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Zadro JR, Harris IA, Abdelshaheed C, Broderick C, Barton CJ, Linklater J, Maher CG. Choosing Wisely after a sport and exercise-related injury. Best Pract Res Clin Rheumatol 2019; 33:16-32. [DOI: 10.1016/j.berh.2019.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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152
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Schreijenberg M, Koes BW, Lin CWC. Guideline recommendations on the pharmacological management of non-specific low back pain in primary care - is there a need to change? Expert Rev Clin Pharmacol 2019; 12:145-157. [PMID: 30618319 DOI: 10.1080/17512433.2019.1565992] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Analgesic drugs are often prescribed to patients with non-specific low back pain (NSLBP). Recommendations for non-invasive pharmacological management of NSLBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy. Areas covered: Recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacological treatment, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized. Expert opinion: Although differences exist between guidelines, publications are universally moving away from pharmacotherapy due to the limited efficacy and the risk of adverse effects. NSAIDs have replaced paracetamol as the first choice analgesics for NSLBP in many guidelines. Opioids are generally considered to be a last resort, but opioid prescriptions have been increasing over recent years. Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.
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Affiliation(s)
- Marco Schreijenberg
- a Department of General Practice , Erasmus MC, University Medical Center , Rotterdam , The Netherlands
| | - Bart W Koes
- a Department of General Practice , Erasmus MC, University Medical Center , Rotterdam , The Netherlands.,b Center for Muscle and Joint Health , University of Southern Denmark , Odense , Denmark
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Alzahrani H, Mackey M, Stamatakis E, Pinheiro MB, Wicks M, Shirley D. The effectiveness of incidental physical activity interventions compared to other interventions in the management of people with low back pain: A systematic review and meta-analysis of randomised controlled trials. Phys Ther Sport 2019; 36:34-42. [PMID: 30620922 DOI: 10.1016/j.ptsp.2018.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/17/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To investigate the effectiveness of incidental (non-structured) physical activity interventions for the management of people with low back pain (LBP). DESIGN Systematic review and meta-analyses of randomised controlled trials. SETTING Eligible published trials from the earliest date available to November 2017. PARTICIPANTS People with non-specific LBP aged 18 years or over. OUTCOME MEASURES Pain, disability and physical activity-related outcomes. RESULTS Three trials were included (including a total of 422 participants). The quality of trials, assessed by PEDro scale, was high (7 out of 10). For pain, the pooled results did not show any significant effects between the incidental physical activity intervention and other interventions at any time point. For disability, incidental physical activity was not statistically more effective than other interventions at short-term; however, the pooled results favoured incidental physical activity at intermediate-term (weighted mean difference (WMD) = -6.05, 95%CI: -10.39 to -1.71) and long-term (WMD = -6.40 95%CI: -11.68 to -1.12) follow-ups among participants with chronic LBP. The overall quality of evidence was rated "moderate-quality" based on the GRADE system. CONCLUSIONS The incidental physical activity intervention provided improvement in disability in intermediate- and long-term for people with chronic LBP, although this improvement was small and may not be clinically significant.
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Affiliation(s)
- Hosam Alzahrani
- The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia; Taif University, Physiotherapy Department, College of Applied Medical Science, Taif, Saudi Arabia.
| | - Martin Mackey
- The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia.
| | - Emmanuel Stamatakis
- The University of Sydney, Charles Perkins Centre, Prevention Research Collaboration, School of Public Health, Sydney, Australia.
| | - Marina B Pinheiro
- The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia; The University of Sydney, School of Public Health, Sydney Medical School, Sydney, Australia.
| | - Manuela Wicks
- The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia.
| | - Debra Shirley
- The University of Sydney, Discipline of Physiotherapy, Faculty of Health Sciences, Sydney, Australia.
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Day MA, Ward LC, Ehde DM, Thorn BE, Burns J, Barnier A, Mattingley JB, Jensen MP. A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain. PAIN MEDICINE 2019; 20:2134-2148. [DOI: 10.1093/pm/pny273] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AbstractObjectiveThis pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP).SettingUniversity of Queensland Psychology Clinic.SubjectsParticipants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP.DesignA pilot, assessor-blinded randomized controlled trial.MethodsParticipants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up.ResultsRatings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures.ConclusionsThis is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.
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Affiliation(s)
- Melissa A Day
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - L Charles Ward
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Beverly E Thorn
- Department of Psychology, University of Alabama, Tuscaloosa, Alabama, USA
| | - John Burns
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Amanda Barnier
- Department of Cognitive Science, Macquarie University, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence in Cognition and its Disorders, Macquarie University, Sydney, New South Wales, Australia
| | - Jason B Mattingley
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
- Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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155
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Finan PH, Remeniuk B, Dunn KE. The risk for problematic opioid use in chronic pain: What can we learn from studies of pain and reward? Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:255-262. [PMID: 28778406 PMCID: PMC5821601 DOI: 10.1016/j.pnpbp.2017.07.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 12/22/2022]
Abstract
Problematic prescription opioid use is cited as a primary contributor to the current 'opioid epidemic' in the United States, which is characterized by recent rapid increases in individuals seeking treatment for opioid dependence and staggering rates of opioid overdose deaths. Individuals with chronic pain are commonly prescribed opioids to treat pain, and by this mere exposure are at increased risk for the development of problematic opioid use. However, the factors contributing to variation in risk across patients have only recently begun to be unraveled. In the present review, we describe the recent and expanding literature on interactions between pain and reward system function in an effort to inform our understanding of risk for problematic opioid use in chronic pain. To that end, we describe the limited experimental evidence regarding opioid abuse liability under conditions of pain, and offer suggestions for how to advance a research agenda that better informs clinicians about the factors contributing to opioid addiction risk in patients with chronic pain. We raise mechanistic hypotheses by highlighting the primary conclusions of several recent reviews on the neurobiology of pain and reward, with an emphasis on describing dopamine deficits in chronic pain, the role of the reward system in mediating the affective and motivational components of pain, and the role of opponent reward/anti-reward processes in the perpetuation of pain states and the development of problematic opioid use behaviors. Finally, we also argue that positive affect-which is directly regulated by the mesolimbic reward system-is a key pain inhibitory factor that, when deficient, may increase risk for problematic opioid use, and present a model that integrates the potential contributions of pain, reward system function, and positive affect to problematic opioid use risk.
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Affiliation(s)
- Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, United States.
| | - Bethany Remeniuk
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, United States
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, United States
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156
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Busse JW, Wang L, Kamaleldin M, Craigie S, Riva JJ, Montoya L, Mulla SM, Lopes LC, Vogel N, Chen E, Kirmayr K, De Oliveira K, Olivieri L, Kaushal A, Chaparro LE, Oyberman I, Agarwal A, Couban R, Tsoi L, Lam T, Vandvik PO, Hsu S, Bala MM, Schandelmaier S, Scheidecker A, Ebrahim S, Ashoorion V, Rehman Y, Hong PJ, Ross S, Johnston BC, Kunz R, Sun X, Buckley N, Sessler DI, Guyatt GH. Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA 2018; 320:2448-2460. [PMID: 30561481 PMCID: PMC6583638 DOI: 10.1001/jama.2018.18472] [Citation(s) in RCA: 409] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Harms and benefits of opioids for chronic noncancer pain remain unclear. OBJECTIVE To systematically review randomized clinical trials (RCTs) of opioids for chronic noncancer pain. DATA SOURCES AND STUDY SELECTION The databases of CENTRAL, CINAHL, EMBASE, MEDLINE, AMED, and PsycINFO were searched from inception to April 2018 for RCTs of opioids for chronic noncancer pain vs any nonopioid control. DATA EXTRACTION AND SYNTHESIS Paired reviewers independently extracted data. The analyses used random-effects models and the Grading of Recommendations Assessment, Development and Evaluation to rate the quality of the evidence. MAIN OUTCOMES AND MEASURES The primary outcomes were pain intensity (score range, 0-10 cm on a visual analog scale for pain; lower is better and the minimally important difference [MID] is 1 cm), physical functioning (score range, 0-100 points on the 36-item Short Form physical component score [SF-36 PCS]; higher is better and the MID is 5 points), and incidence of vomiting. RESULTS Ninety-six RCTs including 26 169 participants (61% female; median age, 58 years [interquartile range, 51-61 years]) were included. Of the included studies, there were 25 trials of neuropathic pain, 32 trials of nociceptive pain, 33 trials of central sensitization (pain present in the absence of tissue damage), and 6 trials of mixed types of pain. Compared with placebo, opioid use was associated with reduced pain (weighted mean difference [WMD], -0.69 cm [95% CI, -0.82 to -0.56 cm] on a 10-cm visual analog scale for pain; modeled risk difference for achieving the MID, 11.9% [95% CI, 9.7% to 14.1%]), improved physical functioning (WMD, 2.04 points [95% CI, 1.41 to 2.68 points] on the 100-point SF-36 PCS; modeled risk difference for achieving the MID, 8.5% [95% CI, 5.9% to 11.2%]), and increased vomiting (5.9% with opioids vs 2.3% with placebo for trials that excluded patients with adverse events during a run-in period). Low- to moderate-quality evidence suggested similar associations of opioids with improvements in pain and physical functioning compared with nonsteroidal anti-inflammatory drugs (pain: WMD, -0.60 cm [95% CI, -1.54 to 0.34 cm]; physical functioning: WMD, -0.90 points [95% CI, -2.69 to 0.89 points]), tricyclic antidepressants (pain: WMD, -0.13 cm [95% CI, -0.99 to 0.74 cm]; physical functioning: WMD, -5.31 points [95% CI, -13.77 to 3.14 points]), and anticonvulsants (pain: WMD, -0.90 cm [95% CI, -1.65 to -0.14 cm]; physical functioning: WMD, 0.45 points [95% CI, -5.77 to 6.66 points]). CONCLUSIONS AND RELEVANCE In this meta-analysis of RCTs of patients with chronic noncancer pain, evidence from high-quality studies showed that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. Comparisons of opioids with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality.
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Affiliation(s)
- Jason W. Busse
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada
| | - Li Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu
| | | | - Samantha Craigie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - John J. Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Luis Montoya
- Krembil Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sohail M. Mulla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Now with the Canadian Agency for Drugs and Technologies in Health (CADTH), Toronto, Ontario, Canada
| | - Luciane C. Lopes
- Pharmaceutical Science, University of Sorocaba, Sao Paulo, Brazil
| | - Nicole Vogel
- Leonardo Hirslanden Klinik Birshof, Münchenstein, Switzerland
| | - Eric Chen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karin Kirmayr
- Department of Internal Medicine, Hospital Alemán de Buenos Aires, Buenos Aires, Argentina
| | - Kyle De Oliveira
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lori Olivieri
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alka Kaushal
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Luis E. Chaparro
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Inna Oyberman
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Ludwig Tsoi
- Accident and Emergency Department, Queen Mary Hospital, Pokfulam, Hong Kong, China
| | - Tommy Lam
- Accident and Emergency Department, Tuen Mun Hospital, Hong Kong, China
| | - Per Olav Vandvik
- Department of Medicine, Gjøvik, Innlandet Hospital Trust, Norway
| | - Sandy Hsu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Stefan Schandelmaier
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Institute for Clinical Epidemiology and Biostatistics, University of Basel Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel Hospital, Basel, Switzerland
| | - Anne Scheidecker
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesiology, Operative Intensive Care, Preclinical Emergency Medicine and Pain Management, University of Basel Hospital, Basel, Switzerland
| | - Shanil Ebrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vahid Ashoorion
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Isfahan Medical Education Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yasir Rehman
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Canadian Academy of Osteopathy, Hamilton, Ontario, Canada
| | - Patrick J. Hong
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Bradley C. Johnston
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Regina Kunz
- Department of Clinical Research, University of Basel Hospital, Basel, Switzerland
| | - Xin Sun
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu
| | - Norman Buckley
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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157
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Abstract
Low back pain affects individuals of all ages and is a leading contributor to disease burden worldwide. Despite advancements in assessment and treatment methods, the management of low back pain remains a challenge for researchers and clinicians alike. One reason for the limited success in identifying effective treatments is the large variation in the manifestations, possible causes, precipitating and maintaining factors, course, prognosis and consequences in terms of activity interference and quality of life. However, despite these challenges, steady progress has been achieved in the understanding of back pain, and important steps in the understanding of the psychological and social risk factors, genetics and brain mechanisms of low back pain have been made. These new findings have given impetus to the development of new diagnostic procedures, evidence-based screening methods and more targeted interventions, which underscore the need for a multidisciplinary approach to the management of low back pain that integrates biological, psychological and social aspects.
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158
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Nunley PD, Deer TR, Benyamin RM, Staats PS, Block JE. Interspinous process decompression is associated with a reduction in opioid analgesia in patients with lumbar spinal stenosis. J Pain Res 2018; 11:2943-2948. [PMID: 30538533 PMCID: PMC6251434 DOI: 10.2147/jpr.s182322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) causes significant pain and functional impairment, and medical management has increasingly included the prescription of opioid-based analgesics. Interspinous process decompression (IPD) provides a minimally-invasive treatment option for LSS. Methods This study estimated the type, dosage, and duration of opioid medications through 5 years of follow-up after IPD with the Superion Indirect Decompression System (Vertiflex Inc., Carlsbad, CA USA). Data were obtained from the Superion-treatment arm of a randomized controlled noninferiority trial. The prevalence of subjects using opiates was determined at baseline through 60 months. Primary analysis included all 190 patients randomized to receive the Superion device. In a subgroup of 98 subjects, we determined opioid-medication prevalence among subjects with a history of opioid use. Results At baseline, almost 50% (94 of 190) of subjects were using opioid medication. Thereafter, there was a sharp decrease in opioid-medication prevalence from 25.2% (41 of 163) at 12 months to 13.3% (20 of 150) at 24 months to 7.5% (8 of 107) at 60 months. Between baseline and 5 years, there was an 85% decrease in the proportion of subjects using opioids. A similar pattern was also observed among subjects with a history of opiates prior to entering the trial. Conclusion Stand-alone IPD is associated with a marked decrease in the need for opioid medications to manage symptoms related to LSS. In light of the current opiate epidemic, such alternatives as IPD may provide effective pain relief in patients with LSS without the need for opioid therapy.
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Affiliation(s)
| | | | | | - Peter S Staats
- National Spine and Pain Centers, Rockville, MD 20852, USA
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159
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Song L, Qiu P, Xu J, Lv J, Wang S, Xia C, Chen P, Fan S, Fang X, Lin X. The Effect of Combination Pharmacotherapy on Low Back Pain. Clin J Pain 2018; 34:1039-1046. [DOI: 10.1097/ajp.0000000000000622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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160
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Urquhart DM, Wluka AE, van Tulder M, Heritier S, Forbes A, Fong C, Wang Y, Sim MR, Gibson SJ, Arnold C, Cicuttini FM. Efficacy of Low-Dose Amitriptyline for Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:1474-1481. [PMID: 30285054 PMCID: PMC6248203 DOI: 10.1001/jamainternmed.2018.4222] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Antidepressants at low dose are commonly prescribed for the management of chronic low back pain and their use is recommended in international clinical guidelines. However, there is no evidence for their efficacy. OBJECTIVE To examine the efficacy of a low-dose antidepressant compared with an active comparator in reducing pain, disability, and work absence and hindrance in individuals with chronic low back pain. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized clinical trial with a 6-month follow-up of adults with chronic, nonspecific, low back pain who were recruited through hospital/medical clinics and advertising was carried out. INTERVENTION Low-dose amitriptyline (25 mg/d) or an active comparator (benztropine mesylate, 1 mg/d) for 6 months. MAIN OUTCOMES AND MEASURES The primary outcome was pain intensity measured at 3 and 6 months using the visual analog scale and Descriptor Differential Scale. Secondary outcomes included disability assessed using the Roland Morris Disability Questionnaire and work absence and hindrance assessed using the Short Form Health and Labour Questionnaire. RESULTS Of the 146 randomized participants (90 [61.6%] male; mean [SD] age, 54.8 [13.7] years), 118 (81%) completed 6-month follow-up. Treatment with low-dose amitriptyline did not result in greater pain reduction than the comparator at 6 (adjusted difference, -7.81; 95% CI, -15.7 to 0.10) or 3 months (adjusted difference, -1.05; 95% CI, -7.87 to 5.78), independent of baseline pain. There was no statistically significant difference in disability between the groups at 6 months (adjusted difference, -0.98; 95% CI, -2.42 to 0.46); however, there was a statistically significant improvement in disability for the low-dose amitriptyline group at 3 months (adjusted difference, -1.62; 95% CI, -2.88 to -0.36). There were no differences between the groups in work outcomes at 6 months (adjusted difference, absence: 1.51; 95% CI, 0.43-5.38; hindrance: 0.53; 95% CI, 0.19-1.51), or 3 months (adjusted difference, absence: 0.86; 95% CI, 0.32-2.31; hindrance: 0.78; 95% CI, 0.29-2.08), or in the number of participants who withdrew owing to adverse events (9 [12%] in each group; χ2 = 0.004; P = .95). CONCLUSIONS AND RELEVANCE This trial suggests that amitriptyline may be an effective treatment for chronic low back pain. There were no significant improvements in outcomes at 6 months, but there was a reduction in disability at 3 months, an improvement in pain intensity that was nonsignificant at 6 months, and minimal adverse events reported with a low-dose, modest sample size and active comparator. Although large-scale clinical trials that include dose escalation are needed, it may be worth considering low-dose amitriptyline if the only alternative is an opioid. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12612000131853.
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Affiliation(s)
- Donna M Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Anita E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Maurits van Tulder
- Department of Health Sciences, Amsterdam Public Health Research Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Chris Fong
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Malcolm R Sim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Stephen J Gibson
- National Ageing Research Institute, Parkville, Australia.,Caulfield Pain Management and Research Centre, Caulfield, Australia
| | - Carolyn Arnold
- Department of Anaesthesia and Perioperative Medicine, Monash University, Alfred Hospital, Melbourne, Australia.,Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
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Hayes CJ, Li X, Li C, Shah A, Kathe N, Bhandari NR, Payakachat N. Health-Related Quality of Life among Chronic Opioid Users, Nonchronic Opioid Users, and Nonopioid Users with Chronic Noncancer Pain. Health Serv Res 2018; 53:3329-3349. [PMID: 29479700 PMCID: PMC6153159 DOI: 10.1111/1475-6773.12836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Evaluate the association between opioid therapy and health-related quality of life (HRQoL) in participants with chronic, noncancer pain (CNCP). DATA SOURCES Medical Expenditure Panel Survey Longitudinal, Medical Conditions, and Prescription Files. STUDY DESIGN Using a retrospective cohort study design, the Mental Health Component (MCS12) and Physical Health Component (PCS12) scores of the Short Form-12 Version 2 were assessed to measure mental and physical HRQoL. DATA COLLECTION Chronic, noncancer pain participants were classified as chronic, nonchronic, and nonopioid users. One-to-one propensity score matching was employed to match chronic opioid users to nonchronic opioid users plus nonchronic opioid users and chronic opioid users to nonopioid users. PRINCIPAL FINDINGS A total of 5,876 participants were identified. After matching, PCS12 was not significantly different between nonchronic versus nonopioid users (LSM Diff = -0.98, 95% CI: -2.07, 0.10), chronic versus nonopioid users (LSM Diff = -2.24, 95% CI: -4.58, 0.10), or chronic versus nonchronic opioid users (LSM Diff = -2.23, 95% CI: -4.53, 0.05). Similarly, MCS12 was not significantly different between nonchronic versus nonopioid users (LSM Diff = 0.76, 95% CI: -0.46, 1.98), chronic versus nonopioid users (LSM Diff = 1.08, 95% CI: -1.26, 3.42), or chronic versus nonchronic opioid users (LSM Diff = -0.57, 95% CI: -2.90, 1.77). CONCLUSIONS Clinicians should evaluate opioid use in participants with CNCP as opioid use is not correlated with better HRQoL.
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Affiliation(s)
- Corey J. Hayes
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
- NIDAT32 Addiction Research Training Program, Psychiatric Research InstituteUniversity of Arkansas for Medical Sciences College of MedicineLittle RockAR
| | - Xiaocong Li
- Department of Health Policy and ManagementUniversity of Arkansas for Medical Sciences College of Public HealthLittle RockAR
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
| | - Anuj Shah
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
| | - Niranjan Kathe
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
| | - Naleen Raj Bhandari
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
| | - Nalin Payakachat
- Division of Pharmaceutical Evaluation and PolicyDepartment of Pharmacy PracticeUniversity of Arkansas for Medical Sciences College of PharmacyLittle RockAR
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Rodondi PY, Dubois J, Bill AS, Koutaïssoff D, Ros J, Aveni E, Pasquier J, Herzig L, Decosterd I, Burnand B. Primary care physicians' attitude and reported prescribing behavior for chronic low back pain: An exploratory cross-sectional study. PLoS One 2018; 13:e0204613. [PMID: 30261029 PMCID: PMC6160127 DOI: 10.1371/journal.pone.0204613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/11/2018] [Indexed: 12/28/2022] Open
Abstract
Objective Recent guidelines for chronic or recurrent low back pain recommend non-pharmacologic treatments as first-line options. The objective of this study was thus to explore the perceived usefulness of several conventional and complementary medicine treatments for chronic or recurrent low back pain by primary care physicians and their reported prescribing behavior. Design An exploratory cross-sectional study. Setting and participants Primary care physicians of the French-speaking part of Switzerland. Main outcome measures Primary care physicians’ perceived usefulness of each conventional and complementary medicine treatment and their reported recommendation behavior were considered dependent variables in multivariate logistic regression models. All correlations were computed between binary variables, and phi coefficients were calculated to estimate correlation strengths. Results 533 primary care physicians answered the questionnaire (response rate: 25.6%). The top 3 conventional treatments most often considered useful by primary care physicians for chronic or recurrent low back pain were physiotherapy (94.8%), nonsteroidal anti-inflammatory drugs (87.9%), and manual therapy (82.5%), whereas the most prescribed conventional treatments were physiotherapy (99.2%), nonsteroidal anti-inflammatory drugs (97.4%), and acetaminophen (94.4%). Osteopathic treatment (78.4%), yoga (69.3%), and therapeutic massage (63.9%) were the complementary medicine treatments most often considered useful by primary care physicians in managing chronic or recurrent low back pain. Being a female physician, younger than 56 years, trained in complementary medicine, or using complementary medicine were all associated with higher perceived usefulness of complementary medicine treatments in general. The most recommended complementary medicine treatments by primary care physicians were osteopathic treatment (87.3%), acupuncture (69.3%), and therapeutic massage (58.7%). Being a female physician, younger than 56, and using complementary medicine were all associated with more complementary medicine recommendation in general. Conclusion Our results highlight the importance of better understanding the prescribing patterns of primary care physicians for chronic or recurrent low back pain. Considering the frequency and burden of chronic or recurrent low back pain, programs focusing on the most (cost-) effective treatments should be implemented.
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Affiliation(s)
- Pierre-Yves Rodondi
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Institute of Family Medicine, University of Fribourg, Fribourg, Switzerland
| | - Julie Dubois
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Institute of Family Medicine, University of Fribourg, Fribourg, Switzerland
- * E-mail:
| | - Anne-Sylvie Bill
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Daria Koutaïssoff
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Jenny Ros
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Eléonore Aveni
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Jérôme Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Isabelle Decosterd
- Pain Center and Center for integrative and complementary medicine, Department of anesthesiology, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Franko TS, Trombetta D. Impact of an innovative pain elective course on student beliefs and attitudes towards opioid medication use. CURRENTS IN PHARMACY TEACHING & LEARNING 2018; 10:1248-1263. [PMID: 30497629 DOI: 10.1016/j.cptl.2018.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 03/20/2018] [Accepted: 06/07/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND PURPOSE To determine if an innovative elective course in chronic pain management focused on a multimodal treatment approach changed student views on opioid use for chronic, non-cancer pain. EDUCATIONAL ACTIVITY AND SETTING Offered to students in the second and third professional year, the course focused on various aspects of the treatment and impact of pain. Students completed two major, self-directed projects as well as four reflection journals throughout the semester. A nine question survey was provided to students on the first and last day of class that identified their beliefs and attitudes towards opioid use in chronic non-cancer pain using a five point Likert scale. FINDINGS There was a statistical difference in one question asking if long acting opioids were effective in controlling pain long term. SUMMARY There was evidence of change in student perceptions. Similar self-directed courses should be considered by other institutions as a means to change student beliefs and attitudes.
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Affiliation(s)
- Thomas S Franko
- Nesbitt School of Pharmacy, Wilkes University, 84 West South Street, Wilkes-Barre, PA 18766, United States.
| | - Dominick Trombetta
- Nesbitt School of Pharmacy, Wilkes University, 84 West South Street, Wilkes-Barre, PA 18766, United States.
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164
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Choi H, Tessier S, Silagi ES, Kyada R, Yousefi F, Pleshko N, Shapiro IM, Risbud MV. A novel mouse model of intervertebral disc degeneration shows altered cell fate and matrix homeostasis. Matrix Biol 2018; 70:102-122. [PMID: 29605718 PMCID: PMC6081256 DOI: 10.1016/j.matbio.2018.03.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/17/2018] [Accepted: 03/18/2018] [Indexed: 12/17/2022]
Abstract
Intervertebral disc degeneration and associated low back and neck pain is a ubiquitous health condition that affects millions of people world-wide, and causes high incidence of disability and enormous medical/societal costs. However, lack of appropriate small animal models with spontaneous disease onset has impeded our ability to understand the pathogenetic mechanisms that characterize and drive the degenerative process. We report, for the first time, early onset spontaneous disc degeneration in SM/J mice known for their poor regenerative capacities compared to "super-healer" LG/J mice. In SM/J mice, degenerative process was marked by decreased nucleus pulposus (NP) cellularity and changes in matrix composition at P7, 4, and 8 weeks with increased severity by 17 weeks. Distinctions between NP and annulus fibrosus (AF) or endplate cartilage were lost, and NP and AF of SM/J mice showed higher histological grades. There was increased NP cell death in SM/J mice with decreased phenotypic marker expression. Polarized microscopy and FTIR spectroscopy demonstrated replacement of glycosaminoglycan-rich NP matrix with collagenous fibrous tissue. The levels of ARGxx were increased in, indicating higher aggrecan turnover. Furthermore, an aberrant expression of collagen X and MMP13 was observed in the NP of SM/J mice, along with elevated expression of Col10a1, Ctgf, and Runx2, markers of chondrocyte hypertrophy. Likewise, expression of Enpp1 as well as Alpl was higher, suggesting NP cells of SM/J mice promote dystrophic mineralization. There was also a decrease in several pathways necessary for NP cell survival and function including Wnt and VEGF signaling. Importantly, SM/J discs were stiffer, had decreased height, and poor vertebral bone quality, suggesting compromised motion segment mechanical functionality. Taken together, our results clearly demonstrate that SM/J mouse strain recapitulates many salient features of human disc degeneration, and serves as a novel small animal model.
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Affiliation(s)
- Hyowon Choi
- Department of Orthopaedic Surgery, Graduate Program in Cell Biology and Regenerative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Steven Tessier
- Department of Orthopaedic Surgery, Graduate Program in Cell Biology and Regenerative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth S Silagi
- Department of Orthopaedic Surgery, Graduate Program in Cell Biology and Regenerative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rutvin Kyada
- Department of Bioengineering, Temple University, Philadelphia, PA, USA
| | - Farzad Yousefi
- Department of Bioengineering, Temple University, Philadelphia, PA, USA
| | - Nancy Pleshko
- Department of Bioengineering, Temple University, Philadelphia, PA, USA
| | - Irving M Shapiro
- Department of Orthopaedic Surgery, Graduate Program in Cell Biology and Regenerative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Makarand V Risbud
- Department of Orthopaedic Surgery, Graduate Program in Cell Biology and Regenerative Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
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165
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Sharma S, Jensen MP, Moseley GL, Abbott JH. Pain education for patients with non-specific low back pain in Nepal: protocol of a feasibility randomised clinical trial (PEN-LBP Trial). BMJ Open 2018; 8:e022423. [PMID: 30099402 PMCID: PMC6089285 DOI: 10.1136/bmjopen-2018-022423] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/23/2018] [Accepted: 07/06/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is the leading cause of years lived with disability in Nepal and elsewhere. Management of LBP that is evidence-based, easily accessible, cost-effective and culturally appropriate is desirable. The primary aim of this feasibility study is to determine if it is feasible to conduct a full randomised clinical trial evaluating the effectiveness of pain education as an intervention for individuals with LBP in Nepal, relative to guideline-based physiotherapy treatment. The findings of the study will inform the planning of a full clinical trial and if any modifications are required to the protocol before undertaking a full trial. METHODS/ANALYSIS This protocol describes an assessor-blinded feasibility clinical trial investigating feasibility of the pain education intervention in patients with non-specific LBP in a physiotherapy hospital in Kathmandu, Nepal. Forty patients with LBP will be randomly allocated to either pain education or guideline-based physiotherapy treatment (control). Outcomes will be assessed at baseline and at a 1 week post-treatment. The primary outcomes are related to feasibility, including: (1) participant willingness to participate in a randomised clinical trial, (2) feasibility of assessor blinding, (3) eligibility and recruitment rates, (4) acceptability of screening procedures and random allocation, (5) possible contamination between the groups, (6) intervention credibility, (7) intervention adherence, (8) treatment satisfaction and (9) difficulty in understanding the interventions being provided. ETHICS/DISSEMINATION The protocol was approved by Nepal Health Research Council (NHRC; registration number: 422/2017) and University of Otago Human Ethics Committee for Health (registration number: H17/157). The results of the study will be presented at national and international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03387228; Pre-results.
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Affiliation(s)
- Saurab Sharma
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Bagmati, Nepal
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, Otago, New Zealand
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - G Lorimer Moseley
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, Otago, New Zealand
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166
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Blanco-Silvente L, Capellà D, Garre-Olmo J, Vilalta-Franch J, Castells X. Predictors of discontinuation, efficacy, and safety of memantine treatment for Alzheimer's disease: meta-analysis and meta-regression of 18 randomized clinical trials involving 5004 patients. BMC Geriatr 2018; 18:168. [PMID: 30041625 PMCID: PMC6057050 DOI: 10.1186/s12877-018-0857-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk-benefit relationship of memantine treatment for Alzheimer's disease (AD) remains unclear. In addition, variability between the results of clinical trials has been observed. The aim of this study was to investigate the risk-benefit relationship of memantine treatment in patients with AD and to determine the predictor effect of patient, intervention, and study design related covariates. METHODS A systematic review and meta-analysis of double-blind, placebo controlled clinical trials was performed. Primary outcomes were all-cause discontinuation, discontinuation due to adverse events (AE) and efficacy on cognitive function. Odds ratio (OR) and standard mean difference (SMD) with 95% confidence intervals were calculated. Meta-regression was conducted to identify related covariates. Cochrane Collaboration tool was used to evaluate the risk of bias of included trials. RESULTS Eighteen studies involving 5004 patients were included. No differences between memantine and placebo were found for all-cause treatment discontinuation (OR=0.97 [0.82, 1.14]) and discontinuation due to AE (OR=1.18 [0.91, 1.53]). Memantine showed small improvement on cognitive function (SMD=0.15 [0.08, 0.22]). Baseline functional ability was positively associated with all-cause treatment discontinuation and discontinuation due to AE. CONCLUSIONS Our study suggests that memantine has a very small efficacy on AD symptomatology and its safety profile is similar to that of placebo. No evidence of treatment discontinuation improvement with memantine is found, indicating a dubious risk-benefit relationship. No intervention characteristic or subgroup of patients clearly shows a significantly better risk-benefit relationship. PROSPERO REGISTRATION CRD42014015696 .
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Affiliation(s)
- Lídia Blanco-Silvente
- TransLab Research Group; Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Emili Grahit, 77, 17003 Girona, Spain
| | - Dolors Capellà
- TransLab Research Group; Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Emili Grahit, 77, 17003 Girona, Spain
| | - Josep Garre-Olmo
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Emili Grahit, 77, 17003 Girona, Spain
- Girona Biomedical Research Institute (IdibGi), Parc Hospitalari Martí i Julià, Salt, Spain
| | - Joan Vilalta-Franch
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Emili Grahit, 77, 17003 Girona, Spain
- Girona Biomedical Research Institute (IdibGi), Parc Hospitalari Martí i Julià, Salt, Spain
| | - Xavier Castells
- TransLab Research Group; Department of Medical Sciences, University of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Emili Grahit, 77, 17003 Girona, Spain
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Fan AY, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Li YM, Matecki A, Camardella L, Koppelman MH, Stone JAM, Meade L, Pang J. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2018; 15:411-425. [PMID: 29103410 DOI: 10.1016/s2095-4964(17)60378-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The United States (U.S.) is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public's opioid dependence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture's cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfil these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care.
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Affiliation(s)
| | - David W Miller
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA.,Pacific College of Oriental Medicine, Chicago, IL 60601, USA
| | - Bonnie Bolash
- The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA
| | - Matthew Bauer
- The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA.,The Acupuncture Now Foundation, La Verne, CA 91750, USA
| | - John McDonald
- The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA.,The Acupuncture Evidence Project, Providence, RI 02860, USA
| | - Sarah Faggert
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,The Acupuncture Society of Virginia, Vienna, VA 22182, USA
| | - Hongjian He
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,The National Federation of Chinese TCM Organizations, New York, NY 11501, USA.,The American Alliance for Professional Acupuncture Safety, Greenwich, CT 06878, USA
| | - Yong Ming Li
- The American Traditional Chinese Medicine Society, New York, NY 11501, USA
| | - Amy Matecki
- The American Alliance for Professional Acupuncture Safety, Greenwich, CT 06878, USA.,Highland Hospital, Alameda Health System, Oakland, CA 94602, USA
| | - Lindy Camardella
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA
| | - Mel Hopper Koppelman
- The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA.,The Acupuncture Evidence Project, Providence, RI 02860, USA
| | - Jennifer A M Stone
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Lindsay Meade
- The American Society of Acupuncturists, Chicago, IL 60618, USA.,The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA
| | - John Pang
- University of California, San Diego School of Medicine, San Diego, CA 92093, USA
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Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, van Tulder M, Koes BW. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2791-2803. [PMID: 29971708 DOI: 10.1007/s00586-018-5673-2] [Citation(s) in RCA: 697] [Impact Index Per Article: 116.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010. METHOD The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines. RESULTS We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Crystian B Oliveira
- Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista (UNESP), Presidente Prudente, SP, Brazil
| | - Chris G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Rafael Z Pinto
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Adrian C Traeger
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Maurits van Tulder
- Department of Health Sciences, Faculty of Sciences and Amsterdam Movement Sciences Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Center for Muscle and Health, University of Southern Denmark, Odense, Denmark.
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Richards GC, Lluka LJ, Smith MT, Haslam C, Moore B, O'Callaghan J, Strong J. Effects of long-term opioid analgesics on cognitive performance and plasma cytokine concentrations in patients with chronic low back pain: a cross-sectional pilot study. Pain Rep 2018; 3:e669. [PMID: 30123859 PMCID: PMC6085139 DOI: 10.1097/pr9.0000000000000669] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Cognitive performance and inflammation are altered in people with chronic low back pain (CLBP). Yet, the magnitude of these changes has been unclear because of the potential influence of opioid analgesics. OBJECTIVES This cross-sectional pilot study aimed to explore whether patients with CLBP receiving long-term opioid analgesics differed from patients not taking opioids on measures of cognitive performance and plasma cytokine concentrations. METHODS Patients with CLBP who were either taking (N = 18) or not taking (N = 22) opioids daily for 3 or more months were recruited from a tertiary care private hospital and compared with healthy adults (N = 20). All groups were administered validated questionnaires to assess depression, anxiety, and stress; a cognitive test of memory, attention, and executive function; and a peripheral blood draw to measure proinflammatory (IL-1β, IL-2, IL-8, IL-12p70, TNF-α, and IFN-γ), anti-inflammatory (IL-4, IL-10, and IL-13), and pleiotropic (IL-6) cytokine concentrations. Patients also completed pain-specific questionnaires. RESULTS Patients receiving opioid analgesics performed significantly (P < 0.05) worse in attention and had significantly (P < 0.05) lower pain self-efficacy beliefs than those patients not taking opioids. Patient groups did not differ in mean pain severity or pain interference scores, tests of memory and executive function, and mean plasma cytokine concentrations, despite long-term opioid analgesics. CONCLUSION Patients receiving long-term opioid analgesics for CLBP have minor differences when compared with patients not taking opioids. This has important clinical implications when considering long-term treatment for patients with CLBP.
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Affiliation(s)
- Georgia C. Richards
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Lesley J. Lluka
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Maree T. Smith
- Centre for Integrated Preclinical Drug Development, School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Catherine Haslam
- School of Psychology, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Australia
| | - Brendan Moore
- Centre for Integrated Preclinical Drug Development, School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Greenslopes Private Hospital, Brisbane, Australia
| | | | - Jenny Strong
- Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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Bagg MK, McLachlan AJ, Maher CG, Kamper SJ, Williams CM, Henschke N, Wand BM, Moseley GL, Hübscher M, O'Connell NE, van Tulder MW, Nikolakopoulou A, McAuley JH. Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: a network meta-analysis. Cochrane Database Syst Rev 2018. [DOI: 10.1002/14651858.cd013045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Matthew K Bagg
- Neuroscience Research Australia; Sydney NSW Australia
- University of New South Wales; Prince of Wales Clinical School; Sydney NSW Australia
- University of New South Wales; New College Village; Sydney NSW Australia
| | - Andrew J McLachlan
- University of Sydney; Faculty of Pharmacy; A15 - Pharmacy Room N405 Sydney NSW Australia 2006
- Concord Repatriation General Hospital; Centre for Education and Research on Ageing; Sydney NSW Australia
| | - Christopher G Maher
- University of Sydney; Sydney School of Public Health; Level 10 North, King George V Building, Missenden Road, Camperdown Sydney NSW Australia 2050
| | - Steven J Kamper
- University of Sydney; Sydney School of Public Health; Level 10 North, King George V Building, Missenden Road, Camperdown Sydney NSW Australia 2050
| | - Christopher M Williams
- University of Newcastle; School of Medicine and Public Health; Longworth Ave Callaghan New South Wales (NSW) Australia 2308
- Hunter Medical Research Institute; New Lambton NSW Australia 2305
| | | | - Benedict M Wand
- The University of Notre Dame Australia Fremantle; School of Physiotherapy; 19 Mouat Street (PO Box 1225) Perth West Australia Australia 6959
| | - G L Moseley
- Neuroscience Research Australia; Sydney NSW Australia
- University of South Australia; Sansom Institute for Health Research; Adelaide Australia
| | | | - Neil E O'Connell
- Brunel University London; Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences; Kingston Lane Uxbridge Middlesex UK UB8 3PH
| | - Maurits W van Tulder
- Vrije Universiteit; Department of Health Sciences, Faculty of Science and Amsterdam Movement Science institute; Amsterdam Netherlands
| | - Adriani Nikolakopoulou
- University of Bern; Institute of Social and Preventive Medicine (ISPM); Bern Switzerland
| | - James H McAuley
- Neuroscience Research Australia; Sydney NSW Australia
- University of New South Wales; School of Medical Sciences; Sydney NSW Australia
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Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 391:2368-2383. [PMID: 29573872 DOI: 10.1016/s0140-6736(18)30489-6] [Citation(s) in RCA: 1171] [Impact Index Per Article: 195.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 07/18/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022]
Abstract
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Johannes R Anema
- Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
| | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Paulo H Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Bart W Koes
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wilco Peul
- Department of Neurosurgery, Leiden University, Leiden, Netherlands
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, NSW, Australia
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Associations Between Early Care Decisions and the Risk for Long-term Opioid Use for Patients With Low Back Pain With a New Physician Consultation and Initiation of Opioid Therapy. Clin J Pain 2018; 34:552-558. [DOI: 10.1097/ajp.0000000000000571] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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173
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García Espinosa MV, Prieto Checa I. [Non-oncologic chronic pain: Where we are and where we want to go]. Aten Primaria 2018; 50:517-518. [PMID: 29735179 PMCID: PMC6836901 DOI: 10.1016/j.aprim.2017.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/06/2017] [Accepted: 12/27/2017] [Indexed: 02/03/2023] Open
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Meske DS, Lawal OD, Elder H, Langberg V, Paillard F, Katz N. Efficacy of opioids versus placebo in chronic pain: a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials. J Pain Res 2018; 11:923-934. [PMID: 29765246 PMCID: PMC5939920 DOI: 10.2147/jpr.s160255] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Opioids have been used for millennia for the treatment of pain. However, the long-term efficacy of opioids to treat chronic non-cancer pain continues to be debated. To evaluate opioids’ efficacy in chronic non-cancer pain, we performed a meta-analysis of published clinical trials for μ-opioid receptor agonists performed for US Food and Drug Administration approval. Methods MEDLINE and Cochrane trial register were searched for enriched enrollment randomized withdrawal studies (before June 2016). Selection criteria included: adults, ≥10 subjects per arm, any chronic pain condition, double-blind treatment period lasting ≥12 weeks, and all μ-agonist opioids approved in the USA. Results Fifteen studies met criteria. Opioid efficacy was statistically significant (p<0.001) versus placebo for pain intensity (standardized mean difference: −0.416), ≥30% and ≥50% improvement in pain (risk difference: 0.166 and 0.137), patient global impression of change (0.163), and patient global assessment of study medication (0.194). There were minor benefits on physical function and no effect on mental function. Conclusion Opioids are efficacious in the treatment of chronic non-cancer pain for up to 3 months in randomized controlled trials. This should be considered, alongside data on opioid safety, in the use of opioids for the treatment of chronic pain.
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Affiliation(s)
| | | | | | - Valerie Langberg
- The Center for Evidence Synthesis in Health, Brown University, Providence, RI, USA
| | | | - Nathaniel Katz
- Analgesic Solutions, Natick, MA, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
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175
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Machado GC, Richards B, Needs C, Buchbinder R, Harris IA, Howard K, McCaffery K, Billot L, Edwards J, Rogan E, Facer R, Lord Cowell D, Maher CG. Implementation of an evidence-based model of care for low back pain in emergency departments: protocol for the Sydney Health Partners Emergency Department (SHaPED) trial. BMJ Open 2018; 8:e019052. [PMID: 29674362 PMCID: PMC5914780 DOI: 10.1136/bmjopen-2017-019052] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Patients with low back pain often seek care in emergency departments, but the problem is that many patients receive unnecessary or ineffective interventions and at the same time miss out on the basics of care, such as advice on self-management. This pattern of care has important consequences for the healthcare system (expensive and inefficient) and for patients (poor health outcomes). We hypothesised that the implementation of an evidence-based model of care for low back pain will improve emergency care by reducing inappropriate overuse of tests and treatments and improving patient outcomes. METHODS AND ANALYSIS A stepped-wedge cluster randomised controlled trial will be conducted to implement and evaluate the use of the Agency for Clinical Innovation (ACI) model of care for acute low back pain at four emergency departments in New South Wales, Australia. Clinician participants will be emergency physicians, nurses and physiotherapists. Codes from the Systematised Nomenclature of Medicine-Clinical Terms-Australian version will be used to identify low back pain presentations. The intervention, targeting emergency clinicians, will comprise educational materials and seminars and an audit and feedback approach. Health service delivery outcomes are routinely collected measures of imaging (primary outcome), opioid use and inpatient admission. A random subsample of 200 patient participants from each trial period will be included to measure patient outcomes (pain intensity, physical function, quality of life and experience with emergency service). The effectiveness of the intervention will be assessed by comparing the postintervention period with the retrospective baseline control period. ETHICS AND DISSEMINATION The study received ethical approval from the Sydney Local Health District (Royal Prince Alfred Hospital zone) Ethics Committee (X17-0043). The results of this study will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER Australia New Zealand Clinical Trials Registry: ACTRN 12617001160325.
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Affiliation(s)
- Gustavo C Machado
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
- Rheumatology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Chris Needs
- Rheumatology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - James Edwards
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Eileen Rogan
- Emergency Department, Canterbury Hospital, Sydney, New South Wales, Australia
| | - Rochelle Facer
- Emergency Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - David Lord Cowell
- Emergency Department, Dubbo Base Hospital, Dubbo, New South Wales, Australia
| | - Chris G Maher
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
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Saïdi H, Pagé MG, Boulanger A, Ware MA, Choinière M. Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry study. Can J Pain 2018; 2:113-124. [PMID: 35005371 PMCID: PMC8730575 DOI: 10.1080/24740527.2018.1451252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to investigate in a real-life context the effectiveness of long-term opioid therapy for reducing pain intensity and interference and improving health-related quality of life (QOL) in patients with chronic noncancer pain. METHODS Participants were 893 patients (age = 52.4 ± 14.1, female = 62.4%) enrolled in the Quebec Pain Registry (2008-2011) who completed questionnaires before their first visit at one of three multidisciplinary pain management clinics and 6 and 12 months thereafter. Based on their opioid use profile (OUP), patients were categorized as nonusers, non-lasting users, or lasting users. Data were analyzed using generalized estimating equations. RESULTS More than 60% of patients newly initiated on opioid therapy stopped their medication mainly because of adverse effects and/or lack of pain relief. OUP significantly predicted pain intensity and interference and physical QOL (pQOL; P values < 0.001). Lasting users of opioids reported higher levels of pain intensity and interference and poorer pQOL than nonusers and/or non-lasting users over the 12-month follow-up (P values < 0.001). However, all effect sizes were small, thus questioning the clinical significance of these group differences. Among lasting users, more than 20% of patients experienced a meaningful amelioration in pain intensity and interference as well as mental QOL (mQOL), whereas only 8% exhibited improved pQOL. DISCUSSION A significant subgroup of patients may benefit from long-term opioid therapy in terms of pain severity and mQOL but the majority do not. The challenge facing clinicians is how to identify who the responders will be.
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Affiliation(s)
- Hichem Saïdi
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Department of Pharmacology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - M. Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Aline Boulanger
- Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre d’expertise en gestion de la douleur du Réseau universitaire intégré en santé de l’Université de Montréal, Montreal, Quebec, Canada
- Québec Pain Research Network
| | - Mark A. Ware
- Québec Pain Research Network
- Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Québec Pain Research Network
- Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada
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177
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Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy. Spine (Phila Pa 1976) 2018; 43:594-602. [PMID: 28837531 DOI: 10.1097/brs.0000000000002385] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort. OBJECTIVE The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD). SUMMARY OF BACKGROUND DATA The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. METHODS Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). RESULTS Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. CONCLUSION Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. LEVEL OF EVIDENCE 3.
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Rizzo RRN, Medeiros FC, Pires LG, Pimenta RM, McAuley JH, Jensen MP, Costa LOP. Hypnosis Enhances the Effects of Pain Education in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. THE JOURNAL OF PAIN 2018; 19:1103.e1-1103.e9. [PMID: 29654980 DOI: 10.1016/j.jpain.2018.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/06/2018] [Accepted: 03/15/2018] [Indexed: 01/03/2023]
Abstract
The potential benefits of combining pain education (PE) with clinical hypnosis (CH) has not yet been investigated in individuals with chronic pain. A total of 100 patients with chronic nonspecific low back pain were randomized to receive either: 1) PE alone, or 2) PE with CH. Outcomes were collected by a blinded assessor at 2 weeks and 3 months after randomization. The primary outcomes were average pain intensity, worst pain intensity (both assessed with 11-point numeric rating scales), and disability (24-item Roland Morris Disability Questionnaire) at 2 weeks. At 2 weeks, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.35 points, 95% confidence interval [CI] = .32-2.37) and disability (mean difference = 2.34 points, 95% CI = .06-4.61), but not average pain intensity (mean difference = .67 point, 95% CI = -.27 to 1.62), relative to participants who received PE alone. PE with CH participants also reported more global perceived benefits at 2 weeks (mean difference = -1.98 points, 95% CI = -3.21 to -.75). At 3 months, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.32 points, 95% CI = .29-2.34) and catastrophizing (mean difference = 5.30 points, 95% CI = 1.20-9.41). No adverse effects in either treatment condition were reported. To our knowledge, this is the first trial showing that additional use of hypnosis with PE results in improved outcomes over PE alone in patients with chronic nonspecific low back pain. PERSPECTIVE This study provides evidence supporting the efficacy of another treatment option for teaching patients to self-manage chronic low back pain that has a relatively low cost and that can be offered in groups.
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Affiliation(s)
- Rodrigo R N Rizzo
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil.
| | - Flavia C Medeiros
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Leandro G Pires
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Rafael M Pimenta
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - James H McAuley
- Neuroscience Research Australia (NeuRA), Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Leonardo O P Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
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Koes BW, Backes D, Bindels PJE. Pharmacotherapy for chronic non-specific low back pain: current and future options. Expert Opin Pharmacother 2018; 19:537-545. [PMID: 29578822 DOI: 10.1080/14656566.2018.1454430] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Low back pain is associated with a large burden-of-illness. It is responsible for the most years lived with disability as compared with any other medical condition. A comprehensive overview of the evidence on pharmacological treatment options for chronic low back pain is lacking. This review evaluates the evidence for the benefits and risks of currently available pharmacological treatments for chronic low back pain. AREAS COVERED The authors focus on the recent (Cochrane) systematic reviews and meta-analyses of randomized clinical trials covering paracetamol (acetaminophen), NSAIDs, muscle relaxants, antidepressants, anticonvulsants, opioids, and other (new) drugs. EXPERT OPINION The overall impression of the efficacy of pharmacological treatments for patients with chronic low back pain is rather sobering. The effects on pain reduction and improvement of function are commonly small to moderate and short lasting when compared to placebo. At the same time, the various types of drugs are not without side-effects. This holds especially true for serious side-effects associated with (prolonged) use of strong opioids. Future studies on patients with chronic back pain should aim to identify subgroups of patients with good response to specific pharmacological treatment to facilitate personalized care.
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Affiliation(s)
- Bart W Koes
- a Department of General Practice , Erasmus MC , Rotterdam , The Netherlands
| | - Daan Backes
- a Department of General Practice , Erasmus MC , Rotterdam , The Netherlands
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Traeger AC, Buchbinder R, Harris IA, Clavisi OM, Maher CG. Avoid routinely prescribing medicines for non-specific low back pain. Br J Sports Med 2018. [DOI: 10.1136/bjsports-2017-098614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 2018; 319:872-882. [PMID: 29509867 PMCID: PMC5885909 DOI: 10.1001/jama.2018.0899] [Citation(s) in RCA: 585] [Impact Index Per Article: 97.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/01/2018] [Indexed: 01/20/2023]
Abstract
Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain. Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects. Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized. Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19). Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, -0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]). Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. Trial Registration clinicaltrials.gov Identifier: NCT01583985.
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MESH Headings
- Acetaminophen/therapeutic use
- Adult
- Aged
- Aged, 80 and over
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Back Pain/drug therapy
- Chronic Pain/drug therapy
- Chronic Pain/etiology
- Drug Therapy, Combination
- Female
- Humans
- Intention to Treat Analysis
- Male
- Middle Aged
- Osteoarthritis, Hip/complications
- Osteoarthritis, Hip/drug therapy
- Osteoarthritis, Knee/complications
- Osteoarthritis, Knee/drug therapy
- Pain Measurement
- Young Adult
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Affiliation(s)
- Erin E. Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Agnes C. Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Elizabeth S. Goldsmith
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minneapolis, Minnesota
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Matthew J. Bair
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
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Borgundvaag B, McLeod S, Khuu W, Varner C, Tadrous M, Gomes T. Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open 2018; 6:E110-E117. [PMID: 29506986 PMCID: PMC5878958 DOI: 10.9778/cmajo.20170151] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Emergency physicians provide primary care to patients and often prescribe opioids for acutely painful self-limiting conditions. The objective of this study was to describe patterns of opioid prescribing by emergency physicians and family physicians and to explore the relation between setting of initiation of opioid treatment and adverse events over the subsequent 2 years. METHODS This was a population-based cohort study using administrative data from Ontario. Opioid-naive patients aged 15-64 years who received an opioid prescription for noncancer pain from an emergency or family physician between Apr. 1, 2008, and Mar. 31, 2012 were eligible for inclusion. RESULTS A total of 34 713 and 45 952 patients were initiated on an opioid by an emergency physicians and family physicians, respectively. Both emergency and family physicians most commonly prescribed codeine-containing products (58.9% and 79.6% of prescriptions, respectively); however, emergency physicians were twice as likely as family physicians to prescribe higher-potency opioids (morphine, oxycodone, hydromorphone, fentanyl, meperidine) (both combination and single-agent preparations) (40.6% v. 19.9%, ∆ = 20.7, 95% confidence interval [CI] 20.0-21.3). Compared to patients in the family physician group, those in the emergency physician group received significantly higher daily dosages, a higher proportion were initiated on a daily dosage of 100 mg of morphine equivalents (MEQs) or more, and had a hospital admission for opioid toxicity within 2 years (0.5% v. 0.3%, ∆ = 0.2%, 95% CI 0.1%-0.3%). A higher proportion of patients in the family physician group than in the emergency physician group had dosage escalation beyond 199 mg MEQs within 2 years (0.7% v. 0.1%, ∆ = 0.6%, 95% CI 0.5%-0.7%). INTERPRETATION Codeine was the most common opioid prescribed by emergency and family physicians. Compared to patients prescribed opioids by family physicians, those prescribed opioids by emergency physicians received higher initial daily dosages and had an increased likelihood of opioid toxicity.
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Affiliation(s)
- Bjug Borgundvaag
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
| | - Shelley McLeod
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
| | - Wayne Khuu
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
| | - Catherine Varner
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
| | - Tara Gomes
- Affiliations: Division of Emergency Medicine (Borgundvaag, McLeod, Varner), Department of Family and Community Medicine, University of Toronto; Schwartz/Reisman Emergency Medicine Institute (Borgundvaag, McLeod, Varner), Mount Sinai Hospital; Li Ka Shing Knowledge Institute (Tadrous), St. Michael's Hospital; Institute for Clinical Evaluative Sciences (Khuu, Gomes); Leslie Dan Faculty of Pharmacy (Tadrous, Gomes), University of Toronto, Toronto, Ont
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183
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Ackerman IN, Zomer E, Gilmartin-Thomas JFM, Liew D. Forecasting the future burden of opioids for osteoarthritis. Osteoarthritis Cartilage 2018; 26:350-355. [PMID: 29129650 DOI: 10.1016/j.joca.2017.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To quantify the current national burden of opioids for osteoarthritis (OA) pain in Australia in terms of number of dispensed opioid prescriptions and associated costs, and to forecast the likely burden to the year 2030/31. DESIGN Epidemiological modelling. METHODS Published data were obtained on rates of opioid prescribing for people with OA and national OA prevalence projections. Trends in opioid dispensing from 2006 to 2016, and average costs for common opioid subtypes were obtained from the Pharmaceutical Benefits Scheme and Medicare Australia Statistics. Using these inputs, a model was developed to estimate the likely number of dispensed opioid prescriptions and costs to the public healthcare system by 2030/31. RESULTS In 2015/16, an estimated 1.1 million opioid prescriptions were dispensed in Australia for 403,954 people with OA (of a total 2.2 million Australians with OA). Based on recent dispensing trends and OA prevalence projections, the number of dispensed opioid prescriptions is expected to nearly triple to 3,032,332 by 2030/31, for an estimated 562,610 people with OA. The estimated cost to the Australian healthcare system was $AUD25.2 million in 2015/16, rising to $AUD72.4 million by 2030/31. CONCLUSION OA-related opioid dispensing and associated costs are set to increase substantially in Australia from 2015/16 to 2030/31. Use of opioids for OA pain is concerning given joint disease chronicity and the risk of adverse events, particularly among older people. These projections represent a conservative estimate of the full financial burden given additional costs associated with opioid-related harms and out-of-pocket costs borne by patients.
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Affiliation(s)
- I N Ackerman
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - E Zomer
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - J F-M Gilmartin-Thomas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - D Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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184
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Witkiewitz K, Vowles KE. Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review. Alcohol Clin Exp Res 2018; 42:478-488. [PMID: 29314075 PMCID: PMC5832605 DOI: 10.1111/acer.13594] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/29/2017] [Indexed: 12/20/2022]
Abstract
The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico, Albuquerque, NM
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185
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Nagpal AS, Eckmann M, Weinstein SM. Maintaining Opioid Prescription for Chronic Back Pain: Pro Versus Con. PM R 2018; 10:83-89. [PMID: 29413121 DOI: 10.1016/j.pmrj.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Ameet S Nagpal
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
| | - Maxim Eckmann
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
| | - Stuart M Weinstein
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
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186
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Owen GT, Bruel BM, Schade CM, Eckmann MS, Hustak EC, Engle MP. Evidence-based pain medicine for primary care physicians. Proc AMIA Symp 2018; 31:37-47. [PMID: 29686550 PMCID: PMC5903506 DOI: 10.1080/08998280.2017.1400290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The last several decades have seen a marked increase in both the recognition and treatment of chronic pain. Unfortunately, patients frequently misunderstand both the nature of pain and the best practices for its treatment. Because primary care physicians treat the majority of chronic pain, they are ideally situated to provide evidence-based pain care. The majority of the medical evidence supports a biopsychosocial model of pain that integrates physical, emotional, social, and cultural variables. The goal of this primer is to assist primary care physicians in their understanding of pain, evaluation of the chronic pain patient, and ability to direct evidence-based care. This article will discuss the role of physical rehabilitation, pain psychology, pharmacotherapy, and procedural interventions in the treatment of chronic pain. Given the current epidemic of drug-related deaths, particular emphasis is placed on the alternatives to opioid therapy. Unfortunately, death is not the only significant complication from opioid therapy, and this article discusses many of the most common side effects. This article provides general guidelines on the most appropriate utilization of opioids with emphasis on the recent Centers for Disease Control and Prevention guidelines, risk stratification, and patient monitoring. Finally, the article concludes with the critical role that a pain medicine specialist can play in the management of patients with chronic pain.
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Affiliation(s)
- Graves T. Owen
- Texas Pain Rehabilitation Institute, PA, Round Rock, Texas
| | - Brian M. Bruel
- University of Texas Southwestern Medical Center, Dallas, Texas
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187
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Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Gabriele Schorr S. Non-Specific Low Back Pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:883-890. [PMID: 29321099 PMCID: PMC5769319 DOI: 10.3238/arztebl.2017.0883] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition. METHODS The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process. RESULTS If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible. CONCLUSION A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.
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Affiliation(s)
- Jean-François Chenot
- Section Family Medicine, Institute for Community Medicine, University Hospital of Greifswald
| | | | - Bernd Kladny
- Department of Orthopedics, Fachklinik Herzogenaurach
| | - Frank Petzke
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
| | - Michael Pfingsten
- ain Clinic, Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Göttingen
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188
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Hirschtritt ME, Delucchi KL, Olfson M. Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993-2014. Prev Med Rep 2017; 9:49-54. [PMID: 29340270 PMCID: PMC5766756 DOI: 10.1016/j.pmedr.2017.12.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 01/22/2023] Open
Abstract
The combined use of opioid and benzodiazepine medications increases the risk of hazardous effects, such as respiratory depression. Although recent increases in outpatient use of opioid prescriptions have been documented, there are limited data regarding rates and correlates of combined opioid and benzodiazepines among adults in outpatient settings. Our objective was to examine annual trends in outpatient visits including opioids, benzodiazepines, and their combination among adults as well as clinical and demographic correlates. We used data from the 1993–2014 National Ambulatory Medical Care Survey (NAMCS) among non-elderly (i.e., ages 18–64 years) adults to examine the probability of a visit including an opioid, benzodiazepine, or their combination, in addition to clinical and demographic correlates. From 1993 to 2014, benzodiazepines-with-opioids visits increased from 9.8 to 62.5 (OR = 9.23, 95% CI = 5.45–15.65) per 10,000 visits. Highest-represented groups among benzodiazepines-with-opioids visits were older (50–64 years) (49.1%), white (88.8%), commercially insured (58.0%) patients during their first visit (87.6%) to a primary-care physician (41.9%). We identified a significant increase in the outpatient co-prescription of opioids and benzodiazepines, notably among adults aged 50–64 years during primary-care visits. Educational and policy changes to provide alternatives to benzodiazepine-with-opioid co-prescription and limiting opioid prescription to pain specialists may reduce rates of this potentially hazardous combination. Current guidelines for prescribing opioids recommend against co-administration with benzodiazepines Concurrent use of opioids and benzodiazepines increases the risk of overdose, respiratory depression, and death. We examined 22 years of outpatient prescribing patterns of opioids and benzodiazepines using a survey of US physicians. Over this period, visits with both opioids and benzodiazepines increased from roughly 9.8 to 62.5 per 10,000 visits. These visits were more likely among older (50–64 years), white, privately insured patients with a low-back pain diagnosis.
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Affiliation(s)
- Matthew E Hirschtritt
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, Box 0984-RTP, San Francisco, CA 94143, United States
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, Box 0984, San Francisco, CA 94143, United States
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
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189
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Megale RZ, Deveza LA, Blyth FM, Naganathan V, Ferreira PH, McLachlan AJ, Ferreira ML. Efficacy and Safety of Oral and Transdermal Opioid Analgesics for Musculoskeletal Pain in Older Adults: A Systematic Review of Randomized, Placebo-Controlled Trials. THE JOURNAL OF PAIN 2017; 19:475.e1-475.e24. [PMID: 29241834 DOI: 10.1016/j.jpain.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/31/2017] [Accepted: 12/02/2017] [Indexed: 11/19/2022]
Abstract
This systematic review with meta-analysis was performed to evaluate the efficacy and safety of using opioid analgesics in older adults with musculoskeletal pain. We searched Cochrane Library, MEDLINE, EMBASE, Web of Science, AMED, CINAHL, and LILACS for randomized controlled trials with mean population age of 60 years or older, comparing the efficacy and safety of opioid analgesics with placebo for musculoskeletal pain conditions. Reviewers extracted data, assessed risk of bias, and evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Random effects models were used to calculate standardized mean differences (when different scales were used across trials), mean differences and odds ratios with respective 95% confidence intervals (CIs). Meta-regressions were carried out to assess the influence of opioid analgesic daily dose and treatment duration on our main outcomes. We included 23 randomized placebo-controlled trials in the meta-analysis. Opioid analgesics had a small effect on decreasing pain intensity (standardized mean difference = -.27; 95% CI = -.33 to -.20) and improving function (standardized mean difference = -.27, 95% CI = -.36 to -.18), which was not associated with daily dose or treatment duration. The odds of adverse events were 3 times higher (odds ratio = 2.94; 95% CI = 2.33-3.72) and the odds of treatment discontinuation due to adverse events 4 times higher (odds ratio = 4.04; 95% CI = 3.10-5.25) in patients treated with opioid analgesics. The results show that in older adults suffering from musculoskeletal pain, using opioid analgesics had only a small effect on pain and function at the cost of a higher odds of adverse events and treatment discontinuation. For this specific population, the opioid-related risks may outweigh the benefits. PERSPECTIVE The systematic review shows that, in older adults suffering from musculoskeletal conditions, opioid analgesics have only a small effect on pain and disability. Conversely, this population is at higher risk of adverse events. The results may reflect age-related physiological changes in pain processing, pharmacokinetics, and pharmacodynamics.
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Affiliation(s)
- Rodrigo Z Megale
- Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School, The University of Sydney, New South Wales, Australia; FHEMIG-Fundacao Hospitalar do Estado de Minas Gerais, Minas Gerais, Brazil.
| | - Leticia A Deveza
- Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney and Ageing and Alzheimer's Institute, Concord Hospital, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney and Ageing and Alzheimer's Institute, Concord Hospital, New South Wales, Australia
| | - Paulo H Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, New South Wales, Australia
| | - Andrew J McLachlan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney and Ageing and Alzheimer's Institute, Concord Hospital, New South Wales, Australia; Faculty of Pharmacy and NHMRC Centre for Research Excellence in Medicines and Ageing, The University of Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Institute of Bone and Joint Research/The Kolling Institute, Sydney Medical School, The University of Sydney, New South Wales, Australia
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190
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Cassidy S, Trenell MI, Anderson KN. The cardio-metabolic impact of taking commonly prescribed analgesic drugs in 133,401 UK Biobank participants. PLoS One 2017; 12:e0187982. [PMID: 29211804 PMCID: PMC5718411 DOI: 10.1371/journal.pone.0187982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 10/30/2017] [Indexed: 11/18/2022] Open
Abstract
Objective There has been a significant increase in the prescribing of medication for chronic non-cancer pain. In a UK population sample, we aimed to assess cardio-metabolic (CM) health in those taking these chronic pain medications. Methods 133,401 participants from the UK Biobank cohort were studied. BMI, waist cm and hypertension were compared between those on drugs prescribed for chronic pain and CM drugs to those on CM drugs only. Multiple confounders were controlled for. Results Those taking opiates and CM drugs had the worst CM health profile with a 95%, 82% and 63% increased odds of reporting obesity, ‘very high risk’ waist circumference and hypertension, respectively (OR [95% CI] 1.95 [1.75–2.17], 1.82 [1.63–2.03], 1.63 [1.45–1.84]), compared to those on CM drugs alone. Those taking neuropathic pain medications and CM drugs also demonstrate worse CM profile than those taking CM drugs only. Conclusions The impact of medications for chronic pain and sleep upon CM health and obesity is of concern for these classes of drugs which have been recently labelled as dependency forming medications. The results from this cross sectional study warrants further investigation and adds further support to calls for these medications to be prescribed for shorter periods.
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Affiliation(s)
- Sophie Cassidy
- Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail:
| | - Michael I. Trenell
- Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kirstie N. Anderson
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
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191
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Henry N, Clouet J, Le Bideau J, Le Visage C, Guicheux J. Innovative strategies for intervertebral disc regenerative medicine: From cell therapies to multiscale delivery systems. Biotechnol Adv 2017; 36:281-294. [PMID: 29199133 DOI: 10.1016/j.biotechadv.2017.11.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 11/17/2017] [Accepted: 11/28/2017] [Indexed: 12/14/2022]
Abstract
As our understanding of the physiopathology of intervertebral disc (IVD) degeneration has improved, novel therapeutic strategies have emerged, based on the local injection of cells, bioactive molecules, and nucleic acids. However, with regard to the harsh environment constituted by degenerated IVDs, protecting biologics from in situ degradation while allowing their long-term delivery is a major challenge. Yet, the design of the optimal approach for IVD regeneration is still under debate and only a few papers provide a critical assessment of IVD-specific carriers for local and sustained delivery of biologics. In this review, we highlight the IVD-relevant polymers as well as their design as macro-, micro-, and nano-sized particles to promote endogenous repair. Finally, we illustrate how multiscale systems, combining in situ-forming hydrogels with ready-to-use particles, might drive IVD regenerative medicine strategies toward innovation.
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Affiliation(s)
- Nina Henry
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France; Institut des Matériaux Jean Rouxel (IMN), Université de Nantes, CNRS, 2 rue de la Houssinière, BP 32229, 44322 Nantes, Cedex 3, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France
| | - Johann Clouet
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France; CHU Nantes, Pharmacie Centrale, PHU 11, Nantes, France; Université de Nantes, UFR Sciences Biologiques et Pharmaceutiques, Nantes, France
| | - Jean Le Bideau
- Institut des Matériaux Jean Rouxel (IMN), Université de Nantes, CNRS, 2 rue de la Houssinière, BP 32229, 44322 Nantes, Cedex 3, France
| | - Catherine Le Visage
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France.
| | - Jérôme Guicheux
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France; CHU Nantes, PHU 4 OTONN, Nantes, France.
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192
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Machado GC, Rogan E, Maher CG. Managing non-serious low back pain in the emergency department: Time for a change? Emerg Med Australas 2017; 30:279-282. [DOI: 10.1111/1742-6723.12903] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/16/2017] [Accepted: 10/24/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Gustavo C Machado
- School of Public Health; Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
| | - Eileen Rogan
- Emergency Department; Canterbury Hospital; Sydney New South Wales Australia
| | - Chris G Maher
- School of Public Health; Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Institute for Musculoskeletal Health; Sydney Local Health District; Sydney New South Wales Australia
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193
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Vigil JM, Stith SS, Adams IM, Reeve AP. Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLoS One 2017; 12:e0187795. [PMID: 29145417 PMCID: PMC5690609 DOI: 10.1371/journal.pone.0187795] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Current levels and dangers of opioid use in the U.S. warrant the investigation of harm-reducing treatment alternatives. PURPOSE A preliminary, historical, cohort study was used to examine the association between enrollment in the New Mexico Medical Cannabis Program (MCP) and opioid prescription use. METHODS Thirty-seven habitual opioid using, chronic pain patients (mean age = 54 years; 54% male; 86% chronic back pain) enrolled in the MCP between 4/1/2010 and 10/3/2015 were compared to 29 non-enrolled patients (mean age = 60 years; 69% male; 100% chronic back pain). We used Prescription Monitoring Program opioid records over a 21 month period (first three months prior to enrollment for the MCP patients) to measure cessation (defined as the absence of opioid prescriptions activity during the last three months of observation) and reduction (calculated in average daily intravenous [IV] morphine dosages). MCP patient-reported benefits and side effects of using cannabis one year after enrollment were also collected. RESULTS By the end of the 21 month observation period, MCP enrollment was associated with 17.27 higher age- and gender-adjusted odds of ceasing opioid prescriptions (CI 1.89 to 157.36, p = 0.012), 5.12 higher odds of reducing daily prescription opioid dosages (CI 1.56 to 16.88, p = 0.007), and a 47 percentage point reduction in daily opioid dosages relative to a mean change of positive 10.4 percentage points in the comparison group (CI -90.68 to -3.59, p = 0.034). The monthly trend in opioid prescriptions over time was negative among MCP patients (-0.64mg IV morphine, CI -1.10 to -0.18, p = 0.008), but not statistically different from zero in the comparison group (0.18mg IV morphine, CI -0.02 to 0.39, p = 0.081). Survey responses indicated improvements in pain reduction, quality of life, social life, activity levels, and concentration, and few side effects from using cannabis one year after enrollment in the MCP (ps<0.001). CONCLUSIONS The clinically and statistically significant evidence of an association between MCP enrollment and opioid prescription cessation and reductions and improved quality of life warrants further investigations on cannabis as a potential alternative to prescription opioids for treating chronic pain.
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Affiliation(s)
- Jacob M. Vigil
- University of New Mexico, Department of Psychology, Albuquerque, New Mexico, United States of America
| | - Sarah S. Stith
- University of New Mexico, Department of Economics, Albuquerque, New Mexico, United States of America
| | - Ian M. Adams
- Industrial Rehabilitation Clinics, Albuquerque, New Mexico, United States of America
| | - Anthony P. Reeve
- Industrial Rehabilitation Clinics, Albuquerque, New Mexico, United States of America
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Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ 2017; 189:E1386-E1395. [PMID: 29133540 PMCID: PMC5687927 DOI: 10.1503/cmaj.170527] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Adrian Traeger
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Rachelle Buchbinder
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Ian Harris
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Chris Maher
- School of Public Health (Traeger, Maher), Sydney Medical School, University of Sydney, Sydney, Australia; Monash Department of Clinical Epidemiology (Buchbinder), Cabrini Institute, Malvern, Australia; Department of Epidemiology and Preventive Medicine (Buchbinder), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Whitlam Orthopaedic Research Centre (Harris), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
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Huang L, Zhou JG, Zhang Y, Wang F, Wang Y, Liu DH, Li XJ, Lv SP, Jin SH, Bai YJ, Ma H. Opioid-Induced Constipation Relief From Fixed-Ratio Combination Prolonged-Release Oxycodone/Naloxone Compared With Oxycodone and Morphine for Chronic Nonmalignant Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Pain Symptom Manage 2017; 54:737-748.e3. [PMID: 28736104 DOI: 10.1016/j.jpainsymman.2017.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/16/2017] [Accepted: 07/06/2017] [Indexed: 01/08/2023]
Abstract
CONTEXT Opioid-induced constipation (OIC) is one of the most frequent and severe adverse events (AEs) after treatment with opioids. Recent studies have indicated that fixed-ratio combination prolonged-release oxycodone/naloxone (OXN PR) could decrease OIC with similar pain relief compared with other opioids. OBJECTIVES We systematically reviewed (PROSPERO registration numbers: CRD42016036244) the constipation relief of OXN PR compared with other opioids regardless of formulation, prolonged release, or extended release used for the relief of chronic pain. METHODS Relevant studies were identified by searching PubMed, EMBASE, Web of Science, and the Cochrane library from inception to May 2016, with an update to December 2016. We quantitatively analyzed OIC (assessed by bowel function index [BFI]), pain intensity, and AEs. RESULTS A total of 167 articles were identified from the databases. Finally seven studies with 3217 patients were included in our meta-analysis, including 1322 patients in OXN PR treatment groups and 1885 patients in prolonged-release oxycodone (OXY PR) or prolonged-release morphine (MOR PR) control group. The relative risk (RR) of OIC was decreased in OXN PR (RR 0.52, 95% CI 0.44; 0.62). Whether BFI was better or worse at baseline, the mean difference (MD) of BFI -17.48 95% CI -21.60; -13.36) was better after treatment with OXN PR with clinical importance at the end of intervention; moreover, the BFI of the OXN PR-treated group was closer to normal BFI scores. However, clinical BFI change from baseline to the end measurement only existed in patients when the baseline BFI was high (mean [SDs] 61.0 [23.39]-67.40 [19.51]), and the MD of the BFI was -15.96 (95% CI -25.56; -15.48). The RR of AEs was also smaller (RR 0.80; 95% CI 0.69-0.93), but the severity or duration of AEs was not reported. Pain intensity was also significantly decreased in the OXN PR treatment groups (MD -3.84, 95% CI -7.14; -0.55), although there was no clinically meaningful difference. CONCLUSION For people with chronic pain, treatment with OXN PR decreases the incidence of OIC and provides intermediate-term bowel function improvement with clinical importance; in addition, pain relief is not weakened. The OIC after treatment with OXN PR for cancer-related pain and over the long term remains unknown.
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Affiliation(s)
- Lang Huang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jian-Guo Zhou
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yu Zhang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fei Wang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Wang
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Da-Hai Liu
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xin-Juan Li
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shui-Ping Lv
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Su-Han Jin
- Affiliated Stomatological Hospital of Zunyi Medical University, Zunyi, China
| | - Yu-Ju Bai
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Hu Ma
- Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
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Guillén-Astete CA, Cardona-Carballo C, de la Casa-Resino C. Tapentadol versus tramadol in the management of low back pain in the emergency department: Impact of use on the need for reassessments. Medicine (Baltimore) 2017; 96:e8403. [PMID: 29137025 PMCID: PMC5690718 DOI: 10.1097/md.0000000000008403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Nontraumatic musculoskeletal disorders are the main reason for presentation to the emergency department (ED), with rachialgia (back pain) being the most common reason to request medical assessment among them. This also generates the highest demand for reassessments due to poor pain control or onset of adverse reactions to the treatment prescribed in the initial assessment.A retrospective observational study based on usual clinical practice was conducted in patients attending the ED due to low back pain during a period of 24 months. The primary objective was to determine the demand for reassessments in the ED by these patients in the following 30 days, according to the type of therapeutic approach used in the initial assessment.A total of 732 patients who requested medical assessment due to back pain in the ED of our hospital were analyzed, 91 of whom were treated with tapentadol whereas 641 received another treatment. In the first month after the initial assessment, reassessments were less common in the tapentadol group; this difference was significant from days 8 to 15 (P = 0.001, odds ratio [OR] 0.252 with 95% confidence interval [CI] 0.100-0.635) and days 15 to 30 (P < 10, OR 0.277 with 95% CI 0.136-0.563). Patients who received tapentadol also had a better clinical evolution of pain compared to those who did not receive it (P < 10) and to those who received tramadol (P < 10).In this study in patients with back pain, tapentadol shows clear advantages over the other analgesics analyzed, in terms of pain control and less need for reassessments.
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Predictors of Outcome in Conservative and Minimally Invasive Surgical Management of Pain Originating From the Sacroiliac Joint: A Pooled Analysis. Spine (Phila Pa 1976) 2017; 42:1664-1673. [PMID: 28350586 PMCID: PMC5636200 DOI: 10.1097/brs.0000000000002169] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A pooled patient-level analysis of two multicenter randomized controlled trials and one multicenter single-arm prospective trial. OBJECTIVE The aim of this study was to identify predictors of outcome of conservative and minimally invasive surgical management of pain originating from the sacroiliac joint (SIJ). SUMMARY OF BACKGROUND DATA Three recently published prospective trials have shown that minimally invasive SIJ fusion (SIJF) using triangular titanium implants produces better outcomes than conservative management for patients with pain originating from the SIJ. Due to limitations in individual trial sample size, analyses of predictors of treatment outcome were not conducted. METHODS We pooled individual patient data from the three trials and used random effects models with multivariate regression analysis to identify predictors for treatment outcome separately for conservative and minimally invasive surgical treatment. Outcome was measured using visual analogue scale (VAS), Oswestry Disability Index (ODI), and EuroQOL-5D (EQ-5D). RESULTS We included 423 patients assigned to either nonsurgical management (NSM, n = 97) or SIJF (n = 326) between 2013 and 2015. The reduction in SIJ pain was 37.9 points larger [95% confidence interval (95% CI) 32.5-43.4, P < 0.0001] in the SIJF group than in the NSM group. Similarly, the improvement in ODI was 18.3 points larger (95% CI 14.3-22.4), P < 0.0001). In NSM, we found no predictors of outcome. In SIJF, a reduced improvement in outcome was predicted by smoking (P = 0.030), opioid use (P = 0.017), lower patient age (P = 0.008), and lower duration of SIJ pain (P = 0.028). CONCLUSIONS Our results support the view that SIJF leads to better treatment outcome than conservative management of SIJ pain and that a higher margin of improvement can be predicted in nonsmokers, nonopioid users, and patients of increased age and with longer pain duration. LEVEL OF EVIDENCE 1.
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Prolonged Preoperative Opioid Therapy in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting. Spine (Phila Pa 1976) 2017; 42:E1140-E1146. [PMID: 28187073 DOI: 10.1097/brs.0000000000002112] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the impact of prolonged opioid use in the preoperative treatment plan of degenerative lumbar stenosis (DLS). SUMMARY OF BACKGROUND DATA Patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. The relative paucity of data on the relationship between preoperative opioid use and clinical outcomes in the workers' compensation (WC) population necessitates further study of this unique population. METHODS We identified 140 Ohio WC patients who underwent lumbar decompression and had received preoperative opioid prescriptions between 1993 and 2013. Our study cohorts were formed based on opioid use duration, which included short-term use (<3 months) and long-term use (>3 months). Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to determine the impact of the duration of preoperative opioid use on return to work rates. We also compared many secondary outcomes after surgery between both groups. RESULTS Patients on opioids less than 3 months had a significantly higher RTW rate compared with those who used opioids longer than 3 months [25/60 (42%) vs. 18/80 (23%); P = 0.01]. A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW (OR: 0.35, 95% CI: 0.13-0.89; P = 0.02). Patients who remained on opioid therapy longer than 3 months cost the Ohio Bureau of Workers' Compensation $70,979 more than patients who were on opioid therapy for less than 3 months (P < 0.01). CONCLUSION Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS. LEVEL OF EVIDENCE 3.
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Krebs EE, Jensen AC, Nugent S, DeRonne B, Rutks I, Leverty D, Gravely A, Noorbaloochi S, Bair MJ, Kroenke K. Design, recruitment outcomes, and sample characteristics of the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. Contemp Clin Trials 2017; 62:130-139. [PMID: 28893675 DOI: 10.1016/j.cct.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/29/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
This manuscript describes the study protocol, recruitment outcomes, and baseline participant characteristics for the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. SPACE is a pragmatic randomized comparative effectiveness trial conducted in multiple VA primary care clinics within one VA health care system. The objective was to compare benefits and harms of opioid therapy versus non-opioid medication therapy over 12months among patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain despite analgesic therapy; patients already receiving regular opioid therapy were excluded. Key design features include comparing two clinically-relevant medication interventions, pragmatic eligibility criteria, and flexible treat-to-target interventions. Screening, recruitment and study enrollment were conducted over 31months. A total of 4491 patients were contacted for eligibility screening; 53.1% were ineligible, 41.0% refused, and 5.9% enrolled. The most common reasons for ineligibility were not meeting pain location and severity criteria. The most common study-specific reasons for refusal were preference for no opioid use and preference for no pain medications. Of 265 enrolled patients, 25 withdrew before randomization. Of 240 randomized patients, 87.9% were male, 84.1% were white, and age range was 21-80years. Past-year mental health diagnoses were 28.3% depression, 17% anxiety, 9.4% PTSD, 7.9% alcohol use disorder, and 2.6% drug use disorder. In conclusion, although recruitment for this trial was challenging, characteristics of enrolled participants suggest we were successful in recruiting patients similar to those prescribed opioid therapy in usual care.
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Affiliation(s)
- Erin E Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA.
| | - Agnes C Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Indulis Rutks
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - David Leverty
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA
| | - Matthew J Bair
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
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Abstract
Sciatica is a debilitating condition affecting approximately 25 % of the population. Typically, the patient will complain of lower limb pain that is more severe than pain in the lower back, usually accompanied by numbness and motor weakness. Most international guidelines recommend pharmacological management for the pain relief of sciatica, including paracetamol, non-steroidal anti-inflammatory drugs, opioid analgesics, anticonvulsants, and corticosteroids, among others. However, the evidence for most of these pharmacological options is scarce, and the majority of clinical trials exclude older patients. There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients with sciatica. This review presents a critical appraisal of the existing evidence for the pharmacological treatment of sciatica, with a special focus on the older adult. The age-related changes in the health of older patients, as well as their impact on the response to pharmacological treatment, including polypharmacy, drug interactions, and drug-disease interactions, is also discussed.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, PO Box M201, Missenden Rd, Sydney, NSW, 2050, Australia. .,Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Andrew McLachlan
- Faculty of Pharmacy and Centre for Education and Research in Ageing, The University of Sydney and Concord Hospital, Sydney, NSW, Australia
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