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Chronic opioid therapy and preventive services in rural primary care: an Oregon rural practice-based research network study.
Buckley DI, Calvert JF, Lapidus JA, et al.
Ann Fam Med. 2010;8(3):237-44.PURPOSE:
For clinicians, using opioid therapy for chronic noncancer pain (CNCP) often gives rise to a conflict between treating their patients' pain and fears of addiction, diversion of medication, or legal action. Consequent stresses on clinical encounters might adversely affect some elements of clinical care. We evaluated a possible association between chronic opioid therapy (COT) for CNCP and receipt of various preventive services.METHODS:
We conducted a retrospective cohort study in 7 primary care clinics within the Oregon Rural Practice-based Research Network (ORPRN). Using medical records of 704 patients, aged 35 to 85 years, seen during a 3-year period, we compared the receipt of 4 preventive services between patients on COT for CNCP and patients not on chronic opioid therapy (non-COT). We used multivariate log-binomial regression analyses to estimate the relative risk of receipt of each preventive service.RESULTS:
After adjustment for plausible confounders, we found that patients using COT had a statistically significantly lower relative risk (RR) of receipt of cervical cancer screening (RR = 0.60; 95% confidence interval [CI], 0.47-0.76) and colorectal cancer screening (RR = 0.42; 95% CI, 0.22-0.80) when compared with non-COT patients. The RR was reduced, without statistical significance, for lipid screening (RR = 0.77; 95% CI, 0.54-1.10), and not notably reduced for smoking cessation counseling (RR = 0.95; 95% CI, 0.78-1.15).CONCLUSIONS:
Patients using COT for CNCP were less likely to receive some preventive services. Research is needed to better understand barriers to and improved methods for providing preventive services for these patients.
For clinicians, using opioid therapy for chronic noncancer pain (CNCP) often gives rise to a conflict between treating their patients' pain and fears of addiction, diversion of medication, or legal action. Consequent stresses on clinical...
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The impact of enrollment in a specialized interdisciplinary neuropathic pain clinic
Garven A, Brady S, Wood S, Hatfield M, Bestard J, Korngut L, Toth C.
Pain Res Manag. 2011 May-Jun;16(3):159-68.BACKGROUND: Chronic pain clinics have been created because of the increasing recognition of chronic pain as a very common, debilitating condition that requires specialized care. Neuropathic pain (NeP) is a multifaceted, specialized form of chronic pain that often requires input from multiple disciplines for assessment and management.
OBJECTIVE: To determine the impact of an interdisciplinary clinic for evaluation and treatment of patients with NeP.
METHODS: Patients with heterogeneous etiologies for NeP were prospectively evaluated using an interdisciplinary approach every six months. Diagnostic evaluation, comorbidity evaluation, education, and pharmacological and⁄or nonpharmacological management were completed. Severity (visual analogue scale) and features of pain (Modified Brief Pain Inventory), sleep difficulties (Medical Outcomes Study - Sleep Scale), mood⁄anxiety disruption (Hospital Anxiety and Depression Scale), quality of life (European Quality-of-Life Five-Domain index), health care resources use, patient satisfaction (Pain Treatment Satisfaction Scale and Neuropathic Pain Symptom Inventory) and self-perceived change in well-being (Patient Global Impression of Change scale) were examined at each visit.
RESULTS: Pain severity only decreased after one year of follow-up, while anxiety and quality- of-life indexes improved after six months. Moderate improvements of sleep disturbance, less frequent medication use and reduced health care resource use were observed during enrollment at the NeP clinic.
DISCUSSION: Despite the limitations of performing a real-world, uncontrolled study, patients with NeP benefit from enrollment in a small interdisciplinary clinic. Education and a complete diagnostic evaluation are hypothesized to lead to improvements in anxiety and, subsequently, pain severity. Questions remain regarding the long-term maintenance of these improvements and the optimal structure of specialized pain clinics.
Chronic pain clinics have been created because of the increasing recognition of chronic pain as a very common, debilitating condition that requires specialized care.
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Association between urine drug test results and treatment outcome in high-risk chronic pain patients on opioids
Barth KS, Becker WC, Wiedemer NL, Mavandadi S, Oslin DW, Meghani SH, Gallagher RM.
J Addict Med. 2010 Sep;4(3):167-73.OBJECTIVE: How to best use urine drug test (UDT) results in the management of opioid pharmacotherapy has not been elucidated. The purpose of this study was to describe how the results of UDTs gathered from a group of chronic pain patients in a high-risk monitored opioid pharmacotherapy program apply to treatment outcome.
METHODS: Retrospective review of the medical records of 335 primary care patients on chronic opioids more than 22 months.
RESULTS: Patients with a UDT containing unprescribed opioids were more likely to demonstrate resolution of aberrant behavior (P = 0.02) and less likely to be discharged from treatment (P = 0.04). Patients with cocaine, alone or in combination, in the UDT were less likely to resolve aberrant behavior (P = 0.007 and 0.001), and were more likely to be electively or administratively discharged from treatment (P = 0.012 and 0.001).
DISCUSSION: In this group of high-risk pain patients on chronic opioids, information gained from UDT results can be used to predict treatment outcomes and inform appropriate interventions. Patients on chronic opioids who have a UDT positive for an illicit opioid or unprescribed opioids alone are more likely to respond to monitored opioid pharmacotherapy. Patients with a UDT positive for cocaine, alone or in combination, are less likely to resolve aberrant behavior within the structure of a monitored opioid pharmacotherapy program and are more likely to be discharged electively or administratively from the program without significant transition to addiction treatment. Further studies are needed to investigate which patient responded best to structured opioid pharmacotherapy programs and how to appropriately handle abnormal UDT results to improve the management and engagement in appropriate treatment for this population.
How to best use urine drug test (UDT) results in the management of opioid pharmacotherapy has not been elucidated.
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The role of core strengthening for chronic low back pain.
Akuthota V, Standaert CJ, Chimes GP.
PM R. 2011 Jul;3(7):664-70.
Akuthota V, Standaert CJ, Chimes GP.
PM R. 2011 Jul;3(7):664-70. -
A different kind of co-morbidity: Understanding posttraumatic stress disorder and chronic pain
Beck JG, Clapp JD.
Psychol Trauma. 2011 Jun;3(2):101-108.Many traumatic events leave lingering physical injuries and chronic pain in their wake, in addition to trauma-related psychopathology. In this review, we provide an overview of developments in the recent literature on co-morbid posttraumatic stress disorder (PTSD) and chronic pain. Starting with the conceptual models presented by Sharp and Harvey (2001) and Asmundson, Coons, Taylor, and Klatz (2002), this review summarizes newer studies that examine prevalence of these co-morbid conditions. Additionally, we present an updated synthesis of research on factors that may maintain both chronic physical pain and PTSD in trauma survivors. Consideration of the impact of this co-morbidity on psychosocial assessment and treatment also is discussed, with particular attention to issues that warrant additional research.
Many traumatic events leave lingering physical injuries and chronic pain in their wake, in addition to trauma-related psychopathology.
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Drug testing, chronic pain,and financial conflicts of interest
Collen M, Leider HL, Dhaliwal J, Davis EJ, Kulakodlu M, Buikema AR.
Am J Manag Care. 2011 Apr 1;17(4):e148-50.
Collen M, Leider HL, Dhaliwal J, Davis EJ, Kulakodlu M, Buikema AR.
Am J Manag Care. 2011 Apr 1;17(4):e148-50. -
Spinal Cord Stimulation Versus Re-operation in Patients With Failed Back Surgery Syndrome: An International Multicenter Randomiz
Prati C, Claudepierre P, Pham T, Wendling D.
Joint Bone Spine. 2011 Oct;78(5):466-70.
Objective: This paper presents the protocol of the EVIDENCE study, a multicenter multinational randomized controlled trial to assess the effectiveness and cost-effectiveness of spinal cord stimulation (SCS) with rechargeable pulse generator versus re-operation through 36-month follow-up in patients with failed back surgery syndrome. Study Design: Study subjects have neuropathic radicular leg pain exceeding or equaling any low back pain and meet specified entry criteria. One-to-one randomization is stratified by site and by one or more prior lumbosacral operations. The sample size of 132 subjects may be adjusted to between 100 and 200 subjects using a standard adaptive design statistical method with pre-defined rules. Crossover treatment is possible. Co-primary endpoints are proportion of subjects reporting ≥50% leg pain relief without crossover at 6 and at 24 months after SCS screening trial or re-operation. Insufficient pain relief constitutes failure of randomized treatment, as does crossover. Secondary endpoints include cost-effectiveness; relief of leg, back, and overall pain; change in disability and quality of life; and rate of crossover. We are collecting data on subject global impression of change, patient satisfaction with treatment, employment status, pain/paresthesia overlap, SCS programming, and adverse events. Discussion: As the first multicenter randomized controlled trial of SCS versus re-operation and the first to use only rechargeable SCS pulse generators, the EVIDENCE study will provide up-to-date evidence on the treatment of failed back surgery syndrome.
This paper presents the protocol of the EVIDENCE study, a multicenter multinational randomized controlled trial to assess the effectiveness and cost-effectiveness of spinal cord stimulation (SCS) with rechargeable pulse generator versus...
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Opioid-Paracetamol Prescription Patterns and Liver Dysfunction: A Retrospective Cohort Study in a Population Served by a US Heal
Mort JR, Shiyanbola OO, Ndehi LN, Xu Y, Stacy JN.
Drug Saf. 2011 Nov 1;34(11):1079-88.
Background: Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF). ALF attributed to paracetamol is most often associated with the following features: an unintentional overdose, a single product, an opioid-paracetamol combination, duration of <7 days, and a median dose of 7.5 g/day. Currently, the recommended maximum daily dose of paracetamol is 4 g. Objectives: The aims of the study were to determine opioid-paracetamol prescription patterns, including prescriptions exceeding the recommended dose of paracetamol (4 g/day) [prescriptions and beneficiaries]; examine factors associated with receiving opioid-paracetamol prescriptions in excess of paracetamol 4 g/day; and evaluate opioid-paracetamol prescription patterns for beneficiaries with liver dysfunction. Methods: A retrospective cohort study examining prescription data of 4.8 million beneficiaries from a US health benefits organization from 1 January 2009 through 31 December 2009. The main outcomes examined were daily paracetamol dose and liver dysfunction. Results: A large proportion (8.1%) of the 5.3 million prescriptions for opioid-paracetamol exceeded the recommended maximum daily dose of paracetamol (4 g/day), putting over one-quarter of a million (255 123 [18.9%]) of the 1.35 million beneficiaries receiving an opioid-paracetamol prescription at risk of toxicity. The most frequently prescribed products that exceeded paracetamol dose guidelines contained dextropropoxyphene and hydrocodone. Multiple factors, including type of product (i.e. dextropropoxyphene or oxycodone-containing), geographical location (Midwest), strength of the paracetamol in the opioid-paracetamol product (>325 mg) and prescriber specialty (dentist, physician assistant), were associated with high-dose paracetamol prescriptions. Liver dysfunction was diagnosed in 3818 cases, and 23.4% of these beneficiaries received an opioid-paracetamol prescription in the 90 days prior to the liver dysfunction diagnosis. Conclusions: Although most opioid-paracetamol prescriptions are written and dispensed for <4 g/day of paracetamol, a significant portion of beneficiaries are being prescribed and dispensed excessive doses of paracetamol. Efforts to curtail this practice may involve provision of prescriber and pharmacist education, utilization of benefit manager systems to flag excessive dosing or that require confirmation of dosing, and implementation of US FDA recommendations supported by these data.
Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF).
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Pacing as a treatment modality in migraine and tension-type headache.
McLean A, Coutts K, Becker WJ. Disabil Rehabil. 2011 Oct 8. [Epub ahead of print]
Purpose: To review the pacing literature; describe the use of pacing in a specialty headache clinic; and provide client feedback regarding the effectiveness of pacing in headache self-management. Method: The evidence for this report was derived from a structured literature review, an established pacing intervention program for patients with headache, and patient self-report questionnaire. Results: There are frequent references to pacing in the chronic pain and rheumatic disease literature, but no universal definition and, until recently, few outcome studies. References to pacing in the headache literature are limited. For a small sub-group of clients at a specialty headache clinic (n = 20), pacing principles taught by occupational therapists were reported to prevent increases in headache intensity (70%); decrease headache intensity (65%), and shorten the duration of a headache (40%). Additionally, 70% of respondents used pacing to prevent headache onset. Pacing was seen to contribute to increased quality of life, headache self-efficacy, function, and independence. There were a variety of opinions regarding the most helpful pacing components. The most frequently endorsed were identify and prioritize responsibilities; balance activity and rest; schedule regular rest breaks; and delegate or eliminate tasks. Conclusions: Pacing appears to play an important role in headache self-management. More pacing research is required in both headache and chronic pain populations.
To review the pacing literature; describe the use of pacing in a specialty headache clinic; and provide client feedback regarding the effectiveness of pacing in headache self-management.
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Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised control
Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM.
Lancet. 2011 Oct 29;378(9802):1560-71. Epub 2011 Sep 28.
BACKGROUND: Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control).
METHODS: 1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406.
FINDINGS: 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 [SD 5·9] vs 3·0 [5·9], between-group difference 1·81 [95% CI 1·06-2·57]) and at 12 months (4·3 [6·4] vs 3·3 [6·2], 1·06 [0·25-1·86]), equating to effect sizes of 0·32 (0·19-0·45) and 0·19 (0·04-0·33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0·039 additional QALYs) and cost savings (£240·01 vs £274·40) compared with the control group.
INTERPRETATION: The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care.
Back pain remains a challenge for primary care internationally.
