Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review.

OBJECTIVES: To investigate the prevalence of chronic pain and opioid management among patients with chronic kidney disease (CKD). DESIGN: Systematic review. METHODS: A systematic search was performed, including citations from 1960 to May 2015. The review highlights methodological quality assessment of the selected studies; prevalence of pain; type, dose, and reason for opioid use; effectiveness of pain control and associated adverse effects of opioids in CKD patients. RESULTS: Twelve of 131 articles met inclusion criteria. There were no randomized controlled trials (RCT) evaluable, and 12 were observational studies. Out of 12 studies, four were of high quality, six were of moderate quality, and the remaining two were low-quality studies. The studies were from different countries with sample size ranging from 10 to 12,782. Several studies showed a high prevalence of chronic uncontrolled pain. The effectiveness of different categories of opioids, dose, duration, and commonly prescribed opioids varied across studies. CONCLUSIONS: Based on a systematic review of the current literature, there is fair evidence for the high prevalence of chronic pain among patients with CKD, which is not being effectively managed, probably due to underprescription of analgesics or opioids in the CKD population. Clinicians are in need of additional and well-designed randomized control trials that focus on the indications for opioid therapy, appropriate opioid doses and dosing intervals, outcomes with adequacy of symptom control, and reporting on the incidence of adverse side effects.

Increased Incidence of Spinal Abscess and Substance Abuse after Implementation of State Mandated Prescription Drug Legislation.

OBJECTIVES: To investigate the incidence of spinal abscess and substance abuse in a tertiary care hospital after state legislation titled "House Bill 1" (HB1) mandated stricter regulation of prescription drugs of abuse in Kentucky in 2012. DESIGN: A retrospective case series study design was used to review the incidence of spinal abscess and drug abuse diagnoses admissions from 2010 to 2014. Variances in the incidence of spinal abscess and substance abuse were plotted across this time frame. RESULTS: The incidence of intraspinal abscess increased 1.56-fold in 2011 (n = 26) and 2012 (n = 25) relative to 2010 (n = 16). However, in 2013, the year following implementation of HB1 legislation, the incidence of intraspinal abscess increased 2.38-fold (n = 38) and then 4.19-fold (n = 67) in 2014. The incidence of intraspinal abscess in subjects with drug abuse diagnosis remained constant between 2010 (n = 3) and 2012 (n = 3). However, it increased twofold (n = 7) in 2013 and then ninefold (n = 27) in 2014. A correlation coefficient (rSAD ) of 0.775 revealed a strong association between the increase incidence of intraspinal abscess and diagnosis of drug abuse. CONCLUSIONS: The results of this retrospective study demonstrate an increased incidence of intraspinal abscess associated with drug abuse after passage of HB1 legislation regulating prescriptions of controlled medications in Kentucky. This increased incidence may be related to individuals relying on nonprescription drugs of abuse due to more highly regulated access to controlled prescription medications. However, additional factors unrelated to HB1 legislation must be taken into account.

Rehabilitation Outcomes in Spinal Abscess Patients With and Without a History of Intravenous Substance Abuse.

OBJECTIVE: The aim of the study was to compare functional outcomes of acute inpatient rehabilitation for spinal epidural abscess patients with and without history of intravenous substance abuse. DESIGN: This is a retrospective case series study in freestanding rehabilitation hospital. METHODS: Charts of 28 spinal epidural abscess patients admitted from January 2012 to September 2015: 13 with intravenous substance abuse and 15 without intravenous substance abuse were reviewed. Both groups received standard-of-care rehabilitation. Statistical analyses of Functional Independence Measure scores were conducted using individual 2 (substance use) × 2 (rehabilitation status) repeated measures analysis of variance. Functional outcomes were defined by total Functional Independence Measure scores as well as motor and cognitive subsets. Length of stay and morphine equivalents were also compared. RESULTS: There were no significant differences between the two groups. There was a significant main effect of treatment on total Functional Independence Measure scores (P < 0.001), Functional Independence Measure motor scores (P < 0.001), and Functional Independence Measure cognitive scores (P < 0.01) from admission to discharge. Subsequent Student's t tests revealed that the scores of both groups significantly improved on all Functional Independence Measure components. There were no group differences on length of stay and morphine equivalents at discharge. CONCLUSIONS: Acute inpatient rehabilitation can effectively improve functional outcomes in spinal epidural abscess patients with or without intravenous substance abuse, even though these two patient groups can vary in clinical factors.

The Effect of Current Low Back Pain on Volitional Preemptive Abdominal Activation During a Loaded Forward Reach Activity.

BACKGROUND: A volitional preemptive abdominal contraction (VPAC) supports trunk stability during functional activity. Pain-free individuals can sustain VPAC during function, but such has not been reported for individuals with current low back pain (cLBP). OBJECTIVE: To examine whether cLBP affects VPAC performance during a loaded forward reach (LFR) task. DESIGN: Observational crossover study. SETTING: Laboratory. PARTICIPANTS: A total of 18 controls and 17 subjects with cLBP with pain ratings of 1/10 to 4/10 on a visual analog scale. INTERVENTIONS: Transverse abdominis (TrA) thickness measurements were recorded by blinded researchers from M-mode ultrasound imaging during 4 conditions: (1) quiet standing without abdominal drawing-in maneuver (ADIM); (2) quiet standing with ADIM; (3) LFR without ADIM; and (4) LFR with ADIM. A physical therapist with 29 years of experience collected historical and examination data. MAIN OUTCOME MEASURES: TrA muscle thickness (mm). RESULTS: A 2 (group) × 2 (contraction) × 2 (reach) analysis of variance demonstrated a significant group × contraction interaction (F [1, 31] = 4.499, P = .04) where ADIM produced greater TrA thickness increases in PLBP subjects (2.18 mm) versus controls (1.36 mm). We observed a significant main effect for reach (F [1, 31] = 14.989, P < .001), where LFR activity produced a greater TrA thickness (6.15 ± 2.48 mm) versus quiet standing (5.30 ± 2.12 mm). CONCLUSIONS: Subjects with cLBP demonstrated a greater increase in TrA activation during ADIM versus controls.

The Effect of Distractive Function on Volitional Preemptive Abdominal Contraction During a Loaded Forward Reach in Normal Subjects.

BACKGROUND: Volitional preemptive abdominal contraction (VPAC) is used to protect the spine and prevent injury. No published studies to data have examined the effect of distraction on VPAC use during function. OBJECTIVE: To examine the effect of an auditory distraction ("Stroop task") on healthy subjects' ability to sustain VPAC by use of the abdominal drawing-in maneuver during loaded forward reach. DESIGN: Within-subjects, repeated-measure cohort design. SETTING: Clinical laboratory setting. PARTICIPANTS: Convenience sample of 42 healthy individuals (ages 20-57 years). METHODS: Transversus abdominis (TrA) thickness was measured with M-mode ultrasound imaging. Each subject performed Stroop versus no Stroop during 4 conditions: (1) without VPAC, quiet standing; (2) with VPAC, quiet standing; (3) without VPAC, forward reach; and (4) with VPAC, forward reach. An investigator blinded to the conditions measured the first 10 subjects to establish intratester reliability of probe/transducer placement and TrA measurement. DATA REDUCTION: TrA thickness (mm) change represented VPAC performance. A single investigator measured onscreen TrA thickness twice at each second from second-6 through -10 on a recorded ultrasound imaging sequence. RESULTS: A 2 (Stroop) × 4 (Activity) repeated-measures analysis of variance found no significant Stroop × Activity interaction [F(3, 93) = 0.345, P = .793] and no main effect for Stroop [F (1,31) = 1.324, P = .259] but found a significant main effect for activity [F (3,93) = 17.729, P < .001]. Tukey post-hoc pairwise comparisons demonstrated significant differences between VPAC versus no-VPAC conditions, except between quiet standing/yes-VPAC and loaded forward reach/no-VPAC conditions (P = .051). The interclass correlation coefficient (3,2) for probe/transducer placement reliability was 0.87, 0.91, 0.92, and 0.93 for conditions 1-4, respectively. The interclass correlation coefficient (3,2) for TrA measurement reliability was 0.96, 0.99, 0.99, and 0.99 for conditions 1-4, respectively. CONCLUSION: A distracting executive function (Stroop task) did not produce a significant negative impact on normal individuals' ability to sustain a VPAC during quiet standing or loaded forward reach activities. LEVEL OF EVIDENCE: II.

Implications of bariatric surgery on chronic pain and opioid use.

Questions from patients about pain conditions, pain treatment, and responses from authors are presented to help educate patients and make them effective self-advocates. The topics addressed in this report are implications of bariatric surgery or weight loss surgery on chronic pain and opioid use, what to expect with regards to pain control, and the need to change opioid dose after bariatric surgery.

Chronic opioid pain management for chronic kidney disease.

Questions from patients about pain conditions, pain treatment, and responses from authors are presented to help educate patients and make them effective self-advocates. The topics addressed in this issue are renal or kidney failure and chronic pain management with opioids, morphine, and oxycodone effect in the body over a period of time. This includes process of absorption, distribution, localization in tissues, biotransformation and excretion in chronic kidney disease, expected side effects and recommendations.

Hypogonadism associated with long-term opioid therapy: A systematic review.

BACKGROUND: Sexual dysfunction and Opioid-Induced Sexual Hormone Deficiency (OPISHD) have been associated with patients on long-term opioid pain therapy. There have been few comprehensive reviews to establish a relation between hypogonadism with chronic opioid pain management. The OPISHD is often not treated and literature guiding this topic is scarce. OBJECTIVE: To investigate hypogonadism associated with long-term opioid therapy based on qualitative data analysis of the available literature. STUDY DESIGN: Systematic review. INTERVENTIONS: The review included relevant literature identified through searches of PubMed, Cochrane, Clinical Trials, US National Guideline Clearinghouse, and EMBASE, for the years 1960 to September 2013. The quality assessment and clinical relevance criteria used were the Cochrane Musculoskeletal Review Group Criteria for randomized control trials and the Newcastle-Ottawa Scale Criteria for observational studies. The level of evidence was classified as good, fair, and poor, based on the quality of evidence. MAIN OUTCOME MEASURES: The primary outcome measures were clinical symptoms and laboratory markers of hypogonadism. Secondary outcome measure was management of OPISHD. RESULTS: Thirty-one studies were identified, of which 14 studies met inclusion criteria. There were no randomized control trials and eight of 14 studies were of moderate quality. The remaining studies were of poor quality. Four studies report most patients on long-term oral opioid therapy have associated hypogonadism and three studies of patients receiving intrathecal opioid therapy suggest that hypogonadism is common. CONCLUSIONS: There is lack of high-quality studies to associate chronic opioid pain management with hypogonadism. At present, there is fair evidence to associate hypogonadism with chronic opioid pain management, and only limited evidence for treatment of OPISHD.

Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache.

BACKGROUND: Cervicogenic headache is a secondary headache that has a source in the upper cervical spine. There is a small but growing body of evidence to establish effectiveness of radiofrequency (RF) neurotomy, and the pulsed RF (PRF) procedure for management of cervicogenic headache. OBJECTIVE: To investigate the clinical utility of RF neurotomy, and PRF ablation for the management of cervicogenic headache. STUDY DESIGN: Systematic review. METHODS: The review included relevant literature identified through searches of PubMed, Cochrane, Clinical trials, U.S. National Guideline Clearinghouse and EMBASE from 1960 to January 2014.The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria for randomized control trials and the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and poor based on the quality of evidence. OUTCOMES MEASURED: The primary outcome measures were reduction in pain scores and improvement in quality of life. RESULTS: The primary outcome measures were headache relief and improved quality of life. Twenty five studies were identified for full text review of these, 9 studies met inclusion criteria. There were 5 non-randomized, among them 4/5 were of moderate quality, 3/5 showed RF ablation and 1/5 showed PRF as an effective intervention for cervicogenic headache. There were 4 randomized trials among them 2/4 were of high quality, 3/4 investigated RF ablation as an intervention for CHA, 1/4 investigated PRF ablation as an intervention for CHA and none of the randomized studies showed strong evidence for RF and PRF ablation as an effective intervention for CHA. LIMITATIONS: In the selected studies there were inconsistencies between randomized trials, flaws in trial design, and gaps in the chain of evidence. CONCLUSION: There is limited evidence to support RF ablation for management of CHA as there are no high quality RCTs and/ or multiple consistent non-RCTs without methodological flaws. There is poor evidence to support PRF for CHA as there are no high quality RCTs or Non-RCTs.

The Effects of Volitional Preemptive Abdominal Contraction on Postural Control Responses in Healthy Subjects.

OBJECTIVE: To investigate the effect of volitional preemptive abdominal contraction by using an abdominal bracing maneuver (ABM) on postural control responses. DESIGN: A within-subjects, repeated-measure, experimental design. SETTING: Laboratory. PARTICIPANTS: Sixty-five healthy subjects between 18 and 50 years of age. METHODS: Subjects performed ABM alternating with No-ABM during 2 rounds of 2 Neurocom computed dynamic posturography tests: the Motor Control Test (MCT) and conditions 1 (eyes open), 2 (eyes closed), and 5 (eyes closed, sway-referenced support) of the Sensory Organization Test (SOT). MAIN OUTCOME MEASUREMENTS: (1) MCT Response Latency (milliseconds) and Response Scaling (magnitude of active postural correction) and (2) SOT Equilibrium Scores and 2-Dimensional Sway (°/second), and SOT Movement Strategy, which measure postural sway and movement strategies (ankle versus hip strategy), respectively. RESULTS: The use of ABM (versus No-ABM) produced: (1) a small but statistically significant decrease in SOT Equilibrium Score for condition 2 (-1.0%; P = .004); (2) an increase in SOT 2-Dimensional Sway (°/second) during conditions 1 (16.9%; P = .0001) and 2 (15.0%; P = .0001); (3) a small decrease in SOT Movement Strategy scores during condition 1 (-0.5%; P = .001) and condition 2 (-1.0%; P = .017); and (4) a reduction of MCT Response Latency by 3 milliseconds (-2.1%; P = .005) and reduction of Response Scaling by 0.33°/second (-9.2%; P = .001). CONCLUSION: Individuals can incorporate the ABM without substantively altering postural control. Although selected SOT and MCT scores exhibited small decreases in postural response integrity, those outcomes did not reflect functionally meaningful changes. These findings can enhance clinicians' confidence in prescribing the ABM as a means to protectively stabilize the spine and potentially prevent injury in healthy subjects without concern for reducing postural control, especially during more complex postural perturbations that introduce sensory conflict.

Effect of recurrent low back pain history on volitional pre-emptive abdominal activation during a loaded functional reach activity.

STUDY DESIGN: A 2 (group) × 2 (abdominal contraction) × 2 (reach activity) crossover mixed design with repeated measures for contraction and activity examined the effects of a loaded (4.6 kg) forward-reach activity and abdominal drawing-in maneuver (ADIM) on transversus abdominis (TrA) contraction in subjects with nonspecific low back pain (NSLBP) history versus controls. OBJECTIVE: We measured TrA contraction during a loaded forward-reach activity while using the ADIM and examined if a NSLBP history affects TrA activity. SUMMARY OF BACKGROUND DATA: The ADIM supports trunk stability during function. Clinicians incorporate ADIM during patients' functional tasks. Pain-free individuals can sustain ADIM during function, such as forward-reach. However, this has not been tested in those with a NSLBP history. METHODS: Eighteen normal subjects and 18 subjects with a history of NSLBP participated. A blinded investigator recorded M-mode ultrasound imaging measurements of TrA thickness (mm) during 4 conditions as follows: (1) quiet standing without ADIM; (2) quiet standing with ADIM; (3) loaded forward-reach without ADIM; and (4) loaded forward-reach with ADIM. RESULTS: A mixed analysis of variance demonstrated a significant main effect for group (F [1, 34] = 5.404, P = 0.026; ), where TrA thickness was greater for NSLBP history (7.41 + 2.34 mm) versus controls (5.9 + 2.46 mm). A significant main effect was observed for abdominal contraction (F [1, 34] = 49.57, P < 0.0001; ), where TrA thickness was greater during ADIM (7.47 + 2.7 mm) versus without ADIM (5.84, 1.92 m). A significant main effect was observed for forward-reach activity (F [1, 34] = 12.79, P = 0.001; ), where TrA thickness was greater during a loaded forward-reach (7.04 + 2.6 mm) versus quiet standing (6.2 + 2.4 mm). There were no significant interactions. CONCLUSION: Individuals can use a volitional pre-emptive ADIM for trunk protection during loaded forward-reach, potentially reducing injury risk. A NSLBP history increases TrA activation during ADIM, suggesting an enhanced protective role. LEVEL OF EVIDENCE: 2.