David Rabago

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search for and review of literature found over 2000 abstracts and resulted in 25 eligible manuscripts (22 published, 3 unpublished: 8 randomized controlled trials, 7 controlled nonrandomized, 6 noncontrolled prospective, and 2 qualitative studies, and 1 case report).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.

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.

The efficacy of prolotherapy for lateral epicondylosis: A pilot study

Objectives:To assess whether prolotherapy, an injection-based therapy, improves elbow pain, grip strength, and extension strength in patients with lateral epicondylosis. Setting:Outpatient Sport Medicine clinic. Study Design:Double-blind randomized controlled trial. Participants:Twenty-four adults with at least 6 months of refractory lateral epicondylosis. Intervention:Prolotherapy participants received injections of a solution made from 1 part 5% sodium morrhuate, 1.5 parts 50% dextrose, 0.5 parts 4% lidocaine, 0.5 parts 0.5% sensorcaine and 3.5 parts normal saline. Controls received injections of 0.9% saline. Three 0.5-mL injections were made at the supracondylar ridge, lateral epicondyle, and annular ligament at baseline and at 4 and 8 weeks. Outcome Measures:The primary outcome was resting elbow pain (0 to 10 Likert scale). Secondary outcomes were extension and grip strength. Each was performed at baseline and at 8 and 16 weeks. One-year follow-up included pain assessment and effect of pain on activities of daily living. Results:The groups were similar at baseline. Compared to Controls, Prolotherapy subjects reported improved pain scores (4.5 ± 1.7, 3.6 ± 1.2, and 3.5 ± 1.5 versus 5.1 ± 0.8, 3.3 ± 0.9, and 0.5 ± 0.4 at baseline and at 8 and 16 weeks, respectively). At 16 weeks, these differences were significant compared to baseline scores within and among groups (P < 0.001). Prolotherapy subjects also reported improved extension strength compared to Controls (P < 0.01) and improved grip strength compared to baseline (P < 0.05). Clinical improvement in Prolotherapy group subjects was maintained at 52 weeks. There were no adverse events. Conclusions:Prolotherapy with dextrose and sodium morrhuate was well tolerated, effectively decreased elbow pain, and improved strength testing in subjects with refractory lateral epicondylosis compared to Control group injections.

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.

A systematic review of prolotherapy for chronic musculoskeletal pain

Objective:Prolotherapy, an injection-based treatment of chronic musculoskeletal pain, has grown in popularity and has received significant recent attention. The objective of this review is to determine the effectiveness of prolotherapy for treatment of chronic musculoskeletal pain. Data Sources:We searched Medline, PreMedline, Embase, CINAHL, and Allied and Complementary Medicine with search strategies using all current and historical names for prolotherapy and injectants. Reference sections of included articles were scanned, and content area specialists were consulted. Study Selection:All published studies involving human subjects and assessing prolotherapy were included. Main Results:Data from 34 case reports and case series and 2 nonrandomized controlled trials suggest prolotherapy is efficacious for many musculoskeletal conditions. However, results from 6 randomized controlled trials (RCTs) are conflicting. Two RCTs on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy. Two RCTs on low back pain reported significant improvements in pain and disability compared with control subjects, whereas 2 did not. All studies had significant methodological limitations. Conclusions:There are limited high-quality data supporting the use of prolotherapy in the treatment of musculoskeletal pain or sport-related soft tissue injuries. Positive results compared with controls have been reported in nonrandomized and randomized controlled trials. Further investigation with high-quality randomized controlled trials with noninjection control arms in studies specific to sport-related and musculoskeletal conditions is necessary to determine the efficacy of prolotherapy.

CAM therapies among primary care patients using opioid therapy for chronic pain

BackgroundComplementary and alternative medicine (CAM) is an increasingly common therapy used to treat chronic pain syndromes. However; there is limited information on the utilization and efficacy of CAM therapy in primary care patients receiving long-term opioid therapy.MethodA survey of CAM therapy was conducted with a systematic sample of 908 primary care patients receiving opioids as a primary treatment method for chronic pain. Subjects completed a questionnaire designed to assess utilization, efficacy and costs of CAM therapies in this population.ResultsPatients were treated for a variety of pain problems including low back pain (38.4%), headaches (9.9%), and knee pain (6.5%); the average duration of pain was 16 years. The median morphine equivalent opioid dose was 41 mg/day, and the mean dose was 92 mg/day. Forty-four percent of the sample reported CAM therapy use in the past 12 months. Therapies utilized included massage therapy (27.3%, n = 248), chiropractic treatment (17.8%, n = 162), acupuncture (7.6%, n = 69), yoga (6.1%, n = 55), herbs and supplements (6.8%, n = 62), and prolotherapy (5.9%, n = 54). CAM utilization was significantly related to age female gender, pain severity income pain diagnosis of neck and upper back pain, and illicit drug use. Medical insurance covered chiropractic treatment (81.8%) and prolotherapy (87.7%), whereas patients primarily paid for other CAM therapies. Over half the sample reported that one or more of the CAM therapies were helpful.ConclusionThis study suggests CAM therapy is widely used by patients receiving opioids for chronic pain. Whether opioids can be reduced by introducing such therapies remains to be studied.

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.

Placebo, Meaning, and Health

Placebos are boon and bane to medical theory and clinical practice. On the one hand, randomized controlled trials employ concealed allocations of placebo to control for effects not due to specific pharmacological mechanisms. As a result, nearly all of evidence-based medicine derives from principles and practices based on placebo. On the other hand, medical researchers and physicians have tended to ignore, minimize, or deride placebos and placebo effects, perhaps due to values emphasizing scientific understanding of mechanistic pathways. We argue that intention, expectation, culture, and meaning are central to placebo-effect phenomena and are substantive determinants of health. We introduce three dualities that are integral to placebo/meaning phenomena: body-mind, subconscious-conscious, and passive-active. These placebo-related dualities should be acknowledged, explored with research, and incorporated in theory. While we view consideration of placebo and meaning effects as essential to any adequate understanding of human health, we feel that lessons from this area of inquiry may already provide practical tools for astute clinicians. Toward this end, we list eight specific clinical actions: speak positively about treatments, provide encouragement, develop trust, provide reassurance, support relationships, respect uniqueness, explore values, and create ceremony. These clinical actions can empower patients to seek greater health and may provide a healthful sense of being cared for.

Musculoskeletal Applications of Platelet-Rich Plasma: Fad or Future?

OBJECTIVE The purpose of this article is to detail the biology of platelet-rich plasma (PRP), critically review the existing literature, and discuss future research applications needed to adopt PRP as a mainstay treatment method for common musculoskeletal injuries. CONCLUSION Any promising minimally invasive therapy such as PRP deserves further investigation to avoid surgery. Diagnostic imaging outcome assessments, including ultrasound-guided needle precision, should be included in future investigations.