John P. Ney

Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.

Abstract Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.

Continuous and routine EEG in intensive care Utilization and outcomes, United States 2005–2009

Objectives: To evaluate the effect of intensive care unit continuous EEG (cEEG) monitoring on inpatient mortality, hospital charges, and length of stay. Methods: A retrospective cross-sectional study was conducted using the Nationwide Inpatient Sample, a dataset representing 20% of inpatient discharges in nonfederal US hospitals. Adult discharge records reporting mechanical ventilation and EEG (routine EEG or cEEG) were included. cEEG was compared with routine EEG alone in association with the primary outcome of in-hospital mortality and secondary outcomes of total hospital charges and length of stay. Demographics, hospital characteristics, and medical comorbidity were used for multivariate adjustments of the primary and secondary outcomes. Results: A total of 40,945 patient discharges in the weighted sample met inclusion criteria, of which 5,949 had reported cEEG. Mechanically ventilated patients receiving cEEG were younger than routine EEG patients (56 vs 61 years; p < 0.001). There was no difference in the 2 groups in income or medical comorbidities. cEEG was significantly associated with lower in-hospital mortality in both univariate (odds ratio = 0.54, 95% confidence interval 0.45–0.64; p < 0.001) and multivariate (odds ratio = 0.63, 95% confidence interval 0.51–0.76; p < 0.001) analyses. There was no significant difference in costs or length of stay for patients who received cEEG relative to those receiving only routine EEG. Sensitivity analysis showed that adjusting for diagnosis-related groups (DRGs) for any neurologic diagnoses, DRGs for neurologic procedures, and specific DRGs for epilepsy/convulsions did not substantially alter the association of cEEG with reduced inpatient mortality. Conclusions: cEEG is favorably associated with inpatient survival in mechanically ventilated patients, without adding significant charges to the hospital stay.

Neurologic uses of botulinum neurotoxin type A

This article reviews the current and most neurologic uses of botulinum neurotoxin type A (BoNT-A), beginning with relevant historical data, neurochemical mechanism at the neuromuscular junction. Current commercial preparations of BoNT-A are reviewed, as are immunologic issues relating to secondary failure of BoNT-A therapy. Clinical uses are summarized with an emphasis on controlled clinical trials (as appropriate), including facial movement disorders, focal neck and limb dystonias, spasticity, hypersecretory syndromes, and pain.

Treatment of chronic low back pain with successive injections of botulinum toxin a over 6 months : A prospective trial of 60 patients

ObjectivesThe aim of this study was to evaluate the effects of two successive neurotoxin treatments for chronic low back pain using multiple pain rating scales in an open-label, prospective study. MethodsAdult patients with chronic low back pain received multiple paraspinal muscle injections with a maximum dosing of 500 units of botulinum A toxin per session. Those with a beneficial clinical response received a second treatment at 4 months. Pain was assessed by visual analog scale (VAS), modified low back pain questionnaire (OLBPQ), and a clinical low back pain questionnaire (CLBPQ) at baseline, 3 weeks, 2 months, 4 months, and 6 months after the first treatment. ResultsEighteen women and 42 men, ages 21 to 79 years (mean 46.6 years), with low back pain of a mean duration of 9.1 years were included. Significant improvement in back and radicular pain occurred at 3 weeks in 60% and at 2 months in 58% of the cohort. Beneficial clinical response to the first injection predicted response to reinjection in 94%. A significant minority of patients had a sustained beneficial effect from the first injection at 4 (16.6%) and 6 months (8.3%). Two patients had a transient flulike reaction after the initial treatment. ConclusionsBotulinum toxin A improves refractory chronic low back pain with a low incidence of side effects. The beneficial clinical response is sustained with a second treatment.

Cost-effectiveness of intraoperative neurophysiological monitoring for spinal surgeries: Beginning steps

highlights Cost-effectiveness modeling of multimodal intraoperative neurophysiologic monitoring (IONM) for spinal surgery relies on assumptions based on pooled results of uncontrolled observational studies, with uncertainty evaluated through probabilistic sensitivity analysis of Monte Carlo simulation results. Multimodal IONM reduces the relative risk of post-operative neurological complications by an estimated 49.4% (p < 0.001) at a cost of

Subarachnoid Pneumocephalus From Epidural Steroid Injection

63,387 (95%CI

Cost-benefit analysis: intraoperative neurophysiological monitoring in spinal surgeries.

61,939–

A Patient with Idiopathic Thrombocytopenic Purpura Presenting with an Acute Ischemic Stroke

64,836) per neurological deficit averted. 2012 Published by Elsevier Ireland Ltd. on behalf of International Federation of Clinical Neurophysiology. The use of evoked potentials (EPs) and electromyograms (EMGs) in the operating room has increased in popularity over the past several decades, beginning with brainstem auditory EPs for acoustic neuroma resections to the most common usage today, neck and back surgeries. Intraoperative neurophysiologic monitoring (IONM) holds the promise of prevention of neurological complications by detecting evolving abnormalities and alerting the operating team to take actions to normalize the electrodiagnostic abnormality, including repositioning the patient, taking a different surgical approach, adjusting anesthesia, giving blood pressure support or waking the patient. By monitoring motor and somatosensory EPs with free run and triggered EMG, multimodal IONM may have greater diagnostic sensitivity than any single modality. However, the evidence for efficacy of IONM in spinal surgeries is scant, as seen in a recent systematic review (Fehlings et al., 2010), which concluded that IONM may be more helpful for complicated surgeries and recommended usage based on the discretion of the operating surgeon. Furthermore, multimodal IONM adds cost to already expensive procedures (average US cost of spinal fusion in 2007 was

Comparative Efficacy of Oral Pharmaceuticals for the Treatment of Chronic Peripheral Neuropathic Pain: Meta‐Analysis and Indirect Treatment Comparisons

24,600 (Elixhauser and Andrews, 2010)). The value of IONM in spinal procedures is in the avoidance of neurological deficits, based on IONM diagnostic characteristics, likelihood of preventing a post-operative injury following an IONM alert, and the baseline (a priori) rate of neurological complications from a given spinal operation. We created an economic decision model which incorporates the available evidence for these parameters. To account for uncertainty inherent in observational, nonrandomized data, the diagnostic characteristics of IONM and neurological complication rates for the eleven studies using multimodal IONM in spinal surgeries identified by Fehlings et al. (n = 2162) were pooled in a random effects meta-analysis to give estimates of average effect size and standard errors. This yielded a 5.0% baseline neurological complication rate for spinal surgeries (95% CI, 3.0– 7.0%), 94.3% sensitivity (95% CI, 92.3–96.3%) and 95.6% specificity (95% CI, 93.3–97.4%). The rate of prevention of post-operative deficits given an IONM alert has only been evaluated in a single study (Wiedemayer et al., 2002), which reported a 52.4% prevention rate (95%CI 37.3–67.3%) when actions were taken subsequent to IONM alerts compared to no actions taken. The per-operation cost of multimodal IONM for four-limb EMG, upper and lower extremity motor and somatosensory EPs and continuous IONM was calculated from 2009 Medicare reimbursement rates (national rating, global fee) for corresponding Current Procedure Terminology codes totaled

Neurologist ambulatory care, health care utilization, and costs in a large commercial dataset

1535. The cost-effectiveness outcome was the cost per undesirable consequence avoided, calculated as the mean expense of IONM divided by the difference in post-operative neurological deficit rates in spinal surgeries using IONM compared with those not using IONM. In the IONM usage arm of the model, the likelihood of preventing a neurological deficit is the baseline risk of neurological deficit for the surgery X diagnostic sensitivity of IONM X probability of prevention of neurological deficit given an IONM alert, where the post-operative neurological deficit rate in the non-IONM arm is equal to the baseline risk of neurological complications for the surgery. To incorporate uncertainty, we conducted a probabilistic sensitivity analysis (PSA) with Monte Carlo simulation. Probability