Dentists Continue to Prescribe Opioids to Adolescents for Pain Relief Interview with:
Adriane Fugh-Berman MD
Professor, Dept. of Pharmacology and Physiology
Georgetown University Medical Center  What is the background for this study?  What are the main findings?

Response: The first exposure of adolescents and young people to opioids is through dentists, who frequently prescribe opioids after dental procedures. Dentists are the highest prescribers of opioids to patients under 18. We conducted a national survey of dentists and received 269 responses from 30 states and 2 territories.

Four of five dentists knew that  that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, but 43% still  regularly prescribed opioids. There was more caution about prescribing opioids  to adolescents aged 11 through 18 years, but only half ( 48%) reported they were less likely to prescribe opioids to young adults 19 -25 years (compared to adults over 25). This is concerning  because adolescents and young adults under 25 are more likely to develop opioid use disorder than adults over 25. 

One-half of those who reported prescribing opioids reported prescribing more opioids than needed, which would result in leftover pills. Leftover pills  pose a risk for later misuse. 

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Tramadol Prescriptions for Pain Relief Linked to More Complications than Codeine Interview with:
Carlen Reyes PhD
Médico de familia
Gestora de proyectos de investigación IDIAP Jordi Gol What is the background for this study? What are the main findings?

Response: Tramadol and codeine are two “weak” opioids frequently prescribed for different non-cancer pain indications, however, few are the studies that compare the adverse outcomes between them using large routinely collected primary care data. We aimed to fulfil this gap by analysing the risk of adverse events with the tramadol and codeine dispensations in a large primary care health care data (SIDIAP database) from Spain. 

We found that the dispensations of tramadol were associated with a greater risk of cardiovascular events, mortality and fractures compared to the dispensations of codeine. 

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Survey of Medical Cannabis Effects on Anxiety and Depression Interview with:
Erin Martin Ph.D. Candidate
Department of Neuroscience
Medical University of South Carolina
Charleston, SC 29425

Erin Martin  What is the background for this study?
Response: Anxiety and depressive disorders are highly prevalent. People with these disorders are increasingly using cannabis products for symptom management, either as an alternative to or in conjunction with traditional antidepressants.

The goal of this study was to examine the effect of medicinal cannabis product use on symptoms of anxiety and depression in a clinical population, and to assess important correlates of anxiety and depression such as chronic pain and quality of life.  

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Study Finds Medical Cannabis Not Likely to Solve Opioid Crisis for Pain Patients Interview with:
Carsten Hjorthøj, senior Researcher
Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital
University of Copenhagen, Department of Public Health
Section of Epidemiology, Copenhagen, Denmark.  What is the background for this study?  What are the main findings?

Response: Denmark introduced a pilot program of medical cannabis in 2018. Medical cannabis, and cannabis-based medicine, has gained a lot of both attention and controversy as a possible way to treat pain disorders, but the evidence base is still sparse. The Danish nationwide unselected registers allow us to perform a high quality pharmacoepidemiologic study with propensity score matched controls.

The main findings are that medical cannabis and cannabis-based medicine did not reduce the use of opioids in pain patients, and might actually lead to an increase in use of opioids. However, patients with neuropathic pain disorders appeared to reduce their use of gabapentin, their use of overall medication (but not opioids!), and the number of days spent in hospital, compared with controls.

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Back Pain: Advice and Education Provide Small Short-Term Improvements in Pain and Disability Interview with:
Caitlin Jones PhD Candidate
The University of Sydney
Faculty of Medicine and Health, Sydney School of Public Health
Institute for Musculoskeletal Health
Royal Prince Alfred Hospita
Australia  What is the background for this study? What are the main findings?

Response: Despite advice being recommended internationally as a treatment for spinal pain, the evidence behind that was uncertain and out of date. We didn’t think that the strong and widespread recommendation to provide advice was reflective of the available evidence. There have been multiple, more recent, trials of advice and education with varying results, so it was a good time to collate and summarise these with a systematic review.

Our main findings were that advice and education had a small effect on pain and disability compared to no advice and education, or placebo in the short term. The effects were around 10 points of improvement for pain and 5 points for disability on a 0 to 100-point scale. There was evidence of no effect at all other time points (immediate, intermediate and long term). The specific content of the advice didn’t seem to make much difference.

We compared simple contemporary advice (such as advice to keep active and to avoid bed rest and reassurance about the positive prognosis) to more comprehensive advice, such as ergonomic advice (specific postural and biomechanical information) or pain neuroscience education, and found them all to be about equally effective. Whether the participants’ symptoms were acute or chronic, the intensity of the intervention in terms of time spent with a therapist, how the intervention was delivered and the depth and type of the content didn’t impact outcomes.

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Chronic Migraine: TOP-PRO Study Compares Propranolol and Topiramate for Pain Relief Interview with:

Dr. Debashish Chowdhury
MBBS; DTCD; MD (Medicine); DM (Neurology); FIAN
Commonwealth Fellow in Stroke Medicine (Edinburg, UK)
Director – Professor and HOD
Department of Neurology, G B Pant Institute of Post Graduate Medical Education and Research,
New Delhi, India

Dr. Chowdhury  What is the background for this study?

Response: Chronic migraine is a highly disabling headache disorder affecting about 2% of the global population. Oral preventive treatment options for chronic migraine are limited. Only topiramate has good evidence of efficacy. Although propranolol has class I evidence of efficacy for the prevention of episodic migraine, it has not been tested for chronic migraine with a robust clinical trial. Hence, we conducted an RCT, called the TOP-PRO study assessing the efficacy and tolerability of propranolol against topiramate for the prevention of chronic migraine using a non-inferiority design.

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Pronounced Declines, but Regional Differences, in Hospital Use of Prescription Opioids

Sarah A. Eidbo, MS
MD Candidate
Geisinger Commonwealth School of Medicine Class of 2023
Scranton, Pennsylvania

Sarah A. Eidbo What is the background for this study?

Response: The United States is still witnessing the fallout from years of a devastating, multifaceted opioid crisis. However, in the wake of this situation, healthcare providers and systems across the nation have implemented many strategies to curb the damage where they can. This study1 used reports from the Drug Enforcement Administration (DEA)2 to quantify the changes and trends in prescription opioid distribution to hospitals in the U.S .over the past two decades.

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Study Addresses How Weather Affects Pain Tolerance Interview with:
Erlend Hoftun Farbu, PhD student
Department of Community Medicine
The Arctic University of Norway
Tromsø, Norway  What is the background for this study?  What are the main findings?

Response: Many report that weather affect their pain condition. Some studies confirm this, others do no. However, these studies have asked “How much pain do you have today?”

We used two tests to assess how much pain a person can tolerate. We then looked at how pain tolerance vary over time and if they are associated with weather.

The results show quite clearly that people can tolerate more pain caused by intense cold temperature in the colder months of the year. There was no such seasonal variation in pain caused by pressure to the leg. On the other hand, we found that both pressure pain tolerance and weather at one day was associated with the next days, but not the next month. When we further linked the weather and pain tolerance, we found that, for example, in some periods a rise in temperature happened at the same time as a rise in pain tolerance. While in other periods, there were no such association. We mean that this is because we adapt to the weather. For example, how we experience 5 °C (41°F) is different in autumn and spring..

Finally, temperature and barometric pressure could predict future values of pressure pain tolerance

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Acetaminophen (paracetamol) During Pregnancy May Alter Fetal Development Interview with:
Ann Z. Bauer ScD
Department of Work Environment
University of Massachusetts Lowell | UML  What is the background for this study?  What are the main findings of the underlying studies?

Response: Acetaminophen (paracetamol, brand name Tylenol) is an over-the-counter medication used to relieve pain and reduce fever. It is an active ingredient in over 600 medications and used by more than 50% of pregnant women worldwide and up to 65% of pregnant women in the US.

Current guidance recommends acetaminophen as the pain reliever of choice during pregnancy, as other pain relievers such as ibuprofen and aspirin are contraindicated during pregnancy, particularly after 20 weeks.

In this consensus statement the authors reviewed the research on acetaminophen use during pregnancy from 1995 through 2020 and found a growing body of evidence that suggests prenatal acetaminophen exposure may alter fetal development increasing the risk of neurodevelopmental, reproductive and urogenital disorders. Importantly, this review identifies a convergence of evidence from the trifecta of research areas -human cohort studies, in vitro and animal models. This statement asking for precaution and more research was supported by a total of 91 clinicians and researchers (13 authors and 78 signatories) from around the world.

Research suggests acetaminophen is an endocrine disruptor meaning it interferes with the proper functioning of hormones, specifically it is an anti-androgen that can significantly reduce testosterone production.  Acetaminophen exposure during pregnancy has been suggested to increase the risk of male undescended testicles (cryptorchidism) and shorter anogenital distance (ADG) a marker of sub-fertility.  Additionally, research suggests increased risk of neurodevelopmental disorders primarily attention deficit hyperactivity disorder (ADHD) and related behavioral abnormalities, but also autism spectrum disorder (ASD), language delays, decreased IQ, and conduct disorders.

Many users do not consider acetaminophen to be a medication with potential side effects. There is high usage, in part, because of a perception  that use is of negligible risk.  However, because use is so common, if acetaminophen is responsible for even a small increase in individual risk it could contribute substantially to these disorders in the overall population.

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Migraine Pain Linked to Stress Varies by Individual Interview with:

Serena L. Orr, MD, MSc, FRCPC, FAHS
Assistant Professor
Depts of Pediatrics, Clinical Neurosciences and Community Health Sciences 
Cumming School of Medicine, University of Calgary
Director, Pediatric Headache Program
Alberta Children’s Hospital

Dr. Orr  What is the background for this study?

Response: Stress has long been felt to be one of the most common trigger factors for migraine. However, there is very little data on the relationship between stress and pain severity in individuals with migraine on a day-to-day basis, and this relationship is even more poorly understood among individuals with more frequent attacks, such as those with chronic migraine (who have at least 15 days/month of headache, 8 or more of which meet criteria for migraine attacks).

This was a study that looked at daily electronic headache diary data for 136 adults with chronic migraine, using data from the N1-Headache application. In this study, we aimed to understand the relationship between perceived stress and pain severity in individuals with chronic migraine. Individuals completed 90 days of daily diary entries where they reported on their headache characteristics, and their perceived stress levels, measured on a scale of 0-10.

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