Pain physician
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With health care expenditures skyrocketing, coupled with pervasive quality deficits, pressures to provide better and more proficient care continue to shape the landscape of the U. S. health care system. Payers, both federal and private, have laid out several initiatives designed to curtail costs, including value-based reimbursement programs, cost-shifting expenses to the consumer, reducing reimbursements for physicians, steering health care to more efficient settings, and finally affordable health care reform. ⋯ The Centers for Medicare and Medicaid Services (CMS) published its proposed outpatient prospective system for ASCs in 2006, setting ASC payments at 62% of HOPD payments. Following multiple changes, the rule was incorporated with a 4-year transition formula which ended in 2010, with full effect taking effect in 2011 with ASCs reimbursed at 57% of HOPD payments. Thus, the landscape of interventional pain management in ambulatory surgery centers has been constantly changing with declining reimbursements, issues of fraud and abuse, and ever-increasing regulations.
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Comparative Study Clinical Trial
Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients.
The challenge for physicians in treating chronic pain with opioids is to eliminate or significantly curtail abuse of controlled prescription drugs while assuring proper treatment when indicated. Urine drug testing (UDT) has been shown to be a useful approach in identifying patterns of compliance, misuse, and abuse. However, significant controversy surrounds the diagnostic accuracy of UDT performed in the office (immunoassay) and the requirement for laboratory confirmation with liquid chromatography tandem mass spectrometry (LC/MS/MS). ⋯ NCT01052155.
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The present evidence illustrates that the placebo effect depends on a variety of neurochemical and neurophysiological mechanisms, which are measurable and modifiable. However, the placebo response is inexorably tied to the treatment context. All medical treatments take place in a particular context; this context includes the therapist's attitudes, psychosocial factors affecting the therapeutic relationship, and the patient's mindset. ⋯ On the contrary, they should try to potentiate it, since this is a very important clinical implication. From the research perspective, the emerging knowledge of placebo continues to cast doubts on the appropriateness of the double-blind placebo-control design in assessing efficacy of treatment--specifically involving interventional techniques or surgery. The research setting itself may introduce nocebo hyperalgesia.
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Therapeutic use, overuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain continue to be an issue for physicians and patients. The challenge is to eliminate or significantly curtail abuse of controlled prescription drugs while still assuring the proper treatment of those patients. Some physicians are apprehensive regarding the use of chronic opioid therapy in chronic non-cancer pain due to a perceived lack of proven evidence, the misuse of opioids, tolerance, dependence, and hyperalgesia. ⋯ UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient's predisposition to, and patterns of, drug misuse/abuse--a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. This comprehensive review provides the role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse.
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Treatment of chronic non-cancer pain with opioid therapy has escalated in recent years, resulting in exploding therapeutic use and misuse of prescription opioids and multiple adverse drug events. Breakthrough pain is defined as a transient exacerbation of pain experienced by individuals who have relatively stable and adequately controlled baseline cancer pain. Further, the definition of breakthrough pain, prevalence, characteristics, implications, and treatment modalities have been extensively described for chronic cancer pain. ⋯ This review illustrates that there is no significant evidence for any type of breakthrough pain in chronic non-cancer pain based on available literature, methodology utilized, and response to opioids in chronic non-cancer pain. The advocacy for increased usage of opioids in the treatment of chronic pain dates back to the liberalization of laws governing opioid prescription for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and is exploding with new pain management standards for inpatient and outpatient medical care implemented by the Joint Commission on Accreditation of Health Care Organizations in 2000, and the advocacy by many physicians and organizations for increased use of opioids. This comprehensive review critically evaluates the available evidence of breakthrough pain in chronic non-cancer pain including its existence, prevalence, and managing symptoms which are described as breakthrough pain or episodic pain.