Concurrent Pain Research Articles

Correlates of opioid and benzodiazepine co-prescription among people living with HIV in British Columbia, Canada: A population-level cohort study

Background:Co-prescribing benzodiazepines and opioids is relatively contraindicated due to the possible overdose risk. However, people living with HIV (PLWH) may have concurrent psychiatric and/or chronic pain diagnoses that may lead to the use of opioids and/or benzodiazepines for symptomatic treatment. Consequently, some PLWH may be at-risk for the health harms associated with the co-prescribing of these medications. Given this, the objectives of this study were to first examine the prevalence of opioids and benzodiazepines co-prescribing, and second, to characterize patient factors associated with the co-prescribing of opioids and benzodiazepines among PLWH in British Columbia (BC), Canada.Methods:Using data derived from a longitudinal BC cohort, we used bivariable and multivariable generalized estimating equation models to establish the prevalence of a benzodiazepine and opioid co-prescription and determine factors associated with this practice.Results:Between 1996 and 2015, 14 484 PLWH were included in the study and were followed for the entire study period. At baseline, 548 people (4%) were co-prescribed opioids and benzodiazepines, 6593 (46%) were prescribed opioids only, 2887 (20%) were prescribed benzodiazepines only, and 4456 (31%) were prescribed neither medication. A total of 3835 (27%) participants were prescribed both medications at least once during the study period. Factors positively associated with concurrent opioid and benzodiazepine prescribing included: depression/mood disorder [adjusted odds ratio (AOR) = 1.32; 95% confidence interval (CI) = 1.22–1.43] and anxiety disorder (AOR = 1.45; 95% CI = 1.27–1.66), whereas female sex (AOR = 0.76; 95% CI = 0.64-0.91) and substance use disorder (SUD) (AOR = 0.82; 95% CI = 0.74–0.90) were negatively associated with the outcome.Conclusion:Our findings indicate that co-prescription of opioids and benzodiazepines was seen at some point during study follow-up in over a quarter of PLWH. Given the known risks associated with this prescribing practice, future research can focus on the outcomes of co-prescribing among this patient population and the development of strategies to reduce the co-prescribing of opioids and benzodiazepines.

Momentary assessment of everyday physical pain in outpatients with borderline personality disorder.

Borderline personality disorder (BPD) is a severe psychiatric disorder associated with dysregulation in multiple domains of functioning. Physical health, and specifically pain, is one such domain that has gone understudied. Although evidence suggests that BPD is associated with chronic pain, few studies have examined nonchronic pain in the disorder. The current study used ambulatory assessment to examine momentary physical pain in everyday life in BPD outpatients (N = 26) and community comparisons (COM; N = 26) not in treatment for chronic pain (Nobservations = 5,458). We predicted and observed that BPD outpatients would report greater pain intensity and greater pain variability than COM comparisons. We also examined the relationship of pain and emotion dysregulation, a core feature of BPD, by testing the association between pain and negative affect concurrently and lagged over time. We predicted that momentary pain and negative affect would be associated in both groups, but that pain would predict negative affect more strongly in the BPD group. As predicted, concurrent pain and negative affect were associated in both groups, and groups differed significantly in terms of the association of lagged pain and next-assessment negative affect, with a negative association in the COM group. The current study represents a preliminary first step, finding that pain is relevant to the everyday experience of BPD individuals. This pain propensity may contribute to the elevated prevalence of BPD in chronic pain samples. Further, BPD individuals demonstrated emotional reactivity to pain, suggesting that pain may be a contributor to emotion dysregulation in this disorder. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The impact of comorbid pain and depression in the United States: results from a nationally representative survey.

Background and aims The co-morbidity between pain and depression is a target of interest for treatment. However most of the published literature on the topic has used clinical cohorts as the population of interest. The goal of this study was to use a nationally representative sample to explore how health outcomes varied across pain and depression status in a cohort sampled from the general US population. Methods This was a cross-sectional analysis of adults ≥18 years in the 2009-2010 National Health and Nutrition Examination Survey. The cohort was stratified into: no pain/depression, pain alone, depression alone, and pain with depression. The primary outcome was self-reported general health status, and secondary outcomes were healthcare visits, overnight hospital stays and functional limitation. Survey weighted logistic regression was used to adjust for potential confounders. Results The cohort consisted of 4,213 individuals, of which 186 (4.4%) reported concurrent pain and depression. 597 (14.2%) and 253 (6.0%) were classified with either pain or depression alone, respectively. The majority of individuals with co-morbid pain and depression reported poor health (65.1%, p<0.001) and were significantly more likely than those with neither condition to rate their health as poor after adjustment (OR: 7.77, 95% CI: 4.24-14.26, p<0.001). Those with pain only or depression only were also more likely to rate their health as poor, albeit to a lesser extent (OR: 2.21, 95% CI: 1.21-2.34, p<0.001; OR: 3.75, 95% CI: 2.54-5.54, p<0.001, respectively). A similar pattern was noted across all secondary outcomes. Most notably, those with co-morbid pain and depression were the most likely to endorse functional limitation (OR: 13.15, 95% CI: 8.00-21.61, p<0.001). Comparatively, a similar trend was noted amongst those with pain only or depression only, though with a reduced effect size (OR: 4.23, 95% CI: 3.12-4.77, p<0.001; OR: 5.13, 95% CI: 3.38-7.82, p<0.001). Conclusions Co-morbid pain and depression in the general population resulted in markedly worse outcomes versus isolated pain or depression. Further, the effect appears to be synergistic. Given the substantial burdens of pain and depression, future treatments should aim to address both conditions simultaneously. Implications As a result of the co-morbidity between pain and depression, patients presenting with either condition should increase the index of suspicion among clinicians and prompt screening for the reciprocal condition. Early intervention for co-morbid pain and depression has the potential to mitigate future incidence of chronic pain and major depression.

Symptom severity and quality of life in patients with concurrent neck pain and dizziness

Purpose: There is little knowledge on how neck pain impacts dizzy patients, and if different diagnoses of dizziness associate with neck pain. The aim was to examine differences in dizziness severity, quality of life and demographics in dizzy patients with and without neck pain. Additionally, we examined if neck pain was associated with a non-vestibular or vestibular diagnosis.Methods: We included 236 consecutive patients referred to an otorhinolaryngological university clinic for vertigo and balance problems. The patients were divided in two groups: Patients with and without neck pain. Patient-reported outcomes measures were the Dizziness Handicap Inventory, RAND-12, neck pain and symptom duration.Results: A total of 59% of the patients reported neck pain. Patients with neck pain reported poorer quality of life (p < .001) and worse handicap due to dizziness (p < .001). There were no associations between reported neck pain and dizziness of non-vestibular or vestibular origin (p = .29).Conclusion: Neck pain is a common complaint among dizzy patients. Patients with concurrent dizziness and neck pain should warrant attention due to poorer general and dizziness-related quality of life. This finding appears unrelated to whether or not they receive a peripheral vestibular diagnosis.IMPLICATION FOR REHABILITATIONNeck pain is common in patients with dizziness and associated with higher dizziness handicap and lower quality of life.Neck pain should be addressed specifically in patients assessed for dizziness, irrespective of diagnosis.Further research is needed to better understand the interactions between neck pain and dizziness.

Analgesic prescribing trends in a national sample of older veterans with osteoarthritis: 2012-2017.

Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.

Factors Associated With Opiate Use Among Psychiatric Inpatients: A Population-Based Study of Hospital Admissions in Ontario, Canada.

Background:Use of opiates, including synthetic opioids, is associated with a number of negative consequences, including increased risk of opioid use disorders and other mental health conditions. However, studies are limited in examining patterns of opiate use among persons in inpatient psychiatry, particularly those that consider the relationship between pain and opiate use.Objective:This study examined the prevalence in the prior 12 months to admission and patterns of opiate use and pain in a population-based study of persons admitted to inpatient psychiatry in Ontario, Canada.Methods:We conducted retrospective cross-sectional study of 165 434 persons admitted to inpatient psychiatry between January 1, 2006 and December 31, 2017. Using data from the Resident Assessment Instrument for Mental Health, we examined prevalence and factors associated with opiate use in the prior 12 months by a number of patient characteristics, including demographics, mental and physical health status, concurrent substance use, pain severity and frequency, and health region of residence.Results:The prevalence of opiate use within 12 months of admission was 7.5%, between 17% and 22% among those experiencing daily pain, and 27% among persons with a primary substance use disorder. Multivariable analyses revealed strong associations among demographic and clinical variables with opiate use (c = 0.91), including being of younger age, use of other substances, greater frequency and severity of pain, and health region of residence.Conclusion:The strong relationship between pain and opiate use in this population, and the regional variation in this pattern, supports the need for integrated care for mental illness and substance use, and therapeutic approaches to pain management that reduce risks of problems associated with substance use for persons with mental health conditions.

Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial

Effective postoperative pain management is a crucial component of recovery following surgery. Narcotics are a cornerstone of postoperative analgesia, but can require a redosing requirement, encompass a lengthy list of side effects and adverse reaction risks, as well as carry a dependency potential. The national focus on decreasing opioid use has directly impacted postoperative pain management. Previous studies have reported the beneficial use of a single intraoperative injection of extended-release liposomal bupivacaine in postoperative pain management, however the same results have not been extensively studied in the urogynecology literature. We sought to evaluate cumulative postoperative vaginalpain on days 1 and 3 after posterior vaginal wall surgery comparing studymedication (extended-release liposomal bupivacaine) to placebo (saline). Secondary aims were to evaluate vaginal pain on postoperative day 7 and total morphine-equivalent narcotic usage on days 1, 3, and7. This is a randomized, double-blinded, placebo-controlled trial with 100 subjects recruited from Walter Reed National Military Medical Center urogynecology clinic. All subjects were age >18 years and scheduled for surgery involving the posterior vaginal wall or muscularis (including posterior colporrhaphy, colpocleisis, sphincteroplasty, perineorrhaphy), excluding those with regular narcotic usage or concurrent pain management requiring the use of epidural anesthesia. A sample size of 96 patients was calculated. Subjects were randomized to receive either 20 mL of extended-release liposomal bupivacaine (Exparel) (Pacira Pharmaceuticals Inc, Parsippany, NJ) or 20 mL of placebo (saline) at the end of surgery. Concealed syringes were used and injected immediately postoperative into the lateral vaginal wall/levator muscle area and perineal body. In-house morphine-equivalent narcotic usage was recorded along with the postoperative day 1 pain scores. Patients were contacted by telephone on postoperative days 3 and 7. Vaginal pain scores were evaluated using the Defense and Veterans Pain Rating Scale, cumulatively and on days 1, 3, and 7. Overall morphine-equivalent narcotics were compared between the 2 groups. From October 2014 through August 2017, 100 patients were enrolled and completed the study; 49 (49%) of the patients were randomized to the study group and 51 (51%) were in the placebo group. There was no significant difference between vaginal pain scores between the study group and the placebo group (postoperative day 1: study medication median score 1 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P= .59]; postoperative day 3: study medication median score 2 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P= .20]; postoperative day 7: study medication median score 3 [interquartile range 1-4], placebo median score 1.5 [interquartile range 0-3] [P= .06]). Cumulative pain scores postoperative day 1-7 were also not significant (study medication median score 6 [interquartile range 1-10], placebo median score 4 [interquartile range 1-8] [P= .14]). Multivariate model for the presence of vaginal pain was calculated and after controlling for body mass index, age, and combined laparoscopy surgery, there was no significant difference between the study and the placebo groups (P= .62). There was no statistically significant difference in morphine equivalents for the 2 groups: study medication 112.5 (interquartile range 45-207) and placebo 101.5 (interquartile range 37.5-195), P= .81. The use of extended-release liposomal bupivacaine in posterior vaginal wall surgeries, injected into the lateral posterior vaginal wall and perineal body, does not provide a significant decrease in postoperative pain or decrease narcotic medication usage when compared to saline.

Predictors of Alcohol Use Disorders Among Baby Boomers Across the Life Course.

Research suggests that baby boomers entering older adulthood may possess unique alcohol use patterns over time. Using the life course perspective as a guiding framework, this empirical study sought to examine correlates of alcohol use disorders among baby boomers by examining representative data from the National Survey on Drug Use and Health at two points in time, 1998 (N = 6,213) and 2010 (N = 5,880). Results from logistic regression analyses suggest that predictors of alcohol use disorders evolve over time as baby boomers continue to age. Risk factors for alcohol use disorders among baby boomers may include concurrent unprescribed pain reliever use, p < .01, while protective factors such as income, p < .01, and social supports, p = .01, may be of increased importance. Based on the findings of this study, practice implications and future research are discussed.

Effects of trait anxiety, somatosensory amplification, and facial pain on self-reported oral behaviors.

Oral behaviors are activities, like gum chewing, teeth clenching, and biting of objects, that go beyond normal functioning demands and contribute to the onset of temporomandibular disorders (TMD). Somatosensory amplification refers to the tendency to experience somatic sensations as intense, noxious, and disturbing and is related to bodily hypervigilance. Clinical experience suggests that individuals with bodily hypervigilance also present with occlusal hypervigilance and continuously check their occlusion. This study aimed at investigating whether somatosensory amplification and trait anxiety, a characteristic correlated with hypervigilance, are associated with a greater incidence of oral behaviors, and verifying how self-reported facial TMD pain affect this relationship. The State-Trait Anxiety Inventory, the Somatosensory Amplification Scale, the Oral Behavior Checklist (OBC), and the TMD-Pain Screener Questionnaire were filled out by 255 University students with self-reported facial TMD pain (PAIN group; 47 subjects, 24.8 ± 4.2years) and without pain (CTR group; 208 subjects, 26.0 ± 4.8years) using a web survey. Trait anxiety, somatosensory amplification, and OBC scores were greater in the PAIN than CTR group (all p < 0.05). Trait anxiety and somatosensory amplification were positively associated with the frequency of oral behaviors, as measured with the OBC (all p < 0.05). A significant effect of the interaction study group*trait anxiety (p = 0.028) on OBC scores was found. Individuals with greater trait anxiety and somatosensory amplification report more frequent oral behaviors. The relationship between anxiety and oral behaviors is affected by concurrent facial pain. Individuals with increased trait anxiety and concurrent facial pain report more frequent oral behaviors than those without pain. Clinicians should evaluate patients' anxiety and somatosensory amplification before starting dental treatment.

Association of metabolic syndrome with knee and hand osteoarthritis: A community-based study of women

ObjectiveIt is unclear whether the association between osteoarthritis (OA) and metabolic syndrome (MetS) varies with the site of the affected joint and the presence of pain. Our aim was to describe the association between MetS and radiographic OA (ROA) affecting the knee or the hand in the presence or absence of concurrent joint pain. MethodsCross-sectional data of 952 women, aged 45–65years from the Chingford study, a population-based longitudinal cohort of middle-aged women initiated in 1988–1989 in London (UK), was analysed. MetS was defined using the National Cholesterol Education Program Treatment Panel III criteria. Data was collected on components of MetS: waist circumference, triglycerides, high-density lipoprotein (HDL), blood pressure and blood glucose. The outcome was four knee and hand OA groups: painful ROA, ROA only, pain only and neither ROA nor pain (reference category). Multinomial logistic regression models adjusted for age and body mass index (BMI) were used to evaluate the effect of presence of MetS and its individual components on OA subgroups for knee and hand separately. Results952 eligible women, aged 45–65years was analysed. A significant association was observed between the presence and the number of MetS with painful knee ROA when adjusted for age; however, this association disappeared when BMI was included in the model. In contrast, the presence and the number of MetS were associated with painful interphalangeal (IPJ) OA after adjusting for both age and BMI. Four out of the five MetS components, including triglycerides, HDL-c, hypertension and glucose, were associated with painful IPJ OA. ConclusionsMetS is associated with painful IPJ OA but not with knee OA once BMI is taking into consideration. Further attention to MetS and OA at different sites is needed to understand the metabolic phenotype in OA.

Mechanical/thermal sensitivity and superficial temperature in the stump of long-term tail-docked dairy cows.

BackgroundTail docking of dairy cows is a painful procedure that affects animal welfare level. The aims of this study were first to evaluate the response to mechanical and thermal stimulation, and second to determine the superficial temperature of the stump of tail-docked dairy cows.MethodsOne hundred and sixty-four dairy cows were enrolled. From these, 133 cows were assigned to the tail-docked (TD) group and 31 cows were selected as control animals. The following sensory assessments to evaluate pain in tail-docked cows were performed. Sensitivity of the tail region in both groups of animals was evaluated using a portable algometer. Cold and heat sensitivity assessment was performed using a frozen pack (0 °C) and warm water (45 °C), respectively. Pinprick sensitivity was evaluated using a Wartenberg neurological pinwheel. Superficial temperature was evaluated using a thermographic camera. All sensory assessments and superficial temperature were evaluated in the ventral surface of the tail stump (TD) and tail (C).ResultsPressure pain threshold was lower in TD cows (5.97 ± 0.19 kg) compared to control cows (11.75 ± 0.43 kg). Heat and cold sensitivity was higher in the TD cows compared to control cows with 29% and 23% of TD cows responding positively, respectively. Similarly, after pinprick sensitivity test was performed, 93% of TD cows elicited a positive response to stimulation. Tail-docked cows had lower superficial temperature (26.4 ± 0.27 °C) compared to control cows (29.9 ± 0.62 °C).DiscussionPressure pain threshold values in both groups of animals were higher than those previously reported for TD pigs, sows and cows. In contrast, pinprick stimulation evaluates the presence of punctate mechanical hyperalgesia/allodynia, usually related to traumatic nerve injury, and this association may reveal that it is possible that these animals developed a disorder associated to the development of a tail stump neuroma and concurrent neuropathic pain, previously reported in TD lambs, pigs and dogs. Thermal sensitivity showed that TD cows responded positively to heat and cold stimulation. These findings suggest that long-term TD cows could be suffering hyperalgesia/allodynia, which may be indicative of chronic pain. Lower superficial temperature in the stump may be associated to sympathetic fiber sprouting in the distal stump, which can lead to vasoconstriction and lower surface temperatures. Further studies are needed in order to confirm neuroma development and adrenergic sprouting.

Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia, Canada

BackgroundPeople who use drugs have a significantly higher prevalence of chronic non-cancer pain compared to the general population, yet little is known about how various policy, economic, physical, and social environments may serve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought to explore perspectives, risks, and harms associated with pain among people who use drugs.MethodsThirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. In total, 83 people who had lived experience with substance use participated in the study. Using an interpretive description approach, themes were conceptualized according to the Rhodes’ Risk Environment and patient-centered care frameworks.ResultsParticipants described how their experiences with inadequately managed pain in various policy, economic, physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack of access to socio-physical support systems, stigma from health professionals, and denial of pain medication leading to risky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patients as experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship.ConclusionsVarious risk environments and non-patient-centered interactions may contribute to an array of health and social harms in the context of inadequately managed pain among people who use drugs.

An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Co-morbid Pain and Depressive Symptoms.

Review recent meta-analyses and clinical trials investigating the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) for concurrent pain and depressive symptoms. Recent meta-analyses have included both pain and depression outcomes in fibromyalgia and chronic pain. Randomized controlled trials have also been conducted in post-herpetic neuralgia, trauma-related headache, and neuropathic pain with attention to both pain and depressive symptoms. In general, studies have demonstrated reduction in pain in patients with fibromyalgia as an add-on treatment, post-herpetic neuralgia, trauma-related headache, and neuropathic pain. There are variable findings for reduction in depressive symptoms in patients with co-morbid pain disorders. Theta burst stimulation (TBS) is a novel rTMS protocol that has recently been investigated in patients with depression and some smaller trials in patients with co-morbid pain disorders. These emerging treatment options may have similar or greater therapeutic potency and may be delivered with greater efficiency. There is evidence to support the use of rTMS for its analgesic effects in various pain syndromes. The variable results between trials for treatment of concurrent depressive symptoms may be due to heterogeneity in treatment protocols including parameters such as site of stimulation (primary motor cortex versus dorsolateral prefrontal cortex) and restrictions in the patient population which usually exclude primary psychiatric diagnoses. Future trials should work to standardize these protocols, investigate novel protocols like TBS, and continue to include standardized assessment of concurrent psychiatric outcomes such as depression and anxiety.

Use of ketamine for acute suicidal ideation in a patient with chronic pain on prescribed cannabinoids

Ketamine is a standard anaesthetic drug that has been studied as a possible treatment for acute suicidal ideation. Aside to the potential psychotropic effects of ketamine, a Cochrane review reported...

85 - The Impact of Concurrent Chronic Pain Conditions on the Development of Chronic Pelvic Pain in Women with Endometriosis

Study Objective: Determine non-gynecologic conditions associated with Chronic Pelvic Pain (CPP) in women with endometriosis.

Changes in pain and concurrent pain medication use following compounded topical analgesic treatment for chronic pain: 3- and 6-month follow-up results from the prospective, observational Optimizing Patient Experience and Response to Topical Analgesics study.

BackgroundOpioids and other controlled substances prescribed for chronic pain are associated with abuse, addiction, and death, prompting national initiatives to identify safe and effective pain management strategies including topical analgesics.MethodsThis prospective, observational study evaluated changes from baseline in overall mean severity and interference scores on the Brief Pain Inventory scale and the use of concurrent pain medications at 3- and 6-month follow-up assessments in chronic pain patients treated with topical analgesics. Changes in pain severity and interference and medication usage were compared between treated patients and unmatched and matched controls.ResultsThe unmatched intervention group (unmatched-IG) included 631 patients who completed baseline and 3-month follow-up surveys (3-month unmatched-IG) and 158 who completed baseline and 6-month follow-up assessments (6-month unmatched-IG). Baseline and 3-month follow-up data were provided by 76 unmatched controls and 76 matched controls (3-month unmatched-CG and matched-CG), and 51 unmatched and 36 matched patients completed baseline and 6-month follow-up surveys (6-month unmatched-CG and matched-CG). Baseline demographic characteristics and mean pain severity and interference scores were similar between groups. There were statistically significant decreases from baseline in mean pain severity and interference scores within the 3- and 6-month unmatched-IG (all P<0.001). Significantly greater decreases in the mean change from baseline in pain severity and interference scores were evident for the 3- and 6-month unmatched-IG versus unmatched-CG (all P<0.001), with similar results when the 3- and 6-month matched-IG and matched-CG were compared. A higher percentage of the 3- and 6-month unmatched-IG and matched-IG de-escalated use of concurrent pain medications (all P<0.001), while significantly higher percentages of the unmatched-CG and matched-CG escalated medication use. Side effects were reported by <1% of the unmatched-IG.ConclusionTopical analgesics appear to be effective and safe for the treatment of chronic pain, with randomized controlled trials needed to confirm these findings.

A regional registry study of 216 patients investigating if patient satisfaction after total knee arthroplasty changes over a time period of five to 20 years

AimsTo determine the temporal changes in patient dissatisfaction following primary knee arthroplasty surgery (TKA). Patients and methodsThree hundred and ninety patients that had previously indicated they were either dissatisfied or unsure with their TKA at one-year post-surgery in our region were mailed a simple questionnaire in addition to the Oxford Knee Score and EQ-5D. ResultsA 55% response rate was achieved. The mean follow-up time period was 9.1years. Of the 120 patients who were initially dissatisfied, 46.7% remained so. Of the 96 patients who were initially unsure, 20.8% remained so, 21.9% and 57.3% became dissatisfied and satisfied, respectively. The primary reason for continued dissatisfaction was persistent pain. Of the 19.4% of patients who had revision surgery, 47.6% remained dissatisfied. 54.2% of patients stated that they would be happy to have a primary TKA again and 55.6% indicated that they would recommend one to a friend. Patients who had concurrent hip pain were six times more likely to remain unsure or dissatisfied over time (OR 6.7, p-value 0.0000). Patients who had back pain or contralateral knee pain were two or three times as likely to remain unsure or dissatisfied. ConclusionIn time half of the patients who stated that they were not satisfied with their arthroplasty, at one year, go on to be satisfied with their knee.

Transient Monocular Vision Loss on Awakening: A Benign Amaurotic Phenomenon.

Transient monocular vision loss (TMVL) is an alarming symptom owing to potentially serious etiologies such as thromboembolism or giant cell arteritis. Our objective is to describe the phenomenon of TMVL present on awakening, which may represent a distinct and benign entity. We performed a retrospective observational case series of 29 patients who experienced TMVL on awakening. Patients who described monocular dimming or blackout of vision were included, and those with blurred vision, concurrent eye pain, and binocular vision loss were excluded. Descriptive statistics were used to summarize the study population. Of the 29 patients we studied, 90% (n = 26) were female and 48% had crowded discs (cup-to-disc ratio ≤0.2). The mean age was 45.4 years, although women were significantly younger than men (mean ages 43.4 and 62.7 years, respectively, P = 0.017). Brain magnetic resonance imaging and vascular imaging (magnetic resonance angiography, computed tomographic angiography, or carotid Doppler) were performed in 69% and 55% of cases, respectively, and were uniformly negative. In 14 patients for whom clear follow-up data could be obtained, no medically or visually significant sequelae of this syndrome were found, and 50% experienced resolution of symptoms. Evaluation was uniformly negative when patients described waking with isolated vision loss in 1 eye with subsequent resolution, usually in less than 15 minutes. The natural history seems benign with symptoms frequently remitting spontaneously. This visual phenomenon may represent an autoregulatory failure resulting in a supply/demand mismatch during low-light conditions.

Serious mental illness among young adult women who use drugs in the club scene: co-occurring biopsychosocial factors

Young women who regularly attend nightclubs are at risk for numerous health and social consequences, including mental distress, sexual and physical victimization and substance dependence. This paper uses a biopsychosocial framework to examine co-occurring mental health problems, victimization, substance dependence, sexual risk and physical pain among a sample of young women who use drugs (N = 222) in Miami’s club scene. The majority of women were under 24 years old, Hispanic, and identified as heterosexual. Almost all the women reported past 90-day use of alcohol, ecstasy/MDMA, marijuana, cocaine and prescription opioids and benzodiazepines; 32% of women reported being in a monogamous relationship while 41.9% reported having three or more sexual partners in the past 90 days; 65.3% met DSM-IV criteria for substance dependence; 60.4% met DSM-IV criteria for serious mental illness (SMI) and 59.9% were victimized as minors. Women who had SMI had higher odds of substance dependence, concurrent physical pain, three or more sexual partners in the past 90 days, childhood victimization and severe abuse-related trauma. The high levels of interconnected mental health, victimization, trauma, physical pain, substance dependence and sexual risk factors observed are underreported in the literature, as young women club scene participants appear to be more similar to other marginalized drug-involved populations than previously considered. While further research is needed, it appears these young women are in great need of outreach for primary health, mental health, HIV prevention, increased social support and substance abuse treatment services.

Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital.

Objective: The objective of this study was to assess the association between liposomal bupivacaine use in patients undergoing knee or hip arthroplasty and concurrent pain control, length of hospitalization, and physical therapy milestones. Methods: This was a retrospective chart review. Patients receiving liposomal bupivacaine during a 1-year period (study group) were compared with patients seen by the same surgeon in the previous year who did not receive liposomal bupivacaine (control group). Clinical outcomes included concurrent opioid use, average pain scores, length of stay, ambulation, and range of motion. Results: A total of 357 patients were included in the study. Knee study group patients received lower amounts of opioid (209 vs 248 mg; P = .02) and had a delayed time to first rescue medication (6.3 ± 4.7 vs 5.0 ± 4.4 hours; P = .02). Hip study group patients had a delay in time to first rescue medication (7.1 ± 6.3 vs 4.9 ± 4.0 hours; P = .046). Both knee and hip study group patients had higher average pain score during the 72-hour postoperative period (6.38 vs 6.06; P = .01, and 6.32 vs 5.80; P = .02, respectively) but decreased median length of stay (2.0 vs 3.0 days; P < .0001, and 2.0 vs 3.0 days; P = .04, respectively). Conclusions: Use of liposomal bupivacaine produced a modest decrease in opioid use among knee patients and a decreased length of stay in both knee and hip patients; however, this was accompanied by a non-clinically significant increase in pain scores for knee and hip patients suggesting limited utility for orthopedic procedures.