Thinking Outside the Traditional Box at AAPM

More than 1,100 healthcare professionals interested in pain management gathered last week — September 21-24, 2010 — in Las Vegas, NV, for the 21st Annual Clinical Meeting of the American Academy of Pain Management (AAPM). This was considered to be an outstanding turnout for a meeting of this type and attendees were greeted by an extensive learning experience: 59 program presentations (almost all were CME/CEU accredited), 77 poster abstracts, and 73 exhibitors. There was a lot to hear, see, and do during an exhausting several days — some brief observations follow below.

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Responsibility is Key to Curbing Opioid Crisis

Opioid analgesics are essential for relieving many types of cancer and noncancer pain, so it is not surprising that the prescribing of opioids has dramatically risen during the past two decades. Along with that, however, prescription opioid misuse, abuse, addiction, diversion, and overdose have become what some have described as a public health crisis of epidemic proportions [Stetka 2010]. Unless those safety problems can be stemmed the availability of opioid analgesics for patients in need may become severely restricted.

All authorities have stressed the need for better patient education to help curb the crisis and this is the mission of Opioids911-Safety [Opioids911.org]. This new, Web-based program for patients and their caregivers provides an understanding of opioid analgesics, their risks, and safe practices to prevent opioid-related problems. Research evidence confirms that a lack of such patient education in the past has resulted in unsafe practices that are driving alarming trends — for example:

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Acupuncture Best for Which Rheumatic Disorders?

There has been a great deal of research on acupuncture for pain relief, including systematic reviews of its effectiveness for rheumatic conditions. A critical review-of-reviews encompassing 13 different painful rheumatic disorders found that acupuncture is a viable treatment alternative for only a few of them.

Investigators conducted electronic searches of 15 databases to locate all systematic reviews of acupuncture studies for rheumatic conditions published since year 2000. They found 30 valid reviews for inclusion relating to the following disorders: fibromyalgia, low back pain, lateral elbow pain, orthopedic diseases, musculoskeletal pain, osteoarthritis (OA), rheumatoid arthritis (RA), shoulder pain, frozen shoulder, neck disorder, ankylosing spondylitis (ie, arthritis of the spine), and sciatica.

In several cases, conclusions of the various reviews were contradictory. However, the authors believe that relatively clear evidence emerged to suggest that acupuncture is effective for OA, low back pain, and lateral elbow pain, and it is largely ineffective for fibromyalgia and RA.

REFERENCE: Ernst E, Lee MS. Acupuncture for rheumatic conditions: an overview of systematic reviews. Rheumatology. 2010;49(10):1957-1961 [abstract here].

Recent Data Deluge Highlights Rx-Opioid Concerns

A flurry of survey data featured in news media during the past several months presents a bleak picture of purported problems with prescription opioids: misuse, abuse, addiction, poisonings, and deaths. Policy makers and regulators often heed such data to guide their actions, so it can be important to understand the numbers and how they may be biased or misleading.

In the news on September 16, 2010, the U.S. Substance Abuse and Mental Health Services Administration released their National Survey on Drug Use & Health, which is a major source of information on the prevalence, patterns, and consequences of substance misuse and abuse in the general U.S. civilian non-institutionalized population aged 12 and older [SAMHSA 2010]. Here are some pertinent findings:

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Detox Strategies for Medication-Overuse Headache

By guest contributor Winnie Dawson, MA, RN, BSN

Many patients who experience a shift from periodic headaches to chronic daily headache syndrome have over-consumed acute pain-relief medications, which can result in medication-overuse headache (MOH). Drugs intended to provide symptom relief eventually cause a worsening of primary headaches and, ultimately, also make preventive medications ineffective. For this reason it is important to accurately identify and detoxify patients with MOH.

Symptoms accompanying progressive headache incidence and severity vary with each patient but can include neck pain, depression or anxiety, nonrestorative sleep, and vasomotor instability. The International Headache Society diagnostic criteria for MOH — previously called “rebound headache” — have been established as chronic headache that has occurred 15 or more days per month for 3 or more months and has worsened with acute medication use [IHS 2008]. The criteria further state that MOH can occur with the overuse of a single agent alone (eg, ergotamine, a triptan, or opioid agent) or by using a combination of these drugs on 10 or more days during a month. Evidence shows that simple analgesic use can cause MOH when used 15 or more days/month.

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Opioid-Analgesic Addiction Risk Factors Reported

Researchers at a large healthcare system found that up to 1 in 4 patients prescribed long-term opioid therapy for noncancer pain may have developed addiction to the medication. However, this is probably not representative of prevalence rates throughout the U.S.

Using electronic health records from the Geisinger Health System in Pennsylvania, investigators identified outpatients receiving 4+ opioid prescriptions in the prior 12 months for back pain and related orthopedic conditions [Boscarino et al. 2010]. Diagnostic interviews were conducted with 705 of those patients to assess opioid use disorders and related risk factors. Their preliminary analyses found that current opioid dependence (addiction) might be as high as 26% [95% confidence interval (CI) = 22.0–29.9] among the patient population studied.

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Surgery Relieves Shoulder Pain, Even in Elderly

Repairing rotator-cuff tears in the shoulders of elderly patients is often discouraged because of concerns about complications. However, a new study conducted at Rush University Medical Center, Chicago, IL, demonstrated that minimally invasive arthroscopic surgery can significantly improve pain and function in these patients.

Tears in the rotator cuff — a complex of four muscles that stabilize the back of the shoulder joint — often resulting from chronic degenerative changes, affect about 1 in 5 persons older than 65 years of age. The disorder causes considerable pain and loss of motion; however, surgery often is not recommended for these patients because circulation and bone quality already may be compromised and there may be other conditions that could compromise the healing process.

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Another UDT Study Distorts Opioid Noncompliance

A newly-reported investigation found via urine drug testing (UDT) that up to a third of patients are noncompliant with prescribed opioid regimens. However, rather than elucidating the causes of noncompliance or supporting the value of UDT, the validity of this sort of “pseudo-research” needs to be questioned.

Despite some limitations regarding the clinical utility and validity of UDT [previously noted here and here], it remains an important tool for many practitioners in assessing whether patients are compliant with prescribed opioid therapy regimens. Writing in the July/August 2010 edition of the Journal of Opioid Management (JOM) investigators describe a retrospective comparison of analgesics prescribed for chronic pain and corresponding UDT findings [West et al. 2010]. Data were derived from UDT results of 20,457 patients recorded during an unspecified time period. Noncompliance was defined as absence of the parent drug and/or metabolite determined by high-sensitivity liquid chromatography-mass spectrometry (LC-MS/MS) assays that allowed for very low drug-detection cutoff levels.

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Is Smoking “Pot” Helpful for Neuropathic Pain?

A recently-published report in the Canadian Medical Association Journal suggests that smoking marijuana, or “pot,” can reduce symptoms of pain, improve mood, and aid sleep in patients with chronic neuropathic pain. However, this study actually provides only a smidgen of valid evidence and much more research is needed before patients are advised to “light up” for better pain relief.

Investigators from McGill University in Montreal, Quebec, conducted a randomized, controlled, cross-over trial to determine the analgesic effect of smoked marijuana (cannabis) in 21 patients — mean age 45 years, 12 women — all of whom were experiencing chronic post-traumatic or postsurgical neuropathic pain [Ware et al. 2010]. During each cycle, participants inhaled a single 25 mg dose of cannabis 3 times daily for 5 days, followed by a 9-day washout period. The cannabis THC level (marijuana drug potency) for each randomly assigned cycle was either 9.4%, 6%, 2.5%, or 0% (placebo).

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Nasty Nocebo Effects Make Pain Worse

Cautioning patients in advance about procedural pain — eg, “This may sting a bit” — could do more harm than good. German researchers found such statements can invoke a nocebo effect, an evil twin of the placebo effect, which can last for many days.

It is generally accepted that an acutely painful experience can be influenced by context information, such as the setting or practitioner statements, which shape a patient’s expectations and modulate attention, arousal, stress, and mood. Rather than invoking a placebo effect that diminishes pain, just the opposite may occur; that is, a nocebo effect that exacerbates pain. However, little is known about the nature, duration, and extent of this nocebo effect, particularly regarding negative expectations.

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Nationwide Drug Take-Back Day Planned in the U.S.

On September 25, 2010, the U.S. Drug Enforcement Agency (DEA) will be coordinating a collaborative effort with state and local agencies to remove potentially dangerous controlled substances from the nation’s medicine cabinets. Collection activities will take place from 10:00 am through 2:00 pm at sites throughout the country.

This first-ever National Drug Take-Back Day provides an opportunity for the public to surrender expired, unwanted, or unused controlled substances and other medications for destruction. These drugs are a potential source of supply for theft, diversion, and illegal use and pose a growing risk to public health and safety. This one-day effort is intended to bring a national focus on the issue of increasing controlled-substance abuse.

The program is anonymous and both prescription and over-the-counter solid dosage medications are accepted. However, injectable solutions and needles will not be accepted, and the collection of illicit substances such as cocaine, heroin, or methamphetamine is not a part of this initiative.

For more information on the program [click here]. To find a collection site near you [click here].