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Approach to pain management in a large outpatient clinic population.

General approaches to chronic pain syndromes

While pain management is not the intended primary focus of outpatient clinics, about one-third of the United States population experiences chronic pain, and pain is the most common reason for patient visits. (1) Providing compassionate and effective control of persistent pain while avoiding inappropriate prescribing of controlled substances remains a perplexing daily challenge, particularly in our region. From 1999 to 2004, West Virginia had the highest increase in unintentional drug overdose mortality (550%) in the United States, (2) the majority occurring with drug diversion of prescribed medications, mainly opioids. (3) This trend does not appear to be abating. The illicit drug trade also results in disruption of families, financial hardship, violence, and sometimes homicide. Our internal medicine outpatient teaching program (West Virginia University Health Sciences Center, Charleston Division/Charleston Area Medical Center) serves a relatively large population, significantly indigent. As it is our ethical obligation to address pain issues, we have sought a practical modification of known guidelines and resources (4-7) to provide more effective opioid screening and monitoring, taking into account difficult time constraints and patient complexity. We write this current communication hoping to provide some practical information, but also to help us better organize and evaluate our own program. Chronic nonmalignant pain, usually musculoskeletal or neuropathic, will be addressed primarily. In general, we attempt to use several combined approaches to treat chronic pain, initially without opioids, if possible, Table 1. These approaches will be briefly reviewed first, followed by discussion of our efforts at opioid screening and management.

Non-judgmental emotional support: Cynicism often tends to develop when caring for patients with long-standing pain. With our residents and students, emphasis is placed on showing unbiased empathy to establish a relationship that may optimize care. Exhibiting respect, including hand-shake and sitting face to face with patients to obtain history, appears to maximize "buying-in" to the treatment plan. We attempt to define expectations and limitations of treatment, and emphasize that effort will be required by both patient and physician. Goals are to improve quality of life and coping, not for cure except in rare conditions that may be completely reversible. In patients found to have substance abuse problems or potential, we attempt to maintain an even but firm approach in regard to pain management.

Evaluation for depression and psychosocial issues: Lifetime prevalence of major depressive disorder appears to range from 10 to 20% in the general population, (8) and nearly half of patients with major depressive disorders have chronic pain. (9) Further, in those with unexplained chronic pain syndromes, the prevalence of underlying mood disorders may approach 80%. (10) Since treating depression may provide significant diminution of pain in many patients, and because depression alone may be a risk factor for opioid abuse, (11) nearly all clinic patients with persistent pain, are evaluated for underlying depression using the PHQ-9 depression scale. (12) We are presently considering implementation of the M-3 checklist, (13) which may provide additional screening for bipolar, anxiety and post traumatic stress disorders. If significant depression is determined, we provide support, and treat accordingly, commonly with a serotonin reuptake inhibitor. Other agents may be considered depending on concomitant clinical presentation such as fibromyalgia or neuropathic pain (see below). Depending on the severity of depression and/or other psychiatric illness (e.g. bipolar disorder, obsessive-compulsive disorder), we co-manage with psychiatry or refer for psychiatric consultation and follow-up. Other approaches may be considered such as cognitive behavioral therapy, depending on coverage and availability. Social and spiritual services are also employed to address significant environmental issues.

Physical interventions: Most chronic nonmalignant pain syndromes are musculoskeletal in origin and may be amenable to physical therapy or other approaches including exercise, massage, stretching regimens, spinal manipulation, and acupuncture. Back pain syndromes are particularly common, with a lifetime prevalence of nearly 80%. (14) Acute or subacute back syndromes are usually self-limiting and managed conservatively, with only brief bed rest, then gradually increasing activity with a goal of maintaining functionality even if resolution is not complete. (14,15) We avoid opioids early on depending on presentation. Patients with persistent pain over several weeks, regardless of musculoskeletal syndrome, are referred for physical therapy. Emphasis is placed on improved strength, increased range of motion, improved functionality, and self-management skill development. Imaging, pain management consultation, and/or surgical intervention are considered in patients with neurologic deficits or intractable pain.

Pharmacologic therapy: A combination of agents is usually required to adequately manage chronic pain syndromes. An initial trial of acetaminophen and/or NSAIDs is begun depending on the cause of pain. If failure of response with one NSAID, switching to a different agent can be surprisingly useful. In general, we avoid NSAIDs in the elderly based on current guidelines (see below). (6) Tramadol (a partial opioid agonist with serotonin and norepinephrine reuptake inhibition) may then be added to the regimen in increasing doses, up to 400 milligrams daily (300 milligrams in the elderly). Advantages include relatively low abuse potential and no narcotic schedule restrictions. In those with chronic neuropathic pain, low-dose tricyclic anti-depressants (TCAs) used as "pain modulators" appear to be effective, safe, and inexpensive relative to other agents, and their use is well supported by guidelines. (16) These medications may be beneficial in other disorders as well, including migraine, fibromyalgia, and insomnia, and may be prescribed to manage several ongoing syndromes in an individual patient. A recent study determined that the combination of nortriptyline, (mean tolerated dose 50.1 mg) and gabapentin (mean tolerated dose 2180 mg) was more effective than either agent alone. (17) The combination regimen is recommended if there is an inadequate response using a single medication. Nortriptyline has the fewest TCA associated anti-cholinergic adverse effects, and may be prescribed in older patients, albeit in lower doses. Serotonin norepinephrine reuptake inhibitors such as duloxitine and venlafaxine are also useful for neuropathic pain, although cost issues may be problematic. Local injection (methylprednisolone and 1% lidocaine) of isolated joint spaces, bursae, or trigger points in conjunction with PT or stretching, often provides at least temporary relief over several weeks and sometimes avoidance of more potent systemic agents. Topical NSAID (diclofenac) or lidocaine can also be used in localized musculoskeletal pain. Other adjuvant agents, including corticosteroids, bisphosphenates, and short courses of muscle relaxants, may be utilized in certain cases. Rheumatology consultation is often required for advanced DMARD therapy, e.g. methotrexate and/or anti-tumor necrosis factor antibody in appropriate conditions.

If other approaches have not provided adequate control of symptoms, opioids are then considered. As mentioned, these agents are first line therapy only in certain circumstances. A consistent screening process is employed prior to opioid prescribing, to be discussed below. We initially prescribe short acting agents such as hydrocodone in low doses and titrate dosage depending on response over several weeks. Explained goals are improved quality of life and increased functionality, not complete resolution of pain. We may eventually consider long-acting agents for intractable pain, with short-acting medications taken as needed for "break-through." High doses of opioids are avoided in general, and dosage titration of long acting agents must be monitored carefully to avoid potentially fatal toxicity, particularly in the aging patient. (18)

Assessing appropriate candidates for long-term opioid therapy

Treatment of certain acute pain syndromes with short term doses of opioids is appropriate and humane. An extremely common dilemma arises when patients present to the clinic complaining of subacute or persistent severe pain, requesting medication for relief. Depending on the age and sex of the patient, risk may vary in regard to substance abuse potential. Young males are at greatest risk for substance abuse and drug diversion, particularly if they are unemployed, under educated, single or divorced. (3) Additional risk factors include smoking, alcohol or illicit drug use history, pain at multiple sites and long-term pain after motor vehicle accidents. (19) Not uncommonly, these patients present to the medical clinic with persistent complaints, having been prescribed opioids for acute or recurrent symptoms in the emergency room. Middle-aged females who have seen many doctors for their symptoms ("doctor shoppers") also have significant substance abuse potential, especially with a history of sexual abuse or familial alcoholism.

In the past year, using modifications based on existing guidelines, (4-7) we have developed a practice policy in regard to opioid prescribing, Table 2. This policy is posted in the clinic nursing stations. Individual items will be discussed:

Documentation: Prior to initiation of opioids, optimum documentation of disease entity or disorder is essential. Imaging studies or prior consultations from specialists (e.g. orthopedics, neurology, and pain management) are the usual form of documentation. Clearly, some patients have disorders which are diagnosed clinically, such as fibromyalgia or complex regional pain syndrome (CRPS), and require clinical judgment in regard to prescribing of opioid agents, usually after other approaches have been exhausted.

Urine drug screen: Integral to compliance monitoring, the patient must initiate an Opioid Access Agreement and Consent to Treatment document which permits sampling of body fluid for prescribed controlled medication and high risk substances (including amphetamine-type stimulants, cocaine, and marijuana). CMS has just introduced new codes for Drug Screening/ Detection Test. As of January 2010, G0430 replaced 80100 for qualitative multiple drug screen test kits. Initial urine drug screen (UDS) is required in all patients considered for controlled substances. If a controlled substance not listed on the patient's documented medication list, and/or an illicit substance is detected, the specimen is submitted for highly accurate confirmation testing using Mayo Clinic chromatography or spectrophotometric testing. (20) Generally, either circumstance excludes a patient from controlled substance prescribing through our clinic, though each case is reviewed individually. Discrepancy on initial UDS may be a cue for referral to a pain or addiction specialist. In addition to initial screening, we perform random UDS on all patients who are prescribed controlled substances. Absence of the prescribed controlled medication on a random sample may indicate diversion and results in closer scrutiny. More than one discrepancy generally results in termination of controlled substance prescribing. Pill counts also are periodically used to provide additional assessment for drug diversion.

Because there are many nuances to urine drug screening, (20) and to provide continuity, every urine drug screen is reviewed by our Nurse Practitioner. Results may require interpretation of various drug metabolites and reports regarding diluents or adulterants (such as vinegar or bleach) used to mask detection. Based on the results, recommendations are made to the patient's primary physician in the clinic. Collaboration and communication between all entities involved including the physician, nurse practitioner, clinic staff, patient, and laboratory personnel are required in order to interpret results accurately.

Board of pharmacy review: The controlled substance monitoring program, the West Virginia Board of Pharmacy, is utilized as another means to initially vet patients for opioid use, and to assess compliance with controlled substances prescribing. This database provides a record of prescribers and pharmacies where prescriptions are filled. Limitations include no interstate data sharing (national data-base) or real-time capabilities at present. Nonetheless, documentation of multiple opioid prescribers and/or pharmacies strongly indicates "doctor shopping" and would preclude initial or continued opioid therapy.

Substance abuse survey: Numerous risk assessment tools are available which vary in sensitivity, specificity, and time of administration. The purpose to these tools is to predict which patients will require the most intense monitoring, or detect patients who represent too great a risk for opioid administration in the primary care setting. The latter should be referred to a pain care and/or addiction specialist, if available. Our current confidential screening format has included three well known risk assessment tools, i.e. CAGE-AID (modified for drugs and alcohol), TICS, and RAFFT, (21-23) which may be self-administered and completed in a short time period, Table 3. The use of these surveys, along with routine screening for depression, should provide a relatively high sensitivity for substance and opioid abuse concerns. We are currently considering routine use of other screening tools, the Screening and Opioid Assessment for Patients with Pain (SOAPP24) and the Opioid Risk Tool, (25) Table 4, which include questions regarding age, smoking, marijuana use, loss of medications, psychosocial history, sexual abuse history, and arrests. Although more time consuming, these tools may enhance prediction of medication abuse, drug diversion, and doctor shopping. Skepticism may be raised as to the validity of patient responses, but we emphasize providing accurate answers, as responses will be "verified" whenever possible. Regardless, the survey provides an additional indication to patients that our program will be strictly monitored and enforced.

Proceeding with opioid treatment

Controlled substances contract: If the guidelines criteria reveal low likelihood of substance abuse potential and the documented pain syndrome is deemed severe enough and only partially responsive to other measures, opioids are considered and a standard controlled substances contract (agreement) is reviewed with the patient. Goals, risks, and responsibilities are explained in a non-threatening fashion, emphasizing that all patients must comply with the document. Grounds for termination of opioid therapy are explained. Main points are briefly mentioned here. Patients are required to choose one pharmacy and only one physician to prescribe their therapy, and emphasis is made on locking up medications to avoid diversion by family members or others. Prescriptions are not re-filled for lost medications. Two missed consecutive appointments will not be acceptable. After thorough explanation of the contract, and if the patient is in agreement, the contract is signed, placed in the chart, and a copy is given to the patient. Any violation of the contract results in a review and consideration of termination of opioid or other controlled substances therapy. If the agreement is dissolved, we avoid a judgmental approach, taper and discontinue the opioid, and offer continued management of other medical problems.

Concern remains that patients with documented severe pain syndromes and ongoing or potential substance abuse will not be adequately managed. In difficult cases, we commonly seek consultation from a pain clinic specialist and/or addiction specialist, though limited numbers of these specialists and payment issues affect availability. We often are left to use best judgment and intuition. For example, in a patient with well documented severe complex regional pain syndrome but known history of substance abuse, we may opt to place him/her on controlled substance contract with extremely close follow-up, including frequent clinic appointments , frequent urine drug screens, board of pharmacy review, and immediate termination if there is any question of discrepancy. Careful documentation of disease entity/substance abuse issues and justification for plans are essential.

Monitoring: Because we follow a large number of patients with complex medical histories, we seek a means of providing brief but effective and consistent monitoring of patients on opioids and other controlled substances. In addition to employing random UDS and periodic board of pharmacy review, we also commonly utilize an easily remembered and implemented tool, "The Four A's," (26) when performing follow-up history: Analgesia (effectiveness of pain control), Activity level (physical and psychological), Adverse events (adverse effects of controlled medication), and Aberrant drug taking (evidence of addictive/abuse behavior). Indicators of drug seeking behavior are posted in the clinic nursing stations, (27) Table 5. Problems noted in any of the "Four A's" should prompt re-evaluation of relevant aspects of the treatment program.

Approach to the elderly patient with chronic pain

The elderly with chronic pain appear to be a separate patient population and should be managed as such. First, documentation of severe painful conditions, e.g. markedly deforming arthritis, is relatively straightforward as compared to many younger patients. Second, the potential for substance abuse/addiction behavior is significantly less than is often seen in the younger population. Therefore, we have a lower threshold for using opioids in the elderly, and we may forego intensive substance abuse screening in given patients. According to 2009 American Geriatrics Society Guidelines, (6) the first line analgesia for chronic pain in the elderly should be acetaminophen, followed by judicious use of opioids if failure of response to acetaminophen. NSAIDs should be "considered rarely, and with extreme caution" in older patients because of potential for significant adverse effects, including fluid retention, renal toxicity and gastrointestinal bleeding. Appropriate opioid use in the elderly is believed to improve quality of life and functional capacity. It is critical to assess competency of patient or caregiver and observe for adverse opioid effects, particularly sedation and constipation. As previously emphasized, diligent, limited dosage titration, particularly of long-acting agents, generally minimizes concern for overdose. (18) Gastrointestinal symptoms are usually obviated by concomitant initiation and continued use of a laxative agent (e.g. senna one to two daily plus a stool softener) with opioid.


Though it is our ethical imperative to minimize discomfort, physicians often struggle to manage pain effectively, mainly due to time constraints, lack of training, and fear of litigation regarding over-prescribing of controlled substances. In addition, physicians also now must face potential litigation for under treatment of persistent pain. This dilemma often leaves the physician with a sense of insecurity and stress. We have provided a brief review of our approach to seek improvement in excluding substance abusers/ drug diverters from those in need of aggressive pain management in the internal medicine outpatient clinics of a teaching institution. Multiple combined treatment modalities are usually employed, including physical interventions, evaluation and treatment of concomitant depression and psychosocial issues, pain modulators and analgesics, and consultations as indicated by clinical presentation. Experience and intuition are required in many cases. In our large volume, high complexity clinic setting, we continue to pursue guidelines to improve and streamline screening for substance abuse or the potential for abuse, particularly in younger individuals. In the elderly, since abuse potential is less likely and disease documentation is often more readily apparent, we feel relatively comfortable in initiating careful prescribing of opioid therapy early on.

As we become more adept at our approach toward pain management issues, we will attempt some assessment of outcomes by observing changes in several parameters, including numbers of opioid prescriptions and comparative adequacy of pain control over time.

National and local pain/addiction information and referral resources are available as follows: http:// www.nationalsubstanceabuseindex .org and http://www.wvupc. org/charleston/painlist


Our main objective was to provide a relatively concise review of the daunting issues facing primary care physicians in regard to management of chronic pain. We have presented approaches which may allow for improved opioid screening and adequate pain control in the face of significant time constraints and patient complexity. We also have reviewed combined use of various modalities and disciplines, as monotherapy is clearly insufficient in caring for patients with persistent pain.


(1.) Hardt J, Jacobsen C, Goldberg J, et al. Prevalence of chronic pain in a representative sample in the United States. Pain Med. 2008;9:803-812.

(2.) Centers for Disease Control and Prevention: Unintentional poisoning deaths--United States, 1999-2004. MMWR Morb Mort Weekly Rep. 2007;56:93-96.

(3.) Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional overdose fatalities. JAMA 2008;300:2613-2620.

(4.) Chou R, Fanciullo J, Fine 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.

(5.) Webster L. Avoiding substance abuse while managing pain. North Branch MN. Sunrise River Press, 2007.

(6.) Pharmacological management of persistent pain in older persons. American Geriatric Association panel on the pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331-1346.

(7.) Gourlay DL, Heit, MD, Ahlmahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112.

(8.) Williams DR, Gonzalez HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from a National Survey of American Life. Arch Gen Psychiatry. 2007;64:305-315.

(9.) Ahayon MM. Specific characteristics of the pain/depression association in the general population. J Clin Psychiatry. 2004;65 Suppl 12;5-9.

(10.) Aquera L, Failde J, Cervilla JA, et al. Medically unexplained pain complaints are associated with underlying unrecognized mood disorders in primary care. BMC Fam Pract. 2010;11:17. http://www. [epub ahead of print]

(11.) Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal overdose drug poisoning in the United States. Am J Prev Med. 2006;31:506-511.

(12.) Lowe B, 8Unutzer J, Callahan CM, et al. Monitoring depression treatment outcomes with the patient questionnaire-9. Med Care. 2004;42:1194-201.

(13.) Gaynes BN, Deveaugh-Geiss J, Weir S, et al. Feasibility and diagnostic validity of the M-3 checklist: self rated screen for depressive, bipolar, anxiety and posttraumatic stress disorders in primary care. Ann Fam Med. 2010;8:160-169.

(14.) Wilson JF. In the clinic--low back pain. Ann Intern Med. 2008 ITC5 1-16.

(15.) Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

(16.) O'Conner AB, Dworkin RH. Treatment of neuropathic pain: An overview of recent guidelines. Am J Med. 2009;122:S22-S32.

(17.) Gilron I, Bailey JM, et al. Nortriptyline and gabapentin, alone or in combination for neuropathic pain: a double-blind, randomized, placebo controlled crossover trial. Lancet. 2009;374:1252-1261.

(18.) Dunn KM, Saunders KW. Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010;152:85-92.

(19.) Manchikanti L, Cash KA, Damron KS, et al. Controlled substance abuse and illicit drug use in chronic pain patients. An evaluation of multiple variables. Pain Physician. 2006; 9:215-225.

(20.) 2008 Drug Testing: An overview of Mayo Clinic Tests Designed for Detecting Drug Abuse. www.Mayo Medical Laboratories. com.

(21.) Brown RL, Rounds LA. Conjoint screening for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94:135-140.

(22.) Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two item conjoint screen for alcohol and other drug problems. Am J Fam Pract. 2001;14:95-106.

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(27.) Vukimir RB. Drug seeking behavior. Am J Drug Alcohol Abuse 2004;30:551-575.

CME Post-test

31. Which state has experienced the nation's largest increase in drug overdose mortality?

a. Kentucky

b. West Virginia

c. Louisiana

32. Which class of medications may be useful as an adjunct in treating several forms of chronic pain, including neuropathic pain, fibromyalgia, and migraine?

a. Opioids

b. Corticosteroids

c. Tricyclic antidepressants

33. If pain control is inadequate with acetaminophen in the elderly patient, which category of medications should be considered next?


b. Opioids

c. Anticonvulsants

Brittain McJunkin, MD, FACP

Professor of Internal Medicine, West

Virginia University Health Sciences

Center, Charleston Division

Mary Ann Riley, DO

Assistant Professor of Internal Medicine,

West Virginia University Health Sciences Center,

Charleston Division

JK Lilly, MD, MS

Clinical Professor of Anesthesiology, West Virginia

University Health Sciences Center,

Charleston Division

Amy Casto, RN, MSN, FNP-BC

Charleston Area Medical Center Outpatient

Care Center

Adina Bowe, MD

Resident in Internal Medicine and Psychiatry ,

West Virginia University Health Sciences Center,

Charleston Division/Charleston Area Medical Center
Table 1. General Approaches to
Pain Management

* Non-judgmental emotional

* Evaluation for depression and
psychosocial issues

* Physical interventions
(physical therapy/exercise,

* Pharmacologic therapy


in neuropathic pain,
fibromyalgia, CPRS, etc.

--Local corticosteroid/lidocaine
injections, topical NSAID, etc.



* Consultations: pain clinic,
substance abuse programs,
psychiatry, surgery, etc.

Table 2. Controlled Substances Prescribing Policy

Except in rare situations, opioid agents will not be prescribed on
initial patient visit with complaint of chronic or persistent pain.
The following information will be required before completion of a
controlled substances contract:

* Documentation of disease entity

* Initial and random urine drug screening (UDS)

* West Virginia Board of Pharmacy review

* Substance abuse survey

Table 3. Substance Abuse Survey


In the past, have you ever:

1) Tried to cut down or change your pattern of alcohol or drug use?

2) Been annoyed or angry by others' concerns about your alcohol or
drug use?

3) Felt guilty about the consequences of your drinking or drug use?

4) Had a drink or used a drug in the morning ("eye opener") to
decrease a hangover or withdrawal symptoms?


1) In the last year, have you ever drunk alcohol or used drugs more
than you meant to?

2) Have you ever felt you wanted or needed to cut down on your
drinking or drug use in the last year?


1) Do you drink/drug to relax, feel better about yourself, or fit

2) Do you ever drink/drug while you are by yourself (alone)?

3) Do you or your closest friends drink/drug?

4) Does a close family member have problems with alcohol/drugs?

5) Have you ever gotten into trouble from drinking/drugging?

Interpretations of tests: In Webster L. Avoiding opiate abuse while
managing pain. North Branch, MN. Sunrise River Press. 2007. Chapter
5. Book located at all clinic stations.

Table 4. Opioid Risk Tool

                                   Mark each
                                   box that    Item score   Item score
Item                                applies    if female     if male

1. Family history of substance

Alcohol                               []           1            3
Illegal drugs                         []           2            3
Prescription drugs                    []           4            4

2. Personal history of substance

Alcohol                               []           3            3
Illegal drugs                         []           4            4
Prescription drugs                    []           5            5

3. Age (mark box if 16-45)            []           1            1

4. History of preadolescent           []           3            0
   sexual abuse

5. Psychologic disease

Attention deficit disorder,           []           2            2
obsessive-compulsive disorder,
bipolar disorder, schizophrenia

Depression                            []           1            1

Total                                              --           --

Total score risk category:
Low risk: Zero--3
Moderate risk: 4--7
High risk: 8 or higher

Table 5. Drug Seeking Behavior

* Multiple visits for same complaint

* Unable to focus on anything
other than the medicine

* Lost prescriptions

* Doctor unavailable

* Allergic to new narcotic

* Desires narcotics

* Common conditions that cannot
be measured

a. Headache

b. Urethral colic

c. Toothache

d. Abdominal pain

* "Unbearable" pain

* Wearing-you-down approach

* Overly creative requests

* Appearance change or alias
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Article Details
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Title Annotation:Scientific Article: Special Issue
Author:McJunkin, Brittain; Riley, Mary Ann; Lilly, J.K.; Casto, Amy; Bowe, Adina
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2010
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