1
|
Kraft KVL, Backmund T, Eberhart L, Schubert AK, Dinges HC, Hagen MK, Gehling M. Does opioid therapy enhance quality of life in patients suffering from chronic non-malignant pain? A systematic review and meta-analysis. Br J Pain 2024; 18:227-242. [PMID: 38751560 PMCID: PMC11092930 DOI: 10.1177/20494637231216352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Background and objective Chronic pain is associated with a poor health-related quality of life (HRQL). Whereas the prescription rate of opioids increased during the last decades, their use in chronic non-malignant pain remains unclear. However, there is currently no clinical consensus or evidence-based guidelines that consider the long-term effects of opioid therapy on HRQL in patients with chronic non-cancer pain. This systematic review aims to address the question of whether opioid therapy improves HRQL in patients with chronic non-malignant pain and provide some guidance to practitioners. Databases and data treatment PubMed, EMBASE and CENTRAL were searched in June 2020 for double-blind, randomized trials (RCTs), comparing opioid therapy to placebo and assessed a HRQL questionnaire. The review comprises a qualitative vote counting approach and a meta-analysis of the Short Form Health Survey (SF-36), EQ-5D questionnaire and the pain interference scale of the Brief pain inventory (BPI). Results 35 RCTs were included, of which the majority reported a positive effect of opioids for the EQ-5D, the BPI and the physical component score (PCS) of the SF-36 compared to placebo. The meta-analysis of the PCS showed a mean difference of 1.82 [confidence interval: 1.32, 2.32], the meta-analysis of the EQ-5D proved a significant advantage of 0.06 [0.00, 0.12]. In the qualitative analysis of the mental component score (MCS) of the SF-36, no positive or negative trend was seen. No significant differences were seen in the MCS (MD: 0.65 [-0.43, 1.73]). A slightly higher premature dropout rate was found in the opioid group (risk difference: 0.04 [0.00, 0.07], p = .07). The body of evidence is graded as low to medium. Conclusion Opioids have a statistically significant, but small and clinical not relevant effect on the physical dimensions of HRQL, whereas there is no effect on mental dimensions of HRQL in patients with chronic non-malignant pain during the initial months of treatment. In clinical practice, opioid prescriptions for chronic non-cancer pain should be individually assessed as their broad efficacy in improving quality of life is not confirmed. The duration of opioid treatment should be determined carefully, as this review primarily focuses on the initial months of therapy.
Collapse
Affiliation(s)
- Karl V. L. Kraft
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Teresa Backmund
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Leopold Eberhart
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Ann-Kristin Schubert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Hanns-Christian Dinges
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Maria K. Hagen
- Department of Physics and Material Sciences Center, Philipps-University Marburg, Marburg, Germany
| | | |
Collapse
|
2
|
Wewege MA, Bagg MK, Jones MD, Ferraro MC, Cashin AG, Rizzo RR, Leake HB, Hagstrom AD, Sharma S, McLachlan AJ, Maher CG, Day R, Wand BM, O'Connell NE, Nikolakopolou A, Schabrun S, Gustin SM, McAuley JH. Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis. BMJ 2023; 380:e072962. [PMID: 36948512 PMCID: PMC10540836 DOI: 10.1136/bmj-2022-072962] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To evaluate the comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, PubMed, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and World Health Organization's International Clinical Trials Registry Platform from database inception to 20 February 2022. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised controlled trials of analgesic medicines (eg, non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids) compared with another analgesic medicine, placebo, or no treatment. Adults (≥18 years) who reported acute non-specific low back pain (for less than six weeks). DATA EXTRACTION AND SYNTHESIS Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (number of participants who reported any adverse event during treatment). Secondary outcomes were low back specific function, serious adverse events, and discontinuation from treatment. Two reviewers independently identified studies, extracted data, and assessed risk of bias. A random effects network meta-analysis was done and confidence was evaluated by the Confidence in Network Meta-Analysis method. RESULTS 98 randomised controlled trials (15 134 participants, 49% women) included 69 different medicines or combinations. Low or very low confidence was noted in evidence for reduced pain intensity after treatment with tolperisone (mean difference -26.1 (95% confidence intervals -34.0 to -18.2)), aceclofenac plus tizanidine (-26.1 (-38.5 to -13.6)), pregabalin (-24.7 (-34.6 to -14.7)), and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol (risk ratio 2.6 (95% confidence interval 1.5 to 4.5)), paracetamol plus sustained release tramadol (2.4 (1.5 to 3.8)), baclofen (2.3 (1.5 to 3.4)), and paracetamol plus tramadol (2.1 (1.3 to 3.4)) compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence. Moderate to low confidence was also noted for secondary outcomes and secondary analysis of medicine classes. CONCLUSIONS The comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain are uncertain. Until higher quality randomised controlled trials of head-to-head comparisons are published, clinicians and patients are recommended to take a cautious approach to manage acute non-specific low back pain with analgesic medicines. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019145257.
Collapse
Affiliation(s)
- Michael A Wewege
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Matthew K Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Perron Institute for Neurological and Translational Science, Perth, WA, Australia
| | - Matthew D Jones
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Michael C Ferraro
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Aidan G Cashin
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Rodrigo Rn Rizzo
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Hayley B Leake
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- IIMPACT in Health, University of South Australia, Adelaide, SA, Australia
| | - Amanda D Hagstrom
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Saurab Sharma
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Gadigal Country, Sydney, NSW, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Gadigal Country, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Richard Day
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Benedict M Wand
- Faculty of Medicine, Nursing and Midwifery and Health Sciences, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Adriani Nikolakopolou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Siobhan Schabrun
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- School of Physical Therapy, University of Western Ontario, London, ON, Canada
- The Gray Centre for Mobility and Activity, Parkwood Institute, London, ON, Canada
| | - Sylvia M Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - James H McAuley
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| |
Collapse
|
3
|
Kopsky DJ, Szadek KM, Schober P, Vrancken AFJE, Steegers MAH. Study Design Characteristics and Endpoints for Enriched Enrollment Randomized Withdrawal Trials for Chronic Pain Patients: A Systematic Review. J Pain Res 2022; 15:479-496. [PMID: 35210848 PMCID: PMC8860756 DOI: 10.2147/jpr.s334840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- David J Kopsky
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
- Institute for Neuropathic Pain, Amsterdam, 1056 SN, the Netherlands
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Correspondence: David J Kopsky Institute for Neuropathic Pain, Vespuccistraat 64-III, Amsterdam, 1056 SN, the NetherlandsTel +31-6-28671847 Email
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
| |
Collapse
|
4
|
Rizzo RRN, Ferraro MC, Wewege MA, Cashin AG, Leake HB, O'Hagan ET, Jones MD, Gustin SM, McLachlan AJ, Day R, McAuley JH. Targeting Neurotrophic Factors for Low Back Pain and Sciatica: A Systematic Review and Meta-analysis. Rheumatology (Oxford) 2021; 61:2243-2254. [PMID: 34677587 DOI: 10.1093/rheumatology/keab785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This meta-analysis aims to investigate the efficacy and safety of medicines that target neurotrophic factors for low back pain (LBP) or sciatica. METHODS We searched published and trial registry reports of randomised controlled trials evaluating the effect of medicines that target neurotrophic factors to LBP or sciatica in seven databases from inception to December 2020. Two reviewers independently identified studies, extracted data, and assessed the risk of bias and certainty in the evidence. RESULTS Nine studies (3349 participants) were included in the meta-analyses. Low certainty evidence showed that anti-NGF may reduce pain at four weeks (MD -6.63, 95% CI -8.51 to -4.76), and 12 weeks (MD -6.10, -8.34 to -3.87), and may increase adverse effects for chronic LBP (OR 1.16, 0.99-1.36). Higher doses of anti-NGF may offer a clinically important reduction in pain at the cost of increased adverse effects for chronic LBP. Very low certainty evidence showed that anti-NGF and glial cell line-derived neurotrophic factor (pro-GDNF) may not reduce pain for sciatica at four weeks (MD -1.40, -8.26-5.46), at 12 weeks (MD -2.91, -13.69-7.67), and may increase adverse effects for sciatica (OR 3.27, 1.78-6.00). CONCLUSION Anti-NGF may offer small reductions in pain intensity for chronic LBP. The effect may depend on the dose and types of medicines. For sciatica, anti-NGF or pro-GDNF may not reduce pain. Medicines that target neurotrophic factors for LBP or sciatica are associated with different adverse effects from commonly prescribed medicines for these conditions.
Collapse
Affiliation(s)
- Rodrigo R N Rizzo
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Michael A Wewege
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Hayley B Leake
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,IIMPACT in Health, University of South Australia, Adelaide, Australia
| | - Edel T O'Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Matthew D Jones
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Sylvia M Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Psychology, University of New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, University of Sydney, Sydney, NSW, 2050, Australia
| | - Richard Day
- Clinical Pharmacology & Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia.,School of Health Sciences, University of New South Wales, Sydney, Australia
| |
Collapse
|
5
|
Wewege MA, Bagg MK, Jones MD, McAuley JH. Analgesic medicines for adults with low back pain: protocol for a systematic review and network meta-analysis. Syst Rev 2020; 9:255. [PMID: 33148322 PMCID: PMC7643321 DOI: 10.1186/s13643-020-01506-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 10/19/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is limited evidence for the comparative effectiveness of analgesic medicines for adults with low back pain. This systematic review and network meta-analysis aims to determine the analgesic effect, safety, acceptability, effect on function, and relative rank according to analgesic effect, safety, acceptability, and effect on function of a single course of [an] analgesic medicine(s) or combination of these medicines for people with low back pain. METHODS We will include published and unpublished randomised trials written in any language that compare an analgesic medicine to either another medicine, placebo/sham, or no intervention in adults with low back pain, grouped according to pain duration: acute (fewer than 6 weeks), sub-acute (6 to 12 weeks), and chronic (greater than 12 weeks). The co-primary outcomes are pain intensity following treatment and safety (adverse events). The secondary outcomes are function and acceptability (all-cause dropouts). We will perform a network meta-analysis to compare and rank analgesic medicines. We will form judgements of confidence in the results using the Confidence in Network Meta-Analysis (CINeMA) methodology. DISCUSSION This network meta-analysis will establish which medicine, or combination of medicines, is most effective for reducing pain and safest for adults with low back pain. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019145257.
Collapse
Affiliation(s)
- Michael A. Wewege
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
| | - Matthew K. Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW 2052 Australia
- New College Village, University of New South Wales, Sydney, Australia
| | - Matthew D. Jones
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
| | - James H. McAuley
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
| |
Collapse
|
6
|
Gudin J, Kaufman AG, Datta S. Are Opioids Needed to Treat Chronic Low Back Pain? A Review of Treatment Options and Analgesics in Development. J Pain Res 2020; 13:1007-1022. [PMID: 32523371 PMCID: PMC7234959 DOI: 10.2147/jpr.s226483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/19/2020] [Indexed: 12/29/2022] Open
Abstract
The continued prevalence of chronic low back pain (CLBP) is a testament to our lack of understanding of the potential causes, leading to significant treatment challenges. CLBP is the leading cause of years lived with disability and the fifth leading cause of disability-adjusted life-years. No single non-pharmacologic, pharmacologic, or interventional therapy has proven effective as treatment for the majority of patients with CLBP. Although non-pharmacologic therapies are generally helpful, they are often ineffective as monotherapy and many patients lack adequate access to these treatments. Noninvasive treatment measures supported by evidence include physical and chiropractic therapy, yoga, acupuncture, and non-opioid and opioid pharmacologic therapy; data suggest a moderate benefit, at most, for any of these therapies. Until our understanding of the pathophysiology and treatment of CLBP advances, clinicians must continue to utilize rational multimodal treatment protocols. Recent Centers for Disease Control and Prevention guidelines for opioid prescribing recommend that opioids not be utilized as first-line therapy and to limit the doses when possible for fear of bothersome or dangerous adverse effects. In combination with the current opioid crisis, this has caused providers to minimize or eliminate opioid therapy when treating patients with chronic pain, leaving many patients suffering despite optimal nonopioid therapies. Therefore, there remains an unmet need for effective and tolerable opioid receptor agonists for the treatment of CLBP with improved safety properties over legacy opioids. There are several such agents in development, including opioids and other agents with novel mechanisms of action. This review critiques non-pharmacologic and pharmacologic treatment modalities for CLBP and examines the potential of novel opioids and other analgesics that may be a useful addition to the treatment options for patients with chronic pain.
Collapse
Affiliation(s)
- Jeffrey Gudin
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA.,Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - Andrew G Kaufman
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Samyadev Datta
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA.,Center for Pain Management, Hackensack, NJ, USA
| |
Collapse
|
7
|
Designing and conducting proof-of-concept chronic pain analgesic clinical trials. Pain Rep 2019; 4:e697. [PMID: 31583338 PMCID: PMC6749910 DOI: 10.1097/pr9.0000000000000697] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction: The evolution of pain treatment is dependent on successful development and testing of interventions. Proof-of-concept (POC) studies bridge the gap between identification of a novel target and evaluation of the candidate intervention's efficacy within a pain model or the intended clinical pain population. Methods: This narrative review describes and evaluates clinical trial phases, specific POC pain trials, and approaches to patient profiling. Results: We describe common POC trial designs and their value and challenges, a mechanism-based approach, and statistical issues for consideration. Conclusion: Proof-of-concept trials provide initial evidence for target use in a specific population, the most appropriate dosing strategy, and duration of treatment. A significant goal in designing an informative and efficient POC study is to ensure that the study is safe and sufficiently sensitive to detect a preliminary efficacy signal (ie, a potentially valuable therapy). Proof-of-concept studies help avoid resources wasted on targets/molecules that are not likely to succeed. As such, the design of a successful POC trial requires careful consideration of the research objective, patient population, the particular intervention, and outcome(s) of interest. These trials provide the basis for future, larger-scale studies confirming efficacy, tolerability, side effects, and other associated risks.
Collapse
|
8
|
Yamato TP, Maher CG, Saragiotto BT, Shaheed CA, Moseley AM, Lin CWC, Koes B, McLachlan AJ. Comparison of effect sizes between enriched and nonenriched trials of analgesics for chronic musculoskeletal pain: a systematic review. Br J Clin Pharmacol 2017. [PMID: 28636752 DOI: 10.1111/bcp.13350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS To investigate the use of an enriched study design on the estimates of treatment effect in analgesic trials for chronic musculoskeletal pain. METHODS Database searches were conducted from 2004 to 2014. We included randomized placebo-controlled trials evaluating pain medications for chronic musculoskeletal pain. Methodological quality was assessed using the PEDro scale. The estimates of treatment effect on pain and adverse events were compared between enriched and nonenriched designs. Metaregression was used to assess the association between the effect size estimate and the study design controlling for analgesic dose and methodological quality. RESULTS We included 108 trials, of which 99 were included in the meta-analysis (n = 44 171). There were no overall differences in effect sizes between enriched and nonenriched designs for pain intensity. There was a significant difference for a reduction in any adverse events favouring enriched designs for opioids, but not for other analgesics or the outcome serious adverse events. There was an association between effect size and methodological quality, with failure to blind the outcome assessor and failure to use intention-to-treat analysis being associated with larger effect sizes. CONCLUSIONS There is no evidence that the use of an enriched study design changes the treatment effect size estimate for pain. There is some evidence that clinical trials that employ enriched designs report a reduced risk of adverse events in trials for chronic musculoskeletal pain, but it is unclear whether enriched designs influence estimates of serious adverse events. Features of trial design and study quality were associated with treatment effect estimates.
Collapse
Affiliation(s)
- Tie P Yamato
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | - Chris G Maher
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | - Bruno T Saragiotto
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | | | - Anne M Moseley
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | | | - Bart Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Andrew J McLachlan
- Faculty of Pharmacy and Centre for Education and Research on Ageing, The University of Sydney and Concord Hospital, Sydney, Australia
| |
Collapse
|