Pain physician
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Review
A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain.
Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. ⋯ This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies.
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Treatment of chronic non-cancer pain with opioid therapy has escalated in recent years, resulting in exploding therapeutic use and misuse of prescription opioids and multiple adverse drug events. Breakthrough pain is defined as a transient exacerbation of pain experienced by individuals who have relatively stable and adequately controlled baseline cancer pain. Further, the definition of breakthrough pain, prevalence, characteristics, implications, and treatment modalities have been extensively described for chronic cancer pain. ⋯ This review illustrates that there is no significant evidence for any type of breakthrough pain in chronic non-cancer pain based on available literature, methodology utilized, and response to opioids in chronic non-cancer pain. The advocacy for increased usage of opioids in the treatment of chronic pain dates back to the liberalization of laws governing opioid prescription for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and is exploding with new pain management standards for inpatient and outpatient medical care implemented by the Joint Commission on Accreditation of Health Care Organizations in 2000, and the advocacy by many physicians and organizations for increased use of opioids. This comprehensive review critically evaluates the available evidence of breakthrough pain in chronic non-cancer pain including its existence, prevalence, and managing symptoms which are described as breakthrough pain or episodic pain.
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Review
A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain.
The prevalence of cancer-related pain and residual pain in cancer survivors is high. Opioids serve as the gold standard for treating moderate to severe cancer pain. The evaluation of the effectiveness of opioids in chronic non-cancer pain has shown a lack of effectiveness, or rather weak evidence for some of the drugs. In contrast, in cancer pain, opioids are expected to be very effective. Due to the nature of the disease, there is evidence of a paucity of randomized trials investigating opioid effectiveness in cancer pain on a long-term basis. Consequently, the effectiveness of opioids in managing cancer-related pain warrants further evidence-based review beyond randomized trials, including observational studies and case reports. ⋯ This systematic review of observational studies indicates Level II-3 evidence for effectiveness of opioids in cancer pain therapy, with 1C/strong recommendation based on observational studies, which could change based on future evidence.
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Comparative Study Clinical Trial
Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients.
The challenge for physicians in treating chronic pain with opioids is to eliminate or significantly curtail abuse of controlled prescription drugs while assuring proper treatment when indicated. Urine drug testing (UDT) has been shown to be a useful approach in identifying patterns of compliance, misuse, and abuse. However, significant controversy surrounds the diagnostic accuracy of UDT performed in the office (immunoassay) and the requirement for laboratory confirmation with liquid chromatography tandem mass spectrometry (LC/MS/MS). ⋯ NCT01052155.
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The pudendal nerve may be strained either between the sacrospinous and sacrotuberous ligaments at the ischial spine level or within Alcock's canal. Alcock's neuralgia is a rare, painful condition caused by compression of the pudendal nerve within Alcock's canal (pudendal canal) which is an aponeurotic tunnel that cannot be stretched. Patients usually present with intense, unilateral pain involving anatomic areas along the pudendal nerve's root, genital, anal, and pelvic regions causing mobility impairment. ⋯ There are 2 types of potential complications that are associated with percutaneous steroid infiltrations: intra-operative (associated with needle placement) and post-operative (infection, bleeding and those associated with the injectate administration). In all cases that steroids were administered within therapeutic doses, no complications were noted. In conclusion, CT-guided percutaneous infiltration with a mixture of long-acting corticosteroid and local anesthetic seems to be a safe and efficient method for the treatment of Alcock's neuralgia.