Hansen RN, Oster G, Edelsberg J, Woods GE, Sullivan SE: Economic costs of nonmedical use of prescription opioids. Clin. J. Pain 27, 194–202 (2011).
This is a very innovative article that uses large databases to reveal the economic costs of the nonmedical use of prescription opioids in the USA. The data are derived from the National Household Survey on Drug Abuse and other national data sources. The authors come up with a total cost of greater than US$50 billion annually, with lost productivity and crime contributing to 94% of the total costs. Hydrocodone, OxyContin® and methadone were the biggest contributers to the total costs. As the authors point out, only looking at costs fails to deal with the many human issues surrounding opioid prescriptions.
Botterman J, Criel N: Inappropriate use of high doses of transdermal fentanyl at admission to a palliative care unit. Palliat. Med. 25, 111–116 (2011).
This retrospective study examined the patterns of strong opioid use in patients admitted to a hospice inpatient unit in Belgium, focusing on use of transdermal fentanyl patches. Case notes of 1154 patients were reviewed, and data were collected for dose and type of opioid on admission and within 24 h of death. At admission, 47% of patients were prescribed strong opioids, of which approximately a third (32%) received oral morphine and a third (36%) received transdermal fentanyl. Median dose at admission (oral morphine equivalent) was 60 mg for patients on morphine and 180 mg for patients on fentanyl. In 58% of the 199 patients using transdermal fentanyl at admission, the patch was either discontinued or the dose was reduced because of toxicity. The authors highlight that the significantly higher oral morphine equivalent for patients on fentanyl is unlikely to be explained by higher pain intensity alone. Inappropriately high doses of fentanyl might also be explained by lack of knowledge of the relative strength of fentanyl compared with morphine by doctors unfamiliar with strong opioids and the failure to recognize opioid toxicity.
Murinson BB, Nenortas E, Mayer RS et al.: A new program in pain medicine for medical students: integrating core curriculum knowledge with emotional and reflective development. Pain Med. 12, 186–195 (2011).
This wonderful article describes a multidisciplinary pain educational program developed and implemented at Johns Hopkins School of Medicine that should serve as a model for and set the standard for curricular development in American medical schools. It is now quite apparent from evaluating primary care practices that the medical schools in the USA are, in general, not adequately preparing physicians for the tasks of managing chronic pain patients. Indeed, it is often the chronic pain patients that drive primary care practitioners into other disciplines. When asked what he would do if confronted by a chronic pain patient one of our recent graduates replied, “run.”
The developmental steps of this course are well described and the results of its first implementation are presented. The course properly focuses on the importance of narrative and the need to understand one‘s own feelings when dealing with chronic pain patients. I think that it would be a privilege to be enrolled in such a course. Those of us involved in medical education need to generate something analogous to this course for all medical schools in the USA.
Rodriguez-Navarro AJ, Berde CB, Wiedmaier G et al.: Comparison of neosaxitoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy. Reg. Anesth. Pain Med. 36, 103–109 (2011).
A total of 137 subjects were assessed in a randomized double-blind trial after laparoscopic cholecystectomy to infiltrate port wounds with 20 cc of either 100 µg of neosaxitoxin or 50 mg of 0.25% bupivacaine. Patients were able to receive morphine and ketorolac in the post-anesthesia care unit and diclofenac in the first four postoperative days. Visual analog scale (VAS) pain score was statistically significantly better in the neosaxitoxin group at rest at both 6 and 12 h, with movement at 12 h (VAS = 0 in neosaxitoxin group, VAS = 2–3 in bupivacaine group). Patients‘ self-reported time to full recovery after surgery was an average of 2 days earlier in the neosaxitoxin group. No serious adverse events were found in either group and there was no difference found in adverse events between the two groups. The authors comment that neosaxitoxin has minimal cardiac myocyte channel blocking properties and does not cross the blood–brain barrier to present a seizure risk. The authors also add that maximum safe doses of neosaxitoxin in humans have not yet been ascertained.
Osborne MD, Ghazi SM, Palmer SC et al.: Spinal cord stimulator – trial lead migration study. Pain Med. 12, 204–208 (2011).
A total of 20 patients undergoing percutaneous spinal cord stimulator trials were prospectively studied. Half had trial leads secured with an anchor sutured to the skin plus tape, while the other half had leads secured with tape only. At the end of the trial (day 3), measurements of trial lead migration were taken via x-ray. The mean lead caudad movement in the skin anchor plus tape group was 24.49 mm and 8.72 mm in the tape only group (p = 0.001). All trials proceeded according to a standardized protocol. In analyzing their data, the authors hypothesized that the firm hold of the sutured anchor at the skin site may have predisposed the lead to inferior migration when compared to the lead that was simply taped. The authors offer several “clinical pearls,” including that the inferior contacts of the trial lead be used for stimulation given the predilection for caudad migration. Another recommendation is that x-rays be obtained at the end of each trial to assay the final position of the lead during the trial.
Yang IY, Oraee S, Viejo C et al.: Computed tomography celiac trunk topography relating to celiac plexus block. Reg. Anesth. Pain Med. 36, 21–25 (2011).
A retrospective review of 200 adult CT images was carried out to assess celiac trunk anatomy. Characteristics noted were: location of the aorta relative to the vertebral body, location of the emergence of the celiac trunk from the aorta, location of the celiac trunk relative to the left, right or middle of the aorta, and anatomic structures potentially traversed by lines beginning 9.0 and 4.5 cm, respectively, from the anatomic midline. The emergence of the celiac trunk was noted as follows: T11–12 (6.5%), T12 (34.0%), T12–L1 (31.0%) and L1 (28.5%). The location of the aorta relative to the vertebral body manifested itself at the anterior-left 70% of the time and at the anterior-middle 29% of the time. The celiac trunk runoff from the aorta was on the anterolateral-left in 63.5% of scans and from the midportion in 36.0% of scans. Lines were drawn on the CT scans to assess potential traversing of the liver, spleen, kidney, aorta, inferior vena cava, portal vein and tumor mass with needle placement. This was found to occur on the right side 88% of the time with the 9-cm line and 64% of the time with the 4.5-cm line. On the left side, this vital organ traversing occurred in 96% of cases with the 9-cm line and in 88% of cases with the 4.5-cm line. Importantly, only 21 out of the 200 patients had pancreatic cancer and only two others had upper abdominal malignancies, conditions for which these procedures are commonly performed. The authors conclude that reviewing CT anatomy prior to performing celiac plexus block is indicated.
Suhonen S, Tikke M, Kivinen S, Kauppila T: The level of unpleasantness of pain influences the choice of home treatment during medical abortion. Scand. J. Pain 2, 19–23 (2011).
Medical abortion has become the routine method in many clinics, replacing surgical abortion. This is a relatively easy procedure, but the uterine contractions will often cause pain in the lower abdomen. There is limited research into treatment of this pain, and it has been questioned whether it is always sufficiently treated. This article discusses how pain may affect the patient‘s ability to be at her home during the process.
Eckmann MS, Ramamurthy S, Griffin JG: Intravenous regional ketorolac and lidocaine in the treatment of complex regional pain syndrome of the lower extremity. Clin. J. Pain 27(3), 206–206 (2011).
Complex regional pain syndrome is a pain disorder with significant autonomic features. Treatment is often difficult. Different procedures, including intravenous regional blockade, have been used without solid evidence for their efficacy. This is a small randomized, double-blind study of intravenous regional blocks with lidocaine in combination with different doses of ketorolac (an injectable nonsteroidal anti-inflammatory drug) in 12 adult patients with complex regional pain syndrome. Except for a non-dose-related efficacy of ketorolac at day 1, there was no effect on primary or secondary efficacy measures, and no long-term effect at doses up to 120 mg of ketorolac in combination with 50 ml of lidocaine 0.5%.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.