Clinical Briefs
Acupuncture for Pain Control after Oral Surgery
September 1999; Volume 2: 95
Source:Lao L, et al. Evaluation of acupuncture for pain control after oral surgery: A placebo-controlled trial. Arch Otolaryngol Head Neck Surg 1999;125:567-572.
Acupuncture is increasingly used by the general U.S. population and investigated by conventional medicine. Studies of acupuncture’s effects on pain still lack adequate control procedures. We sought to evaluate the efficacy of Chinese acupuncture in treating postoperative oral surgery pain, the validity of a placebo-controlled procedure, and the effects of psychological factors on outcomes. We conducted a randomized, double-blind, placebo-controlled trial at the Dental School Outpatient Clinic with 39 healthy subjects, aged 18-40 years, assigned to treatment (n = 19) and control (n = 20) groups, all of whom underwent oral surgery. Mean age was 24 years; 22 of the 39 subjects were men.
Patients self-reported results. Mean pain-free postoperative time was significantly longer in the acupuncture group (172.9 min) than in the placebo group (93.8 min) (P = 0.01), as was time until moderate pain (P = 0.008). Mean number of minutes before requesting pain rescue medication was significantly longer in the treatment group (242.1 min) than in the placebo group (166.2 min) (P = 0.01).
Average pain medication consumption was significantly less in the treatment group (1.1 tablets) than in the placebo group (1.64 tablets ) (P = 0.05). There were no significant between-group differences on total-pain-relief scores or pain-half-gone scores (P > 0.05). Nearly half or more of all patients were uncertain of or incorrect about their group assignment. Outcomes were not associated with psychological factors in multivariate models.
We conclude that acupuncture is superior to the placebo in preventing postoperative dental pain.
Comment
These University of Maryland at Baltimore investigators performed extractions of mandibular partial bony impacted third molars with 3% Carbocaine® locally without vasoconstrictor, and then treated pain. They also attempted to evaluate the placebo control they used.
The intervention group received five acupuncture needles for 20 minutes. The placebo group received a plastic acupuncture needle tube taped next to the bony area next to each acupuncture point, and "a needle with a piece of adhesive tape was then taped to the dermal surface for 20 minutes. Manipulations were made by palpating the surface of the skin with a blunt dental instrument at the same three points in time as the treatment group. In both groups, the patients’ eyes were covered with patches so they could not view the treatment procedure." The treatment was repeated if moderate pain was indicated.
A four-point scale of pain intensity was used; 600 mg acetaminophen with 60 mg of codeine was the standard analgesic. Patients were observed for six hours, asked to record their pain levels hourly for 24 hours, and then followed up in seven days.
The primary motivations of the volunteers were, in order of importance, "a need to save money, curiosity, belief in acupuncture as a good treatment, referral by a physician, and not wanting to take drugs." No numbers are reported with these assessments.
These investigators really wanted to prove a point, and they did—that acupuncture and short-term pain relief are associated. But their work does not show the validity of the noninsertion placebo. Significantly more subjects receiving acupuncture guessed they received it than did controls; the treatment group also had significantly more family members who had received acupuncture than did the control group.
Recommendation
The 1997 NIH Consensus Conference on Acupuncture concluded, in part, that postoperative dental pain is effectively relieved with acupuncture. Patients who are young and curious about it, believe in it, and have a physician who thinks they should try it will likely do well. Consider it, and have codeine on hand. v
DHEA for Depression
September 1999; Volume 2: 95-96
Source:Wolkowitz OM, et al. Double-blind treatment of major depression with dehydroepiandrosterone. Amer J Psychiatry 1999; 156:646-649.
This study was designed to assess possible antidepressant effects of dehydroepiandrosterone (DHEA), an abundant adrenocortical hormone in humans. Twenty-two patients with major depression, either medication-free or on stabilized antidepressant regimens, re-ceived either DHEA (maximum dose = 90 mg/d) or placebo for six weeks in a double-blind manner. Assessment was repeated at baseline and at the end of the six weeks with the Hamilton Depression Rating Scale. Patients previously stabilized with antidepressants had the study medication added to that regimen; others received DHEA or placebo alone. DHEA was associated with a significantly greater decrease in Hamilton Depression Scale ratings than was placebo. Five of the 11 patients treated with DHEA, compared with none of the 11 given placebo, showed a 50% decrease or greater in depressive symptoms. These results suggest that DHEA treatment may have significant antidepressant effects in some patients with major depression. Further, larger-scale trials are warranted.
Comment
The authors of this thoughtful, well-referenced pilot study note that despite the epidemiological evidence for a direct relationship between DHEA and DHEA-S levels and positive mood, reports of levels in patients with major depression are inconsistent. Potential mechanisms include DHEA metabolism to testosterone and estrogen, modulation of testosterone bioavailability, and cortisol antagonism. These actions may also, of course, exacerbate hormone-mediated tumors, including breast, prostrate, uterus, and cervix.
Supported by a grant from the National Alliance for Research in Schizophrenia and Affective Disorders, these UCSF and City of Hope investigators randomized 20 unipolar and two bipolar type II patients (12 males, 10 female, mean age 44 years) to DHEA or placebo. Seven subjects (three in the DHEA group and four in the placebo group) were medication free; the others were on stable doses of antidepressants for at least two months. DHEA was given 30 mg once daily for the first two weeks, then twice daily for two weeks and then three times daily for two weeks. The dosage was chosen to give the high end of the physiological range of healthy young adults. All subjects began with a Hamilton Depression Scale score of 16 or greater.
No one dropped out because of side effects; the drug was equally effective in medication-free subjects and those continuing treatment with antidepressants. The authors note that oily skin, acne, hirsutism, and voice-deepening are reported side effects, together with anecdotal reports of significant negative mood changes.
Recommendation
DHEA for depression has real therapeutic possibilities, though its endo-crinologic effects are worrisome and not all known. Patients who want to try it should be closely monitored and should be enrolled by a research protocol. DHEA should not be recommended without better long-term data.
Dietary Supplement Use Underreported in the Office
September 1999; Volume 2: 96
Source:Hensrud DD, et al. Underreporting the use of dietary supplements and nonprescription medications among patients undergoing a periodic health examination. Mayo Clin Proc 1999;74:443-447.
To compare the use of dietary supplements and nonprescription medications, the researchers conducted a prospective study of 200 subjects randomly selected from patients undergoing a periodic health examination. Written information on self-reported use of supplements and nonprescription medication was obtained as part of a comprehensive medical questionnaire. Subjects were then interviewed and asked about usage and reasons for usage.
The prevalence of the use of dietary supplements was 30.5% by written self-report in comparison with 61% reported during the structured interview. Use of nonprescription medication on the questionnaire was 24.5%; reported use when interviewed was 42.5%. Multivitamins (41.5%), vitamin E (24%), and vitamin C (23%) were the most common dietary supplements taken; aspirin (16.5%) and ibuprofen (13%) were the most common nonprescription medications taken. Most frequently, patients indicated that they were using supplements to promote health.
Half the patients who took dietary supplements and almost half who took nonprescription medications did not report them to their health care provider on the written questionnaire, even though this information was requested. Patients should be specifically and orally asked about usage.
Comment
These Rochester, Minnesota, investigators achieved an 83% response rate from both community residents and from executive patients. Ninety-nine percent of their community patients were white; 84% of the executives were male; overall, 62% were male. Community patients appeared to use nonprescription medications but not dietary supplements less often than did executives. These data were not analyzed for statistical significance, and educational and socioeconomic data about each group were not reported. Most patients took supplements to "promote health," and many took them to "prevent disease"—only 2/122 respondents took them to treat disease.
Why isn’t a questionnaire enough to get accurate information? Patients may forget they are taking supplements, forget to record supplement names on a lengthy questionnaire, be unsure about how or whether to tell, consider them unimportant to their visit, or fear ridicule or embarrassment. In this study, a nonphysician asked about supplements, person to person—all it took to double the number of accurate responses.
Data from the 1992 National Health Interview Survey showed that 24% of the U.S. population used vitamin and mineral supplements daily. Similar data gathered since then suggest accelerated use. The boom in supplements started with the 1994 Dietary Supplement Health and Education Act, which essentially deregulated the area.
Recommendation
Ask the patient what he or she is taking, even if your previsit written assessment asks patients directly. Supplements should be considered medication—by patients and providers.
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