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Background: Intraspinal drug delivery (IDD) therapy has been increasingly employed in patients with intractable, nonmalignant pain. Before implantation of permanent intraspinal pump, an intraspinal opioid screening trial is conducted to demonstrate the efficacy. The patient-controlled continuous epidural opioid infusion trail, performed in an outpatient setting, is widely accepted by many interventional pain specialists.Objective: To report a case of severe edema observed during the continuous epidural hydromorphone infusion trial.Case Report: An otherwise healthy 68-year-old lady with a 5-year history of severe low back pain and bilateral leg pain because of failed back surgery syndrome was referred to our clinic for IDD therapy.A tunneled lumbar epidural catheter was placed at L2- L3 with catheter tip advanced to L1 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone (0.1 mg/ml) at basal rate of 0.3 ml/h. The bolus dose was 0.1 ml with a 60-minute lockout interval. The patient was instructed how to operate the infusion pump. During the following infusion trial, she reported satisfactory analgesia (>70 percent pain reduction) and was able to wean off her other systemic opioids. However, she developed diffuse edema and gained over 16 pounds during the 5-day infusion trial. Her edema finally resolved 3-4 days after termination of the epidural infusion.Conclusion: Edema may occur and persist during epidural hydromorphone infusion. This report represents the first case report, to the best of our knowledge, describing severe edema in a patient on continuous epidural hydromorphone administration during an outpatient epidural infusion trial.

Oxycodone, a semisynthetic opioid analgesic, is widely used in clinical practice. Oxycodone and morphine seem to be equally effective and equipotent; however, morphine is 10 times more potent than oxycodone when given epidurally. This article provides an updated review of the basic pharmacology of oxycodone with a special focus on pharmacokinetic/pharmacodynamics properties. The controversy regarding oxycodone-mediated effects for visceral pain via agonism and the possible role of peripheral opioid analgesia are discussed in the present investigation in an attempt to propose a plausible explanation to the perplexing question of oxycodone analgesia.

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Letter 1: Analyzing the relationship between nonmedical prescription-opioid use and heroin use Letter 2: Simple solution for a complex problem: Rewriting the script Letter 3: Acetaminophen, a reasonable option, but not a panacea

Background: Intraspinal drug delivery therapy has been increasingly used in patients with intractable, nonmalignant pain who have failed to respond to conventional treatment or cannot tolerate systemic opioid(s) due to adverse events. By infusing a small dose of an opioid analgesic directly into the cerebrospinal fluid, near opioid receptors, profound spinal analgesia can be obtained. Before the implantation of permanent intraspinal pump, a neuraxial opioid infusion trial is usually conducted to demonstrate the effectiveness of neuraxial opioid for analgesia. Patient-controlled epidural opioid infusion trial, performed in an outpatient setting, is one of the approaches used to conduct such a trial . Objective: To report a case of severe pruritus observed during the continuous epidural hydromorphone infusion trial and to conduct a focused review of the literature . Case report: An otherwise healthy 56-year-old lady, with a 4-year history of severe low back pain and bilateral leg pain due to failed back surgery syndrome, was referred to our clinic for intraspinal drug delivery therapy. Following a preimplantation psychological evaluation confirming her candidacy, she consented to an outpatient patient-controlled continuous epidural hydromorphone trial. A tunneled lumbar epidural catheter was placed at L3-L4 with catheter tip advanced to L2 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject ™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone 0.3 mL/h (0.06 mg, concentration 0.2 mg/mL) at basal rate of 0.3 mL/h, with bolus dose set at 0.2 mL (0.04 mg) and 30-minute lockout interval. The patient was instructed how to operate the infusion pump prior to discharging home. During the infusion trial, she reported satisfactory analgesia (>90 percent pain reduction) and was able to reduce her oral opioid dose by more than 80 percent. However, she developed severe, persistent itching, unresponsive to meticulous epidural infusion titration or various antipruritic treatments. Her pruritus remained severe and unabated until a few hours after the termination of the epidural hydromorphone infusion . Conclusion: Pruritus may occur and persist during epidural hydromorphone infusion. This report describes severe pruritus in a patient on epidural hydromorphone administration, in the setting of an outpatient infusion trial .

no abstract

Oxycodone, a semisynthetic opioid analgesic, is widely used in clinical practice. Oxycodone and morphine seem to be equally effective and equipotent; however, morphine is 10 times more potent than oxycodone when given epidurally. This article provides an updated review of the basic pharmacology of oxycodone with a special focus on pharmacokinetic/pharmacodynamics properties. The controversy regarding oxycodone-mediated effects for visceral pain via agonism and the possible role of peripheral opioid analgesia are discussed in the present investigation in an attempt to propose a plausible explanation to the perplexing question of oxycodone analgesia.

Insomnia is associated with increased risk for suicide. The Food and Drug Administration (FDA) has mandated that warnings regarding suicide be included in the prescribing information for hypnotic medications. The authors conducted a review of the evidence for and against the claim that hypnotics increase the risk of suicide.This review focused on modern, FDA-approved hypnotics, beginning with the introduction of benzodiazepines, limiting its findings to adults. PubMed and Web of Science were searched, crossing the terms "suicide" and "suicidal" with each of the modern FDA-approved hypnotics. The FDA web site was searched for postmarketing safety reviews, and the FDA was contacted with requests to provide detailed case reports for hypnotic-related suicide deaths reported through its Adverse Event Reporting System.Epidemiological studies show that hypnotics are associated with an increased risk for suicide. However, none of these studies adequately controlled for depression or other psychiatric disorders that may be linked with insomnia. Suicide deaths have been reported from single-agent hypnotic overdoses. A separate concern is that benzodiazepine receptor agonist hypnotics can cause parasomnias, which in rare cases may lead to suicidal ideation or suicidal behavior in persons who were not known to be suicidal. On the other hand, ongoing research is testing whether treatment of insomnia may reduce suicidality in adults with depression.The review findings indicate that hypnotic medications are associated with suicidal ideation. Future studies should be designed to assess whether increases in suicidality result from CNS impairments from a given hypnotic medication or whether such medication decreases suicidality because of improvements in insomnia.

Chronic pain is pervasive and costly. In 2011, the Institute of Medicine (IOM) released a landmark report on chronic pain, which estimated that more than 100 million Americans suffer from chronic pain, making pain a major and significant public health problem. The benefits of interdisciplinary pain management programs are undeniable and have been demonstrated for over a half century. Until health care leaders and other stakeholders such as insurers work together to ensure best practices in pain management, we will certainly end up in a lose-lose situation for both the health care teams and patients. In order to impact health care policy more effectively, we need to better understand the politics of health policy decision making. J Orthop Sports Phys Ther 2016;46(12):1021-1023. doi:10.2519/jospt.2016.0611.

We read with interest the article by Palamar and colleagues (1), published in The American Journal of Drug and Alcohol Abuse. The authors aimed to study the prevalence and correlates of discordant ...

Sir,Deaths in which fentanyl is detected challenge medical examiners, who must decide whether a given death represents therapeutic administration or was an overdose.[1] Numerous independent studies...

Dear Editor, We appreciate the detailed responses and insights of Dr. Linares and colleagues [1] regarding our comments [2] recently published in Pain Medicine . We would like to comment that although there is no controversy regarding the effectiveness of opioids as analgesics, problematic associated events are perplexing. In addition, there is the societal cataclysm of escalating rates of addiction, drug diversions, and fatal overdoses involving opioids, which confounds their important role for pain control [3]. Effective pain care must be based on proper education, training, clinical judgment, and continuous learning of advances in this specific field of practice. Unfortunately, much of what has been published over the years on chronic pain management, especially with regards to opioid drug use, has uncertain validity because of various forms of bias [3]. Indeed, there has been increasing concern that a significant number of published research findings in medicine have been later disproved [4]. More than a decade ago, in one of the most cited scientific articles (cited 3,377 in Google Scholar) entitled “Why Most Published Research Findings Are False,” John Ioannidis, MD, opined that most research designs are flawed, and that the claimed research findings are often accurate …

Dear Editor, We read with interest the article by Tandon and colleagues (1), entitled “Validation of a New ‘Objective Pain Score’ Vs. ‘Numeric Rating Scale’ For the Evaluation of Acute Pain: A Comparative Study”, published in Anesthesiology and Pain Medicine. Tandon et al. reason that although a numeric rating scale (NRS) is widely used, it requires abstract thinking by each patient, and the interpretation of reflected pain severity can, therefore, be biased. They studied the validity of a new 4-point objective pain score (OPS) in the evaluation of acute postoperative pain by comparing with the numeric rating scale (NRS) in 93 patients who underwent laparotomy. Patient-controlled analgesia was used for postoperative pain control. The authors found the NRS and OPS generally agreed across ranges of pain. Tandon et al. conclude that OPS is a good stand-alone pain score and is better than the NRS for defining mild and moderate pain. They further suggest that OPS may even be used to supplement NRS when it is indicative of mild or moderate pain (1). We would like to commend the creative and insightful work by Tandon and colleagues. We agree with the authors that acute post-operative pain should ideally be assessed simultaneously at rest and during movement. We also agree with the authors on the limitation of NRS, since these scores in different patients could potentially mean different degrees of pain, while each OPS score signifies a similar degree of pain. However, we wonder how OPS may perform, in contrast to NRS, on those patients who experience moderate to severe pain or severe postoperative pain, e.g., following more complex abdominal surgeries, such as bowel resection, gastric surgery, and hepatopancreatic surgery? For example, a postoperative NRS of 5/10 of a typical patient may need slight medication titration, while that of 9/10 may warrant much more aggressive workup and therapeutic interventions. However, the OPS scale may not reflect the difference between these scenarios. We speculate that the OPS metric may not be able to provide such pertinent information in more challenging or problematic postoperative pain cases. To this end, we speculate that OPS may need to be used in conjunction with NRS in patients with moderate to severe postoperative pain, contrary to what Tandon et al. have suggested.

Dear Editor, We read with interest the article by Yang and colleagues [1] entitled “FDA Approval of Extended-Release Oxycodone for Children with Severe Pain”, published in Pediatrics . The authors comment on the approval of extended-release (ER) oxycodone for use by children between 11 and 16 years old when alternative treatment options are inadequate. Yang et al. state that for the first time doctors are provided specific dosing guidance for pediatric patients. With this decision, there now is effectively on-label prescribing of ER oxycodone to children [1]. Bazzano and colleagues [2] examined the frequency of off-label prescribing to children at US outpatient visits and determined how drug class, patient age, and physician specialty have related to off-label prescribing. The authors found that 62% of outpatient pediatric visits included off-label prescribing. Approximately 96% of cardiovascular-renal, 86% of pain, 80% of gastrointestinal, and 67% of pulmonary, and 67% of dermatologic medication prescriptions were off-label. Bazzano et al. concluded that despite recent studies and labeling changes of pediatric medications, the majority of pediatric outpatient visits involve off-label prescribing across all medication categories. Further, off-label prescribing is more frequent for younger children and those receiving care from specialist pediatricians [2]. The Policy Statement of the American Academy …

We read with interest the article by Kennedy and Garmon-Jones1 entitled “Self-harm and suicide before and after spinal cord injury: a systematic review”, published in Spinal Cord. The authors studi...