RESUMEN
BACKGROUND AND OBJECTIVE: Chronic low back pain (CLBP) is highly prevalent, with a substantial psychosocial burden. Pain has both sensory and affective components. The latter component is a significant driver of disability and psychiatric comorbidity but is often inadequately treated. Previously we reported that noninvasive transcranial direct current stimulation (tDCS) may modulate pain-associated affective distress. Here we tested whether 10 daily tDCS sessions aimed to inhibit the left dorsal anterior cingulate cortex (dACC), a region strongly implicated in the affective component of pain, would produce selective reduction in pain-related symptoms. METHODS: In this multisite, double-blinded, randomized placebo-controlled trial (RCT), 21 CLBP patients received 10 weekday sessions of 2-mA active tDCS or sham (20 minutes/session). A cathodal electrode was placed over FC1 (10-20 electroencephalography coordinates), and an identical anodal return electrode was placed over the contralateral mastoid. Participants rated pain intensity, acceptance, interference, disability, and anxiety, plus general anxiety and depression. RESULTS: Regression analysis noted significantly less pain interference (P =0.002), pain disability (P =0.001), and depression symptoms (P =0.003) at six-week follow-up for active tDCS vs sham. Omnibus tests suggested that these improvements were not merely due to baseline (day 1) group differences. CONCLUSIONS: To our knowledge, this is the first double-blinded RCT of multiple tDCS sessions targeting the left dACC to modulate CLBP's affective symptoms. Results are encouraging, including several possible tDCS-associated improvements. Better-powered RCTs are needed to confirm these effects. Future studies should also consider different stimulation schedules, additional cortical targets, high-density multi-electrode tDCS arrays, and multimodal approaches.
Asunto(s)
Síntomas Afectivos/diagnóstico , Síntomas Afectivos/terapia , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/terapia , Manejo del Dolor/métodos , Estimulación Transcraneal de Corriente Directa/métodos , Adulto , Síntomas Afectivos/psicología , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Dolor de la Región Lumbar/psicología , Masculino , Adulto JovenAsunto(s)
Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Conducta Adictiva/inducido químicamente , Dolor Crónico/tratamiento farmacológico , Trastornos Relacionados con Opioides/prevención & control , Esquema de Medicación , Humanos , Cuidados a Largo Plazo , Selección de Paciente , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Medición de RiesgoRESUMEN
BACKGROUND: Prescription opioid-acetaminophen products account for the majority of cases of acetaminophen-related acute liver failure in the United States. We sought to examine the frequency of opioid-acetaminophen overuse at the Providence VA Medical Center and improve the quality and safety of opioid-acetaminophen prescription practices in a system employing electronic health records and e-prescribing. RESULTS: During fiscal year 2011, the Providence VA pharmacy dispensed a total of 19,841 acetaminophen prescriptions to a total of 4455 different patients. There were only 15 acetaminophen prescriptions dispensed in excess of 4g/day, and there were only 14 patients exposed to a potential maximum daily dose of acetaminophen greater than 4g. CONCLUSIONS: The Providence VAMC appears to have a low rate of prescription acetaminophen misuse, in contrast to rates seen in previous studies. The VHA electronic health record, accessible to all healthcare providers, appears to offer considerable benefit in reducing the overuse of acetaminophen containing opioid products.
