Lessons learned in the abuse of pain-relief medication: a focus on healthcare costs

An update on epidural steroid injections: is there still a role for particulate corticosteroids?

Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.

International Classification of Diseases (ICD) Codes Fail to Accurately Identify Injection Drug Use Associated Endocarditis Cases

OBJECTIVES

Infective endocarditis (IE) secondary to injection drug use (IDU-IE) is a disease with high morbidity, cost, and rapid demographic evolution. Studies frequently utilize combinations of International Statistical Classification of Diseases (ICD) codes to identify IDU-IE cases in electronic medical records. This is a validation of this identification strategy in a US cohort.

METHODS

Records from January 1, 2004 to September 31, 2015 for those aged ≥18yo with any ICD-coded IE encounter (inpatient or outpatient) were retrieved from the electronic medical record and then manually reviewed and classified as IDU-IE by strict and inclusive criteria. This registry was then used to assess the diagnostic accuracy of 10 identification algorithms that combined substance use, hepatitis C, and IE ICD codes.

RESULTS

IE was present in 629 of the 2055 manually reviewed records; 109 reported IDU within 3 months of IE diagnosis and an additional 32 during their lifetime (141 cases). In contrast, no algorithm identified more than 46 (33%) of these cases. Algorithms assessing encounters with both an IE and substance use code had specificities >99% but sensitivities ≤11% with negative predictive values of 83% to 84% and positive predictive values ranging from 75% to 91%. Use of a hepatitis C OR substance use code with an IE-coded encounter resulted in higher sensitivities of 22% to 32% but more false positives and overall positive predictive value of <70%. This algorithm limited to age ≤45yo had the best, but still low, discrimination ability with an area under the receiver operating characteristic curve of 0.62.

CONCLUSION

Substance use and hepatitis C codes have poor ability to accurately classify an IE-coded encounter as IDU-IE or routine IE.

Phytochemicals and Biological Activities of Barleria (Acanthaceae)

Plant species belonging to the family Acanthaceae are globally known to possess various medicinal properties and have cultural and economic importance in both traditional medicine and horticulture. They are important to both animals and humans and are used as food or for ornamental purposes worldwide. Barleria is the third largest genus in the family Acanthaceae. A few of the highly important and reported species of Barleria include B. prionitis, B. cristata, B. grandiflora, and B. lupulina. The flowers, leaves, stems, roots, and seed extracts of plants belonging to this genus are rich in bioactive compounds and have exhibited significant medicinal potential for the treatment of various ailments and infections. Evidence derived from several studies has demonstrated the antioxidant, antibacterial, antifungal, anti-inflammatory, anticancer, antidiabetic, antiulcer, hepatoprotective, analgesic, antiamoebic, antihelminthic, antiarthritic, antihypertensive, antiviral properties and toxicity of extracts, in addition inhibition of acetylcholinesterase activity and biosynthesis of nanoparticles, of the plant and seed extracts of species belonging to Barleria. Studies have reported that bioactive compounds such as flavonoids, quinones, iridoids, phenylethanoid glycosides, the immunostimulant protein “Sankaranin”, and antibiotics isolated from Barleria species are resposnsible for the above biological activities. Traditionally, the genus Barleria has significant medicinal potential; however, there is a scarcity of information on various species that are yet to be evaluated. This review provides a comprehensive report on existing literature, concerning the phytochemistry and biological activities of the genus Barleria.

Geographical, Socioeconomic, and Gender Inequalities in Opioid Use in Catalonia

Background: In recent years, worldwide opioid use has seen a sharp increase, especially for the treatment of chronic non-cancer pain. Catalonia is no exception to this trend. However, no recent studies have addressed the socioeconomic and gender inequalities in opioid use in the different geographical areas of Catalonia.

Methods: We performed an ecological study to analyse the associations between socioeconomic status, gender and the use of opioids in the 372 Health Areas of Catalonia. Robust Poisson models were performed to analyse the data provided from the Central Register of Insured Persons and dispensing data from the Electronic Prescription Database.

Results: The results show that socioeconomic status has a major impact on opioid use, with the most deprived areas presenting the highest levels of use. There are major inequalities in the DDD/1,000 inhabitants per areas. Moreover, women have much higher utilization rates than men, especially in more deprived areas. The greatest difference is observed in the use of weak opioids in women: the DDD/1,000 inhabitants per day was 2.34 in the area with the lowest use, compared with 22.18 in the area with the highest use.

Conclusions: Our findings suggest that stronger action is needed to promote best practices in prescribing for chronic pain and to reduce socioeconomic and gender variation between geographical areas. This study provides a model for routine monitoring of opioid prescription for targeted interventions aimed at lowering high-dose consumption in specifically identified areas.

Smart stimuli-responsive drug delivery systems based on cyclodextrin: A review

Stimulated by researches in materials chemistry and medicine fields, drug delivery has entered a new stage of development. Drug delivery systems have been extensively studied according to the differences in the drug therapeutic environment such as pH, light, temperature, magnet, redox, enzymes, etc. Cyclodextrin is a smart tool that has been proven to be used in the preparation of drug delivery, and has become a new area of concern in recent years. In this review, we discuss recent research advances in smart stimuli-responsive cyclodextrin-based drug delivery. First, different stimuli-responsive drug delivery systems based on cyclodextrin are introduced and classified. Then, the characteristics of different types of stimuli-responsive drug delivery systems are described, and their applications are emphasized. Finally, current challenges and future development opportunities of smart stimuli-responsive drug delivery systems based on cyclodextrin are discussed.

The Relationship between Cognitive and Emotional Factors and Healthcare and Medication Use in People Experiencing Pain: A Systematic Review

Pain conditions are among the leading causes of global disability, impacting on global healthcare utilization (HCU). Health seeking behavior might be influenced by cognitive and emotional factors (CEF), which can be tackled by specific therapies. The purpose of this study was to systematically review the evidence concerning associations between CEF and HCU in people experiencing pain. Three databases were consulted: PubMed, Web of Science and EconLit. Risk of bias was assessed using the Downs and Black Checklist (modified). A total of 90 publications (total sample n = 59,719) was included after double-blind screening. In people experiencing pain, positive associations between general anxiety symptoms, depressive symptoms and catastrophizing and pain medication use were found. Additionally, there appears to be a relationship between general anxiety and depressive symptoms and opioid use. Symptom-related anxiety and psychological distress were found to be positively related with consulting behavior. Last, a positive association between use of complementary and alternative medicine and level of perceived symptom control was confirmed in people with pain. For other relationships no evidence or inconsistent findings were found, or they were insufficiently studied to draw firm conclusions, indicating that more research on this topic is needed.

Analgesic Effects of Cnidium officinale Extracts on Postoperative, Neuropathic, and Menopausal Pain in Rat Models

Cnidium officinale, widely cultivated in East Asia, has been reported to exhibit pharmacological efficacy in various disorders. However, little has been reported on its role as a pain killer. In this study, we reveal that the C. officinale extract (COE) has great efficacy as a novel analgesic in various in vivo pain models. Administration of COE attenuated hypersensitivity in all postoperative, neuropathic, and menopausal pain models. Decreased hyperalgesia was confirmed by a mechanical withdrawal threshold assay and ultrasonic vocalization call analysis. In addition, application of COE inhibited the induction of the proinflammatory cytokines and calpain-3 on dorsal root ganglion neurons in a spared nerve injury rat model. Treatment with ferulic acid, which was identified as one of the components of COE by HPLC analysis, alleviated nociceptive behaviors. Our findings suggest that ferulic acid is an active compound from COE, and COE is a potential phytomedical source for pain relief by inhibiting the process of inflammation.

A scoping review exploring the opioid prescribing practices of US dental professionals

BACKGROUND

The prescribing practices of dental professionals may play an important role in the opioid epidemic. The authors performed a scoping review of the current original research literature on dental professionals' prescribing practices for opioid analgesics published from 2000 through 2017.

TYPES OF STUDIES REVIEWED

With the use of a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, the inclusion criteria entailed published articles written in English that had an opioid focus, had a dental health care professional prescriber, entailed a US setting, were peer reviewed, had an identified data source, were not review articles, and were not opinion articles. Five databases were searched to identify relevant literature.

RESULTS

Of 221 articles, 18 met the inclusion criteria. Eight distinct and mutually exclusive themes emerged from these studies: impact of patient demographic characteristics on opioid prescribing, comparison of opioid prescribing by different provider type, quantity of opioids prescribed and consumed, types of opioids prescribed by dental professionals, assessment of self-reported opioid prescribing, opioid prescriptions by procedure, impact of pharmacy integration into dental practice, and implementation of risk mitigation strategies.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

There is a surprising paucity of research that investigated the prescribing patterns of dentists. Available research suggests that dental practice does not always align with proposed guidelines for opioid prescribing. Some studies that explored interventions found changes in prescribing, suggesting the potential benefit of developing practical strategies targeted to dental providers who prescribed opioids.

A Review of the Opioid Epidemic: What Do We Do About It?

The opioid epidemic, with its noticeable increase in opioid prescriptions and related misuse, abuse and resultant deaths in the previous 12 years, is a particularly North American phenomenon. Europe, and particularly low- and middle-income countries, appear to be less influenced by this problem. There is undisputable value in using opioids not only in the treatment of acute pain, but in cancer pain as well. However, opioids are progressively being prescribed more and more for chronic non-cancer pain, despite inadequate data on their efficacy. In this paper, we describe the current prevalence of opioid misuse in a number of countries and the rationale for the commencement of opioid therapy. The safe initiation and monitoring of opioid therapy as well as the need for concurrent use of interdisciplinary multimodal therapy is discussed. The possible consequences of long-term use and predictors of high opioid use and overdose are presented. In particular, the management of opioid use disorders and the prevention of opioid abuse and dependence in the young, the old and the pregnant are discussed. Measures to prevent overprescribing and to alleviate risk are described, including the tapering of opioids and the use of opioid deterrents. Finally, the paper looks at the future development of pioneering medications and technologies to potentially treat abuse. In those parts of the world with an opioid epidemic, coroners and medical examiners, private and public health agencies, and agencies that enforce the law need to cooperate in an effort to slow down and reverse the indiscriminate use of prescribing opioids in the long-term for chronic non-cancer pain. Ongoing research is needed to create ways to minimise risks of opioid use, and to provide evidence for effective strategies for treating chronic pain.

Abuse liability assessment for biologic drugs - All molecules are not created equal

The development of novel drug candidates involves the thorough evaluation of potential efficacy and safety. To facilitate the safety assessment in light of global increases in prescription drug misuse/abuse, health authorities have developed guidance documents which provide a framework for evaluating the abuse liability of candidate therapeutics. The guidances do not distinguish between small molecules and biologics/biotherapeutics; however, there are key differences between these classes of therapeutics which are important drivers of concern for abuse. An analysis of these properties, including ability to distribute to the central nervous system, pharmacokinetic properties (e.g., half-life and metabolism), potential for off-target binding, and the physiochemical characteristics of biologic drug products suggests that the potential for abuse of a biologic is limited. Many marketed antibodies and recombinant proteins have been associated with adverse effects such as headache and dizziness. However, biologics have not historically engendered the rapid-onset psychoactive effects typically present for drugs of abuse, thus further underscoring their low risk for abuse potential. The factors to be taken into consideration before conducting nonclinical abuse liability studies with biologics are described herein; importantly, the aggregate assessment of these factors leads to the conclusion that abuse liability studies are unlikely to be necessary for this class of therapeutics.

The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review

Morphine and other opioids are widely used to manage moderate to severe acute pain syndromes, such as pain associated with trauma or postoperative pain, and they have been used to manage chronic pain, even chronic nonmalignant pain. However, recent years have seen a renewed recognition of the potential for overuse, misuse, and abuse of opioids. Therefore, prescribing opioids is challenging for healthcare providers in that clinical effectiveness must be balanced against negative outcomes—with the possibility that neither are achieved perfectly. The current discourse about the dual ‘epidemics’ of under-treatment of legitimate pain and the over-prescription of opioids is clouded by inadequate or inaccurate understanding of opioid drugs and the endogenous pain pathways with which they interact. An understanding of the basic pharmacology of opioids helps inform the clinician and other stakeholders about these simultaneously under- and over-used agents.

Mitigating the prescription drug abuse epidemic

Focused attention on the prescription drug abuse epidemic needs to include evidence-based training for clinicians who manage patients with pain to facilitate accurate screening with consideration of comorbid conditions, diagnosis, selection of the appropriate treatment regimen, and focused monitoring of adherence to the established course of therapy. DEA licensure requirements need to be amended to mandate targeted training focused on pain medication upon initial application and renewal of license. A nationwide mandated real-time dispenser database that requires verification every time a clinician prescribes opioids and other key controlled substances should be a top priority.

Management of lumbar zygapophysial (facet) joint pain

AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.

METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.

RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.

CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Efficacy of Percutaneous Adhesiolysis in the Treatment of Lumbar Post Surgery Syndrome

Context

Lumbar post-surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous adhesiolysis is often contemplated in managing lumbar post surgery syndrome. Recent guidelines and systematic reviews have reached different conclusions about the level of evidence for the efficacy of epidural injections and percutaneous adhesiolysis in managing lumbar post surgery syndrome. The objective of this systematic review was to determine the efficacy of all 3 percutaneous adhesiolysis anatomical approaches (caudal, interlaminar, and transforaminal) in treating lumbar post-surgery syndrome.

Evidence Acquisition

Data Sources: A literature search was performed from 1966 through October 2014 utilizing multiple databases. Study Selection: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and percutaneous adhesiolysis in managing lumbar post-surgery syndrome was performed including methodological quality assessment utilizing Cochrane review criteria, Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB), and grading of evidence using 5 levels of evidence ranging from Level I to Level V. Data Extraction: The search strategy emphasized post-surgery syndrome and related pathologies treated with percutaneous adhesiolysis procedures.

Results

The search criteria yielded 16 manuscripts on percutaneous adhesiolysis assessing post-surgery syndrome. Of these, only 4 randomized trials met inclusion criteria for methodological quality assessment, 3 of them were of high quality; and the fourth manuscript was of low quality. Based on these 3 randomized controlled trials, 2 of them with one-day procedure and one with a 3-day procedure, the level of evidence for the efficacy of percutaneous adhesiolysis is Level II based on best evidence synthesis.

Conclusions

Based on this systematic review, percutaneous adhesiolysis is effective in managing patients with lumbar post-surgery syndrome after the failure of conservative management including fluoroscopically directed epidural injections.

Neurological complications associated with epidural steroid injections

Multiple case reports of neurological complications resulting from intraarterial injection of corticosteroids have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal epidural injections constituted the majority of neurological complications. Utilization data of epidural injections in the Medicare population revealed that cervical transforaminal epidural injections constitute only 2.4 % of total epidural injections and <5 % of all transforaminal epidural injections. Multiple theories have been proposed as the cause of neurological injury including particulate steroid, arterial intimal flaps, arterial dissection, dislodgement of plaque causing embolism, arterial muscle spasm, and embolism of a fresh thrombus following disruption of the intima.

An update on the management of chronic lumbar discogenic pain

Lumbar degenerative disc disease without disc herniation, also known as discogenic pain, is an elusive diagnosis of chronic low back pain. Lumbar provocation discography and fusion surgery have been frequently utilized for several decades as the gold standards for the diagnosis and treatment of symptomatic lumbar discogenic pain, though controversial, based on conjecture, rather than evidence. In addition to lumbar fusion, various other operative and nonoperative modalities of treatments are available in managing chronic lumbar discogenic pain. This review provides an updated assessment of the management of chronic lumbar discogenic pain with a critical look at the many modalities of treatments that are currently available.

Key safety considerations when administering epidural steroid injections

Neurological and other complications of epidural steroid injections have been widely discussed in recent years. Consequently, the US FDA issued a warning about serious neurological events, some resulting in death, and consequently is requiring label changes. Neurological adverse events numbering 131, including 41 cases of arachnoiditis, have been identified by the FDA, and 700 cases of fungal meningitis following injection of contaminated steroids. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, with the majority of them to cervical transforaminal epidural injections. This perspective describes the prevalence of administering epidural injections, complications, pathoanatomy, mechanism of injury and various preventive strategies.

Clinical management of radicular pain

This review provides an overview of the diagnosis and treatment strategies for the management of radicular pain. While it is not as common as axial spinal pain, radicular pain combines the advantage of leveraging appropriate diagnostic strategies and definitive treatments with well-informed outcome measures. Multiple diagnostic measures include not only history and physical examination, but also imaging. The treatment modalities include pharmacologic management, physical and rehabilitation measures, interventional techniques and surgical treatments. Here, the authors describe the prevalence and pathophysiology of radicular pain, risk factors, diagnostic strategies, treatment modalities and the evidence for these management strategies. Finally, the authors show the efficacy of conservative management, despite surgical management being the gold standard.

Prevalence and correlates of nonmedical prescription opioid use among a cohort of sex workers in Vancouver, Canada

BACKGROUND

The nonmedical use of prescription opioids (POs) is a major public health concern, causing extensive morbidity and mortality in North America. Canada has the second highest consumption rate of POs globally and data indicate nonmedical PO use (NPOU) is growing among key populations and increasingly available in street-level drug markets. Despite accumulating evidence documenting the rise of NPOU, few studies have systematically examined NPOU in Canada among key vulnerable populations, such as sex workers. This study prospectively evaluated the prevalence and correlates of NPOU within a Vancouver cohort of sex workers over three-years follow-up.

METHODS

Data were drawn from an open prospective cohort, AESHA (An Evaluation of Sex Workers Health Access) in Metro Vancouver, Canada (2010-2013). Women were recruited through outreach from outdoor street locations and indoor venues. Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine social and structural correlates of NPOU over 36 months.

RESULTS

Of the 692 sex workers at baseline, close to one-fifth (n=130, 18.8%) reported NPOU (injection or non-injection) in the last six months. In multivariable GEE analyses, factors independently correlated with recent NPOU were: exchanging sex while high (AOR 3.26, 95%CI 2.29-4.64), police harassment/arrest (AOR 1.83, 95%CI 1.43-2.35), intimate partner injects drugs (AOR 1.66, 95%CI 1.11-2.49), and recent physical/sexual intimate partner violence (AOR 1.65, 95%CI 1.21-2.24).

CONCLUSION

Our results demonstrate that nearly one-fifth of sex workers in Metro Vancouver report NPOU. Factors independently statistically associated with NPOU included exchanging sex while high, police harassment/arrest, a drug injecting intimate partner and recent physical/sexual intimate partner violence. The high prevalence of NPOU use among sex workers underscores the need for further prevention and management strategies tailored to this key population. The correlates of NPOU uncovered here suggest that structural interventions may be further implemented to ameliorate this growing concern.