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Manchikanti L, Kaye AM, Knezevic NN, Giordano J, Applewhite MK, Bautista A, Soin A, Blank SK, Sanapati MR, Karri J, Christo PJ, Abd-Elsayed A, Kaye AD, Calodney A, Navani A, Gharibo CG, Harned M, Gupta M, Broachwala M, Sehgal N, Kaufman A, Wargo B, Solanki DR, Hsu ES, Limerick G, Dennis A, Swicegood JR, Slavin K, Snook L, Pasupuleti R, Kosanovic R, Justiz R, Barkin R, Atluri S, Shah S, Pampati V, Helm Ii S, Grami V, Myckowiak V, Galan V, Singh V, Manocha V, Hirsch JA. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2023; 26:S7-S126. [PMID: 38117465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - James Giordano
- Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD; Departments of Neurology and Biochemistry and Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington DC
| | - Megan K Applewhite
- Department of Surgery and MacClean Center of Bioethics, University of Chicago, Chicago, IL; Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Alexander Bautista
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | | | - Jay Karri
- Department of Anesthesiology and Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alan D Kaye
- Louisiana State University School of Medicine, Shreveport, LA
| | - Aaron Calodney
- Precision Spine Care, Tyler, TX and Department of Anesthesiology, Louisiana State University, Shreveport, LA, USA
| | - Annu Navani
- Le Reve Regenerative Wellness, Campbell, CA; Stanford University School of Medicine, Stanford, CA; Boomerang Health Care, Walnut Creek, CA, USA
| | - Christopher G Gharibo
- Peri-Operative Care & Pain Medicine and Orthopedics at NYU Grossman School of Medicine, New York, NY, USA
| | - Michael Harned
- Department of Anesthesiology, Perioperative, Critical Care and Pain Medicine, University of Kentucky, Lexington, KY, USA
| | - Mayank Gupta
- Kansas Pain Management and Neuroscience Research Center, LLC, Overland Park, KS; Department of Clinical Education, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | | | - Nalini Sehgal
- Department of Orthopedics and Rehabilitation, UW Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrew Kaufman
- Departments of Pain Management and Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bradley Wargo
- Baptist University, Memphis, TN; Shoals Interventional Pain Management, Muscle Shoals, AL, USA
| | - Daneshvari R Solanki
- University of Texas Medical Branch, Galveston, TX; HD Research, First Surgical Hospital, Bellaire, TX, USA
| | - Eric S Hsu
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Gerard Limerick
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen Dennis
- Advanced Pain Care and Round Rock Surgery Center, Round Rock, TX, USA
| | | | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, and Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Lee Snook
- Metropolitan Pain Management Consultants, Inc., Sacramento, CA
| | | | - Radomir Kosanovic
- Interventional Pain Management, Baptist Health South Florida, Miami, FL, USA
| | - Rafael Justiz
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | | | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, USA
| | | | - Standiford Helm Ii
- Division of Pain Medicine, Department of Anesthesiology and Peri-Operative Care, University of California, Irvine, UCI Health Center for Pain and Wellness, Gottschalk Medical Plaza, Irvine, CA, USA
| | - Vahid Grami
- Department of Anesthesiology and Pain Medicine, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Vicki Myckowiak
- Partner with The Health Law Partners, Farmington Hills, MI, USA
| | - Vincent Galan
- Georgia Pain Care & Affiliated Surgery Center; Center for Pain and Spine, Stockbridge, GA, USA
| | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | - Vivek Manocha
- Department of Surgery, Wright State University School of Medicine, Dayton, OH; Beacon Orthopedics & Sports Medicine, Cincinnati, OH, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Manchikanti L, Knezevic NN, Knezevic E, Abdi S, Sanapati MR, Soin A, Wargo BW, Navani A, Atluri S, Gharibo CG, Simopoulos TT, Kosanovic R, Abd-Elsayed A, Kaye AD, Hirsch JA. A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain. Pain Ther 2022; 12:1-48. [PMID: 36465720 PMCID: PMC9686245 DOI: 10.1007/s40122-022-00455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. Study Design Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. Objective The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. Methods Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. Results Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. Limitations There was a paucity of literature and heterogeneity among the available studies. Conclusion This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-022-00455-0.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY USA
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL USA
- College of Medicine, University of Illinois, Chicago, IL USA
| | - Emilija Knezevic
- College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL USA
| | - Salahadin Abdi
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX USA
| | | | - Amol Soin
- Ohio Pain Clinic and Wright State University, Dayton, OH USA
| | - Bradley W. Wargo
- Interventional Pain Management, Mays & Schnapp Neurospine & Pain, Memphis, TN USA
| | - Annu Navani
- Comprehensive Spine & Sports Center and Le Reve Regenerative Wellness, Campbell, CA USA
| | | | | | - Thomas T. Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Arnold Warfield Pain Management Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA USA
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and UW Pain Clinic, Chronic Pain Medicine, Department of Anesthesiology, and University of Wisconsin School of Medicine and Public Health,, Madison, WI USA
| | - Alan D. Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSUHSC, Shreveport, LA USA
| | - Joshua A. Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
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Manchikanti L, Atluri S, Hirsch JA. Comment on "Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients with Knee Osteoarthritis: The Restore Randomized Clinical Trial". Pain Physician 2022; 25:E698. [PMID: 35793195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Pampati V, Sanapati MR, Kosanovic R, Beall DP, Atluri S, Abdi S, Shah S, Boswell MV, Kaye AD, Soin A, Gharibo CG, Wargo BW, Hirsch JA. COVID-19 Pandemic Reduced Utilization Of Interventional Techniques 18.7% In Managing Chronic Pain In The Medicare Population In 2020: Analysis Of Utilization Data From 2000 To 2020. Pain Physician 2022; 25:223-238. [PMID: 35652763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Multiple publications have shown the significant impact of the COVID-19 pandemic on US healthcare and increasing costs over the recent years in managing low back and neck pain as well as other musculoskeletal disorders. The COVID-19 pandemic has affected many modalities of treatments, including those related to chronic pain management, including both interventional techniques and opioids. While there have not been assessments of utilization of interventional techniques specific to the ongoing COVID-19 pandemic, previous analysis published with data from 2000 to 2018 demonstrated a decline in utilization of interventional techniques from 2009 to 2018 of 6.7%, with an annual decline of 0.8% per 100,000 fee-for-service (FFS) in the Medicare population. During that same time, the Medicare population has grown by 3% annually. OBJECTIVES The objectives of this analysis include an evaluation of the impact of the COVID-19 pandemic, as well as an updated assessment of the utilization of interventional techniques in managing chronic pain in the Medicare population from 2010 to 2019, 2010 to 2020, and 2019 to 2020 in the FFS Medicare population of the United States. STUDY DESIGN Utilization patterns and variables of interventional techniques with the impact of the COVID-19 pandemic in managing chronic pain were assessed from 2000 to 2020 in the FFS Medicare population of the United States. METHODS The data for the analysis was obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. RESULTS The results of the present investigation revealed an 18.7% decrease in utilization of all interventional techniques per 100,000 Medicare beneficiaries from 2019 to 2020, with a 19% decrease for epidural and adhesiolysis procedures, a 17.5% decrease for facet joint interventions and sacroiliac joint blocks, and a 25.4% decrease for disc procedures and other types of nerve blocks. The results differed from 2000 to 2010 with an annualized increase of 10.2% per 100,000 Medicare population compared to an annualized decrease of 0.4% from 2010 to 2019, and a 2.5% decrease from 2010 to 2020 for all interventional techniques. For epidural and adhesiolysis procedures decreases were more significant and annualized at 3.1% from 2010 to 2019, increasing the decline to 4.8% from 2010 to 2020. For facet joint interventions and sacroiliac joint blocks, the reversal of growth patterns was observed but maintained at an annualized rate increase of 2.1% from 2010 to 2019, which changed to a decrease of 0.01% from 2010 to 2020. Disc procedures and other types of nerve blocks showed similar patterns as epidurals with an 0.8% annualized reduction from 2010 to 2019, which was further reduced to 3.6% from 2010 to 2020 due to COVID-19. LIMITATIONS Data for the COVID-19 pandemic impact were available only for 2019 and 2020 and only the FFS Medicare population was utilized; utilization patterns in Medicare Advantage Plans, which constitutes almost 40% of the Medicare enrollment in 2020 were not available. Moreover, this analysis shares the limitations present in all retrospective reviews of claims based datasets. CONCLUSION The decline driven by the COVID-19 pandemic was 18.7% from 2019 to 2020. Overall decline in utilization in interventional techniques from 2010 to 2020 was 22.0% per 100,000 Medicare population, with an annual diminution of 2.5%, despite an increase in the population rate of 3.3% annualized (38.9% overall) and Medicare enrollees of 33.4% and 2.9% annually.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | | | | | | | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | - Mark V Boswell
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | | | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | - Christopher G Gharibo
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Bradley W Wargo
- Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Atluri S, Murphy MB, Dragella R, Herrera J, Boachie-Adjei K, Bhati S, Manocha V, Boddu N, Yerramsetty P, Syed Z, Ganjam M, Jain D, Syed Z, Grandhi N, Manchikanti L. Evaluation of the Effectiveness of Autologous Bone Marrow Mesenchymal Stem Cells in the Treatment of Chronic Low Back Pain Due to Severe Lumbar Spinal Degeneration: A 12-Month, Open-Label, Prospective Controlled Trial. Pain Physician 2022; 25:193-207. [PMID: 35322978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Regenerative medicine interventions are applied to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous/allogenic biologics and it continues to expand. The anti-inflammatory, immunomodulatory, and regenerative properties of bone marrow mesenchymal stem cells (BM-MSCs), and investigation into their therapeutic efficacy and safety in patients with severe chronic low back pain, have not been demonstrated in controlled studies. Multiple pain generators have been hypothesized to be responsible in severe spinal degeneration and it is difficult to identify a single pain generator; consequently, resulting in inadequate therapeutic results. OBJECTIVES The study was undertaken to evaluate the effectiveness of autologous bone marrow MSCs in the treatment of chronic low back pain due to severe lumbar spinal degeneration with involvement of multiple structures. STUDY DESIGN Prospective, open-label, nonrandomized, parallel-controlled, 2-arm exploratory study. SETTING A private, specialized, interventional pain management and regenerative medicine clinic. METHODS The treatment group patients received a one-time bone marrow concentrate injection into spinal structures (i.e., discs, facets, spinal nerves, and sacroiliac joints), along with conventional treatment, whereas, the control group received conventional treatment with nonsteroid anti-inflammatory drugs, over-the-counter drugs, structured exercise programs, physical therapy, spinal injections and opioids, etc., as indicated. OUTCOMES ASSESSMENT Outcomes were assessed utilizing multiple instruments, including the Oswestry Disability Index (ODI), Numeric Rating Scale (NRS-11), EuroQOL 5-Dimensional Questionnaire (EQ-5D-3L), Global Mental Health (GMH), and Global Physical Health (GPH). Multiple outcomes were assessed with primary outcomes being minimal clinically important differences (MCID) in ODI scores between the groups and/or a 2-point reduction in pain scores. In the study group, total nucleated cells, colony forming units-fibroblast, CD34-positive cell numbers and platelets were also recorded, along with post-procedure magnetic resonance imaging changes. Outcomes were assessed at 1, 3, 6, and 12 months. RESULTS Significant improvement was achieved in functional status measured by ODI, pain relief measured by NRS-11, and other parameters measured by EQ-5D-3L, GMH, and GPH, in the study group relative to the control group at all time periods. The results showed significant improvements at 12-month follow-up with 67% of the patients in the study group achieving MCID utilizing ODI when compared to 8% in the control group. Greater than 2-point pain reduction was seen in 74% of the patients at 3 months, 66% of the patients at 6 months, and 56% of the patients at 12 months. Both MCID and pain relief of 2 points were significantly different compared to the control group. Opioid use decreased in the investigational group, whereas, there was a slight increase in the control group. Age, gender, opioid use, and body mass index did not affect the outcomes in the stem cell group. LIMITATIONS Single center, nonrandomized study. CONCLUSIONS The first available controlled study utilizing BM-MSCs in severe degenerative spinal disease with interventions into multiple structures simultaneously, including disc, facet joints, nerve roots, and sacroiliac joint based on symptomatology, showed promising results.
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Affiliation(s)
| | | | - Ryan Dragella
- R&D Regenerative Laboratory Resources, Johnstown, CO
| | | | | | | | - Vivek Manocha
- Interventional Spine and Pain Management Center, Springboro, OH
| | - Navneet Boddu
- Advanced Pain and Regenerative Specialists, Oceanside, CA
| | | | - Zaid Syed
- Tristate Pain Management, Cincinnati, OH
| | | | - Divit Jain
- Tri-State Spine Care Institute, Cincinnati, OH
| | - Zaynab Syed
- Tri-State Spine Care Institute, Cincinnati, OH
| | | | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
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Manchikanti L, Singh VM, Staats PS, Trescot AM, Prunskis J, Knezevic NN, Soin A, Kaye AD, Atluri S, Boswell MV, Abd-Elsayed A, Hirsch JA. Fourth Wave of Opioid (Illicit Drug) Overdose Deaths and Diminishing Access to Prescription Opioids and Interventional Techniques: Cause and Effect. Pain Physician 2022; 25:97-124. [PMID: 35322965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND In the midst of the COVID-19 pandemic, data has shown that age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, and heroin have been increasing, including prescription opioid deaths, which were declining, but, recently, reversing the trends. Contrary to widely held perceptions, the problem of misuse, abuse, and diversion of prescription opioids has been the least of all the factors in recent years. Consequently, it is important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Multiple efforts have been based on consensus on administrative policies for certain harm reduction strategies for individuals actively using illicit drugs and reducing opioid prescriptions leading to curbing of medically needed opioids, which have been ineffective. While there is no denial that prescription opioids can be misused, abused, and diverted, the policies have oversimplified the issue by curbing prescription opioids and the pendulum has swung too far in the direction of severely limiting prescription opioids, without acknowledgement that opioids have legitimate uses for persons suffering from chronic pain. Similar to the opioid crisis, interventional pain management procedures have been affected by various policies being applied to reduce overuse, abuse, and finally utilization. Medical policies have been becoming more restrictive with reduction of access to certain procedures, with the pendulum swinging too far in the direction of limiting interventional techniques. Recent utilization assessments have shown a consistent decline for most interventional techniques, with a 18.7% decrease from 2019 to 2020. The causes for these dynamic changes are multifactorial likely including the misapplication of the 2016 Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain, the relative ease of access to illicit synthetic opioids and more recently issues related to the COVID-19 pandemic. In addition, recent publications have shown association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. These findings are leading to the hypothesis that federal guidelines may inadvertently be contributing to an increase in overall opioid deaths and diminished access to interventional techniques. Together, these have resulted in a fourth wave of the opioid epidemic. METHODS A narrative review. RESULTS The fourth wave results from a confluence of multiple factors, including misapplication of CDC guidelines, the increased availability of illicit drugs, the COVID-19 pandemic, and policies reducing access to interventional procedures. The CDC guidelines and subsequent regulatory atmosphere have led to aggressive tapering up to and including, at times, the overall reduction or stoppage of opioid prescriptions. Forced tapering has been linked to an increase of 69% for overdoses and 130% for mental health crisis. The data thus suggests that the diminution in access to opioid prescriptions may be occurring simultaneously with an increase in illicit narcotic use.Combined with CDC guidelines, the curbing of opioid prescriptions to medically needed individuals, among non-opioid treatments, interventional techniques have been affected with declining utilization rates and medical policies reducing access to such modalities. CONCLUSION The opioid overdose waves over the past three decades have resulted from different etiologies. Wave one was associated with prescription opioid overdose deaths and wave two with the rise in heroin and overdose deaths from 1999 to 2013. Wave three was associated with a rise in synthetic opioid overdose deaths. Sadly, wave four continues to escalate with increasing number of deaths as a confluence of factors including the CDC guidelines, the COVID pandemic, increased availability of illicit synthetic opioids and the reduction of access to interventional techniques, which leads patients to seek remedies on their own.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | | | - John Prunskis
- US Department of Health and Human Resources, Washington, DC; Illinois Pain & Spine Institute, Elgin, IL; DxTx Pain and Spine and Chicago Medical School, Chicago, IL
| | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | | | - Mark V Boswell
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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7
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Soin A, Soin Y, Dann T, Buenaventura R, Ferguson K, Atluri S, Sachdeva H, Sudarshan G, Akbik H, Italiano J. In Response Comments on "Low-Dose Naltrexone Use for Patients with Chronic Regional Pain Syndrome: A Systematic Literature Review". Pain Physician 2021; 24:E1308. [PMID: 34793659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | - Tammy Dann
- Pain Evaluation Management Center of Ohio, Dayton, OH
| | | | | | | | - Harsh Sachdeva
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Jordan Italiano
- Wright State University Boonshoft School of Medicine, Fairborn, OH
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8
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Soin A, Soin Y, Dann T, Buenaventura R, Ferguson K, Atluri S, Sachdeva H, Sudarshan G, Akbik H, Italiano J. Low-Dose Naltrexone Use for Patients with Chronic Regional Pain Syndrome: A Systematic Literature Review. Pain Physician 2021; 24:E393-E406. [PMID: 34213865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Complex regional pain syndrome is a rare, neuropathic disorder that affects fewer than 200,000 individuals in the United States annually. Current treatments often focus on pain management and fall short of relieving symptoms of pain and dystonia in patients. OBJECTIVE The goal of this systematic qualitative review is to evaluate the evidence for the use of low-dose naltrexone in the treatment of chronic pain syndromes. STUDY DESIGN This is a systematic review. METHODS PubMed, Embase, and Web of Science were searched for articles containing the keywords "low-dose naltrexone" AND ("pain" OR "chronic pain" OR "fibromyalgia" OR "complex regional pain syndrome" OR "neuropathic pain" OR "nociceptive pain") between 1950 and July 17, 2020. A total of 30 publications were systematically reviewed. Exclusion criteria were articles that were unavailable in English, focused on acute pain only, and evaluated only animal models. Case studies were included for the purposes of our qualitative review. RESULTS Out of 29 articles, we reviewed 11 prospective studies, 10 case studies, 3 systematic reviews, 2 retrospective studies, 2 simulation models, and one combination study. Articles focused on chronic pain syndromes as well as painful rheumatologic disorders and neurological disorders. We found that low-dose naltrexone treatment was positively associated with symptom relief in patients experiencing chronic pain, dystonia, and sleep disturbances. LIMITATIONS Due to the limited number of available articles focusing on the treatment of complex regional pain syndrome with low-dose naltrexone, the majority of studies analyzed focused on other chronic pain syndromes. CONCLUSIONS There is a need for additional prospective and interventional studies addressing the use of low-dose naltrexone in the treatment of complex regional pain syndrome symptoms.
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Affiliation(s)
- Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | - Tammy Dann
- Pain Evaluation Management Center of Ohio, Dayton, OH
| | | | | | | | - Harsh Sachdeva
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Jordan Italiano
- Wright State University Boonshoft School of Medicine, Fairborn, OH
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9
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Manchikanti L, Vanaparthy R, Atluri S, Sachdeva H, Kaye AD, Hirsch JA. COVID-19 and the Opioid Epidemic: Two Public Health Emergencies That Intersect With Chronic Pain. Pain Ther 2021; 10:269-286. [PMID: 33718982 PMCID: PMC7955940 DOI: 10.1007/s40122-021-00243-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/08/2021] [Indexed: 02/06/2023] Open
Abstract
The COVID-19 pandemic has affected the entire world and catapulted the United States into one of the deepest recessions in history. While this pandemic rages, the opioid crisis worsens. During this period, the pandemic has resulted in the decimation of most conventional medical services, including those of chronic pain management, with the exception of virtual care and telehealth. Many chronic pain patients have been impacted in numerous ways, with increases in cardiovascular disease, mental health problems, cognitive dysfunction, and early death. The epidemic has also resulted in severe economic and physiological consequences for providers. Drug deaths in America, which fell for the first time in 25 years in 2018, rose to record numbers in 2019 and are continuing to climb, worsened by the coronavirus pandemic. The opioid epidemic was already resurfacing with a 5% increase in overall deaths from 2018; however, the preliminary data show that prescription opioid deaths continued to decline, while at the same time deaths due to fentanyl, methamphetamine, and cocaine climbed, with some reductions in heroin deaths. The health tracker data also showed that along with an almost 88% decline in elective surgeries, pain-related prescriptions declined 15.1%. Despite increases in telehealth, outpatient services declined and only began returning towards normal at an extremely slow pace, accompanied by reduced productivity and increased practice costs. This review, therefore, emphasizes the devastating consequences of concurrent epidemics on chronic pain management and the need to develop best practice efforts to preserve access to treatment for chronic pain.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY, USA.
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA, USA.
| | | | | | - Harsh Sachdeva
- Pain Division and Fellowship Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alan D Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Pain Management Fellow Program Director, LSU School of Medicine, Shreveport, LA, USA
- Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA, USA
- Anesthesiology and Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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10
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Thompson A, Price K, Atluri S, Yee D, Hsiao J, Shi V. 657 Characteristics and merits of NIH award recipients of dermatology research. J Invest Dermatol 2021. [DOI: 10.1016/j.jid.2021.02.687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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11
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Manchikanti L, Atluri S, Boswell MV, Calodney AK, Diwan S, Gupta S, Kaye AD, Knezevic NN, Candido KD, Abd-Elsayed A, Pappolla MA, Racz GB, Sachdeva H, Sanapati MR, Shah S, Singh V, Soin A, Hirsch JA. Methodology for Evidence Synthesis and Development of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Pain Physician 2021; 24:S1-S26. [PMID: 33492917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of Medicine) states, "clinical practice guidelines are statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options." The revised definition distinguishes between the term "clinical practice guideline" and other forms of clinical guidance derived from widely disparate development processes, such as consensus statements, expert advice, and appropriate use criteria. OBJECTIVE To assess the literature and develop methodology for evidence synthesis and development of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. METHODS A systematic review of the literature including methodology of guideline development encompassing GRADE approach for guidance on evidence synthesis with recommendations. RESULTS Some of the many factors described in 2011 continue as of 2020 and impede the development of clinical practice guidelines. These impediments include biases due to a variety of conflicts and confluence of interest, inappropriate and poor methodological quality, poor writing and ambiguous presentation, projecting a view that these are not applicable to individual patients or too restrictive with the elimination of clinician autonomy, and overzealous and inappropriate recommendations, either positive, negative, or non-committal. Thus, ideally, a knowledgeable, multidisciplinary panel of experts with true lack of bias and confluence of interest must develop guidelines based on a systematic review of the existing evidence. This manuscript describes evidence synthesis from observational studies, various types of randomized controlled trials (RCTs), and, finally, methodological and reporting quality of systematic reviews. The manuscript also describes various methods utilized in the assessment of the quality of observational studies, diagnostic accuracy studies, RCTs, and systematic reviews. LIMITATIONS Paucity of publications with appropriate evidence synthesis methodology in reference to interventional techniques. CONCLUSION This review described comprehensive evidence synthesis derived from systematic reviews, including methodologic quality and bias measurement. The manuscript described various methods utilized in the assessment of the quality of the systematic reviews, RCTs, diagnostic accuracy studies, and observational studies.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | | | | | - Sanjeeva Gupta
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine
| | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Miguel A Pappolla
- St. Michael's Pain and Spine Clinics, Houston, TX, and Univeristy of Texas Medical Branch, Galveston, TX
| | | | - Harsh Sachdeva
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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12
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Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, Grider J, Harned ME, Cintron L, Gharibo CG, Shah S, Nampiaparampil DE, Candido KD, Soin A, Kaye AD, Kosanovic R, Magee TR, Beall DP, Atluri S, Gupta M, Helm Ii S, Wargo BW, Diwan S, Aydin SM, Boswell MV, Haney BW, Albers SL, Latchaw R, Abd-Elsayed A, Conn A, Hansen H, Simopoulos TT, Swicegood JR, Bryce DA, Singh V, Abdi S, Bakshi S, Buenaventura RM, Cabaret JA, Jameson J, Jha S, Kaye AM, Pasupuleti R, Rajput K, Sanapati MR, Sehgal N, Trescot AM, Racz GB, Gupta S, Sharma ML, Grami V, Parr AT, Knezevic E, Datta S, Patel KG, Tracy DH, Cordner HJ, Snook LT, Benyamin RM, Hirsch JA. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician 2021; 24:S27-S208. [PMID: 33492918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Blaustein Pain Treatment Center, Johns Hopkins Hospital, Baltimore MD
| | - Gerard Limerick
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jay Grider
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | - Michael E Harned
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | - Lynn Cintron
- Dept. of Anesthesiology and Perioperative Care, Adjunct Associate Clinical Professor, University of California, Irvine School of Medicine, Irvine, CA
| | - Christopher G Gharibo
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | | | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine
| | | | | | | | | | | | | | - Myank Gupta
- Kansas Pain Management & Neuroscience Research Center, LLC, Overland Park, KS, and Adjunct Clinical Assistant Professor, Anesthesiology and Pain Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | | | - Bradley W Wargo
- Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center
| | | | - Steve M Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | - Bill W Haney
- Pain Management Centers of America, Louisville, KY
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Ann Conn
- , Advanced Pain Institute, Covington, LA
| | | | - Thomas T Simopoulos
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John R Swicegood
- Advanced Interventional Pain and Diagnostics of Western Arkansas, Fort Smith, AR
| | | | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Ricardo M Buenaventura
- Pain Relief of Dayton, Centerville, OH, and Clinical Associate Professor, Department of Surgery, Wright State University School of Medicine, Dayton, OH
| | | | | | - Sunny Jha
- Department of Anesthesiology, Houston Methodist Hospital, Houston, TX
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | | | | | | | - Nalini Sehgal
- Division of Rehabilitation Medicine, Vice Chair Department of Orthopedics & Rehabilitation and Program Director, Multidisciplinary Pain Medicine Fellowship, University of Wisconsin School of Medicine & Public Health, UW Health, Madison, WI
| | | | | | - Sanjeeva Gupta
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Vahid Grami
- Geisinger Medical Center Interventional Pain Center Woodbine, Danville, PA
| | | | - Emilija Knezevic
- University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL
| | - Sukdeb Datta
- Datta Endoscopic Back Surgery and Pain Center and Professorial Lecturer, Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY
| | - Kunj G Patel
- Center for Regenerative and Interventional Spine and Sports Pain, St. Louis, MO
| | | | - Harold J Cordner
- Florida Pain Management Associates, Sebastian, FL; and Associate Clinical Professor Florida State University College of Medicine, Tallahassee, FL
| | - Lee T Snook
- Metropolitan Pain Management Consultants, Inc., Sacramento, CA
| | - Ramsin M Benyamin
- Millennium Pain Center, Bloomington, IL, Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL, Department of Psychology, Illinois Wesleyan University, and Stimgenics LLC, Bloomington, IL
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Atluri S. Safety and Effectiveness of Intravascular
Mesenchymal Stem Cells to Treat Organ
Failure and Possible Application in COVID-19
Complications. Pain Physician 2020. [DOI: 10.36076/ppj.2020/23/s391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Although only a small percentage of patients with COVID-19 deteriorate to a
critical condition, because of the associated high mortality rate and the sheer number of cases, it
imposes a tremendous burden on the society and unprecedented strains the health care resources.
Albeit lung is the primary organ involved resulting in acute respiratory distress syndrome (ARDS),
many patients additionally present with secondary multiorgan failure. Unfortunately, there is no
definitive or curative treatment for this condition, and the management has been predominantly
confined to supportive care, which necessitates an urgent need for novel therapies. Mesenchymal
stem cell (MSC) therapy has a vast array of preclinical data and early, preliminary clinical data that
suggests its potential to regenerate and restore the function of damaged tissues and organs. To
date, there has been no review of all the clinical trials that have assessed the safety and efficacy
of MSC therapy in organ failure commonly seen in seriously complicated COVID-19 patients.
Objectives: To evaluate the effectiveness of MSC therapy in managing multiorgan failure,
utilizing currently available literature.
Study Design: A review of human randomized controlled trials (RCTs) and observational
studies assessing the role of MSC therapy in managing multiorgan failure.
Methods: PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar,
and prior systematic reviews and reference lists were utilized in the literature search from 1990
through May 2020. Studies that included embryonic stem cells, induced pluripotent stem cells,
differentiated MSCs into specific lineage cells, and hematopoietic stem cells were excluded. Trials
with intraorgan infiltration of MSC were also excluded.
Outcome Measures: The primary outcome evaluated the improvement in clinical assessment
scores and indices of organ function. The secondary outcome assessed the safety of MSC therapy
in the clinical trials.
Results: Based on search criteria, 12 studies were found for lung, 52 for heart, 23 for liver, 16
for stroke, and 9 for kidney. Among the 6 studies that specifically assessed the effectiveness of
MSC therapy in ARDS, 4 showed positive outcomes. Forty-one of the 52 trials that examined
ischemic and nonischemic heart failure reported beneficial effects. Twenty of 23 trials for
liver failure from different etiologies revealed favorable outcomes. Nine out of the 15 studies
evaluating stroke had satisfactory effects. However, only 3 out of the 9 studies for kidney failure
showed positive results. Nonexpanded bone marrow mononuclear cells were used in most of
the negative studies. The incidence of disease worsening or major complications was extremely
rare from MSC therapy.
Limitations: Among the studies evaluated, although there were many RCTs, there were also
numerous case series. Additionally, most recruited a small number of patients. Conclusions: MSC therapy seems to be promising to treat multiorgan failure from COVID-19. More studies are urgently needed
to assess both safety and efficacy.
Key words: Mesenchymal stem cell, multiorgan failure, randomized controlled trial
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14
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Knezevic NN, Manchikanti L, Urits I, Orhurhu V, Vangala BP, Vanaparthy R, Sanapati MR, Shah S, Soin A, Mahajan A, Atluri S, Kaye AD, Hirsch JA. Lack of Superiority of Epidural Injections with Lidocaine with Steroids Compared to Without Steroids in Spinal Pain: A Systematic Review and Meta-Analysis. Pain Physician 2020; 23:S239-S270. [PMID: 32942786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Multiple randomized controlled trials (RCTs) and systematic reviews have been conducted to summarize the evidence for administration of local anesthetic (lidocaine) alone or with steroids, with discordant opinions, more in favor of equal effect with local anesthetic alone or with steroids. OBJECTIVE To evaluate the comparative effectiveness of lidocaine alone and lidocaine with steroids in managing spinal pain to assess superiority or equivalency. STUDY DESIGN A systematic review of RCTs assessing the effectiveness of lidocaine alone compared with addition of steroids to lidocaine in managing spinal pain secondary to multiple causes (disc herniation, radiculitis, discogenic pain, spinal stenosis, and post-surgery syndrome). METHODS This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for literature search, Cochrane review criteria, and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) to assess the methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and quantitative analysis utilizing conventional and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2019. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. OUTCOME MEASURES A hard endpoint for the primary outcome was defined as the proportion of patients with 50% pain relief and improvement in function. Secondary outcome measures, or soft endpoints, were pain relief and/or improvement in function. Effectiveness was determined as short-term if it was less than 6 months. Improvement that lasted longer than 6 months, was defined as long-term. RESULTS Based on search criteria, 15 manuscripts were identified and considered for inclusion for qualitative analysis, quantitative analysis with conventional meta-analysis, and single-arm meta-analysis. The results showed Level II, moderate evidence, for short-term and long-term improvement in pain and function with the application of epidural injections with local anesthetic with or without steroid in managing spinal pain of multiple origins. LIMITATIONS Despite 15 RCTs, evidence may still be considered as less than optimal and further studies are recommended. CONCLUSION Overall, the present meta-analysis shows moderate (Level II) evidence for epidural injections with lidocaine with or without steroids in managing spinal pain secondary to disc herniation, spinal stenosis, discogenic pain, and post-surgery syndrome based on relevant, high-quality RCTs. Results were similar for lidocaine, with or without steroids.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | | | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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15
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Gharibo C, Sharma A, Soin A, Shah S, Diwan S, Buenaventura R, Nampiaparampil DE, Aydin S, Bakshi S, Abdi S, Jha SS, Cordner H, Kaye AD, Abd-Elsayed A, Candido KD, Knezevic NN, Atluri S, Wargo BW, Sanapati MR, Datta S, Hirsch JA, Manchikanti L, Rajput K. Triaging Interventional Pain Procedures During COVID-19 or Related Elective Surgery Restrictions: Evidence-Informed Guidance from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2020; 23:S183-S204. [PMID: 32942785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND The COVID-19 pandemic has worsened the pain and suffering of chronic pain patients due to stoppage of "elective" interventional pain management and office visits across the United States. The reopening of America and restarting of interventional techniques and elective surgical procedures has started. Unfortunately, with resurgence in some states, restrictions are once again being imposed. In addition, even during the Phase II and III of reopening, chronic pain patients and interventional pain physicians have faced difficulties because of the priority selection of elective surgical procedures.Chronic pain patients require high intensity care, specifically during a pandemic such as COVID-19. Consequently, it has become necessary to provide guidance for triaging interventional pain procedures, or related elective surgery restrictions during a pandemic. OBJECTIVES The aim of these guidelines is to provide education and guidance for physicians, healthcare administrators, the public and patients during the COVID-19 pandemic. Our goal is to restore the opportunity to receive appropriate care for our patients who may benefit from interventional techniques. METHODS The American Society of Interventional Pain Physicians (ASIPP) has created the COVID-19 Task Force in order to provide guidance for triaging interventional pain procedures or related elective surgery restrictions to provide appropriate access to interventional pain management (IPM) procedures in par with other elective surgical procedures. In developing the guidance, trustworthy standards and appropriate disclosures of conflicts of interest were applied with a section of a panel of experts from various regions, specialties, types of practices (private practice, community hospital and academic institutes) and groups. The literature pertaining to all aspects of COVID-19, specifically related to epidemiology, risk factors, complications, morbidity and mortality, and literature related to risk mitigation and stratification was reviewed. The evidence -- informed with the incorporation of the best available research and practice knowledge was utilized, instead of a simplified evidence-based approach. Consequently, these guidelines are considered evidence-informed with the incorporation of the best available research and practice knowledge. RESULTS The Task Force defined the medical urgency of a case and developed an IPM acuity scale for elective IPM procedures with 3 tiers. These included urgent, emergency, and elective procedures. Examples of urgent and emergency procedures included new onset or exacerbation of complex regional pain syndrome (CRPS), acute trauma or acute exacerbation of degenerative or neurological disease resulting in impaired mobility and inability to perform activities of daily living. Examples include painful rib fractures affecting oxygenation and post-dural puncture headaches limiting the ability to sit upright, stand and walk. In addition, emergency procedures include procedures to treat any severe or debilitating disease that prevents the patient from carrying out activities of daily living. Elective procedures were considered as any condition that is stable and can be safely managed with alternatives. LIMITATIONS COVID-19 continues to be an ongoing pandemic. When these recommendations were developed, different stages of reopening based on geographical regulations were in process. The pandemic continues to be dynamic creating every changing evidence-based guidance. Consequently, we provided evidence-informed guidance. CONCLUSION The COVID-19 pandemic has created unprecedented challenges in IPM creating needless suffering for pain patients. Many IPM procedures cannot be indefinitely postponed without adverse consequences. Chronic pain exacerbations are associated with marked functional declines and risks with alternative treatment modalities. They must be treated with the concern that they deserve. Clinicians must assess patients, local healthcare resources, and weigh the risks and benefits of a procedure against the risks of suffering from disabling pain and exposure to the COVID-19 virus.
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Affiliation(s)
- Christopher Gharibo
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Amit Sharma
- The American Society of Interventional Pain Physicians, Paducah, KY
| | | | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | | | - Ricardo Buenaventura
- Pain Relief of Dayton, Centerville, OH, and Clinical Associate Professor, Department of Surgery, Wright State University School of Medicine, Dayton, OH
| | | | - Steve Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | | | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Sachin Sunny Jha
- University of Southern California, Department of Anesthesiology, Los Angeles, CA
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine
| | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | | | - Bradley W Wargo
- Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
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Atluri S, Manocha V, Boddu N, Bhati S, Syed Z, Diwan S, Manchikanti L. Safety and Effectiveness of Intravascular Mesenchymal Stem Cells to Treat Organ Failure and Possible Application in COVID-19 Complications. Pain Physician 2020; 23:S391-S420. [PMID: 32942796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Although only a small percentage of patients with COVID-19 deteriorate to a critical condition, because of the associated high mortality rate and the sheer number of cases, it imposes a tremendous burden on the society and unprecedented strains the health care resources. Albeit lung is the primary organ involved resulting in acute respiratory distress syndrome (ARDS), many patients additionally present with secondary multiorgan failure. Unfortunately, there is no definitive or curative treatment for this condition, and the management has been predominantly confined to supportive care, which necessitates an urgent need for novel therapies. Mesenchymal stem cell (MSC) therapy has a vast array of preclinical data and early, preliminary clinical data that suggests its potential to regenerate and restore the function of damaged tissues and organs. To date, there has been no review of all the clinical trials that have assessed the safety and efficacy of MSC therapy in organ failure commonly seen in seriously complicated COVID-19 patients. OBJECTIVES To evaluate the effectiveness of MSC therapy in managing multiorgan failure, utilizing currently available literature. STUDY DESIGN A review of human randomized controlled trials (RCTs) and observational studies assessing the role of MSC therapy in managing multiorgan failure. METHODS PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1990 through May 2020. Studies that included embryonic stem cells, induced pluripotent stem cells, differentiated MSCs into specific lineage cells, and hematopoietic stem cells were excluded. Trials with intraorgan infiltration of MSC were also excluded. OUTCOME MEASURES The primary outcome evaluated the improvement in clinical assessment scores and indices of organ function. The secondary outcome assessed the safety of MSC therapy in the clinical trials. RESULTS Based on search criteria, 12 studies were found for lung, 52 for heart, 23 for liver, 16 for stroke, and 9 for kidney. Among the 6 studies that specifically assessed the effectiveness of MSC therapy in ARDS, 4 showed positive outcomes. Forty-one of the 52 trials that examined ischemic and nonischemic heart failure reported beneficial effects. Twenty of 23 trials for liver failure from different etiologies revealed favorable outcomes. Nine out of the 15 studies evaluating stroke had satisfactory effects. However, only 3 out of the 9 studies for kidney failure showed positive results. Nonexpanded bone marrow mononuclear cells were used in most of the negative studies. The incidence of disease worsening or major complications was extremely rare from MSC therapy. LIMITATIONS Among the studies evaluated, although there were many RCTs, there were also numerous case series. Additionally, most recruited a small number of patients. CONCLUSIONS MSC therapy seems to be promising to treat multiorgan failure from COVID-19. More studies are urgently needed to assess both safety and efficacy.
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Affiliation(s)
| | - Vivek Manocha
- Wright State University School of Medicine, Dayton, OH
| | | | | | - Zaid Syed
- Tristate Pain Management, Cincinnati, OH
| | | | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
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Manchikanti L, Kaye AD, Soin A, Albers SL, Beall D, Latchaw R, Sanapati MR, Shah S, Atluri S, Abd-Elsayed A, Abdi S, Aydin S, Bakshi S, Boswell MV, Buenaventura R, Cabaret J, Calodney AK, Candido KD, Christo PJ, Cintron L, Diwan S, Gharibo C, Grider J, Gupta M, Haney B, Harned ME, Helm Ii S, Jameson J, Jha S, Kaye AM, Knezevic NN, Kosanovic R, Manchikanti MV, Navani A, Racz G, Pampati V, Pasupuleti R, Philip C, Rajput K, Sehgal N, Sudarshan G, Vanaparthy R, Wargo BW, Hirsch JA. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain Physician 2020; 23:S1-S127. [PMID: 32503359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Chronic axial spinal pain is one of the major causes of significant disability and health care costs, with facet joints as one of the proven causes of pain. OBJECTIVE To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions. METHODS The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of facet joint interventions, was reviewed, with a best evidence synthesis of available literature and utilizing grading for recommendations.Summary of Evidence and Recommendations:Non-interventional diagnosis: • The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. • The level of evidence is IV for accurate diagnosis of facet joint pain with physical examination based on symptoms and signs, with weak strength of recommendation. Imaging: • The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. • The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . • The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT) .Interventional Diagnosis:Lumbar Spine: • The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. • Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of ≥80% were included. • The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥80% pain relief.Cervical Spine: • The level of evidence is II with moderate strength of recommendation. • Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant pain relief with a criterion standard of ≥80% were included. • The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability. Thoracic Spine: • The level of evidence is II with moderate strength of recommendation. • Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant pain relief, with a criterion standard of ≥80% were included. • The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%.Therapeutic Facet Joint Interventions: Lumbar Spine: • The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of 3 relevant randomized controlled trials, with long-term improvement. • The level of evidence is IV with weak strength of recommendation for lumbar facet joint intraarticular injections with inclusion of 9 relevant randomized controlled trials, with majority of them showing lack of effectiveness without the use of local anesthetic. Cervical Spine: • The level of evidence is II with moderate strength of recommendation for cervical radiofrequency ablation with inclusion of one randomized controlled trial with positive results and 2 observational studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic cervical facet joint nerve blocks with inclusion of one relevant randomized controlled trial and 3 observational studies, with long-term improvement. • The level of evidence is V with weak strength of recommendation for cervical intraarticular facet joint injections with inclusion of 3 relevant randomized controlled trials, with 2 observational studies, the majority showing lack of effectiveness, whereas one study with 6-month follow-up, showed lack of long-term improvement. Thoracic Spine: • The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies. • The level of evidence is II with moderate strength of recommendation for thoracic therapeutic facet joint nerve blocks with inclusion of 2 randomized controlled trials and one observational study with long-term improvement. • The level of evidence is III with weak to moderate strength of recommendation for thoracic intraarticular facet joint injections with inclusion of one randomized controlled trial with 6 month follow-up, with emerging evidence. Antithrombotic Therapy: • Facet joint interventions are considered as moderate to low risk procedures; consequently, antithrombotic therapy may be continued based on overall general status. Sedation: • The level of evidence is II with moderate strength of recommendation to avoid opioid analgesics during the diagnosis with interventional techniques. • The level of evidence is II with moderate strength of recommendation that moderate sedation may be utilized for patient comfort and to control anxiety for therapeutic facet joint interventions. LIMITATIONS The limitations of these guidelines include a paucity of high-quality studies in the majority of aspects of diagnosis and therapy. CONCLUSIONS These facet joint intervention guidelines were prepared with a comprehensive review of the literature with methodologic quality assessment with determination of level of evidence and strength of recommendations. KEY WORDS Chronic spinal pain, interventional techniques, diagnostic blocks, therapeutic interventions, facet joint nerve blocks, intraarticular injections, radiofrequency neurolysis.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | | | | | | | | | | | | | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Steve Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | | | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | - Ricardo Buenaventura
- Pain Relief of Dayton, Centerville, OH, and Clinical Associate Professor, Department of Surgery, Wright State University School of Medicine, Dayton, OH
| | | | | | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Blaustein Pain Treatment Center, Johns Hopkins Hospital, Baltimore MD
| | - Lynn Cintron
- Dept. of Anesthesiology and Perioperative Care, Adjunct Associate Clinical Professor, University of California, Irvine School of Medicine, Irvine, CA
| | | | - Christopher Gharibo
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Jay Grider
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | - Mayank Gupta
- Kansas Pain Management & Neuroscience Research Center, LLC, Overland Park, KS, and Adjunct Clinical Assistant Professor, Anesthesiology and Pain Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO
| | - Bill Haney
- Pain Management Centers of America, Louisville, KY
| | - Michael E Harned
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | | | | | | | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | | | | | - Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | | | | | | | | | | | | | | | | | - Bradley W Wargo
- Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Atluri S, Manchikanti L, Hirsch JA. Expanded Umbilical Cord Mesenchymal Stem Cells (UC-MSCs) as a Therapeutic Strategy in Managing Critically Ill COVID-19 Patients: The Case for Compassionate Use. Pain Physician 2020; 23:E71-E83. [PMID: 32214286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
COVID-19 has affected the United States leading to a national emergency with health care and economic impact, propelling the country into a recession with disrupted lifestyles not seen in recent history. COVID-19 is a serious illness leading to multiple deaths in various countries including the United States. Several million Americans satisfy the Center for Disease Control and Prevention (CDC) criteria for being high risk. Unfortunately, the available supply of medical beds and equipment for mechanical ventilation are much less than is projected to be needed. The World Health Organization (WHO) and multiple agencies led by the CDC in the United States have attempted to organize intensive outbreak investigation programs utilizing appropriate preventive measures, evaluation, and treatment. The clinical spectrum of COVID-19 varies from asymptomatic forms to conditions encompassing multiorgan and systemic manifestations in terms of septic shock, and multiple organ dysfunction (MOD) syndromes. The presently approved treatments are supportive but not curative for the disease. There are multiple treatments being studied. These include vaccines, medications Remdesivir and hydroxychloroquine and potentially combination therapy. Finally, expanded umbilical cord mesenchymal stem cells or (UC-MSCs) may have a role and are being studied. The cure of COVID-19 is essentially dependent on the patients' own immune system. When the immune system is over activated in an attempt to kill the virus, this can lead to the production of a large number of inflammatory factors, resulting in severe cytokine storm. The cytokine storm may induce organ damage followed by the edema, dysfunction of air exchange, acute respiratory distress syndrome (ARDS), acute cardiac injury, and secondary infection, which may lead to death. Thus, at this point, the avoidance of the cytokine storm may be the key for the treatment of HCOV-19 infected patients.In China, where there was limited availability of effective modalities to manage COVID-19 several patients were treated with expanded UC-MSCs. Additionally, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care have reported guidelines to treat coronavirus patients with stem cells in the hope of decreasing the number of patients going to the ICU, and, also relatively quickly getting them out of ICU. In this manuscript, we describe the urgent need for various solutions, pathogenesis of coronavirus and the clinical evidence for treatment of COVID-19 with stem cells. The limited but emerging evidence regarding UC MSC in managing COVID-19 suggests that it might be considered for compassionate use in critically ill patients to reduce morbidity and mortality in the United States. The administration and Coronavirus Task Force might wish to approach the potential of expanded UC-MSCs as an evolutionary therapeutic strategy in managing COVID-19 illness with a 3-pronged approach: If proven safe and effective on a specific and limited basis…1. Minimize regulatory burden by all agencies so that critically ill COVID-19 patients will have access regardless of their financial circumstance.2. Institute appropriate safeguards to avoid negative consequences from unscrupulous actors.3. With proper informed consent from patients or proxy when necessary, and subject to accumulation of data in that cohort, allow the procedure to be initiated in critically ill patients who are not responding to conventional therapies.KEY WORDS: Coronavirus, COVID-19, cytokine storm, multiorgan failure, expanded umbilical cord mesenchymal stem cells.
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Affiliation(s)
| | - Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Sanapati MR, Pampati V, Soin A, Atluri S, Kaye AD, Subramanian J, Hirsch JA. Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population. Pain Physician 2020; 23:E133-E149. [PMID: 32214289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | | | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Centeno CJ, Atluri S, Albers SL, Shapiro S, Malanga GA, Abd-Elsayed A, Jerome M, Hirsch JA, Kaye AD, Aydin SM, Beall D, Buford D, Borg-Stein J, Buenaventura RM, Cabaret JA, Calodney AK, Candido KD, Cartier C, Latchaw R, Diwan S, Dodson E, Fausel Z, Fredericson M, Gharibo CG, Gupta M, Kaye AM, Knezevic NN, Kosanovic R, Lucas M, Manchikanti MV, Mason RA, Mautner K, Murala S, Navani A, Pampati V, Pastoriza S, Pasupuleti R, Philip C, Sanapati MR, Sand T, Shah RV, Soin A, Stemper I, Wargo BW, Hernigou P. Bone Marrow Concentrate (BMC) Therapy in Musculoskeletal Disorders: Evidence-Based Policy Position Statement of American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2020; 23:E85-E131. [PMID: 32214287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The use of bone marrow concentrate (BMC) for treatment of musculoskeletal disorders has become increasingly popular over the last several years, as technology has improved along with the need for better solutions for these pathologies. The use of cellular tissue raises a number of issues regarding the US Food and Drug Administration's (FDA) regulation in classifying these treatments as a drug versus just autologous tissue transplantation. In the case of BMC in musculoskeletal and spine care, this determination will likely hinge on whether BMC is homologous to the musculoskeletal system and spine. OBJECTIVES The aim of this review is to describe the current regulatory guidelines set in place by the FDA, specifically the terminology around "minimal manipulation" and "homologous use" within Regulation 21 CFR Part 1271, and specifically how this applies to the use of BMC in interventional musculoskeletal medicine. METHODS The methodology utilized here is similar to the methodology utilized in preparation of multiple guidelines employing the experience of a panel of experts from various medical specialties and subspecialties from differing regions of the world. The collaborators who developed these position statements have submitted their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these position statements. The literature pertaining to BMC, its effectiveness, adverse consequences, FDA regulations, criteria for meeting the standards of minimal manipulation, and homologous use were comprehensively reviewed using a best evidence synthesis of the available and relevant literature. RESULTS/Summary of Evidence: In conjunction with evidence-based medicine principles, the following position statements were developed: Statement 1: Based on a review of the literature in discussing the preparation of BMC using accepted methodologies, there is strong evidence of minimal manipulation in its preparation, and moderate evidence for homologous utility for various musculoskeletal and spinal conditions qualifies for the same surgical exemption. Statement 2: Assessment of clinical effectiveness based on extensive literature shows emerging evidence for multiple musculoskeletal and spinal conditions. • The evidence is highest for knee osteoarthritis with level II evidence based on relevant systematic reviews, randomized controlled trials and nonrandomized studies. There is level III evidence for knee cartilage conditions. • Based on the relevant systematic reviews, randomized trials, and nonrandomized studies, the evidence for disc injections is level III. • Based on the available literature without appropriate systematic reviews or randomized controlled trials, the evidence for all other conditions is level IV or limited for BMC injections. Statement 3: Based on an extensive review of the literature, there is strong evidence for the safety of BMC when performed by trained physicians with the appropriate precautions under image guidance utilizing a sterile technique. Statement 4: Musculoskeletal disorders and spinal disorders with related disability for economic and human toll, despite advancements with a wide array of treatment modalities. Statement 5: The 21st Century Cures Act was enacted in December 2016 with provisions to accelerate the development and translation of promising new therapies into clinical evaluation and use. Statement 6: Development of cell-based therapies is rapidly proliferating in a number of disease areas, including musculoskeletal disorders and spine. With mixed results, these therapies are greatly outpacing the evidence. The reckless publicity with unsubstantiated claims of beneficial outcomes having putative potential, and has led the FDA Federal Trade Commission (FTC) to issue multiple warnings. Thus the US FDA is considering the appropriateness of using various therapies, including BMC, for homologous use. Statement 7: Since the 1980's and the description of mesenchymal stem cells by Caplan et al, (now called medicinal signaling cells), the use of BMC in musculoskeletal and spinal disorders has been increasing in the management of pain and promoting tissue healing. Statement 8: The Public Health Service Act (PHSA) of the FDA requires minimal manipulation under same surgical procedure exemption. Homologous use of BMC in musculoskeletal and spinal disorders is provided by preclinical and clinical evidence. Statement 9: If the FDA does not accept BMC as homologous, then it will require an Investigational New Drug (IND) classification with FDA (351) cellular drug approval for use. Statement 10: This literature review and these position statements establish compliance with the FDA's intent and corroborates its present description of BMC as homologous with same surgical exemption, and exempt from IND, for use of BMC for treatment of musculoskeletal tissues, such as cartilage, bones, ligaments, muscles, tendons, and spinal discs. CONCLUSIONS Based on the review of all available and pertinent literature, multiple position statements have been developed showing that BMC in musculoskeletal disorders meets the criteria of minimal manipulation and homologous use. KEY WORDS Cell-based therapies, bone marrow concentrate, mesenchymal stem cells, medicinal signaling cells, Food and Drug Administration, human cells, tissues, and cellular tissue-based products, Public Health Service Act (PHSA), minimal manipulation, homologous use, same surgical procedure exemption.
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Affiliation(s)
| | | | | | | | | | - Gerard A Malanga
- Department of Physical Medicine and Rehabilitation, Rutgers School of Medicine, NJ Medical School, Newark, NJ, and Partner, New Jersey Regenerative Institute, Cedar Knolls, NJ
| | - Alaa Abd-Elsayed
- Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Steve M Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | | | | | - Joanne Borg-Stein
- Department of Physical Medicine & Rehabilitation, Harvard Medical School
| | - Ricardo M Buenaventura
- Pain Relief of Dayton, Centerville, OH, and Clinical Associate Professor, Department of Surgery, Wright State University School of Medicine, Dayton, OH
| | | | | | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and Professor of Clinical Surgery and Anesthesia, University of Illinois College of Medicine
| | | | | | | | | | | | | | - Christopher G Gharibo
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | | | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | | | | | | | - R Amadeus Mason
- Department of Orthopaedics & Family Medicine, Emory Orthopaedics, Sports, Spine
| | | | | | - Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | | | | | | | | | | | | | | | | | | | - Bradley W Wargo
- Department of Interventional and Non-Interventional Pain Management, OrthoSouth Surgery Center
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Atluri S, Boddu N. Two-fold Increase in the Number of Total Nucleated Cells in the Bone Marrow Concentrate Obtained From Bone Marrow Aspirate May Not Be Ideal: Letter to the Editor. Orthop J Sports Med 2019; 7:2325967119835197. [PMID: 30968049 PMCID: PMC6442081 DOI: 10.1177/2325967119835197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Dhami P, Atluri S, Lee J, Knyahntska Y, Courtney D, Shim S, Voineskos A, Croarkin P, Blumberger D, Daskalakis Z, Farzan F. Youth treatment resistant depression and TMS-EEG: insight into neurophysiological alterations of inhibition, excitability, and connectivity in depressed youth prior to rTMS therapy. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Navani A, Manchikanti L, Albers SL, Latchaw RE, Sanapati J, Kaye AD, Atluri S, Jordan S, Gupta A, Cedeno D, Vallejo A, Fellows B, Knezevic NN, Pappolla M, Diwan S, Trescot AM, Soin A, Kaye AM, Aydin SM, Calodney AK, Candido KD, Bakshi S, Benyamin RM, Vallejo R, Watanabe A, Beall D, Stitik TP, Foye PM, Helander EM, Hirsch JA. Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician 2019; 22:S1-S74. [PMID: 30717500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Regenerative medicine is a medical subspecialty that seeks to recruit and enhance the body's own inherent healing armamentarium in the treatment of patient pathology. This therapy's intention is to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous or allogenic biologics. This field is rising like a Phoenix from the ashes of underperforming conventional therapy midst the hopes and high expectations of patients and medical personnel alike. But, because this is a relatively new area of medicine that has yet to substantiate its outcomes, care must be taken in its public presentation and promises as well as in its use. OBJECTIVE To provide guidance for the responsible, safe, and effective use of biologic therapy in the lumbar spine. To present a template on which to build standardized therapies using biologics. To ground potential administrators of biologics in the knowledge of the current outcome statistics and to stimulate those interested in providing biologic therapy to participate in high quality research that will ultimately promote and further advance this area of medicine. METHODS The methodology used has included the development of objectives and key questions. A panel of experts from various medical specialties and subspecialties as well as differing regions collaborated in the formation of these guidelines and submitted (if any) their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these guidelines. The literature pertaining to regenerative medicine, its effectiveness, and adverse consequences was thoroughly reviewed using a best evidence synthesis of the available literature. The grading for recommendation was provided as described by the Agency for Healthcare Research and Quality (AHRQ). SUMMARY OF EVIDENCE Lumbar Disc Injections: Based on the available evidence regarding the use of platelet-rich plasma (PRP), including one high-quality randomized controlled trial (RCT), multiple moderate-quality observational studies, a single-arm meta-analysis and evidence from a systematic review, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best-evidence synthesis. Based on the available evidence regarding the use of medicinal signaling/ mesenchymal stem cell (MSCs) with a high-quality RCT, multiple moderate-quality observational studies, a single-arm meta-analysis, and 2 systematic reviews, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Epidural Injections Based on one high-quality RCT, multiple relevant moderate-quality observational studies and a single-arm meta-analysis, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Facet Joint Injections Based on one high-quality RCT and 2 moderate-quality observational studies, the qualitative evidence for facet joint injections with PRP has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Sacroiliac Joint Injection Based on one high-quality RCT, one moderate-quality observational study, and one low-quality case report, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. CONCLUSION Based on the evidence synthesis summarized above, there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient's needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient's medical history. Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy. Multiple guidelines from the Food and Drug Administration (FDA), potential limitations in the use of biologic therapy and the appropriate requirements for compliance with the FDA have been detailed in these guidelines. KEY WORDS Regenerative medicine, platelet-rich plasma, medicinal signaling cells, mesenchymal stem cells, stromal vascular fraction, bone marrow concentrate, chronic low back pain, discogenic pain, facet joint pain, Food and Drug Administration, minimal manipulation, evidence synthesis.
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Affiliation(s)
- Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
| | | | | | - Jaya Sanapati
- University Pain Medicine and Rehabilitation Center, Newark, NJ
| | | | | | | | - Ashim Gupta
- Associate Director of Research at Millennium Pain Center, Bloomington, IL; Chief Science Officer at South Texas Orthopaedic Research Institute, Laredo, TX; and Adjunct Researcher at Illinois Wesleyan University, Bloomington, IL
| | - David Cedeno
- Millennium Pain Center, Bloomington, IL; Illinois Wesleyan University, Bloomington, Illinois
| | - Alejandro Vallejo
- Millennium Pain Center, Bloomington, Illinois; University of Illinois at Urbana-Champaign, Champaign, Illinois
| | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Miguel Pappolla
- St. Michael's Pain and Spine Clinics, Houston, TX, and Univeristy of Texas Medical Branch, Galveston, TX
| | | | | | | | | | - Steve M Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | | | | | | | | | | | | | | | | | | | - Erik M Helander
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Kaye AD, Manchikanti L, Novitch MB, Mungrue IN, Anwar M, Jones MR, Helander EM, Cornett EM, Eng MR, Grider JS, Harned ME, Benyamin RM, Swicegood JR, Simopoulos TT, Abdi S, Urman RD, Deer TR, Bakhit C, Sanapati M, Atluri S, Pasupuleti R, Soin A, Diwan S, Vallejo R, Candido KD, Knezevic NN, Beall D, Albers SL, Latchaw RE, Prabhakar H, Hirsch JA. Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician 2019; 22:S75-S128. [PMID: 30717501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. STUDY DESIGN Best evidence synthesis. OBJECTIVE To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. METHODS A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. RESULTS 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors.2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety.5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae.6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure.7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant.8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma.9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy.11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed.12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas.13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. LIMITATIONS The continued paucity of the literature with discordant recommendations. CONCLUSION Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. KEY WORDS Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain.
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Affiliation(s)
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
| | | | - Imran N Mungrue
- Department of Pharmacology & Experimental Therapeutics, Louisiana State University- Health Sciences Center-New Orleans, LA
| | - Muhammad Anwar
- Department of Anesthesiology, Tulane Medical Center Center-New Orleans, LA
| | - Mark R Jones
- Department of Anesthesiology, Louisiana State University Health New Orleans
| | - Erik M Helander
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA
| | - Elyse M Cornett
- Assistant Professor, Departments of Anesthesiology and Pharmacology, Toxicology and Neuroscience, Director of Research, Department of Anesthesiology, Assistant Professor of Research, Department of Anesthesiology, Louisiana State University-Health Sciences Center-New Orleans, LA and Shreveport, LA
| | - Matthew R Eng
- Department of Anesthesiology, Louisiana State University-Health Sciences Center-New Orleans, LA
| | - Jay S Grider
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | - Michael E Harned
- Departments of Anesthesiology, University of Kentucky, Chandler Medical Center, Lexington, KY
| | | | | | | | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital/Harvard, Boston, MA; Department of Anesthesiology, LSU School of Medicine, New Orleans, LA
| | | | | | | | | | | | | | | | | | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | | | | | | | - Hari Prabhakar
- MGH Center for Pain Medicine, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Sanapati J, Manchikanti L, Atluri S, Jordan S, Albers SL, Pappolla MA, Kaye AD, Candido KD, Pampati V, Hirsch JA. Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Metaanalysis. Pain Physician 2018; 21:515-540. [PMID: 30508983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time. OBJECTIVE To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain. STUDY DESIGN A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain. DATA SOURCES PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018. STUDY SELECTION Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints. DATA EXTRACTION Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. DATA SYNTHESIS Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies RESULTS: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V). LIMITATIONS Lack of high quality RCTs. CONCLUSION The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques. KEY WORDS Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections.
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Affiliation(s)
- Jaya Sanapati
- University Pain Medicine and Rehabilitation Center, Newark, NJ
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
| | | | | | | | - Miguel A Pappolla
- St. Michael's Pain and Spine Clinics, Houston, TX, and Univeristy of Texas Medical Branch, Galveston, TX
| | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Sanapati J, Benyamin RM, Atluri S, Kaye AD, Hirsch JA. Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic. Pain Physician 2018; 21:309-326. [PMID: 30045589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
UNLABELLED The opioid epidemic has been called the "most consequential preventable public health problem in the United States." Though there is wide recognition of the role of prescription opioids in the epidemic, evidence has shown that heroin and synthetic opioids contribute to the majority of opioid overdose deaths. It is essential to reframe the preventive strategies in place against the opioid crisis with attention to factors surrounding the illicit use of fentanyl and heroin. Data on opioid overdose deaths shows 42,000 deaths in 2016. Of these, synthetic opioids other than methadone were responsible for over 20,000, heroin for over 15,000, and natural and semi-synthetic opioids other than methadone responsible for over 14,000. Fentanyl deaths increased 520% from 2009 to 2016 (increased by 87.7% annually between 2013 and 2016), and heroin deaths increased 533% from 2000 to 2016. Prescription opioid deaths increased by 18% overall between 2009 and 2016. The Drug Enforcement Administration (DEA) mandated reductions in opioid production by 25% in 2017 and 20% in 2018. The number of prescriptions for opioids declined significantly from 252 million in 2013 to 196 million in 2017 (9% annual decline over this period), falling below the number of prescriptions in 2006. In addition, data from 2017 shows significant reductions in the milligram equivalence of morphine by 12.2% and in the number of patients receiving high dose opioids by 16.1%. This manuscript describes the escalation of opioid use in the United States, discussing the roles played by drug manufacturers and distributors, liberalization by the DEA, the Food and Drug Administration (FDA), licensure boards and legislatures, poor science, and misuse of evidence-based medicine. Moreover, we describe how the influence of pharma, improper advocacy by physician groups, and the promotion of literature considered peer-reviewed led to the explosive use of illicit drugs arising from the issues surrounding prescription opioids.This manuscript describes a 3-tier approach presented to Congress. Tier 1 includes an aggressive education campaign geared toward the public, physicians, and patients. Tier 2 includes facilitation of easier access to non-opioid techniques and the establishment of a National All Schedules Prescription Electronic Reporting Act (NASPER). Finally, Tier 3 focuses on making buprenorphine more available for chronic pain management as well as for medication-assisted treatment. KEY WORDS Opioid epidemic, fentanyl and heroin epidemic, prescription opioids, National All Schedules Prescription Electronic Reporting Act (NASPER), Prescription Drug Monitoring Programs (PDMPs).
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
| | - Jaya Sanapati
- University Pain Medicine and Rehabilitation Center, Newark, NJ
| | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Kaye AM, Knezevic NN, McAnally H, Slavin K, Trescot AM, Blank S, Pampati V, Abdi S, Grider JS, Kaye AD, Manchikanti KN, Cordner H, Gharibo CG, Harned ME, Albers SL, Atluri S, Aydin SM, Bakshi S, Barkin RL, Benyamin RM, Boswell MV, Buenaventura RM, Calodney AK, Cedeno DL, Datta S, Deer TR, Fellows B, Galan V, Grami V, Hansen H, Helm Ii S, Justiz R, Koyyalagunta D, Malla Y, Navani A, Nouri KH, Pasupuleti R, Sehgal N, Silverman SM, Simopoulos TT, Singh V, Solanki DR, Staats PS, Vallejo R, Wargo BW, Watanabe A, Hirsch JA. Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician 2017. [PMID: 28226332 DOI: 10.36076/ppj.2017.s92] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use. OBJECTIVES To provide guidance for the prescription of opioids for the management of chronic non-cancer pain, to develop a consistent philosophy among the many diverse groups with an interest in opioid use as to how appropriately prescribe opioids, to improve the treatment of chronic non-cancer pain and to reduce the likelihood of drug abuse and diversion. These guidelines are intended to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique. METHODS The methodology utilized included the development of objectives and key questions. The methodology also utilized trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various specialties and groups. The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed, with a best evidence synthesis of the available literature, and utilized grading for recommendation as described by the Agency for Healthcare Research and Quality (AHRQ).Summary of Recommendations:i. Initial Steps of Opioid Therapy 1. Comprehensive assessment and documentation. (Evidence: Level I; Strength of Recommendation: Strong) 2. Screening for opioid abuse to identify opioid abusers. (Evidence: Level II-III; Strength of Recommendation: Moderate) 3. Utilization of prescription drug monitoring programs (PDMPs). (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 4. Utilization of urine drug testing (UDT). (Evidence: Level II; Strength of Recommendation: Moderate) 5. Establish appropriate physical diagnosis and psychological diagnosis if available. (Evidence: Level I; Strength of Recommendation: Strong) 6. Consider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints. (Evidence: Level III; Strength of Recommendation: Moderate) 7. Establish medical necessity based on average moderate to severe (≥ 4 on a scale of 0 - 10) pain and/or disability. (Evidence: Level II; Strength of Recommendation: Moderate) 8. Stratify patients based on risk. (Evidence: Level I-II; Strength of Recommendation: Moderate) 9. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: Level I-II; Strength of Recommendation: Moderate) 10. Obtain a robust opioid agreement, which is followed by all parties. (Evidence: Level III; Strength of Recommendation: Moderate)ii. Assessment of Effectiveness of Long-Term Opioid Therapy 11. Initiate opioid therapy with low dose, short-acting drugs, with appropriate monitoring. (Evidence: Level II; Strength of Recommendation: Moderate) 12. Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME as a moderate dose, and greater than 91 MME as high dose. (Evidence: Level II; Strength of Recommendation: Moderate) 13. Avoid long-acting opioids for the initiation of opioid therapy. (Evidence: Level I; Strength of Recommendation: Strong) 14. Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses, within FDA recommended doses. (Evidence: Level I; Strength of Recommendation: Strong) 15. Understand and educate the patients of the effectiveness and adverse consequences. (Evidence: Level I; Strength of Recommendation: Strong) 16. Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids. (Evidence: Level I-II; Strength of recommendation: Moderate to strong) 17. Periodically assess pain relief and/or functional status improvement of ≥ 30% without adverse consequences. (Evidence: Level II; Strength of recommendation: Moderate) 18. Recommend long-acting or high dose opioids only in specific circumstances with severe intractable pain. (Evidence: Level I; Strength of Recommendation: Strong)iii. Monitoring for Adherence and Side Effects 19. Monitor for adherence, abuse, and noncompliance by UDT and PDMPs. (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 20. Monitor patients on methadone with an electrocardiogram periodically. (Evidence: Level I; Strength of Recommendation: Strong). 21. Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated. (Evidence: Level I; Strength of Recommendation: Strong)iv. Final Phase 22. May continue with monitoring with continued medical necessity, with appropriate outcomes. (Evidence: Level I-II; Strength of Recommendation: Moderate) 23. Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation. (Evidence: Level III; Strength of Recommendation: Moderate) CONCLUSIONS: These guidelines were developed based on comprehensive review of the literature, consensus among the panelists, in consonance with patient preferences, shared decision-making, and practice patterns with limited evidence, based on randomized controlled trials (RCTs) to improve pain and function in chronic non-cancer pain on a long-term basis. Consequently, chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events.Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversionDisclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."
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Affiliation(s)
| | | | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | | | - Konstantin Slavin
- Stereotactic & Functional Neurosurgery, College of Medicine, University of Illinois at Chicago
| | | | | | | | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | - Steve M Aydin
- Manhattan Spine and Pain Medicine, New York, NY, and Hofstra-North Shore/LIJ School of Medicine, New York, NY
| | | | | | | | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | | | | | - David L Cedeno
- Millennium Pain Center, Bloomington, IL; Illinois State University, Normal, IL
| | | | | | | | | | | | | | | | | | | | | | - Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | | | | | | | | | | | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | | | - Peter S Staats
- Premier Pain Centers, Shrewsbury, NJ and Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Affiliation(s)
- Laxmaiah Manchikanti
- University of Louisville, Louisville, KY; Pain Management Center of Paducah, KY; ,Tri State Spine Care Institute, Cincinnati, OH; ,LSU School of Medicine, New Orleans, LA; and ,Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sairam Atluri
- University of Louisville, Louisville, KY; Pain Management Center of Paducah, KY; ,Tri State Spine Care Institute, Cincinnati, OH; ,LSU School of Medicine, New Orleans, LA; and ,Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alan David Kaye
- University of Louisville, Louisville, KY; Pain Management Center of Paducah, KY; ,Tri State Spine Care Institute, Cincinnati, OH; ,LSU School of Medicine, New Orleans, LA; and ,Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Joshua A Hirsch
- University of Louisville, Louisville, KY; Pain Management Center of Paducah, KY; ,Tri State Spine Care Institute, Cincinnati, OH; ,LSU School of Medicine, New Orleans, LA; and ,Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Manchikanti L, Atluri S, Hirsch JA. Comparison of Triamcinolone vs. Betamethasone Provides Inaccurate Information. Am J Phys Med Rehabil 2015; 94:e121-2. [DOI: 10.1097/phm.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaye AD, Manchikanti L, Abdi S, Atluri S, Bakshi S, Benyamin R, Boswell MV, Buenaventura R, Candido KD, Cordner HJ, Datta S, Doulatram G, Gharibo CG, Grami V, Gupta S, Jha S, Kaplan ED, Malla Y, Mann DP, Nampiaparampil DE, Racz G, Raj P, Rana MV, Sharma ML, Singh V, Soin A, Staats PS, Vallejo R, Wargo BW, Hirsch JA. Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis. Pain Physician 2015; 18:E939-E1004. [PMID: 26606031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results. OBJECTIVE To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain. STUDY DESIGN A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain. METHODS In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. RESULTS A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis. The evidence is Level III for cervical spinal stenosis management with an interlaminar approach. The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level III in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level III with cervical interlaminar epidural injections. LIMITATIONS Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. CONCLUSION This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions.
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Affiliation(s)
| | - Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | | | | | | | | | | | | | | | - Sanjeeva Gupta
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Eugene D Kaplan
- Optimum Health Medical Group, Clifton Park, NY, Kaplan Headache and Facial Pain Center, Clifton Park, NY, and Comprehensive Interventional Pain Management Center, Clifton Park, NY
| | | | | | | | | | | | | | | | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | | | - Peter S Staats
- Premier Pain Centers, Shrewsbury, NJ and Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Atluri S, Benyamin R, Kaye AD. Description of Optimal Angle of Needle Insertion For L5 Transforaminal Epidural Injection Leads to Complications. Pain Physician 2015; 18:E937-E938. [PMID: 26431153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Manchikanti L, Atluri S, Hirsch JA. The effect of abuse-deterrent extended-release oxycodone leads to inappropriate conclusions with over estimation of safety of abuse-deterrent formulations. Pain Physician 2015; 18:E445-E446. [PMID: 26000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Laxmaiah Manchikanti
- University of Louisville Louisville, Kentucky Medical Director Pain Management Center of Paducah Medical Director Tri-State Spine Care Institute Cincinnati, Ohio Department of Radiology Massachusetts General Hospital Harvard Medical School
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Stanley M, Villas P, Brown J, Atluri S. CT and MRI imaging findings following recent hepatic radioembolization: avoiding confusion interpreting benign findings versus pathologic findings. J Vasc Interv Radiol 2015. [DOI: 10.1016/j.jvir.2014.12.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Manchikanti L, Atluri S, Candido KD, Boswell MV, Simopoulos TT, Grider JS, Falco FJE, Hirsch JA. Zohydro approval by food and drug administration: controversial or frightening? Pain Physician 2014; 17:E437-E450. [PMID: 25054396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The actions and regulations of the Food and Drug Administration (FDA) are crucial to the entire population of the U.S., specifically the public who take a multitude of drugs and providers who prescribe drugs and devices. Further, the FDA is relevant to investors, specifically in regards to biotech and pharmaceutical companies involved in developing new drugs. The FDA has been criticized for a lack of independence on the one hand and excessive regulatory and expanding authority without evidence and consistency of the actions on the other hand. The FDA approved a single-entity, long-acting, hydrocodone product (Zohydro, Zogenix, San Diego, CA) on October 25, 2013, against the recommendation of the FDA's own appointed scientific advisory panel, which voted 11 to 2 against the approval of Zohydro. Subsequent to the approval, multiple consumer safety organizations, health care agencies, addiction treatment providers, professional organizations, and other groups on the frontline of the opioid addiction epidemic have expressed concern. In addition, the US Congress and various state attorneys general raised serious concerns about the approval of Zohydro, which is highly addictive and may enhance the opioid addiction epidemic. Supporters of Zohydro contend that it is necessary and essential to manage chronic pain and improve functional status with no additional risk. Over the past 15 years, prescriptions for opioids have skyrocketed with the United States consuming more than 84% of the global oxycodone and more than 99% of the hydrocodone supply. The sharp increase in opioid prescribing has led to parallel increases in opioid addiction and overdose deaths, surpassing motor vehicle injuries in the U.S. Recent studies assessing the trends of medical use and misuse of opioid analgesics from 2000 to 2011 have concluded that the present trend of the continued increase in the medical use of opioid analgesics appears to contribute to increasing misuse, resulting in multiple health consequences, despite numerous regulations enforced by multiple organizations. The approval of Zohydro and its defense from the FDA were based on a misunderstanding of the prevalence of chronic severe disabling pain. Based on inaccurate data from the Institute of Medicine, in part caused by conflicts of interest, 100 million persons have been described to suffer from severe pain - the correct number is 22.6 million. This manuscript analyzes 3 important principles of drug approval and utilization based on safety, efficacy, and medical necessity. Based on the limited literature that the authors were able to review including that which was submitted to the FDA by the manufacturers, it appears the safety, efficacy, and medical necessity were not demonstrated. In fact, the study submitted to the FDA showed a 50% pain improvement in only 48% of the patients in the treatment group and 21% of the patients in the placebo group at 85 day follow-up. This is a statistically significant result but its clinical relevance is unknown. The FDA approval decision occurring against the backdrop of the advisory panel recommendation is concerning and may result in serious consequences in the future.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
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Abstract
Background: The epidemic of medical use and abuse of opioid analgesics is linked to the economic
burden of opioid-related abuse and fatalities in the United States. Multiple studies have estimated
the extent to which prescription opioid analgesics contribute to the national drug abuse problem;
studies also assessing the trends in medical use and abuse of opioid analgesics have confirmed the
relationship between increasing medical use of opioids and increasing fatalities.
The available data is limited until 2002..
Study Design: Retrospective analysis of data from 2004 to 2011 from 2 databases: Automation
of Reports and Consolidated Orders System (ARCOS) for opioid use data and Drug Abuse Warning
Network (DAWN) for drug misuse data.
Objective: To determine the proportion of drug abuse related to opioid analgesics and the various
trends in the medical use and abuse of 8 opioid analgesics commonly used to treat pain: buprenorphine,
codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, and oxycodone.
Methods: The data obtained from DAWN is a nationally representative sample of hospital emergency
department admissions resulting from drug abuse.
Main outcome measure was the identification of trends in the medical use and misuse of opioid
analgesics from 2004 to 2011.
Results: From 2004 to 2011, there was an increase in the medical use of all opioids except for a
20% decrease in codeine. The abuse of all opioids including codeine increased during this period.
Increases in medical use ranged from 2,318% for buprenorphine to 35% for fentanyl, including
140% for hydromorphone, 117% for oxycodone, 73% for hydrocodone, 64% for morphine, and
37% for methadone. The misuse increased 384% for buprenorphine with available data from 2006
to 2011, whereas from 2004 to 2011, it increased 438% for hydromorphone, 263% for oxycodone,
146% for morphine, 107% for hydrocodone, 104% for fentanyl, 82% for methadone, and 39%
for codeine.
Comparison of opioid use showed an overall increase of 1,448% from 1996 to 2011, with increases if
690% from 1996 to 2004 and 100% from 2004 to 2011. In contrast, misuse increased more dramatically:
4,680% from 1996 to 2011, with increases of 1,372% from 1996 through 2004 and 245% from 2004
to 2011. The number of patients seeking rehabilitation for substance abuse also increased 187% for
opioids, whereas it increased 87% for heroin, 40% for marijuana, and decreased 7% for cocaine.
Limitations: Limitations of this assessment include the lack of data from 2003, lack of data
available on meperidine, and that the aggregate data systems used in the study did not identify
specific formulations or commercial products.
Conclusion: The present trend of continued increase in the medical use of opioid analgesics appears
to contribute to increases in misuse, resulting in multiple health consequences.
Key words: Medical use of opioids, inappropriate use of opioids, abuse of opioids, opioid-related
fatalities, Automation of Reports and Consolidated Orders System (ARCOS), Drug Abuse Warning
Network (DAWN), International Narcotics Control Board (INCB)
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Manchikanti L, Atluri S, Boswell MV, Hansen HC. Opioid overuse pain syndrome. J Opioid Manag 2014; 10:81. [PMID: 24946369 DOI: 10.5055/jom.2014.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Author's response also included
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Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician 2014; 17:E119-E128. [PMID: 24658483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The epidemic of medical use and abuse of opioid analgesics is linked to the economic burden of opioid-related abuse and fatalities in the United States. Multiple studies have estimated the extent to which prescription opioid analgesics contribute to the national drug abuse problem; studies also assessing the trends in medical use and abuse of opioid analgesics have confirmed the relationship between increasing medical use of opioids and increasing fatalities.The available data is limited until 2002. STUDY DESIGN Retrospective analysis of data from 2004 to 2011 from 2 databases: Automation of Reports and Consolidated Orders System (ARCOS) for opioid use data and Drug Abuse Warning Network (DAWN) for drug misuse data. OBJECTIVE To determine the proportion of drug abuse related to opioid analgesics and the various trends in the medical use and abuse of 8 opioid analgesics commonly used to treat pain: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, and oxycodone. METHODS The data obtained from DAWN is a nationally representative sample of hospital emergency department admissions resulting from drug abuse. Main outcome measure was the identification of trends in the medical use and misuse of opioid analgesics from 2004 to 2011. RESULTS From 2004 to 2011, there was an increase in the medical use of all opioids except for a 20% decrease in codeine. The abuse of all opioids including codeine increased during this period. Increases in medical use ranged from 2,318% for buprenorphine to 35% for fentanyl, including 140% for hydromorphone, 117% for oxycodone, 73% for hydrocodone, 64% for morphine, and 37% for methadone. The misuse increased 384% for buprenorphine with available data from 2006 to 2011, whereas from 2004 to 2011, it increased 438% for hydromorphone, 263% for oxycodone, 146% for morphine, 107% for hydrocodone, 104% for fentanyl, 82% for methadone, and 39% for codeine. Comparison of opioid use showed an overall increase of 1,448% from 1996 to 2011, with increases of 690% from 1996 to 2004 and 100% from 2004 to 2011. In contrast, misuse increased more dramatically: 4,680% from 1996 to 2011, with increases of 1,372% from 1996 through 2004 and 245% from 2004 to 2011. The number of patients seeking rehabilitation for substance abuse also increased 187% for opioids, whereas it increased 87% for heroin, 40% for marijuana, and decreased 7% for cocaine. LIMITATIONS Limitations of this assessment include the lack of data from 2003, lack of data available on meperidine, and that the aggregate data systems used in the study did not identify specific formulations or commercial products. CONCLUSION The present trend of continued increase in the medical use of opioid analgesics appears to contribute to increases in misuse, resulting in multiple health consequences.
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Affiliation(s)
| | | | - Laxmaiah Manchikanti
- Tri-State Spine Care Institute, Cincinnati, OH; Cincinnati Pain Management Consultants, Cincinnati, OH; Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
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Manchikanti L, Atluri S, Hansen H, Benyamin RM, Falco FJE, Helm Ii S, Kaye AD, Hirsch JA. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician 2014; 17:E1-E10. [PMID: 24452651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY; and University of Louisville, Louisville, KY
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Atluri S. Needle Position Analysis in Cases of Paralysis
From Transforaminal Epidurals: Consider
Alternative Approaches to Traditional Technique. Pain Physician 2013. [DOI: 10.36076/ppj.2013/16/321] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Transforaminal technique for epidural steroid injections, unlike other
approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis.
Objective: To review the literature and analyze the reported cases of paralysis from lumbar
transforaminal epidural steroid injections to possibly establish a cause and to prevent this
complication.
Study Design: Eighteen cases of paralysis from transforaminal epidural injection have been
reported. We could analyze the position of the needle within the neural foramen based on the
available images and/or description among 10 of these 18 cases. Five cases were performed
with computed tomography guidance and 12 cases were performed with fluoroscopic guidance
[unknown in one case]. Additionally, other variables associated with the procedure, including
the technique, were also examined.
Methods: Analysis of the needle position in the neural foramen in cases of paralysis from
transforaminal epidural steroid injections. This analysis is based on images and/or description
provided in published reports.
Results: Paralysis in these cases seems to be associated with a well performed traditional safe
triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the
time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was
in the anterior part of the foramen. This coincides with the location of the radicular artery in the
foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone).
No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events
happened during a left-sided procedure and 8 during a right-sided procedure. No relation to
this complication was noted when other variables like type and size of the needles, side of the
injection, local anesthetic, contrast, or volume of injectate were taken into consideration.
Limitations: Only 18 cases of paralysis from transforaminal epidurals have been reported.
Out of these, only 10 cases included images or descriptions which could be evaluated for our
study.
Conclusion: In light of the anatomical and radiological evidence in the literature that radicular
arteries dwell in the superior part of the foramen and along with our needle position analysis,
we suggest that the traditional technique of placing the needle in the superior and anterior part
of the foramen must be reexamined. Alternative, safer techniques must be considered, one of
which is described.
Key words: Lumbar epidural injection, lumbar transforaminal, approach, selective nerve root
block, paralysis, steroid, particulate, nonparticulate, safe triangle, radicular artery, artery of
Adamkiewicz
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Atluri S, Glaser SE, Shah RV, Sudarshan G. Needle position analysis in cases of paralysis from transforaminal epidurals: consider alternative approaches to traditional technique. Pain Physician 2013; 16:321-334. [PMID: 23877448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Transforaminal technique for epidural steroid injections, unlike other approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis. OBJECTIVE To review the literature and analyze the reported cases of paralysis from lumbar transforaminal epidural steroid injections to possibly establish a cause and to prevent this complication. STUDY DESIGN Eighteen cases of paralysis from transforaminal epidural injection have been reported. We could analyze the position of the needle within the neural foramen based on the available images and/or description among 10 of these 18 cases. Five cases were performed with computed tomography guidance and 12 cases were performed with fluoroscopic guidance [unknown in one case]. Additionally, other variables associated with the procedure, including the technique, were also examined. METHODS Analysis of the needle position in the neural foramen in cases of paralysis from transforaminal epidural steroid injections. This analysis is based on images and/or description provided in published reports. RESULTS Paralysis in these cases seems to be associated with a well performed traditional safe triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was in the anterior part of the foramen. This coincides with the location of the radicular artery in the foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone). No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events happened during a left-sided procedure and 8 during a right-sided procedure. No relation to this complication was noted when other variables like type and size of the needles, side of the injection, local anesthetic, contrast, or volume of injectate were taken into consideration. LIMITATIONS Only 18 cases of paralysis from transforaminal epidurals have been reported. Out of these, only 10 cases included images or descriptions which could be evaluated for our study. CONCLUSION In light of the anatomical and radiological evidence in the literature that radicular arteries dwell in the superior part of the foramen and along with our needle position analysis, we suggest that the traditional technique of placing the needle in the superior and anterior part of the foramen must be reexamined. Alternative, safer techniques must be considered, one of which is described.
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Affiliation(s)
- Sairam Atluri
- Tri-State Spine Care Institute, Cincinnati, OH 45230, USA.
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Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Cash KA, Christo PJ, Cohen SP, Colson J, Conn A, Cordner H, Coubarous S, Datta S, Deer TR, Diwan S, Falco FJE, Fellows B, Geffert S, Grider JS, Gupta S, Hameed H, Hameed M, Hansen H, Helm S, Janata JW, Justiz R, Kaye AD, Lee M, Manchikanti KN, McManus CD, Onyewu O, Parr AT, Patel VB, Racz GB, Sehgal N, Sharma ML, Simopoulos TT, Singh V, Smith HS, Snook LT, Swicegood JR, Vallejo R, Ward SP, Wargo BW, Zhu J, Hirsch JA. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16:S49-S283. [PMID: 23615883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. METHODOLOGY Systematic assessment of the literature. EVIDENCE I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. • The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections. • The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic epidural injections in managing thoracic pain. • The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections. IV. Implantables • The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. • There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox). • There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events. CONCLUSIONS Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed. DISCLAIMER The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."
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Datta S, Manchikanti L, Falco FJE, Calodney AK, Atluri S, Benyamin RM, Buenaventura RM, Cohen SP. Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: systematic review and update of current evidence. Pain Physician 2013; 16:SE97-SE124. [PMID: 23615888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Lumbosacral selective nerve root blocks and/ or transforaminal epidural injections are used for diagnosis and treatment of different disorders causing low back and lower extremity pain. A clear consensus on the use of selective nerve root injections as a diagnostic tool does not currently exist. Additionally, the validity of this procedure as a diagnostic tool is not clear. OBJECTIVE To evaluate and update the accuracy of selective nerve root injections in diagnosing lumbar spinal disorders. STUDY DESIGN A systematic review of selective nerve root blocks for the diagnosis of low back and lower extremity pain. METHODS Methodological quality assessment of included studies was performed using the Quality Appraisal of Reliability Studies (QAREL) checklist. Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and analyzed critically. The level of evidence was classified as good, fair, or limited or poor based on the quality of evidence grading scale developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES In this review, we evaluated studies in which controlled local anesthetic blocks were performed using at least 50% pain relief as the reference standard. RESULTS There is limited evidence for the accuracy of selective nerve root injections as a diagnostic tool for lumbosacral disorders. There is limited evidence for their use in the preoperative evaluation of patients with negative or inconclusive imaging studies. LIMITATIONS The limitations of this systematic review include a paucity of literature, variations in technique, and variable criterion standards for the diagnosis of lumbar radicular pain. CONCLUSIONS There is limited evidence for selective nerve root injections as a diagnostic tool in evaluating low back pain with radicular features. However, their role needs to be further clarified by additional research and consensus.
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Affiliation(s)
- Sukdeb Datta
- Laser Spine & Pain Institute, and Mount Sinai School of Medicine, New York, NY, USA
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Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, Brown KR, Bruel BM, Bryce DA, Burks PA, Burton AW, Calodney AK, Caraway DL, Cash KA, Christo PJ, Damron KS, Datta S, Deer TR, Diwan S, Eriator I, Falco FJE, Fellows B, Geffert S, Gharibo CG, Glaser SE, Grider JS, Hameed H, Hameed M, Hansen H, Harned ME, Hayek SM, Helm S, Hirsch JA, Janata JW, Kaye AD, Kaye AM, Kloth DS, Koyyalagunta D, Lee M, Malla Y, Manchikanti KN, McManus CD, Pampati V, Parr AT, Pasupuleti R, Patel VB, Sehgal N, Silverman SM, Singh V, Smith HS, Snook LT, Solanki DR, Tracy DH, Vallejo R, Wargo BW. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician 2012. [PMID: 22786449 DOI: 10.36076/ppj.2012/15/s67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
RESULTS Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. ( EVIDENCE good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. ( EVIDENCE limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. ( EVIDENCE good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. ( EVIDENCE good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. ( EVIDENCE good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. ( EVIDENCE good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. ( EVIDENCE fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. ( EVIDENCE good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. ( EVIDENCE good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. ( EVIDENCE fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. ( EVIDENCE fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. ( EVIDENCE fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. ( EVIDENCE fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. ( EVIDENCE fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. ( EVIDENCE good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. ( EVIDENCE limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. ( EVIDENCE fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. ( EVIDENCE fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. ( EVIDENCE good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. ( EVIDENCE fair). DISCLAIMER The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."
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Falco FJE, Manchikanti L, Datta S, Wargo BW, Geffert S, Bryce DA, Atluri S, Singh V, Benyamin RM, Sehgal N, Ward SP, Helm S, Gupta S, Boswell MV. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician 2012; 15:E839-E868. [PMID: 23159978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND The prevalence of chronic, recurrent neck pain is approximately 15% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. STUDY DESIGN Systematic review of therapeutic cervical facet joint interventions. OBJECTIVE To determine and update the clinical utility of therapeutic cervical facet joint interventions in the management of chronic neck pain. METHODS The available literature for utility of facet joint interventions in therapeutic management of cervical facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS In this systematic review, 32 manuscripts were considered for inclusion. For final analysis, 4 randomized trials and 6 observational studies met the inclusion criteria and were included in the evidence synthesis. Based on one randomized, sham-controlled, double-blind trial and 5 observational studies, the indicated evidence for cervical radiofrequency neurotomy is fair. Based on one randomized, double-blind, active-controlled trial and one prospective evaluation, the indicated evidence for cervical medial branch blocks is fair. Based on 2 randomized controlled trials, the evidence for cervical intraarticular injections is limited. LIMITATIONS Paucity of the overall published literature and specifically lack of literature for intraarticular cervical facet joint injections. CONCLUSIONS The indicated evidence for cervical radiofrequency neurotomy is fair. The indicated evidence for cervical medial branch blocks is fair. The indicated evidence for cervical intraarticular injections with local anesthetic and steroids is limited.
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Affiliation(s)
- Frank J E Falco
- Mid Atlantic Spine & Pain Physicians of Newark, Newark, DE, USA.
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Abstract
Background: Chronic mid back and upper back pain caused by thoracic facet joints
has been reported in 34% to 48% of the patients based on their responses to controlled
diagnostic blocks. Systematic reviews have established moderate evidence for controlled
comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and
upper back pain.
Objective: To determine the diagnostic accuracy of thoracic facet joint nerve blocks in the
assessment of chronic upper back and mid back pain.
Study Design: Systematic review of the diagnostic accuracy of thoracic facet joint nerve
blocks.
Methods: A methodological quality assessment of included studies was performed using
Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at
least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less
than 50% are presented descriptively and critically analyzed.
The level of evidence was classified as good, fair, and limited (or poor) based on the quality
of evidence developed by the United States Preventive Services Task Force (USPSTF).
Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 to March 2012, and manual searches of the bibliographies of known primary and
review articles.
Outcome Measures: Controlled placebo or local anesthetic blocks were utilized using at
least 50% pain relief as the reference standard.
Results: Three studies were identified utilizing controlled comparative local anesthetic
blocks, with ≥50% pain relief as the criterion standard. The evidence is good for the diagnosis
of thoracic pain of facet joint origin with controlled diagnostic blocks.
Limitations: The limitations of this systematic review include a paucity of literature for
the diagnosis of thoracic facet joint pain, with all included manuscripts originating from one
group of authors.
Conclusions: Based on this systematic review, the evidence for the diagnostic accuracy of
thoracic facet joint injections is good.
Key words: Chronic thoracic pain, mid back or upper back pain, thoracic facet or
zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, controlled
comparative local anesthetic blocks
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Abstract
Background: The use of opioids for chronic non-cancer pain has grown exponentially in
the last 15 years. Associated with that, dramatic increases in abuse and overdose deaths from
opioid use have been noted.
Objectives: Most opioid abuse stems from legitimate prescriptions, putting the onus on
prescribers to use opioids responsibly for chronic pain. Very little evidence-based guidance
exists for those who wish to prescribe opioids for legitimate chronic pain and at the same time
prevent opioid abuse.
Methods: A review of literature was performed for articles focused on guidelines for opioid
use when prescribed for chronic pain, opioid abuse, and overdose, strategies to detect and
prevent abuse of opioids, urine drug screens (UDS) in chronic pain settings, prescription
monitoring programs (PMP), and the relationship between opioid dosing and abuse.
Results: Based on the existing literature, an evidence-based algorithmic approach was
developed to decrease opioid abuse in the chronic pain environment. The pillars of prevention
are the screening of patients into high, medium, and low risk categories using screening tools;
monitoring patients using UDS, PMP, and pill counts, and lastly, dose limitations.
Conclusion: This algorithmic approach may enable physicians to prescribe opioids for patients
with chronic pain and also to reduce opioid abuse.
Key words: Opioids, chronic pain, abuse, prescription, overdose, deaths, overdose deaths,
urine drug screens, prescription monitoring programs, opioid dose, screening, monitoring
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Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, Brown KR, Bruel BM, Bryce DA, Burks PA, Burton AW, Calodney AK, Caraway DL, Cash KA, Christo PJ, Damron KS, Datta S, Deer TR, Diwan S, Eriator I, Falco FJE, Fellows B, Geffert S, Gharibo CG, Glaser SE, Grider JS, Hameed H, Hameed M, Hansen H, Harned ME, Hayek SM, Helm S, Hirsch JA, Janata JW, Kaye AD, Kaye AM, Kloth DS, Koyyalagunta D, Lee M, Malla Y, Manchikanti KN, McManus CD, Pampati V, Parr AT, Pasupuleti R, Patel VB, Sehgal N, Silverman SM, Singh V, Smith HS, Snook LT, Solanki DR, Tracy DH, Vallejo R, Wargo BW. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I--evidence assessment. Pain Physician 2012; 15:S1-S65. [PMID: 22786448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Opioid abuse has continued to increase at an alarming rate since the 1990 s. As documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration, available evidence suggests a wide variance in chronic opioid therapy of 90 days or longer in chronic non-cancer pain. Part 1 describes evidence assessment. OBJECTIVES The objectives of opioid guidelines as issued by the American Society of Interventional Pain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to produce consistency in the application of an opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion. The focus of these guidelines is to curtail the abuse of opioids without jeopardizing non-cancer pain management with opioids. RESULTS 1) There is good evidence that non-medical use of opioids is extensive; one-third of chronic pain patients may not use prescribed opioids as prescribed or may abuse them, and illicit drug use is significantly higher in these patients. 2) There is good evidence that opioid prescriptions are increasing rapidly, as the majority of prescriptions are from non-pain physicians, many patients are on long-acting opioids, and many patients are provided with combinations of long-acting and short-acting opioids. 3) There is good evidence that the increased supply of opioids, use of high dose opioids, doctor shoppers, and patients with multiple comorbid factors contribute to the majority of the fatalities. 4) There is fair evidence that long-acting opioids and a combination of long-acting and short-acting opioids contribute to increasing fatalities and that even low-doses of 40 mg or 50 mg of daily morphine equivalent doses may be responsible for emergency room admissions with overdoses and deaths. 5) There is good evidence that approximately 60% of fatalities originate from opioids prescribed within the guidelines, with approximately 40% of fatalities occurring in 10% of drug abusers. 6) The short-term effectiveness of opioids is fair, whereas the long-term effectiveness of opioids is limited due to a lack of long-term (> 3 months) high quality studies, with fair evidence with no significant difference between long-acting and short-acting opioids. 7) Among the individual drugs, most opioids have fair evidence for short-term and limited evidence for long-term due to a lack of quality studies. 8) The evidence for the effectiveness and safety of chronic opioid therapy in the elderly for chronic non-cancer pain is fair for short-term and limited for long-term due to lack of high quality studies; limited in children and adolescents and patients with comorbid psychological disorders due to lack of quality studies; and the evidence is poor in pregnant women. 9) There is limited evidence for reliability and accuracy of screening tests for opioid abuse due to lack of high quality studies. 10) There is fair evidence to support the identification of patients who are non-compliant or abusing prescription drugs or illicit drugs through urine drug testing and prescription drug monitoring programs, both of which can reduce prescription drug abuse or doctor shopping. DISCLAIMER The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."
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Manchikanti KN, Atluri S, Singh V, Geffert S, Sehgal N, Falco FJE. An update of evaluation of therapeutic thoracic facet joint interventions. Pain Physician 2012; 15:E463-E481. [PMID: 22828694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of patients based on responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain, moderate evidence for therapeutic thoracic medial branch blocks, and limited evidence for radiofrequency neurotomy of thoracic medial branches. STUDY DESIGN Systematic review of therapeutic thoracic facet joint interventions. OBJECTIVE To determine the clinical utility of therapeutic thoracic facet joint interventions in the therapeutic management of chronic upper back and mid back pain. METHODS The available literature for the utility of facet joint interventions in the therapeutic management of thoracic facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS For this systematic review, 13 studies were identified. Of these, 7 studies were excluded, and a total of 4 studies (after removal of duplicate publication) met inclusion criteria for methodological quality assessment with one randomized trial and 3 non-randomized studies. The evidence is fair for therapeutic thoracic facet joint nerve blocks, limited for thoracic radiofrequency neurotomy, and not available for thoracic intraarticular injections. LIMITATIONS The limitation of this systematic review includes a paucity of literature. The only positive studies were of medial branch blocks performed by the same group of authors. CONCLUSION The evidence for therapeutic facet joint interventions is fair for medial branch blocks, whereas it is not available for intraarticular injections, and limited for radiofrequency neurotomy due to lack of literature.
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Atluri S, Singh V, Datta S, Geffert S, Sehgal N, Falco FJE. Diagnostic accuracy of thoracic facet joint nerve blocks: an update of the assessment of evidence. Pain Physician 2012; 15:E483-E496. [PMID: 22828695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on their responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain. OBJECTIVE To determine the diagnostic accuracy of thoracic facet joint nerve blocks in the assessment of chronic upper back and mid back pain. STUDY DESIGN Systematic review of the diagnostic accuracy of thoracic facet joint nerve blocks. METHODS A methodological quality assessment of included studies was performed using Quality Appraisal of Reliability Studies (QAREL). Only diagnostic accuracy studies meeting at least 50% of the designated inclusion criteria were utilized for analysis. Studies scoring less than 50% are presented descriptively and critically analyzed. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to March 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES Controlled placebo or local anesthetic blocks were utilized using at least 50% pain relief as the reference standard. RESULTS Three studies were identified utilizing controlled comparative local anesthetic blocks, with ≥ 50% pain relief as the criterion standard. The evidence is good for the diagnosis of thoracic pain of facet joint origin with controlled diagnostic blocks. LIMITATIONS The limitations of this systematic review include a paucity of literature for the diagnosis of thoracic facet joint pain, with all included manuscripts originating from one group of authors. CONCLUSIONS Based on this systematic review, the evidence for the diagnostic accuracy of thoracic facet joint injections is good.
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Affiliation(s)
- Sairam Atluri
- Tri-State Spine Care Institute, Cincinnati, OH, USA.
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