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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Review
Diagnostic accuracy of thoracic facet joint nerve blocks: an update of the assessment of evidence.
Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on their responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain. ⋯ Based on this systematic review, the evidence for the diagnostic accuracy of thoracic facet joint injections is good.
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The personal and societal impact of chronic low back pain is considerable. The intervertebral disc is considered the etiologic source in up to 40% of patients, with considerable previous efforts directed at developing reliable and efficacious treatments. Recent publications, including a double-blind, randomized, placebo-controlled trial, using a one-time treatment of methylene blue, showed statistically significant, clinically relevant improvements in pain and function in the treatment groups. The postulated mechanism of action of methylene blue is denervation of small nociceptive fibers that grow into the annulus fibrosis, which are implicated in discogenic pain. ⋯ A case series.
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The use of opioids for chronic non-cancer pain has grown exponentially in the last 15 years. Associated with that, dramatic increases in abuse and overdose deaths from opioid use have been noted. ⋯ This algorithmic approach may enable physicians to prescribe opioids for patients with chronic pain and also to reduce opioid abuse.
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The risks associated with percutaneous vertebroplasty (PV) are low. Patients show marked improvement and are able to rapidly resume normal activities after PV. The sudden development of postoperative vertebral compression fracture (VCF) is a common complication, and additional PV is frequently performed in these cases. However, there have been no studies reporting acute compression fractures of an adjacent vertebra immediately after PV. ⋯ To the best of our knowledge, this is the first case report of adjacent VCF that developed almost immediately after PV. Although the exact mechanism underlying this rare complication remains unclear, we assume that the VCF was induced by PV, although this was not proven. However, we suggest that the insertion of the cannula into the fracture line induced the iatrogenic dynamic mobility of the fractured vertebra. Reduction was caused by the cannula and positional gravity. The upward reduction may have had an effect on the upper and adjacent vertebrae.