Ketamine as a Vehicle for Change in Chronic Pain and Comorbid Addiction

2018 ◽  
pp. 35-39
Author(s):  
Siddarth Singh Arora
Keyword(s):  
Chronic Pain ◽  
The United States ◽  
Rapid Onset ◽  
Induction Phase ◽  
Minimal Risk ◽  
Opioid Crisis ◽  
Severe Withdrawal ◽  
Replacement Treatment ◽  
Complex Patients ◽  
High Degree

Chronic pain is a disease that affects hundreds of millions of Americans and costs the United States billions of dollars a year. It is a disease that has both physical and psychological effects, posing a difficult therapeutic challenge. Innovations in interventional treatments continue to improve, but our pharmacological options have yet to catch up, with opioids remaining as one of the more effective treatments still available. Unfortunately, its rapid onset of pain relief coupled with its highly addictive potential has directly contributed to our current opioid crisis. One way to curb the epidemic is the use of a well-established opioid replacement treatment, buprenorphine, which has a high degree of efficacy in chronic pain and minimal risk of intoxication and overdose. A major limitation to its use is the initial induction stage, whereby the patient experiences severe withdrawal, cravings, and worsening pain. A novel solution in treating chronic pain patients with comorbid addiction may be the use of a low dose series of sub-anesthetic intravenous ketamine infusions as a bridge to buprenorphine therapy during the induction phase. There is emerging evidence that subanesthetic doses of ketamine may be a better option in treating these complex patients, as it has been shown to display robust analgesic activity, favorable effects on mood, reductions in relapse rates, and minimal side effects. Here we review the currently available literature supporting this. Given the current opioid crisis and the lack of safe and effective alternative pharmacological treatments, developing a better pain management strategy would be of great clinical and societal value. Key words: Ketamine, opioid withdrawal, chronic pain, opioid addiction, buprenorphine, opioid epidemic

scholarly journals Let’s talk about pain and opioids: Low pitch and creak in medical consultations

2019 ◽  
Vol 22 (2) ◽  
pp. 174-204 ◽  
Author(s):  
Peter Joseph Torres ◽  
Stephen G. Henry ◽  
Vaidehi Ramanathan
Keyword(s):  
Chronic Pain ◽  
Discourse Analysis ◽  
Vocal Tract ◽  
The United States ◽  
Linguistic Features ◽  
Linguistic Resources ◽  
Opioid Crisis ◽  
Medical Consultations ◽  
Context Specific

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources when describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions.

scholarly journals The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients

2021 ◽  
Vol 2 ◽  
Author(s):  
Zahabiya Campwala ◽  
Gregory Davis ◽  
Olga Khazen ◽  
Rachel Trowbridge ◽  
Melisande Nabage ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Healthcare Utilization ◽  
Multidisciplinary Care ◽  
The United States ◽  
Emergency Department Visits ◽  
Complex Patients ◽  
Tertiary Center ◽  
Chronic Pain Patients ◽  
The Impact ◽  
Pain Patients

Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients' numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon's signed rank test. Patients' NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC (p < 0.001). A significant decrease in clinic visits (p < 0.001) and healthcare utilization (p < 0.05) was also observed. Opioid and non-opioid prescriptions did not change significantly (p = 0.43). 83% of providers agreed that MDC improved patient care. While previous studies have shown the effect of multi-disciplinary care, we show notable improvements with a team established around a once-a-month MDC.

Racial and Ethnic Disparities in the Treatment of Chronic Pain

Pain Medicine ◽  
2020 ◽  
Author(s):  
Mary E Morales ◽  
R Jason Yong
Keyword(s):  
Chronic Pain ◽  
Racial Differences ◽  
Current Literature ◽  
Ethnic Disparities ◽  
The United States ◽  
Cross Sectional ◽  
Effective Interventions ◽  
Sociodemographic Profile

Abstract Objective To summarize the current literature on disparities in the treatment of chronic pain. Methods We focused on studies conducted in the United States and published from 2000 and onward. Studies of cross-sectional, longitudinal, and interventional designs were included. Results A review of the current literature revealed that an adverse association between non-White race and treatment of chronic pain is well supported. Studies have also shown that racial differences exist in the long-term monitoring for opioid misuse among patients suffering from chronic pain. In addition, a patient’s sociodemographic profile appears to influence the relationship between chronic pain and quality of life. Results from interventional studies were mixed. Conclusions Disparities exist within the treatment of chronic pain. Currently, it is unclear how to best combat these disparities. Further work is needed to understand why disparities exist and to identify points in patients’ treatment when they are most vulnerable to unequal care. Such work will help guide the development and implementation of effective interventions.

Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States

Pain Practice ◽  
2015 ◽  
Vol 16 (8) ◽  
pp. 1001-1011 ◽  
Author(s):  
Peter W. Park ◽  
Richard D. Dryer ◽  
Rozelle Hegeman-Dingle ◽  
Jack Mardekian ◽  
Gergana Zlateva ◽  
...  
Keyword(s):  
United States ◽  
Chronic Pain ◽  
Delivery System ◽  
The United States ◽  
Cost Burden ◽  
Integrated Delivery System ◽  
Chronic Pain Patients ◽  
Integrated Delivery ◽  
Pain Patients

Narrowing the mindware gap in medicine

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Pat Croskerry
Keyword(s):  
United States ◽  
Cognitive Performance ◽  
Clinical Reasoning ◽  
Medical Errors ◽  
Medical Error ◽  
Causes Of Death ◽  
The United States ◽  
Morbidity And Mortality ◽  
Medical Educators ◽  
High Degree

Abstract Medical error is now recognized as one of the leading causes of death in the United States. Of the medical errors, diagnostic failure appears to be the dominant contributor, failing in a significant number of cases, and associated with a high degree of morbidity and mortality. One of the significant contributors to diagnostic failure is the cognitive performance of the provider, how they think and decide about the process of diagnosis. This thinking deficit in clinical reasoning, referred to as a mindware gap, deserves the attention of medical educators. A variety of specific approaches are outlined here that have the potential to close the gap.

scholarly journals Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism

2018 ◽  
Vol 24 (9_suppl) ◽  
pp. 48S-55S ◽  
Author(s):  
Mateo Porres–Aguilar ◽  
Javier E. Anaya-Ayala ◽  
Gustavo A. Heresi ◽  
Belinda N. Rivera-Lebron
Keyword(s):  
Pulmonary Embolism ◽  
The United States ◽  
Cardiovascular Death ◽  
Pulmonary Embolectomy ◽  
Systemic Thrombolysis ◽  
Cardiopulmonary Support ◽  
Novel Approach ◽  
Adoption And Implementation ◽  
Complex Patients

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

Framing the diaspora and the homeland: language ideologies in the Cuban diaspora

2018 ◽  
Vol 2018 (254) ◽  
pp. 49-69
Author(s):  
Gabriela G. Alfaraz
Keyword(s):  
Language Ideology ◽  
Language Ideologies ◽  
The United States ◽  
Cuban Spanish ◽  
Political Beliefs ◽  
Perceptual Dialectology ◽  
Political Ideologies ◽  
Cuban Diaspora ◽  
The 1960S ◽  
High Degree

Abstract This article discusses language ideologies in relation to political ideologies in the Cuban diaspora in the United States. The findings of three longitudinal attitude studies, two conducted using the methods of perceptual dialectology, and a third with the matched-guise method, indicated that the diaspora’s political beliefs have a robust effect on its beliefs about Cuban Spanish in the diaspora and in the homeland. The perceptions studies showed that the national variety has a high degree of prestige in the diaspora, and that it has very low prestige in Cuba. The results of the matched-guise test showed that participants were unable to differentiate voices recorded in the 1960s and the 1990s, and that social information about residence in Cuba or the diaspora was more important to judgments of correctness than the presence of nonstandard variants. It is argued that the diaspora’s language ideology is maintained through erasure and essentialization: social and linguistic facts are erased, and the homeland is racially essentialized. It is suggested that through its language ideology, the Cuban diaspora claims authenticity and legitimacy vis-à-vis the homeland.

scholarly journals Similarly Lethal Strains of Extraintestinal Pathogenic Escherichia coli Trigger Markedly Diverse Host Responses in a Zebrafish Model of Sepsis

mSphere ◽  
2016 ◽  
Vol 1 (2) ◽  
Author(s):  
Amelia E. Barber ◽  
Brittany A. Fleming ◽  
Matthew A. Mulvey
Keyword(s):  
The United States ◽  
Host Responses ◽  
Inflammatory Condition ◽  
Therapeutic Approaches ◽  
Zebrafish Model ◽  
Life Threatening ◽  
High Degree ◽  
Care Costs ◽  
Variable Impact ◽  
Degree Of Heterogeneity

ABSTRACT Sepsis is a life-threatening systemic inflammatory condition that is initiated by the presence of microorganisms in the bloodstream. In the United States, sepsis due to ExPEC and other pathogens kills well over a quarter of a million people each year and is associated with tremendous health care costs. A high degree of heterogeneity in the signs and symptomology of sepsis makes this disease notoriously difficult to effectively diagnose and manage. Here, using a zebrafish model of sepsis, we find that similarly lethal but genetically distinct ExPEC isolates can elicit notably disparate host responses. These variances are in part due to differences in the levels and types of flagellin that are expressed by the infecting ExPEC strains. A better understanding of the variable impact that bacterial factors like flagellin have on host responses during sepsis could lead to improved diagnostic and therapeutic approaches to these often deadly infections. In individuals with sepsis, the infecting microbes are commonly viewed as generic inducers of inflammation while the host background is considered the primary variable affecting disease progression and outcome. To study the effects of bacterial strain differences on the maladaptive immune responses that are induced during sepsis, we employed a novel zebrafish embryo infection model using extraintestinal pathogenic Escherichia coli (ExPEC) isolates. These genetically diverse pathogens are a leading cause of sepsis and are becoming increasingly dangerous because of the rise of multidrug-resistant strains. Zebrafish infected with ExPEC isolates exhibit many of the pathophysiological features seen in septic human patients, including dysregulated inflammatory responses (cytokine storms), tachycardia, endothelial leakage, and progressive edema. However, only a limited subset of ExPEC isolates can trigger a sepsis-like state and death of the host when introduced into the bloodstream. Mirroring the situation in human patients, antibiotic therapy reduced ExPEC titers and improved host survival rates but was only effective within limited time frames that varied, depending on the infecting pathogen. Intriguingly, we find that phylogenetically distant but similarly lethal ExPEC isolates can stimulate markedly different host transcriptional responses, including disparate levels of inflammatory mediators. These differences correlate with the amounts of bacterial flagellin expression during infection, as well as differential activation of Toll-like receptor 5 by discrete flagellar serotypes. Altogether, this work establishes zebrafish as a relevant model of key aspects of human sepsis and highlights the ability of genetically distinct ExPEC isolates to induce divergent host responses independently of baseline host attributes. IMPORTANCE Sepsis is a life-threatening systemic inflammatory condition that is initiated by the presence of microorganisms in the bloodstream. In the United States, sepsis due to ExPEC and other pathogens kills well over a quarter of a million people each year and is associated with tremendous health care costs. A high degree of heterogeneity in the signs and symptomology of sepsis makes this disease notoriously difficult to effectively diagnose and manage. Here, using a zebrafish model of sepsis, we find that similarly lethal but genetically distinct ExPEC isolates can elicit notably disparate host responses. These variances are in part due to differences in the levels and types of flagellin that are expressed by the infecting ExPEC strains. A better understanding of the variable impact that bacterial factors like flagellin have on host responses during sepsis could lead to improved diagnostic and therapeutic approaches to these often deadly infections. Podcast: A podcast concerning this article is available.

scholarly journals Prevalence of Nonopioid and Opioid Prescriptions Among Commercially Insured Patients with Chronic Pain

Pain Medicine ◽  
2018 ◽  
Vol 20 (10) ◽  
pp. 1948-1954 ◽  
Author(s):  
Gabrielle F Miller ◽  
Gery P Guy ◽  
Kun Zhang ◽  
Christina A Mikosz ◽  
Likang Xu
Keyword(s):  
Chronic Pain ◽  
International Classification Of Diseases ◽  
The United States ◽  
Design Data ◽  
Classification Of Diseases ◽  
Drastic Increase ◽  
Inflammatory Drugs ◽  
Insured Patients ◽  
Evidence Based Guidelines ◽  
The Impact

Abstract Objective The increased use of opioids to treat chronic pain in the past 20 years has led to a drastic increase in opioid prescribing in the United States. The Centers for Disease Control and Prevention’s (CDC’s) Guideline for Prescribing Opioids for Chronic Pain recommends the use of nonopioid therapy as the preferred treatment for chronic pain. This study analyzes the prevalence of nonopioid prescribing among commercially insured patients with chronic pain. Design Data from the 2014 IBM® MarketScan® databases representing claims for commercially insured patients were used. International Classification of Diseases, Ninth Revision, codes were used to identify patients with chronic pain. Nonopioid prescriptions included nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics/antipyretics (e.g., acetaminophen), anticonvulsants, and antidepressant medications. The prevalence of nonopioid and opioid prescriptions was calculated by age, sex, insurance plan type, presence of a depressive or seizure disorder, and region. Results In 2014, among patients with chronic pain, 16% filled only an opioid, 17% filled only a nonopioid prescription, and 28% filled both a nonopioid and an opioid. NSAIDs and antidepressants were the most commonly prescribed nonopioids among patients with chronic pain. Having prescriptions for only nonopioids was more common among patients aged 50–64 years and among female patients. Conclusions This study provides a baseline snapshot of nonopioid prescriptions before the release of the CDC Guideline and can be used to examine the impact of the CDC Guideline and other evidence-based guidelines on nonopioid use among commercially insured patients with chronic pain.

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