Anita Gupta

Patient perception of pain care in hospitals in the United States

Study objective Assessment of patients’ perception of pain control in hospitals in the United States. Background Limited data are available regarding the quality of pain care in the hospitalized patient. This is particularly valid for data that allow for comparison of pain outcomes from one hospital to another. Such data are critical for numerous reasons, including allowing patients and policy-makers to make data-driven decisions, and to guide hospitals in their efforts to improve pain care. The Hospital Quality Alliance was recently created by federal policy makers and private organizations in conjunction with the Centers for Medicare and Medicare Services to conduct patient surveys to evaluate their experience including pain control during their hospitalization. Methods In March 2008, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was released for review for health care providers and researchers. This survey includes a battery of questions for patients upon discharge from the hospital including pain-related questions and patient satisfaction that provide valuable data regarding pain care nationwide. This study will review the results from the pain questions from this available data set and evaluate the performance of these hospitals in pain care in relationship to patient satisfaction. Furthermore, this analysis will be providing valuable information on how hospital size, geographic location and practice setting may play a role in pain care in US hospitals. Results The data indicates that 63% of patients gave a high rating of global satisfaction for their care, and that an additional 26% of patients felt that they had a moderate level of global satisfaction with the global quality of their care. When correlated to satisfaction with pain control, the relationship with global satisfaction and “always” receiving good pain control was highly correlated (r >0.84). In respect to the other HCAHPS components, we found that the patient and health care staff relationship with the patient is also highly correlated with pain relief (r >0.85). The patients’ reported level of pain relief was significantly different based upon hospital ownership, with government owned hospitals receiving the highest pain relief, followed by nonprofit hospitals, and lastly proprietary hospitals. Hospital care acuity also had an impact on the patient’s perception of their pain care; patients cared for in acute care hospitals had lower levels of satisfaction than critical access hospitals. Conclusions The results of this study are a representation of the experiences of patients in US hospitals with regard to pain care specifically and the need for improved methods of treating and evaluating pain care. This study provides the evidence needed for hospitals to make pain care a priority in to achieve patient satisfaction throughout the duration of their hospitalization. Furthermore, future research should be developed to make strategies for institutions and policy-makers to improve and optimize patient satisfaction with pain care.

Pharmacological treatment of opioid-induced hyperalgesia: a review of the evidence.

ABSTRACT Opioids are commonly used to treat moderate to severe pain. Opioid-induced hyperalgesia is a paradoxical response to opioid agonists resulting in an increased perception of pain rather than an antinociceptive effect. Even though there is a debate regarding its clinical relevance, it is becoming a challenge in both acute and chronic pain settings. The study of opioid-induced hyperalgesia is an emerging field with multiple challenges faced by investigators with regard to defining the diagnosis and characterizing the findings. The objective of this study was to review the preliminary evidence related to the treatment and management of opioid-induced hyperalgesia. Lack of data, small patient numbers, short-term follow-up, and variations in study design limited the review. With the literature on this subject being sparse, this study attempts to provide a preliminary look at the available data and to set the stage for an eventual meta-analysis. Case reports in the literature have shown success with various pharmacological interventions. Possible treatment regimens include ketamine, dextromethorphan, and nonsteroidal anti-inflammatory drugs (NSAIDs), opioid switching, amantadine, buprenorphine, α2 agonists, and methadone. These agents are briefly discussed in this paper. Further well-designed, placebo-controlled trials are needed to assess the effectiveness of the interventions investigated in this review.

Effect of MRI on Treatment Results or Decision Making in Patients With Lumbosacral Radiculopathy Referred for Epidural Steroid Injections: A Multicenter, Randomized Controlled Trial

BACKGROUND Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI. METHODS In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received. RESULTS Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed. CONCLUSION Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

Retained intrathecal catheter fragment after spinal drain insertion steps for prevention and management

Background and Objectives: The placement of lumbar spinal drains is being done with increasing frequency to facilitate high-risk surgical procedures. One risk associated with these procedures is catheter shearing, resulting in a retained foreign body in the intrathecal space. Unlike retained epidural fragments, there are no guidelines on the management of this complication. The purpose of this article was to synthesize the literature on this subject to come up with guidelines for preventing and managing this complication. Methods: Case report and review of all published cases. Results: Most cases of retained catheters are associated with difficulty inserting or advancing the catheter. Among those cases treated conservatively, approximately one third of patients developed symptoms. Factors that must be considered when weighing the decision to surgically remove the retained catheter include patient comorbidities and desires, size and location of the fragment, infectious risk, the presence of neurologic symptoms, and scheduled surgical procedure. Conclusions: A retained intrathecal catheter can be managed conservatively in certain contexts. Periodic follow-up visits, with or without repeat imaging, are recommended in these circumstances.

Intrathecal Catheter Granuloma Associated with Continuous Sufentanil Infusion

Intrathecal sufentanil is a minimally utilized opioid for patients with intractable pain refractory to traditional intrathecal medications. We present an 86-year-old female with a history of multiple spine surgeries who eventually progressed to having chronic, intractable, and diffuse low back pain. After failing medical management, she underwent a successful intrathecal trial of opioid therapy and was subsequently treated with an implantable drug delivery system (IDDS) or intrathecal pump. We describe the first reported case of formation of a catheter tip granuloma associated with intrathecal infusion of sufentanil. Due to increasing opioid requirements and gradually escalating pain, a computed tomography myelogram was performed to explore neuraxial etiologies of her symptoms. This investigation revealed the presence of a catheter tip-associated inflammatory mass (granuloma). All patients receiving intrathecal medications, including sufentanil, must be considered for the possibility of catheter-associated granuloma, particularly with symptoms of altered neurological function and/or increasing medication requirements associated with worsening pain.

Cannabinoids for Pain Management

Cannabinoids have been used for thousands of years to provide relief from suffering, but only recently have they been critically evaluated in clinical trials. This review provides an in-depth examination of the evidence supporting cannabinoids in various pain states, along with an overview of potential adverse effects. In summary, there is strong evidence for a moderate analgesic effect in peripheral neuropathic and central pain conditions, and conflicting evidence for their use in nociceptive pain. For spasticity, most controlled studies demonstrate significant improvement. Adverse effects are not uncommon with cannabinoids, though most are not serious and self-limiting. In view of the limited effect size and low but not inconsequential risk of serious adverse events, cannabinoids should be employed as analgesics only when safer and more effective medication trials have failed, or as part of a multimodal treatment regimen.

Evidence-Based Review of the Pharmacoeconomics Related to the Management of Chronic Nonmalignant Pain

ABSTRACT Chronic pain is one of the most common reasons for patients to seek medical care. Chronic pain results in substantial economic losses and remains one of the most costly conditions in modern western society. In 1991, costs were estimated to be approximately

Does Pain Score in Response to a Standardized Subcutaneous Local Anesthetic Injection Predict Epidural Steroid Injection Outcomes in Patients with Lumbosacral Radiculopathy? A Prospective Correlational Study

65 billion annually, comparable to the cost of treating diabetes. Persistent chronic pain and the use of advanced interventional and pharmacological treatments often leads to complex social and psychological maladaptations, health care overutilization, as well as many other substantial direct and indirect costs. Thus, the proper treatment of chronic pain involves intense multidisciplinary management, including pharmacological, behavioral, and psychological interventions. Few studies have assessed the total economic cost of chronic pain. However, many of the chronic pain treatments do not alleviate pain symptoms for most patients and lead to unsuccessful application of resources. The economic consequences of inadequately treated chronic pain translates into lost work days, overutilization of health care resources (excess hospitalizations, and surgical procedures and inappropriate medications) and other out-of-pocket patient expenses. Increasing emphasis on diagnosis and treatment of chronic pain places more importance on the need for efficient and coordinated management of patient with chronic pain. The management of chronic pain is remarkably complex and resource intensive. Therefore, a clear need exists for intensive pharmacoeconomic investigations, specifically evaluating costs related to chronic pain and the associated treatment modalities. Additionally, evaluation of the costs related to chronic pain would measure the economic burden of chronic pain, including an estimate of the amount that could potentially be saved if chronic pain patients are optimally managed.

Prospective, Multicenter, Randomized, Crossover Clinical Trial Comparing the Safety and Effectiveness of Cooled Radiofrequency Ablation With Corticosteroid Injection in the Management of Knee Pain From Osteoarthritis

OBJECTIVE Epidural steroid injections (ESI) are the most commonly performed pain procedures. Despite numerous studies, controversy continues to surround their effectiveness. The purpose of this study is to determine whether a standard, clinical local anesthetic injection can predict outcomes for ESI. STUDY DESIGN In this multicenter study, 103 patients received two ESI 2 weeks apart. Prior to their first injection, subjects rated the pain intensity of a standardized subcutaneous (SQ) injection of lidocaine prior to the full dose. Numerical rating scale pain scores were correlated with leg and back pain relief, and functional improvement, through 3-month follow-up. OUTCOME MEASURES A composite successful outcome was predetermined to be a ≥2-point decrease in leg pain score, coupled with a positive global perceived effect. RESULTS A small but significant relationship was found between SQ pain score and reduction in leg (r = -0.21, 95% CI -0.38 to -0.04; P = 0.03) and back pain (r = -0.22, 95% CI -0.36 to -0.07; P = 0.03). Subjects with a positive outcome at 1 month had a mean SQ pain score of 2.5 (SD 1.9) vs 4.1 (SD 2.7) in those with a negative outcome (P = 0.04). Subjects with SQ pain scores <4/10 had lower leg and back pain scores than those with pain scores ≥4 at 1-month (mean 3.2, SD 2.6 vs 5.1, SD 2.7 for leg, P < 0.01; mean 3.7, SD 2.6 vs 5.0, SD 3.0 for back, P = 0.02) and 3-month (mean 3.8, SD 2.7 vs 5.2, SD 3.1 for leg, P = 0.01; mean 4.0, SD 2.6 vs 4.9, SD 3.1 for back; P = 0.14) follow-up. CONCLUSIONS The results of this study found a weak positive correlation between SQ pain scores and treatment results. Further research should consider whether pain perception in conjunction with other variables might prove to be a reliable predictor for ESI and other procedural outcomes.

Intractable Acute Pain Related to Fluoroquinolone-Induced Peripheral Neuropathy

Background and Objectives Osteoarthritis (OA) of the knee affects the aging population and has an associated influence on the health care system. Rigorous studies evaluating radiofrequency ablation for OA-related knee pain are lacking. This study compared long-term clinical safety and effectiveness of cooled radiofrequency ablation (CRFA) with intra-articular steroid (IAS) injection in managing OA-related knee pain. Methods This is a prospective, multicenter, randomized trial with 151 subjects with chronic (≥6 months) knee pain that was unresponsive to conservative modalities. Knee pain (Numeric Rating Scale [NRS]), Oxford Knee Score, overall treatment effect (Global Perceived Effect), analgesic drug use, and adverse events were compared between CRFA and IAS cohorts at 1, 3, and 6 months after intervention. Results There were no differences in demographics between study groups. At 6 months, the CRFA group had more favorable outcomes in NRS: pain reduction 50% or greater: 74.1% versus 16.2%, P < 0.0001 (25.9% and 83.8% of these study cohorts, respectively, were nonresponders). Mean NRS score reduction was 4.9 ± 2.4 versus 1.3 ± 2.2, P < 0.0001; mean Oxford Knee Score was 35.7 ± 8.8 vs 22.4 ± 8.5, P < 0.0001; mean improved Global Perceived Effect was 91.4% vs 23.9%, P < 0.0001; and mean change in nonopioid medication use was CRFA > IAS (P = 0.02). There were no procedure-related serious adverse events. Conclusions This study demonstrates that CRFA is an effective long-term therapeutic option for managing pain and improving physical function and quality of life for patients with painful knee OA when compared with IAS injection. Clinical Trial Registration ClinicalTrials.gov (NCT02343003).