The study provides support for the integrated trigger point hypothesis and for DN. A paper by Hightower and colleagues found an intriguing link between low magnesium levels in the drink water supply, vitamin D, and myofascial pain, cancer, tendon ruptures, and colon polyps. Contributions originated in the Brazil, China, Germany, Iran, India, Poland, South Korea, Spain, Taiwan, Turkey, and the US.
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Continuous Infusion Nonsteroidal Anti-Inflammatory Drugs for Perioperative Pain Management.
Howard, ML, Isaacs, AN, Nisly, SA
Journal of pharmacy practice. 2018;(1):66-81
Abstract
PURPOSE To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations. METHODS A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review. RESULTS Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups. CONCLUSIONS In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.
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New Advances in Acute Postoperative Pain Management.
Mitra, S, Carlyle, D, Kodumudi, G, Kodumudi, V, Vadivelu, N
Current pain and headache reports. 2018;(5):35
Abstract
PURPOSE OF REVIEW Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management. RECENT FINDINGS Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.
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Fundamental Considerations for Genetically-Guided Pain Management with Opioids Based on CYP2D6 and OPRM1 Polymorphisms.
Ruano, G, Kost, JA
Pain physician. 2018;(6):E611-E621
Abstract
BACKGROUND A major challenge for effective pharmacotherapy in pain management is to provide the drug best suited to the patient's innate characteristics. OBJECTIVE The article illustrates pharmacogenetic principles to optimize treatments for patients and increase the likelihood of pain relief without dependence. Genetic variances are particularly relevant to opioid drugs used in pain control, and can now be harvested for predictive clinical decision support. STUDY DESIGN Clinically actionable polymorphisms in CYP2D6 (cytochrome p450 2D6) and OPRM1 (mu 1 opioid receptor), the most important gene coding, respectively, for a metabolizing enzyme and receptor for opioids are reviewed, and functional effects described. METHODS Risk of dysfunction is calculated from the frequency of the alleles with null function for CYP2D6, and from the low function polymorphism for OPRM1. Integration of genetic variability was performed for 9 combinatorial scenarios for CYP2D6 and OPRM1. Each combination was quantified in frequency and classified for clinical impact. A rational and pharmacological basis for personalized pain management based on pharmacokinetic and pharmacodynamic modeling is extracted from the frequency of the combinations. RESULTS Patients can be classified in 3 broad risk categories for opioid side effects and dependence. Patients at high-risk with dysfunctional CYP2D6 or OPRM1 account for ~14% of the population and are best managed with non-opioids. Patients at medium risk with subnormal CYP2D6 or OPRM1 account for ~48% of the population and can be managed with dose monitoring. Patients at low risk with functional CYP2D6 and OPRM1 account for ~38% of the population and should be availed to opioid therapy. LIMITATIONS Heuristic clinical decision support considerations are not validated yet by deployment in large clinical practices. Environmental modifiers such as other drugs and dietary supplements interact with innate characteristics to modify the genetic predictions. CONCLUSION Through clinical decision support interpreting the genotyping data, drug choices and doses can then be tailored to provide safe and effective therapy for individual patients. This precision affords personalized medicine to be practiced in pain treatment. Genetic factors could help determine why some patients seem more vulnerable than others to opioid side effects and dependence. KEY WORDS Pain management, opioids, CYP2D6, OPRM1, clinical decision support, pharmacokinetics, pharmacodynamics, pharmacogenetics, combinatorial genotypes.