Education Without Barriers

24/08/2025

💊 Buprenorphine Transdermal Patch in Pain Management

🔹 Introduction
• Semi-synthetic opioid derived from thebaine
• In clinical use for over 30 years
• Acts as a non-selective mixed agonist–antagonist opioid receptor modulator
• Unique pharmacodynamic profile – allows for potent analgesia with fewer side effects
o partial agonist with a very high binding affinity for the µ-opioid receptor,
o antagonist for the δ- and κ-opioid receptors,
o agonist for the opioid receptor-like 1 receptor
• Available as transdermal patches (5, 10 & 20 mcg/hr)
• 25–100 times more potent than morphine
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🔹 Advantages of Buprenorphine Transdermal System (TDS)
✨ Sustained Pain Relief
✨ Fewer Side Effects
• Ceiling effect on respiratory depression & euphoria
• Lower addiction potential, less constipation
• No effect on sphincter of Oddi
• Minimal impact on hypothalamic–pituitary–adrenal axis → less risk of hypogonadism
✨ Convenience & Compliance- Once-weekly, non-invasive, reliable
✨ Metabolic Benefits
• Avoids first-pass metabolism
• Safe in elderly & patients with renal/hepatic impairment (no dose adjustments required)
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🔹 Practical Aspects for Healthcare Professionals
Indications:
• Opioid-responsive pain not controlled by non-opioid analgesics
• Effective in both nociceptive and neuropathic pain

Dosage & Administration:
• Opioid-naïve: Start with 5 mcg/hr patch
• Converting from other opioids: Discontinue all other around-the-clock opioids. Buprenorphine has the potential to precipitate withdrawal, so caution is needed.
o Prior Total Daily Dose of Opioid < 30 mg of Oral Morphine Equivalents - initiate treatment with buprenorphine patch 5 mcg/hour
o Prior Total Daily Dose of Opioid Between 30 mg - 80 mg of Oral Morphine Equivalents: start with 10 mcg/hour buprenorphine patch.
o Prior Total Daily Dose of Opioid Greater than 80 mg of Oral Morphine Equivalents per Day: buprenorphine patch 20 mcg/hour may not provide adequate analgesia for patients requiring greater than 80 mg/day oral morphine equivalents. Consider use of alternate analgesics.

Titration & Maintenance:
• Minimum titration interval: 72 hrs
• Max dose: 20 mcg/hr (due to QTc risk)

Discontinuation:
• Do not stop abruptly → taper gradually every 7 days

Application:
• Apply to non-irritated, intact skin (upper arm, chest, upper back, or side of chest)

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🔹 Contraindications & Precautions
❌ Severe respiratory depression
❌ Severe bronchial asthma (unmonitored setting)
❌ GI obstruction
❌ Severe hepatic failure
❌ Long QT syndrome, certain antiarrhythmics

⚠️ Caution with:
• Benzodiazepines
• CYP3A4 inhibitors
• Serotonergic drugs
• Avoid with mixed agonist/antagonist analgesics (may reduce effect or precipitate withdrawal)
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✅ Conclusion
The buprenorphine transdermal patch is a valuable and safe option for managing chronic pain. With its unique pharmacological profile, favorable side-effect spectrum, and convenient once-weekly application, it is particularly suitable for:
• Elderly patients
• Renal or hepatic impairment
• Patients requiring long-term opioid therapy

21/08/2025

BUPRENORPHINE (BUPOXONE) Webinar

We are pleased to invite you to our upcoming webinar session on:

Topic: Transdermal Buprenorphine Patch: A Modern Approach to Chronic Pain Management

📅 Date: 21/08/2025
🕒 Time: 07:30 – 08:30 PM
📍 Link: https://streamgo.in/Bupoxone/

✨ Highlights: Chronic pain management • Practical insights • Q&A session

📲 The attached invite also contains details of the Speaker, Moderator, Panelists, and the registration link.

We look forward to your valuable participation.

02/08/2025

🩺 The most powerful intervention I offered… wasn’t an injeciton or an answer. BUT A QUESTION❓

She cried when I asked what no one had in six years:
“Does the part of your foot that’s missing… hurt?” 💔

A silence followed.
Then tears.
Not because of the pain — But because someone had finally asked.

🦶 Six years ago, a horrific crush injury led to partial amputation of her foot.
She had seen many doctors & specialists. Not once was her pain validated.

She was unsure, She didn’t talk about it:
“Maybe it’s all in my head.”
“How can something that doesn’t exist… hurt?”

She carried it — In silence. In shame. In fear of being dismissed.
Until she sat across from someone who understood.

💡 What she had been living with was phantom limb pain —
It affects 60–80% of amputees, yet often remains undiscussed and unrecognized.🧠It’s real. It’s neurological. And it’s exhausting.

That day, validation was the first true intervention.
She didn’t just need medicine. 💊
She needed to be heard. 👂

💡 This moment taught me something:
✅ Validation can be diagnostic.
✅ Validation can be therapeutic.
✅ Validation can be transformational.

This is what we’re trained to do as pain physicians:
Not just prescribe.
Not just block.
But listen, decode, and understand. 🩺🧠

👩‍⚕️ If you're a clinician seeing amputees — especially in surgery, rehab, or general practice — please don’t skip this step.
👉Ask the question. Open the door. Validate the pain no one else could see.
It might be the most important thing you do that day.

🧠 KNOW Pain. 🚫 NO Pain.
‘Know’ means to recognize and validate — only then can we begin to extinguish it. Without validation, patients remain stuck in doubt, unable to begin the No Pain journey.

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11/06/2025

How to know the real mark of premium care?

A team that keeps learning — long after formal training ends.

At IPC, education isn’t a checkbox. It’s part of how we work.

Our full clinical team comes together for one purpose:
To stay sharp. To stay current. To stay better.

We dive into:
New pain science research via journal club
Evolving clinical frameworks
Complex case discussions
Better diagnostic thinking
Debriefing sessions

We ask:
What’s the new global evidence saying?
What can we do differently next time?
How can this change our next patient’s outcome?

No hierarchies. No assumptions. Just focused time to challenge, question, and improve

This is Education at IPC.

And it doesn’t just update our minds —
It reshapes the way we treat.
You may never sit in these rooms.

But you’ll feel the difference — in the clarity of thought, and the quality of care.

05/06/2025

📣 Tailoring Epidural Steroid Choices- Particulate vs Non-Particulate Steroids: Balancing Safety & Efficacy
‍👩‍⚕️⚕️ By Dr. Ichcha Muku | International Pain Centre

🔍 Did you know not all epidural steroid injections (ESIs) are created equal?
As interventional pain specialists, the choice between particulate and non-particulate steroids is important as it may impact on efficacy and patient safety, particularly during cervical and thoracic spine procedures.
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⚖️ Particulate vs Non-Particulate Steroids: A Quick Comparison

🟡 Particulate Steroids (e.g., Methylprednisolone, Triamcinolone):
✔️ Slower onset
✔️ Longer duration of action
⚠️ Higher risk of embolic vascular events—especially dangerous in cervical and thoracic transforaminal ESIs (TFESIs)

🟢 Non-Particulate Steroids (e.g., Dexamethasone):
⚡ Faster onset
⏳ Shorter duration of action
✅ Safer profile for high-risk injections
⚠️ Note: Dexamethasone may crystallize when combined with ropivacaine
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🤔 The Clinical Dilemma
While non-particulate steroids offer a safer profile, especially in cervical and thoracic regions, some clinicians are concerned about their shorter duration of analgesic effect—particularly in patients with persistent or radicular pain.
➡️ This often creates a clinical balancing act between safety and sustained relief.
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📌 Clinical Recommendations at a Glance

✅ Use non-particulate steroids exclusively for cervical and thoracic TFESIs
✅ Consider non-particulate steroids as first-line for lumbar TFESIs, especially in high-risk patients
✅ Reserve particulate steroids only when the safety profile allows and prolonged action is clearly needed
🎯 Your steroid selection should be guided by both anatomy and risk—because every millimeter matters.
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📚 References :
1. Lee JH, Lee SH. Update on the efficacy and safety of epidural steroid injections. Int J Pain. 2024;10(2):55-62.
2. North American Spine Society. NASS Coverage Policy Recommendations: Epidural Steroid Injections. 2020. https://www.spine.org/Policy
3. Makkar JK, Bhoi D et al. Comparison of particulate versus non-particulate steroids in cervical transforaminal injections: A safety analysis. Pain Physician. 2016;19(4):E643–E650.
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24/05/2025

RETROCALCANEAL BURSITIS: BACK OF HEEL PAIN

Here is a blog in Simplified language on retrocalcaneal bursitis.

Are you experiencing pain at the back of your heel, especially when walking, running, or rising onto your toes? If so, you might be dealing with a common but often misunderstood condition known as retrocalcaneal bursitis.

24/05/2025

Chronic Heel Pain with No Answers? One Quick POCUS Scan solves the problem. 👣🔍

A middle-aged recreational runner walked into clinic after months of persistent heel pain — multiple healthcare visits, footwear changes, rest, insoles — but still no relief or clear diagnosis.

She had no idea what was causing the pain. Until we scanned her heel.

📸 Point-of-care ultrasound revealed a classic case of Retrocalcaneal Bursitis — with clear fluid distension between the Achilles tendon and the calcaneus, right where the inflamed bursa sits.

✅ Diagnosis made at bedside
✅ Management options explained
✅ Patient relieved to finally have an answer

🧠 Why it matters:
Retrocalcaneal bursitis is one of those “not-so-rare-but-often-missed” diagnoses. It can easily masquerade as Achilles tendinopathy, or worse, be dismissed altogether — especially if the patient is still walking around.

👟 Pain is often worse in tight shoes, during dorsiflexion, or when walking uphill. But unless someone thinks about it and images it, it can go unnoticed.

💡 POCUS Pearls:
Look for an anechoic or hypoechoic fluid-filled bursa deep to the Achilles insertion
Assess for associated findings like Haglund’s deformity or Achilles thickening
Helps differentiate from Achilles tendinopathy or partial tears
Avoids unnecessary imaging delays

🛠️ Simple measures often resolve symptoms in 6–8 weeks:
Load modification
NSAIDs or ice
Footwear changes (backless shoes, heel lifts)
Careful stretching (avoiding aggressive calf work early on)
Ultrasound Guided steroid injection if not improving

🔍 Sometimes the right diagnosis isn’t about fancy interventions — it’s about asking the right question and having the right tool at the right time.
If your patient has had “heel pain for months” with no clear diagnosis — think Retrocalcaneal Bursitis, and consider reaching for the probe.

—
📍Shared by Dr Amod Manocha
International Pain Centre

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02/05/2025

🎥 “Nerve Root Blocks 101 | What Every Interventionalist/ Pain Physician Should Know” by Pain Specialist DrAmod Manocha

In this video, we cover basics and what you need to know about nerve root block procedures, including anatomy, techniques, C arm images, contrast flow patterns, documentation standards and safety tips.

Whether you're an interventional pain physician, anesthesiologist, or spine specialist, this presentation is designed to help you sharpen your procedural skills.

✅ What You'll Learn:
• Basics and anatomy
• Different approaches and needle placement
• Step-by-step technique
• To recognize contrast spread patterns
• Common pitfalls to avoid
• Documentation standards
• Expert insights from clinical practice

🔔 Subscribe for More Interventional Pain Education!
This is just a taste—our upcoming videos include advanced techniques, live cases, and masterclasses for those who want to deepen their expertise. “If you're a pain physician looking to level up your interventional skills, hit that subscribe button.”

💬 Join the Pain Physician Community!
Leave a comment below: What's your experience with nerve root blocks? Let's build a community of passionate, skilled pain doctors.

CLICK ON TH ELIN BELOW TO WATCH THE FULL VIDEO

In this video, we cover basics and what you need to know about nerve root block procedures, including anatomy, techniques, C arm images, contrast flow patter...

02/05/2025

I'm pleased to share that I've authored a chapter on Cryoablation in Pain Management in the newly released Interventional Pain Management: A Practical Approach (3rd Edition).

Cryoablation is an evolving technique offering minimally invasive solutions for chronic pain conditions. In this chapter, I delve into its mechanisms, clinical applications, and procedural considerations, aiming to provide insights for practitioners seeking alternative pain management strategies.

Grateful for the opportunity to collaborate with esteemed colleagues (especially Dr Baheti) on this comprehensive resource. I hope this contribution aids fellow clinicians in enhancing patient care. Thank you Jaypee Publishers for the authors copy.

📚 Always happy to connect, discuss, and exchange ideas—especially when it helps us all care better for our patients.

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24/04/2025

Chest Wall Pain with a Twist: Spontaneous Rib Fracture in a Renal Patient Diagnosed by Ultrasound 🔍💥

Pain without trauma? That’s when we dig deeper.
A patient with chronic kidney disease presented with localized chest wall pain, no history of injury. But as pain specialists, we know the story doesn’t end at “normal X-ray.”

🧠 The key to the diagnosis? Ultrasound.
With point-of-care ultrasound (POCUS), we visualized a spontaneous rib fracture—a rare but real complication of renal osteodystrophy and metabolic bone disease. The cortical break was unmistakable.
👉 In patients with renal impairment, bones are fragile even in the absence of trauma. These fractures can masquerade as musculoskeletal or neuropathic pain, leading to delays in diagnosis and management.

✨ Ultrasound gave us: ✔️ Dynamic assessment at the precise localization of tenderness
✔️ A treatment option which could be done at the same time (intercostal block)
✔️ No radiation exposure
✔️ A quick, bedside answer
This case reinforces how ultrasound is not just a diagnostic tool—it’s an extension of our clinical examination and treatment, especially in pain medicine.
If you’re seeing persistent, focal pain in a patient with systemic disease, consider picking up the probe. The diagnosis might be just beneath the surface—literally. 📸

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23/04/2025

“Chronic Backache After Spinal? Here's What Doctors Need to Know” By Dr Amod Manocha-Pain Specialist

Summary
This presentation focuses on the issue of localized back pain following spinal anesthetic procedures. Dr. Amod discusses the prevalence, risk factors, and treatment options for this common yet often dismissed problem. Through a review of various studies, he highlights the importance of understanding this condition, its implications for patients, and the need for proper validation and management of their concerns.

Takeaways:
• Localized back pain is an issue after spinal anesthetics.
• Many patients report persistent back pain post-procedure.
• Research indicates a prevalence of 5-29% for short-term back pain.
• Pregnant women are at a higher risk for back pain.
• The exact cause of post-anesthetic back pain is often unclear.
• Most cases of back pain are self-limiting and respond to conservative treatment.
• The paramedian approach may reduce the incidence of immediate post spinal back pain.
• Patient validation is important to alleviate anxiety and worry.
• Education and reassurance can help manage patient expectations.
• Most patients can expect improvement within three months.

CLICK THE LINK BELOW TO WATCH THE FULL VIDEO

THIS PRESENTATION IS INTENDED FOR HEALTH CARE PROFESSIONALSSummaryThis presentation focuses on the issue of localized back pain following spinal anesthetic p...

11/10/2024

🖐 *A Case to Crack: Complex Hand Neuropathy*

A 25-year-old male patient presented with worsening right hand and wrist pain for the past 2 years. He reports a gradual weakening of his grip, making everyday tasks like buttoning a shirt increasingly difficult. No neck pain.

🔹 *Past History*: Right wrist fracture 9 years ago, managed conservatively.

🔹 *Examination*:
- Noticeable wasting of intrinsic hand muscles (thenar)
- Tenderness in the distal forearm and wrist
- Positive Tinel’s and Prayer’s signs
- Reduced right grip strength

🔹 *Tests*:
- NCV: Normal- repeated twice
- Cervical spine MRI: Normal

CRPS was suggested as a likely diagnosis but something seemed missing. So I decided to do a POC Ultrasound imaging of the right forearm and wrist and surprise surprise…..... See the ultrasound images below. More images in the comments section.

What’s your diagnosis? 🧠

Feel free to share your thoughts or comment below!