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Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options. The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice. This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature. The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed. Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.

Background Opioid-induced bowel dysfunction is a complication of opioid therapy, in which constipation is the most common and problematic symptom. However, it is frequently under-recognised and thus effective management is often not instituted despite a number of treatment options.Objective The central objective of this study is to provide a summary of the pathophysiology and clinical evaluation of opioid-induced constipation and to provide a pragmatic management algorithm for day-to-day clinical practice.Methods This summary and the treatment algorithm is based on the opinion of a European expert panel evaluating current evidence in the literature.Results The pathophysiology of opioid-induced constipation is multi-faceted. The key aspect of managing opioid-induced constipation is early recognition. Specific management includes increasing fluid intake, exercise and standard laxatives as well as addressing exacerbating factors. The Bowel Function Index is a useful way of objectively evaluating severity of opioid-induced constipation and monitoring response. Second-line treatments can be considered in those with recalcitrant symptoms, which include gut-restricted or peripherally acting mu-opioid receptor antagonists. However, a combination of interventions may be needed.Conclusion Opioid-induced constipation is a common, yet under-recognised and undertreated, complication of opioid therapy. We provide a pragmatic step-wise approach to opioid-induced constipation, which should simplify management for clinicians.

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Pain encountered at the site of the implantable pulse generator (IPG) after invasive neuromodulation is a well‐known and important complication. The reported incidence of implant site pain is variable, ranging between 0.4 and 35%. Implant site pain has never been systematically studied and no treatment guidelines are available. We performed an observational study (study registration number mp05728) on the incidence and the determining factors of implant site pain, the subjective rating of intensity by sending questionnaires (n= 554) to our cohort of neuromodulation patients with IPGs. The number of revision surgeries and explants due to implant site pain were also analyzed. Total response rate was 50% (n= 278). Pain patients suffered significantly (p< 0.05) more often from IPG site pain than other patients undergoing neuromodulation therapies. Up to 64% of patients undergoing spinal cord stimulation reported IPG site discomfort or pain. Severe pocket pain was found in up to 8% of patients. No association was found between other variables (age, BMI, duration of follow‐up, gender, smoking, number of pocket surgeries) and implant site pain. Pocket pain represents an important problem after invasive neuromodulation and is more prevalent in pain patients. We believe further technological improvements with miniaturized IPGs will impact the incidence of pocket pain and could even obviate the need for an IPG pocket.

Chronic low back pain (CLBP) is a highly prevalent, costly and disabling condition that is associated with high levels of health-care resource utilization. Over the past few decades, there has been a paradigm shift in our understanding of CLBP. Nowadays, this condition is accepted as a biopsychosocial phenomenon in which anatomical injury interplays with psychosocial factors. The considerable progress made in elucidating the aetiology of low back pain and the sharp increase in related health-care costs have not translated into a decreased prevalence of CLBP or the development of therapies with markedly improved efficacy and safety. Classic medical–technical interventions for CLBP always need to be placed in a broader therapeutic framework comprising physical, psychosocial and behavioural strategies, and must address the patient's welfare in a holistic context. A common key finding in the literature on these interventions for CLBP is their disappointing magnitude of pain reduction and gain in functionality. This Review summarizes general concepts of CLBP and focuses on evidence supporting the classic medical–technical approaches to CLBP; that is, pharmacotherapy, interventional pain management and surgery.