CURRENT LITERATURE

J Oral Maxillofac Surg59:241-245, 2001

AbstractsAdenocarcinoma of the Esophagus With and WithoutBarret Mucosa. Sabel MS, Pastore K, Tonn H, et al. ArchSurg 135:831, 2000

Barret esophagus (BE) has been well identified as a pre-disposing factor for adenocarcinoma of the esophagus.However, this type of mucosal lining also has been associ-ated with a better overall prognosis in patients with adeno-carcinoma of the esophagus. This retrospective study wasdesigned to compare the overall prognosis in patients withadenocarcinoma of the esophagus with and without Barret.A total of 178 cases that were diagnosed with adenocarci-noma of the esophagus at Roswell Park Cancer Institute(Buffalo, NY) between 1991 and 1996 were reviewed.Thirty-seven percent of the cases were positive for BE and63% were negative (endoscopically and pathologically). Aslight male predominance was identified, with a male-to-female ratio of 5.6:1 in the BE group and 3.3:1 in the non-BEgroup. The results showed that the presentation symptomswere the same for both groups (dysphasia and weight loss)and that the gastroesophageal reflux disease (GERD) asso-ciated symptoms represented only 14% (BE) and 4% (non-BE). Smaller and less invasive tumors were identified in theBE group, including cases of carcinoma in situ. A higherpercent of resectable tumors in the BE group (59% vs 35%)was associated with a better overall survival rate (22 monthsfor the BE group vs 16.4 months for the non-BE group). Theauthors conclude that the better prognosis associated withBE is not related with early detection due to GERD symp-toms. The relation between BE and more benign types ofadenocarcinoma is not clear. In addition, the authors be-lieved that more aggressive esophageal adenocarcinomasmay represent tumors that originated from BE, in which themetaplasic changes are difficult to identify or have beendisappeared.—A.F. HERRERA

Reprint requests to Dr Sabel: Roswell Park Cancer Institute, Elmand Carlton Streets, Buffalo, NY 14263.

Aspirin Use is Low Among United States OutpatientsWith Coronary Artery Disease. Stafford RS. Circulation101:1097, 2000

This study evaluates the use of aspirin, an over-the-counter medication, among outpatients with coronary ar-tery disease. Long-term aspirin use is recommended for thesecondary prevention of all forms of coronary artery diseasewith the greatest benefit for acute myocardial infarctions.Aspirin use has increased over time, but not to the extentexpected given the advantages of its studied use. Aspirinuse is more prevalent in hospitalized or recently hospital-ized patients than in outpatients. This retrospective studycollected data from all National Ambulatory Medical CareSurveys (NAMCS) conducted from 1980 through 1996. Thisstudy focused on patients with coronary artery disease thatwere followed up by a cardiologist or primary care physi-cian. Patients with disease processes that were a contrain-dication for aspirin therapy were excluded from the study.The potential exists for aspirin use to be underreported inNAMCS because aspirin is available without a prescription.

Results of the study showed that aspirin use increased from5% of visits in 1980 to 26.2% of visits in 1996 with the mostdrastic increase noted in the early 1990s. Certain predictorsof aspirin use were also noted, including patients who weremale, patients aged less than 80 years, patients with privateinsurance status, patients who smoke, and patients withhyperlipidemia. Furthermore, aspirin use was more likely tobe reported in visits to cardiologists than in visits to inter-nists, family physicians, or general practitioners. Taking intoconsideration the benefits of aspirin use, these findingssuggest that a number of patients with coronary arterydisease still remain at an increased risk for adverse out-comes. Finally, there is the potential for aspirin use to beunderreported by both patients and their physicians be-cause of its availability at low cost and without a prescrip-tion.—G.A. SANTARELLI

Reprint requests to Dr Stafford: Institute for Health Policy, Massa-chusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA02114; e-mail: rstafford@partners.org

Oral Findings in Three Different Groups of Immuno-compromised Patients. Meyer U, Kleinheinz J, HandschelJ, et al. J Oral Pathol Med 29:153, 2000

The authors of this article studied the frequency of oral,dental, and periodontal findings in 3 different groups ofimmunocompromised patients and a healthy control groupto evaluate whether there is a correlation between manifes-tations of disease and immunologic parameters. The surveyincluded 46 patients with a diagnosis of systemic lupuserythematosus, 48 heart transplant recipients, and 53 adultpatients suffering from acute leukemias. Fifty healthy sub-jects were used as a control group. Each patient had toanswer questions on medical and dental health and under-went a thorough oral, dental, and serological investigation.Oral mucosal lesions were found in nearly half of all immu-nocompromised patients (49.6%), but in only 26% of con-trol patients. No significant association was found betweendifferent types of oral lesions and the underlying cause ofimmunosuppression. Leukemia patients showed age-unre-lated higher scores in periodontal indices (P � .05). Labo-ratory parameters failed to be significant in the assessmentof oral health.—N. ASSUDMI

Reprint requests to Dr Meyer: Clinic of Maxillofacial Surgery, Uni-versity of Munster, Waldeyer st. 30, D-48149 Munster, Germany.

Lasers, Facelifting, and the Future. Roberts TL, PoznerJN. Clin Plast Surg 27:293, 2000

Optimal rejuvenation of the aging face requires multimo-dality intervention tailored to the anatomic and histologicchanges that have occurred, including not only changes inthe quality, quantity, turgor, and ptosis of the skin but alsothe atrophy and ptosis of the fatty tissues of the face.Traditional surgical procedures, including facelift, browlift,and blepharoplasty, can result in excellent repositioning ofptotic structures. To rejuvenate the skin, dermabrasion,chemical peels, and, more recently, laser resurfacing have

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been used as an adjunct to incisional procedures to producea more youthful texture and appearance. Goals have beento eliminate actinic damage and produce healthy, rejuve-nated skin with uniform color and texture over the entireface, to reduce wrinkles, and to tighten any residual looseskin, especially in the central face (ie, lower lids, malar bags,and perioral area). Laser resurfacing allows reversal of thesallow color and splotchy pigmentation of actinic damage,dermal improvement, and tightening and reduction of wrin-kles, all of which leads to long-term improvement in skinquality. These improvements are not only aesthetically ap-pealing, but also represent true histologic rejuvenation,with reversal of actinically induced nuclear atypia and dis-orderly epidermal maturation. The future of nonablativelasers, which attempt to tighten the dermis while leavingthe epidermis intact, depends on technologic improve-ments in these lasers, increase in the quality of results, anda decrease in cost, if they are to find a place in the arma-mentarium of aesthetic plastic surgeons.—R.H. HAUG

Reprint requests to Dr Roberts: 100 E Wood St, Suite 100, Spartan-burg, SC 29303-3001.

Precautions Against Cross-Infection During Opera-tions for Maxillofacial Trauma. Pigadas N, Avery CME.Br J Oral Maxillofac Surg 38:110, 2000

Oral and maxillofacial surgeons are at constant riskfor cross-infection during surgical procedures, especiallytrauma. Standard barrier methods such as eye protection,fluid-resistant synthetic gowns, drapes, ball-ended clips, andintermediate trays have been recommended for all expo-sure-prone procedures. The Centers for Disease Controldefines exposure-prone procedures as those that involvedigital palpation of a needle-tip in a body cavity or thesimultaneous presence of fingers and a needle or othersharp instrument within a poorly seen or highly confinedanatomic site. Treatment of facial trauma should obviouslybe considered an exposure-prone procedure, especiallywith the increased inadvertent and often unnoticed inci-dence of glove perforation, which may be as high as 50%according to some studies. However, the use of bone-plat-ing versus wire fixation and the advent of double-glovinghas dramatically reduced the risk for exposure and percu-taneous injury for the oral and maxillofacial surgeon. Todetermine the adherence to current infection control mea-sures, the authors mailed a postal questionnaire to 100National Health Service oral and maxillofacial surgical units.The responses showed that significantly more surgeonsused cross-infection precautions when treating high-riskpatients. For example, only 31% of surgeons routinely useddouble gloves, but 85% did so if the patient was an infectionrisk. It should be noted that double-gloving will not preventa sharp percutaneous injury; however, it does require moreforce to penetrate the gloves. In addition, it may also pro-vide added protection because of the “wipe-off” effect ofpassing a solid infected needle through 2 layers of latex.Therefore, it is recommended that surgeons routinely dou-ble-glove and adhere to universal precautions for all expo-sure-prone procedures.—R. DORIOT

Reprint requests to Mr Avery: Senior Registrar, Queen VictoriaHospital, Holtye Roak, East Grinstead, West Sussex RH19 3DZ,United Kingdom.

Cyclin D1 Expression in Oral Squamous Cell Carcino-mas: Clinicopathological Relevance and CorrelationWith p53 Expression. Lam KY, Ng IO, Yuen AP, et al.J Oral Pathol Med 29:167, 2000

The genetic alteration of p53 and the cyclin D1 gene insquamous cell cancers can be studied by immunohisto-chemistry for the expression of the gene products. Manyinvestigations have shown amplification in cyclin D1 inhead and neck squamous cell carcinomas (SSC); however,these studies mainly used specimens from the larynx, hy-popharynx, and esophagus. This study focused on the ex-pression of p53 and cyclin D1 in oral SSC. Fifty-six patientswith primary SSC with a mean age of 65 years and noevidence of distant metastasis were studied. The oral SSCspecimens were taken from various oral sites and separatedinto grades based on severity. A total of 88 specimens werestudied, some preradiation and some postradiation. Thespecimens were prepared in proper fashion for examina-tion of cyclin D1 and p53 by standard light microscopy. Theresults showed that cyclin D1 was present in 63% of thepatients and p53 expression was present in 73% of patients.Radiation therapy appeared to make no difference in therate of expression. Cyclin D1 expression was more com-monly found in moderately or poorly differentiated SSCthen well-differentiated SSC, where no correlation betweenp53 expression and the grade of tumors was noted. Thesurvival lengths of patients was not related to the presenceof cyclin D1 or p53; however, patients who had earlylesions with cyclin D1 expression had poorer survival rates.In the study, 68% of the SSC specimens were positive forthe expression of both cyclin D1 and p53, however theoncoproteins did occur independently of one another andthe expression in various oral sites were different. Theseresults may indicate different tumor biology of cancers fromdifferent intraoral sites, and could prove helpful in deter-mining the severity and possible prognosis of certain oralSSC.—D. PHILLIPS

Reprint requests to Dr Lam: Department of Pathology, Surgery, andClinical Oncology, the University of Hong Kong, Queen Mary Hos-pital, Hong Kong.

Maternal Risk Factors in Cleft Lip and Palate: CaseControl Study. Natsume N, Kamai T, Ogi N, et al. Br J OralMaxillofac Surg 38:23, 2000

Hereditary and environmental factors are implicated inthe development of cleft lip and/or palate. This case controlstudy examines possible hereditary and environmental linksto cleft lip and/or palate. Three hundred six mothers whogave birth to babies with cleft lip, palate, or both, werecompared with 306 who gave birth to babies without de-fects in the same district around Nagoya during the sametime period. In each group, 157 boys and 149 girls wereincluded. The authors used Fisher’s exact test and the �2

test with the Yates correction, as appropriate, to assess thedifferences between the groups. There were no significantdifferences in the mothers’ age at delivery, body mass in-dex, occupation during early pregnancy, or blood group.Significantly more babies among the cases had a familyhistory of clefts. Combined cleft lip and palate was signifi-cantly more common in boys than girls, whereas isolatedcleft palate was significantly more common in girls. Isolatedcleft lip showed no gender predilection. Weeks of gestationdid not differ significantly. No consistent pattern was seenregarding the months of birth. Order of siblings was similar

242 CURRENT LITERATURE

between the 2 groups. Illness during pregnancy was signif-icantly more common among the cleft lip and/or palategroup than the controls. No dietary preferences showed asignificant difference. The authors conclude the study bystating that larger studies and studies conducted in otherregions are needed for comparison.—M.A. OGHALAI

Reprint requests to Dr Natsume: The Second Department of Oraland Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin Univer-sity, 2-11 Suemori-dori, Chikusa-ku, Nagoya 464-8651, Japan.

The Treatment of Early Cutaneous Capillary Haeman-giomata (Strawberry Naevi) With the Tunable Dye La-ser. Haywood RM, Monk BE, Mahaffey PJ. Br J Plast Surg53:302, 2000

Cutaneous capillary hemangioma occur in approximately10.1% of children under the age of 12 months. They occurmost frequently in the head and neck region (60%). Theselesions rapidly proliferate in the first 6 months of life andusually stop their growth at approximately 10 months.Complete resolution is found in about 50% of lesions by 5years of age. The authors treated 39 early cutaneous capil-lary hemangiomas, in 24 infants, with the tunable dye laserat a wavelength of 585 nm. Average age of the first treat-ment was 13 weeks. The first signs of involution of treatedlesions were seen at 19 weeks of age. Complete resolutionin 61.5% of treated lesions was seen at an average age of 39weeks. There were no complications associated with thelaser treatments. Most treatments were carried out withoutanesthetic and caused minimal distress. The involution andresolution of treated hemangiomas was significantly shorterthan that seen historically with untreated lesions. Earlytreatment of these disfiguring lesions would allow childrenapproaching school age to benefit from a life without thestigma of disfigurement and parents can be spared theanxiety associated with a disfigured child.—ROBERT J. LESNY

Reprint requests to Dr Haywood: Bedford Laser Treatment Centre,Bedford Hospital, Bedford, United Kingdom.

Mucus Retention Cyst of the Maxilla: The EndoscopicApproach. Hadar T, Shuero J, Nageris BI, et al. Br J OralMaxillofac Surg 38:227, 2000

The benign mucus retention cyst of the maxillary sinushas an incidence of 1.5% to 10%. The cyst arises secondaryto an obstruction of a duct or gland within the sinus epi-thelium. This leads to an accumulation of mucus within thesoft tissues of the maxillary sinus. Radiographically, the cystappears as a dome-shaped soft tissue mass most commonlyplaced along the floor of the maxillary sinus. Patients usu-ally have no symptoms and the cyst is found on routineradiographs. However, mucus retention cysts can causeheadaches and periorbital pain, which are indications fortreatment. In the past, treatment consisted of puncture andaspiration through the inferior meatus, excision through anintranasal antrostomy, or excision through a Caldwell-Lucapproach. With the development of the rigid nasal endo-scope and the arrival of functional endoscopic intranasalsinus surgery, the need for incisions and direct vision hasbeen greatly reduced. In this retrospective study, 60 pa-tients who underwent functional endoscopic sinus surgeryto remove large symptomatic mucus retention cysts werereviewed to assess the effectiveness of the endoscopic ap-proach. The patients received topical application of epi-nephrine 1:100,000 and local anesthesia to the nasal cavity

before placement of the endoscope. Initially, the naturalostium was entered to attempt to extract the cyst. If thismethod was unsuccessful, a 5 mm trocar was used to enterthrough the inferior meatus, and the cyst was extractedthrough the inferior antrostomy. A final option was to enterthe sinus through the canine fossa with a 5 mm trocar. In 35patients, the cysts were removed through the natural os-tium. The cyst had to be removed through the inferiorantrostomy in 23 patients, and through the canine fossa in2 patients. Postoperatively, no complications were ob-served and only 4 patients required nasal packing secondaryto bleeding. One-year postoperatively, only 5 patients hadno relief of symptoms. Two of these 5 showed a recurrenceon computed tomography. The cysts were removed endo-scopically without any further complications. Therefore,from this data, it appears that the endoscopic approach tomucus retention cyst removal has some advantages overearlier procedures. These include a low incidence of recur-rence (3% in this study), minimal postoperative bleeding,and the ability to perform the procedure under local anes-thesia.—B. GREGORY

Reprint requests to Dr Hadar: Department of Otolaryngology, RabinMedical Center (Beilinson Campus), Petah Tiqua 49100, Israel.

Deep Inferior Epigastric Perforator Dermal Fat or Adi-posal Flap for Correction of Craniofacial Contour De-formities. Koshima I, Inagawa K, Urishibara K, et al. PlastReconstr Surg 106:10, 2000

Numerous free flaps including the latissimus dorsi mus-culocutaneous flap, transverse rectus abdominus muscleflap, and the radial forearm adipofascial flap have previouslybeen used to reconstruct craniofacial contour deformities.This article summarizes the authors’ use of deep inferiorepigastric perforator dermal fat or adiposal flaps in 8 pa-tients with such deformities. Among these patients, therewere 3 traumatic craniofacial or facial deformities, 1 con-genital craniofacial deformity, 2 hemifacial atrophies (1 dueto radiation and the other to Romberg’s disease), 1 hemifa-cial microsomia, and 1 localized frontonasal lipodystrophy.At the time of flap transfer, the patients ranged in age from12 to 53 years. Stable restoration of the facial contour wasachieved in all 8 patients using a deep inferior epigastricperforator flap, which was vascularized with a muscle per-forator and the deep inferior epigastric vessel. This flapdesign did not incorporate the rectus abdominus muscle.Advantages of this flap include the following: minimal do-nor-site morbidity, because the rectus abdominus muscle ispreserved as a whole; it accommodates pregnancy inwomen; it leaves a more acceptable secondary defect, andit provides a greater tissue yield. Preservation of the rectusabdominus muscle prevents weakness, bulging, and herni-ation of the abdominal wall. Furthermore, a considerableamount of the superficial or deep fatty layer can be removedprimarily, making a bulky flap into a thinner one. This flapalso allows the use of a large transverse abdominal ellipse ofskin, fat, and Scarpa’s fascia with abdominoplasty closure.Disadvantages include a more technically difficult dissec-tion of the muscle perforator and additional minor opera-tions may be necessary to reduce fat volume around theperforator.—A.J. LIBUNAO

Reprint requests to Dr Koshima: Kawasaki Medical School, 577Matsushima, Kurashiki City, Okayama, 707-0192 Japan.

CURRENT LITERATURE 243

Postoperative Laser Care. Weinstein C. Clin Plast Surg27:251, 2000

Laser resurfacing is now accepted as an important com-ponent of facial rejuvenation, with some debate whetherthe carbon dioxide (CO2) or the erbium:yttrium-aluminum-garnet (Er:YAG) laser is preferable. With the introduction ofcomputerized scanning systems for both CO2 and Er:YAGlasers, the actual technique of resurfacing has been greatlysimplified; however, postoperative care still remains a greatchallenge to all physicians, because postoperative morbid-ity after laser resurfacing remains a significant problem.Minor and major complications can arise from poor orinadequate postoperative care. Early postoperative caremay be divided into 1) prere-epithelialization wound careand 2) prevention of early complications (eg, bacterial,viral, and fungal infections and contact allergic dermatitis).The early postoperative period is important both from psy-chologic and physical aspects because this is the periodduring which the patient feels the most anxious and vul-nerable. Reassurance and “hand-holding” play an importantrole in patient satisfaction and should not be underesti-mated. The aim of the closed technique is to use one of thenewer, semiocclusive biosynthetic dressings that have beendesigned to perform similar functions in the normal intactepidermis. They function to reduce excess water loss, allowoxygen to access the dermis, prevent pain, and preventcolonization of pathogenic organisms. Many practitionersfavor the open technique because it is cheaper and does notrequire nursing staff. If this technique is used, topical prep-arations should be selected to closely mimic epidermalfunction by preventing excessive water loss, providing abarrier to infection, and minimizing pain. After laser skinresurfacing, there is a risk of bacterial, fungal, and viralinfections, which can be prevented in most cases. Bacterialinfection remains relatively uncommon, probably becauseof the excellent blood supply to the face. Whenever skinresurfacing is performed, there is a risk of herpes virusinfection, which can spread to the entire resurfaced areaand lead to scarring. Prophylaxis against herpes virus infec-tion is indicated for all individuals even if a previous historyof “cold sores” cannot be elicited. Although uncommon,candidal infection can occur after laser skin resurfacing, ifthe wound is too moist. After re-epithelialization, there arespecial requirements, including: 1) prevention of pigmen-tation, 2) minimization of postoperative erythema, 3) pre-vention of contact irritant and allergic dermatitis, 4) preven-tion of acne, 5) prevention and treatment of scarring, and 6)hypopigmentation. The process of laser resurfacing, whichin most patients is performed for solar-damaged skin, shouldbe part of a lifelong skin care program.—R.H. HAUG

Reprint requests to Dr Weinstein: Laser Surgery Institute of Mel-bourne, 174 Victoria Parade, East Melbourne 3002, Victoria, Aus-tralia.

Interferon Alfa Therapy Against Metastatic Iris Tumorof Renal Cell Carcinoma. Ikeda T, Sato K, Tokuyama T.Arch Ophthalmol 18:846, 2000

Ocular metastasis of renal cell carcinoma is rare, espe-cially to the iris or cilliary body. This report presents a caseof metastatic renal cell carcinoma to the iris treated conser-vatively with interferon alfa therapy. The case reported a55-year-old man with a 1-week history of decreased vision.His medical history was remarkable for radical right ne-phrectomy 2 years before presentation due to renal cell

carcinoma, and left partial pneumonectomy due to lungmetastasis. On physical examination the patient presented awell-circumscribed solid tumor (8 � 4 mm) in the iris of theright eye. Retinal detachment was noted in the peripherybetween the 3- and 7-o’clock positions. The patient wastreated with systemic interferon alfa at an initial dosage of21,000,000 U per week, but it was reduced to 9,000,000 Uper week in the second week due to bone marrow suppres-sion. The dose was further decreased to 6,000,000 U perweek by the third week. Regression on the iris tumor wasinitially seen about 3 weeks after the onset of therapy andappeared to be totally regressed after 16 weeks. The retinaldetachment disappeared, and the tumor was not detectableby ultrasonography. The authors comment that renal cellcarcinoma resist routine chemotherapy and radiotherapy.However, recent in vitro findings showed the antiprolifera-tive effect of interferon alfa on renal cell carcinoma. Thesefindings support its use as a new treatment for this type oftumor. A mean response of 20% has been seen with the useof interferon alfa alone and the reported case represented amarked response to the therapy.—A.F. HERRERA

Reprint requests to Dr Ikeda: Department of Ophtalmology, OsakaCity General Hospital, 2-13-22, Miyakojimahondori, Miyakojima-ku,Osaka 534-0021, Japan.

Annotated Abstracts

Efficacy of Preoperative Decontamination of the OralCavity. Summers AN, Larson DL, Edmiston CE, et al. PlastReconstr Surg 106:895, 2000

This study assessed by questionnaire the opinions ofmaxillofacial surgeons regarding the use and assumed“worth” of antiseptic preparation of the oral cavity beforeintraoral surgery. The survey showed that over 90% ofrespondents used intravenous antibiotics for intraoral sur-gery; 67% used an intraoral preparation routinely, mostcommonly, povidone-iodine; yet only 46% felt that the prep-aration was effective in reducing the bacterial count and35% felt that it helped reduce the incidence of postopera-tive infection. A prospective, controlled study was under-taken to determine whether preparation of the oral cavitywith saline or povidone-iodine was any more effective inreducing the bacterial count than no preparation at all.Buccal swabs for aerobic and anaerobic cultures were takenbefore preparation, after preparation with either saline orpovidone-iodine, and at the end of surgery in 30 patients.The second swab was omitted from the patients who didnot have preparation of the oral cavity. Half the patients ineach group were given prophylactic antibiotics. Beforepreparation, the bacterial count was �107; after prepara-tion with saline, the count was reduced to 107, but this wasnot a significant reduction. Preparation with povidone-io-dine reduced the bacterial count to less than 105, a signifi-cant reduction from pre-preparation. The reductions in bac-terial counts for the saline and povidone-iodine groupsremained until at least the time of the postoperative cultur-ing. The postoperative bacterial count was not influencedby the preoperative administration of intravenous antibiot-ics. None of the patients developed a postoperative infec-tion within the first 30 days. The authors recommendedantiseptic preparation of the oral cavity in, if not all intraoralcases, those with a higher propensity for infection.

244 CURRENT LITERATURE

Reviewer’s Comment: A topic of interest to all oraland maxillofacial surgeons, I would guess that our mem-bers are also divided on the “worth” of antiseptic prepa-ration of the oral cavity before intraoral surgery. Antisep-tic preparation is not a routine for dental extractions, andalthough implant companies recommend aseptic surgery,the practice common to most surgeons in the United Statesis to not prepare the oral cavity before implant placement.This does not seem to affect the incidence of postoperativeinfections or the success rate of dental implants. The“worth” of antiseptic preparation for other procedures,such as orthognathic surgery, is very difficult to deter-mine, because the incidence of infection is so low. Toobtain meaningful data, huge samples would be needed.However, if one believes that the development of infectionrequires a critical concentration of bacteria, then it makessense to decrease the bacterial count by whatever meansare possible. This study clearly showed that this is easilyachieved by a povidone-iodine preparation before sur-gery.—E. ELLIS

Reprint requests to Dr Summers: 621 Ridgely Ave, Annapolis, MD21401; e-mail: asummers@mcw.edu

Psychological Correlates of Opioid Use in PatientsWith Chronic Nonmalignant Pain: A Preliminary Testof the Downhill Spiral Hypothesis. Ciccone DS, Just N,Bandilla EB, et al. J Pain Symptom Manage 20:180, 2000

Many clinicians are convinced that long-term opioid treat-ment for chronic nonmalignant pain leads to a progressiveand measurable social, physical, and psychologic disability.Several authors have coined these collective events as the“pain-opioid downhill spiral” (see Brodner and Taub, MtSinai J Med 45:233, 1978). This study was a retrospectiverecall of 373 consecutive referrals to a tertiary pain serviceat a major urban northeastern medical school between 1995and 1997. The final sample consisted of 243 patients withchronic nonmalignant pain including chronic back pain(�50%), neuropathic pain (�43%), myofascial pain(�33%), reflex sympathetic dystrophy pain (11%), head-ache pain (10%), and sympathetically maintained pain(�3%). Two groups of patients were retrospectively as-signed as opioid users (n � 87) or non-users (n � 156). Theuser group consumed an average of 85.7 � 133.5 morphine-equivalent mg/d for an average of 5.1 � 0.85 years. Dosesranged from 1.4 to 719 mg daily. Opioid users were morelikely than non-users to be taking benzodiazepines, calciumchannel blockers, selective serotonin re-uptake inhibitors,

and alpha adrenergic blockers. The length of disability(number of days during the preceding 6 months), medicalvisitations (self-report), and psychologic battery (painquestionnaire, sickness impact profile, Beck Depression In-ventory, Cognitive-Somatic Anxiety Questionnaire, and So-matization) were collected. Compared with non-users, sta-tistically significant more opioid users were physically dis-abled, depressed, and were reporting greater pain at higherlevels and in more locations. However, hierarchical regres-sion analysis showed that benzodiazepine use and not opi-oid use was statistically associated with diminished domes-tic ability and activity level and greater medical visitationsand disability days. Somatization explained 20% of the vari-ance of depression compared with 1% of the variance dueto opioid use. The authors concluded that long-term opioiduse in chronic nonmalignant pain may be associated withthe observed “downhill spiral” but many of the behavioraloutcomes may be due to benzodiazepine use rather than toopioids when hierarchical analysis is performed.

Reviewer’s Comment: There remains no consensus forthe use of long-term intermediate release opioids for non-malignant pain conditions. Opponents contend thatchronic opioid use actually results in greater social, phys-ical, and psychologic disability independent of thatcaused by the chronic pain condition. This study confirmsthat long-term opioid use (when compared with non-opioid use) results in a pattern of increased disability anddepression consistent with the “pain-opioid downhill spi-ral.” However, the posthoc analysis suggested that adjunc-tive pharmacotherapy, (specifically benzodiazepines andnot opioids) and somatization are responsible for physi-cal and social disability and psychologic depression in thispatient population. The major fault of this study was thatit was performed retrospectively and does not havethe statistical robustness of a prospective, randomized,blinded clinical trial. Thus, whether long-term opioid usedoes or does not result in “downhill spiral” is still contro-versial. However, the clinician must be aware that thisstudy points out that as a group, opioid users are morelikely to demonstrate illness behaviors that produce so-cial, physical, and psychologic disabilities and until clin-ical trials are conducted the use of long-term opioids inchronic nonmalignant pain conditions (such as temporo-mandibular joint disorder) should be performed cau-tiously in a controlled environment.—J. ZUNIGA

Reprint requests to Dr Ciccone: Department of Psychiatry, UMD-New Jersey Medical School, 30 Bergen St, ADMC Building 14,Newark, NJ 07107.

CURRENT LITERATURE 245