Influence of prior opioid exposure on diagnostic facet joint nerve blocks.

OBJECTIVE: To determine the influence of prior opioid use on the diagnostic validity of controlled comparative local anesthetic blocks in the diagnosis of facet joint involvement in chronic spinal pain. METHODS: Data were evaluated from 438 patients with chronic spinal pain who underwent diagnostic facet joint nerve blocks. Patient data were divided into four groups based on the level of opioid use: group I (no opioid use), group II (low opioid use), group III (moderate opioid use), and group IV (high opioid use). Facet joint involvement was diagnosed utilizing controlled comparative local anesthetic blocks with 1 percent preservative-free lidocaine and 0.25 percent preservative-free bupivacaine. RESULTS: Prior and current opioid use did not show relationship to the diagnostic validity of controlled comparative local anesthetic blocks. Among patients not using opioids (group I), the prevalence of facet joint pain was shown to be 33 percent in the cervical spine, 40 percent in the thoracic spine, and 18 percent in the lumbar spine, with false-positive results with a single lidocaine block of 53 percent, 33 percent, and 54 percent, respectively. Facet joint involvement in patients with opioid use ranged from 37 percent to 53 percent in the cervical spine, 13 percent to 67 percent in the thoracic spine, and 28 percent to 33 percent in the lumbar spine. CONCLUSIONS: Overall, this evaluation demonstrated that current or prior opioid use is not associated with interference of the validity of controlled comparative local anesthetic blocks in diagnosing spinal facet joint-related pain.

Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks.

STUDY DESIGN: A retrospective review. OBJECTIVES: Evaluation of the prevalence of facet or zygapophysial joint pain in chronic spinal pain of cervical, thoracic, and lumbar origin by using controlled, comparative local anesthetic blocks and evaluation of false-positive rates of single blocks in the diagnosis of chronic spinal pain of facet joint origin. SUMMARY OF BACKGROUND DATA: Facet or zygapophysial joints are clinically important sources of chronic cervical, thoracic, and lumbar spine pain. The previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, with a prevalence of 15% to 67% variable in lumbar, thoracic, and cervical regions. False-positive rates of single diagnostic blocks also varied from 17% to 63%. METHODS: Five hundred consecutive patients receiving controlled, comparative local anesthetic blocks of medial branches for the diagnosis of facet or zygapophysial joint pain were included. Patients were investigated with diagnostic blocks using 0.5 mL of 1% lidocaine per nerve. Patients with lidocaine-positive results were further studied using 0.5 mL of 0.25% bupivacaine per nerve on a separate occasion. Medial branch blocks were performed with intermittent fluoroscopic visualization, at 2 levels to block a single joint. A positive response was considered as one with at least 80% pain relief from a block of at least 2 hours duration when lidocaine was used, and at least 3 hours or longer than the duration of relief with lidocaine when bupivacaine was used, and also the ability to perform prior painful movements. RESULTS: A total of 438 patients met inclusion criteria. The prevalence of facet joint pain was 39% in the cervical spine [95% confidence interval (CI), 32%-45%]; 34% (95% CI, 22%-47%) in the thoracic pain; and 27% (95% CI, 22%-33%) in the lumbar spine. The false-positive rate with a single block in the cervical region was 45%, in the thoracic region was 42%, and in the lumbar region 45%. CONCLUSIONS: This retrospective review once again confirmed the significant prevalence of facet joint pain in chronic spinal pain.

Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients.

BACKGROUND: Psychopathology (depression, anxiety, somatization disorder) and substance abuse (opioid misuse and illicit drug use) are common in patients with chronic pain and present problems for public health and clinical management. Despite a body of literature describing various methods for identifying psychopathology, opioid misuse, and illicit drug use in chronic pain patients, the relationship between psychopathologies, substance abuse, and chronic pain has not been well characterized. METHODS: This report describes a total of 500 consecutive pain patients prescribed and receiving stable doses of opioids. The patients were evaluated for psychopathology, opioid abuse, and illicit drug use during the course of regular pain management treatment. The relationships between psychopathology and drug abuse and/or illicit drug use in chronic pain patients were examined, and psychological evaluation for depression, anxiety, and somatization disorder was performed. RESULTS: Depression, anxiety, and somatization disorder were documented in 59, 64, and 30 percent of chronic pain patients, respectively. Drug abuse was significantly higher in patients with depression as compared to patients without depression (12 percent with depression versus 5 percent without). Current illicit drug use was higher in women with depression (22 percent) than women without depression (14 percent) and in men with or without depression (12 percent). Current illicit drug use was also higher in men with somatization disorder (22 percent) than men without (9 percent). CONCLUSION: This study demonstrated that the presence of psychological features of depression and somatization disorder may be markers of substance abuse diathesis in chronic pain patients.

Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914.

BACKGROUND: The prevalence of persistent low back pain with the involvement of lumbar facet or zygapophysial joints has been described in controlled studies as varying from 15% to 45% based on the criteria of the International Association for the Study of Pain. Therapeutic interventions utilized in managing chronic low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves. OBJECTIVE: To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain of facet joint origin. DESIGN: A prospective, randomized, double-blind trial. SETTING: An interventional pain management setting in the United States. METHODS: In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of 4 groups. Thirty patients were in a non-steroid group consisting of Groups I (control, with lumbar facet joint nerve blocks using bupivacaine ) and II (with lumbar facet joint nerve blocks using bupivacaine and Sarapin); another 30 patients were in a steroid group consisting of Groups III (with lumbar facet joint nerve blocks using bupivacaine and steroids) and IV (with lumbar facet joint nerve blocks using bupivacaine, Sarapin, and steroids). All patients met the diagnostic criteria of lumbar facet joint pain by means of comparative, controlled diagnostic blocks. OUTCOME MEASURES: Numeric Rating Scale (NRS) pain scale, the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. RESULTS: Significant improvement in pain and functional status were observed at 3 months, 6 months, and 12 months, compared to baseline measurements. The average number of treatments for 1 year was 3.7 with no significant differences among the groups. Duration of average pain relief with each procedure was 14.8 +/- 7.9 weeks in the non-steroid group, and 12.5 +/- 3.3 weeks in the steroid group, with no significant differences among the groups. CONCLUSION: Therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without Sarapin or steroids, may be effective in the treatment of chronic low back pain of facet joint origin.

Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks.

OBJECTIVE: To evaluate the prevalence of facet joint pain in patients with chronic low back pain (CLBP) after surgical intervention(s). DESIGN: A prospective, nonrandomized, consecutive study. SETTING: An ambulatory interventional pain management setting. PARTICIPANTS: The prevalence of facet joint pain was evaluated in patients with CLBP after various surgical intervention(s) referred to an interventional pain management practice. The sample was derived from 282 patients with persistent CLBP after various surgical intervention(s). Of these, 242 patients consented to undergo interventional techniques. A total of 117 consecutive patients with chronic, nonspecific low back pain, after lumbar surgical intervention(s) were evaluated with controlled, comparative local anesthetic blocks. INTERVENTIONS: Controlled, comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by .25% bupivacaine) under fluoroscopic visualization using 0.5mL to block each facet joint nerve. MAIN OUTCOME MEASURES: A positive response was defined as at least 80% reduction of pain with ability to perform previously painful movements. A positive response was considered to be pain relief from the lidocaine block lasting at least 1 hour or at least 2 hours or greater than duration of relief with lidocaine when bupivacaine was used. Controlled, comparative local anesthetic blocks were used to eliminate false-positive results. Valid information is only obtained by performing controlled blocks in the form of comparative local anesthetic blocks, in which, on 2 separate occasions, the same joint is anesthetized by using local anesthetics with different durations of action. If patients obtained appropriate response with both blocks, they were considered a positive. If they obtained appropriate response with lidocaine but not with bupivacaine, they were considered false-positive, whereas if the response was negative with lidocaine, they were considered negative. RESULTS: The prevalence of lumbar facet joint pain in patients with recurrent pain after various surgical intervention(s) was 16% (95% confidence interval, 9%-23%). The false-positive rate with a single block with lidocaine was 49%. CONCLUSIONS: Facet joints are clinically important pain generators in a small but significant proportion of patients with recurrent CLBP after various surgical intervention(s).

Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272.

BACKGROUND: Based on the criteria established by the International Association for the Study of Pain, the prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints has been described in controlled studies as varying from 54% to 67%. Intraarticular injections, medial branch nerve blocks and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin. OBJECTIVES: To determine the clinical effectiveness of therapeutic cervical medial branch blocks in managing chronic neck pain of facet joint origin and to evaluate the effectiveness of the addition of Sarapin and steroids to local anesthetics. DESIGN: A double-blind, randomized, controlled trial. SETTING: An interventional pain management setting in the United States. METHODS: In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of the 4 groups. Thirty patients were in a non-steroid group (combined Group I and II); and 30 patients were in a steroid group (combined Group III and IV). All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks. Four types of interventions were included. Group I served as control, receiving medial branch blocks using bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and Sarapin. Group III consisted of cervical medial branch blocks with bupivacaine and betamethasone. Group IV consisted of cervical medial branch blocks with bupivacaine, Sarapin and betamethasone. OUTCOME MEASURES: Numeric pain scores, Neck Pain Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months and 12 months. RESULTS: Significant pain relief (> or =50%), and functional status improvement was observed at 3 months, 6 months and 12 months. The average number of treatments for 1 year was 3.8 +/- 0.7 in the non-steroid group and 3.4 +/- 1.0 in the steroid group with no significant difference among the groups. Duration of average pain relief with each procedure was 13.4 +/- 3.5 weeks in the nonsteroid group, and it was 15.9 +/- 8.0 weeks in the steroid group with no significant difference among the groups. CONCLUSION: Therapeutic cervical medial branch nerve blocks, with or without Sarapin or steroids, may provide effective management for chronic neck pain of facet joint origin.

Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables.

BACKGROUND: Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Opioid abuse has been demonstrated in 9% to 41% of patients receiving chronic pain management. Illicit drug use has been reported in 14% to 34% of patients in chronic pain management settings. OBJECTIVES: To evaluate and correlate multiple variables with opioid abuse and illicit drug use. DESIGN: A prospective, consecutive study. SETTING: Interventional pain management practice setting in the United States. METHODS: A total of 500 consecutive patients prescribed opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques were evaluated for opioid abuse and for illicit drug use. Abuse was defined as a patient receiving controlled substances from any source other than the prescribing physician at our center with the exception of controlled substances for acute injuries unrelated to the problem being treated, or for emergencies. Urine drug testing for illicit drugs was performed by urine rapid drug screen (Instant Technologies, iCup Norfolk, VA). Results were considered positive if one or more of the monitored illicit drugs including cocaine, marijuana (THC), phencycledane methamphetamine or amphetamines were detected. RESULTS: Opioid abuse was seen in 9% of patients, with illicit drug use in 16% of patients. Significant differences were noted in the prevalence of opioid abuse in patients who developed chronic pain following motor vehicle accident(s) and in patients presenting with pain in three regions of the body. Illicit drug use (marijuana) was more common in females. Illicit drug use was also more common in patients younger than 45, after motor vehicle injury, and in patients with involvement of three regions of the body. CONCLUSION: Opioid abuse and illicit drug use were common in chronic pain patients with a prevalence of 9% and 16%, respectively. Age, pain after motor vehicle accident, involvement of multiple regions and past history of illicit drug use were identified as risk factors.

Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up.

BACKGROUND: The prevalence of persistent upper back and mid back pain due to involvement of thoracic facet joints has been described in controlled studies as varying from 43% to 48% based on IASP criteria. Therapeutic intraventions utilized in managing chronic neck pain and low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves by means of radiofrequency. These interventions have not been evaluated in managing chronic thoracic pain of facet joint origin. OBJECTIVE: To determine the clinical effectiveness of therapeutic thoracic medial branch blocks in managing chronic upper back and mid back pain of facet joint origin. DESIGN: A prospective outcome study. SETTING: Interventional pain management setting in the United States. METHODS: Fifty-five consecutive patients meeting the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks were included in this evaluation. All medial branch blocks were performed in a sterile operating room under fluoroscopic visualization with mild sedation with midazolam and/or fentanyl. Statistical methods incorporated intent-to-treat analysis. OUTCOME MEASURES: Numeric pain scores, significant pain relief > or = 50%), Oswestry Disability Index, work status and Pain Patient Profile (P-3). Significant pain relief was defined as an average 50% or greater reduction of numeric pain rating scores. RESULTS: The results showed significant differences in numeric pain scores and significant pain relief (50% or greater) in 71% of the patients at three months and six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months, compared to baseline measurements. Functional improvement was demonstrated at one year, two years, and three years from baseline. There was significant improvement with increase in employment among the patients eligible for employment (employed and unemployed) from baseline to one year, two years, and three years (61% vs 96% to 100%) and improved psychological functioning. CONCLUSION: Therapeutic thoracic medial branch blocks were an effective modality of treatment in managing chronic thoracic pain secondary to facet joint involvement confirmed by controlled, comparative local anesthetic blocks.

Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids?

BACKGROUND: Prescription drug abuse and illicit drug use are common in chronic pain patients. Adherence monitoring with screening tests, and urine drug testing, periodic monitoring with prescription monitoring programs, has become a common practice in recent years. Random drug testing for appropriate use of opioids and use of illicit drugs is often used in pain management practices. Thus, it is expected that random urine drug testing will deter use of illicit drugs, and also improve compliance. OBJECTIVES: To study the prevalence of illicit drug use in patients receiving opioids for chronic pain management and to compare the results of illicit drug use with the results from a previous study. DESIGN: A prospective, consecutive study. SETTING: Interventional pain management practice setting in the United States. METHODS: A total of 500 consecutive patients on opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques, were studied by random drug testing. Testing was performed by rapid drug screen. Results were considered positive if one or more of the monitored illicit drugs including cocaine, marijuana (THC), methamphetamine or amphetamines were present. RESULTS: Illicit drug use was evident in 80 patients, or 16%, with marijuana in 11%, cocaine in 5%, and methamphetamine and/or amphetamines in 2%. When compared with previous data, the overall illicit drug use was significantly less. Illicit drug use in elderly patients was absent. CONCLUSION: The prevalence of illicit drug abuse in patients with chronic pain receiving opioids continues to be a common occurence. This study showed significant reductions in overall illicit drug use with adherence monitoring combined with random urine drug testing.

Does adherence monitoring reduce controlled substance abuse in chronic pain patients?

BACKGROUND: Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Given that controlled substance abuse and illicit drug use are prevalent phenomena, adherence monitoring of patients that are prescribed opioids is becoming common. Adherence monitoring is carried out by an appropriate history, periodic evaluation of appropriate intake of drugs, random drug testing, and pill counts. Crucial to adherence monitoring is an initial controlled substance agreement and repeated review of the terms of this agreement with on-going education. However, the effect of adherence monitoring on drug abuse is unclear. OBJECTIVE: To identify controlled substance abuse through implementation of the terms of a controlled substance agreement, including periodic review and monitoring outside the organization. STUDY DESIGN: Prospective evaluation with historical controls. METHODS: Five hundred consecutive patients receiving prescription controlled substances were followed in a prospective manner. The evaluation consisted of a chart review to monitor controlled substance intake, with special attention to drugs obtained from outside the organization. Data collection for this purpose included information from records, pharmacies, referring physicians, and all the physicians involved in the treatment of the patient. RESULTS: Results from 500 consecutive patients were evaluated. Controlled substance abuse was seen in 9% of patients; overall, 5% of patients were obtaining controlled substances from other physicians, and 4% from illegal sources. CONCLUSION: Adherence monitoring, including controlled substance agreements and various periodic measures of compliance was associated with a 50% reduction in opioid abuse.

Evaluation of abuse of prescription and illicit drugs in chronic pain patients receiving short-acting (hydrocodone) or long-acting (methadone) opioids.

BACKGROUND: Multiple studies have documented the incidence of illicit drug use and abuse of opioids. Over the years, several hypotheses have been proposed. Short-acting opioids such as hydrocodone are generally considered to predispose patients to poor pain management, dependency, misuse, or abuse; whereas long-acting opioids such as methadone are thought to provide sustained pain management without dependency or abuse. OBJECTIVES: To evaluate and identify the prevalence of illicit drug use and prescription drug abuse or misuse in patients receiving hydrocodone or methadone. STUDY DESIGN: A prospective, comparative evaluation. METHODS: A total of 200 patients from an interventional pain management setting, divided into two groups of 100 consecutive patients receiving either hydrocodone (Group I) or methadone (Group II) were evaluated with urine testing for illicit drug use, and/or misuse or abuse of opioids. Drug testing was carried out by Rapid Drug Screen(R). RESULTS: Results of this study showed that 22% (95% CI, 13% - 30%) of Group I patients receiving hydrocodone used illicit drugs as compared with 24% (95% CI, 15% - 32%) of those in Group II who were receiving methadone. The misuse or abuse of a prescription opioid was seen in 3% (95% CI, 0% - 6%) of the patients in Group I and 12% (95% CI, 5% - 18%) in Group II. In a significant proportion of patients in both groups, the drug prescribed for them was not detected on testing. The combined use of illicit drugs and misuse of prescription drugs was noted in 24% (95% CI, 15% - 32%) in Group I and 33% (95% CI, 23% - 42%) in Group II. CONCLUSIONS: There were no significant differences as to illicit drug use and/or misuse of opioids in patients treated with hydrocodone or methadone. These findings suggest that the use of a long acting opioid formulation by patients with chronic pain does not reduce the risk of drug abuse or improve compliance with medical therapy.