Pain physician
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Intrathecal analgesia has emerged as a key therapeutic option for pain relief for patients who have failed other treatment avenues as well as patients with adequate analgesia on high dose enteral or parenteral therapy but with unacceptable side effects. Intrethecal infusions of analgesics have been increasingly utilized since the later 1980s for the treatment of persistent pain. The purpose of this review is to provide research based clinical insight regarding the safe and appropriate use of the intrathecal infusion modality. ⋯ Novel combinations of intrathecal analgesics such as clonidine and gabapentin deserve future study. The current body of literature supports the use of intrathecal agents for the treatment of moderate or severe pain related to cancer and noncancer origins. Further clinical studies are needed to evaluate the efficacy and safety of new intrathecal drugs, the complications related to these devices, and the proper selection of patients to receive these treatments.
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Review Practice Guideline
Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines.
Opioid abuse has continued to increase at an alarming rate since our last opioid guidelines were published in 2005. Available evidence suggests a continued wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration. ⋯ Opioids are commonly prescribed for chronic non-cancer pain and may be effective for short-term pain relief. However, long-term effectiveness of 6 months or longer is variable with evidence ranging from moderate for transdermal fentanyl and sustained-release morphine with a Level II-2, to limited for oxycodone with a Level II-3, and indeterminate for hydrocodone and methadone with a Level III. These guidelines included the evaluation of the evidence for the use of opioids in the management of chronic non-cancer pain and the recommendations for that management. These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."
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Evidence-based medicine, systematic reviews, and guidelines are part of modern interventional pain management. As in other specialties in the United States, evidence-based medicine appears to motivate the search for answers to numerous questions related to costs and quality of health care as well as access to care. Scientific, relevant evidence is essential in clinical care, policy-making, dispute resolution, and law. ⋯ Appropriately developed guidelines incorporate validity, reliability, reproducibility, clinical applicability and flexibility, clarity, development through a multidisciplinary process, scheduled reviews, and documentation. Thus, evidence-based clinical practice guidelines represent statements developed to improve the quality of care, patient access, treatment outcomes, appropriateness of care, efficiency and effectiveness and achieve cost containment by improving the cost benefit ratio. Part 1 of this series in evidence-based medicine, systematic reviews, and guidelines in interventional pain management provides an introduction and general considerations of these 3 aspects in interventional pain management.
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Mu agonists have been an important component of pain treatment for thousands of years. The usual pharmacokinetic parameters (half-life, clearance, volume of distribution) of opioids have been known for some time. However, the metabolism has, until recently, been poorly understood, and there has been recent interest in the role of metabolites in modifying the pharmacodynamic response in patients, in both analgesia and adverse effects. A number of opioids are available for clinical use, including morphine, hydromorphone, levorphanol, oxycodone, and fentanyl. Advantages and disadvantages of various opioids in the management of chronic pain are discussed. ⋯ Mu receptor agonists and agonist-antagonists have been used throughout recent medical history for the control of pain and for the treatment of opiate induced side effects and even opiate withdrawal syndromes.
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Chronic headache represents a very significant public health and economic issue. One treatment modality for chronic refractory headache involves the use of subcutaneous implanted neurostimulator leads in the occipital region. Varied types of headache etiologies including migraine, transformed migraine, chronic daily headache, cluster headache, hemicrania continua, occipital neuralgia, and cervicogenic headache have been studied with peripheral nerve field stimulation and found responsive to stimulation of the suboccipital region, known commonly as occipital nerve stimulation (ONS). ⋯ ONS is a useful tool in the treatment of chronic severe headaches with at least Level IV (limited) evidence based on multiple positive studies.