Terence W. Starz

Analgesic usage for low back pain: Impact on health care costs and service use

Study Design. Cross-sectional analysis of analgesic use by patients with low back pain (LBP). Objectives. To describe patterns of analgesic use and their cost implications for the use of other care services among individuals with LBP enrolled in a health insurance plan during 2001. It was hypothesized that the use of analgesics would be most frequent among patients with LBP with neurologic findings. Summary of Background Data. National guidelines have recommended analgesics as the primary pharmacologic treatment of LBP. The choice of specific analgesics has major cost and service use implications. Methods. The University of Pittsburgh Health System includes 18 affiliated hospitals, more than 5000 physicians, and a commercial health plan with 255,958 members in 2001. This study uses the System Health Plan’s insurance claims database to identify members who had services provided for one of 66 International Classification of Diseases, Version 9, Clinical Modification codes that identify mechanical LBP (n = 17,148). Results. In 2001, 7631 (43.5%) members with claims for LBP services had no analgesic pharmacy claims. The other 9517 (55.5%) had analgesics claims costing a total of

Feasibility of a dyadic intervention for management of osteoarthritis: A pilot study with older patients and their spousal caregivers

1.4 million; 68% of claimants were prescribed an opioid and 58% nonselective nonsteroidal antiinflammatory drugs (NSAID). The costs of opioids, NSAID, and cyclooxygenase-2 selective NSAID for patients with LBP represented 48%, 24%, and 28%, respectively, of total health plan expenditures for all uses of these drugs, including cancer. Opioid use was associated with the high volume usage of LBP care services. Patients with LBP with and without neurologic involvement and those with acquired lumbar spine structural disorders had similar patterns of analgesic use: those with congenital structural disorders were less likely to use analgesics; and those with psychogenic pain and LBP related to orthopedic devices were more likely to use opioids. Conclusions. With this health plan, a high proportion of patients with LBP had claims for opioids during 2001. The use of opioids by patients with LBP represents a major cost for the health plan, and is associated with specific patient characteristics and their use of other LBP services.

Report of the American College of Rheumatology Pain Management Task Force

This study evaluated a novel intervention for older osteoarthritis (OA) patients and their spousal caregivers that consisted of standard patient education supplemented by information related to effectively managing arthritis as a couple. Twenty-four female OA patients and their husbands were randomly assigned to either an educational intervention that was targeted at both patient and spouse or to a patient education intervention that was targeted at only the patient. Findings revealed that both interventions were evaluated favorably but the couple intervention was better attended than the patient intervention. In addition, patients in the couple intervention experienced greater increased efficacy in managing arthritis pain and other symptoms. The findings of this pilot study point to the utility of a dyadic intervention approach to management of OA in late life.

Couple-Oriented Education and Support Intervention: Effects on Individuals With Osteoarthritis and Their Spouses

Pain is the most common symptom of patients with rheumatic disorders and can occur in both inflammatory and noninflammatory conditions. As a complex phenomenon with a strong subjective component, pain can be influenced by the nature of the underlying disease, personal predisposition (biologic and psychological), as well as environmental and psychosocial factors that impact the pain experience. In the management of patients with musculoskeletal disease, therefore, the characterization of pain (e.g., its onset, duration periodicity, and impact on functioning) is important in establishing the diagnosis and developing a comprehensive treatment plan to reduce pain and to improve quality of life. Although rheumatologists diagnose and treat pain, they do not characterize themselves as “pain physicians.” Rather, in their professional identity, many rheumatologists consider themselves more narrowly as subspecialists who treat musculoskeletal disorders that have a component of acute and chronic nonmalignant pain. Furthermore, rheumatologists have traditionally approached pain from the perspective of the proximal causes of pain such as tissue injury and inflammation, and have concentrated therapy on reducing inflammation either locally or systemically. The therapies used have been predominantly pharmacologic and include nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying agents including biologics, and corticosteroids. Although commonly recommended, nonpharmacologic psychosocial interventions such as cognitive–behavioral therapy or body-based therapies including exercise are generally considered less effective by rheumatologists despite evidence that such approaches can be highly efficacious depending on the setting or disease (1–3). For most conditions treated by rheumatologists, the etiology of pain has been conceptualized primarily in the context of events in peripheral tissue. As a result, rheumatologists have relied heavily on pharmacologic therapies directed at the immune system to control symptoms, especially in inflammatory disease. Correspondingly, for patients with major or irreversible tissue damage, whether arising in inflammatory or noninflammatory disease, surgery has been the mainstay of treatment, with pharmacologic therapy used as a transition until a definitive operation is performed. Given this approach, events in the central nervous systems contributing to the experience of pain have received less attention in treatment, with additional analgesic, psychosocial, or interventional therapies receiving neither extensive investigation nor widespread or appropriate use. This approach may limit the utilization of newer and multidisciplinary approaches to pain manMembers of the American College of Rheumatology Pain Management Task Force are as follows: David Borenstein, MD: Arthritis & Rheumatism Associates, Washington, DC; Roy Altman, MD: University of California, Los Angeles; Alfonso Bello, MD, MHS: Illinois Bone & Joint Institute, Glenview; Winn Chatham, MD: University of Alabama, Birmingham; Daniel Clauw, MD: University of Michigan, Ann Arbor; Leslie Crofford, MD: University of Kentucky, Lexington; Joseph Croft, MD: Bethesda, Maryland; Afton Hassett, PsyD: Robert Wood Johnson Medical School, New Brunswick, New Jersey; Franklin Kozin, MD: Scripps Clinic Medical Group, La Jolla, California; David Pisetsky, MD, PhD: Durham VA Hospital, Durham, North Carolina; Jan Richardson, PT, PhD, Laura Schanberg, MD: Duke University, Durham, North Carolina; Terence Starz, MD: Arthritis & Internal Medical Associates, Pittsburgh, Pennsylvania; James Witter, MD, PhD: NIH, Bethesda, Maryland. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service. Dr. Borenstein has received consultant fees, speaking fees, and/or honoraria (less than

Do patients with juvenile idiopathic arthritis in clinical remission have evidence of persistent inflammation on 3T magnetic resonance imaging

10,000 each) from Pfizer and King, and (more than

Task independence, safety, and adequacy among nondisabled and osteoarthritis-disabled older women.

10,000) from Cephalon. Dr. Altman has received consultant fees, speaking fees, and/or honoraria (less than

AAOS Appropriate Use Criteria: Optimizing the Non-Arthroplasty Management of Osteoarthritis of the Knee

10,000 each) from Nutramax, McKinsey, Endo, Cypress, Theralogix, Forest Laboratories, and NicOx, and (more than

The Drug Information Center Arthritis Project: Providing Patients with Interactive and Reliable Arthritis Internet Education

10,000 each) from Ferring and Smith & Nephew. Dr. Bello has received consultant fees, speaking fees, and/or honoraria (less than

Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment.

10,000 each) from Abbott, BMS, Amgen, Lilly, and UCB, and (more than

Interdisciplinary treatment for fibromyalgia syndrome: Clinical and statistical significance

10,000 each) from Pfizer and Horizon Therapeutics. Dr. Hassett has received consultant fees, speaking fees, and/or honoraria (less than