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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Wang Y, Liu WX, Zhou XH, Yang M, Liu X, Zhang Y, Hai KR, Ye QS. Effects on newborns of applying bupivacaine combined with different doses of fentanyl for cesarean section. World J Clin Cases 2021; 9:6698-6704. [PMID: 34447816 PMCID: PMC8362511 DOI: 10.12998/wjcc.v9.i23.6698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/08/2021] [Accepted: 05/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The choice of anesthesia for cesarean section is very important.
AIM To compare the effects of applying bupivacaine combined with different doses of fentanyl on newborns after cesarean section.
METHODS We randomly divided one hundred and twenty patients undergoing cesarean section into the following 4 groups: group B (bupivacaine group), group BF10 (bupivacaine combined with 10 µg fentanyl), group BF30 (bupivacaine combined with 30 µg fentanyl) and group BF50 (bupivacaine combined with 50 µg fentanyl). The heart rate, mean arterial pressure, block plane fixation time and sensory block time were recorded. Umbilical artery blood was then collected immediately after fetal delivery for blood gas analysis and qualitative detection of fentanyl. Additionally, data on the neonatal 1-min and 5-min Apgar scores, results of umbilical artery blood gas analysis and qualitative detection of fentanyl in umbilical artery blood were recorded.
RESULTS Although the mean arterial pressure decreased in all four groups at 3 min after anesthesia, the percentage of the decrease was less than 20% of the baseline. In addition, there were no significant differences in the 1-min or 5-min Apgar scores or the umbilical artery blood gas analysis among the four groups (P > 0.05). Moreover, the concentration of fentanyl in umbilical artery blood was qualitatively detected using an ELISA kit, and the results in the four groups were negative.
CONCLUSION Bupivacaine combined with fentanyl spinal anesthesia is effective in cesarean section.
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Affiliation(s)
- Yun Wang
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Wen-Xun Liu
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Xiao-Hong Zhou
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Min Yang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, Hubei Province, China
| | - Xin Liu
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Yuan Zhang
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Ke-Rong Hai
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
| | - Qing-Shan Ye
- The First Hospital of Northwest Minzu University (Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region), Yinchuan 750002, Ningxia Hui Autonomous Region, China
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Miyachi T, Ozaki A, Saito H, Sawano T, Tanimoto T, Crump A. Opioids: A 'crisis' of too much or not enough - or simply how rich you are and where you live? Eur J Pain 2021; 25:1181-1194. [PMID: 33822443 DOI: 10.1002/ejp.1767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The 'Opioid Crisis', which originated in Western countries, has been misrepresented and is misinforming the global public. For 20 years, since the advent of the synthetic opioids, 25,000 Americans, on average, have died annually from opioid-related overdoses. The United States produces and consumes by far the greatest amounts of opioids. National regulations introduced to curb overdoses and restrict opioid availability have condemned many Americans, such as cancer patients or those in need of palliative care, to a life of extreme pain due to lack of access to adequate pain management. As is often the case, US-driven laws have informed and guided international regulations. Worldwide, 83% of countries have low or non-existent access to opioids for pain relief. Over 25 million people are at the end-of-life stage, with eight million people dying annually in unnecessary pain and distress. Ineffectively controlled pain is a global public health issue blighting the lives of billions of people worldwide with immeasurable human and socioeconomic costs. International conventions regulate the trade and use of controlled medications, including many opioids. The goal is to balance widespread access to optimal forms of pain management with restrictions to govern the use and prevent the misuse of controlled substances. Those conventions are failing to meet their goals. International guidelines to inform national legislation have been compromised and withdrawn, thanks to undue interference from US-based opioid manufacturers. The new goal must be to ensure equitable access, for all, to opioids and ensure that optimal pain management becomes a central component of Universal Health Coverage. SIGNIFICANCE: The opioid crisis is, more accurately, a multicomponent global crisis and one that is not fully apparent or well understood. Regulations of the wealthy and powerful to control a surfeit of opioids, which encourages misuse, cannot be allowed to govern legislation in the majority of countries worldwide where citizens have little or no access to opioids to reduce pain and suffering. International conventions must be revised to ensure an optimal balance that allows access to opioids for all those who need them.
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Affiliation(s)
| | - Akihiko Ozaki
- Medical Governance Research Institute, Tokyo, Japan.,Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Japan
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Toyoaki Sawano
- Department of Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Japan
| | | | - Andy Crump
- Medical Governance Research Institute, Tokyo, Japan.,Kitasato University, Tokyo, Japan
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Sud A, Armas A, Cunningham H, Tracy S, Foat K, Persaud N, Hosseiny F, Hyland S, Lowe L, Zlahtic E, Murti R, Derue H, Birnbaum I, Bonin K, Upshur R, Nelson MLA. Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review. PLoS One 2020; 15:e0236419. [PMID: 32716982 PMCID: PMC7384622 DOI: 10.1371/journal.pone.0236419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022] Open
Abstract
CONTEXT Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. OBJECTIVE Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. STUDY DESIGN Systematic rapid realist review. DATASET Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. RESULTS 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. CONCLUSIONS Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alana Armas
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Heather Cunningham
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Tracy
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Kirk Foat
- Independent Researcher, London, Ontario, Canada
| | - Navindra Persaud
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Keenan Research Centre, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Fardous Hosseiny
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Leyna Lowe
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Erin Zlahtic
- Kinesiology, Western University, London, Ontario, Canada
| | - Rhea Murti
- Arts & Science, McMaster University, Hamilton, Ontario, Canada
| | - Hannah Derue
- Psychology, University of Guelph-Humber, Toronto, Ontario, Canada
| | - Ilana Birnbaum
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katija Bonin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle L. A. Nelson
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Takayama S, Tomita N, Arita R, Ono R, Kikuchi A, Ishii T. Kampo Medicine for Various Aging-Related Symptoms: A Review of Geriatric Syndrome. Front Nutr 2020; 7:86. [PMID: 32766269 PMCID: PMC7381143 DOI: 10.3389/fnut.2020.00086] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022] Open
Abstract
With the continued growth of the aging population in Japan, geriatric syndrome (GS), which is associated with aging-related symptoms, has become a social problem. GS is caused by physiological and pathological aging and may manifest various symptoms. Physicians use multidisciplinary approaches to provide treatment for individual GS symptoms. Kampo medicine, a Japanese traditional medicine that uses multiple pharmacologically active substances, is useful for many syndromes, conditions, disorders, and diseases associated with GS. Evidence of the effectiveness of Kampo medicine for GS has accumulated in recent years. The effects of Kampo treatment for symptoms related to functional decline of the cardiovascular, respiratory, and digestive systems, cognitive impairment and related disorders, pain and other sensory issues, among others, support the use of Kampo medicine for the management of GS. The role of Kampo medicine for GS is summarized in this review.
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Affiliation(s)
- Shin Takayama
- Department of Kampo and Integrative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Naoki Tomita
- Department of Geriatrics and Gerontology, Institue of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Ryutaro Arita
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Rie Ono
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Akiko Kikuchi
- Department of Kampo and Integrative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
| | - Tadashi Ishii
- Department of Kampo and Integrative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.,Department of Kampo Medicine, Tohoku University Hospital, Sendai, Japan
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Abstract
Kampo, a branch of traditional Japanese herbal medicine, has been the backbone of Japanese medicine for more than 1500 years. The health insurance system in Japan allows patients to access both Western and Kampo medical care at the same time in the same medical institution. Kampo has been used for the treatment of not only acute but also chronic pain in Japan. In this review, we will elaborate on the short history of Kampo, its basic concepts, and use for the treatment of pain.
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