Patient with pain and depression – practical therapeutic implications

Depression and pain are often coexisting phenomena, and the relationship between both phenomena is two-way – the occurrence of depression increases the risk of pain, and both acute and chronic pain increase the risk of depression. Pain may be part of the clinical picture of depression, be a result of comorbid psychiatric disorders, be associated with comorbidities, be a chronic pain syndrome, or be a complication of pharmacotherapy. The comorbidity of pain and depression is associated with a worse prognosis, lower therapeutic response, lower quality of life, impaired functioning, and a greater risk of relapse and suicide. There are indications that the same structures and neurotransmitters are involved in the pathophysiology of pain and depression, which may explain the coanalgesic effect of some antidepressants. The drugs with the best proven effectiveness are serotonin and noradrenaline reuptake inhibitors (especially duloxetine) and amitriptyline. Other drugs that may be of use in the treatment of pain are mirtazapine, mianserin, trazodone, agolemelatine, bupropion, and moclobemide. Selective serotonin reuptake inhibitors are used primarily in the treatment of depression symptomatic pain, but there is little evidence that they are effective in other types of pain. The use of certain psychotropic drugs, incl. SSRIs, clomipramine, benzodiazepines, Z drugs, and anticholinergics may be associated with increased pain. Caution is required when using polypharmacy in the form of a combination of an antidepressant and an analgesic because of the risk of worsening side effects or loss of treatment effectiveness. In the case of opioid drugs, in particular tramadol, the combination with drugs with a serotonergic effect may be associated with the risk of serotonin syndrome.

Glucose supply as a way to reduce procedural pain in newborns. Review of research results

Immediately after birth, most newborns undergo a number of medical procedures to assess how the body functions. Some of these procedures are invasive and involve breaking the continuity of the baby's tissues, leading to pain and discomfort. Confirmation of pain sensation by newborns is relatively one of the newer scientific discoveries - this fact was not acceptable until the end of the 1980s. Therefore, analgesia was used very rarely during all medical procedures. Nowadays, medical personnel are aware that the youngest patients also feel pain and should be knowledgeable about its prevention and treatment. The aim of the study is to analyze the available studies on glucose supply as a way to reduce procedural pain in newborns. The non-systematic review of the literature was carried out according to the following keywords: pain, glucose, newborn, prevention, recommendations. Analyzes carried out in neonatal departments and a literature review have shown that pain prevention and treatment still pose many problems, as there are no clear guidelines as to how and methods to administer the therapy. Oral glucose is the most common pain reliever used in neonates during medical interventions. Its mechanism of action remains unclear, but it is believed to have a calming effect and reduce behavioral indicators of pain. The American Academy of Pediatrics recommends the administration of three doses of sucrose appropriate to the gestational age of the newborn, but there is concern about the long-term use of this preventive measure, especially in premature babies, who are at greater risk of hyperglycemia and disturbances in the development of the nervous system.

REPRINTED WITH PERMISSION OF IASP – PAIN 161 (2020) 880–888: Neck pain and headache after whiplash injury: a systematic review and meta-analysis

Neck pain and headache are 2 of the most common complications of whiplash injury. Therefore, we performed a systematic literature search on PubMed and Embase for publications reporting on the prevalence of neck pain and headache after whiplash injury. The literature search identified 2709 citations of which 44 contained relevant original data. Of these, 27 studies provided data for the quantitative analysis. For non-population-based studies, the present metaanalysis showed that a pooled relative frequency of neck pain was 84% confidence interval (68–95%) and a pooled relative frequency of headache was 60% (46–73%), within 7 days after whiplash injury. At 12 months after injury, 38% (32–45%) of patients with whiplash still experienced neck pain, while 38% (18–60%) of whiplash patients reported headache at the same time interval after injury. However, we also found considerable heterogeneity among studies with I2-values ranging from 89% to 98% for the aforementioned meta-analyses. We believe that the considerable heterogeneity among studies underscores the need for clear-cut definitions of whiplash injury and standardized reporting guidelines for postwhiplash sequelae such as neck pain and headache. Future studies should seek to optimize these aspects paving the way for a better understanding of the clinical characteristics and natural course of whiplash-associated sequelae.

Clinical consequences of abuse and misuse of hypnotics and analgesics in geriatric population

Insomnia and pain coexist with chronic diseases, especially in the elderly, who are therefore the largest group taking hypnotics and analgesics. For this reason, seniors are at high risk of abusing these medications, leading to dangerous and unpredictable clinical outcomes. The article provides a literature review using the Pubmed, Medline, Embase and Google Scholar databases. The articles were analysed using the following keywords: drug abuse, sleeping pills, painkillers, benzodiazepines, opioids. The article presents the characteristics of medical substances belonging to sleeping pills and painkillers, taking into account the consequences of their misuse. Hypnotics and pain relievers, especially benzodiazepines and opioids, are the most abused drug classes in the elderly. In the case of hypnotics, apart from benzodiazepines, these are zolpidem and zopiclone or trazodone, and in the case of analgesics, codeine, tramadol, morphine or oxycodone and also paracetamol and NSAIDs. The problem of abuse and misuse of hypnotics and analgesics in the geriatric population is still growing and therefore more and more attention should be paid to this problem. Although this type of treatment is important to maintain a good quality of life for the elderly, proper education among staff, patients and their carers is also needed. Proper information provided by medical personnel plays an important role in this matter.

Immediate-release oxycodone for pain pharmacotherapy – when, to whom and why?

Pharmacotherapy of pain must take into account the characteristics of pain, patient and drug in order to be optimally effective and safe. One of the drugs available on the pharmaceutical market is immediate-release oxycodone. The potential of this drug in practice is still not used. The paper describes clinical situations in which this form of the drug should be recommended for pain therapy.

The impact of the treatment of chronic pain treatment with transdermal buprenorphine on functional performance and risk of falls in elderly people diagnosed with osteoarthritis

The aim of the study was to evaluate the impact of transdermal buprenorphine on overall functional fitness and the risk for falls in the treatment of chronic pain in elderly patients diagnosed with osteoarthritis. Transdermal buprenorphine was used for 10 days in 60 patients over 64 years old in the treatment of severe chronic pain caused by osteoarthritis. Patients were randomly assigned to 3 groups with a starting dose of 8.75 µg/h, 17.5 µg/h, and 35 µg/h, respectively. On day 1 of the study, the Barthel Index, Instrumental Activities of Daily Living (IADL), Mini–Mental State Examination (MMSE), and the Tinetti balance and gait test were used. On the final day of the study, the Tinetti balance and gait test and the Barthel Index were used again. Pain intensity was evaluated every day with the Brief Pain Inventory – Short Form. No differences in IADL scores between patient groups in baseline assessment were found. An improvement in the Barthel Index overall scores was obtained in all patients with no differences between patient groups. An improvement for both balance and gait in all patient groups of the Tinetti test was found. Regarding balance and overall results, a more significant improvement in group 3 compared to groups 1 and 2 was observed. Transdermal buprenorphine provided satisfactory analgesia regardless of the starting dose of the drug with better toleration of lower initial doses: 8.75 µg/h and 17.5 µg/h compared to a starting dose of 35 µg/h. The treatment of elderly patients with severe chronic pain induced by osteoarthritis with different initial doses of transdermal buprenorphine improved overall physical fitness and reduced the risk for falls. The treatment resulted in satisfactory analgesia with less adverse effects in patients who started with lower initial lower doses of transdermal buprenorphine.

Repeated capsaicin patch applications in patients with localized peripheral neuropathic pain

Neuropathic pain is still a challenging problem. It is experienced by millions of people worldwide, with an approximate prevalence of 7‒10% in the general population. Despite the availability of a variety of treatment methods, a significant proportion of patients suffer from poorly controlled neuropathic pain. Capsaicin is a highly selective TRPV1 (Transient Receptor Potential Vanilloid Type 1) agonist. When applied topically, it leads to the defunctionalisation of hyperactive nociceptive receptors, temporary destruction of peripheral nerve endings, and a significant reduction or cessation of pain. Therefore 8% capsaicin patches are used to treat several peripheral, localized neuropathic pain syndromes. The study aimed to present a case series of patients suffering from peripheral, localized neuropathic pain in case the use of repeated applications of 8% capsaicin patches significantly reduced the intensity of pain. In 5 out of 6 patients we observed a gradual extension of the pain relief period until the pain disappeared, which led to the reduction or discontinuation of systemic pharmacotherapy. In summary, a therapy limited to a certain area of the body, without potential systemic adverse effects, which requires repetition at fairly long intervals, appears to be a good treatment option.

Pharmacotherapy of fibromyalgia – current knowledge

Fibromyalgia is a chronic pain syndrome, which affects 2–4% of the general population. Despite its substantial prevalence in the community, the underlying pathophysiology of fibromyalgia remains largely unknown, and the diagnosis is made using symptom-based criteria. As a result, patients may be classified as suffering from fibromyalgia in spite of differing in the pathogenesis of their complaints. Therefore it is no surprise, that the efficacy of pharmacotherapy of fibromyalgia remains limited. This work aims to provide a summary of current knowledge based on trials which assessed the efficacy of fibromyalgia pharmacotherapy. The drugs with the highest amount of research proving their efficacy in reducing fibromyalgia symptoms are duloxetine, milnacipran, pregabalin and amitriptyline. Studies documenting the efficacy of venlafaxine, gabapentin and antidepressants other than serotonin and noradrenalin reuptake inhibitors are smaller in number. Data obtained in trials verifying the effects of selective serotonin reuptake inhibitors, tramadol or cannabinoids are too sparse to draw any clear conclusions. There are reports indicating that opioids (other than tramadol) are contradicted in fibromyalgia, the use of selective serotonin reuptake inhibitors seems disputable too, due to the risk of inducing a change in the pain phenotype. There is a lack of data suggesting the efficacy of nonsteroid anti-inflammatory drugs in fibromyalgia. Furthermore, there are individual studies showing beneficial effects of other drugs and dietary supplements or combinations thereof in patients with fibromyalgia. In summary, the obtained data show that the amount of medicines whose efficacy in fibromyalgia has been verified in numerous studies is limited. More studies exploring the pathophysiology of fibromyalgia and trials verifying the effects of pharmacotherapy are needed to achieve the optimal efficacy of fibromyalgia pharmacotherapy.

The role of local anaesthesia in intra-operative pain management in dental practice

Intra-operative pain management with the means of local anaesthesia is an important of dental practice. Local anaesthetics are drugs the most commonly used drugs in dentistry, being, at the same time, the safest and most effective pain preventing and pain relieving agents known to medicine.The mechanism of action of local anaesthetics involves interruption of the conduction of nerve impulses. These agents show high affinity for the voltage-dependent sodium channels (Nav), they block them, thus preventing the influx of sodium cations through the membranes of the neuron. The potential threshold is not reached and the potential itself is not present. The potency of local anaesthetic drugs depends primarily on the concentration of the solutions used, while possible side effects depend on the dose. In this paper the characteristics of local anaesthetics used in dental practice were presented as well as characteristics of vasoconstrictors added to anaesthetic solutions. The historical outline, the mechanism of action of local anaesthetics and the currently used both basic and additional methods of anaesthesia are discussed. Possible strategies for improving the effectiveness of anaesthesia by the means of physical and chemical methods were explained. General and local adverse reactions of dental anaesthetics were also discussed, along with ways to prevent and treat them.

REPRINTED WITH PERMISSION OF IASP – PAIN 162 (2021) 999–1006: Pain in the neurodegenerating brain: insights into pharmacotherapy for Alzheimer disease and Parkinson disease

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