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Andrews JS, Kudrow D, Rettiganti M, Oakes T, Bardos JN, Wenzel R, Kuruppu DK, Gaul C, Martinez JM. Impact of Galcanezumab on Total Pain Burden: A Post Hoc Analysis of a Phase 3, Randomized, Double-Blind, Placebo-Controlled Study in Patients with Episodic Cluster Headache. J Pain Res 2021; 14:2059-2070. [PMID: 34267550 PMCID: PMC8275210 DOI: 10.2147/jpr.s305066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/17/2021] [Indexed: 01/03/2023] Open
Abstract
Purpose In a phase 3 study, galcanezumab significantly reduced the frequency of episodic cluster headache attacks across weeks 1–3 (primary endpoint) compared with placebo. However, multiple pain dimensions may contribute to the total burden of episodic cluster headache pain. This post hoc analysis assessed the impact of galcanezumab on the total pain burden of episodic cluster headache using a composite measure. Patients and Methods Patients with episodic cluster headache were randomized 1:1 to galcanezumab 300 mg or placebo once monthly for 8 weeks. Mean weekly total pain burden was calculated (daily cluster headache attack frequency × average duration × average pain severity summed over 7 days) using data collected in an electronic patient-reported outcomes diary. Change from baseline in weekly total pain burden across weeks 1–3 was compared between galcanezumab and placebo. To explore construct validity, mean weekly total pain burden scores were stratified by Patient Global Impression of Improvement (PGI-I) responses at the week 4 clinic visit. Results The reduction from baseline in mean weekly total pain burden was significantly greater with galcanezumab (N=49) than with placebo (N=57): the least squares mean difference was −11.18 severity-weighted hours (p=0.035). Median weekly total pain burden decreased as PGI-I ratings improved, from 33.6 to 5.0 severity-weighted hours for patients who felt “very much worse” and “very much better,” respectively. Conclusion Galcanezumab significantly reduced mean weekly total pain burden compared with placebo in patients with episodic cluster headache. The composite pain measure demonstrated construct validity. Total pain burden may provide a holistic measure of the pain of episodic cluster headache. Clinical Trials ClinicalTrials.gov, NCT02397473.
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Affiliation(s)
| | - David Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | | | - Tina Oakes
- Eli Lilly and Company, Indianapolis, IN, USA
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Benemei S, Lupi C, De Cesaris F, Lombardi N, Bettiol A, Chiarugi A, Geppetti P, Galli V, Pracucci C, Occupati B, Mannaioni G. Low-dose methadone for refractory chronic migraine accompanied by medication-overuse headache: a prospective cohort study. Neurol Sci 2020; 42:987-994. [PMID: 32691178 PMCID: PMC7870632 DOI: 10.1007/s10072-020-04602-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/14/2020] [Indexed: 12/04/2022]
Abstract
Objectives A refractory chronic migraine (RCM) accompanied by medication-overuse headache (MOH) is an extremely disabling disease. Evidence suggests that in selected patients, chronic opioids may be a valuable therapeutic option for RCM. The aim of the present study was to evaluate the effectiveness and safety of prophylaxis with low-dose methadone (LDM) in patients affected by RCM with continuous headache and MOH. Methods A prospective cohort study was performed between May 2012 and November 2015 at the Headache Center and Toxicology Unit of the Careggi University Hospital. Eligible patients were treated with prophylactic LDM and followed up for 12 months. Headache exacerbations, pain intensity, use of rescue medications, and occurrence of adverse drug reactions (ADRs) were recorded. Results Thirty patients (24 females, median age 48 years) were enrolled. Nineteen (63%) patients dropped out, mainly because of early ADRs (n = 10), including nausea, vomiting, and constipation. At last available follow-up, LDM was associated with a significant decrease in the number of headache attacks/month (from a median of 45 (interquartile range 30–150) to 16 (5–30), p < 0.001), in pain intensity (from 8.5 (8–9) to 5 (3–6), p < 0.001), and in the number of rescue medications consumed per month (from 95 (34–240) to 15 (3–28), p < 0.001). No misuse or diversion cases were observed. Conclusion LDM could represent a valuable and effective option in selected patients affected by RCM with continuous headache and MOH, although the frequency of early ADRs poses major safety concerns. Randomized controlled trials are needed to confirm the efficacy and safety of LDM prophylaxis.
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Affiliation(s)
- Silvia Benemei
- Headache Center, Careggi University Hospital, Florence, Italy.
| | - Chiara Lupi
- Headache Center, Careggi University Hospital, Florence, Italy
| | | | - Niccolò Lombardi
- NEUROFARBA Department, Toxicology Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Alessandra Bettiol
- NEUROFARBA Department, Toxicology Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Alberto Chiarugi
- Department of Health Sciences, Headache Center, Careggi University Hospital, University of Florence, Florence, Italy
| | - Pierangelo Geppetti
- Department of Health Sciences, Headache Center, Careggi University Hospital, University of Florence, Florence, Italy
| | - Valentina Galli
- Toxicology Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Pracucci
- Toxicology Unit, Careggi University Hospital, Florence, Italy
| | | | - Guido Mannaioni
- NEUROFARBA Department, Toxicology Unit, Careggi University Hospital, University of Florence, Florence, Italy
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Feingold D, Goor-Aryeh I, Bril S, Delayahu Y, Lev-Ran S. Problematic Use of Prescription Opioids and Medicinal Cannabis Among Patients Suffering from Chronic Pain. PAIN MEDICINE 2018; 18:294-306. [PMID: 28204792 DOI: 10.1093/pm/pnw134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To assess prevalence rates and correlates of problematic use of prescription opioids and medicinal cannabis (MC) among patients receiving treatment for chronic pain. Design Cross-sectional study. Setting Two leading pain clinics in Israel. Subjects Our sample included 888 individuals receiving treatment for chronic pain, of whom 99.4% received treatment with prescription opioids or MC. Methods Problematic use of prescription opioids and MC was assessed using DSM-IV criteria, Portenoy’s Criteria (PC), and the Current Opioid Misuse Measure (COMM) questionnaire. Additional sociodemographic and clinical correlates of problematic use were also assessed. Results Among individuals treated with prescription opioids, prevalence of problematic use of opioids according to DSM-IV, PC, and COMM was 52.6%, 17.1%, and 28.7%, respectively. Among those treated with MC, prevalence of problematic use of cannabis according to DSM-IV and PC was 21.2% and 10.6%, respectively. Problematic use of opioids and cannabis was more common in individuals using medications for longer periods of time, reporting higher levels of depression and anxiety, and using alcohol or drugs. Problematic use of opioids was associated with higher self-reported levels of pain, and problematic use of cannabis was more common among individuals using larger amounts of MC. Conclusions Problematic use of opioids is common among chronic pain patients treated with prescription opioids and is more prevalent than problematic use of cannabis among those receiving MC. Pain patients should be screened for risk factors for problematic use before initiating long-term treatment for pain-control.
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Affiliation(s)
- Daniel Feingold
- Dual Diagnosis Clinic, Lev-Hasharon Medical Center, Pardesiya, Israel
| | | | - Silviu Bril
- Pain Center, Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Delayahu
- Department of Dual Diagnosis, Abarbanel Mental Health Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Lev-Ran
- Dual Diagnosis Clinic, Lev-Hasharon Medical Center, Pardesiya, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Moisset X, Trouvin AP, Tran VT, Authier N, Vergne-Salle P, Piano V, Martinez V. Utilisation des opioïdes forts dans la douleur chronique non cancéreuse chez l’adulte. Recommandations françaises de bonne pratique clinique par consensus formalisé (SFETD). Presse Med 2016; 45:447-62. [DOI: 10.1016/j.lpm.2016.02.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 01/19/2016] [Accepted: 02/23/2016] [Indexed: 02/02/2023] Open
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Norton M, Cho AY, Giebler C, Smith T, Walton K. Buprenorphine/naloxone addiction in a pharmacist as a result of migraine self-treatment. Ment Health Clin 2016; 6:127-130. [PMID: 29955459 PMCID: PMC6007646 DOI: 10.9740/mhc.2016.05.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: A unique case report is presented to demonstrate addiction in a pharmacist through the use of buprenorphine/naloxone film for the self-prescribed treatment of migraine headaches. Case Summary: A 35-year-old female hospital pharmacist was admitted to treatment for opioid use disorder for using buprenorphine/naloxone film to self-medicate her migraine headaches. After daily use of sublingual buprenorphine/naloxone, and several failed attempts to discontinue use, the pharmacist was admitted to a partial hospitalization treatment program. She was prescribed sumatriptan subcutaneous injection for her migraines, while maintaining buprenorphine/naloxone abstinence. Upon completion, the pharmacist transitioned to the aftercare program, where she maintains sobriety and uses her story to help aid in other patients' recoveries at the treatment center. Discussion: Addiction and substance abuse affect a substantial number of health care professionals. Pharmacists are particularly vulnerable to prescription drug misuse and addiction as a result of their direct access and vast pharmacologic knowledge. In a 2004 self-report survey of a random sample of health care providers, 58.7% of pharmacists reported using nonprescribed prescription drugs at least once in their lifetime. This case is a story of rehabilitation and recovery of a pharmacist who has a desire to return to the practice of pharmacy through the use of effective pharmacologic and behavioral interventions.
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Affiliation(s)
- Merrill Norton
- (Corresponding author) Clinical Associate Professor, University of Georgia College of Pharmacy, Athens, Georgia,
| | - Ah Young Cho
- PharmD Candidate, University of Georgia College of Pharmacy, Athens, Georgia
| | - Courtney Giebler
- PharmD Candidate, University of Georgia College of Pharmacy, Athens, Georgia
| | - Taylor Smith
- PharmD Candidate, University of Georgia College of Pharmacy, Athens, Georgia
| | - Kathryn Walton
- PharmD Candidate, University of Georgia College of Pharmacy, Athens, Georgia
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Derakhshan I. The diagnosis and treatment of chronic migraine: the case for daily scheduled opioid treatment in chronic headache. Ther Adv Chronic Dis 2015; 6:389. [PMID: 26568813 DOI: 10.1177/2040622315608648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Iraj Derakhshan
- Private practice - neurology, 1206 Quarrier Street, Suite 101, Charleston, WV 25301, USA
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Udelsmann A, Saccomani P, Dreyer E, da Costa ALC. Treatment of status migrainosus by general anesthesia: a case report. Braz J Anesthesiol 2015; 65:407-10. [PMID: 26323741 DOI: 10.1016/j.bjane.2013.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/09/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The status migrainosus is a complication of migraine characterized by severe headache for more than 72h that did not respond to treatment, with risk of stroke and suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goal is to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia. CASE REPORT Female patient, aged 50 years, with status migrainosus, in the last five days with visits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual Numeric Scale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuronium and maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed. CONCLUSION Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.
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Affiliation(s)
- Artur Udelsmann
- Departamento de Anestesiologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil.
| | - Priscila Saccomani
- Serviço de Anestesia, Hospital das Clínicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Elisabeth Dreyer
- Hospital das Clínicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Udelsmann A, Saccomani P, Dreyer E, Costa ALCD. Tratamento do estado de mal‐enxaquecoso pela anestesia geral: relato de caso. Braz J Anesthesiol 2015; 65:407-10. [DOI: 10.1016/j.bjan.2013.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/09/2013] [Indexed: 10/26/2022] Open
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DeVries A, Koch T, Wall E, Getchius T, Chi W, Rosenberg A. Opioid use among adolescent patients treated for headache. J Adolesc Health 2014; 55:128-33. [PMID: 24581795 DOI: 10.1016/j.jadohealth.2013.12.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 12/11/2013] [Accepted: 12/11/2013] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the pervasiveness of opioid prescribing for adolescents with headache and patient and provider characteristics associated with likelihood of opioid prescribing. METHODS This observational cohort analysis used commercial medical and pharmacy claims between January 1, 2007 and December 31, 2008. Included were adolescents (13-17 years of age) with newly diagnosed headache, ≥2 distinct claims for headache, and ≥12 months health plan eligibility preindex and postindex. Adolescents with a trauma diagnosis at any point were excluded. The primary outcome was current practice patterns, measured by a number of opioid claims, a percentage of patients prescribed opioids, a number of opioid prescriptions per year, a length of opioid therapy, and a frequency of specific comorbidities. A secondary outcome characterized providers and practice settings, comparing patients who received opioids with those who did not. RESULTS AND CONCLUSIONS Of 8,373 adolescents with headache, 46% (3,859 patients) received an opioid prescription. Nearly half (48%) received one opioid prescription during follow-up; 29% received ≥3 opioid prescriptions. Of those with opioid prescriptions, 25% (977 patients) had a migraine diagnosis at index date. Among adolescents who received opioids, 28% (1,076 adolescents) had an emergency department (ED) visit for headache during follow-up versus 14% (608 adolescents) who did not receive opioids (p < .01). ED visits with a headache diagnosis during follow-up were strongly correlated with opioid use after adjusting for other covariates (odds ratio, 2.02; 95% confidence interval, 1.79-2.29). Despite the treatment guidelines recommending against their use, a large proportion of adolescents with headache were prescribed opioids. ED visits were strongly correlated with opioid prescriptions.
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Affiliation(s)
| | - Thomas Koch
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Eric Wall
- American Academy of Family Physicians, Leawood, Kansas
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Krymchantowski AV, Jevoux CDC. Chronic (transformed) migraine and medication overuse: to withdraw or not? Expert Rev Neurother 2014; 7:1065-7. [PMID: 17868003 DOI: 10.1586/14737175.7.9.1065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Morris Levin
- Department of Neurology; Dartmouth Hitchcock Medical Center; Lebanon NH USA
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Huffman KL, Sweis GW, Gase A, Scheman J, Covington EC. Opioid Use 12 Months Following Interdisciplinary Pain Rehabilitation with Weaning. PAIN MEDICINE 2013; 14:1908-17. [DOI: 10.1111/pme.12201] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weimer MB, Macey TA, Nicolaidis C, Dobscha SK, Duckart JP, Morasco BJ. Sex differences in the medical care of VA patients with chronic non-cancer pain. PAIN MEDICINE 2013; 14:1839-47. [PMID: 23802846 DOI: 10.1111/pme.12177] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite a growing number of women seeking medical care in the veterans affairs (VA) system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain. DESIGN Retrospective cohort study using VA administrative data. SUBJECTS The subjects were 17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008. METHODS Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral. RESULTS Compared with male veterans, female veterans were more often diagnosed with two or more pain conditions, and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (adjusted OR [AOR] 0.67, 95% CI 0.58-0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18-1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05-1.33). Primary care utilization was not significantly different between sexes. CONCLUSIONS Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes.
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Affiliation(s)
- Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Ho KY, Chua NHL, George JM, Yeo SN, Main NB, Choo CY, Tan JWT, Tan KH, Ng BY. Evidence-Based Guidelines on the Use of Opioids in Chronic Non-Cancer Pain—A Consensus Statement by the Pain Association of Singapore Task Force. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n3p138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. Materials and Methods: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. Results: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. Conclusion: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as second- or third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.
Key words: Chronic pain, Consensus statement, Guidelines, Non-cancer pain, Opioids
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Affiliation(s)
| | | | | | - Sow Nam Yeo
- The Pain Specialist, Mount Elizabeth Medical Centre, Singapore
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Abstract
Refractory migraine has long been a challenge to all headache specialists. This subgroup of migraine patients experience disability and impaired quality of life, despite optimal treatment. This article reviews the proposed definitions and epidemiology of refractory migraine, as well as the pathophysiology that may contribute to the genesis of this disorder. Aspects of treatment, including pharmacological, complementary/adjunct, and invasive approaches, are reviewed. Comorbid factors, medication overuse, potential pitfalls to treatment, and areas for future investigation are highlighted.
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Affiliation(s)
- Elliott Schulman
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, PA, USA
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Abstract
BACKGROUND Methadone belongs to a class of analgesics known as opioids, that are considered the cornerstone of therapy for moderate-to-severe pain due to life-threatening illnesses; however, their use in chronic non-cancer pain (CNCP) is controversial. Methadone has many characteristics that differentiate it from other opioids, which suggests that it may have a different efficacy and safety profile. OBJECTIVES To assess the analgesic effectiveness and safety of methadone in the treatment of CNCP. SEARCH METHODS We identified both randomized controlled trials (RCTs) and non-randomized studies of methadone use in chronic pain by searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2011, issue 11, MEDLINE (1950 to November 2011), and EMBASE (1980 to November 2011), together with reference lists of retrieved papers and reviews. SELECTION CRITERIA We included RCTs with pain assessment as either the primary or secondary outcome. Quasi-randomized studies, cohorts and case-control trials were also considered for inclusion because we suspected that the beneficial and harmful effects of methadone in CNCP may not be adequately addressed in RCTs. DATA COLLECTION AND ANALYSIS Two review authors independently extracted efficacy and adverse event data and assessed risk of bias. MAIN RESULTS We included two RCTs and one non-randomized study, involving a total of 181 participants. Both RCTs were cross-over studies, one involving 19 participants with diverse neuropathic pain syndromes, the other involving 76 participants with postherpetic neuralgia. Study phases were 20 days and approximately eight weeks, respectively. The non-randomized study retrospectively evaluated 86 outpatients over an average of 8.8 ± 6.3 months.One RCT reported average pain intensity and pain relief, and found statistically significant improvements versus placebo for both outcomes, with 10 mg and 20 mg daily doses of methadone. The second RCT reported differences in pain reduction between methadone and morphine and found morphine to be statistically superior. The non-randomized study found that in patients initially prescribed methadone it was effective in fewer participants than in those initially prescribed other long-acting opioids (28% versus 42%, 33% and 50% for morphine, oxycodone and transdermal fentanyl, respectively).One RCT compared incidences for several individual adverse events, but found a difference between methadone and placebo for only one event, dizziness (P = 0.041). AUTHORS' CONCLUSIONS The three studies provide very limited evidence of the efficacy of methadone for CNCP, and there were too few data for pooled analysis of efficacy or harm, or to have confidence in the results of the individual studies. No conclusions can be made regarding differences in efficacy or safety between methadone and placebo, other opioids, or other treatments.
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Affiliation(s)
- Simon Haroutounian
- Department of Anesthesiology, Washington University School of MedicineDivision of Clinical and Translational Research and Washington University Pain Center660 S. Euclid AveCampus Box 8054St LouisMOUSA63110
| | - Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
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Darnall BD, Stacey BR, Chou R. Medical and psychological risks and consequences of long-term opioid therapy in women. PAIN MEDICINE 2012; 13:1181-211. [PMID: 22905834 DOI: 10.1111/j.1526-4637.2012.01467.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Long-term opioid use has increased substantially over the past decade for U.S. women. Women are more likely than men to have a chronic pain condition, to be treated with opioids, and may receive higher doses. Prescribing trends persist despite limited evidence to support the long-term benefit of this pain treatment approach. PURPOSE To review the medical and psychological risks and consequences of long-term opioid therapy in women. METHOD Scientific literature containing relevant keywords and content were reviewed. RESULTS AND CONCLUSIONS Long-term opioid use exposes women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks. Risks for women appear to vary by age and psychosocial factors may be bidirectionally related to opioid use. Gaps in understanding and priorities for future research are highlighted.
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Affiliation(s)
- Beth D Darnall
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Perret D, Rosen C. A physician-driven solution--the Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain medicine. PAIN MEDICINE 2012; 12:1361-75. [PMID: 21914121 DOI: 10.1111/j.1526-4637.2011.01217.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The practice of contemporary pain medicine is laced with a number of significant ethical challenges. Considerable difficulties include the overutilization of interventional procedures, the application of under-evidenced treatment modalities, and potentially superfluous opioid prescribing. As with many other fields in medicine, including orthopedic surgery, relationships with industry are both common and pervasive, and influence our medical practice through education, publications, and research. This article highlights these ethical challenges and broaches several physician-driven solutions: The Association for Medical Ethics, the Physicians Payment Sunshine inspired by it, and other non-legislative reforms are discussed.
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Affiliation(s)
- Danielle Perret
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, School of Medicine, Orange, California, USA
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Carroll CP, Haythornthwaite J. Maladaptive opioid use behaviors and psychiatric illness: what should we do with what we know? Curr Pain Headache Rep 2012; 15:91-3. [PMID: 21274661 DOI: 10.1007/s11916-011-0177-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
It is well established that opioids are broadly effective for chronic pain. Although there is some agreement that stable, moderate dosing is desirable; longer-term management of patients with chronic pain often confronts clinicians with difficult decisions regarding when to intensify opioid treatment and when to declare failure. Under these circumstances the concern for addiction arises with uncomfortable frequency in specialty settings. An emerging literature has defined a number of plausible markers of risk for aberrant opioid use behaviors in clinical chronic pain populations. Some of these risk factors involve the presence of comorbid psychiatric illnesses, which puts clinicians in the difficult position of deciding whether or not to limit treatment to patients who are more complex. The authors discuss the issues of bad behavioral outcomes in opioid therapy, the implications of this emerging literature for clinicians, and suggest broad areas in which researchers can improve the knowledge base with which clinicians operate.
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Affiliation(s)
- C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Loder EW, Rizzoli P. Tolerance and Loss of Beneficial Effect During Migraine Prophylaxis: Clinical Considerations. Headache 2011; 51:1336-45. [DOI: 10.1111/j.1526-4610.2011.01986.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Symptomatic Treatment of Migraine: When to Use NSAIDs, Triptans, or Opiates. Curr Treat Options Neurol 2010; 13:15-27. [DOI: 10.1007/s11940-010-0107-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Saper JR, Lake AE, Bain PA, Stillman MJ, Rothrock JF, Mathew NT, Hamel RL, Moriarty M, Tietjen GE. A Practice Guide for Continuous Opioid Therapy for Refractory Daily Headache: Patient Selection, Physician Requirements, and Treatment Monitoring. Headache 2010; 50:1175-93. [DOI: 10.1111/j.1526-4610.2010.01733.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nicolson SE, Caplan JP, Williams DE, Stern TA. Comorbid pain, depression, and anxiety: multifaceted pathology allows for multifaceted treatment. Harv Rev Psychiatry 2010; 17:407-20. [PMID: 19968455 DOI: 10.3109/10673220903463226] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The care of patients who suffer from physical pain and a psychiatric illness is typically challenging because of the complex interplay of affective, behavioral, cognitive, and physical aspects of pain. Psychiatrists are often asked to evaluate patients with pain because of a concern for comorbid depression and anxiety, and fears of suicidality as a result of pain. This article reviews the pathophysiology of comorbid pain, anxiety, and depression, along with the treatment modalities (pharmacologic, psychotherapeutic, and "alternative") that may benefit all three conditions.
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Affiliation(s)
- Stephen E Nicolson
- Departments of Psychiatry, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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Wenzel RG, Padiyara RS, Schommer JC. Didactic migraine education in US doctor of pharmacy programs. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2010; 74:4. [PMID: 20221355 PMCID: PMC2829152 DOI: 10.5688/aj740104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 07/06/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To compare didactic migraine education in doctor of pharmacy (PharmD) programs in the United States with the Headache Consortium's evidence-based migraine treatment recommendations. METHODS A self-administered survey instrument was mailed to all 90 Accreditation Council for Pharmacy Education (ACPE) approved PharmD programs in the United States. RESULTS Seventy-seven programs responded (86%) and 69 useable survey instruments were analyzed. Fifty-five percent of programs discussed the Consortium's guidelines, 49% discussed the selection of nonprescription versus prescription agents, 45% recommended a butalbital-containing product as migraine treatment, and 20% educated students about tools for assessing migraine-related debilitation. At least 50% of programs taught information consistent with the remaining Consortium recommendations. CONCLUSION Approximately half of the PharmD programs teach concepts about migraine headache treatment consistent with the US Headache Consortium's recommendations.
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Affiliation(s)
- Richard G Wenzel
- Diamond Headache Clinic Inpatient Unit, St. Joseph Hospital, Chicago, IL 60657, USA.
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Abstract
Specific patient and physician characteristics may contribute to a perception that a particular headache patient is "difficult." Headache patients with psychiatric pathology, multiple unexplained symptoms, substance abuse problems, or refractory headaches are commonly perceived as challenging to manage. Physicians who are younger, under more stress, and who do not use collaborative treatment models are more likely to find patients difficult. General principles that may be helpful in coping with headache patients perceived as difficult include: (1) evaluation for possible psychiatric or substance abuse problems with institution of specific treatment if found; (2) a shift in treatment philosophy away from a goal of cure toward a goal of management; (3) the use of written agreements that outline conditions of treatment, including medication amounts; and (4) an integrated, multimodality treatment approach including behavioral and non-pharmacological treatment.
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Affiliation(s)
- Elizabeth Loder
- Division of Headache and Pain, Department of Neurology, Brigham and Women’s/Faulkner Hospitals, Harvard Medical School, Boston, MA 02130, USA.
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Stillman MJ, Kaniecki RG, Taylor FR. Abstracts and Citations. Headache 2009. [DOI: 10.1111/j.1526-4610.2009.01503.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. THE JOURNAL OF PAIN 2009; 10:113-30. [PMID: 19187889 DOI: 10.1016/j.jpain.2008.10.008] [Citation(s) in RCA: 1434] [Impact Index Per Article: 95.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 10/28/2008] [Accepted: 10/28/2008] [Indexed: 02/07/2023]
Abstract
UNLABELLED Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. PERSPECTIVE Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
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Lake AE, Saper JR, Hamel RL. Comprehensive inpatient treatment of refractory chronic daily headache. Headache 2009; 49:555-62. [PMID: 19245391 DOI: 10.1111/j.1526-4610.2009.01364.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE (1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors. BACKGROUND An evidence-based assessment (2004) concluded that many refractory headache patients appear to benefit from inpatient treatment, underscoring the need for more research, including outcome predictors. METHODS The authors completed a retrospective chart review of 283 consecutive admissions over 6 months. The inpatient program (mean length of stay = 13.0 days) included intravenous and oral medication protocols, drug withdrawal when indicated, cognitive-behavior therapy, and other services when needed, including anesthesiological intervention. Patient-reported pain levels and consensus of medical staff determined outcome status. RESULTS The 267 completers (94%) included 212 women and 55 men (mean age = 40.3 years, range = 13-74) from 43 states and Canada. The modal diagnosis was intractable, chronic daily headache (85%), predominantly migraine. Most (59%) had medication overuse headache (MOH), involving opioids (48%), triptans (16%), or butalbital-containing analgesics (10%). Psychiatric diagnoses included stress-related headache (82%), mood disorders (70%), anxiety disorders (49%), and personality disorders (PD, 26%). More patients with a PD (62%) had opioid-related MOH than those with no PD (38%), P < .005. Of the completers, 78% had moderate to significant pain reduction, with comparable improvement in mood, function, and behavior. Clinical factors predicting moderate-significant headache improvement were limited to MOH (84% vs 69%, P < .007) and presence of a PD (68% vs 81%, P < .03). CONCLUSIONS Most patients (78%) improved following aggressive, comprehensive inpatient treatment. Maintenance of improvement is likely to depend on multiple post-discharge factors, including continuity of care, compliance, and home or work environment.
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Affiliation(s)
- Alvin E Lake
- Michigan Head-Pain and Neurological Institute, Ann Arbor, MI 48104, USA
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37
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Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research Gaps on Use of Opioids for Chronic Noncancer Pain: Findings From a Review of the Evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline. THE JOURNAL OF PAIN 2009; 10:147-59. [DOI: 10.1016/j.jpain.2008.10.007] [Citation(s) in RCA: 214] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 10/03/2008] [Accepted: 10/28/2008] [Indexed: 12/26/2022]
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Bruce BK, Townsend CO, Hooten WM, Rome JD, Moon JS, Swanson JW. Chronic pain rehabilitation in chronic headache disorders. Curr Pain Headache Rep 2009; 13:67-72. [PMID: 19126375 DOI: 10.1007/s11916-009-0014-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Barbara K Bruce
- Mayo Clinic Department of Psychiatry and Psychology, Pain Rehabilitation Center, Mayo Clinic, Generose 2W, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
The understanding of migraine pathophysiology has evolved from the belief that migraine is a vascular disorder, to evidence that better defines migraine as a neurogenic disorder associated with secondary changes in brain perfusion. There is evidence to suggest that the early phase of migraine pain results from neurogenic inflammation affecting cranial blood vessels and dura. Allodynia, hyperalgesia, and expansion of nociceptive fields occur during most well-established migraine attacks. These clinical features of migraine are evocative of those traditionally associated with neuropathic pain. A hypothesis that defines migraine pain as a unique neuropathic pain disorder can imply the potential for neural plasticity and may provide insight into the mechanisms that underlie the transformation of episodic to chronic forms of migraine. The neuropathic pain model of migraine pathophysiology not only paves the way for mechanism-based treatment strategies that can improve the acute and preventive management of migraine attacks, but also opens the door for the discovery of novel therapeutic targets. It also lends momentum to an understanding of clinically intriguing topics such as opiate-induced hyperalgesia and medication-overuse headache (rebound headache), opioid resistance in the treatment of chronic headache, and disease modification in defending against the potential for migraine transformation.
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Saper JR, Lake AE. Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines. Headache 2008; 48:838-49. [PMID: 18549361 DOI: 10.1111/j.1526-4610.2008.01153.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intractable pain, headache or otherwise, is a devastating and life-controlling experience. The need to effectively and aggressively control pain is a fundamental tenet of clinical care. In the past several years, increasing advocacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety. To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity. Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgesia, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients. We believe that COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment. The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.
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Affiliation(s)
- Joel R Saper
- Michigan Head-Pain & Neurological Institute, Ann Arbor, MI, USA
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Braden JB, Fan MY, Edlund MJ, Martin BC, DeVries A, Sullivan MD. Trends in use of opioids by noncancer pain type 2000-2005 among Arkansas Medicaid and HealthCore enrollees: results from the TROUP study. THE JOURNAL OF PAIN 2008; 9:1026-35. [PMID: 18676205 DOI: 10.1016/j.jpain.2008.06.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 05/30/2008] [Accepted: 06/06/2008] [Indexed: 11/19/2022]
Abstract
UNLABELLED Use of prescription opioids for noncancer pain has increased significantly in recent years, but it is not known if trends differ among the most common noncancer pain conditions. We examined trends in opioid prescribing for the years 2000 through 2005 for individuals with arthritis/joint pain, back pain, neck pain, and headaches by type and number of pain diagnoses, using data from claims records from 2 health insurers: HealthCore commercially insured members (N = 3,768,223) and Arkansas Medicaid (N = 127,866). Rates of headache, back pain, and neck pain diagnoses increased significantly in Arkansas Medicaid enrollees but more modestly among HealthCore enrollees. Rates of opioid use increased in both groups, with long-term use (>90 days' supply per year) increasing at twice the rate of any use. Rates of opioid use did not differ widely between noncancer pain conditions, but long-term opioid use rates doubled with each additional pain diagnosis. Mean days supply and cumulative yearly dose increased between 2000 and 2005 for all pain types and with increasing number of pain diagnoses, but dose per day supply remained relatively stable. The greatest increases in dose among all the pain conditions were seen in short-acting DEA Schedule II opioids. PERSPECTIVE This study demonstrates increased use of opioids, particularly long-term use, in noncancer pain over a 6-year period among those with multiple pain types. These results appear to reflect a general increase in use of prescription opioids for noncancer pain rather than a condition-specific change in prescribing practices.
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Affiliation(s)
- Jennifer Brennan Braden
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195-6560 , USA.
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Straube A, May A, Kropp P, Katsarava Z, Haag G, Lampl C, Sándor P, Diener HC, Evers S. Therapie primärer chronischer Kopfschmerzen. Schmerz 2008; 22:531-34, 536-40, 542-3. [DOI: 10.1007/s00482-008-0645-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saper JR. Chronic daily headache: Transformational migraine, chronic migraine, and related disorders. Curr Neurol Neurosci Rep 2008; 8:100-7. [DOI: 10.1007/s11910-008-0017-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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46
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Bruce BK, Townsend CO, Hooten WM, Rome JD, Moon JS, Swanson JW. Chronic pain rehabilitation in chronic headache disorders. Curr Neurol Neurosci Rep 2008; 8:94-9. [DOI: 10.1007/s11910-008-0016-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Chronic nonmalignant pain is less a symptom of a disease than a disease in itself. Accordingly, successful treatments rely less on identifying underlying pathology than on treating neural causes of pain amplification, psychologic causes of disability, and the sequelae of deconditioning and psychiatric illness. The outcome, when such treatment is provided, is remarkably favorable.
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Affiliation(s)
- Edward Covington
- Section of Pain Medicine, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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48
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Sanders SH, Harden RN, Vicente PJ. Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic nonmalignant pain syndrome patients. Pain Pract 2007; 5:303-15. [PMID: 17177763 DOI: 10.1111/j.1533-2500.2005.00033.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This is an update to evidence-based practice guidelines for chronic nonmalignant pain syndrome patients first published in 1995 and revised in 1999. The current guidelines recommend interdisciplinary-focused rehabilitation, which is goal-directed and time-limited. Emphasis is placed on educating patients in active self-management techniques that stress maximizing function. Integrated treatment involving medical, psychological/behavioral, physical/occupational therapy, and disability/vocational interventions are recommended on an outpatient basis whenever clinically possible. Patient selection criteria are delineated. Updated references providing evidence-based support for the recommendations are provided, including the use of opioids and sedative-hypnotic medications, injection and block procedures, acupuncture, implantable spinal infusion and stimulation devices, and other invasive spinal surgery procedures such as intradiscal electrothermal therapy. Guideline integration and early detection and intervention with chronic pain syndrome patients are encouraged.
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Affiliation(s)
- Steven H Sanders
- Siskin Hospital's Center for Pain Rehabilitation, Chattanooga, Tennessee 37403, USA.
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49
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Affiliation(s)
- Seymour Solomon
- Headache Unit, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467, USA
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50
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Ballantyne JC, LaForge SK. Opioid dependence and addiction during opioid treatment of chronic pain. Pain 2007; 129:235-255. [PMID: 17482363 DOI: 10.1016/j.pain.2007.03.028] [Citation(s) in RCA: 327] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Revised: 02/22/2007] [Accepted: 03/23/2007] [Indexed: 11/23/2022]
Abstract
Throughout the long history of opioid drug use by humans, it has been known that opioids are powerful analgesics, but they can cause addiction. It has also been observed, and is now substantiated by multiple reports and studies, that during opioid treatment of severe and short-term pain, addiction arises only rarely. However, when opioids are extended to patients with chronic pain, and therapeutic opioid use is not confined to patients with severe and short-lived pain, compulsive opioid seeking and addiction arising directly from opioid treatment of pain become more visible. Although the epidemiological evidence base currently available is rudimentary, it appears that problematic opioid use arises in some fraction of opioid-treated chronic pain patients, and that problematic behaviors and addiction are problems that need to be addressed. Since the potentially devastating effects of addiction can substantially offset the benefits of opioid pain relief, it seems timely to reexamine addiction mechanisms and their relevance to the practice of long-term opioid treatment for pain. This article reviews the neurobiological and genetic basis of addiction, its terminology and diagnosis, the evidence on addiction rates during opioid treatment of chronic pain and the implications of biological mechanisms in formulating rational opioid treatment regimes.
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Affiliation(s)
- Jane C Ballantyne
- Division of Pain Medicine, Massachusetts General Hospital Pain Center, Boston, MA 02114, USA Harvard Medical School, Boston Massachusetts, USA Finnish Genome Center, The University of Helsinki, Helsinki, Finland
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