Pain Management

A 30-year-old male presents with a one-year history of worsening lower back pain and alternating buttock pain. He mentions his symptoms are typically worse first thing in the morning, but seem to remit later in the day with NSAIDs and exercise. Physical examination reveals swelling of the proximal interphalangeal joints of several digits, restricted lumbar movement, and tenderness of the sacroiliac joint. An X-ray demonstrates the findings seen here. Which of the following extra-articular clinical manifestations is most commonly associated with this patient’s condition?

A) Blurred vision
B) Right lower quadrant pain
C) Plaques with silver scale
D) Shortness of breath

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• Studies link heavy backpacks with low back pain in children.
• Chronic low back pain in children is strongly linked to chronic low back pain in adulthood.
• Low back pain is one of the most frequent causes of missed work days and long-term disability.
• Backpack weight should not exceed 15% to 20% of child’s body weight.
• Societies and associations have published backpack guidelines to reduce incidence of low back pain.
• This cost-free healthcare could prevent extensive future medical interventions.

• State crackdown on high prescribers is associated with more than 1000 fewer deaths.
• CDC reports that prescription drug-related deaths have continued to rise.
• Johns Hopkins researchers find the Florida program to be effective.
• Physicians are being urged to prescribe opioids in fewer cases, to fewer patients, in lower dosages.
• The epidemic of prescription and non-prescription opioid deaths makes clear the need for drug treatment programs and for the widespread use of naloxone kits.

• Music therapy was found to reduce pain scores and analgesic requirements.
• Benefits of music were observed even when patients were under general anesthesia.
• Anxiety scores were also lower among patients receiving music therapy.
• Patient satisfaction was higher among patients in the music groups.
• Effects were observed among cancer patients and surgical patients.

• Implementation of drug monitoring programs was associated with reductions in opioid prescribing, opioid-related overdoses, and opioid-related overdose deaths.
• Prescription-drug monitoring programs, in effect in 49 of 50 states, were found to be effective in reducing opioid-related deaths.
• The programs were found to be cost effective and clinically effective.
• Clinicians expressed satisfaction with the programs in a majority of cases.

• Use of gabapentin was linked to decreased opioid consumption following total knee arthroplasty (TKA).
• The use of gabapentin was also associated with a decreased incidence of pruritus in 6 randomized controlled (RCTs).
• The meta-analysis included 859 participants.
• No significant differences in Visual Analogue Scale (VAS) scores were detected between the gabapentin and placebo groups.

A 40-year-old male presented with a painful mass on his left shoulder. He had previously undergone several courses of chemotherapy and radiation therapy for stage IV Hodgkin lymphoma that had relapsed twice. View this case to find out the cause of the mass and how it was treated.

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• High fat (or negative) emotions are draining; they can heighten the perception of pain.
• Low fat (or positive) emotions are energizing; they can decrease the perception of pain.
• High stress-low reward experiences lead to a diet heavy in high fat (negative emotions) and lead to psychological undernourishment. Alternatively, low-stress, high-reward diets are rich in positive emotions and can lead to a psychologically nourishing state.

• Purdue Pharma’s internal notes indicate the drug maker knew that OxyContin’s effectiveness falls well short of 12 hours in most patients.
• Many patients in Purdue trials were not getting 12 hours of pain relief.
• Purdue Pharma seems to have been aware of this fact since as early as 1996, according to the Los Angeles Times’ investigation.
• Purdue seems to have instructed physicians to prescribe increasing doses in patients who were not getting 12-hour analgesia.

• Fibromyalgia etiology is complex and multifaceted.
• Syndrome affects millions of patients worldwide.
• Fibromyalgia has significant negative personal, interpersonal, professional, and socioeconomic repercussions.
• While fibromyalgia is frequently recalcitrant, pregabalin has been found to be an anchor therapy for the syndrome.
• The syndrome afflicts between 6.5 million and more than 13 million Americans.
• Pharmacoeconomic studies have revealed that pregabalin is cost-effective.

• The American Pain Society (APS) has issued new guidelines for the management postoperative pain.
• While the new guidelines address postop pain specifically, they can be beneficial for patients with both acute and chronic pain.
• The guidelines were clearly drawn with an eye on the opioid abuse epidemic that continues in the U.S.
• The APS recommends a multimodal analgesic approach in all appropriate cases.
• The multimodal approach includes reduce use of opioid analgesics and reduced duration of use when opioids are clinically appropriate.

• Benzodiazepine prescriptions and overdose mortality have increased in recent years.
• Fatal overdoses involving benzodiazepines have plateaued but not decreased among any group of Americans.
• Interventions are needed to reduce the use of benzodiazepines and to improve their safety.
• Between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1% to 5.6%; an annual change of 2.5%.
• The quantity of benzodiazepines dispensed in the U.S. increased from 1.1kg to 3.6kg lorazepam equivalents per 100,000 adults.
• The overdose death rate increased from 0.58 to 3.07 per 100 000 adults, with a plateau seen after 2010.

• Methylnaltrexone is significantly superior to placebo for relief of opioid-induced constipation (OIC).
• The use of methylnaltrexone to treat OIC was found to decrease the use of healthcare resources, increase work productivity, and reduce related system-wide healthcare costs.
• Both the 0.15 mg/kg and 0.30 mg/kg doses every other day, and the 12mg/day dose were found to improve the rate of rescue-medication free bowel movement (RFBM) within 4 hours of administration versus placebo.
• Systematic review and meta-analysis of randomized controlled trials included more than 1200 patients.

• Patients are living longer with cancer pain.
• There is an urgent need for clinicians to provide analgesia without inducing tolerance,  dependence, somnolence, and addiction.
• Evidence supports the use of numerous non-opioid analgesics, as well as devices and techniques for pain relief.
• Chronic pain can be effectively relieved or mitigated through the combination of a number of strategies.

• “This is the largest public health crisis that we have right now,” Joan Papp, MD, told MDalert.com.
• An estimated 16,000 lives are lost to opioid-related overdose in the U.S. each year.
• An opioid-related death in the ER costs about $10,000.
• A naloxone kit costs about $70.