The journal of pain : official journal of the American Pain Society
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Iatrogenic errors producing serious and often preventable injury occur frequently in hospitalized patients, particularly in children. Little is known about the epidemiology of analgesic medication errors in patients being discharged from the hospital. The goal of this study was to describe the epidemiology of controlled substance prescription errors by physicians-in-training for children being discharged from the hospital. We conducted a prospective, observational study of the analgesic prescriptions and discharge forms of 241 pediatric patients discharged from a Children's Center of a major urban teaching hospital from November 2003 to April 2004. All patients who were actively followed by the Pediatric Pain Service at the time of their discharge and were discharged with an analgesic prescription were included in the study. Primary outcome variables were the percentage of prescriptions that contained at least 1 medication error or potential adverse drug event. Errors were defined using the Institute for Safe Medication Practices' (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations, literature review, expert panel consensus, and the Johns Hopkins Department of Pharmacy hospital formulary. Two hundred forty-one patients who received 314 prescriptions were included in this study. Prescription errors were common; 257 of 314 (82%) of the prescriptions examined contained 1 or more errors. The most common errors were missing or wrong patient weight (n = 127, 77%), incomplete dispensing information (n = 167, 53%), and no or wrong date on prescription (n = 19, 6%). Nine prescriptions (2.9%) had the potential for significant medical injury and were considered potential adverse drug events. Discharge prescription errors for children requiring potent, opioid analgesic drugs in the management of pain are common, and nearly 3% could cause significant harm. The high rate of prescribing errors highlights the importance of developing, testing and implementing effective error-prevention strategies, especially in high-risk medications such as narcotics. ⋯ Narcotic prescriptions written by trainees at discharge from a pediatric hospital are error prone and nearly 3% have the potential to cause significant harm. With a low therapeutic profile, the hospital may consider a review/verification process to reduce the risk of patient harm.
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Multicenter Study Clinical Trial
A single-blind, placebo run-in study of duloxetine for activity-limiting osteoarthritis pain.
Osteoarthritis pain is a significant problem for our aging population. Antidepressants that are serotonin-norepinephrine reuptake inhibitors are effective for other forms of chronic pain and may provide a new treatment option for osteoarthritis pain. We performed a single-blind, placebo run-in trial of 60 to 90 mg of duloxetine in 25 subjects with activity-limiting osteoarthritis pain. Each subject received 2 weeks of placebo followed by 10 weeks of duloxetine. The primary outcome was reduction in average pain intensity between 2 and 12 weeks for subjects completing the trial. Average pain on the Brief Pain Inventory (BPI) was 5.7 at baseline, 4.8 after the 2-week placebo run-in, and 3.5 at 12 weeks for the 17 patients completing the trial (28% decrease between 2 and 12 weeks, P = .122). Eight of 15 study completers who had nonmissing BPI results (53%) reported at least 30% pain reduction between weeks 2 and 12. The Western Ontario McMaster Osteoarthritis Index (WOMAC) pain score at baseline was 2.3, 1.8 after 2 weeks, and 1.3 after 12 weeks (30% decrease between 2 and 12 weeks, P = .018). Ten of 17 patients (59%) reported at least 30% pain relief between weeks 2 and 12 on the WOMAC. Significant improvements in self-reported physical and role function were reported but observed physical function did not improve. ⋯ Duloxetine did not significantly reduce pain intensity on the BPI but did improve pain intensity and self-reported function on the WOMAC. Duloxetine warrants further investigation as a novel treatment for osteoarthritis pain.
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Practice Guideline
Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. ⋯ Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
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Intraplantar injection of bee venom (BV) produces persistent spontaneous nociception (PSN) and hyperalgesia, as well as obvious inflammatory swelling, in the paws of injected rats. The present study was designed to determine the peripheral roles of mitogen-activated protein kinase (MAPK) signal transduction pathways in BV-induced nociception and inflammation. We examined the effect of intraplantar injection of an ERK1/2 inhibitor, PD98059, and a p38 inhibitor, SB202190, on BV-induced PSN, mechanical hyperalgesia, and inflammatory swelling. We found that (1) pretreatment with SB202190 (0.1 to 10 microg) had no effect on BV-induced PSN, whereas pretreatment with PD98059 (0.1 to 100 microg) produced a significant and dose-dependent inhibition of BV-induced PSN; (2) pretreatment with PD98059 (0.1 to 100 microg) had no effect on BV-induced decreases in paw withdrawal mechanical threshold (PWMT), while pretreatment with SB202190 (0.1 to 10 microg) produced an obvious prevention of the BV-induced decrease in PWMT; and (3) pretreatment with PD98059 (0.1 to 100 microg) had no effect on BV-induced increase in paw volume (PV), whereas pretreatment with SB202190 (0.1 to 10 microg) produced a dose-related inhibition of BV-induced increases in PV. No contralateral drug treatments, even at the highest dose, had any effect on BV-induced PSN, PWMT or PV, ruling out the systemic effect of these drugs. These results suggest that peripheral MAPK signal transduction pathways may play differential roles in bee venom-induced nociception and inflammation. Targeting specific peripheral MAPKs might prove effective in the treatment of persistent pain and inflammation. ⋯ The present article showed that intraplantar injection of different MAPK inhibitors produced differential effects on bee venom-induced nociception and inflammation, suggesting that the peripheral MAPK signal transduction pathways have differential roles. Targeting specific peripheral MAPKs might prove effective in the treatment of persistent pain and inflammation.
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Clinical Trial
Actigraphy quantifies reduced voluntary physical activity in women with primary dysmenorrhea.
We assessed whether an activity data logger was able to detect and measure the reduced physical activity reported by women with moderate to severe primary dysmenorrhea. Twelve young women with a history of primary dysmenorrhea and 12 young women without a history of dysmenorrhea wore an activity data logger on their hip for 3 days when menstruating and for 3 matched days of the week when not menstruating. A visual analog scale was use to assess intensity of pain. When menstruating, the women with a history of primary dysmenorrhea, compared with when they were not menstruating, were significantly less active by about 40% on their day of worst pain (P < .001), day of intermediate pain (P < .001), and day of least pain (P < .001). There was no significant difference in the voluntary physical activity of the group on the 3 menstrual days. The women without a history of dysmenorrhea experienced mild menstrual pain but no significant decrease in physical activity (P = .82). We show that data loggers are able to detect and quantify the decrease in physical activity reported by the women with a history of moderate to severe dysmenorrhea and that menstrual pain but not menstruation itself was associated with decreased voluntary physical activity. ⋯ We have shown that a miniature activity data logger, when worn on the hip of women with a history of dysmenorrhea, detected a 40% decrease in physical activity when the women were experiencing moderate to severe primary dysmenorrhea. Actigraphy is a useful tool for measuring pain-related debilitation and its management.