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Issue 20 - 29 June 2012


1. Prescription Drug Monitoring Programs-Lack of Effectiveness or a Call to Action?
Pain Medicine. May 2011, Vol. 12 Issue 5: p687-689
The authors reflect on the study on the effectiveness of prescription drug monitoring programs (PDMPs). They argue that the utilization of PDMPs by health care providers was not assessed or accounted for when determining the impact PDMPs had on overdose mortality or opioid consumption rates. They suggest that the findings of the study serves as a call-to-action for health care providers and policymakers to fully embrace PDMPs as an intervention to improve public health..

2. Can Pain Studies Influence Regulatory Policy?
By EMBURY, STEPHEN H. Pain Medicine. May 2011, Vol. 12
Issue 5: p690-691
The author reflects on the study that examines the pain experienced by patients with sickle cell disease. He contends that the study was a reanalysis of the data generated by the gold standard trial of sickle cell disease pain prevention. He argues that the findings suggest that such small daily decrements in pain score could be acceptable regulatory end points. He believes that the findings may influence regulatory policy and facilitate drug development..

3. The Value of the Case Report in the Age of Evidence-Based Medicine
By CLARK, LAURA L. Pain Medicine. May 2011, Vol. 12
Issue 5: p692-694
The author reflects on the relationship between evidence and clinical practice. She cites the case report which addresses the importance of a pain management team as well as its incorporation into the health care team. She argues that the clinical judgment is tempered by the devastating threat of masking a condition that could result in a permanent nerve injury. She suggests that the evolution of medicine is enjoying an explosion of knowledge..

4. If Not Us, Then Who?
By FINE, PERRY G. Pain Medicine. May 2011, Vol. 12 Issue 5: p695-696
The author shares his experience as a medical intern, who is taking care of a patient with cancer. He states that being an intern, he is taught effectively manage his own horror by mastering the treatment imperative, focusing on the disease, and fighting the disease. He argues that the misapprehension that acknowledging mortality is somehow tantamount to acquiescing to disease..

5. The Association Between Hydroxyurea Treatment and Pain Intensity, Analgesic Use, and Utilization in Ambulatory Sickle Cell Anemia Patients
By Smith, Wally R.; Ballas, Samir K.; McCarthy, William F.; Bauserman, Robert L.; Swerdlow, Paul S.; Steinberg, Martin H.& Waclawiw, Myron A. Pain Medicine. May 2011, Vol. 12
Issue 5: p697-705
We compared daily pain, home analgesic use, and utilization among ambulatory adults in the randomized Multicenter Study of Hydroxyurea in Sickle Cell Anemia (MSH). We related the fetal hemoglobin (HbF) hydroxyurea response to these response variables. Patients rated their sickle cell pain intensity (0-9), use of analgesics, and visits for pain daily. Diaries were collected biweekly, and intensity was collapsed into single interval ratings. The interval proportions of days of analgesic use and medical visits for pain were also calculated. Group comparisons were made by intention to treat as well as by HbF change levels from baseline to 2 years of treatment (placebo and low, medium, high, or very high response). A total of 134 (44.8%) enrollees completed 2 years of follow-up. Pain intensity correlated with analgesic use ( r = 0.83, P > 0.0001) and utilization (r = 0.50, P < 0.0001). Pain intensity was lower for patients on hydroxyurea (2.51 ± 0.062 vs 2.82 ± 0.063 placebo, F(1,270) = 11.65, P = 0.0007). The difference, though small, appeared early and was sustained. Analgesic use and utilization were also slightly lower (analgesic use: F(1,270) = 11.97, P = 0.0006; utilization: F(1,270) = 32.0, P < 0.0001). Each was statistically significantly lower among hydroxyurea patients with higher HbF treatment responses to hydroxyurea. Hydroxyurea usage led to a small, statistically significant reduction in daily pain, analgesic use, and utilization in adults in MSH, corroborating previously shown larger reductions in crises and mortality. The degree of daily symptomatic reduction was related to the size of the HbF treatment response, further confirming HbF response as a useful laboratory correlate. [ABSTRACT FROM AUTHOR].

6. Effect of an Interdisciplinary Outpatient Pain Management Program (IOPP) for Chronic Pain Patients with and without Migration Background: A Prospective, Observational Clinical Study
By Scascighini, Luca; Litschi, Martin; Walti, Martina & Sprott, Haiko. Pain Medicine. May 2011, Vol. 12 Issue 5: p706-716
Short- and long-term effects of an interdisciplinary outpatient pain program (IOPP) in terms of quality of life, coping strategies, experiencing of pain and pain intensity as well as the influence of age, gender, or migration background. Single, prospective cohort with assessments at baseline, posttreatment, and at 3, 6, 12 months follow-up. A total of 175 patients with chronic, nonmalignant pain syndromes (32.1% male and 67.9% female; age 43 ± 9.6 years). Multi-professional, biopsychosocial-oriented pain program for the duration of 8 weeks. Pain intensity, Pain Disability Index (German Version of Pain Disability Index, PDI-G), cognitive and behavioral coping strategies (Verarbeitung chronischer Schmerzen FESV), Marburger questionnaire about habitual subjective well-being, and processing of chronic pain (Veränderungsfragebogen des Erlebens und Verhaltens, VEV). The migration background was considered to determine whether this variable influences the clinical outcomes. All the mentioned variables except pain intensity improved significantly after the program ( P < 0.05); whereas, after the 1-year follow-up, most of the parameters returned to the baseline values. Solely the subscale 'pain-related psychological strain' remained significantly better compared with baseline ( P < 0.05). The variable 'migration background' influenced the outcomes PDI-G, habitual well-being, and FESV ( P < 0.001; variance of 16.7% [95% confidence interval 7.8-25.5]). After 12 months, 49.4% showed an improvement with regard to the VEV outcome measurement, 22.6% showed no changes, and 28% showed worsening of the symptoms. Gender and age did not influence the results at 12 months ( P = 0.408; P = 0.964). This study provides evidence for the short-term effect of the IOPP in chronic pain patients as well as the long-term effect for the variable 'pain-related psychological strain.'

7. Neurotoxicity of Intrathecally Administered Fentanyl in a Rat Spinal Model
By Fukushima, Sayano; Takenami, Tamie; Yagishita, Saburo; Nara, Yoshihiro; Hoka, Sumio & Okamoto, Hirotsugu.
Pain Medicine. May 2011, Vol. 12 Issue 5: p717-725
Intrathecally administered fentanyl rarely causes drug tolerance or formation of inflammatory masses and might therefore be a suitable treatment option for chronic pain. However, the neurotoxicity of intrathecally administered fentanyl remains to be clarified. We examined the histological changes, neurodysfunction, and side effects of intrathecal fentanyl in rats. The rats received fentanyl at 0.12 µL/g body weight (0, 50, 1,000, 2,000, and 5,000 µg/mL in saline) via an intrathecal catheter. Seven days after the injection, the spinal cord with both roots were removed for histological examination. The neurological function was evaluated by monitoring walking behavior and latencies to radiant heat. Side effects were also recorded. No histological abnormalities were observed in the spinal cord, anterior and posterior roots, cauda equina nerves, or arachnoid membrane. Formation of white neomembrane was noted around the catheter in some animals, but there was no significant difference in the incidence among the groups. The sensory threshold was significantly higher at 1 and 2 hours after injection in the 50 and 5,000 µg/mL groups, respectively. However, there was no significant difference in the sensory threshold among the five groups at 7 days postinjection. All of the rats walked normally within 4 hours even after injection of 5,000 µg/mL fentanyl. The incidence of apnea, muscular rigidity, and bradycardia increased significantly at =1,000 µg/mL dose. The side effects of intrathecally administered fentanyl were concentration-dependent, although no neuronal tissue damage, inflammation, or irreversible neurodysfunction were observed even at 5,000 µg/mL. [ABSTRACT FROM AUTHOR].

8. Incidence and Characteristics of Complications from Epidural Steroid Injections
By McGrath, Jacob M.; Schaefer, Michael P.& Malkamaki,
Daniel M. Pain Medicine. May 2011, Vol. 12 Issue 5: p726-731
Epidural steroid injections are frequently used in the management of spinal pain, but reports on the incidence of complications from this procedure vary. This study seeks to determine the incidence of complications resulting from this procedure, and to compare the rate of complications in transforaminal vs interlaminar injections. The design of the study was a retrospective chart review of epidural steroid injections in our academic physiatry practice over a 7-year period. A query of our electronic medical record identified all injection patients who contacted their physician or had a clinic visit or emergency department visit within 10 days of the procedure. Charts were individually reviewed for both major complications and minor complaints. A total of 4,265 injections were performed on 1,857 patients over 7 years; 161 cervical interlaminar injections, 123 lumbar interlaminar injections, 17 caudal injections, and 3,964 lumbar transforaminal injections. No major complications were identified. There were 103 minor complications, for an overall complication per injection rate of 2.4%. The most common complications were increased pain (1.1%), pain at injection site (0.33%), persistent numbness (0.14%), and 'other' (0.80%). Complications were less common in transforaminal injections (2.1%), than in interlaminar injections (6.0%). One patient experienced a self-limited headache resulting from dural puncture during an interlaminar injection. Fluoroscopically guided epidural steroid injections are a safe and well-tolerated intervention for cervical or lumbar pain and radiculopathy. Minor complications are uncommon, and most involve increases in pain. Transforaminal injections may result in fewer minor complications than interlaminar injections.

9. Etiology of Chronic Low Back Pain in Patients Having Undergone Lumbar Fusion
By DePalma, Michael J.; Ketchum, Jessica M.& Saullo, Thomas R. Pain Medicine. May 2011, Vol. 12 Issue 5: p732-739
: To estimate the prevalence of lumbar internal disc disruption, zygapohyseal joint pain, sacroiliac joint pain, and soft tissue irritation by fusion hardware in post-fusion low back pain patients compared with non-fused patients utilizing diagnostic spinal procedures. Retrospective chart review. University spine center. Patients presenting to a community-based, multidisciplinary, academic spine center (65.9% female, mean age 54.4 years, median pain duration 12 months). Charts of consecutive low back pain cases completing diagnostic spinal procedures including provocation discography and zygapohyseal joint, sacroiliac joint, and fusion hardware blockade were retrospectively reviewed. Based on the results of discography and/or diagnostic blockades, subjects were classified with internal disc disruption, zygapohyseal joint pain, sacroiliac joint pain, or fusion hardware related pain. The diagnoses of 28 fusion cases identified from 170 low back pain patients undergoing diagnostic procedures included 12 with sacroiliac joint pain, seven with internal disc disruption, five with zygapohyseal joint pain, and four due to soft tissue irritation from fusion hardware. No significant differences were noted in zygapohyseal joint mediated pain with and without fusion history. Mean ages of patients were similar with and without fusion history for cases diagnosed as internal disc disruption. In patients' recalcitrant to non-interventional care, the sacroiliac joint is the most likely source of low back pain after lumbar fusion followed by internal disc disruption, zygapohyseal joint pain, and soft tissue irritation due to fusion hardware. Sacroiliac joint pain is more common after fusion, while internal disc disruption is more common in non-fusion patients. [ABSTRACT FROM AUTHOR].

10. Primary Care Monitoring of Long-Term Opioid Therapy among Veterans with Chronic Pain
By Krebs, Erin E.; Ramsey, Darin C.; Miloshoff, James M.& Bair, Matthew J. Pain Medicine. May 2011, Vol. 12 Issue 5, p740-746
To characterize long-term opioid prescribing and monitoring practices in primary care. Retrospective medical record review. Primary care clinics associated with a large Veterans Affairs (VA) medical center. Adult patients who filled =6 prescriptions for opioid medications from the outpatient VA pharmacy between May 1, 2006 and April 30, 2007. Indicators of potential opioid misuse, documentation of guideline-recommended opioid-monitoring processes. Ninety-six patients (57%) received a long-acting opioid, 122 (72%) received a short-acting opioid, and 50 (30%) received two different opioids. Indicators of some form of potential opioid misuse were present in the medical records of 55 (33%) patients. Of the seven guideline-recommended opioid-monitoring practices we examined, the mean number documented within 6 months was 1.7 (standard deviation [SD] 1.5). Pain reassessment was the most frequently documented process (N = 105, 52%), and use of an opioid treatment agreement was the least frequent (N = 19, 11%). Patients with indicators of potential opioid misuse had more documented opioid-monitoring processes than those without potential misuse indicators (2.4 vs 1.3, P < 0.001). After adjustment, potential opioid misuse was positively associated with the number of documented guideline-recommended processes (mean = 1.0 additional process, 95% confidence interval [CI] 0.4, 1.5). Guideline-recommended opioid management practices were infrequently documented overall but were documented more often for higher risk patients who had indicators of potential opioid misuse. The relationship between guideline-concordant opioid management and high-quality care has not been established, so our findings should not be interpreted as evidence of poor quality opioid management. Research is needed to determine optimal methods of monitoring opioid therapy in primary care. [ABSTRACT FROM AUTHOR].

11. Prescription Drug Monitoring Programs and Death Rates from Drug Overdose
By Paulozzi, Leonard J.; Kilbourne, Edwin M. & Desai, Hema A. Pain Medicine. May 2011, Vol. 12 Issue 5: p747-754
: Drug overdoses resulting from the abuse of prescription opioid analgesics and other controlled substances have increased in number as the volume of such drugs prescribed in the United States has grown. State prescription drug monitoring programs (PDMPs) are designed to prevent the abuse of such drugs. This study quantifies the relation of PDMPs to rates of death from drug overdose and quantities of opioid drugs distributed at the state level. Observational study of the United States during 1999-2005. Rates of drug overdose mortality, opioid overdose mortality, and opioid consumption by state. PDMPs were not significantly associated with lower rates of drug overdose or opioid overdose mortality or lower rates of consumption of opioid drugs. PDMP states consumed significantly greater amounts of hydrocodone (Schedule III) and nonsignificantly lower amounts of Schedule II opioids. The increases in overdose mortality rates and use of prescription opioid drugs during 1999-2005 were significantly lower in three PDMP states (California, New York, and Texas) that required use of special prescription forms. While PDMPs are potentially an important tool to prevent the nonmedical use of prescribed controlled substances, their impact is not reflected in drug overdose mortality rates. Their effect on overall consumption of opioids appears to be minimal. PDMP managers need to develop and test ways to improve the use of their data to affect the problem of prescription drug overdoses.

12. Long-Term Safety of Remoxy
By Friedmann, Nadav; Klutzaritz, Vicki & Webster, Lynn. Pain Medicine. May 2011, Vol. 12 Issue 5: p755-760
: Evaluate the long-term safety, tolerability, and efficacy of Remoxy (extended-release oxycodone) in patients with chronic pain related to osteoarthritis of the hip and/or knee or chronic low back pain. Open-label, 12-month, phase 3 trial. Fifty-nine US sites. Men and women with moderate to severe hip and/or knee pain caused by osteoarthritis or persistent moderate to severe low back pain. Remoxy 5 mg twice daily, which could be increased in fixed increments up to 80 mg twice daily. Safety and tolerability assessments included adverse events (AEs), laboratory tests, vital signs, physical examinations, and electrocardiograms. Efficacy was assessed through ratings of pain intensity, quality of analgesia, and global assessment of study drug. Of the 828 patients enrolled, 823 received =1 dose of Remoxy, with 469 exposed for =180 days and 381 for =358 days. At least one AE was experienced by 678 patients (82%), the most common of which were opioid related, including constipation, nausea, and somnolence; 173 patients (21%) discontinued treatment because of AEs. No clinically relevant changes were seen in other safety assessments. Mean pain intensity scores decreased significantly from baseline at all time points ( P < 0.001). At month 12, quality of analgesia and global assessment of study drug were rated positively (good, very good, or excellent) by 64% and 61% of patients (last observation carried forward), respectively. Long-term treatment with Remoxy was safe, well tolerated, and efficacious in patients with chronic pain related to osteoarthritis of the hip and/or knee or chronic low back pain. [ABSTRACT FROM AUTHOR].

Journal - Table of Contents

13. From New Zealand College of Midwives Midwifery News, June 2012
. Why midwives are saying enough [Collective protest on the rise; Collective Wisdom; Individual versus representative or collective opinion; Human rights and maternity; National Maternity Quality and Safety Programme]
13B. Lest we forget - why unity is strength [Norma Campbell, Midwifery Advisor] Its been twenty two years since the Nurses Amendment Act was changed enabling midwifery to regain professional autonomy in New Zealand.
13C. MERAS Report: Measuring and meeting the demand for care; What is Care Capacity Demand Management (CCDM); Nelson Marlborough Pilot; What Next.
13D. MMPO Report - Chris Hendry, Executive Director, MMPO [Midwives from Japan applaud "proud' and "gentle' New Zealand Colleagues
13E. Nationally Facilitated Workshops by Regions 1st June 2012 - 31st March 2013
13F. Projects Update [IT membership database and website re-development project; Smoking in pregnancy demonstration project; Medicines Act regulations submission - Midwives prescribing controlled drugs; Formation of Rural Health Alliance Aotearoa New Zealand (RHANZ); Shaken Baby project; Maternity Quality and safety Programme "roadshow".
13G. Pioneers of modern midwifery [Celia Rodley; Jan Thomas; Sarah Hodgetts
13H. Where to look to find information which supports decisions in relation to prescribing? [The New Zealand Formulary]
13I. Facing up to facebook
13J. Quality programme to improve maternity care across the country
13K. Government has lost momentum on development of women says new report
13L. It was just not ok [Midwives in and around Whanganui and Palmerston North launched a campaign to protest at proposed changes to maternity services]
13M. Managing the media to get a message across
13N. New Zealand midwives invited to volunteer in Rwanda
13O. Research roundup: Studies point to high cost of caesarean section


14. Everyday Mindfulness for Health Professionals: A residential retreat
2-7 September 2012
Venue: Mana Retreat Centre, Coromandel
Register at:

News - National

15. Minister releases online cultural competency training
20 June 2012

Associate Health Minister Tariana Turia today released New Zealand’s first online foundation course on cultural competency designed specifically for health workforce professionals. The free online training tool – the Foundation Course in Cultural Competency – provides a basic understanding of cultural competency and health literacy. Mrs Turia said everyone in the regulated and non-regulated health workforces should have the ability and knowledge to understand health behaviours and how they are influenced by culture.

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