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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_427"
                     title="AAPM: Botox May Relieve Postherpetic Neuralgia (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAPM/tb/18345?impressionId=1265773137516"
                     
      &lt;p&gt;SAN ANTONIO  --  Subcutaneous injection of botulinum toxin A (Botox) significantly reduced postherpetic neuralgia compared with lidocaine and saline placebo in a small randomized clinical study, researchers reported here.&lt;/p&gt;
&lt;p&gt;Patients randomized to receive botulinum toxin also had significant improvement in sleep and a significant reduction in opioid requirements compared with the lidocaine and saline groups. The differences emerged within one week and persisted to 90 days.&lt;/p&gt;
&lt;p&gt;&quot;Our preliminary data suggest that Botox may be useful for the treatment of refractory postherpetic neuralgia,&quot; Lizu Xiao, MD, of Nanshan Hospital in Shenzhen, China, said at the American Academy of Pain Medicine meeting. &quot;Patients were assessed for side effects at each visit, and none were observed, suggesting this is a simple, safe technique with essentially no adverse effects.&lt;/p&gt;
&lt;p&gt;&quot;Its use is particularly appropriate in older individuals who cannot tolerate antineuropathic medications.&quot;&lt;/p&gt;
&lt;p&gt;The analgesic mechanisms of botulinum toxin remains unclear. The neurotoxin inhibits the release of acetylcholine at the synapse and blocks the release of several other neurotransmitters involved in pain perception, said Xiao.&lt;/p&gt;
&lt;p&gt;Botulinum toxin has produced favorable results in limited clinical experience involving neuromuscular and myofascial conditions, such as strabismus and tension-type headache.&lt;/p&gt;
&lt;p&gt;Botulinum toxin also has provided pain relief in patients with neuropathic conditions, such as diabetic neuropathy and complex regional pain syndrome. The positive findings provided the impetus for the randomized controlled clinical trial of botulinum toxin in postherpetic neuralgia.&lt;/p&gt;
&lt;p&gt;The study involved 60 patients with diagnosed postherpetic neuralgia. They were randomized to subcutaneous injections of botulinum toxin, lidocaine, or saline, administered at a dosage of 1 mL/cm of affected area.&lt;/p&gt;
&lt;p&gt;The primary outcomes were improvement in pain assessed by visual analog scale (VAS), improvement in sleep on day one and day seven, and change in opioid use at day seven and three months.&lt;/p&gt;
&lt;p&gt;The patients&apos; mean age was 65 to 70. The baseline pain score was about 8 on a 10-point scale, and the duration of postherpetic pain averaged about one year.&lt;/p&gt;
&lt;p&gt;Patients randomized to lidocaine had the greatest improvement in pain on day one, a decrease to a VAS score of about 5, compared with a mean of 6 to 7 for the botulinum toxin and saline groups. The average pain score declined significantly in the lidocaine group compared with baseline and compared with the other two groups (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;By day seven, the average pain score had declined to about 3 compared with about 5 in the other two groups (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01). At the three-month follow-up, the mean VAS score remained at 5 in the lidocaine and saline groups (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01 versus baseline), while the mean in the botulinum toxin group was less than 4 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01 versus baseline and the other two groups).&lt;/p&gt;
&lt;p&gt;Baseline sleep time averaged three hours in all three groups and increased to five hours in the lidocaine group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01) by day one and to four hours in the other two groups.&lt;/p&gt;
&lt;p&gt;By day seven, average sleep time in the botulinum toxin group had increased to six hours (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01 versus baseline) compared with about four hours in the other two groups (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01 versus botulinum toxin).&lt;/p&gt;
&lt;p&gt;At 90 days the mean sleep time exceeded six hours in the botulinum toxin group, which remained significantly better than the other two groups, whose sleep time had increased to about five hours (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;Opioid requirements in the botulinum toxin group had declined to 20% of baseline by day seven, compared with about 50% in the lidocaine group and more than 60% in the saline group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;At the three-month follow-up, opioid use had declined to 30% to 40% of baseline in the lidocaine and saline groups, whereas opioid use remained at 20% of baseline in the botulinum toxin group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Chinese government.&lt;/p&gt;&lt;p&gt;Xiao had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_426"
                     title="AAPM: Spine Stimulation Leads to Durable Pain Relief (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAPM/tb/18344?impressionId=1265773137516"
                     
      &lt;p&gt;SAN ANTONIO  --  Spinal cord stimulation provided durable pain relief for patients with complex regional pain syndrome (CRPS) but did not halt progression, a retrospective analysis of a small clinical series showed.&lt;/p&gt;
&lt;p&gt;During follow-up for as long as 20 years, patients continued to rate their pain as significantly below baseline levels. Improvements in depression, medication use, and quality of life also proved durable.&lt;/p&gt;
&lt;p&gt;However, the pain syndrome progressed to other areas in all patients.&lt;/p&gt;
&lt;p&gt;&quot;All patients in this series experienced a gradual enlargement in the area affected over time,&quot; Krishna Kumar, MB, BS, of Regina Qu&apos;appelle Health Region in Regina, Saskatchewan, said at the American Academy of Pain Medicine meeting. &quot;Stimulation does not appear to retard disease spread.&quot;&lt;/p&gt;
&lt;p&gt;Nonetheless, 22 of the 25 patients in the series said they were satisfied with their pain relief and would have the procedure again.&lt;/p&gt;
&lt;p&gt;In a separate presentation at the meeting, Kumar reported that spinal cord stimulation led to significantly better outcomes than medical management in patients with failed back surgery syndrome.&lt;/p&gt;
&lt;p&gt;CRPS has an undetermined etiology, and there&apos;s no cure. The condition responds poorly to conventional medical therapy and to interventions such as transcutaneous electrical nerve stimulation, chemical blocks, sympathectomy, and physical therapy, said Kumar.&lt;/p&gt;
&lt;p&gt;Several studies and meta-analyses have shown that spinal cord stimulation relieves pain and other symptoms of CRPS during short- and mid-term follow-up. Whether the benefits persisted over the long term was unclear, Kumar continued.&lt;/p&gt;
&lt;p&gt;To assess long-term outcomes after spinal cord stimulation, Kumar and colleagues examined records of 196 patients who underwent spinal cord stimulation procedures. They identified 25 patients who met International Association for the Study of Pain criteria for CRPS and who agreed to participate.&lt;/p&gt;
&lt;p&gt;The cohort had a median follow-up of 63 months, a mean of 88 months, and a range of 18 to 235 months. The group comprised 13 men and 12 women whose mean age was 51 and whose ages ranged from 32 to 91. Ten of the 25 had upper-extremity pain and 15 had lower-extremity pain. In all cases the pain had not responded to conventional medical therapy.&lt;/p&gt;
&lt;p&gt;Assessment of each patient included pain rating by a visual analog scale (VAS), an index of physical functioning, a depression scale, a general health status survey, and a quality-of-life survey. Patients were assessed at implantation, three months and one year after implantation, and at last follow-up.&lt;/p&gt;
&lt;p&gt;All categories of medication use remained below baseline levels at last follow-up, including antidepressants, anticonvulsants, anti-inflammatory drugs, and narcotic drugs.&lt;/p&gt;
&lt;p&gt;Average scores on all of the survey instruments improved significantly from implantation to three months (&lt;em&gt;P&lt;/em&gt;=0.002 to &lt;em&gt;P&lt;/em&gt;=0.000). One-year results showed some reversal of the improvement, but scores for all outcomes remained below baseline levels.&lt;/p&gt;
&lt;p&gt;At last follow-up, mean scores remained significantly improved over baseline values (&lt;em&gt;P&lt;/em&gt;=0.003 to &lt;em&gt;P&lt;/em&gt;=0.001).&lt;/p&gt;
&lt;p&gt;The greatest improvement in health status and pain scores occurred in patients who were 40 or younger, who had stage I CRPS, and who underwent spinal cord stimulation within a year of diagnosis, said Kumar.&lt;/p&gt;
&lt;p&gt;&quot;Spinal cord stimulation is equally effective for men and women and for upper- and lower-limb CRPS,&quot; he said. &quot;Early institution is necessary to secure optimal patient outcomes, as delay exceeding one year appears to limit the effectiveness of the intervention.&quot;&lt;/p&gt;
&lt;p&gt;&quot;On the basis of these results, we conclude that spinal cord stimulation is an effective long-term management modality for CRPS and should be considered earlier in the treatment continuum, preferably within the first year of symptom onset,&quot; Kumar added.&lt;/p&gt;
&lt;p&gt;In a separate poster presentation, Kumar reported findings from a study of 100 patients with failed back surgery syndrome who were treated at 12 centers worldwide. Half the patients received conventional medical management and half had medical management plus spinal cord stimulation. The primary outcome was pain at six and 24 months after treatment.&lt;/p&gt;
&lt;p&gt;At six months, 48% of patients with spinal cord stimulation had at least 50% improvement in leg pain, compared with 9% of patients who received only medical treatment. Additionally, 38% of the spinal stimulation-group reported at least 30% improvement in back pain at six months versus 14% of the medically managed patients.&lt;/p&gt;
&lt;p&gt;Patients who were dissatisfied with their assigned treatment after six months were allowed to switch to the opposite therapy. Kumar reported that 30 of 50 patients in the medical group opted for spinal cord stimulation, compared with four of 50 in the spinal stimulation group who opted for continued treatment with medication alone.&lt;/p&gt;
&lt;p&gt;At 24 months, 42 of the original 50 patients remained in the spinal stimulation group, compared with 11 of 50 in the medical group. Differences observed at six months were maintained, including leg pain (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), physical functioning (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0002), and quality of life (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Kumar disclosed relationships with Medtronic and Boston Scientific.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_358"
                     title="Poststroke Antidepressant Boosts Mental Agility (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18240?impressionId=1265773137516"
                     
      &lt;p&gt;Antidepressants in the first months after a stroke may aid cognitive recovery for patients without depression, according to a randomized trial analysis.&lt;/p&gt;
&lt;p&gt;Global cognitive function scores improved significantly more with escitalopram (Lexapro) than with problem-solving therapy or placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), according to Ricardo E. Jorge, MD, of the University of Iowa in Iowa City, and colleagues.&lt;/p&gt;
&lt;p&gt;Memory scores rose significantly higher with the antidepressant as well (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), with both effects independent of those on depression, they reported in the February &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability,&quot; the researchers concluded.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; target=&quot;_blank&quot;&gt;primary analysis&lt;/a&gt; of the trial, reported in the &lt;em&gt;Journal of the American Medical Association on&lt;/em&gt; May 28, 2008, showed that prophylactic escitalopram treatment would prevent poststroke depression in one patient for every 7.2 treated &lt;em&gt;(P&lt;/em&gt;&amp;lt;0.001 compared with placebo). That article ultimately raised a controversy over an undisclosed conflict of interest.&lt;/p&gt;
&lt;p&gt;Escitalopram is a selective serotonin reuptake inhibitor (SSRI). Since serotonin plays a role in neuroplastic changes in the developing brain as well as in depression, Jorge&apos;s group analyzed whether there might be such an effect after a stroke.&lt;/p&gt;
&lt;p&gt;The study randomized patients to double-blind treatment with escitalopram (10 mg/d under age 65 or 5 mg/day age 65 and older) or placebo or unblinded problem-solving therapy (12 sessions of going through steps to arrive at a course of action for a patient-selected problem).&lt;/p&gt;
&lt;p&gt;The intent-to-treat analysis included 129 patients treated starting within the first three months after their mild to moderate severity stroke and who did not meet criteria for major or minor depression.&lt;/p&gt;
&lt;p&gt;Overall, global cognitive functioning was significantly changed between groups as measured on the Repeatable Battery for the Assessment of Neuropsychological Status (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After controlling for change in depression score and type of stroke, escitalopram was associated with the best cognitive recovery, an adjusted mean change of 9.9 points compared with 1.9 for problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01) and 4.0 for placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;Similarly, for delayed memory scores on the same test battery, escitalopram came out on top (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After adjustment for depression score change and stroke mechanism, the antidepressant was associated with an 11.2 point improvement in delayed memory, compared with a change of -0.7 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 3.9 with placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;On test of immediate memory, escitalopram again yielded the best recovery.&lt;/p&gt;
&lt;p&gt;The researchers found mean improvement of 13.4 points with the antidepressant compared with 2.0 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 7.2 with placebo (&lt;em&gt;P&lt;/em&gt;=0.04), after adjustment for time between stroke and treatment, depression score change, and stroke type.&lt;/p&gt;
&lt;p&gt;These mental benefits appeared to have an impact on functional status as well.&lt;/p&gt;
&lt;p&gt;Cognitive domain scores on the Functional Independence Measure were better for escitalopram-treated patients than those who didn&apos;t get the drug (&lt;em&gt;P&lt;/em&gt;=0.05), as were memory domain scores on the same measure (&lt;em&gt;P&lt;/em&gt;=0.03).&lt;/p&gt;
&lt;p&gt;At baseline, the global cognitive functioning and delayed and immediate memory scores were nonsignificantly lower in the antidepressant group than in the other two groups, which could have biased the results.&lt;/p&gt;
&lt;p&gt;However, the treatment effects appeared to be real, Jorge explained in an interview.&lt;/p&gt;
&lt;p&gt;In an unpublished regression analysis, the baseline scores were not a significant covariate. &quot;If [the results were] related only to the difference in baseline, this would be significant but it wasn&apos;t,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Moreover, with an initially lower score it might have been expected that the escitalopram-treated group would have had a lower score at the end of the study than the other groups, added co-author Robert G. Robinson, MD, also of the University of Iowa.&lt;/p&gt;
&lt;p&gt;But that wasn&apos;t the case, he said in an interview. With regard to delayed memory, for example, &quot;the escitalopram-treated group went from the most impaired to the best performing.&quot;&lt;/p&gt;
&lt;p&gt;The researchers didn&apos;t compare end scores for the escitalopram, problem solving therapy, and placebo groups, but they were: &lt;ul&gt; &lt;li&gt;For global cognitive functioning 89.8, 89.1, and 91.0 points, respectively&lt;/li&gt; &lt;li&gt;For delayed memory, 96.6, 89.1, and 94.2, respectively&lt;/li&gt; &lt;li&gt;For immediate memory, 95.1, 94.9, and 98.5, respectively&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The treatment showed no effect on other individual cognitive measurements, including those for attention, language, and IQ. Nor were there significant differences in changes in occupational or living conditions.&lt;/p&gt;
&lt;p&gt;Although SSRIs such as escitalopram have been associated with hospitalization for GI bleeding and falls in prior studies, these complications did not occur in Jorge&apos;s study.&lt;/p&gt;
&lt;p&gt;&quot;Long-term administration of SSRIs appears to be an effective and safe treatment option to improve cognitive outcomes among patients with cerebrovascular disease,&quot; they concluded in the &lt;em&gt;Archives&lt;/em&gt; paper.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study was limited by lack of CT or MRI scans and the younger age of escitalopram-treated patients, compared with other groups. That may have been a source of bias, although age did not appear to be a significant factor in the trial results.&lt;/p&gt;
&lt;p&gt;In this analysis, the researchers emphasized that the trial was not financially supported in any way by any drug company  --  a declaration hinting at the controversy that brewed last year over failure of one of the authors of the original &lt;em&gt;JAMA&lt;/em&gt; article to &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; target=&quot;_blank&quot;&gt;properly disclose ties&lt;/a&gt; to Forest Pharmaceuticals, which makes escitalopram.&lt;/p&gt;
&lt;p&gt;Another scientist who discovered that omission published the information in a competing journal, inducing &lt;em&gt;JAMA&lt;/em&gt; to issue a gag rule on reporting of undisclosed conflicts of interest. That policy encourages those who discover such conflicts to report them to &lt;em&gt;JAMA&apos;s&lt;/em&gt; editors but prohibits them from disclosing the conflicts publicly pending an investigation by the journal.&lt;/p&gt;
&lt;p&gt;In the current analysis, the disclosure statement indicated that co-author Robertson, had received honoraria and speakers&apos; bureau fees from Forest, with the caveat that &quot;none of the design, analysis, or expenses (including the cost of medications) of this study were supported by monies, materials, or any intellectual input from Forest Laboratories.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported solely by a grant from the National Institute of Mental Health.&lt;/p&gt;&lt;p&gt;Jorge reported having received travel awards to participate in national meetings from the former Hamilton Pharmaceutical Company and Avanir Pharmaceutical Company.&lt;/p&gt;&lt;p&gt;Co-authors reported financial conflicts of interest with Merck, NMT Medical, Eli Lilly, Centocor, Sanofi-Bristol-Meyers-Squibb, Boerhringer-Ingelheim, Schering-Plough, AstraZeneca, and GlaxoSmithKline, the former Hamilton Pharmaceutical Company, Avanir Pharmaceutical Company, Lubeck, Forest Laboratories, and Pfizer.&lt;/p&gt;&lt;p&gt;No pharmaceutical company donated medications for or had any financial interest in the study.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_296"
                     title="FDA Okays Morphine for Tolerant Patients"
                     score="0.005"
                     href="http://www.medpagetoday.com/PainManagement/PainManagement/tb/18157?impressionId=1265773137516"
                     
      &lt;p&gt;WASHINGTON  --  The FDA has approved the first high-concentration, oral morphine sulfate solution as part of its unapproved drugs initiative.&lt;/p&gt;
&lt;p&gt;The drug is indicated for opioid-tolerant patients with moderate-to-severe acute and chronic pain, as well as end-of-life care.&lt;/p&gt;
&lt;p&gt;Opioid tolerance was defined as a patient using 60 mg of an opioid per day, Sharon Hertz, MD, deputy director of the Division of Anesthesia, Analgesics, and Rheumatoid Products at the Center for Drug Evaluation and Research, said in a conference call.&lt;/p&gt;
&lt;p&gt;The new solution is available in 100 mg per 5 mL and 20 mg per 1 mL concentrations.&lt;/p&gt;
&lt;p&gt;Although morphine use in pain management has been a common practice, this form and concentration of the drug was not previously FDA approved.&lt;/p&gt;
&lt;p&gt;Approval for the new drug was based on efficacy and safety data already available, which applicants can use when seeking approval for unapproved formulations of drugs with a known safety profile, Hertz said.&lt;/p&gt;
&lt;p&gt;The FDA initiated the unapproved drugs initiative in March, 2009, when it sent warning letters to nine companies requesting they pull a number of morphine sulfate, oxycodone, and hydromorphone products from the market. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/13526&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/13526&quot; target=&quot;_blank&quot;&gt;FDA Acts Against Unapproved Narcotic Drugs&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Seven of the warned companies produced unapproved concentrated morphine sulfate, but the FDA granted a reprieve from the initiative when it could not find a suitable approved replacement for the drug without disrupting patient care. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/13682&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/13682&quot; target=&quot;_blank&quot;&gt;FDA Gives Temporary Reprieve to Unapproved Morphine Elixir&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;The agency worked with manufacturer Roxane Laboratories to ensure that a sufficient supply of the drug was available and to develop a prescription and use guide for the medication.&lt;/p&gt;
&lt;p&gt;As part of the approval, the manufacturer needed to establish a safety profile prior to approval to address the risks of morphine misuse, abuse, and overdose.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_184"
                     title="Higher Opioid Dose Linked to Greater Overdose Risk (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/Psychiatry/PainManagement/tb/18025?impressionId=1265773137516"
                     
      Higher prescribed doses of opioids for chronic pain significantly increased the risk of overdose, data from a large retrospective study showed.&lt;br&gt;
&lt;br&gt;Patients prescribed opioid doses of 100 mg/d or more had almost nine times the overdose risk of patients prescribed daily doses of 1 to 20 mg.&lt;br&gt;
&lt;br&gt;Patients taking 50 to 99 mg/d had almost four times the risk of low-dose patients, investigators reported in the Jan. 19 issue of &lt;em&gt;Annals of Internal Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;This study was the first to look at opioid overdose, nonfatal as well as fatal, among people who we know were getting opioids for chronic pain from a physician,&quot; Michael Von Korff, ScD, of the Group Health Research Institute in Seattle, said in an interview.&lt;br&gt;
&lt;br&gt;Although prescribed opioids had a low overall risk of overdose, patients who receive higher doses require careful monitoring. The findings have considerable clinical relevance, given evidence that higher opioid doses do not lead to better pain control, he added.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Increasingly, patients with chronic noncancer pain receive long-term opioid therapy, prescribed by healthcare providers. Previous studies of opioid overdose had focused on drug diversion and abuse, said Von Korff. The overdose risk associated with medically prescribed opioids had not been examined.&lt;/p&gt;
&lt;p&gt;To explore this risk, Von Korff and colleagues analyzed opioid prescription data from a large healthcare system. They identified patients who initiated opioid therapy for chronic noncancer pain from 1997 through 2005, who filled three or more prescriptions for opioids within the first 90 days of the pain episode, and who had no opioid prescriptions in the previous six months.&lt;/p&gt;
&lt;p&gt;The analysis identified 9,940 patients for inclusion. Follow-up from the initial 90-day prescription period averaged 42 months.&lt;/p&gt;
&lt;p&gt;The authors compared the average daily opioid dose over the prior 90 days with reported fatal and nonfatal overdoses. The analysis revealed 51 opioid-related overdoses, six of which were fatal.&lt;/p&gt;
&lt;p&gt;Patients prescribed daily opioid doses of 1 to 20 mg had an annual overdose rate of 0.2%. Patients taking 50 to 99 mg/d had an annual overdose rate of 0.7%, roughly 3.7 times greater than patients taking lower doses (95% CI 1.5 to 9.5). Daily opioid doses of 100 mg or greater were associated with an annual overdose risk of 1.8%, an 8.9-fold increase compared with patients taking 1 to 20 mg/d (95% CI 4.0 to 19.7).&lt;/p&gt;
&lt;p&gt;Patients who had not recently received opioids had less than one-third the overdose risk of patients who received the lowest daily doses of opioid drugs (HR 0.31).&lt;/p&gt;
&lt;p&gt;&quot;Observational studies suggest that many patients receiving opioids for chronic noncancer pain often continue to experience appreciable pain and activity limitations,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;Because of uncertainties regarding effectiveness and risks, long-term opioid therapy should be prescribed with awareness of risk and close patient monitoring, which may not be happening consistently at present,&quot; they added.&lt;/p&gt;
&lt;p&gt;The findings make a case for user-friendly, real-time, prescription-drug monitoring programs that allow physicians to track all opioid prescriptions for a patient, A. Thomas McLellan, PhD, of the White House Office of National Drug Control Policy, wrote in an accompanying editorial. Promising systems have been designed, but none is satisfactory at this point.&lt;/p&gt;
&lt;p&gt;&quot;Frankly, we do not know how to increase clinical diligence without additional work, time, or money, although technology can facilitate some of these suggested practice changes,&quot; McLellan wrote. &quot;The threat to patient safety is too great to allow current pain management and opioid-prescribing practices to remain as they are.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institutes of Health.&lt;/p&gt;&lt;p&gt;Von Korff disclosed a relationship with Johnson &amp;amp; Johnson. Co-author Mark D. Sullivan disclosed relationships with Eli Lilly, ABT Bio-Pharma, Wyeth, Aetna, Johnson &amp;amp; Johnson, and Ortho-McNeil. Co-author Kathleen W. Saunders disclosed a relationship with Merck &amp;amp; Co.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>