Mehta, Neel D

Patients receiving opioid analgesics may experience constipation [ie, opioid-induced constipation (OIC)], require treatment to induce laxation, and may be at risk for gastrointestinal perforation, an uncommon but potentially life-threatening condition. Management of OIC includes treatment with over-the-counter laxatives and peripherally acting μ-opioid receptor antagonists (PAMORAs; methylnaltrexone, naloxegol, naldemedine). In patients receiving treatment for OIC, gastrointestinal perforation may result from the laxation process, causing disruption of the gastrointestinal lining that may already have compromised integrity. A PubMed literature review and a search of the US Food and Drug Administration Adverse Event Reporting System database identified several cases of gastrointestinal perforation (life-threatening or with mortality) across the range of agents administered for the treatment of OIC or other constipation types. Methylnaltrexone in the subcutaneous form was the first PAMORA approved for OIC. Its real-world use in the ∼6 years before the availability of another OIC-indicated PAMORA helped establish the adverse-event profile of the class, and experience has been gained in identifying and treating appropriate patient populations. Class labeling of PAMORAs includes a contraindication in patients with known or suspected gastrointestinal obstruction or increased risk of recurrent obstruction. Appropriate patient selection during laxation therapy for OIC, regardless of treatment plan, involves consideration of the overall risk versus benefit in patients at increased risk of perforation due to comorbid medical conditions, concurrent medications, or recent gastrointestinal procedures. After initiating treatment for OIC, clinicians should assess the effectiveness of laxation therapy and carefully monitor for signs of gastrointestinal perforation.

This study reports the needs-based development, effectiveness and feasibility of a novel, comprehensive spinal cord stimulation (SCS) digital curriculum designed for pain medicine trainees. The curriculum aims to address the documented systematic variability in SCS education and empower physicians with SCS expertise, which has been linked to utilization patterns and patient outcomes. Following a needs assessment, the authors developed a three-part SCS e-learning video curriculum with baseline and postcourse knowledge tests. Best practices were used for educational video production and test-question development. The study period was from 1 February 2020 to 31 December 2020. A total of 202 US-based pain fellows across two cohorts (early-fellowship and late-fellowship) completed the baseline knowledge assessment, while 122, 96 and 88 participants completed all available post-tests for Part I (Fundamentals), Part II (Cadaver Lab) and Part III (Decision Making, The Literature and Critical Applications), respectively. Both cohorts significantly increased knowledge scores from baseline to immediate post-test in all curriculum parts (p<0.001). The early-fellowship cohort experienced a higher rate of knowledge gain for Parts I and II (p=0.045 and p=0.027, respectively). On average, participants viewed 6.4 out of 9.6 hours (67%) of video content. Self-reported prior SCS experience had low to moderate positive correlations with Part I and Part III pretest scores (r=0.25, p=0.006; r=0.37, p<0.001, respectively). Initial evidence suggests that Pain Rounds provides an innovative and effective solution to the SCS curriculum deficit. A future controlled study should examine this digital curriculum’s long-term impact on SCS practice and treatment outcomes.