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Background: medical cannabis refers to the use of cannabis or cannabinoids as medical therapy to treat disease or alleviate symptoms. In the United States, 23 states and Washington DC (May 2015) have introduced laws to permit the medical use of cannabis. Within the European Union, medicinal cannabis laws and praxis vary wildly between Countries., Objectives: to provide evidence for benefits and harms of cannabis (including extracts and tinctures) treatment for adults in the following indications: control of spasticity and pain in patients with multiple sclerosis; control of pain in patients with chronic neuropathic pain; control of nausea and vomiting in adults with cancer receiving chemotherapy., Methods: we searched the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE from inception to September 2016. We also searched for on-going studies via ClinicalTrials.gov and the World Health Organization and International Clinical Trials Registry Platform (ICTRP) search portal. All searches included also non-English language literature. All relevant randomized controlled trials (RCTs) evaluating the safety and efficacy of cannabis (including extracts and tinctures) compared with placebo or other pharmacological agents were included. Three authors independently evaluated the titles and abstracts of studies identified in the literature searches for their eligibility. For studies considered eligible, we retrieved full texts. Three investigators independently extracted data. For the assessment of the quality of evidence, we used the standard methodological procedures recommended by Cochrane and GRADE working Group., Results: 41 trials (4,550 participants) were included; 15 studies considered efficacy and safety of cannabis for patients with multiple sclerosis, 12 for patients with chronic pain, and 14 for patients with cancer receiving chemotherapy. The included studies were published between 1975 and 2015, and the majority of them were conducted in Europe. We judged almost 50% of these studies to be at low risk of bias. The large majority (80%) of the comparisons were with placebo; only 8 studies included patients with cancer receiving chemotherapy comparing cannabis with other antiemetic drugs. Concerning the efficacy of cannabis (compared with placebo) in patients with multiple sclerosis, confidence in the estimate was high in favour of cannabis for spasticity (numerical rating scale and visual analogue scale, but not the Ashworth scale) and pain. For chronic and neuropathic pain (compared with placebo), there was evidence of a small effect; however, confidence in the estimate is low and these results could not be considered conclusive. There is uncertainty whether cannabis, including extracts and tinctures, compared with placebo or other antiemetic drugs reduces nausea and vomiting in patients with cancer requiring chemotherapy, although the confidence in the estimate of the effect was low or very low. In the included studies, many adverse events were reported and none of the studies assessed the development of abuse or dependence., Conclusions: there is incomplete evidence of the efficacy and safety of medical use of cannabis in the clinical contexts considered in this review. Furthermore, for many of the outcomes considered, the confidence in the estimate of the effect was again low or very low. To give conclusive answers to the efficacy and safety of cannabis used for medical purposes in the clinical contexts considered, further studies are needed, with higher quality, larger sample sizes, and possibly using the same diagnostic tools for evaluating outcomes of interest.

The treatment of neuropathic pain is a medical challenge. The responsiveness to the different classes of drugs is often unsatisfactory and frequently associated to a wide range of side effects. International guidelines suggest for the "localized" neuropathic pain the topical treatment with 5% lidocaine medicated plaster, alone or associated to systemic drugs, as the first choice since its favorable efficacy and tolerability profile. Many clinical experiences support the rationale for using 5% lidocaine medicated plaster in different kinds of localized neuropathic pain, such as postherpetic and trigeminal neuralgia, compressive syndromes, painful diabetic polyneuropathy and pain secondary to trauma or surgical interventions. This paper reports a series of clinical cases whose heterogeneity suggests the wide burden of applicability of the topical 5% lidocaine, either alone and associated to systemic drugs. All the described conditions were characterized by a highly intense pain, not adequately controlled by actual medications, which improved after the use of topical lidocaine. The good response to lidocaine allowed the reduction, of even the withdrawal, of concurrent drugs and improved the patients' quality of life.

Localized neuropathic pain (LNP) is a type of neuropathic pain characterized by consistent and circumscribed area(s) of maximum pain, which are associated with negative or positive sensory signs and/or spontaneous symptoms typical of neuropathic pain. This description outlines the clinical features of a group of pathologies, in which a LNP can be diagnosed and for whom topical targeted treatment with 5% Lidocaine medicated plaster can be suggested. Indeed both American as well as European guidelines already suggest 5% Lidocaine medicated plaster as a first line treatment in post herpetic neuralgia and in general in the treatment of conditions such as diabetic painful polyneuropathy and post surgical pain where a LNP can be ascertain. In a daily practice of a Pain Unit however the usual case mix encompasses also other causes of LNP, most of them with a scanty pain control in spite of a ongoing polytherapy. Aims of this paper were to focus on 5% Lidocaine medicated plaster as a first line treatment in LNP and to add new insight on its possible use as add-on therapy reporting our data on a consecutive series of 42 patients affected by LNP under unsatisfactory polytherapy in which 5% Lidocaine medicated plaster was able to achieve a satisfactory pain control.

Aim: The aim of this paper is to confirm the efficacy and safety in clinical practice of 5% lidocaine medicated plaster (LMP) in the treatment of localized neuropathic pain., Methods: Retrospective, observational study carried out in the period 2006-2012, in patients with various forms of localized peripheral neuropathic pain treated with LMP. Only patients with at least one follow-up visit after prescription of the drug were assessed., Results: One hundred and one patients were assessable, 60.4% of whom suffered from postherpetic neuralgia (PHN), while the remainder reported mainly post-traumatic/post-surgical neuropathic pain and other superficial localized neuralgias. In baseline conditions, the mean pain intensity measured on the NRS was 6.1. The median treatment time with LMP was 41 days, at the end of which there was a 64% fall in NRS, with no significant differences between the patients with PHN or other localized neuralgias. A better NRS reduction trend was also observed in those patients who, in our study, started treatment with LMP from the first visit, compared with those patients to whom LMP was prescribed later. The tolerability was good, with few adverse events at the application site, which led to suspension of treatment in just three cases., Conclusion: In our experience, LMP proved to be an effective and well-tolerated drug in the treatment of PHN and other superficial localized neuralgias. This observation is in agreement with the international guidelines, which suggest LMP as first line treatment for the management of localized peripheral neuropathic pain.

Chronic or acute pain related to skin ulcers or their management (medication, debridement) is a typical case of mixed pain, both neuropathic and nociceptive. It represents a disabling clinical condition that deteriorates the patient's quality of life. The pharmaceutical therapy must be based on both, intensity and the type of pain. Although NSAIDs, Non Steroidal Anti-Inflammatory Drugs are notoriously effective on nociceptive pain, do not give great results on neuropathic and mixed pain. Also the consumption of NSAIDs is affected by a series of side effects that may involve several organs. In case of neuropathic pain, the benefit deriving from the use of a single active principle is relative. This sets the rational grounds for the use of combined drugs. The paracetamol/tramadol combination represents an innovative solution in the treatment of both the neuropathic and nociceptive components of the pain, since both active principles have a different action mechanism, multiple targets and different pharmacokinetics. It is very interesting, from the clinical point of view, that tramadol is a pure antagonist, not selective, of µ, δ, and κ receptors and carries out and important inhibition action of serotonin and norepinephrine reuptake. This double mechanism, opioid and non-opioid, explains its analgesic efficacy also on neuropathic pain. Besides, since its opioid action is rather weak, it does not induce the severe side effects typical of traditional opioids. The benefit of such combination comes from their complementary pharmacokinetic profile, since the first has a quick action insurgence, while tramadol has a more prolonged effect. Therefore, this combination allows to obtain a quick and long lasting effect with a high tolerability profile also when treating skin ulcer pain.

Neuropathic pain is usually considered an "hard pain" both for the intrinsic difficulties in a correct diagnosis, and for the modest efficacy of the most part of conventional treatments. The most frequently used drugs in clinical practice are tricyclic antidepressants and anticonvulsants, while a minor role is reserved to NSAIDs or to strong opiates. Aim of our work was to systematically analyze all the evidences of literature about the treatment options against neuropathic pain in oncology, focusing our attention upon the efficacy and the safety of the different therapeutic options assessed as Number-Needed-to-Treat (NNT) and Number-Needed-to-Harm (NNH). A critical analysis of literature was finally performed using the GRADE system. On the basis of our review and the NNT and NNH ratio, gabapentin, pregabalin and strong opiates seem to be the most effective and well tolerated options against neuropathic pain in oncology, while carbamazepine, amitryptiline, tramadol and NSAIDs do not seem to be valid options in front line approach against oncologic neuropathic pain, either for a minor efficacy or for an unfavorable safety profile. Further trials comparing the different effective options are needed to better define the correct approach against neuropathic pain in oncology.

Purpose: The authors sought to evaluate indications, technical feasibility and clinical efficacy of computed tomography (CT)-guided pudendal nerve infiltration in patients with chronic anoperineal pain by reviewing the role of the CT technique in their personal experience and in the recent interventional literature., Materials and Methods: Twenty-eight women, mean age 50 years, and with a diagnosis of pudendal neuralgia on the basis of clinical and electromyographic criteria were enrolled in the study. CT-guided pudendal nerve injections were performed during three consecutive sessions held 2 weeks apart. In each session, patients received two percutaneous injections: one in the ischial spine, and the other in the pudendal (Alcock's) canal., Results: One patient dropped out of the study after the first session. At clinical assessment, 24h h after treatment, 21/27 patients reported significant pain relief. At follow-up at 3, 6, 9 and 12 months, 24/27 patients reported a>or=20% improvement in the Quality of Life (QOL) index., Conclusions: In pudendal nerve entrapment, CT-guided perineural injection in the anatomical sites of nerve impingement is a safe and reproducible treatment with a clinical efficacy of 92% at 12 months.

The paper considers the difficulty of pain control in acute herpes zoster and the considerable incidence of NPH in patients given the conventional medical therapies. After a short account of physiopathology of herpetic pain, the treatment of acute cases with epidural or sympathetic blockages using anaesthetics and cortisone is proposed. Personal experience in a series of patients with either acute herpes zoster or NPH who were treated with this method is reported with details of peculiarities and results.

The efficacy of tricyclic antidepressants in association with neuroleptics having been demonstrated in patients suffering from so-called tardive post-herpetic neuralgia, 43 patients were given this treatment either alone or in association with transcutaneous nerve stimulation (TENS). Of the 33 patients given drug treatment alone, 25 found relief from pain in 3-18 months, 5 produced a partial result and in 3 the treatment failed. The results obtained suggest that this is the most effective treatment as long as it is continuous and given for at least 3-6 months. The use of TENS produced no benefit.

A study of 46 patients has shown that Clonazepam is an effective drug in preventing attacks of pain in essential trigeminal and glossopharyngeal neuralgia and in Sluder's syndrome. The therapeutic action of the drug is less evident in different types of migraine, among which only the combined headache presents good results to the treatment. The effective dose of this drug is generally not greater than 3 mg/die and does not give rise to side effects in long-term prescription.

The clinical results obtained with phloctaphenin in an "open" study comprising cases of real neuralgia and spinal radicular pain syndromes and in a "double-blind" study comparing the preparation with a placebo, and involving algico-vasomotor syndromes of the face, are reported. The results obtained confirm the antalgic power of phloctaphenin for by the third day, subacute or chronic pain syndromes already presented a significant improvement in simptomatology, while in algico-vasomotor syndromes of the face, the treatment proved effective in eliminating pain attacks.