Characteristics of patients with chronic pain

Pain relief and tolerability balance of immediate release tapentadol or oxycodone treatment for patients with moderate to severe osteoarthritis or low back pain

PURPOSE

Opioid treatment effectiveness may be best compared using definitions of treatment response, which combine measures assessing pain reduction and the occurrence of adverse events (AEs). This analysis of data from two phase III clinical trials was conducted to examine the pain relief and tolerability (PRT) balance of immediate release (IR) tapentadol and oxycodone in patients with moderate to severe osteoarthritis (OA) or low back pain.

METHODS

This was a post hoc analysis of two multicenter, randomized, double-blind studies (10-day and 90-day) that evaluated the efficacy and safety of tapentadol IR in patients with moderate-severe OA pain. PRT was defined as adequate pain reduction (30% or 50% pain intensity improvement from baseline) and no gastrointestinal AE or other type of treatment-emergent AE. The percentage of patients and mean number of days per patient meeting the PRT criteria were summarized.

RESULTS

In the 10-day trial, the percentages of patients meeting PRT criteria (30% reduction) for both tapentadol groups were consistently above that for oxycodone 10 mg, although only significantly different for the 50 mg formulation. The mean number of days per patient meeting the PRT criteria was 3.7, 3.2, and 2.3 days for tapentadol 50 mg, 75 mg and oxycodone 10 mg, respectively. No significant difference between the groups was observed using the 50% pain reduction criterion. For the 90-day trial, using multiple definitions, tapentadol IR showed a significantly higher proportion of days meeting PRT criteria.

CONCLUSION

Pain reduction and tolerability are both important attributes of an effective analgesic treatment. Based on data from two trials, tapentadol IR produced an improved PRT balance compared with oxycodone IR.

The effectiveness of Proctofoam-HC for treatment of hemorrhoids in late pregnancy

OBJECTIVE

Currently no topical anti-hemorrhoidal agents have been studied for effectiveness in pregnancy. This study evaluated the effectiveness of Proctofoam-HC used during the last trimester of pregnancy.

METHODS

In this prospective, open-label, observational study, pregnant women prescribed Proctofoam-HC were asked to complete two telephone interview questionnaires.

RESULTS

A total of 88 women completed the study. All hemorrhoidal symptoms, including pain, pruritus, swelling, itching, decreased significantly (P < 0.001) and overall well-being improved. The improvement was clinically very significant after correction for potential placebo effect.

CONCLUSIONS

Proctofoam-HC appears to provide effective treatment of hemorrhoids in late pregnancy.

Factors Predicting Pain Reduction in Chronic Back and Neck Pain After Multimodal Treatment

OBJECTIVES

To determine whether treatment related pain reduction on the short- and long-term is predicted by different baseline variables, and with different accuracy, in patients with chronic low back pain as compared with those with chronic neck pain.

DESIGN AND METHODS

A single blinded prospective cohort study based on patients with chronic musculoskeletal pain in the lower back (N = 167) or the neck (N = 136) who completed a 4-week multimodal rehabilitation program. At admission, each patient was evaluated on 17 potential predictors, including pain characteristics and physical, sociodemographic, and psychosocial-behavioral variables. Changes in self-reported pain intensity in the lower back or the neck between the pretreatment evaluation and those performed immediately after, and 12 months after the rehabilitation program, were assessed.

RESULTS

Logistic regression models revealed that change in pain intensity could be predicted with good specificity but with poor sensitivity both for patients with chronic low back pain and chronic neck pain. Significant predictors among the neck pain patients were high endurance, low age, high pain intensity, few other symptoms, low need of being social, to do things with others, and to be helped, along with optimistic attitudes on how the pain will interfere with daily life. Among the low back pain patients, high pain intensity, low levels of pain severity, and high affective distress were important predictors. Variables such as sex, sick leave history, working status, accident, pain duration, and depressive symptoms demonstrated no predictive value. Short- and long-term pain outcome was equally predictable and predicted by almost the same variables.

CONCLUSIONS

Patients who reported unchanged or increased pain after multimodal treatment could be predicted with good accuracy, whereas those who reported decreased pain were more difficult to identify. Treatment-related pain alteration in chronic low back pain seems to be predicted by partly different variables than in chronic neck pain.

The efficacy of a risk factor-based cognitive behavioral intervention and electromyographic biofeedback in patients with acute sciatic pain. An attempt to prevent chronicity

STUDY DESIGN

An investigation of the efficacy of an individually scheduled, risk factor-based cognitive behavioral therapy and a standardized electromyographic biofeedback intervention in the prevention of chronicity in patients with acute sciatica and psychosocial risk factors for chronicity.

OBJECTIVES

To investigate the possibility of enhancing pain relief and preventing chronicity in patients with acute sciatica, based on a screening for psychosocial high-risk factors of chronification.

SUMMARY OF BACKGROUND DATA

Psychological interventions were evaluated mainly in patients with chronic low back pain. Numerous randomized trials have demonstrated their efficacy, whereas the amount of pain relief was found to be marginal.

METHODS

Subjective and behavioral outcome parameters were compared with the respective parameters in age-, gender-, and diagnosis-matched high- and low-risk patients. No additional behavioral treatment for in-patient medical therapy was offered to the patients. Outcome of these patients also was compared with that of a group of refusers of behavioral therapy. Psychological, functional, and behavioral variables were measured before and after treatment and at 3-, 6-, 12- and 18-month follow-up visits. Changes over time, group differences, and possible group x time interactions were analyzed by analysis of variance and nonparameteric comparisons.

RESULTS

Data analysis showed a statistically and clinically significant, beneficial effect of both behavioral interventions. However, risk factor-based cognitive behavioral therapy was superior to electromyographic biofeedback intervention with respect to pain relief and application for early retirement. The cognitive behavioral therapy showed a similar good outcome (e.g., 90% showed a clinical significant pain reduction) as the low-risk patients (83% pain reduction). High risk patients and refusers of therapy showed a poor outcome in pain (33% and 20% pain reduction, respectively), disability, and work performance.

CONCLUSIONS

Individually scheduled, risk factor-based cognitive behavior therapy could be a beneficial treatment modality, which can be offered, in addition to a medical treatment, to patients with acute sciatica and psychosocial high risk factors for chronicity. It may be an effective way to prevent chronification in these patients.

Provider, payor, and patient outcome expectations in back pain rehabilitation

Return to work is used routinely to define successful back pain treatment. This study examined how the patient and three professional groups defined success for each of five categories of patients: not sponsored and working, sponsored and working, sponsored on modified duty, sponsored and off work for less than 10 weeks, and sponsored and off work for more than 10 weeks. The groups sampled were treating staff (n = 98), referring physicians (n = 98), third-party sponsors (n = 133), and patients (n = 648) representing all five patient categories. Each group provided a priority ranking for six objectives of treatment: Return to Work, Pain Control, Functional Improvement, Increased Strength and Range of Movement, Positive Attitude Shift, and Acquired Knowledge. The results indicated that the work status of the patient had a significant effect on the ranking of objectives by the treating staff and third-party sponsors. Physicians and patients considered pain control most important regardless of the patient category. Success in back pain rehabilitation is defined by different criteria. The determination of successful outcome must consider the patient's circumstances and acknowledge the perspective of the individual who is defining success.

Neglected topics in chronic pain treatment outcome studies: determination of success

Although literature on chronic pain treatment outcome has made substantial strides in improving the quality of the studies reported, there remain a number of factors that lead to qualification of the generally positive results. In the two previous papers in this series a set of migrating factors was discussed, namely, representativeness of the samples treated in these outcome studies, relapse, and non-compliance with therapeutic recommendations. Additional limitations include the lack of agreement on the criteria on which to base evaluation of the success of treatment outcome and the percentage of treated patients included in follow-up data. In this paper, the most common methods for determining success are described (group effects based on standard and quasi-standard outcome measures). The limitations of this approach are discussed and alternative strategies are presented that focus not only on traditional criteria based on group means but on additional criteria including: (a) importance of change (i.e., clinical vs. statistical significance), (b) proportion of patients who improve, (c) cost, (d) efficiency in treatment delivery, (e) and consumer acceptance and satisfaction.

Neglected factors in chronic pain treatment outcome studies--referral patterns, failure to enter treatment, and attrition

An increasing number of chronic pain treatment outcome studies have appeared in the literature. In general, these studies support the efficacy of multidisciplinary pain programs, as well as specific treatment modalities such as biofeedback and relaxation. Reviews of this literature have tended to be cautiously optimistic. Some concerns, however, have been raised about the methodological adequacy of these studies, particularly in terms of the lack of control groups, the brief duration of follow-up periods, and the vague criteria used for establishing the success of the therapeutic interventions. Other factors that mitigate conclusions regarding the generalizability of the favorable results reported need to be considered. In this paper 3 rarely discussed topics that are implicit within most treatment outcome studies and that need to be given greater attention are examined. These topics include: (1) referral patterns to pain clinics (who are referred to pain clinics, when, and how representative is the referred sample?); (2) failure to enter treatment (e.g., exclusion criteria, lack of available financial support to cover the cost of treatment, patient's refusal to accept recommendations), and consequently, the representativeness of the treated sample; and (3) patient's attrition. In this paper we discuss each of these factors as they underscore important qualifications that have to be made in evaluating treatment outcome studies.