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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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2
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Kleykamp BA, Dworkin RH, Turk DC, Bhagwagar Z, Cowan P, Eccleston C, Ellenberg SS, Evans SR, Farrar JT, Freeman RL, Garrison LP, Gewandter JS, Goli V, Iyengar S, Jadad AR, Jensen MP, Junor R, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, McDermott MP, Mease PJ, O'Connor AB, Patel KV, Raja SN, Rowbotham MC, Sampaio C, Singh JA, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations. Pain 2022; 163:1006-1018. [PMID: 34510135 PMCID: PMC8904641 DOI: 10.1097/j.pain.0000000000002475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.
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Affiliation(s)
- Bethea A Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, CT, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | | | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy L Freeman
- Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders, Boston, MA, United States
| | - Louis P Garrison
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Veeraindar Goli
- Pfizer, Inc, New York, NY, United States. Dr. Goli is now with the Emeritus Professor, Duke University School of Medicine, Durham, NC, United States
| | - Smriti Iyengar
- Division of Translational Research, NINDS, NIH, Rockville, MD, United States
| | - Alejandro R Jadad
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Beati, Inc, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Wayland, MA, United States
| | | | | | - Dmitri Lissin
- DURECT Corporation, Cupertino, CA, United States. Dr. Lissin is now woth the Scilex Pharmaceuticals, Inc., San Diego, CA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Philip J Mease
- Division of Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C Rowbotham
- Department of Anesthesia, UCSF School of Medicine, Research Institute, CPMC Sutter Health, San Francisco, CA, United States
| | - Cristina Sampaio
- Clinical Pharmacology Lab, Faculdade de Medicina de Lisboa, University Lisbon, Lisbon, Portugal
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, United States
- Department of Medicine at the School of Medicine, University of Alabama (UAB) at Birmingham, Birmingham, AL, United States
- Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, United States
| | - Ilona Steigerwald
- Chief Medical Officer SVP Neumentum, Inc, Morristown NJ, United States
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, United States
| | - Leslie A Tive
- Department of Biopharmaceuticals, Pfizer, Inc, New York, NY, United States
| | | | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, United States
| | - Hilary D Wilson
- Patient Affairs and Engagement, Boehringer Ingelheim, Ridgefield, CT, United States
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3
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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4
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Rowbotham MC, Arendt-Nielsen L. A year like no other: introduction to a special issue on COVID-19 and pain. Pain Rep 2021; 6:e915. [PMID: 33997584 PMCID: PMC8116039 DOI: 10.1097/pr9.0000000000000915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/12/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Michael C. Rowbotham
- Pain Management Center, University of California School of Medicine, San Francisco, CA, USA
- Treasurer, International Association for the Study of Pain (IASP), Washington, DC, USA
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), School of Medicine, Aalborg University, Aalborg, Denmark
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5
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Smith SM, Dworkin RH, Turk DC, McDermott MP, Eccleston C, Farrar JT, Rowbotham MC, Bhagwagar Z, Burke LB, Cowan P, Ellenberg SS, Evans SR, Freeman RL, Garrison LP, Iyengar S, Jadad A, Jensen MP, Junor R, Kamp C, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, Mease PJ, O'Connor AB, Patel KV, Raja SN, Sampaio C, Schoenfeld D, Singh J, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Interpretation of chronic pain clinical trial outcomes: IMMPACT recommended considerations. Pain 2020; 161:2446-2461. [PMID: 32520773 PMCID: PMC7572524 DOI: 10.1097/j.pain.0000000000001952] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Interpreting randomized clinical trials (RCTs) is crucial to making decisions regarding the use of analgesic treatments in clinical practice. In this article, we report on an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, the purpose of which was to recommend approaches that facilitate interpretation of analgesic RCTs. We review issues to consider when drawing conclusions from RCTs, as well as common methods for reporting RCT results and the limitations of each method. These issues include the type of trial, study design, statistical analysis methods, magnitude of the estimated beneficial and harmful effects and associated precision, availability of alternative treatments and their benefit-risk profile, clinical importance of the change from baseline both within and between groups, presentation of the outcome data, and the limitations of the approaches used.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P McDermott
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | | | - John T Farrar
- Departments of Epidemiology, Neurology, and Anesthesia, University of Pennsylvania, Philadelphia, PA, United States
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Rallybio, New Haven, CT, United States
| | - Laurie B Burke
- School of Pharmacy, University of Maryland, Baltimore, MD, United States
- LORA Group, LLC, Royal Oak, MD, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Susan S Ellenberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Epidemiology and Biostatistics, The George Washington University, Washington, DC, United States
| | - Roy L Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Louis P Garrison
- Department of Pharmacy, University of Washington, Seattle, WA, United States
| | | | - Alejandro Jadad
- Department of Anesthesia, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Cornelia Kamp
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Clinical Materials Services Unit, University of Rochester Medical Center, Rochester, NY, United States
| | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Natick, MA, United States
| | | | | | - Dmitri Lissin
- Scilex Pharmaceuticals, Palo Alto, CA, United States
| | - John D Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Philip J Mease
- Rheumatology Clinical Research, Swedish Medical Center, Seattle, WA, United States
- University of Washington School of Medicine, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cristina Sampaio
- Faculdade Medicinda de Lisboa, Universidade de Lisboa, Lisboa, Portugal
- CHDI Foundation, Princeton, NJ, United States
| | - David Schoenfeld
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jasvinder Singh
- Departments of Medicine and Epidemiology, University of Alabama at Birmingham School of Medicine, Birmingham, AB, United States
| | | | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, CA, United States
| | | | - Jeffrey Tobias
- Aquila Consulting Group, LLC, Petaluma, CA, United States
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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6
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Rowbotham MC, Wallace M. Evolution of Analgesic Tolerance and Opioid-Induced Hyperalgesia Over 6 Months: Double-Blind Randomized Trial Incorporating Experimental Pain Models. J Pain 2020; 21:1031-1046. [PMID: 32006699 DOI: 10.1016/j.jpain.2020.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/10/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
Contributors to the ongoing epidemic of prescription opioid abuse, addiction, and death include opioid tolerance, withdrawal symptoms, and possibly opioid-induced hyperalgesia (OIH). Thirty stable chronic nonmalignant pain patients entered a 6-month long, randomized, double-blind, dose-response, 2-center trial of the potent opioid levorphanol, conducted over a decade ago during an era of permissive opioid prescribing. Eleven were taking no opioids at study entry and eleven were taking between 35 and 122 morphine equivalents. Five weeks titration preceded twenty weeks stable dosing. Tolerance and OIH were inferred individually based on chronic pain ratings, brief pain inventory scores, and results of the brief thermal sensitization model at 5 opioid dosing sessions. Seventeen patients completed. The average final daily opioid dose was 132; range 14 to 300; average addition 105 morphine equivalents. After observed dosing, the brief thermal sensitization area of hyperalgesia changed minimally but the painfulness of skin heating was reduced. Weekly 0 to 100 visual analog scale pain ratings (average 64 at study entry, 48 at end titration, 45 at end stable dosing) decreased a median 19%, but 8 completed with higher visual analog scale ratings. Three completers had evidence of both tolerance and hyperalgesia. A fully-powered trial similar to this feasibility study is ethically questionable. A large-scale pragmatic trial is more realistic. TRIAL REGISTRATION: NCT00275249 Evolution of Analgesic Tolerance With Opioids PERSPECTIVE: A double-blind, 6-month, high-dose opioid feasibility trial, completed years ago, provides critically important data for clinically defining analgesic tolerance and OIH. Overall benefit was small, and 18% of patients had evidence of both tolerance and OIH. Future work requires a different approach than a classic randomized controlled trial design.
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Affiliation(s)
- Michael C Rowbotham
- CPMC Research Institute, San Francisco, California; UCSF Pain Clinical Research Center, Departments of Neurology and Anesthesia, University of California San Francisco, San Francisco, California.
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, California
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7
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Scholz J, Finnerup NB, Attal N, Aziz Q, Baron R, Bennett MI, Benoliel R, Cohen M, Cruccu G, Davis KD, Evers S, First M, Giamberardino MA, Hansson P, Kaasa S, Korwisi B, Kosek E, Lavand’homme P, Nicholas M, Nurmikko T, Perrot S, Raja SN, Rice ASC, Rowbotham MC, Schug S, Simpson DM, Smith BH, Svensson P, Vlaeyen JW, Wang SJ, Barke A, Rief W, Treede RD. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain 2019; 160:53-59. [PMID: 30586071 PMCID: PMC6310153 DOI: 10.1097/j.pain.0000000000001365] [Citation(s) in RCA: 462] [Impact Index Per Article: 92.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The upcoming 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) of the World Health Organization (WHO) offers a unique opportunity to improve the representation of painful disorders. For this purpose, the International Association for the Study of Pain (IASP) has convened an interdisciplinary task force of pain specialists. Here, we present the case for a reclassification of nervous system lesions or diseases associated with persistent or recurrent pain for ≥3 months. The new classification lists the most common conditions of peripheral neuropathic pain: trigeminal neuralgia, peripheral nerve injury, painful polyneuropathy, postherpetic neuralgia, and painful radiculopathy. Conditions of central neuropathic pain include pain caused by spinal cord or brain injury, poststroke pain, and pain associated with multiple sclerosis. Diseases not explicitly mentioned in the classification are captured in residual categories of ICD-11. Conditions of chronic neuropathic pain are either insufficiently defined or missing in the current version of the ICD, despite their prevalence and clinical importance. We provide the short definitions of diagnostic entities for which we submitted more detailed content models to the WHO. Definitions and content models were established in collaboration with the Classification Committee of the IASP's Neuropathic Pain Special Interest Group (NeuPSIG). Up to 10% of the general population experience neuropathic pain. The majority of these patients do not receive satisfactory relief with existing treatments. A precise classification of chronic neuropathic pain in ICD-11 is necessary to document this public health need and the therapeutic challenges related to chronic neuropathic pain.
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Affiliation(s)
- Joachim Scholz
- Departments of Anesthesiology and Pharmacology, Columbia University Medical Center, New York, NY, USA
| | - Nanna B. Finnerup
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Nadine Attal
- INSERM U 987 and Assistance Publique – Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France and Université Versailles Saint Quentin en Yvelines, Versailles, France
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Ralf Baron
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Michael I. Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| | - Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers, Newark, NJ, USA
| | - Milton Cohen
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia
| | - Giorgio Cruccu
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Karen D. Davis
- Department of Surgery and Institute of Medical Science, University of Toronto, and Division of Brain, Imaging and Behavior in Systems Neuroscience, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, and Faculty of Medicine, University of Münster, Münster, Germany
| | - Michael First
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
| | - Maria Adele Giamberardino
- Department of Medicine and Science of Aging, and Centro Studi dell’ Invecchiamento e Medicina Traslazionale (CeSI-Met), G D’Annunzio University of Chieti, Chieti, Italy
| | - Per Hansson
- Department of Pain Management and Research Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway, and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC); Department of Oncology, Oslo University Hospital, Norway; University of Oslo, Oslo, Norway
| | - Beatrice Korwisi
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institute Stockholm, Stockholm, Sweden
| | - Patricia Lavand’homme
- Department of Anesthesiology and Acute Postoperative Pain Service, Saint Luc Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Michael Nicholas
- Pain Management Research Institute, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Turo Nurmikko
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Serge Perrot
- Pain Clinic, Hôtel Dieu Hospital, Paris Descartes University, INSERM U 987, Paris, France
| | - Srinivasa N. Raja
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrew S. C. Rice
- Pain Research, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Michael C. Rowbotham
- California Pacific Medical Center Research Institute, San Francisco, California, USA
| | - Stephan Schug
- Medical School, University of Western Australia, and Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - David M. Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Blair H. Smith
- Division of Population Health Sciences, University of Dundee, Dundee, Scotland
| | - Peter Svensson
- Section of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus, Denmark, and Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
| | - Johan W.S. Vlaeyen
- Research Group Health Psychology, University of Leuven, Leuven, Belgium and Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital and Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Antonia Barke
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Winfried Rief
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Rolf-Detlef Treede
- Department of Neurophysiology, CBTM, Medical Faculty Mannheim of Heidelberg University, Germany
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Smith SM, Dworkin RH, Turk DC, Baron R, Polydefkis M, Tracey I, Borsook D, Edwards RR, Harris RE, Wager TD, Arendt-Nielsen L, Burke LB, Carr DB, Chappell A, Farrar JT, Freeman R, Gilron I, Goli V, Haeussler J, Jensen T, Katz NP, Kent J, Kopecky EA, Lee DA, Maixner W, Markman JD, McArthur JC, McDermott MP, Parvathenani L, Raja SN, Rappaport BA, Rice ASC, Rowbotham MC, Tobias JK, Wasan AD, Witter J. The Potential Role of Sensory Testing, Skin Biopsy, and Functional Brain Imaging as Biomarkers in Chronic Pain Clinical Trials: IMMPACT Considerations. J Pain 2017; 18:757-777. [PMID: 28254585 PMCID: PMC5484729 DOI: 10.1016/j.jpain.2017.02.429] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/19/2017] [Accepted: 02/16/2017] [Indexed: 02/08/2023]
Abstract
Valid and reliable biomarkers can play an important role in clinical trials as indicators of biological or pathogenic processes or as a signal of treatment response. Currently, there are no biomarkers for pain qualified by the U.S. Food and Drug Administration or the European Medicines Agency for use in clinical trials. This article summarizes an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting in which 3 potential biomarkers were discussed for use in the development of analgesic treatments: 1) sensory testing, 2) skin punch biopsy, and 3) brain imaging. The empirical evidence supporting the use of these tests is described within the context of the 4 categories of biomarkers: 1) diagnostic, 2) prognostic, 3) predictive, and 4) pharmacodynamic. Although sensory testing, skin punch biopsy, and brain imaging are promising tools for pain in clinical trials, additional evidence is needed to further support and standardize these tests for use as biomarkers in pain clinical trials. PERSPECTIVE The applicability of sensory testing, skin biopsy, and brain imaging as diagnostic, prognostic, predictive, and pharmacodynamic biomarkers for use in analgesic treatment trials is considered. Evidence in support of their use and outlining problems is presented, as well as a call for further standardization and demonstrations of validity and reliability.
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10
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Gewandter JS, Kitt RA, Hunsinger MR, Poku J, Lozano J, Chaudari J, Evans S, Gross RA, McDermott MP, Rowbotham MC, Turk DC, Dworkin RH. Reporting of data monitoring boards in publications of randomized clinical trials is often deficient: ACTTION systematic review. J Clin Epidemiol 2017; 83:101-107. [PMID: 28126598 PMCID: PMC5780643 DOI: 10.1016/j.jclinepi.2016.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 10/07/2016] [Accepted: 12/01/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine whether primary reports of randomized clinical trials (RCTs) in six high-impact, general medical journals reported (1) whether or not a Data Monitoring Committee/Data and Safety Monitoring Board (DMC/DSMB) was used and (2) the composition of the responsibilities of the reported DSMB/DMCs. STUDY DESIGN AND SETTING Systematic review of RCTs published in 2014 in Annals of Internal Medicine, BMJ, NEJM, JAMA, JAMA Internal Medicine, and Lancet. RESULTS Of the 294 articles identified, 174 (59%) mentioned using a DMC/DSMB. Of these 174, 126 (72%) indicated at least one responsibility of the DMC/DSMB, 26% listed the names of the DMC/DSMB members, and another 14% listed both their names and affiliations. Only one article stated that a DSMB was not used. The remaining 119 articles did not report whether or not a DMC/DSMB was used, although 59 had previously stated in a clinical trials registry entry or a published protocol that a DMC/DSMB was to be used. CONCLUSIONS Considering the major role that DMC/DSMBs play in protecting participant safety, data quality, and interim analyses in RCTs, we recommend that authors of publications of RCTs report whether a DMC/DSMB was used and the responsibilities and members of DMC/DSMBs to increase transparency regarding study conduct.
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Affiliation(s)
- Jennifer S Gewandter
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA.
| | - Rachel A Kitt
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Matthew R Hunsinger
- School of Graduate Psychology, Pacific University, College Way, Hillsboro, OR, USA
| | - Joseph Poku
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Jacqueline Lozano
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Jenna Chaudari
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Scott Evans
- Department of Biostatistics, Harvard University, Elmwood Avenue, Boston, MA, USA
| | - Robert A Gross
- Department of Neurology, University of Rochester, Elmwood Avenue, Rochester, NY, USA; Department of Pharmacology & Physiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
| | - Michael C Rowbotham
- California Pacific Medical Center Research Institute, Brannan St, San Francisco, CA, USA
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, NE Pacific Street, Seattle, WA, USA
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester, Elmwood Avenue, Rochester, NY, USA
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11
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Tranah GJ, Yaffe K, Katzman SM, Lam ET, Pawlikowska L, Kwok PY, Schork NJ, Manini TM, Kritchevsky S, Thomas F, Newman AB, Harris TB, Coleman AL, Gorin MB, Helzner EP, Rowbotham MC, Browner WS, Cummings SR. Mitochondrial DNA Heteroplasmy Associations With Neurosensory and Mobility Function in Elderly Adults. J Gerontol A Biol Sci Med Sci 2015; 70:1418-24. [PMID: 26328603 DOI: 10.1093/gerona/glv097] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/05/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mitochondrial DNA (mtDNA) heteroplasmy is a mixture of normal and mutated mtDNA molecules in a cell. High levels of heteroplasmy at specific mtDNA sites lead to inherited mitochondrial diseases with neurological, sensory, and movement impairments. Here we test the hypothesis that heteroplasmy levels in elderly adults are associated with impaired function resembling mild forms of mitochondrial disease. METHODS We examined platelet mtDNA heteroplasmy at 20 disease-causing sites for associations with neurosensory and mobility function among 137 participants from the community-based Health, Aging, and Body Composition Study. RESULTS Elevated mtDNA heteroplasmy at four mtDNA sites in complex I and tRNA genes was nominally associated with reduced cognition, vision, hearing, and mobility: m.10158T>C with Modified Mini-Mental State Examination score (p = .009); m.11778G>A with contrast sensitivity (p = .02); m.7445A>G with high-frequency hearing (p = .047); and m.5703G>A with 400 m walking speed (p = .007). CONCLUSIONS These results indicate that increased mtDNA heteroplasmy at disease-causing sites is associated with neurosensory and mobility function in older persons. We propose the novel use of mtDNA heteroplasmy as a simple, noninvasive predictor of age-related neurologic, sensory, and movement impairments.
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Affiliation(s)
- Gregory J Tranah
- California Pacific Medical Center Research Institute, San Francisco.
| | - Kristine Yaffe
- Department of Psychiatry, Department of Neurology and Department of Epidemiology, University of California San Francisco and the San Francisco VA Medical Center
| | | | | | - Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, University of California San Francisco. Institute for Human Genetics, University of California San Francisco
| | - Pui-Yan Kwok
- Institute for Human Genetics, University of California San Francisco
| | - Nicholas J Schork
- J. Craig Venter Institute and the University of California, San Diego
| | - Todd M Manini
- Department of Aging and Geriatric Research, University of Florida, Gainesville
| | - Stephen Kritchevsky
- Sticht Center on Aging, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fridtjof Thomas
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis
| | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh, Pennsylvania
| | - Tamara B Harris
- Intramural Research Program, Laboratory of Epidemiology and Population Sciences, National Institute on Aging, Bethesda, Maryland
| | - Anne L Coleman
- Jules Stein Eye Institute and UCLA Department of Ophthalmology, Los Angeles, California
| | - Michael B Gorin
- Jules Stein Eye Institute and UCLA Department of Ophthalmology, Los Angeles, California
| | - Elizabeth P Helzner
- Department of Epidemiology and Biostatistics, SUNY Downstate Medical Center, Brooklyn, New York
| | | | - Warren S Browner
- California Pacific Medical Center Research Institute, San Francisco
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12
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Dufka FL, Munch T, Dworkin RH, Rowbotham MC. Results availability for analgesic device, complex regional pain syndrome, and post-stroke pain trials: comparing the RReADS, RReACT, and RReMiT databases. Pain 2015; 156:72-80. [PMID: 25599303 PMCID: PMC4280280 DOI: 10.1016/j.pain.0000000000000009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 09/01/2014] [Accepted: 10/16/2014] [Indexed: 11/24/2022]
Abstract
Evidence-based medicine rests on the assumption that treatment recommendations are robust, free from bias, and include results of all randomized clinical trials. The Repository of Registered Analgesic Clinical Trials search and analysis methodology was applied to create databases of complex regional pain syndrome (CRPS) and central post-stroke pain (CPSP) trials and adapted to create the Repository of Registered Analgesic Device Studies databases for trials of spinal cord stimulation (SCS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). We identified 34 CRPS trials, 18 CPSP trials, 72 trials of SCS, and 92 trials of rTMS/tDCS. Irrespective of time since study completion, 45% of eligible CRPS and CPSP trials and 46% of eligible SCS and rTMS/tDCS trials had available results (peer-reviewed literature, results entered on registry, or gray literature); peer-reviewed publications could be found for 38% and 39%, respectively. Examining almost 1000 trials across a spectrum of painful disorders (fibromyalgia, diabetic painful neuropathy, post-herpetic neuralgia, migraine, CRPS, CPSP) and types of treatment, no single study characteristic consistently predicts unavailability of results. Results availability is higher 12 months after study completion but remains below 60% for peer-reviewed publications. Recommendations to increase results availability include supporting organizations advocating for transparency, enforcing existing results reporting regulations, enabling all primary registries to post results, stating trial registration numbers in all publication abstracts, and reducing barriers to publishing "negative" trials. For all diseases and treatment modalities, evidence-based medicine must rigorously adjust for the sheer magnitude of missing results in formulating treatment recommendations.
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Affiliation(s)
- Faustine L. Dufka
- Research Institute, California Pacific Medical Center, San Francisco, CA, USA
| | - Troels Munch
- Research Institute, California Pacific Medical Center, San Francisco, CA, USA
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Robert H. Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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13
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McKeown A, Gewandter JS, McDermott MP, Pawlowski JR, Poli JJ, Rothstein D, Farrar JT, Gilron I, Katz NP, Lin AH, Rappaport BA, Rowbotham MC, Turk DC, Dworkin RH, Smith SM. Reporting of sample size calculations in analgesic clinical trials: ACTTION systematic review. J Pain 2014; 16:199-206.e1-7. [PMID: 25481494 DOI: 10.1016/j.jpain.2014.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED Sample size calculations determine the number of participants required to have sufficiently high power to detect a given treatment effect. In this review, we examined the reporting quality of sample size calculations in 172 publications of double-blind randomized controlled trials of noninvasive pharmacologic or interventional (ie, invasive) pain treatments published in European Journal of Pain, Journal of Pain, and Pain from January 2006 through June 2013. Sixty-five percent of publications reported a sample size calculation but only 38% provided all elements required to replicate the calculated sample size. In publications reporting at least 1 element, 54% provided a justification for the treatment effect used to calculate sample size, and 24% of studies with continuous outcome variables justified the variability estimate. Publications of clinical pain condition trials reported a sample size calculation more frequently than experimental pain model trials (77% vs 33%, P < .001) but did not differ in the frequency of reporting all required elements. No significant differences in reporting of any or all elements were detected between publications of trials with industry and nonindustry sponsorship. Twenty-eight percent included a discrepancy between the reported number of planned and randomized participants. This study suggests that sample size calculation reporting in analgesic trial publications is usually incomplete. Investigators should provide detailed accounts of sample size calculations in publications of clinical trials of pain treatments, which is necessary for reporting transparency and communication of pre-trial design decisions. PERSPECTIVE In this systematic review of analgesic clinical trials, sample size calculations and the required elements (eg, treatment effect to be detected; power level) were incompletely reported. A lack of transparency regarding sample size calculations may raise questions about the appropriateness of the calculated sample size.
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Affiliation(s)
- Andrew McKeown
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Jennifer S Gewandter
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joseph R Pawlowski
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joseph J Poli
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Daniel Rothstein
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - John T Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Gilron
- Queen's University, Kingston, Ontario, Canada
| | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts; Department of Anesthesiology, Tufts University, Boston, Massachusetts
| | - Allison H Lin
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
| | - Bob A Rappaport
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
| | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
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14
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Gewandter JS, McKeown A, McDermott MP, Dworkin JD, Smith SM, Gross RA, Hunsinger M, Lin AH, Rappaport BA, Rice ASC, Rowbotham MC, Williams MR, Turk DC, Dworkin RH. Data interpretation in analgesic clinical trials with statistically nonsignificant primary analyses: an ACTTION systematic review. J Pain 2014; 16:3-10. [PMID: 25451621 DOI: 10.1016/j.jpain.2014.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/03/2014] [Accepted: 10/13/2014] [Indexed: 11/18/2022]
Abstract
UNLABELLED Peer-reviewed publications of randomized clinical trials (RCTs) are the primary means of disseminating research findings. "Spin" in RCT publications is misrepresentation of statistically nonsignificant research findings to suggest treatment benefit. Spin can influence the way readers interpret clinical trials and use the information to make decisions about treatments and medical policies. The objective of this study was to determine the frequency with which 4 types of spin were used in publications of analgesic RCTs with nonsignificant primary analyses in 6 major pain journals. In the 76 articles included in our sample, 28% of the abstracts and 29% of the main texts emphasized secondary analyses with P values <.05; 22% of abstracts and 29% of texts emphasized treatment benefit based on nonsignificant primary results; 14% of abstracts and 18% of texts emphasized within-group improvements over time, rather than primary between-group comparisons; and 13% of abstracts and 10% of texts interpreted a nonsignificant difference between groups in a superiority study as comparable effectiveness. When considering the article conclusion sections, 21% did not mention the nonsignificant primary result, 22% were presented with no uncertainty or qualification, 30% did not acknowledge that future research was required, and 8% recommended the intervention for clinical use. PERSPECTIVE This article identifies relatively frequent "spin" in analgesic RCTs. These findings highlight a need for authors, reviewers, and editors to be more cognizant of how analgesic RCT results are presented and attempt to minimize spin in future clinical trial publications.
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Affiliation(s)
- Jennifer S Gewandter
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | - Andrew McKeown
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Robert A Gross
- Department of Pharmacology and Physiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Matthew Hunsinger
- School of Professional Psychology, Pacific University, Hillsboro, Oregon
| | - Allison H Lin
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Bob A Rappaport
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Mark R Williams
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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15
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Dufka FL, Dworkin RH, Rowbotham MC. How transparent are migraine clinical trials? Repository of Registered Migraine Trials (RReMiT). Neurology 2014; 83:1372-81. [PMID: 25194013 PMCID: PMC4189098 DOI: 10.1212/wnl.0000000000000866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/10/2014] [Indexed: 12/03/2022] Open
Abstract
Transparency in research requires public access to unbiased information prior to trial initiation and openly available results upon study completion. The Repository of Registered Migraine Trials is a global snapshot of registered migraine clinical trials and scorecard of results availability via the peer-reviewed literature, registry databases, and gray literature. The 295 unique clinical trials identified employed 447 investigational agents, with 30% of 154 acute migraine trials and 11% of 141 migraine prophylaxis trials testing combinations of agents. The most frequently studied categories in acute migraine trials were triptans, nonsteroidal anti-inflammatory drugs, antiemetics, calcitonin gene-related peptide antagonists, and acetaminophen. Migraine prophylaxis trials frequently studied anticonvulsants, β-blockers, complementary/alternative therapies, antidepressants, and botulinum toxin. Overall, 237 trials were eligible for a results search. Of 163 trials completed at least 12 months earlier, 57% had peer-reviewed literature results, and registries/gray literature added another 13%. Using logistic regression analysis, studies with a sample size below the median of 141 subjects were significantly less likely to have results, but the dominant factor associated with availability of results was time since study completion. In unadjusted models, trials registered on ClinicalTrials.gov and trials with industry primary sponsorship were significantly more likely to have results. Recently completed trials rarely have publicly available results; 2 years after completion, the peer-reviewed literature contains results for fewer than 60% of completed migraine trials. To avoid bias, evidence-based therapy algorithms should consider factors affecting results availability. As negative trials are less likely to be published, special caution should be exercised before recommending a therapy with a high proportion of missing trial results.
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Affiliation(s)
- Faustine L Dufka
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY
| | - Robert H Dworkin
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY
| | - Michael C Rowbotham
- From the California Pacific Medical Center Research Institute (F.L.D., M.C.R.), San Francisco; and the University of Rochester School of Medicine and Dentistry (R.H.D.), NY.
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Gewandter JS, Dworkin RH, Turk DC, McDermott MP, Baron R, Gastonguay MR, Gilron I, Katz NP, Mehta C, Raja SN, Senn S, Taylor C, Cowan P, Desjardins P, Dimitrova R, Dionne R, Farrar JT, Hewitt DJ, Iyengar S, Jay GW, Kalso E, Kerns RD, Leff R, Leong M, Petersen KL, Ravina BM, Rauschkolb C, Rice ASC, Rowbotham MC, Sampaio C, Sindrup SH, Stauffer JW, Steigerwald I, Stewart J, Tobias J, Treede RD, Wallace M, White RE. Research designs for proof-of-concept chronic pain clinical trials: IMMPACT recommendations. Pain 2014; 155:1683-1695. [PMID: 24865794 PMCID: PMC4500524 DOI: 10.1016/j.pain.2014.05.025] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/21/2022]
Abstract
Proof-of-concept (POC) clinical trials play an important role in developing novel treatments and determining whether existing treatments may be efficacious in broader populations of patients. The goal of most POC trials is to determine whether a treatment is likely to be efficacious for a given indication and thus whether it is worth investing the financial resources and participant exposure necessary for a confirmatory trial of that intervention. A challenge in designing POC trials is obtaining sufficient information to make this important go/no-go decision in a cost-effective manner. An IMMPACT consensus meeting was convened to discuss design considerations for POC trials in analgesia, with a focus on maximizing power with limited resources and participants. We present general design aspects to consider including patient population, active comparators and placebos, study power, pharmacokinetic-pharmacodynamic relationships, and minimization of missing data. Efficiency of single-dose studies for treatments with rapid onset is discussed. The trade-off between parallel-group and crossover designs with respect to overall sample sizes, trial duration, and applicability is summarized. The advantages and disadvantages of more recent trial designs, including N-of-1 designs, enriched designs, adaptive designs, and sequential parallel comparison designs, are summarized, and recommendations for consideration are provided. More attention to identifying efficient yet powerful designs for POC clinical trials of chronic pain treatments may increase the percentage of truly efficacious pain treatments that are advanced to confirmatory trials while decreasing the percentage of ineffective treatments that continue to be evaluated rather than abandoned.
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Affiliation(s)
| | | | | | | | | | | | - Ian Gilron
- Queen’s University, Kingston, Ontario, Canada
| | - Nathaniel P. Katz
- Analgesic Solutions, Natick, MA, and Tufts University, Boston, MA, USA
| | | | | | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Paul Desjardins
- Desjardins Associates and Rutgers University, Newark, NJ, USA
| | | | | | | | | | | | - Gary W. Jay
- Virtuous Pharma, Inc., Raleigh-Durham, NC, USA
| | - Eija Kalso
- University of Helsinki, Helsinki, Finland
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- University of California San Diego, San Diego, CA, USA
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O'Connor AB, Turk DC, Dworkin RH, Katz NP, Colucci R, Haythornthwaite JA, Klein M, O'Brien C, Posner K, Rappaport BA, Reisfield G, Adams EH, Balster RL, Bigelow GE, Burke LB, Comer SD, Cone E, Cowan P, Denisco RA, Farrar JT, Foltin RW, Haddox DJ, Hertz S, Jay GW, Junor R, Kopecky EA, Leiderman DB, McDermott MP, Palmer PP, Raja SN, Rauschkolb C, Rowbotham MC, Sampaio C, Setnik B, Smith SM, Sokolowska M, Stauffer JW, Walsh SL, Zacny JP. Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations. Pain 2014; 154:2324-2334. [PMID: 24148704 DOI: 10.1016/j.pain.2013.06.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.
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Affiliation(s)
- Alec B O'Connor
- Department of Medicine, University of Rochester, Rochester, NY, USA Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA Department of Anesthesiology, University of Rochester, Rochester, NY, USA Analgesic Solutions, Natick, MA, USA Department of Anesthesiology, Tufts University School of Medicine, Boston, MA, USA Colucci & Associates LLC, Newtown, CT, USA Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA United States Food and Drug Administration, Silver Spring, MD, USA Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA Center for Suicide Risk Assessment, New York State Psychiatric Institute/College of Physicians and Surgeons, Columbia University, New York, NY, USA Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA Covance, Princeton, NJ, USA Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA American Chronic Pain Association, Rocklin, CA, USA National Institute on Drug Abuse, Rockville, MD, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Purdue Pharma LP, Stamford, CT, USA Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA Pfizer Inc, Ann Arbor, MI, USA Eisai Limited, Woodcliff Lake, NJ, USA Endo Pharmaceuticals Inc, Chadds Ford, PA, USA CNS Drug Consulting LLC, McLean, VA, USA Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA AcelRx Pharmaceuticals Inc, Redwood City, CA, USA Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore School of Medicine, MD, USA Johnson & Johnson Pharmaceutical Research & Development LLC, Raritan, NJ, USA California Pacific Medical Center Research Institute, San Francisco, CA, USA Clinical Pharmacology and Therapeutics Laboratory, Faculdade de Medicina de Lisboa, Lisbon, Portugal King Pharmaceuticals Inc, Cary, NC, USA Grünenthal USA Inc, Bedminster, NJ, USA Durect Corporation, Cupertino, CA, USA Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, KY, USA Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
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18
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Farrar JT, Troxel AB, Haynes K, Gilron I, Kerns RD, Katz NP, Rappaport BA, Rowbotham MC, Tierney AM, Turk DC, Dworkin RH. Effect of variability in the 7-day baseline pain diary on the assay sensitivity of neuropathic pain randomized clinical trials: an ACTTION study. Pain 2014; 155:1622-1631. [PMID: 24831421 DOI: 10.1016/j.pain.2014.05.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 04/21/2014] [Accepted: 05/05/2014] [Indexed: 11/28/2022]
Abstract
The degree of variability in the patient baseline 7-day diary of pain ratings has been hypothesized to have a potential effect on the assay sensitivity of randomized clinical trials of pain therapies. To address this issue, we obtained clinical trial data from the Food and Drug Administration (FDA) through the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership, and harmonized patient level data from 12 clinical trials (4 gabapentin and 8 pregabalin) in postherpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN). Models were developed using exploratory logistic regression to examine the interaction between available baseline factors and treatment (placebo vs active medication) in predicting patient response to therapy (ie, >30% improvement). Our analysis demonstrated an increased likelihood of response in the placebo-treated group for patients with a higher standard deviation in the baseline 7-day diary without affecting the likelihood of a response in the active medication-treated group, confirming our hypothesis. In addition, there was a small but significant age-by-treatment interaction in the PHN model, and small weight-by-treatment interaction in the DPN model. The patient's sex, baseline pain level, and the study protocol had an effect only on the likelihood of response overall. Our results suggest the possibility that, at least in some disease processes, excluding patients with a highly variable baseline 7-day diary has the potential to improve the assay sensitivity of these analgesic clinical trials, although reductions of external validity must be considered when increasing the homogeneity of the investigated sample.
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Affiliation(s)
- John T Farrar
- Department of Biostatistics and Epidemiology, Anesthesiology, and Neurology, University of Pennsylvania, Philadelphia, PA, USA University of Pennsylvania, Philadelphia, PA, USA Queen's University, Kingston, ON, Canada Pain Research Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare, New Haven, CT, USA Department of Psychiatry, Yale University, New Haven, CT, USA Analgesic Solutions, Natick, MA, USA Tufts University, Boston, MA, USA United States Food and Drug Administration, Silver Spring, MD, USA California Pacific Medical Center Research Institute, San Francisco, CA, USA University of Washington, Seattle, WA, USA University of Rochester, Rochester, NY, USA
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Munch T, Dufka FL, Greene K, Smith SM, Dworkin RH, Rowbotham MC. RReACT goes global: perils and pitfalls of constructing a global open-access database of registered analgesic clinical trials and trial results. Pain 2014; 155:1313-1317. [PMID: 24726925 DOI: 10.1016/j.pain.2014.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/29/2014] [Accepted: 04/04/2014] [Indexed: 11/19/2022]
Abstract
Eliminating publication bias requires ensuring public awareness of studies and access to results. Clinical trial registries provide basic trial information, but access to unbiased trial results is inadequate. Nearly all studies of trial registration and results reporting have been limited to the ClinicalTrials.gov registry. We analyzed trial registration, registry functionality, cross-registry harmonization, and results reporting on all 15 primary registries in the World Health Organization International Clinical Trials Registry Platform (ICTRP) for postherpetic neuralgia, painful diabetic neuropathy, and fibromyalgia. A total of 447 unique trials were identified, with 86 trials listed on more than one registry. A comprehensive search algorithm was used to find trial results in the peer-reviewed literature and the grey literature. Creating a global database of registered trials and trial results proved surprisingly difficult for several reasons: (1) ICTRP does not reliably identify trials listed on multiple registries, manual searches are necessary; (2) Searching ICTRP yields different results than searching individual registries; (3) Outcome measure descriptions for multiply registered trials vary between registries; (4) Registry-publication pairings are often inaccurate or incomplete; (5) Grey literature results are not permanent. Overall, only 46% of all trials had results available. Trials registered on ClinicalTrials.gov were significantly more likely to have results (52% vs. 18%, P<0.001), partly due to the ability to post results directly to the registry. In addition to the simple remedy of including trial registration numbers on all meeting abstracts and peer-reviewed papers, specific strategies are offered to facilitate identifying multiply registered studies and ensuring accurate pairing of results and publications.
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Affiliation(s)
- Troels Munch
- California Pacific Medical Center Research Institute, San Francisco, CA 94107, USA Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
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20
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Tzabazis A, Aparici CM, Rowbotham MC, Schneider MB, Etkin A, Yeomans DC. Correction: Shaped Magnetic Field Pulses by Multi-Coil Repetitive Transcranial Magnetic Stimulation (rTMS) Differentially Modulate Anterior Cingulate Cortex Responses and Pain in Volunteers and Fibromyalgia Patients. Mol Pain 2014; 10:174480691016. [PMID: 30110879 PMCID: PMC3942267 DOI: 10.1186/1744-8069-10-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alexander Tzabazis
- 1 Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Carina M Aparici
- 2 Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | | | - M B Schneider
- 4 Cervel Neurotech Inc, Foster City, CA, USA.,5 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,6 Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA. 7California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Amit Etkin
- 3 Sierra-Pacific Mental Illness Research Education and Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,5 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - David C Yeomans
- 1 Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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21
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Tzabazis A, Aparici CM, Rowbotham MC, Schneider MB, Etkin A, Yeomans DC. Shaped magnetic field pulses by multi-coil repetitive transcranial magnetic stimulation (rTMS) differentially modulate anterior cingulate cortex responses and pain in volunteers and fibromyalgia patients. Mol Pain 2013; 9:33. [PMID: 23819466 PMCID: PMC3750766 DOI: 10.1186/1744-8069-9-33] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 06/29/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) has shown promise in the alleviation of acute and chronic pain by altering the activity of cortical areas involved in pain sensation. However, current single-coil rTMS technology only allows for effects in surface cortical structures. The ability to affect activity in certain deep brain structures may however, allow for a better efficacy, safety, and tolerability. This study used PET imaging to determine whether a novel multi-coil rTMS would allow for preferential targeting of the dorsal anterior cingulate cortex (dACC), an area always activated with pain, and to provide preliminary evidence as to whether this targeted approach would allow for efficacious, safe, and tolerable analgesia both in a volunteer/acute pain model as well as in fibromyalgia chronic pain patients. METHODS Part 1: Different coil configurations were tested in a placebo-controlled crossover design in volunteers (N = 16). Tonic pain was induced using a capsaicin/thermal pain model and functional brain imaging was performed by means of H2(15)O positron emission tomography - computed tomography (PET/CT) scans. Differences in NRS pain ratings between TMS and sham treatment (NRS(TMS)-NRS(placebo)) which were recorded each minute during the 10 minute PET scans. Part 2: 16 fibromyalgia patients were subjected to 20 multi-coil rTMS treatments over 4 weeks and effects on standard pain scales (Brief Pain Inventory, item 5, i.e. average pain NRS over the last 24 hours) were recorded. RESULTS A single 30 minute session using one of 3 tested rTMS coil configurations operated at 1 Hz consistently produced robust reduction (mean 70% on NRS scale) in evoked pain in volunteers. In fibromyalgia patients, the 20 rTMS sessions also produced a significant pain inhibition (43% reduction in NRS pain over last 24 hours), but only when operated at 10 Hz. This degree of pain control was maintained for at least 4 weeks after the final session. CONCLUSION Multi-coil rTMS may be a safe and effective treatment option for acute as well as for chronic pain, such as that accompanying fibromyalgia. Further studies are necessary to optimize configurations and settings as well as to elucidate the mechanisms that lead to the long-lasting pain control produced by these treatments.
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22
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Dworkin RH, Turk DC, Peirce-Sandner S, He H, McDermott MP, Farrar JT, Katz NP, Lin AH, Rappaport BA, Rowbotham MC. Assay sensitivity and study features in neuropathic pain trials: an ACTTION meta-analysis. Neurology 2013; 81:67-75. [PMID: 23700332 PMCID: PMC3770199 DOI: 10.1212/wnl.0b013e318297ee69] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 03/13/2013] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Our objective was to identify patient, study, and site factors associated with assay sensitivity in placebo-controlled neuropathic pain trials. METHODS We examined the associations between study characteristics and standardized effect size (SES) in a database of 200 publicly available randomized clinical trials of pharmacologic treatments for neuropathic pain. RESULTS There was considerable heterogeneity in the SESs among the examined trials. Univariate meta-regression analyses indicated that larger SESs were significantly associated with trials that had 1) greater minimum baseline pain inclusion criteria, 2) greater mean subject age, 3) a larger percentage of Caucasian subjects, and 4) a smaller total number of subjects. In a multiple meta-regression analysis, the associations between SES and minimum baseline pain inclusion criterion and age remained significant. CONCLUSIONS Our analyses have examined potentially modifiable correlates of study SES and shown that a minimum pain inclusion criterion of 40 or above on a 0 to 100 scale is associated with a larger SES. These data provide a foundation for investigating strategies to improve assay sensitivity and thereby decrease the likelihood of falsely negative outcomes in clinical trials of efficacious treatments for neuropathic pain.
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Affiliation(s)
- Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Smith SM, Wang AT, Katz NP, McDermott MP, Burke LB, Coplan P, Gilron I, Hertz SH, Lin AH, Rappaport BA, Rowbotham MC, Sampaio C, Sweeney M, Turk DC, Dworkin RH. Adverse event assessment, analysis, and reporting in recent published analgesic clinical trials: ACTTION systematic review and recommendations. Pain 2013; 154:997-1008. [PMID: 23602344 DOI: 10.1016/j.pain.2013.03.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/28/2013] [Accepted: 03/01/2013] [Indexed: 11/18/2022]
Abstract
The development of valid and informative treatment risk-benefit profiles requires consistent and thorough information about adverse event (AE) assessment and participants' AEs during randomized controlled trials (RCTs). Despite a 2004 extension of the Consolidated Standards of Reporting Trials (CONSORT) statement recommending the specific AE information that investigators should report, there is little evidence that analgesic RCTs adequately adhere to these recommendations. This systematic review builds on prior recommendations by describing a comprehensive checklist for AE reporting developed to capture clinically important AE information. Using this checklist, we coded AE assessment methods and reporting in all 80 double-blind RCTs of noninvasive pharmacologic treatments published in the European Journal of Pain, Journal of Pain, and PAIN® from 2006 to 2011. Across all trials, reports of AEs were frequently incomplete, inconsistent across trials, and, in some cases, missing. For example, >40% of trials failed to report any information on serious adverse events. Trials of participants with acute or chronic pain conditions and industry-sponsored trials typically provided more and better-quality AE data than trials involving pain-free volunteers or trials that were not industry sponsored. The results of this review suggest that improved AE reporting is needed in analgesic RCTs. We developed an ACTTION (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks) AE reporting checklist that is intended to assist investigators in thoroughly and consistently capturing and reporting these critically important data in publications.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Pereira MP, Werner MU, Ringsted TK, Rowbotham MC, Taylor BK, Dahl JB. Does naloxone reinstate secondary hyperalgesia in humans after resolution of a burn injury? A placebo-controlled, double-blind, randomized, cross-over study. PLoS One 2013; 8:e64608. [PMID: 23741350 PMCID: PMC3669421 DOI: 10.1371/journal.pone.0064608] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 04/16/2013] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Development of secondary hyperalgesia following a cutaneous injury is a centrally mediated, robust phenomenon. The pathophysiological role of endogenous opioid signalling to the development of hyperalgesia is unclear. Recent animal studies, carried out after the resolution of inflammatory pain, have demonstrated reinstatement of tactile hypersensitivity following administration of μ-opioid-receptor-antagonists. In the present study in humans, we analyzed the effect of naloxone when given after the resolution of secondary hyperalgesia following a first-degree burn injury. METHODS Twenty-two healthy volunteers were included in this placebo-controlled, randomized, double-blind, cross-over study. Following baseline assessment of thermal and mechanical thresholds, a first-degree burn injury (BI; 47°C, 7 minutes, thermode area 12.5 cm(2)) was induced on the lower leg. Secondary hyperalgesia areas around the BI-area, and separately produced by brief thermal sensitization on the contralateral thigh (BTS; 45°C, 3 minutes, area 12.5 cm(2)), were assessed using a polyamide monofilament at pre-BI and 1, 2, and 3 hours post-BI. At 72 hrs, BI and BTS secondary hyperalgesia areas were assessed prior to start of a 30 minutes intravenous infusion of naloxone (total dose 21 microg/kg) or placebo. Fifteen minutes after start of the infusion, BI and BTS secondary hyperalgesia areas were reassessed, along with mechanical and thermal thresholds. RESULTS Secondary hyperalgesia areas were demonstrable in all volunteers 1-3 hrs post-BI, but were not demonstrable at 72 hrs post-burn in 73-86% of the subjects. Neither magnitude of secondary hyperalgesia areas nor the mechanical and thermal thresholds were associated with naloxone-treated compared to placebo-treated subjects. CONCLUSION Naloxone (21 microg/kg) did not reinstate secondary hyperalgesia when administered 72 hours after a first-degree burn injury and did not increase BTS-generated hyperalgesia. The negative results may be due to the low dose of naloxone or insufficient tissue injury to generate latent sensitization.
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Affiliation(s)
- Manuel P Pereira
- Neuroscience Center, Rigshospitalet, Copenhagen University Hospitals, Copenhagen, Denmark.
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Werner MU, Petersen KL, Rowbotham MC, Dahl JB. Healthy volunteers can be phenotyped using cutaneous sensitization pain models. PLoS One 2013; 8:e62733. [PMID: 23671631 PMCID: PMC3650051 DOI: 10.1371/journal.pone.0062733] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 03/25/2013] [Indexed: 11/24/2022] Open
Abstract
Background Human experimental pain models leading to development of secondary hyperalgesia are used to estimate efficacy of analgesics and antihyperalgesics. The ability to develop an area of secondary hyperalgesia varies substantially between subjects, but little is known about the agreement following repeated measurements. The aim of this study was to determine if the areas of secondary hyperalgesia were consistently robust to be useful for phenotyping subjects, based on their pattern of sensitization by the heat pain models. Methods We performed post-hoc analyses of 10 completed healthy volunteer studies (n = 342 [409 repeated measurements]). Three different models were used to induce secondary hyperalgesia to monofilament stimulation: the heat/capsaicin sensitization (H/C), the brief thermal sensitization (BTS), and the burn injury (BI) models. Three studies included both the H/C and BTS models. Results Within-subject compared to between-subject variability was low, and there was substantial strength of agreement between repeated induction-sessions in most studies. The intraclass correlation coefficient (ICC) improved little with repeated testing beyond two sessions. There was good agreement in categorizing subjects into ‘small area’ (1st quartile [<25%]) and ‘large area’ (4th quartile [>75%]) responders: 56–76% of subjects consistently fell into same ‘small-area’ or ‘large-area’ category on two consecutive study days. There was moderate to substantial agreement between the areas of secondary hyperalgesia induced on the same day using the H/C (forearm) and BTS (thigh) models. Conclusion Secondary hyperalgesia induced by experimental heat pain models seem a consistent measure of sensitization in pharmacodynamic and physiological research. The analysis indicates that healthy volunteers can be phenotyped based on their pattern of sensitization by the heat [and heat plus capsaicin] pain models.
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Affiliation(s)
- Mads U Werner
- Multidisciplinary Pain Center, Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Rowbotham MC, Gilron I, Glazer C, Rice AS, Smith BH, Stewart WF, Wasan AD. Can pragmatic trials help us better understand chronic pain and improve treatment? Pain 2013; 154:643-646. [DOI: 10.1016/j.pain.2013.02.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/28/2013] [Accepted: 02/28/2013] [Indexed: 11/16/2022]
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Reda H, Greene K, Rice FL, Rowbotham MC, Petersen KL. Natural history of herpes zoster: late follow-up of 3.9 years (n=43) and 7.7 years (n=10). Pain 2013; 154:2227-2233. [PMID: 23719573 DOI: 10.1016/j.pain.2013.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/04/2013] [Accepted: 04/03/2013] [Indexed: 12/01/2022]
Abstract
Postherpetic neuralgia (PHN) is a common complication after herpes zoster (HZ). Subjects who completed a longitudinal observational 6-month study (4 visits) of the natural history of HZ were recontacted for 2 additional follow-up visits that included pain and sensory symptom assessment, quantitative sensory testing, capsaicin response test, and 3-mm punch skin biopsies in HZ-affected, mirror-image, and control skin sites. Forty-three subjects (14 with PHN at 6 months) of the original 94 subjects in the cohort were comprehensively assessed at a median 3.9 years after HZ onset (visit 5), and 10 subjects underwent a final assessment at a median 7.7 years after HZ onset (visit 6). At 3.9 years, none of the 29 subjects who had been pain free at 6 months had a recurrence of pain. Only 2 of the 14 subjects with PHN at 6 months still had pain at 3.9 years. One subject with PHN at 6 months was free of symptoms at 3.9 years but had very mild pain at 7.7 years. Sensory function continued on a path toward normalization, but was still abnormal in many subjects, especially those who met criteria for PHN at 6 months. Even at 7.7 years, reinnervation of HZ-affected skin was not apparent.
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Affiliation(s)
- Haatem Reda
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA California Pacific Medical Center Research Institute, San Francisco, CA 94107, USA Albany Medical College, Albany, NY 12208, USA
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Abstract
Informed consent is the cornerstone of human research subject protection. Many subjects sign consent documents without understanding the study purpose, procedures, risks, benefits, and their rights. Proof of comprehension is not required and rarely obtained. Understanding might improve by using an interactive system with multiple options for hearing, viewing and reading about the study and the consent form at the subject's own pace with testing and immediate feedback. This prospective randomized study compared the IRB-approved paper ICF for an actual clinical research study with an interactive presentation of the same study and its associated consent form using an iPad device in two populations: clinical research professionals, and patients drawn from a variety of outpatient practice settings. Of the 90 participants, 69 completed the online test and survey questions the day after the session (maximum 36 hours post-session). Among research professionals (n = 14), there was a trend (p = .07) in the direction of iPad subjects testing better on the online test (mean correct = 77%) compared with paper subjects (mean correct = 57%). Among patients (n = 55), iPad subjects had significantly higher test scores than standard paper consent subjects (mean correct = 75% vs 58%, p < .001). For all subjects, the total time spent reviewing the paper consent was 13.2 minutes, significantly less than the average of 22.7 minutes total on the three components to be reviewed using the iPad (introductory video, consent form, interactive quiz). Overall satisfaction and overall enjoyment slightly favored the interactive iPad presentation. This study demonstrates that combining an introductory video, standard consent language, and an interactive quiz on a tablet-based system improves comprehension of research study procedures and risks.
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Affiliation(s)
- Michael C Rowbotham
- California Pacific Medical Center Research Institute, San Francisco, California, USA.
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Finnerup NB, Scholz J, Attal N, Baron R, Haanpää M, Hansson P, Raja SN, Rice ASC, Rief W, Rowbotham MC, Simpson DM, Treede RD. Neuropathic pain needs systematic classification. Eur J Pain 2013; 17:953-6. [PMID: 23339030 DOI: 10.1002/j.1532-2149.2012.00282.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 12/22/2022]
Affiliation(s)
- N B Finnerup
- Danish Pain Research Center, Aarhus University, Denmark.
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Smith SM, Chang DR, Pereira A, Shah N, Gilron I, Katz NP, Lin AH, McDermott MP, Rappaport BA, Rowbotham MC, Sampaio C, Turk DC, Dworkin RH. Adherence to CONSORT harms-reporting recommendations in publications of recent analgesic clinical trials: An ACTTION systematic review. Pain 2012; 153:2415-2421. [DOI: 10.1016/j.pain.2012.08.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 08/09/2012] [Accepted: 08/15/2012] [Indexed: 11/30/2022]
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Comer SD, Zacny JP, Dworkin RH, Turk DC, Bigelow GE, Foltin RW, Jasinski DR, Sellers EM, Adams EH, Balster R, Burke LB, Cerny I, Colucci RD, Cone E, Cowan P, Farrar JT, Haddox DJ, Haythornthwaite JA, Hertz S, Jay GW, Johanson CE, Junor R, Katz NP, Klein M, Kopecky EA, Leiderman DB, McDermott MP, O'Brien C, O'Connor AB, Palmer PP, Raja SN, Rappaport BA, Rauschkolb C, Rowbotham MC, Sampaio C, Setnik B, Sokolowska M, Stauffer JW, Walsh SL. Core outcome measures for opioid abuse liability laboratory assessment studies in humans: IMMPACT recommendations. Pain 2012; 153:2315-2324. [PMID: 22998781 DOI: 10.1016/j.pain.2012.07.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 07/19/2012] [Accepted: 07/31/2012] [Indexed: 11/18/2022]
Abstract
A critical component in development of opioid analgesics is assessment of their abuse liability (AL). Standardization of approaches and measures used in assessing AL have the potential to facilitate comparisons across studies, research laboratories, and drugs. The goal of this report is to provide consensus recommendations regarding core outcome measures for assessing the abuse potential of opioid medications in humans in a controlled laboratory setting. Although many of the recommended measures are appropriate for assessing the AL of medications from other drug classes, the focus here is on opioid medications because they present unique risks from both physiological (e.g., respiratory depression, physical dependence) and public health (e.g., individuals in pain) perspectives. A brief historical perspective on AL testing is provided, and those measures that can be considered primary and secondary outcomes and possible additional outcomes in AL assessment are then discussed. These outcome measures include the following: subjective effects (some of which comprise the primary outcome measures, including drug liking; physiological responses; drug self-administration behavior; and cognitive and psychomotor performance. Before presenting recommendations for standardized approaches and measures to be used in AL assessments, the appropriateness of using these measures in clinical trials with patients in pain is discussed.
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Affiliation(s)
- Sandra D Comer
- Division on Substance Abuse, New York State Psychiatric Institute/College of Physicians and Surgeons, Columbia University, New York, NY, USA Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA Department of Anesthesiology, University of Rochester, Rochester, NY, USA Department of Anesthesiology, University of Washington, Seattle, WA, USA Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA Department of Medicine, Johns Hopkins University, Baltimore, MD, USA Kendle Early Phase Toronto, Formerly Decision Line Clinical Research Corporation, Toronto, Ontario, Canada Covance, Princeton, NJ, USA Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA United States Food and Drug Administration, Silver Spring, MD, USA Colucci and Associates LLC, Newtown, CT, USA American Chronic Pain Association, Rocklin, CA, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Purdue Pharma L.P., Stamford, CT, USA Pfizer Inc., New London, CT, USA Psychiatry and Behavioral Sciences, Wayne State University, Detroit, MI, USA Eisai Limited, Woodcliff Lake, NJ, USA Analgesic Research, Needham, MA, USA Department of Anesthesiology, Tufts University, Boston, Massachusetts, USA Endo Pharmaceuticals Inc., Chadds Ford, PA, USA CNS Drug Consulting LLC, McLean, VA, USA Department of Biostatistics, University of Rochester, Rochester, NY, USA Department of Neurology, University of Rochester, Rochester, NY, USA Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA Department of Medicine, University of Rochester, Rochester, NY, USA AcelRx Pharmaceuticals Inc., Redwood City, CA, USA Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA Johnson and Johnson Pharmaceutical Research and Development LLC, Raritan, NJ, USA Research Institute, California Pacific Medical Center, San Francisco, CA, USA Clinical Pharmacology and Therapeutics Laboratory, Faculdade de Medicina de Lisboa, Lisbon, Portugal King Pharmaceuticals Inc., Cary, NC, USA Grünenthal USA Inc., Bedminster, NJ, USA Durect Corporation, Cupertino, CA, USA Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, KY, USA
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Dworkin RH, Turk DC, Peirce-Sandner S, Burke LB, Farrar JT, Gilron I, Jensen MP, Katz NP, Raja SN, Rappaport BA, Rowbotham MC, Backonja MM, Baron R, Bellamy N, Bhagwagar Z, Costello A, Cowan P, Fang WC, Hertz S, Jay GW, Junor R, Kerns RD, Kerwin R, Kopecky EA, Lissin D, Malamut R, Markman JD, McDermott MP, Munera C, Porter L, Rauschkolb C, Rice ASC, Sampaio C, Skljarevski V, Sommerville K, Stacey BR, Steigerwald I, Tobias J, Trentacosti AM, Wasan AD, Wells GA, Williams J, Witter J, Ziegler D. Considerations for improving assay sensitivity in chronic pain clinical trials: IMMPACT recommendations. Pain 2012; 153:1148-1158. [PMID: 22494920 DOI: 10.1016/j.pain.2012.03.003] [Citation(s) in RCA: 213] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/23/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
A number of pharmacologic treatments examined in recent randomized clinical trials (RCTs) have failed to show statistically significant superiority to placebo in conditions in which their efficacy had previously been demonstrated. Assuming the validity of previous evidence of efficacy and the comparability of the patients and outcome measures in these studies, such results may be a consequence of limitations in the ability of these RCTs to demonstrate the benefits of efficacious analgesic treatments vs placebo ("assay sensitivity"). Efforts to improve the assay sensitivity of analgesic trials could reduce the rate of falsely negative trials of efficacious medications and improve the efficiency of analgesic drug development. Therefore, an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting was convened in which the assay sensitivity of chronic pain trials was reviewed and discussed. On the basis of this meeting and subsequent discussions, the authors recommend consideration of a number of patient, study design, study site, and outcome measurement factors that have the potential to affect the assay sensitivity of RCTs of chronic pain treatments. Increased attention to and research on methodological aspects of clinical trials and their relationships with assay sensitivity have the potential to provide the foundation for an evidence-based approach to the design of analgesic clinical trials and expedite the identification of analgesic treatments with improved efficacy and safety.
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Affiliation(s)
- Robert H Dworkin
- Departments of Anesthesiology and Neurology and Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY 14642, USA University of Washington, Seattle, WA, USA University of Rochester, Rochester, NY, USA United States Food and Drug Administration, Silver Spring, MD, USA University of Pennsylvania, Philadelphia, PA, USA Queen's University, Kingston, ON, Canada Analgesic Solutions, Natick, MA, USA Tufts University, Boston, MA, USA Johns Hopkins University, Baltimore, MD, USA California Pacific Medical Center Research Institute, San Francisco, CA, USA University of Wisconsin, Madison, WI, USA University of Kiel, Kiel, Germany University of Queensland, Brisbane, Australia Bristol-Myers Squibb, Wallingford, CT, USA American Chronic Pain Association, Rocklin, CA, USA DePuy Spine, Raynham, MA, USA Pfizer, New London, CT, USA Eisai Limited, Mosquito Way, Hatfield, UK Department of Veterans Affairs, West Haven, CT, USA Yale University, New Haven, CT, USA Nuvo Research, West Chester, PA, USA Endo Pharmaceuticals Inc., Chadds Ford, PA, USA Durect Corporation, Cupertino, CA, USA AstraZeneca, Wilmington, DE, USA Purdue Pharma, Stamford, CT, USA National Institutes of Health, Bethesda, MD, USA Johnson & Johnson Pharmaceutical Research & Development, Titusville, NJ, USA Imperial College, London, UK Faculdade de Medicina de Lisboa, Lisbon, Portugal Eli Lilly & Co., Indianapolis, IN, USA King Pharmaceuticals (currently Pfizer), Cary, NC, USA Oregon Health and Science University, Portland, OR, USA Grünenthal GmbH, Aachen, Germany NeurogesX, Inc., San Carlos, CA, USA Harvard Medical School, Boston, MA, USA University of Ottawa, Ottawa, ON, Canada Smith & Nephew, Durham, NC, USA German Diabetes Center, Heinrich Heine University, Düsseldorf, Germany
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Rowbotham MC, Nothaft W, Duan RW, Wang Y, Faltynek C, McGaraughty S, Chu KL, Svensson P. Oral and cutaneous thermosensory profile of selective TRPV1 inhibition by ABT-102 in a randomized healthy volunteer trial. Pain 2011; 152:1192-1200. [PMID: 21377273 DOI: 10.1016/j.pain.2011.01.051] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 01/24/2011] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
Abstract
The capsaicin receptor (TRPV1) antagonist ABT-102 demonstrates efficacy in multiple preclinical pain models. However, evolving clinical data for this compound class suggest potentially profound drug-induced thermosensory impairment. Safety and tolerability of ABT-102 were assessed in a multiple-dose, double-blind, placebo-controlled, randomized healthy volunteer trial. Thirty-six participants were randomized in a 2:1 ratio to ABT-102:placebo in 3 dose groups (1 mg, 2 mg, and 4 mg twice a day) and confined to an inpatient research unit for a 7-day treatment period and 3 follow-up days. Outcome measures included: oral and cutaneous cold detection, warm detection (WDT), and heat pain thresholds (HPT); oral perceived heat intensity (oral liquid test); time to hand withdrawal (water bath test); and cutaneous pain intensity (long thermal stimulus). Significant dose-dependent (placebo- and baseline-adjusted) increases in HPT and reduced painfulness of suprathreshold heat were present from days 1-7. For ABT-102 4 mg twice a day, model-based mean differences from placebo (95% confidence interval) were as follows: oral HPT, day 1=2.5°C (0.6-4.4), day 5=4.4°C (2.5-6.3); cutaneous HPT, day 2=3.3°C (1.4-5.3), day 5=5.3°C (3.3-7.2); oral WDT, day 1=2.6°C (0.5-4.7), day 5=2.7°C (0.6-4.9); cutaneous WDT, day 2=1.3 (0.0-2.6), day 5=1.6 (0.3-2.8) (all P<0.05). Oral liquid test and water bath test results followed a similar pattern. There was no effect on cutaneous cold detection. All effects were fully reversed by day 10. There were no other relevant safety findings. Core body temperature remained below 39°C in all participants. In conclusion, ABT-102 potently and reversibly increased HPT and reduced painfulness of suprathreshold oral/cutaneous heat.
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Affiliation(s)
- Michael C Rowbotham
- California Pacific Medical Center Research Institute, San Francisco, CA, USA Abbott Pain Care, Abbott Park, IL, USA Abbott Neuroscience and Pain Discovery, Abbott Park, IL, USA MINDLab, Center of Functionally Integrative Neuroscience, Aarhus University Hospital & Department of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus C, Denmark
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Abstract
Background The effect of pregabalin on acute herpes zoster pain has not been previously evaluated. Methods In a randomized, double-blind, placebo-controlled, two-session crossover study the effect of a single oral dose of pregabalin (150 mg) on pain and allodynia was evaluated in 8 subjects with herpes zoster. Results Over 6 hours of observation, pain decreased by a mean of 33% with pregabalin and 14% with placebo (p < 0.10). Effects on allodynia and SF-MPQ were not significant. Conclusions Compared to an earlier study of gabapentin 900 mg for acute zoster pain and allodynia that followed a nearly identical protocol, pregabalin had a similar effect on pain and was well tolerated, with no difference from placebo on sleepiness. Common side effects of light-headedness, unsteady gait, and slowed thinking were almost identical to that observed in the earlier study of gabapentin. Subject recruitment proved difficult in part due to the widespread off-label use of gabapentin and pregabalin for acute zoster pain in our region of the USA. Trial Registration ClinicalTrials.gov Identifier: NCT00352651
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Dworkin RH, Turk DC, Katz NP, Rowbotham MC, Peirce-Sandner S, Cerny I, Clingman CS, Eloff BC, Farrar JT, Kamp C, McDermott MP, Rappaport BA, Sanhai WR. Evidence-based clinical trial design for chronic pain pharmacotherapy: a blueprint for ACTION. Pain 2010; 152:S107-S115. [PMID: 21145657 DOI: 10.1016/j.pain.2010.11.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 11/08/2010] [Accepted: 11/09/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA Analgesic Solutions, Natick, MA, USA Tufts University, Boston, MA, USA California Pacific Medical Center, San Francisco, CA, USA United States Food and Drug Administration, Bethesda, MD, USA Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Chapman CR, Lipschitz DL, Angst MS, Chou R, Denisco RC, Donaldson GW, Fine PG, Foley KM, Gallagher RM, Gilson AM, Haddox JD, Horn SD, Inturrisi CE, Jick SS, Lipman AG, Loeser JD, Noble M, Porter L, Rowbotham MC, Schoelles KM, Turk DC, Volinn E, Von Korff MR, Webster LR, Weisner CM. Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base. J Pain 2010; 11:807-29. [PMID: 20430701 DOI: 10.1016/j.jpain.2010.02.019] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 02/04/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence. PERSPECTIVE Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.
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Affiliation(s)
- C Richard Chapman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Petersen KL, Rice FL, Farhadi M, Reda H, Rowbotham MC. Natural history of cutaneous innervation following herpes zoster. Pain 2010; 150:75-82. [DOI: 10.1016/j.pain.2010.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 03/01/2010] [Accepted: 04/05/2010] [Indexed: 12/26/2022]
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Abstract
The natural history of sensory function in the first 6months after herpes zoster (HZ) was determined in a cohort of 94 subjects at elevated risk for developing post-herpetic neuralgia (PHN). All four visits included ratings of pain and sensory symptoms, mapping areas of altered sensation and allodynia, and quantitative thermal and mechanical sensory testing. The last three visits included the capsaicin response test. Sensory thresholds in distant control skin were stable. Mirror-image skin was persistently hyperesthetic to warming and mechanical stimuli and hyperalgesic to heat compared to distant control skin. HZ skin showed deficits in all thermal modalities. Sensory recovery was limited and selective. Allodynia area and severity, hyperalgesia to von Frey hair, and cold detection threshold improved, but deficits to warmth and heat pain did not. Capsaicin on HZ skin significantly aggravated pain and allodynia in the majority of subjects at 6-8weeks after HZ onset. At study entry, eventual PHN subjects had significantly more impairment in detecting warmth and cold, a larger area of altered sensation, a larger area of allodynia, and more severe allodynia. The results support the study hypothesis that severity of initial injury predicts PHN, especially impaired cold sensation in HZ skin. The hypothesis that PHN develops because of a failure to recover normal neural function was not supported. Sensory recovery proceeded at the same rate in eventual pain-free and eventual PHN subjects and is not a requirement for pain resolution. Early interventions that reduce neural injury or enhance recovery should be of benefit.
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Affiliation(s)
- Karin L Petersen
- UCSF Pain Clinical Research Center, Department of Neurology, University of California, San Francisco, CA, USA
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Rowbotham MC, Duan RW, Thomas J, Nothaft W, Backonja MM. A randomized, double-blind, placebo-controlled trial evaluating the efficacy and safety of ABT-594 in patients with diabetic peripheral neuropathic pain. Pain 2009; 146:245-252. [DOI: 10.1016/j.pain.2009.06.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2009] [Revised: 05/27/2009] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
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Affiliation(s)
- Michael C Rowbotham
- Departments of Neurology and Anesthesia, University of California, San Francisco, CA 94115, USA Medical Research Institute, California Pacific Medical Center, San Francisco, CA, USA
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Mitchell JM, Bergren LJ, Chen KS, Rowbotham MC, Fields HL. Naltrexone aversion and treatment efficacy are greatest in humans and rats that actively consume high levels of alcohol. Neurobiol Dis 2009; 33:72-80. [DOI: 10.1016/j.nbd.2008.09.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 09/10/2008] [Accepted: 09/12/2008] [Indexed: 11/26/2022] Open
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Rowbotham MC. The impact of selective publication on clinical research in pain. Pain 2008; 140:401-404. [DOI: 10.1016/j.pain.2008.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 10/23/2008] [Accepted: 10/29/2008] [Indexed: 11/28/2022]
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Rowbotham MC. How should treatment results from clinical practice be reported? Pain 2008; 138:475-476. [DOI: 10.1016/j.pain.2008.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 08/04/2008] [Indexed: 11/26/2022]
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Stacey BR, Barrett JA, Whalen E, Phillips KF, Rowbotham MC. Pregabalin for postherpetic neuralgia: placebo-controlled trial of fixed and flexible dosing regimens on allodynia and time to onset of pain relief. J Pain 2008; 9:1006-17. [PMID: 18640074 DOI: 10.1016/j.jpain.2008.05.014] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Revised: 05/12/2008] [Accepted: 05/28/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Time to onset of pain relief and improvement in allodynia in 269 patients with postherpetic neuralgia was examined in a 4-week randomized trial comparing flexibly dosed pregabalin (150-600 mg/d), fixed-dose pregabalin (300 mg/d), and placebo. For each patient with clinically meaningful pain reduction (>or=30%) at end point, onset of pain relief was defined as the first study day on which a patient reported >or=1-point reduction in pain relative to baseline. Average dose achieved was 396 mg/d in the flexible-dose group compared with 295 mg/d in the fixed-dose group. Median pain relief onset times were 3.5 days (flexible-dose), 1.5 days (fixed-dose), and >4 weeks (placebo). Compared with placebo, significantly more patients in both pregabalin treatment groups achieved >or=30% and >or=50% pain reduction at end point. Almost 95% of patients had brush-evoked allodynia, with 68% having moderate to severe allodynia (>or=40/100 mm). At baseline, pain and allodynia were highly correlated. Independent of treatment assignment, improvement in pain and improvement in allodynia were significantly correlated. Allodynia could serve as a useful surrogate outcome measure in future studies. Pregabalin was significantly better than placebo in alleviating allodynia (flexible-dose reduction, 26 mm; fixed-dose, 21 mm; placebo, 12 mm). Discontinuation rates due to adverse events were more frequent in the fixed-dose group. PERSPECTIVE A flexible-dose regimen reduces discontinuations, facilitates higher final doses, and results in a slightly greater pain relief. Allodynia (touch-evoked pain) can be of disabling severity and is present in nearly all patients with postherpetic neuralgia. Allodynia severity is correlated with pain severity and improvement in allodynia is correlated with clinical response.
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Affiliation(s)
- Brett R Stacey
- Oregon Health and Science University, Comprehensive Pain Center, Portland, Oregon, USA
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Petersen KL, Meadoff T, Press S, Peters MM, LeComte MD, Rowbotham MC. Changes in morphine analgesia and side effects during daily subcutaneous administration in healthy volunteers. Pain 2007; 137:395-404. [PMID: 17977662 DOI: 10.1016/j.pain.2007.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 09/20/2007] [Accepted: 09/24/2007] [Indexed: 10/22/2022]
Abstract
Tolerance to the anti-nociceptive effects of opioids develops rapidly in animals. In contrast, humans with chronic pain show little or no loss of pain relief in prospective opioid trials of 4-8 weeks duration. Employing the Brief Thermal Sensitization model to induce transient cutaneous secondary hyperalgesia, we tested the hypothesis that opioid analgesic tolerance would develop rapidly. In this outpatient randomized placebo-controlled study, subjects in the MMMMP group received two injections of subcutaneous morphine 6 mg (150 min apart) on Monday-Thursday (total 48 mg over 4 days) and matching saline placebo on Friday. Subjects in the PPPPM group received placebo on Monday-Thursday and morphine (total 12 mg) on Friday. Sixty-one healthy volunteers were enrolled; morphine side effects accounted for all nine non-completions. Compared to the first placebo day, the reduction in the area of secondary hyperalgesia on the first morphine day was significant and robust in both groups. Morphine suppression of the painfulness of skin heating and elevation of the heat pain detection threshold were also significant. During 4 days of twice-daily injections, the decline in anti-hyperalgesic effects of morphine did not reach statistical significance (p=0.06) compared to placebo. Morphine side effects did not correlate with anti-hyperalgesic effects and withdrawal symptoms did not emerge. As 4 days is the threshold for demonstrating analgesic tolerance to twice-daily morphine in animal models, a longer period of opioid exposure in healthy volunteers might be needed to detect analgesic tolerance.
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Affiliation(s)
- Karin Lottrup Petersen
- UCSF Pain Clinical Research Center, Department of Neurology, University of San Francisco, CA, USA Ernest Gallo Clinic and Research Center, Department of Neurology, University of California, San Francisco, CA, USA
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Affiliation(s)
- Michael C Rowbotham
- Department of Neurology, UCSF Pain Clinical Research Center, University of California, School of Medicine, San Francisco, CA 94115, USA.
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Petersen KL, Rowbotham MC. Relief of post-herpetic neuralgia by surgical removal of painful skin: 5 years later. Pain 2007; 131:214-8. [PMID: 17451877 PMCID: PMC2020855 DOI: 10.1016/j.pain.2007.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 01/24/2007] [Accepted: 03/06/2007] [Indexed: 11/24/2022]
Abstract
Surgical removal of painful skin was first attempted as a treatment for chronic intractable post-herpetic neuralgia (PHN) more than a century ago, but long-term follow-up has rarely been reported. A patient who underwent surgical excision of 294cm(2) of thoracic skin comprising the entire area of pain and allodynia in October 2000 has been followed for 5.5years post-surgery. Our initial report presented evidence of benefit in the form of reduced pain, elimination of allodynia, and reduced medication consumption during the first post-operative year. Unfortunately, pain steadily increased and now exceeds pre-surgery levels despite increased medication use. Pain topography and characteristics are different from pre-surgery and may relate to the pathophysiology of PHN. Skin resection cannot be recommended as a treatment for PHN.
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Affiliation(s)
- Karin Lottrup Petersen
- UCSF Pain Clinical Research Center, Department of Neurology, University of California, San Francisco, CA 94115, USA.
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Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, Petersen KL. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology 2007; 68:515-21. [PMID: 17296917 DOI: 10.1212/01.wnl.0000253187.66183.9c] [Citation(s) in RCA: 415] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the effect of smoked cannabis on the neuropathic pain of HIV-associated sensory neuropathy and an experimental pain model. METHODS Prospective randomized placebo-controlled trial conducted in the inpatient General Clinical Research Center between May 2003 and May 2005 involving adults with painful HIV-associated sensory neuropathy. Patients were randomly assigned to smoke either cannabis (3.56% tetrahydrocannabinol) or identical placebo cigarettes with the cannabinoids extracted three times daily for 5 days. Primary outcome measures included ratings of chronic pain and the percentage achieving >30% reduction in pain intensity. Acute analgesic and anti-hyperalgesic effects of smoked cannabis were assessed using a cutaneous heat stimulation procedure and the heat/capsaicin sensitization model. RESULTS Fifty patients completed the entire trial. Smoked cannabis reduced daily pain by 34% (median reduction; IQR = -71, -16) vs 17% (IQR = -29, 8) with placebo (p = 0.03). Greater than 30% reduction in pain was reported by 52% in the cannabis group and by 24% in the placebo group (p = 0.04). The first cannabis cigarette reduced chronic pain by a median of 72% vs 15% with placebo (p < 0.001). Cannabis reduced experimentally induced hyperalgesia to both brush and von Frey hair stimuli (p < or = 0.05) but appeared to have little effect on the painfulness of noxious heat stimulation. No serious adverse events were reported. CONCLUSION Smoked cannabis was well tolerated and effectively relieved chronic neuropathic pain from HIV-associated sensory neuropathy. The findings are comparable to oral drugs used for chronic neuropathic pain.
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Affiliation(s)
- D I Abrams
- Community Consortium, Positive Health Program, San Francisco General Hospital, San Francisco, CA 94110, USA.
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Mitchell JM, Fields HL, White RL, Meadoff TM, Joslyn G, Rowbotham MC. The Asp40 mu-opioid receptor allele does not predict naltrexone treatment efficacy in heavy drinkers. J Clin Psychopharmacol 2007; 27:112-5. [PMID: 17224736 DOI: 10.1097/jcp.0b013e31802e68b0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, Betts RF, Gershon AA, Haanpaa ML, McKendrick MW, Nurmikko TJ, Oaklander AL, Oxman MN, Pavan-Langston D, Petersen KL, Rowbotham MC, Schmader KE, Stacey BR, Tyring SK, van Wijck AJM, Wallace MS, Wassilew SW, Whitley RJ. Recommendations for the management of herpes zoster. Clin Infect Dis 2007; 44 Suppl 1:S1-26. [PMID: 17143845 DOI: 10.1086/510206] [Citation(s) in RCA: 434] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.
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Affiliation(s)
- Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, 14642, USA.
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