Opioid-Sparing Effect of Intravenous Outpatient
Ketamine Infusions Appears Short-Lived
in Chronic-Pain Patients with High Opioid
Requirements

Background and Objectives: Ketamine is opioid-sparing. It attenuates the onset of opioid tolerance, and suppresses opioid-induced hyperalgesia. This study evaluated whether or not repeated outpatient infusions of intravenous ketamine reduced the amount of pain and the amount of opioid requirements for patients suffering with chronic, noncancerous pain. Study Design: Retrospective study Setting: Outpatient pain clinic Methods: We reviewed the records of 18 patients taking high doses of opioids chronically and nonetheless reporting poorly controlled pain. A comparison control group of 18 similar patients with high opioid requirements who were not given ketamine were selected from our clinic population. Intervention: Intravenous ketamine infusions Measurement: VAS pain scores and opioid use Results: Morphometric and demographic characteristics, baseline opioid use, and pain scores were similar in the ketamine and comparison groups. Five patients given ketamine experienced no benefit and discontinued treatment after 1-2 infusions. One patient developed a supraventricular arrhythmia which immediately resolved upon cessation of the infusion. And another, despite pain relief, felt overly-anxious and opted out. Eleven patients thus completed 3-6 weekly ketamine infusions. At 6 months, 5 patients maintained less than 50% of their baseline opioid use, while the remaining patients returned to the baseline opioid use or increased their requirements. There was no significant difference in pain scores at 6 months in patients who received ketamine infusions and control group patients. Limitations: Retrospective nature of the study Conclusions: Outpatient intravenous ketamine infusions did not improve long-term pain scores in patients with high opioid requirements and only a few were able to substantially reduce opioid use. Considering infusion risks and cost of such outpatient treatment, ketamine infusions do not appear to be a feasible option for improving pain relief and decreasing opioid use in high-opioid requirement patients. Key words: Ketamine; anesthesia; chronic pain; opioids; continuous infusion; opioid requirements

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Effects of intraoperative liposomal bupivacaine on pain control and opioid use after pediatric Chiari I malformation surgery: an initial experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.6.peds20370 ◽

2021 ◽

Vol 27 (1) ◽

pp. 9-15

Author(s):

Victor M. Lu ◽

David J. Daniels ◽

Dawit T. Haile ◽

Edward S. Ahn

Keyword(s):

Pain Control ◽

Potential Role ◽

Chiari I Malformation ◽

Control Group ◽

Initial Experience ◽

Opioid Use ◽

Liposomal Bupivacaine ◽

Pain Scores ◽

Significant Difference ◽

Chiari I

OBJECTIVEPediatric Chiari I malformation decompression is a common neurosurgical procedure. Liposomal bupivacaine (LB) is a novel formulation that can have an impact on postoperative recovery for particular procedures, but its potential role in pediatric neurosurgery is largely unexplored. The authors sought to describe and assess their initial experience with LB in pediatric Chiari I malformation decompression to better define its potential role as an analgesic agent in a procedure for which the postoperative course is often remarkably painful.METHODSA retrospective review of all pediatric Chiari procedures performed at the authors’ institution between 2018 and 2020 was conducted. Patients were divided into those who were treated with a single intraoperative dose of LB (LB group) and those who were not (control group). Comparisons of total opioid use and pain control were made using chi-square and Wilcoxon rank-sum tests.RESULTSA total of 18 patients were identified, 9 (50%) in the LB group and 9 (50%) in the control group. Overall, there were 13 (72%) female and 5 (28%) male patients with a mean age of 15.9 years. No surgical complications were observed over a mean length of stay of 2.7 days. Within the first 24 hours after surgery, the LB group had significantly lower total opioid use than the control group (17.5 vs 47.9 morphine milligram equivalents, respectively; p = 0.03) as well as lower mean pain scores reported by patients using a 10-point visual analog scale (3.6 vs 5.5 for the LB vs control groups, p = 0.04). However, from the first 24 postoperative hours to discharge, total opioid use (p = 0.51) and mean pain scores (p = 0.09) were statistically comparable between the two groups. There were 2/9 (22%) LB patients versus 0/9 (0%) control patients who did not require opioid analgesia at any point during hospitalization.CONCLUSIONSThe use of a single intraoperative dose of LB in pediatric Chiari I malformation surgery appears to be safe and has the potential to reduce pain scores and opioid use when administered during the first 24 postoperative hours. From that time period to discharge, however, there may be no significant difference in total opioid use or pain scores.

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Effectiveness of Transcranial Direct Current Stimulation and Pharmacotherapy in Pain Management in Patients with Chronic Pain

Modern Care Journal ◽

10.5812/modernc.119154 ◽

2021 ◽

Vol 18 (4) ◽

Author(s):

Atefeh Lotfi Jabali ◽

Mina Mojtabaei ◽

Malek Mirhashemi

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Direct Current ◽

Transcranial Direct Current Stimulation ◽

Pain Clinic ◽

Control Group ◽

Mcgill Pain Questionnaire ◽

Statistical Population ◽

Direct Current Stimulation ◽

Significant Difference

Background: A variety of pharmacological and nonpharmacological methods are used to treat chronic pain. Transcranial direct current stimulation (tDCS) through stimulating the central and peripheral nerves is a different and promising method for the treatment of chronic pain. Objectives: The present study aimed to investigate the effectiveness of tDCS and pharmacotherapy in pain management in patients with chronic pain in Tehran, Iran. Methods: The present study followed a clinical trial design. The statistical population comprised all patients with chronic pain who were referred to Pardis Multidisciplinary Pain Clinic in Tehran within 2020 - 21. A total of 60 patients willing to participate in the study were selected using convenience sampling. The participants were randomly divided into three groups, including pharmacotherapy (treatment by gabapentin with a dosage of 600 mg twice per day), tDCS, and control (n = 20 per group). The research instrument included the McGill Pain Questionnaire. The data were analyzed using repeated-measures analysis of variance with SPSS software (version 24.0). Results: The results showed that both pharmacotherapy and tDCS interventions led to a reduction in the mean scores of pain management components, compared to the control group (P < 0.001). Furthermore, there was no significant difference between the effects of the two experimental groups on pain management components. Conclusions: The tDCS and pharmacotherapy were both shown to be effective in pain management in patients with chronic pain. Therefore, in addition to pharmacotherapy, tDCS is also recommended for the treatment of chronic pain.

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Long-term efficacy of 1–1.2 kHz subthreshold spinal cord stimulation following failed traditional spinal cord stimulation: a retrospective case series

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-000003 ◽

2019 ◽

Vol 44 (1) ◽

pp. 107-110 ◽

Cited By ~ 7

Author(s):

Leonardo Kapural ◽

Shervin Harandi

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Spinal Cord Stimulation ◽

Case Series ◽

Low Frequency ◽

Opioid Use ◽

Retrospective Case ◽

Pain Scores ◽

Significant Difference

Background and objectiveWe investigated whether an effective long-term pain relief could be achieved using subthreshold 1–1.2 kHz spinal cord stimulation (SCS) among patients who were initially implanted with traditional paresthesia-based SCS but who failed to maintain an adequate pain relief.MethodsRetrospective chart review was conducted of patients’ electronic records who underwent a trial of subthreshold 1–1.2 kHz SCS. One hundred and nine patients implanted and programmed at traditional paresthesia-based frequencies 40–90 Hz (low-frequency SCS) with unsatisfactory pain relief or unpleasant paresthesias were identified. Patients’ settings were switched to 1–1.2 kHz and 60–210 µs, and variable amplitude adjusted to subthreshold. Pain scores and medication usage were collected. Complete data are presented on 95 patients.ResultsData were collected from 36 men and 59 women who were converted from above-threshold 40–90 Hz SCS to 1–1.2 kHz SCS, with a minimum follow-up of 12 months. Nearly a third (63/95 or 66.3%) of the subjects deemed 1–1.2 kHz SCS ineffective and returned to low-frequency SCS within 1 week after switch, and one-sixth (16/95 or 16.8%) of the subjects returned to low-frequency SCS within 1 month. Only 13 (13.7%) subjects continued using 1–1.2 kHz subthreshold SCS for 3 months or longer and 2.1% (2/95) of subjects continued using it at 12 months. A comparison of their pain scores and opioid use before and during the time we used 1–1.2 kHz SCS revealed no significant difference.ConclusionThe results from our single center failed to show additional long-term clinical benefit of 1–1.2 kHz subthreshold SCS in patients with chronic pain failing traditional low-frequency SCS.

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Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opab040 ◽

2021 ◽

Author(s):

Jonathan P Scoville ◽

Evan Joyce ◽

Joshua Hunsaker ◽

Jared Reese ◽

Herschel Wilde ◽

...

Keyword(s):

Hospital Stay ◽

Chart Review ◽

Statistical Tests ◽

Case Series ◽

Length Of Hospital Stay ◽

Retrospective Chart Review ◽

Opioid Use ◽

Pain Scores ◽

Surgical Methods ◽

Significant Difference

Abstract BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

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Examining Metabolic Profiles in Opioid-‎Dependent Patients ‎

International Journal of Medical Toxicology and Forensic Medicine ◽

10.32598/ijmtfm.v10i3.28681 ◽

2020 ◽

Vol 10 (3) ◽

pp. 28681

Author(s):

Nader Molavi ◽

Amir Ghaderi ◽

Hamid Reza Banafshe

Keyword(s):

Control Group ◽

Study Group ◽

Metabolic Profiles ◽

Opioid Use ◽

Serum Samples ◽

Social Burden ◽

Study Results ◽

Significant Difference ◽

Hs Crp ◽

Opioid Users

Background: Drug abuse is a social burden and a public health disorder. Previous evidence suggested numerous illicit substances (e.g., opioids, amphetamines, cocaine, & cannabis) affect immune system functions, oxidative stress mechanisms, inflammatory cytokines, and reactive oxygen species production. This study aimed to determine the extent of these metabolic parameters in opioid-dependent patients. We also compared these patients with a healthy control group. Methods: This study was conducted in Amirie Clinic, Kashan, Iran. Plasma and serum samples from 50 illicit opioid users (study group) and 50 non-opioid users (control group) were studied. Metabolic levels for MDA, NO, TAC, GSH, Insulin, HOMA-IR, and hs-CRP were assessed in both research groups (N=100). Results: There was a significant difference in the status of MDA (P=0.003), NO (P=0.01), TAC (P=0.003), GSH (P=0.001), insulin (P=0.04), HOMA-IR (P=0.02), and hs-CRP (P=0.001) between the study and control groups. Furthermore, there was a significant correlation among the duration of illicit opioid use and MDA concentrations (r=-0.424, P=0.002), as well as TAC levels (r=0.314, P=0.02). Conclusion: The study results suggested metabolic profiles were impaired in the study group, compared to the controls.

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High Frequency Spinal Cord Stimulation in a Patient with Bilateral Cochlear Implants

Pain Management Case Reports ◽

10.36076/pmcr.2021.5.189 ◽

2021 ◽

pp. 189-191

Keyword(s):

Spinal Cord ◽

Chronic Pain ◽

Pain Relief ◽

Cochlear Implant ◽

Cochlear Implants ◽

Spinal Cord Stimulation ◽

High Frequency ◽

Pain Clinic ◽

Bilateral Cochlear Implants ◽

Patient Reported

BACKGROUND: High-frequency spinal cord stimulation (HF-SCS) has become very popular in the management of chronic pain worldwide. As it relies on generating high-frequency electrical impulses, there is a risk of interference with other devices such as cochlear implants that utilize similar principles. A literature search did not reveal any case reports of HF-SCS implantation in a patient with cochlear implants. CASE REPORT: A 75-year-old White woman with a history of bilateral cochlear implants (Cochlear Americas Nucleus® with cp910 processor) for severe sensorineural hearing loss presented to our chronic pain clinic with lumbosacral radiculopathy. The patient underwent a HF-SCS trial with entry point at the L1-L2 space and the leads positioned at the top and bottom of T8. The patient did not experience any auditory interference with her Cochlear implant at triple the average SCS stimulation strength. During the follow-up visit the next week, the patient reported nearly 80% symptomatic pain relief and significant functional improvement. There was no change in her hearing and no evidence of interference. The patient ultimately underwent percutaneous SCS paddle electrode placement and at 3 months, continues to have excellent pain relief without any auditory interactions. CONCLUSION: We successfully implanted a HF-SCS at the thoracic level in a patient with bilateral cochlear implants without any auditory interference. KEY WORDS: Cochlear implant, lumbar radiculopathy, spinal cord stimulation

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P46 Swimmer’s thoracic outlet: it doesn’t have quite the same ring as tennis elbow!

Rheumatology ◽

10.1093/rheumatology/kez416.013 ◽

2019 ◽

Vol 58 (Supplement_4) ◽

Author(s):

Kathryn Shepherd ◽

Nandita Pai ◽

Ellie Potts ◽

Ann-Maria Ahern ◽

Swati BhagatJones ◽

...

Keyword(s):

Chronic Pain ◽

Conflicts Of Interest ◽

Tennis Elbow ◽

Anatomical Variation ◽

Full Range ◽

Colour Change ◽

Arterial Flow ◽

Pain Clinic ◽

Significant Difference ◽

The Right

Abstract Background We present a case that was referred and seen in our chronic pain clinic, and highlight the importance of keeping an open mind about alternative diagnoses when reviewing these patients. Methods Please refer to the results section. Results A 12 year-old girl was referred with right sided neck and shoulder pain associated with occasional pins and needles. The patient was a competitive swimmer, training and competing five times a week at her peak. She did not have a history of mottling or colour change, and clinically she had full range of motion of her joints and no neurological deficit. On repeated assessments, she had reproducible pain on horizontal flexion and reduced muscle bulk of the right shoulder, although power was preserved. Functionally the patient had to reduce her participation in swimming due to pain, and found it difficult to carry or lift things, brush or wash her hair, or write for extended periods of time. Imaging with shoulder X-ray and shoulder and cervical spine MRI did not reveal a cause, and she did not have an anatomical variation such as a thoracic rib. Due to the reproducibility on swimming, an ultrasound looking at the insertion of the biceps insertion during dynamic movements was arranged and was also normal with no subluxation noted. As she failed to improve with chronic pain education, chronic pain approach to physiotherapy sessions and graded reintroduction of swimming, ultrasound angiology was arranged. This showed minor disease in the right subclavian, axillary, brachial, radial and ulnar arteries, with significant reduction in right brachial arterial flow with the patient supine, right arm in horizontal flexion and contralateral head turn. This suggested arterial thoracic outlet syndrome (TOS). All other positions resulted in no significant difference in arterial flow. TOS is traditionally broken into two categories – neurogenic and vascular, the latter can be broken down further into arterial or venous. While in adults, the vast majority (90-95%) present as neurogenic, in the paediatric population there is a higher proportion of vascular cases. This has implications, as vascular TOS can be complicated by vessel disease and thrombus formation. There are a number of case reports in which management is reported as decompression of the thoracic outlet with partial first rib resection, with or without scalene muscle resection. Consideration of hypercoagulable states is also warranted. We have referred our patient to the vascular team for an urgent review and await their assessment and feedback about management. Conclusion A proportion of patients managed with chronic pain syndrome will have an alternative explanation for their pain. In particular, if a patient has focal pain or pain that is reproducible on a particular movement or activity, consider alternate diagnoses. Conflicts of Interest The authors declare no conflicts of interest.

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Acupuncture for Chronic Pain-Related Insomnia: A Systematic Review and Meta-Analysis

Evidence-based Complementary and Alternative Medicine ◽

10.1155/2019/5381028 ◽

2019 ◽

Vol 2019 ◽

pp. 1-10

Author(s):

Fushui Liu ◽

Jianyu You ◽

Qi Li ◽

Ting Fang ◽

Mei Chen ◽

...

Keyword(s):

Chronic Pain ◽

Sample Size ◽

Small Sample Size ◽

Meta Analysis ◽

Sham Acupuncture ◽

Small Sample ◽

Control Group ◽

Large Sample Size ◽

Cure Rate ◽

Significant Difference

Objectives. Acupuncture has been widely used to relieve chronic pain-related insomnia (CPRI). However, the efficacy of acupuncture for CPRI is uncertain. The purpose of this study was to evaluate the efficacy of acupuncture for CPRI. Methods. Seven electronic databases were searched from inception to December 2018. Randomized controlled trials (RCTs) were included if acupuncture was compared to sham acupuncture or conventional drug therapies for treating CPRI. Two reviewers screened each study and extracted data independently. Statistical analyses were conducted by RevMan 5.3 software. Results. A total of nine studies involving 944 patients were enrolled. The pooled analysis indicated that acupuncture treatment was significantly better than control group in improving effective rate (OR = 8.09, 95%CI = [4.75, 13.79], P < 0.00001) and cure rate (OR = 3.17, 95%CI = [2.35, 4.29], P < 0.00001), but subgroup analysis showed that there was no statistically significant difference between acupuncture and sham acupuncture in improving cure rate (OR =10.36, 95% CI [0.53, 201.45], P=0.12) based on one included study. In addition, meta-analysis demonstrated that acupuncture group was superior to control group in debasing PSQI score (MD = -2.65, 95%CI = [-4.00, -1.30], P = 0.0001) and VAS score (MD = -1.44, 95%CI = [-1.58, -1.29], P < 0.00001). And there was no significant difference in adverse events (OR =1.73, 95%CI = [0.92, 3.25], P =0.09) between the two groups. Conclusions. Acupuncture therapy is an effective and safe treatment for CPRI, and this treatment can be recommended for the management of patients with CPRI. Due to the low quality and small sample size of the included studies, more rigorously designed RCTs with high quality and large sample size are recommended in future.

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The Impact of Alvimopan on Return of Bowel Function After Major Spine Surgery – A Prospective, Randomized, Double-Blind Study

Neurosurgery ◽

10.1093/neuros/nyz005 ◽

2019 ◽

Vol 85 (2) ◽

pp. E233-E239

Author(s):

Lauren K Dunn ◽

Robert H Thiele ◽

Michelle C Lin ◽

Edward C Nemergut ◽

Marcel E Durieux ◽

...

Keyword(s):

Spine Surgery ◽

Bowel Movement ◽

Bowel Function ◽

Blind Study ◽

Double Blind Study ◽

Opioid Use ◽

Double Blind ◽

Pain Scores ◽

Significant Difference ◽

The Impact

Abstract BACKGROUND Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. OBJECTIVE To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. RESULTS A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P < .001], passing of flatus [median (range): alvimopan: 22 h (7-63) vs placebo: 28 h (10-58), P < .001], and first bowel movement [median (range): alvimopan: 50 h (22-80) vs placebo: 64 h (40-114), P < .001]. The alvimopan group had higher pain scores (maximum, minimum, and median); however, there was no significant difference between the groups with postoperative opioid use. CONCLUSION This study shows that the perioperative use of alvimopan significantly reduced the time to return of bowel function with no increase in postoperative opioid use despite a slight increase in pain scores.

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An Audit of Self Acupuncture for Chronic Musculoskeletal Pain

Acupuncture in Medicine ◽

10.1136/aim.24.2.80 ◽

2006 ◽

Vol 24 (2) ◽

pp. 80-86 ◽

Cited By ~ 6

Author(s):

Silje Teig ◽

Sue Peacock ◽

Lorraine Stevens ◽

Kimberley Tordoff ◽

Edwina Maguire ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

Pain Relief ◽

Cost Effective ◽

Postal Questionnaire ◽

Pain Clinic ◽

Acupuncture Points ◽

Retrospective Audit ◽

The Cost

Background Acupuncture is increasingly offered as a treatment for chronic pain, but continued treatment is expensive. Self acupuncture might offer a cost effective alternative. The aim of this project was to investigate the effectiveness and safety of self acupuncture in a pain clinic. Methods A retrospective audit was conducted by postal questionnaire of all patients with chronic pain who were taught self acupuncture as a home pain management strategy in the previous three years. The study was conducted by a researcher not involved in the patient's treatment. The patients selected for self acupuncture were those who had responded to acupuncture previously, met certain criteria, and had been taught self acupuncture successfully. Patients were taught self acupuncture using three acupuncture points (LI4, ST44, LR3). Results Of 52 eligible patients (70% female) who were approached, 38 valid questionnaires were returned, giving a response rate of 73.1%. Of these, 76.3% were female; 86.8% (33) still used self acupuncture and 13.3% (5) had stopped; 86.8% of the patients continued to experience pain reduction with self acupuncture. The reported pain relief gained was 5.7 (SD 2.6) measured on a visual analogue scale, improvement in quality of life was reported by 73.7% and no serious adverse effects were reported. Conclusion This audit suggests that self acupuncture is effective for pain relief and improves quality of life in this selected group of patients. Safety can be maintained provided that pre-selection is done with care, and appropriate training is carried out. Self acupuncture has considerable potential to reduce clinic waiting lists and appointment times for patients. Further research is required to determine the cost effectiveness of this approach.

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