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Purpose of Review: Pain management in dermatologic conditions can be complicated by the primary disease burden and associated decreased quality of life, disability, and psychosocial issues. This review focuses on pain management strategies in some of the more painful dermatologic conditions., Recent Findings: Pain management in painful dermatologic conditions such as pyoderma gangrenosum, postherpetic neuralgia, lower limb ulcers, and hidradenitis suppurativa revolves around treatment of the underlying disease process. Topical agents such as topical steroids and systemic immunosuppressants with over-the-counter analgesics usually suffice in mild to moderate pain. Severe pain may need neuropathic agents and referral to interventional pain physicians for consideration of advanced techniques such as epidural steroid injections and sympathetic nerve blocks. Part of the treatment process is for dermatologists to establish patient expectations and to treat pain within their scope of practice. More research is needed towards pain control in painful dermatologic conditions with elucidation of treatment algorithms unique to each condition.

Purpose of Review: Psoriasis and psoriatic arthropathy are inflammatory autoimmune conditions that can lead to profound emotional distress, social stigmatization, isolation, disfigurement, pain, disability, unemployment, and decreased quality of life. Thus, this disease has immense psychological, social, and economic implications as the pain experienced is closely associated with the primary disease burden. This review focuses on discussing the primary disease burden of psoriasis and psoriatic arthropathy, as well as management of different types of pain in these patients., Recent Findings: Pain affects over 40% of patients with psoriasis, ranging from neuropathic to nociceptive. Treatment of pain largely focuses on treating the underlying disease with mild topical steroids and non-steroidal medications including vitamin D analogs followed by systemic immunomodulatory agents for more severe disease. Interventional options such as corticosteroid injections are available for select cases (conditional recommendation). Psoriasis and psoriatic arthropathy have been associated with underreporting and resultant undertreatment of pain. Pain control in these conditions is complex and requires a multidisciplinary approach. More research and guidelines are needed in the areas of reporting of psoriatic disease, associated pain, psoriatic nociception, and optimal clinical management.

Purpose of Review: The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant., Recent Findings: The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Purpose of Review: Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management., Recent Findings: Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

Purpose of Review: The goal of this review is to evaluate the global supply and demand of opioids used for pain management and discuss how it relates to the utilization of opioids around the world. The purpose of the review is also to determine the factors that contribute to inappropriate pain management., Recent Findings: The total global production of opium for opioid manufacturing is enough to supply the growing global demands. However, licit opioids are only consumed by 20% of the world population. Most people throughout the world had no access to opioid analgesics for pain relief in case of need. Opioid misuse and abuse is not only a phenomena plague by the USA but globally across many countries. Many countries have a lack of availability of opioids, contributing factors being strict government regulations limiting access, lack of knowledge of the efficacy of opioid analgesics in treating acute and chronic pain and palliative care, and the stigma that opioids are highly addictive. For the countries in which opioids are readily available and prescribed heavily, diversion, misuse, abuse, and the resurgence of heroin have become problems leading to morbidity and mortality. It is pertinent to find a balance between having opioids accessible to patients in need, with ensuring that opioids are regulated along with other illicit drugs to decrease abuse potential.

Purpose of Review: In the present investigation, current literature on the relationship between substance abuse and pain is evaluated in order to improve clinical management and its implications on the increasingly challenging chronic pain and substance abuse epidemic. The relationship between substance abuse and chronic pain are evaluated, and this review provides recommendations on the management of this special patient population., Recent Findings: Currently, there are limited guidelines for prescribing opioids and other analgesics in the chronic pain population. As this field of practice continues to evolve, it is essential for clinicians to serve as the gatekeepers to monitor for misuse and safety. Multiple studies have indicated that illicit drug use and opioid abuse affect over 9% of patients. Although there are numerous reasons for seeking illicit drugs and abusing them, it is essential that clinicians identify factors which place certain patients at high risk and accordingly, to screen these patients in order to optimize their management. The high prevalence of patients with chronic pain who also screen positive for drug use emphasizes the importance and increasingly pressing need to evaluate and to manage chronic pain in this population.

Purpose of Review: The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances., Recent Findings: Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.

Purpose of Review: Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction., Recent Findings: Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.