Avoid Trouble: Consider Opioid-Drug Interactions

Patients treated for pain conditions often receive an opioid analgesic and also take other prescription or non-Rx drugs, which can lead to opioid-drug interactions that have potential for adverse effects or even fatal outcomes. To avoid problems, prescribers need to be aware of all medications and other substances their patients are taking and the likelihood of toxicity resulting from their interaction. However, this is no easy matter.

Much of the literature and discussions in the pain management field these days are so focused on prescription opioid misuse, abuse, and addiction that other safety concerns relating to prescribing seem to be overlooked. Far more prevalent problems, and ones that can be more readily controlled, involve potentially harmful interactions between opioids and other medications or substances. Prior research has observed that 70% of patients taking an opioid analgesic also take at least one nonprescription drug or substance and a majority also are prescribed one or more adjunctive medications. Such polypharmacy can set in motion physiologic processes that are a recipe for trouble; so, prudent practitioners must understand and be alert for opioid-drug interactions.

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Benefits of Clinical Massage Therapy May Run Deep

Appropriately applied clinical massage therapy may do far more than soothe achy muscles, according to new research. In fact, positive effects appear at the cellular level, mustering the body’s defences against stress and inflammation.

Researchers at Cedars-Sinai Medical Center and the David Geffen School of Medicine at University of California, Los Angeles, CA, recruited 53 healthy adults (ages 18-45) and randomly assigned 29 of them to a 45-minute session of deep-tissue Swedish massage and the other 24 to a session of light-touch massage as a control group [Rapaport et al. 2010]. Blood samples taken from each subject immediately before and up to an hour after massage demonstrated that a single session of Swedish massage therapy produced measurable and beneficial biologic effects.

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Painful Feet in Older Patients Untreated. Why?

Musculoskeletal-related foot pain is highly prevalent in persons aged 50 years or more. Yet, only about 1 in 5 foot-pain sufferers seek medical care for their debilitating conditions, according to a new study, and reasons for this are not entirely clear.

Researchers in England examined data from 13,986 people ≥50 years of age who took part in a regional survey on osteoarthritis [Menz et al. 2010]. Foot problems were defined as affirmative responses to the questions: “Have you had any problems with your feet over the last year?” or “Have you had pain in the last year in and around the foot?” A primary outcome measure was a record of a musculoskeletal foot-related consultation with a primary care provider within 18 months following the survey.

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Can Love Squelch Pain? Brain Research Says “Yes”

Romantic relationships, characterized by intense feelings of elation, well-being, and preoccupation with the person of affection may activate reward systems in the brain that help to counter pain. New research demonstrates that merely viewing pictures of a romantic partner can diminish the perception of pain but the clinical implications of this need further examination.

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Opioid Overdose Rescue: Can Hands-Only CPR Help?

With growing concerns about overdose deaths involving opioid analgesics, it is time for healthcare providers, patients, and family caregivers to assume greater responsibility for life-saving measures that might avert such tragedies. New research stresses the practicality and effectiveness of “Hands-Only CPR” but there may be questions about its appropriateness in opioid overdose. However, any CPR may be better than no CPR.

According to the most current data, in 2007 there were nearly 12,000 overdose deaths in the United States alone from opioid-analgesics; nearly twice the number for cocaine and more than 5 times the number involving heroin [CDC 2010]. The primary cause of such fatalities is respiratory depression due to adverse opioid effects leading to respiratory failure and cardiac arrest; survival depends on prompt action to resuscitate the victim.

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Painful Arthritis Afflicts 50 Million Americans

Painful arthritic conditions afflict more than 1 in every 5 American adults at an estimated annual cost of $128 billion, according to a new report. This makes arthritis the most common cause of disability; yet, relatively few national resources are dedicated to arthritis research and treatment.

According to the U.S. Centers for Disease Control and Prevention (CDC), which examined data from the National Health Interview Surveys (NHIS) of 2007 to 2009, 22.2% of all adults aged ≥18 years (about 50 million) had self-reported physician-diagnosed arthritis, and 42% of those persons (or 21 million) also experienced arthritis attributable activity limitations (AAAL) [Cheng et al. 2010]. In the survey, arthritis prevalence was defined rather broadly by affirmative answers to the question, “Have you ever been told by a doctor or other healthcare professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”

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When is Pain Relief “Meaningful”?

Understanding Evidence-Based Pain Management (EBPM)

An important deficiency of many research reports is that they focus on pain relief of a therapy as a statistical phenomenon, rather than examining whether there were clinically meaningful benefits for patient care. A recent study investigated characteristics of “responders” to fibromyalgia therapy that can make a difference in achieving successful outcomes that are durable over time.

Clinical trials of drugs and other treatments for pain often demonstrate “statistically significant” pain reductions in patients without demonstrating any “clinically meaningful” reductions, wrote Gabriel Miller in the September edition of Pain Medicine News [Miller 2010]. The article was based on a presentation at the 2010 meeting of the American Pain Society (APS) in which researchers noted how, with an adequately large sample size, a one-point reduction on a visual analog scale (VAS) can be statistically significant, yet may do nothing to truly improve a patient’s pain or quality of life.

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New Study: What Works Best for Frequent Migraine?

Migraine is relatively common, affecting about 14% of women and 6% of men worldwide, and a third of them experience 3 or more debilitating attacks per month. In a recent report, investigators suggest an approach for significantly bolstering the acute pharmacologic treatment of migraines; however, this may not be attainable in everyday clinical practice.

Researchers at the University of Ohio designed a randomized, placebo-controlled trial to determine if the addition of preventive drug treatment (a β blocker; eg, propranolol or nadolol), behavioral migraine management, or both would improve the outcome of acute pharmacological treatment for the management of frequent migraine [Holroyd et al. 2010]. Participants included 232 adults (mean age 38 years; 79% female) with a diagnosis of migraine with or without aura, who recorded at least 3 migraines with disability per month (mean 5.5 migraines/30 days), during an optimized run-in of acute treatment. The acute treatment included a triptan (5-HT agonist) with an NSAID (eg, ibuprofen), antiemetic (eg, metoclopramide), and/or rescue drug (eg, steroid) added as necessary.

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Opioids as Mentally Beneficial? Worth Pondering.

According to new research, the long-term use of opioid analgesics for chronic noncancer-related pain may also help slow or prevent increases in depression or anxiety while maintaining a positive outlook. This and other evidence suggests that opioids might confer mental health benefits in addition to their pain-relieving qualities.

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Why Do Patients Dislike Pain Care Providers?

Chronic pain is a common complaint among patients seeking treatment from primary care providers. Yet, as confirmed by a recent investigation, patients report low levels of satisfaction with their pain care providers, the care they receive, and the outcomes. Unfortunately, these perspectives come as no surprise and there are a number of reasons for them.

Researchers at the University of Massachusetts, Boston, MA, conducted focused interviews involving 17 groups of patients (3-7 participants/group; 11 in English, 6 in Spanish) to assess their perspectives on pain care [Upshur et al. 2010]. A total of 72 adult patients participated (68% female, 44% Latino, mean age = 48.1 years) from 4 primary care practices in Central Massachusetts. Across all groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their healthcare providers when seeking care for chronic pain.

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Glucosamine, Chondroitin Useless for OA, Data Say

Understanding Evidence-Based Pain Management (EBPM)

The latest and most extensive investigation to date found no clinically relevant benefits of glucosamine, chondroitin, or their combination for osteoarthritis (OA) pain or disease progression. Put simply, they do not work any better than placebo and claims of their efficacy may reflect deficiencies and biases of prior research evidence.

Writing in the British Medical Journal, researchers at the University of Bern, Switzerland conducted an exhaustive review and sophisticated analysis of trials examining glucosamine and/or chondroitin for improvements of joint pain and radiological progression in osteoarthritis of the hip or knee [Wandel et al. 2010]. Relevant databases through June 2010 were searched for larger-scale randomized controlled trials enrolling patients with osteoarthritis of the knee or hip and comparing glucosamine, chondroitin, or their combination with placebo or head to head.

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Oct2010 – Pain Product Announcements & Warnings

Featured Items: OTC NSAID product labeling changes — stomach-bleed risk warning, pegloticase (Krystexxa) approval for gout.
— Brand names are trademarks of their respective manufacturers. Compiled by Winnie Dawson, MA, RN, BSN.

OTC Analgesic & Antirheumatic Products — More Product Labeling Changes
In keeping with the FDA's decision to add "organ-specific warnings" to oral analgesic, antipyretic, and antirheumatic over-the-counter (OTC) NSAID product labels, there were several additional changes during August and September. The following product labels must now include a warning about risks of severe stomach bleeding: Aleve® capsules (naproxen sodium), Combunox™ tablets (ibuprofen and oxycodone HCl), Advil® Cold and Sinus tablets (ibuprofen and pseudoephedrine hydrochloride), Advil® Allergy Sinus caplets (ibuprofen, chlorpheniramine maleate, and pseudoephedrine), and Children's Advil® oral suspension (ibuprofen).

Pegloticase (Krystexxa™) — FDA Approved For Refractory Gout
Savient Pharmaceuticals announced the September 2010 approval of Krystexxa (pegloticase) for the treatment of gout in adult patients who have not responded to or cannot tolerate conventional drug therapies. Gout is the result of excess uric acid that can form crystals in tissues and joints to cause swelling, pain, and stiffness. Pegloticase, an enzyme, works by metabolizing uric acid to form a harmless chemical that is excreted in the urine. When administered as an intravenous infusion every two weeks as prescribed, trial data showed significant clinical improvement by reversing the course of the disease within 6 months of treatment. Due to incidents of severe allergic reaction in about 25% of cases, patients should be premedicated with a corticosteroid and an antihistamine to minimize the risk of anaphylaxis and infusion reaction. Healthcare professionals are also advised to prescribe pegloticase cautiously in patients with congestive heart failure since the drug was not studied in this population. For full information on administration and safety concerns, see the prescribing information and medication guide for Krystexxa.