All Pharmacological Articles

Tapentadol: A Real-World Look at Misuse, Abuse, and Diversion

This article is appearing online in December 2019, in advance of print in the January/February 2020 issue of Practical Pain Management.

Analgesics of the Future: Inside the Potential of 3 Drug Delivery Systems

Overview For some patients, traditional oral or intravenous (IV) formulations may not be sufficient for pain control, come with undesirable adverse effects, or may not be clinically optimal. Therefore, alternative routes of delivery must be considered. Scilex Pharmaceuticals, AcelRx Pharmaceuticals, and iX Biopharma have created novel dosage formulations of analgesic medications.

Medication Management of Chronic Pain in Patients with Comorbid Cardiovascular Disease

Cases provide insight into treatment options for OA and DPN, complicated by CV diseases. Introduction

What topicals exist for post-herpetic neuralgia pain?

Post-herpetic neuralgia (PHN) is the most common chronic complication of herpes zoster, defined as dermatomal pain lasting at least 90 days after the appearance of an acute herpes zoster rash.

What is the evidence to support clonidine as an adjuvant analgesic?

Clonidine may be beneficial for neuropathic pain, but further mechanisms of action are lacking research.

Medical Marijuana Does Not, In Fact, Reduce Opioid Deaths, According to Study

Stanford’s follow-up to a 2014 UPenn study shows no such correlation.

Gabapentin and Suicidal Ideation: Is There a Link?

With an increasing demand for non-opioid alternatives, the suicide risk potential for gabapentinoids (gabapentin and pregabalin) is yet to be understood.

Special Report: The Abuse Potential of Gabapentin & Pregabalin

Despite their inherent abuse potential, gabapentinoids (gabapentin and pregabalin) may be safer than presumed and offer prescribers an effective opioid-alternative treatment for certain types of neuropathic pain.

Considering Comorbidities When Selecting Medications for Pain (Part 4)

A case presentation on the use of opioids in those with chronic kidney disease and diabetic peripheral neuropathy.

Analgesics of the Future: Inside the Potential of Nerve Growth Factor Antagonists

A review of the pipeline nerve growth factor (NGF) inhibitors tanezumab (Pfizer, Eli Lilly) and fasinumab (Regeneron, Teva).

The Use of Antidepressants in Multimodal Pain Management

For more than two decades, chronic pain was delineated from acute pain if it continued beyond the expected healing period and persisted for 90 days or beyond.

Cannabis Impact on Depression, Anxiety, and Suicide in Adolescents

Better drug prevention and education programs are needed, urge researchers.

The Medical Marijuana Issue

A primer on the terminology and current legality of medical marijuana.

Talking to Patients about Medical Cannabis

How doctors can talk to patients about trying medical marijuana for pain and related symptoms.

How to Communicate with a Medical Marijuana Dispensary

How doctors can communicate with dispensaries when recommending or prescribing medical marijuana for patients.

Analgesics of the Future: The Potential of the Endocannabinoid System

How the endocannabinoid system works and the potential of available and pending medical cannabis products for the treatment of pain and other related symptoms.

A Combination of Opioids and Medical Marijuana May Prove Beneficial

A study in monkeys suggest that using the two drugs together may reduce risk of dependency, without associated cognitive problems

Analgesics of the Future: Inside the Potential of Glial Cell Modulators

Inside the potential of glial cell modulators for disease modification and pain management including OUD, opioid tolerance, and hyperalgesia.

Predicting Opioid-Induced Respiratory Depression

Medtronic’s new risk-assessment platform may help to identify vulnerable patients before opioid therapy begins.

Rx Data Deemed Ineffective for Measuring Opioid Crisis

The majority of Medicare Part D patients diagnosed with OUD were not identified as overutilizers.

Antidepressants May Lower Prodrug Opioid Effects

Direct-acting opioids may be a better options for depressed patients on SSRIs.

Compounded Pain Creams Shown Ineffective in New Trial

Results bring into question the high cost of the products and use over FDA-approved variations.

Projecting the Rate of US Overdose Deaths in the Near Future

Tracking the prevention methods of prescription opioid misuse and overdose deaths by 2025.

Prescribing Patterns of Benzodiazepines

Benzodiazepines are accounted for a growing number of overdose-related deaths

“Blended” Therapy: A Novel Approach to Reduce Opioid Use

A compounded formula using codeine could lower patients’ overall opioid doses, according to one doctor's novel research.

Editorial: Have We Gone Too Far? Can We Get Back?

Beyond the opioid crisis, new challenges—and hopes—await the pain practice community.

Demystifying Opioid-Induced Hyperalgesia

Insurance companies decline to continue paying for opioid medications, citing opioid-induced hyperalgesia (OIH). Why?

Analgesics of the Future: NKTR-181

Inside the unique properties of Nektar Therapeutics’ new abuse-deterrent opioid, NKTR-181, and its potential for treating low back pain.

Medical Marijuana May Be On the Rise—But I See a Downfall

New Jersey is the latest state to allow medical cannabis to be used as an adjunct to medically assisted treatment for Opioid Use Disorder (read the full story). Here, PPM

New Jersey to Allow Medical Marijuana for Opioid Addiction Treatment
New Jersey becomes the third state to allow medical marijuana treatment for opioid use disorder.

FDA Recommends Co-Prescribing Naloxone with Opioids
In a close vote, panel members remain divided. More news coming soon.

Prescribing Patterns of Opioids in the Pediatric Population
While opioid prescribing rates decreased over a nine-year period, certain factors led to differences in prescribing.

Systemic Review of Opioids for the Treatment of Chronic Non-Cancer Pain
While use was associated with reduced pain and improved physical functioning, there was an increased incidence of vomiting.

Buprenorphine Conversions
An update has been made to the PPM Opioid Calculator to remove conversions to and from buprenorphine.

Buvidal Given Positive Recommendation, Approval by European Committee
Buvidal is the latest opioid dependence and withdrawal medication currently in the pipeline.

Cardiovascular Surgery in Patients with Opioid Use Disorder
What are the associations of opioid use disorder with outcomes of cardiovascular surgery?

Intranasal Ketamine for Acute Pain in Children
Comparing intranasal fentanyl and intranasal ketamine for the treatment of limb pain in pediatric patients.

Medication Selection for Comorbid Pain Management (Part 3)
Medication options for managing chronic pain and comorbidities: a patient with diabetic peripheral neuropathy, kidney disease, and an alcohol/substance use disorder.

Opioid Conversion Calculations and Changes
Dr. Mary Lynn McPherson's second edition of her book, focusing on opioid conversion, offers healthcare providers strategies for calculating and prescribing opioid dosages.

How to Treat Opioid Use Disorder in Pregnant Women
Opioid use disorder (OUD) is on the rise among pregnant women: what clinicians can do to help monitor and treat pain in female patients.

Challenges & Opportunities for Pain Management In Veterans
Pain practitioners should turn to VA resources when assessing and treating chronic pain in Veterans.

Medication Management in the Aging
Clinical anecdotes to assist practitioners in medication selection for complex chronic pain problems in the elderly patient population.

Pain Management in the Elderly
Clinical vignettes provide insight into assessment and management of pain in the geriatric patient population.

Sickle Cell Disease: Could Medical Cannabis and Crizanlizumab Prove Helpful?
Two promising treatments may reduce common pain crises related to SCD.

Opioid Misuse Among College Population
Common characteristics of opioid misusers among college students were found in a new study.

Is Cannabis the Next Opioid Epidemic?
Wilson Compton, MD, NIDA (Source: NIDA) A Q&A with Wilson Compton, MD, MPE, Deputy Director, National Institute on Drug Abuse (NIDA)

Nerve Growth Factor and Targeting Chronic Pain
Until recently, the methods used to treat pain have been mainly focused on opioids and NSAIDs—neither being an ideal option due to undesirable side effects, according to Leonard Goldstein, DDS, PhD, assistant vice president for clinical education development at AT Still University in Mesa, AZ, and PPM editorial advisor As the focus on decreasing prescribed opioid

A Commentary on Medical Cannabis
Medicinal marijuana in pain management is a promising non-pharmacological therapy that clinicians should know more about.

Demystifying Opioid Abuse-Deterrent Technologies
Inside abuse-deterrent formulations – and their potential impact on the opioid epidemic.

Managing Opioid Use Disorder
Despite evidence of benefitting OUD, MAT treatments are not made available to the vast majority of patients.

Medication Selection for Comorbid Pain Management (Part 2)
A case study of buprenorphine as an alternative option for a patient with chronic osteoarthritic pain and COPD.

How can cyproheptadine manage complicated chronic pain cases?
Cyproheptadine may be useful in treating chronic pain conditions such as sleep disorders, sexual dysfunction, refractory headaches, and more.

New Line of OTC Pain Relievers from Sunascen
Sunascen Therapeutics have developed a line of non-habit forming pain relievers that are developed with the patient in mind.

Nerve Growth Factor Targets Continue the Fight To Enter Market
Tanezumab is the first investigational humanized monoclonal immunoglobulin G2 antibody, preventing the binding of NGF to its receptors to block the pain response pathway.

Chronic Pain Patients’ Perception of Opioids May Determine How Well the Medications Work
What do patients really think about opioid vs non-opioid medications for chronic pain?

Topical Analgesics for Chronic Pain Conditions
Alternative therapies for MSK pain, osteoarthritis, post-herpetic neuralgia, and peripheral neuropathy.

What’s the safest, effective way to taper a patient off of opioid therapy?
The author presents effective strategies to tapering your patients off of opioid therapy.

Research on Stopping Long-Term Opioid Use Opens Up Treatment Alternatives
Chronic pain remains the same or gets better after stopping opioid treatment, according to a new study.

Opioid Painkiller Buprenorphine, Z Drugs for Dementia Show an Increased Risk for Harmful Side Effects
Medications which are commonly prescribed to people with dementia have been linked to an increase in harmful side-effects.

FDA Encourages More Development of Generic Versions of Abuse Deterrent Formulations
Agency continues its efforts to broaden access to generic versions of opioids formulated to deter abuse.

FDA Committee Votes Against Approval of Abuse-Deterrent Opioid Formulation
FDA will complete its review of REMOXY ER in August 2018.

Resource for Your Practice: Medication Management of Chronic Pain
In his new book, Medication Management of Chronic Pain: What You Need to Know, Gerald M. Aronoff, MD, DABPM, DABPN, medical director of Carolina Pain Associates in Charlotte, North Carolina, and former president of the American Academy of Pain Medicine, presents data to assist practitioners in their decision-making regarding medication management of complex chronic pain problems.

Fentanyl: Separating Fact from Fiction
This article provides a sneak preview into the upcoming July/August 2018 issue of Practical Pain Management.

FDA Approves First Generic Versions of Suboxone Sublingual Film
The agency said it will continue to evaluate the use of market drugs and take regulatory action where needed.

With concerns over opioids, could novel receptors be useful?
With opioid misuse and abuse on the rise, other opioid receptors may be targeted for pain relief.

Editorial: The Emergence of Trackable Pill Technology: Hype or Hope?
Knowing a patient has consumed their prescribed medication may prevent improper diversion of pills and overdose.

IV Tramadol Shown Effective in New Phase 3 Trial
If approved by FDA, IV tramadol would be the first Schedule IV intravenous opioid in the US.

EMA Recommends DZUVEO for Moderate to Severe Pain
AcelRx is planning on resubmitting an NDA for DSUVIA to FDA in Q2 2018.

Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Elevated use of gabapentinoid misuse and abuse may be a problem with monitoring opioids.

Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
A case presentation examines treatment options for a patient with chronic pain, complicated by hypertension and PTSD.

New Formulation of Hydrocortisone May Soon Be Available for Children
Small doses could help children suffering from various types of inflammation and pain.

FDA Grants Orphan Drug Designation to Cannabis Pellet
For the rare complex regional pain syndrome, help may be on the way in the form of this cannabidiol.

Canadian Physicians Release Guidelines for Opioid Use Disorder
With appropriate treatment and follow-up, individuals can reach sustained long-term remission from OUD.

Nonopioid Management Just as Impactful as Opioids for Back and Knee OA Pain
Nonopioid Management Just as Impactful as Opioids for Knee/OA Pain

Could Novel Gene Variant Reduce Opioid Physical Dependence?
New lead into understanding the pathophysiology of opioid physical dependence

Gabapentin Not as Effective as Previously Thought
Chronic neuropathy treatment does not offer much pain relief for patients.

Ask the Expert: Is there evidence to prescribe cyclobenzaprine long-term?
Further studies of the long-term use of cyclobenzaprine for chronic pain management are needed to confirm its efficacy.

The Inter-Connection between Smoking and Opioid Misuse
The use of cigarettes to alleviate chronic pain may be increasing patients' symptoms and putting them at higher risk of opioid misuse. and upping their risk of opioid misuse.

A Fresh Look at Opioid Antagonists in Chronic Pain Management
Opioid antagonists, such as naltrexone and naloxone, may help reduce side effects and address drug deficiencies in chronic pain treatment.

Are biosimilars as effective as their biologic counterparts?
FDA approval of biosimilars in comparison to biologics for the treatment of chronic pain raises issues of efficacy.

United Nations Says Untreated Pain Is “Inhumane and Cruel”
UN calls untreated pain cruel and inhumane, yet in the US chronic pain patients are losing access to needed opioid therapy to manage severe, intractable pain conditions.

Preemptive and Preventive Analgesia for Chronic Postsurgical Pain
The best approaches to manage pain relief to most effectively address post-surgical pain.

What are Nav1.7 inhibitors and how are they used in the treatment of neuropathic pain?
Ask the Expert: A discussion of the pain relief potential from Na1.7 Inhibitors for neuropathic pain disorders.

Letters to the Editor: Dependence vs Addiction, Opioid Metabolism
Readers raise questions about the one-sided view of the so-called opioid-epidemic, hormone therapy, and long-term opioid care.

Opioid Rotation From Opana ER Following FDA Call for Removal
Expert give you advice on how to switch from Opanan ER to another long-acting opioid.

Justification of Morphine Equivalent Opioid Dosage Above 90 mg
An argument in support of providing patients with an opioid prescription for dosages over 90 MME daily to manage severe chronic pain.

A Plea for Proper Opioid Tapering
While there are people who misuse and abuse opioids, there are also many patients with severe, chronic, intractable pain for whom a safe and effective weaning approach is needed.

Are Abuse-Deterrent Opioid Products A Double-Edged Sword?
Assessment of abuse-deterrent opioid medications designed to lessen access to active ingredients while maintaining analgesic effects for chronic pain patients with appropriate need.

CMS Tackles Opioid Prescribing
This month's Editor's Memo focuses on how Medicare and Medicaid are planning on adopting CDC Guidelines for Safe Opioid Prescribing.

The 5 Most Misunderstood Terms in Pain Medicine
A perspective on several common terms that are widely used by pain practitioners but often are misunderstood by professionals, patients, the general public, and the media.

Pain Management in the Elderly: Focus on Safe Prescribing
A multitude of pharmacokinetic changes that occur with aging should be considered when pain prescribers consider which medications to prescribe to avoid drug-drug interactions in the elderly.

Painful Genetic Diseases
Pain practitioners are urged to recognize painful genetic disorders, which fall into 3 categories: connective tissue, metabolic, and neurologic, as they require aggressive, palliative pain care for these usually progressive conditions.

Does Opioid Cessation Prior to Surgery Help or Hurt?
Patients on chronic opioid therapy need special attention when it comes to preoperative and postoperative care. In this article, clinicians debate the benefits of reducing opioids prior to surgery.

Duloxetine and Liver Function Tests
Recommendations concerning liver function tests for Duloxetine, prescribed for neuropathic pain.

Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
In this Guest Editor's Memo, Seddon R. Savage, MD, MS, discusses issues of treating opioid use disorder in patients with chronic pain.

Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Family physicians are presented with a pain management roadmap for setting realistic treatment expectations with the chronic pain patient, including when and how to wean off opioids.

Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Challenging insurance policies that hinder management of opioid use disorders.

Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
In a patient with chronic pain who develops an opioid use disorder (OUD), what factors go into the decision of whether or not to wean the patient off opioids? Jordan L. Newmark, MD

Letters to the Editor: Opioid Calculator; Metformin
Readers are better informed about use of the PPM Opioid Calculator and the benefits of metformin.

A Brief History of the FDA’s Role in the Ongoing Effort to Ensure Safe Opioid Use
Given the recent focus on the opioid abuse epidemic, Practical Pain Management asked the authors to review what efforts the FDA has taken to help combat abuse of these medications.

Ketamine for the Treatment of CRPS?
Ask the Expert authors examine the role for low-dose ketamine for treatment of CRPS.

Living With CDC Opioid Guidelines
Dr. Forest Tennant, MD, explores the impact that the CDC opioid-prescribing guidelines have had on chronic pain patients.

Gabapentin Dosing for Neuropathic Pain
Pain expert offers clinical guidance to a commonly asked question about the proper, safe, and effective dose of gabapentin when treating neuropathic pain.

Opioid-Induced Constipation: New and Emerging Therapies—Update 2016
2016 review of current and emerging therapies for opioid-induced constipation, a common side effect of chronic opioid therapy.

IV Acetaminophen Reduces Need for Opioids in Burn Patients
To help reduce the need for opioids, IV acetaminophen could be included in the initial and perioperative pain control protocol of burn patients based on its analgesic effect, safety profile, and easy accessibility.

2016 Practical Clinical Advances: Ketamine and Metformin
Forest Tennant, MD, DrPH, picks for 2016 Practical Clinical Advances in pain management—oral ketamine and metformin.

Benzodiazepines and Opioids: Only Trained Pain Practitioners Should Prescribe
Forest Tennant, MD, DrPH, advice for those thinking of co-prescribing benzos and opioids—leave it to the pain experts.

Levorphanol: An Optimal Choice for Opioid Rotation
Call the forgotten opioid, physicians are rediscovering levorphanol as a safe and effective pain medication.

IV Treatment of Centralized Pain and Headache
Dr. John Claude Krusz describes his protocol for the use of subanesthetic dosages of IV agents—ketamine, lidocaine, propofol—in an outpatient headache clinic.

Prescribing Opioids: How New Policies Are Affecting Medical Specialties
Learn how emergency room physicians, dentists, rheumatologists, and orthopedic surgeons are dealing with new regulations and guidelines for pain management.

No Perfect Medicine—What You Need to Know About NSAIDs and Opioids
There are no perfect medications. This applies to both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. A high level of mortality is associated with both NSAIDs and opioids.

Life-Saving Naloxone: Review of Currently Approved Products

EpiPens and Opioids: Common Ground
EpiPen’s astronomical price increase from $100 in 2007 to $600 today has caused quite a furor among parents and advocacy groups.

A Perspective on Tapentadol Therapy
We wish to address 3 underappreciated, but salient points regarding tapentadol therapy using a case-based approach: First, the rarity of a true opioid allergy; second, the chemical similarity of phenylpropylamine opioids (tramadol, tapentadol); and, third, the unique pharmacodynamic attributes of tapentadol in the treatment of complex regional pain syndrom

6 Common Concerns Regarding Medical Marijuana
Canadian researchers discuss 6 common concerns of patients and physicians regarding cannabis use for pain management.

What Pain Specialists Need to Know About Medicinal Cannabis
Barth Wilsey, MD, shares his unique perspective and knowledge on the benefits and risks of therapeutic cannabis (medical marijuana).

10 Pain Medication Myths
10 Medication Myths. Learn more about what is and is not true about medical management of chronic pain.

The Use of Medical Marijuana for Pain in Canada
Learn more about the correct dosing of different strains of medicinal cannabis used in Canada for the treatment of various pain conditions.

Genetic Testing in High-Dose Opioid Patients
Genetic testing for metabolic abnormalities are critical tools for identifying patients who may require high-dose opioids.

My Experience With OxyContin 12-Hour Dosing
Dr. Jennifer Schneider describes her experience with prescribing extended-release OxyContin to chronic pain patients.

Los Angeles Times Versus Purdue Pharma: Is 12-Hour Dosing of OxyContin Appropriate?
A closer look at the debate between the Los Angeles Time reporters and Purdue Pharma regarding OxyContin's 12-hour dosing schedule.

A Review of Skeletal Muscle Relaxants for Pain Management
Skeletal muscle relaxants are commonly prescribed for the management of spasticity and spasm. Learn more about these agents used in pain management.

Tapering Chronic Pain Patients Off of Opioids
Presentation by Chantal Berna, MD With the growing concern about misuse and abuse of opioids, it may be prudent to review the treatment plan of noncancer patients on long term opioids, with the goal of tapering them off when possible.

Tapering Opioids May Improve Arthroplasty Outcomes
Interview with Kevin J. Bozic, MD, MBA Managing pain from knee or hip osteoarthritis (OA) is oftentimes a top priority—both for patients and physicians.1 Although there is no cure for OA, opioids have become a common therapy for managing pain,2,3 especially in patients who are unresponsive or can not tolerate anti-inflammatory medication.

Sports-Related Pain: Topical Treatments
Guide to topical therapy for acute and chronic sports-related pain, including tendinopathies, bursitis, strains, and sprains.

Don't Flinch From Prescribing Pain Medications!
Dr. Forest Tennant shares his views on the new CDC Guidlines on Opioid Prescribing, as well as introduces Don L. Goldenberg, MD, the newest member of the PPM Editorial Board.

Marijuana Use Disorder: Common and Often Untreated
Marijuana use disorder is common in the United States, is often associated with other substance use disorders, behavioral problems, and disability.

Opioid-Maintained Patients Who Require Surgery
Learn more about how the new APS guidelines on postoperative pain management effects chronic pain patients already on opioids.

Comorbid Substance Use Disorders: Primer for Pain Management
Doctors are increasingly being charged assessing patients for pain management, including their risk of opioid addiction. Learn more about the signs and treatment for substance use disorders.

Zohydro vs Hysingla: What is the Difference in These Extended-Release Agents?

Timely- versus Delayed-Use of TNFi’s: Which Approach Is Better?
In some cases, tumor necrosis factor inhibitors (TNFi) may be the first-choice agent for patients with psoriatic arthritis. Learn why.

Is Tapentadol a Glorified Tramadol?
Practical Pain Managements experts answer the question: Is tapentadol a glorified tramadol?

Medication Guide for Pain—A Short Primer for Primary Care

QT Intervals and Antidepressants
Our experts answer the question about which antidepressant is the least likely to cause cardiac problems, including QT prolongation.

Opioid-Induced Constipation: New and Emerging Therapies—Update 2015
Opioid-induced constipation affects many patients. But instead of suffering in silence, patients may benefit from new and emerging therapies directed at the root cause of the constipation.

Oxycodone Metabolism
Question: Should I discharge a patient on Percocet (oxycodone/acetaminophen) for chronic back pain with unexpected oxymorphone detected in her urine drug screen?

Oral Opioids: Not for Everybody
What do you do when a patient can not absorb oral pain medications? Read Dr. Forest Tennant's Editor's Memo to find out.

Opioid Withdrawal: A New Look at Medication Options
Learn more about the myriad of agents that can be used to reduce the symptoms of opioid withdrawal.

Steroids for Complex Regional Pain Syndrome?
Are corticosteroids safe and effective therapy for complex regional pain syndrome? Read what our experts have to say.

Legacy Patients From High-Dose Opioid Era
What does the pain community do with patients who have been taking high-dose opioids for years? Read Dr. Forest Tennant's Editor's Memo to find out.

Letters to the Editors: Prednisone and Microglia Modulators
Practical Pain Management answer your Letters to the Editor. This month features questions about prednisone dosing and microglia modulators.

Legal Considerations of Medical Marijuana
Many experts recommend reclassifying marijuana from a Schedule I to Schedule II substance. Learn more about how reclassification may open the way to more research avenues to study the medicinal role of cannabis.

Call for Standardization and Quality Assurance for Medical Marijuana Products
Marijuana edible products often are mislabeled, leading to calls to reschedule marijuana and install better oversight of this burgeoning industry. Learn more about the call to standardize medical marijuana products.

Medical Marijuana Dispensed by Pharmacists in Connecticut
Q: Please explain the medical marijuana law in Connecticut and the role of pharmacists in dispensing medical marijuana products.

Recommending Medical Marijuana for Pain Conditions
Neuropathic pain, fibromyalgia, spinal cord injury—these are just a few of the chronic pain conditions being treated with medical marijuana. Learn more about who is a good candidate for medical marijuana.

Letters to the Editor: Antibiotics and Microbiome, Hormone Panel
Antibiotics and Microbiome I had a few questions after reading the “Editor’s Memo” in the June issue of Practical Pain Management.1 Dr. Tennant mentions treatment aimed at over-activated glial cells. In the use of tetracyclines, in what time frame do you begin to see results?

The Inhumane and Dangerous Game of Forced Opioid Reduction
Many pain patients are being forced to reduce or limit their use of prescribed opioid medications. Dr. Forest Tenant discusses the sad state of affairs surrounding opioid prescribing.

My Policy on Marijuana
The use of marijuana may interfere with the therapeutic effect of pain medications and can increase cognitive dysfunction. Therefore, Dr. Gerald M. Aronoff advises against writing a prescription for a controlled substance (including opioids) to any patients testing positive for illicit drugs, including recreational marijuana.

Marijuana: Does it Cause Cognitive Impairment During Driving?
Evidence has shown that cannabis is associated with an increased risk of motor vehicle accidents, especially when combined with alcohol. Presented here is one clinician’s guide and for screening for marijuana in a chronic pain practice.

NSAID Sensitivity
Drug safety is always a concern. Our experts answer your questions about NSAID-related sensitivity.

Is There a Role for NSAIDs in Patients With Cardiovascular Disease?
The recent action by the US Food and Drug Administration (FDA) to strengthen the warning label of nonsteroidal anti-inflammatory drugs (NSAIDs) to reflect an increase risk of heart attack or stroke raises questions about how safe are these medications for patients with pre-existing cardiovascular disease (CVD).

Status Report on Role of Stimulants in Chronic Pain Management
Stimulants are a class of compounds that have a sympathomimetic or uplighting action on the central nervous system (CNS). Internal or endogenous stimulants are known as catecholamines because a portion of the molecule is catechol. The best known examples are dopamine, norepinephrine, and epinephrine.

Antihistamine for G-CSF–Induced Bone Pain
Cancer patients undergoing chemotherapy can develop febrile neutropenia. However, the treatment can also lead to bone pain. Learn how antihistamines may help treat G-CSF–induced bone pain.

Is Topical Ketamine Ready For Prime Time?
Topical analgesics are appealing to clinicians because their lack of systemic absorption results in limited adverse effects (AEs).1 Other benefits of topical analgesics include direct access to target sites, convenience, ease of use, painless administration, and improved patient acceptance and adherence, all of which may reduce overall treatment costs.2-4 Most topical anal

Gabapentin Abuse
Q: Why is there abuse of gabapentin? A: Gabapentin (Gralise, Neurontin) is a widely prescribed drug used for the management of a number of neuropathic pain syndromes.

Tables Turn on Pain Psychologist
Table turn on pain psychologist who undergoes rotator cuff surgery. Steven D. Passik, PhD, experiences first-hand how pain management and assessment is handled in a busy orthopedic practice.

Microglial Modulators: A New Therapeutic Class
Old medications are getting renewed interest in the treatment of pain. They are being investigated because of their ability to inhibit microglia activation, and show promise in the treatment of neuropathic pain.

Abuse-Deterrent Formulations
Dr. Lynn Webster sits down with PPM to discuss abuse-deterrent formulations for reducing abuse of opioids.

Opioid Therapy Clinical Guidelines
Guidelines for opioid prescribing suggest starting low, and going slow--usually with a short-acting opioids and then transitioning to long-acting opioid.

Editor's Memo: Prescription Opioid Abuse is Declining
After a steep climb between 2002-2010, abuse of prescription opioids appears to be on the decline--in part due to improved regulations and new formulations of opioids.

Magnesium Sulfate Helpful in Treatment of Acute Migraines
Many people with migraines have lower than normal levels of magnesium. Treatment with magnesium supplements may help manage acute migrain attacks.

Practical Guide to the Safe Use of Methadone
Methadone is an inexpensive, long-acting opioid that may be particularly beneficial in patients with neuropathic pain or opioid-induced hyperalgesia. However, methadone is challenging to use. This guide describes Methadone’s unique characteristics.

Rationale for Medical Management
Many states are now requiring that physicians justify or provide a rationale for daily opioid dosages above a specified amount. The “trigger” dosage usually ranges from 80 to 120 mg. The authors present a rationale for treating moderate to severe chronic pain with opioids.

Ask the Expert: DMARDs and Opioids
For patient with rheumatoid arthritis who are currently taking a disease-modifying antirheumatic drugs (DMARDs), the use of opioids may be beneficial for those with chronic pain. However, there are no long-term studies with definitive results to support their concurrent use. Patients and clinicians also should be aware of the risk related to use of DMARDs and opioids, and therapy should be regularly reviewed for efficacy and safety.

Combating Opioid-Induced Constipation: New and Emerging Therapies
Studies in the United States suggested that the prevalence of opioid-induced constipation (OIC) in patients with non-cancer pain ranged between 40% and 50%. Patients do not develop a tolerance to this side effect of opioids. This article reviews new and emerging therapies that target the cause of OIC.

Editor's Memo: Care With Caution
The November/December Editor's Memo by Forest Tennant, MD, DrPH, reviews two recent reports on the status of pain management today. His conclusion: Provide care with caution.

Using Pharmacogenetic Testing in a Pain Practice
Pharmacogenetic testing may be used to direct patient care by individualizing medications regimens and dosages

Ask the Expert: What are the products to prevent NSAID-related peptic ulcers?
For patients at risk of developing an NSAID-induced ulcer who require chronic NSAID therapy, a COX-2 selective agent (Celebrex) may be considered in patients without cardiovascular risk. If a preventive therapy is required, misoprostol and proton pump inhibitors have been found to be more effective than histamine 2 receptor antagonists.

Preparing Patients Taking Sublingual Buprenorphine to Treat Addiction for Surgery
The use of buprenorphine products to help treat opioid dependence has increased over the last decade. This trend has been paralleled by an increase in the number of surgeries involving patients taking buprenorphine products.

The Role of Endogenous Morphine and Nitric Oxide in Pain Management
The discovery of dysfunction of endogenous morphine, which leads to the development of many chronic pain conditions, may lead to promising new safe and effective treatments.

Treating Pain in Patients With Chronic Kidney Disease: A Review of the Literature
Seventy percent of the 20 million people in the United States with chronic kidney disease report having pain. The presence of pain in these patients is association with lower quality of life, including lower functional capacity.

Ask the Expert: NSAIDs After Bariatric Surgery
Q: Can NSAIDs be used to treat chronic pain in a patient who has had bariatric surgery?

Dialysis, Opioids, and Pain Management: Where’s the Evidence?
Almost half of all diaylsis patients suffer from chronic pain. However, there are virtually no recommendations for pain management in the dialysis setting.

Ask the Expert: Dependence vs. Addiction
A patient asked to be taken off her opioid because her family thinks she has become addicted. Dr. Jennifer Schneider walks through the difference between opioid dependence and opioid addiction in this Ask the Expert column.

Interactions Between Pain Medications and Illicit Street Drugs
Fatal drug interactions between opioids and benzodiazepines, alcohol, and other sedative-hypnotic drugs have been well publicized and studied. Less publicized, however, are serious and potentially fatal drug interaction between pain medications and illicit drugs, including the ever-growing number of novel street drugs.

Guest Editor's Memo: The Forgotten Patients: Those Who Benefit From Opioid Treatment
Recently, healthcare professionals and the general public have been deluged with information about deaths from opioid (and other drug) overdoses, about patients who misuse or divert their prescribed opioids, about doctors who are, in fact, criminals who run pill mills, etc.

Ask the Expert: Multiple Benzo Prescriptions
A patient requested refills for 2 benzodiazepine agents at the same time (alprazolam and clonazepam). Is this ever appropriate?

Editor's Memo: Toxic Insurance Plans

Case Challenge: Chronic Opioid Use Causing Adrenal Insufficiency
History A 24-year-old African American female with a history of sickle cell disease was admitted to the hospital for severe pain in her arms and legs bilaterally, which was typical of her previous episodes of sickle cell crisis. Since the age of 12, the patient has had more than 20 sickle cell attacks a year.

History of Pain: The Treatment of Pain
“The stronger person is not the one making the most noise but the one who can quietly direct the conversation toward defining and solving problems.” —Aaron T. Beck, MD (1921- ), Founder of Cognitive Behavioral Therapy

We Need More “Tolerance” in Medical Pain Management
From what I can ascertain, therapeutic tolerance is the most misunderstood aspect of the medical management of pain. What’s worse, everyone including physicians and non-physicians either seems to think they’re an expert on tolerance or feel tolerance is irrelevant.

Benzodiazepines in Pain Practice: Necessary But Troubling
I have yet to find a pain practitioner who really likes prescribing benzodiazepines. In just about every guideline or protocol that involves prescribing opioids, there’s always an admonition to not mix opioids and benzodiazepines. No wonder. Practically every opioid overdose involves the addition of one or more benzodiazepines.

Buprenorphine With Naloxone for Chronic Pain
Question: Does adding naloxone to buprenorphine offer any benefit over using buprenorphine alone for the treatment of chronic pain?

The Stanford Opioid Management Model
It is not uncommon for patients to present to their first pain clinic appointment with the expectation that they will receive opioid medications to treat their non-

Treating Rebound or Chronic Daily Headaches
Question: What is better for treating rebound headaches—long-acting or short-acting NSAIDs?

More on Nitrous Oxide and Meperidine in Pain Care
Thank you for your responses to my letter about a patient whose back pain was “cured” after a dental procedure where he received meperidine (Demerol) and nitrous oxide.1 I suspected that these two drugs would in some way “realign the stars” but I have not seen much published data regarding the effect on N-methyl-D-aspartate (NMDA) receptors or oth-er mechanisms of changing centr

Zohydro Debate: Drug Hysteria or True Concern
Much has been written about the controversy surrounding the release of Zohydro (hydrocodone), which won Food and Drug Administration approval despite a 12 to 2 vote against the agent by the advisory committee. Many experts in pain management and drug psychiatry are concerned that the new drug will become another focal point in the country’s epidemic of opioid abuse.

Benefit of Long-acting Versus Short-acting Opioids?
Question: Is there a benefit to using long-acting versus short-acting opioids for chronic pain?

Why Is There Hydromorphone In My Patient’s Urine?
Drug testing commonly is used in clinical, criminal, and workplace settings.

Opioid Bias Hurts Pain Patients
As I travel around the country, two issues keep surfacing: 1) the abrupt cutting off of legitimate patients from opioids, producing withdrawal and re-emergence of their pain; and 2) the bias against the use of opioids by states, even for legitimate pain patients.

Can misoprostol be used for refractory chronic constipation?
Question: Can misoprostol be used for refractory chronic constipation?

Practical Guide To Safe Use of Nonprescription Pain Medications
Nonprescription, or over-the-counter (OTC), analgesics accounted for 11% of all nonprescription drug sales in 2011.1 Benefits of OTC analgesic medication use include direct, rapid access to medications for pain relief, decreased health care utilization resulting in lower costs, and increased engagement of the patient with their own health care.

Genetic Mutations in Cytrochrome P 450 2D6
Question: A patient recently found out that she has a genetic mutation, cytochrome P 450 (CYP450) 2D6, and that she is a poor metabolizer. One of her alleles is null, while the other works at a very low rate. I am not that familiar with these mutations, and I am hoping you may be able to give me some more information on what the mutation is?

Current Access to Opioids—Survey of Chronic Pain Patients
Prescription opioid misuse, abuse, addiction, overdose, and diversion have become crises on local and national levels.1-6 The latest statistics from Drug Abuse Warning Network (DAWN) estimates that over 1.2 million emergency department visits in 2011 involved nonmedical use of prescription medicines, over-the-counter drugs, or other types of pharmaceuticals.

Opioid Prescribing Part 2: Appropriate Documentation of Follow-up Visits
Pain is one of the most common reasons patients visit a health care professional. Professionals spend a great deal of time learning how to diagnose and treat pain-related medical problems but much less time learning how to document the process.

Are Antibiotics a Treatment Option for Low Back Pain?
Question: Are antibiotics a treatment option for low back pain?

Are patients taking acetaminophen (Tylenol) at risk for developing serious skin conditions?
Acetaminophen (Tylenol) is widely used due to its analgesic and antipyretic effects and its inclusion in myriad over-the-counter and prescription products.1 Although acetaminophen’s mechanism of action is unknown, it is theorized to involve inhibition of cyclooxygenase enzymes in the central nervous system.2 The most concerning adverse effect of acetaminophen has long been

Ask the Expert: Do NSAIDs Cause More Deaths Than Opioids?
Question: I have recently read a lot on Twitter that NSAIDs cause more deaths than opioids. Can you clarify if that is true?

Letters to the Editor
PPM Editorial Board answers letters from readers. Can nitrous oxide potentiate pain management or eliminate pain altogether?

Ask the Expert: Should You Test For and Treat Opioid-induced Hypogonadism?
Question: Should you test for and treat opioid-induced hypogonadism?

A Practical Approach to Discontinuing NSAID Therapy Prior to a Procedure
Discontinuing NSAIDs prior to surgery can be confusing to both patients and physicians. Stopping medications before surgery should be based on pharmacokinetics of individual NSAIDs.

Opioid-induced Osteoporosis: Assessing Causes and Treatments
Osteoporosis is being recognized more frequently as a side effect of long-term opioid therapy. Screening should be considered in all patients on chronic opioid medication because treatment is much more effective when osteoporosis is detected early.

PROP Versus PROMPT: FDA Speaks
FDA rules on extended-release and long-acting opioids. Read PROP and PROMPT responses, as well as PPM Editorial Board comments.

Editor's Memo: Long-Acting Opioids: More Than a Labeling Issue
The US Food and Drug Administration (FDA) announced labeling changes for all extended-release and long-acting (ER/LA) opioids.

Use of Long-term Muscle Relaxants
Pain experts answer the question "What is the evidence for the use of long-term skeletal muscle relaxants in the treatment of chronic low back pain"?

Letters to The Editor

Safe Usage of Analgesics in Patients with Chronic Liver Disease: A Review of the Literature
Navigating the Dos and Don'ts of common analgesics in pain patients with chronic liver disease.

PROP versus PROMPT: FDA Speaks
After over a year of debate, petitions, and hearings, in September of 2013, the FDA announced class-wide safety labeling changes and new post-market study requirements for all extended-release and long-acting (ER/LA) opioid analgesics intended to treat pain. PPM asked the authors of PROP and PROMPT, as well as our Editorial Board, to weight in on the ruling.

Letters to the Editor: Hormones and Genetic Testing

Is Buprenorphine a ‘Partial Agonist’? Preclinical and Clinical Evidence
Buprenorphine has a unique pharmacological profile, and while much remains to be learned, it is clear that it is an important treatment option for the management of moderate to severe cancer and non-cancer pain syndromes

Ask the Expert: Intranasal Ketamine for Migraine Therapy

Chronic Pain and Depression—Why Antidepressants Treat Both
Pain and depression are often linked. Antidepressants are often effective at treating both disorders.

Pharmaceutical Treatment of Insomnia In Intractable Pain Patients
Insomnia is a profound problem in patients with severe, intractable pain that is poorly controlled.

Ask the Expert: Which NSAIDs are Most Selective for COX-1 and COX-2?
QUESTION: Which NSAIDs Are Most Selective For COX-1 and COX-2?

Evaluation and Comparison of Online Equianalgesic Opioid Dose Conversion Calculators
This article will review the substantial differences among the available opioid conversion calculators.

Obesity and Pain Management
The obese patient poses specific clinical challenges for pain specialists, and often presents with related risk factors that directly contribute to chronic pain

You Ordered the Urine Drug Test: Now What?
UDT should be something you do “for our patients.” Ordering the “right test” for the “wrong purpose” can result in completely erroneous information being presented and applied to the clinical care of the patient.

Letters to The Editor: Guidelines for Opioid Prescribing, Drug Legislation

Ask the Expert: Cash Patient on High-Dose Oxycodone With Negative Urine Screens
A 38-year-old man who weighs 280 lbs owns his own business and takes 300 to 450 mg of oxycodone 30-mg tablets each day. He attends the pain clinic with his wife who is a licensed registered nurse. He and his wife state that with opioids he works full time. The problem is that recent urine screens show no oxycodone. Both patient and wife claim he faithfully takes his oxycodone as prescribed. What should the physician do?

Malabsorption of Opioid Medications
Not all patients respond the same to any given opioid. This fact is well known to pain practitioners. In this journal, we have previously discussed some of the reasons why this occurs—genetic polymorphism, pharmacokinetics, and pharmacodynamics. But one less obvious reason may be opioid malabsorption.

Long-term Opioids, Sickle Cell Disease, and Pain Patches
The American Pain Society annual meeting was held in May in New Orleans, Louisiana. Forest Tennant, MD, Editor in Chief of Practical Pain Management, reports on long-term opioids, sickle cell disease, and pain patches.

Letters to the Editor: Testosterone, Ultra-high Dose Opioids
Testosterone Deficiency Do you know what would be the incidence of testosterone deficiency in a 57-year-old male on chronic opioid use (OxyContin)? —Carlos Omar Viesca, MD

How Changing Hydrocodone Scheduling Will Affect Pain Management
Since the FDA changed hydrocodone combination products from a schedule III controlled substance to a schedule II, pain practitioners and their patients need to know their options.

Letters to the Editor May 2013
Readers write in about identifying trigger points in migraine patients, treating TMD as an orthopedic problem, and how you taper high-dose opioid patients.

How Do We Get Enough Physicians to Medically Manage The Difficult (High-dose Opioid) Pain Patient?
Managing high-dose opioid pain patients can be challenging for pain physicians. Our board members recommend a strong push for collaboration and education.

Ask the Expert May 2013
Our experts explore effective carbamazepine concentrations in trigeminal neuralgia patients and review opioid efficacy evidence in moderate-to-severe pain.

Ultra-high Dose Opioid Therapy: Uncommon and Declining, But Still Needed
The author explores the need for ultra-high dose opioid use in chronic pain patients, and outlines personal procedures to ensure safety and efficacy.

Ask the Expert: Monitoring Liver Function

Educating Patients About Pain Medications
It is the clinician’s job to properly introduce the patient to the medication by sharing the drug’s story with them.

Ask the Expert: Rectally Administered Morphine
Can Sustained-release Morphine Tablets Be Administered Rectally?

Interpretations and Actions Following Cytochrome P450 Testing
The Editor in Chief of Practical Pain Management gives practical guidelines for understanding CYP enzyme test results.

Is It Safe to Restart an NSAID Following an Endoscopically Confirmed NSAID-Induced GI Bleed?
Ask the Expert question and answer: Pharmacists answer a question about when it's safe to restart an NSAID after a confirmed GI bleed.

Improving a Practice Model for Prescribing Opioids
PPM sat down with Steven D. Passik, PhD, a leading pain and addiction expert, to discuss how clinicians can better equip their practices to properly identify pain patients best suited for opioid therapy.

A Modest Proposal (Thanks to Jonathan Swift—1667-1745)
YALE, 1981— I was walking down the hall with William Collins, MD, chairman and Cushing professor of neurosurgery, talking about the Pain Clinic. He told me about a case of a man in his mid-30s suffering from intermittently moderate to severe rectal spasms, which had failed to respond to multiple therapies for more than a decade.

Best Practices For High-dose Opioid Prescribing
Experts weigh in on best practices for prescribing opioids when there is concern about potential abuse.

Does Sulindac Affect Renal Function Less Than Other NSAIDs?
December 2012 Ask the Expert looks at conflicting evidence regarding clinically significant renal effects of sulindac.

New Ideas for Helping Difficult Pain Patients
Most pain practitioners have a few patients who use up their pain medication more quickly than expected. They often claim their medication is just not enough to cover their level of pain.

Methamphetamine Urine Toxicology: An In-depth Review
When a patient’s urine drug screen tests positive for methamphetamine by mass spectrometry, the result has serious implications for the patient and the provider. Determining the source of the methamphetamine is an important next step and is not always as straightforward as it appears.

Proper Disposal of Fentanyl Patches: What Patients Need to Know
Patients and providers should be aware of the abuse potential, the risk for respiratory depression and death, the possibility of drug interactions, the dangers of heat exposure, and the risks associated with accidental exposure to fentanyl patches.

Off-label Use of Pain Treatment No Longer Covered by Insurance
What should prescribing physicians do when insurers refuse to pay for patients' fentanyl products?

The Next Barriers to Care: Your Local Pharmacy
In their efforts to curb prescription drug abuse, the authorities have come perilously close to throwing the pain management baby out with the drug abuse bathwater.

PROP vs PROMPT: Who Speaks for the Pain Doctor?
The debate continues about whether opioids are safe and effective for long-term use in the treatment of chronic non-cancer pain. Exclusive report on PROP vs PROMPT from October 2012 in PPM.

Risk Evaluation and Mitigation Strategy Compliance
In an effort to curb the abuse and misuse of long-acting/extended-release opioid analgesics, the FDA created a voluntary risk evaluation and mitigation strategy (REMS), which requires prescriber education and patient counseling.

PROP’s Petition: PPM’s Editorial Board Weighs in
Members of Practical Pain Management's Editorial Board weigh in on the PROP petition.

Methadone Management in a Patient With Pain and History Of Addiction
In Ask the Expert, Dr. Jennifer Schneider argues that methadone is an excellent drug for treating chronic pain--but that it is not a long-acting analgesic.

Assessment of Long-term Outcomes Of Opioid Treatment: How to Set Goals and Objectives
Article provides 3 simple assessments pain practitioners can adopt or modify for use in their own long-term outcome evaluations.

PROP Answers Questions Raised About Opioid Label Changes
PPM asked Andrew Kolodny, MD, president of PROP, to answer questions that have been raised about requested opioid label changes.

Mathematical Model For Methadone Conversion Examined
A new model for methadone conversions aims to better mirror the continuity that prescribing physicians may expect to occur over a range of dosing conversions.

September 2012 Pain Research Updates
FDA Issues Warning Following Codeine Deaths in Children The Food and Drug Administration (FDA) has issued a safety warning following the deaths of three children, and one case of respiratory depression, after taking codeine following tonsillectomies and adenoidectomies performed to treat obstructive sleep apnea syndrome.1

Common Opioid-Drug Interactions: What Clinicians Need to Know
Educational review highlights potential drug-drug interactions for clinicians so they can develop strategies to avoid or ameliorate them.

Cash Patient: A Clinical Dilemma
Dr. Forest Tennant, Editor-in-Chief of PPM, discusses a clinical challenge: the patient who can't afford medications or other pain treatments. How do you approach this patient?

Discharging a Patient Suspected of Diversion
An addiction medicine specialist answers a reader's question about opioid diversion: how do you know if the patient is diverting? Ask the Expert from the August 2012 issue of Practical Pain Management.

Cytochrome P450 Testing In High-dose Opioid Patients
Article recommends genetic testing for cytochrome P450 deficiencies in patients who require high-dose opioid therapy.

Understanding the Sources of Morphine
Currently, morphine is used medicinally worldwide in acute and chronic pain management. Article details 4 commonly recognized sources of morphine.

Managing the Diabetic Patient with Dementia
A patient using neuropathic agents and opioids lives alone, and her doctor notes increasing dementia. What is your ethical responsibility for making sure she's safely taking her medications? A pain expert addresses this opioid-related question.

Managing Adverse Drug Effects in Pain: Focus on Muscle Relaxants
Part 2 of a two-part series on adverse drug effects in pain management examines muscle relaxants.

Junk The Term Narcotics—Call Them Opioids
PPM Editor in Chief Forest Tennant discusses the semantic debate surrounding the terms "narcotics" and "opioids."

Managing Adverse Drug Effects in Pain: Focus on Triptans and NSAIDs
Educational review from Practical Pain Management of managing adverse drug effects of triptans and NSAIDs. Written by pharmacists; full of useful management tips.

When Prescribed Opioids Go Unused
What's the proper way to dispose of prescription medications, especially opioids? Learn what you should be telling your patients.

Opioid Disposal: Dos and Don’ts
How should you recommend your patients dispose of opioids? Tips from pain experts.

Opioid-induced Constipation: Causes and Treatments
Opioid can cause opioid-induced constipation. This review is the first part of a series of articles that will focus on opioid-induced complications.Focuses on bowel dysfunction (OIBD), and more specifically opioid-induced constipation (OIC).

PPM Launches Online Opioid Calculator
Visit the PPM Opioid Calculator. PPM: What are the challenges facing physicians when prescribing [dosing] opioids, or switching from one opioid to another?

PPM Editorial Board Discusses Methadone Prescription Safety Measures
Practical Pain Management recently surveyed our Editorial Board members and asked them what safety measures they’d recommend when prescribing methadone. Read their answers here, and they may help you in your pain practice.

What Are Best Safety Practices For Use of Methadone In the Treatment Of Pain?
Practical Pain Management wanted to address the major safety concerns for prescribing physicians and patients regarding methadone use in pain management. To explore this topic, we spoke to Lynn R. Webster, MD, FACPM, FASAM, and Mary Lynn McPherson, PharmD.

Methadone for Pain Management
In-depth article on the use of methadone in chronic pain management.

Tapering a Patient Off Opioids
A pain expert answers the question: What is the best way to taper a chronic pain patient off opioids?

ECG Screening Prior to Initiating Methadone: Is it Really Necessary?
Editor's Memo from the March 2012 issue of Practical Pain Management. The issue focuses on the use of methadone in treating chronic pain, and the Memo focuses on if ECG screening should be done before initiating methadone.

Understanding the Toxicology of Diazepam
Because of its widespread use as an anxiolytic, muscle relaxant, preoperative sedative, and seizure medication, diazepam (Valium) is one of the most commonly encountered drugs on urine toxicology reports. Learn how to interpret these toxicology reports.

PPM Editorial Board Examines Steps to Prevent Accidental Overdoses
How do you prevent an accidental overdose of opioids in chronic pain patients? The Practical Pain Management Editorial Board provides useful opioid management tips.

Ask the Expert: Escalating Opioids
How do you manage a patient who self-escalates his or her opioid use? Two pain experts answer this opioid management question.

Is Your Patient Using Heroin?
Heroin Use

Hydrocodone, Carisoprodol, and Alprazolam—A Most Lethal Combination
Tips on prescribing opioids to chronic pain patients: a pain management specialist tells pain practitioners which three opioids to never prescribe in combination.

Excerpt from the Book Avoiding Opioid Abuse While Managing Pain
Prescription drugs are newsworthy, particularly when they are abused in violation of their intended medical purpose. Conservative radio commentator Rush Limbaugh grabbed many headlines when he admitted his own misuse of the painkilling opium derivatives known as opioids.

Tolerance to Opioids
Ask the Expert question on opioid tolerance in chronic pain patients: what should you know?

Renewing Opioid Prescriptions Over the Phone
What do you do when a patient can't make it to an appointment, but he or she needs an opioid prescription renewed? This Ask the Expert features answers from a lawyer and a pain management specialist.

Insights Into Patients’ Views About Topical Opioids: Observations From a Small Clinical Study
This article describes my definition of central pain, the method and results from my study, and the conclusions I have drawn from the results. Although I recognize that the study is small and relies on patients’ self-reports, I do believe that the results provide an interesting insight into the fundamental question of which treatments patients with central pain find helpful.

Drug Interactions Among HIV Patients Receiving Concurrent Antiretroviral and Pain Therapy
The advent of highly active antiretroviral therapy (HAART) represented a huge breakthrough in the treatment of HIV. However, antiretroviral therapy (ART) has been implicated in significant interactions with a variety of drug classes used to treat comorbid conditions in patients with HIV.

Risk for Sedation and Car Accidents
A pain physician is worried about the risk of overdose or sedation caused by opioids. In this Ask the Expert article, a pain management specialist responds to those opioid concerns.

The Essential FDA/PDR Indications and Warnings For Opioid Prescribing
The new indications in the PDR for opioids now carry the highest mandate for prescribing this class of drugs to patients. Learn more about the FDA and PDR indications and warnings for opioids.

Medications for Chronic Pain—Other Agents
Chronic pain is frequently treated with opioid and non-opioid analgesics. In addition, a variety of medications that were originally developed for indications other than analgesia are emerging as effective agents for the treatment of pain.

Medications for Chronic Pain—Opioid Analgesics
Various treatments are available for chronic pain, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, and other treatments such as anticonvulsants and antidepressants. This article will discuss opioid analgesics.

Medications for Chronic Pain—Nonopioid Analgesics
Nonopioid analgesics are preferred treatments in a multitude of practice guidelines; a brief overview of specific guidelines for low back pain, osteoarthritis, and migraine is presented here because these are the most common types of pain identified by adults.

New Report of a High-Dose Morphine Metabolite
Article discusses a previously unreported metabolite of high-dose morphine treatment—hydromorphone—for chronic pain patients.

Office-based Treatment of Opioid Physical Dependence
Article describes opioids for chronic pain management. Learn about office-based treatment for opioid dependence.

Oxycodone to Morphine Rotation
Article discusses oxycodone to morphine rotation. Provides one opioid rotational procedure found to be effective in chronic pain patients.

Focus on Urine Drug Monitoring
Chronic pain is a significant problem in the U.S. today. 35% of patients have chronic pain. Over 50 million Americans are partially or totally disabled by chronic pain. Over the age of 50, one out of two people suffer from chronic pain. Under-treatment of chronic pain runs as high as 50%.

Adjuvant Analgesia for Management of Chronic Pain
To date, clinical pain practice relies on opioids as the primary analgesics for the management of moderate to severe pain. Adjuvant analgesics use has become increasingly important especially in the management of mild to moderate pain.

Tumblin’ Dice–Why Does Random Matter?
Random urine drug testing—applied fairly and without prejudice—can mitigate the stigma associated with drug monitoring of patients taking controlled substances.

Urine Drug Testing and Monitoring in Pain Management
Scientifically sound urine drug testing of pain patients can be an effective means to augment pharmacotherapy and assist with complex medical/legal aspects of the current healthcare environment.

An Overview of Sleep Medications
Insomnia is a common co-morbidity of chronic pain. Article reviews treatments for sleep problems in patients with chronic pain.

‘High Dosage’ Opioid Management
The criteria for optimal opioid dosing for a specific patient must be clinically adequate pain control and functional improvement while avoiding cognitive impairment and respiratory depression.

‘Opiophobia’ Past and Present
The one drug class that has the optimum profile to manage severe, unremitting, intractable pain—opioids—is often shunned due to social stigma, lack of dosing guidelines, misunderstanding of side effects (addiction, respiratory depression), and a pervasive fear of unwarranted regulatory persecution.

Ziconotide for Chronic Severe Pain
Article discusses the emerging use of ziconotide for chronic severe pain, which shows potential of becoming a powerful non-opioid analgesic in the pain physician's armamentarium.

Urinary Drug Testing in Pain Management
Urinary drug testing as a means to assure compliance and monitoring of proper medication use is becoming common place in the clinical practice of pain management.

Iatraddiction: A Diagnostic Term In Lieu Of Pseudoaddiction
Iatraddiction more precisely describes the etiology of behaviors currently referred to as “pseudoaddiction.”

Therapeutic Drug Monitoring
To prevent drug diversion and get an accurate picture of drug usage, drug monitoring in a clinical pain management practice must test for patient compliance within specified therapeutic ranges.

Opioid Blood Levels in Chronic Pain Management
Determination of opioid levels in the blood is emerging as an important tool for ensuring the safety, effectiveness, and integrity of opioid analgesic therapy in the treatment of chronic pain.

Pain Drug Use Policy
State boards of medical examiners are responsible for adopting and enforcing a policy for the use of controlled substances for the treatment of pain within the limits of federal-controlled substance laws and regulations.

Targeted Peripheral Analgesics in Chronic Pain Syndromes
New compounding formulations and certain "off-label" uses of available analgesics—in topical and transdermal distribution—offer increased potency with fewer side effects to other body systems.

DEA Enforcement versus Pain Practice
As more opioids are prescribed, doctors need to be increasingly vigilant about documentation. Article outlines how aggressive DEA action against drug abuse and diversion ensnares some legitimate prescribers.

Treatment of Acute Pain in the Orthopedic Patient
Treatment of acute pain in the orthopedic patient is discussed in this article. A review of the mechanisms of acute pain and treatment strategies in orthopedic patients with special emphasis on pre-emptive analgesia is also discussed.

Opioid Therapy in Chronic Non-cancer Pain Management
Despite fears fueled by negative press, opioid therapy—with proper evaluation and safeguards—is a legitimate, viable, and essential tool in managing severe, intractable, non-cancer pain.

Antidepressants in Pain Treatment
Antidepressants have become a routine adjunctive therapy for most forms of chronic pain. Review your options to help you choose the best for your chronic pain patients.

Chronic Opioid Rules
Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances. Learn about opioid abuse and diversion.

Mastering Medications
This article discusses adjuvants and their application in managing pain.

Chronic Opioid Treatments
Selected chronic pain patients, treated with opioids in a structured program, can improve function and maintain employment.

Managing Pediatric Pain
Pharmacological techniques are quite useful for treating pain in children.

Identifying Pain-Drug Abusers and Addicts
Characterization and profiling of patients with deviant addictive behaviors helps weed out abusers from pain practices.

Breaking Down the Barriers of Pain: Part 5
Medication reviews of drugs used to treat musculoskeletal pain.

Relieving Pain with Pharmaceuticals
New pharmaceuticals are available to treat patients who have chronic pain caused by migraines and other pain conditions.

Pharmaceutical Therapies
Numerous medications can be used to treat chronic pain, and effective pain relief can be achieved through the newest medications on the market.

Opioid Rotation: Mechanisms, Concepts, and Benefits
For patients experiencing side effects from opioids, switching the delivery and type of pharmaceutical can often provide pain relief.

How Genetics Can Complicate Pain Treatment
History: A 37-year-old white male was referred for pain treatment by a physician in a local methadone clinic. The patient’s pain started 3 years earlier when he suffered an industrial injury while pulling a heavy, electric cable.

Antidepressants in the Treatment of Chronic Pain
There are 4 points upon which there is broad consensus in the field and that we should discuss immediately:

Are Opioids More Harmful Than NSAIDs for Elderly Patients?
A pair of investigations recently published in the Archives of Internal Medicine report that elderly patients with chronic noncancer pain taking opioid analgesics have higher risks of serious adverse events (AEs) than those taking NSAIDs; plus, the opioids varied among themselves in AE potential.1,2 These studies appear to contradict current guidelines and caution against

Genetic Screening for Defects in Opioid Metabolism: Historical Characteristics and Blood Levels
There continues to be great interest in the study of genetic defects of chronic pain patients who have difficulty metabolizing opioids. This is especially true as more and more pain patients are requiring high opioid dosages and/or an unusual regimen.1,2

Simultaneous Use of Stimulants  and Opioids
It’s a puzzling situation. History and science are pretty clear: the simultaneous use of stimulants and opioids have, for over a century, been reported to be a superior combination for pain relief. 1 So, based on history, why isn’t every patient who’s taking opioids also taking a stimulant?

Intranasal Naloxone for At-home Opioid Rescue
Naloxone is a well-tested antidote for reversing often-fatal respiratory depression due to opioid overdose poisoning. So, the prescription of naloxone for at-home intranasal administration, along with complete instructions for its emergency use, may be the best antidote for stemming rising rates of prescription-opioid overdoses and fatalities in the United States population.

Misuse of ‘Hyperalgesia’ to Limit Care
John (not his real name) is a 51-year-old chronic pain patient that I have been seeing since 2003. His pains began in 1981 with a motor vehicle accident. In1985 he broke an ankle and in 2000 he developed chronic inflammatory demyelinating poly-neuropathy. John had another motor vehicle accident in 2002, developed diabetes and, in 2008, added a diagnosis of Stage IV lung cancer.

Use of Opioids in Pain Patients with Psychiatric Disorders
Opioid medications are a reasonable treatment option for carefully selected patients who suffer from psychiatric endogenous opioid dysfunction syndrome and who have not responded to typical neuropsychiatric medications or other treatments.

Selecting an Antidepressant for Pain Patients
The potential loss of brain tissue should motivate all pain clinicians to look for undiagnosed mood disorders. Treating both pain and mood disorders aggressively will increase the likelihood of a better outcome. Not treating, or undertreating either, will most likely result in treatment failures for both conditions.

Cannabis as Medicine
This article explains the use of cannabis as a treatment for chronic pain. Article also discusses the concerns and benefits of cannabis in pain medicine.

Why Some Patients Require High Dose Opioid Therapy
Article explains chronic pain syndrome and discusses why some patients require high dose opioid therapy.

Urine Drug Testing as an Evaluation of Risk
Implementation of multiple risk assessment and monitoring strategies appears to lower the rate of inappropriate urine drug testing results in a clinical setting.

FDA’s Proposed Risk Evaluation and Mitigation Strategy (REMS) for Opioids
A brief overview and critique.

Doctors May Now Electronically Prescribe Schedule II Drugs
An in-depth look into the past, present and future of the electronic prescribing of controlled substances. Especially important for doctors prescribing opioids.

Electronic Prescription of Controlled Substances
A major milestone in healthcare IT history has been reached with DEA lifting restrictions on e-prescribing. Especially important for those who prescribe opioids.

Making Practical Sense of Cytochrome P450
Guidelines for the likely 20 to 30% of pain patients who have a genetic defect involving one of three major CYP450 enzymes and so cannot effectively metabolize certain opioids that must be converted to a metabolite to be effective.

Compliance Monitoring and Effective Risk Mitigation Strategy
Compliance monitoring using laboratory screening and confirmation, together with physician education, can support an effective risk mitigation strategy. Important article for pain physicians prescribing opioids.

Non-responsive Pain Patients with CYP-2D6 Defect
Pain patients who do not respond to the analgesic properties of opioids have a chance of being genetically incapable of generating the clinically active metabolite of these medications. Get tips on when to suspect a patient has CYP-2D6 deficiency.

Taking Advantage of the Peripheral Opioid Receptor
Opioids applied in a topical cream that directly target the peripheral opioid receptors (which grow in inflammatory pain sites to attract natural endorphin compounds for pain relief and immune enhancement) may have advantages relative to oral opioids.

FDA’s Risk Evaluation and Mitigation Strategies Program
Proceed with Extreme Caution

Opioid Treatment 10-year Longevity Survey Final Report
Patients in this long-term study were found to be functioning quite well after 10 or more years on generally stable opioid dosages, with the vast majority able to care for themselves and even drive. Read what chronic pain patients taking opioids say about themselves.

Pain Management in the Elderly
Structured methods help identify and assess pain in older adults while appropriate analgesic selection and dosing can reduce adverse drug reactions.

In My Opinion
Thoughts on tolerance, hyperalgesia, and short-acting opioids.

Medication-induced Xerostomia Secondary to Pain Management
Long-term pain management, with its usage of prescriptive medications, may have serious negative oral health side-effects including significant dental pathology, soft-tissue problems, and potential loss of dentition.

Opioid Treatment Longevity Study: Interim Report
Article highlights an interim report on the opioid treatment longevity study for chronic pain patients.

Opioid Antagonists in Pain Management
Available evidence suggests that the opioid antagonists naloxone and naltrexone offer potential benefits for enhancing opioid analgesia as well as monotherapy for managing certain challenging pain conditions.

Effective Monitoring of Opiates in Chronic Pain Patients
Laboratory testing for patients receiving prescription opioid pain relievers has been recommended by several organizations and governmental agencies to assure patient compliance, safe use to minimize risk, and assist in the identification of possible drug diversion or misuse of the drug.

Anomalous Opiate Detection in Compliance Monitoring
There are multiple variables outside of laboratory testing to consider when interpreting a patient's test results and deciding whether or not they are compliant with their medication.

Simultaneous Use of Opioid and Electromagnetic Treatments
Concurrent therapeutic electromagnetic applications complement opioid treatment and promote enhanced pain control in chronic pain patients.

Keeping Prescribers on Board if Certification Becomes Part of REMS
Consequences need to be acknowledged and serious thought given to the full impact that the FDA's proposed Risk Evaluation and Mitigation Strategies (REMS) plan might have.

Patients Who Require Ultra-high Opioid Doses
The goal of ultra-high opioid dosage therapy is to relieve pain and improve function in those chronic pain patients that are profoundly ill, impaired, and/or bed- or house-bound. However, ultra-high opioid dosage should not sedate them. Read which patients require ultra-high opioid dosage.

Identifying Abusers Prior to Initiating Chronic Opioid Therapy
Strategies for prescribing physicians to identify chronic pain patients at high risk for inappropriate utilization of prescription opioid analgesics.

Urine Drug Tests in a Private Chronic Pain Practice
Urine drug testing is one way to check for compliance in your patients on opioids. Article reviews study that looked at utility of urine drug testing.

Role of Sustained-release Opioids in Treating Chronic Pain
Article provides an overview of the role of SR opioids in treating chronic pain as well as how to maintain a chronic pain patient on opioids.

Commonsense Opioid-Risk Management in Chronic Non-cancer Pain
While opioids have been a mainstay in the treatment of acute pain, the role of opioids in treating chronic pain is less well defined and overshadowed by persistent concerns of misuse, abuse, and addiction. Fortunately, during the past 20 years, there have been major advances in clarifying these issues.

Opioids in Patients with Renal or Hepatic Dysfunction
The use of opioids in geriatric patients and those with hepatic or renal insufficiency can present significant challenges for clinicians.

Maximizing Safety with Methadone and Other Opioids
Risks associated with opioids can be safely and effectively managed while providing life-saving analgesia to chronic pain patients.

Long-term Therapy Using Short Acting Opioids for Chronic Non-cancer Pain
A cohort study explores the role of conditioning factors, dosage stability, opioid agreement violations, patient satisfaction, and the patient's own estimated improve-ment in overall quality of life.

Eye Screening and Intractable Pain Management
How to interpret and use eye signs to help prescribe opioids for intractable pain.

‘Head to Toe’ Nonprescription Drug History
A practical approach to assess nonprescription drug history in pain patients in the context of formulating a treatment strategy is discussed in this article.

Safe Analgesic Use in Patients With Renal Dysfunction
Article highlighted the general guidelines for appropriate use of analgesics and co-analgesic adjuvants in pain patients with co-existing renal insufficiency.

Longitudinal Study of Long-term Opioid Patients
A 10- and 20-year follow-up of severe, chronic pain patients treated with daily opioids indicates that some chronic pain patients greatly benefit from long-term opioid therapy.

Topical Use of Morphine
When used as an adjunct in severe chronic pain patients who take systemic opioids, topical morphine enhances pain relief, decreases pain flares, promotes stretching and walking, and reduces overall cost of treatment.

Multidisciplinary Pain Clinics vs Opioid Treatment for Chronic Pain
A pain management specialist responds to questions about using opioids in chronic pain treatment. Also discusses multidisciplinary pain clinics and their role in treatment.

Opioid-induced Sexual Dysfunction
Causes, diagnosis, and treatment of a common but an often undiagnosed problem in chronic opioid pain patients, opioid-induced sexual dysfunction.

Self-Protection Against “Off-label” Lawsuits
The current medico-legal climate is hampering the long-standing medical prerogative to prescribe a particular drug for a therapeutic effect deemed beneficial to the patient.

Viewpoint: Methadone Successes and Cautions
Article describes a pain professional's viewpoint on methadone successes and cautions.

Avoiding the Pitfalls of Opioid Reversal with Naloxone
With its wide margin of safety, low cost, and multiple routes of administration, naloxone is an ideal antidote for opioid toxicity but it should only be used to reverse respiratory depression while closely monitoring the patient.

Structuring Opioid Therapy
Structuring opioid therapy for chronic pain patients as well as how patient stratification for certain characteristics can minimize the risk of sleep apnea and respiratory depression are discussed.

Oxycodone to Oxymorphone Metabolism
Interpreting urine drug tests in pain patients treated with oxycodone requires an understanding that oxymorphone, although considered a minor metabolite, can sometimes equal or exceed urine concentrations of oxycodone.

A Clinical Guide to Weaning Off Intrathecal Opioids
This article discusses the guidelines for how to wean patients off intrathecal opioid therapy, including why patients should undergo a risk assessment before beginning the weaning process.

Critical Transition from Short-to-Long-Acting Opioid Therapy
While most pain patients are initially treated with short-acting opioids, severe unremitting pain involving biological manifestations requires transitioning to long-acting opioids. Pain management specialist discusses this opioid transition.

A Practical Guide for the Use of Opioids in Chronic Pain
Despite the availability of mono-graphs, papers, lectures, and web sites to teach about o

Viewpoint: The OxyContin
The Unwarranted Attacks on Doctors, Pharmaceutical Companies, and Opioids Must Stop

Pharmacotherapy: Pharmacologic Management of Opioid-Induced Adverse Effects
When lifestyle changes and non-pharmacological treatments fail, adjuvant drug therapies

Urine And Blood Tests
Why and when to use each test in pain treatment.

Viewpoint: Is It a Bad Time to Be in Pain?
Article gives viewpoint on the lawsuit that involved the pharmaceutical company that manufactures OxyContin.

Pharmacotherapy
Walking the Tightrope of Appropriate Pain Management

Urine Drug Screening in Everyday Practice
Routine urine testing is more readily accepted by patients when it is implemented as an integral part of a drug therapy program.

Viewpoint
Methadone Deaths and Warnings

Complex Interplay of Participants in Opioid Therapy
An historical and contemporary view of societal, medical, manufacturer, payer, and legal interactions affecting the prescription and use of opioids for pain management.

Pharmacotherapy
Using Methadone Effectively and Safely as Analgesic

Gastrointestinal Adverse Effects of Opioids
A review of the pathophysiology of opioid-related gastrointestinal effects together with treatment options.

Guidelines for Opioid Management of Pain
Guidelines for Opioid Management of Pain

Opioid Malabsorption: Can You Stomach This?
Practical Pain Management's editor takes on this question: what causes opioid malabsorption? And what can you do about it for your chronic pain patients?

Tennant Blood StudySummary Report
Opioid blood levels in high dose, chronic pain patients.

Tennant Blood Study  First Update
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.

Tennant Blood Study: Preliminary Report
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.

Distinguishing Intractable Pain Patients from Drug Addicts
A comparison of intractable pain patients’ characteristics to those found in drug addicts shows how to discern the difference-both to give the IP patient due care and minimize drug abuse and diversion.

Pharmaceuticals in the Pipeline - Anti-rheumatic Drugs
A review of the newest anti-rheumatic drugs available on the market.

Pain Treatments
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Opioids
Tapering
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stigma from those who don’t understand chronic pain

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