THE PHARMACOTHERAPY OF COMMON FUNCTIONAL SYN DROMES: EVIDENCE-BASED GUIDELINES FOR PRIMARY CARE PRACTICE. Pe ter Manu, MD, FACP. New York, The Haworth Med i cal Press, 2000, ISBN: 0-7890-0589-1 (soft), 320 pages, List Price: $39.95. , by Pe ter Manu This book pro vides an ev i dence-based over view of the treat ment of four com mon, yet of ten ig nored or misdiagnosed, func tional syn dromes: chronic fa tigue syn drome, fibromyalgia, ir ri ta ble bowel syn drome, and premenstral syn drome. This ref er ence is par tic u larly use ful, since most text books or hand books do not ad e quately cap ture the phar ma co logic treat ment of each these con di tions in one book. The book is not in tended to pro vide the reader with a com pre hen sive over view of the syn dromes them selves. Rather, em pha sis is placed on the pharmacotherapy re spec tive to each syn drome. Each of the four sec tions is di vided into six chap ters: def i ni tion and meth od olog i cal is sues, ef fec tive ther a pies (with the ex cep tion of chronic fa tigue syn drome), con tro ver sial ther a pies, in ef fec tive ther a pies, un replicated tri als, and ev i dence-based ther apy rec om men da tions. Each
(2001). Selected Web Sites for Pain Management Clinicians. Journal of Pharmaceutical Care in Pain & Symptom Control: Vol. 9, No. 1, pp. 53-55.
The number needed to treat (NNT) is regularly reported in systematic reviews concerning pain treatments. When used effectively, the NNT is a powerful tool for decision making. The NNT can allow clinicians to assess whether new treatments are applicable to their patient population as well as an individual patient. Clinicians who understand the statistical terms associated with the NNT are better equipped to make decisions regarding a specific treatment and NNT described in a trial. Many authors describe new ways to describe and utilize the NNT. This paper reviews these new methods and reviews the statistical terms associated with the NNT, using specific examples from the pain literature.KEYWORDS: Number needed to treatNNTodds ratioORsystematic reviewstatisticsrelative riskRRconfidence intervalabsolute risk reductionARRanalgesiaeffectiveness
Meperidine, a phenylpiperidine derivative, was the first synthetic opioid. Introduced in 1939, it has remained a widely used agent. It has been estimated to constitute approximately 40% of total analgesic utilization in Western countries.1 Despite this widespread utilization, there is considerable debate on the wisdom of the continued use of this drug. Chalverus2 in this issue of the Journal of Pharmaceutical Care in Pain & Symptom Control has made a contribution to this debate by reviewing the toxicity of this opioid. The pharmacokinetics of meperidine certainly make it far from an ideal opioid. There is extensive first-pass hepatic metabolism; the oral bioavailability has been reported to range from 40 to 60%.3 Administered intravenously, single dose meperidine provides a short duration of analgesia. Extensive redistribution initially to well perfused regions occurs and repetitive dosing results in uptake by adipose tissue. Despite the acknowledged relatively short duration of action of meperidine of one to three hours, it is not uncommonly administered at intervals of ev-
The American Pain Society (APS) held its 19th Annual Scientific meeting in Atlanta, Georgia last November 2 through 5. Over 1,500 clinical and basic scientists, clinicians and others interested in the science and practice of pain management attended the meeting. The APS held a series of eight half-day professional development courses on the day before the meeting. The topics of these courses were chronic visceral pain, management of life threatening illnesses, motivating patients in pain rehabilitation, opioids in persistent noncancer pain, myofascial pain syndrome, the JCAHO pain standards, psychological aspects of pain care and complementary and alternative medicine in pain management. Antonio Damasio, MD, PhD, presented the keynote address, “Emotion, Consciousness and the Body in Pain,” Plenary presentations included Hypnosis and Pain, Advances and Future Directions in Local Anesthesia, Activity-Dependant Plasticity in Brain Stem Pain Modulatory Circuitry After Inflammation, Catastrophizing and Pain, Forebrain Mechanisms of Chronic Pain States and Neural Mechanism of Pain Modulation. The program also included twenty-seven full symposia, eight breakfast symposia, and six industry-supported educational events. A total of 858 poster presentations also took place at the meeting.
(2001). Expanding into the Journal of Pain & Palliative Care Pharmacotherapy. Journal of Pharmaceutical Care in Pain & Symptom Control: Vol. 9, No. 4, pp. 1-3.
Colorectal cancer is the second leading cause of cancer death. Current treatments include assessment of risk factors, early detection, surgery, chemotherapy and immunotherapy. Early studies done in animal models indicate that nonsteroidal antiinflammatory agents (NSAIDs) may have tumor inhibiting effects. Multiple case control and cohort studies indicate that NSAID use may reduce the incidence of colorectal cancer in humans. There is currently only one randomized controlled trial published on this topic. In this study, no difference was seen in the incidence of colorectal cancer between patients taking aspirin or placebo at twelve years post randomization. Overall, however, the study cohort had an 18% reduction in risk as compared with the general population. Based on the observational studies there appears to be a relationship between NSAID use and colorectal cancer. However, sufficient evidence does not exist to routinely recommend their use for this indication at this time.
A Pediatric Analgesia and Sedation Subcommittee, under the auspices of the San Francisco General Hospital Department of Pediatrics, Quality Assurance Committee, was created and charged with the development of pediatric guidelines. Membership included all health care providers who treated children in all care areas of the hospital: pediatricians, emergency physicians, family practitioners, neurologists, surgeons, intensivists, anesthesiologists, registered nurses, and pharmacists. Guiding principles were that the pediatric pain and sedation guidelines would be effective, easy to employ, based on well-accepted medications, and be child friendly. The focus was to develop analgesia and sedation guidelines for patients undergoing a wide range of medical and surgical procedures. The subcommittee then constructed a series of tables with the appropriate management strategies (including specific medications, doses and delivery routes) for pediatric orthopedic, surgical, and diagnostic procedures, and for sickle cell pain crisis. A detailed account of the implementation of these guidelines is also presented.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (DHHS) commissioned this Medicare Hospice Benefit study to provide information on the role of the Medicare hospice benefit and more specific information about how end of life care is provided to institutionalized beneficiaries. This report presents information on Medicare's hospice benefit, who is using it, how it is being used, what costs are associated with its use, what costs precede hospice enrollment and how these vary by type of enrollee. This information will be important for understanding the role of Medicare's hospice benefit in the context of the other benefits Medicare provides to one of the program's most expensive populations, the terminally ill, and understanding whether the current policies meet the needs of the population enrolling in hospice. Also included are snapshot contrasts of two groups of enrollees, those who were enrolled in HMOs or on Medicaid at least once during the 12 months between July 1995 and July 1996. This report is intended to provide background information on the overall Medicare hospice population. The office of the Department of Health and Human Services (DHHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) initiated this study to better understand the use of hospice by dually-covered hospice enrollees in nursing facilities and this report provides the contrast for the nursing facility-based enrollee discussed in the two next reports in this study. Questions have been raised about whether hospice patients who live in nursing facilities are on the benefit for a longer time, receive different services, or otherwise use it differently than those residing in the community. This report describes the benefit's use by all enrollees in 1996.
In May, 2000, an American Psychological Association (APA) Working Group on Assisted Suicide and End-of-Life Decisions issued a report to the Association Board of Directors on the present status of psychologists with respect to providing clinical services, conducting research, and educating professionals and the public in the palliative care arena. As reported by the APA's monthly magazine, the report finds that psychologists are “virtually absent” in end-of-life care arenas. This commentary addresses the validity of that claim, discusses ways in which psychologists have contributed to palliative care to date, and suggests some ways in which the profession may increase its visibility and value in the field of palliative care.
LYMPHOEDEMA. Edited by Robert Twycross, Karen Jenns and Jacquelyne Todd. Radcliffe Medical Press, Oxan, UK 2000, 363 pages of text, 2 pages of foreword, one page of preface, eight color plates, plus index, paperbound, ISBN: 1-85775-377-1 List price: £35.00 (British pounds sterling: a price in U.S. dollars is not listed). , edited by Robert Twycross, Karen Jenns and Jacquelyne Todd Lymphoedema is a comprehensive examination of an often misunderstood and therefore often inappropriately treated symptom. I came away from reading this book with not only an increased knowledge of lymphoedema, but also a deep appreciation of the impact of this symptom–often visible and disabling–on the sufferer’s quality of life. The first chapter, The Patient’s Perspective, by Madeleine Robertson Squire, someone who lives the experience of lymphoedema, sets the tone for the remainder of this work. It is unusual for a book aimed at healthcare professionals to include such a chapter. If present, it is often relegated to the end, as an afterthought. I applaud the editors for placing the patient’s perspective at the beginning. As I read the remainder of the book, I kept the words of Ms. Squire in mind, especially the following:
Although management of cancer pain is relatively easy to accomplish in most cases, patients in many developing and developed countries are deprived access to appropriate analgesic medications due to governmental, bureaucratic, and physician barriers, such as restrictions on quantity, type, and storage of drugs. Many of these governmental and bureaucratic barriers are discussed as are steps being taken to overcome them in the different countries.
The growth of the cancer pain initiative movement form the inception of the Wisconsin Cancer Pain Initiative in 1986 through the establishment of initiatives across the nation is traced. The development of the American Alliance of Cancer Pain Initiatives into a national coordinating body is described. Organizational formats of the initiatives, collaborations with other organizations, funding issues, research and other activities of the programs are reported. Challenges to the initiative movement are discussed.
The National Institute of Dental Research [NIDR] (subsequently redesignated the National Institute of Dental and Craniofacial Research [NIDCR] of the National Institutes of Health [NIH]) has created a historical report on the development of pain research at the NIH over the past half century. This report documents that history and explains how much of what is now known about the pathophysiology and management of pain evolved from work of that Institute. Beginning with an exploration of dental pain, the work resulted in creation of animal models and clinical research that has proved understanding of mechanisms and treatments. The pioneering work of Dr. Ronald Dubner and many of his colleagues at the NIDR, the development of the Neurobiology and Anesthesiology Branch, the interdisciplinary approach developed within the Institute, the drug testing program and the ongoing work of the Institute are described.
The undertreatment of pain is a major health issue in the United States, with children, elderly, and minorities at risk. An in-depth interview survey was conducted of 1,000 persons living at home with pain due to a medical condition to assess their attitudes toward pain, medications, and their doctors, as well as to identify the size and scope of undertreatment. Sixty-one percent have experienced pain for at least five years. For 40% of these patients the pain is constant; for 60%, intermittent; for 49%, moderate; for 22%, severe. Ninety percent have seen a physician; 67% are presently under a doctor's care; 86% see the same clinician for the pain and its cause; 50% see a general practitioner or family physician (GP/FP); only 13% have seen a pain specialist. Twenty-one percent have been scored on a pain scale; in half (49%) of those who were scored, a numeric scale was used; a verbal scale was used in 22%. Forty-two percent say their prescription analgesic is less than very effective; 67% indicated that their daily lives have been altered by pain; 51% say they cannot remember what it feels like not to be in pain.
The Amer i can So ci ety of Health-Sys tem Phar ma cists (ASHP) Mid year Clin i cal meet ing is con sis tently the larg est and best at tended pro fes sional meet ing of phar ma cists in the world. The year 2000 meet ing, which was held in Las Ve gas, Ne vada last De cem ber 3 to 7, was the larg est and most suc cess ful mid year meet ing ever. Nearly 20,000 at ten dees par tic i pated in a broad range of sym po sia, short courses, re search re ports, clin i cal net work ing ses sions, case stud ies and poster pre sen ta tions. In ad di tion to prac ti tio ners from all 50 states, col leagues from 33 other coun tries also par tic i pated. The open ing gen eral ses sion set a theme of avoid ing ad verse drug events. Five half-day sym po sia on pain-re lated top ics were pre sented. A meet ing of the pain man age ment fo cus group and a nu mer ous post ers re lat ing to pain and symp tom con trol also were in cluded in the meet ing. Other sym po sia ad dressed top ics of di rect rel e vance to pain prac ti tio ners in clud ing eth ics, laws, genomics and im prov ing med i ca tion safety. ASHP Pres i dent Max L. Hunt ad dressed the open ing gen eral ses sion of the meet ing and touched upon a range of top ics im por tant to all health pro fes sion als. Hunt noted that in for ma tion tech nol ogy ad vances are bring ing about im mense changes in the way health pro fes sion als and con sum ers ac cess and use drug in for ma tion, now and into the fu ture.
Palliative care continues to grow and gain acceptance as an important alternative to curative when cure appears futile throughout the United States and many other countries. Hospices, which have grown from one program in Connecticut 1975 to over 3,000 programs in all of the states just a quarter of a century later, remain the principle providers of palliative care. But increasing numbers of hospital and long-term care facility palliative care programs and even academic and hospital departments of pain medicine and palliative care have been established. Both the American Academy of Hospice and Palliative medicine and the Association of Hospice and Palliative Care Nurses continue to grow and credential more physicians and nurses as palliative care providers. The Board of Pharmaceutical Specialties is examining the possibility of creating a bard specialty for palliative care pharmacists. Palliative care has grown well beyond the provision of symptom control at the end of life. Integrated palliative care programs now function within curative care settings. This writer strongly believes that palliative care should be initiated at the time of diagnosis of a potentially life-limiting disease, not just after attempts at cure have failed. I recently learned that in Mexico, pain medicine and palliative care are a single specialty. Physicians being trained in pain management are concurrently trained in palliative care. While specialty palliative care society meetings are the major venues for presentation on symptom control in advanced disease, the quantity and quality of papers relating to palliative care are being presented at pain society meetings. Pain management and palliative care have many common feature and share a body of literature. But there are unique aspects to each. One field often provides useful ideas and clinical strategies to the other. There is value in cross training and sharing of ideas among pain and palliative care clinicians. This Journal is committed to supporting such sharing. Effective with Volume 10 next year, the Journal of Pharmaceutical
