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BACKGROUND: A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk. OBJECTIVE: This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department. METHODS: To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for acupuncture and acupuncture therapy and acute pain, surgery, peri-operative, trauma, emergency department, urgent care, review(s) , systematic review, meta-analysis, with additional manual review of titles, links, and reference lists. RESULTS: There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings. CONCLUSION: The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

Osteoarthritis (OA) is a progressive joint disease, that occurs frequently in the aging population and is a major cause of disability worldwide. Both glucosamine and chondroitin are biologically active molecules that are substrates for proteoglycan, an essential component of the cartilage matrix. Evidence supports the use of glucosamine and chondroitin as symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) with impact on OA symptoms and disease-modifying effects in the long term. Glucosamine and chondroitin are administered in exogenous form as a sulfate salt and multiple formulations of these agents are available, both as prescription-grade products and nutritional supplements. However, while all preparations may claim to deliver a therapeutic level of glucosamine or chondroitin not all are supported by clinical evidence. Only patented crystalline glucosamine sulfate (pCGS) is shown to deliver consistently high glucosamine bioavailability and plasma concentration in humans, which corresponds to demonstrated clinical efficacy. Similarly, clinical evidence supports only the pharmaceutical-grade chondroitin sulfate. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) advocates, through careful consideration of the evidence base, that judicious choice of glucosamine and chondroitin formulation is essential to maximize clinical benefit, patient adherence and satisfaction with treatment. In future, the ESCEO recommends that complex molecules with biological activity such as pCGS may be treated as "biosimilars" akin to the European Medicines Agency guidance on biological medicinal products. It seems likely that for all other complex molecules classed as SYSADOAs, the recommendation to use only formulations clearly supported by the evidence-base should apply.

Aim: This study was aimed at investigating the availability and prescription of different medicinal variants of cannabis and their status in European countries., Methods: A -web-based survey was sent to all member societies of the -European Federation of Addiction Societies (EUFAS) in 2 waves during the summer of 2017. All 34 member societies in 19 different European countries were invited to participate., Results: We received 28 responses from 17 European countries. The cannabis extract nabiximol (Sativex®) is the most prevalent cannabis-based medicinal product marketed in Europe. Synthetic cannabinoids and standardized cannabis are less prevalent, and no country allows the growing of cannabis for personal medical use. The bringing of medical cannabis products from across borders to countries where the drug is not marketed is quite limited. The use of medical cannabis is restricted to some central medical conditions, but off-label use is prevalent in some countries., Conclusion: The use of medical cannabis in Europe seems to be restricted mostly to the use of the cannabis extract, nabiximol. There is only limited use of the cannabis plant as such for medical purposes, possibly indicating a different scenario in Europe as compared to the USA. Position Statement: EUFAS as an umbrella association of European addiction societies stresses the need for further studies on the efficacy of medical cannabis and warrants for possible dangers associated with the increasing popularity of medical cannabis. We need regulations at European level concerning registration and medical indications, development of uniform compounds and strength of products, and rules concerning sales and marketing., (© 2018 S. Karger AG, Basel.)

Purpose: Chronic low back pain is a leading cause of disability worldwide. A clinical model for its cause is lacking. Defining a cause based clinical model and a framework of understanding back pain in terms of peripheral structural and central functional pain is essential for optimal management., Materials and Methods: We describe the results of the largest published audit of 41 chronic low back pain patients, receiving outpatient sublingual ketamine therapy for defined central functional pain along with conventional peripheral structural pain management. Our clinical model assigns Movement Dysfunction as the primary cause for low back pain symptoms and restores it with Movement Therapy focused rehabilitation which is also defined. Patients were derived from a tertiary single neurosurgical specialist practice in Brisbane Australia over a three year period., Results: Severe pain and disability measurements more than halved and only 13% of patients ceased ketamine prematurely due to predominantly non-sinister side effects common to all pharmaceutical therapies. All other surveyed metrics of utility were highly favourable in this challenging cohort of chronic back pain patients biased to poor outcomes., Conclusions: Outpatient ketamine maintains high efficacy and safety used in conjunction with a unique clinical model that describes chronic low back pain.

Abstract: Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Background: Basic data on migraine headache characteristics, including frequency and severity, headache-associated impairment, and the intake of pain killer medications, may be influenced by the recording manner of these data. Headache diary can be used for that purpose. This study was done to evaluate if the regular use of headache diary can make a difference for patients with chronic migraine or not. Methods: This study included the patients with chronic migraine with improper headache control, who were coming to neurology outpatient clinic and were asked to record their data using either paper or digital diary. Results: Fifty patients mainly from females were included in our study, showed better compliance and headache control by detection and management of their reported triggers. The most reported triggering factors were stress followed by sleep deprivation. Conclusions: Headache diary regular recording is helpful in better management of headache attacks regarding frequency, duration, and pain intensity in patients with chronic migraine. [ABSTRACT FROM AUTHOR]

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Author(s): Samir Jaber [sup.1], Giuseppe Citerio [sup.2] [sup.3], Daniel Talmor [sup.4] Author Affiliations: (1) grid.414352.5, Intensive Care Unit and Transplantation, Department of Anesthesia and Critical Care B (DAR B), Hôpital [...]

Opioid misuse is a widespread public health problem, and opioids are often prescribed in the dental environment. These recommendations provide alternatives to opioids to reduce or eliminate dental procedure–related acute pain. A multidisciplinary working group developed these clinical recommendations to specifically address procedure-related acute pain. These recommendations, which are based on published peer-reviewed research and guidelines, include therapies used before, during, and after dental procedures. When evidence is not definitive, the best practices, which are based on experts' consensus, are included. The recommendations are not intended to be exhaustive. These recommendations are a summary of the evidence and best practices for opioid alternatives to treat acute pain related to dental procedures. Dental providers should prioritize opioid stewardship when managing procedure-related pain with strategies such as thorough preprocedure pain assessment, minimally invasive techniques, preemptive analgesia, intraprocedure pain management, and appropriately selected postprocedure pharmacologic therapy. These recommendations are a concise resource for clinical providers. It is important to address patients' procedure-related pain, using nonopioids whenever possible. Alternatives are outlined, allowing providers to make informed decisions. [ABSTRACT FROM AUTHOR]

This discussion article examines narrative positioning related to pain management for people who use substances at the end of life. We explore how dominant narrative genres associated with biomedicine, such as 'restitution' and narratives common within the context of drug services such as 'recovery' can hinder effective pain management within this population. We argue that these discourses can marginalise the ethical self-identity of patients who use substances at the end of life. It can also trouble health and social care professionals in supporting patients and generating counter-narratives that challenge those often associated with substance use. Stigma is a common experience for this population with stereotyping as 'junkies' and associated with criminality. They are positioned as drug-seeking, and this requires more surveillance at the end of life when opioid therapy is potentially more available and authorised. This can make it challenging to generate 'companion' stories that are positive and maintain moral adequacy. Dominant biomedical narrative genres often prevent the recognition of the fractured stories that people using substances can often present with. This can lead to narrative silencing and to the under treatment of pain. The person's self-identity is invested in narratives of recovery, and opioid use symbolises their addicted past because for practitioners, this population is at clinical risk with the potential for drug seeking behaviours. Whilst not requiring formal ethical review this discussion paper was constructed in accordance with good scientific practice with the work of other researchers respected and cited appropriately. [ABSTRACT FROM AUTHOR]

The adulteration of whiskey with analgesics and sedation drugs has been a common practice to prevent hangover the following day and promote loss of consciousness. In both situations, the portable and low cost detection platforms are of paramount importance for forensic investigations. This report describes the use of electrochemical paper‐based analytical devices (ePADs) fabricated by pencil drawing for detecting metamizole, paracetamol and midazolam maleate in whiskey. Different types of paper substrates and graphite pencils were initially characterized with ferrocyanide. The best results were achieved using vegetal paper and Aquarelle/6B pencils. ePADs revealed a decrease in current signal indicating a short lifetime, thus limiting their use to disposable sensors. Despite the short lifetime, the graphite pencil ePADs revealed good electrochemical reproducibility (RSD=3.3 %). The forensic feasibility of the proposed ePADs was demonstrated through the analysis of metamizole and paracetamol in whiskey. The limit of detection (LOD) achieved for paracetamol and metamizole were 45 and 20 mg L−1, respectively. ePADs were also tested to detect midazolam maleate in whiskey. The signal recorded exhibited linear correlation in a wide concentration range (25–1000 mg L−1) and a LOD of ca. 5 mg L−1. Considering the disposability and operational simplicity, ePADs offer a good strategy for detecting adulterations in alcoholic beverages at the point‐of‐need. [ABSTRACT FROM AUTHOR]

Poor research reporting is a major contributing factor to low study reproducibility, financial and animal waste. The ARRIVE (Animal Research: Reporting of In Vivo Experiments) guidelines were developed to improve reporting quality and many journals support these guidelines. The influence of this support is unknown. We hypothesized that papers published in journals supporting the ARRIVE guidelines would show improved reporting compared with those in non-supporting journals. In a retrospective, observational cohort study, papers from 5 ARRIVE supporting (SUPP) and 2 non-supporting (nonSUPP) journals, published before (2009) and 5 years after (2015) the ARRIVE guidelines, were selected. Adherence to the ARRIVE checklist of 20 items was independently evaluated by two reviewers and items assessed as fully, partially or not reported. Mean percentages of items reported were compared between journal types and years with an unequal variance t-test. Individual items and sub-items were compared with a chi-square test. From an initial cohort of 956, 236 papers were included: 120 from 2009 (SUPP; n = 52, nonSUPP; n = 68), 116 from 2015 (SUPP; n = 61, nonSUPP; n = 55). The percentage of fully reported items was similar between journal types in 2009 (SUPP: 55.3 ± 11.5% [SD]; nonSUPP: 51.8 ± 9.0%; p = 0.07, 95% CI of mean difference -0.3–7.3%) and 2015 (SUPP: 60.5 ± 11.2%; nonSUPP; 60.2 ± 10.0%; p = 0.89, 95%CI -3.6–4.2%). The small increase in fully reported items between years was similar for both journal types (p = 0.09, 95% CI -0.5–4.3%). No paper fully reported 100% of items on the ARRIVE checklist and measures associated with bias were poorly reported. These results suggest that journal support for the ARRIVE guidelines has not resulted in a meaningful improvement in reporting quality, contributing to ongoing waste in animal research. [ABSTRACT FROM AUTHOR]

Three peptide analogs of beta-endorphin which are substituted in positions 17, 18 or 19 have been synthesized and their analgesic potencies have been measured by the tail-flick method in mice. The results showed that the replacement of Phe-18 or Lys-19 by alanine reduced the potency to 15% whereas the replacement of Leu-17 by alanine reduced the analgesic potency to 68%.

The solid-phase syntheses of [Sar2]-, [Ala2]-, [D-Leu2]-, [D-Lys2]-beta-endorphins and [Pro5]-, [Leu5]-, [D-Leu5]-, [D-Ala2, D-Leu5]-beta-endorphins are described. The synthetic peptides were purified by chromatography on carboxymethylcellulose and partition chromatography on Sephadex G-50. They were characterized by partition chromatography on agarose, thin-layer chromatography, paper electrophoresis, and amino acid analyses of acid and enzymic hydrolysates. Bioassay of the synthetic analogs for analgesic activity by the tail-flick method showed the D-Leu2 analog to be 48% as potent as betah-endorphin while the Ala2, D-Lys2, Leu5, and [D-Ala2, D-Leu5] analogs were 8 to 17% as active. The Sar2, D-Leu5, and Pro5 analogs were less than 1% as potent.

An introduction is presented in which the editor discusses articles in the issue on topics including mental health disorders, and opioid crisis.

The United States is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public's opioid dependence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture's cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfill these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care. [ABSTRACT FROM AUTHOR]

Purpose: Given the current and increasing awareness of the opioid crisis, this study aimed to characterise the types of analgesic prescription for conservatively managed renal colic., Methods: This was a retrospective cohort study of consecutive patients presenting to the Emergency Department (ED) in 2014-2019. Patients were included if they had radiographically confirmed obstructing calculus, managed conservatively without intervention, and were given a prescription for analgesia on discharge. Patient demographics were recorded and analysed. Opioid, non-opioid, and alpha-blocker medications were compared according to patient and disease parameters, and clinician training. Oral morphine equivalents (OMEs) were used to compare prescribed quantities. Subgroup analyses of stone size and location were performed., Results: Our analysis included 1761 patients with confirmed renal colic: median age of 50 years (16-96). Altogether, 88% of included patients were prescribed opioids on discharge, while only 68% were prescribed non-opioids (p < 0.001). Oxycodone immediate release was the most frequently prescribed analgesic. Logistic regression modelling controlling for patient and disease characteristics significantly predicted more non-opioid (p < 0.001) and alpha-blocker (p = 0.037) prescription with clinician training < 3 years. Linear regression modelling demonstrated that clinicians training < 3 years predicted lower OMEs per prescription compared to clinicians with ≥ 3 years of training (p = 0.001). Subgroup analyses supported similar predictions with training., Conclusions: Prescribing patterns are associated with different clinician experience levels. However, a substantial amount of opioids are still given overall on patient discharge regardless of the clinician experience. Educational interventions aimed at reducing the opioid prescription rate and quantities may be considered for clinicians of all training levels.

When tested in the acetic acid-induced writhing and formalin-induced paw-licking tests, the ethanol extract of Vernonia patula (VP) aerial parts showed significant antinociceptive activity. In neuropharmacological tests, it also significantly delayed the onset of sleep, increased the duration of sleeping time, and significantly reduced the locomotor activity and exploratory behaviour of mice. Five phenolic compounds, namely gallic acid, vanillic acid, caffeic acid, quercetin and kaempferol, were detected in VP following HPLC-DAD analysis. The presence of these phenolic compounds in VP provides some support for the observed antinociceptive and sedative effects. A computational study was performed to predict the binding affinity of gallic acid, vanillic acid, caffeic acid, quercetin and kaempferol towards the cannabinoid type 1 (CB1) receptor. Caffeic and vanillic acid showed the highest probable ligand efficiency indices towards the CB1 target. Vanillic acid displayed the best blood-brain barrier penetration prediction score. These findings provide some evidence for the traditional use of VP to treat pain., (© 2020 The Authors. Phytotherapy Research published by John Wiley & Sons Ltd.)

Objective. Understanding factors while selecting an analgesic and its usage pattern by Indian healthcare practitioners (HCPs). Methods. Questionnaire-based survey was conducted among six healthcare specialties. Results. Total 448 HCPs participated. Patient’s age (72.8%, 74.4%, 87.5%, and 78.9%) and duration of therapy (70.8%, 66.2%, 69.6%, and 73.6%) were main attributes for selecting an opioid according to general practitioners (GPs), dentists, consulting physicians (CPs), and surgeons, respectively. Patient’s age was important factor while selecting NSAID according to 77.60%, 66.91%, and 84.20% of GPs, dentists, surgeons, respectively. For mild pain, paracetamol was the choice according to 77%, 78.57% and 74% of GPs, CPs, and surgeons, respectively. For moderate pain, 77%, 87.50%, 68%, and 80.30% of GPs, CPs, surgeons and orthopedicians, respectively, preferred the use of paracetamol + tramadol combination. For moderate pain, NSAID + paracetamol and paracetamol+diclofenac were used by 68.94% and 47.73% of orthopedicians, respectively. Lack of pain clinic (38.8%) in city was commonly cited reason for not referring patients to pain clinics. Conclusion. Patient’s age, duration of therapy, comorbid conditions, frequency of dosing, and severity of pain are important parameters while selecting analgesics. Paracetamol and its combinations are commonly used for mild and moderate pain, respectively. Pain clinics currently have limited presence in India. [ABSTRACT FROM AUTHOR]

Chronic mechanical low back pain (cLBP) is a leading cause of disability and a major socio-economic burden internationally. The lifetime prevalence of non-specific LBP is approximately 84%, with the prevalence of cLBP at about 23%. Clinically available analgesic/adjuvant medications often provide inadequate pain relief in patients experiencing cLBP. Hence, the urgency for discovery of effective and better tolerated medications. Fourteen days after the induction of five shallow annular punctures (5X) in the lumbar intervertebral discs at L4/L5 and L5/L6 in male Sprague-Dawley rats, mechanical hyperalgesia was fully developed in the lumbar axial deep tissues at L4/L5 (primary) and L1 (secondary). Importantly, mechanical allodynia in the hindpaws was absent. From day 28, we assessed the face validity of our mild to moderate LBP-5X rat model using four clinically available analgesic/adjuvant drugs, namely gabapentin, morphine, meloxicam and amitriptyline relative to vehicle. Additionally, the anti-hyperalgesic effects of J-2156, a highly selective small molecule somatostatin type 4 receptor agonist was assessed. Single i.p. bolus doses of gabapentin and meloxicam at the highest doses tested (100 and 30 mg/kg, respectively) alleviated secondary hyperalgesia (L1) but not primary hyperalgesia (L4/5). Morphine at 1 mg/kg alleviated both primary and secondary hyperalgesia in these tissues, whereas amitriptyline at the doses tested, lacked efficacy. These findings attest to the face validity of our model. J-2156 at 10 and 30 mg/kg alleviated secondary hyperalgesia in the lumbar axial deep tissues at L1 with a non-significant trend for relief of primary hyperalgesia in the corresponding tissues at L4/L5 in these animals., (© 2020 John Wiley & Sons Australia, Ltd.)

Objective: To assess the effect of perioperative pregabalin on pain behavior in dogs after intervertebral disc surgery., Study Design: Prospective, randomized, controlled clinical trial with a blinded observer., Animals: Forty-six client-owned dogs undergoing intervertebral disc surgery., Methods: Dogs were randomly assigned to two groups, with the placebo group receiving opioids alone and the pregabalin group receiving opioids plus pregabalin. Opioid analgesia consisted of 0.6 mg/kg l-methadone given intravenously at anesthetic induction, followed by 0.2 mg/kg given at 8, 16, and 24 hours after extubation and fentanyl patches applied at the end of surgery. Pregabalin was given orally (4 mg/kg) 1 hour before anesthesia, followed by postoperative treatment three times per day (4 mg/kg) for 5 days. The outcome measures were the treatment-group differences in peri-incisional mechanical sensitivity and Glasgow Composite Measure Pain Scale (CMPS-SF) assessed during the first 5 postoperative days. Pregabalin serum concentrations were measured after 24, 72, and 120 hours., Results: Pregabalin reduced pain levels in the treatment group by a mean of 2.5 CMPS-SF units (95% confidence interval [CI] = -3.19 to -1.83, P < .001) compared with the control group during the study period. Pregabalin increased the mechanical nociceptive threshold by a mean of 6.89 N per day (95% CI = 1.87-11.92, P < .001) and of 7.52 N per day (95% CI = 2.29-12.77, P < .001) during the study period, depending on location. Mean levels of serum pregabalin were 5.1, 4.71, and 3.68 μg/mL at 24, 72, and 120 hours postoperatively, respectively., Conclusion: Postoperative signs of pain after surgical treatment of intervertebral disc herniation (IVDH) were reduced when dogs received perioperative pregabalin rather than opioids alone., Clinical Significance: Perioperative pregabalin reduces postoperative pain after surgical treatment of IVDH., (© 2020 The American College of Veterinary Surgeons.)

General Purpose: To provide information about the effectiveness of topical analgesic and local anesthetic agents for reducing pain associated with chronic leg ulcers., Target Audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care., Learning Objectives/outcomes: After participating in this educational activity, the participant will:1. Distinguish adverse reactions to topical analgesics and local anesthetic agents.2. Evaluate the effectiveness of topical analgesics and local anesthetic agents for pain associated with chronic leg ulcers.3. Identify substances used as topical analgesics and local anesthetic agents and the application of those agents., Abstract: To examine the evidence related to the effectiveness of topical analgesic and topical local anesthetic agents for reducing pain associated with chronic leg ulcers.A systematic search and review of the literature were undertaken using key search terms such as leg ulcers, topical anesthetics, topical analgesics, and pain. Six databases were electronically searched for articles published between January 1990 and August 2019.A total of 23 articles were identified that met the inclusion criteria. Data were extracted using content analysis. Most of the included studies were randomized controlled trials; however, the reported methodology for most of studies was poor, so the validity and reliability of the evidence are uncertain. Lidocaine/prilocaine cream, ibuprofen foam, and morphine gel were the most examined topical agents. Lidocaine/prilocaine cream significantly improved wound-related pain compared with all other studied agents. For topical analgesic agents, ibuprofen foam reduced chronic leg ulcer pain significantly, whereas morphine gel was ineffective.Lidocaine/prilocaine cream and ibuprofen foam are effective agents for reducing wound-related pain associated with chronic leg ulcers. Effective use of topical agents could reduce the need for systemic pain relief agents, mitigating potential adverse effects, while giving clinicians another treatment option to manage wound-related pain associated with chronic leg ulcers.

Aims: To explore recollections of pain and pain management during induced abortions., Design: Mixed-methods exploratory study in Sweden., Methods: A web-based survey was distributed between October 2017 - July 2018 via Swedish discussion boards and social media. Open-ended questions were asked about recollection of pain and pain management, followed by self-reported ratings. The survey was answered by 185 participants, responses were analysed with qualitative content analysis., Findings: Recollections of pain intensity illustrated considerable pain and a traumatic event, described in temporal aspects and likened to other painful conditions such as dysmenorrhoea and childbirth. Recollections of pain management illustrated experiences of insufficient treatment of pain and dissatisfaction with pain management, including inefficient treatment and lack of professional attendance. Psychological aspects and consequences illustrated that participants related psychological distress to physical pain, felt unprepared for the physical pain and emphasized the importance of psychological support. Those who experienced intense pain described long-term psychological consequences, including fear of childbirth., Conclusion: Physical pain and psychological distress can manifest as considerable challenges during induced abortion. Abortion-related pain is a multidimensional phenomenon involving physical and psychological components that needs to be rigorously treated. When physical pain is unsuccessfully treated, women may experience long-term psychological consequences after an abortion., Impact: The results illustrate the importance of holistic abortion care where the multidimensional components of abortion-related pain are considered. Patients need to be offered sufficient preparatory information about potential physical pain and psychological distress. This study indicates that there is room for improvement in pain management. Larger studies are needed., (© 2019 John Wiley & Sons Ltd.)

Previous literature suggests that increases in the medical use of opioids over the early 1990s did not contribute to increased morbidity secondary to opioid abuse. Our objective was to evaluate the period 1997–2001 to analyze trends in medical use and medical abuse of three classes of opioid analgesics that are commonly used in sustained-release formulations: fentanyl, morphine, and oxycodone. A retrospective analysis of the Drug Abuse Warning Network (DAWN) database and the Automation of Reports and Consolidated Orders System (ARCOS) database for the years 1997–2001 was used for this study. The analysis of the DAWN database showed that there was an 83.5% increase in all opioid analgesic mentions from 1997 to 2001. Mentions involving any fentanyl compound increased 249.8%, any morphine compound increased 161.8%, and any oxycodone-containing compound increased 267.3%. Mentions of each of these three classes of opioids remained less than 2% of all total drug mentions per year for each year studied. Medical use of the selected opioid classes, as reported in the ARCOS database and measured by grams distributed, all increased substantially (fentanyl 151.2%, morphine 48.8%, oxycodone 347.9%). Using this method of analysis, the rates of drug abuse, and resultant morbidity secondary to the use of opioid analgesics, remain low in spite of the increase in medical use of these substances. [ABSTRACT FROM AUTHOR]

To determine the safety of hydromorphone delivered by continuous intrathecal infusion via implanted delivery systems in sheep. Sheep implanted with intrathecal infusion systems were randomly assigned to receive either 1.5, 3, or 6 mg/day hydromorphone HCl or saline control (3 sheep/dose level) at a fixed infusion rate of 1.92 mL/day for 28–31 days. Infusions were initiated approximately 5 days after surgical implantation of the delivery systems (pumps and intrathecal catheters), and investigators were blinded to doses administered. An additional group of sheep (N=3) received hydromorphone (open label) at a dose of 12 mg/day. All animals were examined daily during drug infusion for changes in behavior and neurologic function. Cerebrospinal fluid was analyzed for protein, cytology, and hydromorphone concentration in samples collected prior to and at the end of drug infusion. The spinal cord with the catheter in situ was removed en bloc and fixed in formalin for microscopic analysis. All sheep receiving intrathecal hydromorphone exhibited gaiting deficits and biting behavior over the caudal lumbar area above the infusion site. Animals treated with 12 mg/day were sedate and lethargic, and exhibited repeated biting behavior over the caudal lumbar area during the study. No lesions were noted in any animal upon gross evaluation of the spinal cord. Microscopic changes were comparable between hydromorphone- and saline-treated animals with one exception. Mild inflammation 5 cm cranial to the catheter tip was present in two of three sheep receiving 12 mg/day and in one of three sheep receiving 1.5 mg/day. Mild chronic inflammation hydromorphone in the vicinity of the catheter was also presented in saline-treated animals. Hydromorphone was not associated with inflammatory mass formation in the sheep model. Further studies are necessary to determine whether hydromorphone is a safer alternative to morphine for continuous intrathecal infusion for the treatment of chronic pain. [ABSTRACT FROM AUTHOR]