People with chronic pain faced potential treatment disruption during the COVID-19 pandemic in Singapore, as the focus of healthcare shifted. A model of rapid integration of a pain centre with community healthcare teams was implemented to care for vulnerable older patients with chronic pain and multiple comorbidities. Telemedicine and home visits by community nurses were used, with risk-mitigation measures, ensuring comprehensive assessment and treatment compliance. Medications from pain physicians were delivered at home through a hospital pharmacy. A secure national electronic health records system used by all teams ensured seamless access and documentation. Potential emergency department visits, admissions and delayed discharges were thus avoided. Integration of community teams with chronic pain management services can be recommended to ensure pandemic preparedness.
Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions.Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.
This is the first study to show that a single session of SMS resulted in significant improvement of pain associated with lumbar spondylosis in a randomized, double-blind, placebo-controlled setting. The novel findings support the potential of this technique for future studies pertaining to neuropathic pain.
BackgroundPain from cervical spondylosis (CS) may result from degenerative spinal canal stenosis (cervical spondylotic myelopathy (CSM)) or lateral recesses compromise, leading to nerve root compression (cervical spondylotic radiculopathy (CSR)). Pregabalin was shown to be effective in randomized, placebo-controlled trials for post-herpetic neuralgia and diabetic neuropathy. We evaluate its efficacy in CS with underlying CSR or CSM in a prospective study comprising Asian patients for the first time.MethodsPatients with CS and CSR or CSM (clinical, MRI, or electrophysiological evidence) presenting with neuropathic pain were recruited. We excluded patients with diabetes, underlying neurological disease or who were previously on antiepileptics. Pregabalin 75 mg bd was administered for 4 weeks, after which dosage was increased to 150 mg bd for another 4 weeks if the visual analog scale (VAS) was not reduced by 50%. In addition, we monitored the short form McGill pain questionnaire (SFMPQ) at baseline, 4 weeks and 8 weeks. Mood changes were monitored using the hospital anxiety and depression score (HADS) with an identical timeline.ResultsWe recruited 50 patients, of which 23 completed the trial. Of the 27 who withdrew, 12 (44%) were for somnolence. Thirteen patients’ (54%) dosages remained at 75 mg and 11 patients’ (46%) dosages were escalated to 150 mg bd. There were significantly reducing trends from baseline for VAS (ANOVA, F(1, 21) = 25.4, P < 0.0005), SFMPQ (sensory) (F(1, 22) = 11.2, P = 0.003), and SFMPQ (affective) (F(1, 21) = 10.9, P = 0.008). For VAS, there was significant reduction at 4 weeks (P = 0.001) and 8 weeks (P < 0.0005) compared to baseline. For SFMPQ (sensory), there was significant reduction at 4 weeks (P = 0.01) and 8 weeks (P = 0.006) in scores compared to baselines. For SFMPQ (affective), there was significant reduction at 4 weeks (P = 0.04) and 8 weeks (P = 0.008) in scores compared to baseline. No significant anxiety (F(1, 4) = 1.3, P = 0.32) or depression (F(1, 4) = 0.06, P = 0.82) changes were observed in the HADS.ConclusionPregabalin is efficacious in alleviation of pain symptoms related to CSR as a first-line single agent, evaluated by quantitative severity and other experiential scales. No significant mood changes reported in other studies were demonstrated. Somnolence was commonest adverse effect leading to high dropout rates, occurring early even at the lowest dose. The findings suggest the need for further studies of efficacy at lower dosages, particularly in the Asian population.
India is a key nation which is endemic and epidemic to tuberculosis and diabetes. An association between diabetes and TB is biological plausible, where diabetes impairs the immune system and making it harder for the body to fight against infection. Methodology: Patients on DOTS therapy in continuation phase of anti-TB therapy, Patients with TB and Diabetes and Patients with TB alone were included in the study. Blood samples were collected and Fasting Blood Glucose (FBG), Post Prandial Glucose (PPG) and Glycated Hemoglobin (HbA1c) were measured to understand the glycemic status and its impact on TB treatment outcomes. Results: Our study confirms the fact that type II diabetes is a strong risk factor for tuberculosis and is associated with a slower response to TB treatment and a higher mortality rate. Incidence of TB is greatest among those with conditions impairing immunity such as DM. Diabetes impairs the immune system, making it harder for the body to fight against infection.
Introduction: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. Materials and Methods: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. Results: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. Conclusion: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as second- or third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required. Key words: Chronic pain, Consensus statement, Guidelines, Non-cancer pain, Opioids
INTRODUCTIONThe use of opioids in chronic non-cancer pain (CNCP) is controversial, as it presents both benefits and risks. There is currently no available data on the incidence, prescription pattern, functional outcomes and adverse effects of opioids in patients with CNCP in Singapore. This study aimed to address the aforementioned deficit. METHODSAll records of patients who were prescribed strong opioids (for > 3 months per year) for the management of CNCP over a two-year period were retrospectively analysed. Factors including type of opioid, indications for opioid prescription, uncontrolled side effects, functional status, coexisting psychological issues and suspicion of aberrant drug-seeking behaviour were studied. RESUlTSOut of the 1,389 new patients who visited the centre, 42 (3.0%) with CNCP received strong opioids for more than three months a year. The most commonly prescribed opioid was methadone (42.9%). The principal diagnosis for opioid prescription was spinal pain (38.1%). Ten patients had severe side effects. 15 patients saw improvement in activities of daily living scores. Although ten patients returned to work, one stopped following the commencement of opioids. Aberrancy was seen in 5 (11.9%) patients, while 19 (45.2%) had psychological issues and 10 (23.8%) required psychiatric co-management.CONClUSION Opioids are not a panacea for chronic pain. Therefore, functional outcomes should be considered more important end points than mere reductions in pain scores. A multidisciplinary team approach is essential for the effective management of patients with CNCP who are on opioids.
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