The findings of an expert panel convened to review critically how best to apply evidence-based guidelines for the treatment of acute pain in the Middle East region are presented. The panel recommended a three-step treatment protocol. Patients with mild-to-moderate levels of acute pain should be treated with paracetamol (step 1). If analgesia is insufficient after 1 -2 days, a selective cyclo-oxygenase-2 inhibitor or, if gastrointestinal safety and bleeding risk are not an issue, a non-specific nonsteroidal anti-inflammatory drug, should be used (step 2). If analgesia remains inadequate, treatment with tramadol, or paracetamol plus codeine/tramadol is recommended (step 3). Patients reporting severe pain should be referred to a pain clinic or specialist for opioid analgesic treatment. Measures of pain and functioning that have been validated in Arabic, with culturally appropriate and easy to understand descriptors, should be used. Early and aggressive acute pain management is important to reduce the risk of pain becoming chronic, especially in the presence of neuropathic features.

The limited access to opioids remains a reality in developing countries. Recent evidence suggests that opioid epidemics are getting worse with the COVID-19 crisis. The increase in opioid abuse could be attributed to the extended lockdowns and the social distancing recommendations, hindering chronic pain patients’ access to regular office visits and monitoring in addition to limited access to behavioral services like group therapies and other pain management interventions. Use of telemedicine as an alternative to in-person follow-up visits has faced many limitations due to technological challenges and cost.Chronic pain patients living in developing countries face extra burden during the pandemic. Limited access to outpatient clinics and hesitance to visit hospitals due to COVID-19 pandemic, in addition to reduction in supply of opioids, are some of the limiting factors. Unfortunately, the low-income class with limited financial capabilities faces further barriers to access the chronic pain services and treatments like opioid prescriptions.Medical entities involved in care of chronic pain patients have adopted different strategies to overcome these challenges. In addition to expanding on educational programs to medical staff and patients, modifying the strict opioid prescribing and dispensing regulations has been successful. Another positive trend has been the growing use of opioid sparing interventions, such as multimodal analgesia, regional blocks, and interventional pain procedures.

Our preliminary data suggest possible efficacy of thoracic epidural steroid and clonidine mixture in the treatment of chronic post-thoracotomy pain. No serious adverse effects were noted in this pilot study.

Background: Resistin is a hormone that is linked to the development of insulin resistance (IR), but information on the direct relationship of resistin levels in humans with nonalcoholic fatty liver disease (NAFLD), and their effect on the histological severity of NAFLD, is lacking. Objective: The aim of the current study is to determine the circulating resistin levels obtained from patients with NAFLD and to correlate them with insulin resistance and hepatic histological features. Methods: Blood samples were collected from 30 consecutive patients with liver-biopsy-proven NAFLD and 30 subjects as controls. Serum resistin levels were measured. Body mass index (BMI) was calculated for all subjects, and serum insulin, C-peptide, and lipoprotein levels were also measured. Results: Mean serum resistin level and BMI in the NAFLD group were significantly higher than in the controls (both P < 0.001). Both men and women in the NAFLD group had higher mean serum resistin levels than did the men and women in the control group (all P < 0.001). Multivariate analysis showed that the percentage of hepatic steatosis, sex, BMI, and homeostasis model assessment of insulin resistance [HOMA(IR)] were related to serum resistin levels. Conclusion: These data suggest increased resistin levels in NAFLD patients which are related to histological severity of the disease. These findings support the link between resistin, insulin resistance and BMI in these patients.

Introduction: Nalbuphine, a synthetic kappaopioid receptor (KOR) agonist and a partial lopioid receptor (MOR) antagonist, has been used for years as an effective analgesic. It has been shown to have a better safety profile than morphine. Considering the long history of use of this drug, it is interesting that only a limited amount of information exists on how gender