Intersectional Risk and the Significant Gap in Care for Persons With Co-occurring Chronic Pain and Opioid Withdrawal.

OBJECTIVES: Persons with chronic pain and women tend to enter treatment for opioid use disorder with greater opioid withdrawal severity than persons without chronic pain and men, respectively. This study examined characteristics of facilities with opioid withdrawal treatment, including gender-based services, as a function of whether they reported having a tailored pain management program. METHODS: The National Survey of Substance Abuse Treatment Services 2020 was used to examine 3942 facilities with opioid withdrawal treatment in the United States. Using a multivariable binary logistic regression model, facilities were examined for the presence of a tailored program for individuals with co-occurring pain. Regional location of the facility, ownership status, and availability of tailored gender programs, nonhospital residential services, and outpatient services served as independent variables in the analysis. RESULTS: A slight majority of the sample had a program for both adult men and adult women ( n = 2010, 51.0%). Most facilities had outpatient services ( n = 3289, 83.4%) and did not have a tailored program for addressing co-occurring pain ( n = 2756, 69.9%). Binary logistic regression analysis showed that among opioid withdrawal facilities, programs with nonhospital residential services, government or private nonprofit funding, or tailored gender programming had higher odds of reporting having a tailored program for pain and substance use disorder. Facilities in the Western United States were most likely to have tailored programs for pain and substance use disorder. CONCLUSIONS: Future research should investigate what support patients may receive and how to better scale access to pain management during opioid withdrawal treatment.

Fentanyl Absorption, Distribution, Metabolism, and Excretion: Narrative Review and Clinical Significance Related to Illicitly Manufactured Fentanyl.

OBJECTIVES: This narrative review summarizes literature on pharmaceutical fentanyl's absorption, distribution, metabolism, and excretion patterns to inform research on illicitly manufactured fentanyl (IMF). RESULTS: Fentanyl is highly lipophilic, lending itself to rapid absorption by highly perfused tissues (including the brain) before redistributing from these tissues to muscle and fat. Fentanyl is eliminated primarily by metabolism and urinary excretion of metabolites (norfentanyl and other minor metabolites). Fentanyl has a long terminal elimination, with a documented secondary peaking phenomenon that can manifest as "fentanyl rebound." Clinical implications in overdose (respiratory depression, muscle rigidity, and "wooden chest syndrome") and opioid use disorder treatment (subjective effects, withdrawal, and buprenorphine-precipitated withdrawal) are discussed. The authors highlight research gaps derived from differences in medicinal fentanyl studies and IMF use patterns, including that medicinal fentanyl studies are largely conducted with persons who were opioid-naive, anesthetized, or had severe chronic pain and that IMF use is characterized by supratherapeutic doses and frequent and sustained administration patterns, as well as adulteration with other substances and/or fentanyl analogs. CONCLUSIONS: This review reexamines information yielded from decades of medicinal fentanyl research and applies elements of the pharmacokinetic profile to persons with IMF exposure. In persons who use drugs, peripheral accumulation of fentanyl may be leading to prolonged exposure. More focused research on the pharmacology of fentanyl in persons using IMF is warranted.

Operational definition of precipitated opioid withdrawal.

Background: Opioid withdrawal can be expressed as both a spontaneous and precipitated syndrome. Although spontaneous withdrawal is well-characterized, there is no operational definition of precipitated opioid withdrawal. Methods: People (N = 106) with opioid use disorder maintained on morphine received 0.4 mg intramuscular naloxone and completed self-report (Subjective Opiate Withdrawal Scale, SOWS), visual analog scale (VAS), Bad Effects and Sick, and observer ratings (Clinical Opiate Withdrawal Scale, COWS). Time to peak severity and minimal clinically important difference (MCID) in withdrawal severity were calculated. Principal component analysis (PCA) during peak severity were conducted and analyzed with repeated measures analyses of variance (ANOVA). Results: Within 60 min, 89% of people reported peak SOWS ratings and 90% of people had peak COWS scores as made by raters. Self-reported signs of eyes tearing, yawning, nose running, perspiring, hot flashes, and observed changes in pupil diameter and rhinorrhea/lacrimation were uniquely associated with precipitated withdrawal. VAS ratings of Bad Effect and Sick served as statistically significant severity categories (0, 1-40, 41-80, and 81-100) for MCID evaluations and revealed participants' identification with an increase of 10 [SOWS; 15% maximum percent effect (MPE)] and 6 (COWS; 12% MPE) points as meaningful shifts in withdrawal severity indicative of precipitated withdrawal. Conclusion: Data suggested that a change of 10 (15% MPE) and 6 (12% MPE) points on the SOWS and COWS, respectively, that occurred within 60 min of antagonist administration was identified by participants as a clinically meaningful increase in symptom severity. These data provide a method to begin examining precipitated opioid withdrawal.

Genome-wide SNPs resolve phylogenetic relationships in the North American spruce budworm (Choristoneura fumiferana) species complex.

High throughput sequencing technologies have revolutionized the potential to reconcile incongruence between gene and species trees, and numerous approaches have been developed to take advantage of these advances. Genotyping-by-sequencing is becoming a regular tool for gathering phylogenetic data, yet comprehensive evaluations of phylogenetic methods using these data are sparse. Here we use multiple phylogenetic and population genetic methods for genotyping-by-sequencing data to assess species relationships in a group of forest insect pests, the spruce budworm (Choristoneura fumiferana) species complex. With few exceptions, all methods agree on the same relationships, most notably placing C. pinus as basal to the remainder of the group, rather than C. fumiferana as previously suggested. We found strong support for the monophyly of C. pinus, C. fumiferana, and C. retiniana, but more ambiguous relationships and signatures of introgression in a clade of western lineages, including C. carnana, C. lambertiana, C. occidentalis occidentalis, C. occidentalis biennis, and C. orae. This represents the most taxonomically comprehensive genomic treatment of the spruce budworm species group, which is further supported by the broad agreement among multiple methodologies.

Joint laxity in the performing arts.

Traditional scoring systems for the assessment of joint flexibility are reviewed and reasons for variation in joint laxity are defined. The value of controlled joint laxity in the hands and arms of musicians is then discussed as well as the desirability of adjusting laxity at the various joints used in the different styles of dance, some of them ethnic, that depend on the specific articular characteristics of each different dancer.

Total hip replacement in dancers.

A case report of a professional contemporary dancer who successfully returned to the stage after bilateral total hip replacements (THR) for osteoarthritis is presented, together with her own commentary and a retrospective cohort study of total hip replacements in dancers. In the presented cohort, there were no post-operative dislocations or infections, the original pain had been relieved, rehabilitation was objectively normal and all resumed their dance (teaching) activities. Nevertheless, they were disappointed about the prolonged rehabilitation. Due to their high demands as professional dancers, post-operative expectations were too optimistic in view of the usual quick and favourable results of THR in the older and less physically active, general population. In all dancers with unilateral osteoarthritis, the left hip was involved, which may reflect the tendency to use the left leg as standing leg and be suggestive that strenuous physical activity may lead to osteoarthritis. Better rehabilitation guidelines are needed for dancer patients undergoing THR, especially drawing their attention to realistic post-operative expectations.

Measuring and enhancing proprioception in musicians and dancers.

Proprioception is important to many musicians and all dancers. Methods of measuring proprioception in the hands of musicians and globally in dancers are reviewed. Their uses in defining proprioception in performers and thereby reducing the risk of injury as well as enhancing performance are discussed.

A dancer with rheumatoid arthritis: a role for biologics.

A case study is presented in which a student dancer who developed rheumatoid arthritis during her degree course was able to complete her course with meticulous treatment including the use of biologics. She describes her own reactions to the disease occurring at this crucial phase in her career.

Overuse syndrome in musicians.

Overuse syndromes of the upper limb are common in musicians. This reflects the long hours spent playing. Possible pathological causes are discussed as well as the ergonomic patterns of playing required of some instruments and other anatomical factors that predispose.

Scoliosis in musicians and dancers.

Scoliosis, although often considered a condition of athletes, is very common as a cause of symptoms in performing artists. Three typical case histories are presented with a physiotherapy review. Surprisingly, scoliosis is often more of a problem in musicians than in dancers.

"Extreme" or tariff sports: their injuries and their prevention (with particular reference to diving, cheerleading, gymnastics, and figure skating).

The interface between sports medicine and performing arts medicine is closest for "tariff" sports, where the sportsperson can select their own programme of varying difficulty with the more complex skills carrying potential for higher marks. Inevitably, some performers over-reach themselves. Examples of injuries and prevention strategies to avoid such injuries are discussed in a preliminary analysis of four sports: diving, cheerleading, gymnastics, and figure skating.

Hypermobility in dance: asset, not liability.

Opinions vary on whether joint hypermobility is an asset or liability in dance. This paper argues that it is an asset, the arguments for its being a liability often confounded by inadequate scoring systems inappropriately applied. The ambiguity and distress this presents to dancers, the several different causes of joint hypermobility and the separate needs of the many different diverse styles of dance are all discussed. A strategy for the future care and training of hypermobile dancers is proposed.

Comparison of speed and agility performance of college football players on field turf and natural grass.

The purpose of this study was to determine the difference in 40-yd dash and proagility times performed on field turf (FT) and natural grass (NG). Red-shirt freshmen National Collegiate Athletic Association Division II college football players (n = 24) performed 2 trials each of a 40-yd dash and proagility run on each surface. Sprints were timed by an electronic timing system (ET) and by 2 hand timers (HTs). Agility was timed on each surface by 2 HTs. There was no significant difference in 40-yd dash times between FT and NG using ET (FT: 5.34 ± 0.30 seconds, NG: 5.33 ± 0.33 seconds) or HT (FT: 5.06 ± 0.31 seconds, NG: 5.11 ± 0.29 seconds). Hand timer 40-yd dashes were significantly faster than ET 40-yd dashes on both surfaces, with the difference between HT and ET on FT (-0.28 ± 0.11 seconds) significantly greater than the difference on NG (-0.22 ± 0.06 seconds). The time differences between surfaces were significantly correlated (r = 0.12, p = 0.56). Proagility times were significantly faster on FT (4.49 ± 0.28 seconds) than on grass (4.64 ± 0.33 seconds). Thus, it appears that straight-ahead sprint speed is similar between FT and NG, but change-of-direction speed may be significantly faster on FT.

Asthma and airways collapse in two heritable disorders of connective tissue.

OBJECTIVES: This study investigated the clinical impression that there was an increased prevalence of respiratory disorders in both the Hypermobility Syndrome (HMS)/Benign Joint Hypermobility Syndrome (BJHS) and Ehlers-Danlos Syndrome (EDS), compared with the normal population. METHODS: A questionnaire was distributed to 509 subjects (221 healthy controls, 126 HMS, 162 EDS) who documented respiratory symptoms and previously diagnosed respiratory and atopic disorders. A subgroup of 157 responders underwent full clinical and serological assessments, and 57 subjects were assessed physiologically. RESULTS: A significant increase in the frequency of a wide range of respiratory symptoms and reduced exercise tolerance was observed in subjects with both HMS and EDS compared with controls. In particular, there was an increased prevalence of asthmatic symptoms (HMS: OR 2.4, 95% CI 1.4-4.1, p = 0.002; EDS: OR 3.1, 95% CI 1.8-5.2, p<0.001) and atopy (HMS: OR 2.7, 95% CI 1.6-4.5, p<0.001; EDS: OR 2.6, 95% CI 1.6-4.4, p<0.001), which was subsequently confirmed by clinical assessment. Pulmonary physiological studies revealed increased lung volumes, impaired gas exchange and an increased tendency of both the lower and upper airways to collapse. CONCLUSIONS: We have demonstrated, for the first time, that individuals with HMS/BJHS and EDS have respiratory symptoms in association with various pulmonary physiological abnormalities. The increased prevalence of asthma may be due to linkage disequilibrium between the genes causing these conditions or a function of the connective tissue defect itself. In the non-asthmatic population, changes in the mechanical properties of the bronchial airways and lung parenchyma may underlie the observed increased tendency of the airways to collapse.

Antidepressants in child and adolescent depression: where are the bugs?

OBJECTIVE: To examine the data on the effect of antidepressant medication in depressed children and adolescents and the causes of the results obtained. METHOD: A systematic literature search was conducted, supplemented by a manual search, and a search of public online information on paediatric antidepressant trials reviewed by regulatory agencies. RESULTS: Data gathered from published and unpublished randomized controlled trials vary in their findings, with most of the studies showing a lack of efficacy characterized by a high placebo response rate. CONCLUSION: Differences from efficacy results with the same drugs in adult depression may be because of neurobiological developmental correlates, developmental differences in pharmacokinetics and pharmacodynamics, high rates of placebo response in children, and a number of methodological influences. There are several areas needing more attention in paediatric antidepressant clinical trials. Judicious use of published and unpublished studies to assess who may benefit from treatment with antidepressants seems warranted.