Pharmacologic management of chronic neuropathic pain: Review of the Canadian Pain Society consensus statement.

OBJECTIVE: To provide family physicians with a practical clinical summary of the Canadian Pain Society (CPS) revised consensus statement on the pharmacologic management of neuropathic pain. QUALITY OF EVIDENCE: A multidisciplinary interest group within the CPS conducted a systematic review of the literature on the current treatments of neuropathic pain in drafting the revised consensus statement. MAIN MESSAGE: Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are the first-line agents for treating neuropathic pain. Tramadol and other opioids are recommended as second-line agents, while cannabinoids are newly recommended as third-line agents. Other anticonvulsants, methadone, tapentadol, topical lidocaine, and botulinum toxin are recommended as fourth-line agents. CONCLUSION: Many pharmacologic analgesics exist for the treatment of neuropathic pain. Through evidence-based recommendations, the CPS revised consensus statement helps guide family physicians in the management of patients with neuropathic pain.

A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone.

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Landmark-Guided and Ultrasound-Guided Approaches for Trochanteric Bursa Injection: A Cadaveric Study.

BACKGROUND: Trochanteric bursa (TB) injection with local anesthetic and corticosteroid is a treatment for patients suffering from greater trochanteric pain syndrome. Both landmark (LM)-guided and ultrasound (US)-guided methods have been used, but their accuracies have not been determined. This study examined the accuracy of these injections with cadaveric dissection. METHODS: Twenty-four hip specimens were randomized to receive TB injections with methylene blue under either LM-guided or US-guided approach. After dissection, the locations of the dye were classified into 3 categories: intrabursal, extrabursal, or combined intrabursal and extrabursal. The presence of dye in the intrabursal space with or without extrabursal leak was considered a successful injection. Accuracy was defined as the percentage of successful injection. RESULTS: The accuracies of the LM-guided and US-guided injection were 0.67 (95% confidence interval 0.35-0.90) and 0.92 (95% confidence interval 0.62-1.00), respectively, with no significant difference. CONCLUSIONS: This is the first cadaveric study examining the accuracy of both the US-guided and LM-guided techniques for TB injection. Future clinical studies are required to compare the outcomes of LM-guided and US-guided greater trochanteric pain syndrome injection.

Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service.

AIM: To identify the 3-month incidence of chronic postsurgical pain and long-term opioid use in patients at the Toronto General Hospital. METHODS: 200 consecutive patients presenting for elective major surgery completed standardized questionnaires by telephone at 3 months after surgery. RESULTS: 51 patients reported a preoperative chronic pain condition, with 12 taking opioids preoperatively. 3 months after surgery 35% of patients reported having surgical site pain and 13.5% continued to use opioids for postsurgical pain relief. Postoperative opioid use was associated with interference with walking and work, and lower mood. CONCLUSION: Chronic postsurgical pain and ongoing opioid use are concerns that warrant the implementation of a Transitional Pain Service to modify the pain trajectories and enable effective opioid weaning following major surgery.