Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics.

BACKGROUND: The main objective of this study was to determine the prevalence of multiple providers for different controlled substances using the largest electronic prescription monitoring program (PMP) in the United States. A secondary objective was to explore patient and medication variables associated with prescriptions involving multiple providers. PMPs monitor the final allocation of controlled substances from pharmacist to patient. The primary purpose of this scrutiny is to diminish the utilization of multiple providers for controlled substances. METHODS: This is a secondary data analysis of the California PMP, the Controlled Substance Utilization Review and Evaluation System (CURES). The prevalence of multiple provider episodes was determined using data collected during 2007. A series of binomial logistic regressions was used to predict the odds ratio (OR) of multiple prescriber episodes for each generic type of controlled substance (i.e., opioid, benzodiazepine, stimulant, or diet pill (anorectic) using demographic and prescription variables. RESULTS: Opioid prescriptions (12.8%) were most frequently involved in multiple provider episodes followed by benzodiazepines (4.2%), stimulants (1.4%), and anorectics (0.9%), respectively. The greatest associations with multiple provider episodes were simultaneously receiving prescriptions for different controlled substances. CONCLUSIONS: Opioids were involved in multiple provider prescribing more frequently than other controlled substances. The likelihood of using multiple providers to obtain one class of medications was substantially elevated as patients received additional categories of controlled substances from the same provider or from multiple practitioners. Polypharmacy represents a signal that requires additional vigilance to detect the potential presence of doctor shopping.

Forensic issues in pain: review of current practice.

Forensic activity in pain practice is reviewed with reference to the differing roles of the pain clinician and the independent expert. Ethical guidelines and recommendations for assessment, documentation, record review, and court testimony are discussed. Specific issues include the assessment of disability and impairment, malingering, and application of the Daubert standard in forensic pain practice. Examples of case law are reviewed for civil liability and CRPS, malpractice with opioid prescribing, and practice issues in a correctional setting.

A review of sympathetically maintained pain syndromes in the cancer pain population: the spectrum of ambiguous entities of RSD, CRPS, SMP and other pain states related to the sympathetic nervous system.

Accepted wisdom contends that sympathetically maintained pain is rare in cancer pain syndromes. But this may be more of an artifact of how we diagnose this condition than a reflection of its true prevalence. One area in which one might suspect this to be true is in postsurgical states. While there are case reports of sympathetically maintained pain occurring after radical neck dissection, orbital and maxillary exenteration, it has not been reported in the more common areas of postsurgical pain. For instance, although one should suspect that the nerve damage that accompanies post-thoracotomy and postmastectomy pain syndromes would bring into being a certain incidence of sympathetically maintained pain, it is difficult to find collaborative reports. This may have more to do with the difficulty inherent in diagnosing sympathetically maintained pain than its actual contribution to these persistent cancer pain syndromes. The reason that it is more commonly reported in limb amputation is less comprehensible since blocking the sympathetic fibers that travel to an extremity is easier than those going to the thoracic cavity. In addition to surgically induced sympathetically maintained pain, medical patients with lymphoma and leukemia may have an element of sympathetically maintained pain when they develop postherpetic neuralgia. While the contribution of sympathetically maintained pain in these cases is not totally ignored, its involvement, as in the surgical patients mentioned above, is worthy of another analysis. This paper will discuss the topics introduced above and suggest diagnostic and therapeutic options available for this condition.

Adherence monitoring and drug surveillance in chronic opioid therapy.

Monitoring adherence with chronic opioid therapies is a critical yet often difficult task. Because chronic opioid therapy is often fraught with complex pharmacological, psychological, social, and legal issues, its application is often controversial or altogether avoided. Improved drug monitoring and surveillance may help reduce some of the reluctance to use chronic opioid therapy in patients with chronic pain states. We review the literature on patient adherence/compliance with chronic administration of opioids as well as novel methods by which adherence with opioid therapy can be measured.

The role of vitamins in the prevention and control of anaemia.

OBJECTIVE: While iron deficiency is regarded as the major cause of nutritional anaemia, changes in vitamins A, B12, C and E, folic acid and riboflavin status have also been linked to its development and control. This paper provides a systematic review of vitamin supplementation trials relating to the control of nutritional anaemia. METHODS: A MEDLINE search was used to find reports of vitamin supplementation trials that reported changes in anaemia or iron status. RESULTS: Vitamin A can improve haematological indicators and enhance the efficacy of iron supplementation. Both folate and vitamin B12 can cure and prevent megaloblastic anaemia. Riboflavin enhances the haematological response to iron, and its deficiency may account for a significant proportion of anaemia in many populations. Vitamin C enhances the absorption of dietary iron, although population-based data showing its efficacy in reducing anaemia or iron deficiency are lacking. Vitamin E supplementation given to preterm infants has not reduced the severity of the anaemia of prematurity. Vitamin B6 effectively treats sideroblastic anaemia. Multivitamin supplementation may raise haemoglobin (Hb) concentration, but few studies have isolated the effect of multivitamins from iron on haematological status. CONCLUSIONS: In general, the public health impact of vitamin supplementation in controlling anaemia is not clear. Neither are the complex interactions involving multiple vitamins in haematopoiesis sufficiently understood to explain the observed variability in haematological responses to vitamins by age, population, vitamin mixture and dosages. Further research is needed to understand the roles of individual and combined vitamin deficiencies on anaemia to design appropriate micronutrient interventions to prevent anaemia.

The opioid contract in the management of chronic pain.

Although the "opioid contract" is widely used in the administration of chronic opioid therapy, its use has not been well defined and there are few guidelines for developing or revising such tools. We reviewed opioid contracts from 39 major academic pain centers and analyzed every statement for its core meaning. These statements were grouped into general categories and then into specific statement groups. Substantial diversity in the content of the 39 contracts was found. Statements could be grouped into 12 general categories, 43 statements groups, and 125 individual statements. Each of the 39 contracts reviewed contained 22.5% +/- 10.9% of the entire list of 125 statements and 32.6% +/- 11.2% of the 43 statement categories. Contract length averaged less than 3 pages (range: 1 to 1 mean 2.2). We describe frequent and infrequent themes that may be well suited for inclusion in any given contract. While there are many significant issues related to the usage of a formal contract in chronic opioid therapy, there was substantial consistency among the contracts in their universal attempts to improve care through dissemination of information, facilitate a mutually agreed-upon course, or enhance compliance. This study serves as an initial step in considering the risk and benefits of an opioid contract as well as its ideal content and presentation.

Injection of the piriformis muscle by fluoroscopic and electromyographic guidance.

BACKGROUND: There is not a universally accepted single technique for injection of the piriformis muscle that has validated exact placement of the needle tip within the piriformis muscle. OBJECTIVE: We sought a methodology that would precisely document needle placement within the piriformis muscle that is reliable, relatively uncomplicated, and reproducible. METHODS: Patients with piriformis syndrome underwent injections of the piriformis muscle under fluoroscopic and electromyographic guidance. This technique used electrophysiological confirmation of needle placement within the piriformis muscle and image-guided identification of the piriformis muscle with radiopaque contrast media under fluoroscopy. RESULTS: Using this methodology, injections on 17 occasions in 11 patients resulted in needle placement within the piriformis muscle.

Hypercapneic ventilatory response in patients with panic disorder before and after alprazolam treatment and in pre- and postmenstrual women.

We tested the ventilatory and anxiety response to hypercapneic (CO2) challenge in women with panic disorder as well as in normal women in the premenstrual phase and mid-points of their menstrual cycles. Panic disorder patients were challenged on two occasions, each time while in the premenstrual phase of the menstrual cycle, receiving an open trial of alprazolam through the intervening 8 weeks between tests. This study confirms previous reports indicating increased sensitivity to CO2 in patients with panic disorder and that this sensitivity can be attenuated by treatment. We found a significant decrease in the ventilatory response of panic disorder patients comparing pre- and post-therapy. We also observed that normal females, while in the premenstrual phase of their menstrual cycle, have a heightened anxiety response to CO2 challenge.

Basic mechanisms of pain.

It has been well established that pain reflects complex, linked neuroendocrine responses that go far beyond a sensory alarm system. Accordingly, there may be significant medical consequences of inadequate recognition or treatment of pain.

Quantitative relationships between plasma beta-endorphin immunoactivity and hemodynamic performance in preoperative cardiac surgical patients.

To quantitate the importance of cardiac dysfunction as a stimulus for plasma immunoactive beta-endorphin (iBE) secretion, we measured iBE and hemodynamic indices in 65 patients prior to anesthetic induction for coronary artery bypass grafting or valve replacement. Linear regression analysis for the group as a whole showed significant correlations between iBE and stroke index (SI), pulmonary artery wedge pressure (PCW), and right atrial pressure (RAP), but not mean arterial pressure (MAP). Two patient subgroups were identified (P less than 0.001 by F-test): those with low SI and high iBE, or those with high SI and low iBE (cutoffs at 40 ml/m2 and 35 pg/ml, respectively). Correlations between hemodynamics and iBE were always stronger within the low-SI than the high-SI subgroups. These correlations were greater for patients with coronary artery than with valvular heart disease. Cardiac output (CO) and cardiac index (CI) correlated with iBE in valve-replacement and coronary-grafting groups. These findings were not an artifact of impaired iBE clearance due to renal dysfunction. Our results quantitate the importance of hemodynamic dysfunction for iBE secretion, and indicate that this relationship is particularly strong when stroke index declines below 40 ml/m2.

Clonazepam blockade of spontaneous and CO2 inhalation-provoked panic in a patient with panic disorder.

A 30-year-old woman with panic disorder and phobic avoidance responded partially to treatment with alprazolam but recovered fully while receiving clonazepam, which blocked her panic attacks and anticipatory anxiety. Before treatment, the patient underwent a carbon dioxide inhalation test as a challenge and sustained a full-featured panic attack. After clonazepam therapy and retesting under identical conditions, no panic attack was reported. This is the first report of provoked panic blocked by clonazepam, a putative, clinically effective antipanic agent.

A case of bupropion-induced seizure.

Bupropion is a novel new antidepressant without the undesirable anticholinergic, cardiotoxic, sedative, or sexual side effects of other available antidepressants. However, like many other antidepressants, there is a small risk that patients on bupropion may develop a seizure even at moderate doses and moderate blood levels and even in the absence of any premorbid history or other predisposing factors to epilepsy. The report presents the case of a 25-year-old woman with a 12-year history of agoraphobia and panic attacks treated with bupropion in a research protocol. She was in good physical health, with normal physical and neurological examination, and normal complete blood count, serum mineral analysis-12, and urinalysis laboratory values. She had no premorbid history of epilepsy or neurological illness, nor any other known predisposing factors to epilepsy. On day 28 of the study, immediately after her dose of bupropion was increased from 450 to 600 mg/day, she had a generalized convulsion with tonic and clonic phases, loss of consciousness, and postictal confusion that was reliably witnessed by several observers. The EEG abnormality had cleared 15 days later. Further EEGs after 4 weeks and 10 weeks were normal. Five years later she remains seizure-free, off all antiseizure medication, and without any further complications from this incident. This seizure occurred at a modest blood level of bupropion (83 ng/ml) and at a dose not considered excessive (600 mg/day). Other confounding organic and neurological illness or use of other medication was carefully and systematically ruled out, leaving the bupropion as the most likely explanation for her seizure.(ABSTRACT TRUNCATED AT 250 WORDS)

Vasopressin response to lactate infusion in normals and patients with panic disorder.

Infusions of sodium lactate evoke panic symptoms in patients with panic disorder but not in normal subjects. Although plasma vasopressin (AVP) is known to rise in response to other forms of stress, its response during this maneuver has not previously been reported. We measured plasma AVP in double-blind infusions of sodium lactate in 5 normal subjects, 6 patients with panic disorder, and, again in 4 patients after chronic alprazolam. In all groups administered lactate, AVP rose significantly above baseline values (p less than 0.05) though no change was seen in a control group of patients during D5NS infusion. No difference in AVP response to lactate was apparent between untreated patients (who experienced panic) and normals or chronically treated patients (who had minimal symptoms). Thus, the presence of panic symptoms induced by lactate is insufficient to provoke an abnormal pattern of AVP release.

Thyroid indices in panic disorder.

Eighty-two patients suffering from panic attacks with or without phobias were examined for evidence of thyroid disease. None of the patients had abnormal total T4 or T3 resin uptake measurements, regardless of whether they were nonmedicated or treated with one of three antipanic drugs: alprazolam, phenelzine, or imipramine. A higher than expected incidence of undetectable TSH levels (22% overall) appeared in all groups. The clinical relevance of this finding is currently uncertain.