Opioids and the Predilection for Violence in the Pain Clinic: A Physician’s Perspective Abstract Pain physicians, more so than any other specialty, interact with a patient population that is significantly more likely to engage in violence. In this commentary on the article “Patient-on-Provider Violence in the Pain Clinic” by Judy George, we echo some of the points mentioned in the manuscript. There needs to be a better system in place to identify and to deal with problem patients seeking drugs. Although there has been a push recently to move away from opioids with a patient-specific multimodal analgesic treatment plan with a focus on interventional pain procedures, opioids are still a part of the pain physician’s practice. The medical community must stand behind ensuring these doctors and their staff can practice in an environment that is safe for them and the patients they are caring for. This response fully complies with ethical guidelines. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

Extensive Degeneration of Vertebral Body Leading to Baastrup’s Disease: A Radiographic Review of an Image Abstract Baastrup’s disease, known colloquially as “kissing spine disease”, is a degenerative process, most commonly occurring in the lumbar spine, in which adjacent spinous processes closely approximate or even touch (Filippiadis et al. in Insights Imaging. https://doi.org/10.1007/s13244-014-0376-7, 2015). We present the case of an 86-year-old woman presenting with left low back, hip, and anterolateral thigh pain. Magnetic resonance imaging noted an approximation of the L2/3 spinous processes, with degeneration of the vertebral processes. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors. Informed consent for publication was obtained from the participant.

A Case Study of Combined Perception-Based and Perception-Free Spinal Cord Stimulator Therapy for the Management of Persistent Pain after a Total Knee Arthroplasty Abstract Introduction Total knee arthroplasty (TKA) is an effective treatment modality for severe osteoarthritis of the knee. Causes of pain following TKA are poorly understood; however, patient-specific biology and various neuropathic underlying mechanisms such as neuroma formation and complex regional pain syndrome (CRPS) have been suggested. Our case demonstrated the successful treatment of CRPS in the knee with the use of combination therapy in spinal cord stimulator. Case We present a 71-year-old Caucasian non-Hispanic male who presented with chronic left knee pain after undergoing a total knee arthroplasty (TKA) 18 months prior. Following his TKA, he reported doing well in the acute post-operative period but began to develop progressively worsening left knee pain at approximately the third post-operative week. He underwent a successful spinal cord stimulator (SCS) trial and subsequent implantation of two 16-contact Boston Scientific leads with a Boston Scientific Spectra WaveWriterTM SCS system. Upon first post-procedural follow-up, and moreover at his 6-month follow-up, the patient reported complete resolution of his symptoms. Discussion The development of persistent pain following TKA is a significant complication that is often challenging to treat. Our case demonstrated the successful treatment of CRPS in the knee with the use of combination therapy in spinal cord stimulator therapy. We anticipate that more data will continue to emerge to assess for the safety and efficacy of combination therapy.

Work-Related Factors Associated with Low Back Pain Among Nurse Professionals in East and West Wollega Zones, Western Ethiopia, 2017: A Cross-Sectional Study Abstract Introduction Low back pain (LBP) is yet the persistent public health challenges around the globe. It substantially affects quality of life and poses disability, particularly to the global working population. The profound losses in productivity and compensation premiums due to the condition have also been a challenge to contemporary occupational health. As such, it no doubt demands informed management and due response. The objective of this research was therefore to investigate the prevalence and work-related factors associated with low back pain among nurses in public hospitals in western Ethiopia. Methods A health facility-based cross-sectional study was conducted from March to April 2017. A sample of 422 nurses was selected using systematic random sampling technique. The standardized Nordic Musculoskeletal survey was interviewer-administered for data collection. The association of different explanatory variables with LBP was explored using a binary logistic regression analysis. The significance of associations was ascertained at a p value of < 0.05 and odds ratios (OR) with 95% confidence intervals (CI). Results The response rate was 99% (N = 418). The mean age was 31.39 (standard deviation ± 7.01) years. The prevalence of LBP in the past 12 months was 63.6% (N = 266) [95% CI (58.9, 68.2)]. About 34.2% (n = 91) of the victims had sought medical care. The prevalence in the last 7 days was 53.4% (n = 142). The majority, 72.2% (n = 192), indicated that their activity was limited. Work experience [AOR 4.332; 95% CI (2.550, 7.360)], shift work [AOR 2.118; 95% CI (1.165, 3.850)], and health and safety training [AOR 2.058; 95% CI (1.127, 3.063)] were significantly associated with low back pain. Conclusions The prevalence of low back pain was high, as in many other studies. The finding implies that practices and implementations that focus on the prevention and control of back pain injuries should target proper management of workplace conditions, like shift work and provision of health and safety training.

Viscosupplementation for Management of Knee Osteoarthritis from an Indian Perspective: An Expert Consensus Report Abstract Introduction Knee osteoarthritis (OA) is a progressive degenerative condition and is a significant contributor toward physical disability in the aging population. The current treatment modalities for this condition focus on joint preservation with alleviation of symptoms. Intra-articular hyaluronic acid (IAHA) injections have emerged as the promising mainstay of nonsurgical treatment of OA, especially in patients with mild-to-moderate OA and in certain subgroups of severe OA with comorbidities or with poor response to first-line therapy. The absence of standard guidelines or recommendations for the use of IAHA in India has led to vast variations in the usage of IAHA among practitioners. Hence, this consensus-based document aims to address the issue and establish simplified and easily implemented recommendations on the use of IAHA. Methods A group of 78 expert orthopedic surgeons discussed in detail the evidence on appropriate criteria for diagnosis, patient selection, and follow-up evaluation for knee OA at two national meetings. In subsequently held regional meetings, key discussion points and clinical experience-based answers were translated into a questionnaire to develop the final expert consensus-based statements for the use of IAHA in patients with knee OA. Results Various consensus statements were obtained on the basis of scientific evidence obtained from PubMed, Cochrane-indexed database, and guidelines related to viscosupplementation and knee OA as well as the experts’ clinical experience. This document was drafted, reviewed, validated, and modified by the expert panel until a final agreement was reached. Conclusion In this pioneering attempt, the document lays down structured, expert consensus-based statements to guide and align practitioners on the appropriate use of IAHA in the Indian setting. Funding Dr. Reddy’s Laboratories Ltd.

In Memoriam: Daniel Callahan (1930–2019)

The Epidemiology of Herpes Zoster and Postherpetic Neuralgia in China: Results from a Cross-Sectional Study Abstract Introduction Few studies have examined the epidemiology of herpes zoster (HZ) and postherpetic neuralgia (PHN) in China. The aim of this study was to estimate the prevalence of HZ and PHN in China, and to examine the clinical characteristics of patients identified with PHN. Methods This was a cross-sectional study conducted in 24 hospitals in seven cities in China. Prevalence of HZ and PHN was determined by physician (n = 100) chart review of patients (n = 36,170) aged ≥ 40 years seeking medical care over a 30- to 60-day period. The health history of patients identified with PHN was obtained and included time since diagnosis of HZ or PHN, time since onset of PHN-related pain, and the methods used for diagnosing HZ and PHN. Results The prevalence rates of HZ and PHN were 7.7% [95% confidence interval (CI) 7.5–8.0] and 2.3% (95% CI 2.2–2.5), respectively. Of patients with HZ, 29.8% developed PHN. Rates of HZ and PHN increased with age and were highest in patients aged ≥ 70 years (10.6% and 4.1%, respectively). The majority of patients with PHN were diagnosed with HZ (80.9%) and PHN (83.8%) for < 1 year, and had experienced PHN-related pain for < 1 year (80.5%). Patient description and clinical examination were most commonly used to diagnose HZ and PHN. Conclusion These results provide current estimates of the prevalence of HZ and PHN in the general adult population in urban China. These rates are similar to previously reported rates in China and worldwide, and highlight the global nature of HZ and PHN. Funding Pfizer Inc.

Rescue Analgesic Medication Use by Patients Treated with Triamcinolone Acetonide Extended-Release for Knee Osteoarthritis Pain: Pooled Analysis of Three Phase 2/3 Randomized Clinical Trials Abstract Introduction In clinical trials for knee osteoarthritis (OAK), rescue medication is commonly provided to manage uncontrolled index-knee pain. The impact of treatment on rescue medication utilization provides important information on the robustness of analgesic effect. In randomized controlled OAK trials (NCT01487161, NCT02116972, NCT02357459), intra-articular (IA) triamcinolone acetonide extended-release (TA-ER) demonstrated substantial, prolonged analgesia versus saline-placebo and TA crystalline solution (TAcs) as assessed by patient-reported pain scales. This pooled analysis assessed the impact of TA-ER on rescue medication use. Methods Patients (N = 798) with OAK (American College of Rheumatology criteria; Kellgren–Lawrence grade 2/3) and baseline average daily pain intensity score ≥ 5 to ≤ 9 (0–10 numeric rating scale) received a single IA injection of TA-ER (N = 324), saline-placebo (N = 262), or TAcs (N = 212). Acetaminophen/paracetamol tablets were provided to treat uncontrolled pain (knee or otherwise). Rescue medication consumption was monitored through a daily diary; pill counts were confirmed at the clinical site. Differences in rescue medication use were measured by least-squares mean (LSM) differences, number of rescue medication tablets used per day, and in area under the effect (AUE) curves of rescue medication tablets used per week. Results The overall number of rescue medication tablets used per day through week 24 was significantly less (p ≤ 0.05) for TA-ER versus saline-placebo (LSM difference, − 0.43) and TAcs (− 0.24). Rescue medication use was significantly (p ≤ 0.05) lower following TA-ER versus saline-placebo across weeks 1–12 (AUEweeks1–12; LSM difference, − 24.5) and weeks 1–24 (AUEweeks1–24; − 51.6) and versus TAcs across weeks 1–12 (AUEweeks1–12; − 21.1). Conclusions In patients with painful OAK, reduced rescue medication use may be a potential benefit of TA-ER and further supports its analgesic efficacy. Additional research is needed to assess whether TA-ER impacts the use of other common oral analgesics (nonsteroidal anti-inflammatory drugs, opioids) for patients with OAK. Funding Flexion Therapeutics, Inc., Burlington, MA, USA. Plain Language Summary Plain language summary available for this article.

Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting Abstract Introduction Complete and accurate documentation of opioids administered by patient-controlled analgesia (PCA) pumps is critical for ensuring a high-quality medication record and an accurate conversion of the intravenous (IV) regimen to oral therapy. Incomplete charting of PCA usage through a manual process may be associated with fragmented documentation of delivered therapy affecting the completeness of the medical record and the IV to oral dose conversion. This study is the first to evaluate the association between auto-documentation of opioid administration provided by PCA smart pump—electronic health record (EHR) interoperability and the completion of PCA opioid administration charting tasks. Methods This retrospective cohort study was conducted at Lancaster General Hospital, Lancaster, Pennsylvania. Patients were assigned to pre-auto-documentation (n = 55) or post-auto-documentation groups (n = 58) based on whether they received PCA therapy prior to or after PCA-EHR interoperability was implemented. Charting of PCA therapy included documentation of the number of patient attempts, number of doses given, and total volume infused for both pre- and post-auto-documentation groups. In addition, total dose delivered was documented for the post-auto-documentation group. The overall chart-field completion rate was evaluated as the primary outcome. Individual chart completion percentages were assessed by stratified groups as secondary outcomes. Results PCA smart pump—EHR interoperability with auto-documentation was associated with an increase in overall chart-field completion rate from 69.9 to 97.0% (p < 0.001). Auto-documentation was also associated with an increase in fully completed charts from 38 to 91% (139.3% increase, p < 0.001) and reductions of incomplete records in each stratified group (p < 0.001). Conclusions PCA smart pump—EHR interoperability with auto-documentation is associated with significant improvements in the completion of opioid administration chart-fields. Improved documentation of PCA administered opioids may have implications for the safety of opioid administration. Additional studies will be needed to assess the potential clinical impact of these results. Funding ICU Medical, Inc.

Stopping or Decreasing Opioid Therapy in Patients on Chronic Opioid Therapy Abstract With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.