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Reducing New Persistent Opioid Use After Surgery: A Review of Interventions.

This review aims to summarize interventions used in the perioperative period to reduce the development of new persistent postoperative opioid use in opioid-naïve patients.

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Diversity of receptor expression in central and peripheral mouse neurons estimated from single cell RNA sequencing.

Because somatosensory PNS neurons, in particular nociceptors, are specially tuned to be able to detect a wide variety of both exogenous and endogenous signals, one might assume that these neurons express a greater variety of receptor genes. This assumption has not been formally tested. Because cells detect such signals via cell surface receptors, we sought to formally test the hypothesis that PNS neurons might express a broader array of cell surface receptors than CNS neurons using existing single cell RNA sequencing resources from mouse. We focused our analysis on ion channels, G-protein coupled receptors (GPCRS), receptor tyrosine kinase and cytokine family receptors. In partial support of our hypothesis, we found that mouse PNS somatosensory, sympathetic and enteric neurons and CNS neurons have similar receptor expression diversity in families of receptors examined, with the exception of GPCRs and cytokine receptors which showed greater diversity in the PNS. Surprisingly, these differences were mostly driven by enteric and sympathetic neurons, not by somatosensory neurons or nociceptors. Secondary analysis revealed many receptors that are very specifically expressed in subsets of PNS neurons, including some that are unique among neurons for nociceptors. Finally, we sought to examine specific ligand-receptor interactions between T cells and PNS and CNS neurons. Again, we noted that most interactions between these cells are shared by CNS and PNS neurons despite the fact that T cells only enter the CNS under rare circumstances. Our findings demonstrate that both PNS and CNS neurons express an astonishing array of cell surface receptors and suggest that most neurons are tuned to receive signals from other cells types, in particular immune cells.

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Pain-like behavior in mice can be induced by the environmental context in which the pain stimulus was previously given.

It has been known for decades that classical conditioning influences pain perception. However, the precise mechanism of pain modified by conditioning remains unclear, partly because of the lack of dedicated behavioral tests. In the present study, we aimed to develop a new method to detect conditioned pain using mice that were injected with formalin as an unconditioned nociceptive stimulus into the hind paw repetitively under a neutral environment. On the test day, the mice exhibited a pain-like behavior without the application of a pain stimulus in the environment. These results demonstrate that a conditioned nociceptive response can be induced by exposure alone to the environmental context in which the pain was previously experienced. The conditioned nociceptive response was sustained for at least 2 weeks. Furthermore, the conditioned nociceptive response was reduced by fentanyl but not by ibuprofen, pregabalin or fluvoxamine. This method may be useful for studying the mechanisms of irritable chronic pain and for the development of novel therapeutic strategies.

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Left to themselves: Time to Target Chronic Pain in Childhood Rare Diseases.

Chronic pain is prevalent among patients with rare diseases (RDs); however, little is understood about the integration of biopsychosocial mechanisms as they relate to the unique set of clinical features and therapeutic challenges inherent in the pain conditions of patients with RDs.

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Alpha entrainment drives pain relief using visual stimulation in a sample of chronic pain patients: a proof-of-concept controlled study.

One-third of the population in the UK and worldwide struggle with chronic pain. Entraining brain alpha activity through noninvasive visual stimulation has been shown to reduce experimental pain in healthy volunteers. Neural oscillations entrainment offers a potential noninvasive and nonpharmacological intervention for patients with chronic pain, which can be delivered in the home setting and has the potential to reduce use of medications. However, evidence supporting its use in patients with chronic pain is lacking. This study explores whether (a) alpha entrainment increase alpha power in patients and (b) whether this increase in alpha correlates with analgesia. In total, 28 patients with chronic pain sat in a comfortable position and underwent 4-min visual stimulation using customised goggles at 10 Hz (alpha) and 7 Hz (control) frequency blocks in a randomised cross-over design. 64-channel electroencephalography and 11-point numeric rating scale pain intensity and pain unpleasantness scores were recorded before and after stimulation. Electroencephalography analysis revealed frontal alpha power was significantly higher when stimulating at 10 Hz when compared to 7 Hz. There was a significant positive correlation between increased frontal alpha and reduction in pain intensity (r = 0.33; P < 0.05) and pain unpleasantness (r = 0.40; P < 0.05) in the 10 Hz block. This study provides the first proof of concept that changes in alpha power resulting from entrainment correlate with an analgesic response in patients with chronic pain. Further studies are warranted to investigate dose-response parameters and equivalence to analgesia provided by medications.

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Plantar incision with severe muscle injury can be a cause of long-lasting postsurgical pain in the skin.

Although chronic local inflammation in deeper tissues after skin wound healing might produce chronification of acute postsurgical pain, its mechanisms have not been fully elucidated. We hypothesized that muscle injury and severe inflammation would prolong acute postsurgical pain by its central nervous system mechanisms.

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Cannabinoid receptor agonists from Conus venoms alleviate pain-related behavior in rats.

Cannabinoid (CB) receptor agonists show robust antinociceptive effects in various pain models. However, most of the clinically potent CB1 receptor-active drugs derived from cannabis are considered concerning due to psychotomimetic side effects. Selective CB receptor ligands that do not induce CNS side effects are of clinical interest. The venoms of marine snail Conus are a natural source of various potent analgesic peptides, some of which are already FDA approved. In this study we evaluated the ability of several Conus venom extracts to interact with CB1 receptor. HEK293 cells expressing CB1 receptors were treated with venom extracts and CB1 receptor internalization was analyzed by immunofluorescence. Results showed C. textile (C. Tex) and C. miles (C. Mil) samples as the most potent. These were serially subfractionated by HPLC for subsequent analysis by internalization assays and for analgesic potency evaluated in the formalin test and after peripheral nerve injury. Intrathecal injection of C. Tex and C. Mil subfractions reduced flinching/licking behavior during the second phase of formalin test and attenuated thermal and mechanical allodynia in nerve injury model. Treatment with proteolytic enzymes reduced CB1 internalization of subfractions, indicating the peptidergic nature of CB1 active component. Further HPLC purification revealed two potent antinociceptive subfractions within C. Tex with CB1 and possible CB2 activity, with mild to no side effects in the CB tetrad assessment. CB conopeptides can be isolated from these active Conus venom-derived samples and further developed as novel analgesic agents for the treatment of chronic pain using cell based or gene therapy approaches.

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Effectiveness of placebo interventions for patients with non-specific low back pain: a systematic review.

Little is known about the effectiveness of placebo interventions in patients with non-specific low back pain (LBP). This systematic review assessed the magnitude of the effects of placebo interventions as compared to no intervention in randomized controlled trials(RCTs) including patients with LBP. Embase, Medline(Ovid) and Cochrane CENTRAL databases were searched from inception to December 5th, 2019. RCTs comparing placebo intervention versus no intervention in adult patients with non-specific LBP were included. Pain intensity, physical functioning and health-related quality of life (hrQoL) measured at short-, medium- and long-term follow-up were the outcomes of this review. Twenty-one RCTs were included; one concerning acute LBP and one sub-acute LBP, while 19 studies reported on chronic LBP. In chronic LBP, placebo interventions were more effective than no intervention at short-term for pain intensity [standardized mean difference (SMD) = -0.37, 95% CI = -0.55 to -0.18, moderate quality evidence], physical functioning (SMD -0.19, 95% CI = -0.39 to 0.01, moderate quality evidence), and physical quality of life (Mean Difference = -2.71, 95% CI = -4.71 to 0.71, high quality evidence), respectively. These effects were not significant at medium-term follow-up and no data was available at long-term follow-up. These results show placebo interventions are more effective than no intervention at short-term in patients with chronic LBP. However, the magnitude of the effects is probably not clinically relevant (approximately 8 points on a 0-100 pain scale). Future research should identify effect modifiers and causal mechanisms explaining the short-term effects of placebo interventions in patients with chronic LBP. (PROSPERO Registration number CRD42019127465).

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The encoding of cutaneous stimuli by lamina I projection neurons.

Lamina I of the dorsal horn, together with its main output pathway, lamina I projection neurons, have long been implicated in the processing of nociceptive stimuli, as well as the development of chronic pain conditions. However, the study of lamina I projection neurons is hampered by technical challenges, including the low throughput and selection biases of traditional electrophysiological techniques. Here we report on a technique which employs anatomical labelling strategies and in vivo imaging to simultaneously study a network of lamina I projection neurons in response to electrical and natural stimuli. While we were able to confirm the nociceptive involvement of this group of cells, we also describe an unexpected preference for innocuous cooling stimuli. We were able to characterize the thermal responsiveness of these cells in detail and found cooling responses decline when exposed to stable cold temperatures maintained for more than a few seconds, as well as to encode the intensity of the end temperature, while heating responses showed an unexpected reliance on adaptation temperatures.

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‘Reassurance and health care seeking in people with persistent musculoskeletal low back pain consulting orthopaedic spine practitioners: A prospective cohort study’.

Guidelines recommend self-management for most people living with persistent musculoskeletal low back pain (PMLBP) when surgery is ruled out. Conveying this message to patients can be challenging. This study examined patients' perceptions of reassuring communications from surgical spine team practitioners attempting to deliver this message in a single consultation.

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