The journal of pain : official journal of the American Pain Society
-
Several medications are recommended for relief of postherpetic neuralgia (PHN). A sequential treatment algorithm has been suggested, but its cost-effectiveness is unclear. We developed a decision model to estimate the cost-effectiveness of this algorithm compared with other sequential medication strategies in 70-year-olds with PHN, using literature data to model medication-related PHN relief while also accounting for severe medication side effects. Hypothetical patients with and without coronary artery disease (CAD) were considered separately, with and without localized pain. Sequential medication switches occurred as the result of inadequate relief or intolerable side effects. Probabilistic sensitivity analyses were performed to estimate the favorability of each medication early in treatment sequences. In patients without CAD, tricyclic and gabapentin were equally favored as initial therapy if mortality with tricyclic use was not increased, but gabapentin was strongly favored if it was. In patients with CAD, gabapentin was overwhelmingly favored. In either patient group, opioids, pregabalin, and tramadol were not favored as initial therapy but were sensible choices later in treatment sequences. The lidocaine patch was a reasonable first choice in patients with localized PHN. Our analysis supports the suggested treatment algorithm, with cost-effectiveness ratios within acceptable ranges for medications given sequentially, based on literature-based estimates of effectiveness and tolerability. ⋯ This article examines the cost-effectiveness of recommended sequential treatment strategies for postherpetic neuralgia. This decision analysis-based synthesis of effectiveness and cost data found that recommended treatment algorithms are also economically reasonable.
-
Associations among pain, functional disability, and self-perceived competence were examined in a retrospective record review of the initial clinical evaluations of 115 adolescents (ages 13 to 18 years) with chronic musculoskeletal pain not associated with a specific organic cause. Adolescents self-reported on pain intensity, functional disability, and 9 developmentally relevant domains of self-perceived competence, using the Self-Perception Profile for Adolescents (Harter, 1988). Results confirmed a relation between usual pain intensity and functional disability (r = 0.47, P < .001). A series of multiple regression analyses revealed that adolescents' perceptions of global self-worth significantly moderated the relation between pain and disability. These findings extend our understanding of the relations among self-perception, chronic pain, and disability to include adolescents with chronic musculoskeletal pain syndromes and have future research and therapeutic implications. ⋯ Adolescents with chronic pain syndromes can face significant challenges in accomplishing developmental goals with respect to the pain and disability they experience. Perceptions of self-worth appear to play an important role in understanding the relation between pain and functional disability among adolescents with chronic pain.
-
Randomized Controlled Trial Comparative Study
Assessor status influences pain recall.
Anecdotal clinical reports suggest that patients report differing levels of pain, depending on the status within the medical hierarchy of the individual gathering the pain rating. This observation has clinical relevance, given the practice of delegating the assessment of pain to lower status clinic staff members. In this study, both pain and mood were assessed in 70 patients diagnosed with low back pain at pretreatment, immediately after epidural lumbar injection, and again 2 weeks later by phone. At the 2-week follow-up, patients were also asked to recall the postprocedural rating that they had given immediately after the injection. This rating was obtained by either the treating physician or by a research assistant who was present at the time of injection, on a randomly determined basis. Current ratings of pain and mood did not differ for either group before the epidural injection, after the epidural injection, or at the 2-week follow-up. Two-week recall of postprocedural pain did, however, differ depending on assessor status. Those called by the physician provided recalled pain ratings that closely matched the ratings provided immediately after the procedure. Those called by the research assistant provided ratings that were 86% higher (that is, worse) than their original ratings. This status-driven bias in recalled postprocedural pain reporting is discussed in the context of social demands inherent in the physician-patient relationship, with implications for assessing treatment effectiveness in clinical practice and research. ⋯ Accurate assessment of patients' pain is critical to effective pain management and treatment planning. This study found evidence of a status-based bias in which physicians elicited lower ratings of previously experienced pain associated with treatment procedures than did staff members of lower status.
-
Sodium channel blockers such as lidocaine, lamotrigine, and carbamazepine can be effective in the treatment of neuropathic pain. Though not approved for neuropathic pain indications, tricyclic antidepressants are often considered first-line treatment for conditions such as post-herpetic neuralgia and diabetic neuropathy. Several tricyclic antidepressants have been shown to block peripheral nerve sodium channels, which may contribute to their antihyperalgesic efficacy. In this study, we compared the sodium channel-blocking potency of a number of antidepressants, including tricyclic antidepressants and selective serotonin reuptake inhibitors. All compounds tested inhibited Na(V)1.7 in a state- and use-dependent manner, with affinities for the inactivated state ranging from 0.24 micromol/L for amitriptyline to 11.6 micromol/L for zimelidine. The tricyclic antidepressants were more potent blockers of Na(V)1.7. Moreover, IC(50)s for block of the inactivated state for amitriptyline, nortriptyline, imipramine, desipramine, and maprotiline were in the range of therapeutic plasma concentrations for both the treatment of depression as well as neuropathic pain. By contrast, fluoxetine, paroxetine, mianserine, and zimelidine had IC(50)s for Na(V)1.7 outside their therapeutic concentration ranges and generally were not efficacious against post-herpetic neuralgia or diabetic neuropathy. These results suggest that block of peripheral nerve sodium channels may contribute to the antihyperalgesic efficacy of certain antidepressants. ⋯ Tricyclic antidepressants are often considered first-line treatment for neuropathic pain. Some tricyclic antidepressants block sodium channels, which may contribute to their antihyperalgesic efficacy. In the current study, we compared the potency of peripheral sodium channel blockade for several tricyclic antidepressants and selective serotonin reuptake inhibitors with their therapeutic efficacy.
-
The aim of the present study was to evaluate ethnic differences of the tactile detection threshold (TDT), the filament-prick pain detection threshold (FPT), the pressure pain detection threshold (PPT), and the pressure pain tolerance detection threshold (PTOL) in the orofacial region of symptom-free subjects. Twenty-two men and 22 women in Belgium and in Japan (age range from 20 to 31 years) participated. The TDT and the FPT were measured on the cheek skin (CS) overlying the masseter muscles (MM), on the maxillary gingiva (MG), and at the tip of the tongue (TT), using Semmes-Weinstein monofilaments. The PPT and PTOL were measured at the central part of the MM, using a pressure algometer. A general linear model was used in each case to capture ethnic and gender effects. Japanese women had the lowest TDT at CS, in contrast to Belgian men, who had the highest value; a significant ethnic and gender effect was found (P=.026 and P<.001, respectively). Similar results were found for FPT at CS with significant ethnic and gender effects (P<.001 for both). There was no significant ethnic effect regarding intra-oral TDT and FPT or regarding PPT and PTOL. ⋯ Our findings clearly indicate that future studies of tactile and pain measurements need to standardize and control for gender and ethnicity. Further, a comprehensive evaluation of results from various stimulation modalities may better clarify the pain mechanisms and gender/ethnic characteristics, as well as comparisons between normal subjects and patients.