Pain, Stress and Fear in Hurricane Katrina Victims
Persons with chronic pain displaced during a natural disaster experience more pain, which is associated with stress and fear. On August 29, 2005, Katrina, a category-4 hurricane, ravaged the Gulf Coast of Louisiana, Mississippi and Alabama. Mandatory evacuations displaced hundreds of thousands from their homes. To evaluate pain patterns and management in evacuees following a natural disaster a cross-sectional survey of 52 patients with physical pain was compiled by one physician over eight days who saw patients in the Reliant Astrodome and four Houston-area shelters. The survey interview inquired about demographics, pain scores (0-10) and pain medications before and after Katrina, satisfaction with pain management (0-10), level of stress and fear from Katrina (0-10), and past medical and surgical history.
Of the 52 patients surveyed, 45 (86.5%) suffered from chronic pain and 7 (13.5%) from acute pain caused by injuries sustained during evacuation. Mean age was 50.8 years, 55% were male, 70 % were African American and 24 % were Caucasian. The chronic pain group reported the following mean pain scores (0-10 scale): before Katrina=4.9; the period between Katrina and the present=5.9; and current pain=6.5. Stress and fear levels (0-10 scale) associated with Katrina were 7.1 and 6.3 respectively. Preliminary analyses suggest a correlation between self-reported pain, stress and fear. 73% of the chronic pain groups were not satisfied with their level of pain relief.
The investigators recommend additional research on the effects and treatment of pain during and after natural disasters.
Investigators: Rishin Patel, MD, Philadelphia VA Medical Center; Rollin M. Gallagher, MD, Philadelphia VA Medical Center and University of Pennsylvania; and Donna Bloodworth, MD, Quentin Mease Community Hospital, Houston, TX.
Chronic and Acute Pain Management Before, During and After Hurricane Katrina - A Ground Zero Perspective
Persons living in their communities after a natural disaster demonstrate resilience such as improved coping and adaptation. Clinicians and health officials should consider these effects in planning for the health care needs of populations caught in natural disasters.
The researchers collected demographics and pre- and post-Katrina variables including pain scores, medication requirements, phone calls, and noncompliance from 400 patients treated in a pain clinic immediately after the hurricane to further understand pain patterns and management in a sample of pain clinic patients during and following a natural disaster. To evaluate the effects of a community's physical damage on coping with chronic pain in disaster, the researchers stratified the sample based upon the severity of damage to each town estimated in governmental reports - these ranged from complete destruction to modest inconvenience.
Initial post-Katrina data showed a drop in pain scores, no escalation of medication requests, and fewer calls. Patients demonstrated resilience in the face of disaster, focusing on survival not pain. They generally coped when challenged by a new task, such as boarding a house, climbing a roof and providing for life's essentials. Many suffered post-traumatic stress without escalation in medication requests or need for additional pain management. Further analyses will reveal characteristics of patients and the environment that determine coping outcomes in natural disaster when afflicted by chronic pain.
Investigators: Yen Chou Joe Chen, MD, Suncoast Pain Management Center, Ocean Springs, MS; B. Todd Sitzman, MD, Advanced Pain Therapy, Hattiesburg, MS; and Rollin M. Gallagher, MD, Philadelphia VA Medical Center and University of Pennsylvania.
Hip Joint Pain Referral Patterns: A Descriptive Study
Buttock pain is the most common pain referral area from a symptomatic hip joint, while the traditionally accepted groin and thigh referral areas were less common.
Hip joint pain referral has been classically thought to occur most commonly in the groin and front of the thigh. The authors believe this is the first study assessing hip joint pain referral patterns based on a diagnostic fluoroscopically guided intra-articular (FGIA) hip injection.
This retrospective descriptive study of 51 patients with hip joint pain pathology characterized hip joint pain referral patterns. The hip joint was shown to cause pain in traditionally accepted referral areas to the groin and thigh in 55% and 57% of patients, respectfully. However, pain referral was also seen in the buttock and leg 71% and 22%, respectively. Foot and knee pain were seen in only 6% and 2% of patients, respectively, while lower lumbar spine referral did not occur. The investigators observed 12 pain referral patterns.
Investigators: John M. Lesher, University of Washington; Seattle, Paul Dreyfuss, University of Washington, Seattle; Nelson Hager, University of Washington, Seattle; Michael Kaplan, Gem City Bone and Joint, Laramie, WY; and Michael Furman, Physical Medicine and Rehabilitation, Orthopaedic and Spine Specialists, York, PA.
Cardiac Pacemaker and Spinal Cord Stimulator. Do they Interfere?
Electrical device-to-device interference was not found between implantable dual chamber pacemakers and modern spinal cord stimulators.
The presence of an implantable cardiac pacemaker frequently is considered as a relative contraindication to spinal cord stimulators, because they both include a power source, circuitry and electrodes. However, many people require both cardiac pacemakers and spinal cord stimulators. Because there are no particular guidelines for these surgical procedures, each individual experience with combined treatment of cardiac disease and degenerative discs disease requires close attention.
The researcher studied five patients with implanted cardiac pacemakers and spinal cord stimulators. Intracardiac electrocardiogram showed no atrial or ventricular sensing in all five cases. Final analysis showed no dependency of cardiac pacemaker from spinal cord stimulator.
Investigator: Alexander A. Krakovsky, Interventional Pain Management, Galileo Medical Center, San Luis Obispo, CA.
The Role of Body Mass Index on Quality of Life among African Americans and Caucasians with Chronic Pain
The researchers found that body mass index (BMI) is associated with disability and physical functioning in patients with chronic pain. BMI data was not included in the electronic medical records of patients most at risk for health disparities. Surprisingly, BMI was not associated with mental health outcomes (as suggested in the literature). The investigators recommend further study to clarify whether the emotional distress associated with increased BMI is hidden by the impact of chronic pain.
Obesity is a widespread public health problem that contributes to several chronic pain conditions. Yet, little is known about how obesity impacts the chronic pain course.
The researchers studied electronic medical records of 183 African American and Caucasian chronic pain patients (64% women, 46% African American) between 18 and 50 years of age to better understand the presence or absence of body mass index (BMI) information in medical records, group differences in BMI, and how BMI and pain contribute to mental and physical outcomes.
The patients who were least likely to have BMI data reported were African Americans and people with higher scores for pain, affective distress and posttraumatic stress disorder. These same individuals also had a trend for higher disability and poorer mental functioning. BMI data was available for 143 subjects with African Americans having a higher BMI than Caucasians (31.6 vs. 27.6). No gender, education or marital status differences were found. BMI was positively associated with African American ethnicity and age and predicted poorer physical functioning and greater disability. Pain was not predicted by ethnicity or age but was associated with all four outcome variables.
Investigators: Carmen Green, MD, University of Michigan Medical Center, Ann Arbor, MI; Tamera Hart-Johnson, University of Michigan, Ann Arbor, MI; S. Khady Ndao-Brumblay, University of Michigan, Ann Arbor, MI; and Katharine George, University of Michigan, Ann Arbor, MI.
Intranasal Morphine, a Non-Invasive Alternative to Injectable Morphine, Relieves Moderate-to-Severe Postsurgical Pain
Rylomine intranasal morphine provides dose-dependent pain relief superior to placebo and comparable to IV morphine in post-operative patients.
Intravenous (IV) morphine is the existing "standard" of care for treating moderate-to-severe postsurgical pain. Rylomine is currently under development as an alternative to IV morphine. The investigators studied post-orthopedic patients with moderate-to-severe pain to compare the safety and efficacy of Rylomine to IV morphine and placebo. They found that Rylomine (15 mg or 30 mg dose) or IV morphine demonstrated statistically superior pain relief compared to placebo. Step-down testing indicated that the minimum effective dose of Rylomine was 7.5 mg. Regardless of administration route, adverse reactions were dose related and consistent with general opioid effects, including dizziness, nausea, sedation, and vomiting.
Investigators: Douglas Stoker, Jean Brown Research Center, Salt Lake City, UT; Keith Reber, Foot & Ankle Institute, St. George, UT; Daniel Carr, Javelin Pharmaceuticals, Inc., New York, NY; Cynthia Ernst, Javelin Pharmaceuticals, Inc., New York, NY; Daniel Gawarecki, Javelin Pharmaceuticals, Inc., New York, NY; Douglas Hamilton, Javelin Pharmaceuticals, Inc., New York, NY; Edward Liao, Javelin Pharmaceuticals, Inc., New York, NY; Fred Mermelstein, Javelin Pharmaceuticals, Inc., New York, NY; Lynn Waltzman, Javelin Pharmaceuticals, Inc., New York, NY; and Curtis Wright, Javelin Pharmaceuticals, Inc., New York, NY.
Opioid Blood Levels in High Dose, Chronic Pain Patients
Higher than expected opioid blood concentrations in pain patients treated with opioid therapies lead a pain medicine researcher to suggest that monitoring opioid blood concentration become routine clinical practice.
Checking opioid blood concentrations can aid in determining compliance with prescribing instructions, determination of therapeutic effectiveness, and medicolegal protection for the prescribing physician and pharmacist. There is scant information concerning opioid blood concentrations in chronic pain patients treated with high doses of opioids.
The researcher requested that physician readers of Practical Pain Management voluntarily submit a data sheet without a patient's name and report opioid blood concentrations of chronic pain patients treated with opioids. Data collected included age, gender, weight, cause of pain, opioid and daily dosage, and the patient's function status including the ability to drive and work. Patients had blood samples taken approximately one to two hours after a regularly, prescribed opioid dosage. The physician utilized his/her usual commercial laboratory. Currently, 10 to 30 blood concentrations have been reported for each of the following opioids: methadone, morphine, oxycodone, hydromorphone, hydrocodone, fentanyl, and meperidine. Patients had well-known chronic, painful conditions such as spine degeneration, autoimmune disorders, and neuropathies. All patients were described as functional in that they could care for themselves, and more than 80% could drive a car. Dosages of opioids were high. The majority of blood concentrations were above the therapeutic ranges published for non-tolerant persons, and many concentrations were above levels often described as "toxic" or "lethal."
Investigator: Forest Tennant, Tennant Intractable Pain Clinic, West Covina, CA.
Founded in 1983, AAPM is a medical specialty society representing physicians practicing in the field of pain medicine. Information is available on the practice of pain medicine at www.painmed.org.
For more information, contact Amy Jenkins at 312/836-0613 or email amy@jenkinspr.com or Echo Morgan at emorgan@connect2amc.com.