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.

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.

Empirical Relationships between Species Richness, Evenness, and Proportional Diversity.

Diversity (or biodiversity) is typically measured by a species count (richness) and sometimes with an evenness index; it may also be measured by a proportional statistic that combines both measures (e.g., Shannon-Weiner index or H'). These diversity measures are hypothesized to be positively and strongly correlated, but this null hypothesis has not been tested empirically. We used the results of Caswell's neutral model to generate null relationships between richness (S), evenness (J'), and proportional diversity (H'). We tested predictions of the null model against empirical relationships describing data in a literature survey and in four individual studies conducted across various scales. Empirical relationships between log S or J' and H' differed from the null model when <10 species were tested and in plants, vertebrates, and fungi. The empirical relationships were similar to the null model when >10 and <100 species were tested and in invertebrates. If >100 species were used to estimate diversity, the relation between log S and H' was negative. The strongest predictive models included log S and J'. A path analysis indicated that log S and J' were always negatively related, that empirical observations could not be explained without including indirect effects, and that differences between the partials may indicate ecological effects, which suggests that S and J' act like diversity components or that diversity should be measured using a compound statistic.

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.

Effects of Resource Availability on Carbon Allocation and Developmental Instability in Cloned Birch Seedlings.

Abundant nitrogen improves seedling growth and establishment. Vigorous growth brings about changes in rates and patterns of plant development and changes in the relationship between primary and secondary metabolism, which may make seedlings more susceptible to herbivores and pathogens than are slow-growing seedlings. We studied how nitrogen fertilization and manual defoliation of source leaves affect growth, carbon allocation, and developmental instability in cloned seedlings of white birch (Betula pubescens Ehrh.). Biomass was higher, whereas concentrations of most classes of phenolic compounds were lower in the nitrogen-rich environment. Interestingly, fertilization did not change the concentrations of cell wall-bound proanthocyanidins, which represent an important fraction of the group of phenolic compounds. Nitrogen enrichment increased levels of fluctuating asymmetry, an index of developmental instability. This result confirms that not only stress but also any deviation from normal resource availability may increase leaf developmental instability in birches. In contrast to fertilization, a one-time defoliation of source leaves did not shape seedling growth, development, or carbon allocation. This could be the result of compensatory growth or of the fact that the defoliation treatment was not strong enough to induce detectable effects until the end of the growing season.

Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients.

OBJECTIVE: Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis to evaluate the diagnostic and therapeutic value of local anesthetic sympathetic blocks. DESIGN: Patients rated their pain on a visual analog scale before and after blocks and were tested for mechanical allodynia one-half hour after blocks. Thereafter, they rated their pain intensity in diaries four times a day for 7 days. Each patient received two blocks, S and LA, and served as his own control. RESULTS: Both S and LA injections of sympathetic ganglia produced large reductions in pain intensity in 6 of 7 patients 30 minutes after block. These large reductions were accompanied by the reversal of mechanical allodynia in both S and LA. The mean difference between initial peak reduction in pain intensity produced by saline (68.7%) and active local anesthetic (74.4%) did not approach statistical significance. In striking contrast, the mean duration of pain relief was reliably longer in the case of LA (3 days, 18 hours) as compared with S ( 19.9 hours), a difference that occurred in all 7 patients. In a larger sample of 41 CRPS patients, signs of sympathetic efferent blockade, including Homer' s syndrome or skin surface temperature change, were not predictive of initial peak magnitude of pain relief from sympathetic blockade but were predictive of duration of pain reduction. CONCLUSION: The combination of these results provides evidence that duration of pain relief is affected by injection of local anesthetics into sympathetic ganglia. These results indicate that both magnitude and duration of pain reduction should be closely monitored to provide optimal efficacy in procedures that use local anesthetics to treat CRPS.

Incremental intravenous nitroglycerin for control of afterload during anesthesia in patients undergoing myocardial revascularization.

In 25 patients undergoing coronary artery bypass grafting hemodynamic measurements (including values obtained with Swan-Ganz catheterization in 21 of the patients) were made before and after administering a bolus injection of 64 or 96 mcg of nitroglycerin to relieve intraoperative hypertension. This pharmacological agent reduced afterload and preload without raising heart rate. The effect was apparent within 1-3 min and lasted 5-10 min. Untoward hypotension was not encountered in any instance. This intervention appears to be a safe approach to the treatment of intraoperative hypertension in patients with coronary artery disease.