A Survey of Spinal Cord Stimulator Use by Chronic Pain Patients While Driving.

OBJECTIVE: The study aims to assess utilization of spinal cord stimulator (SCS) devices while driving a vehicle and potential association with motor vehicle accidents (MVAs). MATERIALS AND METHODS: A telephone survey study was conducted in two phases, from 2001 to 2008 and from 2009 to 2011. Patients selected for the survey were age 18 or older and at least one year post-SCS implantation, demonstrating stable analgesic use for at least six months, and reporting a minimum of 50% pain relief and enhancement of activities of daily living. Both phases of the study evaluated for degree of utilization of SCS while driving a motor vehicle as well as associated accidents. Additionally, patients with active SCS use while driving were further asked in the second phase of the study about mileage per week and first activation of the device postimplant. RESULTS: Ninety-seven percent of the 78 patients contacted were active drivers and of these, 80% reported chronic and consistent use of SCS for the analgesic benefit while operating a motor vehicle. Eleven percent reported MVAs, which were not related to SCS. In the second phase of the study, participants reported a median of 100 miles driven per week with the SCS device on and began use of the device at a median of 21 days postimplant for up to 49 months. CONCLUSION: Because of the perceived benefits of pain reduction, there is high utilization of active SCS while driving a motor vehicle and that does not seem predispose toward MVAs.

Low and therapeutic doses of antidepressants are associated with similar response in the context of multimodal treatment of pain.

BACKGROUND: Antidepressants are prescribed in a wide range of doses to treat both depression and chronic pain, with optimal psychopharmacology individualized for each patient. In the past decade more antidepressants from different chemical classes have become available and are being used for the treatment of both chronic pain and depression. OBJECTIVE: To review the utilization pattern changes and compare response rates of different classes and doses of antidepressants for various pain conditions in the context of multimodal therapies. DESIGN: Chart review. METHODS: We reviewed 5,916 records at an outpatient multidisciplinary pain center. Of these, 379 records were for patients diagnosed with cancer pain. Because the mechanisms and treatment approaches to cancer pain can differ greatly from non-cancer chronic pain, these records were excluded from the analysis. We assessed 1,506 medical records for patients with chronic non-caner pain who had used at least one antidepressant, with the main outcome measure being the Numeric Rating Pain Scale, 0-10. RESULTS: Of the 5,916 charts reviewed, 1,506 (25.4%) chronic non-cancer pain charts recorded the prescription of at least one antidepressant. Most patients received a combination of medications and procedures. Of the 450 patients receiving secondary amines, favorable responses were recorded for 340 (76%) patients, while 103 (23%) did not respond and 7 had unknown responses. Of the 492 patients receiving tertiary amines, favorable responses were recorded for 375 (76%) patients, while 113 (23%) did not respond, and 4 had unknown responses. Of the 533 patients receiving SSRI/SNRIs, favorable responses were recorded for 382 (72%) patients, while 147 (28%) did not respond, and 4 had unknown responses. Of the 369 patients receiving atypical antidepressants, favorable responses were recorded for 272 (74%) patients, while 94 (25%) did not respond, and 3 had unknown responses. LIMITATIONS: A retrospective study design and the use of antidepressants as a part of multimodal treatment of pain. CONCLUSION: The data suggest that in the context of multimodal treatment for chronic pain, antidepressant therapy at both low and therapeutic doses demonstrates similar response rates. Tricyclic antidepressants (TCAs), which include secondary and tertiary amines, as well as SSRI/SNRIs and atypicals, all appear to show similar favorable response rates.

Dealing with difficult patients in your pain practice.

Pain patients can be difficult. They can provoke negative feelings of frustration and anger among clinicians and damage the doctor-patient relationship. This article helps practitioners to identify those pain patients who would be prone to difficult behavior and sheds light on some of the reasons behind the behavior that give rise to difficult feelings. Issues of comorbid psychopathology, hostility, suicidality, aberrant drug behavior, and chronic noncompliance are discussed. Specific recommendations are also given of the best ways to manage patients with difficult behavior.

Labetalol for prophylactic treatment of intractable migraine during pregnancy.

Headaches tend to improve in the majority of migraineurs during pregnancy, but some patients report a worsening of migraine and present a management challenge because of the restrictions of pharmacotherapy during pregnancy. Treatment options become even more limited for pregnant migraineurs who develop preeclampsia. Labetalol was tried successfully in reducing the frequency, duration, and intensity of migraine attacks in a pregnant woman with preeclampsia. There were no significant side effects and the patient delivered a healthy baby without complications.