Exploring the Role of Chronic Pain Clinics: Potential for Opioid Reduction.

BACKGROUND: The management of chronic nonmalignant pain with high-dose opioids has partially contributed to the current opioid epidemic, with some responsibility shared by chronic pain clinics. Traditionally, both primary care providers and patients used chronic pain clinics as a source for continued medical management of patients on high-dose opioids, often resulting in tolerance and escalating doses. Although opioids continue to be an important component of the management of some chronic pain conditions, improvement in function and comfort must be documented. Pain clinics are ideally suited for reducing opioid usage while improving pain and function with the use of a multimodal approach to pain management. We assessed whether the application of multimodal treatment directed by pain specialists in a pain clinic provides for improved function and reduced dosages of opioid analgesics. OBJECTIVE: We evaluated the role of a pain clinic staffed by fellowship-trained pain physicians in reducing pain and opioid use in chronic nonmalignant pain patients. STUDY DESIGN: This study used a retrospective design. SETTING: The research took place in an outpatient pain clinic in a tertiary referral center/teaching hospital. METHODS: Of 1268 charts reviewed, 296 patients were on chronic opioids at the time of first evaluation. After a thorough evaluation, the patients were treated with nonopioid pharmacotherapy and interventional pain procedures as necessary. The data utilized from patients' latest follow-up visit included current pain level using the Numerical Rating Scale (NRS-11), opioid usage, and various functional parameters. RESULTS: NRS-11 scores decreased by 33.8% from 6.8 (± 0.1)/10 to 4.5 (± 0.2)/10. The pain frequency and number of pain episodes improved by 36.8 ± 2 and 36.2 ± 2.1, respectively. Additionally, the ability to sleep, work, and perform chores significantly improved. Total opioid use decreased by about 55.4% from 53.8 ± 4 to about 24 ± 2.8 MME/patient/day. LIMITATION: This study is not a randomized prospective controlled study. The patients analyzed are still getting therapy and their pain status may change. Some opioids are underrepresented in the analyzed cohort. Finally, this study lacks in-depth stratification by type of pain, age, gender, and duration of opioid use. CONCLUSION: Chronic pain clinics can play a pivotal role in reducing opioid usage while improving pain and function in patients on chronic opioids. We wish to emphasize the importance of allocating resources toward nonopioid treatments that may improve the function and well-being of patients. KEY WORDS: Pain clinic, pain management, multimodal pain management, chronic pain, opioid reduction, improved pain, improved functional capacity.

Analysis of hyponatraemia associated post-operative mortality in 3897 hip fracture patients.

Hyponatraemia is common in hospitalised patients. In recent years the relationship between hyponatraemia and bone metabolism, falls and fractures has become more established. This study evaluates the prevalence of hyponatraemia (plasma sodium<135mmol/l) in 3897 patients undergoing operative treatment for hip fracture and the relationship between hyponatraemia and mortality in these patients. Hyponatraemia was an independent risk factor for increased post-operative mortality on multivariate analysis. Median age at admission was 83 years. Hyponatraemia was present in 19.1% of patients with hip fracture on admission, 29.5% of patients in the first 24h post-operatively and 20% of patients at discharge. There was a significant association between hyponatraemia and time from admission to surgery indicating that patients admitted with hyponatraemia waited longer. The median follow-up time was 863 (range 0-4352) days. There were 2460 deaths (63.1% of the original 3897 patients) prior to the censor date. A total of 1144 patients (29.4% of the original 3897 patients) died within 12 months of discharge. Median time to death for patients with and without hyponatraemia on admission was 34 months (SE 1.7 months) and 41 months (SE 2.5 months) respectively (p=0.003). Median time to death for patients with and without hyponatraemia within 24h post-operatively was 35 months (SE 2.5 months) and 42 months (SE 1.7 months) respectively (p=0.004). Following elimination of other independent variables associated with increased mortality, hyponatraemia on admission was associated with an increased risk of death (adjusted HR 1.15, p=0.005). Post-operative hyponatraemia was also associated with an increased risk of death (adjusted HR 1.15, p=0.006). Trends suggested that hyponatraemia within 48h of discharge was associated with an increased risk of death (adjusted HR 1.15, p=0.636). Hyponatraemia is common in elderly patients with hip fractures both at initial presentation and during admission. In this vulnerable patient group, hyponatraemia may delay time to definitive surgery and is a potentially reversible cause of increased post-operative mortality. Every effort should be made to identify and correct hyponatraemia in hip fracture patients.

Primary total knee arthroplasty in patients with Parkinson's disease: analysis of outcomes.

The prevalence of Parkinson's disease is expected to rise. We evaluated the short-term clinical outcomes following primary Total Knee Arthroplasty (TKA) in a group of patients with Parkinson's disease in a case controlled study. Within the review period 32 TKAs were implanted in patients with Parkinson's disease and 33 TKAs were implanted in an age-matched control group (mean age: 73 years). Pre-operatively there were no between-group differences in Knee Society Score, Pain score, Knee Society Function Score or range of movement. Knee Society Score (KSS) improved in both groups post-operatively with no significant between-group differences (p = 0.707). Pain score also improved in both groups. There was no functional improvement following TKA in the Parkinson group. Total Knee Arthroplasty provided excellent pain relief in patients with Parkinson's disease with an acceptable complication profile, although functional ability did not improve.

The identification of synthetic organic pigments in modern paints and modern paintings using pyrolysis-gas chromatography-mass spectrometry.

A collection of more than 70 synthetic organic pigments were analysed using pyrolysis-gas chromatography-mass spectrometry (Py-GC-MS). We report on the analysis of diketo-pyrrolo-pyrrole, isoindolinone and perylene pigments which are classes not previously reported as being analysed by this technique. We also report on a number of azo pigments (2-naphthol, naphthol AS, arylide, diarylide, benzimidazolone and disazo condensation pigments) and phthalocyanine pigments, the Py-GC-MS analysis of which has not been previously reported. The members of each class were found to fragment in a consistent way and the pyrolysis products are reported. The technique was successfully applied to the analysis of paints used by the artist Francis Bacon (1909-1992), to simultaneously identify synthetic organic pigments and synthetic binding media in two samples of paint taken from Bacon's studio and micro-samples taken from three of his paintings and one painting attributed to him.

The simultaneous analysis of proteins, lipids, and diterpenoid resins found in cultural objects.

We report a GC-MS method for the simultaneous analysis of proteins oil, and diterpenoid resins found in cultural objects. The method was initially designed for protein analysis of protenaceous paints and adhesives and involves acid hydrolysis as the first step. The amino acids in the protein hydrolysates, thus obtained, are treated with propan-l-ol/ hydrogen chloride and then pentafluoropropionic anhydride. The procedure was found also to yield the propyl esters of fatty acids derived from lipids and diterpenoid acids derived from natural resins, and thus allows the choice of a single method for the analysis of artists media which contain either oil s or proteins or mixtures of both proteins and oils or even resins. Thus natural mixtures such as egg yolk and also mixtures made by the artist such as animal glue/seed oil emulsions can be analysed. Coupled with FTIR analysis of paints and the staining of cross sections, to indicate layer structure the method can help to elucidate the paints and adhesives used by artists.