Home Medicine Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
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Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study

  • Kehua Zhou , Sen Sheng and Gary G. Wang EMAIL logo
Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

Abstract

Background and aims

The use of intrathecal morphine therapy has been increasing. Intrathecal morphine therapy is deemed the last resort for patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions. However, effective treatments for patients with CNCP who “failed” this last resort because of severe side effects and lack of optimal pain control remain unclear.

Methods and results

Here we report two successfully managed patients (Ms. S and Mr. T) who had intractable pain and significant complications years after the start of intrathecal morphine therapy. The two patients had intrathecal morphine pump implantation due to chronic consistent pain and multiple failed surgical operations in the spine. Years after morphine pump implantation, both patients had significant chronic pain and compromised function for activities of daily living. Additionally, Ms. S also had four episodes of small bowel obstruction while Mr. T was diagnosed with end stage severe “dementia”. The successful management of these two patients included the simultaneous multidisciplinary approach for pain management, opioids tapering and discontinuation.

Conclusion

The case study indicates that for patients who fail to respond to intrathecal morphine pump therapy due to side effects and lack of optimal pain control, the simultaneous multidisciplinary pain management approach and opioids tapering seem appropriate.

Keywords: Intrathecal morphine therapy; Side effect; Multidisciplinary; Pain management; Opioid tapering

1 Introduction

The clinical use of intrathecal morphine was firstly introduced as continuous spinal alagesia for obstetric analgesia in 1979 [1,2]. This was followed by the introduction of programmable intrathecal morphine pump (PIMP) for pain related to malignancies in 1981 [3,4]. The PIMP devices allow for non-invasive dose changes and refills and can decrease adverse effects of opioids such as sedation and constipation [4]. Since the 1980s, the use of intrathecal morphine therapy has been increasing [5], and has been expanded to the treatment of patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions [6]. The increase in intrathecal morphine therapy use is supported by its effectiveness and ease of use, although large randomized control trials are still lacking [5,6].

Intrathecal morphine therapy is deemed the last resort for patients with CNCP. However, years after morphine pump implantation, adverse events of morphine, sometimes including small bowel obstruction and severe sedation, respiratory depression and even death, may become increasingly common [7]. Additionally, studies also found that patients with chronic morphine use may present with poor pain control, decreased quality of life, and frequent emergency room visits, all of which are common side effects from chronic morphine use [8,9].

While the emergent management of the patient with pain and severe side effects while on long-term intrathecal morphine therapy focuses on life saving with opioid antagonist for side effects and/or bolus opioid injection for pain, optimal management of these patients may include tapering of intrathecal morphine and the management of CNCP. Methadone taper is the most commonly used method for opioid tapering where patients on long-term opioids are firstly stabilized with a dose of methadone that mitigates withdrawal followed by gradual opioid taper [10]. For CNCP itself, a multidisciplinary approach is usually recommended [12]. Nonetheless, research studies on combining methadone taper with a multidisciplinary pain management approach for patients with pain and severe side effects while on long-term intrathecal morphine therapy are still scarce in the literature, and optimal treatments for these patients remain unclear. Here we report two patients with intractable pain and significant complications while on long-term intrathecal morphine therapy. The two patients were successfully treated with methadone taper in combination with the multidisciplinary pain management.

2 Case presentation

2.1 Case 1

Ms. S was 67 years old when she had the PIMP implantation for her prolonged consistent low back pain in 2004. Prior to that, Ms. S had 4 failed back surgeries and received the implantation of an implantable spinal cord stimulator. After the PIMP implantation, Ms. S was also given oxycodone and hydrocodone for breakthrough pain. With the highest intrathecal morphine dosage of 3.60 mg/day and bolus morphine dosing, the treatment protocol had become unsatisfactory as Ms. S had increased visits at hospital emergency departments for respiratory compromise-induced pneumonia, small bowel obstruction, constipation, on top of intolerable pain aggravation.

By the end of 2009, Ms. S restarted to use fentanyl patch with increasing doses as she believed that morphine no longer worked for her, despite the continuous treatment of intrathecal morphine. From 2009 to 2011, Ms. S received three additional surgeries for her back pain. In October, 2011, Ms. S was admitted to the hospital due to facial numbness, tingling, and sensory changes with anxiety and intractable lower back pain. We saw the patient on October 20th, 2011 for pain management and rehabilitation.

By that moment, Ms. S had been unable to sit or stand and had difficulties in transferring in and out of bed for more than two years. Besides morphine per pump (3.60 mg/day), Ms. S was also receiving fentanyl patch 50 mcg/h for pain control. After relevant examination and lab work, Ms. S was diagnosed with anxiety, trochanteric bursitis as well as lumbosacral radiculopathy and plexopathy. We thus treated the patient with bursa injection and lumbosacral plexus block. We also recommended methadone (2.5 mg, twice a day) for the tapering of both intrathecal morphine and fentanyl. After three days of methadone use, we discontinued fentanyl patch and increased methadone to 5 mg three times daily. We then decreased the dosing of morphine (initially 20% decrease monthly) while slightly modulating the dosing of methadone (5 mg given three to five times a day depending on patient’s response).

Meanwhile, we adopted a multidisciplinary approach for pain management which included patient education and counselling, therapeutic exercises, fluoxetine, clonidine, lamotrigine, mir- tazepine, and alternative and complementary medicine [heating and cold pad, acupuncture, and massage when appropriate]. Additionally, short-term meloxicam, naproxen, oxacarbazepine, and pregabalin had also been used separately or in combination during the long treatment course. We completely discontinued Ms. S’s morphine per pump and started methadone weaning on June 27th, 2013. We slowly decreased methadone quantity and then frequency. By the time patient took methadone for the last time on July 20th, 2014, Ms. S’s pain was well controlled and she was able to stand, sit, walk with rolling walker, and drive for community activities. She underwent another operation to remove her morphine pump in late 2014 after pain was under control with exercise and other non-opioid medications for around five months.

2.2 Case 2

Mr. T was 65 years old in 2004 when he had the PIMP implantation after multiple failed back and cervical surgeries for his work related injuries. Although the morphine pump originally provided some help, his pain over the lumbar and cervical spine increased over time. Since 2006, Mr. T had been receiving intrathecal morphine 3.373 mg/day and bupivicaine 0.8432 mg/day with the use of additional oral hydrocodone, oxycodone and hydromorphine for pain control. Mr. T had gradually lost his ability to stand and walk, and became totally wheelchair bound. Additionally, he also had gradually developed confusion, agitation, delirium, bowel and bladder incontinence, and frequent episodes of hypoxaemia from 2006 to 2011. In early 2011, Mr. T was diagnosed with end stage severe “dementia” and was under hospice care at a nursing home. On March 1st, 2012, Mr. T was brought in our office by her family for a second opinion.

After a close examination and evaluation, we found it was not sufficient to diagnose Mr. T with dementia while he was on large doses of opioids. We recommended weaning down the opioid medications using methadone taper while managing Mr. T’s pain with the comprehensive multidisciplinary approach. Similar to the aforementioned case, we decreased the dosing of morphine (initially 20% decrease monthly) while slightly modulating the dosing of methadone (5 mg given three to five times a day depending on patient’s response) after initially 2.5 mg twice a day for one week tolerance (allergy) test. Additionally, treatments including family education and counselling, physical therapy, tapering dose of methadone as well as adjuvant medications such as clonidine, lam-otrigine, mirtazepine, oxcarbazepine, and citalopram were used.

During the methadone taper process, Mr. T’s dementia-like symptoms improved gradually. By the summer of 2012, Mr. T was discharged home from nursing home. With pain well-controlled, on November 29th, 2012, we stopped the use of morphine per pump and started gradual methadone weaning via slowly decreasing methadone quantity and then frequency. On April 11th, 2013, his methadone use was completely discontinued when Mr. T had been tolerating well with standing and walking training with therapists, had no pain for most of the time, and was also able to ambulate with rolling walker inside his house with dementia-like symptoms completely resolved. The pump was later removed in early 2014.

3 Discussion

Both patients had unsatisfactory pain control and general weakness after years of opioid use. The suppressed endogenous opioid peptide system may be one of the potential culprits. The human body is constantly secreting endogenous opioid peptides [13]. The endogenous opioids participate in various physiological activities including the secretion of various hormones [13,14]. Van Bock-staele [15] reported decrease in endogenous opioid peptides in the rat medullo-coerulear pathway after chronic morphine treatment.

Additional side effects from intrathecal morphine may include the frequent emergency room visits and hospitalization in Ms. S and the nursing home stay because of severe sedation (“dementia”) in Mr. T.

Unsatisfactory pain control and concerning side effects exceeding benefits are indications for opioid tapering [11]. For the presented two patients, clinicians need to focus their plan of care to the simultaneous pain management with opioid tapering. Chronic pain involves the complex and dynamic interactions among psychological, social, and physiological factors [12]; therefore, management of patients with chronic pain should include a comprehensive multidisciplinary approach to maximize benefits, reduce side effects, and expedite recovery [16]. For successful opioid tapering, important pharmaceutical treatments in these situations including clonidine to decrease withdraw effects, antidepressants to manage anxiety and depression, lamotrigine for mood stabilization and potential neurogenic pain may be used separately or in combination [17].

Opioid medications are divided into long and short acting opioids depending on their half-lives [18]. Morphine has a half-life of 2–3 h; methadone has a half-life of 24 h [18]. Short-acting opioids may be more likely to cause fluctuations in the functions of the available opioids (endogenous opioid peptides and externally given opioids) in the human body because of their short half-lives and requirement for more frequent dosing [18]. These fluctuations of opioids might be causing alternating pain and happiness in patients [14] and thus anxiety and depression, which in turn aggravate the symptom fluctuations. Because of drug seeking, patients may have increases in opioid dosing quantity and frequency, more so in patients on short-acting opioids [19]. Upon many occasions, clinicians use other short-acting opioid medications (like oxycodone, hydrocodone, hydromorphine, morphine) for breakthrough pain or uncontrolled pain after morphine pump implantation. Peripheral and/or central sensitization (hyperexcitability) have been suggested to be related to the development of breakthrough pain which is defined as transient worsening of pain in patients with an ongoing steady pain [20]. While short-term use of short-acting opioid medications may be necessary, the long-term use of additional opioids in patients with morphine pump implantation should be highly cautious. Chronic short-acting opioid use may create more fluctuations of symptoms in patients [18].

Additionally, the unsatisfactory pain control in intrathecal morphine therapy may be related to the development of opioid dependence and tolerance as functions of the endogenous opioid peptides and/or their receptors may decrease in the human body [15,19]. Worse still, hyperalgesia which is related to decreased balance point (threshold) for pain and increased balance point (threshold) for happiness after long term exogenous opioid use is also common [19]. Because of the fluctuations in symptoms [18], hyperalgesia maybe more prominent, if additional long-term short-acting opioids are used on top of intrathecal morphine therapy. After morphine pump implantation, both patients gradually developed significant uncontrolled pain, side effects, and compromised function of activities of daily living while on relatively large dose (3.60 mg/day and 3.373 mg/day) intrathecal morphine therapy with multiple other short-acting opioid medications.

Methadone is the traditional long acting opioid conferring reliable absorption and steady effects over two to three days

[18]. Methadone is the traditional medication used in medication assisted treatment for opioid use disorders [18]. With the use of long-acting opioids like methadone, we may minimize the fluctuation of symptoms while conferring more steady levels of opioids inside the human body. Additionally, as a result of the longer halflife of methadone, dependence may take longer to develop and pain and mood are more likely to be kept relatively stable. With better baseline and stable pain control, the transitional use of methadone in opioid tapering will also decrease the risk of anxiety in patients [19]. Tapering of the transitional methadone and intrathecal morphine requires the continuous application of the multidisciplinary pain managements including adjuvant medications like clonidine, a commonly used medication for withdrawal symptoms. The last 2.5 mg per day of methadone was usually difficult to taper. The tapering of methadone in Ms. S took one year and took longer than four month in Mr. T. Nonetheless, methadone taper for discontinuing intrathecal morphine seems possible.

Admittedly, we should be cautious when using methadone taper with the comprehensive multidisciplinary approach for the management of patients who failed intrathecal morphine pump therapy. First, large variability in methadone half-life (10-60 h) and potential for delayed toxicity have been described for methadone [21]. Second, the combinational use of adjuvant medications raises concerns for polypharmacy which increases the risk of drug interactions and side-effects [22].

4 Conclusion

For patients with intractable chronic pain and significant complications while on long-term intrathecal morphine therapy, the simultaneous multidisciplinary pain management approach and methadone taper seems appropriate for these conditions.

Highlights

  • Intrathecal morphine therapy is deemed the last resort for chronic pain.

  • Two patients experienced severe side effects and lack of optimal pain control.

  • Treatment using a multidisciplinary approach and opioid tapering was effective.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.09.003.

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  1. Conflict of interest: No actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Acknowledgement

The authors would like to thank Professor Yuan Bo Peng MD, PhD for his valuable input during the manuscript drafting and revision process.

References

[1] Bier A. Attempts over Cocainisirung of the Ruckenmarkers. Langenbecks Arch Klin ChirVer Dtsch Z Chir 1899;51:361–9 [German].Search in Google Scholar

[2] Alper MH. Intrathecal morphine: a new method of obstetric analgesia? Anesthesiology 1979;51:378–9.Search in Google Scholar

[3] Onofrio BM, Yaksh TL, Arnold PG. Continuous low-dose intrathecal morphine administration in the treatment of chronic pain of malignant origin. Mayo Clin Proc 1981;56:516–20.Search in Google Scholar

[4] Wallace M, Yaksh TL. Long-term spinal analgesic delivery: a review of the preclinical and clinical literature. Reg Anesth Pain Med 2000;25:117–57.Search in Google Scholar

[5] Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, Caraway D, Cousins M, De Andres J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell 2nd GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic consensus conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation 2012;15:436–64.Search in Google Scholar

[6] Bottros MM, Christo PJ. Current perspectives on intrathecal drug delivery. J Pain Res 2014;7:615–26.Search in Google Scholar

[7] Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Phys 2008;11:105–20.Search in Google Scholar

[8] Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006;125:172–9.Search in Google Scholar

[9] Jones CM, McAninch JK. Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med 2015;49:493–501.Search in Google Scholar

[10] Schuckit MA. Treatment of opioid-use disorders. N Engl J Med 2016;375:357–68.Search in Google Scholar

[11] Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315:1624–45.Search in Google Scholar

[12] Roditi D, Robinson ME. The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Manag 2011;4:41–9.Search in Google Scholar

[13] Bodnar RJ. Endogenous opiates and behavior: 2014. Peptides 2016;75:18–70.Search in Google Scholar

[14] Vuong C, Van Uum SH, O’Dell LE, Lutfy K, Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev 2010;31:98–132.Search in Google Scholar

[15] Van Bockstaele EJ, Peoples J, Menko AS, McHugh K, Drolet G. Decreases in endogenous opioid peptides in the rat medullo-coerulear pathway after chronic morphinetreatment. J Neurosci 2000;20:8659–66.Search in Google Scholar

[16] Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014;69:119–30.Search in Google Scholar

[17] Berna C, Kulich RJRJ. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90:828–42.Search in Google Scholar

[18] Argoff CE, Silvershein DI. A comparison of long- and short-acting opioids forthe treatment of chronic noncancer pain: tailoring therapy to meet patient needs. Mayo Clin Proc 2009;84:602–12.Search in Google Scholar

[19] Hyman SM, Fox H, Hong KI, Doebrick C, Sinha R. Stress and drug-cue-induced craving in opioid-dependent individuals in naltrexone treatment. Exp Clin Psychopharmacol 2007;15:134–43.Search in Google Scholar

[20] Svendsen KB, Andersen S, Arnason S, Arner S, Breivik H, Heiskanen T, Kalso E, Kongsgaard UE, Sjogren P, Strang P, Bach FW, Jensen TS. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain 2005;9:195–206.Search in Google Scholar

[21] National Highway Traffic Safety Administrations.Drugs and human performance face sheets: methadone.https://one.nhtsa.gov/people/injury/research/job185drugs/methadone.htm [accessed 24.06.17].Search in Google Scholar

[22] Molokhia M, Majeed A. Current and future perspectives on the management of polypharmacy. BMC Fam Pract 2017;18:70.Search in Google Scholar
Received: 2017-04-25
Revised: 2017-06-26
Accepted: 2017-07-05
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2017.07.006
Keywords for this article
Intrathecal morphine therapy; Side effect; Multidisciplinary; Pain management; Opioid tapering

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  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
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  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
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  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
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  34. Effects of validating communication on recall during a pain-task in healthy participants
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  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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