An observational study of health-related quality of life and pain outcomes in chronic low back pain patients treated with fentanyl transdermal system

The relationship between kinesiophobia severity and clinical parameters in patients with mechanical low back pain

BACKGROUND

Low back pain is an important widespread health problem that can occur at any age, causing serious socioeconomic losses.

OBJECTIVE

The objective of this study is to investigate the relationship between kinesiophobia severity and pain severity, depression, and quality of life in patients with mechanical low back pain.

METHODS

The study sample consisted of 155 patients, of whom 72 were female and 83 were male, aged between 18 and 75 years with mechanical low back pain. Quality of life was assessed with the 36-Item Short Form Health Survey (SF-36), pain intensity with the Visual Analogue Scale (VAS), kinesiophobia with the Tampa Kinesiophobia Scale (TKS), and depression with the Beck Depression Inventory (BDI). Patients were divided into the low (TKS ⩽ 37) and high kinesiophobia (TKS > 37) groups according to the scores they obtained from TKS.

RESULTS

VAS-pain severity and BDI scores were significantly higher in the high kinesiophobia group than in the low kinesiophobia group (p< 0.001). On the other hand, the SF-36 subscale scores were significantly higher in the low kinesiophobia group than in the high kinesiophobia group (p< 0.001). The TKS scores were moderately correlated with VAS-pain severity (r= 0.470; p< 0.001) and BDI scores (r= 0.584; p< 0.001) in the positive direction, and strongly correlated with all sub-parameters of quality of life in the negative direction (p< 0.001).

CONCLUSION

The results indicated that the severity of kinesiophobia in patients with non-inflammatory low back pain is associated with pain severity, depression, and poor quality of life.

Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial

BACKGROUND

Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems.

DESIGN

The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss).

SUMMARY

The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

Predicting Persistent Disabling Low Back Pain in Veterans Affairs Primary Care Using the STarT Back Tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT Back) is a stratified care approach to low back pain (LBP) treatment. The predictive validity of STarT Back in Veterans Affairs (VA) primary care has not been demonstrated.

OBJECTIVE

To examine the validity of the STarT Back tool for predicting future persistent disabling LBP in VA primary care.

DESIGN

Cohort study.

SETTING

VA primary care in Washington State.

PARTICIPANTS

Veterans seeking care for LBP in VA primary care clinics.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The STarT Back tool was used to classify Veterans according to their baseline risk group (low vs medium vs high). The primary study outcome, persistent disabling LBP, was defined as a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 7 at 6-month follow-up. Analyses examined discrimination and calibration of the baseline STarT Back risk groups for prediction of persistent disabling LBP at 6-month follow-up.

RESULTS

Of the study sample, 9% were female and 80% reported longstanding LBP (>5 year duration). Among 538 participants, the baseline STarT Back risk groups were associated with future persistent disabling LBP at 6-month follow-up. Within each baseline STarT Back risk group, the proportions with future persistent disabling LBP at 6-month follow-up were 54% (low risk), 88% (medium risk), and 97% (high risk). The baseline STarT Back risk groups had useful discrimination (area under the curve [AUC] 0.79) for predicting future persistent disabling LBP, but the proportion of Veterans with persistent disabling LBP at 6-month follow-up was substantially higher than that observed in non-VA primary care settings.

CONCLUSIONS

The STarT Back risk groups had useful discrimination (AUC = 0.79) for future persistent disabling LBP, but calibration was poor, underestimating the risk of persistent disabling LBP. The STarT Back tool may require updating for use in VA primary care.

Cost-effectiveness of Yoga for Chronic Low Back Pain in Veterans

BACKGROUND

Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP).

OBJECTIVE

Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care.

METHODS

Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon.

RESULTS

Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost.

DISCUSSION/CONCLUSIONS

Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.

Prevalence of Low Back Pain and Relationship to Mental Health Symptoms and Quality of Life After a Deployment-related Lower Limb Amputation

STUDY DESIGN

Retrospective, cross-sectional study.

OBJECTIVE

To assess the prevalence and association of low back pain (LBP) with psychosocial factors in Service members with amputations.

SUMMARY OF BACKGROUND DATA

LBP is a common secondary health condition after amputation with important implications related to function and quality of life. A growing body of evidence suggests that psychosocial factors influence LBP in patients without amputation. However, there is a dearth of information regarding the association of psychosocial factors and LBP after amputation.

METHODS

Seventy-nine individuals with lower limb amputations who were a part of the Wounded Warrior Recovery Project were included in the analysis. Data on posttraumatic stress disorder (PTSD), depression, and quality of life (QOL) were collected from the Wounded Warrior Recovery Project, while data on LBP and LBP chronicity were extracted from the Military Health System Data Repository. General linear models were utilized to analyze associations between LBP and psychosocial factors, while controlling for injury severity and time since amputation.

RESULTS

In individuals with amputations, 19.0% had acute LBP and 49.4% had recurrent LBP. Individuals with amputations and recurrent LBP reported higher PTSD symptom severity compared with those without LBP (B = 9.213, P < 0.05). More severe depression symptoms were observed in those with amputations and recurrent LBP compared with those without LBP (B = 5.626, P < 0.05). Among individuals with amputations, those with recurrent LBP reported lower QOL compared with those without LBP (B = -0.058, P < 0.05). There were no differences in PTSD, depression or QOL in those with amputations with and without acute LBP.

CONCLUSIONS

Presence of recurrent LBP after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower QOL. Further research is needed to assess the efficacy of addressing psychosocial factors for improving pain and function in service members with amputations and LBP.

LEVEL OF EVIDENCE

3.

Patient Experience of Living with Orofacial Pain: An Interpretive Phenomenological Study

This study investigated the experience of living with chronic orofacial pain. Participating in this study's individual in-depth interviews were 6 participants with chronic orofacial pain who were undergoing treatment at a pain clinic. In consideration of the empirical nature of the study, the interviews were transcribed verbatim and analyzed from an interpretive phenomenological approach. The participants in the study experienced various types of loss as a result of chronic pain, such as the loss of employment, self-identity, and the ability to enjoy eating and engaging in social activities. Other findings revealed a disbelief among the families and medical community in the pain reported by the participants in this study. In addition, the current study explores the dissatisfaction of these participants with their journey through the health care system. Previous studies have concentrated on chronic pain predominantly through quantitative methods based on measurements, such as questionnaires. The biomedical aspects of pain are essential to report, yet the emphasis on this can result in overlooking the experience of living with chronic pain. Qualitative methodologies are necessary for gaining a more profound understanding of and appreciation for the individual patient and his or her unique perspective. The present study may benefit those living with chronic pain, since this sharing of experiences can help sufferers feel less isolated in their agony. The current article's intention is to report these experiences in such a way that chronic pain sufferers and laypeople can comprehend and relate to them. In addition, the findings of this study should promote the knowledge and understanding of health care providers who deal with chronic pain sufferers, so that treatment is provided with more empathy and compassion. Knowledge Transfer Statement: The findings of the present study may assist health care professionals interacting regularly with sufferers of chronic pain to gain a deeper understanding of the chronic pain experience and how to best support these patients.

The effect of manual therapy and exercise in patients with chronic low back pain: Double blind randomized controlled trial

BACKGROUND AND OBJECTIVES

To determine the effects of spinal stabilization exercises (SSE) and manual therapy methods on pain, function and quality of life (QoL) levels in individuals with chronic low back pain (CLBP).

METHODS

A total of one-hundred thirteen patients diagnosed as CLBP were enrolled to the study. The patients allocated into Spinal Stabilization group (SG) and manual therapy group (MG), randomly. While SSE performed in SG, soft tissue mobilizations, muscle-energy techniques, joint mobilizations and manipulations were performed in MG. While the severity of pain was assessed with Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form 36 (SF-36) assessments were performed to evaluate the functional status and QoL, respectively. All assessments were repeated before and after the treatment.

RESULTS

Intragroup analyses both treatments were effective in terms of sub parameters of pain, function and life quality (p< 0.05). Inter group analyses, there was more reduction in pain and improvement in functional status in favor of MG (p< 0.05).

CONCLUSIONS

This study showed that SSE and manual therapy methods have the same effects on QoL, while the manual treatment is more effective on the pain and functional parameters in particular.

Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial

INTRODUCTION

Chronic low back pain (cLBP) is prevalent, especially among military veterans. Many cLBP treatment options have limited benefits and are accompanied by side effects. Major efforts to reduce opioid use and embrace nonpharmacological pain treatments have resulted. Research with community cLBP patients indicates that yoga can improve health outcomes and has few side effects. The benefits of yoga among military veterans were examined.

DESIGN

Participants were randomized to either yoga or delayed yoga treatment in 2013-2015. Outcomes were assessed at baseline, 6 weeks, 12 weeks, and 6 months. Intention-to-treat analyses occurred in 2016.

SETTING/PARTICIPANTS

One hundred and fifty military veterans with cLBP were recruited from a major Veterans Affairs Medical Center in California.

INTERVENTION

Yoga classes (with home practice) were led by a certified instructor twice weekly for 12 weeks, and consisted primarily of physical postures, movement, and breathing techniques.

MAIN OUTCOME MEASURES

The primary outcome was Roland-Morris Disability Questionnaire scores after 12 weeks. Pain intensity was identified as an important secondary outcome.

RESULTS

Participant characteristics were mean age 53 years, 26% were female, 35% were unemployed or disabled, and mean back pain duration was 15 years. Improvements in Roland-Morris Disability Questionnaire scores did not differ between the two groups at 12 weeks, but yoga participants had greater reductions in Roland-Morris Disability Questionnaire scores than delayed treatment participants at 6 months -2.48 (95% CI= -4.08, -0.87). Yoga participants improved more on pain intensity at 12 weeks and at 6 months. Opioid medication use declined among all participants, but group differences were not found.

CONCLUSIONS

Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. The magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use. The findings support wider implementation of yoga programs for veterans.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02524158.

Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial

BACKGROUND

Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations.

METHODS/DESIGN

This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records.

DISCUSSION

This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02224183.

Yoga for veterans with chronic low back pain: Design and methods of a randomized clinical trial

Chronic low back pain (CLBP) afflicts millions of people worldwide, with particularly high prevalence in military veterans. Many treatment options exist for CLBP, but most have limited effectiveness and some have significant side effects. In general populations with CLBP, yoga has been shown to improve health outcomes with few side effects. However, yoga has not been adequately studied in military veteran populations. In the current paper we will describe the design and methods of a randomized clinical trial aimed at examining whether yoga can effectively reduce disability and pain in US military veterans with CLBP. A total of 144 US military veterans with CLBP will be randomized to either yoga or a delayed treatment comparison group. The yoga intervention will consist of 2× weekly yoga classes for 12weeks, complemented by regular home practice guided by a manual. The delayed treatment group will receive the same intervention after six months. The primary outcome is the change in back pain-related disability measured with the Roland-Morris Disability Questionnaire at baseline and 12-weeks. Secondary outcomes include pain intensity, pain interference, depression, anxiety, fatigue/energy, quality of life, self-efficacy, sleep quality, and medication usage. Additional process and/or mediational factors will be measured to examine dose response and effect mechanisms. Assessments will be conducted at baseline, 6-weeks, 12-weeks, and 6-months. All randomized participants will be included in intention-to-treat analyses. Study results will provide much needed evidence on the feasibility and effectiveness of yoga as a therapeutic modality for the treatment of CLBP in US military veterans.

Quality of life under oxycodone/naloxone, oxycodone, or morphine treatment for chronic low back pain in routine clinical practice

OBJECTIVE

To compare the quality of life of patients with moderate-to-severe chronic low back pain under treatment with the WHO-step III opioids oxycodone/naloxone, oxycodone, or morphine in routine clinical practice.

STUDY DESIGN

Prospective, 12-week, randomized, open-label, blinded end-point study in 88 medical centers in Germany.

PATIENTS AND METHODS

A total of 901 patients requiring around-the-clock pain treatment with a WHO-step III opioid were randomized to either morphine, oxycodone, or oxycodone/naloxone (1:1:1). Changes from baseline to week 12 in quality of life were assessed using different validated tools (EuroQoL-5 Dimensions [EQ-5D], Short Form 12 [SF-12], quality of life impairment by pain inventory [QLIP]).

RESULTS

EQ-5D weighted index scores significantly improved over the 12-week treatment period under all three opioids (P<0.001) with significantly greater improvements under oxycodone/naloxone (65.2% vs 49.6% for oxycodone and 48.2% for morphine, P<0.001). The proportion of patients without EQ-5D complaints was also significantly higher under oxycodone/naloxone (P<0.001). Although quality of life ratings with the QLIP inventory showed significant improvements in all the three treatment arms, improvements were significantly higher under oxycodone/naloxone than under oxycodone and morphine (P<0.001): 90.7% of all oxycodone/naloxone patients achieved ≥30% improvements in quality of life, 72.8% had ≥50%, and 33.2% ≥70% improvements. Similarly, both physical and mental SF-12 component scores showed significantly greater improvements under oxycodone/naloxone with both scores close to the German population norm after 12 weeks.

CONCLUSION

Treatment with morphine, oxycodone, or oxycodone/naloxone under routine daily practice conditions significantly improved state of health and quality of life of patients with moderate-to-severe low back pain over a 12-week treatment period. Comparison between the treatment groups showed significantly greater improvements for oxycodone/naloxone than for the other two opioids.

Quality of life increases in patients with painful diabetic neuropathy following treatment with spinal cord stimulation

Purpose

This study aims to explore the changes in pain intensity and quality of life (QoL) experienced by patients with painful diabetic neuropathy (PDN) treated with spinal cord stimulation (SCS) and conventional medical practice (CMP).

Methods

Patient-reported pain intensity and QoL data were obtained from participants in an international multicentre randomised controlled trial comparing SCS versus CMP. Data were collected at randomisation and 6 month follow up by means of a visual analogue scale for pain intensity, the EuroQoL Visual Analogue Scale (EQ VAS) and the EuroQol EQ-5D index. Quality-adjusted life years (QALYs) were calculated for each treatment using the ‘area under the curve’ method. Differences in QALYs were calculated after adjusting for between-treatment imbalances in baseline QoL.

Results

At 6 months, patients allocated to SCS reported larger reductions in pain intensity and improvements in QoL measured by the EQ-5D utility score and EQ VAS as compared to those allocated to CMP. Initial calculations of QALYs for the SCS and CMP groups suggested no statistical differences between the groups. Adjusting for imbalances in baseline EQ-5D scores showed SCS to be associated with significantly higher QALYs compared to CMP.

Conclusions

SCS resulted in significant improvement in pain intensity and QoL in patients with PDN, offering further support for SCS as an effective treatment for patients suffering from PDN. From a methodological point of view, different results would have been obtained if QALY calculations were not adjusted for baseline EQ-5D scores, highlighting the need to account for imbalances in baseline QoL.

Systematic literature review and meta-analysis of the efficacy and safety of prescription opioids, including abuse-deterrent formulations, in non-cancer pain management

OBJECTIVE

This study was conducted to compare safety and efficacy outcomes between opioids formulated with technologies designed to deter or resist tampering (i.e., abuse-deterrent formulations [ADFs]) and non-ADFs for commonly prescribed opioids for treatment of non-cancer pain in adults.

METHODS

PubMed and Cochrane Library databases were searched for opioid publications between September 1, 2001 and August 31, 2011, and pivotal clinical trials from all years; abstracts from key pain conferences (2010-2011) were also reviewed. One hundred and ninety-one publications were initially identified, 68 of which met eligibility criteria and were systematically reviewed; a subset of 16 involved a placebo group (13 non-ADFs vs placebo, 3 ADFs vs placebo) and reported both efficacy and safety outcomes, and were included for a meta-analysis. Summary estimates of standardized difference in mean change of pain intensity (DMCPI), standardized difference in sum of pain intensity difference (DSPID), and odds ratios (ORs) of each adverse event (AE) were computed through random-effects estimates for ADFs (and non-ADFs) vs placebo. Indirect treatment comparisons were conducted to compare ADFs and non-ADFs.

RESULTS

Summary estimates for standardized DMCPI and for standardized DSPID indicated that ADFs and non-ADFs showed significantly greater efficacy than placebo in reducing pain intensity. Indirect analyses assessing the efficacy outcomes between ADFs and non-ADFs indicated that they were not significantly different (standardized DMCPI [0.39 {95% confidence interval (CI) 0.00-0.76}]; standardized DSPID [-0.22 {95% CI -0.74 to 0.30}]). ADFs and non-ADFs both were associated with higher odds of AEs than placebo. Odds ratios from indirect analyses comparing AEs for ADFs vs non-ADFs were not significant (nausea, 0.87 [0.24-3.12]; vomiting, 1.54 [0.40-5.97]; dizziness/vertigo, 0.61 [0.21-1.76]; headache, 1.42 [0.57-3.53]; somnolence/drowsiness, 0.47 [0.09-2.58]; constipation, 0.64 [0.28-1.49]; pruritus 0.41 [0.05-3.51]).

CONCLUSION

ADFs and non-ADFs had comparable efficacy and safety profiles, while both were more efficacious than placebo in reducing pain intensity.

Experiences with spinal cord stimulator in patients with chronic neuropathic back pain

Neuropathic pain is a complex, chronic, and disabling condition that has physical, functional, and psychosocial repercussions. Although the estimated prevalence of neuropathic pain in the general population ranges from 1.5% to 8%, neuropathic pain is frequently underdiagnosed and undertreated. The aims of this study were to examine the experience of patients treated with spinal cord stimulation as a pain-relieving treatment and how this may influence the patient's ability to participate in everyday life activities. A qualitative approach based on seven telephone interviews was performed. The participants were recruited from a university hospital in Norway, and all used spinal cord stimulation as a pain-relieving treatment. Qualitative content analysis was used. Two thematic findings emerged: (1) pain relief with spinal cord stimulation as a complex and individual experience and (2) challenges in adaptations in everyday life with spinal cord stimulation. Findings indicate that spinal cord stimulation can offer pain relief that can help patients achieve a meaningful life despite chronic pain. Spinal cord stimulation also may have disadvantages that should be considered before offering this treatment. It seems evident that extended information needs about working mechanism of SCS and precautions as well as follow-up are required to meet unexpected challenges in adaptation. Here the nurse has an important role when informing and following this patient group.

Buprenorphine transdermal system and quality of life in opioid-experienced patients with chronic low back pain

OBJECTIVES

To evaluate the impact of 12 weeks of treatment with Butrans® (buprenorphine) transdermal system (BTDS) on the health-related quality of life (HRQoL) for patients with chronic low back pain (CLBP), and the maintenance of effects over 52 weeks.

RESEARCH DESIGN AND METHODS

A multicenter, enriched, double-blind (DB), randomized trial comparing BTDS 20 μg/h (BTDS 20) against 5 μg/h (BTDS 5) for treatment of opioid-experienced patients with moderate-to-severe CLBP, including a 52-week open-label (OL) extension phase.

MAIN OUTCOME MEASURES

QoL was measured with the SF-36v2 survey before and after an OL run-in period with BTDS 20, three times during the DB phase, and seven times over the extension phase. This post hoc analysis tested for SF-36v2 score differences between treatment groups during the DB phase and maintenance of effects over the extension phase.

RESULTS

At 12 weeks, BTDS 20 produced larger improvements than BTDS 5 in role limitations due to physical health, bodily pain and overall physical QoL (p < 0.01). Treatment group differences in overall physical QoL were sustained throughout the DB phase. Quality-of-life improvements associated with BTDS 20 persisted through the extension phase.

CONCLUSIONS

These data suggest that opioid-experienced moderate-to-severe CLBP patients receiving BTDS 20 exhibited better QoL than patients receiving BTDS 5.

The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain

BACKGROUND

Chronic pain is distressing for patients and a burden on healthcare systems and society. Recent research demonstrates different aspects of the negative impact of chronic pain and the positive impact of successful treatment, making an overview of the costs and consequences of chronic pain appropriate.

OBJECTIVE

To examine recent literature on chronic noncancer and neuropathic pain prevalence, impact on quality and quantity of life, societal and healthcare costs, and impact of successful therapy.

METHODS

Systematic reviews (1999 to February 2012) following PRISMA guidelines were conducted to identify studies reporting appropriate outcomes.

RESULTS

Chronic pain has a weighted average prevalence in adults of 20%; 7% have neuropathic pain, and 7% have severe pain. Chronic pain impeded activities of daily living, work and work efficiency, and reduced quality and quantity of life. Effective pain therapy (pain intensity reduction of at least 50%) resulted in consistent improvements in fatigue, sleep, depression, quality of life, and work.

CONCLUSION

Strenuous efforts should be put into obtaining good levels of pain relief for people in chronic pain, including the opportunity for multiple drug switching, using reliable, validated, and relatively easily applied patient-centered outcomes. Detailed, thoughtful and informed decision analytic policy modeling would help understand the key elements in organizational change or service reengineering to plan the optimum pain management strategy to maximize pain relief and its stream of benefits against budgetary and other constraints. This paper contains the information on which such models can be based.

A randomized, placebo-controlled study of the impact of the 7-day buprenorphine transdermal system on health-related quality of life in opioid-naïve patients with moderate-to-severe chronic low back pain

This study evaluated the impact of treatment with Buprenorphine Transdermal System (BTDS) on the health-related quality of life for patients with moderate-to-severe chronic low back pain (CLBP), and the correspondence between quality of life and pain. A multicenter, enriched, double-blind (DB), placebo-controlled, randomized trial evaluated BTDS 10 and 20 μg/hour for treatment of opioid-naïve patients with moderate-to-severe CLBP. The SF-36v2 survey, which measures 8 domains of quality of life, was administered at screening and following an open-label run-in period with BTDS and at weeks 4, 8, and 12 of the DB phase. Post hoc analyses compared SF-36v2 scores between BTDS and placebo groups during the DB phase. Condition burden was examined through comparisons with a U.S. general population sample. Correlations examined the correspondence between quality of life and pain measures. BTDS produced larger improvements than placebo at 12 weeks in all quality-of-life domains (Ps < .05). Treatment group differences in both physical and mental quality of life emerged by 4 weeks. Patients' pretreatment quality of life was worse than that in the general population (Ps < .05); only BTDS treatment eliminated deficits in pain, social functioning, and role limitations due to emotional health. Improvements in quality of life were moderately associated with pain reduction. These data suggest that moderate-to-severe CLBP patients receiving BTDS exhibited better quality of life than patients receiving placebo.

PERSPECTIVE

This post hoc analysis suggests that patients with moderate-to-severe CLBP treated with BTDS exhibit better health-related quality of life than those using placebo within 4 weeks of treatment, and were more likely to exhibit clinically meaningful improvements in quality of life following 12 weeks of treatment.

Opioids in chronic musculoskeletal conditions

The use of opioids for benign disorders has been limited by concerns about these compounds' potential adverse events and their possible misuse. However, during the last few years an increased use in nonmalignant disorders, including rheumatologic diseases, has been observed. Herein, we review the scientific evidence for opioid therapy in three common scenarios in clinical rheumatology. Low back pain is a very frequent reason for consultation. Overall, the large majority of studies show a positive, yet rather moderate, effect of opioids in pain control, as well as in other outcomes including mood, work disability and anxiety. Similarly, opioids seem to have a role in the management of hip and knee osteoarthritis; indeed, they have been included in all international guidelines for the treatment of these conditions. However, clinical studies addressing opioid use in clinical situations are plagued by methodological limitations; furthermore, the large majority of these studies only provide short-term information about opiod utilization in these patients. Finally, opioids are currently being used as complementary therapy in inflammatory joint conditions whereby they may significantly improve the quality of life of some of these patients. Regarding their safety, severe adverse events, including abnormal drug-seeking behaviour, are very rare, but mild adverse events are frequent leading to drug discontinuation in a significant number of cases.

Transdermal fentanyl for chronic low back pain

PURPOSE

Chronic low back pain is a common clinical problem. As medication, non-steroidal anti-inflammatory drugs are generally used; however, they are sometimes non-effective. Recently, opioids have been used for the treatment of chronic low back pain, and since 2010, transdermal fentanyl has been used to treat chronic non-cancer pain in Japan. The purpose of the current study was to examine the efficacy of transdermal fentanyl in the treatment of chronic low back pain.

MATERIALS AND METHODS

This study included patients (n=62) that suffered from chronic low back pain and were non-responsive to non-steroidal anti-inflammatory drugs. Their conditions consisted of non-specific low back pain, multiple back operations, and specific low back pain awaiting surgery. Patients were given transdermal fentanyl for chronic low back pain. Scores of the visual analogue scale and the Oswestry Disability Index, as well as adverse events were evaluated before and after therapy.

RESULTS

Overall, visual analogue scale scores and Oswestry Disability Index scores improved significantly after treatment. Transdermal fentanyl (12.5 to 50 μg/h) was effective in reducing low back pain in 45 of 62 patients; however, it was not effective in 17 patients. Patients who experienced the most improvement were those with specific low back pain awaiting surgery. Adverse events were seen in 40% of patients (constipation, 29%; nausea, 24%; itching, 24%).

CONCLUSION

Transdermal fentanyl significantly improved visual analog scale scores and Oswestry Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations.

Evaluation of efficacy and safety of fentanyl transdermal patch (Durogesic D-TRANS) in chronic pain

PURPOSE

Opioids are used in controlling several types of pain. This study was designed to evaluate the efficacy and safety of the fentanyl transdermal patch-type system (Durogesic® D-TRANS).

METHODS

Patients who complained of chronic moderate to severe pain were enrolled. Administration dosages of fentanyl patch started from 12.5 μg/h and could be increased by 12.5 μg/h or 25 μg/h, if the average pain score of 4 or higher occurred within 72 h. The total administration period was 12 weeks. The type, location, characteristics, and duration of pain were evaluated. Also, on day 0, weeks of 4, 8, and 12, the physician's assessment of pain intensity, the patient's assessment of pain intensity, the assessment of impact of pain on functions, and the assessment of the impact of pain on sleep were assessed. In addition, side effects were evaluated during the study duration.

RESULTS

A total of 65 cases were enrolled, and the final evaluated cases were 41. Before treatment, the average physician's assessment of pain intensity was 6.70 ± 1.41, and the average patient's assessment of pain intensity was 7.02 ± 1.63. In the final visit, the average physician's assessment of pain intensity was 2.58 ± 1.72, and the average patient's assessment of pain intensity was 2.86 ± 1.78.

CONCLUSIONS

This prospective study shows that the fentanyl patch is effective in alleviating moderate to severe chronic noncancer pain including neuropathic pain down to mild pain. Therefore, the fentanyl patch should be considered before other invasive intervention procedures in chronic moderate to severe noncancer pain.

Relationship between health-related quality of life, pain, and functional disability in neuropathic pain patients with failed back surgery syndrome

OBJECTIVES

Patients with failed back surgery syndrome (FBSS) and chronic neuropathic pain experience levels of health-related quality of life (HRQoL) that are considerably lower than those reported in other areas of chronic pain. The aim of this article was to quantify the extent to which reductions in (leg and back) pain and disability over time translate into improvements in generic HRQoL as measured by the EuroQoL-5D and SF-36 instruments.

METHODS

Using data from the multinational Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome trial, we explore the relationship between generic HRQoL--assessed using two instruments often used in clinical trials (i.e., the SF-36 and EuroQol-5D)--and disease-specific outcome measures (i.e., Oswestry disability index [ODI], leg and back pain visual analog scale [VAS]) in neuropathic patients with FBSS.

RESULTS

In our sample of 100 FBSS patients, generic HRQoL was moderately associated with ODI (correlation coefficient: -0.462 to -0.638) and mildly associated with leg pain VAS (correlation coefficient: -0.165 to -0.436). The multilevel regression analysis results indicate that functional ability (as measured by the ODI) is significantly associated with HRQoL, regardless of the generic HRQoL instrument used. On the other hand, changes over time in leg pain were significantly associated with changes in the EuroQoL-5D and physical component summary scores, but not with the mental component summary score.

CONCLUSIONS

Reduction in leg pain and functional disability is statistically significantly associated with improvements in generic HRQoL. This is the first study to investigate the longitudinal relationship between generic and disease-specific HRQoL of neuropathic pain patients with FBSS, using multinational data.

Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain

Background

There is little evidence that short-acting opioids as rescue medication for breakthrough pain is an optimal long-term treatment strategy in chronic non-malignant pain. We compared clinical studies of long-acting opioids that allowed short-acting opioid rescue medication with those that did not, to determine the impact of opioid rescue medication use on the analgesic efficacy and tolerability of chronic opioid therapy in patients with chronic non-malignant pain.

Methods

We searched MEDLINE (1950 to July 2006) and EMBASE (1974 to July 2006) using terms for chronic non-malignant pain and long-acting opioids. Independent review of the search results identified 48 studies that met the study selection criteria. The effect of opioid rescue medication on analgesic efficacy and the incidence of common opioid-related side-effects were analysed using meta-regression.

Results

After adjusting for potentially confounding variables (study design and type of opioid), the difference in analgesic efficacy between the ‘rescue’ and the ‘no rescue’ studies was not significant, with regression coefficients close to 0 and 95% confidence intervals that excluded an effect of more than 18 points on a 0–100 scale in each case. There was also no significant difference between the ‘rescue’ and the ‘no rescue’ studies for the incidence of nausea, constipation, or somnolence in both the unadjusted and the adjusted analyses.

Conclusions

We found no evidence that rescue medication with short-acting opioids for breakthrough pain affects analgesic efficacy of long-acting opioids or the incidence of common opioid-related side-effects among chronic non-malignant pain patients.

A comparison of long- and short-acting opioids for the treatment of chronic noncancer pain: tailoring therapy to meet patient needs

Management of chronic noncancer pain (CNCP) requires a comprehensive assessment of the patient, the institution of a structured treatment regimen, an ongoing reassessment of the painful condition and its response to therapy, and a continual appraisal of the patient's adherence to treatment. For many patients with CNCP, the analgesic regimen will include opioids. Physicians should consider the available evidence of efficacy, the routes of administration, and the pharmacokinetics and pharmacodynamics of the various formulations as they relate to the temporal characteristics of the patient's pain. When making initial decisions, physicians should decide whether to prescribe a short-acting opioid (SAO) with a relatively quick onset of action and short duration of analgesic activity, a long-acting opioid (LAO) with a longer duration of analgesic action but a potentially longer onset of action, or both. Studies suggest that SAOs and LAOs are both effective for most types of CNCP. A review of published studies found no data to suggest that either SAOs or LAOs are generally more efficacious for treating any particular CNCP condition. The LAOs may provide more stable analgesia with less frequent dosing; however, opioid therapy should be tailored to the pain state and the individual patient, and SAOs may be appropriate for some patients with CNCP. MEDLINE and PubMed searches were conducted to locate relevant studies published from January 1975 to April 2008 using the following search terms: opioids, short-acting opioids, long-acting opioids, chronic pain, chronic pain AND opioids, and narcotics. English-only randomized controlled trials and nonrandomized studies were considered.

Yoga for veterans with chronic low-back pain

OBJECTIVES

Chronic back pain affects a large proportion of both the general population and of military veterans. Although numerous therapies exist for treating chronic back pain, they can be costly and tend to have limited effectiveness. Thus, demonstrating the efficacy and cost-effectiveness of additional treatment alternatives is important. The purpose of our study was to examine the benefits of a yoga intervention for Veterans Administration (VA) patients. SUBJECTS/INTERVENTION: VA patients with chronic back pain were referred by their primary care providers to a yoga program as part of clinical care. Before starting yoga, a VA physician trained in yoga evaluated each patient to ensure that they could participate safely.

DESIGN

The research study consisted of completing a short battery of questionnaires at baseline and again 10 weeks later.

OUTCOME MEASURES

Questionnaires included measures of pain, depression, energy/fatigue, health-related quality of life, and program satisfaction. Paired t-tests were used to compare baseline scores to those at the 10-week follow-up for the single group, pre-post design. Correlations were used to examine whether yoga attendance and home practice were associated with better outcomes.

RESULTS

Baseline and follow-up data were available for 33 participants. Participants were VA patients with a mean age of 55 years. They were 21% female, 70% white, 52% married, 68% college graduates, and 44% were retired. Significant improvements were found for pain, depression, energy/fatigue, and the Short Form-12 Mental Health Scale. The number of yoga sessions attended and the frequency of home practice were associated with improved outcomes. Participants appeared highly satisfied with the yoga instructor and moderately satisfied with the ease of participation and health benefits of the yoga program.

CONCLUSIONS

Preliminary data suggest that a yoga intervention for VA patients with chronic back pain may improve the health of veterans. However, the limitations of a pre-post study design make conclusions tentative. A larger randomized, controlled trial of the yoga program is planned.

Functionality and health-status benefits associated with reduction of osteoarthritis pain

OBJECTIVE

To evaluate the association between pain intensity improvement and improvements in functionality and health status in patients with chronic osteoarthritis pain of the hip or knee.

METHODS

Data were obtained from a 12-week, randomized, double-blind, placebo-controlled study of tramadol ER 100 mg, 200 mg, 300 mg, or 400 mg once daily. Patients reported pain intensity with a 100-mm visual analog scale (0 = no pain, 100 = extreme pain) and functionality and health status with the disease-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and the generic Short-Form-36 Health Survey (SF-36). Pain intensity improvement from baseline was categorized as < 0%, 0-14%, 15-29%, 30-49%, 50-69%, and >or= 70%, and mean changes in WOMAC and SF-36 scores were determined for patients in each category.

RESULTS

A total of 1011 patients received placebo (n = 205) or tramadol ER 100 mg (n = 202), 200 mg (n = 201), 300 mg (n = 201), or 400 mg (n = 202). The degree of pain intensity improvement was correlated with the degree of improvement in WOMAC and SF-36 scores; as little as 15% reduction of pain intensity was associated with notable improvements in function and health status. Potential limitations included the lack of established thresholds to assess clinically meaningful changes in these outcomes.

CONCLUSIONS

Pain intensity improvement is associated with corresponding improvements in function and health status. While large improvements in pain intensity are associated with large improvements in health status and functionality, modest pain reductions are also associated with improvement of certain health status parameters.

Epidemiology of Refractory Neuropathic Pain

Although neuropathic pain can be acute in nature, in most patients the pain is persistent (or "refractory"). Patients with chronic neuropathic pain are seen most often in clinical practice. It consists of a number of different disease-specific indications, each of which can have differing diagnostic definitions and cutoffs. Consequently, it is difficult to estimate precisely the prevalence and incidence of neuropathic pain. The limited currently available epidemiological literature is reviewed in this article. The burden of neuropathic pain on patients and healthcare systems appears to be potentially large, with an estimated prevalence of 1.5%. Patients with neuropathic pain experience a poor health-related quality of life and consume a high level of healthcare resources, and costs. The future prioritization by healthcare policy makers for neuropathic pain treatment funding requires further data to clarify its epidemiology, the burden on the health of patients, and the demand on healthcare budgets.

Do strong opioids have a role in the early management of back pain? Recommendations from a European expert panel

BACKGROUND

Since chronic low back pain (CLBP) is a complex biopsychosocial problem the ideal treatment is multimodal and multidisciplinary. However, in many countries, primary-care physicians care for many people with CLBP and have a pivotal role in selecting patients for more intensive treatments when these are available. Guidelines on the general use of strong opioids in chronic non-cancer pain have been published but, until now, no specific guidelines were available on their use in chronic low back pain. Given the prevalence of CLBP, and the complex nature of this multifactorial condition, it was felt that specific, evidence-based recommendations, with a focus on primary-care treatment, would be helpful.

METHODS

An expert panel drawn from across Europe including pain specialists, anaesthetists, neurologists, rheumatologists, a general practitioner, an epidemiologist and the chairman of a pain charity was therefore convened. The aim of the group was to develop evidence-based recommendations that could be used as a framework for more specific guidelines to reflect local differences in the availability of specialist pain services and in the legal status and availability of strong opioids. Statements were based on published evidence (identified by a literature search) wherever possible, and supported by clinical experience when suitable evidence was lacking.

RECOMMENDATIONS

Strong opioids have a role in the treatment of low back pain when other treatments have failed. They should be prescribed as part of a multimodal, and ideally interdisciplinary, treatment plan. The aim of treatment should be to relieve pain and facilitate rehabilitation.