Chiari - pain and Questions for Joanna - pop quiz comming !

[Guest guest]

I've been chasing some info. that might help me with pain mannagement of

greatly distressing neck /shoulders sensory stuff and being puzzled what I

should do /what I've done to make it worse ect . this morning .

.. The following article startled me in it's discussion of using opiods for

headaches , and soft tissue /fibromyaligia patients where it states

" Dr. Audette noted that, thus far, these syndromes have not been found to be

associated with pathologic changes in muscle. There is some evidence for

central sensitization: serotonin deficiency and increased substance P (SP) in

the cerebrospinal fluid,[8-10] and abnormal activation of NMDA receptors.[10]

People with fibromyalgia have a high incidence of Arnold-Chiari

malformations.[11] Nonsteroidal anti-inflammatory drugs are not effective for

treatment of soft tissue pain syndromes. Tramadol does show some benefit.[12]

"

so out of curiosity -- anyone useing Tramadol and finding it helps ?

the article full article is pasted in below just cause I'm lazy at the moment

and don't want to have to send it a few extra times to those of us who can't

get metscape to work -- LOL ..

anyone intrested the other articles in the report of the 21st Annual

Scientific Meeting of the American Pain Society if you go to the website

given below in Medscape . For those new to Medscape you register free to use

it at http://medscape.com then paste the url below into your browser to

access the article ) . At the website you'll find links to the other articles

presented that may help answer questions ( at least be a GOOD workout for

Joanna's brain -tehehe-- I know she's bored -- and we gotta keep her OUT of

hot water occupied and distracted somehow -- pop quiz comming . )

in Paradise

http://www.medscape.com/viewarticle/433604

Opioid Therapy: Controversies and Considerations

Disclosures

Presented by:

, MD (Moderator)

Fishman, MD

ph Audette, MD

Summarized by:

Zahid H. Bajwa, MD, and Ho, MD

Pain management specialists are beginning to use opioid therapy for

intractable nonmalignant pain. One example of the growing acceptance of

opioids is the development of new opioid medications, such as buprenorphine

transdermal system, for the treatment of osteoarthritis.[1] Nonetheless, this

is a topic of great controversy among nonspecialist physicians because of

fears of patient addiction and drug abuse. The issues of urine screening,

opioid contracts, and the use of opioids for headaches and soft tissue pain

were examined in a symposium, " Controversial Issues Involving Chronic Opioid

Therapy. " [2]

Urine Drug Testing

Moderator , MD, Chief of the Pain Service at University of

Pittburgh Medical Center, Pennsylvania, began the session with a discussion

of urine drug testing. The urine drug screen was designed to detect illicit

drugs, not to monitor legitimate opioid use. For this reason and others, the

very idea of testing can be inflammatory and upsetting, leading to feelings

of discrimination and even guilt for the patient who requires opioids.

Nonetheless, Dr. recommends testing everyone being prescribed opioids

at least once, making testing regular, and not singling anyone out. Drug

monitoring and surveillance may ameliorate some of the reluctance to use

long-term opioid therapy for patients who suffer nonmalignant pain states.

From the standpoint of the prescribing physician, urine drug screens may help

protect the physician from issues of diversion and/or substance abuse. The

use of urine drug screening and expectations should be clearly explained to

the patient from the beginning.

A good working relationship with the laboratory and lab director is also

required to ensure the accuracy and consistency of the test results. Most

labs use commercially available urine drug screens, but either gas

chromatography (GC) or mass spectrometry (MS) is also needed. While other

methods are acceptable and standard for the initial screening process, GC/MS

are the only legally defensible testing methods and should always be used for

confirming positive results. On occasion, a medical review officer -- a

licensed physician who has the appropriate medical training to interpret and

evaluate a drug test -- may be needed. These cases also require a thorough

history and physical of the patient in question, along with a list of all

medications he or she receives.

The laboratory should be certified by the US Department of Health and Human

Services. The urine testing usually covers the " Federal 5 " : cocaine

(benzoylecgonine), marijuana (tetrahydrocannabinol), phencyclidine,

amphetamines, and opiates. The sensitivities for the screening immunoassays

are determined by the US Substance Abuse and Mental Health Services

Administration (SAMHSA) and the US Department of Health and Human Services

(Table).

Table. Cut-off Concentrations for the " Federal 5 "

Drug Cut-off Concentration

Cocaine 300 ng/mL

Marijuana 50 ng/mL

Phencyclidine 25 ng/mL

Amphetamine 1000 ng/mL

Opiate 300 ng/mL

Some of the synthetic or semisynthetic opioids such as meperidine, fentanyl,

methadone, and oxycodone are generally not detected in the opiate screen.

Because they are metabolized to morphine, heroin and codeine use will result

in a test that is positive for opiates. In the past, ingestion of poppy seeds

caused the opiate screen to be positive, but the screening level has been

raised so that ingestion of a poppy seed bagel no longer screens as positive.

Herbal teas and local anesthetics should not produce a positive result. A

substance in Vicks VapoRub, ephedrine/pseudoephedrine, and the prescription

drug methylphenidate can lead to a positive amphetamine screen. A ratio can

be determined of the methamphetamine/amphetamine level to attempt to

distinguish results from other amphetamines.

The urine collection itself requires special procedures. Patients should be

observed as much as possible during the collection so that substitutions or

contamination of the urine cannot occur. The collection area should be free

of sinks and basins, and water in the toilets should be colored (preferably

blue). Once collected, the color and temperature of the urine sample should

be checked. Presumably if the urine is not body temperature, it may have been

a substituted sample. Chain of custody should be observed: patient and

collector should document when the urine was collected and each person coming

in contact with the sample should document their custody of the urine.

The Opioid Contract

Next, Fishman, MD, University of California, (UCD), Medical

Center, Sacramento, described the opioid contract, its use and content. Such

a contract is an explicit bilateral agreement stating expectations for the

physician as well as the patient. An opioid contract helps a patient take a

more active role and provides some protection for the prescribing physician.

According to Dr. Fishman, clinical studies have not proved the efficacy of

the opioid contracts. However, he noted that most of these studies involved

methadone maintenance and not pain patients. A review[3] of contracts from 39

major academic pain centers found such documents to range from 1 to 10 pages

in length. The various contracts included 12 different categories -- terms,

treatment, behavior, points of termination, patient's responsibilities,

issues about education, additional treatments, emergency situations, goals,

role, discouraged behaviors, and prescriptions -- but there was substantial

diversity among contracts. The basic core contract included patient

responsibilities, education, and termination criteria.

Dr. Fishman noted that the core contract should also include expectations on

the part of the patient and the physician, how medication changes may be

made, use of a single pharmacy, and requirements of the primary care

physician. Examples of opioid contracts can be found in the Journal of Pain

and Symptom Management and the American Academy of Pain Medicine website.[4]

Very few contracts mentioned the responsibilities of the physician. And

though they are often viewed as a kind of informed consent, very few could be

used as such.

Dr. Fishman reported that at UCD, they use a trilateral contract that

includes the patient, pain physician, and primary care physician (PCP). The

PCP must be willing to take over the opioid prescribing as soon as the

patient has been stabilized. The PCP also has to sign the contract; in a

follow-up survey, UCD pain clinic staff found that 45% of the PCPs had signed

and returned the contract. The remaining 55% were contacted by telephone and

the reasons for not signing the contracts included: " did not see the

contract, " " did not read the contract but started prescribing the opioid, "

and " not sure why the contract was not returned. "

Should Opioids Be Used for Headache?

As opioids are gaining acceptance for the treatment of chronic pain from

nonmalignant sources, it would seem to follow that they would be useful in

the management of headache.[5-7] Zahid Bajwa, MD, Director of the

Comprehensive Headache Center and Director of Clinical Pain Research at Beth

Israel Deaconess Medical Center, Boston, Massachusetts, discussed the issue

of using opioids for headache treatment. He noted that opioids are not useful

as prophylactic medications for headache, nor are they abortive medications,

so the question exists: should they be used for acute headache treatment? His

answer: opioids should be tried only when other analgesic measures have

failed to improve the headache.

The key for the physician is to exhaust all treatment possibilities.

According to Dr. Bajwa, only about 5% to 10% of headache patients will not

respond to conventional headache therapy. In addition to establishing a

relationship and level of trust between the patient and physician, an opioid

contract should be used. Contraindications to opioid therapy for a given

patient include a history of substance abuse and any personality disorders.

Dr. Bajwa suggested an individual trial to test the probable efficacy of

opioids for the treatment of headaches. An infusion of fentanyl during a

headache is usually a good predictor of treatment success. Once the

likelihood of success is established, Dr. Bajwa recommended using long-acting

oral medications such as methadone, levorphanol, or sustained-release

morphine. Several opioids may have to be tried before an effective medication

is found for an individual. For the treatment of chronic daily headaches

unresponsive to other treatments, Dr. Bajwa advised around the clock rather

than " as needed " dosing, using 1 long-acting medication and 1 short-acting

medication, for break-through pain.

Close monitoring of treatment is crucial. The number of headaches, efficacy

of treatment, and side effects should be noted at each visit. A headache

diary may be useful as a reference point for future medication adjustments.

Because the headaches may continue at some level, functionality is a better

measure of opioid efficacy.

Opioids for Soft Tissue Pain Syndromes

The soft tissue pain syndromes are poorly researched and controversial in and

of themselves, but the use of opioids to manage them augments the controversy

because these syndromes can be generated by certain medications. ph

Audette, MD, from the Massachusetts General Hospital, Boston, reported on

opioid use for soft tissue pain syndromes, primarily fibromyalgia and

myofascial pain.

Fibromyalgia is a soft tissue pain syndrome that is symmetric, right and

left, and includes the presence of tender points. In some patients, it may

manifest as generalized hyperalgesia. Myofascial pain is more localized and

is associated with trigger points. It appears to be stress-related and

associated with syndromes such as chronic fatigue syndrome and pelvic pain

syndrome. Many clinicians are reluctant to treat the soft tissue syndromes

with opiates since we do not know what we are treating and have no evidence

of benefit. Patients who are given opiates are those in whom other treatments

-- physical therapy, invasive therapies, rehabilitation, and adequate trials

of other analgesics -- have failed. The opioids are not to meant to

ameliorate pain but to improve the function of life.

Dr. Audette noted that, thus far, these syndromes have not been found to be

associated with pathologic changes in muscle. There is some evidence for

central sensitization: serotonin deficiency and increased substance P (SP) in

the cerebrospinal fluid,[8-10] and abnormal activation of NMDA receptors.[10]

People with fibromyalgia have a high incidence of Arnold-Chiari

malformations.[11] Nonsteroidal anti-inflammatory drugs are not effective for

treatment of soft tissue pain syndromes. Tramadol does show some benefit.[12]

The use of opioids for this type of nonmalignant pain may actually increase

the patient's sensitivity to pain. In his lecture, Dr. Audette[2] presented 2

cases in whom use of opiates led to generalized hyperalgesia and whole body

allodynia, with some resolution of pain achieved with the gradual weaning of

opiates.

References

1. Spyker D, St Ville J, Lederman M, et al. Analgesic efficacy and safety of

buprenorphine transdermal system (BTDS) in patients with osteoarthritis.

Program and abstracts of the 21st Annual Scientific Meeting of the American

Pain Society; March 14-17, 2002; Baltimore, land. Abstract 645.

2. H, Fishman S, Audette J, Bajwa Z. Controversial issues involving

chronic opioid therapy. Program and abstracts of the 21st Annual Scientific

Meeting of the American Pain Society; March 14-17, 2002; Baltimore, land.

Symposium 309.

3. Fishman SM, Bandman TB, A, et al. The opioid contract in the

management of chronic pain. J Pain Symptom Manage. 1999;18:27-37.

4. American Academy of Pain Medicine sample agreement. Available at:

http://www.painmed.org/productpub/statements/sample.html. Accessed April 30,

2002.

5. Silberstein SD, McCrory DC. Opioids. Cephalalgia. 2000;20:854-864,

discussion 851-853.

6. Ziegler DK. Opioids in headache treatment. Is there a role? Neurol Clin.

1997;15:199-207.

7. Markley HG. Chronic headache: appropriate use of opiate analgesics.

Neurology. 1994;44(5 suppl 3):S18-24.

8. Cook D, Lange G, Ciccone D, et al. Functional imaging of pain in

fibromyalgia: central sensitization and hypervigilance. Program and abstracts

of the 21st Annual Scientific Meeting of the American Pain Society; March

14-17, 2002; Baltimore, land. Abstract 654.

9. IJ, Michalek J, Xiao Y, et al. Cerebrospinal fluid [CSF]

substance P [sP] in fibromyalgia syndrome [FMS] is reduced by tizanidine

therapy. Program and abstracts of the 21st Annual Scientific Meeting of the

American Pain Society; March 14-17, 2002; Baltimore, land. Abstract 658.

10. Larson AA, Giovengo SL, IJ, et al. Changes in the concentrations

of amino acids in the cerebrospinal fluid that correlate with pain in

patients with fibromyalgia: implications for nitric oxide pathways. Pain.

2000;87:201-211.

11. Bradley LA, Alarcon GS. Is Chiari malformation associated with increased

levels of substance P and clinical symptoms in persons with fibromyalgia?

Arthritis Rheum. 1999;42:2731-2732.

12. Biasi G, Manca S, Manganelli S, et al. Tramadol in the fibromyalgia

syndrome: a controlled clinical trial versus placebo. Int J Clin Pharmacol

Res. 1998;18:13-19.

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