scholarly journals An audit on prescribing practice and risk of serotonin syndrome among patients with chronic pain

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S152-S152
Author(s):  
Salakan Rai ◽  
Aizad Yusof
Keyword(s):  
At Risk ◽  
Chronic Pain ◽  
Pain Management ◽  
Drug Interactions ◽  
Serotonin Syndrome ◽  
Pain Clinic ◽  
Antidepressant Agents ◽  
Concurrent Use ◽  
Prescribing Practice ◽  
Serotonin Toxicity

AimsTo determine the incidence of prescribing practice with associated risk of serotonin toxicity among patients with chronic pain conditions.BackgroundSerotonin syndrome is a potentially life-threatening condition caused by excessive serotonergic activity, usually from drug interactions. Concurrent use of antidepressants is strongly linked to serotonin syndrome, with recent data revealing record numbers of NHS prescribed antidepressants in 2019. Antidepressant medications are also used in chronic pain management for their anti-neuropathic pain properties. However, it is well-recognised that a significant number of chronic pain patients suffer from anxiety and depression. This cohort of patients is therefore vulnerable to being exposed to multiple concurrent antidepressant agents, and thus at relatively higher risk of serotonin syndrome compared to other patient groups. Additionally, these patients are likely to be exposed to the concurrent use of antidepressants and certain analgesic agents particularly phenylpiperidine derivatives which increases serotonin toxicity risk.MethodMedications of patients presenting to a secondary care pain clinic within the last year were looked into. Patients were selected at random by pain management secretaries. Concurrent use of multiple antidepressant agents including Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin Noradrenaline Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants (TCAs) or Tetracyclic Antidepressant (TeCA) was noted. Additionally, concurrent use of any of these antidepressant agents and phenylpiperidine derivatives such as Fentanyl and Tramadol was noted.ResultData on medications of 97 patients were collected. A total of 28 patients (28.8%) were observed to have at-risk medication combinations. Out of these, five patients were on both SSRI and TCA. Two patients were on both TCA and TeCA. Four other patients were on either a combination of SSRI and SNRI, SNRI and TCA, SSRI and TeCA, or TCA and TCA. Three patients were on both Fentanyl patches and an antidepressant. Fourteen patients were on both an antidepressant and Tramadol. None of these patients were diagnosed with serotonin syndrome; however, it is unclear as to whether these patients experienced milder symptoms of the syndrome.ConclusionA considerable number of patients in this group were on medication combinations putting them at risk of serotonin syndrome. Despite no documented patient harm, there is an urgent need for an increased awareness among prescribers on drug interactions which may lead to this syndrome and a subsequent change in prescribing practice.

Mexiletine Usage in a Chronic Pain Clinic: Indications, Tolerability, and Side Effects

2018 ◽  
Vol 1 (21;1) ◽  
pp. E573-E579 ◽  
Author(s):  
Adam Romman
Keyword(s):  
Chronic Pain ◽  
Neuropathic Pain ◽  
Cohort Study ◽  
Pain Management ◽  
Side Effects ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Primary Diagnosis ◽  
Pain Clinic ◽  
Chronic Pain Management

Background: Background: Intravenous lidocaine has multiple applications in the management of acute and chronic pain. Mexiletine, an oral lidocaine analogue, has been used in a number of chronic pain conditions although its use is not well characterized. Objectives: To report our experience using mexiletine in a chronic pain population, specifically looking at tolerability, side effects, and EKG changes. Study Design: Retrospective, cohort study. Setting: Multiple pain clinic locations in an integrated multispecialty health system. Methods: All patients who had a mexiletine prescription between August 2015 and August 2016 were queried via the electronic medical record. Each chart was examined for demographics, QTc changes on EKG, length of use, and reasons for stoppage. Results:There were 74 total patients identified in the chronic pain management clinics as receiving at least 1 mexiletine prescription over the 1-year time period. Twice as many women as men received mexiletine prescriptions. Neuropathic pain was the most common primary diagnosis (64%) which included diabetic neuropathy, radiculopathy, and others. Fibromyalgia was the next most common primary diagnosis (28%). A QTc change on the EKG showed a mean decrease of 0.1 ms and median increase of 1.5 ms. At 6 months (180 days), approximately 30% of the patients remained on mexiletine therapy, and 28% remained on the therapy at 1 year (360 days). Median duration of use was 60 days and the mean was 288 days. Neurologic and gastrointestinal side effects were the most commons reason for stoppage. All side effects were mild and resolved with stoppage. After side effects, lack of response, or loss of efficacy, were the next most common reasons for stoppage. Limitations: Pain relief and outcomes were not specifically examined due to confounding factors including interventional treatments and multiple treatment modalities. This was a retrospective, cohort study limited to our specific clinic population with a relatively high loss to follow-up rate. Conclusion:Mexiletine is rarely a first line option for chronic pain management and is often used when multiple other modalities have failed. By reporting our experience, we hope other clinicians may have more familiarity with the drug’s use in a chronic pain practice. It appears reasonably tolerable, may not require frequent EKG monitoring, and can be an appropriate adjunct in the chronic pain population. More research is needed regarding efficacy and dose titration for mexiletine in chronic pain. Key Words: Chronic pain, mexiletine, IV lidocaine, pain, neuropathic pain, neuropathy, fibromyalgia, QTc, tolerability

Psychiatry has Much to Offer for Chronic Pain

2001 ◽  
Vol 35 (2) ◽  
pp. 145-149 ◽  
Author(s):  
Saxby Pridmore ◽  
Gajinder Oberoi ◽  
Newman Harris
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Psychiatric Disorders ◽  
Emotional Experience ◽  
Pain Clinic ◽  
Emotional States ◽  
Chronic Pain Management ◽  
Personality Features ◽  
Chronic Pain Clinic ◽  
And Training

Objective: The objective of this study was to make an argument in favour of the inclusion of psychiatrists on chronic pain clinic teams. Method: The argument takes the form of answers to four central questions: (i) does pain involve an emotional experience; (ii) do psychiatric disorders accompany chronic pain; (iii) can psychiatric disorders present as chronic pain; and (iv) which patients present to pain units, and what do we know of their personalities? Results: The affirmative case was substantiated in respect of the first three questions. In examining the last question, evidence indicates that patients who present to chronic pain units frequently have personality features that make assessment and therapy difficult. Conclusions: Psychiatry is the field of medicine where practitioners have the most experience with emotional states and personality, and is the only field where they have specialized skills in the diagnosis and treatment of psychiatric disorders. Psychiatry has much to offer in chronic pain management and chronic pain management teams should include a psychiatrist. This conclusion has resourcing and training implications.

Biofeedback and Integrative Medicine in the Pain Clinic Setting

Biofeedback ◽  
2014 ◽  
Vol 42 (3) ◽  
pp. 111-114 ◽  
Author(s):  
Eric Willmarth ◽  
Fred Davis ◽  
Kevin Fitzgerald
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Integrative Medicine ◽  
Management Practice ◽  
Psychosocial Interventions ◽  
Pain Clinic ◽  
Health Practices ◽  
Integrative Health ◽  
Case Vignettes ◽  
Chronic Pain Conditions

Formal pain management clinics have now existed for more than 30 years and from the beginning have incorporated integrative approaches to assist patients suffering from chronic pain conditions. This article will describe the development of these programs and the role that biofeedback and other psychosocial interventions have played in this development. Case vignettes and interviews are used to demonstrate the value of integrating biofeedback and other integrative health practices into a formal pain management practice.

scholarly journals The Schulich Pain Medicine residency

2018 ◽  
Vol 87 (1) ◽  
pp. 65-67
Author(s):  
Dino D'Andrea ◽  
Emily N Dzongowski
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Residency Program ◽  
Pain Clinic ◽  
Pain Medicine ◽  
University Of Toronto ◽  
Pain Specialist ◽  
Wide Range ◽  
First Pain ◽  
The University

Dr Bellingham completed his medical school and anesthesiology residency at Western University. He followed this with a fellowship in Chronic Pain Management at the University of Toronto, with a focus on interventional pain management using fluoroscopy and ultrasound guided techniques. Dr Bellingham returned to Western University to work in the Department of Anesthesia and Perioperative Medicine in his capacity as an anesthetist and as a chronic pain specialist. Here at Western, he directs the Pain Clinic at St. Joseph’s Health Care and also played a key role in the development of Canada’s first Pain Medicine residency program. We had an opportunity to chat with Dr Bellingham and discuss a wide range of topics including his choice of career path, the Pain Medicine residency program, and other pain medicine topics in the context of the current opioid epidemic.

scholarly journals Exploring the Role of Chronic Pain Clinics: Potential for Opioid Reduction

2018 ◽  
Vol 1 (21;1) ◽  
pp. E603-E610
Author(s):  
Mohab Ibrahim
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Pain Clinic ◽  
High Dose ◽  
Opioid Use ◽  
Pain Clinics ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain ◽  
And Function

Background: The management of chronic nonmalignant pain with high-dose opioids has partially contributed to the current opioid epidemic, with some responsibility shared by chronic pain clinics. Traditionally, both primary care providers and patients used chronic pain clinics as a source for continued medical management of patients on high-dose opioids, often resulting in tolerance and escalating doses. Although opioids continue to be an important component of the management of some chronic pain conditions, improvement in function and comfort must be documented. Pain clinics are ideally suited for reducing opioid usage while improving pain and function with the use of a multimodal approach to pain management. We assessed whether the application of multimodal treatment directed by pain specialists in a pain clinic provides for improved function and reduced dosages of opioid analgesics. Objective: We evaluated the role of a pain clinic staffed by fellowship-trained pain physicians in reducing pain and opioid use in chronic nonmalignant pain patients. Study Design: This study used a retrospective design. Setting: The research took place in an outpatient pain clinic in a tertiary referral center/teaching hospital. Methods: Of 1268 charts reviewed, 296 patients were on chronic opioids at the time of first evaluation. After a thorough evaluation, the patients were treated with nonopioid pharmacotherapy and interventional pain procedures as necessary. The data utilized from patients’ latest follow-up visit included current pain level using the Numerical Rating Scale (NRS-11), opioid usage, and various functional parameters. Results: NRS-11 scores decreased by 33.8% from 6.8 (± 0.1)/10 to 4.5 (± 0.2)/10. The pain frequency and number of pain episodes improved by 36.8 ± 2 and 36.2 ± 2.1, respectively. Additionally, the ability to sleep, work, and perform chores significantly improved. Total opioid use decreased by about 55.4% from 53.8 ± 4 to about 24 ± 2.8 MME/patient/day. Limitation: This study is not a randomized prospective controlled study. The patients analyzed are still getting therapy and their pain status may change. Some opioids are underrepresented in the analyzed cohort. Finally, this study lacks in-depth stratification by type of pain, age, gender, and duration of opioid use. Conclusion: Chronic pain clinics can play a pivotal role in reducing opioid usage while improving pain and function in patients on chronic opioids. We wish to emphasize the importance of allocating resources toward nonopioid treatments that may improve the function and well-being of patients. Key words: Pain clinic, pain management, multimodal pain management, chronic pain, opioid reduction, improved pain, improved functional capacity

scholarly journals Exploring perceptions and experiences of patients who have chronic pain as state prescription opioid policies change: a qualitative study in Indiana

BMJ Open ◽  
2017 ◽  
Vol 7 (11) ◽  
pp. e015083 ◽  
Author(s):  
Morhaf Al Achkar ◽  
Debra Revere ◽  
Barbara Dennis ◽  
Palmer MacKie ◽  
Sumedha Gupta ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Pain Management ◽  
Qualitative Study ◽  
Inappropriate Prescribing ◽  
Primary Care Providers ◽  
Pain Clinic ◽  
Care Providers ◽  
Opioid Prescription ◽  
The Impact

ObjectivesThe misuse and abuse of prescription opioids (POs) is an epidemic in the USA today. Many states have implemented legislation to curb the use of POs resulting from inappropriate prescribing. Indiana legislated opioid prescribing rules that went into effect in December 2013. The rules changed how chronic pain is managed by healthcare providers. This qualitative study aims to evaluate the impact of Indiana’s opioid prescription legislation on the patient experiences around pain management.SettingThis is a qualitative study using interviews of patient and primary care providers to obtain triangulated data sources. The patients were recruited from an integrated pain clinic to which chronic pain patients were referred from federally qualified health clinics (FQHCs). The primacy care providers were recruited from the same FQHCs. The study used inductive, emergent thematic analysis.ParticipantsNine patient participants and five primary care providers were included in the study.ResultsLiving with chronic pain is disruptive to patients’ lives on multiple dimensions. The established pain management practices were disrupted by the change in prescription rules. Patient–provider relationships, which involve power dynamics and decision making, shifted significantly in parallel to the rule change.ConclusionsAs a result of the changes in pain management practice, some patients experienced significant challenges. Further studies into the magnitude of this change are necessary. In addition, exploring methods for regulating prescribing while assuring adequate access to pain management is crucial.

scholarly journals Serotonin syndrome: a spectrum of toxicity

2015 ◽  
Vol 21 (5) ◽  
pp. 324-332 ◽  
Author(s):  
Rabia Ellahi
Keyword(s):  
Mental Illness ◽  
Drug Interactions ◽  
Serotonin Syndrome ◽  
Diagnostic Overshadowing ◽  
Holistic Review ◽  
The Uk ◽  
Serotonin Toxicity

SummarySerotonin syndrome (serotonin toxicity or serotonin toxidrome) is a potentially serious and theoretically predictable reaction that appears to be rarely diagnosed in practice in the UK. Some symptoms of serotonin syndrome overlap with features of other presentations in psychiatry and thus may be misattributed to mental illness (‘diagnostic overshadowing’). Further, there may be diagnostic dilemmas in patients on combinations of drugs, those receiving drugs with previously unknown serotonergic properties or where there are drug interactions. Prescriber vigilance and holistic review of the patient, including the pharmacotherapy, may be helpful in avoiding progression of serotonin syndrome to more serious outcomes.

Bioethical correctness of integrative medicine in the treatment of chronic pain in the historical perspective

Ból ◽  
2020 ◽  
Vol 21 (3) ◽  
pp. 1-6
Author(s):  
Anna Paprocka-Lipińska
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Integrative Medicine ◽  
Technical Progress ◽  
Historical Perspective ◽  
Biomedical Ethics ◽  
Pain Clinic ◽  
Multidisciplinary Management ◽  
Chronic Pain Management ◽  
Chronic Pain Clinic

A reflection on progress in medicine – bioethics appeared in the 1970s. „Principless of biomedical ethics” – the monograph by Tom Beachamp and James Childress – was to change the concept of ethical evaluation of new possibilities of diagnostic and therapy and making decisions in medicine. In the 70’s there was also the development of chronic pain management. A pioneering concept of multidisciplinary management of a patient suffering from chronic pain by John Bonica is a part of the process of implementing four bioethical principles. The idea of integrative medicine – combining the methods resulting from the scientific and technical progress of Western medicine with the methods of traditional Eastern medicine has enabled the implementation of beneficience, nonmaleficence, autonomy, and justice. This article will present facts related to the Bonica’s concept in the first chronic pain clinic created in Poland in the 1970s.

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