Letters to the Editor

Additional Letters to the Editor Available Online (www.aafp.org/afp/20030301/lettersonline.html): Misuse of the Evidence-Based Medicine Approach James H. Matthews, M.D. FPs Should Reconsider the Use of Hospitalists for Patients David Platt, M.D.

Calf Muscle Therapy for Achilles Tendinosis

TO THE EDITOR: The most important message from the article, "Common Conditions of the Achilles Tendon,"¹ was conservative therapy with nonsteroidal anti-inflammatory drugs, ice, rest, stretching, increased warm-up, and heel lifts. Based on the current literature, heavy eccentric calf muscle training should be given greater consideration as the preferred therapy.

The authors¹ mention that "one study² showed that calf muscle training is associated with a faster recovery time." The referenced study² of treatment of chronic Achilles tendinosis compared heavy-load eccentric calf muscle training with standard conservative therapy. Eccentric muscle training applies resistance only during the lengthening of a muscle. In the study,² 15 recreational athletes were treated with conservative therapy and another 15 recreational athletes were treated with heavy eccentric calf muscle training. The mean age was 44 years in the treatment group and 40 years in the control group. All patients had degenerative changes in the tendon 2 to 6 cm above the Achilles tendon insertion on the calcaneus seen on ultrasonographs, and had pain in this area for at least three months. The result of the study² was that all members of the treatment group were running pain-free in three months, and none of the patients in the "conservative therapy" group had regained full function. Although the treatment group was small (15 patients), the results were compelling. These results are supported by similar studies^3,4 of eccentric calf training. Heavy-load eccentric calf muscle training appears to be an effective, safe, and reasonable treatment of a difficult chronic condition.²

The patient population I serve here at the Womack Army Medical Center at Fort Bragg, N.C., is an active one, and Achilles tendinosis is a common complaint. My experience with using this technique of calf muscle training in the treatment of chronic Achilles tendinosis has been that it is effective and superior to conservative measures. One of the greatest values of this treatment is that people can continue to run during therapy. Patients who are prone to recurrent bouts of this condition continue the therapy at a reduced intensity (three times per week) as effective prophylaxis. Active patients do not respond well to clinical recommendations that require (1) prolonged decrease in activity or (2) surgery with a prolonged recovery period.

SEAN MULVANEY, M.D.
Womack Army Medical Center
Fort Bragg, NC 28310

REFERENCES

1. Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician 2002;65:1805-10.
2. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-6.
3. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001;9:42-7.
4. Taunton JE, Maron H, Wilkinson JG. Anaerobic performance in middle and long distance runners. Can J Appl Sport Sci 1981;6:109-13.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department of the U.S. Army Service at large.

IN REPLY: I want to thank Dr. Mulvaney for his input and clinical insight into Achilles tendinosis. I agree that calf-strengthening exercises should be considered in the treatment of patients with Achilles tendinosis because it may lead to fast recovery time, as we mentioned in our article.¹ The studies^2-4 do show promising results; however, using these exercises as the only therapy may be premature because (1) the studies were small and included patients who were followed very closely, and (2) the studies are not strong enough to show that no harm would come to some patients using this method. One risk of this condition is a full Achilles rupture, which is caused by the microtears of tendinosis, and could be enhanced by the exercises. Therefore, though eccentric calf-strengthening exercises should be used, this method of management should be used cautiously and the methods of ice, stretching, the decrease (not elimination) of activity, and heel lifts should still be used.

MICHAEL F. MAZZONE, M.D.
210 N.W. Barstow St.
Suite 201
Waukesha, WI 53188

REFERENCES

1. Mazzone MF, McCue T. Common conditions of the Achilles tendon. Am Fam Physician 2002;65:1805-10.
2. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-6.
3. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001;9:42-7.
4. Taunton JE, Maron H, Wilkinson JG. Anaerobic performance in middle and long distance runners. Can J Appl Sport Sci 1981;6:109-13.

Preventing Hypotension Effect of Calcium Channel Blockers

TO THE EDITOR: Thank you for the excellent review, "Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control."¹ I'm glad that it has become universally accepted that calcium channel blockers are excellent first-line therapy for ventricular rate control, and that digoxin should only be used adjunctively because it is less effective. My concern is the hypotensive effect of calcium channel blockers, especially in elderly patients in whom atrial fibrillation is more common. During my experience as a physician in an emergency department, I've noted that hypotension is common in this setting. Recently I caused an episode of hypotension, angina, syncope, and renal insufficiency with my "usual dose" of intravenous diltiazem, which is just less than what is recommended in the article.¹ Finally, a student asked me why I wasn't pretreating patients with intravenous calcium. A MEDLINE search found a good review² and confirmed that pretreatment with calcium salts has been effective in preventing hypotension without interfering in slowing the rate. The review² recommended calcium gluconate, 1 g over three minutes. Others recommend 200 mg of calcium chloride (2 mL of a 10 percent solution).³

RICHARD ALLEN, M.D.
Box 550
Cardston, Alberta, Canada T0K0K0

REFERENCES

1. King DE, Dickerson LM, Sack JL. Acute management of atrial fibrillation: Part I. Rate and rhythm control. Am Fam Physician 2002;66:249-56.
2. Moser LR, Smythe MA, Tisdale JE. The use of calcium salts in the prevention and management of verapamil-induced hypotension. Ann Pharmacother 2000;34:622-9.
3. Gomella LG, Haist SA. Clinician's Pocket Reference. 9th ed. New York: McGraw-Hill; 2002.

IN REPLY: I read with interest Dr. Allen's comments regarding the use of intravenous calcium channel blockers to control the ventricular rate in atrial fibrillation. Dr. Allen shared a recent anecdote regarding an episode of hypotension caused by the administration of intravenous diltiazem and suggested that intravenous calcium salts be considered to treat hypotension in these situations.

We share the concern for the possibility of hypotension associated with the use of intravenous calcium channel blockers, which is more common with verapamil than with diltiazem.¹ In fact, the study² Dr. Allen cites refers to verapamil, not diltiazem. We could not find any studies that discussed the use of intravenous calcium salts to prevent diltiazem-induced hypotension. Further, using a diltiazem drip, as suggested in our article,¹ offers the advantage of being able to slow the rate of infusion or stop the infusion altogether if a side effect such as hypotension is noted. Fluid replacement, Trendelenburg positioning, and vasoconstriction using norepinephrine or dopamine should also be considered in the treatment of hypotension. Finally, rapid infusion of calcium can be deleterious and may cause vasodilation, hypotension, bradycardia, arrhythmias, syncope, and cardiac arrest.³ Specifically, severe bradyarrhythmias have been reported in a 45-year-old patient receiving intravenous calcium as pretreatment for the use of intravenous verapamil.⁴

When hypotension occurs during the use of intravenous diltiazem to control the ventricular rate in atrial fibrillation, reduce the rate of infusion or stop the infusion of diltiazem, replace intravenous fluids, and consider using digoxin to control the ventricular rate rather than an antihypertensive agent with rate-lowering properties.

DANA E. KING, M.D.
LORI M. DICKERSON, PHARM D.
JONATHAN L. SACK, M.D.
Medical University of South Carolina
295 Calhoun St.
P.O. Box 250192
Charleston, SC 29425

REFERENCES

1. King DE, Dickerson LM, Sack JL. Acute management of atrial fibrillation: Part I. Rate and rhythm control. Am Fam Physician 2002;66:249-56.
2. Moser LR, Smythe MA, Tisdale JE. The use of calcium salts in the prevention and management of verapamil-induced hypotension. Ann Pharmacother 2000;34:622-9.
3. MICROMEDEX Healthcare Series: MICROMEDEX, Greenwood Village, Colorado Vol. 114 (Edition expires 12/2002).
4. Kuhn M. Severe bradyarrhythmias following calcium pretreatment. Am Heart J 1991;121:1812-3.

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Possible Dangerous Interaction of OxyContin and Carisoprodol

TO THE EDITOR: OxyContin is a time-release-controlled formulation of oxycodone that can be taken every 12 hours for the effective treatment of pain caused by cancer and other types of chronic pain. However, abuse of OxyContin is common; no other prescription drug in the past 20 years has been so widely misused so soon after its release.¹ Carisoprodol (Soma) is a skeletal muscle relaxant that, although not a federally controlled substance, also has shown potential for abuse.² We report here a case of a possible dangerous interaction of OxyContin and carisoprodol.

A 49-year-old woman received treatment for severe degenerative disease of the lumbar spine with 40 mg of OxyContin twice daily for more than a year. Although she continued to complain of pain and paravertebral muscle spasm, her physician was reluctant to increase the dosage of OxyContin. One tablet (350 mg) of carisoprodol four times daily was prescribed. After taking this regimen for a week without relief, she increased the dosage to eight to 10 tablets a day, assuming this would be safe. Her boyfriend called an ambulance after finding her lying unconscious on the floor and being unable to awaken her.

An examination revealed blood pressure of 130/60 mm Hg and respirations of 14 per minute that were decreased in depth. She was responsive only to painful stimuli. Her pupils were small but equal and reactive. She was given 2 mg of naloxone intravenously with rapid return of alertness. A count of her remaining supply of medications verified that she had not taken any extra OxyContin and a drug screen was negative except for opiates.

The most likely explanation for this patient's adverse reaction would be a response to the additive depressant effects on the central nervous system (CNS) of both OxyContin and carisoprodol. Although OxyContin's effects are well known in the medical community, many physicians are unaware that carisoprodol is metabolized to meprobamate (Miltown), a Class IV controlled substance with significant physiologic effects and the potential for abuse and dependency.³ Previous reports^4,5 have suggested that substance abusers may use carisoprodol to augment or modify the effects of illicit drugs and that combinations of carisoprodol and tramadol (Ultram) may have potent psychotropic effects.

Carisoprodol and OxyContin should only be prescribed concomitantly with extreme caution because of the abuse potential of each drug and because of the potentially dangerous additive CNS-depressant effect of the two drugs. While numerous deaths related to OxyContin have occurred,¹ it should be noted that a retrospective review⁶ of autopsy cases in Jefferson County, Alabama, from January 1, 1986 to October 31, 1997 found carisoprodol to be present in 24 cases; the reviewers concluded that the drug was probably partly responsible for those deaths.⁶ The interactions of carisoprodol with other CNS-depressant drugs appears to be particularly significant. Carisoprodol has been made a controlled substance in the state of Alabama⁶ and may eventually be made a controlled substance in other states or at the federal level.

ROY R. REEVES, D.O., PH.D.
JAMES E. MACK, PH.D.
University of Mississippi School of Medicine
VA Medical Center
1500 E. Woodrow Wilson Dr.
Jackson, MS 39216

REFERENCES

1. Charatan F. Time-release analgesic drug causes fatal overdoses in United States. West J Med 2001; 175:82.
2. Littrell RA, Hayes LR, Stillner V. Carisoprodol (Soma): a new and cautious perspective on an old agent. South Med J 1993;86:753-6.
3. Littrell RA, Sage T, Miller W. Meprobamate dependence secondary to carisoprodol (Soma) use. Am J Drug Alcohol Abuse 1993;19:133-4.
4. Reeves RR, Carter OS, Pinkofsky HB. Use of carisoprodol by substance abusers to modify the effects of illicit drugs. South Med J 1999;92:441.
5. Reeves RR, Liberto V. Abuse of combinations of carisoprodol and tramadol. South Med J 2001;94: 512-4.
6. Davis GG, Alexander CB. A review of carisoprodol deaths in Jefferson County, Alabama. South Med J 1998;91:726-30.

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Probable Relationship Between Opioid Abuse and Heroin Use

TO THE EDITOR: The abuse of OxyContin has received considerable attention in the past few years. Other prescription opioid analgesics are also widely abused. The Ohio Substance Abuse Monitoring (OSAM) Network,¹ a statewide epidemiologic surveillance system, has identified a significant increase in opioid abuse in Ohio. Data from the national level have indicated the same trend.² We documented a connection between prescription opioid abuse, subsequent heroin use, and the adoption of high-risk behaviors.

The OSAM Network is supported by the Ohio Department of Alcohol and Drug Addiction Services and operated by Wright State University School of Medicine.¹ The purpose of the OSAM Network is to gather timely epidemiologic data on substance abuse trends throughout Ohio for public health officials and policy-makers. Regional epidemiologists use data from individual and focus group interviews with drug users, treatment providers, and law enforcement officials, as well as statistical data from county coroners, local law enforcement agencies, and regional crime laboratories to develop biannual epidemiologic reports.

Between June 2001 and January 2002, the OSAM Network conducted an investigation of recently initiated heroin users. In Dayton, 10 subjects, aged 18 to 33 years, were interviewed. Five subjects reported abusing prescription opioids, most notably OxyContin, before initiating heroin use. They reported tolerance to the drug's effects and physical withdrawal symptoms when deprived of OxyContin. They reported that heroin was more readily available and less expensive than OxyContin and that they would never have tried heroin had they not become addicted to OxyContin. This trend has been identified throughout Ohio, and similar patterns have been identified in other areas of the United States.^3-6

These findings are limited by the small convenience sample. However, we continually identify persons who report a similar progression from prescription opioid abuse to heroin injection. Death statistics from several county coroners' offices corroborate this increase in opioid abuse. A county in rural southeast Ohio reported seven or eight opioid-related overdose deaths in 2001, most involving heroin. Montgomery County (Dayton) reported a 36 percent increase between 2000 and 2001 in drug-related deaths involving opioids, most involving heroin and/or prescription opioid analgesics.

The results of this investigation suggest that the abuse of opioid analgesics constitutes a new route to heroin abuse, placing new populations at risk for heroin addiction. This is a reversal of the classic pattern in which heroin users would turn to prescription opioids when heroin was unavailable. In addition, although many new heroin users may begin by snorting the drug, most progress to injection drug use as their tolerance develops and the quality of heroin varies. The implications for the spread of blood-borne pathogens, such as human immunodeficiency virus, hepatitis B virus, and hepatitis C virus, are clear.

Drug abuse prevention programming aimed at young people needs to address the dangers of prescription opioid abuse as well as heroin use. In addition, physician education is needed to raise awareness of the differences between patients seeking drugs for their euphoric effects and those seeking pain relief.

HARVEY A. SIEGAL, PH.D.
ROBERT G. CARLSON, PH.D.
DERIC R. KENNE, M.S.
MARIA G. SWORA, PH.D., M.P.H.
Wright State University School of Medicine
Center for Interventions, Treatment and Addictions Research
216 Medical Sciences Bldg.
Dayton, OH 45435

REFERENCES

1. Siegal HA, Carlson RG, Kenne DR, Starr S, Stephens RC. The Ohio Substance Abuse Monitoring Network: constructing and operating a statewide epidemiologic intelligence system. Am J Public Health 2000;90:1835-7.
2. Results from the 2001 National Household Survey on Drug Abuse. Rockville, Md.: US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2002. DHHS publication SMA 02-3758.
3. Hart A. Savannah arrest shows problem of prescription pill abuse. Savannah Morning News. August 28, 2002. Retrieved January 2003 at: http://savannahnow.com/stories/082802/LOCPHARMA.shtml.
4. Callahan J. Medications led to student's death. The Star Banner. August 29, 2002. Retrieved January 2003 at: www.mapinc.org/drugnews/v02/n1610/ a04.html.
5. Information bulletin. OxyContin diversion and abuse; 2001. Publication no. 2001-L0424-001. 2001. Retrieved January 2003 from www.usdoj. gov/ndic/pubs/651.
6. Pulse check: trends in drug abuse, July-December 2001 reporting period. Washington, DC: Office of National Drug Control Policy; 2002.

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Corrections

The article "Perioperative Management of Diabetes" (January 1, 2003, page 93) contained an error in the rate of insulin infusion. On page 95, in the fourth paragraph, sixth line, under the subheading Insulin, the starting rate of insulin infusion should have been given as 0.5 to 1 U per hour.

The answer block for the "Clinical Quiz" in the October 1, 2002 issue (page 1348) gave an incorrect answer for Question 4, pertaining to the article "Diagnosis and Treatment of Premenstrual Dysphoric Disorder," on page 1239. The correct answers to this question are C and D. In addition, the question is Type X, rather than Type A. The corrected question is printed below.

Q4. Which of the following drugs is/are approved by the U.S. Food and Drug Administration for the treatment of premenstrual dysphoric disorder?

		A. Citalopram (Celexa).
		B. Clomipramine (Anafranil).
		C. Fluoxetine (Sarafem).
		D. Sertraline (Zoloft).

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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