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Pathophysiology of medication overuse headache: Insights and hypotheses from preclinical studies.
Meng ID, Dodick D, Ossipov MH, Porreca F.
Cephalalgia. 2011 Mar 28.
Medication overuse headache (MOH) is a clinical concern in the management of migraine headache. MOH arises from the frequent use of medications used for the treatment of a primary headache. Medications that can cause MOH include opioid analgesics as well as formulations designed for the treatment of migraine, such as triptans, ergot alkaloids, or drug combinations that include caffeine and barbiturates. Literature review: Gathering evidence indicates that migraine patients are more susceptible to development of MOH, and that prolonged use of these medications increases the prognosis for development of chronic migraine, leading to the suggestion that similar underlying mechanisms may drive both migraine headache and MOH. In this review, we examine the link between several mechanisms that have been linked to migraine headache and a potential role in MOH. For example, cortical spreading depression (CSD), associated with migraine development, is increased in frequency with prolonged use of topiramate or paracetamol. Conclusions: Increased CGRP levels in the blood have been linked to migraine and elevated CGRP can be casued by prolonged sumatriptan exposure. Possible mechanisms that may be common to both migraine and MOH include increased endogenous facilitation of pain and/or diminished diminished endogenous pain inhibition. Neuroanatomical pathways mediating these effects are examined.
Medication overuse headache (MOH) is a clinical concern in the management of migraine headache. MOH arises from the frequent use of medications used for the treatment of a primary headache. Medications that can cause MOH include opioid analgesics...
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Psychosocial Issues in Cancer Pain.
Porter LS, Keefe FJ
Curr Pain Headache Rep. 2011 Mar 15
Cancer pain is a complex and multidimensional experience that affects and is affected by psychological and social factors. This article reviews recent research that points to a number of key psychosocial factors associated with pain, including psychological distress, coping, and social support, as well as the impact of socioeconomic factors on barriers to pain management. We also review recent research suggesting that psychosocial interventions, including education, coping-skills training, and hypnosis, may be useful adjuncts to medical management of pain. Clinical implications and recommendations for future research are discussed.
Cancer pain is a complex and multidimensional experience that affects and is affected by psychological and social factors. This article reviews recent research that points to a number of key psychosocial factors associated with pain, including...
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The role of the Health Insurance Industry in Perpetuating Suboptimal Pain Management.
Schatman ME
Pain Med. 2011 Mar;12(3):415-26.
Unlike pain practitioners, health care insurers in the United States are not expected to function according to a system of medical ethics. Rather, they are permitted to function under the business "ethic" of cost-containment and profitability. Despite calls for balancing the disparate agendas of stakeholders in pain management in a pluralistic system, the health insurance industry has continued to fail to take the needs of suffering chronic pain patients into consideration in developing and enacting their policies that ultimately dictate the quality and quantity of pain management services available to enrollees. This essay examined these self-serving strategies, which include failure to reimburse services and certain medications irrespective of their evidence-bases for clinical efficacy and cost-efficiency; "carving out" specific services from interdisciplinary treatment programs; and delaying and/or interrupting the provision of medically necessary treatment. Blatant and more subtle strategies utilized by insurers to achieve these ethically questionable goals are examined. Additionally, this essay addressed some of the insurance industry's efforts to delegitimize chronic pain and its treatment as a whole. Conclusion. The author concludes that the outlook for chronic pain sufferers is not particularly bright, until such time that a not-for-profit single-payer system replaces the current treatment/reimbursement paradigm.
Unlike pain practitioners, health care insurers in the United States are not expected to function according to a system of medical ethics. Rather, they are permitted to function under the business "ethic" of cost-containment and profitability.
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A systematic literature review of psychological characteristics as determinants of outcome for spinal cord stimulation therapy.
Sparkes E, Raphael JH, Duarte RV, et al.
Pain. 2010 Aug;150(2):284-9.
Psychological factors are deemed important when considering patients for suitability for Spinal Cord Stimulation (SCS). However, there is to date no consensus on which psychological characteristics or tests to undertake. This review analyses the literature to determine findings concerning the psychological characteristics observed and their impact on SCS efficacy for chronic pain. A search in the databases Cochrane, EBSCOhost (CINAHL, MEDLINE, PsycINFO and PsycARTICLES) and a hand search of reference lists from selected articles were performed, resulting in nine relevant articles. The Minnesota Multiphasic Personality Inventory was the most commonly used tool for assessing psychological factors. Only one study used a semi-structured interview instead of questionnaires. Studies lacked long term followup. Depression was identified in six studies as a factor that reduces efficacy, also as a characteristic that can improve after successful SCS by two studies. One study did not include patients with depression, due to previous research indicating depression as a contra-indication. Hypochondriasis and hysteria had conflicting results for prediction of efficacy. Mania was predicted by only two studies as a positive indicator for success. Further long term studies of psychological factors on outcome from SCS are needed.
Psychological factors are deemed important when considering patients for suitability for Spinal Cord Stimulation (SCS). However, there is to date no consensus on which psychological characteristics or tests to undertake.
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Pain Quality Predicts Lidocaine Analgesia among Patients with Suspected Neuropathic Pain
Carroll IR, Younger JW, Mackey SC.
Pain Med. 2010 Mar 4.
Abstract Objective. Oral sodium channel blockers have shown mixed results in randomized controlled trials despite the known importance of sodium channels in generating pain. We hypothesized that differing baseline pain qualities (e.g. "stabbing" vs "dull") might define specific subgroups responsive to intravenous (IV) lidocaine-a potent sodium channel blocker. Design. A prospective cohort study of 71 patient with chronic pain suspected of being neuropathic were recruited between January 2003 and July 2007 and underwent lidocaine infusions at Stanford University Hospital in a single-blind nonrandomized fashion. Baseline sensory pain qualities were measured with the Short-Form McGill Pain Questionnaire (SF-MPQ). Pain intensity was measured with a visual analog scale (VAS). Results. Factor analysis demonstrated two underlying pain quality factors among SF-MPQ sensory items: a heavy pain and a stabbing pain. Baseline heavy pain quality, but not stabbing quality predicted subsequent relief of pain intensity in response to lidocaine. In contrast, these factors did not predict divergent analgesic responses to placebo infusions. In response to each 1 mcg/mL increase in lidocaine plasma level, patients with high heavy pain quality drop their VAS 0.24 (95% CI 0.05-0.43) more points than those with low heavy pain quality (P < 0.013). Conclusions. "Heavy" pain quality may indentify patients with enhanced lidocaine responsiveness. Pain quality may identify subgroups among patients with suspected neuropathic pain responsive to IV lidocaine. Further investigation is warranted to validate and extend these findings.
Abstract Objective. Oral sodium channel blockers have shown mixed results in randomized controlled trials despite the known importance of sodium channels in generating pain. We hypothesized that differing baseline pain qualities (e.g....
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Quantitative Sensory Testing and Mapping: Nonautomated Quantitative Methods for Examination of the Patient With Neuropathic Pain
Walk D, Sehgal N, Moeller-Bertram T, et al.
Clin J Pain. 2009 Sep;25(7):632-40.
OBJECTIVES: Despite a growing interest in neuropathic pain, neurologists and pain specialists do not have a standard, validated, office examination for the evaluation of neuropathic pain signs to complement the neurologic, musculoskeletal, and general physical examinations. An office neuropathic pain examination focused on quantifying sensory features of neuropathic pain, ranging from deficits to allodynia and hyperalgesia, and evoked by a physiologically representative array of stimuli, will be an essential tool to monitor treatment effectiveness and for clinical investigation into the mechanisms and management of neuropathic pain. Such an examination should include mapping of areas of stimulus-evoked neuropathic pain and standardized, reproducible quantitative sensory testing (QST) of tactile, punctuate, pressure, and thermal modalities. METHODS: We review quantitative sensory testing methodology in general and specific tests for the evaluation of neuropathic pain phenomena. RESULTS: Numerous quantitative sensory testing techniques for dynamic mechanical, pressure, vibration, and thermal sensory testing and mapping have been described. We propose a comprehensive neuropathic pain evaluation protocol that is based upon these available techniques. CONCLUSIONS: A comprehensive neuropathic pain evaluation protocol is essential for further advancement of clinical research in neuropathic pain. A protocol that uses tools readily available in clinical practice, when established and validated, can be used widely and thus accelerate data collection for clinical research and increase clinical awareness of the features of neuropathic pain.
OBJECTIVES: Despite a growing interest in neuropathic pain, neurologists and pain specialists do not have a standard, validated, office examination for the evaluation of neuropathic pain signs to complement the neurologic, musculoskeletal, and...
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Integrating nonpharmacologic and alternative strategies into a comprehensive management approach for older adults with pain.
Bruckenthal P.
Pain Manag Nurs. 2010 Jun;11(2 Suppl):S23-31. The U.S. population aged >or=65 years is estimated to grow from 35 million in 2000 to 71.5 million in 2030, and the number of those aged >or=85 years is expected to increase from 5.3 million in 2006 to 21 million in 2050. Due to this demographic shift, the complexities of chronic pain management in the elderly will become increasingly important, necessitating a deeper understanding in the medical community of both the normal physiologic changes that occur with aging and the increased risks and vulnerabilities to pain that may be related to illness, comorbidities, or cognitive impairment. A number of factors complicate treating pain in the elderly. First, the cause of pain is often a condition that is typically not reversible. Second, effective treatment can be hampered by side effects of medications and complications from polypharmacy. Furthermore, depression, behavioral changes, and cognitive impairment commonly complicate therapy and make assessment more difficult. Both inappropriate prescribing and medication underuse are common in the elderly, as is the undertreatment of pain in this patient population in different care settings. The goal of this paper was to review appropriate use of nonpharmacologic, complementary, and alternative therapies for the comprehensive management of pain in older adults.
The U.S. population aged >or=65 years is estimated to grow from 35 million in 2000 to 71.5 million in 2030, and the number of those aged >or=85 years is expected to increase from 5.3 million in 2006 to 21 million in 2050.
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Diagnosis of fibromyalgia syndrome-a comparison of AMSS in Germany, survey, and ACR criteria
Häuser W, Hayo S, Biewer W, et al.
Clin J Pain. 2010 Jul-Aug;26(6):505-11.
OBJECTIVES: The survey and the Association of the Medical Scientific Societies in Germany (AWMF) criteria had been developed to overcome problems associated with tender point criterion of the American College of Rheumatology (ACR) (lacking validation for clinical diagnosis, inconsistent use by rheumatologists, and nonrheumatologists) for the clinical diagnosis of fibromyalgia syndrome (FMS). We compared the concordance between these 3 criteria. METHODS: Consecutive patients of different clinical settings referred for the evaluation of chronic widespread pain or management of established FMS diagnosis were assessed by medical history, a complete physical examination including tender points, and questionnaires [self-constructed symptoms questionnaire, regional pain scale (RPS), Patient Health Questionnaire (PHQ 9 and 15)]. FMS according to AWMF-criteria was diagnosed by the history of widespread pain (axial and all 4 extremities), the symptoms sleep disturbances, fatigue, and feeling of swelling or stiffness of the hands or feet or face (Numeric rating scale >or=1/10 each symptom) and the exclusion of somatic diseases sufficiently explaining the symptoms. FMS according to survey criteria was diagnosed by regional pain scale score >or=8 and fatigue score >or=6/10 on a visual analogue scale. RESULTS: Out of 310 patients, 292 could be analysed. AWMF and ACR were concordant in 86.6%, AWMF and survey criteria were concordant in 78.8% and survey and ACR-criteria were concordant in 79.5% of the cases. DISCUSSION: AWMF, survey, and ACR criteria were moderately concordant. As AWMF and survey criteria do not require tender point examination, these criteria can be used by nonrheumatologists for the clinical diagnosis of FMS.
OBJECTIVES: The survey and the Association of the Medical Scientific Societies in Germany (AWMF) criteria had been developed to overcome problems associated with tender point criterion of the American College of Rheumatology (ACR) (lacking...
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Individual and contextual determinants of regional variation in prescription drug use
Morgan, SG. Cunningham, CM. Hanley, GE.
PLoS One. 2010 Dec 29;5(12):e15883.
BACKGROUND: Increasing attention is being paid to variations in the use of prescription drugs because their role in health care has grown to the point where their use can be considered a proxy for health system performance. Studies have shown that prescription drug use varies across regions in the US, UK, and Canada by more than would be predicted based on age and health status alone. In this paper, we explore the determinants of variations in the use of prescription drugs, drawing on health services theories of access to care. METHODS: We conducted a cross-sectional analysis using population-based administrative health care data for British Columbia (BC), Canada. We used logistic and hierarchical regressions to analyze the effects of individual- and area-level determinants of use of prescriptions overall and rates of purchase of prescriptions from five therapeutic categories representing a range of indications: antihypertensives, statins, acid reducing drugs, opioid drugs, and antidepressants. To indicate the relative scale of regional variations and the importance of individual- and area-level variables in explaining them, we computed standardized rates of utilization for 49 local health areas in BC. RESULTS: We found that characteristics of individuals and the areas in which they live affect likelihood of prescription drug purchase. Individual-level factors influenced prescription drug purchases in ways generally consistent with behavioral models of health services use. Contextual variables exerted influences that differed by type of drug studied. Population health, education levels, and ethnic composition of local areas were associated with significant differences in the likelihood of purchasing medications. Relatively modest regional variations remained after both individual-level and area-level determinants were taken into account. CONCLUSIONS: The results of this study suggest that individual- and area-level factors should be considered when studying variations in the use of prescription drugs. Some sources of such variations, including individual- and area-level socioeconomic status, warrant further investigation and possible intervention to address inequities.
BACKGROUND: Increasing attention is being paid to variations in the use of prescription drugs because their role in health care has grown to the point where their use can be considered a proxy for health system performance.
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"They don't want anything to do with you": patient views of primary care management of chronic pain.
Upshur, CC. Bacigalupe, G. Luckmann, R.
Pain Med. 2010 Dec;11(12):1791-8.
OBJECTIVE: Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. DESIGN: Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. PATIENTS: Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. RESULTS: Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. CONCLUSIONS: Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.
OBJECTIVE: Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of...
