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Doneray H, Tavlas G, Ozden A, Ozturk N. The role of breast milk beta-endorphin and relaxin-2 on infant colic. Pediatr Res 2023; 94:1416-1421. [PMID: 37142649 DOI: 10.1038/s41390-023-02617-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The relationship between infant colic and breast milk beta-endorphin (BE) and relaxin-2 (RLX-2) has not been studied before. METHODS Thirty colic infants and their mothers constituted the study group, and the same sex, similar age and healthy infants and their mothers formed the control group. Maternal predisposing factors were analysed with questionnaires. RESULTS The frequency of headache and myalgia in the mothers was significantly higher in the study group compared to the control group. Sleep quality of mothers in the study group was worse than in the control group (p = 0.028). While breast milk RLX-2 level in the study group was not different from the control group, breast milk BE level in the study group was significantly higher than the control group (p = 0.039). A positive correlation was found between breast milk BE levels and crying times, and between sleep quality scores and crying times. Headache, myalgia, sleep quality and breast milk BE levels were found to have a significant effect on infant colic. CONCLUSIONS Breast milk RLX-2 has no role on infant colic. Breast milk BE may act as a biological mediator in transmitting of maternal predisposing factors such as poor sleep quality, headache and myalgia from mother to infant. IMPACT The relationship between infant colic and breast milk beta-endorphin (BE) and elaxin-2 (RLX-2) has not been studied before. Maternal sleep quality, headache, and myalgia are predisposing factors associated with infant colic. Breast milk RLX-2 has no effect on infant colic. Breast milk BE may play a role as a biological mediator in transmitting the effects of predisposing factors from mother to infant. Breast milk BE may be a mediator in biological communication between mother and infant.
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Affiliation(s)
- Hakan Doneray
- Department of Pediatric Endocrinology, Ataturk University Faculty of Medicine, Erzurum, Türkiye.
- Clinical Research Development and Design Application and Research Center, Ataturk University, Erzurum, Türkiye.
| | - Guzide Tavlas
- Department of Pediatrics, Ataturk University Faculty of Medicine, Erzurum, Türkiye
| | - Ayse Ozden
- Department of Pediatric Endocrinology, Erzurum Regional Training & Research Hospital, Erzurum, Türkiye
| | - Nurinnisa Ozturk
- Department of Medical Biochemistry, Ataturk University Faculty of Medicine, Erzurum, Türkiye
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Abstract
The opioid crisis in the United States (US) is one of the most high-profile public health scandals of the 21st century with millions of people unknowingly becoming dependent on opioids. The United Kingdom (UK) had the world's highest rate of opioid consumption in 2019, and opiate-related drug poisoning deaths have increased by 388% since 1993 in England and Wales. This article explores the epidemiological definitions of public health emergencies and epidemics in the context of opioid use, misuse, and mortality in England, to establish whether England is facing an opioid crisis.
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Affiliation(s)
- Antonia-Olivia Roberts
- Medical Sciences Division, University of Oxford, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
| | - Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Noori A, Sadeghirad B, Wang L, Siemieniuk RAC, Shokoohi M, Kum E, Jeddi M, Montoya L, Hong PJ, Zhou E, Couban RJ, Juurlink DN, Thabane L, Bhandari M, Guyatt GH, Busse JW. Comparative benefits and harms of individual opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2022:S0007-0912(22)00288-4. [PMID: 35817616 DOI: 10.1016/j.bja.2022.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most systematic reviews of opioids for chronic pain have pooled treatment effects across individual opioids under the assumption they provide similar benefits and harms. We examined the comparative effects of individual opioids for chronic non-cancer pain through a network meta-analysis of randomised controlled trials. METHODS We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials to March 2021 for studies that enrolled patients with chronic non-cancer pain, randomised them to receive different opioids, or opioids vs placebo, and followed them for at least 4 weeks. Certainty of evidence was evaluated using the GRADE approach. RESULTS We identified 82 eligible trials (22 619 participants) that evaluated 14 opioids. Compared with placebo, several opioids showed superiority to others for analgesia and improvement in physical function; however, when restricted to pooled-effect estimates supported by moderate certainty evidence, no differences between opioids were evident. Among opioids with moderate certainty evidence, all increased the risk of gastrointestinal adverse events compared with placebo, although no opioids were more harmful than others. Low to very low certainty evidence suggests that extended-release vs immediate-release opioids may provide similar benefits for pain relief and physical functioning, and gastrointestinal harms. CONCLUSIONS Our findings support the pooling of effect estimates across different types and formulations of opioids to inform effectiveness for chronic non-cancer pain.
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Ginalis EE, Ali S, Mammis A. The Role of Intrathecal Pumps in Nonmalignant Pain. Neurosurg Clin N Am 2022. [DOI: 10.1016/j.nec.2022.02.007] [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] [Indexed: 11/22/2022]
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Pickering AP, Bache NJ, Estrup S. Guided self-determination in treatment of chronic pain - a randomized, controlled trial. Scand J Pain 2022; 22:288-297. [PMID: 34333889 DOI: 10.1515/sjpain-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/13/2021] [Accepted: 07/10/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To test whether Guided Self-Determination (GSD) used in chronic pain management could improve the health-related quality of life, patient activation and sense of coherence (SoC) as a measurement of life skills in patients with chronic pain. The method has been shown to be effective in other chronic conditions, but has not been tested in chronic pain. METHODS A three-site randomised, controlled trial at three major multidisciplinary pain centres in Denmark. 200 patients were included and randomised. In the intervention period, both groups had regular visits to the pain centre with both doctors and nurses. The intervention group additionally received the GSD intervention with weekly sessions for eight weeks. Data were collected from February 2013 to July 2016 and consisted of three questionnaires answered before and after the 8-week intervention period, and after six months. The primary outcome was self-reported health related quality of life. Secondary outcomes included self-reported activation and SoC. RESULTS We found no clinically relevant difference between the groups for health-related quality of life, patient activation or SoC at either baseline, at three months or at six months. We also analysed data for trends over time using mixed model analysis, and this did not show any significant differences between groups. CONCLUSIONS GSD did not improve health-related quality of life, patient activation or SoC when administered to patients with chronic pain treated in a multidisciplinary pain centre. New research is recommended using a combination of self-reported and objective measures and longer follow-up.
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Affiliation(s)
- Anne Paarup Pickering
- Multidisciplinary Pain Center, Department of Anaesthesia and Intensive Care, Naestved Hospital, Næstved, Denmark
| | - Nina Jeanette Bache
- Multidisciplinary Pain Center, Department of Anaesthesia and Intensive Care Zealand University Hospital, Køge, Denmark
| | - Stine Estrup
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
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Moreira de Barros GA, Baradelli R, Rodrigues DG, Toffoletto O, Domingues FS, Gayoso MV, Lopes A, Barros Afiune J, Nunes Guimarães GM. Use of methadone as an alternative to morphine for chronic pain management: a noninferiority retrospective observational study. Pain Rep 2021; 6:e979. [PMID: 34938934 DOI: 10.1097/PR9.0000000000000979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/14/2021] [Accepted: 10/26/2021] [Indexed: 12/21/2022] Open
Abstract
Methadone administration for outpatient was noninferior to morphine as analgesic on chronic pain. In addition, it was associated with lesser side effects. Introduction: Chronic pain causes disability and is prevalent in the general population. Opioids are a part of a multimodal strategy for pain management. Methadone, a cheap and long-acting synthetic opioid, may represent an option for those who have limited access to the aforementioned class of analgesics. We aimed to provide a real-world evidence for the analgesic use of methadone, compared with morphine. Methods: We conducted a noninferiority, retrospective observational single center study of patients with chronic pain, managed with either methadone or morphine at an outpatient specialized clinic. We extracted data from the electronic health records of patients who underwent an active treatment between August 2012 and January 2020 and were examined for at least 2 consecutive medical visits, after the administration of one of the aforementioned drugs. Data were analyzed using a generalized additive model with random-effects mixed linear method to account for the individual-related, time-related, and drug-related variations. The numeric verbal scale (0–10) was used to assess the pain severity. Results: From the database of 3373 patients, we included 262 patients (175 methadone and 87 morphine). In an unadjusted analysis, methadone was superior to morphine, and the mean worst pain was 0.86 points lower (95% confidence interval, −1.29 to −0.43). Moreover, methadone was superior to morphine in the adjusted analysis, with the worst pain mean being 1.24 points lower. This provided evidence for the noninferiority of methadone than morphine. Conclusion: Methadone was superior to morphine in a 20% noninferiority margin for reducing worst pain.
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Frimerman L, Verner M, Sirois A, Scott K, Bruneau A, Perez J, Shir Y, Martel MO. Day-to-day hedonic and calming effects of opioids, opioid craving, and opioid misuse among patients with chronic pain prescribed long-term opioid therapy. Pain 2021; 162:2214-24. [PMID: 33729213 DOI: 10.1097/j.pain.0000000000002220] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/16/2020] [Indexed: 12/28/2022]
Abstract
ABSTRACT Concerns have been raised regarding the misuse of opioids among patients with chronic pain. Although a number of factors may contribute to opioid misuse, research has yet to examine if the hedonic and calming effects that can potentially accompany the use of opioids contribute to opioid misuse. The first objective of this study was to examine the degree to which the hedonic and calming effects of opioids contribute to opioid misuse in patients with chronic pain. We also examined whether the hedonic and calming effects of opioids contribute to patients' daily levels of opioid craving, and whether these associations were moderated by patients' daily levels of pain intensity, catastrophizing, negative affect, or positive affect. In this longitudinal diary study, patients (n = 103) prescribed opioid therapy completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. The hedonic and calming effects of opioids were not significantly associated with any type of opioid misuse behavior. However, greater hedonic and calming effects were associated with heightened reports of opioid craving (both P's < 0.005). Analyses revealed that these associations were moderated by patients' daily levels of pain intensity, catastrophizing, and negative affect (all P's < 0.001). Results from this study provide valuable new insights into our understanding of factors that may contribute to opioid craving among patients with chronic pain who are prescribed long-term opioid therapy. The implications of our findings for the management of patients with chronic pain are discussed.
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Laigaard J, Bache N, Stottmeier S, Mathiesen O, Estrup S. Cognitive Function During Opioid Tapering in Patients with Chronic Pain: A Prospective Cohort Study. J Pain Res 2020; 13:3385-3394. [PMID: 33363405 PMCID: PMC7754260 DOI: 10.2147/jpr.s273025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/13/2020] [Indexed: 01/06/2023] Open
Abstract
Purpose Evidence for efficacy and safety lacks for long-term opioid therapy in patients with chronic non-cancer pain and adverse effects, including affection of cognitive function and quality of life, is of concern. We aimed to investigate cognitive function and health-related quality of life in patients with chronic non-cancer pain during opioid reduction. Patients and Methods At two multidisciplinary pain centers, all patients with planned opioid reduction were screened for eligibility. Cognitive function was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail Making Test A and B. Health-related quality of life was assessed using Short Form-36 (SF36) and Hospital Anxiety and Depression Scale (HADS). Results We included 51 participants and 40 participants attended follow-up of median 254 (IQR 106–357) days. Baseline RBANS score was 82 (IQR 65–93) with reference population norm value of 100 (SD±15). Daily opioid consumption was reduced from median 80 (IQR 45–161) oral morphine milligram equivalents to 19 (IQR 0–60) mg. RBANS score estimate increased by 6.2 (95% CI 3.1–9.3, p=0.0004) points after tapering. No differences were observed for Trail Making Test times, HADS or SF36 scores. Conclusion Generally, cognitive function showed minor improvement after opioid tapering with stationary health-related quality of life, depression and anxiety scores. The clinical significance is unclear, as no minimal clinically important difference in RBANS score is available.
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Affiliation(s)
- Jens Laigaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Nina Bache
- Multidisciplinary Pain Center, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Stefan Stottmeier
- Multidisciplinary Pain Center, Department of Anesthesiology, Holbæk Hospital, Holbæk, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stine Estrup
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
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Yoo S, Yang HC, Lee S, Shin J, Min S, Lee E, Song M, Lee D. A Deep Learning-Based Approach for Identifying the Medicinal Uses of Plant-Derived Natural Compounds. Front Pharmacol 2020; 11:584875. [PMID: 33519445 PMCID: PMC7845697 DOI: 10.3389/fphar.2020.584875] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/06/2020] [Indexed: 12/25/2022] Open
Abstract
Medicinal plants and their extracts have been used as important sources for drug discovery. In particular, plant-derived natural compounds, including phytochemicals, antioxidants, vitamins, and minerals, are gaining attention as they promote health and prevent disease. Although several in vitro methods have been developed to confirm the biological activities of natural compounds, there is still considerable room to reduce time and cost. To overcome these limitations, several in silico methods have been proposed for conducting large-scale analysis, but they are still limited in terms of dealing with incomplete and heterogeneous natural compound data. Here, we propose a deep learning-based approach to identify the medicinal uses of natural compounds by exploiting massive and heterogeneous drug and natural compound data. The rationale behind this approach is that deep learning can effectively utilize heterogeneous features to alleviate incomplete information. Based on latent knowledge, molecular interactions, and chemical property features, we generated 686 dimensional features for 4,507 natural compounds and 2,882 approved and investigational drugs. The deep learning model was trained using the generated features and verified drug indication information. When the features of natural compounds were applied as input to the trained model, potential efficacies were successfully predicted with high accuracy, sensitivity, and specificity.
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Affiliation(s)
- Sunyong Yoo
- School of Electronics and Computer Engineering, Chonnam National University, Gwangju, South Korea
| | - Hyung Chae Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Seongyeong Lee
- School of Electronics and Computer Engineering, Chonnam National University, Gwangju, South Korea
| | - Jaewook Shin
- School of Electronics and Computer Engineering, Chonnam National University, Gwangju, South Korea
| | - Seyoung Min
- School of Electronics and Computer Engineering, Chonnam National University, Gwangju, South Korea
| | - Eunjoo Lee
- Big Data Steering Department, National Health Insurance Service, Wonju, South Korea
| | - Minkeun Song
- Department of Physical and Rehabilitation Medicine, Research Institute of Medical Science, Cardiovascular Research Institute, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Doheon Lee
- Bio-Synergy Research Center, Daejeon, South Korea.,Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, South Korea
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Chuang E, Gil EN, Gao Q, Kligler B, McKee MD. Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care. Pain Med 2020; 20:1528-1533. [PMID: 30184213 DOI: 10.1093/pm/pny169] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population. DESIGN This is a cross-sectional observational study. SETTING Subjects were recruited from six urban primary care health centers. SUBJECTS Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included. METHODS Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment. RESULTS Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics. CONCLUSIONS This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.
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Affiliation(s)
| | - Eric N Gil
- Departments of Family and Social Medicine
| | - Qi Gao
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Benjamin Kligler
- Department of Family Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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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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Al-Kaisy A, Van Buyten JP, Carganillo R, Caraway D, Gliner B, Subbaroyan J, Panwar C, Rotte A, Amirdelfan K, Kapural L. 10 kHz SCS therapy for chronic pain, effects on opioid usage: Post hoc analysis of data from two prospective studies. Sci Rep 2019; 9:11441. [PMID: 31391503 DOI: 10.1038/s41598-019-47792-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/24/2019] [Indexed: 12/29/2022] Open
Abstract
Chronic pain, including chronic low back and leg pain are prominent causes of disability worldwide. While patient management aims to reduce pain and improve daily function, prescription of opioids remains widespread despite significant adverse effects. This study pooled data from two large prospective trials on 10 kHz spinal cord stimulation (10 kHz SCS) in subjects with chronic low back pain and/or leg pain and performed post hoc analysis on changes in opioid dosage 12 months post 10 kHz SCS treatment. Patient-reported back and leg pain using the visual analog scale (VAS) and opioid dose (milligrams morphine equivalent/day, MME/day) were compared at 12 months post-10 kHz SCS therapy to baseline. Results showed that in the combined dataset, 39.3% of subjects were taking >90 MME dose of opioids at baseline compared to 23.0% at 12 months post-10 kHz SCS therapy (p = 0.007). The average dose of opioids in >90 MME group was significantly reduced by 46% following 10 kHz SCS therapy (p < 0.001), which was paralleled by significant pain relief (P < 0.001). In conclusion, current analysis demonstrates the benefits of 10 kHz SCS therapy and offers an evidence-based, non-pharmaceutical alternative to opioid therapy and/or an adjunctive therapy to facilitate opioid dose reduction whilst delivering significant pain relief. Healthcare providers involved in management of chronic non-cancer pain can include reduction or elimination of opioid use as part of treatment plan when contemplating 10 kHz SCS.
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Sens E, Mothes-Lasch M, Lutz JF. [Interdisciplinary pain assessment in the hospital setting : Merely a door-opener to multimodal pain therapy?]. Schmerz 2017; 31:568-79. [PMID: 28717823 DOI: 10.1007/s00482-017-0237-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments. METHODS This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015. RESULTS The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients' individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients. DISCUSSION Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.
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Urquhart DM, Wluka AE, van Tulder M, Heritier S, Forbes A, Fong C, Wang Y, Sim MR, Gibson SJ, Arnold C, Cicuttini FM. Efficacy of Low-Dose Amitriptyline for Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:1474-1481. [PMID: 30285054 PMCID: PMC6248203 DOI: 10.1001/jamainternmed.2018.4222] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Antidepressants at low dose are commonly prescribed for the management of chronic low back pain and their use is recommended in international clinical guidelines. However, there is no evidence for their efficacy. OBJECTIVE To examine the efficacy of a low-dose antidepressant compared with an active comparator in reducing pain, disability, and work absence and hindrance in individuals with chronic low back pain. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized clinical trial with a 6-month follow-up of adults with chronic, nonspecific, low back pain who were recruited through hospital/medical clinics and advertising was carried out. INTERVENTION Low-dose amitriptyline (25 mg/d) or an active comparator (benztropine mesylate, 1 mg/d) for 6 months. MAIN OUTCOMES AND MEASURES The primary outcome was pain intensity measured at 3 and 6 months using the visual analog scale and Descriptor Differential Scale. Secondary outcomes included disability assessed using the Roland Morris Disability Questionnaire and work absence and hindrance assessed using the Short Form Health and Labour Questionnaire. RESULTS Of the 146 randomized participants (90 [61.6%] male; mean [SD] age, 54.8 [13.7] years), 118 (81%) completed 6-month follow-up. Treatment with low-dose amitriptyline did not result in greater pain reduction than the comparator at 6 (adjusted difference, -7.81; 95% CI, -15.7 to 0.10) or 3 months (adjusted difference, -1.05; 95% CI, -7.87 to 5.78), independent of baseline pain. There was no statistically significant difference in disability between the groups at 6 months (adjusted difference, -0.98; 95% CI, -2.42 to 0.46); however, there was a statistically significant improvement in disability for the low-dose amitriptyline group at 3 months (adjusted difference, -1.62; 95% CI, -2.88 to -0.36). There were no differences between the groups in work outcomes at 6 months (adjusted difference, absence: 1.51; 95% CI, 0.43-5.38; hindrance: 0.53; 95% CI, 0.19-1.51), or 3 months (adjusted difference, absence: 0.86; 95% CI, 0.32-2.31; hindrance: 0.78; 95% CI, 0.29-2.08), or in the number of participants who withdrew owing to adverse events (9 [12%] in each group; χ2 = 0.004; P = .95). CONCLUSIONS AND RELEVANCE This trial suggests that amitriptyline may be an effective treatment for chronic low back pain. There were no significant improvements in outcomes at 6 months, but there was a reduction in disability at 3 months, an improvement in pain intensity that was nonsignificant at 6 months, and minimal adverse events reported with a low-dose, modest sample size and active comparator. Although large-scale clinical trials that include dose escalation are needed, it may be worth considering low-dose amitriptyline if the only alternative is an opioid. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12612000131853.
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Affiliation(s)
- Donna M Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Anita E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Maurits van Tulder
- Department of Health Sciences, Amsterdam Public Health Research Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the Netherlands
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Chris Fong
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Malcolm R Sim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
| | - Stephen J Gibson
- National Ageing Research Institute, Parkville, Australia.,Caulfield Pain Management and Research Centre, Caulfield, Australia
| | - Carolyn Arnold
- Department of Anaesthesia and Perioperative Medicine, Monash University, Alfred Hospital, Melbourne, Australia.,Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
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Affiliation(s)
- Christopher Littlejohn
- Centre for Addiction Research and Education Scotland, Department of Psychiatry, University of Dundee, Dundee, Scotland, UK
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Cucu A, Shreder K, Kraft D, Rühle PF, Klein G, Thiel G, Frey B, Gaipl US, Fournier C. Decrease of Markers Related to Bone Erosion in Serum of Patients with Musculoskeletal Disorders after Serial Low-Dose Radon Spa Therapy. Front Immunol 2017; 8:882. [PMID: 28791026 PMCID: PMC5524779 DOI: 10.3389/fimmu.2017.00882] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/11/2017] [Indexed: 12/29/2022] Open
Abstract
Musculoskeletal disorders (MSDs) are the most frequent cause of disability in Europe. Reduced mobility and quality of life of the patients are often associated with pain due to chronic inflammation. The inflammatory process, accompanied by a destruction of the cartilage and bone tissue, is discussed as a result of (A) the infiltration of immune cells into the joints, (B) an altered homeostasis of the joint cavity (synovium) with a critical role of bone remodeling cells, and (C) release of inflammatory factors including adipokines in the arthritic joint. In addition to the classical medication, low-dose radiation therapy using photons or radon spa treatments has shown to reduce pain and improve the mobility of the patients. However, the cellular and molecular mechanisms of anti-inflammatory effects of radon are yet poorly understood. We analyzed blood and serum samples from 32 patients, suffering from MSDs, who had been treated in the radon spa in Bad Steben (Germany). Before and after therapy, we measured the levels of markers related to bone metabolism (collagen fragments type-1, cartilage oligomeric matrix protein, receptor activator of NFκB ligand, and osteoprotegerin) in the serum of patients. In addition, adipokines related to inflammation (visfatin, leptin, resistin, and adiponectin) were analyzed. Some of these factors are known to correlate with disease activity. Since T cells play an important role in the progression of the disease, we further analyzed in blood samples the frequency of pro- and anti-inflammatory T cell subpopulations (CD4+IL17+ T cells and CD4+FoxP3+ regulatory T cells). Overall, we found a decrease of collagen fragments (CTX-I), indicating decreased bone resorption, presumably by osteoclasts, in the serum of MSD patients. We also observed reduced levels of visfatin and a consistent trend toward an increase of regulatory T cells in the peripheral blood, both indicating attenuation of inflammation. However, key proteins of bone metabolism were unchanged on a systemic level, suggesting that these factors act locally after radon spa therapy of patients with MSDs.
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Affiliation(s)
- Aljona Cucu
- GSI Helmholtz Center for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Kateryna Shreder
- GSI Helmholtz Center for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Daniela Kraft
- GSI Helmholtz Center for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Paul Friedrich Rühle
- Department of Radiation Oncology, Universitätklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Gerhart Klein
- Association for Spa Research and Medical Practice for Cardiology, Bad Steben, Germany
| | - Gerhard Thiel
- Membrane Biophysics Group, Department of Biology, Technical University Darmstadt, Darmstadt, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Claudia Fournier
- GSI Helmholtz Center for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
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Dureja GP, Jain PN, Joshi M, Saxena A, Das G, Ahdal J, Narang P. Addressing the barriers related with opioid therapy for management of chronic pain in India. Pain Manag 2017; 7:311-330. [PMID: 28699380 DOI: 10.2217/pmt-2016-0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
India has a high prevalence of chronic disorders which may be associated with persistent pain. Despite the availability of multiple treatment options, chronic pain is largely untreated and contributes to disability and mortality. Medical consumption of opioids remains low due to various barriers that prevent access to opioids for patients and healthcare practitioners. Stringent regulatory provisions outlined in the Narcotic Drugs and Psychotropic Substances Act (1985) have been major deterrents to adequate opioid use. Although multiple amendments to the act have ensured ease of opioid access for medicinal purposes, concerns such as lack of awareness and prescribing practices and attitudes of physicians/patients still need to be addressed. This review aims to identify these barriers and suggest recommendations to overcome them.
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Affiliation(s)
| | | | | | - Ashok Saxena
- Department of Anesthesiology, Pain Clinic, University College of Medical Sciences, University of Delhi, New Delhi, India
| | - Gautam Das
- Daradia Pain Clinic, Kolkata, West Bengal, India
| | - Jaishid Ahdal
- Medical Affairs, Johnson & Johnson Pvt. Ltd., Mumbai, Maharashtra, India
| | - Prashant Narang
- Medical Affairs, Johnson & Johnson Pvt. Ltd., Mumbai, Maharashtra, India
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Kim ED, Lee JY, Son JS, Byeon GJ, Yeo JS, Kim DW, Yoo SH, Hong JH, Park HJ. Guidelines for prescribing opioids for chronic non-cancer pain in Korea. Korean J Pain 2017; 30:18-33. [PMID: 28119768 PMCID: PMC5256264 DOI: 10.3344/kjp.2017.30.1.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/07/2016] [Accepted: 12/09/2016] [Indexed: 11/05/2022] Open
Abstract
As the treatment of chronic non-cancer pain gradually increases, clinicians have more opportunities to encounter opioid prescription. However, guidelines for prescribing opioids for chronic non-cancer pain have never been published in Korea. The present guidelines were prepared by reviewing various research data. In cases in which the data were insufficient, recommendations were presented following discussion among experts affiliated with the Opioids Research Group in the Korean Pain Society. The present guidelines may need to be continuously revised and amended as more clinical evidence is acquired.
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Affiliation(s)
- Eung Don Kim
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Ji Seon Son
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Hospital, School of Medicine, Chonbuk National University, Jeonju, Korea
| | - Gyeong Jo Byeon
- Department of Anesthesiology and Pain Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Korea
| | - Jin Seok Yeo
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Do Wan Kim
- Department of Anesthesiology and Pain Medicine, Kimchan Hospital, Suwon, Korea
| | - Sie Hyeon Yoo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang Univertisy, Cheonan, Korea
| | - Ji Hee Hong
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Korea
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Rhodes LA. Pain Management for Sarcoma Patients. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_14] [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] [Indexed: 10/19/2022] Open
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Petzke F, Welsch P, Klose P, Schaefert R, Sommer C, Häuser W. [Opioids in chronic low back pain. A systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks duration]. Schmerz 2016; 29:60-72. [PMID: 25503883 DOI: 10.1007/s00482-014-1449-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The efficacy and safety of opioid therapy in chronic low back pain (CLBP) is under debate. We updated a recent systematic review on the efficacy and safety of opioids in CLBP. METHODS We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CLBP. We included double-blind randomized placebo-controlled studies of at least 4 weeks duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. RESULTS We included 12 RCTs with 17 treatment arms and 4375 participants. Median study duration was 12 (4-16) weeks. Of the 17 treatment arms, seven (41.2 %) used oxycodone; four (23.6 %) tramadol; buprenorphine and oxymorphone were each used in two (11.8 %) and hydromorphone and tapentadol each in one (5.8 %). The results for studies with parallel/cross-over design were as follows (with 95 % confidence interval, CI): opioids were superior to placebo in reducing pain intensity (SMD - 0.29 [- 0.37, - 0.21], p < 0.0001; six studies with 2896 participants). Opioids were superior to placebo in 50 % pain reduction (RD 0.05 [0.01, 0.10], p = 0.01; two studies with 1492 participants; number needed to benefit (NNTB) 19 [95 % CI 10-107]). Opioids were not superior to placebo in reports of much or very much improved pain (RD 0.16 [- 0.01, 0.34], p = 0.07; two studies with 1153 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.22 [- 0.31, - 0.12], p < 0.0001; four studies with 1895 participants). Patients dropped out less frequently with opioids than with placebo due to lack of efficacy (RD - 0.10 [- 0.16, - 0.04], p = 0.001; five studies with 3168 participants; NNTB 10 [8-13]). Patients dropped out more frequently with opioids than with placebo due to adverse events (RD 0.12 [0.05, 0.19], p = 0.0007; six studies with 2910 participants; number needed to harm (NNTH) 7 [95 % CI 6-8]). There was no significant difference between opioids and placebo in terms of the frequency of serious adverse events or deaths. CONCLUSION Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. Opioids and placebo did not differ in terms of safety during the study period. The conclusion on the safety of opioids compared to placebo is limited by the low number of serious adverse events and deaths. Short-term and intermediate-term opioid therapy may be considered in selected CLBP patients. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").
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Affiliation(s)
- F Petzke
- Schmerz-Tagesklinik und -Ambulanz, Universitätsmedizin Göttingen, Göttingen, Deutschland
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Urquhart DM, Wluka AE, Sim MR, van Tulder M, Forbes A, Gibson SJ, Arnold C, Fong C, Anthony SN, Cicuttini FM. Is low-dose amitriptyline effective in the management of chronic low back pain? Study protocol for a randomised controlled trial. Trials 2016; 17:514. [PMID: 27770809 PMCID: PMC5075416 DOI: 10.1186/s13063-016-1637-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 10/04/2016] [Indexed: 12/25/2022] Open
Abstract
Background Low back pain is a major clinical and public health problem, with limited evidence-based treatments. Low-dose antidepressants are commonly used to treat pain in chronic low back pain. However, their efficacy is unproven. The aim of this pragmatic, double-blind, randomised, placebo-controlled trial is to determine whether low-dose amitriptyline (an antidepressant) is more effective than placebo in reducing pain in individuals with chronic low back pain. Methods/design One hundred and fifty individuals with chronic low back pain will be recruited through hospital and private medical and allied health clinics, advertising in local media and posting of flyers in community locations. They will be randomly allocated to receive either low-dose amitriptyline (25 mg) or an active placebo (benztropine mesylate, 1 mg) for 6 months. The primary outcome measure of pain intensity will be assessed at baseline, 3 and 6 months using validated questionnaires. Secondary measures of self-reported low back disability, work absence and hindrance in the performance of paid/unpaid work will also be examined. Intention-to-treat analyses will be performed. Discussion This pragmatic, double-blind, randomised, placebo-controlled trial will provide evidence regarding the effectiveness of low-dose antidepressants compared with placebo in reducing pain, disability, work absenteeism and hindrance in work performance in individuals with chronic low back pain. This trial has major public health and clinical importance as it has the potential to provide an effective approach to the management of chronic low back pain. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12612000131853; registered on 30 January 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1637-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donna M Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia.
| | - Anita E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Malcolm R Sim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Maurits van Tulder
- Department of Health Sciences and EMGO+, Institute for Health and Care Research, VU University, 1081 HV, Amsterdam, The Netherlands
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Stephen J Gibson
- National Ageing Research Institute, Parkville, Melbourne, 3052, VIC, Australia.,Caulfield Pain Management and Research Centre, Caulfield, Melbourne, 3162, VIC, Australia
| | - Carolyn Arnold
- Caulfield Pain Management and Research Centre, Caulfield, Melbourne, 3162, VIC, Australia.,Department of Anaesthesia and Perioperative Medicine, Monash University, Alfred Hospital, Melbourne, 3004, VIC, Australia
| | - Chris Fong
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Melbourne, 3128, VIC, Australia
| | - Shane N Anthony
- Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, 3800, VIC, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
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Shah D, Anupindi VR, Vaidya V. Pharmacoeconomic Analysis of Pain Medications Used to Treat Adult Patients with Chronic Back Pain in the United States. J Pain Palliat Care Pharmacother 2016; 30:300-307. [DOI: 10.1080/15360288.2016.1231735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hassamal S, Haglund M, Wittnebel K, Danovitch I. A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series. Scand J Pain 2016; 13:27-31. [DOI: 10.1016/j.sjpain.2016.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
Abstract
Background
Spine surgery candidates are commonly treated with long-term opioid analgesia. However, chronic opioid analgesia is associated with poor pain control, psychological distress, decreased functional status and operative complications. Therefore, our medical centre piloted an outpatient biopsychosocial interdisciplinary opioid reduction program for spine surgery candidates on chronic opioid analgesia.
Methods
Our case series reviews the outcomes of the first 5 interdisciplinary program completers. Data was collected on admission to the program, preoperatively at completion of the program, and 1 month postoperatively. We recorded changes in pain interference scores, physical functioning, and symptoms of depression and anxiety as captured by the Patient-Reported Outcome Measurement Information System (PROMIS-29) Profile.
Results
The mean duration of the preoperative opioid reduction program was 6–7 weeks. The mean morphine equivalent daily dose (SD) decreased from 238.2 (226.9) mg on admission to 157.1 (161.0) mg preoperatively and 139.1 (84.0) mg one month postoperatively. Similarly, the mean pain interference score (SD) decreased from 72.4 (5.1) on admission to 66.5 (6.9) preoperatively and 67.7 (5.4) one month postoperatively. The preoperative opioid dose and pain interference scores decreased in all 5 patients, but one month postoperatively increased in one patient related to a surgical complication. Pre- and postoperative depression, anxiety and fatigue improved in all patients. Satisfaction with participation in social roles, sleep disturbances, and physical functioning improved in most patients.
Conclusions
Pre- and post-operative pain improved despite the opioid dose being tapered. These preliminary data suggest that a short-term outpatient preoperative interdisciplinary biopsychosocial opioid reduction program is safe, feasible, and improves patient-centred outcomes.
Implications
Our preliminary data support the rationale for expansion of the opioid reduction program; opioid use and pain should be evaluated in all surgical candidates. These findings need to be replicated in larger studies.
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Affiliation(s)
- Sameer Hassamal
- Department of Addiction Psychiatry , University of California Los Angeles/Kern Medical , Bakersfield, CA , United States
- Department of Psychiatry and Neurology , University of California Riverside , Riverside, CA , United States
| | - Margaret Haglund
- Department of Psychiatry and Behavioral Neurosciences , Cedars-Sinai Medical Center , Los Angeles, CA , United States
| | - Karl Wittnebel
- Department of Internal Medicine , Cedars-Sinai Medical Center , Los Angeles, CA , United States
| | - Itai Danovitch
- Department of Psychiatry and Behavioral Neurosciences , Cedars-Sinai Medical Center , Los Angeles, CA , United States
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Abstract
In elderly patients, persistent pain negatively impacts quality of life. An interdisciplinary approach to pain management and emphasis on quality improvement will help to achieve better therapeutic outcomes. Managing pain in the geriatric population is challenging because of age-related changes in pain perception, cognition, pharmacokinetics, and drug effects. Improvement and maintenance of physical and emotional function is the goal. Pharmacotherapy should be initiated conservatively and titrated to effective doses with minimal adverse effects. Milder pain should be treated with non-opioid analgesics with a progression toward opioids and/or adjuvant medications as the pain intensifies. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvant medications represent most of the analgesic agents used in pain management. Knowing the underlying mechanism of pain will help guide pharmacologic therapy. The patient should be monitored initially, with every dose change, and periodically to assess efficacy and severity of adverse effects.
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Affiliation(s)
- Meri D. Hix
- Midwestern University Chicago College of Pharmacy and Clinical Pharmacist-Internal Medicine at Loyola University Medical Center,
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Abstract
BACKGROUND This is the third updated version of a Cochrane review first published in Issue 4, 2003 of The Cochrane Library and first updated in 2007. Morphine has been used for many years to relieve pain. Oral morphine in either immediate release or modified release form remains the analgesic of choice for moderate or severe cancer pain. OBJECTIVES To determine the efficacy of oral morphine in relieving cancer pain, and to assess the incidence and severity of adverse events. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE (1966 to October 2015); and EMBASE (1974 to October 2015). We also searched ClinicalTrials.gov (1 October 2015). SELECTION CRITERIA Published randomised controlled trials (RCTs) using placebo or active comparators reporting on the analgesic effect of oral morphine in adults and children with cancer pain. We excluded trials with fewer than 10 participants. DATA COLLECTION AND ANALYSIS One review author extracted data, which were checked by another review author. There were insufficient comparable data for meta-analysis to be undertaken or to produce numbers needed to treat (NNTs) for the analgesic effect. We extracted any available data on the number or proportion of participants with 'no worse than mild pain' or treatment success (very satisfied, or very good or excellent on patient global impression scales). MAIN RESULTS We identified seven new studies in this update. We excluded six, and one study is ongoing so also not included in this update. This review contains a total of 62 included studies, with 4241 participants. Thirty-six studies used a cross-over design ranging from one to 15 days, with the greatest number (11) for seven days for each arm of the trial. Overall we judged the included studies to be at high risk of bias because the methods of randomisation and allocation concealment were poorly reported. The primary outcomes for this review were participant-reported pain and pain relief.Fifteen studies compared oral morphine modified release (Mm/r) preparations with morphine immediate release (MIR). Fourteen studies compared Mm/r in different strengths; six of these included 24-hour modified release products. Fifteen studies compared Mm/r with other opioids. Six studies compared MIR with other opioids. Two studies compared oral Mm/r with rectal Mm/r. Three studies compared MIR with MIR by a different route of administration. Two studies compared Mm/r with Mm/r at different times and two compared MIR with MIR given at a different time. One study was found comparing each of the following: Mm/r tablet with Mm/r suspension; Mm/r with non-opioids; MIR with non-opioids; and oral morphine with epidural morphine.In the previous update, a standard of 'no worse than mild pain' was set, equivalent to a score of 30/100 mm or less on a visual analogue pain intensity scale (VAS), or the equivalent in other pain scales. Eighteen studies achieved this level of pain relief on average, and no study reported that good levels of pain relief were not attained. Where results were reported for individual participants in 17 studies, 'no worse than mild pain' was achieved by 96% of participants (362/377), and an outcome equivalent to treatment success in 63% (400/638).Morphine is an effective analgesic for cancer pain. Pain relief did not differ between Mm/r and MIR. Modified release versions of morphine were effective for 12- or 24-hour dosing depending on the formulation. Daily doses in studies ranged from 25 mg to 2000 mg with an average of between 100 mg and 250 mg. Dose titration was undertaken with both instant release and modified release products. A small number of participants did not achieve adequate analgesia with morphine. Adverse events were common, predictable, and approximately 6% of participants discontinued treatment with morphine because of intolerable adverse events.The quality of the evidence is generally poor. Studies are old, often small, and were largely carried out for registration purposes and therefore were only designed to show equivalence between different formulations. AUTHORS' CONCLUSIONS The conclusions have not changed for this update. The effectiveness of oral morphine has stood the test of time, but the randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants and did not provide appropriate data for meta-analysis. Only a few reported how many people had good pain relief, but where it was reported, over 90% had no worse than mild pain within a reasonably short time period. The review demonstrates the wide dose range of morphine used in studies, and that a small percentage of participants are unable to tolerate oral morphine. The review also shows the wide range of study designs, and inconsistency in cross-over designs. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing participants over in cross-over design studies. It was not clear if these trials were sufficiently powered to detect any clinical differences between formulations or comparator drugs. New studies added to the review for the previous update reinforced the view that it is possible to use modified release morphine to titrate to analgesic effect. There is qualitative evidence that oral morphine has much the same efficacy as other available opioids.
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Affiliation(s)
- Philip J Wiffen
- Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Pain Research Unit, Churchill Hospital, Oxford, Oxfordshire, UK, OX3 7LE
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Chen YC, Lin WC. Can anti-osteoporotic therapy reduce adjacent fracture in magnetic resonance imaging-proven acute osteoporotic vertebral fractures? BMC Musculoskelet Disord 2016; 17:151. [PMID: 27052323 PMCID: PMC4823884 DOI: 10.1186/s12891-016-1003-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 03/31/2016] [Indexed: 11/26/2022] Open
Abstract
Background Adjacent fracture of the cemented vertebrae result from crushed fragile trabeculae during follow-up, suggesting impaired bone marrow integrity. This study aimed to determine if anti-osteoporotic therapy can decrease the risk of adjacent fracture in patients after vertebroplasty. Methods This retrospective study reviewed of cases of osteoporotic patients with magnetic resonance imaging (MRI)-proven acute vertebral fractures between 2001 and 2007. Osteoporotic patients were investigated as determined by pre-operative MRI with subsequent adjacent fracture of the cemented vertebrae and for the possibility of anti-osteoporotic therapy decreasing the progression of collapse after a minimum of 6 months follow-up. All associated co-morbidities were recorded, as well as the use of anti-osteoporotic drugs (i.e., bisphosphonate, raloxifen, calcitonin, and teriparatide). Cox regression analysis was also performed. Results The 192 vertebral fractured patients who underwent vertebroplasty and anti-osteoporotic therapy had a mean age of 74.40 ± 6.41. The basic characteristics of patients with and without adjacent fracture differed in age, body mass index, rheumatoid arthritis, and use of glucocorticoids and anti-osteoporotic drugs (Table 1). Using the Kaplan-Meier curve, anti-osteoporotic therapy after vertebroplasty had a significant effect on adjacent fracture (p = 0.037, by log rank text). After adjusting for potential confounders, patients with anti-osteoporotic therapy still had a lower adjacent fracture rate than patients without anti-osteoporotic therapy (p = 0.006; HR: 2.137, 95 % CI: 1.1238–3.690). The adjacent fracture rate also increased in old age (p = 0.019; HR: 1.049; 95 % CI:1.008–1.039) and among smokers (p = 0.026; HR: 3.891; 95 % CI: 1.175–12.890). Conclusions In this study, adjacent fracture of cemented vertebrae is inevitable after vertebroplasty but can be mitigated by anti-osteoporotic therapy to increase bone mass.
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Affiliation(s)
- Ying-Chou Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung, 833, Taiwan.
| | - Wei-Che Lin
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, 833, Taiwan
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Wasan AD, Michna E, Edwards RR, Katz JN, Nedeljkovic SS, Dolman AJ, Janfaza D, Isaac Z, Jamison RN. Psychiatric Comorbidity Is Associated Prospectively with Diminished Opioid Analgesia and Increased Opioid Misuse in Patients with Chronic Low Back Pain. Anesthesiology 2015; 123:861-72. [PMID: 26375824 DOI: 10.1097/ALN.0000000000000768] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids are frequently prescribed for chronic low back pain (CLBP), but there are little prospective data on which patient subgroups may benefit. Psychiatric comorbidity, such as high levels of depression and anxiety symptoms (termed comorbid negative affect [NA]), is a common presentation and may predict diminished opioid analgesia and/or increased opioid misuse. METHODS The authors conducted a 6½-month prospective cohort study of oral opioid therapy, with an active drug/placebo run-in period, in 81 CLBP patients with low, moderate, and high levels of NA. Treatment included an opioid titration phase with a prescribing physician blinded to NA group assignment and a 4-month continuation phase, during which subjects recorded daily pain levels using an electronic diary. The primary outcome was the percent improvement in average daily pain, summarized weekly. RESULTS There was an overall 25% dropout rate. Despite the high NA group being prescribed a higher average daily dose of morphine equivalents, linear mixed model analysis revealed that the 24 study completers in each of the high NA and low NA groups had an average 21 versus 39% improvement in pain, respectively (P < 0.01). The high NA group also had a significantly greater rate of opioid misuse (39 vs. 8%, P < 0.05) and significantly more and intense opioid side effects (P < 0.01). CONCLUSIONS These results indicate that the benefit and risk considerations in CLBP patients with high NA versus low NA are distinctly different. Thus, NA is an important phenotypic variable to characterize at baseline, before deciding whether to prescribe opioids for CLBP.
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Straube S, Werny B, Friede T. A systematic review identifies shortcomings in the reporting of crossover trials in chronic painful conditions. J Clin Epidemiol 2015; 68:1496-503. [DOI: 10.1016/j.jclinepi.2015.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 04/03/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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Abstract
Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for patients with chronic pain who are at risk for opioid misuse are presented. Specific behavioral interventions designed to improve adherence with prescription opioids among persons treated for chronic pain, such as frequent monitoring, periodic urine screens, opioid therapy agreements, opioid checklists, and motivational counseling, are also reviewed. Use of state-sponsored prescription drug monitoring programs is also encouraged. Areas requiring additional investigation are identified, and the future role of abuse-deterrent opioids and innovative technology in addressing issues of opioid therapy and pain are presented.
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Affiliation(s)
- Robert N Jamison
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Jianren Mao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Abstract
BACKGROUND Incidence of vertebral compression fractures (VCFs) is increasing due to increase in human life expectancy and prevalence of osteoporosis. Vertebroplasty had been traditional treatment for pain, but it neither attempts to restore vertebral body height nor eliminates spinal deformity and is associated with a high rate of cement leakage. Balloon kyphoplasty involves introduction of inflatable balloon into the fractured body of vertebra for elevation of the end-plates prior to fixation of the fracture with bone cement. This study evaluates short term functional and radiological outcomes of balloon kyphoplasty. The secondary aim is to explore short-term complications of the procedure. MATERIALS AND METHODS A retrospective study of 199 kyphoplasty procedures in 135 patients from March 2009 to March 2012 were evaluated with short form-36 (SF-36) score, visual analogue scale (VAS), detailed neurological and radiological evaluations. The mean followup was 18 months (range 12-20 months). Statistical analysis including paired sample t-test was done with statistical package for social sciences. RESULTS Statistically significant improvements in SF-36 (from 34.29 to 48.53, an improvement of 14.24, standard deviation (SD) - 20.08 P < 0.0001), VAS (drop of 4.49, from 6.74 to 2.24, SD - 1.44, P < 0.0001), percentage restoration of lost vertebral height (from 30.62% to 16.19%, improvement of 14.43%, SD - 15.37, P < 0.0001) and kyphotic angle correction (from 17.41° to 10.59°, improvement of 6.82, SD - 7.26°, P < 0.0001) were noted postoperatively. Six patients had cement embolism, 65 had cement leak and three had adjacent level fracture which required repeat kyphoplasty later. One patient with history of ischemic heart disease had cardiac arrest during the procedure. No patients had neurological deterioration in the followup period. CONCLUSIONS Kyphoplasty is a safe and effective treatment for VCFs. It improves physical function, reduces pain and corrects kyphotic deformity.
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Affiliation(s)
- B Praveen Saxena
- Department of Orthopaedic Surgery, The Spine Clinic, Shalby Hospitals, Ahmedabad, Gujarat, India
| | - B Viral Shah
- Department of Orthopaedic Surgery, The Spine Clinic, Shalby Hospitals, Ahmedabad, Gujarat, India
| | - S Prateek Joshi
- Department of Orthopaedic Surgery, The Spine Clinic, Shalby Hospitals, Ahmedabad, Gujarat, India,Address for correspondence: Dr. S. Prateek Joshi, No. H/102, Shaligram Flora, Near Sangeeni Bunglows, Opposite Shaligram-3, Thaltej, Ahmedabad - 380 054, Gujarat, India. E-mail:
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Hegmann KT, Weiss MS, Bowden K, Branco F, Dubrueler K, Els C, Mandel S, Mckinney DW, Miguel R, Mueller KL, Nadig RJ, Schaffer MI, Studt L, Talmage JB, Travis RL, Winters T, Thiese MS, Harris JS. ACOEM Practice Guidelines: Opioids for Treatment of Acute, Subacute, Chronic, and Postoperative Pain. J Occup Environ Med 2014; 56:e143-59. [DOI: 10.1097/jom.0000000000000352] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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St Marie B. Health care experiences when pain and substance use disorder coexist: "just because i'm an addict doesn't mean i don't have pain". Pain Med 2014; 15:2075-86. [PMID: 25041442 PMCID: PMC4300296 DOI: 10.1111/pme.12493] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report the health care experiences of 34 individuals with coexisting substance use disorder (SUD) and chronic pain. DESIGN Narrative inquiry qualitative study of 90-minute interviews. SETTING Midwest metropolitan methadone clinic. SUBJECTS All individuals had SUD and were treated for SUD with methadone. They all self-identified as having pain longer than 6 months. METHODS This qualitative design allowed exploration of how participants made sense of events related to living with SUD and chronic pain. Narrative inquiry gives a consistent story from the participants' perspective, and researchers can perform additional analysis using the storyline. Thematic analysis occurred of their health care experiences. RESULTS Results revealed that participants 1) spoke about how they used deception to obtain opioids when their drug cravings were out of control; 2) were disturbed by health care providers having little understanding or ability to help them with their painful condition; 3) felt they wanted to abuse opioids again when receiving poor treatment by the health care team; 4) related what went well in their health care to help them maintain their sobriety; and 5) recommended improvements on health care interventions that included effective treatment of pain. CONCLUSIONS Coexisting chronic pain and SUD create unique health care needs by mutually activating and potentiating the other. There are very few comparable studies exploring the experiences of individuals when pain and SUD coexist. The health care team can better develop treatment plans and test interventions sensitive to their unique needs when they understand the experiences of this population.
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Kanbara T, Nakamura A, Shibasaki M, Mori T, Suzuki T, Sakaguchi G, Kanemasa T. Morphine and oxycodone, but not fentanyl, exhibit antinociceptive effects mediated by G-protein inwardly rectifying potassium (GIRK) channels in an oxaliplatin-induced neuropathy rat model. Neurosci Lett 2014; 580:119-24. [DOI: 10.1016/j.neulet.2014.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/26/2014] [Accepted: 08/04/2014] [Indexed: 11/16/2022]
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Nakamura A, Fujita M, Ono H, Hongo Y, Kanbara T, Ogawa K, Morioka Y, Nishiyori A, Shibasaki M, Mori T, Suzuki T, Sakaguchi G, Kato A, Hasegawa M. G protein-gated inwardly rectifying potassium (KIR3) channels play a primary role in the antinociceptive effect of oxycodone, but not morphine, at supraspinal sites. Br J Pharmacol 2014; 171:253-64. [PMID: 24117458 DOI: 10.1111/bph.12441] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 07/12/2013] [Revised: 09/17/2013] [Accepted: 09/25/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Oxycodone and morphine are μ-opioid receptor agonists prescribed to control moderate-to-severe pain. Previous studies suggested that these opioids exhibit different analgesic profiles. We hypothesized that distinct mechanisms mediate the differential effects of these two opioids and investigated the role of G protein-gated inwardly rectifying potassium (K(IR)3 also known as GIRK) channels in their antinociceptive effects. EXPERIMENTAL APPROACH Opioid-induced antinociceptive effects were assessed in mice, using the tail-flick test, by i.c.v. and intrathecal (i.t.) administration of morphine and oxycodone, alone and following inhibition of K(IR)3.1 channels with tertiapin-Q (30 pmol per mouse, i.c.v. and i.t.) and K(IR)3.1-specific siRNA. The antinociceptive effects of oxycodone and morphine were also examined after tertiapin-Q administration in the mouse femur bone cancer and neuropathic pain models. KEY RESULTS The antinociceptive effects of oxycodone, after both i.c.v. and i.t. administrations, were markedly attenuated by K(IR)3.1 channel inhibition. In contrast, the antinociceptive effects of i.c.v. morphine were unaffected, whereas those induced by i.t. morphine were attenuated, by K(IR)3.1 channel inhibition. In the two chronic pain models, the antinociceptive effects of s.c. oxycodone, but not morphine, were inhibited by supraspinal administration of tertiapin-Q. CONCLUSION AND IMPLICATIONS These results demonstrate that K(IR)3.1 channels play a primary role in the antinociceptive effects of oxycodone, but not those of morphine, at supraspinal sites and suggest that supraspinal K(IR)3.1 channels are responsible for the unique analgesic profile of oxycodone.
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Affiliation(s)
- Atsushi Nakamura
- Pain & Neurology, Medicinal Research Laboratories, Shionogi Co., Ltd., Osaka, Japan; Department of Toxicology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, Tokyo, Japan
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Campbell G, Mattick R, Bruno R, Larance B, Nielsen S, Cohen M, Lintzeris N, Shand F, Hall WD, Hoban B, Kehler C, Farrell M, Degenhardt L. Cohort protocol paper: the Pain and Opioids In Treatment (POINT) study. BMC Pharmacol Toxicol 2014; 15:17. [PMID: 24646721 PMCID: PMC4000138 DOI: 10.1186/2050-6511-15-17] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/07/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Internationally, there is concern about the increased prescribing of pharmaceutical opioids for chronic non-cancer pain (CNCP). In part, this is related to limited knowledge about the long-term benefits and outcomes of opioid use for CNCP. There has also been increased injection of some pharmaceutical opioids by people who inject drugs, and for some patients, the development of problematic and/or dependent use. To date, much of the research on the use of pharmaceutical opioids among people with CNCP, have been clinical trials that have excluded patients with complex needs, and have been of limited duration (i.e. fewer than 12 weeks). The Pain and Opioids In Treatment (POINT) study is unique study that aims to: 1) examine patterns of opioid use in a cohort of patients prescribed opioids for CNCP; 2) examine demographic and clinical predictors of adverse events, including opioid abuse or dependence, medication diversion, other drug use, and overdose; and 3) identify factors predicting poor pain relief and other outcomes. METHODS/DESIGN The POINT cohort comprises around 1,500 people across Australia prescribed pharmaceutical opioids for CNCP. Participants will be followed-up at four time points over a two year period. POINT will collect information on demographics, physical and medication use history, pain, mental health, drug and alcohol use, non-adherence, medication diversion, sleep, and quality of life. Data linkage will provide information on medications and services from Medicare (Australia's national health care scheme). Data on those who receive opioid substitution therapy, and on mortality, will be linked. DISCUSSION This study will rigorously examine prescription opioid use among CNCP patients, and examine its relationship to important health outcomes. The extent to which opioids for chronic pain is associated with pain reduction, quality of life, mental and physical health, aberrant medication behavior and substance use disorders will be extensively examined. Improved understanding of the longer-term outcomes of chronic opioid therapy will direct community-based interventions and health policy in Australia and internationally. The results of this study will assist clinicians to better identify those patients who are at risk of adverse outcomes and who therefore require alternative treatment strategies.
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Affiliation(s)
- Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Richard Mattick
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Milton Cohen
- St Vincent’s Clinical School, UNSW Medicine, UNSW, Darlinghurst, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Fiona Shand
- Black Dog Institute, UNSW, Randwick, Australia
| | - Wayne D Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Queensland, Australia
- National Addiction Centre, Kings College, London, England
| | - Bianca Hoban
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Chyanne Kehler
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Global Health, School of Public Health, University of Washington, Seattle, USA
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Trudeau J, Van Inwegen R, Eaton T, Bhat G, Paillard F, Ng D, Tan K, Katz NP. Assessment of pain and activity using an electronic pain diary and actigraphy device in a randomized, placebo-controlled crossover trial of celecoxib in osteoarthritis of the knee. Pain Pract 2014; 15:247-55. [PMID: 24494935 DOI: 10.1111/papr.12167] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/27/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The primary goal was to determine whether a composite measure of pain and activity is a more responsive assessment of analgesic effect than pain alone or activity alone in patients with osteoarthritis (OA) of the knee. DESIGN We conducted a randomized, double-blind, placebo-controlled, 2-period, crossover study of celecoxib vs. placebo in subjects with chronic pain due to knee OA. Patients with knee OA and baseline pain intensity score ≥4 on a 0-10 numerical rating scale (NRS) before each period were randomized. Pain endpoints included in-clinic pain score (24-hour and 1-week recall), daily paper diary pain score, current pain on an electronic pain diary (each on NRS), and WOMAC pain subscale. Activity measures included WOMAC function subscale and actigraphy using a device. Three composite pain-activity measures were prespecified. RESULTS Sixty-three patients were randomized and 47 completed the study. The WOMAC pain subscale was the most responsive of all five pain measures. Pain-activity composites resulted in a statistically significant difference between celecoxib and placebo but were not more responsive than pain measures alone. However, a composite responder defined as having 20% improvement in pain or 10% improvement in activity yielded much larger differences between celecoxib and placebo than with pain scores alone. Actigraphy was more responsive than the WOMAC function scale, possibly due to lower placebo responsiveness. CONCLUSION We have identified composite pain-activity measures that are similarly or more responsive than pain-alone measures in patients with OA. Further research is warranted to determine the optimal method for computing these composites.
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Affiliation(s)
- Jeremiah Trudeau
- Analgesic Solutions, Natick, Massachusetts, U.S.A; Hampshire College, Amherst, Massachusetts, U.S.A
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Hjsted J, Ekholm O, Kurita GP, Juel K, Sjgren P. Addictive behaviors related to opioid use for chronic pain: A population-based study. Pain 2013; 154:2677-2683. [DOI: 10.1016/j.pain.2013.07.046] [Citation(s) in RCA: 48] [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: 03/18/2013] [Revised: 07/23/2013] [Accepted: 07/25/2013] [Indexed: 02/09/2023]
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Abstract
BACKGROUND The use of opioids in the long-term management of chronic low-back pain (CLBP) has increased dramatically. Despite this trend, the benefits and risks of these medications remain unclear. This review is an update of a Cochrane review first published in 2007. OBJECTIVES To determine the efficacy of opioids in adults with CLBP. SEARCH METHODS We electronically searched the Cochrane Back Review Group's Specialized Register, CENTRAL, CINAHL and PsycINFO, MEDLINE, and EMBASE from January 2006 to October 2012. We checked the reference lists of these trials and other relevant systematic reviews for potential trials for inclusion. SELECTION CRITERIA We included randomized controlled trials (RCTs) that assessed the use of opioids (as monotherapy or in combination with other therapies) in adults with CLBP that were at least four weeks in duration. We included trials that compared non-injectable opioids to placebo or other treatments. We excluded trials that compared different opioids only. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data onto a pre-designed form. We pooled results using Review Manager (RevMan) 5.2. We reported on pain and function outcomes using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (95% CI). We used absolute risk difference (RD) with 95% CI to report adverse effects. MAIN RESULTS We included 15 trials (5540 participants). Tramadol was examined in five trials (1378 participants); it was found to be better than placebo for pain (SMD -0.55, 95% CI -0.66 to -0.44; low quality evidence) and function (SMD -0.18, 95% CI -0.29 to -0.07; moderate quality evidence). Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD -2.47, 95%CI -2.69 to -2.25; very low quality evidence), but no difference compared to placebo for function (SMD -0.14, 95%CI -0.53 to 0.25; very low quality evidence). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), examined in six trials (1887 participants), were better than placebo for pain (SMD -0.43, 95%CI -0.52 to -0.33; moderate quality evidence) and function (SMD -0.26, 95% CI -0.37 to -0.15; moderate quality evidence). One trial (1583 participants) demonstrated that tramadol may make little difference compared to celecoxib (RR 0.82, 95% CI 0.76 to 0.90; very low quality evidence) for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for either pain (SMD 0.21, 95% CI -0.03 to 0.45; very low quality evidence), or function (SMD -0.11, 95% -0.63 to 0.42; very low quality evidence). The included trials in this review had high drop-out rates, were of short duration, and had limited interpretability of functional improvement. They did not report any serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism). In general, the effect sizes were medium for pain and small for function. AUTHORS' CONCLUSIONS There is some evidence (very low to moderate quality) for short-term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-RCTs supporting the effectiveness and safety of long-term opioid therapy for treatment of CLBP.
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Affiliation(s)
| | - Andrea D Furlan
- Institute for Work & Health481 University Avenue, Suite 800TorontoONCanadaM5G 2E9
| | - Amol Deshpande
- University Health NetworkTWH‐Comprehensive Pain Unit399 Bathurst St4th FloorTorontoONCanadaM5T 2S8
| | - Angela Mailis‐Gagnon
- Toronto Western Hospital Comprehensive Pain ProgramDepartment of Medicine399 Bathurst StreetFell Pavillion 4F811TorontoOntarioCanadaM5T 2S8
| | - Steven Atlas
- Massachusetts General HospitalMedical Practices Evaluation Center50 Staniford Street9th FloorBostonMAUSA02114
| | - Dennis C Turk
- University of WashingtonDepartment of Anesthesiology and Pain MedicineBox 356540SeattleWashingtonUSA98195
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Abstract
BACKGROUND This is the second updated version of a Cochrane review first published in Issue 4, 2003 of The Cochrane Library and first updated in 2007. Morphine has been used for many years to relieve pain. Oral morphine in either immediate release or modified release form remains the analgesic of choice for moderate or severe cancer pain. OBJECTIVES To determine the efficacy of oral morphine in relieving cancer pain, and assess the incidence and severity of adverse effects. SEARCH METHODS We searched the following databases: Cochrane Pain, Palliative and Supportive Care Group Trials Register (June 2013); Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 5, May); MEDLINE (1966 to June 2013); and EMBASE (1974 to June 2013). SELECTION CRITERIA Published randomised controlled trials (RCTs) using placebo or active comparators reporting on the analgesic effect of oral morphine in adults and children with cancer pain. Trials with fewer than ten participants were excluded. DATA COLLECTION AND ANALYSIS One review author extracted data, which were checked by another review author. There were insufficient comparable data for meta-analysis to be undertaken or to produce numbers needed to treat (NNTs) for the analgesic effect. We extracted any available data on the number or proportion of participants with 'no worse than mild pain' or treatment success (very satisfied, or very good or excellent on patient global impression scales). MAIN RESULTS Ten new studies (638 participants) were identified for this update, bringing the total of included studies to 62, with 4241 participants. Thirty-six studies used a cross-over design ranging from one to 15 days, with the greatest number (11) for seven days for each arm of the trial.Fifteen studies compared oral morphine modified release (Mm/r) preparations with morphine immediate release (MIR). Fourteen studies compared Mm/r in different strengths; six of these included 24-hour modified release products. Fifteen studies compared Mm/r with other opioids. Six studies compared MIR with other opioids. Two studies compared oral Mm/r with rectal Mm/r. Three studies compared MIR with MIR by a different route of administration. Two studies compared Mm/r with Mm/r at different times and two compared MIR with MIR given at a different time. One study was found comparing each of the following: Mm/r tablet with Mm/r suspension; Mm/r with non-opioids; MIR with non-opioids; and oral morphine with epidural morphine.In this update a standard of 'no worse than mild pain' was set equivalent to a score of 30/100 mm or less on a visual analogue pain intensity scale (VAS), or the equivalent in other pain scales. Eighteen studies achieved this level of pain relief on average, and no study reported that good levels of pain relief were not attained. Where results were reported for individual participants in 17 studies, 'no worse than mild pain' was achieved by 96% of participants (362/377), and an outcome equivalent to treatment success in 63% (400/638).Morphine is an effective analgesic for cancer pain. Pain relief did not differ between Mm/r and MIR. Modified release versions of morphine were effective for 12- or 24-hour dosing depending on the formulation. Daily doses in studies ranged from 25 mg to 2000 mg with an average of between 100 mg and 250 mg. Dose titration was undertaken with both instant release and modified release products. A small number of participants did not achieve adequate analgesia with morphine. Adverse effects were common and approximately 6% of participants discontinued treatment because of intolerable adverse effects. AUTHORS' CONCLUSIONS The effectiveness of oral morphine has stood the test of time, but the randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants and did not provide appropriate data for meta-analysis. Only a few reported how many people had good pain relief, but where it was reported, over 90% had no worse than mild pain within a reasonably short time period. The review demonstrates the wide dose range of morphine used in studies, and that a small percentage of participants are unable to tolerate oral morphine. The review also shows the wide range of study designs, and inconsistency in cross-over designs. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing participants over in cross-over design studies. It was not clear if these trials are sufficiently powered to detect any clinical differences between formulations or comparator drugs. New studies added to the review reinforce the view that it is possible to use modified release morphine to titrate to analgesic effect. There is qualitative evidence that oral morphine has much the same efficacy as other available opioids.
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Affiliation(s)
- Philip J Wiffen
- Pain Research and Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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Abstract
BACKGROUND For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected. METHODS Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles). RESULTS Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles. CONCLUSION There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.
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Affiliation(s)
- Igor Kissin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- William E McAuliffe
- Department of Psychiatry, Harvard Medical School, Cambridge Health Alliance, 8 Grant Street, Natick, MA 01760, USA
| | - Silvia Minozzi
- Department of Epidemiology; Italian National Health Service; via di S. Costanza 53; Rome; 00198; Italy
| | - Laura Amato
- Department of Epidemiology; Italian National Health Service; via di S. Costanza 53; Rome; 00198; Italy
| | - Marina Davoli
- Department of Epidemiology; Italian National Health Service; via di S. Costanza 53; Rome; 00198; Italy
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Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gachon University School of Medicine, Incheon, Korea
| | - Jae Yong Shim
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND AND OBJECTIVES There are limited data examining the real-world use of gabapentin and pregabalin for the treatment of post-herpetic neuralgia (PHN). This study examines dosing patterns, therapy outcomes, healthcare utilization and costs of patients with PHN who initiate treatment with gabapentin or pregabalin. METHODS This was a retrospective administrative claims data analysis from July 2005 to February 2010. Patients with PHN initiating gabapentin or pregabalin (index therapy) from January 2006 to February 2009 were identified and were observed for 12 months after index therapy initiation. Outcomes were mean daily dosages of the index therapy, attainment of minimally effective dosages of gabapentin (≥ 1,800 mg/day) or pregabalin (≥ 150 and ≥ 300 mg/day) persistence, discontinuation, index therapy switching, addition of neuropathic pain medications to index therapy, and healthcare resource use and costs. RESULTS 1,645 patients were identified. The mean daily dosage was 826 mg for gabapentin and 187 mg for pregabalin. Only 52.6 % of patients initiating gabapentin and 56.9 % initiating pregabalin obtained a refill during the post-index period. Approximately 14 % of patients treated with gabapentin reached the target dosage (1,800 mg/day). For pregabalin, 87 % reached ≥ 150 mg/day and 27 % reached ≥ 300 mg/day. On average, patients took 10 weeks to reach 1,800 mg/day gabapentin, and 5.0 and 9.2 weeks to reach ≥ 150 mg/day and ≥ 300 mg/day pregabalin, respectively. Approximately one-third of patients in both index therapy cohorts added a pain medication; more than half added opioids. The percentage of patients switching from either drug (57 %) or adding a therapy (34 %) were similar between index therapy cohorts; opioids were the most common therapy patients switched to or added. CONCLUSION It appears that gabapentin and pregabalin are not used effectively to treat PHN. Suboptimal dosing and discontinuation may be associated with supplementary use of other analgesics, especially opioids.
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Affiliation(s)
- Phaedra Johnson
- Health Economics and Outcomes Research, OptumInsight, 12125 Technology Drive MN002-0258, Eden Prairie, MN 55344, USA.
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