Does pain interfere with antidepressant depression treatment response and remission in patients with depression and pain? An evidence-based structured review.

OBJECTIVE: The objective of this evidence-based structured review was to determine if there is consistent evidence that pain interferes with achieving antidepressant treatment response/remission of depression in patients with depression and pain. METHODS: After exclusion criteria were applied, of 2,801 studies/reports, 17 studies addressed this question. They were sorted into the four hypotheses outlined herein after. The percentage of studies supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence for each hypothesis were rated according to the Agency for Health Care Research and Quality (AHRQ) guidelines. RESULTS: For the first hypothesis (pretreatment pain levels will predict antidepressant depression response), nine out of 10 (90%) studies supported it. For the second hypothesis (treatment decreases in pain will be associated with antidepressant depression response), two out of two (100%) studies supported it. For the third hypothesis (pretreatment pain levels will predict antidepressant depression remission), six out of six (100%) studies supported it. For the fourth hypothesis (treatment decreases in pain will be associated with antidepressant depression remission), five out of five (100%) supported it. Utilizing these percentages and AHRQ guidelines, hypotheses 1, 3, and 4 received an A rating for consistency of studies in supporting them. A consistency rating for hypothesis 2 could not be generated because of too few studies in that group. CONCLUSIONS: Consistent evidence was found that antidepressant treatment of depression in patients with depression and pain can be negatively impacted by pain for achieving depression response/remission. However, the overall number of studies supporting each hypothesis was small. In addition, several potential confounders of the results of this study were identified.

What is the evidence that neuropathic pain is present in chronic low back pain and soft tissue syndromes? An evidence-based structured review.

OBJECTIVES: The objectives of this evidence-based review were to review the evidence for whether neuropathic pain (NP) is associated with chronic low back pain (CLBP) and soft tissue syndromes (STS), and review the reported prevalence percentages for NP within these syndromes. METHODS: Of 816 reports, 11 addressed the diagnosis of NP in CLBP and five of NP in STS. Studies were grouped by the method of arrival at an NP diagnosis, e.g., physical examination, type of NP inventory utilized, etc. The reported prevalence of NP was determined by aggregating all the patients in all the studies in each grouping. Similarly, the reported prevalence of NP within CLBP and STS was determined by aggregating all the patients with NP from all the studies in those groups. Each study was independently rated by two raters according to 11 quality criteria generating a quality score. The strength and consistency (SAC) of the evidence represented by each grouping was rated according to Agency for Health Care Policy and Research guidelines. RESULTS: In each grouping, 100% of the studies reported some prevalence of NP (none reported zero prevalence). Aggregated NP prevalence for CLBP was 36.6% (SAC level A [consistent multiple studies]) and for STS 41.1% (SAC level A). There was significant variation in prevalence according to the method utilized to diagnose NP. CONCLUSION: There is consistent evidence by all methods that NP is present in CLBP and STS. Reported prevalence percentages by all methods are substantial. This has significant implications for the treatment of CLBP and STS.

Is smoking associated with alcohol-drug dependence in patients with pain and chronic pain patients? An evidence-based structured review.

OBJECTIVE: The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs). METHODS: Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines. RESULTS: In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other. CONCLUSIONS: There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure.

What is the evidence for chronic pain being etiologically associated with the DSM-IV category of sleep disorder due to a general medical condition? A structured evidence-based review.

DESIGN: This is a structured evidence-based review of all available studies on the relationship between chronic pain and sleep problems as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) category of sleep disorder due to a general medical condition. OBJECTIVES: To determine whether chronic pain is etiologically associated with this sleep category. METHODS: Computer and manual literature searches yielded 146 references that addressed this area of study. One hundred and five studies were excluded from detailed review based on exclusion criteria detailed by this category of sleep disorders. Forty-one studies were reviewed in detail and sorted according to six natural groupings: multivariate analysis, prospective studies, path analysis, correlation between pain and sleep problems, univariate analysis using comparison groups, and do nonsedating drugs with analgesic properties improve sleep? Study characteristics were abstracted into tabular form and each report was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines. Each study was independently evaluated by two raters according to 12 quality criteria and an independent quality score was calculated. Studies were not utilized in the calculations unless their quality score (utilizing both raters) was greater than 60%. For each of the above groupings, an average quality score was calculated and a calculation performed as to the percentage of studies that supported the hypothesis that pain is etiologically related to the above DSM-IV category of sleep disorders. Finally, the strength and consistency of the evidence for this hypothesis was rated according to the AHCPR guidelines. RESULTS: Of the 41 reports, all had quality scores greater than 60%. In all the above groupings except for multivariate analysis, 100% of the studies supported this hypothesis. In the multivariate analysis grouping, 77.2% of the studies supported this hypothesis. The strength and consistency of this evidence was rated at A (highest possible) for all study groupings except multivariate (B rating) and path analysis where there were too few studies to generate a conclusion. For all the studies combined, 89.7% of the studies supported this hypothesis. This evidence was rated as A: consistent, multiple studies. CONCLUSIONS: The results of this evidence-based structured review indicate that for the pain-sleep studies defined by the DSM-IV category of sleep disorder due to a general medical condition,chronic pain may be etiologically related to that sleep problem. However, these results do not preclude this relationship from being bidirectional.

Is chronic pain associated with somatization/hypochondriasis? An evidence-based structured review.

STUDY DESIGN: This is an evidence-based structured review. OBJECTIVES: The objectives of this review were to answer the following questions: (1) Are somatization/hypochondriasis associated with chronic pain? (2) Is the degree of somatization/hypochondriasis related to pain levels? (3) Does pain treatment improve somatization/hypochondriasis? (4) Are some pain diagnoses differentially associated with somatization/hypochondriasis? METHODS: Fifty-seven studies which fulfilled inclusion criteria and had high quality scores were sorted by the above-mentioned objectives. Agency for health care policy and research guidelines were utilized to type and characterize the strength/consistency of the study evidence within each objective. RESULTS: Somatization and hypochondriasis were both consistently associated with chronic pain (consistency ratings B and A, respectively). Study evidence indicated a correlation between pain intensity and presence of somatization and hypochondriasis (consistency rating A and B, respectively). Pain treatment improved somatization and hypochondriasis (consistency rating B and A, respectively). Some chronic pain diagnostic groups somatized more (consistency rating B). CONCLUSIONS: Somatization is commonly associated with chronic pain and may relate to pain levels.

Do opioids induce hyperalgesia in humans? An evidence-based structured review.

UNLABELLED: DESIGN/OBJECTIVES: Consistent rodent evidence indicates that opioid exposure will decrease the rodent's pain threshold (ptr). This is termed opioids-induced hyperalgesia (OIH). Currently, the consistency of the evidence for the occurrence of OIH in humans is unclear. This is a structured evidence-based review for all levels of evidence (all studies and case reports) on OIH in humans in order to determine the consistency of this evidence. METHODS: Computer and manual literature searches yielded 504 OIH references (human and animal). Of these, 48 remained after application of inclusion/exclusion criteria. These references addressed 10 hypotheses that the OIH literature has utilized to test for the possibility of OIH in humans. These are the following: opioid addicts maintained on opioids will have decreased ptr and/or tolerance; detoxifying opioid addicts from opioids will increase their ptr and/or tolerance; stopping, decreasing, or rotating to a different opioid or detoxifying from an opioid will improve pain and/or allodynia; chronic pain patients(CPPs) placed on opioids will develop decreased ptr and/or tolerance; CPPs on opioids will have decreased ptr and/or tolerance vs CPPs not on opioids; opioid infusion in normal volunteers or CPPs will decrease ptr and/or tolerance; former opioid addicts exposed to opioids will demonstrate a decrease in ptr and/or tolerance; opioid infusion in normal volunteers will increase secondary hyperalgesia as measured by allodynia or hyperalgesia; perioperative opioids will increase postoperative pain and/or opioid requirements; and placement on opioids postsurgery leads to progressive increased intake (acute tolerance). Each report was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 14 quality criteria with a quality score calculated. For studies under each hypothesis, an average quality score and the percentage of studies supporting the hypothesis was calculated. Finally, for studies under each hypothesis, utilizing AHCPR criteria, a consistency rating was derived based on the percentage score of studies supporting the hypothesis. RESULTS: Two studies had quality scores below 65% and were not utilized. Overall, the strongest evidence (consistent, A) came from opioid infusion studies in normal volunteers as measured by secondary hyperalgesia. This evidence was supported by inconsistent evidence (C) from: studies addressing opioid infusions in normal volunteers or CPPs for decreasing ptr and/or tolerance; and studies addressing increases in postop opioid requirements or pain if peri-opioids were utilized. For the other seven hypotheses, there were too few studies to draw a conclusion or the evidence for the hypothesis were case reports or the results of the studies within the hypothesis were not interpretable. CONCLUSIONS: There is not sufficient evidence to support or refute the existence of OIH in humans except in the case of normal volunteers receiving opioid infusions. Prospective CPP clinical studies measuring ptrs and tolerances pre- and post-opioid placement with CPP non-opioid control groups are required.

Alleged medical abandonment in chronic opioid analgesic therapy: case report.

OBJECTIVES: The objectives of this medicolegal case report were the following: 1) present details of a chronic pain patient (CPP) on chronic opioid analgesic therapy (COAT), who diverted her opioids and was terminated from treatment, and subsequently committed suicide; 2) present both the plaintiff's and defendant's (the COAT prescriber) expert witnesses' opinions as to the allegation of medical abandonment of this patient and other allegations; and 3) based on these opinions, to develop some recommendations as to how pain physicians can minimize their medicolegal risk when termination of the physician-patient relationship is warranted. METHODS: This is a case report of a CPP treated by a pain physician who demonstrated aberrant drug-related behaviors and required large doses of controlled-release oxycodone. RESULTS: Differences between the plaintiff's and defendant's experts' opinions are presented by utilizing the COAT literature. Options for avoiding allegations of abandonment are proposed. CONCLUSIONS: To avoid and protect themselves against potential abandonment allegations when termination of the physician-patient relationship is warranted, physicians are advised to consider following the outlined procedures.

Are chronic low back pain patients who smoke at greater risk for suicide ideation?

OBJECTIVES: There is significant psychiatric literature indicating that smoking is associated with all forms of suicidality, including suicide ideation. The goal of this study was to determine if smoking is associated with suicide ideation in chronic low back pain (CLBP) patients. DESIGN: CLBP patients identified themselves as either current smokers (N = 81) or nonsmokers (N = 140) and completed a number of evaluation instruments, which included the Beck Depression Inventory (BDI) and the Coping Strategies Questionnaire (CSQ). BDI question number 9 was utilized to define CLBP with suicide ideation and subsequently, in addition, items number 3 and number 6 from the CSQ were added to the BDI item number 9 in order to fully capture CLBP with suicide ideation. Utilizing this expanded definition of suicide ideation (BDI plus CSQ), CLBP smokers were compared with CLBP nonsmokers for the frequency of suicide ideation. Regression analysis was utilized to investigate the CLBP smoking suicide ideation group. Finally, we investigated whether heavy use of alcohol and coffee impacted on CLBP heavy smokers in terms of increasing suicide ideation risk. SETTING: CLBP patients were recruited from a pain facility. RESULTS: CLBP smokers were more likely to complain of suicide ideation, and this relationship correlated with the number of cigarettes smoked per day. Seventy-eight percent of the CLBP smokers were classified correctly in terms of the presence of suicide ideation by three variables: diagnosis of major depression, Function Assessment Questionnaire total score, and BDI total score. The relative risk of suicide ideation was increased by combining heavy smoking (greater than one pack per day) with heavy alcohol use. CONCLUSIONS: CLBP smokers appear to be at greater risk for suicide ideation than nonsmoking CLBP patients. The risk of suicide ideation is even greater if the CLBP patient is a heavy smoker and has problems with alcohol.

Alleged breaches of "standards of medical care" in a patient overdose death possibly related to chronic opioid analgesic therapy, application of the controlled substances model guidelines: case report.

OBJECTIVES: The objectives of this medicolegal case report are the following: 1) to present details of a chronic pain patient (CPP) who was placed on chronic opioid analgesic therapy (COAT), and subsequently overdosed on multiple drugs, some of which were not prescribed by his COAT physician; 2) to present both the plaintiff's and defendant's (the COAT prescriber) expert witnesses' opinions as to the allegation that COAT prescribing was the cause of death; and 3) based on these opinions, to develop some recommendations on how pain physicians can utilize the use of Controlled Substances Model Guidelines in order to protect the patient and themselves from such an occurrence. METHODS: This is a case report of a CPP treated by a pain physician. RESULTS: Differences between the plaintiff's and defendant's expert's opinions are explained utilizing the Controlled Substances Model Guidelines. CONCLUSIONS: Some CPPs may withhold information critical to their COAT treatment. Application of the Controlled Substances Model Guidelines and the newer Federation of State Medical Boards' policy on opioid prescribing can be helpful in improving patient care and may be helpful in protecting the physician medicolegally.

Does smoking status affect multidisciplinary pain facility treatment outcome?

OBJECTIVES: Smoking may be a major problem in chronic low back pain (LBP) patients. The goal of this study was to determine whether smoking status affected multidisciplinary pain facility treatment outcome. DESIGN: As part of a grant study, chronic LBP patients identified themselves as either current smokers (N = 81) or current nonsmokers (N = 140), and were compared by chi-square for employment status at 1, 6, 12, and 24 months after multidisciplinary pain facility treatment. Smokers who were unemployed at each time interval were then compared with employed smokers for a large number of assessment scales and clinical variables of interest by chi-square or Student's t-test. The significant independent variables from these analyses were then utilized in a logistic regression to determine predictors for smoker nonemployment. SETTING: Pain facility. RESULTS: Current smokers were less likely to be employed at each follow-up time point. Pain levels over the previous 24 hours predicted employment status for current smokers at 1-, 12-, and 24-month follow-up, while worker compensation status predicted employment status at 6 months. CONCLUSIONS: Current smoking status appears to be associated with poorer treatment outcome after multidisciplinary pain facility treatment. Return to work within smokers is predicted by pain and worker compensation status. Pain facilities should target current smokers with significant perceived pain for close treatment monitoring in an attempt to improve treatment outcome.

What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review.

DESIGN: This is a structured evidence-based review of all available studies on the development of abuse/addiction and aberrant drug-related behaviors (ADRBs) in chronic pain patients (CPPs) with nonmalignant pain on exposure to chronic opioid analgesic therapy (COAT). OBJECTIVES: To determine what percentage of CPPs develop abuse/addiction and/or ADRBs on COAT exposure. METHOD: Computer and manual literature searches yielded 79 references that addressed this area of study. Twelve of the studies were excluded from detailed review based on exclusion criteria important to this area. Sixty-seven studies were reviewed in detail and sorted according to whether they reported percentages of CPPs developing abuse/addiction or developing ADRBs, or percentages diagnosed with alcohol/illicit drug use as determined by urine toxicology. Study characteristics were abstracted into tabular form, and each report was characterized according to the type of study it represented based on the Agency for Health Care Policy and Research Guidelines. Each study was independently evaluated by two raters according to 12 quality criteria and a quality score calculated. Studies were not utilized in the calculations unless their quality score (utilizing both raters) was greater than 65%. Within each of the above study groupings, the total number of CPPs exposed to opioids on COAT treatment was calculated. Similarly, the total number of CPPs in each grouping demonstrating abuse/addiction, ADRBs, or alcohol/illicit drug use was also calculated. Finally, a percentage for each of these behaviors was calculated in each grouping, utilizing the total number of CPPs exposed to opioids in each grouping. RESULTS: All 67 reports had quality scores greater than 65%. For the abuse/addiction grouping there were 24 studies with 2,507 CPPs exposed for a calculated abuse/addiction rate of 3.27%. Within this grouping for those studies that had preselected CPPs for COAT exposure for no previous or current history of abuse/addiction, the percentage of abuse/addiction was calculated at 0.19%. For the ADRB grouping, there were 17 studies with 2,466 CPPs exposed and a calculated ADRB rate of 11.5%. Within this grouping for preselected CPPs (as above), the percentage of ADRBs was calculated at 0.59%. In the urine toxicology grouping, there were five studies (15,442 CPPs exposed). Here, 20.4% of the CPPs had no prescribed opioid in urine and/or a nonprescribed opioid in urine. For five studies (1,965 CPPs exposed), illicit drugs were found in 14.5%. CONCLUSION: The results of this evidence-based structured review indicate that COAT exposure will lead to abuse/addiction in a small percentage of CPPs, but a larger percentage will demonstrate ADRBs and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol/illicit drug use or abuse/addiction.

Can the neuropathic pain scale discriminate between non-neuropathic and neuropathic pain?

OBJECTIVES: 1) To determine if the neuropathic pain scale (NPS) can be used to classify chronic pain patients (CPPs) as having primarily neuropathic vs non-neuropathic pain, and furthermore; 2) to determine what, if any, cut-off score can be used to reliably make this determination. DESIGN: A total of 305 CPPs consecutive admissions to The Rosomoff Pain Center were administered the NPS and were assigned a diagnosis according to the physical examination and all available test results. CPPs with a diagnosis of chronic radiculopathy and spondylolysis/degenerative arthritis were segregated into two groups for the purposes of having a group representative of neuropathic pain (chronic radiculopathy) and non-neuropathic pain (spondylolysis/degenerative arthritis). Applying neuropathic pain criteria to each "of these two groups": a neuropathic pain "subtype" was identified within the chronic radiculopathy group; and, a non-neuropathic pain "subtype" was identified within the spondylolysis/degenerative arthritis group. This step was performed in order to assure that the CPPs selected for further analysis were truly representative of neuropathic and non-neuropathic pain. Discriminant function analysis was then employed to determine if NPS scoring could differentiate between these two "subtypes." Results from the discriminant function analysis model were utilized to derive an NPS cut-off score above which CPPs would be classified as having neuropathic pain. For the diagnoses of myofascial pain syndromes, spinal stenosis, epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome, a predicted NPS score was calculated and compared with the cut-off score. SETTING: Multidisciplinary pain facility. PATIENTS: Chronic pain patients. RESULTS: The NPS appeared to be able to separate CPPs into neuropathic pain vs non-neuropathic pain subtypes. The derived cut-off score from the model was 5.53. Myofascial pain syndrome and spinal stenosis had predictive scores lower than this cut-off score at 3.81 and 4.26, respectively. Epidural fibrosis, fibromyalgia, complex regional pain syndromes 1 and 2, and failed back surgery syndrome had predictive scores higher than the cut-off score at 6.15, 6.35, 6.87, 9.34, and 7.19, respectively. CONCLUSIONS: The NPS appears to be able to discriminate between neuropathic and non-neuropathic pain. A debate is currently raging as to whether diagnoses, such as fibromyalgia and complex regional pain syndrome 1, can be classified as neuropathic. Our NPS cut-off score results suggest that these diagnoses may have a neuropathic pain component. The reliability and validity of our NPS method will need to be tested further in other neuropathic pain models, such as diabetic peripheral neuropathic pain.

Variables associated with current smoking status in chronic pain patients.

OBJECTIVES: Smokers may report more pain and may be at greater risk for psychiatric comorbidity. Smoking may be a major problem in chronic pain patients (CPPs). The goal of this study was to determine if pain and psychiatric comorbidity are associated with smoking status in CPPs. DESIGN: As part of a return-to-work grant study CPPs who could potentially return to work identified themselves as either current smokers (N=81) or nonsmokers (N=140). These two groups were compared on a large number of demographic, function, pain, disability, behavior, and psychiatric diagnoses variables gathered at admission into the grant study. The incidence of smoking was tested with either the student's t-test or chi-square to detect differences in continuous and categorical variables, respectively. Logistic regression was utilized to determine the predictive variables for smoking status by inputting significant independent variables (P<0.01) from the prior analyses. SETTING: Pain facility. RESULTS: Five variables were found to explain 38.8% of the variance for smoking status. These were education; race (Caucasian); cups of coffee per day; a diagnosis of current alcohol abuse/dependence; and personality disorder. CONCLUSIONS: Smoking status in CPPs is associated with some variables that are similar for smoking in the general and psychiatric populations (education, race, alcoholism). However, a number of variables expected to be relevant (e.g., mood disorders) were not associated with smoking status in CPPs. These results may not be generalizable to all CPPs as they are derived from CPPs who are return-to-work candidates.

Medicolegal rounds: medicolegal issues and alleged breaches of standards of medical care in a patient motor vehicle accident allegedly related to chronic opioid analgesic therapy.

The objective of this medicolegal case report is to present the details of the case of a chronic pain patient (CPP) who was placed on chronic opioid analgesic therapy (COAT) and was involved in a motor vehicle accident, alleged in litigation to be related to COAT. COAT standards are in a process of evolution, and this process is influenced by recent literature developments. We aim to present both the plaintiffs and defendant's expert witnesses' opinions on whether the defendant physician fell below the "standard" in allowing the CPP to drive. Both the methadone and the driving literature are utilized to explain the defendant's and plaintiffs experts' opinions and the differences between them. Based on these opinions, we have attempted to develop some recommendations on how pain physicians should approach the problem of deciding whether patients should be allowed to drive when on COAT.

Chronic pain and the measurement of personality: do states influence traits?

STUDY DESIGN: This is a structured evidence-based review of all available studies on the effect of pain, (a state phenomenon) on the measurement of personality characteristics (a trait phenomenon). OBJECTIVES: To determine whether pain treatment changes trait scores. SUMMARY OF BACKGROUND DATA: Recent evidence from the psychiatric literature indicates that the measurement of personality characteristics (traits) can be affected or changed by the presence of state psychiatric disorders, for example, depression. At issue then is whether the measurement of chronic pain patients' (CPPs') trait characteristics is affected by the presence of pain, a state problem. METHODS: Computer and manual literature searches for pain studies that reported a prepain treatment and postpain treatment (test-retest) personality test or inventory score produced 35 such reports. These references were reviewed in detail and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized as to the type of study it represented according to the guidelines developed by the Agency of Health Care Policy and Research (AHCPR). In addition, a list of 15 quality criteria was utilized to measure the quality of each study. Each study was independently categorized for each criterion as positive (criterion filled), negative (criterion not filled), or not applicable, by two of the authors. Only studies having a quality score of 65% or greater were utilized to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. RESULTS: Of the 35 reports, 32 had quality scores of 65% or greater. According to the AHCPR guidelines, there was a consistent finding that the Minnesota Multiphasic Personality Inventory (MMPI) scores changed (improved) with treatment. In reference to the Millon Behavioral Health Inventory, Locus of Control, the Symptom Checklist-90-Revised (SCL-90-R), trait anxiety, and personality disorders, there were not enough studies to draw conclusions about consistency. In reference to coping/self-efficacy inventories, somatization/illness behavior inventories, and personality questionnaire studies, there was a generally consistent finding that these tests changed (improved) with pain treatment. Overall, of the 32 reports, 92.3% demonstrated a change in trait scores (improvement) with pain treatment. This evidence was categorized as consistent. Finally, 100% of a subgroup of reports (N = 12) that had controlled for pain indicated that there was a relationship between a change in pain scores and a change in trait scores. CONCLUSIONS: Based on the above results, it was concluded that some trait tests and inventories may not be pain state independent. Therefore, caution is warranted in interpreting postpain development personality profiles as being indicative of the true prepain personality structure, if measured by these tests. Why trait scores may change with treatment, confounding test-retest issues, and whether trait tests actually measure what they allegedly measure are discussed.

Lidocaine 5% patch: an open-label naturalistic chronic pain treatment trial and prediction of response.

OBJECTIVE: There have been a few open-label nonplacebo reports on the successful use of lidocaine 5% patch (L5P) for other types of pain besides postherpetic neuralgia, such as chronic low back pain. With the these reports, we began to utilize L5P routinely for chronic pain patients (CPPs) with various pain diagnoses. The purpose of this report was to describe the results of a retrospective review of this open-label naturalistic L5P chronic pain treatment trial and to attempt to delineate predictors of perceived clinical response. DESIGN: Consecutive CPPs were selected for this clinical trial according to the following inclusion criteria: the CPPs with pain greater than 6-month duration and either a hyperalgesic pain area or trigger point, which could be covered by one L5P, were offered a 3-day L5P naturalistic treatment trial. The purpose of this trial was to determine which CPPs would perceive improvement and continue using L5P. CPPs entering the trial completed the neuropathic pain scale (NPS) at entrance and completion of the trial. The senior author also completed a baseline information tool on each CPP entering this naturalistic trial. At the completion of the 3-day trial, the CPPs were asked if they perceived pain improvement with the use of L5P. In the retrospective review, the CPPs were thus segregated into two groups, those with and without perceived clinical improvement, and were statistically compared for available clinical variables. Logistic regression was then utilized to determine which significant independent variables contributed to the correct prediction of perceived improvement. SETTING: Multidisciplinary pain facility. PATIENTS: Patients with chronic pain. RESULTS: Of 362 consecutive CPPs, 114 or 31.5% were deemed candidates for this naturalistic trial. None of the CPPs refused or fulfilled exclusion criteria eliminating them from the trial. The total sample (N = 114) showed statistical improvement on all 10 NPS scales (except scales 4 and 6) plus the NPS 4, NPS nonallodynic 8, and NPS 10. The perceived clinically improved group (N = 87, 76.3% of those entering the trial), also showed perceived improvement on all preceding scales except 4 and 6. The perceived clinically nonimproved group (N = 27, 23.7% of those entering the trial) showed statistical improvement on scales B and NPS 10. Perceived improvement was predicted by the following variables: pain wakes patient up, patch placement not low back, and not in litigation. These variables explained 9.8%, 20%, and 14% of the variance, respectively. Overall, 44.5% of the variance was explained. CONCLUSIONS: A significant percentage of CPPs exposed to an L5P 3-day naturalistic trial perceived clinical improvement. However, this can only be concluded as an initial effect, and whether or not this effect is attributable to L5P cannot be derived from our data as the effect could have been nonspecific. The apparent CPP perceived clinical improvement was not associated with any particular useful clinical indicator. As such, at present, no variable can be recommended for use in selecting CPPs for such a naturalistic L5P clinical treatment trial. However, this study indicates that such a trial can be useful in selecting CPPs who may perceive benefit from L5P.

Multidisciplinary pain facility treatment outcome for pain-associated fatigue.

OBJECTIVES: Fatigue is frequently found in chronic pain patients (CPPs) and may be etiologically related to the presence of pain. Fishbain et al. have recently demonstrated that chronic low back pain (LBP) and chronic neck pain patients are more fatigued than controls. The purpose of this study was to determine whether chronic LBP- and chronic neck pain-associated fatigue responded to multidisciplinary multimodal treatment not specifically targeted to the treatment of fatigue. DESIGN: A total of 85 chronic LBP and 33 chronic neck pain patients completed the Multidimensional Fatigue Inventory (MFI), Neuropathic Pain Scale (NPS), and Beck Depression Inventory on admission. In addition, an information tool was completed on each CPP by the senior author. This tool listed demographic information, primary and secondary pain diagnoses, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) psychiatric diagnoses assigned, pain location, pain precipitating event, type of injury, years in pain, number of surgeries, type of surgery, type of pain pattern, opioids consumed per day in morphine equivalents, worker compensation status, and whether, according to the clinical examination, the CPP had a neuropathic pain component. At completion of the multidisciplinary multimodal treatment, each CPP again completed the MFI. Student's t-test was utilized to test for statistical changes on the MFI five scales from pre- to post-treatment. Pearson and point-biserial correlations were utilized to determine which variables significantly correlated with MFI change scores. Variables found significant at less than or equal to 0.01 were utilized in a stepwise aggression analysis to find variables predictive of change in MFI scores. SETTING: Multidisciplinary pain facility. PATIENTS: Chronic LBP and chronic neck pain patients. RESULTS: Multidisciplinary multimodal treatment significantly improved CPP fatigue as measured by the MFI. The available variables utilized to predict fatigue best explained only a small percentage (28.9%) of the variance. Improvement in fatigue was related to NPS-10 scale scores (neuropathic pain) and a previous diagnosis of fibromyalgia. CONCLUSIONS: Multidisciplinary multimodal pain facility treatment improves chronic LBP- and neck pain-associated fatigue. At the present time we cannot predict this improvement with significant accuracy.

Do the second-generation "atypical neuroleptics" have analgesic properties? A structured evidence-based review.

STUDY DESIGN: This is a structured, evidence-based review of all available studies on the potential effectiveness of the atypical neuroleptics for the treatment of pain (analgesia). To determine what evidence, if any, exists for, or against, the effectiveness of the atypical neuroleptics for analgesia. SUMMARY OF BACKGROUND DATA: There has been significant controversy over whether the conventional neuroleptics (non-atypicals) have analgesic properties. A recent review (Patt et al. 1994) did conclude that the evidence for effectiveness was sparse, except for methotrimeprazine. However, that review did not include a new class of neuroleptics: the atypicals such as olazapine, risperidone, quetiapine, etc. METHODS: A computer and manual search for studies relating to the atypicals and their analgesic effectiveness produced 10 studies/reports. These were reviewed in detail, and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized by the type of study it represented according to the guidelines developed by the Agency for Health Care Policy and Research (AHCPR). The strength and consistency of the evidence represented by the 10 studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. RESULTS OF DATA SYNTHESIS: Of the 10 studies/reports, four were characterized by AHCPR guidelines as Type II (experimental), two were Type III (quasiexperimental), two were Type IV (nonexperimental), and two were Type V (case reports). Of these studies/reports, 90% indicated that the atypicals did have an analgesic effect. The overall strength and consistency of this evidence using the AHCPR guidelines was, therefore, categorized as B (generally consistent from Type II, Type III, and Type IV studies). CONCLUSIONS: Based on the above results, it was concluded that the reviewed data were generally consistent, suggesting that some of the atypicals may have an analgesic effect. There were, however, few double-blind, placebo-controlled studies, and many of the reports/studies had less than 50 patients. As such, this question requires further research.

Are patients with chronic low back pain or chronic neck pain fatigued?

OBJECTIVES: The objectives of this study were the following: to determine if fatigue is present in chronic low back pain (LBP) and chronic neck pain patients to a greater extent than in controls (nonpatients); to determine which variables are associated with the presence of fatigue; and to determine which of the above chronic pain patient (CPP) groups is more fatigued. To the authors' knowledge, this is the first such study in the literature. DESIGN: Totals of 175 chronic LBP and 33 chronic neck pain patients completed the Multidimensional Fatigue Inventory (MFI), Neuropathic Pain Scale (NPS), and Beck Depression Inventory rating scales on admission. In addition, an information tool was completed on each CPP and contained the following information: demographics, primary and secondary pain diagnoses, DSM-IV psychiatric diagnoses assigned, pain location, pain precipitating event, type of injury, years in pain, number of surgeries, types of surgery, type of pain pattern, opioids consumed per day in morphine equivalents, workers' compensation status, and whether, according to the clinical examination, the pain did or did not have a neuropathic component. Scores on the MFI were then compared with published norms for controls (nonpatients) via chi-squared tests. Bivariate analyses were conducted between the MFI subscales and the variables selected for analysis. Pearson correlations, analyses of variance, and t-tests were used to test for relationships between MFI scale scores and the appropriate variables. In the next step of the analysis, stepwise regression analyses were used to predict each of the MFI subscale scores using the variables that were found to be significantly (P < 0.05) related to fatigue by the preceding analysis. In the final analysis, the variables that were significant predictors of the fatigue subscales were controlled for as covariates in an analysis of variance in order to determine if chronic LBP patients had scores on the MFI subscales that were significantly different from those of chronic neck pain patients. SETTING: Multidisciplinary pain facility. PATIENTS: Chronic LBP and chronic neck pain patients. RESULTS: Chronic LBP and chronic neck pain patients were found to be significantly more fatigued than controls (nonpatients). Most of the MFI subscale scores could be predicted by four major variables: presence of neuropathic pain, female gender, presence of depression, and total number of DSM-IV diagnoses. Chronic LBP patients were as fatigued as chronic neck pain patients. CONCLUSIONS: The complaint of fatigue appears to be a significant problem for chronic LBP and chronic neck pain patients. This complaint may be associated with neuropathic pain, female gender, and psychiatric comorbidities.

Genetic testing for enzymes of drug metabolism: does it have clinical utility for pain medicine at the present time? A structured review.

STUDY DESIGN: This is a structured review of genomic (genetic) testing for enzymes of drug metabolism. OBJECTIVES: Recently, industry began offering genomic testing for enzymes of drug metabolism. As such, the objective of this review was to determine if genomic testing for enzymes of drug metabolism has any imminent clinical relevance for the practice of pain medicine. METHODS: Relevant references relating to pharmacogenetics, pharmacogenomics, and the metabolizing of drugs used in pain medicine by cytochrome P-450 enzymes were located and reviewed in detail. The P-450 enzymes that metabolize each drug and whether that drug had been identified as being subject to a clinical consequence of a genetic polymorphism of the P-450 enzyme involved in its metabolism were placed into tabular form. RESULTS OF DATA SYNTHESIS: 1) For a large number of drugs, we do not yet know which cytochrome P-450 enzymes are involved in their metabolism; 2) For a large number of drugs, the consequences of a P-450 genetic polymorphism have yet to be determined; 3) Genetic polymorphism can lead to important potential clinical consequences for some opioids, anticonvulsants (phenytoin), benzodiazepines (diazepam), muscle relaxants (succinylcholine), antidepressants (imipramine, nortriptyline, venlafaxine), typical neuroleptics, alcohol, antihypertensives (propranolol, timolol), local anesthetics (procainamide), L-dopa, nicotine, and warfarin. Based on these results, factors for and against using genomic testing were reviewed. CONCLUSIONS/RECOMMENDATIONS: It was concluded that genomic testing for enzymes of drug metabolism has significant potential for improving the efficacy of drug treatment and reducing adverse drug reactions. Recommendations for when such testing would be useful are outlined.