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All Pharmacological Articles

Clonidine may be beneficial for neuropathic pain, but further mechanisms of action are lacking research.
Stanford’s follow-up to a 2014 UPenn study shows no such correlation.
With an increasing demand for non-opioid alternatives, the suicide risk potential for gabapentinoids (gabapentin and pregabalin) is yet to be understood.
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.
A case presentation on the use of opioids in those with chronic kidney disease and diabetic peripheral neuropathy.
A review of the pipeline nerve growth factor (NGF) inhibitors tanezumab (Pfizer, Eli Lilly) and fasinumab (Regeneron, Teva).
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.
Better drug prevention and education programs are needed, urge researchers.
A primer on the terminology and current legality of medical marijuana.
How doctors can talk to patients about trying medical marijuana for pain and related symptoms.
How doctors can communicate with dispensaries when recommending or prescribing medical marijuana for patients.
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 study in monkeys suggest that using the two drugs together may reduce risk of dependency, without associated cognitive problems
Inside the potential of glial cell modulators for disease modification and pain management including OUD, opioid tolerance, and hyperalgesia.
Medtronic’s new risk-assessment platform may help to identify vulnerable patients before opioid therapy begins.
The majority of Medicare Part D patients diagnosed with OUD were not identified as overutilizers.
Direct-acting opioids may be a better options for depressed patients on SSRIs.
Results bring into question the high cost of the products and use over FDA-approved variations.
Tracking the prevention methods of prescription opioid misuse and overdose deaths by 2025.
Benzodiazepines are accounted for a growing number of overdose-related deaths
A compounded formula using codeine could lower patients’ overall opioid doses, according to one doctor's novel research.
Beyond the opioid crisis, new challenges—and hopes—await the pain practice community.
Insurance companies decline to continue paying for opioid medications, citing opioid-induced hyperalgesia (OIH). Why?
Inside the unique properties of Nektar Therapeutics’ new abuse-deterrent opioid, NKTR-181, and its potential for treating low back pain.
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 becomes the third state to allow medical marijuana treatment for opioid use disorder.
In a close vote, panel members remain divided. More news coming soon.
While opioid prescribing rates decreased over a nine-year period, certain factors led to differences in prescribing.
While use was associated with reduced pain and improved physical functioning, there was an increased incidence of vomiting.
An update has been made to the PPM Opioid Calculator to remove conversions to and from buprenorphine.
Buvidal is the latest opioid dependence and withdrawal medication currently in the pipeline.
What are the associations of opioid use disorder with outcomes of cardiovascular surgery?
Medication options for managing chronic pain and comorbidities: a patient with diabetic peripheral neuropathy, kidney disease, and an alcohol/substance use disorder.
Dr. Mary Lynn McPherson's second edition of her book, focusing on opioid conversion, offers healthcare providers strategies for calculating and prescribing opioid dosages.
Opioid use disorder (OUD) is on the rise among pregnant women: what clinicians can do to help monitor and treat pain in female patients.
Comparing intranasal fentanyl and intranasal ketamine for the treatment of limb pain in pediatric patients.
Pain practitioners should turn to VA resources when assessing and treating chronic pain in Veterans.
Clinical anecdotes to assist practitioners in medication selection for complex chronic pain problems in the elderly patient population.
Clinical vignettes provide insight into assessment and management of pain in the geriatric patient population.
Two promising treatments may reduce common pain crises related to SCD.
Common characteristics of opioid misusers among college students were found in a new study.
Wilson Compton, MD, NIDA (Source: NIDA) A Q&A with Wilson Compton, MD, MPE, Deputy Director, National Institute on Drug Abuse (NIDA)
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
Medicinal marijuana in pain management is a promising non-pharmacological therapy that clinicians should know more about.
Inside abuse-deterrent formulations – and their potential impact on the opioid epidemic.
Despite evidence of benefitting OUD, MAT treatments are not made available to the vast majority of patients.
Cyproheptadine may be useful in treating chronic pain conditions such as sleep disorders, sexual dysfunction, refractory headaches, and more.
Sunascen Therapeutics have developed a line of non-habit forming pain relievers that are developed with the patient in mind.
Tanezumab is the first investigational humanized monoclonal immunoglobulin G2 antibody, preventing the binding of NGF to its receptors to block the pain response pathway.
What do patients really think about opioid vs non-opioid medications for chronic pain?
Alternative therapies for MSK pain, osteoarthritis, post-herpetic neuralgia, and peripheral neuropathy.
The author presents effective strategies to tapering your patients off of opioid therapy.
Chronic pain remains the same or gets better after stopping opioid treatment, according to a new study.
Medications which are commonly prescribed to people with dementia have been linked to an increase in harmful side-effects.
Agency continues its efforts to broaden access to generic versions of opioids formulated to deter abuse.
FDA will complete its review of REMOXY ER in August 2018.
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.
This article provides a sneak preview into the upcoming July/August 2018 issue of Practical Pain Management.
The agency said it will continue to evaluate the use of market drugs and take regulatory action where needed.
With opioid misuse and abuse on the rise, other opioid receptors may be targeted for pain relief.
Knowing a patient has consumed their prescribed medication may prevent improper diversion of pills and overdose.
If approved by FDA, IV tramadol would be the first Schedule IV intravenous opioid in the US.
AcelRx is planning on resubmitting an NDA for DSUVIA to FDA in Q2 2018.
Elevated use of gabapentinoid misuse and abuse may be a problem with monitoring opioids.
Small doses could help children suffering from various types of inflammation and pain.
For the rare complex regional pain syndrome, help may be on the way in the form of this cannabidiol.
With appropriate treatment and follow-up, individuals can reach sustained long-term remission from OUD.
Nonopioid Management Just as Impactful as Opioids for Knee/OA Pain
New lead into understanding the pathophysiology of opioid physical dependence
Chronic neuropathy treatment does not offer much pain relief for patients.
Further studies of the long-term use of cyclobenzaprine for chronic pain management are needed to confirm its efficacy.
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.
Opioid antagonists, such as naltrexone and naloxone, may help reduce side effects and address drug deficiencies in chronic pain treatment.
FDA approval of biosimilars in comparison to biologics for the treatment of chronic pain raises issues of efficacy.
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.
The best approaches to manage pain relief to most effectively address post-surgical pain.
Ask the Expert: A discussion of the pain relief potential from Na1.7 Inhibitors for neuropathic pain disorders.
Readers raise questions about the one-sided view of the so-called opioid-epidemic, hormone therapy, and long-term opioid care.
Expert give you advice on how to switch from Opanan ER to another long-acting opioid.
An argument in support of providing patients with an opioid prescription for dosages over 90 MME daily to manage severe chronic pain.
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.
Assessment of abuse-deterrent opioid medications designed to lessen access to active ingredients while maintaining analgesic effects for chronic pain patients with appropriate need.
This month's Editor's Memo focuses on how Medicare and Medicaid are planning on adopting CDC Guidelines for Safe Opioid Prescribing.
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.
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.
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.
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.
Recommendations concerning liver function tests for Duloxetine, prescribed for neuropathic pain.
In this Guest Editor's Memo, Seddon R. Savage, MD, MS, discusses issues of treating opioid use disorder in patients with chronic pain.
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.
Challenging insurance policies that hinder management of opioid use disorders.
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
Readers are better informed about use of the PPM Opioid Calculator and the benefits of metformin.
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.
Ask the Expert authors examine the role for low-dose ketamine for treatment of CRPS.
Dr. Forest Tennant, MD, explores the impact that the CDC opioid-prescribing guidelines have had on chronic pain patients.
Pain expert offers clinical guidance to a commonly asked question about the proper, safe, and effective dose of gabapentin when treating neuropathic pain.
2016 review of current and emerging therapies for opioid-induced constipation, a common side effect of chronic opioid therapy.
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.
Forest Tennant, MD, DrPH, picks for 2016 Practical Clinical Advances in pain management—oral ketamine and metformin.
Forest Tennant, MD, DrPH, advice for those thinking of co-prescribing benzos and opioids—leave it to the pain experts.
Call the forgotten opioid, physicians are rediscovering levorphanol as a safe and effective pain medication.
Dr. John Claude Krusz describes his protocol for the use of subanesthetic dosages of IV agents—ketamine, lidocaine, propofol—in an outpatient headache clinic.
Learn how emergency room physicians, dentists, rheumatologists, and orthopedic surgeons are dealing with new regulations and guidelines for pain management.
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.
EpiPen’s astronomical price increase from $100 in 2007 to $600 today has caused quite a furor among parents and advocacy groups.
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
Canadian researchers discuss 6 common concerns of patients and physicians regarding cannabis use for pain management.
Barth Wilsey, MD, shares his unique perspective and knowledge on the benefits and risks of therapeutic cannabis (medical marijuana).
10 Medication Myths. Learn more about what is and is not true about medical management of chronic pain.
Learn more about the correct dosing of different strains of medicinal cannabis used in Canada for the treatment of various pain conditions.
Genetic testing for metabolic abnormalities are critical tools for identifying patients who may require high-dose opioids.
Dr. Jennifer Schneider describes her experience with prescribing extended-release OxyContin to chronic pain patients.
A closer look at the debate between the Los Angeles Time reporters and Purdue Pharma regarding OxyContin's 12-hour dosing schedule.
Skeletal muscle relaxants are commonly prescribed for the management of spasticity and spasm. Learn more about these agents used in pain management.
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.
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.
Guide to topical therapy for acute and chronic sports-related pain, including tendinopathies, bursitis, strains, and sprains.
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 is common in the United States, is often associated with other substance use disorders, behavioral problems, and disability.
Learn more about how the new APS guidelines on postoperative pain management effects chronic pain patients already on opioids.
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.
In some cases, tumor necrosis factor inhibitors (TNFi) may be the first-choice agent for patients with psoriatic arthritis. Learn why.
Practical Pain Managements experts answer the question: Is tapentadol a glorified tramadol?
Our experts answer the question about which antidepressant is the least likely to cause cardiac problems, including QT prolongation.
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.
Question: Should I discharge a patient on Percocet (oxycodone/acetaminophen) for chronic back pain with unexpected oxymorphone detected in her urine drug screen?
What do you do when a patient can not absorb oral pain medications? Read Dr. Forest Tennant's Editor's Memo to find out.
Learn more about the myriad of agents that can be used to reduce the symptoms of opioid withdrawal.
Are corticosteroids safe and effective therapy for complex regional pain syndrome? Read what our experts have to say.
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.
Practical Pain Management answer your Letters to the Editor. This month features questions about prednisone dosing and microglia modulators.
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.
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.
Q: Please explain the medical marijuana law in Connecticut and the role of pharmacists in dispensing medical marijuana products.
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.
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?
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.
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.
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.
Drug safety is always a concern. Our experts answer your questions about NSAID-related sensitivity.
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).
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.
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.
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
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.
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.
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.
Dr. Lynn Webster sits down with PPM to discuss abuse-deterrent formulations for reducing abuse of opioids.
Guidelines for opioid prescribing suggest starting low, and going slow--usually with a short-acting opioids and then transitioning to long-acting opioid.
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.
Many people with migraines have lower than normal levels of magnesium. Treatment with magnesium supplements may help manage acute migrain attacks.
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.
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.
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.
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.
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.
Pharmacogenetic testing may be used to direct patient care by individualizing medications regimens and dosages
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.
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 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.
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.
Q: Can NSAIDs be used to treat chronic pain in a patient who has had bariatric surgery?
Almost half of all diaylsis patients suffer from chronic pain. However, there are virtually no recommendations for pain management in the dialysis setting.
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.
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.
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.
A patient requested refills for 2 benzodiazepine agents at the same time (alprazolam and clonazepam).  Is this ever appropriate?  
  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.
“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
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.
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.
Question: Does adding naloxone to buprenorphine offer any benefit over using buprenorphine alone for the treatment of chronic pain?
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-
Question: What is better for treating rebound headaches—long-acting or short-acting NSAIDs?
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
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.
Question: Is there a benefit to using long-acting versus short-acting opioids for chronic pain?
Drug testing commonly is used in clinical, criminal, and workplace settings.
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. 
Question: Can misoprostol be used for refractory chronic constipation?
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.
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?
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.
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.
Question: Are antibiotics a treatment option for low back pain?
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
Question: I have recently read a lot on Twitter that NSAIDs cause more deaths than opioids. Can you clarify if that is true?  
PPM Editorial Board answers letters from readers. Can nitrous oxide potentiate pain management or eliminate pain altogether?
Question: Should you test for and treat opioid-induced hypogonadism?
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.
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.
FDA rules on extended-release and long-acting opioids. Read PROP and PROMPT responses, as well as PPM Editorial Board comments.
The US Food and Drug Administration (FDA) announced labeling changes for all extended-release and long-acting (ER/LA) opioids.
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"?
Navigating the Dos and Don'ts of common analgesics in pain patients with chronic liver disease.
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.
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
Pain and depression are often linked. Antidepressants are often effective at treating both disorders.
Insomnia is a profound problem in patients with severe, intractable pain that is poorly controlled.
QUESTION: Which NSAIDs Are Most Selective For COX-1 and COX-2?
This article will review the substantial differences among the available opioid conversion calculators.
The obese patient poses specific clinical challenges for pain specialists, and often presents with related risk factors that directly contribute to chronic pain
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.
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?
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.
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.
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
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.
Readers write in about identifying trigger points in migraine patients, treating TMD as an orthopedic problem, and how you taper high-dose opioid patients.
Managing high-dose opioid pain patients can be challenging for pain physicians. Our board members recommend a strong push for collaboration and education.
Our experts explore effective carbamazepine concentrations in trigeminal neuralgia patients and review opioid efficacy evidence in moderate-to-severe pain.
The author explores the need for ultra-high dose opioid use in chronic pain patients, and outlines personal procedures to ensure safety and efficacy.
It is the clinician’s job to properly introduce the patient to the medication by sharing the drug’s story with them.
Can Sustained-release Morphine Tablets Be Administered Rectally?
The Editor in Chief of Practical Pain Management gives practical guidelines for understanding CYP enzyme test results.
Ask the Expert question and answer: Pharmacists answer a question about when it's safe to restart an NSAID after a confirmed GI bleed.
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.
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.
Experts weigh in on best practices for prescribing opioids when there is concern about potential abuse.
December 2012 Ask the Expert looks at conflicting evidence regarding clinically significant renal effects of sulindac.
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.
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.
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.
What should prescribing physicians do when insurers refuse to pay for patients' fentanyl products?
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.
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.
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.
Members of Practical Pain Management's Editorial Board weigh in on the PROP petition.
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.
Article provides 3 simple assessments pain practitioners can adopt or modify for use in their own long-term outcome evaluations.
PPM asked Andrew Kolodny, MD, president of PROP, to answer questions that have been raised about requested opioid label changes.
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.
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
Educational review highlights potential drug-drug interactions for clinicians so they can develop strategies to avoid or ameliorate them.
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?
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.
Article recommends genetic testing for cytochrome P450 deficiencies in patients who require high-dose opioid therapy.
Currently, morphine is used medicinally worldwide in acute and chronic pain management. Article details 4 commonly recognized sources of morphine.
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.
Part 2 of a two-part series on adverse drug effects in pain management examines muscle relaxants.
PPM Editor in Chief Forest Tennant discusses the semantic debate surrounding the terms "narcotics" and "opioids."
Educational review from Practical Pain Management of managing adverse drug effects of triptans and NSAIDs. Written by pharmacists; full of useful management tips.
What's the proper way to dispose of prescription medications, especially opioids? Learn what you should be telling your patients.
How should you recommend your patients dispose of opioids? Tips from pain experts.
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).
Visit the PPM Opioid Calculator.   PPM: What are the challenges facing physicians when prescribing [dosing] opioids, or switching from one opioid to another?
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.
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.
In-depth article on the use of methadone in chronic pain management.
A pain expert answers the question: What is the best way to taper a chronic pain patient off opioids?
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.
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.
How do you prevent an accidental overdose of opioids in chronic pain patients? The Practical Pain Management Editorial Board provides useful opioid management tips.
How do you manage a patient who self-escalates his or her opioid use? Two pain experts answer this opioid management question.
Tips on prescribing opioids to chronic pain patients: a pain management specialist tells pain practitioners which three opioids to never prescribe in combination.
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.
Ask the Expert question on opioid tolerance in chronic pain patients: what should you know?
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.
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.
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.
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 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.
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.
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.
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.
Article discusses a previously unreported metabolite of high-dose morphine treatment—hydromorphone—for chronic pain patients.
Article describes opioids for chronic pain management. Learn about office-based treatment for opioid dependence.
Article discusses oxycodone to morphine rotation. Provides one opioid rotational procedure found to be effective in chronic pain patients.
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%.
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.
Random urine drug testing—applied fairly and without prejudice—can mitigate the stigma associated with drug monitoring of patients taking controlled substances.
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.
Insomnia is a common co-morbidity of chronic pain. Article reviews treatments for sleep problems in patients with chronic pain.
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.
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.
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 as a means to assure compliance and monitoring of proper medication use is becoming common place in the clinical practice of pain management.
Iatraddiction more precisely describes the etiology of behaviors currently referred to as “pseudoaddiction.”
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.
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.
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.
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.
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 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.
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 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.
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.
This article discusses adjuvants and their application in managing pain.
Selected chronic pain patients, treated with opioids in a structured program, can improve function and maintain employment.
Pharmacological techniques are quite useful for treating pain in children.
Characterization and profiling of patients with deviant addictive behaviors helps weed out abusers from pain practices.
Medication reviews of drugs used to treat musculoskeletal pain.
New pharmaceuticals are available to treat patients who have chronic pain caused by migraines and other pain conditions.
Numerous medications can be used to treat chronic pain, and effective pain relief can be achieved through the newest medications on the market.
For patients experiencing side effects from opioids, switching the delivery and type of pharmaceutical can often provide pain relief.
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.
There are 4 points upon which there is broad consensus in the field and that we should discuss immediately:
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
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
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?
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.
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.
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.
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.
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.
Article explains chronic pain syndrome and discusses why some patients require high dose opioid therapy.
An in-depth look into the past, present and future of the electronic prescribing of controlled substances. Especially important for doctors prescribing opioids.
Implementation of multiple risk assessment and monitoring strategies appears to lower the rate of inappropriate urine drug testing results in a clinical setting.
A major milestone in healthcare IT history has been reached with DEA lifting restrictions on e-prescribing. Especially important for those who prescribe opioids.
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 using laboratory screening and confirmation, together with physician education, can support an effective risk mitigation strategy. Important article for pain physicians prescribing opioids.
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.
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.
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.
Structured methods help identify and assess pain in older adults while appropriate analgesic selection and dosing can reduce adverse drug reactions.
Thoughts on tolerance, hyperalgesia, and short-acting opioids.
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.
Article highlights an interim report on the opioid treatment longevity study for chronic pain patients.
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.
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.
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.
Concurrent therapeutic electromagnetic applications complement opioid treatment and promote enhanced pain control in chronic pain patients.
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.
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.
Strategies for prescribing physicians to identify chronic pain patients at high risk for inappropriate utilization of prescription opioid analgesics.
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.
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.
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.
The use of opioids in geriatric patients and those with hepatic or renal insufficiency can present significant challenges for clinicians.
Risks associated with opioids can be safely and effectively managed while providing life-saving analgesia to chronic pain patients.
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.
How to interpret and use eye signs to help prescribe opioids for intractable pain.
A practical approach to assess nonprescription drug history in pain patients in the context of formulating a treatment strategy is discussed in this article.
Article highlighted the general guidelines for appropriate use of analgesics and co-analgesic adjuvants in pain patients with co-existing renal insufficiency.
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.
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.
A pain management specialist responds to questions about using opioids in chronic pain treatment. Also discusses multidisciplinary pain clinics and their role in treatment.
Causes, diagnosis, and treatment of a common but an often undiagnosed problem in chronic opioid pain patients, opioid-induced sexual dysfunction.
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.
Article describes a pain professional's viewpoint on methadone successes and cautions.
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 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.
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.
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.
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.
Despite the availability of mono-graphs, papers, lectures, and web sites to teach about o
The Unwarranted Attacks on Doctors, Pharmaceutical Companies, and Opioids Must Stop
When lifestyle changes and non-pharmacological treatments fail, adjuvant drug therapies
Why and when to use each test in pain treatment.
Article gives viewpoint on the lawsuit that involved the pharmaceutical company that manufactures OxyContin.
Walking the Tightrope of Appropriate Pain Management
Methadone Deaths and Warnings
Routine urine testing is more readily accepted by patients when it is implemented as an integral part of a drug therapy program.
An historical and contemporary view of societal, medical, manufacturer, payer, and legal interactions affecting the prescription and use of opioids for pain management.
Using Methadone Effectively and Safely as Analgesic
A review of the pathophysiology of opioid-related gastrointestinal effects together with treatment options.
Guidelines for Opioid Management of Pain
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?
Opioid blood levels in high dose, chronic pain patients.
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.
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.
A review of the newest anti-rheumatic drugs available on the market.
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