Aleksandra Zgierska

Mindfulness Meditation for Substance Use Disorders: A Systematic Review

ABSTRACT Relapse is common in substance use disorders (SUDs), even among treated individuals. The goal of this article was to systematically review the existing evidence on mindfulness meditation-based interventions (MM) for SUDs. The comprehensive search for and review of literature found over 2000 abstracts and resulted in 25 eligible manuscripts (22 published, 3 unpublished: 8 randomized controlled trials, 7 controlled nonrandomized, 6 noncontrolled prospective, and 2 qualitative studies, and 1 case report). When appropriate, methodological quality, absolute risk reduction, number needed to treat, and effect size were assessed. Overall, although preliminary evidence suggests MM efficacy and safety, conclusive data for MM as a treatment of SUDs are lacking. Significant methodological limitations exist in most studies. Further, it is unclear which persons with SUDs might benefit most from MM. Future trials must be of sufficient sample size to answer a specific clinical question and should target both assessment of effect size and mechanisms of action.

Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study

PURPOSE Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influence on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians. METHODS A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures. RESULTS Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales—Emotional Exhaustion (P =.009), Depersonalization (P = .005), and Personal Accomplishment (P <.001); (2) on the Depression (P =.001), Anxiety (P =.006), and Stress (P = .002) subscales of the Depression Anxiety Stress Scales-21; and (3) for perceived stress (P = .002) assessed with the Perceived Stress Scale. There were no significant changes on the 14-item Resilience Scale and the Santa Clara Brief Compassion Scale. CONCLUSIONS In this uncontrolled pilot study, participating in an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.

A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma

Objective: To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE). Design: Systematic review. Data sources: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine. Search strategy: names and descriptors of the therapies and LE. Study Selection: All human studies assessing the four therapies for LE. Main results: Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen’s d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size. Conclusions: There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

Patient Satisfaction, Prescription Drug Abuse, and Potential Unintended Consequences

Patient-centered care can improve treatment outcomes and its implementation has become the focus of national and local efforts to optimize health and health care delivery. Patients’ satisfaction with care is one of the pillars of patient-centered care.1 As such, results from patient satisfaction surveys (i.e., “patient experience of care measures”) can be a driving force behind changes in health care delivery - with institutions and individual clinicians hoping for and actively seeking optimal survey scores. Although such initiatives generally promote improvements in practice that are responsive to patients’ expressed needs, they may paradoxically promote prescribing of opioids and other addictive medications. Complaints of chronic pain are increasing in the aging, sedentary population. Although opioid management for severe acute pain is often beneficial, the effectiveness of long-term opioids for chronic non-cancer-related pain is controversial and may have significant negative effects on individuals and society.2 The United States is facing an epidemic of prescription drug misuse and diversion resulting in increased rates of addiction, health care utilization, and overdose deaths.3 Prescribed opioids constitute the main supply of these drugs for 70% of opioid abusers.4 Federal3 and addiction specialty5 policy statements recommend implementation of measures to decrease inappropriate prescribing, including enhanced physician training in opioid-based pain management, tailored patient education, and development of safer treatment strategies for pain. Thus, authorizing fewer prescriptions for opioids in some instances could constitute an improvement in medical practice, according to some analyses. The complexity, as well as competing interests of clinical practice often do not lead to straightforward answers. Some patients diagnosed with non-malignant chronic pain have no identifiable underlying organic pathology.6 Care of these patients is difficult and can involve practice patterns that are not used for other conditions. For example, opioid prescribing guidelines5 suggest patient adherence monitoring, urine drug testing, pill counts, or written treatment agreements that bind the clinician as well as the patient to specific behaviors. Medical quality committees and even licensure boards can determine that care is substandard if clinicians exclude these components. Before prescribing opioids, clinicians may be expected to recommend non-opioid interventions and refer patients to consultants even if what the patient wants is an opioid prescription. Combined with overall poor treatment outcomes in chronic pain and difficulties reported by most clinicians regarding issues surrounding prescription drug abuse, it is not surprising that clinicians’ satisfaction and comfort level with management of care for patients with opioid-treated chronic pain are low.7 This general picture sets a stage for the following considerations. First, office visits in primary care are brief and the pressure on clinicians to maximize “throughput” to meet patient volume benchmarks has intensified. In the context of these time pressures, how should a clinician respond to the patients request for inappropriate opioid pain medication? Guidelines5 suggest discussion of treatment alternatives such as pharmacological alternatives, lifestyle changes, and a clear statement that opioids are not the best choice. However, such patient encounters are challenging, time-consuming, and exact an emotional toll on clinicians, contributing to diminished practice satisfaction and burn-out.7 Given that compensation favors interventional procedures and high patient volume rather than time-consuming discussion, many physicians may behave in a way even they think is questionable: write the requested opioid prescription, and move on. The clinician saves time, but may be left with emotional and moral distress. Second, patient expectations shape the health encounter. Many patients expect to receive an intervention that only a clinician can provide, a prescription for a medication. Patients may not be interested in alternatives to opioids and may be dissatisfied if their requests are not met. Research suggests this is a common pattern and confirms that fulfillment of patient expectations usually results in a more satisfied patient. Conversely, nonfulfillment correlates to patient dissatisfaction, which can translate to lower treatment satisfaction scores.8 In addition to reporting their dissatisfaction on a survey, patients may also file a complaint about the physician with a patient ombudsman. Third, clinicians are experiencing increased pressure to produce positive results from their clinical activities. For example, a portion of a physicians compensation may depend on the “quality” of services provided, part of which may be based on patient satisfaction targets. Patients can report dissatisfaction based on real or perceived problems including whether a clinician did or did not prescribe a desired medication. In some institutions, the first question on the patient satisfaction survey queries the extent of agreement with the statement: “I was satisfied with the way my doctor treated my pain.” Many health care systems set benchmarks and provide normative values for patient satisfaction scores, in addition to considering them when reviewing a physicians salary. Of even greater importance, a physicians job retention or ability to be promoted may be directly linked to satisfaction-related results. What is the effect of these conflicting forces simultaneously occurring in a brief office visit? On an individual level, patients may be frustrated or angry when they do not receive the treatment they want and have a misperception that receiving the treatment they want equals good medical care. Physicians who comply with unreasonable requests may find themselves in the role of “customer service” providers rather than medical professionals or healers9; physicians who do not comply with patient requests may be the recipients of poor ratings on patient satisfaction scores, possibly resulting in emotional, financial, and professional penalties. These issues may be inadvertent but powerful disincentives for physicians to provide medically correct care and may contribute to the erosion of trust needed in a healthy patient-physician relationship. These factors may also encourage difficult patients to be referred out of a clinicians practice (“patient dumping”) thus shifting the burden from those clinicians to others. From a societal perspective, inappropriate prescribing may contribute to increased availability of circulating opioids and the national problem of prescription opioid diversion, misuse, and related harms.10 Although behavioral techniques (e.g., motivational interviewing, conflict resolution), knowledge of the diagnosis, and management of chronic pain and addiction can improve clinician and patient satisfaction, patient dissatisfaction may not always reflect lower-quality medical care; it should be assessed more carefully. Patient satisfaction and its assessment are essential. However, unintended consequences may result from inappropriate use of patient satisfaction scores and it is important to ensure that incentives for clinicians are consistent with good medical practice. Although there is no single solution, an initial first step is to acknowledge the potential conflict in patient-physician interactions at the intersection of patient satisfaction and controlled substance prescribing. This will enable health care systems to move beyond the rigid use of quality measures, examine the issue locally, and develop realistic quality management systems to balance patient satisfaction with appropriate medical care.

The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms.

OBJECTIVE: To assess quality of life (QOL) in patients with sinonasal symptoms in response to hypertonic saline nasal irrigation (HSNI), and to assess HSNI use patterns. STUDY DESIGN AND SETTING: The study was an uncontrolled 12-month follow-up to a randomized controlled trial (RCT) and used HSNI in a community setting. We included 54 participants with recurrent or chronic sinonasal symptoms. Forty participants had been in the intervention group of a previous study; 14 had been control participants. Primary outcome measures were the Rhinosinusitis Disability Index (RSDI), a sinus-symptom severity assessment (SIA), and the Sino-Nasal Outcomes Test (SNOT-20). Secondary outcome measures were frequency and pattern of HSNI use, side effects and satisfaction. RESULTS: Among participants using HSNI in the prior RCT, RSDI scores continued to improve, from 73.2 ± 2.6 points to 80.6 ± 2.4 points (P < 0.001). SIA and SNOT-20 scores remained stable. Former control participants reported QOL improvement similar to that of HSNI users in the prior RCT. RSDI scores improved from 62.0 ± 3.9 points to 79.7 ± 3.7 points (P < 0.05), SNOT-20 scores improved from 43.5 ± 5.7 points to 28.4 ± 4.8 points, and SIA scores improved from 4.2 ± 0.3 points to 2.6 ± 0.3 points (P < 0.01). Mean HSNI use for all participants was 2.4 irrigations per week; 33% of participants used HSNI regularly, 55% when symptomatic. Side effects were minor; satisfaction was high. CONCLUSIONS: Participants with chronic sinonasal symptoms reported improved QOL and frequent, satisfying use of HSNI. SIGNIFICANCE: HSNI is an effective adjunctive treatment of chronic sinonasal symptoms.

Mindfulness meditation for alcohol relapse prevention: a feasibility pilot study.

Objectives:Meditation is a promising treatment for alcohol dependence. This 16-week prospective case series was designed to gather preliminary data about the efficacy of meditation for relapse prevention and to evaluate study methods feasibility. Methods:Nineteen adult alcohol-dependent graduates of an intensive outpatient program were enrolled. Fifteen subjects completed the 8-week meditation course supplemented by at-home meditation and “standard of care” therapy. Outcome measures included surveys and 2 stress-responsive biomarkers. Results:Subjects (N = 19, 38.4 standard deviation [SD] = 8.6-year-old) were abstinent for 30.9 (SD = 22.2) days at enrollment. Completers (N = 15) attended 82% of meditation course sessions and meditated on average 4.6 (SD = 1.1) days per week; they were abstinent on 94.5% (SD = 7.4) of study days, with 47% reporting complete abstinence and 47% reporting 1 or more heavy drinking days. Their severity of depression, anxiety, stress (P < 0.05), and craving (P < 0.08), documented relapse triggers, decreased, and the degree of mindfulness increased (P < 0.05). The meditation course was rated as a “very important” (8.7/10, SD = 1.8) and “useful relapse prevention tool” (8.5/10, SD = 2.1); participants reported being “very likely” to continue meditating (9.0/10, SD = 1.5). “Gaining skills to reduce stress,” “coping with craving,” and “good group support” were the most common qualitative comments about the course value. Compared with baseline, at 16 weeks, interleukin-6 levels decreased (N = 12, P = 0.05); cortisol levels (N = 10) were reduced but not significantly. There were no adverse events or side effects. Conclusions:Meditation may be an effective adjunctive therapy for relapse prevention in alcohol dependence, worthy of investigation in a larger trial. The study methods are appropriate for such a trial.

Meditation or Exercise for Preventing Acute Respiratory Infection: A Randomized Controlled Trial

PURPOSE This study was designed to evaluate potential preventive effects of meditation or exercise on incidence, duration, and severity of acute respiratory infection (ARI) illness. METHODS Community-recruited adults aged 50 years and older were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate-intensity sustained exercise, or observational control. The primary outcome was area-under-the-curve global illness severity during a single cold and influenza season, using the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) to assess severity. Health care visits and days of missed work were counted. Nasal wash collected during ARI illness was assayed for neutrophils, interleukin-8, and viral nucleic acid. RESULTS Of 154 adults randomized into the study, 149 completed the trial (82% female, 94% white, mean age 59.3 ± 6.6 years). There were 27 ARI episodes and 257 days of ARI illness in the meditation group (n = 51), 26 episodes and 241 illness days in the exercise group (n = 47), and 40 episodes and 453 days in the control group (n = 51). Mean global severity was 144 for meditation, 248 for exercise, and 358 for control. Compared with control, global severity was significantly lower for meditation (P = .004). Both global severity and total days of illness (duration) trended toward being lower for the exercise group (P=.16 and P=.032, respectively), as did illness duration for the meditation group (P=.034). Adjusting for covariates using zero-inflated multivariate regression models gave similar results. There were 67 ARI-related days of-work missed in the control group, 32 in the exercise group (P = .041), and 16 in the meditation group (P <.001). Health care visits did not differ significantly. Viruses were identified in 54% of samples from meditation, 42% from exercise, and 54% from control groups. Neutrophil count and interleukin-8 levels were similar among intervention groups. CONCLUSIONS Training in meditation or exercise may be effective in reducing ARI illness burden.

Impact of patient satisfaction ratings on physicians and clinical care

Background Although patient satisfaction ratings often drive positive changes, they may have unintended consequences. Objective The study reported here aimed to evaluate the clinician-perceived effects of patient satisfaction ratings on job satisfaction and clinical care. Methods A 26-item survey, developed by a state medical society in 2012 to assess the effects of patient satisfaction surveys, was administered online to physician members of a state-level medical society. Respondents remained anonymous. Results One hundred fifty five physicians provided responses (3.9% of the estimated 4,000 physician members of the state-level medical society, or approximately 16% of the state’s emergency department [ED] physicians). The respondents were predominantly male (85%) and practicing in solo or private practice (45%), hospital (43%), or academia (15%). The majority were ED (57%), followed by primary care (16%) physicians. Fifty-nine percent reported that their compensation was linked to patient satisfaction ratings. Seventy-eight percent reported that patient satisfaction surveys moderately or severely affected their job satisfaction; 28% had considered quitting their job or leaving the medical profession. Twenty percent reported their employment being threatened because of patient satisfaction data. Almost half believed that pressure to obtain better scores promoted inappropriate care, including unnecessary antibiotic and opioid prescriptions, tests, procedures, and hospital admissions. Among 52 qualitative responses, only three were positive. Conclusion These pilot-level data suggest that patient satisfaction survey utilization may promote, under certain circumstances, job dissatisfaction, attrition, and inappropriate clinical care among some physicians. This is concerning, especially in the context of the progressive incorporation of patient satisfaction ratings as a quality-of-care metric, and highlights the need for a rigorous evaluation of the optimal methods for survey implementation and utilization.

Dextrose Prolotherapy for Knee Osteoarthritis: A Randomized Controlled Trial

PURPOSE Knee osteoarthritis is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. We conducted a 3-arm, blinded (injector, assessor, injection group participants), randomized controlled trial to assess the efficacy of prolotherapy for knee osteoarthritis. METHODS Ninety adults with at least 3 months of painful knee osteoarthritis were randomized to blinded injection (dextrose prolotherapy or saline) or at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed additional treatments at weeks 13 and 17. Exercise participants received an exercise manual and in-person instruction. Outcome measures included a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points); knee pain scale (KPS; individual knee), post-procedure opioid medication use, and participant satisfaction. Intention-to-treat analysis using analysis of variance was used. RESULTS No baseline differences existed between groups. All groups reported improved composite WOMAC scores compared with baseline status (P <.01) at 52 weeks. Adjusted for sex, age, and body mass index, WOMAC scores for patients receiving dextrose prolotherapy improved more (P <.05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 ± 3.5 vs 7.6 ± 3.4, and 8.2 ± 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference. Individual knee pain scores also improved more in the prolotherapy group (P = .05). Use of prescribed postprocedure opioid medication resulted in rapid diminution of injection-related pain. Satisfaction with prolotherapy was high. There were no adverse events. CONCLUSIONS Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.

Hypertonic Dextrose Injections (Prolotherapy) for Knee Osteoarthritis: Results of a Single-Arm Uncontrolled Study with 1-Year Follow-Up

OBJECTIVE The objective of this study was to determine whether prolotherapy, an injection-based complementary treatment for chronic musculoskeletal conditions, improves pain, stiffness, and function in adults with symptomatic knee osteoarthritis (KOA) compared to baseline status. DESIGN This was a prospective, uncontrolled study with 1-year follow-up. SETTING The study was conducted in an outpatient setting. PARTICIPANTS Adults with at least 3 months of symptomatic KOA, recruited from clinical and community settings, participated in the study. INTERVENTIONS Participants received extra-articular injections of 15% dextrose and intra-articular prolotherapy injections of 25% dextrose at 1, 5, and 9 weeks, with as-needed treatments at weeks 13 and 17. OUTCOME MEASURES Primary outcome measure was the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC). Secondary outcome measure was the validated Knee Pain Scale (KPS). Tertiary outcome measure was procedure-related pain severity and participant satisfaction. RESULTS Thirty-six (36) participants (60 ± 8.7 years old, 21 female) with moderate-to-severe KOA received an average of 4.3 ± 0.7 prolotherapy injection sessions over a 17-week treatment period and reported progressively improved scores during the 52-week study on WOMAC and KPS measures. Participants reported overall WOMAC score improvement 4 weeks after the first injection session (7.6 ± 2.4 points, 17.2%), and continued to improve through the 52-week follow-up (15.9 ± 2.5 points, p<0.001, 36.1%). KPS scores improved in both injected (p<0.001) and uninjected knees (p<0.05). Prescribed low-dose opioid analgesia effectively treated procedure-related pain. Satisfaction was high and there were no adverse events. Female gender, age 46-65 years old, and body-mass index of 25 kg/m(2) or less were associated with greater improvement on the WOMAC instrument. CONCLUSIONS In adults with moderate to severe KOA, dextrose prolotherapy may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores. Randomized multidisciplinary effectiveness trials including evaluation of potential disease modification are warranted to further assess the effects of prolotherapy for KOA.