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November-December 2005; Premiere EditionPredicting Medication Abuse in Opioid-Treated Patients This edition of News/Research Updates was compiled and edited by Stewart B. Leavitt, PhD; Medical reviewers were: James D. Toombs, MD and Lee A. Kral, PharmD, BCPS; Posting Date: December 15, 2005. Predicting Medication Abuse in Opioid-Treated PatientsThe objective of this investigation was to develop for clinicians a brief screening tool to accurately predict which individuals might develop aberrant medication-use behaviors when prescribed opioids for chronic pain. A self-administered Opioid Risk Tool (ORT) questionnaire was completed by 185 consecutive new patients treated in a pain clinic in Salt Lake City, Utah. The 10-item ORT measured a number of critical risk factors associated in the scientific literature with substance abuse, including: personal and family history of substance abuse; age; history of preadolescent sexual abuse; and certain psychological diseases. Depending on their scores, patients were categorized as low, moderate, or high risk relative to the probability of their displaying opioid-related aberrant behaviors. All patients were monitored for such behaviors for 12 months after their initial visits. Conclusion: In this preliminary study among patients prescribed opioids for chronic pain the ORT exhibited a high degree of sensitivity and specificity for determining which individuals are at risk for opioid-related, aberrant behaviors. During the 12-month observation period, about 40% of all patients exhibited one or more aberrant behaviors associated with their opioid-medications; these behaviors were characterized as abuse in 20% and as consistent with opioid addiction in an estimated 2-5%. See graphic. Commentary: This topic will be discussed further in an upcoming article in Pain Treatment Topics, along with a complete description of the ORT that can be put into practice. There might be some question as to whether patients would answer a questionnaire such as this truthfully; however, the high concordance of responses on the ORT with actual observed behaviors during this long-term study suggest this is not a difficulty. – SB. Leavitt, PhD. Reference: Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005(Nov);6(6):432-442. < Back to Top > How Older Adults Deal With Their Pain, StudyThe objective of this study was to describe the use and perceived effectiveness of pain management strategies in a sample of older adults and to explore the associations of these variables with demographic and psychosocial characteristics. Adults 65 years old or more and living in retirement facilities who reported persistent pain –– n=235, mean 82 years, 84% female, 94% white –– completed measures of demographics, pain, depression, self-efficacy for managing pain, and a Pain Management Strategies Survey. Acetaminophen, regular exercise, prayer, and heat or cold were the most frequently used pain management strategies. Strategies used by >25% of the sample that were rated moderately or more helpful included: prayer, opioids, regular exercise, heat/cold, nonsteroidal anti-inflammatory drugs, and acetaminophen. Persons aged 65-74 years reported use of significantly more strategies than did those older than 85. Perceived helpfulness of strategy use was significantly associated with pain intensity, self-efficacy, and depression. Observations: Persistent pain is a common, often debilitating, problem in older adults; however, few studies have focused on the experiences of these patients in managing their pain. On average, older adults view the strategies they use for persistent pain as only moderately helpful. The associations between perceived helpfulness and self-efficacy and depression suggest that avenues of pain management should be pursued that are focused less on specific treatments and more on how older persons with persistent pain think about their pain. Source: Kemp CA, Ersek M, Turner JA. A descriptive study of older adults with persistent pain: Use and perceived effectiveness of pain management strategies. BMC Geriatr. 2005(Nov);5(1):12. < Back to Top > Older Drinkers May Numb Pain With AlcoholMany older adults suffer from pain and a significant proportion have unhealthy alcohol use. To examine the relationship between pain and alcohol problems among the elderly, researchers studied 401 community-dwelling adults aged 62-72 years at the start of the study (baseline) and 3 years later. Drinking problems were determined by a Drinking Problems Index questionnaire. At baseline, 43% of problem drinkers, compared with only 30% of non-problem drinkers, reported moderate to very severe pain. A third of the problem drinkers experienced functional impairment from pain, versus 18% of non-problem drinkers. Alcohol was used by a greater proportion of problem drinkers to manage their pain (approximately 38% vs 14%); and, among those with moderate to very severe pain the proportions were higher; 58% versus 21%. At the 3-year follow-up, baseline use of alcohol to manage pain predicted more chronic health problems and injuries in men and more drinking problems in women, particularly among those with more alcohol problems at baseline. Clinical Implications: Older adults, especially those with drinking problems, often may use alcohol to manage pain. There are immediate dangers of mixing alcohol with analgesics and a risk of poor health in the future. The authors suggest that clinicians need to ask patients with problem drinking about pain and, conversely, ask patients with pain about their alcohol use. Patients should be cautioned about the risks of using alcohol as an analgesic, and safer, more effective methods of pain relief should be explored. Reference: Brennan PL, Schutte KK, Moos RH. Pain and use of alcohol to manage pain: prevalence and 3-year outcomes among older problem and non-problem drinkers. Addiction. 2005(Oct);100(6):777-786. < Back to Top > Does Pain Affect Black Women More Intensely?Gender-based differences in pain epidemiology, pain threshold, attitudes toward pain management, as well as coping styles and social roles are well described; however, little is known about the chronic pain experience in women or the role race plays. A retrospective analysis of self-reported data using a secondary clinical database was performed to elucidate the relationship between race and pain severity, depression, physical disability, post-traumatic stress disorder (PTSD), and affective distress in women with chronic pain. White (n=1088) and black (n=104) adult women suffering from chronic pain were compared based on their responses to the McGill Pain Questionnaire, Beck Depression Inventory, Pain Disability Index (PDI), Post-traumatic Chronic Pain Test, and items from the West-Haven Yale Multidisciplinary Pain Inventory. The study did not examine what caused the women's pain symptoms. After accounting for sociodemographic, medical, psychological, and physical confounders, there was no significant race effect for pain severity or affective distress. However, black women with chronic pain experience significantly more physical impairments than white women with chronic pain (p < 0.005). Except for family/home responsibilities, similar differences were found on all PDI subscales. It also was found that disability mediates the race-depression relationship such that black women are comparatively more vulnerable to depression as a result of higher disability. The black women also had more anxiety, more PTSD, and increased pain scores. Conclusions: Due to the economic, social, and emotional impact that disability has on women with chronic pain and their families, these findings have important implications for chronic pain management in black women. Although it is unclear why these differences occur, the evidence that black women with chronic pain are more likely to be physically impaired by their pain, and more likely to suffer from depression and post-traumatic stress disorder (PTSD), should alert clinicians to special needs in these patients. Reference: Ndao-Brumblay SK, Green CR. Racial differences in the physical and psychosocial health among black and white women with chronic pain. J Natl Med Assoc. 2005(Oct);97(10):1369-1377. < Back to Top > Opioid Pain Meds Scarce at Minority, Low-Income Area PharmaciesPhysical barriers to adequate pain treatment for minorities are largely unexplored; therefore, this investigation examined sociodemographic determinants of pain medication availability in Michigan pharmacies. A cross-sectional survey-based study with census data and data provided by Michigan community retail pharmacists was designed. Pharmacies located in minority (> or = 70% minority residents) compared with white (> or = 70% white residents) zip code areas were randomly selected and the response rate was 80%. Sufficient opioid analgesic supply was defined as stocking at least one long-acting, short-acting, and combination opioid analgesic. Among the 190 pharmacies surveyed, those in white areas and non-corporate pharmacies were significantly more likely to have sufficient opioid analgesic supplies (p < 0.005). Racial differences in the odds of having a sufficient supply were significantly higher in low income areas when compared with high income areas. Having a pharmacy located near a hospital did not change the availability of opioid analgesics. When asked about the insufficient supplies of these medications, the most common reason cited by pharmacists participating in the study in both white and minority areas was low demand (93%), which did not differ by racial composition or income. The fear that patients might use opioid analgesics for illicit purposes was the second most common reason (8.5%), followed by too much paperwork and fear of robbery (about 1% each). Perspective: Michigan pharmacies in minority zip codes were 52 times less likely to carry sufficient opioid analgesics than pharmacies in white zip codes regardless of income. Lower-income area and corporate pharmacies were less likely to carry sufficient opioid analgesics. Further studies will be needed to determine if the findings generalize to the rest of the country, and if this is found to be the case persons living in predominantly minority areas may experience significant barriers to accessing prescribed opioid pain medications, with greater disparities in low income areas regardless of ethnic composition. There also appear to be differences on the basis of pharmacy type, suggesting variability in pharmacists' decision making. Source: Green CR, Ndao-Brumblay SK, West B, Washington T. Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan. J Pain. 2005(Oct);6(10):689-699. < Back to Top > How Pharmacists Can Aid Patients in PainMillions of Americans live with persistent pain caused by disease, chronic health conditions, or accidents. Pain management is a highly collaborative effort among physicians, pharmacists, and other health care professionals that is designed to improve a patient's quality of life. It can include medications as well as physical and behavioral therapy and requires ongoing communication between the patient and his or her healthcare team about the success of the pain-control regimen. The American Society of Health-System Pharmacists (ASHP) suggests that pharmacists can play a number of roles in the pain-management process, including:
More information for patients on pain management and the pharmacist's vital patient-care role can be found online at: http://www.safemedication.com. For further information on ASHP, visit: www.ashp.org. Source: American Society of Health-System Pharmacists (ASHP). October 20, 2005. Distributed via Newswise Online. < Back to Top > Acceptance of Chronic Pain: Key to Patient FunctioningAcceptance of chronic pain is emerging as an important concept in understanding how chronic pain sufferers can remain engaged with valued aspects of life. Recent studies have relied heavily on cross-sectional investigations at a single time point. This present study sought to prospectively investigate relations between acceptance of chronic pain and patient functioning. A sample of adults referred for interdisciplinary treatment of severe and disabling chronic pain was assessed twice, an average of about 4 months apart. Results showed that patients who reported greater acceptance at Time 1 reported better emotional, social, and physical functioning, less medication consumption, and better work status at Time 2. Clinical Implications: These data suggest that for patients with chronic pain their willingness to accept pain, and to engage in activity regardless of pain, can lead to more healthy functioning. Source: McCracken LM, Eccleston C. A prospective study of acceptance of pain and patient functioning with chronic pain. Pain. 2005(Nov);118(1-2):164-169. < Back to Top > Sexual Dysfunction in Chronic Pain: Psychological Factors ImportantResearchers from Australia reported two studies examining the prevalence of sexual dysfunction, and the role of psychological variables on sexual activity in patients at the commencement of an outpatient cognitive–behavioral pain management program. In the first study, 151 patients with non-cancer pain, predominantly of musculoskeletal origin, completed a range of standardized measures, including the Pain Disability Index, Beck Depression Inventory, and Coping Strategies Questionnaire. Sexual dysfunction was common and was found to be more frequently reported by those with greater disability and depression, shorter pain duration, and infrequent use of coping mechanisms. Study 2 was a pilot investigation of the impact of sexual dysfunction on quality of life (QoL, as measured by the WHOQOL-100) in a similar sample (n = 41). Although sexual dysfunction was again commonly reported, subjects perceived it had less importance in affecting QoL than did other factors. The combined results support the previously proposed notion of adaptation to the impact of chronic illness on sexual function. Conclusion: Sexual dysfunction is common in patients with chronic pain and is predicted by psychological factors and pain duration. However, other issues may impact more significantly on QoL. Therapeutic approaches to sexual dysfunction in these patients might best be focused on improving psychological factors, particularly depression and coping skills. Reference: Kwana KSH, Roberts LJ, Swalm DM. Sexual dysfunction and chronic pain: the role of psychological variables and impact on quality of life. Eur J Pain. 2005(Dec);9(6):643-652. < Back to Top > Supplements for Joint Pain ChallengedA large, prospective, 16-site, National Institutes of Health trial compared pain relief in patients with osteoarthritis of the knee who were randomized to either placebo, celecoxib (200 mg/day), glucosamine (500 mg tid), chondroitin sulfate (400 mg tid), or both supplements together (glucosamine + chondroitin at the above doses). All patients were allowed up to 4000 mg/day acetaminophen as rescue analgesia, except within 24 hours of study visits. Researchers reported on a total of 1258 patients and those improving 20% or more on a pain scale were considered as responders. Overall, 60% of patients responded to placebo, 70% to celecoxib, 64% to glucosamine, 65% to chondroitin sulfate, and 67% to the combined supplements. Results for celecoxib were significantly greater than placebo overall (p = 0.008) and in subgroups with either moderate-to-severe or mild pain. The combined supplements – glucosamine + chondroitin – were significantly better than placebo only for moderate-to-severe pain (p = 0.002), but not for mild pain, and neither supplement alone was better than placebo. Conclusions: The study authors surmise that, while the supplement combination appears to be of benefit in treating higher pain levels, the lack of response in mild pain may be due to a “floor effect” whereby the pain barrier was set too low to detect a response. Patients with moderate-to-severe pain made up only 20% of study participants; however, in this group the combined supplements seemed to alleviate pain as well as celecoxib. Individually, glucosamine or chondroitin did not offer improvement over placebo. Source: Clegg DO, Reda DJ, Harris CL, Klein MA. The efficacy of glucosamine and chondroitin sulfate in patients with painful knee osteoarthritis: The glucosamine/chondroitin arthritis intervention trial (GAIT). Presented at the ACR/ARHP Annual Scientific Meeting; November 12-17, 2005; San Diego, CA. Presentation No. 622. < Back to Top > Advantages of Opioids in Osteoarthritis DiscussedIn this review, the authors note that, as life expectancy increases every decade, the incidence and prevalence of osteoarthritis (OA) also will increase. Despite progress in our knowledge of the pathophysiology of OA, the management of OA-mediated pain continues to challenge physicians. Concern regarding the cardiovascular effects of cyclooxygenase-2 inhibitors and the gastrointestinal and renal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in general has limited the use of these medications in the management of chronic non-cancer pain. Appropriately dosed and monitored use of opioids for OA pain, when more conservative methods have failed, has potentially fewer life-threatening complications associated with it than the more commonly and often less successfully employed pharmacotherapeutic approaches. Practice Pointers: When used as part of a multimodal approach to pain control, opioids are a safe and effective treatment for joint pain, including that of OA. Patients for whom NSAIDs are contraindicated, or for whom combined acetaminophen, tramadol, and NSAID therapy is ineffective, may be started on low-dose opioids and titrated as needed and tolerated. Patient education, exercise, complementary medicine, and the use of a controlled substance agreement increases the likelihood of patient compliance with opioid-treatment guidelines, improving functional capacity and quality of life. Reference: Goodwin JL, Kraemer JJ, Bajwa ZH. The use of opioids in the treatment of osteoarthritis: when, why, and how? Curr Pain Headache Rep. 2005(Dec);9(6):390-398. < Back to Top > Chiropractic Cost-Effective in Treating Chronic Back PainA practice-based, nonrandomized, comparative study evaluated relative provider costs, clinical outcomes, and patient satisfaction in the treatment of low back pain (LBP). Patients (n=2780) were self-referring to 60 doctors of chiropractic and 111 medical doctors in community clinics during a 2-year period. They were included in the study if they were at least 18 years old, ambulatory, and had low back pain of mechanical origin. Chiropractic care included spinal manipulation, physical therapies, an exercise plan, and self-care patient education. Medical care consisted of prescription drugs, an exercise plan, self-care advice, and referral to a physical therapist in approximately 25% of cases. The costs of treatment and patients' pain, disability, and satisfaction with their health care were assessed at 3 and 12 months after the initial visit to the healthcare provider. Chiropractic office costs were higher for both acute and chronic patients (p < 0.01); however, when referrals to physical therapists or other specialists and costs of advanced imaging were included, there were no significant differences between provider types in either patient group. Acute and chronic chiropractic patients experienced significantly better outcomes in pain, functional disability, and patient satisfaction; although, clinically important differences in pain and disability improvement were found for chronic patients only. Clinical Implications: Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP; whereas, chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: that is, manipulation-based therapy is at least as good as or, in some cases, better than other therapies, according to the authors of this current investigation. Reference: Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manipulative Physiol Ther. 2005(Oct);28(8):555-563. < Back to Top > Back-Pain Exercises Do More Harm Than Good?Researchers sought to estimate the effects of recreational physical activity compared with back-specific exercises on low back pain, related disability, and psychological distress among patients randomized to chiropractic or medical care in a managed care setting. Patients with low back pain (n=681) were randomized and followed for 18 months. Participation in recreational physical activities, use of back exercises, low back pain and related disability, and psychological distress were measured at baseline, at 6 weeks, and at 6, 12, and 18 months. Participation in recreational physical activities was inversely associated with low back pain, related disability, and psychological distress. In contrast, back-specific exercises were positively associated with low back pain and related disability. In short, back-specific exercises increased the odds of low back pain and disability by 64% and 44%, respectively. And among participants who did lower-back exercises, those who did them least reported lower pain levels. Practice Implications: These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health. The study showed that general physical activity – such as 3 hours or more of walking or similar activity per week – reduces acute, chronic and disabling back pain, as well as psychological distress. However, the researchers did not collect data on which back exercises each person performed, nor did they determine why the exercises might worsen back pain. Poor form and improper exercises may explain the results, they conceded. Reference: Hurwitz EL, Morgenstern H, Chiao C. Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA low back pain study. Amer J Pub Health. 2005(Oct);95(10):1817-1824. < Back to Top > Fentanyl vs SR Morphine in Chronic LBPThis open-label, randomized, parallel-group multicenter trial compared the efficacy and safety of transdermal fentanyl (TDF) and sustained release morphine (SRM) in patients with chronic low back pain (CLBP) who were naïve to strong opioid medications. Patients requiring regular strong-opioid therapy received either TDF or SRM for 13 months. Starting doses were 25 micrograms/hr fentanyl patches every 72 hours or 30 mg oral morphine every 12 hours; doses were adjusted according to response. Participants assessed pain relief and bowel function using weekly diaries. Other assessments included quality of life, disease progression, and side effects. Data from 680 patients showed that TDF and SRM provided similar levels of pain relief, but TDF was associated with significantly less constipation than SRM, indicating a greater likelihood of satisfactory pain relief with TDF. Other ratings were similar for TDF and SRM, but TDF provided greater relief of pain at rest and at night. Conclusions: Most studies of TDF and SRM have involved patients already receiving strong opioids. This is the first large-scale study focusing on strong-opioid naïve patients with CLBP and it indicates that sustained-release strong opioids can safely be used in such patients. TDF provided some pain-relief advantages and was associated with less constipation. Warning: according to FDA-approved product labeling, “DURAGESIC® (fentanyl transdermal system) should ONLY be used in patients who are already receiving opioid therapy, who have demonstrated opioid tolerance, and who require a total daily dose at least equivalent to DURAGESIC® 25 mcg/h.” For more information see; http://www.duragesic.com/ . Source: Allan L, Richarz U, Simpson K, Slappendel R. Transdermal fentanyl versus sustained release oral morphine in strong-opioid naive patients with chronic low back pain. Spine. 2005(Nov);30(22):2484-2490. < Back to Top > Long-term Opioids Improve QoL in Chronic, Non-malignant PainThe use of opioids in the management of non-malignant pain remains controversial since, for many physicians, pain relief stemming from opioid use is not enough unless there also is a noticeable change in quality of life (QoL) and patient functioning. This systematic review presents the results of 11 studies that evaluated long-term treatment with opioids in patients with chronic, non-malignant pain and also assessed QoL (n=2877). Six of the studies were randomized trials and the remaining 5 were observational studies. Of the 4 randomized studies in which baseline QoL was reported, 3 showed an improvement in QoL. Similarly, of the 5 observational studies, a significant improvement in QoL was reported in 4 of them. Conclusion: The authors found that there is ample evidence suggesting that long-term treatment with opioids can lead to significant improvements in functional outcomes and QoL in patients with chronic, non-malignant pain. However, further investigations will help to confirm the long-term QoL benefit of opioid treatment in such patients, and to clarify any effects of physical tolerance, opioid withdrawal syndrome, and/or addiction – all potentially associated with long-term use of opioids – on patients' continued functional status. Source: Devulder J, Richarz U, Nataraja SH. Impact of long-term use of opioids on quality of life in patients with chronic, non-malignant pain. Curr Med Res Opin. 2005(Oct);21(10):1555-1568. < Back to Top > Chest Pain History of Limited Value in Diagnosing ACS/AMIConflicting data exist about the usefulness of the chest pain history and which components are most useful in helping clinicians identify acute coronary syndromes (ACS) and acute myocardial infarction (AMI) in patients presenting with chest pain. This extensive systematic literature review revealed specific chest pain characteristics that decrease the likelihood of ACS or AMI, namely pain that is stabbing, pleuritic, positional, or reproducible by palpation. Conversely, chest pain that radiates to one shoulder or both shoulders or arms or is precipitated by exertion is associated with increased likelihood of ACS. The chest pain history itself has not proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing. Combinations of elements of the chest pain history, such as a lack of prior coronary artery disease (CAD), with other initially available information have identified certain groups that may be safe for discharge without further evaluation, but more study is needed before such a recommendation can be considered reasonable. Practice Perspectives: The chest pain history, physical examination, determination of CAD risk factors, and the initial electrocardiogram compose the information immediately available to clinicians to help determine the probability of AMI or ACS in patients with chest pain. Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing. Reference: Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623-2629. < Back to Top > Psychiatric Implications in Noncardiac Chest PainApproximately 30% of coronary angiograms are negative for significant coronary artery disease and patients are classified as having noncardiac chest pain (NCCP). So far, there is no systematic diagnostic approach to patients with NCCP investigating for possible esophageal, psychiatric, and musculoskeletal abnormalities. Furthermore, coping strategies and quality of life are poorly characterized in NCCP patients. Practice Recommendation: Compared with GERD patients, those with psychiatric disorders showed a diminished quality of life, more frequent chest pain, and less treatment satisfaction. Immediate combined psychiatric and orthopedic evaluation, as well as esomeprazole administration following exclusion of coronary artery disease, may confirm the causes of noncardiac chest pain. Identification of psychiatric disorders seems especially warranted, since this is a frequent diagnosis and these patients experience a reduced quality of life and exhibit pathologic coping strategies. Source: Husser D, Bollmann A, Kühne C, Molling J, Klein HU. Evaluation of noncardiac chest pain: diagnostic approach, coping strategies and quality of life. Eur J Pain. 2006(Jan);10(1):51-55. < Back to Top > New Approach Needed for Noncardiac Chest PainChest pain is common; 1 in 4 persons have an episode annually. Of those who present at hospitals, nearly two-thirds have noncardiac chest pain (NCCP), and more than half of these NCCP cases might have gastroesophageal reflux disease, according to this report from researchers in Australia. Opinions differ as to the most appropriate application of current diagnostic investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option. If acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including: 24-hour or 48-hour esophageal pH testing; esophageal manometry; and, symptom provoking tests. However, there is no consensus as to which methods are most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders also are common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy; however, recent studies have failed to demonstrate an improved outcome using this exhaustive diagnostic approach. [Also see News item above.] Recommendation: A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of “therapy as investigation” might be a superior methodology, according to the authors. Source: Eslick GD, Coulshed DS, Talley NJ. Diagnosis and treatment of noncardiac chest pain. Nat Clin Pract Gastroenterol Hepatol. 2005(Oct);2(10):463-472. < Back to Top > OTC Painkillers Equivalent in Relieving Muscle PainUse of the painkiller paracetamol (known in the U.S. as acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs), or the combination of the two, are equally effective for treating pain after musculoskeletal injuries, a study shows. In the study, investigators at a University Hospital in the New Territories of Hong Kong examined the safety and efficacy of oral paracetamol compared with oral NSAIDs such as indomethacin and diclofenac, or combination therapy in treating pain after blunt limb injury in 300 adults seen in an emergency department. This was a double-blind, randomized, controlled study. Pain scores fell significantly and similarly in all groups, the authors report. There were no significant differences among any of the treatment groups at any time, although combination therapy was the first to generate a clinically significant reduction in pain. Both treatment strategies were safe and well tolerated, with fewer than 7% of patients experiencing side effects. Conclusion: In this study, any analgesic benefit of oral paracetamol-NSAID combinations over single NSAID or paracetamol treatment was small and of doubtful clinical significance. NSAIDs, paracetamol, and diclofenac-paracetamol combinations appeared equally effective and safe in the management of musculoskeletal pain. Reference: Woo WWK, Man S-Y, Lam PKW, Rainer TH. Randomized double-blind trial comparing oral paracetamol and oral nonsteroidal antiinflammatory drugs for treating pain after musculoskeletal injury. Ann Emerg Med. 2005(October);46(4):352-361. < Back to Top > Aspirin + Other NSAIDs A Harmful CombinationNew research has confirmed that patients taking over-the-counter pain medications ibuprofen and naproxen alone or along with aspirin have an increased risk of gastrointestinal complications like ulcers and bleeding. Investigators from the University of Utah conducted a retrospective review of medical records of more than 3 million persons; nearly 12,000 naproxen users and about 38,500 ibuprofen users were included. Results showed that people taking ibuprofen and naproxen alone were 2.5 to 2.74 times more likely to have serious gastrointestinal problems than people not taking these pain medications. In people taking ibuprofen plus aspirin, the patients had a 3.4-times higher risk of serious gastrointestinal problems than those taking ibuprofen alone. Those taking naproxen plus aspirin had a 2-times higher risk of problems than people only taking naproxen alone. Clinical Implication: Aspirin can significantly increase the risk of GI problems among patients using other over-the-counter NSAIDs such as ibuprofen and naproxen, which incur their own risks. Patients should be advised of these potential risks. Source: Presentation at the 70th Annual Scientific Meeting of the American College of Gastroenterology; Honolulu, Hawaii; October 28 - November. 2, 2005. Reported via Ivanhoe Medical Newswire, November 1, 2005. < Back to Top > Public Unaware of NSAID & OTC Analgesic RisksTwo surveys totalling 9062 American respondents were performed to assess the public's use of and attitudes toward prescription and OTC nonsteroidal anti-inflammatory drugs (NSAIDs): the Roper survey conducted in 1997, and the National Consumers League (NCL) survey conducted in December 2002. In both surveys, ibuprofen-based drugs were the most frequently used OTC NSAID (57% Roper, 33% NCL). In the Roper survey, 17% of respondents used NSAIDs, with 38% of those persons using both prescription and OTC products. Forty-six percent of exclusive OTC users believed those analgesics were safer, while 56% of exclusive users of prescription NSAIDs believed that those were safer. Sixty percent and 29% of exclusive OTC users were neither aware of nor believed they were at risk for side effects from NSAIDs, respectively. Of importance, 26% of respondents used more than the recommended dose on the label, while 22% believed warning symptoms would always precede any NSAID-induced complications. In the NCL survey, 83% had used an OTC NSAID agent in the last year, with 15% reporting daily use, and 49% were not concerned about potential side effects. In this survey, 30% believed there was less risk with OTC analgesics than prescription NSAIDs, and 44% consumed more than the recommended dosage on the label. Clinical Implications: OTC NSAIDs are widely used, are frequently taken inappropriately and potentially dangerously, and users are generally unaware of the potential for adverse side effects. Educational intervention directed toward both patients and physicians appears warranted. Source: Wilcox CM, Cryer B, Triadafilopoulos G. Patterns of use and public perception of over-the-counter pain relievers: focus on nonsteroidal antiinflammatory drugs. J Rheumatol. 2005(Nov);32(11):2218-2224 < Back to Top > Local Anesthetics Effective for Neuropathic PainLidocaine, mexiletine, tocainide, and flecainide are local anesthetics that also provide an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when investigations reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials meeting high quality standards, the authors of this report reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to assess their benefit and harm, and to better define their role in therapy. Via an extensive systematic search, the authors identified 32 controlled clinical trials meeting the selection criteria; 2 were duplicate articles. In all, the studies covered 371 patients given local anesthetics and 379 patients given placebos. The treatment drugs included intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (1 trial), and tocainide (1 trial). Lidocaine and mexiletine were statistically superior to placebo (p < 0.00001), and limited data showed no difference in efficacy or adverse effects of these agents compared with carbamazepine, amantadine, gabapentin, or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life-threatening toxicities. Results: Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. However, more emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful. Reference: Challapalli V, Tremont-Lukats IV, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. The Cochrane Database of Systematic Reviews. 2005, Issue 4. < Back to Top > DEA Denied Role in Approving New PainkillersIn early November 2005, a U.S. House-Senate conference committee abandoned a controversial provision that gave the Drug Enforcement Administration (DEA) authority to review, and potentially block, the sale of all new prescription narcotics. The legislation, promoted by Rep. Frank R. Wolf (R-Va.) and attached to a multi-department appropriations bill, had passed last year with little notice. But this year the Food and Drug Administration (FDA), many drug makers, and doctors who treat pain patients objected to renewing it. The provision was stripped from the bill, reported the Washington Post. Opponents said the provision was an unwarranted intrusion by a law enforcement agency into the FDA's drug-review system. Pain specialists also said the DEA reviews could jeopardize development of new drugs needed by patients with chronic pain. Source: Kaufman M. Drug enforcement agency stripped of role on new painkillers. Washington Post. Saturday, November 5, 2005: A13. < Back to Top > Grants Available: Preventing Opioid Abuse in Pain PatientsPrograms seeking to lower the risk of addiction among patients receiving powerful opioid drugs for the treatment of pain may apply for funding from the National Institutes of Health. The $5.7 million in “Prescription Opioid Use and Abuse in the Treatment of Pain” awards will be granted to governments, schools, tribes, nonprofit groups, and for-profits that help “provide a scientific foundation that can help inform healthcare providers on how to treat pain successfully while minimizing the risks of abuse and addiction to opioids.” Both risk and protective factors may be explored. Application deadline is Feb. 23, 2006. For more details, see the grant announcement online at: http://grants.nih.gov/grants/guide/rfa-files/RFA-DA-06-005.html. From: Department of Health and Human Services announcement, November 2005. < Back to Top >
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For those patients in the low-risk category, 17 out of 18 (94.4%) did not display an aberrant behavior; conversely, in the high-risk patients 40 out of 44 (90.9%) did display an aberrant behavior. Using the c statistic to validate the ORT, which simultaneously assesses sensitivity and specificity, the questionnaire displayed excellent discrimination in both males and females.
German researchers applied a simple diagnostic approach to 43 consecutive patients with angina-like chest pain and normal coronary angiograms. See pie chart. Twenty-one patients (49%) were found to suffer from psychiatric disorders (10 = combined depression/anxiety; 5 = depression alone; 3 = panic disorder; 3 = somatization). Sixteen patients (37%) had an improvement of their chest pain after oral esomeprazole (40 mg for 7 days) and were therefore diagnosed with gastroesophageal reflux disease (GERD). In 6 patients with GERD, there were multiple diagnoses, including 3 each with GERD plus depression and GERD plus musculoskeletal disorders. Six patients (14%) were diagnosed with musculoskeletal abnormalities including costochondritis (n=4), thoracic spondylodynia (n=1), and fibromyalgia (n=1).