Anthony J. Mariano

Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors.

OBJECTIVES Opiates are commonly used to treat patients with chronic nonmalignant pain. There is much controversy over the definition, incidence, and risk factors of prescription opiate abuse in chronic pain treatment. The present study, done at the Seattle VA Medical Center, was designed to create opiate abuse criteria, test inter-rater reliability of the criteria, apply the criteria to a group of chronic pain patients, and correlate the risk of opiate abuse with the results of alcohol and drug testing. DESIGN/OUTCOME MEASURES A committee of experienced pain providers designed a five-point prescription opiate abuse checklist based on DSM-III-R parameters. The criteria were then applied to patients enrolled in the pain clinic. The reliability of the criteria were determined using two providers who were familiar with every patient in the clinic. Drug, alcohol, and psychosocial testing were correlated with the risk of opiate abuse. RESULTS A total of 19% (76/403) of all pain clinic patients were using chronic opiates. Thirty-four percent (26/76) met one, and 27.6% (21/76) met three or more of the abuse criteria. The criteria had an inter-rater reliability of > 0.9. There were no differences between chronic opiate users (n = 76) and opiate abusers (n = 21) for a history of drug or alcohol abuse or on psychosocial testing. CONCLUSIONS Prescription opiate abuse criteria for use in patients with chronic nonmalignant pain were designed. The criteria had good reliability and can be applied during normal clinic interactions. The percentage of chronic opiate users who become opiate abusers in pain treatment is within the range reported by others. Past opiate or alcohol abuse or psychosocial testing on clinic admission failed to predict who would become an opiate abuser. The criteria can be used to identify patients who will subsequently require more intensive treatment or intervention or can be used as an outcome to measure to test the effectiveness of treatment strategies.

The use of oral mexiletine for the treatment of pain after peripheral nerve injury

Neuropathic pain is often a difficult condition to treat. Clinical and laboratory studies using intravenously administered local anesthetics or antiarrhythmic agents support the use of these drugs for the treatment of neuropathic pain. The availability of the oral antiarrhythmic medication, mexiletine, has made it possible to study the effects of an orally administered medication on chronic neuropathic pain. The study used a double-blind placebo-controlled design to examine 11 subjects in whom treatment with conventional pain medications had been unsuccessful. Subjects had a history of peripheral nerve injury or dysfunction, and all complained of symptoms consistent with neuropathic pain. After baseline pain measurements, mexiletine or placebo was given in gradually increasing doses to a maximum daily dose of 750 mg mexiletine. After 1 month at steady state, the subject received the alternative medication. Mexiletine was found to produce a statistically significant reduction in reported pain when compared to baseline or placebo. Pain scores were rated on a scale from 0 (no pain) to 10 (unbearable pain). Median pain scores prior to mexiletine were 7, after placebo treatment 7, and while receiving mexiletine (750 mg/day) 4. Side effects were mild and well-tolerated. Mexiletine may be effective in reducing neuropathic pain for patients in whom alternative pain medications have been unsatisfactory.

Chronic pain and spinal cord injury.

With the medical progress that has given spinal cord injured individuals greater longevity and better overall health, chronic pain has emerged as a major challenge in treating this population. Over the past 40 years, estimates of prevalence of severe/disabling chronic pain in spinal cord injury (SCI) patients have ranged from 18% to 63%. Beyond this finding, the extant literature is extremely limited. This review summarizes the empirical findings with regard to the prevalence and clinical significance of chronic pain in the SCI population. In spite of widespread clinical beliefs, there is little evidence that characteristics of the SCI such as the level, completeness, or etiology of the injury are associated with either the development or severity of pain. Until recently, psychosocial issues have been almost totally ignored in spite of the importance such variables have demonstrated in chronic pain in other populations. A major purpose of the present article is to expand the scope of inquiry to include these factors and to emphasize the importance of employing a biopsychosocial model. Evidence is reviewed which suggests that chronic pain is associated with psychosocial impairment in this population. It is concluded that rather than being a minor problem in comparison to the other limitations imposed by SCI, chronic pain represents a significant additional challenge to the SCI patient that may be best addressed by a multidisciplinary approach.

A comparison of the effects of intrathecal fentanyl and lidocaine on established postamputation stump pain

&NA; Eight patients with established lower limb postamputation stump pain were given lumbar intrathecal fentanyl 25 &mgr;g and lidocaine 70 mg 2 weeks apart in an attempt to better understand the role of peripheral and central mechanisms in this condition. Baseline pain was recorded and then analgetic and side effects and their duration were assessed. Three self‐administered questionnaires with appropriate psychometric proprieties were given to the patients. Intrathecal fentanyl always abolished the pain. Its onset was rapid being heralded within 1–2.5 min by a pleasant sensation of warmth involving the lower trunk and legs. Analgesia was complete by 5–10 min and had a median duration of 8 h. The patients had a sense of well being and were unable to elicit discomfort by pain aggravating maneuvers. Normal motor and sensory functions were retained. Pruritus was the only adverse effect unique to intrathecal fentanyl. Intrathecal lidocaine usually relieved the discomfort but was unable to abolish it in 3 of 8 patients despite adequate neural blockade. Its onset of action was slower and duration of effect shorter than fentanyl. Intrathecal fentanyl provided profound analgesia associated with normalization of stump sensations and euphoria, probably due to a segmental spinal action. The effects of lidocaine were inferior to fentanyl due to the associated motor and sensory paralyses as well as the absence of euphoria. This study suggests that, while peripheral mechanisms played a role, central mechanisms involving the spinal cord were more important in the modulation of established stump pain in the 8 subjects evaluated.

Narcotics for chronic pain yes or no? A useless dichotomy

Abstract Two opposing views have developed regarding the place of narcotics in the treatment of chronic nonmalignant pain. The authors believe the foundations of these views are based on treatment models that can be characterized as biomedical, behavioral, and moral. Conflicts arise when these incomplete models are used to addeess a very complex problem. The authors describe a biopsychosocial model and give treatment guidelines in which the prescription of opioids is a tool among others to achieve multiple goals individualized for each patient with chronic nonmalignant pain. A specific opioid protocol is used and narcotics are rarely initiated and usually discontinued over-time with the concurrence of the patient. However, a number of patients remain on low stable doses for years in the context of other nonpharmacological treatments.

Simultaneous interview technique for patients with persistent pain.

The biomedical model of illness as applied to the management of persistent pain is untenable and consequently we have adopted a biopsychosocial approach [2]. Recognising that the mind and body are inseparable, we manage all patients attending our outpatient pain clinic using a technique whereby they are interviewed simultaneously by a psychologist and a physician; the simultaneous interview technique (SIT). We wish to introduce this method which we have developed for the management of this patient population [4]. Patients with entrenched persistent pain are difficult to manage. Complaints of incapacitating pain and unrelievable suffering [l] are often seen in a context of undiagnosable pathology and appear to be grossly exaggerated in light of established physical findings. Noncompliance, disillusionment with the health care system, depression, and social dysfunction are frequently noted 131. Contemporary multidisciplinary approaches traditionally deliver services via a consultation model in which each discipline provides independent treatment while attempting to coordinate goals and plans with other members of the team [6]. In contrast, we provide treatment using a technique (SIT) whereby each patient is interviewed simultaneously by a psychologist and a physician. The simultaneous interview technique (SIT) radically transforms the traditional patient-provider interaction and appears to facilitate patient management. A major difficulty in treating persistent pain patients appears to be the widely divergent views patients and providers maintain regarding chronic pain. Many patients with persistent pain rigidly adhere to a philosophy of mind/body dualism and stridently defend their

The psychosocial impact of opioid treatment

T he major goal of our focus article was to show that much of the disagreement regarding the role of narcotics in treating chronic nonmalignant pain has been due to the conflicting and often implicit conceptual models of the various proponents. A secondary purpose was to introduce our own position and briefly describe the way we utilize narcotic medications. We are pleased to take this opportunity to respond to commentaries of Fordyce and Portenoy. Both Fordyce5 and Portenoy” have recognized the value of examining fundamental assumptions about pain and explicated their previous positions within the context of a more comprehensive biopsychosocial model of pain. Fordyce’s emphasis on the important role of behavioral outcome assessment and Portenoy’s call for therapeutic trials of opioids extend the arguments each has made within this debate. Our focus article proposed a treatment paradigm that emphasizes the interaction between the provider and patient in which the patient is actively engaged as part of the treatment team and assumes, albeit gradually, much of the responsibility for his or her health care. This codisciplinary model of treatment and our emphasis on the interpersonal process has been described elsewhere.‘sg In our view, chronic pain treatment is fundamentally a psychosocial interaction involving a patient and health care providers. In our therapeutic approach, emphasis is placed on communication between the patient and provider team. Prescription constitutes an important part of

Electronic Medical Record Alert Associated With Reduced Opioid and Benzodiazepine Coprescribing in High-risk Veteran Patients

Background: Over the past decade, overdoses involving opioids and benzodiazepines have risen at alarming rates, making reductions in coprescribing of these medications a priority, particularly among patients who may be susceptible to adverse events due to high-risk conditions. Objectives: This quality improvement project evaluated the effectiveness of a medication alert designed to reduce opioid and benzodiazepine coprescribing among Veterans with known high-risk conditions (substance use, sleep apnea, suicide-risk, age 65 and above) at 1 Veterans Affairs (VA) health care system. Methods: Prescribers were exposed to the point-of-prescribing alert for 12 months. For each high-risk cohort we used interrupted time series design to examine population trends in coprescribing 12 months after alert launch adjusting for coprescribing 12 months before launch, demographics and clinical covariates. Trends at the alert site were compared with those of a similar VA health care system without the alert. Secondary analyses examined population trends in opioid and benzodiazepine prescribing separately. Results: Over 12 months, the alert activated for 1332 patients. Proportions of patients with concurrent prescriptions decreased significantly postalert launch among substance use [adjusted odds ratio (AOR)=0.97; 95% confidence interval (CI)=0.96–0.99; 12-month decrease=25.0%], sleep apnea (AOR=0.97, 95% CI=0.95–0.98, 12-month decrease=38.5%), and suicide-risk (AOR=0.94, 95% CI=0.91–0.98, 12-month decrease=61.5%) cohorts at the alert site. Decreases in coprescribing were significantly different from the comparison site among suicide-risk (AOR=0.92, 95% CI=0.86–0.97) and sleep apnea (AOR=0.98, 95% CI=0.96–1.00) cohorts. Significant decreases in benzodiazepine prescribing trends were observed at the alert site only. Conclusions: Medication alerts hold promise as a means of reducing opioid and benzodiazepine coprescribing among certain high-risk groups.

New dreams: back to the future.

guinal hernias are less likely to have other anesthetics (i.e., children with hernia are otherwise healthier than the background population, which would be difficult to argue for biologically). For clarity, as requested by Flick and Warner, we included all children in Denmark born from 1986 to 1990 who underwent surgery for inguinal hernia before the age of 1 yr (n 2,689); of those had 2,445 (90.9%) had one hernia operation, 221 (8.2%) had two hernia operations, 20 (0.7%) had three hernia operations, 2 (0.1%) had four hernia operations, and 1 (0.0%) had five hernia operations. Our 5% randomly selected background population consisted of 14,575 individuals of the same cohort, excluding children who underwent hernia repair. Children who underwent additional surgeries were not excluded from the exposure or the control group. We are studying the effects of multiple episodes of anesthesia (and surgery) among other children (including neonates) operated on during the first year of life. We expect this group to have bigger learning problems later in life than the background population, but it will be difficult to disentangle the effect of the more severe underlying disease(s) that prompted several episodes of anesthesia from the potential effect of multiple episodes of anesthesia. Thus, we reported on all children with hernia in our first report because they represent a group for whom the underlying morbidities are unlikely directly to affect later learning disabilities. Finally, Flick and Warner question whether we may have missed cases in our cohort because the Danish National Hospital Register did not include outpatients before 1995. In Denmark during the period 1986 –1990, all infants and young children who underwent anesthesia and surgery (including inguinal hernia repair) were inpatients.