Pain physician
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Various methods exist for trialing patients for intrathecal drug delivery. Currently no standards exist regarding "best practices" for trialing techniques. ⋯ Opioid taper and a 6 week opioid-free period may 1) improve long-term analgesia versus a combination of oral/ intrathecal drug delivery system therapy 2) it may be possible to maintain analgesia at microgram doses and 3) opioid tolerance may be reversible in 6 weeks. Further it appears that a dose response relationship for effective analgesia may be less than 400 μg of intrathecal morphine.
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Morphine sulfate and naltrexone hydrochloride extended-release capsules (EMBEDA, King Pharmaceuticals, Inc., Bristol, TN), indicated for management of chronic, moderate-to-severe pain, contain pellets of extended-release morphine sulfate with a sequestered naltrexone core (MS-sNT). Taken as directed, morphine provides analgesia while naltrexone remains sequestered; if tampered with by crushing, naltrexone is released to mitigate morphine-induced euphoric effects. While it is necessary to establish that formulations intended to reduce attractiveness for abuse are successful in doing so, it is also necessary to demonstrate that product therapeutic integrity is maintained for patients. ⋯ When MS-sNT capsules are crushed, all of the sequestered naltrexone (relative to oral NS) is released and immediately available to mitigate morphine-induced effects. When MS-sNT was crushed, the naltrexone released abated drug liking and euphoria relative to that from an equal dose of immediate-release morphine from MSS administration in a majority of participants. Naltrexone concentrations were low over a period of 12 months without evidence of accumulation, and there were no observable opioid withdrawal symptoms when MS-sNT was taken as directed.
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Randomized Controlled Trial
The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc.
Intervertebral disc herniations are the most common cause of lumbosacral radiculopathy, and transforaminal epidural steroid injection (TFESI) is an important tool in treating lumbosacral radiculopathy. But the ideal dose of corticosteroid in the epidural management of lumbosacral radiculopathy has yet to be determined. ⋯ We recommend a minimal effective dose of corticosteroid (triamcinolone 10 mg) in TFESI for patients with lumbosacral radiculopathy.
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Randomized Controlled Trial
Lumbar retrodiscal versus post-ganglionic transforaminal epidural steroid injection for the treatment of lumbar intervertebral disc herniations.
Lumbar transforaminal epidural steroid injections (TFESIs) are procedures often utilized in the treatment of radicular pain. TFESIs with a preganglionic approach have been reported to be more effective than TFESIs performed using a classic approach. However, it is unknown whether TFESIs using a retrodiscal approach are as effective as other approaches. ⋯ In this study, TFESIs performed using a retrodiscal or classic approach had similar effects on radicular pain. The classic and the retrodiscal transforaminal steroid injection resulted in equivalent pain relief.
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Up to 90% of patients with metastatic or advanced stage cancer will experience significant cancer-related pain. Approximately half or more of patients diagnosed with cancer may experience bone pain. It has been estimated that tumor metastases to the skeleton affect roughly 400,000 United States citizens annually. ⋯ Although the mechanisms underlying the development of bone metastases are not completely understood, there appears to be important bi-directional interactions between the tumor and the bone microenvironment. A greater understanding of the pathophysiology of painful osseous metastases may lead to better and more selective targeted analgesic therapy. Additionally, potential future therapeutic approaches to painful osseous metastases may revolutionize approaches to analgesia for this condition, leading to optimal outcomes with maximal pain relief and minimal adverse effects.