Pain physician
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Opioids are broad-spectrum analgesics with potent pain-relieving qualities but also with potential adverse effects related to both short-term and long-term therapy. Researchers have attempted to alter existing opioid analgesics, utilize different routes/formulations, or combine opioid analgesics with other compounds in efforts to improve analgesia while minimizing adverse effects. Exogenous opioids, administered in efforts to achieve analgesia, work by mimicking the actions of endogenous opioids. ⋯ This notion has been supported by the observation that the quaternary compound morphine methyliodide, which does not as readily cross the bloodbrain barrier and enter the CNS, produced antinociception following intradermal administration into the hindpaw, but not when the same dose was administered systemically (subcutaneously at a distant site). With a growing appreciation of peripheral endogenous opioids, peripheral endogenous opioid receptors, and peripheral endogenous opioid analgesic systems, investigators began growing hopeful that it may be possible to achieve adequate analgesics while avoiding unwanted central untoward adverse effects (e.g. respiratory depression, somnolence, addiction). Peripherally-acting opioids, which capitalize on peripheral endogenous opioid analgesic systems, may be one potential future strategy which may be utilized in efforts to achieve potent analgesia with minimal side effects.
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It has been appreciated for some time now that humans react differently to opioids. A specific opioid such as morphine sulfate may have specific analgesic effects for certain patients with postherpetic neuralgia whereas in other patients with postherpetic neuralgia, it may provide quite different analgesic qualities. Also, in any one individual patient a particular opioid may provide better analgesia than other opioids. ⋯ In the future, knowledge gained from databases on knockout rodents, pharmacogenetics, and gene polymorphisms may impact on the ability of clinicians to predict patient responses to doses of specific opioids in efforts to individualize optimal opioid analgesic therapy. It is conceivable that eventually information of this type may translate into improved patient care. In the future, armed with data of this type, clinicians may become quite adept at tailoring appropriate opioid therapy as well as optimal opioid rotation strategies.
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Randomized Controlled Trial Comparative Study Clinical Trial
Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914.
Lumbar facet joints have been implicated as the source of chronic pain in 15% to 45% of patients with chronic low back pain. Various therapeutic techniques including intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin. ⋯ Therapeutic lumbar facet joint nerve blocks, with or without steroid, may provide a management option for chronic function-limiting low back pain of facet joint origin.
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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 pelvic pain can present in various pain syndromes. In particular, interventional procedure plays an important diagnostic and therapeutic role in 3 types of pelvic pain syndromes: pudendal neuralgia, piriformis syndrome, and "border nerve" syndrome (ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy). The objective of this review is to discuss the ultrasound-guided approach of the interventional procedures commonly used for these 3 specific chronic pelvic pain syndromes. ⋯ The ultrasound machine is portable and is more readily available to the pain specialist. It prevents patients and healthcare professionals from the exposure to radiation during the procedure. Because it allows the visualization of a wide variety of tissues, it potentially improves the accuracy of the needle placement, as exemplified by various interventional procedures in the pelvic regions aforementioned.