Category: Pain Management

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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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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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

Categories : Pain ManagementTags :

Intraosseous Morphine Reduces Pain after Knee Replacement Surgery

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Knee pain
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In knee replacement patients, injecting a combination of morphine and the antibiotic vancomycin into the tibia of their knee joint resulted in less pain post-surgery compared to those who received the infusion without morphine during surgery. The findings were published in The Journal of Arthroplasty.

“Despite many technological advances, controlling pain after total knee arthroplasty can be challenging; most patients experience considerable pain and discomfort, especially in the first couple of weeks into their recovery,” explained Kwan “Kevin” Park, MD, orthopaedic surgeon at Houston Methodist. “Intraosseous infusion, which involves injecting medication directly into the bone marrow, allows us to control pain pre-emptively so that patients don’t have to take as much pain medicine later on.”

Total knee replacement is the recommended treatment to alleviate chronic pain caused by damage to the knee joint from arthritis or injury.

Despite the high frequency and favourable outcomes of the surgical procedure, the manipulation of soft tissue and resurfacing damaged bones during knee replacement cause pain in the early postoperative periods.

“Twenty years ago, patients would remain in the hospital for several days after their surgery and receive extremely high-dose narcotics to help with their postoperative pain,” Dr Park said. “But there has been a paradigm shift; patients are often discharged the same day after knee replacement surgery, and we use multimodal pain management techniques that work much better for pain control and require fewer narcotics.”

These multimodal regimens, he added, often include a combination of medications, such as nonsteroidal anti-inflammatory drugs, opioids and neurogenic agents that act on the nervous system, administered both pre-emptively and after the surgery. However, opioid medications, although very effective in managing pain, have known side effects, like constipation and nausea, and some individuals are allergic to opiates. Opioid medication can be highly addictive, as well. Furthermore, a consensus on the optimal preoperative protocol to mitigate pain is lacking.

Previously, the researchers demonstrated that injecting the antibiotic vancomycin directly into the tibia before surgery helped in reducing infection by reaching a higher concentration of the drug in the knee. Motivated by this success, they investigated whether adding morphine into the tibial bone with a standard antibiotic solution could improve postoperative pain management.

For the study, the team included 48 patients needing total knee replacement surgery. Of these patients, half were randomised to receive vancomycin and morphine injected directly into the bone marrow, using an infusion device that was inserted into the tibial tubercle region, and the remainder were only administered vancomycin as controls. Post-surgery, the researchers monitored patient-reported pain, nausea and opioid use for up to 14 days after surgery. Serum levels of morphine and interleukin-6 were measured in all study participants for 10 hours after the operation.

Analysis showed that the vancomycin and morphine group had lower pain scores after their knee replacements compared to the controls. This was effective up to two weeks after surgery. Further, these patients also reported having less pain for several days even though they had similar interleukin-6 inflammatory marker levels as the control group. Taken together, although the patients who received pain medication infused directly into the tibia during surgery had comparable inflammation, these patients were taking less pain medication post-surgery.

Dr Park noted that this infusion of opiates directly into the bone marrow during surgery could potentially even facilitate a swifter recovery of the knee joint.

“By infusing pain medication intraosseously we’re able to reduce postoperative pain for up to two weeks, reduce the number of pain pills patients need and even possibly improve the function of the knee over time,” he said. “Our technique also can improve the multimodal pain management protocol we have been using for knee replacement over the years.” 

Source: Houston Methodist

Categories : Pain ManagementTags :

Clinical Trial Finds Dry Cupping Relieves Chronic Back Pain

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In the Journal of Acupuncture and Meridian Studies, researchers report that combining ear acupuncture with dry cupping to treat chronic back pain, and showed that it can provide effective relief over acupuncture alone.

Dating back to ancient times, cupping therapy is a technique that uses cups placed over the skin to create negative pressure through suction. In 400 BC, Herodotus listed wet and dry cupping as a treatment for many ailments, including maldigestion, lack of appetite, and headaches. Ear acupuncture, also known as ‘battlefield acupuncture’ has also been modernised by the US military as a simple treatment method in challenging environments.

The open-label, randomised, parallel-group controlled clinical trial recruited 198 adults with chronic back pain. The people were randomised to receive only ear acupuncture as the control group or receive ear acupuncture along with dry cupping as the experimental group.

Interventions were performed in five sessions, once a week, lasting five weeks. Evaluations were performed before the first session, after the last session, and seven days after the second evaluation, using the Brief Pain Inventory to assess the impact of pain on daily activities and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) to assess the quality of life.

Between the initial and final sessions, there were significant changes in daily activities , activity, work, mood, relationships, sleep, and in the physical, psychological and social relationships domains for both the control and experimental groups. Improved perception of quality of life and satisfaction with health were observed for the participants in the experimental group.

Source: Keck School of Medicine USC

Categories : New Compounds and Treatments Pain ManagementTags :

A Potent New Non-opioid Analgesic

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Researchers co-led by University of Warwick have discovered a potent new non-opioid analgesic with potentially fewer side effects compared to other potent painkillers.

Their study found that a compound called BnOCPA (benzyloxy-cyclopentyladenosine), is a potent and selective analgesic which is non-addictive. BnOCPA also has a unique mode of action and potentially opens a new pipeline for the development of new analgesic drugs.

The research is published in Nature Communications.

Chronic pain has a negative impact on quality of life and many commonly prescribed analgesics come with side effects. Opioid drugs, such as morphine and oxycodone, can lead to addiction and are dangerous in overdose.

Drugs that act on G protein-coupled receptors (GPCRs) are one possibility, but their development is hampered by the propensity of GPCRs to couple to multiple intracellular signalling pathways. A unique feature of BnOCPA is that it only activates one type of GPCR, leading to very selective effects and thus reducing potential side effects.

University of Warwick’s Dr Mark Wall, who led the research said: “The selectivity and potency of BnOCPA make it truly unique and we hope that with further research it will be possible to generate potent painkillers to help patients cope with chronic pain.”

Source: University of Warwick

Categories : Pain ManagementTags :

Mechanism Behind Sound and Pain Suppression Identified in Mice

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Sound is known to suppress the sensation of pain, and now scientists have identified the neural mechanisms through which sound blunts pain in mice. The findings, which could inform development of safer methods to treat pain in humans, were published in Science.

“We need more effective methods of managing acute and chronic pain, and that starts with gaining a better understanding of the basic neural processes that regulate pain,” said the director of the National Institute of Dental and Craniofacial Research (NIDCR), Rena D’Souza, DDS, PhD. “By uncovering the circuitry that mediates the pain-reducing effects of sound in mice, this study adds critical knowledge that could ultimately inform new approaches for pain therapy.”

Studies as far back as 1960, have shown that music and other kinds of sound can help alleviate acute and chronic pain in humans, including pain from dental and medical surgery, labour and delivery, and cancer. Yet the mechanism behind this remained elusive.

“Human brain imaging studies have implicated certain areas of the brain in music-induced analgesia, but these are only associations,” said co-senior author Yuanyuan (Kevin) Liu, PhD, at NIDCR. “In animals, we can more fully explore and manipulate the circuitry to identify the neural substrates involved.”

The researchers first exposed mice with inflamed paws to three types of sound: a pleasant piece of classical music, an unpleasant rearrangement of the same piece, and white noise. Surprisingly, all three types of sound, when played at a low intensity relative to background noise (about the level of a whisper) reduced pain sensitivity in the mice. Higher volume had no effect on their pain sensitivity.

Researchers discover how sound reduces pain in mice
Inhibition of auditory cortex inputs to the thalamus drives sound-induced analgesia. Credit: Conghuan Ye

“We were really surprised that the intensity of sound, and not the category or perceived pleasantness of sound would matter,” Dr Liu said.

To explore the brain circuitry underlying this effect, the researchers trace connections between brain regions using fluorescent protein-tagged viruses. They identified a route from the auditory cortex to the thalamus, which relays sensory signals, including pain, from the body. In freely moving mice, low-intensity white noise reduced the activity of neurons at the receiving end of the pathway in the thalamus.

Without sound, suppressing the pathway with light- and small molecule-based techniques mimicked the pain-blunting effects of low-intensity noise, while turning on the pathway restored animals’ sensitivity to pain.

Dr Liu said it is unclear if similar brain processes are involved in humans, or whether other aspects of sound, such as its perceived harmony or pleasantness, are important for human pain relief.

“We don’t know if human music means anything to rodents, but it has many different meanings to humans – you have a lot of emotional components,” he said.

The results could give scientists a starting point for studies to determine whether the animal findings apply to humans, and ultimately could inform development of safer alternatives to opioids for treating pain.

Source: National Institutes of Health

Categories : Pain ManagementTags :

Hyaluronic Acid of Little Value in Knee Osteoarthritis

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Knee pain
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Treating knee osteoarthritis with hyaluronic acid injections (known as viscosupplementation) makes almost no difference to pain or functioning and might raise risk of adverse events, suggests a review of 50 years of literature on the procedure.

Viscosupplementation has been used to treat knee osteoarthritis since the 1970s, but there are long-standing questions over its safety and efficacy.

Some 560 million people worldwide suffer from knee osteoarthritis, which involves inflammation and structural changes of the joints, resulting in joint pain and limitations to physical movement.

National and international guidelines vary in their recommendations, but most advise against the use of viscosupplementation. Researchers therefore set out to review 50 years’ worth of studies to evaluate the safety and efficacy of viscosupplementation. The studies compared viscosupplementation to placebo or no treatment.

Published in The BMJ, the main analysis of this review found that viscosupplementation was associated with a small reduction in pain compared with placebo, but the difference was tiny and was described as “clinically irrelevant.”

Their analysis showed that since 2009, there has been conclusive evidence that viscosupplementation and placebo treatment have led to the same clinical result in terms of pain reduction, meaning there is no point to having the injections.

They also found from 15 large trials on 6462 randomised participants that viscosupplementation was linked to a 49% higher risk of serious adverse events than placebo.

The authors say that based on their analysis of the studies between 2009 and 2021 alone, more than 12 000 patients were arguably unnecessarily subjected to these injections in viscosupplementation trials, which raises ethical concerns.

The study has some limitations in that it represents summary estimates and does not necessarily exclude the possibility that selected patient populations could benefit from viscosupplementation. Also, the researchers looked at adverse events that emerged rather than adverse events directly and clearly related to treatment.

However, strengths include the fact that this is the largest collection of randomised trials on viscosupplementation reported to date, which significantly decreases the risk of bias influencing the results.

As such, the authors conclude: “There is strong, conclusive evidence that among patients with knee osteoarthritis, viscosupplementation, compared with placebo, is associated with a clinically irrelevant reduction in pain intensity and with an increased risk of serious adverse events.

“The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis.”

Source: The BMJ