Pain physician
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Opioids are broad spectrum analgesics that may be beneficial to alleviate the intense perception of algesia in patients suffering with pain. They have been one of the most controversial analgesics, in part because of their potential for addiction. Opioids or any currently available analgesic will not provide effective analgesia for every patient with chronic neuropathic pain (NP), but overall opioids are considered to be a second or third line class of analgesics that may provide reasonable analgesia to some patients with chronic NP. ⋯ Conversely, opioid therapy may contribute to nociceptive processes that may be involved in neuropathic pain such as opioid-induced cholecystokinin release. Furthermore, within NP, peripheral NP appears to be the most opioid responsive, followed by spinal NP while supraspinal NP tends to be the least responsive to opioids. Although, there is no robust evidence that any specific opioid agent is better than any other opioid at effectively treating NP, it is conceivable that some opioids/opioid-like analgesic agents may be particularly well suited to alleviate NP in certain patients suffering from neuropathic pain.
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Intervertebral disc herniation, spinal stenosis, intervertebral disc degeneration without disc herniation, and post lumbar surgery syndrome are the most common diagnoses of chronic persistent low back and lower extremity symptoms, resulting in significant economic, societal, and health care impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, and transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Multiple systematic reviews conducted in the evaluation of the effectiveness of interlaminar epidural injections have been marred with controversy. Consequently, the debate continues with regards to the effectiveness, indications, and medical necessity of interlaminar epidural injections. ⋯ The evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids.
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Exercise is an effective treatment for various chronic pain disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis, and chronic low back pain. Although the clinical benefits of exercise therapy in these populations are well established (i.e. evidence based), it is currently unclear whether exercise has positive effects on the processes involved in chronic pain (e.g. central pain modulation). ⋯ A dysfunctional response of patients with chronic pain and aberrations in central pain modulation to exercise has been shown, indicating that exercise therapy should be individually tailored with emphasis on prevention of symptom flares. The paper discusses the translation of these findings to rehabilitation practice together with future research avenues.
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Review
Diagnostic accuracy of thoracic facet joint nerve blocks: an update of the assessment of evidence.
Chronic mid back and upper back pain caused by thoracic facet joints has been reported in 34% to 48% of the patients based on their responses to controlled diagnostic blocks. Systematic reviews have established moderate evidence for controlled comparative local anesthetic blocks of thoracic facet joints in the diagnosis of mid back and upper back pain. ⋯ Based on this systematic review, the evidence for the diagnostic accuracy of thoracic facet joint injections is good.
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Driving under the influence of drugs (DUID) is a term used to designate the action of driving an automobile after the consumption of drugs or medications other than alcohol that interfere with the capacity to operate a vehicle safely. Unlike recreational drugs, prescription medications pose a unique challenge to those attempting to harness their benefits yet protect the driving public. As studies demonstrate a steady increase in opioid use and abuse in the United States, these same constituencies must regulate a significant percentage of drivers who are under the influence of opioids. ⋯ A sizable percentage of the driving public has detectable levels of opioids within their bodies. The best available evidence demonstrates psychomotor impairment following acute administration of opioids or an increase in opioid dosage, but impairment diminishes with chronic, stable opioid usage. Policy makers must account for this evidence when balancing the benefit of pain relief against the need for public roadway protection when drafting DUID legislation.