More Than Half of Surveyed Chronic Pain Patients Report Opioid-Induced Constipation Interview with:

Dr. Joseph Pergolizzi MD Senior Partner and Director of Research Naples Anesthesia and Pain Associates Naples, Florida Adjunct Assistant Professor Johns Hopkins University School of Medicine Baltimore, Maryland

Dr. Pergolizzi

Dr. Joseph Pergolizzi MD
Senior Partner and Director of Research
Naples Anesthesia and Pain Associates
Naples, Florida What is the background for this study? What are the main findings? 

Response: There are roughly 100 million Americans living with chronic pain and many battle debilitating side effects because of their pain medication, including Painstipation otherwise known as opioid-induced constipation (OIC.) In fact, OIC is the most common side effect with approximately 40-80 percent of patients on chronic opioid therapy experiencing it.

To better understand this community, the Painstipation survey, conducted by Salix Pharmaceuticals in partnership with the U.S. Pain Foundation, surveyed 441 U.S. adults with chronic pain who were on opioid therapy and suffering from OIC. It gave great insight into this community as it found:

  • More than half (51 percent) of chronic pain patients have been suffering from opioid-induced constipation  for three years or longer
  • Most patients (73 percent) agree that one of the biggest challenges of having OIC is that medications don’t work quickly enough to relieve pain associated with OIC.
  • 53 percent of patients say they want relief for OIC in under four hours
  • Only half of patients surveyed (73 percent) surveyed said they were informed by their doctors that taking opioid medications might result in constipation before they began taking them
  • 77 percent of respondents reported suffering from OIC for at least one year
  • When asked, roughly one-third (32 percent) of patients reported that their doctor does not talk to them specifically about potential adverse drug-to-drug interactions (DDI) of their current prescription and/or over-the-counter medications.

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Migraine Linked To Increased Risk of Heart Disease and Stroke Interview with:

Islam Elgendy MD Division of Cardiovascular Medicine University of Florida  

Dr. Elgendy

Islam Elgendy MD
Division of Cardiovascular Medicine
University of Florida What is the background for this study? What are the main findings? 

Response: Migraine headache is a prevalent medical condition, often being chronic and debilitating to many. Previous studies have shown that migraine, particularly migraine with aura, is associated with an increased risk of cardiovascular events. Recently, a number of these studies have reported long-term follow up data. To better understand the long-term morbidity that is associated with migraines, we performed a systematic evaluation to study the link between migraine and risk of cardiovascular and cerebrovascular events.

This study demonstrated that migraine is associated with an increased risk of major adverse cardiovascular and cerebrovascular events, which was driven by an increased long-term risk of myocardial infarction and stroke. This effect was predominantly observed in migraineurs who have aura.  Continue reading

Tai Chi At Least As Beneficial As Standard Therapy For Fibromyalgia Interview with:
“tai chi 11.4.09” by Luigi Scorcia is licensed under CC BY 2.0Chenchen Wang MD, MSc
Professor of Medicine
Tufts University School of Medicine
Director, Center For Complementary And Integrative Medicine
Division of Rheumatology
Tufts Medical Center Boston, MA 02111 What is the background for this study?

Response: Patients with chronic widespread pain often try many different types of pain medications, anti-depressants, physical therapy, and other approaches, and commonly find that none of these therapies work for them. Finding safe, effective approaches for pain management is an urgent priority. Previous evidence suggested that Tai Chi, a multi-dimensional mind-body practice that integrates physical, psychosocial, and behavioral elements, may be especially suited to address both chronic pain and associated psychological and somatic symptoms. In our most recent study published in the BMJ, we directly compared the effectiveness of Tai Chi versus aerobic exercise, which is a standard care non-drug treatment for fibromyalgia. Continue reading

Hand Osteoarthritis: Hydroxychloroquine No More Effective Than Placebo Interview with:
Dr Sarah Kingsbury PhD
Osteoarthritis Strategic Lead
Deputy Section Head, Musculoskeletal Medicine and Imaging
Leeds Institute of Rheumatic and Musculoskeletal Medicine
University of Leeds What is the background for this study? What are the main findings?

Response: Osteoarthritis of the hand is a painful and disabling condition, estimated to effect up to 31 per cent of people aged over 70. It can stop people from carrying out everyday activities and can limit their quality of life. The first-line pharmacological treatments for hand osteoarthritis, including paracetamol and non-steroidal anti-inflammatory drugs, are often not effective and are associated with side effects. Doctors have used hydroxychloroquine, an established treatment for rheumatoid arthritis, as an off-label alternative, supported by increasing evidence that inflammation is a factor in osteoarthritis. Until now, there has not been a large-scale study into whether using hydroxychloroquine works.

HERO was a 12 month randomised, double-blind, placebo controlled, pragmatic trial, designed with a view to replicate anecdotal reports of hydroxychloroquine use in clinical practice, and  powered to detect a moderate effect equivalent to that for NSAIDs in this population. The study involved 248 patients at 13 NHS hospitals in England: all had the condition for at least 5 years, had changes to the joints in their hands consistent with osteoarthritis and reported moderate to severe pain on at least half of the days in the previous three months to the study commencing.

Participants were randomised 1:1 to either hydroxychloroquine or placebo and followed up at 3 monthly intervals for 12 months. The study found that patients initially reported a small reduction in the severity of pain before the improvement plateaued. However, a similar amount of change was seen in both the group receiving hydroxychloroquine medication and the group taking the placebo.

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Migraine Linked To Increased Risk of Stroke, AFib, PE and Cardiovascular Disease Interview with:
“Headache.” by Avenue G is licensed under CC BY 2.0
Kasper Adelborg, MD, PhD
Postdoctoral Fellow
Department of Clinical Epidemiology
Aarhus University Hospital What is the background for this study? What are the main findings? 

Response: Around one billion people worldwide are affected by migraine. Migraine has considerable impact on quality of life and imposes a substantial burden on society. Migraine is primarily a headache disorder, but previous studies have suggested a link between migraine and stroke and myocardial infarction, particularly among women, while the link between migraine and other heart problems are less well known.

In this large register-based Danish study published in the BMJ, we confirmed that migraine is associated with increased risks of stroke and myocardial infarction, but we also found that migraine was associated with increased risks of other cardiovascular diseases (specifically, venous thromboembolism and atrial fibrillation). Migraine was not associated with increased risks of heart failure or peripheral artery disease.

In contrast to most previous studies, our study had a very large sample size and an age- and sex- matched comparison cohort from the general population, which allowed us to put migraine in a population context and to perform several subgroup analyses. Here, we found several interesting findings.

  • In general, the associations were strongest in the first year after diagnosis but persisted in the long term (up to 19 years after diagnosis).
  • Most associations applied to both migraine patients with aura (warning signs before a migraine, such as seeing flashing lights) and in those without aura, and in both women and in men. 

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Migraine Surgery Markedly Reduced Pain Intensity and Disability Interview with:
“Migraine” by makelessnoise is licensed under CC BY 2.0Lisa Gfrerer, MD PhD

Clinical Fellow in Surgery
Brigham and Women’s Hospital
William Gerald Austen MD
Chief, Plastic and Reconstructive Surgery
Chief, Division of Burn Surgery
Massachusetts General Hospital What are the main findings?

Response: Migraine surgery patients at our institution are chronic pain patients who have failed conservative therapy and are severely disabled by their disease.

We initiated this study to understand two important points. First, it was previously unclear how to categorize these patients in terms of pain intensity and disability on the spectrum of better known pain conditions such as chronic back pain/ nerve pain/ carpal tunnel.  This is very important to appreciate the extent of this disease. Second, instead of collecting migraine characteristic such as decrease in migraine days/ duration/ pain, we wanted to understand how functionally disabled these patients are in their daily lives and how much better they get after surgery. This is ultimately what matters to patients.

We therefore decided to evaluate our outcomes by using the Pain Self Efficacy Questionnaires (PSEQ). This validated pain questionnaire has been used to describe pain intensity/disability in patients with different acute and chronic pain conditions.

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Family Members of Patients Prescribed Opioids More Likely To Fill Opioid Prescriptions Themselves Interview with:
“Pills” by Victor is licensed under CC BY 2.0Marissa J. Seamans, Ph.D

Postdoctoral Fellow
Department of Mental Health
Johns Hopkins School of Public Health
Baltimore, MD 21205 What is the background for this study? What are the main findings?

Response: Many patients report sharing their prescriptions for opioids with family members. What we didn’t know is whether family members of opioid users are more likely to fill opioid prescriptions themselves than family members of non-opioid users. Our study found that the 1-year risk of prescription opioid initiation among family members of prescription opioid users was an absolute 0.71% higher than among family members of non-opioid users. The risks were particularly higher for initial prescriptions with refills or longer days supply.

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Survey Finds Americans Routinely Ignore Over-the-Counter Pain Medication Labels Interview with:

Charles Melbern (Mel) Wilcox, MD, MSPH Director of the division of Gastroenterology and Hepatology University of Alabama-Birmingham

Dr. Wilcox

Charles Melbern (Mel) Wilcox, MD, MSPH
Director of the division of Gastroenterology and Hepatology
University of Alabama-Birmingham What is the background for this survey? What are the main findings?

Response: Nearly every person experiences pain at some point in their life – for many, the pain is acute and occasional, but for others, the pain is chronic and can be debilitating. Research shows that more than 25.3 million Americans suffer from daily pain and, every year, consumers purchase more than $20 billion per year on over-the-counter (OTC) pain medicines. In my work with the American Gastroenterological Association, we set out to explore the behaviors, beliefs, and misunderstandings that Americans have when it comes to OTC pain medicines. We surveyed 1,015 U.S. adults and 251 gastroenterologists to gain insight on how they were approaching pain management and OTC pain medicine use.

The survey found that Americans are routinely ignoring OTC pain medicine labels and are not consulting their health-care professionals about their pain before taking OTC pain medicines. As a direct result, gastroenterologists are noticing their patients experiencing complications and unintentional overdose symptoms. They see an average of 90 overdose cases each year, about two a week, due to OTC pain medicine overdose.

Ninety percent of gastroenterologists believe their patients require more and better education on how to use OTC pain medicine safely. They find that patients are not fully understanding the harms associated with taking too much. When asked why patients take more than the recommended dose, Americans say that they are confident in their ability to manage their medication (32 percent) or they wanted to feel better faster, mistakenly thinking more medicine would be the solution (73 percent).

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Thunderclap Headache: Ottawa Rule To Exclude Subarachnoid Bleeding Interview with:

Jeff Perry, MD, MSc, CCFP-EM Professor, Department of Emergency Medicine Senior Scientist, Ottawa Hospital Research Institute Research Chair in Emergency Neurological Research, University of Ottawa Emergency Physician and Epidemiology Program The Ottawa Hospital Ottawa, Ontario

Dr. Perry

Jeff Perry, MD, MSc, CCFP-EM
Professor, Department of Emergency Medicine
Senior Scientist, Ottawa Hospital Research Institute
Research Chair in Emergency Neurological Research, University of Ottawa
Emergency Physician and Epidemiology Program
The Ottawa Hospital
Ottawa, Ontario What is the background for this study? What are the main findings?

Response: Headache accounts for about 1-2% of all emergency department visits.  One of the most feared diagnosis within these patients is subarachnoid hemorrhage. While investigations are clearly warranted for patients with a diminished level of consciousness or new focal neurological deficits, approximately 50% of patients with subarachnoid hemorrhage (SAH) have no focal or global neurological findings. Deciding whether to image headache patients with no deficits is difficult, especially since timely diagnosis and treatment results in substantially better outcomes.

The desire to never miss a subarachnoid hemorrhage, however, contributes to escalating neuroimaging rates and a dogmatic adherence to lumbar puncture, even if the scan is negative, despite the very high sensitivity of computed tomography. However, a recent population-based study suggested that over 5% of confirmed subarachnoid hemorrhages were missed at initial presentation, especially in smaller hospitals. Therefore, identifying which headache patients require investigations to rule-out SAH is of great importance.

We have previously derived (N=1,999) and refined (N=2,131) the Ottawa SAH Rule. In this study, we conducted an multicenter prospective cohort study at six tertiary care hospitals, and found that the Ottawa SAH Rule performed well, with an 100% sensitivity, and specificity of 13.6%.

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Pulsed Radiofrequency As a Surgical Free Approach To Low Back Pain Interview with:
Dr. Alessandro Napoli

Dipartimento di Scienze Radiologiche
Unità di Terapia con Ultrasuoni Focalizzati
Sapienza Università di Roma, Policlinico Umberto I
Rome What is the background for this study? What are the main findings?

Response: Low back pain and sciatica are very common conditions affecting at least 80% of the population (once in life) with detrimental impact on quality of life. Pain cause is often a lumbar disc herniation with sciatic nerve compression. Treatment strategy is primarily conservative (drugs and physical therapy) and when symptoms are persisting for more than 4 consecutive weeks, surgery is advocated.

Many patients prefer to avoid surgery for multiple reasons (recurrence rate, risk-related to the intervention and post-surgical sequela).

Technology advances with percutaneous techniques allowed more recently to fill the gap between conservative strategy and surgery for the management of lumbar disc herniation and related low back pain extending to the leg(s). Patients are offered local injection for symptoms relief with limited results. Therefore, other non-to-mini invasive approaches are clinically tested for prolonged clinical efficacy. Pulsed radiofrequency is a promising percutaneous approach mainly used for chronic pain. We aimed to test pulsed radiofrequency in patients refractory to conservative treatments, indicated to surgery.

Our study demonstrated that radiofrequency with pulsed technique, performed under CT image guidance, is able to control pain in a surgical-free, single session, lasting 10 minutes. The procedure is highly attractive since can be considered nearly risk-free with high rate of success. In our series 80% of patients treated with pulsed radiofrequency resulted pain free (VAS pain score 0 out of 10) at 1, 3 and 12 months follow-up; 90% did not required anymore surgery.

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