Characterisation of the effects of pulsed radio frequency treatment of the dorsal root ganglion on cerebrospinal fluid cellular and peptide constituents in patients with chronic radicular pain: A randomised, triple-blinded, controlled trial.

INTRODUCTION: Chronic radicular neuropathic pain is a major clinical problem with a life time prevalence of more than 50%. Pulsed radiofrequency (PRF) treatment is a recognised therapy. However, the pathophysiology of chronic neuropathic pain (CNP) and the mechanism of action of PRF remains ill-defined. Improving our knowledge of the mechanisms of CNP and PRF action will enhance our ability to treat patients with this common debilitating problem more effectively. This study aims to characterise the CSF cellular and peptide constituents in patients with CNP and the effect of pulsed radiofrequency (PRF) on these constituents and reported pain. MATERIALS AND METHODS: Prospective randomised tripled-blinded control trial of patients receiving PRF treatment versus sham for radicular pain. All patients received local anaesthetic to the appropriate dermatome to confirm diagnosis. Clinical assessment using standard clinical assessment tools and examination of CSF using flow cytometry and ELISA for cellular and peptide constituents was carried out before and 3 months after treatment. RESULTS: Ten patients were randomised to PRF (n = 5) or Sham (n = 5) treatment. PRF resulted in a significant reduction in pain score (NRS) at 3 months (6.8 to 2.6, p < .05). PRF reduced the TNF-α concentration and CD3+ count in CSF. CD4/CD8 ratio of patients with CNP was lower than historical controls (1.4 versus 3.0-4.2). The majority of CD3+ cells in the CNP patients were activated effector memory cells (80%) versus the surveillance central memory cells (85%) seen in healthy controls. CONCLUSIONS: PRF is superior to local anaesthetic administration for the management of radicular pain and is associated with CSF constituent modulation in vivo. Patients with CNP have lymphocyte characteristics which suggest immune activation.

A micro-costing study: comparing a standard intravenous patient-controlled analgesia system with a novel sublingual patient-controlled analgesia system.

BACKGROUND: Judicious spending in healthcare is of paramount importance, particularly when introducing new devices or interventions. These products or interventions need to be economically efficient both directly and indirectly. An accepted method of cost estimation is micro-costing. Micro-costing involves direct enumeration and costing of every input consumed in the treatment of a particular patient when using new device, medicine or intervention. In our study, we investigated the cost of using a novel sublingual (SL) patient-controlled analgesia (PCA) device and compared it with our conventional intravenous (IV) PCA device. METHODS: A previous study performed in our institution produced a cost per use of IV PCA device at €97. This compared with a previous European study published in this journal in 2010 which showed a similar figure of €96 per use of IV PCA device. In our comparative study, we used a case record form (CRF) to incorporate a cost to all consumables used, staff time and equipment used to both the SL PCA and the IV PCA. RESULTS: A total of 60 patients of similar demographic were included in our study. The cost of an IV PCA episode was €97.89 and €182.32 for an SL PCA episode. Standl et al. (2010) showed that the average cost of an IV PCA episode was €96.40 with 78% of this being made up of staff time. SL PCA was more efficacious in certain patient groups and in certain surgical groups. CONCLUSION: After performance of a micro-costing study, the less costly IV PCA episode was statistically significant compared with a SL PCA episode. However, the associated staff costs were less with a SL PCA episode. We performed a micro-costing study on a novel sublingual PCA device and compared it with a conventional intravenous PCA device. All resources were included and compared.

Employee assistance programs, drug testing, and workplace injury.

INTRODUCTION: Little is known about the effects of employee assistance programs (EAPs) on occupational injuries. MATERIALS AND METHODS: Multivariate regressions probed a unique data set that linked establishment information about workplace anti-drug programs in 1988 with occupational injury rates for 1405 establishments. RESULTS: EAPs were associated with a significant reduction in both no-lost-work and lost-work injuries, especially in the manufacturing and transportation, communication and public utilities industries (TCPU). Lost-work injuries were more responsive to specific EAP characteristics, with lower rates associated with EAPs staffed by company employees (most likely onsite). Telephone hotline services were associated with reduced rates of lost-work injuries in manufacturing and TCPU. Drug testing was associated with reductions in the rate of minor injuries with no lost work, but had no significant relationship with lost-work injuries. PRACTICAL APPLICATIONS: This associational study suggests that EAPs, especially ones that are company-staffed and ones that include telephone hotlines, may prevent workplace injuries.

School and work status, drug-free workplace protections, and prescription drug misuse among Americans ages 15-25.

OBJECTIVE: We assessed the prevalence and characteristics of prescription drug misuse among youth ages 15-25 to examine differences by student and employment status, and associations with workplace antidrug policies and programs. METHOD: Multivariate logistic regressions analyzed associations in weighted data on the 20,457 young adults in the combined 2004-2008 National Surveys on Drug Use and Health. Demographic controls included sex, race, community size, and age group. RESULTS: After we accounted for demographic controls, at ages 15-25, students were less likely than nonstudents to misuse prescription drugs. Segmenting student from nonstudent groups, working consistently was associated with a further reduction in misuse for those ages 18-25. When we controlled for demographics and substance use history, both Employee Assistance Program (EAP) services and awareness that one's employer had a drug-free workplace policy were associated with significantly lower misuse of prescription drugs (OR = 0.85 for each program, 95% CI [0.73, 1.00] and [0.72, 1.00]). Associations of workplace antidrug policies and programs with marijuana use and with Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, criteria for alcohol abuse and dependence contrasted sharply with these patterns. All four aspects were significantly associated with lower marijuana use. None was associated with problem drinking. CONCLUSIONS: Protective effects of drug-free workplace policy and EAPs persist after other substance use was controlled for. Comparing the effects of workplace programs on illicit drug use and problem drinking versus prescription misuse suggests that those protective associations do not result from selection bias. Thus, drug-free workplace policies and EAPs appear to help protect younger workers against prescription misuse. If workplace substance use disorder programs focused prevention messages and interventions on prescription drug misuse, their impact on misuse might increase.

Perceived Unfair Treatment and Problem Drinking among U.S. Navy Careerists.

This mixed method paper assessed interrelationships of unfair treatment at work, stress, and problem drinking amongst a sample of U.S. Navy careerists. Survey data from current drinkers (n=2380) were analyzed, along with qualitative interviews from a quota sample of 81. More women than men (51.4% vs. 16.2%) reported gender unfair treatment; approximately 20% of respondents reported ethnic/racial unfair treatment. Unfair treatment was associated with likelihood of problem drinking, but associations were attenuated after adjusting for frequency of work problems and expecting alcohol to alleviate stress. Qualitative results revealed contexts of unfair treatment within bureaucratic structures, tradition, norms, and role modeling.

Postdisaster course of alcohol use disorders in systematically studied survivors of 10 disasters.

CONTEXT: Although several studies have suggested that alcohol use may increase after disasters, it is unclear whether any apparent postdisaster increases regularly translate into new cases of alcohol use disorders. OBJECTIVE: To determine the relationship of predisaster and postdisaster prevalence of alcohol use disorders and to examine the incidence of alcohol use disorders in relation to disasters. DESIGN: Data from 10 disasters, studied within the first few postdisaster months and at 1 to 3 years postdisaster, were merged and examined. PARTICIPANTS: Six hundred ninety-seven directly exposed survivors of 10 disasters. MEASURES: The Diagnostic Interview Schedule for DSM-III-R provided lifetime diagnoses of alcohol abuse and dependence, and onset and recency questions allowed a determination of whether the disorder had been present either prior to or following the event, or both. RESULTS: While the postdisaster prevalence of alcohol use disorders was 19%, only 0.3% of the sample developed an acute new postdisaster alcohol use disorder. Most of those in recovery, however, consumed alcohol after the disaster (83%) and coped with their emotions by drinking alcohol (22%). Those with a postdisaster alcohol use disorder were more than 4 times as likely as those without to cope with their disaster-related emotions by drinking alcohol (40% vs 9%). CONCLUSIONS: The vast majority of postdisaster alcohol use disorders represented the continuation or recurrence of preexisting problems. Findings suggest that those in recovery as well as those who drink to cope with their emotions represent groups warranting potential concern for postdisaster mental health intervention. Further research is needed to clarify the clinical significance of changes in alcohol use after disasters.

Substance-use problems: are uninsured workers at greater risk?

OBJECTIVE: This study examined how problem drinking and drug use and their related treatment received by workers varied by health insurance coverage and employment characteristics. METHOD: We used National Survey on Drug Use and Health data on civilian workers ages 18 years and older from the 2002 and 2003 public-use files. Multivariate logistic regressions estimated the relationship between workers' uninsured status and problem use, dependence, and treatment while controlling for worker demographics, education, income, and job characteristics. RESULTS: Controlling for differences in worker and workplace characteristics, uninsured workers were significantly more likely than privately insured workers to be illicit drug users or heavy drinkers. Among dependent workers, the lack of insurance was associated with a reduction in treatment received for problem drinkers (odds ratio = 0.31, p = .13). By contrast, a large, positive-albeit statistically nonsignificant-association between being uninsured and receiving treatment prevailed among uninsured workers using illicit drugs. Workplace substance-use policies were associated with a significant reduction in the odds of treatment received or treatment needed among problem drinkers without insurance coverage. Employee assistance programs were not good predictors of treatment received among uninsured workers. CONCLUSIONS: Uninsured workers were more likely to be heavy drinkers or illicit drug users than were workers with health insurance. Health insurance coverage was not significantly associated with treatment received among workers reporting problem use. Uninsured workers may be unable to benefit fully from employee assistance programs' treatment and referral services, whose utility depends on adequate behavioral health coverage for workers.

Substance abuse and the uninsured worker in the United States.

Although millions of US workers lack health insurance, the relationship of insurance coverage with substance abuse and access to workplace treatment services remains unexplored. Our analysis shows uninsured workers have higher rates of heavy drinking and illicit drug use than insured workers. Young and part-time workers are, moreover, less likely to have insurance coverage than workers with lower substance abuse risks. Compared to the insured, uninsured workers have less access to employee assistance programs (EAPs) and less drug and alcohol testing by employers. The effectiveness of workplace substance abuse programs and policies designed for insured populations is untested among uninsured workers. Issues include EAP effectiveness with referrals to public treatment and the return on investment for adding coverage of substance abuse treatment. Workers in countries with universal health insurance but inadequate treatment capacity may face similar problems to uninsured workers in the US.

Misuse of methamphetamine and prescription stimulants among youths and young adults in the community.

BACKGROUND: Gender differences in the prevalence and characteristics of misuse of methamphetamine (meth) and prescription stimulants were examined in a representative US sample of youths and young adults aged 16-25 (N=24,409). METHODS: Stimulant misusers were categorized into three mutually exclusive subgroups: meth users only, meth and prescription stimulant users, and prescription stimulant users only (e.g., Benzedrine, Ritalin, or Dexedrine). Multinominal logistic regression analyses identified the characteristics associated with misuse of meth and prescription stimulants. RESULTS: About 1 in 10 youths reported any misuse of stimulants in their lifetime. Prescription stimulant misuse occurred earlier and was more frequent than meth misuse. About 47% of meth misusers also reported prescription stimulant misuse. Among misusers of meth and prescription stimulants, males were more likely than females to misuse methylphenidate (82% versus 65%) but were less likely to misuse diet pills or amphetamines (37% versus 49%). Multinominal logistic regression analyses indicated that all subgroups of lifetime stimulant misuse were associated with past year substance abuse. The characteristics of meth misusers differed slightly from prescription stimulants misusers. CONCLUSIONS: Multidrug use is common among stimulant misusers. Parents should be informed about the risk of prescription stimulant misuse by their youths.

Employer costs of alcohol-involved injuries.

BACKGROUND: This study estimates the annual cost of alcohol-related injuries to employers in 1998-2000. METHODS: Incidence was estimated with occupational injury data, motor vehicle crash data and health care data for 1998-2000. Employer costs were estimated from federal estimates of injury costs by source of payment using data on the percentage of varied payment streams (e.g., health insurance, sick leave) paid by employers. RESULTS: The annual employer cost of alcohol-related injuries to employees and their dependents exceed US dollars 28.6 billion. Out of this, US dollars 13.2 billion comes from job-related, alcohol-involved injuries. The annual employer cost of motor vehicle crashes in which at least one driver was alcohol-impaired is over US dollars 9.2 billion. Out of this, only US dollars 3.4 billion comes from job-related alcohol involvement. CONCLUSION: Safety programs can reduce the fringe benefit bill without reducing the benefits offered to employees.

Concurrent use of methamphetamine, MDMA, LSD, ketamine, GHB, and flunitrazepam among American youths.

BACKGROUND: The magnitude and the characteristics of the use of methamphetamine, MDMA (Ecstasy), LSD (d-lysergic acid diethylamide), ketamine, GHB (gamma-hydroxybutyrate), and flunitrazepam (Rohypnol) were examined in a probability sample of the U.S. civilian population that included multiethnic urban, suburban, and rural youths aged 16-23 (N=19,084). METHODS: Data were drawn from the National Survey on Drug Use and Health (NSDUH). Logistic regression analyses were conducted to identify the characteristics associated with the use of each of these drugs and of multiple drugs. RESULTS: Approximately 20% of youths aged 16-23 reported having ever used one or more of these drugs. Less than 1% of club drug users used club drugs only, and 82% of them had ever used three or more drug classes. Females were more likely than males to report using multiple club drugs. Recent users of methamphetamine were most likely to be females and adolescents aged 16 or 17. Recent users of MDMA tended to be young adults aged 18-21 and residents of metropolitan areas. Most recent users of LSD were adolescents aged 16-19 and those in low-income families. Ketamine users were primarily employed youths. Staying in school and getting married were associated with decreased odds of club drug use. Club drug use was highly associated with the presence of criminal behaviors and recent alcohol abuse or dependence. CONCLUSIONS: Adolescents are more likely than young adults to use multiple drugs. The clustering of multidrug use and alcohol use disorder is a cause of concern.

Impact of the September 11 attack on flight attendants: a study of an essential first responder group.

This paper discusses a study (funded by the Center for Substance Abuse Prevention) of the health/mental health and work-related well-being of flight attendants in the aftermath of September 11. Flight attendants, as an occupational group, had a distinctive exposure to September 11. In addition to work-related exposure in the immediate aftermath of the attacks, flight attendants have experienced major and ongoing changes in their work environment and job description and many have been exposed to potentially traumatic incidents on the job. Analysis of survey and focus group data from flight attendants in the Association of Flight Attendants showed high reported stress and related mental health and behavioral impacts among flight attendants since September 11. A significant new finding is that the effect of continued trauma in the flight attendants' work environment impacted their ability to recover from the original trauma associated with the events of that day. This study highlights the role of the after-effects of a traumatic event on trauma response and suggests that direct exposure, as traditionally defined, is not necessarily a primary mediating factor in trauma response for this occupational group.

The relationship between employment and substance use among students aged 12 to 17.

PURPOSE: To examine the association between employment status and substance use among students aged 12 to 17 years. METHODS: Secondary analysis of data from the 1995 and 1996 National Household Surveys on Drug Abuse was conducted. The survey is a primary source of data on licit and illicit drug use among noninstitutionalized Americans aged 12 years or older. Participants are interviewed at their places of residence. Multiple logistic regression procedures yielded estimated associations. RESULTS: About one in six adolescents reported both going to school and holding a job. Approximately one-fourth of students smoked cigarettes, and one-third consumed alcohol in the past year. An estimated 1.6% of students were current heavy cigarette smokers, and 2.6% were current heavy alcohol users. One-year prevalence estimates of any illicit drug use and heavy illicit drug use were 16.7% and 1.8%, respectively. Among students employed full time, prevalence estimates increased to 9.7% for heavy cigarette smoking, 13.1% for heavy alcohol use, 38.1% for any illicit drug use, and 5.0% for heavy illicit drug use. Logistic regression analyses supported relatively high rates of cigarette use, alcohol use, illicit drug use, and heavy substance use among working students. Mental health problems, especially externalizing behavioral syndromes, were found to coexist with the use and heavy use of substances. The observed associations varied somewhat by gender. CONCLUSIONS: The workplace may be an appropriate venue for establishing substance use prevention and early intervention programs focused on younger workers, including adolescents who work part time.