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.

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.

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.