Pain physician
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In the midst of the COVID-19 pandemic, data has shown that age-adjusted overdose death rates involving synthetic opioids, psychostimulants, cocaine, and heroin have been increasing, including prescription opioid deaths, which were declining, but, recently, reversing the trends. Contrary to widely held perceptions, the problem of misuse, abuse, and diversion of prescription opioids has been the least of all the factors in recent years. Consequently, it is important to properly distinguish between the role of illicit and prescription opioids in the current opioid crisis. Multiple efforts have been based on consensus on administrative policies for certain harm reduction strategies for individuals actively using illicit drugs and reducing opioid prescriptions leading to curbing of medically needed opioids, which have been ineffective. While there is no denial that prescription opioids can be misused, abused, and diverted, the policies have oversimplified the issue by curbing prescription opioids and the pendulum has swung too far in the direction of severely limiting prescription opioids, without acknowledgement that opioids have legitimate uses for persons suffering from chronic pain. Similar to the opioid crisis, interventional pain management procedures have been affected by various policies being applied to reduce overuse, abuse, and finally utilization. Medical policies have been becoming more restrictive with reduction of access to certain procedures, with the pendulum swinging too far in the direction of limiting interventional techniques. Recent utilization assessments have shown a consistent decline for most interventional techniques, with a 18.7% decrease from 2019 to 2020. The causes for these dynamic changes are multifactorial likely including the misapplication of the 2016 Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain, the relative ease of access to illicit synthetic opioids and more recently issues related to the COVID-19 pandemic. In addition, recent publications have shown association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. These findings are leading to the hypothesis that federal guidelines may inadvertently be contributing to an increase in overall opioid deaths and diminished access to interventional techniques. Together, these have resulted in a fourth wave of the opioid epidemic. ⋯ The opioid overdose waves over the past three decades have resulted from different etiologies. Wave one was associated with prescription opioid overdose deaths and wave two with the rise in heroin and overdose deaths from 1999 to 2013. Wave three was associated with a rise in synthetic opioid overdose deaths. Sadly, wave four continues to escalate with increasing number of deaths as a confluence of factors including the CDC guidelines, the COVID pandemic, increased availability of illicit synthetic opioids and the reduction of access to interventional techniques, which leads patients to seek remedies on their own.
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Review
The Analysis of Pain Research through the Lens of Artificial Intelligence and Machine Learning.
Traditional pain assessment methods have significant limitations due to the high variability in patient reported pain scores and perception of pain by different individuals. There is a need for generalized and automatic pain detection and recognition methods. In this paper, state-of-the-art machine learning (ML) and deep learning methods in this field are analyzed as well as pain management techniques. ⋯ While a majority of the studies focused on classification tasks, very few studies have explored the diagnosis and management of pain. Usage of ML techniques as support tools for clinicians holds an immense potential in the field of pain management.
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Randomized Controlled Trial
Comparison of Increase in the Optic Nerve Sheath Diameter between Epidural Saline and Contrast Medium Injections.
Normal saline or contrast medium is one of the widely used injection materials during fluoroscopic guided injections. Optic nerve sheath diameter (ONSD) measurement is a reliable and noninvasive method for intracranial pressure evaluation. ⋯ Thoracic epidural injection of 5 mL normal saline or contrast medium resulted in a significant increase of ONSD compared to baseline; however, the degree of ONSD increase was more attenuated in the contrast group than the saline group.
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Optimal approaches for treating surgical spine pathology in very geriatric patients, such as those over the age of 80, remain unclear. ⋯ Endoscopic spine surgery offers octogenarians a safe and effective option for the treatment of lumbar degenerative spine disease and may represent a valuable treatment strategy in a growing patient population.
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Spinal cord stimulation (SCS) is a common treatment for neuropathic pain. There are 2 main categories of SCS leads: paddle leads and cylindrical leads. Paddle leads have reduced long-term complications and provide better coverage of target dermatomes when compared to cylindrical leads. However, insertion of a paddle lead requires invasive surgery that comes with significantly higher costs and more short-term complications, such as postoperative pain and infection. In contrast, cylindrical leads can be inserted minimally invasively using percutaneous techniques but provide less coverage of targeted dermatomes and have a higher tendency to migrate from intended neuronal targets. ⋯ The unique shape memory property of nitinol shows promise in allowing cylindrical spinal cord stimulation leads to expand into a more optimal geometry within the epidural space. By having a body temperature-dependent geometry change, nitinol-based cylindrical leads could reduce lead migration, increase dermatomal coverage, and increase electrode density while maintaining the advantages of minimally invasive insertion.