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Objective: Targeted intrathecal drug delivery (TIDD) is an effective interventional pain management modality often used in postlaminectomy patients with refractory chronic low back pain. A combination of intrathecal bupivacaine with an opioid is often used. However, intrathecal catheter tip granulomas have occurred with use of morphine or hydromorphone but generally not with fentanyl. The objective of this study was to compare the efficacy of TIDD using bupivacaine/fentanyl vs bupivacaine/hydromorphone in patients with chronic intractable low back pain postlaminectomy., Materials and Methods: A retrospective comparative analysis of consecutive patients with lumbar postlaminectomy syndrome who were trialed and later received TIDD with a combination of bupivacaine/hydromorphone or bupivacaine/fentanyl between June 2009 and May 2016 at a single tertiary medical center., Results: We identified a cohort of 58 lumbar postlaminectomy patients receiving a TIDD admixture of either hydromorphone/bupivacaine (30 patients) or low-dose fentanyl/bupivacaine (28 patients) with at least two years of follow-up. The fentanyl group had significantly lower baseline opioid consumption and a lower rate of intrathecal opioid dose escalation. Both groups had similar and significant reductions in pain scores over the two-year follow-up period. No granulomas were observed., Conclusion: TIDD using a low-dose fentanyl admixture with bupivacaine in patients with postlaminectomy syndrome and refractory chronic low back pain results in similar pain relief to TIDD with hydromorphone and bupivacaine. Low-dose intrathecal fentanyl leads to a lower rate of opioid escalation and may be safer than hydromorphone., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: We examined the proportion of patients initiating extended-release (ER) opioids who become long-term users and describe how pain-related diagnoses before initiation of opioid therapy vary between drugs and over time., Methods: Using MarketScan (2006-2015), a US national commercial insurance database, we examined pain-related diagnoses in the 182-day baseline period before initiation of ER opioid therapy to characterize indications for opioid initiation. We report the proportion who became long-term users, the median length of opioid therapy, and the proportion with cancer and other noncancer chronic pain, by active ingredient., Results: Among 1,077,566 adults initiating ER opioids, 31% became long-term users, with a median length of use of 209 days. The most common ER opioids prescribed were oxycodone (26%) and fentanyl (23%), and the most common noncancer pain diagnoses were back pain (65%) and arthritis (48%). Among all long-term users, 16% had a diagnosis of cancer. We found notable variation by drug. Eighteen percent of patients initiating drugs approved by the Food and Drug Administration >10 years ago had evidence of cancer during baseline compared with only 8% of patients who received newer drugs., Conclusions: In a national sample of adults with private insurance, back pain was the most common diagnosis preceding initiation of opioid therapy. Opioids that have been approved within the last 10 years were more frequently associated with musculoskeletal pains and less frequently associated with cancer. Amid increasing concerns regarding long-term opioid therapy, our findings provide context regarding the conditions for which long-term opioid therapy is prescribed., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Controlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility., Methods: Two protocols were compared: FSD (2014-2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010-2014): N = 127, starting dose: 70% of the patient's daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0-64); secondary: change in pain intensity on a numeric rating scale (0-10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05., Results: The mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups., Conclusions: The FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions., Methods: A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models., Results: About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures., Conclusions: New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted., (© 2018 American Academy of Pain Medicine.)

Objective: Much is known about racial and ethnic disparities in receipt of opioids for pain in emergency departments. Less is known about such disparities in the evaluation and management of pain in the outpatient setting., Methods: Using the nationally representative National Ambulatory Medical Care Survey (NAMCS), we estimated disparities in visit time with physicians and opioid receipt in the outpatient setting. We focused on patients whose reason for visiting was abdominal pain or back pain. Our sample included 4,764 white patients, 692 black patients, and 682 Hispanic patients., Results: Back pain visits of Hispanic patients lasted 1.6 fewer minutes than those of white non-Hispanic patients (P = 0.04 for the difference). Black patients were 6.0% less likely than white patients to receive opioids for abdominal pain (P = 0.04 for the difference) and 7.1% less likely than white patients to receive opioids for back pain (P = 0.046 for the difference). Hispanic patients were 6.3% less likely than white patients to receive opioids for abdominal pain (P = 0.003 for the difference) and 14.8% less likely than white patients to receive opioids for back pain (P < 0.001 for the difference). Hispanic patients were more likely than white patients to receive nonopioids instead of opioids for both abdominal pain and back pain. Differences in opioid receipt did not narrow during the examined time period., Conclusions: Identifying causes of racial and ethnic disparities in the evaluation and treatment of pain in the outpatient setting is important to improving the health and function of patients., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Opioids are frequently prescribed for chronic low back pain (CLBP), but there are broad individual differences in the benefits and risks of opioid therapy, including the development opioid-induced hyperalgesia. This study examined quantitative sensory testing (QST) data among a group of CLBP patients undergoing sustained oral opioid treatment. We investigated whether individual differences in psychological characteristics were related to opioid-induced changes in pain perception and pain modulation., Design: The six-month, open-label trial evaluated patients with low to high levels of negative affect (e.g., symptoms of distress, depression and anxiety); participants underwent QST at baseline (prior to initiating treatment) and during oral opioid treatment., Setting: A chronic pain management center., Patients: The 31 study participants had chronic discogenic back pain, with a pain intensity rating >3/10. Participants were divided into groups with high vs. low levels of Negative Affect (NA)., Results: In the previously-published manuscript describing the clinical outcomes of the trial, high NA patients achieved only about half of the analgesic effect observed in the low NA group (Wasan AD, Michna E, Edwards RR, et al. Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 2015;123:861-72). The QST findings reported here suggested that tolerance to experimental (cold pressor) pain and conditioned pain modulation tended to decrease in the high NA group over the course of opioid treatment, while temporal summation of mechanical pain declined in the low NA group., Conclusions: These results reveal that while the low NA group seemed to exhibit a generally adaptive, analgesic pattern of changes during opioid management, the high NA group showed a pattern more consistent with opioid-induced hyperalgesic processes. A greater susceptibility to hyperalgesia-promoting changes in pain modulation among patients with high levels of distress may contribute to a lower degree of benefit from opioid treatment in high NA patients., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To characterize emergency department (ED) patients' knowledge and beliefs about the addictive potential of opioids., Design: Mixed methods analysis of data from a randomized controlled trial., Setting: Urban academic ED (>88,000 visits)., Subjects: One hundred and seventy four discharged ED patients prescribed hydrocodone-acetaminophen for acute pain., Methods: The study analyzed data collected from a randomized controlled trial investigating patients' knowledge of opioids. ED patients discharged with hydrocodone-acetaminophen completed an audio-recorded phone interview 4–7 days later. This analysis focuses on responses about addiction. Responses were categorized using content analysis; thematic analysis identified broad themes common across different categories., Results: Participants' mean age was 45.5 years (SD, 14.8), 58.6% female, 50.6% white, and the majority had an orthopedic diagnosis (24.1% back pain, 52.3% other injuries). Responses were categorized first based on whether the patient believed that opioids could be addictive (categorized as: yes, 58.7%; no, 19.5%; depends, 17.2%; or do not know, 4.6%), and second based on whether or not the patient discussed his/her own experience with the medication (categorized as: personalized, 35.6%; or not personalized, 64.4%). Cohen's Kappa was 0.84 for all categories. Three themes emerged in the thematic analysis: theme 1) patients expect to “feel” addicted if they are addicted, theme 2) patients fear addiction, and theme 3) side effects affected patient views of addiction., Conclusion: In this sample, patients had misconceptions about opioid addiction. Some patients did not know opioids could be addictive, others underestimated their personal risk of addiction, and others overtly feared addiction and, therefore, risked inadequate pain management. Despite limited data, we recommend providers discuss opioid addiction with their patients., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine. 2016. This work is written by US Government employees and is in the public domain in the US.)

Background: Older patients with back pain are more likely to visit their general practitioner (GP) and are more likely to be prescribed analgesics., Objective: To assess analgesic use in older adults with back pain in general practice., Methods: The BACE study in the Netherlands is a prospective cohort study. Patients (aged >55 years) with back complaints were recruited when consulting their GP or shortly thereafter. Measurements took place at baseline and at 3- and 6-month follow-up. For medication use, patients were asked if they had used any medication for their back pain in the previous 3 months and, if so, to specify the medication name, dosage used, frequency of usage, and whether the medication was prescribed or purchased over the counter., Results: Of the 1,402 patients who were approached to enter the study, 675 were included. Of these patients, 484 (72%) reported medication use at baseline. Nonsteroidal anti-inflammatory drugs (NSAIDs) (57%) were more often used than paracetamol (49%). Paracetamol was mostly obtained over the counter (69%), and NSAIDs were mostly obtained by prescription (85%). At baseline, patients with severe pain (numerical rating scale score ≥7) used more paracetamol, opioids, and muscle relaxants. Patients with chronic pain (back pain >3 months) used more paracetamol, while patients with a shorter duration of pain used more NSAIDs. During follow-up there was an overall decline in medication use; however, at 3- and 6-month follow-up, 36% and 30% of the patients, respectively, still used analgesics., Conclusions: In these older adults consulting their GP with back pain, 72% used analgesics at baseline. Despite a decrease in medication use during follow-up, at 3 and 6 months a considerable proportion still used analgesics., (Wiley Periodicals, Inc.)

Objective: To assess whether the immediate anesthetic response of pain relief (sensory blockade) or weakness (motor blockade) after lumbar transforaminal epidural steroid injection (TFESI) is associated with longer term effectiveness in pain relief and functional recovery., Design: Retrospective observational study., Setting: Single academic radiology practice., Subjects: Three thousand six hundred forty-five lumbar TFESIs performed on 2,634 subjects., Methods: Subjects completed a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to and immediately after TFESI (NRS) and at 2 weeks and 2 months follow-up. Successful pain relief was ≥50% NRS reduction; functional success was ≥40% R-M reduction. Post-procedure motor weakness was recorded. Logistic regression models assessed association of immediate post-procedure NRS response, and NRS or R-M response at 2 weeks, with successful outcomes at 2 months. C-index assessed model discrimination; values closer to 1.0 indicated better discrimination., Results: Immediate NRS response was weakly associated with 2-month outcomes (C-index = 0.58). NRS and R-M responses at 2 weeks were more strongly associated with the 2-month response (C-indices 0.77, 0.80, respectively). Post-procedure motor blockade had little association with successful 2-month NRS or R-M outcomes (C-indices 0.51, 0.50, respectively). Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks (odds ratio = 6.49, confidence interval 5.38, 7.84)., Conclusion: Immediate post-TFESI pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes., (Wiley Periodicals, Inc.)

Objective: To provide pediatric care providers with insight into lidocaine infusions for analgesia., Aim: This retrospective review was conducted to describe lidocaine infusions for chronic refractory pain within the adolescent and young adult pain population., Setting: Although lidocaine infusions have been used for pain management in adults, their analgesic utility in the adolescent and young adult population is limited and so is the evidence for their efficacy and safety., Methods: After Institutional Board Review approval, a retrospective review of efficacy and safety data for analgesic use of lidocaine was conducted., Results: Fifteen patients received 58 infusions with 76% receiving relief where maximum relief was seen among patients with starting pain scores ≥6/10 (mean reduction 2.3 vs. 0.5, P value = 0.006) and when a patient had three or more infusions (mean reduction 1.7 compared with 1.2). No serious side effects were encountered, but only mild or moderate side effects that did not require any intervention. Incidence of tingling or numbness and nausea or vomiting seemed to correlate with total dose of lidocaine per kilogram body weight. Patients reported reduced pain scores (6.3 ± 2.3 to 4.6 ± 2.5 before compared with after the infusion [as mean ± standard deviation]) during 80% of infusions., Conclusions: Our limited experience suggests that lidocaine infusions are well tolerated in the adolescent and young adult pain population, with side effects resolving quickly with interruption or discontinuation of the infusion if necessary. Future studies are warranted to examine safety, efficacy, mechanism of actions, and its long-term impact on a developing central nervous system., (Wiley Periodicals, Inc.)

Objectives: To assess the clinical effectiveness of single lumbar transforaminal epidural steroid injections (TFESIs) in subjects with radicular pain with or without radiculopathy., Design: Retrospective observational series., Setting: Single academic radiology pain management practice., Subjects: Two thousand twenty-four subjects undergoing single lumbar TFESIs at the L4-5, L5-S1, or S1 neural foramina., Methods / Outcome Measures: Subjects were assessed with a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M, 23-point Deyo modification) prior to TFESI and at 2 weeks and 2 months follow-up. Successful pain relief (responders) was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score., Results: There were statistically significant (P < 0.0001) reductions in mean NRS and R-M scores at 2 weeks and 2 months postinjection. For NRS, 40.9% were responders at 2 weeks and 45.6% at 2 months. For R-M, 31.9% were responders at 2 weeks and 41.3% at 2 months. The proportion of responders for NRS and R-M was higher when there was <3 months of pain (odds ratio 2-month NRS = 2.42 [95% confidence interval: 1.82, 3.24], odds ratio 2-month R-M = 2.61 [1.96, 3.48]). For subjects with <3 months of pain, the proportion of responders was 62.4% (56.5, 68.3%) for NRS and 59.3% (53.3, 65.3%) for R-M scores., Conclusions: This retrospective observational study suggests TFESIs are clinically effective in the treatment of lumbar radicular pain. Subjects with a shorter duration of pain are more likely to achieve a successful outcome., (Wiley Periodicals, Inc.)

Objective: This was a prospective, randomized, double-blind, placebo-controlled, 12-week, multicenter study to evaluate the efficacy and tolerability of fixed location injections of botulinum type A toxin (BoNT-A, Dysport) in predetermined injection sites in patients with myofascial pain syndrome of the upper back., Design: Patients with moderate-to-severe myofascial pain syndrome affecting cervical and/or shoulder muscles (10 trigger points, disease duration 6-24 months) and moderate-to-severe pain intensity were randomized to BoNT-A (N = 81) or saline (N = 72)., Intervention: Patients received treatment into 10 predetermined fixed injection sites in the head, neck, and shoulder (40 units of BoNT-A per site or saline, a total of 400 units of BoNT-A)., Outcome Measures: The primary efficacy outcome was the proportion of patients with mild or no pain at week 5 (responders). Secondary outcomes included changes in pain intensity and the number of pain-free days per week., Results: At week 5, 49% (37/76) of BoNT-A patients and 38% (27/72) of placebo patients had responded to treatment (P = 0.1873). Duration of daily pain was reduced in the BoNT-A group compared with the placebo group from week 5, with statistically significant differences at weeks 9 and 10 (P = 0.04 for both). Treatment was well tolerated., Conclusion: Fixed-location treatment with BoNT-A of patients with upper back myofascial pain syndrome did not lead to a significant improvement of the main target parameter in week 5 after treatment. Only in week 8 were significant differences found. Several secondary parameters, such as physicians' global assessment and patients' global assessment, significantly favored BoNT-A over placebo at weeks 8 and 12., (Wiley Periodicals, Inc.)

Objective: Describe the first reported human intrathecal (IT) botulinum toxin injection., Design: Case report., Setting and Patients: We report here the sequelae to an unintended IT injection of botulinum toxin type B (BTB) in a 60-year-old woman with chronic back pain., Results: Following the IT administration of BTB, the patient experienced the onset of symmetric ascending stocking distribution painful dysesthesias, which persisted for approximately 6 months before receding. Objective neurologic deficits were not appreciated, and analgesic effects were prominently absent., Conclusions: Analgesic actions of botulinum toxins in animals and in humans have led to speculation that IT botulinum toxin might exert significant analgesic effects. The unusual and unexpected subsequent clinical course, neurologic sequelae, dysesthesias, and absence of analgesia suggest that botulinum toxin will not be a therapeutic modality to treat pain as proposed by those studying botulinum toxin in animal models., (Wiley Periodicals, Inc.)

Objective: 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., Design: 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., Results: A total of 4265 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., Conclusions: 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., (Wiley Periodicals, Inc.)

Objective: Prior to testing the feasibility/potential efficacy of a newly developed self-management pain program for seniors with back pain, this study sought to: 1) determine prospective consumers' prior exposure to self-management pain programs, 2) determine their willingness to participate in the new program, and 3) ascertain perceived barriers/facilitators to program participation., Design: Cross-sectional survey., Setting: Six senior centers located in New York City., Participants: We enrolled a race/ethnicity stratified (African American, Hispanic, or non-Hispanic White) sample of 90 subjects who were ages 60 years or older and had chronic back pain., Results: While 60% of non-Hispanic Whites reported prior participation in a self-management pain program, fewer Hispanic (23%) and African Americans (20%) participants reported prior participation. Most participants (80%) were strongly willing to participate in the new program. Multivariate analyses revealed that only pain intensity had a trend toward significance (P = 0.07), with higher pain scores associated with greater willingness to participate. Few barriers to participation were identified, however, respondents felt that tailoring the course to best meet the needs of those with physical disabilities, providing flexibility in class timing, and informing individuals about program benefits prior to enrollment could help maximize program reach. No race/ethnicity differences were identified with respect to willingness to participate or program participation barriers., Conclusions: These data support efforts to disseminate self-management pain programs in older populations, particularly minority communities. The recommendations made by participants can help to guide implementation efforts of the newly developed pain program and may help to enhance both their reach and success.

Objectives: Chronic back pain and its sequelae can influence cognitive, affective, and neuromuscular functioning. Speech production--a complex sensorimotor activity--integrates shared cognitive, neuromuscular, and musculoskeletal resources, and therefore could be altered by chronic pain. The purpose of this preliminary investigation was twofold: 1) to determine whether speech alternating motion rates (i.e., speech AMRs) which require rapid, reciprocally coordinated articulatory movements were associated with chronic back pain; and 2) to identify factors that might mediate any observed alterations., Design: Fifty participants, fully or partially disabled by chronic back pain, completed standardized protocols related to pain, depression, disability, medications, as well as speech AMRs., Results: Higher levels of back pain were significantly associated with slower speech AMRs. Stepwise multiple regression assessed the unique and cumulative effects of specific variables such as degree of back pain, depression, level of disability, and medication use on speech motor performance. Speech motor slowness was uniquely related to back pain and the use of nonprescription pain medications, but not to level of depression or disability., Conclusions: Chronic back pain independently influences speech motor rates. Several explanatory models are proposed including pain-induced centrally mediated motor retardation/inhibition, reduced selective attention, and peripherally based "bracing/holding" of shared musculoskeletal environments.

Objective: To investigate whether grouping of patients with back pain into similar behavioral patient profiles using SF-36 scores is predictive of outcome following 1-year treatment in a multidisciplinary spine center beginning with referral for epidural steroid injection., Design: A prospective observational study was conducted on 81 consecutive patients selected for epidural steroid injections by independent physicians following common institutional criteria. Each patient completed a baseline SF-36 questionnaire as well as a numerical response pain scale. The initial SF-36 data were used to place each patient into one of three subgroups (Highly Functional, Emotional Adapters, and Dysfunctional). Follow-up SF-36 and numerical response pain scale questionnaires were completed by the patients at 1 month and 12 months following the initial epidural steroid injection., Results: Results revealed significant improvement among all three patient subgroups following multidisciplinary treatment at both 1 month and 12 months. Few differences in outcome occurred among the subgroups., Conclusion: The SF-36-determined subgroups did not predict response to a multidisciplinary pain clinic. All three subgroups showed similar improvement following treatment.

Objectives: Cervical transforaminal epidural injections of corticosteroids have been used in the treatment of radicular pain. Particulate agents have been associated with rare adverse neurological outcomes. It is unknown whether nonparticulate preparations are any less effective than particulate preparations. Therefore, a study was designed to determine whether there is a basis for promoting a theoretically safer nonparticulate corticosteroid preparation., Design: Volunteer patients were randomized to receive a single cervical transforaminal epidural injection with one of two corticosteroid preparations., Setting: This study was undertaken in a private practice setting., Patients: Those with single-level, unilateral radicular pain with advanced imaging demonstrating single-level neural compression., Interventions: Patients received a single cervical transforaminal epidural injection with either dexamethasone or triamcinolone., Outcome Measures: Ratings were obtained by an independent unbiased assessor at 4 weeks via a telephone interview. A visual analog pain scale was used preprocedurally and a verbal integer scale was used at 4 weeks to assess the severity of the patient's radicular pain. As a secondary outcome measure, a patient-specified functional outcome measure was obtained., Results: Both groups exhibited statistically and clinically significant improvements in pain at 4 weeks. Although the triamcinolone group exhibited a somewhat greater improvement, the difference between groups was not significantly different., Conclusion: The study found that the effectiveness of dexamethasone was slightly less than that of triamcinolone, but the difference was neither statistically nor clinically significant. A theoretically safer nonparticulant agent appears to be a valid alternative to particulate agents that have been used to date, and which have been associated with hazard.

A 47-year-old woman who underwent allogenic peripheral blood stem cell transplant developed withdrawal symptoms soon after Fentanyl 25 mcg/h patch was stopped, which has not been reported at this dose. Possible causes, such as the inhibition of CYP3A4 induced by cyclosporine causing elevations of serum fentanyl, are discussed.