Pain physician
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The synthetic opioid methadone is a promising analgesic for the management of chronic neuropathic pain. Methadone therapy is increasing as its advantages are being realized over other opioids. Methadone's lack of known active metabolites, high oral bioavailability, low cost, and its additional receptor activity as an antagonist of N-methyl-D-aspartate receptors make it an attractive analgesic. ⋯ The majority of survey responders (90%) prescribed methadone in their pain practice, but on a very limited basis; 59% state <20% of their patients are on methadone. Three times a day dosing schedule was the most typical regimen (57%) while 77% prefer to titrate up on the dosage. It seems interesting that many clinicians do not prescribe methadone as a primary analgesic. One reason for this is due to the social stigma of its use in treatment of heroin addicts. Also, a lack of widely recognized treatment algorithms or guidelines to assist clinicians with opioid conversions and maintenance might be playing a role. The role of stigma as a barrier to adequate treatment of chronic pain among pain physicians prescribing practices is a fundamental, yet unexplored issue.
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Case Reports
Spinal cord stimulation for the treatment of chronic knee pain following total knee replacement.
Chronic pain after total knee replacement is common but remains poorly understood. Management options for patients with this condition are traditionally limited to pharmacological approaches. ⋯ Spinal cord stimulation might be an option in the management of refractory knee pain following total knee replacement.
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Microglial cells appear to play a vital role in the initiation of certain neuropathic pain states. In order to initiate neuropathic pain, microglia need to be activated. Microglia activation in the spinal cord involves both hypertrophy as well as hyperplasia, progressing through a hypertrophic morphology, with thickened and retracted processes (observed within the first 24 hours after nerve injury), and an increase in cell number (observed around 2-3 days after nerve injury). ⋯ These 5 pathways will be discussed and are identified by their main signaling mediator and/or receptor which include fractalkine, interferon-gamma, monocyte chemoattractant protein-1, TLR4, and P2X4. Thus, one or more of these mediators/pathways which lead to microglial activation might contribute to neuropathic pain. A greater appreciation of the roles of various mediators/paths which activate microglia might help lead to future novel therapeutic targets in efforts to ameliorate severe symptoms of neuropathic pain.
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Review Historical Article
Importance of urine drug testing in the treatment of chronic noncancer pain: implications of recent medicare policy changes in kentucky.
Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. ⋯ Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse.
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Nucleoplasty is a minimally invasive procedure for treating pain caused by symptomatic disc herniation that is refractory to conservative therapy. Observational studies have reported differing outcomes for this procedure and thus its effectiveness is yet to be determined. ⋯ Observational studies suggest that nucleoplasty is a potentially effective minimally invasive treatment for patients with symptomatic disc herniations who are refractory to conservative therapy. The recommendation is a level 1C, strongly supporting the therapeutic efficacy of this procedure. However, prospective randomized controlled trials with higher quality of evidence are necessary to confirm efficacy and risks, and to determine ideal patient selection for this procedure.