Opioid use and dependence among persons with migraine: results of the AMPP study

Objective.— To assess the frequency of opioid use for acute migraine treatment and characterize use groups by sociodemographics, health‐care resource utilization (HRU), comorbidities and probable dependence within a large, US population‐based sample of persons with migraine. Background.— Opioids are used in the acute treatment of migraine. However, their use is controversial. Methods.— Data from the 2009 American Migraine Prevalence and Prevention (AMPP) study were used to categorize persons with migraine into 4 groups based on reported opioid use: nonusers (between 2005 and 2009), previous users (history of use between 2005 and 2008 but no‐use in 2009), and current opioid users (those reporting use of opioids in the 3 months preceding the 2009 American Migraine Prevalence and Prevention survey). Current opioid users were divided into nondependent and probable dependence users according to criteria for dependence adapted for inclusion in the survey from the Diagnostic and Statistical Manual of Mental Disorders–4th edition. All opioid‐use groups were contrasted by sociodemographics, headache characteristics, medical and psychiatric comorbidities (depression [measured by the Patient Health Questionnaire‐9], anxiety [measured by the Primary Care Evaluation of Mental Health Disorders, PRIME‐MD], and cardiovascular events and risk factors), and headache‐related HRU. Results.— In a sample of 5796 migraineurs, 4076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users. Among current opioid users, 153 (16.6%) met criteria for probable dependence and 769 (83.4%) did not. Headache‐related disability (Migraine Disability Assessment sum scores) increased across groups as follows: nonusers: 7.8, previous users: 13.3, current nondependent users: 19.1, and current probable dependence users: 44.4, as did monthly headache frequency: nonusers: 3.2 days/month, previous users: 4.3 days/month, current nondependent users: 5.6 days/month, and current probable dependence users: 8.6 days/month. The prevalence of depression and anxiety was highest among current users with probable dependence. Rates of headache‐related HRU were higher for all opioid‐use groups for emergency department/urgent care, primary care, and specialty care visits compared to nonusers. Conclusions.— Opioid use for migraine is associated with more severe headache‐related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), and greater HRU for headache. Longitudinal studies are needed to further assess the directionality and causality between opioid use and the outcomes we examined.     

Addressing adolescent substance use with a public health prevention framework: the case for harm reduction

Adolescence is a developmental stage defined in part by risk-taking. Risk-taking is critical to normal development and has important benefits including trying new activities and exploring new relationships. Risk-taking is also associated with the initiation of substance use. Because substance use often begins in adolescence, much focus has been on primary prevention with the goal of preventing initial substance use. Secondary or tertiary prevention approaches, such as counselling to eliminate substance use or offering treatment, are common approaches for adolescents with problematic substance use or a substance use disorder. While this is important, for some adolescents, treatment or cessation of use may not be desired. In these cases, Healthcare Practitioners (HCPs) can offer clear advice that incorporates harm reduction. Harm reduction, which is often applied for adults who use substances, reduces the negative impacts associated with drug use without requiring abstinence. Harm reduction is crucial to keeping adolescents safe and healthy and can offer opportunities for future engagement in treatment. The objective of this review is to describe strategies for integrating harm reduction principles in clinical settings that are developmentally appropriate. A patient-centered, harm reduction approach can validate perceived benefits of substance use, offer strategies to minimise harm, and advise reduction of use and abstinence.

KEY MESSAGES:

• Substance use often begins in adolescence and traditional approaches are often rooted in prevention framework.
• Harm reduction should be incorporated for adolescents with problematic substance use or a substance use disorder.
• This review offers strategies for integration of harm reduction principles tailored towards adolescents.

     

The effectiveness of a traditional Persian medicine preparation in the treatment of chronic cough: A randomized,double-blinded,placebo-controlled clinical trial

ObjectivesThe roots and rhizomes of licorice (Glycyrrhiza glabra L.) are used in traditional Persian medicine for the treatment of numerous diseases. A chronic cough is a non-specific reaction to irritation anywhere in the respiratory system. It usually lasts for more than eight weeks. The current study aimed to evaluate the effect of a modified traditional Persian medicine preparation, licorice pastille, in healing a chronic cough.MethodsThrough a randomized, double-blinded, placebo-controlled clinical trial was performed in a respiratory disease clinic in Shiraz, Iran; between October 2016 and December 2017. Seventy participants with a chronic cough took part in the trial. The outcome measures were as the daily cough scores (the score being logged via patient symptoms, diary, and the visual analogue scale) and the quality of life measure of chronic cough according to the Leicester Cough Questionnaire.ResultsAt baseline, there were no significant differences in the demographic or clinical (cough score) characteristics between the two groups. There was complete adherence to protocol in both groups but, the drop-out rate was 4 patients in the placebo and 6 ones in the intervention groups. The results at the end of the trial (Week 2) and follow-up (Week 4) demonstrated the efficacy of the licorice pastille in terms of the cough severity score against the placebo group. This item showed a significant decrease in the intervention group (1.2 ± 0.93) comparing to the placebo one (1.8 ± 1.03) at follow-up time. No major side effects were reported during the study and follow-up time.ConclusionsLicorice pastille could be a promising choice in the treatment of a chronic cough of unknown origin.     

Deaths related to MDMA (ecstasy/molly): Prevalence,root causes,and harm reduction interventions

Recent data show that MDMA (3,4 methylenedioxymethamphetamine) related deaths (MRDs) are on the rise in several countries. This rise in MRDs has caught the attention of public health officials and treatment practitioners. Although MDMA is not a new drug, misinformation regarding the root causes of MRDs is still widespread. For example, MRDs continue to be reported as “overdoses” in the media and by government. This erroneously gives the impression that these deaths are caused by ingesting too high a dose, when in fact MRDs are usually due to factors such as hyperthermia, dehydration, drug interactions, or hyponaetremia. When the real culprits behind MRDs are obscured, we are left with an inaccurate picture about the extent and nature of the risk of consuming the drug. This also inhibits the implementation of effective drug education and risk reduction messages. The purpose of this paper, therefore, is to explore MRDs further by: 1) providing a brief history of MDMA, 2) summarizing international prevalence rates of MRDs, 3) discussing factors that contribute to MRDs, and 4) identifying promising interventions to reduce MRDs. The information presented in this paper is particularly important given the international resurgence of recreational MDMA use (as molly) and the renewed interest in the drug’s therapeutic benefits.     

Development of the Persian version of the Modified Modified Ashworth Scale: translation,adaptation, and examination of interrater and intrarater reliability in patients with poststroke elbow flexor spasticity

Purpose: Development of the Persian version of the Modified Modified Ashworth Scale (MMAS), and to investigate the interrater and intrarater reliability of the Persian MMAS when used to quantify elbow flexor spasticity in patients after stroke. Methods: The Persian MMAS was developed by the forward and backward translation procedure, a final review by an expert committee, and testing for acceptability and the clarity of item wording so that the scale could be used by Persian-speaking examiners. Psychometric testing included interrater and intrarater reliability. Elbow flexor spasticity was examined by two raters in 30 patients after stroke twice on two occasions using the Persian MMAS. The weighted κ was used for the statistical analysis. Results: The interrater and intrarater reliability was very good for the Persian MMAS (weighted κ: 0.81–0.91; 95% CI 0.68–0.98) with statistically significant agreement between raters and within raters (all p < 0.001). Conclusions: The Persian version of the MMAS was successfully developed. The Persian MMAS showed very good interrater and intrarater reliability in patients with elbow flexor spasticity after stroke. The results support the use of the Persian version of the MMAS both in clinical and research settings.

Implications for Rehabilitation

• The new Modified Modified Ashworth Scale (MMAS) is a clinical measure of spasticity, which was published in 2006 by Ansari et al.

• The MMAS was successfully translated and adapted into a Persian version. The Persian version of the MMAS showed very good interrater and intrarater reliability comparable to the original English version. The Persian version of the MMAS can be recommended for the assessment of muscle spasticity in Persian-speaking countries.

     

Parents who use drugs: the well-being of parent and child dyads among people receiving harm reduction interventions for opiate use

Background: This article provides baseline measurement of health outcomes for parent and child dyads among people receiving interventions for opiate use.

Method: A cohort study was implemented among 171 participants with 235 children in three urban sites in Ireland in 2010/11. Adult and child outcomes were measured using the Short Form 12, the Becks Depression and Anxiety Inventories, the Strength and Difficulties Questionnaire and the Kidscreen 27.

Results: Over 60% (95% CI 52.5%–68.8%) of adult participants grew up in a household with at least one person who used substances. The main substance used was alcohol (80.7%; 95% CI 71.9%–89.5%) followed by heroin (11.4%; 95% CI 4.2%–18.6%). A correlation was found between increasing adult anxiety and growing up in a home with a person using substances (r = 0.169, p = 0.040). Children of current parents had more difficulties with emotional and conduct problems, as compared to international norms (t = 5.85, p < 0.01; t = 3.39, p < 0.01). Correlations existed between current parental depression and anxiety and child conduct disorder (r = 0.344, p = 0.008; r = 0.374, p = 0.004).

Conclusions: Parents who use drugs are part of the so-called “sandwich generation”. Monitoring and evaluation of interventions that address outcomes across generations of parental and child dyads are lacking.     

Closed reduction of hip dislocation associated with ipsilateral lower extremity fractures: A case report and review of the literature

BACKGROUNDTraumatic hip dislocation usually occurs following high-velocity trauma. It is imperative that the dislocation be reduced in a timely manner, especially in a closed manner, as an orthopedic emergency. However, closed reduction can hardly be achieved in patients who also have ipsilateral lower extremity fractures. Herein, we focus on hip dislocation associated with ipsilateral lower extremity fractures, excluding intracapsular fractures (femoral head and neck fractures), present an early closed hip joint reduction method for this injury pattern, and review the literature to discuss the appropriate closed reduction technique for this rare injury pattern.CASE SUMMARYWe report a case of a 37-year-old male who sustained a left acetabular posterior wall fracture, an ipsilateral comminuted subtrochanteric fracture and dislocation of the hip. The hip dislocation was reduced urgently in a closed manner using the joy-stick technique with a T-shaped Schanz screw. The fractures were reduced and fixed as a 2nd-stage surgery procedure. At the 17-month postoperative follow-up, the patient had full range of motion of the affected hip.CONCLUSIONClosed reduction of a hip dislocation associated with ipsilateral lower extremity fractures is rarely achieved by regular maneuvers. Attempts at closed reduction, by means of indirectly controlling the proximal fracture fragment or reconstructing the femoral leverage rapidly with the aid of various external reduction apparatuses, were shown to be effective in some scenarios. Mandatory open reduction is indicated in cases of failed closed reduction, particularly in irreducible dislocations.     

A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country,Regional, and Global Levels

ABSTRACT

The objective of this study was to propose a rough but simple method for estimating the total population need for opioids for treating all various types of moderate and severe pain at the country, regional, and global levels. We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access. Policies should seek a balance between maximizing access for medical use and minimizing abuse and dependence. Countries should aim to increase the medical consumption to the magnitude needed to address the totality of moderate and severe pain.     

Changes in biomechanical dysfunction and low back pain reduction with osteopathic manual treatment: Results from the OSTEOPATHIC Trial

The purpose of this study was to measure changes in biomechanical dysfunction following osteopathic manual treatment (OMT) and to assess how such changes predict subsequent low back pain (LBP) outcomes. Secondary analyses were performed with data collected during the OSTEOPATHIC Trial wherein a randomized, double-blind, sham-controlled, 2 × 2 factorial design was used to study OMT for chronic LBP. At baseline, prevalence rates of non-neutral lumbar dysfunction, pubic shear, innominate shear, restricted sacral nutation, and psoas syndrome were determined in 230 patients who received OMT. Five OMT sessions were provided at weeks 0, 1, 2, 4, and 6, and the prevalence of each biomechanical dysfunction was again measured at week 8 immediately before the final OMT session. Moderate pain improvement (≥30% reduction on a 100-mm visual analogue scale) at week 12 defined a successful LBP response to treatment. Prevalence rates at baseline were: non-neutral lumbar dysfunction, 124 (54%); pubic shear, 191 (83%); innominate shear, 69 (30%); restricted sacral nutation, 87 (38%), and psoas syndrome, 117 (51%). Significant improvements in each biomechanical dysfunction were observed with OMT; however, only psoas syndrome remission occurred more frequently in LBP responders than non-responders (P for interaction = 0.002). Remission of psoas syndrome was the only change in biomechanical dysfunction that predicted subsequent LBP response after controlling for the other biomechanical dysfunctions and potential confounders (odds ratio, 5.11; 95% confidence interval, 1.54–16.96). These findings suggest that remission of psoas syndrome may be an important and previously unrecognized mechanism explaining clinical improvement in patients with chronic LBP following OMT.     

The effect of an occupational therapy mental health day treatment centre on the use of inpatient services in the Western Cape,South Africa

Purpose: The aim of this study was to determine whether attendance at an occupational therapy-led day treatment centre for mental health care users affects the use of inpatient services in South Africa.

Methods: A retrospective pre-test/post-test quasi-experimental study design was used to compare admissions and days spent in hospital during the 24?months before and after attendance at the centre, using the hospital’s electronic records. Total population sampling yielded data for 44 mental health care users who made first contact with the service between July 2009 and June 2010. Data were compared using the Kruskal–Wallis test, Wilcoxon Signed Ranks test and Mann–Whitney U test.

Results: There was a significant decrease in the number of admissions (z?=??4.093, p?=?0.00) and the number of days spent in hospital (z?=??4.730, p?=?0.00). Participants were admitted to psychiatric care 33 times less in the 24?months’ post-intervention, indicating a medium effect (r?=?0.436). They also spend 2569?days less in hospital, indicating a large effect (r?=?0.504).

Conclusion: The findings suggest that an occupational therapy-led day treatment centre could be effective in reducing the use of inpatient mental health services in South Africa.

• Implications for Rehabilitation

• Attendance at an occupational therapy-led community day treatment centre decreases the number of admissions and number of days spent in hospital and is therefore beneficial to mental health care users and service providers.

• The study indicates that the successful implementation of a community day treatment centre for mental health care users on the grounds of a tertiary hospital by utilising existing resources is possible.