PM&R
Volume 2, Issue 6 , Pages 544-558 , June 2010

Strategies to Optimize Pain Management With Opioids While Minimizing Risk of Abuse

  • Michael J. Brennan, MD

      Affiliations

    • The Pain Center of Fairfield, 140 Sherman Street, 2nd Floor, Fairfield, CT 06824
    • Corresponding Author InformationAddress correspondence to: M.J.B.
  • ,
  • Steven Stanos, DO

      Affiliations

    • Center for Pain Management Rehabilitation Institute of Chicago, Chicago, IL

Received 4 November 2009 ,Accepted 8 March 2010.

References 

  1. Gallagher RM, Rosenthal LJ. Chronic pain and opiates: Balancing pain control and risks in long-term opioid treatment. Arch Phys Med Rehabil. 2008;89:S77–S82
  2. Katz WA, Barkin RL. Dilemmas in chronic/persistent pain management. Am J Ther. 2008;15:256–264
  3. Portenoy R, Ugarte C, Fuller I, Haas G. Population-based survey of pain in the United States: Differences among white, African American, and Hispanic subjects. J Pain. 2004;5:317–328
  4. Trescot AM, Boswell MV, Atluri SL, Hansen HC, Deer TR, Abdi S, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006;9:1–39
  5. Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, et al. Opioids in the management of chronic non-cancer pain: An update of American Society of the Interventional Pain Physicians' (ASIPP Guidelines). Pain Physician. 2008;11:S5–S62
  6. Katz NP, Adams EH, Chilcoat H, Colucci RD, Comer SD, Goliber P, et al. Challenges in the development of prescription opioid abuse-deterrent formulations. Clin J Pain. 2007;23:648–660
  7. Gagnon AM, Kahan M, Srivastava A. Opioid use and abuse: Is there a problem?. Clin J Pain. 2007;23:661–662
  8. Kuehn BM. Opioid prescriptions soar: Increase in legitimate use as well as abuse. JAMA. 2007;297:249–251
  9. US Department of Health and Human Services. Identification of Drug and Biological Products Deemed to Have Risk Evaluation and Mitigation Strategies for Purposes of the Food and Drug Administration Amendments Act of 2007 (Docket No. FDA-2008-N0174). Federal Register. 2008;73:16313–16314
  10. Chronic Pain in America: Roadblocks to Relief; a study conducted by Roper Starch Worldwide for American Academy of Pain Medicine, American Pain Society and Janssen Pharmaceutica. January 1999;
  11. Katz NP, Adams EH, Benneyan JC, Birnbaum HG, Budman SH, Buzzeo RW, et al. Foundations of opioid risk management. Clin J Pain. 2007;23:103–118
  12. McCarberg B, Stanos S. Key patient assessment tools and treatment strategies for pain management. Pain Pract. 2008;8:423–432
  13. McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: Results from pain sufferers and physicians participating in an Internet survey. Am J Ther. 2008;15:312–320
  14. Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice (A five year experience). J Gen Intern Med. 2007;22:485–490
  15. Stanos S. Use of opioids. J Fam Pract. 2007;56:23–32
  16. Sloan P, Babul N. Extended-release opioids for the management of chronic non-malignant pain. Expert Opin Drug Deliv. 2006;3:489–497
  17. Wilson JF. Strategies to stop abuse of prescribed opioid drugs. Ann Intern Med. 2007;146:897–900
  18. Nwokeji ED, Rascati KL, Brwon CM, Eisenberg A. Influences of attitudes on family physicians' willingness to prescribe long-acting opioid analgesics for patients with chronic nonmalignant pain. Clin Ther. 2007;29:2589–2602
  19. IMS NPA Rx Monthly. IMS Health Web site. http://www.imshealth.comAccessed September 23, 2009
  20. Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.
  21. Birnbaum HG, White AG, Reynolds JL, Greenberg PE, Zhang M, Vallow S, et al. Estimated costs of prescription opioid analgesic abuse in the United States in 2001: A societal perspective. Clin J Pain. 2006;22:667–676
  22. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Various stimulant drugs show continuing gradual declines among teens in 2008, most illicit drugs hold steady. Ann Arbor, M.I: University of Michigan News Service; December 11, 2008;http://monitoringthefuture.org/pressreleases/08drugpr.pdfAccessed September 23, 2009
  23. Inciardi JA, Surratt HLKSP, Cicero TJ. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Med. 2007;8:171–183
  24. Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.
  25. Denisco RA, Chandler RK, Compton WM. Addressing the intersecting problems of opioid misuse and chronic pain treatment. Exp Clin Psychopharmacol. 2008;16:417–428
  26. Inciardi JA, Surratt HL, Cicero TJ, Beard RA. Prescription opioid abuse and diversion in an urban community: The results of an ultrarapid assessment. Pain Med. 2009;10:537–548
  27. Gourlay DL, Heit HA. Pain and addiction: Managing risk through comprehensive care. J Addictive Dis. 2008;27:23–30
  28. Passik S. The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Exp Clin Psychopharmacol. 2008;16:400–404
  29. Harden RN. Chronic pain and opiates: A call for moderation. Arch Phys Med Rehabil. 2008;89:S72–S76
  30. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8:573–582
  31. Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, Perhac JS, Potisek NM, et al. Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Serv Res. 2006;6:46
  32. Cicero TJ, Surratt H, Inciardi JA, Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiol Drug Saf. 2007;16:827–840
  33. Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, et al. Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116–127
  34. Manchikanti L, Singh A. Therapeutic opioids: A ten year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11:S63–S88
  35. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? (A structured evidence-based review). Pain Med. 2008;9:444–459
  36. Rosenblum A, Marsch LA, Joseph H. Opioids and the treatment of chronic pain: Controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16:405–416
  37. Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. JAMA. 2003;289:2370–2378
  38. Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain. 2002;18:S28–S38
  39. McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility. JAMA. 2008;300:2672–2673
  40. Under the counter: the diversion and abuse of controlled prescription drugs in the US (The National Center on Addiction and Substance Abuse at Columbia University). http://www.casacolumbia.org/absolutenm/articlefiles/380-Under%20the%20Counter%20-%20Diversion.pdfJuly 2005;Accessed September 24, 2009
  41. Blake S, Ruel B, Seamark C, Seamark D. Experiences of patients requiring strong opioid drugs for chronic non-cancer pain: A patient-initiated study. Br J Gen Pract. 2007;57:101–108
  42. White AG, Birnbaum HG, Mareva MN, Daher M, Vallow S, Schein J, et al. Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm. 2005;11:469–479
  43. Manchikanti L. Prescription drug abuse: What is being done to address this new drug epidemic? (Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources). Pain Physician. 2006;9:287–321
  44. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010;152:85–92
  45. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Opioid treatment guidelines (Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain). J Pain. 2009;10:113–130
  46. Højsted J, Sjogren P. Addiction to opioids in chronic pain patients: A literature review. Eur J Pain. 2007;11:490–518
  47. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Med. 2005;6:432–442
  48. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94:135–140
  49. Coambs RB, Larry JL, Santhiapillai AC, Abrahamsohn RV, Atance CM. The SISAP: A new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain wihtin general medical practice. Pain Res Manage. 1996;1:155–162
  50. Passik SD, Kirsh KL, McDonald MV, Ahn SS, Russak SM, Martin L, et al. A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients. J Pain Symptom Manage. 2000;19:274–286
  51. Cowan DT, Wilson-Barnett J, Griffiths P, Allan LG. A survey of chronic noncancer pain patients prescribed opioid analgesics. Pain Med. 2003;4:340–351
  52. Friedman R, Li V, Mehrotra D. Treating pain patients at risk: Evaluation of a screening tool in opioid-treated pain patients with and without addiction. Pain Med. 2003;4:182–185
  53. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112:65–75
  54. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32:287–293
  55. Adams LL, Gatchel RJ, Robinson RC, Polatin P, Gajraj N, Deschner M, et al. Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manage. 2004;27:440–459
  56. Holmes CP, Gatchel RJ, Adams LL, Stowell AW, Hatten A, Noe C, et al. An opioid screening instrument: Long-term evaluation of the utility of the pain medication questionnaire. Pain Pract. 2006;6:74–88
  57. Butler SF, Budman SH, Fernandez KC, Houle B, Benoit C, Katz N, et al. Development and validation of the current opioid misuse measure. Pain. 2007;130:144–156
  58. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9:360–372
  59. Compton PA, Wu SM, Schieffer B, Pham QNBD. Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement compliance. J Pain Symptom Manage. 2008;336:383–395
  60. Compton P, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and “problematic” substance use: Evaluation of a pilot assessment tool. J Pain Symptom Manage. 1998;16:355–363
  61. Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: Clinical criteria, incidence, and predictors. Clin J Pain. 1997;13:150–155
  62. Manchikanti L, Atluri S, Trescot AM, Giordano J. Monitoring opioid adherence in chronic pain patients: Tools, techniques, and utility. Pain Physician. 2008;11:S155–S180
  63. Michna E, Ross EL, Hynes WL, Nedeljkovic SS, Soumekh S, Janfaza D, et al. Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage. 2004;28:250–258
  64. Turk DC, Swanson KS, Garchel RJ. Predicting opioid misuse by chronic pain patients (A systematic review and literature synthesis). Clin J Pain. 2008;24:497–508
  65. Passik SD, Kirsh KL, Whitcomb L, Portenoy RK, Katz NP, Kleinman L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004;26:552–561
  66. Passik SD, Kirsh KL. Screening for opioid abuse potential. Pain. 2008;16:1–4
  67. Wu SM, Compton P, Bolus R, Schieffer B, Pham Q, Baria A, et al. The addiction behaviors checklist: Validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manage. 2006;32:342–351
  68. Belgrade MJ, Schamber CD, Lindgren BR. The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. J Pain. 2006;7:671–681
  69. Skinner HA. The drug abuse screening test. Addict Behav. 1982;7:363–371
  70. Benyamin R, Trescot AM, Datta S, Buenmaventura R, Adlaka R, Sehgal N, et al. Opioid complications and side effects. Pain Physician. 2008;11:S105–S120
  71. Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid dosing for chronic non-cancer pain: An educational pilot to improve care and safety with opioid treatment (Agency Medical Directors Group). March 2007 http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdfAccessed September 24, 2009
  72. Atluri SL, Sudarshan G. Development of a screening tool to detect the risk of inappropriate prescription opioid use in patients with chronic pain. Pain Physician. 2004;7:333–338
  73. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005;6:107–112
  74. Nafziger AN, Bertino JS. Utility and applications of urine drug testing in chronic pain management with opioids. Clin J Pain. 2009;25:73–79
  75. Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37:301–314
  76. Compton P. The role of urine toxicology in chronic opioid analgesic therapy. Pain Manage Nurs. 2007;8:166–172
  77. Wasan AD, Michna E, Janafsca D, Greenfield S, Teter CJ, Jamison RN. Interpreting urine drug tests: Prevalence of morphine metabolism to hydromoprhone in chronic pain patients treated with morphine. Pain Med. 2008;9:918–923
  78. Thompson AR. The importance of opioid tolerance: a therapeutic paradox. J Am Coll Surg. 2003;196:321–324
  79. Collett BJ. Opioid tolerance: The clinical perspective. Br J Anaesth. 1998;81:58–68
  80. Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskovski C. Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline. J Pain. 2009;10:147–159
  81. Ballantyne JC, Shin NS. Efficacy of opioids for chronic pain. Clin J Pain. 2008;24:469–478
  82. Noble M, Tregear SJ, Treadwell JR, Schoelles K. Long-term opioid therapy for chronic noncancer pain: A systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage. 2008;35:214–228
  83. Portenoy RK, Farrar JT, Backonja MM, Cleeland CS, Yang K, Friedman M, et al. Long-term use of controlled-release oxycodone for noncancer pain: Results of a 3-year registry study. Clin J Pain. 2007;23:287–299
  84. Soin A, Cheng J, Brown L, Moufawad S, Mekhail N. Functional outcomes in patients with chronic nonmalignant pain on long-term opioid therapy. Pain Pract. 2008;8:379–384
  85. Devulder J, Richarz U, Nataraja SH. Impact of long-term use of opioids on quality of life in patients with chronic, non-malignant pain. Curr Med Res Opin. 2005;21:1555–1568
  86. Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10:399–424
  87. Gilson AM, Joranson DE, Maurer MA, Ryan KM, Garthwaite JP. Progress to achieve balanced state policy relevant to pain management and palliative care. J Pain Palliat Care Pharmacother. 2005;19:13–26
  88. Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: A primary care, managed approach to opiod therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8:573–584
  89. Harris JM, Elliott TE, Davis BE, Chabal C, Fulgineti JV, Fine PG. Educating generalist physicians about chronic pain: Live experts and online education can providedurable benefits. Pain Med. 2008;9:555–563
  90. Simoni-Wastila L, Tompkins C. Blancing diversion control and medical necessity: The case of prescription drugs with abuse potential. Substance Abuse Misuse. 2001;36:1275–1296
  91. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613–2620
  92. Fudala PJ, Johnson RE. Development of opioid formulations with limited diversion and abuse potential. Drug Alcohol Depend. 2006;83(Suppl 1):S40–S47
  93. Butler SF, Budman SH, Licari A, Cassidy TA, Lioy K, Dickinson J, et al. National addictions vigilance intervention and prevention program (NAVIPPRO-TM: A real-time, product-specific. public health surveillance system for monitoring prescription drug abuse. Pharmacol Drug Safety. 2008;[In press]
  94. Paulozzi LJ. Trends in unintentional drug overdose deaths (Testimony before Senate Judiciary Committee on Crime and Drugs). March 12, 2008 http://www.hhs.gov/asl/testify/2008/03/t20080312b.htmlAccessed January 21, 2010
  95. TheraQuest Biosciences. Our product candidates. http://www.theraquestinc.com/pipeline/products.htm2006Accessed February 20, 2009
  96. TheraQuest Biosciences. Ultram-ER extended-release tablets. 2008 http://www.theraquest.comAccessed February 20, 2009
  97. TheraQuest Biosciences. 2009 http://www.theraquest.comAccessed February 20, 2009
  98. TheraQuest Biosciences. TheraQuest's IND for abuse deterrent strong opioid (TQ-1015) accepted by FDA. November 13, 2008 http://www.theraquestinc.com/news/pressrelease/pr_08_11_13.htmAccessed February 23, 2009
  99. Lavine G. Abuse deterrence focus of upcoming opioid formulations. Am J Health Syst Pharm. 2008;65:381;, 385
  100. Gershell L, Goater JJ. Making gains in pain. Nat Rev Drug Discov. 2006;5:889–890
  101. Webster LR. PTI-821: Sustained-release oxycodone using gel-cap technology. Expert Opin Investig Drugs. 2007;16:359–366
  102. Pain Therapeutics' Remoxy cleared for US Clinical trials. Pain Therapeutics, Inc. September 2, 2004. Available online at: http://investor.paintrials.com/releasedetail.cfm?ReleaseID=297384. Accessed September 23, 2009.
  103. IntelliPharmaCeutics announces successful completion of a pilot clinical trial for its abuse and alcohol resistant sustained release oxycodone. IntelliPharmaCeutics Ltd. March 27, 2008. Available online at: http://www.intellipharmaceutics.com/contact/news_2008_march_27.htm. Accessed August 7, 2009.
  104. Akela Pharmaceuticals, Inc. Akela Pharmaceuticals initiates its first abuse deterrent opioid phase I clinical trial. March 6, 2008 http://www.akelapharma.com/modules.php?op=modload&name=News&file=article&sid=67Accessed September 23, 2009
  105. Collegium Pharmaceutical Inc. Collegium Pharmaceutical Inc. announces FDA acceptance of IND for its abuse deterrent sustained release opioid product. July 12, 2007 http://www.collegiumpharma.com/news/20070712.htmlAccessed September 24, 2009
  106. Collegium Pharmaceutical Inc. Collegium Pharmaceutical Inc. announces submission of a request for special protocol assessment to FDA for pivotal trial for tamper resistant, extended release opioid (COL-003). [press release]. June 10, 2009 http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20090610005046&newsLang=en
  107. Sathyan G, Sivakumar K, Thipphawong J. Pharmacokinetic profile of a 24-hour controlled-release OROS formulation of hydromorphone in the presence of alcohol. Curr Med Res Opin. 2008;24:297–305
  108. Sathyan G, Xu E, Thipphawong J, Gupta SK. Pharmacokinetic investigation of dose proportionality with a 24-hour controlled-release formulation of hydromorphone. BMC Clin Pharmacol. 2007;7:3–8
  109. Webster LR, Bath B, Medve RA. Opioid formulations in development designed to curtail abuse: Who is the target?. Expert Opin Investig Drugs. 2009;18:255–263
  110. Webster L. Update on abuse-resistant and abuse-deterrent approaches to opioid formulations. Pain Med. 2009;10:S124–S133
  111. Neuromed Pharmaceuticals, Inc. Neuromed announces Exalgo (hydromorphone HCl) extended-release tablet [press release]. PharmaLive.com news archive. March 23, 2009.
  112. CombintoRx, Incorporated and Neuromed Pharmaceuticals Inc. FDA extends NDA review for Exalgo extended-release tablets [press release]. PharmaLive.com news archive. November 20, 2009.
  113. Innovators in pain management. Egalet a/s. http://www.egalet.comAccessed January 11, 2010
  114. Egalet a/s. Effects of a single dose of Egalet®. morphine combined with a single dose of alcohol in healthy moderate drinkers. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000-[January 11, 2010]. Available online at: http://clinicaltrials.gov/ct2/show/NCT00802308 NLM Identifier: NCT00802308.
  115. Andersen C, Jespersen L. Egalet® morphine, a once-a-day abuse resistant opioid analgesic: A.double-blind, randomized, cross-over efficacy study in cancer patients. J Pain. 2009;10:S36
  116. Egalet a/s. Single dose pharmacokinetics of Egalet® oxycodone. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000-[January 11, 2010]. Available online at: http://clinicaltrials.gov/ct2/show/NCT00801788 NLM Identifier: NCT00801788.
  117. Egalet a/s. Single dose pharmacokinetics of Egalet® hydrocodone. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000-[January 11, 2010]. Available online at: http://clinicaltrials.gov/ct2/show/NCT00802087 NLM Identifier: NCT00802087.
  118. Embeda [package insert]. Bristol, TN: King Pharmaceuticals®, Inc.; June, 2009.
  119. Purdue Pharma L.P.. Meeting background material. Joint meeting of the Anesthetic and Life Support Drugs Advisory Committee (ALSDAC) and Drug Safety and Risk Management Advisory Committee (DSaRM). May 5, 2008;155–159

 Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org

PII: S1934-1482(10)00201-7

doi: 10.1016/j.pmrj.2010.03.011

PM&R
Volume 2, Issue 6 , Pages 544-558 , June 2010