Commentary in response to Paulozzi et al.: prescription drug abuse and safe pain management.
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Analgesics, Opioid↗
Biomedical subjects
Scott M Fishman
Publications and source records attributed to Scott M Fishman.
Legal aspects of chronic opioid therapy.
Although many Americans suffer from undertreated pain, the regulatory and legal environment for the use of opioids in pain relief is currently in a state of flux. The federal government's efforts to curb drug abuse have complicated the use of opioids for pain relief. Recent actions by the US Drug Enforcement Agency have added to an atmosphere of mistrust and confusion and have increased physician concerns about increased scrutiny and legal, regulatory, or administrative sanctions. Despite a disturbing shift in regulatory authority over opioid analgesics away from health agencies and toward law enforcement agencies, recent state policies and guidelines from national medical organizations are playing an important role in promoting the use of opioids for pain treatment and helping to reduce practitioners' concerns over regulatory oversight. Current and future trends concerning the legal and regulatory aspects of chronic opioid treatment are discussed in this article.
Analgesics, Opioid↗
Pain medicine specialists imaging the brain for pain.
This feature presents information for patients in a question and answer format. It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend. Issues addressed in this issue are pain medicine as a specialty and how the brain can be imaged for pain.
Acute Disease↗
Botox for back pain and "regular" versus migraine headaches.
This feature presents information for patients in a question and answer format. It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend. Issues addressed in this issue are the use of botulinum toxin to treat back pain and differences between tension-type and migraine headaches.
Back Pain↗
Surgery for leg numbness with back pain, patient controlled analgesia, phantom limb pain.
This feature presents information for patients in a question and answer format. It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend. Issues addressed in this issue are why back pain surgery may relieve leg numbness but not the associated back pain, patient controlled analgesia, and phantom limb pain.
Analgesia, Patient-Controlled↗
The role of the pain psychologist, trigger point injections, reflex sympathetic dystrophy.
This feature presents information for patients in a question and answer format. It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend. Issues addressed in this issue are the role of the pain psychologist, trigger point injections, and reflex sympathetic dystrophy.
Acupuncture Points↗
Prescription opioid abuse in the emergency department.
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Chronic Disease↗
Opioid side effects, addiction, and anti-inflammatory medications.
Patients in pain often fear medications prescribed or recommend to them by their clinicians. Fear of side effects can contribute greatly to medication non-adherence (noncompliance). Patients often have fears that exceed the potential problems with which their medications are associated. Questions and answers relating to the side effects and the risk of addiction associated with opioids are presented.
Analgesics, Opioid↗
Addiction.
Addiction to opioid analgesics is a great and often exaggerated concern to many patients and their support groups. This consultation describes a way to explain the disease of addiction to patients.
Analgesics, Opioid↗
Epidural steriods.
The use of steroids administered into the epidural space to manage low back pain is described in a manner that a clinician might use to explain this intervention to a patient or care-giver.
Anti-Inflammatory Agents↗
Pain as the fifth vital sign: how can I tell when back pain is serious.
An increasingly common query from patients relate to the recommendation that pain be considered the fifth vital sign. The American Pan Society championed that effort several years ago to increase patients' awareness that pain should be asked about, monitored, and managed. Now the federal Department of Veterans Affairs has also adopted this terminology in its pain management programs. Another common question from patients is when back pain should be considered serious. These two topics are addressed in language suitable for patient counseling.
Back Pain↗
Regulating opioid prescribing through prescription monitoring programs: balancing drug diversion and treatment of pain.
Social policies have evolved to address the associated concerns related to the public health crises of drug abuse and undertreated pain. Prescription monitoring programs (PMPs) have been used for many years in this effort but are undergoing re-evaluation and restructuring in light of changes in technology as well as changes in our understanding of the collateral impact of such programs. We reviewed the state of PMPs in the United States and highlighted recent changes in these programs that have occurred nationally. The current changes occurring in California, with the most physicians of any U.S. state as well as the oldest triplicate-based serialized prescription program, are reviewed, with focus on the transition to tamper-resistant prescriptions that use security paper forms. Future trends for PMPs are described, including the potential for widespread use of electronic prescribing, which is gaining favor with the Drug Enforcement Agency.
Analgesics, Opioid↗
The case for pain medicine.
Pain Medicine has its roots in multiple primary specialties and has developed into a discrete specialty with disparate practice styles. Its identity is in flux and is threatened by forces that may fragment this new field before it can set firm roots. The public health crisis of under treated pain parallels medicine's struggle to adequately classify Pain Medicine as a specialty. We review the case for Pain Medicine as a discrete discipline, with specialized knowledge, treatments, training and education. Without recognition of the specialty of Pain Medicine, and resolution of the fragmentation of the field throughout healthcare, medicine's approach to the current problem of under treated pain is likely to continue to be inadequate.
Humans↗
Challenges and choices in drug therapy for chronic pain.
By treating chronic pain effectively, physicians can improve the quality of their patients' lives considerably. This article reviews the mechanisms and treatment of chronic pain, with emphasis on overcoming the barriers to effective analgesia.
Analgesics↗
The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract.
We have extended the traditional use of opioid contracts to involve the primary care physician (PCP). The PCP was asked to collaborate with the pain specialist's decision to use opioids by cosigning an opioid contract. Explicit in the agreement was the understanding that the primary care physician would assume prescribing the refills for these medications once the opioid regimen had become stabilized. The present study was a retrospective chart review of the first 81 patients with non-malignant chronic pain who received an opioid agreement requiring the participation of the primary care physician. Sixty-nine of the 81 patients (85%) agreed to the terms of the contract initially, but only 50 of these 69 individuals (72%) successfully obtained their PCP's written agreement for the prescribing of opioids for chronic pain management. Despite expecting reluctance on the part of the PCP to enter into this agreement, the low compliance rate was due to lack of commitment on the part of the patient, who either refused to sign the contract outright or, after initially agreeing to sign the contract, did not have it signed by the PCP. If the PCP did not agree to sign the opioid contract, the patient was tapered off the medication. If the contract was approved and signed by the PCP, there were no subsequent reversals by this physician in terms of agreeing to continue to prescribe opioids. In all cases in which a contract was completed, the patient was successfully stabilized on an appropriate opioid regimen and then discharged back to the care of the PCP for long-term opioid treatment. The opioid contract may be an effective tool for networking specialty and primary care services in the delivery of chronic opioid therapy.
Contracts↗
Methadone reincarnated: novel clinical applications with related concerns.
Methadone has numerous advantages as an analgesic, which have supported its recent increase in use. However, methadone also has a pharmacological profile as an opioid that differentiates it from other, better known or more widely used opioids. It also has unusual pharmacodynamics, pharmacokinetics, and metabolism that must be considered for safe use of methadone as an analgesic. This review looks at the history of methadone use as an analgesic and its properties that distinguish it as an unusual, and potentially, unstable opioid.
Journal Article↗
An injection from the past: fluoroscopic evidence of remote injections of radiopaque substances.
OBJECTIVE: Although uncommon, residual effects from contrast agents used more than 2 decades ago are possible. This case report is to alert clinicians to the implications of residual oil-based ionic contrast agents in the intrathecal space. CASE REPORT: A 70-year-old female with evidence of degenerative disc disease underwent a series of lumbar epidural steroid injections. Fluoroscopy during the procedure revealed diffuse residual intrathecal iophendylate (Pantopaque) dye. We were able to demonstrate unrestricted epidural spread of 1 mL iohexol (Omnipaque 180) alongside the preexisting dye. CONCLUSIONS: The goal of this case report is to highlight the potential of residual myelographic dye to complicate interventional procedures. Such residual dye can increase the level of difficulty in performing interventional pain treatments and perhaps the rate of complications associated with epidural injections, such as dural puncture. The presence of large amounts of residual oil-based intrathecal dye can lead to erroneous interpretations of the dye patterns as intraspinal lipoma or hemorrhage. As a consequence, the patient can be submitted to unnecessary diagnostic and therapeutic interventions. In addition, concerns of worsening oil-based dye-induced arachnoiditis with the use of epidural steroid injections can complicate the treatment of patients with back pain.
Adrenal Cortex Hormones↗