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Woodcock C, Cornwall N, Dikomitis L, Harrisson SA, White S, Helliwell T, Knaggs R, Hodgson E, Pincus T, Santer M, Mallen C, Ashworth J, Jinks C. Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study. BJGP Open 2024:BJGPO.2023.0221. [PMID: 38631722 DOI: 10.3399/bjgpo.2023.0221] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. AIM To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. DESIGN & SETTING Primary care multi-method qualitative study. METHOD Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n=15, 73% female) and an online discussion forum (n=31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within-domains to generate subthemes, and subtheme comparison to form across-domain overarching themes. The behaviour change technique taxonomy v.1 and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. RESULTS 32 facilitator and barrier subthemes for patients reducing opioids were identified across 13 TDF domains. These combined into six overarching themes: learning to live with pain, opioid reduction expectations, assuming a medical model, pharmacist-delivered reviews, pharmacist-patient relationship and patient engagement. Subthemes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. CONCLUSION This study generated theoretically-informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.
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Affiliation(s)
- Charlotte Woodcock
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
| | - Nicola Cornwall
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
| | - Lisa Dikomitis
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, United Kingdom
| | - Sarah A Harrisson
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, United Kingdom
| | - Toby Helliwell
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
- Primary Integrated Community Services Ltd, Nottingham, United Kingdom
| | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, United Kingdom
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, United Kingdom
| | - Christian Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Julie Ashworth
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, United Kingdom
| | - Clare Jinks
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, United Kingdom
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Lohan C, Coates G, Clewes P, Stevenson H, Wood R, Tritton T, Massey L, Knaggs R, Dickson AJ, Walsh D. Estimating the cost and epidemiology of mild to severe chronic pain associated with osteoarthritis in England: a retrospective analysis of linked primary and secondary care data. BMJ Open 2023; 13:e073096. [PMID: 38030255 PMCID: PMC10689390 DOI: 10.1136/bmjopen-2023-073096] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Osteoarthritis (OA) affects 10% of adults in the UK. Despite over one-third of people with OA experiencing chronic pain, few studies have examined the population-level impact of chronic pain associated with OA. We compared resource-use and epidemiological outcomes in patients with mild, moderate and severe chronic OA-associated pain and matched controls without known OA. DESIGN Retrospective, longitudinal, observational cohort study (July 2008 to June 2019). SETTING Electronic records extracted from Clinical Practice Research Datalink GOLD primary care linked to Hospital Episode Statistics (HES). PARTICIPANTS Patients (cases; n=23 016) aged ≥18 years with chronic OA-associated pain. Controls (n=23 016) without OA or chronic pain matched on age, sex, comorbidity burden, general practitioner practice and available HES data. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Total healthcare resource use (HCRU), direct healthcare costs in 0-12, 12-24 and 24-36 months postindex. Secondary outcomes included incidence and prevalence of chronic OA-associated pain and pharmacological management. RESULTS HCRU was consistently greater in cases versus controls for all resource categories during preindex and postindex periods. Across follow-up periods, resource use was greatest in patients with severe pain. In the first 12 months postindexing, mean total costs incurred by cases were four times higher versus matched controls (£256 vs £62); costs were approximately twice as high in cases vs controls for months 12-24 (£166 vs £86) and 24-36 (£150 vs £81; all p<0.0001). The incidence of new cases of chronic pain associated with OA was 2.64 per 1000 person-years; the prevalence was 1.4%. CONCLUSIONS This study highlights the real-world cost of chronic pain associated with OA in cases versus matched controls. We included patients with mild, moderate and severe pain associated with OA, and showed HCRU in discrete 1-year time frames. The true economic burden of pain associated with OA is likely to be considerably higher when indirect costs are considered.
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Affiliation(s)
- Christoph Lohan
- Pfizer Australia Pty Ltd, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | - Roger Knaggs
- Pain Centre Versus Arthritis and NIHR Nottingham Biomedical Research Centre, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Alastair J Dickson
- Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK
- The North of England Low Back Pain Pathway, NIHR Applied Research Collaboration (ARC) North East and North Cumbria, Saint Nicholas Hospital, Newcastle upon Tyne, UK
| | - David Walsh
- Pain Centre Versus Arthritis and NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Liu S, Patanwala AE, Naylor JM, Levy N, Knaggs R, Stevens JA, Bugeja B, Begley D, Khor KE, Lau E, Allen R, Adie S, Penm J. Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study. Anaesthesia 2023; 78:1237-1248. [PMID: 37365700 PMCID: PMC10952779 DOI: 10.1111/anae.16070] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/28/2023]
Abstract
Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3-13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.
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Affiliation(s)
- S. Liu
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
- Department of PharmacyPrince of Wales HospitalRandwickNWSAustralia
| | - A. E. Patanwala
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
- Pharmacy DepartmentRoyal Prince Alfred HospitalCamperdownNSWAustralia
| | - J. M. Naylor
- Orthopaedic Department, Whitlam Orthopaedic Research CentreLiverpool HospitalLiverpoolNSWAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNSWAustralia
| | - N. Levy
- Department of Anaesthesia and Peri‐operative MedicineWest Suffolk HospitalBury St. EdmundsUK
| | - R. Knaggs
- School of PharmacyUniversity of Nottingham and Primary Integrated Community ServicesNottinghamUK
| | - J. A. Stevens
- School of Clinical Medicine, St Vincent's Clinical CampusUniversity of New South WalesSydneyNSWAustralia
- School of MedicineUniversity of Notre DameSydneyNSWAustralia
| | - B. Bugeja
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
| | - D. Begley
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
| | - K. E. Khor
- Department of Pain ManagementPrince of Wales HospitalSydneyNSWAustralia
- Prince of Wales Clinical SchoolUniversity of New South Wales Medicine and HealthSydneyNSWAustralia
| | - E. Lau
- Department of PharmacySt George HospitalKogarahNSWAustralia
| | - R. Allen
- Pain Management UnitSt George HospitalKogarahNSWAustralia
| | - S. Adie
- St George and Sutherland Clinical SchoolUniversity of New South WalesSydneyNSWAustralia
| | - J. Penm
- Department of PharmacyPrince of Wales HospitalRandwickNWSAustralia
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNSWAustralia
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Coates G, Clewes P, Lohan C, Stevenson H, Wood R, Tritton T, Knaggs R, Dickson AJ, Walsh D. Health economic impact of moderate-to-severe chronic pain associated with osteoarthritis in England: a retrospective analysis of linked primary and secondary care data. BMJ Open 2023; 13:e067545. [PMID: 37438077 DOI: 10.1136/bmjopen-2022-067545] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE Despite the prevalence of osteoarthritis (OA) in England, few studies have examined the health economic impact of chronic pain associated with OA. The aim of this study was to compare outcomes in patients with moderate-to-severe chronic pain associated with OA and matched controls without known OA. DESIGN Retrospective, longitudinal, observational cohort study. SETTING Electronic records extracted from the Clinical Practice Research Datalink GOLD primary care database linked to Hospital Episode Statistics (HES) data set. PARTICIPANTS Patients (cases; n=5931) ≥18 years and with existing diagnosis of OA and moderate-to-severe pain associated with their OA, and controls matched on age, sex, comorbidity burden, general practitioner (GP) practice and availability of HES data. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Total healthcare resource use (HCRU) and direct healthcare costs during 0-6, 0-12, 0-24 and 0-36 months of follow-up. Secondary outcomes measures included pharmacological management and time to total joint replacement. RESULTS Patients with moderate-to-severe chronic pain associated with OA used significantly more healthcare services versus matched controls, reflected by higher HCRU and significantly higher direct costs. During the first 12 months' follow-up, cases had significantly more GP consultations, outpatient attendances, emergency department visits and inpatient stays than matched controls (all p<0.0001). Total mean costs incurred by cases during 0-12 months' follow-up were five times higher in cases versus controls (mean (SD): £4199 (£3966) vs £781 (£2073), respectively). Extensive cycling through pharmacological therapies was observed; among cases, 2040 (34.4%), 1340 (22.6%), 841 (14.2%), 459 (7.7%) and 706 (11.9%) received 1-5, 6-10, 11-15, 16-20 and >20 lines of therapy, respectively. CONCLUSIONS This wide-ranging, longitudinal, observational study of real-world primary and secondary care data demonstrates the impact of moderate-to-severe chronic pain associated with OA in patients compared with matched controls. Further studies are required to fully quantify the health economic burden of moderate-to-severe pain associated with OA.
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Affiliation(s)
| | | | - Christoph Lohan
- Pfizer Australia Pty Ltd, Sydney, New South Wales, Australia
| | | | | | | | - Roger Knaggs
- Pain Centre Versus Arthritis and NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alastair J Dickson
- Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK
- The North of England Low Back Pain Pathway, NIHR Applied Research Collaboration North East and North Cumbria, St Nicholas' Hospital, Newcastle Upon Tyne, UK
- AD Outcomes Ltd, York, UK
| | - David Walsh
- Pain Centre Versus Arthritis and NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Zedan Y, Knaggs R, Cooper D, Kurien T, Walsh DA, Auer DP, Scammell BE. Is there a difference in the analgesic response to intra-articular bupivacaine injection in people with knee osteoarthritis pain with or without central sensitisation? Protocol of a feasibility randomised controlled trial. BMJ Open 2023; 13:e072138. [PMID: 37433734 DOI: 10.1136/bmjopen-2023-072138] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Pain is the main symptom of osteoarthritis (OA) with approximately 50% of patients reporting moderate-to-severe pain. Total knee replacement (TKR) is the ultimate treatment option to alleviate pain in knee OA. Nevertheless, TKR does not provide complete relief for all as approximately 20% of patients experience chronic postoperative pain. Painful peripheral stimuli may alter the central nociceptive pathways leading to central sensitisation that can influence treatment response in patients with OA. Currently, there is no objective protocol for detecting whether a patient will respond to a given treatment. Therefore, there is a need for a better mechanistic understanding of individual factors affecting pain relief, consequently informing personalised treatment guidelines. The purpose of this research is to examine the feasibility of conducting a full-scale mechanistic clinical trial in painful knee OA investigating the analgesic response to intra-articular bupivacaine between those with or without evidence of central sensitisation. METHODS AND ANALYSIS The Understanding Pain mechanisms in KNEE osteoarthritis (UP-KNEE) study is a feasibility, double-blinded, placebo-controlled randomised parallel study in participants with radiographically defined knee OA and with self-reported chronic knee pain. The study involves the following assessments: (1) a suite of psychometric questionnaires; (2) quantitative sensory testing; (3) magnetic resonance imaging (MRI) scan of the knee and brain; (4) a 6-minute walk test; and (5) an intra-articular injection of bupivacaine or placebo (sodium chloride 0.9%) into the index knee. Assessments will be repeated post intra-articular injection apart from the MRI scan of the knee. Our aim is to provide proof of concept and descriptive statistics to power a future mechanistic trial. ETHICS AND DISSEMINATION Ethical approval was obtained from the Health Research Authority (HRA) (REC: 20/EM/0287). Results will be disseminated via peer-reviewed journals and scientific conferences. The results will also be shared with lay audiences through relevant channels, such as Pain Centre Versus Arthritis website and patient advocacy groups. TRIAL REGISTRATION NUMBER NCT05561010.
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Affiliation(s)
- Yasmine Zedan
- Radiological Sciences, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, School of Medicine, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Roger Knaggs
- Clinical Pharmacy Practice, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Dale Cooper
- School of Allied Health Professions, Keele University, Keele, UK
| | - Thomas Kurien
- Pain Centre Versus Arthritis, School of Medicine, University of Nottingham, Nottingham, UK
- Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - David Andrew Walsh
- Pain Centre Versus Arthritis, School of Medicine, University of Nottingham, Nottingham, UK
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dorothee P Auer
- Radiological Sciences, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, School of Medicine, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Brigitte E Scammell
- Pain Centre Versus Arthritis, School of Medicine, University of Nottingham, Nottingham, UK
- Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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Joseph R, Knaggs R, Coupland C, Taylor A, Vinogradova Y, Butler D, Waldram D, Iyen B, Akyea R, Ashcroft D, Avery A, Jack R. Observational study assessing the frequency and impact of medication reviews in UK primary care for people aged ≥65 years. Br J Gen Pract 2023; 73:bjgp23X733545. [PMID: 37479307 DOI: 10.3399/bjgp23x733545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Medication reviews are considered an opportunity for reducing polypharmacy. However, there is little evidence about their impact in a real-world setting. AIM To quantify numbers of older adults having a medication review in 2019, identify systematic differences in access to medication reviews, and assess the impact of medication reviews on the numbers of medicines prescribed. METHOD We defined a population of people aged ≥65 years with at least one active prescription on 01/01/2019 using anonymised electronic health records from the Clinical Practice Research Datalink. We used Cox regression to compare characteristics of people who did and did not have a medication review recorded in their health records in 2019. We compared the maximum number of concurrent prescriptions ('polypharmacy count') in the 3 months before and after a recorded medication review. RESULTS Of 591 552 people (median age = 74 years, 54.5% female), 305 503 (51.6%) had a medication review in 2019. Living in a care home (hazard ratio [HR] 1.51, 95% confidence interval [CI] =1.40 to 1.62), a prior medication review in 2018 (HR 1.83, 95% CI = 1.69 to 1.98), and increasing baseline polypharmacy count (5-9 medicines versus 1 medicine HR 1.41, 95% CI = 1.37 to 1.46) were most strongly associated with having a review. Overall, there was a small mean increase in polypharmacy count after a review (+0.13 medicines, 0.12-0.14). For people prescribed ≥10 medicines before the review, polypharmacy count decreased on average (mean -0.14 medicines, -0.15 to -0.12). CONCLUSION Although a majority (>50%) of people had a recorded medication review in 2019, these reviews had a small overall impact on polypharmacy in this study population.
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Cox F, Knaggs R. All Change at the BJP. Br J Pain 2023; 17:116. [PMID: 37057250 PMCID: PMC10088423 DOI: 10.1177/20494637231167722] [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: 04/15/2023] Open
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Iqbal A, Knaggs R, Anderson C, Toh LS. Logic model for opioid safety in chronic non-malignant pain management, an in-depth qualitative study. Int J Clin Pharm 2023; 45:220-232. [PMID: 36434367 PMCID: PMC9702900 DOI: 10.1007/s11096-022-01493-6] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Opioids are commonly used for the management of chronic non-malignant pain in Pakistan; but there is a lack of literature around precursors or motivators in the use of opioids. AIM The study holistically explored factors contributing towards the unsafe use of opioids and identifies strategies to overcome them. METHOD Exploratory qualitative methods using interviews, focus groups and non-participant observational case studies were used. Interviews and focus groups were carried out face-to-face as well as virtually and observations were conducted in community pharmacies in Islamabad and Khyber Pukhtoon Khuwa province, Pakistan. Data were collected from 4 stakeholder groups; pharmacy policy makers (n = 11), people with chronic non-malignant pain (n = 14), doctors (n = 31) and community pharmacists (n = 36) by purposive critical case sampling method. Data were analysed inductively using reflexive thematic analysis and then deductively mapped to a social ecological framework. Non-participant observations were analysed using a cross case synthesis using explanation building technique. Data from all three methods were triangulated to develop a logic model. RESULTS Identified factors at macro (regulation), meso (social perceptions of pain and opioids) and micro levels (uncontrolled pain, self-medication, health literacy) and strategies are presented holistically and were used to develop a logic model for the prevention and mitigation of factors currently causing unsafe use of opioids. CONCLUSION The study provides an in-depth view of factors contributing towards diversion of pharmaceutical opioids and can help guide national and international policy makers in their future initiatives to promote safe use of opioids in the management of chronic non-malignant pain in Pakistan.
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Affiliation(s)
- Ayesha Iqbal
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK.
| | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
- Primary Integrated Community Services, Unit H4 Ash Tree Court, Nottingham Business Park, Nottingham, NG8 6PY, UK
| | - Claire Anderson
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Li Shean Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
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Abstract
BACKGROUND This is an update of the original Cochrane Review first published in Issue 10, 2016. For people with advanced cancer, the prevalence of pain can be as high as 90%. Cancer pain is a distressing symptom that tends to worsen as the disease progresses. Evidence suggests that opioid pharmacotherapy is the most effective of these therapies. Hydromorphone appears to be an alternative opioid analgesic which may help relieve these symptoms. OBJECTIVES To determine the analgesic efficacy of hydromorphone in relieving cancer pain, as well as the incidence and severity of any adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and clinical trials registers in November 2020. We applied no language, document type or publication status limitations to the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared hydromorphone with placebo, an alternative opioid or another active control, for cancer pain in adults and children. Primary outcomes were participant-reported pain intensity and pain relief; secondary outcomes were specific adverse events, serious adverse events, quality of life, leaving the study early and death. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We calculated risk ratio (RR) and 95% confidence intervals (CI) for binary outcomes on an intention-to-treat (ITT) basis. We estimated mean difference (MD) between groups and 95% CI for continuous data. We used a random-effects model and assessed risk of bias for all included studies. We assessed the evidence using GRADE and created three summary of findings tables. MAIN RESULTS With four new identified studies, the review includes a total of eight studies (1283 participants, with data for 1181 participants available for analysis), which compared hydromorphone with oxycodone (four studies), morphine (three studies) or fentanyl (one study). All studies included adults with cancer pain, mean age ranged around 53 to 59 years and the proportion of men ranged from 42% to 67.4%. We judged all the studies at high risk of bias overall because they had at least one domain with high risk of bias. We found no studies including children. We did not complete a meta-analysis for the primary outcome of pain intensity due to skewed data and different comparators investigated across the studies (oxycodone, morphine and fentanyl). Comparison 1: hydromorphone compared with placebo We identified no studies comparing hydromorphone with placebo. Comparison 2: hydromorphone compared with oxycodone Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured using a visual analogue scale (VAS)) in people treated with hydromorphone compared with those treated with oxycodone, but the evidence is very uncertain (3 RCTs, 381 participants, very low-certainty evidence). Participant-reported pain relief We found no studies reporting participant-reported pain relief. Specific adverse events We found no clear evidence of a difference in nausea (RR 1.13 95% CI 0.74 to 1.73; 3 RCTs, 622 participants), vomiting (RR 1.18, 95% CI 0.72 to 1.94; 3 RCTs, 622 participants), dizziness (RR 0.91, 95% CI 0.58 to 1.44; 2 RCTs, 441 participants) and constipation (RR 0.92, 95% CI 0.72 to 1.19; 622 participants) (all very low-certainty evidence) in people treated with hydromorphone compared with those treated with oxycodone, but the evidence is very uncertain. Quality of life We found no studies reporting quality of life. Comparison 3: hydromorphone compared with morphine Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured using the Brief Pain Inventory (BPI) or VAS)) in people treated with hydromorphone compared with those treated with morphine, but the evidence is very uncertain (2 RCTs, 433 participants; very low-certainty evidence). Participant-reported pain relief We found no clear evidence of a difference in the number of clinically improved participants, defined by 50% or greater pain relief rate, in the hydromorphone group compared with the morphine group, but the evidence is very uncertain (RR 0.99, 95% CI 0.84 to 1.18; 1 RCT, 233 participants; very low-certainty evidence). Specific adverse events At 24 days of treatment, morphine may reduce constipation compared with hydromorphone, but the evidence is very uncertain (RR 1.56, 95% CI 1.12 to 2.17; 1 RCT, 200 participants; very low-certainty evidence). We found no clear evidence of a difference in nausea (RR 0.94, 95% CI 0.66 to 1.30; 1 RCT, 200 participants), vomiting (RR 0.87, 95% CI 0.58 to 1.31; 1 RCT, 200 participants) and dizziness (RR 1.15, 95% CI 0.71 to 1.88; 1 RCT, 200 participants) (all very low-certainty evidence) in people treated with hydromorphone compared with those treated with morphine, but the evidence is very uncertain. Quality of life We found no studies reporting quality of life. Comparison 4: hydromorphone compared with fentanyl Participant-reported pain intensity We found no clear evidence of a difference in pain intensity (measured by numerical rating scale (NRS)) at 60 minutes in people treated with hydromorphone compared with those treated with fentanyl, but the evidence is very uncertain (1 RCT, 82 participants; very low-certainty evidence). Participant-reported pain relief We found no studies reporting participant-reported pain relief. Specific adverse events We found no studies reporting specific adverse events. Quality of life We found no studies reporting quality of life. AUTHORS' CONCLUSIONS The evidence of the benefits and harms of hydromorphone compared with other analgesics is very uncertain. The studies reported some adverse events, such as nausea, vomiting, dizziness and constipation, but generally there was no clear evidence of a difference between hydromorphone and morphine, oxycodone or fentanyl for this outcome. There is insufficient evidence to support or refute the use of hydromorphone for cancer pain in comparison with other analgesics on the reported outcomes. Further research with larger sample sizes and more comprehensive outcome data collection is required.
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Affiliation(s)
- Yan Li
- Department for Anesthesiology and Pain Management, The People's Hospital of Jizhou District, Tianjin, Tianjin, China
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guijun Lu
- Pain Medicine Department, Beijing Tsinghua Changgung Hospital, Bejing, China
| | - Zhi Dou
- Pain Medicine Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Jun Xia
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Sai Zhao
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Sitong Dong
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Liqiang Yang
- Pain Medicine Department, Xuanwu Hospital, Capital Medical University, Beijing, China
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Evans C, Poku B, Pearce R, Eldridge J, Hendrick P, Knaggs R, Blake H, Yogeswaran G, McLuskey J, Tomczak P, Thow R, Harris P, Conway J, Collier R. Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review. BMJ Open 2021; 11:e048171. [PMID: 34353799 PMCID: PMC8344309 DOI: 10.1136/bmjopen-2020-048171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/23/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK. DESIGN A scoping review was undertaken following JBI methodological guidance. METHODS 13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative. RESULTS 191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway. CONCLUSION This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.
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Affiliation(s)
- Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Brenda Poku
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Ruth Pearce
- School of Education, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jeanette Eldridge
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Hendrick
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Holly Blake
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Gowsika Yogeswaran
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - John McLuskey
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Philippa Tomczak
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Ruaridh Thow
- Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Harris
- Health Education England East Midlands, Leicester, UK
| | - Joy Conway
- College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
| | - Richard Collier
- Centre for Advancing Practice, Health Education England, Leeds, UK
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11
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Morgan CL, Jenkins-Jones S, Knaggs R, Currie C, Conway P, Poole CD, Berni E. Characterization and Associated Costs of Constipation Relating to Exposure to Strong Opioids in England: An Observational Study. Clin Ther 2021; 43:968-989. [PMID: 33931241 DOI: 10.1016/j.clinthera.2021.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/16/2020] [Revised: 02/10/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Opioid use is associated with gastrointestinal adverse events, including nausea and constipation. We used a real-world dataset to characterize the health care burden associated with opioid-induced constipation (OIC) with particular emphasis on strong opioids. METHODS This retrospective cohort study was conducted using the Clinical Practice Research Datalink, a large UK primary care dataset linked to hospital data. Patients prescribed opioids during 2016 were selected and episodes of opioid therapy constructed. Episodes with ≥84 days of exposure were classified as chronic, with date of first prescription as the index date. The main analysis focused on patients prescribed strong opioids who were laxative naive. Constipation was defined by ≥2 laxative prescriptions during the opioid episode. Patients for whom initial laxative therapy escalated by switch, augmentation, or dose were defined as OIC unstable, and the first 3 lines of OIC escalation were classified. Health care costs accrued in the first 12 months of the opioid episode were aggregated and compared. FINDINGS A total of 27,629 opioid episodes were identified; 5916 (21.4%) involved a strong opioid for patients who were previously laxative naive. Of these patients, 2886 (48.8%) were defined as the OIC population; 941 (33.26%) were classified as stable. Of the 1945 (67.4%) episodes classified as unstable, 849 (43.7%), 360 (18.5%), and 736 (37.8%) had 1, 2, and ≥3 changes of laxative prescription, respectively. Patients without OIC had lower costs per patient year (£3822 [US$5160/€4242]) compared with OIC (£4786 [US$6461/€5312]). Costs increased as patients had multiple changes in therapy: £4696 (US$6340/€5213), £4749 (US$6411/€5271), and £4981 (US$6724/€5529) for 1, 2, and ≥3 changes, respectively. The adjusted cost ratio relative to non-OIC was 1.14 (95% CI, 1.09-1.32) for those classified as stable and 1.19 (95% CI, 1.09-1.32) for those with ≥3 laxative changes. Similar patterns were observed for patients taking anyopioid, with costs increased for those classified as having OIC (£3727 [US$5031/€4137] vs £2379 [US$3212 /€2641),and for those patients classified as unstable versus stable (£3931 [US$5307/€4363] vs £3432 [US$4633/€3810). Costs increased with each additional line of therapy from £3701 (US$4996/€4108), £3916 (US$5287/€4347), and £4318 (US$5829/€4793). IMPLICATIONS OIC was a common adverse event of opioid treatment and was poorly controlled for a large number of patients. Poor control was associated with increased health care costs. The impact of OIC should be considered when prescribing opioids. These results should be interpreted with consideration of the caveats associated with the analysis of routine data.
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Affiliation(s)
| | | | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, United Kingdom
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12
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Srivastava D, Hill S, Carty S, Rockett M, Bastable R, Knaggs R, Lambert D, Levy N, Hughes J, Wilkinson P. Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom. Br J Anaesth 2021; 126:1208-1216. [PMID: 33865553 DOI: 10.1016/j.bja.2021.02.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
There are significant concerns regarding prescription and misuse of prescription opioids in the perioperative period. The Faculty of Pain Medicine at the Royal College of Anaesthetists have produced this evidence-based expert consensus guideline on surgery and opioids along with the Royal College of Surgery, Royal College of Psychiatry, Royal College of Nursing, and the British Pain Society. This expert consensus practice advisory reproduces the Faculty of Pain Medicine guidance. Perioperative stewardship of opioids starts with judicious opioid prescribing in primary and secondary care. Before surgery, it is important to assess risk factors for continued opioid use after surgery and identify those with chronic pain before surgery, some of whom may be taking opioids. A multidisciplinary perioperative care plan that includes a prehabilitation strategy and intraoperative and postoperative care needs to be formulated. This may need the input of a pain specialist. Emphasis is placed on optimum management of pain pre-, intra-, and postoperatively. The use of immediate-release opioids is preferred in the immediate postoperative period. Attention to ensuring a smooth care transition and communication from secondary to primary care for those taking opioids is highlighted. For opioid-naive patients (patients not taking opioids before surgery), no more than 7 days of opioid prescription is recommended. Persistent use of opioid needs a medical evaluation and exclusion of chronic post-surgical pain. The lack of grading of the evidence of each individual recommendation remains a major weakness of this guidance; however, evidence supporting each recommendation has been rigorously reviewed by experts in perioperative pain management.
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Affiliation(s)
- Devjit Srivastava
- Department of Anaesthesia and Pain Medicine, Raigmore Hospital, Inverness, UK.
| | - Susan Hill
- Department of Vascular Surgery, University Hospital Wales, Cardiff, UK
| | - Suzanne Carty
- Anaesthetics and Pain Medicine, Taunton and Somerset NHS Foundation Trust, Taunton, Somerset, UK
| | - Mark Rockett
- Anaesthesia and Pain Medicine, Plymouth Hospitals NHS Trust, Plymouth, UK
| | | | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - David Lambert
- Department of Cardiovascular Sciences, Division of Anaesthesia Critical Care & Pain Management, Leicester Royal Infirmary, Leicester, UK
| | - Nicholas Levy
- Anaesthesia and Perioperative Medicine, West Suffolk Hospital, Bury St Edmunds, Suffolk, UK
| | - John Hughes
- Pain Management Unit, James Cook University Hospital, Middlesbrough, UK
| | - Paul Wilkinson
- Department of Anaesthesia, Newcastle Pain Management Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne, Newcastle, UK
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13
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Schofield P, Dunham M, Martin D, Bellamy G, Francis SA, Sookhoo D, Bonacaro A, Hamid E, Chandler R, Abdulla A, Cumberbatch M, Knaggs R. Evidence-based clinical practice guidelines on the management of pain in older people – a summary report. Br J Pain 2020; 16:6-13. [PMID: 35111309 PMCID: PMC8801690 DOI: 10.1177/2049463720976155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: The objective of this study is to develop an update of the evidence-based guidelines for the management of pain in older people. Design: Review of evidence since 2010 using a systematic and consensus approach is performed. Results: Recognition of the type of pain and routine assessment of pain should inform the use of specific environmental, behavioural and pharmacological interventions. Individualised care plans and analgesic protocols for specific clinical situations, patients and health care settings can be developed from these guidelines. Conclusion: Management of pain must be considered as an important component of the health care provided to all people, regardless of their chronological age or severity of illness. By clearly outlining areas where evidence is not available, these guidelines may also stimulate further research. To use the recommended therapeutic approaches, clinicians must be familiar with adverse effects of treatment and the potential for drug interactions.
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14
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Foo I, Macfarlane AJR, Srivastava D, Bhaskar A, Barker H, Knaggs R, Eipe N, Smith AF. The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety. Anaesthesia 2020; 76:238-250. [PMID: 33141959 DOI: 10.1111/anae.15270] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
Intravenous lidocaine is used widely for its effect on postoperative pain and recovery but it can be, and has been, fatal when used inappropriately and incorrectly. The risk-benefit ratio of i.v. lidocaine varies with type of surgery and with patient factors such as comorbidity (including pre-existing chronic pain). This consensus statement aims to address three questions. First, does i.v. lidocaine effectively reduce postoperative pain and facilitate recovery? Second, is i.v. lidocaine safe? Third, does the fact that i.v. lidocaine is not licensed for this indication affect its use? We suggest that i.v. lidocaine should be regarded as a 'high-risk' medicine. Individual anaesthetists may feel that, in selected patients, i.v. lidocaine may be beneficial as part of a multimodal peri-operative pain management strategy. This approach should be approved by hospital medication governance systems, and the individual clinical decision should be made with properly informed consent from the patient concerned. If i.v. lidocaine is used, we recommend an initial dose of no more than 1.5 mg.kg-1 , calculated using the patient's ideal body weight and given as an infusion over 10 min. Thereafter, an infusion of no more than 1.5 mg.kg-1 .h-1 for no longer than 24 h is recommended, subject to review and re-assessment. Intravenous lidocaine should not be used at the same time as, or within the period of action of, other local anaesthetic interventions. This includes not starting i.v. lidocaine within 4 h after any nerve block, and not performing any nerve block until 4 h after discontinuing an i.v. lidocaine infusion.
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Affiliation(s)
- I Foo
- Western General Infirmary, Edinburgh, UK
| | | | | | - A Bhaskar
- Imperial College Healthcare NHS Trust, London, UK
| | - H Barker
- Ashford and St Peter's Hospitals NHS Foundation Trust, Chertsey, UK
| | - R Knaggs
- University of Nottingham, Nottingham, UK
| | - N Eipe
- Ottowa Hospital, Ottowa, Canada
| | - A F Smith
- Royal Lancaster Infirmary, Lancaster, UK
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15
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Mody S, Kirkdale CL, Thornley T, Dickinson A, Avery AJ, Knaggs R, Rann S, Bastable R. Over-The-Counter Codeine: Can Community Pharmacy Staff Nudge Customers into Its Safe and Appropriate Use? Pharmacy (Basel) 2020; 8:pharmacy8040185. [PMID: 33049965 PMCID: PMC7712583 DOI: 10.3390/pharmacy8040185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 01/23/2023] Open
Abstract
The misuse of opioids, including codeine which is sold over-the-counter (OTC) in United Kingdom (UK) community pharmacies, is a growing public health concern. An educational Patient Safety Card was developed and piloted to see if it nudged customers into the safe and appropriate use of OTC codeine. Exploratory analysis was conducted by (i) recording quantitative interactions for people requesting OTC codeine in community pharmacies; and (ii) a web-based pharmacy staff survey. Twenty-four pharmacies submitted data on 3993 interactions using the Patient Safety Card. Staff found the majority of interactions (91.3%) to be very or quite easy. Following an interaction using the card, customers known to pharmacy staff as frequent purchasers of OTC codeine were more likely not to purchase a pain relief medicine compared to customers not known to staff (5.5% of known customers did not purchase any pain relief product versus 1.1% for unknown customers (χ2 = 41.73, df = 1, p < 0.001)). These results support both the use of a visual educational intervention to encourage appropriate use of OTC codeine in community pharmacy and the principles behind better self-care.
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Affiliation(s)
- Sapana Mody
- Boots UK, Thane Road, Nottingham NG90 1BS, UK
| | | | - Tracey Thornley
- Boots UK, Thane Road, Nottingham NG90 1BS, UK
- School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | | | - Anthony J Avery
- Division of Primary Care, School of Medicine, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
| | - Sarah Rann
- Formerly CDAO East of England, NHS, Medical Directorate, Victoria House, Capital Park, Cambridge CB21 5XE, UK
| | - Ruth Bastable
- HMP Littlehey, Huntingdon PE28 0SR, UK
- National Health Service, London SE1 6JW, UK
- Royal College of General Practitioners, London NW1 2FB, UK
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16
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Munglani R, Knaggs R, Eyre G. Particulate steroids in axial spinal blockade and the increasing role of patient consent: Les grains de sable dans l'engrenage. Br J Pain 2020; 14:141-146. [PMID: 32537153 DOI: 10.1177/2049463720921199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/15/2022] Open
Abstract
The complexity of modern medical practice is such that it is very unlikely that on any single issue we can give a definitive answer in any circumstance, and in our view the medical debate as to the use of particulate corticosteroid medicines in axial spinal blockade is one such argument. The medical discussion of the use of particulate corticosteroids has to be set against the uncertain risk and benefits of axial spinal procedures in which the drugs are utilised, and in which the most likely catastrophic complication may occur with their use, and then, as the law now demands, involve the patient in the relevant consenting issues.
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Affiliation(s)
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
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17
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Evans C, Poku B, Pearce R, Eldridge J, Hendrick P, Knaggs R, McLuskey J, Tomczak P, Thow R, Harris P, Conway J, Collier R. Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol. BMJ Open 2020; 10:e036192. [PMID: 32439696 PMCID: PMC7247387 DOI: 10.1136/bmjopen-2019-036192] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective. METHODS AND ANALYSIS This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework). DISSEMINATION The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.
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Affiliation(s)
- Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Brenda Poku
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Ruth Pearce
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Paul Hendrick
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - John McLuskey
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Philippa Tomczak
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Ruaridh Thow
- Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Harris
- Health Education England East Midlands, Nottingham, UK
| | - Joy Conway
- College of Health and Life Sciences, Brunel University, Uxbridge, UK
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18
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Abstract
OBJECTIVES Inhaled corticosteroids (ICS) reduce exacerbation rates and the decline in lung function in people with chronic obstructive pulmonary disease (COPD). There is evidence that smoking causes 'steroid resistance' and thus reduces the effect of ICS. This systematic review aimed to investigate the effect of smoking on efficacy of ICS in COPD in terms of lung function and exacerbation rates. DESIGN Systematic review. DATA SOURCES An electronic database search of PubMed, Ovid MEDLINE, Ovid Embase and Cochrane Library (January 2000 to January 2020). ELIGIBILITY CRITERIA Fully published randomised controlled trials (RCTs), in the English language, evaluating the use of ICS in COPD adults that stratified the participants by smoking status. Trials that included participants with asthma, lung cancer and pneumonia were excluded. The primary outcome measures were changes in lung function and yearly exacerbation rates. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias using the Cochrane Collaboration's tool. RESULTS Seven studies were identified. Four trials (17 892 participants) recorded change in forced expiratory volume in one second (FEV1) from baseline to up to 30 months after starting treatment. Heavier smokers (>36 pack years) using ICS had a greater decline in FEV1 that ranged from -22 mL to -75 mL in comparison to lighter smokers. Smokers using ICS had mixed results in FEV1 change: -8 mL to +77 mL in comparison to ex-smokers. Four trials (21 270 participants) recorded difference in COPD exacerbation rates at 52 weeks. The rate ratios favoured more exacerbations in ICS users who were current or heavier smokers than those who were ex-smokers or lighter smokers (0.81 to 0.99 vs 0.92 to 1.29). CONCLUSIONS In COPD, heavier or current smokers do not gain the same benefit from ICS use on lung function and exacerbation rates as lighter or ex-smokers do, however effects may not be clinically important. PROSPERO REGISTRATION NUMBER CRD42019121833.
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Affiliation(s)
| | | | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
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19
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20
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Eccleston C, Fisher E, Thomas KH, Hearn L, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev 2017; 11:CD010323. [PMID: 29130474 PMCID: PMC6486018 DOI: 10.1002/14651858.cd010323.pub3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This is the first update of the original Cochrane Review published in 2013. The conclusions of this review have not changed from the 2013 publication. People with chronic non-cancer pain who are prescribed and are taking opioids can have a history of long-term, high-dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple, unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain. OBJECTIVES To investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non-cancer pain in adults compared to controls. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, and Embase in January 2017, as well as bibliographies and citation searches of included studies. We also searched one trial registry for ongoing trials. SELECTION CRITERIA Included studies had to be randomised controlled trials comparing opioid users receiving an intervention with a control group receiving treatment as usual, active control, or placebo. The aim of the study had to include a treatment goal of dose reduction or cessation of opioid medication. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function. We planned to assess the certainty of the evidence using the GRADE approach, however, due to the heterogeneity of studies, we were unable to combine outcomes in a meta-analysis and therefore we did not assess the evidence with GRADE. MAIN RESULTS Three studies are new to this update, resulting in five included studies in total (278 participants). Participants were primarily women (mean age 49.63 years, SD = 11.74) with different chronic pain conditions. We judged the studies too heterogeneous to pool data in a meta-analysis, so we have summarised the results from each study qualitatively. The studies included acupuncture, mindfulness, and cognitive behavioral therapy interventions aimed at reducing opioid consumption, misuse of opioids, or maintenance of chronic pain management treatments. We found mixed results from the studies. Three of the five studies reported opioid consumption at post-treatment and follow-up. Two studies that delivered 'Mindfulness-Oriented Recovery Enhancement' or 'Therapeutic Interactive Voice Response' found a significant difference between groups at post-treatment and follow-up in opioid consumption. The remaining study found reduction in opioid consumption in both treatment and control groups, and between-group differences were not significant. Three studies reported adverse events related to the study and two studies did not have study-related adverse events. We also found mixed findings for pain intensity and physical functioning. The interventions did not show between-group differences for psychological functioning across all studies. Overall, the risk of bias was mixed across studies. All studies included sample sizes of fewer than 100 and so we judged all studies as high risk of bias for that category. AUTHORS' CONCLUSIONS There is no evidence for the efficacy or safety of methods for reducing prescribed opioid use in chronic pain. There is a small number of randomised controlled trials investigating opioid reduction, which means our conclusions are limited regarding the benefit of psychological, pharmacological, or other types of interventions for people with chronic pain trying to reduce their opioid consumption. The findings to date are mixed: there were reductions in opioid consumption after intervention, and often in control groups too.
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22
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Janknegt R, van den Beuken M, Schiere S, Überall M, Knaggs R, Hanley J, Thronaes M. Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis. Eur J Hosp Pharm 2017; 25:e2. [PMID: 29732145 PMCID: PMC5931243 DOI: 10.1136/ejhpharm-2016-001127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/17/2016] [Accepted: 11/28/2016] [Indexed: 11/20/2022] Open
Abstract
Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.
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Affiliation(s)
- Robert Janknegt
- Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Sittard, The Netherlands
| | | | | | - Michael Überall
- IFNAP Institute for Neurosciences, Algesiology and Paediatrics, Nürnberg, Germany
| | - Roger Knaggs
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Morten Thronaes
- Faculty of Medicine, Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre (PRC), Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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23
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Wiffen PJ, Knaggs R, Derry S, Cole P, Phillips T, Moore RA. Paracetamol (acetaminophen) with or without codeine or dihydrocodeine for neuropathic pain in adults. Cochrane Database Syst Rev 2016; 12:CD012227. [PMID: 28027389 PMCID: PMC6463878 DOI: 10.1002/14651858.cd012227.pub2] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Paracetamol, either alone or in combination with codeine or dihydrocodeine, is commonly used to treat chronic neuropathic pain. This review sought evidence for efficacy and harm from randomised double-blind studies. OBJECTIVES To assess the analgesic efficacy and adverse events of paracetamol with or without codeine or dihydrocodeine for chronic neuropathic pain in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to July 2016, together with reference lists of retrieved papers and reviews, and two online study registries. SELECTION CRITERIA We included randomised, double-blind studies of two weeks' duration or longer, comparing paracetamol, alone or in combination with codeine or dihydrocodeine, with placebo or another active treatment in chronic neuropathic pain. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality and potential bias. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE. MAIN RESULTS No study satisfied the inclusion criteria. Effects of interventions were not assessed as there were no included studies. We have only very low quality evidence and have no reliable indication of the likely effect. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that paracetamol alone, or in combination with codeine or dihydrocodeine, works in any neuropathic pain condition.
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Affiliation(s)
| | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
| | | | - Peter Cole
- Churchill Hospital, Oxford University Hospitals NHS TrustOxford Pain Relief UnitOld Road HeadingtonOxfordUKOX3 7LE
| | - Tudor Phillips
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Churchill HospitalOxfordUKOX3 7LJ
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Knaggs R. Personalised medicine and medicines optimisation. Br J Pain 2016; 10:167. [DOI: 10.1177/2049463716671224] [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: 11/16/2022] Open
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Abstract
BACKGROUND Opioid drugs, including fentanyl, are commonly used to treat neuropathic pain, and are considered effective by some professionals. Most reviews have examined all opioids together. This review sought evidence specifically for fentanyl, at any dose, and by any route of administration. Other opioids are considered in separate reviews. OBJECTIVES To assess the analgesic efficacy of fentanyl for chronic neuropathic pain in adults, and the adverse events associated with its use in clinical trials. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to June 2016, together with the reference lists of retrieved articles, and two online study registries. SELECTION CRITERIA We included randomised, double-blind studies of two weeks' duration or longer, comparing fentanyl (in any dose, administered by any route, and in any formulation) with placebo or another active treatment in chronic neuropathic pain. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality and potential bias. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE. MAIN RESULTS Only one study met our inclusion criteria. Participants were men and women (mean age 67 years), with postherpetic neuralgia, complex regional pain syndrome, or chronic postoperative pain. They were experiencing inadequate relief from non-opioid analgesics, and had not previously taken opioids for their neuropathic pain. The study used an enriched enrolment randomised withdrawal design. It was adequately blinded, but we judged it at unclear risk of bias for other criteria.Transdermal fentanyl (one-day fentanyl patch) was titrated over 10 to 29 days to establish the maximum tolerated and effective dose (12.5 to 50 µg/h). Participants who achieved a prespecified good level of pain relief with a stable dose of fentanyl, without excessive use of rescue medication or intolerable adverse events ('responders'), were randomised to continue with fentanyl or switch to placebo for 12 weeks, under double-blind conditions. Our prespecified primary outcomes were not appropriate for this study design, but the measures reported do give an indication of the efficacy of fentanyl in this condition.In the titration phase, 1 in 3 participants withdrew because of adverse events or inadequate pain relief, and almost 90% experienced adverse events. Of 258 participants who underwent open-label titration, 163 were 'responders' and entered the randomised withdrawal phase. The number of participants completing the study (and therefore continuing on treatment) without an increase of pain by more than 15/100 was 47/84 (56%) with fentanyl and 28/79 (35%) with placebo. Because only 63% responded sufficiently to enter the randomised withdrawal phase, this implies that only a maximum of 35% of participants entering the study would have had useful pain relief and tolerability with transdermal fentanyl, compared with 22% with placebo. Almost 60% of participants taking fentanyl were 'satisfied' and 'very satisfied' with their treatment at the end of the study, compared with about 40% with placebo. This outcome approximates to our primary outcome of moderate benefit using the Patient Global Impression of Change scale, but the group was enriched for responders and the method of analysis was not clear. The most common adverse events were constipation, nausea, somnolence, and dizziness.There was no information about other types of neuropathic pain, other routes of administration, or comparisons with other treatments.We downgraded the quality of the evidence to very low because there was only one study, with few participants and events, and there was no information about how data from people who withdrew were analysed. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that fentanyl works in any neuropathic pain condition.
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Affiliation(s)
| | - Cathy Stannard
- NHS Gloucestershire CCGSanger House, 5220 Valiant CourtGloucester Business ParkBrockworthUKGL3 4FE
| | - Peter Cole
- Churchill Hospital, Oxford University Hospitals NHS TrustOxford Pain Relief UnitOld Road HeadingtonOxfordUKOX3 7LE
| | | | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
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Abstract
BACKGROUND Cancer pain is an important and distressing symptom that tends to increase in frequency and intensity as the cancer advances. For people with advanced cancer, the prevalence of pain can be as high as 90%. It has been estimated that 30% to 50% of people with cancer categorise their pain as moderate to severe, with between 75% and 90% of people with cancer experiencing pain that they describe as having a major impact on their daily life. Epidemiological studies suggest that approximately 15% of people with cancer pain fail to experience acceptable pain relief with conventional management. Uncontrolled pain can lead to physical and psychological distress and can, consequently, have a drastic effect on people's quality of life. OBJECTIVES To determine the analgesic efficacy of hydromorphone in relieving cancer pain, as well as the incidence and severity of any adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and clinical trials registers up to April 2016. There were no language, document type or publication status limitations applied in the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared hydromorphone with placebo or other active pain medication for cancer pain in both adults and children. The four main outcomes selected have previously been identified as important to people with cancer; pain no worse than mild pain, and the impact of the treatment on consciousness, appetite and thirst. We did not consider physician-, nurse- or carer-reported measures of pain. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We used a random-effects model and assessed the risk of bias for all included studies. A meta-analysis was not completed on any of the primary outcomes in this review due to the lack of data. We assessed the evidence using GRADE and created two 'Summary of findings' tables. MAIN RESULTS We included four studies (604 adult participants), which compared hydromorphone to oxycodone (two studies) or morphine (two studies). Overall, the included studies were at low or unclear risk of bias, rated unclear due to unknown status of blinding of outcome assessment; we rated three studies at high risk of bias for potential conflict of interest. Data for 504 participants were available for analysis. We collected data on endpoint participant-reported pain intensity measured with a visual analogue scale (VAS) (mean ± standard deviation (SD): hydromorphone 28.86 ± 17.08, n = 19; oxycodone 30.30 ± 25.33, n = 12; scale from 0 to 100 with higher score indicating worse pain), and Brief Pain Inventory (BPI) 24 hours worst pain subscale (mean ± SD: hydromorphone 3.5 ± 2.9, n = 99; morphine 4.3 ± 3.0, n = 101, scale from 0 to 10 with higher score indicating worse pain). The data demonstrated a similar effect between groups with both comparisons. The pain intensity data showed that participants in all four trials achieved no worse than mild pain. There were several adverse events: some were the expected opioid adverse effects such as nausea, constipation and vomiting; others were not typical opioid adverse effects (for example, decreased appetite, dizziness and pyrexia, as shown in Table 1 in the main review), but generally showed no difference between groups. There were three deaths in the morphine group during the trial period, considered to be due to disease progression and unrelated to the drug. Three trials had over 10% dropout, but the reason and proportion of dropout was balanced between groups. The overall quality of evidence was very low mainly due to high risk of bias, imprecision of effect estimates and publication bias. There were no data available for children or for several participant-important outcomes, including participant-reported pain relief and treatment impact on consciousness, appetite or thirst. AUTHORS' CONCLUSIONS This review indicated little difference between hydromorphone and other opioids in terms of analgesic efficacy. Data gathered in this review showed that hydromorphone had a similar effect on participant-reported pain intensity as reported for oxycodone and morphine. Participants generally achieved no worse than mild pain after taking hydromorphone, which is comparable with the other drugs. It produced a consistent analgesic effect through the night and could be considered for use in people with cancer pain experiencing sleep disturbance. However, the overall quality of evidence was very low mainly due to risk of bias, imprecision of effect estimates and publication bias. This review only included four studies with limited sample size and a range of study designs. Data for some important outcomes, such as impact of the treatment on consciousness, appetite or thirst, were not available. Therefore, we were unable to demonstrate superiority or inferiority of hydromorphone in comparison with other analgesics for these outcomes. We recommend that further research with larger sample sizes and more comprehensive outcome data collection is required.
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Affiliation(s)
- Yan J Bao
- Guang'anmen Hospital, China Academy of Chinese Medical SciencesDepartment of OncologyBeixiange 5BeijingChina100053
| | - Wei Hou
- Guang'anmen Hospital, China Academy of Chinese Medical SciencesDepartment of OncologyBeixiange 5BeijingChina100053
| | - Xiang Y Kong
- China Academy of Chinese Medical SciencesInstitute of Chinese Materia MedicaNanxiaojie, Dongzhimennei AveBeijingChina100700
| | - Liping Yang
- Guang'anmen Hospital, China Academy of Chinese Medical SciencesDepartment of NephrologyBeixiange 5BeijingChina100053
| | - Jun Xia
- Systematic Review Solutions Ltd89 Russell DriveNottinghamUK264000
| | - Bao J Hua
- Guang'anmen Hospital, China Academy of Chinese Medical SciencesDepartment of OncologyBeixiange 5BeijingChina100053
| | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
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Abstract
Tapentadol is a single molecule able to deliver analgesia by two distinct mechanisms, a feature which differentiates it from many other analgesics. Pre-clinical data demonstrate two mechanisms of action: mu-opioid receptor agonist activity and noradrenaline re-uptake inhibition. From these, one may predict that tapentadol would be applicable across a broad spectrum of pain from nociceptive to neuropathic. The evidence in animal models suggests that norepinephrine re-uptake inhibition (NRI) is a key mechanism and may even predominate over opioid actions in chronic (and especially neuropathic) pain states, reinforcing that tapentadol is different to classical opioids and may, therefore, be an a priori choice for the treatment of neuropathic and mixed pain. The clinical studies and subsequent practice experience and surveillance support the concept of opioid and non-opioid mechanisms of action. The reduced incidence of some of the typical opioid-induced side effects, compared to equianalgesic doses of classical opioids, supports the hypothesis that tapentadol analgesia is only partially mediated by opioid agonist mechanisms. Both the pre-clinical and clinical profiles appear to be differentiated from those of classical opioids.
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Wiffen PJ, Knaggs R, Derry S, Cole P, Phillips T, Moore RA. Paracetamol (acetaminophen) with or without codeine or dihydrocodeine for neuropathic pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
BACKGROUND Opioid drugs, including hydromorphone, are commonly used to treat neuropathic pain, and are considered effective by some professionals. Most reviews have examined all opioids together. This review sought evidence specifically for hydromorphone, at any dose, and by any route of administration. Other opioids are considered in separate reviews.This review is part of an update of a previous review, Hydromorphone for acute and chronic pain that was withdrawn in 2013 because it needed updating and splitting to be more specific for different pain conditions. This review focuses only on neuropathic pain. OBJECTIVES To assess the analgesic efficacy of hydromorphone for chronic neuropathic pain in adults, and the adverse events associated with its use in clinical trials. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), via the CRSO; MEDLINE via Ovid; and EMBASE via Ovid from inception to 17 November 2015, together with reference lists of retrieved papers and reviews, and two online study registries. SELECTION CRITERIA We included randomised, double-blind studies of two weeks' duration or longer, comparing hydromorphone (at any dose, by any route of administration, or in any formulation) with placebo or another active treatment in chronic neuropathic pain. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). MAIN RESULTS Searches identified seven publications relating to four studies. We excluded three studies. One post hoc (secondary) analysis of a study published in four reports assessed the efficacy of hydromorphone in neuropathic pain, satisfied our inclusion criteria, and was included in the review. The single included study had an enriched enrolment, randomised withdrawal design with 94 participants who were successfully switched from oral morphine to oral hydromorphone extended release (about 60% of those enrolled). These participants were then randomised to continuing hydromorphone for 12 weeks or tapering down the hydromorphone dose to placebo. The methodological quality of the study was generally good, but we judged the risk of bias for incomplete outcome data as unclear, and for study size as high.Since we identified only one study for inclusion, we were unable to carry out any analyses. The included study did not report any of our prespecified primary outcomes, which relate to the number of participants achieving moderate or substantial levels of pain relief. It did report a slightly larger increase in average pain intensity for placebo in the randomised withdrawal phase than for continuing with hydromorphone. It also reported the number of participants who withdrew due to lack of efficacy in the randomised withdrawal phase, which may be an indicator of efficacy. However, in addition to using an enriched enrolment, randomised withdrawal study design, there was an unusual choice of imputation methods for withdrawals (about 50% of participants); the evidence was of very low quality and inadequate to make a judgement on efficacy. Adverse events occurred in about half of participants with hydromorphone, the most common being constipation and nausea. A similar proportion of participants experienced adverse events with placebo, the most common being opioid withdrawal syndrome (very low quality evidence). Most adverse events were mild or moderate in intensity. One in eight participants withdrew while taking hydromorphone during the conversion and titration phase, despite participants being opioid-tolerant (very low quality evidence).We downgraded the quality of the evidence to very low because there was only one study with few participants, it did not report clinically useful efficacy outcomes, and it was a post hoc analysis. AUTHORS' CONCLUSIONS There was insufficient evidence to support or refute the suggestion that hydromorphone has any efficacy in any neuropathic pain condition.
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Affiliation(s)
- Cathy Stannard
- NHS Gloucestershire CCGSanger House, 5220 Valiant CourtGloucester Business ParkBrockworthUKGL3 4FE
| | - Helen Gaskell
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)OxfordOxfordshireUK
| | - Sheena Derry
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)OxfordOxfordshireUK
| | | | - Peter Cole
- Churchill Hospital, Oxford University Hospitals NHS TrustOxford Pain Relief UnitOld Road HeadingtonOxfordUKOX3 7LE
| | - Tess E Cooper
- Pain Research Unit, Churchill HospitalCochrane Pain, Palliative and Supportive Care GroupChurchill HospitalOxfordOxfordshireUKOX3 7LE
| | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
| | - Philip J Wiffen
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)OxfordOxfordshireUK
| | - R Andrew Moore
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)OxfordOxfordshireUK
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Abdulla A, Adams N, Bone M, Elliott A, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Evidence-based clinical practice guidelines on the management of pain in older people: executive summary. Br J Pain 2015; 7:152-4. [PMID: 26516516 DOI: 10.1177/2049463713495669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Nicola Adams
- School of Health, Community and Education Studies, Northumbria University, Newcastle, UK
| | - Margaret Bone
- Pain Management Service, University Hospitals of Leicester, Leicester, UK
| | - Alison Elliott
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | | | - Derek Jones
- School of Health, Community and Education Studies, Northumbria University, Newcastle, UK
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham; Pain Management Service & Pharmacy Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Denis Martin
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Liz Sampson
- Marie Curie Palliative Care Research Unit, Research Department of Mental Health Sciences, University College London Medical School, London, UK
| | - Pat Schofield
- Centre of Health & Social Care, University of Greenwich, London, UK
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Abstract
BACKGROUND Opioid drugs, including buprenorphine, are commonly used to treat neuropathic pain, and are considered effective by some professionals. Most reviews have examined all opioids together. This review sought evidence specifically for buprenorphine, at any dose, and by any route of administration. Other opioids are considered in separate reviews. OBJECTIVES To assess the analgesic efficacy of buprenorphine for chronic neuropathic pain in adults, and the adverse events associated with its use in clinical trials. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from inception to 11 June 2015, together with reference lists of retrieved papers and reviews, and two online study registries. SELECTION CRITERIA We included randomised, double-blind studies of two weeks' duration or longer, comparing any oral dose or formulation of buprenorphine with placebo or another active treatment in chronic neuropathic pain. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality. We did not carry out any pooled analyses. MAIN RESULTS Searches identified 10 published studies, and one study with results in ClinicalTrials.gov. None of these 11 studies satisfied our inclusion criteria, and so we included no studies in the review. AUTHORS' CONCLUSIONS There was insufficient evidence to support or refute the suggestion that buprenorphine has any efficacy in any neuropathic pain condition.
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Affiliation(s)
| | | | | | - Cathy Stannard
- NHS Gloucestershire CCGSanger House, 5220 Valiant CourtGloucester Business ParkBrockworthUKGL3 4FE
| | | | - Peter Cole
- Churchill Hospital, Oxford University Hospitals NHS TrustOxford Pain Relief UnitOld Road HeadingtonOxfordUKOX3 7LE
| | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
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Moore RA, Derry S, Wiffen PJ, Stannard C, Aldington D, Cole P, Knaggs R. Buprenorphine for neuropathic pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011603] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Derry S, Knaggs R, Wiffen PJ, Stannard C, Aldington D, Cole P, Moore RA. Fentanyl for neuropathic pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011605] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Windmill J, Fisher E, Eccleston C, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev 2013:CD010323. [PMID: 23996347 DOI: 10.1002/14651858.cd010323.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with chronic non-cancer pain who are prescribed and are taking opioids can have a history of long term high dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain. OBJECTIVES To investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non-cancer pain. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE from inception to 8th April 2013, as well as bibliographies. SELECTION CRITERIA Included studies had to be randomised controlled trials comparing opioid users receiving an intervention with a control group receiving treatment as usual, active control, or placebo. The aim of the study had to include a treatment goal of dose reduction or cessation of opioid medication. DATA COLLECTION AND ANALYSIS We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function. MAIN RESULTS Two studies provided information on 86 participants. One compared electroacupuncture with sham acupuncture for 20 minutes twice a week for six weeks; there was no difference between treatments. The other followed 11 weeks of cognitive behavioural therapy with either therapeutic interactive voice response through a computer for four months or usual treatment; the active group had a significant reduction in opioid use, while the usual care group had a significant increase. AUTHORS' CONCLUSIONS Both included studies were at significant risk of bias because of their small size, together with other important issues, including blinding. Because of this risk and the paucity of relevant studies, no conclusions can be drawn regarding the effectiveness of interventions for opioid withdrawal in chronic non-cancer pain.
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Affiliation(s)
- Jude Windmill
- Pain Research and Nuffield Department of Clinical Neurosciences, University of Oxford, Churchill Hospital, Oxford, UK, OX3 7LE
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Langford R, Knaggs R. Guest Editorial: British Journal of Pain: the story so far. Br J Pain 2013; 7:120. [DOI: 10.1177/2049463713496078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Richard Langford
- Immediate Past President, The British Pain Society, Consultant in Anaesthesia and Pain Medicine, Barts Health NHS Trust, London, UK
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Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Guidance on the management of pain in older people. Age Ageing 2013; 42 Suppl 1:i1-57. [PMID: 23420266 DOI: 10.1093/ageing/afs200] [Citation(s) in RCA: 381] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.
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Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Guidance on the management of pain in older people. Age Ageing 2013. [PMID: 23420266 DOI: 10.1093/ageing/afs200115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.
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Abdulla A, Bone M, Adams N, Elliott AM, Jones D, Knaggs R, Martin D, Sampson EL, Schofield P. Evidence-based clinical practice guidelines on management of pain in older people. Age Ageing 2013; 42:151-3. [PMID: 23335785 DOI: 10.1093/ageing/afs199] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Windmill J, Fisher E, Eccleston C, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010323] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Knaggs R, Stannard C. Response to Letter to the Editor. Br J Pain 2012; 6:93. [DOI: 10.1177/2049463712450106] [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: 11/15/2022] Open
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Knaggs R, Bennett MW. Change of datasheet for ketorolac. Anaesthesia 2004; 59:305; discussion 305. [PMID: 14984539 DOI: 10.1111/j.1365-2044.2004.03692.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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