Using opioid therapy for pain in clinically challenging situations. Questions for clinicians

Healthcare professionals and organizations increasingly face the conundrum of treating patients with active substance use disorder, a history of personal or familial substance use disorder, or those at elevated risk for substance abuse. Such patients need compassionate care when facing painful conditions; in fact, denying them pain control makes it likely that they will seek out ways to self-medicate with illicit drugs. Yet it remains unclear how to safely and effectively treat patients in these challenging situations. The authors have formulated ten questions to address in order to provide adequate analgesia for such patients. These questions demand a highly individualized approach to analgesia. These ten questions involve understanding the painful condition (presumed trajectory, duration, type of pain), using validated metrics such as risk assessment tools, guidelines, protocols, and safeguards within the system, selection of the optimal analgesic product(s) or combination therapy, and never starting opioid therapy without clear treatment objectives and a definitive exit plan. It is tempting but inaccurate to label these individuals as “inappropriate patients,” rather they are high-risk individuals in very challenging clinical situations. The challenge is that both options — being in pain or being treated with opioids to control pain — expose the patient to a risk of rekindling an addiction. The question is how do we, as clinicians, adequately respond to these very perplexing clinical challenges

Developments in combined analgesic regimens for improved safety in postoperative pain management

Introduction: Fixed-dose combination analgesic regimens may be similarly effective to opioid monotherapy but with potentially less risk. A number of individualized combination regimens can be created, including nonopioid agents such as acetaminophen and nonsteroidal anti-inflammatory drugs, opioids, and adjunctive agents such as gabapentin, pregabalin, and muscle relaxants. Areas covered: When such combinations have a synergistic effect, analgesic benefits may be enhanced. Many combination analgesic regimens are opioid sparing, which sometimes but not always results in reduced opioid-associated side effects. Safety concerns for all analgesics must be considered but postoperative analgesia is typically administered for a brief period (days), reducing risks that may occur with prolonged exposure. Expert opinion: Judiciously considered combination analgesic regimens can be effective postoperative analgesics that reduce opioid consumption without compromising pain control, which are important factors for patient recovery and satisfaction. The specific combinations used must be based on the patient, the type and duration of the surgical procedure, and complementary mechanisms of action of the agents used. In opioid-sparing combination analgesic regimens, the short-term use of small doses of opioids in this setting may be helpful for appropriate patients

Red wine triggers may lead to better understanding of migraine headache. A narrative review

Migraine headache is a prevalent condition that places a substantial burden on the healthcare system. It is known that certain foods, food additives, alcohol, caffeine, stress, sensory stimuli, disruptions in sleep-wake patterns, hormonal changes, and many other things may trigger migraines. Red wine is a frequently reported trigger for migraines and other headaches but it is unclear what substance(s) in red wine triggers headache and why red wine is more associated with headache than white wine, sparkling wines, or spirits. Implicated as headache triggers are biogenic amines (histamine, phenylethylamine, tyramine, and others), phenols, polyphenols, and sulfites. Enzymatic action in the metabolism of phenols and polyphenols may cause fluctuations in dopamine and serotonin levels which, in turn, have been implicated as headache triggers. The role of sulfotransferase enzymes and dopamine appears to offer a promising explanation of the red wine headache. The investigation of potential red wine triggers may better elucidate headache pathogenesis

Statins and muscle pain

Introduction: Statins remain among the most frequently prescribed drugs and constitute a cornerstone in the prevention of cardiovascular disease. However, muscle symptoms are often reported from patients on statins. Muscle symptoms are frequently reported as adverse events associated with statin therapy. Areas covered: In the present narrative review, statin-associated muscle pain is discussed. It elucidates potential mechanisms and possible targets for management. Expert opinion: In general, the evidence in support of muscle pain caused by statins is in some cases equivocal and not particularly strong. Reported symptoms are difficult to quantify. Rarely is it possible to establish a causal link between statins and muscle pain. In randomized controlled trials, statins are well tolerated, and muscle-pain related side-effects is similar to placebo. There are also nocebo effects of statins. Exchange of statin may be beneficial although all statins have been associated with muscle pain. In some patients reduction of dose is worth trying, especially in primary prevention Although the benefits of statins outweigh potential risks in the vast majority of cases, careful clinical judgment may be necessary in certain cases to manage potential side effects on an individual basis

Thermodynamic Characterization of High-Speed and High-Enthalpy Plasma Flows

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Pressure mat analysis of naturally occurring lameness in young pigs after weaning

BACKGROUND: Lameness is a common problem in modern swine husbandry. It causes welfare problems in affected pigs as well as financial problems for farmers. To minimize these negative consequences of lameness, new treatment and prevention strategies need to be developed and validated using objective and quantitative measurement techniques. An example of such a putative diagnostic tool is the use of a pressure mat. Pressure mats are able to provide both objective loading (kinetic) as well as objective movement (kinematic) information on pig locomotion.In this study, pressure mat analysis was used to assess compensatory force redistribution in lame pigs; in particular a predefined set of four pressure mat parameters was evaluated for its use to objectively distinguish clinically lame from sound pigs. Kinetic data from 10 clinically lame and 10 healthy weaned piglets were collected. These data were analyzed to answer three research questions. Firstly the pattern of compensatory weight distribution in lame animals was studied using the asymmetry indices (ASI) for several combinations of limbs. Secondly, the correlation between total left-right asymmetry index and visual scores of lameness was assessed. Thirdly, by using receiver-operated curve (ROC) analysis, optimal cutoff values for these ASIs were then calculated to objectively detect lame pigs. RESULTS: Lame animals generally showed a shift in loading towards their diagonal and contralateral limbs, resulting in a clear left-right asymmetry. The degree of lameness as graded by visual scoring correlated well with the total left-right ASIs. Lame pigs could be objectively distinguished from sound pigs based on clear cutoff points calculated by ROC analysis for the complete set of four evaluated parameters. CONCLUSIONS: The gait of lame pigs is asymmetric, due to the unloading of the affected limb and concomitant weight redistribution towards other limbs. This asymmetry objectively expressed as total left-right asymmetry, correlates well with the subjective visual lameness scoring and can be used to objectively distinguish lame from sound pigs. Pressure mat gait analysis of pigs, therefore, appears to be a promising and useful tool to objectively quantify and possibly early detect lameness in pigs