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Poster 359 Chronic Opioid Therapy in Pain Rehabilitation
S298
Setting: Outpatient chronic pain clinic. Participants: The study included 31 patients, between ages 28 and 64 years old. with chronic pain; 64.5% of subjects were women (n⫽20), and 35.5% was men (n⫽11). Interventions: Not applicable, Results: The mean pupil size for the hydrocodone group was OD 4.00 mm, OS 4.14 mm; for the oxycodone group was OD 3.00 mm, OS 3.00 mm; for the morphine sulfate group was OD 3.20, OS 3.20 mm; and for the fentanyl group was propoxyphene OD 4.80 mm, OS, 4.80 mm. We found a significant difference in pupil diameter between hydrocodone usage and fentanyl usage (P⬍.01) as well as between hydrocodone and morphine sulfate. However, there was no significant difference when comparing hydrocodone and propoxyphene or when comparing fentanyl and morphine sulfate. There was no significant difference in the measured pupil diameter when comparing groups of treatment duration. Conclusions: There is a significant difference in measured pupil diameter between schedule II and schedule III opioid usage. There was no significant association between measured pupil diameter and length of opioid usage. This is the first study that compared the effects of various opioids on pupil diameter in the chronic pain population.
Poster 359 Chronic Opioid Therapy in Pain Rehabilitation. Hany R. Nosir, MD (Johns Hopkins University/Advanced Pain Management, Greenfield, WI, United States). Disclosures: H. R. Nosir, none. Objective: Opioids have been an important part of treatment of individuals with chronic pain, but this treatment requires proper patient selection and poses a challenge for the treating physician. Biases about the use of opioids, with the potential for abuse and dependence, and treatment of the increasing numbers of geriatric patients add to controversy of this treatment option. The objective is to guide physiatrists for proper use of chronic opioid analgesic therapy in the chronic pain patient population. Design: Data source: A systematic review of the literature regarding the role of opioid therapy in chronic pain syndrome. Sixty research and clinical reports published between 1994 and 2009 were reviewed for treatment outcomes of opioid therapy. Setting: Academic private setting. Participants: None. Interventions: Study selections: studies regarding the role of opioids in chronic pain syndrome were reviewed based on Cochrane Collaboration evidence review criteria and meta-analysis of opioids therapy. Multimodal opioid therapy, cost-effectiveness analysis, prospective randomized controlled, prospective without control, and retrospective studies were reviewed. Main Outcome Measures: Data Extraction: the mechanisms of chronic pain and mechanism of action of opioids in treating chronic pain syndromes is complex. Safe and effective treatment with opioids in patients with chronic pain requires that the clinicians should optimize outcome and understand the risks of potential abuse, addiction, and diversion by proper selection and monitoring of these patients. Results: Data synthesis: opioid therapy has shown a positive effective role with regard to continued pain relief, increased level of functioning, and improved quality of life. Conclusions: With proper patient selection and adequate mon-
PRESENTATIONS
itoring, opioid analgesics are widely accepted pain control agents as part of a comprehensive multimodal approach to the management of patients with chronic pain. The health care practitioners fear about prescribing medications with abuse potential is still a common finding in clinical practice. All patients who use opioids should receive a level of monitoring process. Patients should feel comfortable and receive adequate education during the monitoring process.
Poster 360 Sacroiliac Joint Syndrome After a Rear-ended Motor Vehicle Collision: A Case Report. David E. Fish, MD, MPH (UCLA/Greater LA VA, Los Angeles, CA, United States); Daniel A. Fung, MD, Antoine Jones. Disclosures: D. E. Fish, none. Patients or Programs: A single patient subject with right sacroiliac joint (SIJ) syndrome after a rear-ended motor vehicle collision. Program Description: A 40-year-old woman with a 6-month history of low back and right hip pain after a rear-ended motor vehicle collision. Workup was negative for infection, fracture, or herniated disk but did reveal low back and right hip pain, with tightness of the iliotibial band and pain over the trochanteric bursa suspicious for trochanteric bursitis versus SIJ syndrome. Initial trochanteric bursa injections gave mild relief of pain. After 6 months of conservative care, the patient’s pain persisted. A diagnostic injection of bilateral SIJ greatly relieved the patient’s pain temporarily, and the decision was made to proceed with radiofrequency ablation of bilateral SIJ. Setting: An outpatient musculoskeletal clinic. Results: The patient underwent radiofrequency ablation of the bilateral SIJ with complete pain relief that lasted 1 year. The patient returned after 1 year for repeated radiofrequency ablation of bilateral SIJ, once again with complete resolution of pain. Discussion: SIJ syndrome can be a cause of low back pain after a rear-ended motor vehicle collision impact with the ipsilateral foot on the brake. Motor vehicle accidents in general have been shown to be responsible for a small portion of SIJ cases. Conservative management includes rest, ice, heat, anti-inflammatory medication, and therapy. Further interventions include injection of the SIJ and radiofrequency ablation. Conclusions: In this case report, radiofrequency ablation of the SIJ led to complete resolution of pain for up to 1 year.
Poster 361 Rehabilitation Challenge in a Patient With Bilateral Hip Injury After Gunshot Injury: A Case Report. Bobby Oommen, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States); Marcel G. Bayol, MD, Matthew Dounel, MD, MPH, Shinto Koshy, MD. Disclosures: B. Oommen, none. Patients or Programs: A 57-year-old African American. Program Description: Case description: The above patient was admitted via the emergency department with bilateral hip pain after a gunshot injury. Radiography of the pelvis with both hips showed fracture of the right proximal femur and a pellet lodged in the head of the left femur. The patient underwent intramedullary nailing of the right femoral fracture but had severe pain in the left hip rather than the right hip, especially on range of motion exercises. Computed tomography of the pelvis revealed a pellet on the articular
Setting: Outpatient chronic pain clinic. Participants: The study included 31 patients, between ages 28 and 64 years old. with chronic pain; 64.5% of subjects were women (n⫽20), and 35.5% was men (n⫽11). Interventions: Not applicable, Results: The mean pupil size for the hydrocodone group was OD 4.00 mm, OS 4.14 mm; for the oxycodone group was OD 3.00 mm, OS 3.00 mm; for the morphine sulfate group was OD 3.20, OS 3.20 mm; and for the fentanyl group was propoxyphene OD 4.80 mm, OS, 4.80 mm. We found a significant difference in pupil diameter between hydrocodone usage and fentanyl usage (P⬍.01) as well as between hydrocodone and morphine sulfate. However, there was no significant difference when comparing hydrocodone and propoxyphene or when comparing fentanyl and morphine sulfate. There was no significant difference in the measured pupil diameter when comparing groups of treatment duration. Conclusions: There is a significant difference in measured pupil diameter between schedule II and schedule III opioid usage. There was no significant association between measured pupil diameter and length of opioid usage. This is the first study that compared the effects of various opioids on pupil diameter in the chronic pain population.
Poster 359 Chronic Opioid Therapy in Pain Rehabilitation. Hany R. Nosir, MD (Johns Hopkins University/Advanced Pain Management, Greenfield, WI, United States). Disclosures: H. R. Nosir, none. Objective: Opioids have been an important part of treatment of individuals with chronic pain, but this treatment requires proper patient selection and poses a challenge for the treating physician. Biases about the use of opioids, with the potential for abuse and dependence, and treatment of the increasing numbers of geriatric patients add to controversy of this treatment option. The objective is to guide physiatrists for proper use of chronic opioid analgesic therapy in the chronic pain patient population. Design: Data source: A systematic review of the literature regarding the role of opioid therapy in chronic pain syndrome. Sixty research and clinical reports published between 1994 and 2009 were reviewed for treatment outcomes of opioid therapy. Setting: Academic private setting. Participants: None. Interventions: Study selections: studies regarding the role of opioids in chronic pain syndrome were reviewed based on Cochrane Collaboration evidence review criteria and meta-analysis of opioids therapy. Multimodal opioid therapy, cost-effectiveness analysis, prospective randomized controlled, prospective without control, and retrospective studies were reviewed. Main Outcome Measures: Data Extraction: the mechanisms of chronic pain and mechanism of action of opioids in treating chronic pain syndromes is complex. Safe and effective treatment with opioids in patients with chronic pain requires that the clinicians should optimize outcome and understand the risks of potential abuse, addiction, and diversion by proper selection and monitoring of these patients. Results: Data synthesis: opioid therapy has shown a positive effective role with regard to continued pain relief, increased level of functioning, and improved quality of life. Conclusions: With proper patient selection and adequate mon-
PRESENTATIONS
itoring, opioid analgesics are widely accepted pain control agents as part of a comprehensive multimodal approach to the management of patients with chronic pain. The health care practitioners fear about prescribing medications with abuse potential is still a common finding in clinical practice. All patients who use opioids should receive a level of monitoring process. Patients should feel comfortable and receive adequate education during the monitoring process.
Poster 360 Sacroiliac Joint Syndrome After a Rear-ended Motor Vehicle Collision: A Case Report. David E. Fish, MD, MPH (UCLA/Greater LA VA, Los Angeles, CA, United States); Daniel A. Fung, MD, Antoine Jones. Disclosures: D. E. Fish, none. Patients or Programs: A single patient subject with right sacroiliac joint (SIJ) syndrome after a rear-ended motor vehicle collision. Program Description: A 40-year-old woman with a 6-month history of low back and right hip pain after a rear-ended motor vehicle collision. Workup was negative for infection, fracture, or herniated disk but did reveal low back and right hip pain, with tightness of the iliotibial band and pain over the trochanteric bursa suspicious for trochanteric bursitis versus SIJ syndrome. Initial trochanteric bursa injections gave mild relief of pain. After 6 months of conservative care, the patient’s pain persisted. A diagnostic injection of bilateral SIJ greatly relieved the patient’s pain temporarily, and the decision was made to proceed with radiofrequency ablation of bilateral SIJ. Setting: An outpatient musculoskeletal clinic. Results: The patient underwent radiofrequency ablation of the bilateral SIJ with complete pain relief that lasted 1 year. The patient returned after 1 year for repeated radiofrequency ablation of bilateral SIJ, once again with complete resolution of pain. Discussion: SIJ syndrome can be a cause of low back pain after a rear-ended motor vehicle collision impact with the ipsilateral foot on the brake. Motor vehicle accidents in general have been shown to be responsible for a small portion of SIJ cases. Conservative management includes rest, ice, heat, anti-inflammatory medication, and therapy. Further interventions include injection of the SIJ and radiofrequency ablation. Conclusions: In this case report, radiofrequency ablation of the SIJ led to complete resolution of pain for up to 1 year.
Poster 361 Rehabilitation Challenge in a Patient With Bilateral Hip Injury After Gunshot Injury: A Case Report. Bobby Oommen, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States); Marcel G. Bayol, MD, Matthew Dounel, MD, MPH, Shinto Koshy, MD. Disclosures: B. Oommen, none. Patients or Programs: A 57-year-old African American. Program Description: Case description: The above patient was admitted via the emergency department with bilateral hip pain after a gunshot injury. Radiography of the pelvis with both hips showed fracture of the right proximal femur and a pellet lodged in the head of the left femur. The patient underwent intramedullary nailing of the right femoral fracture but had severe pain in the left hip rather than the right hip, especially on range of motion exercises. Computed tomography of the pelvis revealed a pellet on the articular