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opioids

The Canadian Spine Surgeon’s Perspective: Avoiding Opioid Use in Spine Patients

Teaser: 

Alexandra Stratton, MD, MSc, FRCSC,1
Dr. Darren Roffey, PhD,2
Dr. Erica Stone, MD, FRCPC,3
Mohamed M. El Koussy, BSc,4
Dr. Eugene Wai, MD,5

1Orthopaedic Spinal Surgeon, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
2University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
3Anesthesiology, PGY 6 Pain Medicine, The Ottawa Hospital, Ottawa, ON.
4Clinical Research Assistant, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
5is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.

CLINICAL TOOLS

Abstract: Opioids are drugs with pain relieving properties; however, there is evidence that opioids are no more effective than non-opioid medications in treating low back pain (LBP), and opioid use results in higher adverse events and worse surgical outcomes. First line treatment should emphasize non-pharmacological modalities including education, self-care strategies, and physical rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered an appropriate introduction into pharmacological treatment when deemed necessary. Non-opioid adjunct medications can be considered for specific features related to LBP such as neuropathic leg pain. Primary care providers should exhaust first and second line treatments before considering low-dose opioids, and only then in consultation with evidence-based clinical practice guidelines.
Key Words: Pharmacological; low back pain; radiculopathy; opioids; analgesia.

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1. First line treatment for low back and radicular leg pain is non-pharmacological.
2. Second line treatment includes NSAIDs (with or without proton pump inhibitor), and muscle relaxants (3 weeks maximum), gabapentinoids and antidepressants.
3. Exhausting non-opioid analgesics includes trialing different medications within the same class and at different doses since many of these medications have wide therapeutic dose ranges.
A "start low and go slow" approach is recommended for initiating pharmacological treatments for low back and radicular leg pain, especially when using neuroleptics and antidepressants.
When treating low back pain with neuropathic leg pain, patients who fail a trial of pregabalin may tolerate gabapentin, or vice versa.
Antidepressants have a role in managing low back pain, particularly chronic, even in the absence of mood disorder.
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Disclaimer: 
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Spinal Cord Stimulation: An Under-utilized and Under-recognized Pain Treatment Modality

Spinal Cord Stimulation: An Under-utilized and Under-recognized Pain Treatment Modality

Teaser: 

Philip Chan, MD, FRCPC (Anesthesiology, Pain Medicine), FIPP,

Director, Chronic Pain Clinic, Department of Anesthesia/Chronic Pain Clinic, St. Joseph's Healthcare, Hamilton, Ontario, Assistant Clinical Professor, Department of Anaesthesia, Faculty of Health Sciences, McMaster University, Program Director, Pain Medicine Residency Program, McMaster University, Medical Director, Neuromodulation Program, Hamilton Health Sciences Corporation, Hamilton, ON.

CLINICAL TOOLS

Abstract: There is increasing concern in Canada about the overuse and misuse of opioids. While there are no simple answers to this complex societal problem, adequate and timely access to proper multidisciplinary chronic pain care is important in decreasing the reliance on opioids when treating chronic pain in Canada. Neuromodulation therapy, especially spinal cord stimulation (SCS), offers patients the potential for pain relief without repeated injections or ongoing medication use. SCS is effective in the treatment of persistent postoperative neuropathic pain and complex regional pain syndrome. Prospective SCS candidates should undergo a full multidisciplinary assessment to evaluate both physical and psychological factors that may adversely affect results.
Key Words: chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain.

The best studied indications for SCS are persistent postoperative neuropathic pain (so-called failed back surgery syndrome [FBSS]) and complex regional pain syndrome (CRPS).
The key to success with SCS is to generate a pattern of paresthesia that overlaps with the patient’s area of pain while avoiding extraneous paresthesia that may cause discomfort.
SCS is a cost-effective treatment, whereby the long-term savings in terms of diagnostic imaging, physician visits, medications, and rehabilitative services outweighed the higher upfront cost.
Contraindications for SCS implantation include: systemic infection, cognitive impairment, and low platelet counts.
Well-accepted positive predictive factors for long-term success with SCS include: patients whose etiology of pain have a predominately peripheral neuropathic pain component, treatment early in the course of the pain syndrome, and the presence of allodynia and other features suggestive of neuropathic pain. Significantly depressed mood, low energy levels, somatization, anxiety, and poor coping skills are important predictors of poor outcome.
SCS is a non-destructive procedure; the device can be explanted at any point if it no longer provides pain relief, and it does not preclude other treatment modalities, including spinal surgery, in the future.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is only $20 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Disclaimer: 
This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.

Pain Management in Moderate and Advanced Dementias

Pain Management in Moderate and Advanced Dementias

Teaser: 

Eric Widera, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
Alex Smith, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.

This article highlights the complex challenges seen when managing pain in patients with moderate or advanced dementia. Recent evidence demonstrates that pain is often poorly recognized and treated in patients with cognitive impairment. The progressive decline in cognitive function often leads to difficulties in expressing and recalling painful experiences. Making pain assessments routine and combining patient reports, caregiver reports, and direct observation may help alleviate this poor recognition of pain. Once pain is confirmed, a comprehensive history and physical examination are central in determining the underlying cause of pain and in choosing the best modality to treat the pain.
Key words: dementia, cognitive impairment, pain, opioids, assessment.

Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them

Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them

Teaser: 

Marc Ginsburg, RN, MScN, NP, Medical Student, University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles.
Shawna Silver, MD, PEng, Resident, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON.
Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network; Associated Medical Services Fellow in End-of-Life Care Education, University of Toronto; Centre for Innovation In Complex Care, University Health Network, Toronto, ON.

The use of opioid medications and converting among them in the older adult population can often be challenging. Physiological changes in older adults may affect metabolism and cognitive abilities. Due to renally cleared metabolites, some opioids, such as morphine, should be used with caution among older adults. Others, such as meperidine, should never be used at all. When prescribing or changing opioids, the choice of the correct formulation, appropriate counselling, and close follow-up are essential for optimal pain management and in order to prevent adverse outcomes.
Key words: opioids, pain management, older adults, analgesia, opioid conversion.

A Rational Approach to Constipation

A Rational Approach to Constipation

Teaser: 

Hershl Berman, MD, FRCPC, Assistant Professor, University of Toronto Faculty of Medicine, Department of Medicine, University Health Network, Toronto, ON.
Laura Brooks, RegN, MscN, APN, Advanced Practice Nurse in Palliative Care, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, MD, PEng, Hospital for Sick Children; University of Toronto, Toronto, ON.

Constipation is a common complaint, especially in older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy. Treatment should aim to address the underlying cause, as should the choice of laxative. In general, it is best to clear out hard stool in the distal bowel before using an aggressive oral regimen.
Key words: constipation, laxatives, older adults, opioids.

Postoperative Pain Management for the Aging Patient

Postoperative Pain Management for the Aging Patient

Teaser: 


Deborah Dillon McDonald, RN, PhD, Associate Professor, University of Connecticut School of Nursing, Storrs, CT.

Older adults experience moderate to severe postoperative pain during and after their hospital stay. Preoperative education about pain management decreases postoperative pain. Postoperative pain management should generally include concurrent treatment of pre-existing chronic pain problems and a multimodal approach that incorporates postoperative opioids, nonopioids, and nonpharmacologic pain treatments. Opioids should be started at 25-50% of the adult dose and titrated until pain is reduced to a mild level. Older adults should be monitored closely to prevent side effects from opioid accumulation. A consistent pain scale that the older adult understands should be used to evaluate the pain response.
Key words: postoperative pain, pain assessment, opioids, nonopioids, nonpharmacologic treatments.

Treatment of Pain in the Older Adult

Treatment of Pain in the Older Adult

Teaser: 


Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

Pain in the older adult can present unique challenges. Cognitive impairment and polypharmacy can make assessment and treatment difficult. An interdisciplinary team that includes family caregivers is essential. A rational approach to the ambulatory older patient with nociceptive pain would be to begin with regularly dosed acetaminophen, then add an NSAID if appropriate. The next step would be to add a low-dose opioid. If the patient uses a sufficient quantity of the opiate, dosing should be spread out throughout the day. Once a stable dose is reached, one can use a sustained-release formulation. Nonopioids should be continued throughout the titration process.
Key words: pain, analgesia, opioids, older adult, pain assessment.

Aging and the Neurobiology of Addiction

Aging and the Neurobiology of Addiction

Teaser: 

Paul J. Christo, MD, Assistant Professor; Director, Pain Treatment Center & Multidisciplinary Pain Fellowship, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Greg Hobelmann, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Amit Sharma, MD, Postdoctoral Fellow, Division of Pain Medicine, Department of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. *Current Address: Assistant Professor, College of Physicians & Surgeons of Columbia University, New York, NY.

CME: Chronic Noncancer Pain Management in Older Adults

CME: Chronic Noncancer Pain Management in Older Adults

Teaser: 

Jacqueline Gardner-Nix, MBBS, PhD, MRCP(UK), Assistant Professor, Department of Anaesthesia, University of Toronto; Chronic Pain Consultant, Sunnybrook & Women’s College Health Sciences Centre; St. Michael’s Hospital Pain Clinic, Department of Anaesthesia, Toronto, ON.

Older adults pose additional challenges in pain management when noncancer pain has become chronic. Health care professionals are increasingly aware of the effect of past and current life stressors on the pain experience, and the roles of gender, genetics and culture. Reduced activity as individuals age often amplifies the disabling effects of pain. Pain medications are more problematic in this age group due to many factors, including polypharmacy, comorbidities and reduced renal function. However, judicious use of opioid analgesics in a subset of the population may allow increased function and access to activities, which become part of their pain management.
Key words: older adults, opioids, pain management, noncancer pain, holistic.

Management of Cancer Pain in the Older Adult

Management of Cancer Pain in the Older Adult

Teaser: 

Sharon Watanabe, MD, FRCPC and Yoko Tarumi, MD, Tertiary Palliative Care Unit, Regional Palliative Care Program, Edmonton, AB.

Cancer pain is a significant problem in older adults. Management in this population is made more challenging by issues such as comorbid conditions and age-related alterations in drug disposition. The first step is to perform a multidimensional assessment in order to identify the various factors that may influence the perception and expression of pain. The second step is to apply a process of targeted interventions, which optimizes the use of pharmacological and non-pharmacological therapies and takes into consideration the unique characteristics of the older patient.
Key words: cancer pain, pain assessment, opioids, adjuvant analgesics.