Pain physician
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Practice Guideline
American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance.
Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. ( ⋯ The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."
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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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Case Reports
Erectile dysfunction as rare side effect in the simultaneous intrathecal application of morphine and clonidine.
We report on the case of a 52-year-old man who presented with a history of chronic neuropathic pain treated with intrathecal application of morphine for many years. In spite of significant dose escalation, considerable pain relief had not been achieved. Ziconotide had been tried but not only did it not provide pain relief, but it also caused severe side effects in this patient. ⋯ Although common in systemic application, erectile dysfunction caused by the intrathecal application of clonidine has not been described yet in the literature. In this patient, this rare side effect decisively impaired life quality, subjectively outweighing the considerable pain relief which could be achieved after formerly inefficacious treatment. Further and prospective investigation might be needed to estimate the connection of erectile dysfunction to intrathecal application of clonidine.
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Sublingual buprenorphine-naloxone (buprenorphine SL) is a preparation that is used to treat opioid dependence. In addition, the Drug Enforcement Administration (DEA) has acknowledged the legality of an off-label use to treat pain with a sublingual buprenorphine preparation. Buprenorphine SL is unique among the opioid class of analgesics; this compound has a high affinity for the mu-receptor, yet only partially activates it. Thus, buprenorphine SL can provide analgesia, yet minimize opioid side effects. Many patients on high doses of traditional opioid medication develop tolerance. Despite escalating medication dosage, a subset of patients had a paradoxical increase in pain, which has been characterized as opioid-induced hyperalgesia (OIH). Buprenorphine SL, on the other hand, may even be anti-hyperalgesic and may have utility in treating these challenging patients. ⋯ Patients continuing buprenorphine SL therapy for more than 60 days reported significant decreases in pain (2.3 points). Patients on doses of opioid medication between 100-199 mg morphine equivalents seemed to fare better with conversion to buprenorphine SL than patients on the highest doses (> 400 mg morphine equivalents). The opioid drug used by the patient before buprenorphine SL induction appears to have some effect on buprenorphine SL conversion success. Patients previously taking morphine, oxycodone, and fentanyl had the greatest decrease in pain after conversion to buprenorphine SL.
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Resiniferatoxin (RTX) is a potent synthetic agonist for transient receptor potential vanilloid subtype 1 (TRPV1), which has a selectivity for antinociception. The analgesic effect of epidural RTX in a rat model of neuropathic pain has not yet been studied. ⋯ RTX has potential to be used in an epidural route for neuropathic pain in a rat model with a relatively small amount, which produces transitory improvement of mechanical hypersensitivity and prolonged thermal analgesic response.