Nalini Vadivelu

Management of chronic pain in the elderly: focus on transdermal buprenorphine

Chronic pain in the elderly is a significant problem. Pharmacokinetic and metabolic changes associated with increased age makes the elderly vulnerable to side effects and overdosing associated with analgesic agents. Therefore the management of chronic cancer pain and chronic nonmalignant pain in this growing population is an ongoing challenge. New routes of administration have opened up new treatment options to meet this challenge. The transdermal buprenorphine matrix allows for slow release of buprenorphine and damage does not produce dose dumping. In addition the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly. Its safe use in the presence of renal failure makes it an attractive choice for older individuals. Recent scientific studies have shown no evidence of a ceiling dose of analgesia in man but only a ceiling effect for respiratory depression, increasing its safety profile. It appears that transdermal buprenorphine can be used in clinical practice safely and efficaciously for treating chronic pain in the elderly.

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

Spinal cord stimulation: principles of past, present and future practice: a review

Electric energy have been in use for the treatment of various ailments, including pain, since the time of Pharaohs. The theoretical basis of electrotherapy of pain was provided by the Gate Control Theory of Melzak and Wall. In 1965, Shealey et al. first introduced electrical stimulation of spinal cord for treating pain. At present spinal cord stimulation (SCS) is a well established form of treatment for failed back surgery syndrome, complex regional pain syndrome and refractory pain due to ischemia. The indications for SCS is growing and the technology involved in this is rapidly advancing, however, high level of scientific evidence is still lacking to support this form of therapy due to difficulties in blinding and comparing with control groups. Future developments in SCS could include, combined SCS-drug delivery system, bio feedback and closed loop systems.

Preventive analgesia for postoperative pain control: a broader concept

Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.

Tapentadol extended-release for treatment of chronic pain: a review

Tapentadol is a centrally acting analgesic with a dual mechanism of action of mu receptor agonism and norepinephrine reuptake inhibition. Tapentadol immediate-release is approved by the US Food and Drug Administration for the management of moderate-to-severe acute pain. It was developed to decrease the intolerability issue associated with opioids. Tapentadol extended-release has a 12-hour duration of effect, and has recently been evaluated for pain in patients with chronic osteoarthritis, low back pain, and pain associated with diabetic peripheral neuropathy. Tapentadol extended-release was found to provide safe and highly effective analgesia for the treatment of chronic pain conditions, including moderate-to-severe chronic osteoarthritis pain and low back pain. Initial trials demonstrating efficacy in neuropathic pain suggest that tapentadol has comparable analgesic effectiveness and better gastrointestinal tolerability than opioid comparators, and demonstrates effectiveness in settings of inflammatory, somatic, and neuropathic pain. Gastrointestinal intolerance and central nervous system effects were the major adverse events noted. Tapentadol will need to be rigorously tested in chronic neuropathic pain, cancer-related pain, and cancer-related neuropathic pain.

Acute Pain in Undergraduate Medical Education: An Unfinished Chapter!

Inadequately treated acute pain is a global healthcare problem that causes significant patient suffering and disability, risk of chronicity, increased resource utilization, and escalating healthcare costs. Compounding the problem is the lack of adequate instruction in acute pain management available in medical schools worldwide. Incorporating acute pain diagnosis and management as an integral part of the medical school curriculum will allow physicians to develop a more comprehensive, compassionate approach to treating patients with acute pain syndromes and should be considered a healthcare imperative. In this article, we review the current status of pain education in educational institutions across the world, focusing on achievements, lacunae, and inadequacies. We appeal to all concerned—pain management specialists, health educators, and policymakers—to consider incorporating education on acute pain and its management at undergraduate medical levels in an integrated manner.

Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient

The epidemic use of illicit drugs has led to an increasing number of patients with drug addiction and dependence presenting for perioperative care. There are a wide variety of drugs commonly abused including opioids, such as heroin and prescription drugs; stimulants, such as amphetamine and cocaine; depressant drugs, such as alprazolam and diazepam; and hallucinogens, such as lysergic acid diethylamide, phencyclidine, and marijuana. Treatment of opioid dependence by office-based buprenorphine and methadone maintenance programs has expanded opportunities for therapy. Treatment of these patients in the perioperative period is challenging. In addition to pain control, management of anxiety, psychological states, and hemodynamic control are the factors to be considered to provide optimum treatment. Although opioids are the mainstay for the control of acute pain, other therapeutic options include alternative routes of administration of local anesthetic, ketamine infusion, and the use of regional anesthesia. We discuss optimum perioperative management, the role of perioperative urine testing, and special considerations in patients on methadone and buprenorphine.

Pain Relief in Laparoscopic Cholecystectomy—A Review of the Current Options

Abstract:  Pain relief after laparoscopic cholecystectomy (LC) is an issue of great practical importance. Pain after LC has several origins: incisional, local visceral, peritoneal, and referred. Several modalities have been employed for achieving effective and safe analgesia: nonsteroidal anti‐inflammatory drugs (NSAIDs) and cyclooxygenase‐2 (COX‐2) inhibitors, gabapentinoids, local anesthetics, and transversus abdominis plane (TAP) block. They have their advantages and disadvantages, and multimodal approaches are often followed because of the multiple sources of pain. Among COX‐2 inhibitors, parecoxib and valdecoxib are useful, and fears regarding their cardiovascular adverse effects in noncardiac surgery (such as LC) have not been substantiated when used in short term. Gabapentin is useful but more data are needed regarding pregabalin because of inconsistent results. Local anesthetics (LA) can be particularly useful, both port‐site infiltration and intraperitoneal instillation in the intra‐operative period. Factors enhancing the effectiveness of these agents include early instillation before creating the pneumoperitoneum, larger volume of medium used for instillation, and favorable pharmacological characteristics of the agent. Combination of LA with either NSAID/COX‐2 inhibitors or fibrin sealant appears to be effective, although more research is required for determining the exact combinations and efficacy using direct comparisons with single‐modality interventions. Finally, newer procedures such as TAP block appear promising if replicated.▪

Recent advances in elucidating pain mechanisms.

Purpose of review The purpose of this review is to highlight the important recent advances in this fast developing field of pain mechanisms. It is now recognized that acute tissue and neural injuries can result in nociceptor sensitization (primary hyperalgesia) and spinal cord hyperexcitability or central sensitization that results in secondary hyperalgesia and allodynia. Recent findings New findings regarding peripheral and central sensitization are presented in this review. Newer ideas on pain modulation, pain states and pain syndromes, mechanisms of chronic pain, newer opioid and non opioid medications including newer N-methyl-D-asparate antagonists, cyclooxygenase-2 inhibitors and membrane stabilizing analgesics as well as pain control at the genetic level are discussed. Summary The research of the last decade has focused on the biochemical and structural plasticity of the nervous system following tissue and nerve injury. The mechanisms involved in the transition from acute to chronic pain are complex with the involvement of interacting receptor systems and intracellular ion flux, second messenger systems, new synaptic connections and apoptosis.

Tapentadol extended release in the management of peripheral diabetic neuropathic pain

Tapentadol, a μ-opioid agonist and norepinephrine reuptake inhibitor, has been found to be an effective medication for a wide variety of chronic pain conditions, including back pain, cancer-related pain, and arthritic pain. It has also been found to have fewer gastrointestinal side effects than more traditional opioid-based therapies. More recently, tapentadol extended release has been demonstrated to be effective in the management of painful diabetic neuropathy, an often debilitating condition affecting approximately one-third of all patients with diabetes. This review highlights the most up-to-date basic and clinical studies by focusing on the mechanisms of action of tapentadol and its clinical efficacy, especially with regard to painful diabetic neuropathy.