Biomedical subjects

H L Rosomoff

Publications and source records attributed to H L Rosomoff.

At least 19 recordsLinked to original sources

PubMed2004

Genetic testing for enzymes of drug metabolism: does it have clinical utility for pain medicine at the present time? A structured review.

STUDY DESIGN: This is a structured review of genomic (genetic) testing for enzymes of drug metabolism. OBJECTIVES: Recently, industry began offering genomic testing for enzymes of drug metabolism. As such, the objective of this review was to determine if genomic testing for enzymes of drug metabolism has any imminent clinical relevance for the practice of pain medicine. METHODS: Relevant references relating to pharmacogenetics, pharmacogenomics, and the metabolizing of drugs used in pain medicine by cytochrome P-450 enzymes were located and reviewed in detail. The P-450 enzymes that metabolize each drug and whether that drug had been identified as being subject to a clinical consequence of a genetic polymorphism of the P-450 enzyme involved in its metabolism were placed into tabular form. RESULTS OF DATA SYNTHESIS: 1) For a large number of drugs, we do not yet know which cytochrome P-450 enzymes are involved in their metabolism; 2) For a large number of drugs, the consequences of a P-450 genetic polymorphism have yet to be determined; 3) Genetic polymorphism can lead to important potential clinical consequences for some opioids, anticonvulsants (phenytoin), benzodiazepines (diazepam), muscle relaxants (succinylcholine), antidepressants (imipramine, nortriptyline, venlafaxine), typical neuroleptics, alcohol, antihypertensives (propranolol, timolol), local anesthetics (procainamide), L-dopa, nicotine, and warfarin. Based on these results, factors for and against using genomic testing were reviewed. CONCLUSIONS/RECOMMENDATIONS: It was concluded that genomic testing for enzymes of drug metabolism has significant potential for improving the efficacy of drug treatment and reducing adverse drug reactions. Recommendations for when such testing would be useful are outlined.

Analgesics↗

PubMed2004

Are patients with chronic low back pain or chronic neck pain fatigued?

OBJECTIVES: The objectives of this study were the following: to determine if fatigue is present in chronic low back pain (LBP) and chronic neck pain patients to a greater extent than in controls (nonpatients); to determine which variables are associated with the presence of fatigue; and to determine which of the above chronic pain patient (CPP) groups is more fatigued. To the authors' knowledge, this is the first such study in the literature. DESIGN: Totals of 175 chronic LBP and 33 chronic neck pain patients completed the Multidimensional Fatigue Inventory (MFI), Neuropathic Pain Scale (NPS), and Beck Depression Inventory rating scales on admission. In addition, an information tool was completed on each CPP and contained the following information: demographics, primary and secondary pain diagnoses, DSM-IV psychiatric diagnoses assigned, pain location, pain precipitating event, type of injury, years in pain, number of surgeries, types of surgery, type of pain pattern, opioids consumed per day in morphine equivalents, workers' compensation status, and whether, according to the clinical examination, the pain did or did not have a neuropathic component. Scores on the MFI were then compared with published norms for controls (nonpatients) via chi-squared tests. Bivariate analyses were conducted between the MFI subscales and the variables selected for analysis. Pearson correlations, analyses of variance, and t-tests were used to test for relationships between MFI scale scores and the appropriate variables. In the next step of the analysis, stepwise regression analyses were used to predict each of the MFI subscale scores using the variables that were found to be significantly (P < 0.05) related to fatigue by the preceding analysis. In the final analysis, the variables that were significant predictors of the fatigue subscales were controlled for as covariates in an analysis of variance in order to determine if chronic LBP patients had scores on the MFI subscales that were significantly different from those of chronic neck pain patients. SETTING: Multidisciplinary pain facility. PATIENTS: Chronic LBP and chronic neck pain patients. RESULTS: Chronic LBP and chronic neck pain patients were found to be significantly more fatigued than controls (nonpatients). Most of the MFI subscale scores could be predicted by four major variables: presence of neuropathic pain, female gender, presence of depression, and total number of DSM-IV diagnoses. Chronic LBP patients were as fatigued as chronic neck pain patients. CONCLUSIONS: The complaint of fatigue appears to be a significant problem for chronic LBP and chronic neck pain patients. This complaint may be associated with neuropathic pain, female gender, and psychiatric comorbidities.

Chronic Disease↗

PubMed2004

Do the second-generation "atypical neuroleptics" have analgesic properties? A structured evidence-based review.

STUDY DESIGN: This is a structured, evidence-based review of all available studies on the potential effectiveness of the atypical neuroleptics for the treatment of pain (analgesia). To determine what evidence, if any, exists for, or against, the effectiveness of the atypical neuroleptics for analgesia. SUMMARY OF BACKGROUND DATA: There has been significant controversy over whether the conventional neuroleptics (non-atypicals) have analgesic properties. A recent review (Patt et al. 1994) did conclude that the evidence for effectiveness was sparse, except for methotrimeprazine. However, that review did not include a new class of neuroleptics: the atypicals such as olazapine, risperidone, quetiapine, etc. METHODS: A computer and manual search for studies relating to the atypicals and their analgesic effectiveness produced 10 studies/reports. These were reviewed in detail, and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized by the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). The strength and consistency of the evidence represented by the 10 studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. RESULTS OF DATA SYNTHESIS: Of the 10 studies/reports, four were characterized by AHCPR guidelines as Type II (experimental), two were Type III (quasiexperimental), two were Type IV (nonexperimental), and two were Type V (case reports). Of these studies/reports, 90% indicated that the atypicals did have an analgesic effect. The overall strength and consistency of this evidence using the AHCPR guidelines was, therefore, categorized as B (generally consistent from Type II, Type III, and Type IV studies). CONCLUSIONS: Based on the above results, it was concluded that the reviewed data were generally consistent, suggesting that some of the atypicals may have an analgesic effect. There were, however, few double-blind, placebo-controlled studies, and many of the reports/studies had less than 50 patients. As such, this question requires further research.

Analgesics↗

PubMed2004

Modafinil for the treatment of pain-associated fatigue: review and case report.

Fatigue is a symptom that is frequently found in chronic pain patients with low back pain and/or neck pain. At the present time, no specific psychopharmacological treatment for this problem has been identified. Modafinil is a wakefulness-promoting agent that the FDA has approved for the treatment of excessive daytime sleepiness associated with narcolepsy. There have been reports on the use of modafinil for the treatment of fatigue in various neurological syndromes. This literature is reviewed. As such, modafinil treatment was initiated for a patient with severe fatigue associated with chronic low back pain and neck pain. There was dramatic improvement in fatigue and associated function. This case is described. It is the first such case report in the literature. The significance of this finding to the treatment of pain-associated fatigue is discussed.

Adult↗

PubMed2003

Do the proposed cervicogenic headache diagnostic criteria demonstrate specificity in terms of separating cervicogenic headache from migraine?

Diagnostic criteria for cervicogenic headache (CH) have been proposed. These criteria are controversial in that they appear to overlap or include characteristics that usually are attributed to migraine headache (MH). Whether these criteria are specific enough to separate CH patients from MH patients remains to be controversial. The literature on this issue is reviewed. In addition, the authors report the results of a study attempting to build a model of variables typically associated with CH or MH, which would identify patients with CH. A significant model could not be built that did not include MH symptoms. As such, it has been concluded that it is unlikely that the criteria for CH will have the specificity required to separate CH patients from MH patients.

Adult↗

PubMed2003

Is pain fatiguing? A structured evidence-based review.

STUDY DESIGN: This is a structured, evidence-based review of all available studies on the coexistence of fatigue and pain. OBJECTIVES: To determine what evidence, if any, exists for or against the existence of an association between fatigue and pain and a potential etiological relationship between pain and fatigue. SUMMARY OF BACKGROUND DATA: Pain physicians have noted fatigue as a frequent complaint in chronic pain patients (CPPs), and previous studies have reported the association of fatigue and pain. METHODS: Computer and manual literature searches for studies relating to fatigue and pain produced 23 reports. These references were reviewed in detail, and information relating to the above problems was abstracted and placed into tabular form. Each report was also categorized for the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 15 quality criteria was utilized in order to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 15 minus the total number of not applicable, and multiplying by 100. Only studies having a quality score of 75% or greater were utilized to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies was then categorized according to the AHCPR guidelines. Conclusions of this review were based on those results. RESULTS OF DATA SYNTHESIS: Of the 23 reports, 17 had quality scores of 75% or greater. Of these 17 reports, 94.1% indicated that there was an association between fatigue and pain. In addition, 100% of a subgroup of 13 reports (all with quality scores of 75% or greater) indicated that there may be an etiological relationship between pain and fatigue. The overall strength and consistency of this evidence according to AHCPR guidelines was therefore categorized as A (highly consistent findings from multiple studies). CONCLUSIONS: Based on the above results, it was concluded that there is an association between fatigue and pain and that there may be an etiological relationship between pain and fatigue. Pain physicians and other pain treatment professionals should be aware of the high prevalence of fatigue in pain patients. In addition, future research might investigate possible mechanisms for the relationship between pain and fatigue.

Chronic Disease↗

PubMed2003

A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs.

STUDY DESIGN: This is a structured, evidence-based review of all available studies addressing the concept of nonorganic findings: Waddell signs (WSs). OBJECTIVES: To determine what evidence, if any, exists for the various interpretations for the presence of WSs on physical examination. SUMMARY OF BACKGROUND DATA: WSs are a group of eight physical findings divided into five categories, the presence of which has been alleged at times to have the following interpretations: Malingering/secondary gain, hysteria, psychological distress, magnified presentation, abnormal illness behavior, abnormal pain behavior, and somatic amplification. At the present time, there is, therefore, significant confusion as to what these findings mean. METHODS: A computer and manual literature search produced 61 studies and case series reports relating to WSs. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: 1) Reliability (test-retest); 2) Reliability (inter-rater); 3) Reliability (factor analysis); 4) Validity, psychological distress; 5) Validity, correlation Minnesota Multiphasic Pain Inventory (MMPI); 6) Validity, correlation abnormal illness behavior; 7) Validity, other behaviors; 8) Validity, as a nonorganic phenomenon; 9) Validity, correlation pain drawing; 10) Validity, functional performance; 11) Validity, treatment outcome; 12) Validity, predicting surgical treatment outcome; 13) Validity, return to work outcome; 14) Validity, secondary gain correlation; and 15) Validity, pain correlation. Each study in each topic area was classified according to the type of study it represented according to the type of evidence guidelines developed by the Agency for Health Care Policy and Research (AHCPR). In addition, a list of 14 study quality criteria was used to measure the quality of each study. Each study was categorized for each criterion as positive, (criterion filled), negative (criterion not filled), or not applicable independently by two of the authors. A percent quality score was obtained for each study by counting the total number of positives obtained, dividing by 14 minus the total number of not applicables, and multiplying by 100. Only studies having a quality score of 75% or greater were used to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies in each topic area (above) was then categorized according to the strength and consistency AHCPR guidelines. Conclusions of this review for each topic area are based on these results. RESULTS OF DATA SYNTHESIS: Of the 61 studies, four had quality scores below 75% and were not used to generate the results of this review. According to the AHCPR guidelines for strength and consistency of the reviewed data, the following results were obtained: 1) There was consistent evidence for WSs being associated with decreased functional performance, poor nonsurgical treatment outcome, and greater levels of pain; 2) There was generally consistent evidence for WSs not being associated with psychological distress, abnormal illness behavior, or secondary gain; 3) There was also generally consistent evidence that WSs are an organic phenomenon and that they cannot be used to discriminate organic from nonorganic problems; 4) There was inconsistent evidence that WSs do demonstrate inter-rater reliability, do not correlate with the neurotic triad of the MMPI, are associated with poorer surgical treatment outcome, and are associated with nonreturn to work; 5) There was little or no evidence that WSs demonstrate test-retest reliability, or reliable factors, and are associated with self-esteem problems, catastrophizing, or the nonorganic pain drawing. CONCLUSIONS: Based on the above results, the following conclusions were made: 1) WSs do not correlate with psychological distress; 2) WSs do not discriminate organic from nonorganic problems; 3) WSs may represent an organic phenomenon; 4) WSs are associated with poorer treatment outcome; 5) WSs are associated with greater pain levels; 6) WSs are not associated with secondary gain; and 7) As a group, WS studies demonstrate some methodological problems.

Acute Disease↗

PubMed2003

Medico-legal rounds: medico-legal issues and alleged breaches of "standards of medical care" in opioid rotation to methadone: a case report.

OBJECTIVES: The objectives of this medico-legal case report were the following: 1) To present an example of a medico-legal problem that developed as a result of a decision to rotate a chronic pain patient (CPP) to methadone in order to taper the CPP from oxycodone; 2) To present both the plaintiff's and defendant's expert witnesses' opinions as to if and where the care of that patient fell below the "standard of medical care;" and 3) Based on these opinions, to develop some recommendations on how, in the future, pain medicine physicians and other physicians should proceed, in order to avoid allegations of breach of "standards of care" when using methadone. METHODS: This is a case report of a CPP treated at a regional hospital pain clinic. Methadone rotation was used in order to taper the CPP from oxycodone because of addictive disease. RESULTS: During the rotation process, the CPP expired. This had medico-legal consequences. Expert witnesses differed as to whether methadone caused the death. CONCLUSION: Pain physicians should proceed with caution in using methadone for opioid rotation.

Adult↗

PubMed2003

Is the location of nondermatomal sensory abnormalities (NDSAs) related to pain location?

OBJECTIVES: Nondermatomal sensory abnormalities (NDSAs) are alleged to be nonorganic physical findings, where one finds diminished sensation to light touch, pinprick, and, sometimes, other modalities fitting a "nondermatomal pattern." The presence of NDSAs has historically been classified as a conversion symptom. We wished to determine if, in chronic pain patients (CPPs), NDSA location was associated with pain location. METHODS: The setting was a multidisciplinary pain facility. Patients included in the study were those CPPs who, on physical examination by two independent examiners, were found to have NDSAs. NDSA location and pain location were recorded for each CPP. Chi-square analyses (Fisher exact tests) and Kappa statistics were used to test for a relationship between NDSA location and pain location in three patient groups: Pain, upper body only; pain, lower body only; and pain, both lower and upper body. RESULTS: Of 283 consecutive CPPs, 74 were found to have NDSAs, by both examiners, and to fulfill the inclusion criteria of this study. The relationship between NDSA location and pain location was found to be significant (Fisher exact test) for all three patient subsets: Upper body P < 0.05, lower body P < 0.0001, and upper and lower body P < 0.000001. Similarly, the relationship between NDSA location and pain location was found to be statistically significant for all three patient subsets using the Kappa statistic. CONCLUSIONS: The findings of this study suggest that NDSA location is associated with perceived pain location. This finding has implications for whether the presence of NDSAs is considered a conversion symptom.

Adult↗

PubMed2002

Can patients taking opioids drive safely? A structured evidence-based review.

A structured evidence-based literature review was completed to determine if there was epidemiological evidence of an association of opioid use and intoxicated driving, motor vehicle accidents (MVA) and MVA fatalities; to rate the quality of this research evidence according to Agency for Health Care Policy and Research (AHCPR) type of evidence and strength and consistency of the evidence rating scales; and according to this evidence determine whether patients taking opioids can drive safely. Relevant references were located from Medline, Psychological Abstracts, Science Citation Index and the National Library of Medicine Data Query databases by appropriate subject headings. A manual search was also performed utilizing the reference lists of the retrieved articles. All references relating to intoxicated driving, MVA and MVA fatalities were retrieved and reviewed in detail. Of these, references addressing opioid use were isolated and research information from these references was placed into tabular form under three major headings: Intoxicated driving and opioids; MVA and opioids; and MVA fatalities and opioids. Data were extracted from these references according to the following format: research question addressed, sample size, statistical analysis and results. The type of evidence each study represented was rated according to the AHCPR type of evidence rating scale. Each research area (intoxicated driving, MVA, MVA fatalities) represented by all the studies in each table was then rated utilizing the strength and consistency of the evidence AHCPR rating scale. Of the 6 reports addressing intoxicated driving, 5 were well designed non-experimental studies and one was a well designed experimental study. All studies in this group reported a prevalence for opioid use which was approximately 1/10 that of the point prevalence use for opioids in the general population. This evidence indicated that opioids probably are not associated with intoxicated driving. Overall, the evidence indicates that opioids are not associated with MVA. Of the 9 studies addressing MVA, 5 were well designed quasi-experimental studies and 4 were well designed experimental studies. All reports in this group except one indicated that opioids are not associated with MVA. Of the 10 studies addressing MVA fatalities, 10 represented Type IV studies. For the vast majority of the studies, the prevalence percentages for an opioid association with MVA fatalities was 1/5 that of the point prevalence percentage for opioid use reported in the general population. Only 1 study reported a possible association between opioid use and MVA fatalities. The evidence in this review indicates that opioids do not appear to be associated with intoxicated driving, MVA and MVA fatalities, and consistently indicated that opioids are not associated with MVA. Although the comparison of point prevalence rates to the point prevalence may be problematic, the results of this systematic review support the contention that patients taking opioids may be allowed to drive. As in all clinical decisions, this determination should be individualized according to clinical factors.

Accidents, Traffic↗

PubMed2001

Identifying patients at risk for loss to follow-up after pain center treatment.

OBJECTIVE: This study was designed to identify, at admission to a pain treatment facility, characteristics of patients who will be lost to follow-up after treatment completion. METHOD: Patients were divided into 3 groups depending on how they responded to the 12-month follow-up. The analysis was a between-subjects design using prospective data collected at a comprehensive pain treatment facility. Low back pain patients (n = 168) received 4 weeks of multidisciplinary pain treatment. The main outcome measure was response/nonresponse to follow-up questionnaires. RESULTS: showed that patients who were later lost to follow-up, or who were reluctant to answer follow-ups, could be predicted at treatment admission by measures of pain and functioning. The prediction equation was validated by a second group of patients, treatment noncompleters (n = 55). CONCLUSION: Chronic pain patients who are more likely to be lost to follow-up can be identified upon admission to a pain facility. Procedures that should decrease follow-up attrition could be implemented at program admission.

Journal Article↗

PubMed2001

Pain-determined dissociation episodes.

OBJECTIVES: Dissociation disorders are a group of conditions characterized by a disruption of integrated function of consciousness, memory, or perception. The purpose of this report is to describe the impact of increased pain levels on the genesis of two types of dissociation disorders, dissociative fugue ( DF) and dissociative identity disorder ( DID), in patients with chronic pain ( PWCP). DESIGN/PATIENTS/INTERVENTIONS/OUTCOME MEASURES: From November 1992 to July 2000, 2 DID and 4 DF patients were identified from 2,544 consecutive PWCP evaluated and/or treated at the University of Miami Comprehensive Pain and Rehabilitation Center. The salient features of these six dissociation PWCP are presented. All four DF PWCP completed a dissociation experience scale first at the time of identification of the dissociation disorder (with chronic pain) and one alleging their experiences with dissociation predevelopment of chronic pain. RESULTS: Frequency percentage for dissociation for this population was 0.235%. For all four of the DF PWCP, dissociation episodes began after the onset of chronic pain. All six (100%) PWCP described or associated their episodes of dissociation to times when their pain would increase. Mean dissociation scale scores for the four DF PWCP were 1.4 +/- 1.11 pre-chronic pain and 20.53 +/- 16.82 at time of identification of the dissociative disorder (with chronic pain). CONCLUSIONS: The frequency percentage for dissociation within PWCP is small compared with psychiatric populations. There may be an etiological association between the development of dissociation episodes and the development of chronic pain and/or increases in chronic pain.

Journal Article↗

PubMed2001

Millon behavioral health inventory scores of patients with chronic pain associated with myofascial pain syndrome.

OBJECTIVES: Normative data for the coping styles and psychogenic attitudes of the Millon Behavioral Health Inventory (MBHI) for male and female chronic pain patients (CPPs) with mixed pain diagnoses have previously been reported and compared with normative MBHI manual data. However, results from other studies have suggested that CPPs with myofascial pain syndrome (MPS) may need to be considered as a distinct group in psychiatric/psychological studies. The purpose of the present study was then to provide normative data for each MBHI scale for male and female CPPs with MPS and to compare these data with MBHI manual norms for similarities and differences. SETTING: Multidisciplinary pain facility. PATIENTS: CPPs with an associated diagnosis of MPS. OUTCOME MEASURE: MBHI base rate scores. METHODS: CPPs with an associated diagnosis of MPS were first broken down into two groups: males and females. Analyses were then performed using the MBHI base rate scores of these two groups. For each group, the percentages of CPPs who had a base rate of 75 or above were calculated for each individual coping style and psychogenic attitude. These percentages were then compared by chi square with percentages of patients with base rate scores of 75 or above for each coping style and psychogenic attitude to the MBHI Manual normative sample. RESULTS: Female CPPs with MPS differed from MBHI Manual normative counterparts on two of the six psychogenic attitude scales (future despair and somatic anxiety); no differences were found in any of the eight coping style scales. Male CPPs with MPS differed from MBHI Manual normative counterparts on one coping style scale (sociable) and three psychogenic attitude scales (premorbid pessimism, future despair, and somatic anxiety). CONCLUSIONS: The pattern of the results indicated that CPPs with MPS, especially males, differ from the MBHI Manual normative data counterparts. These differences appear to be greater than those for CPPs with mixed pain diagnoses. Differences in MBHI scale scores between CPPs with MPS and MBHI Manual normative data counterparts may be related to a number of issues, such as whether differences in state factors reflecting depression and anxiety might affect trait factors purportedly measured by the MBHI.

Journal Article↗

PubMed2001

International Headache Society headache diagnostic patterns in pain facility patients.

OBJECTIVE: Previous studies have indicated that many patients with chronic pain (PWCP) referred to pain facilities for the treatment of neck and/or low back pain complain of associated headaches. The purpose of this study was to characterize the nature of these headaches according to International Headache Society (IHS) headache diagnostic criteria. DESIGN: In preparation for this study, a questionnaire that reflected IHS headache diagnostic criteria was developed. All consecutive patients admitted to our pain facility complaining of headache completed this questionnaire and received a physical and neurologic examination focused on key aspects of headache. A headache interview was also conducted, using the questionnaire as a question guide. All questionnaires were entered in a computerized database, and IHS diagnoses were arrived at for each patient. As many IHS diagnoses as possible were assigned to each PWCP as long as IHS criteria were fulfilled. In addition, a frequency distribution for headache precipitants and neck-associated symptoms was developed and evaluated by discriminant analysis to determine the diagnostic value of these factors in relation to each IHS diagnostic group. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive PWCP. RESULTS: Of 1,466 PWCP, 154 (10.5%) were identified as suffering from severe headache interfering with function. Of these, 55.8% indicated that their headaches were related to an injury for which they were seeking treatment and 83.7% had neck pain. Migraine headache represented the most common diagnostic group (90.3%), with cervicogenic headache representing the second most common (33.8%). Of the total group, 44.2% had more than one headache diagnosis, that is, there was overlap. Cervicogenic headache patients had the greatest percentage of overlap (94.2%), with migraine patients being second (68.3%). The most frequent headache precipitant was mental stress, followed by neck position and activity/exercise. The migraine and cervicogenic headache groups had a statistically significant greater number of neck-associated symptoms when compared with the remaining patients. Of the total headache group, 74.6% complained that they had a tender point at the back of their neck. Cervicogenic, migraine, and tension PWCP had the greatest frequency of head or neck tender points. The discriminant analysis for neck-associated symptoms yielded the following symptoms as the most common predictors of headache across IHS diagnostic groups: clues to onset were severe headache beginning at the neck or tender point and numbness in arms and legs; headache brought on by neck position and arms overhead; and neck symptoms consisting of a tender point in the neck and feeling severe headache in the neck. CONCLUSIONS: Headache can and should be considered a frequent comorbid condition in PWCP. Because of the overlap data, more precise diagnostic criteria may be required to separate cervicogenic headache from migraine headache. Neck-associated symptoms seem to be important even to those PWCP diagnosed with migraine headache.

Headache↗

PubMed2000

Risk for violent behavior in patients with chronic pain: evaluation and management in the pain facility setting.

OBJECTIVE: Recent evidence indicates that physicians are at high risk for patient-perpetrated violence. The objectives of this article, in association with case reports of patients with chronic pain (PWCP), are the following: to review the literature and determine if pain physicians could be at risk for PWCP-perpetrated violence; to review the current evaluation and management procedures for potentially violent patients; and to identify some situations specific to PWCPs that can heighten the risk of PWCP-perpetrated violence. DESIGN: Previous literature on patient-perpetrated violence against physicians was reviewed. In addition, literature on the evaluation for risk of violent behavior and management of violent behavior was also reviewed. Seven potentially violent PWCPs are described, including some who had threatened pain physicians and institutions. PWCP-specific situations thought to be instrumental in increasing the risk of PWCP-associated violence were identified. SETTING: Pain facility (multidisciplinary center). RESULTS OF REVIEW AND ANALYSIS OF CASE REPORTS: The literature on patient-perpetrated violence against physicians indicates that, statistically, pain physicians could be at risk for this type of violence. Seven PWCP cases of threatened or potentially violent behavior are described. These case report data indicate that PWCPs with the potential for violence against physicians or institutions do present for treatment at pain facilities. All seven PWCPs were in a number of situations specific to chronic pain that increased the possibility of violent behavior. These situations are described. CONCLUSIONS: In the evaluation for risk of violence against physicians or institutions by PWCPs, one needs to understand PWCP-specific situations. Management of potential violent behavior cannot be effective without this understanding.

Journal Article↗

PubMed2000

Evidence-based data from animal and human experimental studies on pain relief with antidepressants: a structured review.

OBJECTIVE: It has been hypothesized that serotonin reuptake inhibitor antidepressants (ADs) are only weakly antinociceptive but augment noradrenergic (NA) antinociception. Thus, ADs with combined serotonergic (SN) and NA activity, (i.e., the serotonergic/noradrenergic (SN/NA) ADs) should have greater antinociceptive activity versus the NA ADs, which in turn should have more antinociceptive activity than the SN ADs. The objective of this structured review was to test this hypothesis by reviewing relevant basic science literature on the treatment of experimental pain with the above different types of ADs. DESIGN, SETTING, PARTICIPANTS, OUTCOME, MEASURES: Animal or human experimental AD pain treatment studies were located by the usual search methods. For animal studies only placebo-controlled studies were included for review. For human studies only double blind placebo-controlled studies were selected for review. The animal and human studies were then sorted according to the pain model represented, e.g., neuropathic pain model. Studies were then characterized according to the type of AD utilized, and the antinociceptive outcome of the AD trial. RESULTS: Twenty-two animal studies and 5 human studies fulfilled the inclusion criteria of this structured review. Within the animal nonspecific pain model there were 10 SN/NA AD trials, 9 NA AD trials and 7 SN AD trials. Of these trials 100%, 88.9%, and 14.3% respectfully demonstrated a positive AD antinociceptive effect. Overall, for all the animal models there were 25 SN/NA, 9 NA, and 8 SN trials. Of these trials 92%, 88.9%, and 25% respectfully demonstrated a positive AD antinociceptive effect. For the human pain models, only the SN/NA ADs had been utilized in 7 trials. Here in 42.8% of the trials there was a reported antinociceptive effect. CONCLUSIONS: Overall, the results of this structured review support the above hypothesis.

Journal Article↗

PubMed2000

Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain.

OBJECTIVE: A number of case reports and nonplacebo controlled studies have documented the efficacy of clonazepam (Klonopin) in the treatment of a number of chronic pain syndromes including lancinating and neuropathic/deafferentation pain. There are, however, no data on the efficacy of clonazepam for chronic pain (CP) associated with myofascial pain syndrome (MFPS). Therefore, we wish to report the results of an open clinical treatment trial of clonazepam for CP associated with MFPS. DESIGN: Forty-six patients with chronic pain (PWCP) and a diagnosis of MFPS were recruited into a clonazepam pain treatment open clinical trial. At entrance and completion of the study the patients completed a 10-cm visual analog scale (VAS) requesting them to rate their pain over the last 24 hours. Clonazepam was titrated upwards from 0.5 mg per day, at 0.5 mg increments, every 2 days. These patients rated their perceived pain relief daily on a 3-point rating scale: none, partial, total. Once a patient claimed partial pain relief clonazepam increases were stopped. Patients who complained of intolerable side effects before partial pain relief were withdrawn from the study. For a subgroup of patients claiming partial pain relief, clonazepam serum levels were determined. Because of the reported efficacy of clonazepam for neuropathic/deafferentation type of pain, patients with this diagnosis were withdrawn from the partial response group. Statistical analyses were performed on this remaining patient group with myofascial pain syndrome without a secondary diagnosis of neuropathic/deafferentation pain and partially responsive to clonazepam. Descriptive statistics were calculated for this group. Drop in pain level from entrance to partial response was tested for statistical significance via t test. In addition, 17 independent variables such as presence of trigger points, presence of burning pain etc, were utilized in a regression analysis, with drop in pain level as the dependent variable. A Pearson correlation analysis was first performed in order to determine which of the independent variables significantly correlated with decrease in pain level. Independent variables having a Pearson r of.3687 or greater were selected for the regression procedure. SETTING: Multidisciplinary pain facility. PATIENTS: Patients with chronic pain with a diagnosis of MFPS and without neuropathic/deafferentation pain. RESULTS: Of the 46 patients entered into the study, 9 were not titrated to partial pain relief because of intolerable sedation and 9 had a diagnosis of neuropathic/deafferentation pain. For the remaining group (n = 28), mean drop in VAS pain level from beginning of the study to partial response was 2.78 (SD = 1.94). This was statistically significant (t = 5.49, P <.001). Mean clonazepam dosage to reach partial response was 2.41 (SD = 1.62) mg/day and the mean dosage per kilogram body weight per day was 0.04 (SD = 0.03) mg. Mean clonazepam serum level was 30.58 (SD = 24.53) microg/L. Decrease in pain level was associated with the presence of the following independent variables: trigger points (r =.451); range of motion restriction (r =.653); non anatomical sensory abnormalities (r =.370); chronic low back pain (r =.451); and burning pain (r =.482). In the regression analysis, restricted range of motion and presence of burning pain accounted for 42% and 16% of the variance respectfully. CONCLUSION: Clonazepam may have an antinociceptive effect for pain associated with myofascial pain syndrome.

Journal Article↗

PubMed2000

What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?

OBJECTIVE: Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups. RESULTS: Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability. CONCLUSIONS: Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.

Chronic Disease↗