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BMJ 2002 Dec 14;325(7377):1387
Department of Radiology, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ. cng@mdanderson.org
[Medline record in process]
OBJECTIVES: To evaluate the impact of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause on length of hospital stay and accuracy of diagnosis. DESIGN: Randomised, prospective controlled trial. SETTING: Teaching hospital in England. PARTICIPANTS: 120 patients admitted with acute abdominal pain for which no immediate surgical intervention or computed tomography was indicated. INTERVENTION: 55 participants were prospectively randomised to early computed tomography (within 24 hours of admission) and 65 to standard practice (radiological investigations as indicated). MAIN OUTCOME MEASURES: Length of hospital stay, accuracy of diagnosis, and, owing to a possible effect on inpatient mortality, deaths during the study. RESULTS: Early computed tomography reduced the length of hospital stay by 1.1 days (geometric mean 5.3 days (range 1 to 31) v 6.4 days (1 to 60)), but the difference was non-significant (95% confidence interval, 8% shorter stay to 56% longer stay, P=0.17). Early computed tomography missed significantly fewer serious diagnoses. Seven inpatients in the standard practice arm died. Only 50% (59 of 118) of diagnoses on admission were correct at follow up at 6 months, but this improved to 76% (90) of diagnoses after 24 hours. CONCLUSIONS: Early abdominopelvic computed tomography for acute abdominal pain may reduce mortality and length of hospital stay. It can also identify unforeseen conditions and potentially serious complications.
PMID: 12480851, UI: 22368045
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BMJ 2002 Nov 9;325(7372):1082
Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT. rosalind.raine@lshtm.ac.uk
OBJECTIVES: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence. DESIGN: Systematic review. DATA SOURCES: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians. STUDY SELECTION: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality. RESULTS: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome. CONCLUSIONS: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.
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PMID: 12424170, UI: 22310674
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Clin J Pain 2002 Jul-Aug;18(4 Suppl):S99-107
Pain Medicine Program, Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, Pennsylvania 19107-4414, USA. Mitchell.J.Cohen@mail.tju.edu
The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. Chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.
PMID: 12479260, UI: 22366775
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S91-8
amgilson@wisc.edu
Undertreatment of pain is likely to occur among patients with active addiction or those who have a history of addiction. One of the factors that can contribute to the inadequate treatment of pain in this patient population is the presence of laws and regulations that, when implemented, could impede effective pain management. This article describes the current status of federal and state policy governing the medical use of opioid analgesics for pain management with patients who have an addictive disease in the U.S. Three types of policy barriers are discussed: (1) those that can affect pain management in any patient, (2) those that can lead to patients in pain being classified as "addicts," and (3) those that relate specifically to patients with a high risk of addiction. Also presented are recent policy initiatives that can improve the use of controlled substances to treat pain and, thus, ultimately enhance pain relief for patients with an addictive disease.
PMID: 12479259, UI: 22366774
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S83-90
Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA. stanley_chapman@emoryhealthcare.org
The authors review research on the intermediate- and long-term effects of taking opioid medication on cognitive functioning in patients with chronic cancer and noncancer pain. Opioids seem to be more likely to worsen cognitive performance during the first few days of use and during the first few hours after a given dose, particularly on timed performance in psychomotor tasks. Results have been inconsistent regarding what decrements in cognitive performance are observed when patients with chronic pain who have been using opioids for more than three days are compared with healthy volunteers. Relatively few differences have been found when cognitive performance in these patients is compared with their performance before taking opioids, or with the performance of a comparable pain population not taking opioids. Major unresolved questions remain regarding such important issues as effects of different types of opioids, dose effects, interactions with other medications, and subject variables.
PMID: 12479258, UI: 22366773
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S61-9
Division of General Medicine and Primary Care, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298-0109, USA. Mfweaver@hsc.vcu.edu
Patients may present to physicians with complaints of acute or chronic pain. Some of these patients will have a history of addiction to drugs or alcohol, and a few will have active addiction. Controlled-substance prescriptions, especially opioid pain medications, can be very beneficial for treatment of pain in patients. There are clear differences between physical dependence on medication, active addiction, addiction in remission, and pseudoaddiction. A search of the medical literature revealed different rates of addiction in patients with chronic pain because different criteria were used to define addiction and the types of chronic pain. It appears that rates of addiction in patient populations with chronic pain are no different than rates of addiction in the general population, according to some recent studies. "Drug-seeking behavior" may be seen with either active addiction or pseudoaddiction. A way to distinguish between these conditions is by giving the patient more pain medication and observing the patient's pattern of behavior. Some patients may be at higher risk to abuse prescription opioids, and some types of drug-seeking behavior may be more predictive of active addiction than pseudoaddiction. General guidelines can improve physicians' comfort level in prescribing opioids for patients with chronic pain, even those with a history of addiction. These include using a medication agreement or contract, setting appropriate goals with the patient, giving appropriate amounts of pain medication, monitoring with drug screens and pill counts, and documenting the case carefully. Even patients with a history of addiction can benefit from opioid pain medications if the patients are monitored appropriately.
PMID: 12479255, UI: 22366770
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S52-60
Symptom Management and Palliative Care Program, Markey Cancer Center, University of Kentucky, Lexington, Kentucky 40536-0093, USA.
The assessment of addiction-related outcomes is crucial to the management of chronic pain with opioid drugs in all patients. Pain management for patients who have concomitant drug abuse or addiction issues is a particularly complex task involving a need for a common nomenclature as well as empirically derived data to support management strategies during treatment regimens. Complicating the issue is the notion of pseudoaddiction, which is an abuse of medications driven by unrelieved pain that appears on the surface to be very similar to the behavior patterns of addicts. For proper adherence to medical therapy and safety during treatment, it is necessary to address and manage substance abuse-related behaviors. Aberrant drug-taking behavior presents many threats to the integrity of pain treatment. Unfortunately, the current state of the art still has a long way to go before clear guidelines for treatment and management can emerge. What is ultimately needed is a broad-based spectrum of research that highlights the epidemiology of drug-taking behaviors for different medical illnesses ranging from cancer to back pain. This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain.
PMID: 12479254, UI: 22366769
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S39-51
Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
Clinical experience supports the notion that opioids can be used successfully to treat many chronic pain conditions. Unfortunately, few controlled trials have assessed which individuals benefit from long-term opioid therapy, and there is concern about the use of long-term opioid therapy in individuals with a substance-abuse history. This article contains three sections relevant to the assessment of individuals with chronic pain and a substance-abuse history who are receiving long-term opioid therapy. The first reviews the literature on opioid therapy, with a critique of biologic and environmental susceptibility factors for addiction. The second briefly reviews uncontrolled and controlled trials of opioid therapy for pain. The third reviews areas critical in assessing treatment efficacy and substance abuse in patients with chronic pain, both in terms of documentation of past behaviors and as a measure of outcome of opioid therapy. Potential guidelines for use of opioids in patients with chronic noncancer pain are outlined. Finally, questions are posed for future investigations of the efficacy of opioid therapy for patients with chronic pain and a substance-abuse history.
PMID: 12479253, UI: 22366768
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S28-38
Department of Anesthesiology, Dartmouth Medical School, Manchester Veterans Administration Medical Center, New Hampshire Regional Medical Opioid Treatment and Education Project, Bradford, New Hampshire, USA. seddon.savage@dartmouth.edu
The identification of the disease of addiction is important to safe and effective clinical management of pain in persons with addictive disorders. The disease of addiction affects approximately 10% of the general population, and its prevalence may be higher in subpopulations of patients with pain. The presence of active addiction may facilitate the experience of pain. Both active and recovering addiction may complicate the use of medications, such as opioids, important to the management of pain. There is, further, persistent misunderstanding among health care providers, regulators, and the general population regarding the nature and manifestations of addiction that may result in undertreatment of pain and stigmatization of patients using opioids for pain control. The author seeks to clarify understanding of addiction, to underscore the importance of identifying addiction in the context of pain treatment, and to provide a rational approach to assessment for addiction in patients with pain. Current scientific understanding of addiction as a chronic illness is briefly reviewed. Recent definitions related to addiction are presented. The impact of addictive disorders on pain and pain treatment are explored. The roles of medical interview, physical examination, laboratory studies, and standard addiction screening tools in assessing for addiction are outlined. Differential considerations in distinguishing therapeutic use of opioids for analgesia from addictive or other nontherapeutic use of opioids are discussed. In summary, the article provides salient background and a detailed approach to assessment for addictive disorders in the context of pain treatment.
PMID: 12479252, UI: 22366767
Clin J Pain 2002 Jul-Aug;18(4 Suppl):S3-13
Department of Pharmacology, Weill Medical College of Cornell University, Pain and Palliative Care Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
The pharmacological effects of the opioid analgesics are derived from their complex interactions with three opioid receptor types (mu, delta, and kappa; morphine is an agonist at the mu opioid receptor). These receptors are found in the periphery, at presynaptic and postsynaptic sites in the spinal cord dorsal horn, and in the brain stem, thalamus, and cortex, in what constitutes the ascending pain transmission system, as well as structures that comprise a descending inhibitory system that modulates pain at the level of the spinal cord. The cellular effects of opioids include a decrease in presynaptic transmitter release, hyperpolarization of postsynaptic elements, and disinhibition. The endogenous opioid peptides are part of an endogenous pain modulatory system. A number of opioids are available for clinical use, including morphine, hydromorphone, levorphanol, oxymorphone, methadone, meperidine, oxycodone, and fentanyl, and their advantages and disadvantages for the management of pain are discussed. An understanding of the pharmacokinetic properties, as well as issues related to opioid rotation, tolerance, dependence, and addiction are essential aspects of the clinical pharmacology of opioids for pain.
PMID: 12479250, UI: 22366765
JAMA 2002 Nov 27;288(20):2541-2; author reply 2542
PMID: 12444856, UI: 22337087
JAMA 2002 Nov 27;288(20):2541; author reply 2542
PMID: 12444855, UI: 22337086
PMID: 12444854, UI: 22337085
Neurology 2002 Dec 10;59(11):1694-700
University of California-San Diego School of Medicine (Dr. Wallace) and University of California-San Francisco (Dr. Rowbotham).
BACKGROUND: Nerve injury results in increases in spinal glutamate, which opens the NMDA ionophore channel, causing an influx of calcium. A glycine-binding site must be occupied for the channel to open. GV196771 is a selective antagonist of the glycine-binding site of the NMDA ionophore. OBJECTIVE: To determine the efficacy of GV196771 in subjects with chronic neuropathic pain in a proof-of-concept study. METHODS: With informed consent, 63 subjects (31 placebo, 32 GV196771) with neuropathic pain (diabetic neuropathy, postherpetic neuralgia, complex regional pain syndrome, or peripheral nerve injury), a visual analogue score averaging >/=30 mm during the screening period, and a well-defined primary area of mechanical allodynia were recruited for the study. A multicenter, randomized, double-blind, placebo-controlled, parallel-group study design was utilized. Subjects came to the research center for a total of five visits over a 21-day period, which consisted of a 14-day treatment period followed by a 7-day washout period. Spontaneous and evoked pain scores, mechanical sensory testing, quantitative sensory testing, Short Form McGill Pain Questionnaire, patient global satisfaction, and safety assessments were made during the study. RESULTS: There was no significant effect of GV196771 on spontaneous or evoked pain, quantitative sensory testing, or patient global satisfaction. There was a significant effect of GV196771 on the area of dynamic and static allodynia on days 7 and 14. The overall incidence of adverse events during treatment was similar for GV196771 (56%) and placebo (71%). The incidence of drug-related adverse events during treatment was higher for placebo (42%) than GV196771 (28%). CONCLUSIONS: Although the glycine antagonists show anti-hyperalgesic action in animal models of neuropathic pain, GV196771 does not appear to be an effective treatment in subjects with chronic neuropathic pain. This may be due to insufficient penetration of GV196771 to central sites of action, differences between the human and animal glycine receptors, or differences between neuropathic pain in animal models and humans.
PMID: 12473754, UI: 22362090
Support Care Cancer 2002 Sep;10(6):480-5
Department of Anaesthesiology, University of Cologne, Cologne, Germany. Lukas.Radbruch@uni-koeln.de
Patients' and caregivers' fear of addiction to and concern about side effects of morphine have been found to be among the major barriers to adequate pain relief in cancer patients. In contrast, the transdermal administration of opioids by means of fentanyl patches does not seem to evoke such fears. In a qualitative study, 60 patients in our outpatient pain clinic recorded up to five associations with a list of diseases, drugs and administration routes. Cancer and AIDS were associated most often with death, followed by suffering, anxiety and hopelessness. Migraine was associated predominantly with pain and other physical symptoms. Aspirin was associated less with pain in general than with headache and, sometimes, specifically with alcohol or hangover. Morphine was associated predominantly with pain and pain relief, but fears of intoxication, abuse and addiction and concerns about side effects were frequently named. Major differences were evident from the associations with the different routes of administration. The word 'pill' was mostly associated with contraception. Associations with 'tablets' were more pharmacological in nature, and side effects were frequently named. Patches were associated with wounds, cuts, bruises, and blisters and with protection. Some associations with patches were related to comfort. Injections and infusions were associated with physicians or the hospital environment. In conclusion, patients expressed major differences in their perceptions of the different drugs and routes of administration. The results may give a first hint that minor cultural differences even between western European countries may lead to major differences in prescribing habits and treatment regimens.
PMID: 12353127, UI: 22240296