Pain physician
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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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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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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.
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Neuromodulation with spinal cord stimulation is a proven cost effective treatment for the management of common conditions such as chronic radicular leg pain from failed back surgery syndrome, complex regional pain syndrome, and other painful neuropathic pain syndromes. The traditionally instructed method for percutaneous spinal cord stimulator (SCS) lead placement promotes the use of a "loss of resistance" (LOR) technique under anteroposterior (AP) fluoroscopic guidance to assure midline lead placement and proper entry into the epidural space. ⋯ This fluoroscopic technique provides an alternative means for placing percutaneous cervical SCS leads without the use of the traditional loss of resistance technique.
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Review
A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain.
The prevalence of cancer-related pain and residual pain in cancer survivors is high. Opioids serve as the gold standard for treating moderate to severe cancer pain. The evaluation of the effectiveness of opioids in chronic non-cancer pain has shown a lack of effectiveness, or rather weak evidence for some of the drugs. In contrast, in cancer pain, opioids are expected to be very effective. Due to the nature of the disease, there is evidence of a paucity of randomized trials investigating opioid effectiveness in cancer pain on a long-term basis. Consequently, the effectiveness of opioids in managing cancer-related pain warrants further evidence-based review beyond randomized trials, including observational studies and case reports. ⋯ This systematic review of observational studies indicates Level II-3 evidence for effectiveness of opioids in cancer pain therapy, with 1C/strong recommendation based on observational studies, which could change based on future evidence.