Abstracts from FEDELAT 2016 meeting: Latin American Federation of IASP chapters

We are pleased to share the abstracts of presentations from the recent XI Congreso Latinoamericano de dolor FEDELAT, June 15 to 17, 2016 in Costa Rica. The Latin American Federation of IASP Chapters (FEDELAT, in Spanish) was founded in 1990 by the presidents of the Mexican, Colombian, Argentinian, and Puerto Rico's IASP Chapters. To date FEDELAT is composed of 18 IASP chapters. The main purpose of the Federation is to encourage education and networking relations among chapters strengthening regional collaboration. Over the last 14 years FEDELAT has maintained a close relation with the Spanish and Portuguese IASP chapters. Together, the 3 institutions, conducted the Ibero-American Reunion (RIAD, in Spanish). This event takes place every year, gathers professionals from both Europe and Latin-America, and exposes the regional advances on diverse pain issues. FEDELAT had an important collaboration in events that promote education in Latin America. The former president, Dr Fabián Piedimonte, from both FEDELAT and the Argentinian IASP chapter represented the regional committee that organized the IASP World Pain Congress in Buenos Aires. FEDELAT's president is Dr Elias Atencio. Dr Atencio and the directive board have continued this work and over the last 2 years had organised the following events: (1) The Hands-On Course on interventional techniques for pain control which took place in Buenos Aires (Argentina) from April 20 to 30, 2016; another will take place in Panama City (Panama) from November 10 to 20, 2016. (2) The Annual RIAD occurred in Sevilla, Spain in 2015 and in San Jose, Costa Rica in 2016. In Costa Rica most lectures were centered on “articular pain” according to the IASP International Day Against Pain. (3) FEDELAT is collaborating with the Mexican IASP Chapter to promote and organize the IASP Pain Management Camp. This second event in Latin America will include lectures about articular pain, cancer pain, acute pain, and opioids pharmacology and will take place October 10 to 15, 2016 in Mexico City, Mexico. (4) Also the federation is developing research protocols to assess epidemiological aspects of chronic pain and conducted Practice Guidelines adapted to Latin American needs. These guidelines were published in a peer reviewed medical journal indexed in LILIACS. During the Annual RIAD 4 general modules were discussed cancer pain and palliative care, research and education to improve pain curricula in Latin America, pharmacological pain relief, and interventional techniques for pain relief. In conclusion, the Federation and regional IASP Chapters are working together, harder than ever, in order to achieve a Latin America Without Pain. Alfredo Covarrubias-Gómez, MD Pain and Palliative Medicine http://www.covarrubias-gomez.org Federación Latinoamericana de Asociaciones para el Estudio del Dolor (FEDELAT) Latin-American Federation of Associations for the Study of Pain Secretary Mexican Association for the Study and Treatment of Pain: An International Association for the Study of Pain Chapter Past president National Centre for the Study of Pain CEO and founder Department of Pain and Palliative Medicine, Mexican NHI on Internal Medicine Attending physician/Associate professor Acknowledgement: We thank Dr Melissa Garcia-Pons for her invaluable help with translation of some of the abstracts. Abstracts Cancer related pain: an update Alfredo Covarrubias-Gomez, MD Department of Pain and Palliative Medicine at the National Institute of Internal Medicine, Mexican NIH. It is being reported that about 50% of cancer patients will report pain. Opioid therapy has been considered safe and effective in the management of moderate to severe pain intensity in cancer patients. Morphine Consumption Data has been considered as an indicator to assess the efficacy of cancer pain treatment. Worldwide opioid consumption shows a significant disparity. Average opioid consumption in Latin-American countries is about 6 mgME “per cápita” (mgME, milligrams in morphine equivalence) while in Canada and USA report an average of 722.7 mgME and 717.8 mgME “per cápita” respectively. Opioid therapy for cancer-related pain management poses 3 major issues: (1) limited opioid use promoting an inefficient pain control, (2) rightful concerns about inappropriate opioid use even in the cancer population, and (3) presence of chronic pain in cancer survivors. Pharmacological management includes: (1) Non-steroid Anti-inflammatory Drugs (NSAIDs): These drugs had shown insufficient analgesia in moderate and severe pain intensity, an analgesic ceiling effect without dose-dependent relation, and a dose-dependent occurrence of adverse effects. (2) Opioid therapy includes Fentanyl, Oxycodone, Tapentadol, Methadone, Buprenorphine, and Morphine. These drugs are effective and safe for cancer-related pain management. However some of them pose issues related to the strength of the evidence (Methadone and Tapentadol). Transcutaneous Fentanyl had been studied in at least 4 meta-analyses for breakthrough pain. Non-pharmacological management includes: (1) Neurolytic celiac plexus block: This approach reported a persistent benefit in a long-term follow-up beyond 3 months. (2) Transcutaneous Electrical Nerve Stimulation (TENS): This technique failed to provide sufficient evidence to determine its effectiveness in cancer-related pain. (3) Acupuncture: This approach failed to provide sufficient evidence to determine its effectiveness in cancer-related pain. (4) Massage: Despite being weak, the available evidence suggests a beneficial effect of massage techniques for cancer pain relief. (5) Traditional herbal medicine: This approach combined with conventional therapy might be efficacious as an adjunctive therapy for patients with cancer pain. Pain in cancer survivors is observed in 30% to 60% of survivors. Although there is not any specific guideline opioids may be considered for moderate to severe pain that has been unresponsive to non-opioid therapies and non-pharmacologic approaches and when the chronic opioid therapy is likely to possess equivalent or better risk-to-benefit ratios. Ozone therapy and pain Ana Pedro, MD Hospital Professor Doutor Fernando Fonseca, Rua José Ferrão Castelo Branco, no. 1, Paço de Arcos, Lisboa, 2770-098, Portugal Treatment with ozone is increasing worldwide as a result of its simplicity of application, high efficiency, good tolerance and almost no side effects. In 1785, Dr Martin van Marum, notes that a gaseus substance with characteristic odor and oxidative properties is produced as a result of a strong electrical discharge in the air. In 1840 Prof Cristian Schobein correlated the described changes with the formation of a gas called ozone. Composed by 3 oxygen atoms, the ozone is an unstable gas, denser and more soluble in water than oxygen. It is a powerful oxidant that can be produced by chemical electrolysis, electric discharge and ultra-violet radiation. Ozone cannot be stored and must be used immediately after its production because of its instability and rapid decomposition. At the concentrations used in clinical practice, ozone is believed to have immunomodulatory, anti-inflammatory, antibacterial, antiviral, fungicidal and analgesic characteristics. The application of ozone for treatment of pain is based on its potent analgesic and anti-inflammatory effect, resulting from decreased production of inflammatory mediators and oxidation (inactivation) of mediators of pain, improvement of microcirculation and tissue oxygenation, elimination of toxins and activation of endogenous analgesic mechanisms. Ozone therapy has several clinical indications in the area of ​​pain, especially in low back pain, herniated discs, disc-radicular disease and osteo-articular pathology. It can be applied locally or parenterally, and may be used more than one pathway in combination with a synergistic effect between them. Inhalation is contraindicated because it is highly toxic to the lungs. Further, direct intravenous injection of ozone is not recommended because of the risk of embolism. Ozone can be administered locally to intervertebral disc, paravertebral or epidural spaces, intramuscular, intraarticular, subcutaneous, in trigger points, vagina, bladder, urethra and rectum. Another way is parenteral auto-hemotherapy, consisting of a mixture of ozone and blood withdrawn from the patient by a specific device. Blood is then reinfused, without contact with the external environment. Medical use of cannabis and cannabinoids: evidence and controversy Maria A. Rico, MD Anestesiologist/Pain Specialist, Clinica Alemana Santiago, Chile Introduction: In recent years there is a growing interest of patients and their families in the potential benefit derived from cannabis sativa use, to relieve cáncer related pain and other symptoms, and other chronic diseases. The existence of an endocannabinoids system and specific receptors are known since 1990. Mechanism of action: Agonism of CB1 receptors modulate synaptic transmission of excitatory and inhibitory circuits. Effects depend on the specific neural area stimulated, acting upon analgesia, memory process, appetite, muscle tone, etc. Activation of CB2 receptors may influence the activity of cytokines in the immune response to inflammation. Scientific evidence of cannabinoids in medicine: Nausea/vomiting in patients with cancer and chemotherapy, using synthetic derivatives as dronabinol and nabilone, showed significant benefit until year 2000. The introduction of antiemetic agents, such HT3 blockers, leave cannabinoids as a third line indication. The effect of increased appetite with THC derivatives is significant only in HIV patients; it has not been seen in cancer patients. Anxiolytic effects and improved night sleep, although they are popular, they are not support in the literature. Benefits in epilepsy and multiple sclerosis has been stated. The use in refractory epilepsy, is becoming very popular, but it is still anecdotal. Cannabinoids as analgesics: Comparative studies of cannabinoids and opioids demonstrate an efficacy equivalent to a weak opioid as dihydrocodeine, with limitation of adverse effects in increasing doses (Dizziness, dry mouth, fatigue, drowsiness, euphoria, agitation). Non oncologic pain: Systematic reviews show studies in a wide variety of pathologies and doses. Cannabinoids were administrated as natural and synthetic forms, via inhaled, oral and transmucosal route. The results are generally modest, with a relative greater efficacy in neuropathic pain, but always the benefits are limited by its non-negligible adverse effects when increasing doses. Then, the evidence of benefits is rather weak. In palliative care: For pain control, it seems beneficial as an adjuvant to opioids treatment, allowing for reduction of their doses, and not as a single analgesic. It has also been pointed out that cannabinoids can contribute to a better quality of life, related to reduced anxiety, better night time sleep, appetite and are generally well appreciated by patients and families. Conclusion: Cannabinoids in pharmaceutical forms could be useful in a selected group of patients, for the management of some symptoms. Indications for interventional techniques in refractory chronic pain management Dr Marco Antonio Narváez Tamayo Attending Specialist, Study and Treatment of Pain Unit at the Hospital Obrero No. 1 (Hospital materno-infantil), Caja Nacional de Salud, La Paz, Bolivia Introduction: Minimally invasive percutaneous techniques have drastically changed the therapeutic paradigm of conventional surgery. Current training, skills, instruments, image accuracy among other factors have brought us forward, achieving access to what was unthinkable many years, so we now can inhibit, control or solve problems that detract greatly the quality of life of our patients with refractory chronic pain. Objective: Determine the indications of interventional techniques in the refractory chronic pain management. Material and method: A non-systematic review of the literature was conducted, identifying articles on the basis of the following MeSH terms: indications, interventional treatment, technologies, blockade, radiofrequency, refractory chronic pain or neurolysis. Those who presented more than 3 terms were included in the search. Considerations included place or site where the study has developed, and the number of cases reviewed. Different techniques commonly used in specialized units of treatment pain were reviewed, selecting the most frequent and those enrolled with the strongest evidence available to date. These include thermal radiofrequency of the medial branch of dorsal roots, cervical epidural analgesia, percutaneous epidural neuroplasty with Catheter Racz, radiofrequency of the sacroiliac joint, vertebroplasty, kyphoplasty, cementing the hip in mode femoro-cementoplasty, disc nucleoplasty by radiofrequency, neurolysis of stellate ganglion, selective inhibition of the splanchnic nerves, celiac plexus neurolysis, superior hypogastric plexus and ganglion Walther (odd node), radiofrequency of the dorsal root ganglion, foraminoplasty, in chronic cancer pain, among the most In order to review the indications for invasive treatment, they were 4 major and neurolysis. In this we show the results of some of the most techniques of this also included control or of chronic pain in patients and of A for most of invasive has been the low in the pain intensity the as well as in the the is represented by the low and a of adverse effects in this research Conclusion: The increasing of invasive techniques is in recent years, results in relation to the of chronic pain refractory to These techniques are safe when in specialized with interventional pain techniques and the guidelines for the quality of the are use of opioids MD Hospital de de Spain Opioid are effective for the treatment of moderate to severe pain of that are of the and of but it is important to to and the in opioid of opioid in America Europe might factors in the The main controversy is about opioids for pain management of or in which therapies might be review of recent medical and literature most recent published in of in order to the with the in the of existence of of with opioid and even of in It was that opioids may contribute to the of a of which has to the of clinical guidelines for and specific by both medical and the by the group of patients and their In to to to be although a time to determine will be while the controversy over the use or of opioid still will in The of one of or another to the pain of be considered in the of pain in the of to the treatment, the response that the has shown to its beneficial and even the in this that the patient can in other of treatment for in as are other in of for cancer pain Prof Pain and Palliative Cancer Hospital of Pain is one of the most of over of the patients the of their treatment. In cases pain is to as severe in the and it from multiple In order to this the World an approach to the treatment of cancer pain patients using a 3 system in which opioids are as the to the treatment, but also the of This has been considered effective in pain, pain in of patients, 30% of cancer patients still developing refractory pain. For interventional techniques have been as a in the analgesic pain have considered this approach in the of treatment in order to therapy for cancer can be several the injection of of the celiac plexus is for patients with cancer with severe pain, although it may be to other such as and to the of the pain, opioid and of side and as with analgesic of the superior hypogastric plexus may be used to control cancer pain. ganglion neurolysis is effective for pain from cancer or from is effective to pain from to the study showed that of the patients greater than 50% improvement in pain and reduced their analgesic use after the evidence for those is weak as it from or neurolysis is a therapy to patients from refractory pain. this can significant and it is for patients with low life and Although evidence for this neurolysis is it is also derived from quality To interventional techniques may be used to promote better pain control for patients refractory to opioid or who are limited by side effects. since are invasive and are not from must benefits and with the anti-inflammatory and Department of and National and and them the most and used in drugs on a worldwide of review articles with the anti-inflammatory adverse events has been (1) are one of the most adverse events related to The relative risk of and is of in to It is recommended to risk factors and presence of use of and other The selective are with the of and the use of can (2) use is with a but events in by the although the can be with a potential (3) events: is but its risk is increased in those patients with or or (4) by especially by are the most frequent drugs (5) events: and are low to the that is a studies have to be and (1) The selective are not more efficacious than (2) intravenous or of not adverse events and are not more (3) use of 2 or more not their but their (4) The can be used in low risk patients for of (5) to is in Latin America, Spain and other to a Mexican, Latin America, Spanish and is an with a very and of epidural Attending Specialist, Department of Pain Medicine at the Caja de Panama City, Panama The with the injection of are but a recent report an in in the a of cases with with this of from the toxic effects of the in the they are the reported from this A recent study a of epidural in patients were cervical and were were increased pain pain in the site persistent and The were with the than with the In general can be as (1) and to The is as and low back and pain, increased and muscle in the back and and The second is a that of pain in the and in severe cases It is to determine which of the is the suggests that is the is no treatment for or for treatment is the (2) potential include by the injection injection a with (3) Pharmacological effects such as effects and of the and its interventional treatment Fabián in the for and of Medicine, Buenos Aires Buenos The of suggests 3 of (1) or (2) with persistent and (3) by a other that in a clinical the by has a and more the pain in based on their and In terms of its suggests that the is by a of the root close to the a blood or a to a of by by is an of some of the available studies that the in the general between and and the of to is about It can at any but over of the cases being its of between and years The of in multiple sclerosis is than in the general Pain is with only of and are the most commonly or while is The medical treatment is based on the use of drugs The according to treatment guidelines based on be and The treatment, with of or other and of medical treatment to such as (1) (2) percutaneous to the ganglion by drugs by radiofrequency, or and (3) by to pharmacological treatment for patients with chronic pain in Mexico Alfredo A. Ana and Palliative Medicine, at Nacional de Objective: To of therapy in patients with chronic pain in a Mexican Pain A and committee research Those that were was with the pain and therapeutic number of drugs by the patient for and with analgesic number of and other of and of and and were cases were were The average was had a of number of was and number of was cases had chronic pain those cases had pain 2 cases pain 2 cases neuropathic pain 10 cases had both and neuropathic Average of analgesic drugs for the treatment of chronic pain was pain was the most Conclusion: This study that pain intensity correlated with It was also that on the of pain the is a that could on to studies are to the of in and Latin-American Cancer pain pharmacological Department of and pain, National Cancer is one of the main for in the and cancer cases are to by over the 20 The World pain pain in 60% to patients, but has to the that cancer patients have a to and are by neuropathic pain. The management of pain based on has over the years, to the in to This study included a for cancer pharmacological management or treatment, over the last 10 that the of cancer pain management has to be based on pain that and Pharmacological The of pharmacology has with the therapeutic to and as well as the in the of the inhibitory (1) Morphine to be the most used as its such as analgesic efficiency, and low and are useful drugs (2) opioids can be used only pain is because they have a recommended after which the adverse effects more than the analgesic to problems by their its used is not recommended for and for of patients. (3) and have moderate when it to neuropathic pain (4) Fentanyl is useful in breakthrough pain. In there are or adjuvant and Non drugs such as effects of and must be In conclusion, the pain is more for patients that are at the of their It is a to chronic pain as it was acute or life pain. The is to opioids and their adverse events a pain analgesic treatment, using analgesia, and management.

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