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Some patients have headaches that are refractory to standard treatments, and they require chronic administration of opioid analgesics. The use of opioids in a clinical setting must be closely monitored due to the medications' potential for addiction, abuse, and fatal interactions. Limited access to opioids and the demand for them outside the clinical setting leads to another danger. Patients can mislead their providers into prescribing opioids, intending to sell the medications instead of using them to alleviate their own pain. For protection of the patient, as well as the community, it is vital that such activity be prevented. We recently encountered a patient we suspected of abusing or misusing OxyContin (oxycodone). In order to determine whether the patient was taking the medication as prescribed, we ordered a urine-based immunoassay drug screen. The results were negative; the patient appeared to not have oxycodone in his system. Based on these results, we dismissed the patient from our practice. At the patient's request, a second test was performed, this time using gas chromatography-mass spectrometry. It indicated that the patient did indeed have sufficiently high levels of oxycodone in the urine. The minimum level threshold was too high to detect the presence of oxycodone in the immunoassay. We would like to help prevent future misunderstandings such as we experienced. To do so, we will first present the case of our patient, followed by a discussion of the actions taken. Finally, we will provide an overview of analgesic monitoring systems.

OBJECTIVE To analyze the cost-effectiveness of antiepileptics in migraine prophylaxis. METHODS A cost-effectiveness analysis was performed using efficacy data from three recent, double-blind, placebo-controlled, clinical trials of antiepileptic drugs studied for migraine prevention and cost data. Two measures of cost-effectiveness were used: cost per headache prevented and the cost-equivalent number. RESULTS In the double-blind, placebo-controlled, clinical trials evaluated, three antiepileptic drugs were shown to be effective in migraine prevention. All three antiepileptic drugs had high costs per migraine reduced. Gabapentin was the most costly at dollars 138.00 per migraine prevented, whereas the cost per migraine prevented with topiramate was US dollars 114.80 and with divalproex sodium was US dollars 48.00. For migraine prevention divalproex sodium became cost-effective with 10 migraines per month, whereas gabapentin and topiramate required considerably more migraines per month to be cost-effective. CONCLUSIONS Antiepileptic drugs have proven effectiveness in migraine prophylaxis. However, in patients responsive to their acute care medications, the antiepileptic drugs are only cost-effective for those patients with a high frequency of migraines and those with comorbid diseases. Future studies should be done with antiepileptic drugs in patients exhibiting a migraine frequency of 10 or more headaches per month.

Study objective Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions. Methods We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation. Results Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%). Conclusion Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Migraine preventive medications considered effective reduce headache frequency by 50 percent in approximately 50 percent of treated patients. In spite of similar effectiveness, these medications vary tremendonsly in their prices. Knowledge of medication prices and employing cost-effective strategies may greatly reduce treatment costs.

Objective To provide medication price data and cost-reducing strategies for the acute treatment of migraine. Methods Retail prices for common acute care medications were found at http://www.drugstore.com. Cost-reduction tactics were obtained from literature searches and clinical experience. Results Several strategies can reduce cost without sacrificing treatment outcome. In mild to moderate migraine, low-priced nonsteroidal anti-inflammatory drugs can be used as first-line medications due to their proven efficacy and favorable tolerability. For patients with more severe migraine, implementing a stratified care approach-using migraine-specific medications early in acute treatment-is cost-effective for most patients. Stratified care not only improves outcome and decreases disability, but also reduces cost. Pill splitting and early administration of triptans within an attack enhance their value. Supplying rescue medications, such as opioids, sedatives, and phenothiazines, can prevent emergency department visits. Minimizing multiple dosing of triptans and reducing utilization of expensive health care resources are key factors in reducing the cost of effective migraine treatment. An important affordability factor for patients with co-payments is the number of triptan pills per package. Sumatriptan, naratriptan, and frovatriptan each contain 9 tablets per package, while most other triptan packages contain 6. Current triptan retail prices (per unit) include: Amerge 1 and 2.5 mg, 17.78 dollars; Axert 6.25 and 12.5 mg, 16.31 dollars; Frova 2.5 mg, 13.89 dollars; Imitrex 50 mg, 14.96 dollars; Imitrex 100 mg, 14.41 dollars; Imitrex Nasal Spray 20 mg, 21.61 dollars; Imitrex SQ 6 mg, 50.26 dollars; Maxalt 5 and 10 mg, 15 dollars; Maxalt-MLT 5 and 10 mg, 15 dollars; Relpax 40 mg, 13.58 dollars; Zomig 2.5 mg, 13.67 dollars; Zomig 5 mg, 15.89 dollars; Zomig-ZMT 2.5 mg, 13.67 dollars; and Zomig-ZMT 5 mg, 15.89 dollars. Conclusions Practitioners can optimize the use of health care dollars without compromising quality of care through awareness of cost-saving treatment strategies, as well as price variations among medications.

Objective.—To assess the efficacy of extended-release venlafaxine in the prophylaxis of migraine and chronic tension-type headache. Background.—Venlafaxine, a structurally novel antidepressant, is a selective serotonin-norepinephrine reuptake inhibitor. This study is the first to test the effects of extended-release venlafaxine on headaches. Methods.—Patients were evaluated on a retrospective basis. Fifty-six patients with chronic tension-type headache and 114 patients with migraine were prescribed extended-release venlafaxine. Nearly all the study subjects had been resistant to several previous preventive medications. Patients took venlafaxine for an average of 6 months with a median dose of 150 mg (range, 37.5 to 300 mg). Results.—The mean frequency of headaches in the group with chronic tension-type headache fell from 24.0 to 15.2 per month (P