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Category Archives: Other Physical Injuries

Washington Attempts to Battle Prescription Drug Abuse: New Rules May Have Unintended Effects

Categories: Other Physical Injuries

By PI-Advisor. Posted on .

On January 2, 2012, doctors in Washington became subject to new rules regarding prescription of widely-used pain medication. These rules affect treatment of patients with chronic pain not associated with cancer or end-of-life pain control.

Citing a 395% increase in unintentional poisoning from prescription pain medication between 1995 and 2009, the Washington state legislature passed a law in 2010 (ESHB 2876) requiring five different medical boards to create new rules for prescription of opioid medication. The rules are intended to improve patient safety and provide doctors with guidelines for prescription of these powerful drugs.

The regulatory boards for seven types of practitioners developed rules for prescription of pain medication. The practitioners covered by the new rules include physicians and physician assistants, osteopaths and osteopathic physician assistants, advanced registered nurse practitioners, dentists, and podiatrists.

The new rules apply to drugs known as opioid analgesics. Opioids are a class of drugs that affect specific pain receptors in the brain. Natural opioids are derived from a specific alkaloid in the opium poppy. There are now many synthetic opioids as well. Common drugs within this class, and covered by the new rules, include methadone, morphine, codeine, hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContin, Percocet), fentanyl and many others.

The new rules do not apply to prescriptions for acute pain, such as a new injury, or for post-surgical pain. They are intended to provide guidelines for treating patients who have chronic pain, defined as pain lasting over three months and not related to treatment for cancer or hospice care.

Physicians will be required to keep thorough records of a patient’s history, potential for drug abuse, and the need for opioid medication. In certain circumstances, such as dosage over a set limit, doctors are required to consult a pain management specialist in one of several ways. Criteria for exemption from the consultation rule and for qualification as a pain management specialist are also set out.

While the new rules are intended to reduce the incidence of prescription drug abuse and death associated with these drugs, the real effects of the regulations will only be known with time. Treatment of pain is an important part of the practice of medicine. However, the potential for abuse of prescription medication makes some doctors are wary of prescribing these drugs. Some doctors are relieved to have guidelines to follow. Some doctors find the requirements daunting and intend to simply refuse to treat chronic pain patients and require them to obtain prescriptions from a pain management specialist. There is concern that this will result in some patients being unable to obtain necessary prescriptions either as a result of the availability of specialists in their area or lack of insurance coverage for such specialists.

For some, the inability to access necessary medication may result in reduced functionality, poor quality of life and unnecessary suffering. For others, the new rules may provide enough of a barrier to avoid dependence and addiction. As with any new law, time will tell.

Viscosupplementation and Post-traumatic Osteoarthritis

Categories: Other Physical Injuries

By Jacob W. Gent. Posted on .

One of the first steps in the treatment of any traumatic injury is pain management.  A relatively effective approach to the treatment osteoarthritis following joint injuries, especially knee joints, is viscosupplementation.  Pain relievers, like ibuprofen or nonsteroidal anti-inflammatory drugs (NSAIDs) are normally used along with physical therapy, topical analgesics, or even corticosteroid injections in such cases. Unfortunately, some patients react adversely to NSAIDs and these agents typically provide only temporary relief.

The procedure involves injecting a solution of hyaluronic acid into the joint where it acts as a lubricant to allow bones to move smoothly over each other and as a shock absorber for joint loads.

Immediate Effects:

Hyaluronic acid does not have an immediate pain-relieving effect.  Patients may notice a local reaction, such as pain, warmth, or mild swelling immediately following the injection. These symptoms generally do not last long and icing usually reduces them.  Patients should avoid
jogging, heavy lifting, excessive weightbearing or standing for long periods for the first 48 hours following the injection.

Longer Term Effects:

Over the course of the injections, patients notice decreased pain as hyaluronic acid seems to have anti-inflammatory and pain-relieving properties. The injections may also stimulate the body to produce more of its own hyaluronic acid.  These effects may last several months.


Any swelling due to excess fluid (effusion) in the knee will be removed (aspirated) prior to injection of the hyaluronic acid. This is usually done at the same time, with only one needle injected into the joint, although some doctors may prefer to use two separate syringes. Depending on the product used, 3 to 5 injections will be administered over several weeks.

Viscosupplementation may be helpful for people who do not respond to basic treatments. It is most effective if the arthritis is in its early stages (mild to moderate). Some patients may feel pain at the injection site, and occasionally the injections result in increased swelling. The long term effects of viscosupplementation is not yet known, and research is in this area is ongoing.


Defining Thoracic Outlet Syndrome and Treatment

Categories: Other Physical Injuries

By PI-Advisor. Posted on .

Thoracic Outlet Syndrome (TOS) is a condition in which the neurovascular bundle passing through the anterior and middle scalenes is compressed. This can lead to pain in the neck/shoulder and upper extremity, tingling or numbness and, occasionally, coldness or decoloration of the hand. Compression can affect the nerves only (neurogenic TOS), the subclavian vein (venous TOS) or the subclavian artery (arterial TOS).  Neurogenic TOS is, by far, the most common form.

When thoracic outlet syndrome is diagnosed, there is a continuum of options regarding appropriate treatment. Conservative care, in the form of chiropractic, massage and physical therapy, is well accepted as the appropriate course of care in the majority of cases. However, when symptoms persist despite these efforts, surgery is looked upon as an option of last resort.

After surgery, a patient outcomes following are problematic, particularly with neurogenic TOS (NTOS).   Diagnosis is one of exclusion made primarily through patient reports of symptoms, history, and, more recently, response to scalene muscle blocks. With neurogenic TOS, negative EMG or nerve conduction studies do not rule out NTOS as a diagnosis. In vascular TOS, diagnosis can be confirmed through objective findings of blood flow compromise. Patient selection and operative techniques have been cited as explanations for the differences in patient outcomes. Some studies suggest that a highly selective process for screening surgical candidates is required and improves the rate of successful outcomes.1

Anesthetic block of the anterior scalene muscles has become a dual-purpose procedure, providing diagnostic confirmation of TOS and as a reliable indicator of which patients may respond favorably to surgery. An anterior scalene muscle (ASM) block is an injection of anesthetic, such as lidocaine, directly into the scalene muscles. Relaxation of the anterior scalene muscles via blocks may partially simulate the results of surgical decompression. Additionally, an effective block, where surgery is not an option, can give an indication of the potential use of Botox injections for temporary (3 to 4 months) relief.


1. Scali S, Stone D, Bjerke A, Chang C, Rzucidio E, Gooney P, Walsh D.  Long-Term functional results for the surgical management of neurogenic thoracic outlet syndrome. Vasc Endovascular Surg. 2010 44:550.