Publications by authors named "Paul J Christo"

71 Publications

Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency.

Front Pain Res (Lausanne) 2021 16;2:691720. Epub 2021 Nov 16.

Paolo Procacci Foundation, Rome, Italy.

A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for "chemical coping" as much as for pain control.
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http://dx.doi.org/10.3389/fpain.2021.691720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8915703PMC
November 2021

Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older.

Curr Med Res Opin 2022 05 29;38(5):811-825. Epub 2022 Mar 29.

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Acute pain is among the most common reasons that people consult primary care physicians, who must weigh benefits versus risks of analgesics use for each patient. Paracetamol (acetaminophen) is a first-choice analgesic for many adults with mild to moderate acute pain, is generally well tolerated at recommended doses (≤4 g/day) in healthy adults and may be preferable to non-steroidal anti-inflammatory drugs that are associated with undesirable gastrointestinal, renal, and cardiovascular effects. Although paracetamol is widely used, many patients and physicians still have questions about its suitability and dosing, especially for older people or adults with underlying comorbidities, for whom there are limited clinical data or evidence-based guidelines. Inappropriate use may increase the risks of both overdosing and inadequate analgesia. To address knowledge deficits and augment existing guidance in salient areas of uncertainty, we have researched, reviewed, and collated published evidence and expert opinion relevant to the acute use of paracetamol by adults with liver, kidney, or cardiovascular diseases, gastrointestinal disorders, asthma, or/and who are older. A concern is hepatotoxicity, but this is rare among adults who use paracetamol as directed, including people with cirrhotic liver disease. Putative epidemiologic associations of paracetamol use with kidney or cardiovascular disease, hypertension, gastrointestinal disorders, and asthma largely reflect confounding biases and are of doubtful relevance to short-term use (<14 days). Paracetamol is a suitable first-line analgesic for mild to moderate acute pain in many adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, and/or who are older. No evidence supports routine dose reduction for older people. Rather, dosing for adults who are older and/or have decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma that is known to be cross-sensitive to paracetamol, should be individualized in consultation with their physician, who may recommend a lower effective dose appropriate to the circumstances.
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http://dx.doi.org/10.1080/03007995.2022.2049551DOI Listing
May 2022

Evaluation and Management of Neurogenic Thoracic Outlet Syndrome with an Overview of Surgical Approaches: A Comprehensive Review.

J Pain Res 2021 5;14:3085-3095. Epub 2021 Oct 5.

Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Neurogenic thoracic outlet syndrome (NTOS) represents a disorder believed to involve compression of one or more neurovascular elements as they exit the thoracic outlet. This comprehensive literature review will focus on the occurrence, classification, etiology, clinical presentation, diagnostic measures, and both nonoperative and operative therapies for NTOS. NTOS represents the most common subtype of thoracic outlet syndrome and can significantly impair quality of life. Botulinum toxin injection into the anterior scalene muscle, or even the middle scalene or pectoralis minor muscles, can reduce the symptoms of this syndrome. The best available evidence for botulinum toxin therapy to the cervicothoracic muscles supports the value of this treatment for reducing pain in the affected extremity, and for an approximate duration of 2 months or more. Surgical approaches and newer minimally invasive surgical approaches offer high rates of improvement in select centers.
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http://dx.doi.org/10.2147/JPR.S282578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502052PMC
October 2021

Pharmacologic agents directed at the treatment of pain associated with maladaptive neuronal plasticity.

Expert Opin Pharmacother 2022 Jan 30;23(1):105-116. Epub 2021 Aug 30.

Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.

Introduction: The definition of nociplastic pain in 2016 has changed the way maladaptive chronic pain is viewed in that it may emerge without neural lesions or neural disease. Many endogenous and pharmacologic substances are being investigated for their role in treating the pain associated with neuronal plasticity.

Areas Covered: The authors review promising pharmacologic agents for the treatment of pain associated with maladaptive neuronal plasticity. The authors then provide the reader with their expert opinion and provide their perspectives for the future.

Expert Opinion: An imbalance between the amplification of ascending pain signals and the poor activation of descending inhibitory signals may be at the root of many chronic pain syndromes. The inhibitory activity of noradrenaline reuptake may play a role in neuropathic and nociplastic analgesia. A better understanding of the brain's pain matrix, its signaling cascades, and the complex bidirectional communication between the immune system and the nervous system may help meet the urgent and unmet medical need for safe, effective chronic pain treatment, particularly for pain with a neuropathic and/or nociplastic component.
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http://dx.doi.org/10.1080/14656566.2021.1970135DOI Listing
January 2022

Review of the Current State of Urine Drug Testing in Chronic Pain: Still Effective as a Clinical Tool and Curbing Abuse, or an Arcane Test?

Curr Pain Headache Rep 2021 Feb 17;25(2):12. Epub 2021 Feb 17.

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD, 21205, USA.

Purpose Of Review: Therapeutic use, misuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain remain a major concern for physicians, the government, payers, and patients. The challenge remains finding effective diagnostic tools that can be clinically validated to eliminate or substantially reduce the abuse of controlled prescription drugs, while still assuring the proper treatment of those patients in pain. Urine drug testing still remains an important means of adherence monitoring, but questions arise as to its relevance and effectiveness. This review examines the role of UDT, determines its utility in current clinical practice, and investigates its relevance in current chronic pain management.

Recent Findings: A review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature was searched from year 2000 to present examining the relevance and role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. There are only a limited number of reviews and investigations on UDT, despite the fact that clinicians who prescribe controlled medications for chronic states commonly are expected to utilize UDT. Therefore, despite highly prevalent use, there is a limited publication base from which to draw in this present study. Regardless of experience or training background, physicians and healthcare providers can much more adequately assess opioid therapy with the aid of UDT, which often requires confirmatory testing by a laboratory for clinical and therapeutic prescribing decisions. It has become a strongly recommended aspect of pain care with controlled substances locally, regionally, and nationally. Incorporating UDT for all patients in whom chronic opioid therapy is undertaken is consistent with state and national guidelines and best practice strategies. Practice standards vary as to the frequency of UDT locally, regionally, and nationally, however.
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http://dx.doi.org/10.1007/s11916-020-00918-zDOI Listing
February 2021

Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain.

Pain Ther 2021 Jun 11;10(1):181-209. Epub 2021 Feb 11.

Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39-45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient's recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.
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http://dx.doi.org/10.1007/s40122-021-00235-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119532PMC
June 2021

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines.

Pain Physician 2021 01;24(S1):S27-S208

, Advanced Pain Institute, Covington, LA.

Background: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines.

Objective: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine.

Methods: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and  recommendations were provided.

Results: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections.

Limitations: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain.

Conclusions: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
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January 2021

Potential neurological manifestations of COVID-19: a narrative review.

Postgrad Med 2022 May 11;134(4):395-405. Epub 2021 Jan 11.

Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Neurological manifestations are increasingly reported in a subset of COVID-19 patients. Previous infections related to coronaviruses, namely Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS) also appeared to have neurological effects on some patients. The viruses associated with COVID-19 like that of SARS enters the body via the ACE-2 receptors in the central nervous system, which causes the body to balance an immune response against potential damage to nonrenewable cells. A few rare cases of neurological sequelae of SARS and MERS have been reported. A growing body of evidence is accumulating that COVID-19, particularly in severe cases, may have neurological consequences although respiratory symptoms nearly always develop prior to neurological ones. Patients with preexisting neurological conditions may be at elevated risk for COVID-19-associated neurological symptoms. Neurological reports in COVID-19 patients have described encephalopathy, Guillain-Barré syndrome, myopathy, neuromuscular disorders, encephalitis, cephalgia, delirium, critical illness polyneuropathy, and others. Treating neurological symptoms can pose clinical challenges as drugs that suppress immune response may be contraindicated in COVID-19 patients. It is possible that in some COVID-19 patients, neurological symptoms are being overlooked or misinterpreted. To date, neurological manifestations of COVID-19 have been described largely within the disease trajectory and the long-term effects of such manifestations remain unknown.
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http://dx.doi.org/10.1080/00325481.2020.1837503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799377PMC
May 2022

Opioids May be Appropriate for Chronic Pain.

Authors:
Paul J Christo

J Law Med Ethics 2020 06;48(2):241-248

Paul J. Christo, M.D., M.B.A., is Associate Professor, Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine. He earned a B.S. from University of Notre Dame, Notre Dame, IN, an M.D. from University of Louisville School of Medicine, Louisville, KY, and an M.B.A. from The Johns Hopkins Carey School of Business, Baltimore, MD.

Patients living with chronic pain require appropriate access to opioid therapy along with improved access to pain care and additional therapeutic options. It's both medically reasonable and ethical to consider opioid therapy as a treatment option in the management of chronic, non-cancer pain for a subset of patients with severe pain that is unresponsive to other therapies (e.g., injections, other medications, integrative strategies), negatively impacts function or quality of life, and will likely outweigh the potential harms. This paper will examine opioid therapy in the setting of the opioid epidemic, why critics feel that the CDC guideline has resulted in harsh consequences for patients and their physicians, and the rationale for opioid therapy as a means of providing ethical and compassionate pain care.
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http://dx.doi.org/10.1177/1073110520935335DOI Listing
June 2020

Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines.

Pain Physician 2020 05;23(3S):S1-S127

Axis Spine Center, Coeur d'Alene, ID.

Background: Chronic axial spinal pain is one of the major causes of significant disability and health care costs, with facet joints as one of the proven causes of pain.

Objective: To provide evidence-based guidance in performing diagnostic and therapeutic facet joint interventions.

Methods: The methodology utilized included the development of objectives and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of facet joint interventions, was reviewed, with a best evidence synthesis of available literature and utilizing grading for recommendations.Summary of Evidence and Recommendations:Non-interventional diagnosis: • The level of evidence is II in selecting patients for facet joint nerve blocks at least 3 months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. • The level of evidence is IV for accurate diagnosis of facet joint pain with physical examination based on symptoms and signs, with weak strength of recommendation. Imaging: • The level of evidence is I with strong strength of recommendation, for mandatory fluoroscopic or computed tomography (CT) guidance for all facet joint interventions. • The level of evidence is III with weak strength of recommendation for single photon emission computed tomography (SPECT) . • The level of evidence is V with weak strength of recommendation for scintography, magnetic resonance imaging (MRI), and computed tomography (CT) .Interventional Diagnosis:Lumbar Spine: • The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. • Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of ≥80% were included. • The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with ≥80% pain relief.Cervical Spine: • The level of evidence is II with moderate strength of recommendation. • Ten relevant diagnostic accuracy studies, 9 of the 10 studies with either controlled comparative local anesthetic blocks or placebo controls with concordant pain relief with a criterion standard of ≥80% were included. • The prevalence and false-positive rates ranged from 29% to 60% and of 27% to 63%, with high variability. Thoracic Spine: • The level of evidence is II with moderate strength of recommendation. • Three relevant diagnostic accuracy studies, with controlled comparative local anesthetic blocks, with concordant pain relief, with a criterion standard of ≥80% were included. • The prevalence varied from 34% to 48%, whereas false-positive rates varied from 42% to 58%.Therapeutic Facet Joint Interventions: Lumbar Spine: • The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with 2 negative studies and 4 studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of 3 relevant randomized controlled trials, with long-term improvement. • The level of evidence is IV with weak strength of recommendation for lumbar facet joint intraarticular injections with inclusion of 9 relevant randomized controlled trials, with majority of them showing lack of effectiveness without the use of local anesthetic. Cervical Spine: • The level of evidence is II with moderate strength of recommendation for cervical radiofrequency ablation with inclusion of one randomized controlled trial with positive results and 2 observational studies with long-term improvement. • The level of evidence is II with moderate strength of recommendation for therapeutic cervical facet joint nerve blocks with inclusion of one relevant randomized controlled trial and 3 observational studies, with long-term improvement. • The level of evidence is V with weak strength of recommendation for cervical intraarticular facet joint injections with inclusion of 3 relevant randomized controlled trials, with 2 observational studies, the majority showing lack of effectiveness, whereas one study with 6-month follow-up, showed lack of long-term improvement. Thoracic Spine: • The level of evidence is III with weak to moderate strength of recommendation with emerging evidence for thoracic radiofrequency ablation with inclusion of one relevant randomized controlled trial and 3 observational studies. • The level of evidence is II with moderate strength of recommendation for thoracic therapeutic facet joint nerve blocks with inclusion of 2 randomized controlled trials and one observational study with long-term improvement. • The level of evidence is III with weak to moderate strength of recommendation for thoracic intraarticular facet joint injections with inclusion of one randomized controlled trial with 6 month follow-up, with emerging evidence. Antithrombotic Therapy: • Facet joint interventions are considered as moderate to low risk procedures; consequently, antithrombotic therapy may be continued based on overall general status. Sedation: • The level of evidence is II with moderate strength of recommendation to avoid opioid analgesics during the diagnosis with interventional techniques. • The level of evidence is II with moderate strength of recommendation that moderate sedation may be utilized for patient comfort and to control anxiety for therapeutic facet joint interventions.

Limitations: The limitations of these guidelines include a paucity of high-quality studies in the majority of aspects of diagnosis and therapy.

Conclusions: These facet joint intervention guidelines were prepared with a comprehensive review of the literature with methodologic quality assessment with determination of level of evidence and strength of recommendations.

Key Words: Chronic spinal pain, interventional techniques, diagnostic blocks, therapeutic interventions, facet joint nerve blocks, intraarticular injections, radiofrequency neurolysis.
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May 2020

Treatment of Déjerine-Roussy syndrome pain with scrambler therapy.

Pain Manag 2020 May 12;10(3):141-145. Epub 2020 May 12.

Anesthesiology & Critical Care Medicine-Pain Medicine (PJC), Neuro-oncology (DOK), & Palliative Care Programs Sidney Kimmel Comprehensive Cancer Center (TJS), all at Johns Hopkins University, Baltimore, MD 21287, USA.

Déjerine-Roussy syndrome or central thalamic pain can be devastating, and treatment with drugs and even deep brain stimulation can be unsatisfactory. Scrambler therapy is a form of neuromodulation that uses external skin electrodes to send a 'non-pain' signal to the brain, with some success in difficult-to-treat syndromes such as neuromyelitis optica spectrum disorder. We used scrambler therapy to treat a patient with 6 years of disabling Déjerine-Roussy syndrome pain. A 56-year-old man received multiple daily then monthly treatments with electrode pairs placed just above the area of distal pain. Each treatment was for 40 min. His allodynia and hyperalgesia resolved within 10 min, and his pain score fell to almost zero after 30 min. Months later, he resumed normal activity and is off all his pain medications. No side effects were noted. Scrambler therapy appeared to reverse 6 years of disabling pain safely and economically, and continues to be effective. Further multi-institutional trials are warranted for this rare syndrome.
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http://dx.doi.org/10.2217/pmt-2019-0065DOI Listing
May 2020

The Use of Peripheral μ-Opioid Receptor Antagonists (PAMORA) in the Management of Opioid-Induced Constipation: An Update on Their Efficacy and Safety.

Drug Des Devel Ther 2020 11;14:1009-1025. Epub 2020 Mar 11.

Cardiology Research Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.

Peripherally acting μ-opioid receptor antagonists (PAMORAs) constitute a class of drugs which reverse opioid-induced constipation (OIC) with similar opioid analgesic effects. OIC differs from other forms of constipation in that it is an iatrogenic condition that occurs when an opioid acts on the dense network of μ-opioid receptors in the enteric system, which affect a variety of functions including gastrointestinal motility, secretion, and other factors that can cause bowel dysfunction. Unfortunately, laxative products, bowel regimens, dietary changes, and lifestyle modifications have limited effectiveness in preventing OIC, Opioid-associated adverse effect which occurs in 40% to 80% of opioid patients and may led to cessation of the treatment. PAMORAs are μ-receptor opioid antagonists specifically developed so that they have very limited ability to cross the blood-brain barrier and thus they are able to antagonize peripheral but not central μ-opioid receptors. PAMORAs are designed to have no effect on the analgesic benefits of opioid pain relievers but to relieve but antagonizing the effects of the opioid in the gastrointestinal system. The three main PAMORAS are methyltrexone (oral or parenteral), naldemedine (oral only), and naloxegol (oral only). Clinical studies demonstrate the safety and efficacy of these agents for alleviating constipation without diminishing the analgesic effect of opioid therapy. The aim of this narrative review to update the current status of PAMORAs for treating OIC in terms of safety and efficacy.
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http://dx.doi.org/10.2147/DDDT.S221278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075239PMC
February 2021

A prospective randomized controlled study of auricular point acupressure to manage chronic low back pain in older adults: study protocol.

Trials 2020 Jan 20;21(1):99. Epub 2020 Jan 20.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Chronic low back pain (cLBP) is a major health problem and the most common pain condition among those aged 60 years or older in the US. Despite the development of pharmacological and nonpharmacological interventions, cLBP outcomes have not improved and disability rates continue to rise. This study aims to test auricular point acupressure (APA) as a non-invasive, nonpharmacological self-management strategy to manage cLBP and to address current shortcomings of cLBP treatment.

Methods/design: For this prospective randomized controlled study, participants will be randomly assigned to three groups: (1) APA group (active points related to cLBP), (2) Comparison group-1 (non-active points, unrelated to cLBP), and (3) Comparison group-2 (enhanced educational control, an educational booklet on cLBP will be given and the treatment used by participants for their cLBP will be recorded). The ecological momentary assessment smartphone app will be used to collect real-time cLBP outcomes and adherence to APA practice. Treatment and nonspecific psychological placebo effects will be measured via questionnaires for all participants. This proposed trial will evaluate the APA sustained effects for cLBP at 12-month follow-up. Monthly telephone follow-up will be used to collect study outcomes. Blood will be collected during study visits at baseline, post APA treatment, and follow-up study visits at 1, 3, 6, 9 and 12 months post completion of treatment for a total of seven assessments. Appointments will start between 9 and 11 am to control for circadian variation in cytokine levels.

Discussion: This study is expected to provide vital information on the efficacy, sustainability, and underlying mechanism of APA on cLBP necessary for APA to gain acceptance from both healthcare providers and patients, which would provide a strong impetus for including APA as part of cLBP management in clinical and home settings.

Trial Registration: ClinicalTrials.gov, ID: NCT03589703. Registered on 22 May 2018.
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http://dx.doi.org/10.1186/s13063-019-4016-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6972012PMC
January 2020

Progress in noninvasive, abortive neuromodulation therapy for treating acute pain in primary headache disorders.

Pain Manag 2019 01 3;9(1):9-11. Epub 2018 Dec 3.

Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine. The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 21287.

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http://dx.doi.org/10.2217/pmt-2018-0055DOI Listing
January 2019

Reframing the Role of Neuromodulation Therapy in the Chronic Pain Treatment Paradigm.

Pain Physician 2018 11;21(6):507-513

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Blaustein Pain Treatment Center, Johns Hopkins Hospital, Baltimore MD.

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November 2018

The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation.

Neuromodulation 2019 Jan 24;22(1):1-35. Epub 2018 Sep 24.

Vertex Spine, Franklin, TN, USA.

Introduction: The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes.

Methods: The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations.

Results: The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation.

Conclusion: The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
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http://dx.doi.org/10.1111/ner.12845DOI Listing
January 2019

Spinal Cord Stimulation for Treating Chronic Pain: Reviewing Preclinical and Clinical Data on Paresthesia-Free High-Frequency Therapy.

Neuromodulation 2018 Jan 3;21(1):10-18. Epub 2017 Nov 3.

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Background: Traditional spinal cord stimulation (SCS) requires that paresthesia overlaps chronic painful areas. However, the new paradigm high-frequency SCS (HF-SCS) does not rely on paresthesia.

Study Design: A review of preclinical and clinical studies regarding the use of paresthesia-free HF-SCS for various chronic pain states.

Methods: We reviewed available literatures on HF-SCS, including Nevro's paresthesia-free ultra high-frequency 10 kHz therapy (HF10-SCS). Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, and manual searches of the bibliographies of known primary and review articles.

Outcome Measures: The primary goal is to describe the present developing conceptions of preclinical mechanisms of HF-SCS and to review clinical efficacy on paresthesia-free HF10-SCS for various chronic pain states.

Results: HF10-SCS offers a novel pain reduction tool without paresthesia for failed back surgery syndrome and chronic axial back pain. Preclinical findings indicate that potential mechanisms of action for paresthesia-free HF-SCS differ from those of traditional SCS.

Conclusions: To fully understand and utilize paresthesia-free HF-SCS, mechanistic study and translational research will be very important, with increasing collaboration between basic science and clinical communities to design better trials and optimize the therapy based on mechanistic findings from effective preclinical models and approaches. Future research in these vital areas may include preclinical and clinical components conducted in parallel to optimize the potential of this technology.
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http://dx.doi.org/10.1111/ner.12721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5766402PMC
January 2018

Nanotechnology: A Promising New Paradigm for the Control of Pain.

Pain Med 2018 02;19(2):232-243

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.

Objective: The objective of this article is to critically review both preclinical and clinical studies that focus on the use of nanotechnology for both acute and chronic pain management, surveying both diagnostic and therapeutic applications. The article also provides information on nanotechnology for pain practitioners, so that they may better understand how this technology works and how it may be applied to their day-to-day clinical practice.

Study Design: Narrative review.

Methods: The Pubmed NCBI and EMBASE databases were utilized to review published reports of in vivo and clinical studies that focus on using nanotechnology for pain management applications in both the acute and chronic pain settings.

Results: Articles were screened by title, abstract, and full article review. They were then analyzed by specific clinical indications, and appropriate data were presented based on a critical analysis of those articles.

Conclusions: As the development of nanomedical applications in acute and chronic pain management continues, medical practitioners should consider their growing potential to enhance the care of patients who are consistently living with pain. Current barriers to implementation include manufacturing scale-up for commercial viability, long-term nanoparticle toxicity considerations, and high cost for successful passage through clinical trials. These challenges will need to be overcome with ongoing translational research efforts in collaboration with industry and government bodies such as the Food and Drug Administration (FDA).
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http://dx.doi.org/10.1093/pm/pnx131DOI Listing
February 2018

Stem Cell Therapy for Chronic Pain Management: Review of Uses, Advances, and Adverse Effects.

Pain Physician 2017 05;20(4):293-305

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Blaustein Pain Treatment Center, Johns Hopkins Hospital, Baltimore MD.

Background: This review article outlines the recent advances, uses, and adverse effects of cell-based therapy for chronic pain management. Cell based therapies are gaining increasing ground as novel treatment modalities for a variety of pain pathologies that include, but are not limited to, neuropathic pain and degenerative disc disease. As these treatment modalities become more common practice, we have focused our review to provide pain practitioners and other practicing physicians an understanding of the technology and to summarize key clinical data and existing clinical trials that are being pursued by clinical investigators worldwide.

Objective: Review of stem cell technology and applications in pain management.

Study Design: Narrative review.

Methods: The Pubmed NCBI and EMBASE databases was utilized to review published reports of clinical studies reported from 2000 to 2015, and ClinicalTrials.gov (www.clinicaltrials.gov/ct2/search) search function was used to document ongoing clinical trials [keywords: "chronic pain," "disc pain," "cell therapy," "osteoarthritis," "neuropathic," "stem cell"] currently active and recruiting patients.

Results: Articles were screened by title, abstract, and full article review. They were then analyzed by specific clinical indications and appropriate data were presented based on critical analysis of those articles.

Limitations: More studies looking at the systematic use of stem cells in pain management will be required to draw conclusions about the benefits of the technology.

Conclusion: Though the data from existing studies look promising for the use of stem cells as a novel therapeutic strategy for discogenic pain, neuropathic pain, and osteoarthritis, additional clinical studies will be needed to validate the benefit of the technology for clinical use. However, we hope that this narrative review will help guide pain physicians in making informed decisions for their patients about the potential of cell-based therapy for treating chronic pain conditions.
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May 2017

Review of Recent Advances in Peripheral Nerve Stimulation (PNS).

Curr Pain Headache Rep 2016 Nov;20(11):60

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, 21287, MD, USA.

Peripheral nerve stimulation (PNS) for the treatment of chronic pain has become an increasingly important field in the arena of neuromodulation, given the ongoing advances in electrical neuromodulation technology since 1999 permitting minimally invasive approaches using an percutaneous approach as opposed to implantable systems. Our review aims to provide clinicians with the recent advances and studies in the field, with specific emphasis on clinical data and indications that have been accumulated over the last several years. In addition, we aim to address key basic science studies to further emphasize the importance of translational research outcomes driving clinical management.
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http://dx.doi.org/10.1007/s11916-016-0590-8DOI Listing
November 2016

Effectiveness of Spinal Cord Stimulation in Chronic Spinal Pain: A Systematic Review.

Pain Physician 2016 Jan;19(1):E33-54

Comprehensive Spine Center at Rhode Island Hospital, Providence, RI.

Background: Chronic neuropathic pain has been recognized as contributing to a significant proportion of chronic pain globally. Among these, spinal pain is of significance with failed back surgery syndrome (FBSS), generating considerable expense for the health care systems with increasing prevalence and health impact.

Objective: To assess the role and effectiveness of spinal cord stimulation (SCS) in chronic spinal pain.

Study Design: A systematic review of randomized controlled trials (RCTs) of SCS in chronic spinal pain.

Methods: The available literature on SCS was reviewed. The quality assessment criteria utilized were Cochrane review criteria to assess sources of risk of bias and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM - QRB) criteria for randomized trials.The level of evidence was based on a best evidence synthesis with modified grading of qualitative evidence from Level I to Level V.Data sources included relevant literature published from 1966 through March 2015 that were identified through searches of PubMed and EMBASE, manual searches of the bibliographies of known primary and review articles, and all other sources.

Outcome Measures: RCTs of efficacy with a minimum 12-month follow-up were considered for inclusion. For trials of adaptive stimulation, high frequency stimulation, and burst stimulation, shorter follow-up periods were considered.

Results: Results showed 6 RCTs with 3 efficacy trials and 3 stimulation trials. There were also 2 cost effectiveness studies available. Based on a best evidence synthesis with 3 high quality RCTs, the evidence of efficacy for SCS in lumbar FBSS is Level I to II. The evidence for high frequency stimulation based on one high quality RCT is Level II to III. Based on a lack of high quality studies demonstrating the efficacy of adaptive stimulation or burst stimulation, evidence is limited for these 2 modalities.

Limitations: The limitations of this systematic review continue to require future studies illustrating effectiveness and also the superiority of high frequency stimulation and potentially burst stimulation.

Conclusion: There is significant (Level I to II) evidence of the efficacy of spinal cord stimulation in lumbar FBSS; whereas, there is moderate (Level II to III) evidence for high frequency stimulation; there is limited evidence for adaptive stimulation and burst stimulation.
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January 2016

Review of the Uses of Vagal Nerve Stimulation in Chronic Pain Management.

Curr Pain Headache Rep 2015 Dec;19(12):54

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, USA.

Recent human and animal studies provide growing evidence that vagal nerve stimulation (VNS) can deliver strong analgesic effects in addition to providing therapeutic efficacy in the treatment of refractory epilepsy and depression. Analgesia is potentially mediated by vagal afferents that inhibit spinal nociceptive reflexes and transmission and have strong anti-inflammatory properties. The purpose of this review is to provide pain practitioners with an overview of VNS technology and limitations. It specifically focuses on clinical indications of VNS for various chronic pain syndromes, including fibromyalgia, pelvic pain, and headaches. We also present potential mechanisms for VNS modulation of chronic pain by reviewing both animal and human studies.
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http://dx.doi.org/10.1007/s11916-015-0528-6DOI Listing
December 2015

Dynamic Pain Phenotypes are Associated with Spinal Cord Stimulation-Induced Reduction in Pain: A Repeated Measures Observational Pilot Study.

Pain Med 2015 Jul 20;16(7):1349-60. Epub 2015 Mar 20.

Anesthesiology, Johns Hopkins University School of Medicine Baltimore, Maryland, USA.

Objective: Spinal cord stimulation (SCS) has become a widely used treatment option for a variety of pain conditions. Substantial variability exists in the degree of benefit obtained from SCS and patient selection is a topic of expanding interest and importance. However, few studies have examined the potential benefits of dynamic quantitative sensory testing (QST) to develop objective measures of SCS outcomes or as a predictive tool to help patient selection. Psychological characteristics have been shown to play an important role in shaping individual differences in the pain experience and may aid in predicting responses to SCS. Static laboratory pain-induction measures have also been examined in their capacity for predicting SCS outcomes.

Methods: The current study evaluated clinical, psychological and laboratory pain measures at baseline, during trial SCS lead placement, as well as 1 month and 3 months following permanent SCS implantation in chronic pain patients who received SCS treatment. Several QST measures were conducted, with specific focus on examination of dynamic models (central sensitization and conditioned pain modulation [CPM]) and their association with pain outcomes 3 months post SCS implantation.

Results: Results suggest few changes in QST over time. However, central sensitization and CPM at baseline were significantly associated with clinical pain at 3 months following SCS implantation, controlling for psycho/behavioral factors and pain at baseline. Specifically, enhanced central sensitization and reduced CPM were associated with less self-reported pain 3 months following SCS implantation.

Conclusions: These findings suggest a potentially important role for dynamic pain assessment in individuals undergoing SCS, and hint at potential mechanisms through which SCS may impart its benefit.
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http://dx.doi.org/10.1111/pme.12732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504785PMC
July 2015

Specimen validity testing in urine drug monitoring of medications and illicit drugs: clinical implications.

J Opioid Manag 2015 Jan-Feb;11(1):53-9

Millennium Research Institute, San Diego, California; Vice President, Clinical Research and Advocacy, Millennium Health, San Diego, California.

Objective: To discuss the importance of specimen validity testing (SVT) in urine drug testing (UDT) and the clinical role it plays in identifying efforts to subvert the UDT process.

Methods: A discussion of the clinical impact of SVT is presented.

Results: A discussion of pH, specific gravity, creatinine, and oxidation for monitoring the adulteration of UDT samples is presented along with the clinical significance of such tests.

Significance: SVT has a significant place in healthcare efforts to measure patient adherence, behavior, and honesty in communication with clinicians. SVT is typically ordered by treating clinicians who use the results to make therapeutic decisions regarding specific medical problems of their patient, including those related to medication and illicit drug use. In the absence of SVT, a healthcare provider may fail to identify a patient's adulteration of their urine sample in an attempt at deceiving the provider. Moreover, the presence of some underlying medical conditions may obfuscate the UDT results.
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http://dx.doi.org/10.5055/jom.2015.0252DOI Listing
May 2015

Current perspectives on intrathecal drug delivery.

J Pain Res 2014 6;7:615-26. Epub 2014 Nov 6.

Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Advances in intrathecal analgesia and intrathecal drug delivery systems have allowed for a range of medications to be used in the control of pain and spasticity. This technique allows for reduced medication doses that can decrease the side effects typically associated with oral or parenteral drug delivery. Recent expert panel consensus guidelines have provided care paths in the treatment of nociceptive, neuropathic, and mixed pain syndromes. While the data for pain relief, adverse effect reduction, and cost-effectiveness with cancer pain control are compelling, the evidence is less clear for noncancer pain, other than spasticity. Physicians should be aware of mechanical, pharmacological, surgical, and patient-specific complications, including possible granuloma formation. Newer intrathecal drug delivery systems may allow for better safety and quality of life outcomes.
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http://dx.doi.org/10.2147/JPR.S37591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4227625PMC
November 2014

Applying JIT principles to resident education to reduce patient delays: a pilot study in an academic medical center pain clinic.

Pain Med 2015 Feb 16;16(2):312-8. Epub 2014 Sep 16.

Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Objectives: This study investigated the effect on patient waiting times, patient/doctor contact times, flow times, and session completion times of having medical trainees and attending physicians review cases before the clinic session. The major hypothesis was that review of cases prior to clinic hours would reduce waiting times, flow times, and use of overtime, without reducing patient/doctor contact time.

Design: Prospective quality improvement.

Setting: Specialty pain clinic within Johns Hopkins Outpatient Center, Baltimore, MD, United States.

Participants: Two attending physicians participated in the intervention. Processing times for 504 patient visits are involved over a total of 4 months.

Intervention: Trainees were assigned to cases the day before the patient visit. Trainees reviewed each case and discussed it with attending physicians before each clinic session.

Primary And Secondary Outcome Measures: Primary measures were activity times before and after the intervention. These were compared and also used as inputs to a discrete event simulation to eliminate differences in the arrival process as a confounding factor.

Results: The average time that attending physicians spent teaching trainees while the patient waited was reduced, but patient/doctor contact time was not significantly affected. These changes reduced patient waiting times, flow times, and clinic session times.

Conclusions: Moving some educational activities ahead of clinic time improves patient flows through the clinic and decreases congestion without reducing the times that trainees or patients interact with physicians.
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http://dx.doi.org/10.1111/pme.12543DOI Listing
February 2015

Assessment of methodologic quality of randomized trials of interventional techniques: development of an interventional pain management specific instrument.

Pain Physician 2014 May-Jun;17(3):E263-90

Pain Management Center of Paducah, Paducah, KY and University of Louisville, Louisville, KY; Massachusetts General Hospital and Harvard Medical School, Boston, MA; Johns Hopkins University School of Medicine, Baltimore, MD.

Background: A major component of a systematic review is an assessment of the methodological quality and bias of randomized trials. The most commonly utilized methodological quality assessment and bias assessment for randomized trials is by the Cochrane Review Group. While this is not a "gold standard," it is an indication of the current state-of-the-art review methodology. There is, however, no specific instrument to assess the methodological quality of manuscripts published for interventional techniques.

Objectives: Our objective was to develop an instrument specifically for interventional pain management, to assess the methodological quality of randomized trials of interventional techniques.

Methods: Item generation for the instrument was based on a definition of quality, to the extent to which the design and conduct of the trial were congruent with the objectives of the trial. Applicability was defined as the extent to which the trial produced procedures could be applied with contemporary interventional pain management techniques. Multiple items based on Cochrane review criteria were utilized along with specific requirements for interventional techniques.

Results: A total of 22 items were developed which formed IPM-QRB or Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool. This included 9 of the 12 items from the Cochrane review criteria with definition of some items that were repetitive or duplicate, and the addition of 13 new items. The results were compared for inter-rater reliability of Cochrane review criteria and IPM-QRB, and inter-instrument reliability. The assessment was performed in multiple stages with an initial learning curve. The final assessment was for 4 randomized controlled trials (RCTs) utilizing both Cochrane review criteria and IPM-QRB criteria. The inter-rater agreement for Cochrane review criteria with overall intra-class correlation coefficient was 0.407 compared to an intra-class correlation coefficient of 0.833 for IPM-QRB criteria. The inter-rater agreement was superior for IPM-QRB criteria compared to Cochrane review criteria despite twice the items of Cochrane review criteria as IPM-QRB criteria with the detailed nature of assessment.

Limitations: Limited validity or accuracy assessment of the instrument and the large number of items to be scored.

Conclusion: We have developed a new comprehensive instrument to assess the methodological quality of randomized trials of interventional techniques. This instrument is superior to Cochrane review methodology criteria in that it provides more extensive and specific information for interventional techniques that will be useful in assessing the methodologic quality and bias of interventional techniques.
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June 2015

Targeting systemic inflammation in patients with obesity-related pain: Neurogenic thoracic outlet syndrome: an often overlooked but treatable condition.

J Fam Pract 2013 Sep;62(9 Suppl CHPP):S16-21

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.

Rely primarily on a patient's history and your physical examination findings in considering the diagnosis. Physical therapy, tricyclic antidepressants or SNRIs, and botulinum toxin type A injections can help control symptoms.
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September 2013

An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations.

Pain Physician 2013 Apr;16(2 Suppl):S49-283

American Society of Interventional Pain Physicians.

Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain.

Methodology: Systematic assessment of the literature.

Evidence: I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. • The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections. • The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic epidural injections in managing thoracic pain. • The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections. IV. Implantables • The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. • There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox). • There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events.

Conclusions: Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed.

Disclaimer: The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."
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April 2013

Complementary and alternative treatments for chronic pelvic pain.

Curr Pain Headache Rep 2013 Feb;17(2):316

Harvard Medical School, Division of Pain Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 15 Parkman Street, Room 330, Boston, MA 02114, USA.

Chronic pelvic pain (CPP) is a significant clinical entity that affects both men and women alike. The etiologies of CPP are multifactorial, and treatments are myriad. Complementary and Alternative Medicine (CAM) refers to non-allopathic health systems, and its use is popular in the United States. In particular, several recent studies have investigated the efficacy of various CAM practices in the treatment of CPP. The authors systematically evaluated recent literature in this area by searching the PubMed database for English-language studies published between January 2007 and August 2012.
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http://dx.doi.org/10.1007/s11916-012-0316-5DOI Listing
February 2013
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