A primer of ethical issues involving opioid therapy for chronic nonmalignant pain in a multidisciplinary setting.

OBJECTIVE: This forum presents a clinical vignette of orofacial pain and expounds on ethical issues related to opioid therapy in the context of multidisciplinary treatment. The purpose of this forum is to assist health care providers from different disciplines in identifying ethical issues and conflicts regarding opioid therapy encountered in multidisciplinary clinical pain practices. DESIGN: We use the case vignette and opioid therapy as a backdrop for a discussion of 1) an overview of ethics terminology; 2) a presentation of key ethics principles; 3) our conceptualization of ethical obligations of patients regarding opioid therapy; and 4) the process of developing an appropriate treatment plan within the context of the discussed ethical principles.

Neurocognitive measures of prefrontal cortical dysfunction in schizophrenia.

Frontal lobe dysfunction in individuals with schizophrenia has frequently been detected using both neuroimaging and neuropsychological testing. Results from previous studies vary in the findings of regional specificity vs. generalized frontal cortical dysfunction. We sought to examine potential regional differences in frontal cortical functioning among patients with schizophrenia vs. a comparison group using two different neurocognitive tasks: the Gambling Task (GT) and the Wisconsin Card Sorting Test (WCST). In general, the GT is thought to reflect function of the ventromedial prefrontal cortex (VMPFC), while the WCST reflects function of the dorsolateral prefrontal cortex (DLPFC). Twenty individuals with schizophrenia or schizoaffective disorder and 15 nonpsychiatrically ill comparison subjects underwent an assessment battery consisting of the GT, WCST, and positive and negative symptom ratings. Patients with schizophrenia performed worse on the GT with respect to total monetary gain (p=0.05) and total monetary loss (p<0.05). They also preferred disadvantaged vs. advantaged cards (p<0.04). Surprisingly, WCST performance was poor in both groups and was not significantly different between groups. These findings are at some variance with those in the previously reported literature, but nonetheless support the idea that prefrontal cortical areas mediating different cognitive tasks may be distinguished by specific neurocognitive assessments.

Ontogeny of ionotropic glutamate receptor subunit expression in the rat hippocampus.

The ionotropic glutamate receptors play key roles in multiple developmental mechanisms, including regulation of neuronal migration and differentiation, and synaptic organization. In this study, we investigated the developmental expression of these glutamate receptors in the postnatal rat hippocampus. We examined the transcripts encoding the subunits composing the N-methyl-D-aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA), and kainate (KA) subtypes of glutamate receptors by in situ hybridization at multiple time points from postnatal day (PND) 1 to PND 35. In the case of the AMPA receptor, gluR1 expression did not change over this time period, while gluR2, gluR3, and gluR4 did. These three subunits each underwent a transient period of increased expression at either PND 7 or PND 18. All five of the kainate receptor subunits changed during this time, all starting at relatively high levels of expression that declined by PND 35. Similar to most of the AMPA subunits, all of the kainate subunits had transient periods of significantly increased expression. The NMDA receptors all changed during over time as well, and each had a period of increased expression. The periods of transiently increased expression of all of these subunits coincide with known periods of plasticity and other critical times in development. These results suggest the different glutamate receptor subtypes may be critical at specific times during postnatal brain development.