Pain physician
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Opioid misuse and abuse occurring in association with the treatment of chronic non-cancer pain are not new phenomena, but their increasing prevalence in recent years is unprecedented. Advancements in pharmaceutical technologies have provided opioid-related drugs, which lack the pure mu agonist activity characteristic of the typical opioid congeners. This absent or altered mu receptor activity imparts an opioid receptor antagonistic or partial agonistic pharmacologic action, which serves to modulate the development of opioid-induced tolerance and physical dependence and facilitate detoxification and withdrawal from opioids. Opioid antagonists and partial agonists are being used in abuse deterrent strategy regimens to prevent opioid tolerance and the development of dependence, as well as in the management of opioid detoxification and treatment of withdrawal. The specific opioid antagonists and partial agonists used in these various therapeutic modalities will be the focus of this review. ⋯ Opioid dependency, whether it results from the misuse or abuse of prescription or street drugs, continues to be a significant public health issue. Passage of DATA 2000 and US Food and Drug Administration approval of buprenorphine and buprenorphine/ naloxone has revolutionized opioid dependence therapy. The traditional addiction medicine therapy regimen of methadone maintenance, with its inherent legal limitations and restrictions, has been challenged by an office-based dependence practice with buprenorphine serving as a prominent therapeutic tool.
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Human Immunodeficiency Virus (HIV) patients have an increased rate of chronic pain, particularly peripheral neuropathy. This disease burden causes considerable disability and negatively affects quality of life. Pain is undertreated and more complex to manage in these patients for a number of reasons, including complex anti-retroviral drug regimens, higher risks of side effects, and higher rates of comorbid psychiatric illness and substance abuse. Pain management must take these factors into account and use all available modalities, including nonopioid pain relievers, adjuvant medications, and psychosocial therapies in addition to opioid analgesics. Here we review recent recommendations regarding acute and chronic opioid treatment of pain and the treatment of opioid dependence in HIV-infected patients, and provide suggestions regarding aberrant behavior in pain treatment. ⋯ Pain management in HIV patients must take these factors into account and use all available modalities for treatment, including nonopioid analgesics, adjuvant medications, and psychosocial therapies. Opioid analgesics should be prescribed with caution in accordance with current guidelines and after careful risk assessment.
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The non-medical use of and harms related to prescription opioid (PO) analgesics - key medications to treat severe and chronic pain - are an emerging public health concern globally. PO use is proportionally highest in North America, where, consequently, nonmedical PO use (NMPOU) and morbidity/mortality are high and well documented for the United States. Canada is the country with the second highest PO consumption rate in the world - with steeper recent increases in PO use than the US - mainly driven by substantial increases in the use of strong opioids (e.g., oxycodone). Indications and select data of NMPOU and PO-related morbidity and mortality have emerged in recent years, yet a systematic and comprehensive collection of relevant data to characterize the phenomenon in Canada does not exist. ⋯ Corresponding to its increasing and high overall PO consumption levels, NMPOU and PO-related harms in Canada are high based on available data, and likely now constitute the third highest level of substance use burden of disease (after alcohol and tobacco). The data and monitoring situation in Canada regarding NMPOU and PO-related harms are fragmented, un-systematic, and insufficient. While major and concerted policy initiatives - primarily from the federal level - are absent to date, these urgently require vastly improved national data indicators and monitoring in order to allow for and evaluate evidence-based interventions on this urgent and extensive public health problem.
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Spinal cord or nerve root compression from an epidural metastasis occurs in 5-10% of patients with cancer and in up to 40% of patients with preexisting nonspinal bone metastases. Most metastatic spine diseases arise from the vertebral column, with the posterior half of the vertebral body being the most common initial focus, and/or the paravertebral region, tracking along the spinal nerves to enter the spinal column via the intervertebral foramina. An 82-year-old man diagnosed with sigmoid colon cancer and liver metastases experienced intractable pain described as being like an electric shock on the right T11 dermatome. ⋯ PVP at T11 was performed through the right osteolytic pedicle. The paroxysmal pain disappeared immediately after the operation without any complications. Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care without lung deflation may be an effective and safe modality for minimally invasive pain management of a single-level spinal tumor metastasis causing intractable radicular pain in patients with cancer who have generalized debilitation.
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In all recommended guidelines put forth for the treatment of cancer pain, opioids continue to be an important part of a physician's armamentarium. Though opioids are used regularly for cancer pain, there is a paucity of literature proving efficacy for long-term use. Cancer is no longer considered a "terminal disease"; 50% to 65% of patients survive for at least 2 years, and there are about 12 million cancer survivors in the United States. There is a concern about side effects, tolerance, abuse and addiction with long-term opioid use and a need to evaluate the effectiveness of opioids for cancer pain. ⋯ This systematic review of RCTs of opioids for cancer pain showed fair evidence for the efficacy of transdermal fentanyl and poor evidence for morphine, tramadol, oxycodone, methadone, and codeine.