Pain medicine : the official journal of the American Academy of Pain Medicine
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There has been considerable progress identifying pathophysiologic mechanisms of neuropathic pain, but analgesic medications with improved efficacy, safety, and tolerability still represent an unmet public health need. Numerous treatments examined in recent randomized clinical trials (RCTs) have failed to show efficacy for neuropathic pain, including treatments that had previously demonstrated efficacy. This suggests that at least some negative results reflect limited assay sensitivity of RCTs to distinguish efficacious treatments from placebo. ⋯ The US Food and Drug Administration recently launched the Analgesic Clinical Trial Innovations, Opportunities, and Networks (ACTION) public-private partnership, which is designed to facilitate the discovery and development of analgesics with improved efficacy, safety, and tolerability for acute and chronic pain conditions. ACTION will establish a collaborative effort to prioritize research objectives, develop a standardized analgesic database platform, and conduct methodologically focused studies to increase the assay sensitivity and efficiency of analgesic clinical trials. The results of these activities have the potential to inform and accelerate the development of improved pain management interventions of all types, not just pharmacologic treatments.
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The study aims to highlight the potentially serious consequences of inadvertent soft-tissue injection of intrathecal drugs such as clonidine, during refills of implanted drug delivery devices, and to suggest strategies to reduce this complication. ⋯ Inadvertent soft-tissue injection is possibly an underappreciated and underreported complication of intrathecal analgesia via an implanted drug delivery device. Under some circumstances, large doses of other intrathecal drugs such as bupivacaine, opioids, ziconotide, and baclofen may also be delivered by inadvertent soft-tissue injection with potentially life-threatening consequences. We recommend that practitioners, institutions, and professional bodies who manage patients with intrathecal analgesia via intrathecal drug delivery devices highlight and audit this complication and develop systems to manage it.
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Randomized Controlled Trial
Efficacy of gabapentin enacarbil vs placebo in patients with postherpetic neuralgia and a pharmacokinetic comparison with oral gabapentin.
The efficacy of gabapentin in some patients with postherpetic neuralgia (PHN) may be limited by suboptimal drug exposure from unpredictable and saturable absorption. Gabapentin enacarbil (GEn) was designed for absorption by high-capacity transporters expressed throughout the intestine and undergoes rapid postabsorption hydrolysis to gabapentin. GEn extended-release tablets provide sustained, dose-proportional gabapentin exposure. This study assessed the efficacy of GEn vs placebo and compared the pharmacokinetics of gabapentin after oral dosing of GEn or gabapentin in patients with PHN. ⋯ GEn was effective in providing PHN pain relief, improved gabapentin exposure compared with gabapentin capsules, and was generally safe and well tolerated in patients with PHN.
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To ascertain whether a small sample of patients with chronic pelvic pain experienced any pain-related cognitions in the form of mental images. ⋯ Negative pain-related cognitions in the form of intrusive mental imagery were reported by women with chronic pelvic pain. Targeting such imagery has led to interesting treatment innovation in the emotional disorders. Thus, imagery, hitherto neglected in pain phenomenology, could provide a novel target for cognitive behavioral therapy in chronic pain. These exciting yet preliminary results require replication and extension in a broader population of patients with chronic pain.
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Historical Article
The business of pain medicine: the present mirrors antiquity.
The practice of pain medicine is often considered a fledgling field, as are the economic, business, and related ethical issues associated with providing these services. This article first traces the history of pain care and its relationships to industry and business, as well as the impact of government regulations over the ages. The authors challenge the view that the commonly discussed health care issues facing pain medicine are new by tracing the business and regulatory-related antecedents of pain care practice from the first through 21st century. ⋯ These arguments are reflected against the pain medicine Ethics Charters of the American Academy of Pain Medicine throughout the document. Finally, we outline the challenges for the present and future. With an understanding of these eight historical events as a backdrop, we may be at an opportune time to better address these issues in a manner that could provide the most effective pain care in our society.