Role of primary care physicians in intrathecal pain management: a narrative review of the literature.

OBJECTIVES: The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan. METHODS: The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors' clinical and research expertise. RESULTS: IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a µ-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist. CONCLUSIONS: Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.

Outcomes after supratherapeutic escitalopram ingestions.

Escitalopram (ESC) is a new selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. There are limited data regarding accidental and intentional ESC exposure. We conducted a retrospective chart review of isolated ESC ingestions reported to our regional poison center during 2003-2004. Twenty-eight patients met inclusion criteria. The average patient age was 28.1 years (range 2-75 years) and the average amount of ESC ingested was 62.5 mg (range 5-300 mg from 19 cases). The most common formulation ingested was the 20-mg tablet. There were eight accidental ingestions and 20 intentional overdoses. Six of the eight accidental ingestions were observed at home with follow-up in 24 h, and no adverse outcomes were reported. The other two accidental overdoses were observed in the Emergency Department (ED) and discharged home with no adverse events reported. Nineteen of the intentional overdoses were observed in the ED for approximately 4-6 h and discharged home or to an inpatient psychiatry ward. One of the intentional overdose patients was admitted for persistent lethargy, but had a good outcome. ESC toxicity can theoretically be life threatening, but no patients in our series had adverse sequealae after accidental or intentional overdose.