Category: Pain Management

Categories : Pain ManagementTags :

Vitamin D is no Help for Statin Muscle Pains, Study Finds

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Vitamin D pills
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Some clinicians have recommended vitamin D supplements to ease the muscle aches of patients taking a statin, but a new study published in the journal JAMA Cardiology shows the vitamin appears to have no substantial impact.

While non-randomised studies have reported vitamin D to be an effective treatment for statin-associated muscle symptoms, the new study, which is the first randomised clinical trial to look at the effect of vitamin D on statin-associated muscle symptoms, was large enough to rule out any important benefits.

In the randomised, double-blind trial, 2083 participants took either 2000 units of vitamin D supplements daily or a placebo. The study found participants in both categories were equally likely to develop muscle symptoms and discontinue statin therapy.

Over 4.8 years of follow-up, statin-related muscle pain was reported by 31% of the participants assigned vitamin D and 31% assigned a placebo.

“We had high hopes that vitamin D would be effective because in our clinic and across the country, statin-associated muscle symptoms were a major reason why so many patients stopped taking their statin medication,” said senior author Dr Neil Stone, professor at Northwestern University. “So, it was very disappointing that vitamin D failed a rigorous test. Nevertheless, it’s important to avoid using ineffective treatments and instead focus on research that can provide an answer.”

Statins and vitamin D supplements are two of the most commonly used medications in American adults. About 30 to 35 million Americans are prescribed statins, and about half of the population aged 60 and older take a vitamin D supplement.

“We took advantage of a large placebo-controlled randomised trial to test whether vitamin D would reduce statin-associated muscle symptoms and help patients keep taking their statins,” said lead study author Dr Mark Hlatky, a professor of health policy and cardiovascular medicine at Stanford. “The placebo control in the study was important because if people think vitamin D is supposed to reduce their muscle pains, they just might feel better while taking it, even if vitamin D has no specific effect.”

Trial was a sub study within a larger clinical trial

The 2083 patients were among the larger cohort of participants in the VITamin D and Omega-3 Trial (VITAL), which randomised nearly 26 000 participants to double-blind vitamin D supplementation to determine whether it would prevent cardiovascular disease and cancer. This provided researchers a unique opportunity to test whether vitamin D reduces muscle symptoms among participants who initiated statins during the follow-up period of the larger VITAL trial. The mean age of the study participants was 67, and 51% were women.

“Randomised clinical trials are important because many very good ideas don’t work as well as we had hoped when they are put to the test,” Hlatky said. “Statistical associations do not prove a cause-and-effect relationship. Low levels of vitamin D are associated with many medical problems, but it turns out that giving people vitamin D does not generally fix those problems.”

For patients who report statin-associated muscle pains

Dr Stone noted that sometimes the secret for understanding patients who have difficulty with statins is analysing other medications they’re taking, determining whether or not they have associated metabolic or inflammatory conditions, counselling them on their ability to hydrate adequately and, importantly, discussing “pill anxiety.”

“For those who have difficulties with statins, a systematic appraisal by a physician with experience in dealing with these matters is still very important,” Stone said.

Source: Northwestern University

Categories : Pain ManagementTags :

US CDC Pivots to a Less Rigid Approach to Opioid Prescription

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The US Centers for Disease Control have released new opioid prescribing guidelines that do not promote strict thresholds for dose and duration of pain medications. The new guidelines, which update and replace the controversial 2016 guidelines, are published in Morbidity and Mortality Weekly Report.

The previous guidelines had been interpreted as imposing strict opioid dose and duration limits and was misapplied by some organisations, leading to a clarification being released in 2019. Other organisations, such as the European Pain Federation, had stated that overly strict guidelines for their own countries were hampering effective pain management.

The 2022 recommendations are voluntary and give clinicians and patients flexibility to support individual care, said Christopher Jones, PharmD, DrPH, MPH, acting director of CDC’s National Center for Injury Prevention and Control in a press briefing. He stressed that they should not be used as a inflexible rule, or applied as a rigid standard of care, or replace clinical judgement on personalised treatment.

“Patients with pain should receive compassionate, safe, and effective pain care,” Jones stated. “We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life.”

The guidance covers four key areas: opioids initiation for pain, opioid and dosage selection, deciding prescription duration and conducting follow-up, and assessing risk and potential harms of opioids. It also suggests that clinicians work with patients to incorporate plans to mitigate risks, including offering naloxone.

The document indicates opioids should not be considered as first-line or routine therapy for subacute or chronic pain, and points out that, for many kinds of acute pain, non-opioid therapies are often better choices.

“For patients receiving opioids for 1 to 3 months (the timeframe for subacute pain), the 2022 guideline recommends that clinicians avoid continuing opioid treatment without carefully reassessing treatment goals, benefits, and risks in order to prevent unintentional initiation of long-term opioid therapy,” noted Deborah Dowell, MD, MPH and colleagues in a commentary published in the New England Journal of Medicine.

For chronic pain, clinicians should make maximal use of non-opioid therapies and consider initiating opioid therapy only if pain reduction benefits outweigh the risk, Dowell and colleagues noted. When needed, clinicians should initiate opioids at the minimum effective dose, assess risks and benefits before increasing dosage, and avoid raising dosage above levels likely to yield diminishing returns, they added.

The new guideline offers tips for tapering opioids when warranted, but is not intended to lead to rapid opioid tapering or discontinuation, Jones noted. The recommendations do not apply to sickle cell disease-related pain, cancer pain, and palliative or end-of-life care.

The 2022 document incorporated public feedback since the new version was first proposed in February, including patients discussing their experiences with pain or opioid addiction and barriers to pain care.

“The science on pain care has advanced over the past 6 years. During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians,” said Dowell in a statement. “We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care.”

Source: MedPage Today

Categories : Metabolic Disorders Pain ManagementTags :

High-fat Diet can Cause Pain Sensitivity without Obesity or Diabetes

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Woman holding her wrist in pain

A new study using a mouse model suggests that a short-term exposure to a high-fat diet may be linked to pain sensations, such as from a light touch, even without a prior injury or a pre-existing condition like obesity or diabetes. This finding may help in part explain the severity of the opioid crisis.

The study, published in Scientific Reports, compared the effects of eight weeks of different diets on two cohorts of mice. One group received normal chow, while the other was fed a high-fat diet in a way that did not precipitate the development of obesity or high blood sugar, both of which are conditions that can result in diabetic neuropathy and other types of pain.

The researchers found that the high-fat diet induced hyperalgesic priming – a neurological change that represents the transition from acute to chronic pain – and allodynia, which is pain resulting from stimuli that do not normally provoke pain.

“This study indicates you don’t need obesity to trigger pain; you don’t need diabetes; you don’t need a pathology or injury at all,” said Dr Michael Burton, assistant professor of neuroscience and corresponding author of the article. “Eating a high-fat diet for a short period of time is enough – a diet similar to what almost all of us in the US eat at some point.”

The study also compared obese, diabetic mice with those that just experienced dietary changes.

“It became clear, surprisingly, that you don’t need an underlying pathology or obesity. You just needed the diet,” Burton said. “This is the first study to demonstrate the influential role of a short exposure to a high-fat diet to allodynia or chronic pain.”

Diet itself caused markers of neuronal injury.

Western diets are rich in fats – in particular saturated fats, which have proved to be responsible for an epidemic of obesity, diabetes and associated conditions. Individuals who consume high amounts of saturated fats – like butter, cheese and red meat – have high amounts of free fatty acids circulating in their bloodstream that in turn induce systemic inflammation.

Recently, scientists have shown that these high-fat diets also increase existing mechanical pain sensitivity in the absence of obesity, and that they can also aggravate pre-existing conditions or imped injury recovery. To date, no studies have explained how high-fat diets alone can be a sensitising factor in inducing pain from nonpainful stimuli, such as a light touch on the skin, Burton said.

“We’ve seen in the past that, in models of diabetes or obesity, only a subsection of the people or animals experience allodynia, and if they do, it varies across a spectrum, and it isn’t clear why,” Burton said. “We hypothesized that there had to be other precipitating factors.”

The researchers examined blood levels of fatty acids in the mice. They found that a fatty acid called palmitic acid, the most common saturated fatty acid in animals, binds to a particular receptor on nerve cells, a process that results in inflammation and mimics injury to the neurons.

“The metabolites from the diet are causing inflammation before we see pathology develop,” Burton said. “Diet itself caused markers of neuronal injury.

The mechanism behind this transition is important because it is the presence of chronic pain – from whatever source – that is fuelling the opioid epidemic

“Now that we see that it’s the sensory neurons that are affected, how is it happening? We discovered that if you take away the receptor that the palmitic acid binds to, you don’t see that sensitising effect on those neurons. That suggests there’s a way to block it pharmacologically.”

Burton said the next step will be to focus on the neurons themselves – how they are activated and how injuries to them can be reversed. It is part of a larger effort to understand better the transition from acute to chronic pain.

“The mechanism behind this transition is important because it is the presence of chronic pain – from whatever source – that is fuelling the opioid epidemic,” he said. “If we figure out a way to prevent that transition from acute to chronic, it could do a lot of good.”

Burton said he hopes his research encourages health care professionals to consider the role diet plays in influencing pain.

“The biggest reason we do research like this is because we want to understand our physiology completely,” he said. “Now, when a patient goes to a clinician, they treat a symptom, based off of an underlying disease or condition. Maybe we need to pay more attention to how the patient got there: Does the patient have diabetes-induced or obesity-induced inflammation; has a terrible diet sensitised them to pain more than they realized? That would be a paradigm shift.”

Source: University of Texas at Dallas

Categories : Pain ManagementTags :

An Effective Short-term Therapy for Knee Osteoarthritis

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Knee pain
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With few solutions available, treatment of knee osteoarthritis is challenging, but a randomised control trial published in Arthritis and Rheumatology has found that, at least for short-term relief, ultrasound-guided genicular nerve block (GNB) was effective.

The global prevalence of knee osteoarthritis (OA) is ~22.9% of over-40s. Knee OA is a significant cause disability and potentially loss of independence. Treatment remains challenging, with nonsurgical management options such as education, weight loss, exercise therapy, and walking aids. Few recommended pharmacotherapeutic options exist for knee OA, with surgical joint replacement being a definitive treatment strategy for patients with severe disease who are unresponsive to conservative care. For many patients, such as people who are frail or elderly or people with complex comorbidities, surgical intervention may not be suitable.

In a 12-week parallel-group, placebo-controlled randomised trial of GNB, patients in the active arm received 3 injections of 5.7 mg celestone chronodose (1ml) and 0.5% bupivacaine (3ml) to the inferomedial, superomedial, and superolateral genicular nerves. Patients in the placebo arm received saline injections. An experienced radiologist or rheumatologist with the assistance of a senior sonographer used ultrasound to locate the nerves.

At baseline and at weeks 2, 4, 8, and 12, patients recorded their pain and disability on self-report scales. Patients in the active group reported improvements in pain scores at 2, 4, 8, and 12 weeks with a diminution of the effect over time. 

These results reflect comparator groups, which also reported an effect reduction at 12 weeks.

“This study demonstrates that genicular nerve block is an effective short-term therapy for pain management in people with knee osteoarthritis,” said corresponding author Ernst M. Shanahan, BMBS, MPH, MHPE, PhD, FAFOEM, FRACP, of Flinders University. “We think it may be a useful treatment option for this group of people, in particular those waiting for, or wishing to defer surgery.”

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Shedding Light on Propofol’s Poorly Understood Anaesthetic Mechanism

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In a new study published in Molecular Biology of the Cell, a team of Rensselaer Polytechnic Institute researchers identified a previously unknown propofol anaesthetic mechanism, which, despite its frequent clinical application, is poorly understood. The study found that propofol exposure impacted the transportation of proteins to the surface of neurons, interrupting their function.

Almost all animal cells, including human cells, are highly compartmentalised and rely on efficient movement of protein material between compartments in vesicles. This transport must be efficient and highly specific to maintain cellular organisation and function.

The research team was led by Dr Marvin Bentley, associate professor at Rensselaer Polytechnic Institute, whose laboratory studies vesicle transport in neurons. Neurons are particularly reliant on vesicle transport because axons, often organised in nerve bundles. can span distances of up to 100cm in humans. Errors in vesicle transport have been linked to neurodevelopmental and neurodegenerative diseases such as Alzheimer’s and Parkinson’s.

This new study found that propofol affects a family of proteins called kinesins – small ‘motor proteins’ that move vesicles on tiny filaments called microtubules.

Dr Bentley’s team observed that vesicle movement of two prominent kinesins, Kinesin-1 and Kinesin-3, was substantially reduced in cells exposed to propofol. The team then showed that propofol-induced transport delays led to a significant drop in protein delivery to axons.

“The mechanism by which propofol works is not fully understood,” Bentley said. “What we discovered was unexpected: propofol altered the trafficking of vesicles in live neurons.”

Overall, the research contributes significantly to our understanding of how propofol works. Most studies on propofol’s anaesthetic mechanism have instead focused on its interaction with an ion channel called the GABAA receptor, which inhibits neurotransmission when activated.

This new study demonstrates that vesicle transport is an additional mechanism that may be important for propofol’s anaesthetic effect. Discovery of this new propofol effect has important applications for human health and may lead to the development of better anaesthetic drugs.

Source: Rensselaer Polytechnic Institute

Categories : Pain Management Substance UseTags :

Many Medical Cannabis Users also Use Nicotine

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Users of medical cannabis are more likely to also use nicotine products than the general population, according to a Rutgers University study published in the American Journal on Addictions.

“Simultaneous use of cannabis and nicotine is a growing concern, but while the relationship between recreational cannabis and nicotine use is well-established, little is known about nicotine use among users of medical cannabis,” said Mary Bridgeman, a clinical professor at Rutgers Ernest Mario School of Pharmacy.

The researchers surveyed 697 patients aged 18–89 at a medical marijuana dispensary on their nicotine and cannabis use, how they self-administered the cannabis (smoked, vaped) and the medical conditions that qualified them for using therapeutic cannabis.

Nearly 40% of medical marijuana users reported using nicotine – sharply higher than the 14% of US adults who smoke.

Therapeutic cannabis users who also used electronic cigarettes or didn’t use nicotine at all were about four times more likely to vape, rather than smoke, cannabis than those who exclusively smoked cigarettes.

The study also found 75% of the respondents smoked cannabis rather than vaped and about 80% of the cigarette smokers reported planning to quit in the next six months.

“These findings reveal that while medical cannabis dispensaries may recommend vaping rather than smoking cannabis due to the health concerns associated with combustible products, this recommendation alone may not influence patients who also smoke cigarettes,” said Professor Marc Steinberg, co-author of the study.

“Between the higher rates of nicotine use in those using medical cannabis, the fact that cigarette smokers opt to smoke cannabis as well and that those people also are seeking to quit using nicotine presents a strong argument that dispensaries provide tobacco control messaging at the point-of-sale to encourage cigarette smokers to quit,” Prof Steinberg added. “The strategy also could increase the chances that a medical cannabis user would vape the product, which is a less harmful route than smoking.”

Source: Rutgers University

Categories : Paediatrics Pain ManagementTags :

E-learning Helps Nurses Gauge Newborns’ Pain

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For newborns, caregivers have to identify and evaluate any pain they may be in. Until the turn of this century, many clinicians did not even recognise that neonates could even experience pain, resulting in infrequent, nonstandard training for medical workers. The COVID pandemic also disrupted opportunities for training. Now, researchers are reporting that a flexible e-learning program improves neonate pain management knowledge and skills for nurses.

They published the results of their randomised, controlled study in Pain Management Nursing.

“Continuing education is essential to maintain and increase nurses’ proficiency in neonatal pain assessment and treatment,” said corresponding author Mio Ozawa, associate professor in the Graduate School of Biomedical and Health Science at Hiroshima University. “Our results showed that e-learning programs were more effective as compared to no training.”

The researchers randomly divided recruited certified neonatal intensive care nurses from across Japan into two groups. One group received four weeks of online training in pain measurement, using structured scales designed for pre-term newborns, called the e-Pain Management of Neonates program. The other group did not receive training. Both groups took pre- and post-tests. While the pre-test results were the same across both groups, the e-learning group scored higher for both knowledge and skill.

The research builds on a prior pilot study, in which 52 nurses completed the e-learning program and improved their test scores. However, without a control group for comparison, the evidence was not sufficient to illustrate the intervention’s effectiveness, according to Prof Ozawa.

“In the current study, we tested the e-learning program with a randomised control trial, a more powerful research design than used with the pilot study,” Prof Ozawa said. “To the best of our knowledge, this is the first such trial that investigates the effects of e-learning on the knowledge and skill in neonatal pain measurement for certified nurses across NICUs across multiple hospitals.”

The e-learning program consists of four modules, each of which takes about 15 minutes to complete. Participants could save their progress and return at any point, as well as review as many times as they wanted. While more nurses were more likely to access the program in the middle of the day or late at night on a weekday, participants still accessed the program at odd hours and over the weekend.

“An e-learning program may be a more efficient method as nurses can participate in the program at their own convenience,” Prof Ozawa said. “In comparison with other health care professionals, NICU nurses stay at the bedside of newborns for the longest time to provide care, including invasive procedures. It is vital for nurses to be educated and train in using the neonatal pain management scale.”

Prof Ozawa stressed that while this study did not demonstrate e-learning’s superiority as a learning method compared to traditional approaches, such as in-person training, it does indicate that e-learning can improve skills and knowledge.

“Learning in this program would allow nurses to acquire knowledge and skills concerning newborn pain, which is preferred over no education,” Prof Ozawa said. “Further research is needed to determine how nurses’ training through e-learning programs is related to patient outcomes, such as more frequent pain assessment of infants by nurses and improved pain management.”

Source: Hiroshima University

Categories : Obstetrics & Gynaecology Pain ManagementTags :

Study Finds No Adverse Effects Denying Nitrous Oxide in Labour

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Birthing women denied nitrous oxide(N20) to relieve labour pain as a result of the COVID pandemic received opioids instead, without any adverse outcomes for mother or child, according to a new study published in the Australian and New Zealand Journal of Obstetrics and Gynaecology. Some anaesthetists have also argued for reducing N20 use as it is a greenhouse gas.

The study, conducted at Lyell McEwin Hospital in Australia, looked at the impact of withholding nitrous oxide (N20), a decision adopted by many hospitals worldwide over fears of virus transmission from the aerosol-generating procedure.

Anaesthetist Professor Bernd Froessler and colleagues compared patient notes for all 243 women birthing at Lyell McEwin over a seven week period in March/April 2020, half of whom did not have access to N20.

They found that although opioid use “significantly increased” when N20 was withheld, there was no increase in epidural use and no change in labour duration, Caesarean section rates, birthing complications or newborn alertness.

Nitrous oxide is used by more than 50% of Australian women to relieve pain in labour, followed by epidurals (40%) and opioids (12%), according to the Australian Institute of Health and Welfare.

However, N20 represents 6% of global greenhouse gas emissions, with 1% due to medical use (ie, around 0.06% of total global warming is due to medical N20). This has led to a debate in medical circles whether it should be replaced with other methods of pain relief.

Many obstetricians argue that effective pain relief in childbirth should be the priority, particularly given the low percentage of emissions, but the Australian and New Zealand College of Anaesthetists has advocated for a reduction in N20 use in a bid to improve environmental sustainability in anaesthesia.

“Obviously no-one wants to deprive labouring women of adequate and easy pain relief but given there are other analgesic options, including epidurals and opioids, perhaps these could be considered,” said Prof Froessler.

UniSA statistician and researcher Dr Lan Kelly said that the findings should reassure women that pain relief besides N20 does not compromise their health or their baby’s.

However, in a recent Sydney Morning Herald article, principal midwifery officer at the Australian College of Midwives, Kellie Wilton, said mothers should not be made to feel guilty about their pain relief choices and suggested hospitals could introduce nitrous oxide destruction systems to allow for its ongoing use.

When nitrous oxide destruction systems were introduced in Swedish hospitals, the carbon footprint from the gas was halved.

Source: University of South Australia

Categories : Paediatrics Pain ManagementTags :

Ways to Reduce Kids’ Needle-related Fear and Pain

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Image of a syring for vaccination
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In the COVID era, when vaccinations are all the more important, new research published in the European Journal of Pain shows that children’s vaccination and needle fear can be reduced with a couple of different techniques used by nurses.

These techniques divide the children’s attention or redress their fears by framing the positive elements of their experience.

Working with children aged 8–12 years, the preliminary study found that two new nurse-led techniques show promise in reducing needle fear in primary-aged children:

  • Divided Attention – where a child’s attention and expectations are drawn away from the needle.
  • Positive Memory Reframing – where a child’s exaggerations about the distress and discomfort of needles are redressed through discussion about the positive elements of the experience so that the form more realistic memories of the event.

Dr Felicity Braithwaite, lead researcher of the study, said that helping children reduce fear and distress around vaccinations is a key area of research in the COVID era.

“For many children, undergoing a needle procedure can be painful and distressing,” Dr Braithwaite said.

“Negative experiences of vaccinations in childhood can often lead to medical avoidance and vaccine hesitancy into adulthood, which can have devastating consequences when it comes to outbreaks of preventable diseases.

“By investing more time into techniques to help children manage their fears about needles, we hope to change these outcomes and deliver better health outcomes for the next generation.”

The study involved 41 children and their parents, with participants randomised to one of four groups – usual care, divided attention, positive memory reframing, or a combination of the latter two interventions. Clinical outcomes were assessed at baseline, immediately post-vaccination and at two-weeks post-vaccination. 

The Divided Attention technique involved a one to two minute distraction game where a nurse tapped the child’s arm above and below the vaccination spot in a random order, with the child focussing their attention on guessing which spot was touched each time. This game takes advantage of the potential analgesic effects of distraction.

The Positive Memory Reframing technique involved talking to children about a past injection and emphasising positive aspects, such as how brave the child was and praising specific strategies they used to reduce their own distress, for example, deep breathing and looking away. The aim is to foster a sense of self-efficacy to help children better cope.

Both techniques were tested outside of clinical locations, such as in schools, to maximise their applicability in real-world settings.

Source: University of South Australia

Categories : Pain Management

Working to Reduce the Pain that Children Suffer from Chemotherapy

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Male doctor with young girl patient
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At the University of Queensland, researchers are seeking ways to educe the pain that children experience when they undergo chemotherapy from feeling pain and other debilitating side-effects. Due to differences in metabolism and their immune responses, children react differently to cancer treatments which are usually designed with adults in mind.

An example of their research was the discovery that anakinra, a drug normally used to treat arthritis in children, could potentially relieve the pain and unpleasant effects of the chemotherapy drug vincristine.

Dr Hana Starobova at UQ has been awarded a Fellowship Grant from the Children’s Hospital Foundation to continue her research to relieve children from the side-effects of cancer treatments.

“Although children have a higher survival rate than adults following cancer treatments, they can still be suffering side-effects well into their adulthood,” Dr Starobova said.

“A five-year-old cancer patient could be suffering severe pain, gastrointestinal problems, or difficulty walking 20 years on from treatment.

“There has been a lack of studies on children, which is an issue because they are not just small adults – they suffer from different cancers, their immune systems work differently and they have a faster metabolism, all of which affect how treatments work.

“Our aim is to treat children before the damage happens, so the side-effects are dramatically reduced or don’t occur in the first place.”

In her previous research, Dr Starobova found an anti-inflammatory drug substantially reduced nerve pain associated with a chemotherapy drug, and did not reduce the effectiveness of the cancer treatment.

Dr Starobova is currently analysing how specific drugs could prevent a cascade of inflammation caused by chemotherapy drugs, which lead to tingling and numbness in hands and feet, and muscle pain and weakness that makes everyday tasks, like walking and doing up buttons, a challenge.

Her focus is on acute lymphoblastic leukaemia, one of the most frequently diagnosed cancers in children.

A woman in a white lab coat, goggles and gloves holds a piece of equipment in a laboratory, she is smiling at the camera
Dr Hana Starobova

In collaboration with Brisbane’s Queensland Children’s Hospital and Mater Children’s Hospital, and Perth’s Telethon Kids Institute, Dr Starobova and her team share a strong motivation to improve quality of life for children.

“We are studying the most commonly used chemotherapy treatment for children, which is a mix of drugs that are very toxic, but have to be used to treat the cancer fast and stop it becoming resistant to the drugs,” Dr Starobova said.

“It’s a fine balance – too little chemotherapy and the cancer won’t be killed but sometimes the side-effects are so bad, patients have to stop the therapy.

“I hope that by having a treatment to reduce side-effects, it will be one less thing for these kids and their families to worry about.”

Source: University of Queensland