Best Guidance on Mitigating Opioid Risks Compiled

Last week's articles on rheumatology topics in the major non-rheumatology journals.

Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic PainAnnals of Internal Medicine, November 12, 2013

Despite limited evidence and variable development methods, recent guidelines on chronic pain agree on several opioid risk mitigation strategies. These include upper dosing thresholds, cautions with certain medications, attention to drug–drug and drug–disease interactions, and use of risk assessment tools, treatment agreements, and urine drug testing.

A majority of the guidelines recommend that clinicians avoid doses greater than 90 to 200 mg of morphine equivalents per day and have additional knowledge to prescribe methadone. Clinicians also should recognize risks of fentanyl patches, titrate cautiously, and reduce doses by at least 25% to 50% when switching opioids.

Guidelines also agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks.

Most recommendations are supported by observational data or expert consensus, according to researchers who evaluated the quality and content of current guidance.

Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomized controlled trialBMJ, November 14, 2013

The interspinous process device was no better than standard bony decompression, and the repeat surgery rate was much higher, in a randomized controlled trial of 159 participants with intermittent neurogenic claudication due to lumbar spinal stenosis.

The interspinous process device group had a repeat surgery rate of 29% vs. 8% in standard bony compression.

Images in Clinical Medicine, Unusual Bursal FluidNew England Journal of Medicine, November 14, 2013

Cholesterol crystals are occasionally seen in the bursal fluid of patients who have rheumatoid arthritis (RA), even with normal serum cholesterol.

A 73-year-old man with RA in remission with methotrexate, presented with left olecranon bursitis. On aspiration, the bursal fluid was viscous, thick and purulent.

Polarized light microscopy revealed large, rectangular, birefringent platelike crystals identified as cholesterol. Serum cholesterol was normal.

After local injections of glucocorticoids had no effect, the patient was referred for surgical removal of the bursa.


Targeting of αv integrin identifies a core molecular pathway that regulates fibrosis in several organsNature Medicine, November 10, 2013

Mouse research suggests a new drug target that may be effective against fibrosis. Researchers found that they could prevent fibrosis in mice by deleting the gene encoding a subunit of αv integrin.

Previous research has shown αv integrins to be major mediators of fibrosis in many organs. the same team found that they could also prevent fibrosis in mice with a small molecule (CWHM 12) that blocks αv integrins.