Support utilization by partners of self-identified sex addicts.

This online survey examined the support resources used by partners of sex addicts. Partners (N = 92) answered questions about which sources of support they found most useful, relationship functioning, and demographic and background variables. Partners rated therapists, spirituality, support groups, and friends as most useful; and the mate, their children, and their other family members as least useful. Participants indicated that they used intrapersonal religious/spiritual activities (e.g., prayer and meditation) more than interpersonal religious/spiritual activities (e.g., religious services and support groups). Older partners sought more religious/spiritual support, and more educated partners rated therapy as more useful. Rating the mate as useful was most strongly associated with positive relationship outcomes. The authors conclude with recommendations for working with partners of sex addicts.

Atypical femur fractures: 81 individual personal histories.

CONTEXT: An online voluntary association of individuals who had incurred one or more atypical femur fractures (AFFs) while taking bisphosphonates for prevention or treatment of osteoporosis provided an opportunity to collect long-term histories. SETTING: Individuals from a nationwide general community completed an anonymous survey documenting their history. PARTICIPANTS: Within a larger cadre, cases were selected where the documentation, including fracture radiographs, verified the diagnosis based on published standards. Eighty-one of this group responded to the anonymous survey. INTERVENTIONS: We describe passively collected observational data only. OUTCOME MEASURES: The incidence of a large number of potential variations was determined. RESULTS: The mean duration of bisphosphonate treatment was 9.5 yr. Prevention was the initial indication in 68% of the subjects; 94% started on alendronate, 77% reported prodromal pain, only 16% of these were diagnosed with incident stress fractures, and 39.5% experienced a contralateral AFF from less than 1 month to 49 months after the first. Of 71 subjects with a completed first AFF, 38% reported delayed healing, 11% had a complete contralateral AFF, and 22% underwent prophylactic rodding for a contralateral stress AFF. Forty-four percent of subjects with complete AFFs were continued on a bisphosphonate after the fracture. Thirty-five percent incurred a metatarsal fracture. CONCLUSIONS: AFF patients experienced delayed healing, prodromal pain, and persisting risk of a contralateral and/or other fracture. Femur pain evaluation in patients on long-term bisphosphonates may facilitate early diagnosis of stress AFFs, permitting intervention, thus reducing completed and/or contralateral or other fracture risk. The details of these histories will assist in counseling regarding prognosis after an initial AFF.

Abuse-deterrent and tamper-resistant opioid formulations: what is their role in addressing prescription opioid abuse?

About one in every three individuals will experience chronic pain in their lifetime, and opioids are known to be an effective means to treat this condition. Much attention, however, has been given to the fact that prescription opioid analgesics are some of the most frequently abused drugs, and misuse is prominent in patients with chronic pain. Several new opioid formulations that are designed to prevent or deter the abuse of opioids are currently in development, and two have been approved for marketing (morphine sulphate co-formulated with naltrexone hydrochloride [Embeda®] and a new formulation of the extended-release oxycodone [OxyContin®]). In this article, we review the various types of abuse-deterrent and tamper-resistant formulations in clinical development. We believe that continued advances in opioid formulations can help mitigate risk for those with legitimate need for pain control, but only if used rationally in the context of good clinical practice.

Defining clinical issues around tolerance, hyperalgesia, and addiction: a quantitative and qualitative outcome study of long-term opioid dosing in a chronic pain practice.

Treatment with opioid medications has grown over the past decades, but has been surrounded by some ongoing controversy and debate to whether it is causing more harm than good for patients. To this end, the field of pain management has suffered from a lack of clarity about some basic definitions on concepts such as tolerance and hyperalgesia. Some characterize these issues as inevitable parts of opioid therapy while other schools of thought look at these issues as relatively rare occurrences. Unfortunately, most of the rhetoric around these topics has occurred with very little in the realm of real world data. To this end, the authors have reviewed the charts of 197 patients treated by a pain specialist for at least 1 year to better illustrate whether notions of tolerance and hyperalgesia are common occurrences and, more importantly, whether they occur within any type of specified timeframe. A total of 197 patient charts were reviewed. The sample had an average age of 49.39 years (range = 19-87 years; standard deviation [SD] = 12.48) and comprised 66 men (33.5 percent) and 131 women (66.5 percent). The patients were seen in the pain practice for an average of 56.52 months (range = 12-155 months; SD = 31.26). On average, the patients maintained an average daily dose of 180 mg morphine equivalents for a period of 35.1 months (range = 3-101 months; SD = 21.3). Looking at the pattern of medication usage change over time, 34.5 percent experienced dose stabilization after the initial titration, 13.2 percent had early dose stabilization within one dose change, and an additional 14.7 percent actually had dose decreases after surgeries or other interventional procedures. Only 6.6 percent of the sample had to be discharged or weaned from controlled substances over time in the clinic. Thus, it appears that tolerance and hyperalgesia are not foregone conclusions when considering placing a patient on long-term opioid therapy.

Bisphosphonates and low-impact femoral fractures: current evidence on alendronate-fracture risk.

Several recent medical articles have described multiple cases of unusual low-impact subtrochanteric stress fractures or completed fractures of the femur in patients who have been on the bisphosphonate alendronate for several years for osteoporosis or osteopenia. Some patients have experienced such fractures in both femurs. The fractures are often preceded by pain in the affected thigh, may have a typical x-ray appearance, and many have delayed healing. It has been hypothesized that in some patients, long-term alendronate causes oversuppression of bone turnover, resulting in bones that are brittle despite improved bone density. In patients with atypical or low-impact fractures of the femoral shaft, consider the possible connection with alendronate use. Some bone specialists now recommend stopping alendronate in most patients after 5 years.

Chronic pain management in older adults: with coxibs under fire, what now?

Chronic non-cancer pain is notoriously undertreated, especially when the source cannot be identified by objective testing. Effective treatment often requires a combination of pharmacologic and non-pharmacologic approaches. This article describes current medication management of chronic pain, with particular attention to opioids. Acetaminophen and anti-inflammatories are first-line drugs for mild to moderate pain. For neuropathic pain, anticonvulsants are finding an increasing role, as are topical agents. Antidepressants are often advisable. Regarding opioids, the article addresses concerns about addiction potential; distinguishes between addiction and physical dependency; details the role of tolerance to different effects of opioids; and discusses their safety. With appropriate dosing, vigilant management, and careful tapering, opioids are a safe and effective choice for pain management in older adults. Appropriate follow-up guidelines are presented.