Modern concepts of acute and chronic pain management

The legitimacy of pain according to sufferers

Pain is an unpleasant experience that we will all experience in some form over the course of our lives, with chronic pain affecting a significant proportion of the global population. Given these circumstances, this study investigates whether pain is a legitimated phenomenon and considers the processes involved in the creation of such a status. This is an exploratory investigation based on semi-structured interviews with people suffering from chronic pain as a consequence of physical, psychological, emotional, or social circumstances. Our principal objective is to explore the fundamental elements of legitimacy and the processes that bring it into being-i.e., to understand how it is socially constructed. The main finding, however, is that many sufferers of chronic physical, psychiatric/psychological, emotional and social pain perceive that their pain is not considered legitimate when no clear cause can be identified, when the pain prevents them from developing the norms imposed by social roles or when it inhibits them to make a productive contribution to the society in which they live. This is generally due to the disruptive aspect of pain and its impact on the social structure, specifically on productivity, which nowadays constitutes a key element in the legitimation of any social phenomenon.

Spinal Cord Stimulation (SCS) reduces Morphine Milligram Equivalents (MME) in patients using Opioid analgesics for Chronic Non-Cancer Pain

Summary of background data

Chronic Pain is a prevalent condition that affects many people in the United States. Spinal Cord Stimulation (SCS) has been documented to help reduce perceived pain; however, few studies have analyzed the impact of perceived pain on opioid consumption before and after SCS.

Objectives

This retrospective cohort study aimed to evaluate the impact of spinal cord stimulation on opioid consumption after permanent SCS implant.

Methods

This IRB-approved retrospective single-center study investigated the opioid consumption of 26 adults at three different times: (1) Initial date of service-baseline- (2) SCS implant date, and (3) 6 months post-SCS implant date. Mean opioid consumption was calculated over the month prior and after to visit of (1), (2), and (3) to generate 3 separate month averages. Opioid consumptions were measured using Morphine Milligram Equivalents (MME). To determine the difference in MME consumption from baseline to permanent SCS implantation, we conducted a series of paired-sample t-tests.

Results

Patients' MME significantly decreased from baseline (M = 52.63, SD = 45.07) to 6-months post-SCS implantation (M = 24.64, SD = 31.97, t (25) = 4.29, p < .001). The effect of this difference was large (d = 0.84). Whereas patients' morphine equivalents decreased from date of SCS implantation (M = 35.73, SD = 52.78) to 6-months post-SCS implantation (M = 24.64, SD = 31.97), this difference was not significant (t (25) = 1.66, p = .11) but yielded a small effect size (d = 0.34).

Discussions/conclusion

In our study, patients using opioids for non-cancer pain management, SCS moderated the perception of pain neurocircuitry and noxious stimuli-manifestation, resulting in a reduced sense of pain and decreased opioid usage.

Exploring the Potential of Transcranial Direct Current Stimulation for Relieving Central Post-Stroke Pain: A Randomized Controlled Pilot Study

The potential of transcranial direct current stimulation (tDCS) as a non-invasive brain stimulation technique for treating pain has been studied. However, its effectiveness in patients with central post-stroke pain (CPSP) and the impact of lesion location remain unclear. This study investigated tDCS's pain reduction effects in patients with CPSP. Twenty-two patients with CPSP were randomized into the tDCS or sham groups. The tDCS group received stimulation of the primary motor cortex (M1) for 20 min, five times weekly, for two weeks, and underwent evaluations at baseline, immediately after the intervention, and one week after the intervention. The tDCS group had no significant improvement compared to the sham group in pain, depression, and quality of life. Nevertheless, significant changes were identified within the tDCS group, and the pain trends appeared to be influenced by the lesion location. These findings provide important insights into the use of tDCS in patients with CPSP, which could inform further research and development of pain treatment options.

Evaluation of the analgesic effect of ɑ-lipoic acid in treating pain disorders: A systematic review and meta-analysis of randomized controlled trials

Neuropathic pain is the most prevalent form of chronic pain caused by a disease of the nervous system, such as diabetic polyneuropathy. ɑ-Lipoic acid (ALA) is an antioxidant that has been widely studied for the treatment of pain symptoms in diverse conditions. Therefore, this study aimed to investigate the efficacy of ALA in the treatment of different types of pain through a systematic review and meta-analysis of randomized clinical trials. The study protocol was registered in the International Prospective Registry of Systematic Reviews (CRD42021261971). A search of the databases resulted in 1154 articles, 16 of which were included in the review (9 studies with diabetic polyneuropathy and 7 studies with other painful conditions). Most of the included studies had a low risk of bias. ALA showed efficacy for the treatment of headache, carpal tunnel syndrome and burning mouth syndrome. Meta-analysis was conducted only with the studies using diabetic polyneuropathy. Compared to placebo, ALA treatment decreased the total symptom score (TSS). The subgroup meta-analysis indicated a decrease of stabbing pain, burning, paraesthesia, and numbness in ALA-treated patients compared to placebo. In addition, both routes of administration, intravenous and oral, demonstrated the efficacy to reduce TSS. Therefore, ALA should be used to treat diabetic polyneuropathy pain symptoms. However, the standardization of treatment time and the dose may advance for the approval of ALA for clinical use in diabetic polyneuroneuropathy.

Nurses' Knowledge and Attitude towards Postoperative Pain Management in Ghana

Background

Pain management is a very important aspect of nursing care among postoperative patients. Deficit in the knowledge and bad attitude towards pain management among nurses remain a problem in Ghana. In order to manage pain better in the surgical wards, nurses should be well equipped with knowledge of pain assessment and management.

Purpose

The purpose of the study was to determine nurse's knowledge and attitude towards pain management among postoperative patients in surgical units in Ghana. Methodology. This study used the quantitative study approach with a descriptive cross-sectional study design. A sample of 211 nurses was recruited using the convenience sampling method. Data were collected using a questionnaire regarding postoperative pain management. Descriptive statistics, Pearson's correlation coefficient, and the chi-squared test were used to analyze the data using SPSS version 16.0.

Results

The mean age of the nurses was 29.77, with the youngest nurse being 23 years and oldest being 39 years. Majority (72.5%) of nurses had moderate knowledge, and 89.6% of the nurses had negative attitude towards pain management. There was no significant relationship between nurse's knowledge and years of experience as a nurse (r = −0.03, p=0.64), as well as no significant relationship between knowledge and number of years working in the surgical ward (r = 0.06, p=0.36). Also, there was no significant relationship between nurses' knowledge and nurses' attitude (r = 0.06, p=0.36). Conclusion and recommendation. The level of knowledge and attitude towards postoperative management were generally inadequate among nurses. Therefore, there is the need to implement in-service training on pain management for nurses working in the surgical units frequently.

Validating Invalidation: Examining the Construct Validity of the Illness Invalidation Inventory Among Individuals With Chronic Low Back Pain

OBJECTIVES

The Illness Invalidation Inventory (3*I) was designed to assess individuals' perceived invalidation regarding chronic pain experiences. However, no study has yet investigated the psychometric properties of the 3*I among individuals with chronic low back pain (CLBP). Given the personal and societal impact of CLBP and the potential for invalidation associated with this condition, the current study sought to examine the psychometric properties of the 3*I among individuals with CLBP.

MATERIALS AND METHODS

Community-dwelling adults with CLBP living in the Southwestern United States (N=134) completed the 3*I. In line with previous literature, current analyses focused on the 3*I "family members" subscale. Exploratory and confirmatory factor analysis was performed on participant responses. Hierarchical linear regression analyses examined the relationship between the identified factors and participant self-reported pain severity, disability, and depression.

RESULTS

Exploratory factor analysis conducted on the 3*I "family members" subscale found 2 factors with high internal consistency (α>0.70) that cumulatively accounted for 49.04% of the variance in scores. Consistent with previous findings, factor loadings suggested that these factors correspond to "discounting" and "lack of understanding." Subsequent confirmatory factor analysis found that this 2-factor model demonstrated a good fit with the data. Greater perceived discounting by family members was associated with greater pain severity, disability, and depression.

DISCUSSION

The 2-factor model of the 3*I "family members" subscale identified in the current study reflects previous findings and extends the psychometric validity of the 3*I to a US multiethnic sample of individuals with CLBP.

Tapentadol: an analgesic that differs from classic opioids due to its noradrenergic mechanism of action

Chronic pain treatment represents one of the most complex clinical challenges and even though opioids exhibit particular efficacy on nociceptive pain, their use must be controlled to avoid the risk of adverse reactions. A useful approach, aimed at maintaining analgesia and mitigating side effects, is represented by the use of a new class of analgesics endowed of µ-opioid (MOR) receptor agonism and noradrenaline reuptake inhibition (NRI) mechanisms. Tapentadol is the progenitor of this new class of drugs called MOP-NRI. A literature review has been conducted to gain information about the efficacy and the tolerability profile of tapentadol shifting from MOR agonism (acute pain) to NRI activity (chronic pain). The tolerability and therapeutic safety of tapentadol in neuropathic pain models, as well as in clinical settings, has been analyzed showing a good gastrointestinal tolerability profile, a moderate effect on hormone levels (in healthy volunteers and in patients) and on cognitive performance, a lack of significant alteration of the electrocardiogram recording and no changes of the QT/QTc interval, a minimal effect on serotonin reuptake in vivo with a low risk of serotonin syndrome, a longer time for the onset of analgesic tolerance and a less occurrence of abuse liability compared to formulations containing other comparator compounds. Tapentadol represents a great innovation in chronic pain therapy with a unique analgesic profile different form classical opioids, therefore, thanks to its synergistic MOR-NRI action, it may be a good option for the treatment of chronic, neuropathic and mixed pain.

Meperidine (pethidine) versus morphine in acute pain management of opioid-dependent patients

The present study aimed to evaluate the effectiveness of morphine and meperidine (pethidine) as pain relief in opioid-dependent patients with acute pain. A total of 122 opioid-dependent patients with acute pain were included in the study. Their pain severity was assessed, using visual analog scale (VAS) scores ranging from 0 to 10. The patients randomly received intravenous morphine (up to 0.15 mg/kg) or meperidine (up to 1.5 mg/kg) for pain control by patient control analgesia (PCA) pump. The clinical opioid withdrawal scale (COWS) was employed for the assessment of withdrawal symptoms. The pain relief and the emergence of withdrawal symptoms were measured at 15, 30, and 60 minutes after drug administration. The patients who received morphine reported a better pain control compared to those who received meperidine (mean ± standard deviation [SD] VAS scores 4.11±1.90 vs 5.85±2.08 at the end of the study; P<0.001). On the other hand, the patients who received meperidine indicated prominent withdrawal symptoms (mean ± SD COWS scores 4.80±2.18 vs. 1.98±0.82 at the end of the study; P<0.001). Our findings revealed that morphine can be recommended in acute pain management of opioid-dependent patients. In addition, emergency physicians should ask their patients about any drug dependence before selecting the appropriate drug for their acute pain management.

Pacing: a concept analysis of the chronic pain intervention

BACKGROUND

The intervention of pacing is regularly recommended for chronic pain patients. However, pacing is poorly defined and appears to be interpreted in varying, potentially contradictory manners within the field of chronic pain. This conceptual lack of clarity has implications for effective service delivery and for researchers' ability to conduct rigorous study. An examination of the background literature demonstrates that while pacing is often one part of a multidisciplinary pain management program, outcome research is hindered by a lack of a clear and shared definition of this currently ill-defined construct.

OBJECTIVES

To conduct a formal concept analysis of the term 'pacing'.

METHODS

A standardized concept analysis process (including literature scoping to identify all uses of the concept, analysis to determine defining attributes of the concept and identification of model, borderline and contrary cases) was used to determine what the concept of pacing does and does not represent within the current evidence base.

RESULTS

A conceptual model including the core attributes of action, time, balance, learning and self-management emerged. From these attributes, an evidence-based definition for pacing was composed and distributed to stakeholders for review. After consideration of stakeholder feedback, the emergent definition of pacing was finalized as follows: "Pacing is an active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities".

CONCLUSION

The findings of the present concept analysis will help to standardize the use and definition of the term pacing across disciplines for the purposes of both pain management and research.

Real-world treatment pattern and outcomes among patients who took tapentadol IR or oxycodone IR

OBJECTIVE

To evaluate differences in patient characteristics, healthcare resource utilization, and healthcare costs among patients receiving immediate release (IR) formulations of tapentadol (TAP IR) or oxycodone (OXY IR).

METHODS

Patients (≥18 years) who took TAP IR or OXY IR (6/1/2009-7/31/2011) were selected from the OptumInsight Clinformatics Data Mart claims database. Patients were assigned to the TAP IR or OXY IR cohort based on initial drug usage (index event). Continuous health plan coverage 60 days before (baseline period) and after (follow-up period) the index event was required. TAP IR patients were matched to OXY IR patients (1:1) using exact match of key patient characteristics and propensity score matching with patient demographics and clinical characteristics as covariates. T-test and chi-squared test were utilized to evaluate differences in patient characteristics, healthcare utilization and charges among cohorts.

RESULTS

Patient profiles during the baseline period significantly differed among TAP IR users (n = 17,539) and OXY IR users (n = 85,821) in the overall study population. The matched sample of TAP IR and OXY IR patients (n = 10,185 in both cohorts) had similar patient characteristics. During the 60-day follow-up period, patients who took TAP IR had a shorter mean hospital LOS (0.21 vs 0.35 days, p < 0.0001), a lower mean number of hospitalizations (0.07 vs 0.10, p < 0.0001), and lower mean inpatient ($2900 vs $4382, p < 0.001) and outpatient healthcare charges ($10,550 vs $11,084, p = 0.047). The higher index opioid prescription charge of TAP IR ($190 vs $150, p < 0.0001) was offset by other lower healthcare charges.

CONCLUSIONS

The characteristics of patients who took TAP IR were different from patients who took OXY IR in many respects. In the sub-set of patients matched on demographic and clinical characteristics, those who took TAP IR used healthcare resources to a lesser extent, which was reflected in their lower healthcare charges, relative to OXY IR users.

Antinociceptive efficacy of verticinone in murine models of inflammatory pain and paclitaxel induced neuropathic pain

Verticinone, an isosteroidal alkaloid separated from Bulbus Fritillaria (Chinese name "Bei-mu"), was evaluated for its analgesic activities in murine models of inflammatory and neuropathic pain. It was shown that oral administarion of verticinone could significantly inhibit acetic acid-induced writhing response in a dose-dependent way, and the writhing inhibition of 3 mg/kg verticinone was 66.2%, which was approximately higher than that of 200 mg/kg aspirin. In the formalin test, a high dose of (3 mg/kg) verticinone could inhibit the nociceptive response of both phases, but the lower dose (1.5 mg/kg) could only inhibit the second phase response, which suggested that verticinone might exert its analgesic effect through both central and peripheral mechanisms. In addition, in formalin and acetic acid tests, the spontaneous locomotive activities of the mice treated with verticinone were transiently greatly decreased when compared with the vehicle group. In the rat model of paclitaxel induced neuropathic pain, in contrast to the declined analgesic effect of morphine after repeated administration with the same dose, a relatively constant analgesic effect of verticinone was observed. These investigations suggested that verticinone could exert a good antinociceptive effect on inflammatory pain and cancer-related neuropathic pain probably through both peripheral and central mechanisms, and it might be partly involved with some sedation effects. Verticinone is expected to become a potentially novel sedative-analgesic agent without producing tolerance and dependence, but further studies are still urgently needed to elucidate the precise mechanisms and activities of it.

Tapentadol immediate release: a new treatment option for acute pain management

The undertreatment of acute pain is common in many health care settings. Insufficient management of acute pain may lead to poor patient outcomes and potentially life-threatening complications. Opioids provide relief of moderate to severe acute pain; however, therapy with pure μ-opioid agonists is often limited by the prevalence of side effects, particularly opioid-induced nausea and vomiting. Tapentadol is a novel, centrally acting analgesic with 2 mechanisms of action, μ-opioid receptor agonism and norepinephrine reuptake inhibition. The analgesic effects of tapentadol are independent of metabolic activation and tapentadol has no active metabolites; therefore, in theory, tapentadol may be associated with a low potential for interindividual efficacy variations and drug-drug interactions. Previous phase 3 trials in patients with various types of moderate to severe acute pain have shown that tapentadol immediate release (IR; 50 to 100 mg every 4 to 6 hours) provides analgesia comparable to that provided by the pure μ-opioid agonist comparator, oxycodone HCl IR (10 or 15 mg every 4 to 6 hours), with a lower incidence of nausea, vomiting, and constipation. Findings suggest tapentadol may represent an improved treatment option for acute pain.

Tapentadol immediate release for the relief of moderate-to-severe acute pain

Tapentadol is a novel, centrally acting analgesic with two mechanisms of action: micro-opioid receptor agonism and norepinephrine reuptake inhibition. It has demonstrated broad analgesic efficacy across multiple pain models. This article reviews the clinical development of tapentadol immediate release (IR), including results from Phase II and III clinical trials that evaluated the efficacy and safety of tapentadol IR in patients with moderate-to-severe acute pain. In clinical studies in patients with moderate-to-severe acute postoperative pain, osteoarthritis pain and/or low back pain, tapentadol IR 50, 75 or 100 mg every 4 - 6 h has demonstrated analgesic efficacy similar to that observed with the micro-opioid receptor agonist oxycodone HCl IR 10 or 15 mg every 4 - 6 h. However, at doses providing comparable analgesic efficacy, tapentadol IR has been associated with significantly lower incidences of nausea and/or vomiting and constipation, and a significantly lower rate of treatment discontinuation compared with oxycodone IR. The observed efficacy across different pain models and favorable gastrointestinal tolerability profile associated with tapentadol IR indicate that this novel analgesic is an attractive treatment option for the relief of moderate-to-severe acute pain.

Postoperative pain management and acupuncture: a case report of meniscal cyst excision

We report a case of pain management after a meniscal cyst excision, with the use of electroacupuncture (EA). There are a few reports which indicate that postoperative pain management is prerequisite for the patient's optimal recovery, but surveys in the UK and the USA have identified an unacceptable prevalence of poor pain control after surgery, which might increase the risk of a chronic pain state. The conventional treatment of postoperative pain includes systemic medications such as opioids, non-steroidal anti-inflammatory drugs and other non-opioid agents. In our case, the rehabilitation lasted for 6 months without significant benefit. After that period our patient was treated with EA. By the end of the first EA session the relief of pain was notable and after a course of 10 treatments the patient reported complete relief of the symptoms with no recurrence during a 2 year follow up period. In conclusion, this might indicate that EA could be useful for postoperative pain management.