590 Nonpharmacologic Pain Management in Pediatric Burn Patients: A Systematic Review

Introduction Pain is a universal feature of pediatric burns that is associated with long-term mental health consequences in this population. While pharmacologic therapy can alleviate pain, it does not always provide complete control and carries its own risks. Current literature suggests nonpharmacologic treatment may provide improved pain control as an effective adjunct in pediatric burn patients. The aim of this systematic review is to summarize the literature of nonpharmacologic pain management in pediatric burn patients. Methods A systematic review was conducted using PubMed, Ovid MEDLINE, Scopus, and Web of Science. Keywords included: analgesia, pain, children, pediatric, paediatric, child, young, adolescent, burn, and scald. Papers were included if they were randomized, controlled, had original data, collected pain scores as a function of nonpharmacologic treatment, and were conducted on pediatric burn patients. Reviews, case reports, and opinion papers were excluded. Data were extracted on pain scale, pain score during and after treatment, and significance of results. Pain reduction was calculated as the percent difference between experimental and control pain scores, and treatments with significant pain reduction were considered effective. Results Sixteen studies were included, with nonpharmacologic treatments categorized as interactive (n=12) or passive (n=4). Interactive treatments required patient activity throughout treatment and included virtual reality (n=6), distraction devices (n=3), child life therapy (n=1), directed play (n=1) and digital tablet games (n=1). Passive treatments included cartoons (n=1), hypnosis (n=1), massage therapy (n=1) and music (n=1). Mean age was 8.39 years and percent total body surface area (%TBSA) burned was 5.95%. Treatment was effective in 9 out of 16 studies. Compared to controls, nonpharmacologic treatments reduced mid procedure pain by 24.3% (n=12) and post-procedure pain by 33.6% (n=5). Of the studies reporting mid procedure pain, pain reduction was greater in interactive treatments (32.3% n=10) than in passive treatments (-15.6% n=2) (p=.016). Conclusions Nonpharmacologic therapy can be an effective adjunct in pediatric burn pain management. Significantly greater pain reduction in interactive treatments suggests distraction may lead to greater analgesia; however, the number of passive treatments for comparison was low. This study shows promise in the application of nonpharmacologic therapy, and further research will allow standardized algorithms to integrate nonpharmacologic therapy with medications.

Psychopharmacology for Eating Disorder

The treatment of eating disorders should include the utilization of nonpharmacologic therapy and, when appropriate, pharmacotherapy to address symptoms of the eating disorder and any psychiatric comorbidities present. Due to the complex nature of eating disorders, a multi-disciplinary team approach to care is an essential component for maximizing treatment outcomes. Currently there are no FDA approved medications for anorexia nervosa; however, SSRI antidepressants may help with comorbid symptoms. The SSRI, fluoxetine, is FDA approved for use in bulimia nervosa for symptoms associated with bulimia, also addressing psychiatric comorbidities. Lisdexamfetamine is an FDA approved treatment for use in binge-eating disorder, helping to reduce binge episodes. Other pharmacotherapeutic options have demonstrated efficacy benefits in eating disorders, such as topiramate treatment in bulimia and binge eating disorder; however, nonpharmacologic therapy remains an essential first-line treatment across eating disorders and should always be employed regardless of whether or not pharmacotherapy is also part of the treatment plan. This review contains 3 tables, 4 figures, and 30 references. Keywords : Anorexia, bulimia, binge-eating disorder, pharmacotherapy, treatment, psychopharmacology, serotonin, olanzapine, eating disorders

Evaluating the Safe Use of Antidepressants in Older Adults: A Case-Based Approach

Depression in older adults is a mood disorder associated with physical and/or cognitive impairment. Though it may be present in a variety of settings, depression is a prominent health concern among long-term care and nursing facility residents. Pharmacologic therapy may be considered in patients with depression who have not responded to nonpharmacologic therapy or are experiencing considerable disability. There are a variety of commonly prescribed antidepressant drug options for this indication. Examples may include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, or serotonin modulators. As the use of these agents continues in older adults, senior care pharmacists should be familiar with the evaluation of its safe and combined use (e.g., drug interactions, adverse effects).

Management of Nonsurgical Refractory Low Back Pain in the United States: A Retrospective Analysis

INTRODUCTION Low back pain (LBP) is the leading cause of disability worldwide. Patients with persistent LBP despite multiple interventions and who are ineligible for spine surgery are considered to have nonsurgical refractory back pain (NSRBP). We investigated the utilization of medications and nonpharmacologic therapies in this population in the United States. METHODS The IBM MarketScan® Research databases were used to identify adult patients with LBP diagnoses (excluding instability and nonmechanical etiologies) and a negative history of failed back surgery syndrome or spine surgery within the study period (2009-2016). Patients must have had medications prescribed within 2 wk of diagnosis or nonpharmacologic therapies for >30 d within the 3 to 24 mo following LBP diagnoses. The frequency of utilization of these therapies was calculated at 0 to 6, 6 to 12, and 12 to 24 mo postdiagnosis. RESULTS Among 55 945 patients, 69.8% of patients used nonpharmacologic therapy in the first 6 mo, 66.0% over the next 6 to 12 mo, and 78.7% in the second year. At all time points, the most-utilized therapies were chiropractic therapy, physical therapy (PT), and epidural or facet joint steroid injections. In the first 6 mo, 42.1% of patients saw a chiropractor, and 43.5% of patients attended PT; 13.6% of patients underwent ≥1 steroid injection. Over the next 6 mo, 38.5% of patients visited a chiropractor, 37.2% used PT, and 12.6% received ≥1 steroid injection. During the second year, 45.3% saw a chiropractor, 45.1% engaged PT, and 16.6% had ≥1 steroid injection. On average, 49.1% of patients used prescription pain medications over the 2 yr, most commonly opioids (40.5%), muscle relaxants (21.5%), and anticonvulsants (17.8%). CONCLUSION The majority of NSRBP patients used nonpharmacologic therapy, and almost half used prescription medications throughout the 2 yr. The most-utilized therapies were chiropractic therapy, PT, opioids, muscle relaxants, and anticonvulsants. Over 40% of patients engaged chiropractors or PT or used opioids.