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Caring for chronic pain patients under opioid therapy is challenging. Opioid treatments above 50 milligrams morphine equivalents (MME) per day are associated with an increased risk of morbidity and mortality. A tapering or a discontinuation should be discussed. Shared decision-making with individualized goals and motivational interviewing principles should be used. Tapering should be slow, with initial rate based on the duration of opioid use and with regular monitoring of patients. Inability to taper may require further reassessment of opioid dependence. Temporary increases in pain may occur at the start of tapering, but pain may improve or remain unchanged upon completion of tapering.

BACKGROUND: Chronic pain is the leading cause of disability worldwide and is strongly associated with the epidemic of opioid overdosing events. However, the causal links between chronic pain, opioid prescriptions, and mortality remain unclear.METHODS: This study included 13,884 US adults aged ≥20 years who provided data on chronic pain in the National Health and Nutrition Examination Survey 1999-2004 with linkage to mortality databases through 2015. We employed the generalized form of the front-door formula within the structural causal model framework to investigate the causal effect of chronic pain on all-cause mortality mediated by opioid prescriptions.RESULTS: We identified a total of 718 participants at 3 years of follow-up and 1260 participants at 5 years as having died from all causes. Opioid prescriptions increased the risk of all-cause mortality with an estimated odds ratio (OR) (95% confidence interval) = 1.5 (1.1, 1.9) at 3 years and 1.3 (1.1, 1.6) at 5 years. The front-door formula revealed that chronic pain increased the risk of all-cause mortality through opioid prescriptions; OR = 1.06 (1.01, 1.11) at 3 years and 1.03 (1.01, 1.06) at 5 years. Our bias analysis showed that our findings based on the front-door formula were likely robust to plausible sources of bias from uncontrolled exposure-mediator or mediator-outcome confounding.CONCLUSIONS: Chronic pain increased the risk of all-cause mortality through opioid prescriptions. Our findings highlight the importance of careful guideline-based chronic pain management to prevent death from possibly inappropriate opioid prescriptions driven by chronic pain.

Intrathecal drug delivery appeared in the early eighties and allows to administer high concentrate analgesic medications in the cerebrospinal fluid with higher efficacy and a limited incidence of systemic side effects. Opioids are still the first line treatment with high-quality evidence for chronic cancer pain, and limited evidence for chronic non-cancer pain, being often considered as a last resort therapy. Device implantation requires a strict patient's selection with a close follow-up in order to adapt therapy, refill the reservoir and detect and prevent potential severe complications.

BACKGROUND: Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC). METHODS: The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment. RESULTS: The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation. CONCLUSIONS: Opioids remain a treatment option for some selected patients with CNCP under careful surveillance. SIGNIFICANCE: In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients. ispartof: EUROPEAN JOURNAL OF PAIN vol:25 issue:5 pages:949-968 ispartof: location:England status: published

CASE DESCRIPTION: A frail 85-year-old woman with chronic neuropathic pain after hip surgery, not responding to treatment with acetaminophen and morphine patches. Should she be prescribed a gabapentinoid? DISCUSSION: Gabapentinoids and antidepressants are considered first-line therapies. They achieve clinically relevant (i.e. ≥ 50%) pain reduction in approximately one-third of patients with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is limited. Adverse events occur frequently and are mostly mild in nature; serious adverse effects are rare. Prescription of gabapentinoids in specific patient groups (e.g. elderly patients and patients with a history of depression or substance abuse) deserves careful consideration, because the risk/benefit ratio in those groups may be altered. In order to reduce the risk of withdrawal symptoms, slow tapering is recommended. CONCLUSION: Chronic neuropathic pain often has a negative impact on the quality of life and is difficult to treat. In general, treatment with a gabapentinoid is a possible first-line treatment option. However, they may be relatively contraindicated in vulnerable patients.

Democratization of the cannabis consumption and its derivatives incite patients to ask ever more for medical cannabinoid prescriptions, especially in the context of chronic pain. Its use is only validated in certain limited cases, in particular spasticity linked to multiple sclerosis and refractory epilepsies. All other prescriptions require a special request to the OFSP. Moreover, cannabinoid intake may produce several dose-dependent side effects that require a close monitoring with a slow and gradual initiation of its dosage. In the absence of clear medical evidence, many other mechanisms of action need to be investigated with ongoing and future studies to clarify their indication.

Small observational studies suggest that local glucocorticoid (GC) injection may be effective in the management of the greater trochanteric pain syndrome (GTPS). The objective was to perform the first randomised double-blind placebo-controlled trial to investigate the efficacy of local GC injection in the management of GTPS. The trial was conducted between November 2011 and May 2015. Inclusion criteria included lateral hip pain (LHP) for greater than 1 month, a LHP score of ≥ 4/10 and typical LHP reproduced by palpation of the greater trochanter. Participants were randomised in a 1:1 ratio to injection with a combination of local anaesthetic and GC (intervention) or injection with normal saline solution (placebo). The primary outcome of interest was the difference in pain intensity at 4 weeks post-injection between the two groups. Patients were followed for 6 months. A total of 46 patients were included. There were no significant differences between the two groups in terms of pain reduction at 1 month (p = 0.23). When including all measures in the first 4 weeks and using multilevel regression, there was a trend towards improvement in pain scores in favour of the intervention group (p = 0.08). There were no significant differences in pain scores between groups at 3 and 6 months. In the management of GTPS, local glucocorticoid injections are of no greater efficacy than injection of normal saline solution. Given the lack of long-term improvement and the potential for cortisone-related side effects, this intervention is of limited benefit.

Treatment of cancer pain is generally based on the three-step World Health Organization (WHO) pain relief ladder, which utilizes a sequential approach with drugs of increasing potency. Goals of pain management include optimization of analgesia, optimization of activities of daily living, minimization of adverse effects, and avoidance of aberrant drug taking. In addition, it is recommended that analgesic regimens are individualized and simplified to help ensure patient compliance and should provide the least invasive, easiest, and safest route of opioid administration to ensure adequate analgesia. Buprenorphine and fentanyl are two opioids available for the relief of moderate-to-severe cancer pain. Available clinical data regarding the transdermal (TD) formulations of these opioids and the extent to which they fulfill the recommendations mentioned earlier are systematically reviewed, with the aim of providing additional information for oncologists and pain specialists regarding their comparative use. Due to lack of studies directly comparing TD buprenorphine with TD fentanyl, data comparing these with other step-3 opioids are also evaluated in a network fashion., Video abstract

CASE DESCRIPTION: A frail 85-year-old woman with chronic neuropathic pain after hip surgery, not responding to treatment with acetaminophen and morphine patches. Should she be prescribed a gabapentinoid?DISCUSSION: Gabapentinoids and antidepressants are considered first-line therapies. They achieve clinically relevant (i.e. ≥ 50%) pain reduction in approximately one-third of patients with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is limited. Adverse events occur frequently and are mostly mild in nature; serious adverse effects are rare. Prescription of gabapentinoids in specific patient groups (e.g. elderly patients and patients with a history of depression or substance abuse) deserves careful consideration, because the risk/benefit ratio in those groups may be altered. In order to reduce the risk of withdrawal symptoms, slow tapering is recommended.CONCLUSION: Chronic neuropathic pain often has a negative impact on the quality of life and is difficult to treat. In general, treatment with a gabapentinoid is a possible first-line treatment option. However, they may be relatively contraindicated in vulnerable patients.

Background: The rationale for total pancreatectomy in painful, treatment refractory, chronic pancreatitis is pain control. Concomitant islet cell autotransplantation can prevent the loss of islet cell function. This study aimed to systematically examine the impact of total pancreatectomy with islet cell autotransplantation on pain and quality of life. Methods: This meta-analysis was conducted according the Meta-analyses of Observational Studies in Epidemiology guideline. The Cochrane Library, PubMed, and Embase were searched for the following terms (1990 through April 2018): total pancreatectomy and chronic pancreatitis. Studies were included when addressing total pancreatectomy with islet cell autotransplantation for chronic pancreatitis in adults. Studies that reported no data on pain, endocrine function, or quality of life were excluded. Quality was assessed using the Newcastle-Ottawa scale for evaluation of all studies. Results: We included 15 observational studies evaluating 1,255 patients, of whom 28% had had endoscopic and 23% operative therapy. One year after total pancreatectomy with islet cell autotransplantation, the opioid-free rate had improved from between 0% and 15% to 63% (95% CI 46–77), and the insulin-free rate had decreased from between 89.5% and 100% to 30% (95% CI 20–43). An alcoholic etiology was associated with a lesser insulin-free rate after total pancreatectomy with islet cell autotransplantation. Quality of life improved statistically after total pancreatectomy with islet cell autotransplantation. Publication bias was present for both opioid and insulin outcomes. Conclusion: In selected patients with painful, treatment refractory, chronic pancreatitis, evidence shows that total pancreatectomy with islet cell autotransplantation is effective for pain control in almost two-thirds of patients, whereas the insulin-free rate is relatively low.

Background The rationale for total pancreatectomy in painful, treatment refractory, chronic pancreatitis is pain control. Concomitant islet cell autotransplantation can prevent the loss of islet cell function. This study aimed to systematically examine the impact of total pancreatectomy with islet cell autotransplantation on pain and quality of life. Methods This meta-analysis was conducted according the Meta-analyses of Observational Studies in Epidemiology guideline. The Cochrane Library, PubMed, and Embase were searched for the following terms (1990 through April 2018): total pancreatectomy and chronic pancreatitis. Studies were included when addressing total pancreatectomy with islet cell autotransplantation for chronic pancreatitis in adults. Studies that reported no data on pain, endocrine function, or quality of life were excluded. Quality was assessed using the Newcastle-Ottawa scale for evaluation of all studies. Results We included 15 observational studies evaluating 1,255 patients, of whom 28% had had endoscopic and 23% operative therapy. One year after total pancreatectomy with islet cell autotransplantation, the opioid-free rate had improved from between 0% and 15% to 63% (95% CI 46–77), and the insulin-free rate had decreased from between 89.5% and 100% to 30% (95% CI 20–43). An alcoholic etiology was associated with a lesser insulin-free rate after total pancreatectomy with islet cell autotransplantation. Quality of life improved statistically after total pancreatectomy with islet cell autotransplantation. Publication bias was present for both opioid and insulin outcomes. Conclusion In selected patients with painful, treatment refractory, chronic pancreatitis, evidence shows that total pancreatectomy with islet cell autotransplantation is effective for pain control in almost two-thirds of patients, whereas the insulin-free rate is relatively low.

Antidepressants are frequently prescribed as co-analgesics in chronic pain. While their efficacy is well documented for neuropathic pain, the evidence is less clear in musculoskeletal pain conditions. The present study therefore evaluated the effect of the tricyclic antidepressant imipramine on chronic low-back pain in a randomized, double-blinded placebo-controlled design. To explore the mechanisms of action and the influence of drug metabolism, multimodal quantitative sensory tests (QST) and genotyping for cytochrome P450 2D6 (CYP2D6) were additionally performed. A single oral dose of imipramine 75 mg was compared to active placebo (tolterodine 1 mg) in 50 patients (32 females) with chronic non-specific low-back pain. Intensity of low-back pain was assessed on a 0–10 numeric rating scale at baseline and every 30 minutes after drug intake. Multimodal QST were performed at baseline and in hourly intervals for 2 hours. Pharmacogenetic influences of cytochrome P450 were addressed by CYP2D6 genotyping. No significant analgesic effect was detected neither on low-back pain nor on any of the sensory tests in the overall analyses. However, evidence for an interaction of the imipramine effect and CYP2D6 genotype was found for electrical and for pressure pain detection thresholds. Intermediate but not extensive metabolizers had a 1.20 times greater electrical pain threshold (95%-CI 1.10 to 1.31) and a 1.10 times greater pressure pain threshold (95%-CI 1.01 to 1.21) 60 minutes after imipramine than after placebo (p

Patients with complex chronic pain conditions are often difficult to treat with analgesia alone. Psychosocial intervention is needed to help them gain control and find an appropriate level of activity. This article summarizes the possibilities of psychosocial treatment of pain patients at the general practitioners and in specialist units of multidisciplinary pain treatment. The theoretical frame used is cognitive behavioural therapy. In practice, psychoeducation, mindfulness, and relaxation exercises are introduced to the patients to help them with daily life activity and work.

Acetaminophen (paracetamol) is the most commonly used analgesic worldwide and recommended as first-line treatment in all pain conditions by WHO. We performed a systematic literature review to evaluate the efficacy of acetaminophen when used for chronic pain conditions. Applying three broad search strategies for acetaminophen use in chronic pain in both Embase and PubMed, 1551 hits were obtained. After cross-reference searches of both trials and 38 reviews, seven studies comparing acetaminophen in continuous dosing regimens of more than 2 weeks with placebo were included. The review was conducted according to the PRISMA guidelines. All studies were conducted in patients with hip- or knee osteoarthritis and six of seven studies had observation periods of less than 3 months. All included studies showed no or little efficacy with dubious clinical relevance. In conclusion, there is little evidence to support the efficacy of acetaminophen treatment in patients with chronic pain conditions. Assessment of continuous efficacy in the many patients using acetaminophen worldwide is recommended.

The low back pain has become one of the greatest public health problems worldwide. The author based on the current international standards summarizes the knowledge necessary for every day treatment of low back pain. In acute low back pain the author underlines the necessity of the rapid, accurate diagnosis and separation for specific and non-specific low back pain. In specific acute low back pain the treatment should focus on to eliminate the root causes. In non-specific cases pain killing treatment and early active mobilization is the choice for the therapeutic process. Beside analgesia, the primary goal of the treatment is to prevent becoming chronic the symptomatology. Objectives of the management of chronic low back pain are effective pain reduction, continuous maintainance of physical activity, prevention of permanent disability, and restoration of working ability. Analgesics, non steroid anti-inflammatory drugs, and muscle relaxants reduce pain, while multidisciplinary management programs, personalized and guided physiotherapy, cognitive behavioral therapy, as well as short training programs will help to restore function. Surgical treatment is only indicated in degenerative cases and only after the failure of conservative therapy. Orv. Hetil., 2015, 156(33), 1315–1320.

In Switzerland, medical cannabinoids can be prescribed under compassionate use after special authorization in justified indications such as refractory pain. Evidence of efficacy in pain is limited and the clinical benefit seems to be modest. Their drug-drug interactions (DDI) profile is poorly documented. Cytochromes P450 (CYP) 2C9 and 3A4 are involved in the metabolism of tetrahydrocannabinol and cannabidiol, which implies possible DDI with CYP450 inhibitor and inducer, such as anticonvulsivants and HIV protease inhibitors, which may be prescribed in patients with neuropathic pain.