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Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach.
Fourney DR, Andersson G, Arnold PM, Dettori J, Cahana A, Fehlings MG, Norvell D, Samartzis D, Chapman JR. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S1-9.
Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach.
"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength based rehabilitation, cognitive behavioral therapy, pain management and manipulative care. As direct and indirect costs continue to rise, many authors have systematically evaluated the body of evidence in an effort to demonstrate the effectiveness (or lack thereof) for various diagnostic and therapeutic interventions. The objective of this Spine Focus issue is not to replicate previous work in this area. Rather, our expert panel has chosen a set of potentially controversial topics for more in-depth study and discussion. A recurring theme is that chronic LBP is a heterogeneous condition, and this affects the way it is diagnosed, classified, treated, and studied. The efficacy of some treatments may be appreciated only through a better understanding of heterogeneity of treatment effects (i.e., identification of clinically relevant subgroups with differing responses to the same treatment). Current clinical guidelines and payer policies for LBP are systematically compared for consistency and quality. Novel approaches for data gathering, such as national spine registries, may offer a preferable approach to gain meaningful data and direct us towards a "results-based medicine." This approach would require more high-quality studies, more consistent recording for various phenotypes and exploration of studies on genetic epidemiologic undertones to guide us in the emerging era of "results based medicine."
"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength...
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Painful Diabetic Peripheral Neuropathy: Consensus Recommendations on Diagnosis, Assessment and Management.
Tesfaye S, Vileikyte L, Rayman G, Sindrup S, Perkins B, Baconja M, Vinik A, Boulton A; on behalf of the Toronto Expert Panel on Diabetic Neuropathy*.
Diabetes Metab Res Rev. 2011 Jun 21. doi: 10.1002/dmrr.1225.
Painful Diabetic peripheral neuropathy (painful DPN) is common, is associated with significant reduction in quality of life and poses major treatment challenges to the practising physician. Although poor glucose control and cardiovascular risk factors are proven to contribute to the aetiology of DPN, risk factors specific for painful DPN remain unknown. A number of instruments have been proven to assess the character, intensity and impact of painful DPN on quality of life, activities of daily living and mood. Management of the patient with DPN must be tailored to individual requirements, taking into consideration co-morbidities and other factors. Pharmacological agents with proven efficacy for painful DPN include the tricyclic antidepressants (TCA), the selective serotonin and noradrenaline reuptake inhibitors (SNRIs), anticonvulsants, opiates, membrane stabilizers, the antioxidant alpha-lipoic acid and topical agents including capsaicin. Current first-line therapies for painful DPN include a TCA, the SNRI duloxetine and the anticonvulsants pregabalin and gabapentin: when prescribing any of these agents, other co-morbidities and costs must be taken into account. Second line approaches include use of opiates such as the synthetic opioid tramadol, morphine and oxycodone controlled release. There is a limited literature with regard to combination treatment. In extreme cases of painful DPN unresponsive to pharmacotherapy, occasional use of electrical spinal cord stimulation might be indicated. There are a number of unmet needs in the therapeutic management of painful DPN, and these include the need for randomised controlled trials with active comparators, and the long-term efficacy of agents used as most trials have lasted for less than 6 months. Finally, there is a need for appropriately designed studies to investigate non-pharmacological approaches.
Painful Diabetic peripheral neuropathy (painful DPN) is common, is associated with significant reduction in quality of life and poses major treatment challenges to the practising physician.
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The metabolism of opioid agents and the clinical impact of their active metabolites.
Smith HS.
Clin J Pain. 2011 Nov;27(9):824-38.
BACKGROUND: The metabolism of opioids is critical to consider for multiple reasons. The most commonly prescribed opioid agents often have metabolites that are active and are the source of both analgesic activity and an increased incidence of adverse events. Many opioids are metabolized by cytochrome P450 enzymes. Polymorphisms in cytochrome P450 genes and inhibition or induction of cytochrome P450 enzymes by coadministered drugs may significantly impact the systemic concentration of opioids and their metabolites and the associated efficacy or adverse events.
METHODS: This is a narrative review of the metabolism of various opioids that will highlight the impact of their active metabolites, and the potential impact of cytochrome P450 activity on analgesic activity.
RESULTS: An understanding of "opioid metabolic machinery," cytochrome P450 activity, and drug-drug interactions in the context of opioid selection may benefit clinicians and patients alike.
CONCLUSIONS: A greater appreciation of the metabolism of commonly prescribed opioid analgesics and the impact of their active metabolites on efficacy and safety may aid prescribers in tailoring care for optimal outcomes.
The metabolism of opioids is critical to consider for multiple reasons.
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Managing palliative care for adults with advanced heart failure.
Kaasalainen S, Strachan PH, Brazil K, Marshall D, Willison K, Dolovich L, Taniguchi A, Demers C.
Can J Nurs Res. 2011 Sep;43(3):38-57.
The purpose of this study was to explore the care processes experienced by community-dwelling adults dying from advanced heart failure, their family caregivers, and their health-care providers. A descriptive qualitative design was used to guide data collection, analysis, and interpretation. The sample comprised 8 patients, 10 informal caregivers, 11 nurses, 3 physicians, and 3 pharmacists. Data analysis revealed that palliative care was influenced by unique contextual factors (i.e., cancer model of palliative care, limited access to resources, prognostication challenges). Patients described choosing interventions and living with fatigue, pain, shortness of breath, and functional decline. Family caregivers described surviving caregiver burden and drawing on their faith. Health professionals described their role as trying to coordinate care, building expertise, managing medications, and optimizing interprofessional collaboration. Participants strove towards 3 outcomes: effective symptom management, satisfaction with care, and a peaceful death.
The purpose of this study was to explore the care processes experienced by community-dwelling adults dying from advanced heart failure, their family caregivers, and their health-care providers.
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Mortality in spondylarthritis.
Prati C, Claudepierre P, Pham T, Wendling D.
Joint Bone Spine. 2011 Oct;78(5):466-70.
Ankylosing spondylitis (AS) is a chronic inflammatory joint disease that can lead to chronic pain in axial and peripheral joints and to functional impairments after several years. Excess mortality has been reported in patients with AS. We reviewed recent studies of patients with AS who were treated and monitored according to the improved methods developed in the past few years, without radiation therapy. Our results do not support excess mortality in these patients. Long-term follow-up data from patients enrolled in biologics registries will provide additional information. Cardiovascular disease is the leading cause of death in patients with AS, as in the general population. However, the cardiovascular mortality rate may be slightly increased in patients with AS, probably as a result of dyslipidemia and early endothelial dysfunction. Similarly, and as expected, there is excess mortality related to the spinal disease itself and to renal and gastrointestinal disease. More surprisingly, alcohol abuse and injury or suicide cause excess mortality compared to the general population. In the absence of radiation or radium-224 therapy, and regardless of the other treatments used, the evidence does not support an increased rate of lymphoma or other malignancies compared to the general population. In this review, we discuss the causes and rates of mortality in patients with AS.
Ankylosing spondylitis (AS) is a chronic inflammatory joint disease that can lead to chronic pain in axial and peripheral joints and to functional impairments after several years.
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Spinal cord stimulation for visceral pain from chronic pancreatitis.
Kapural L, Cywinski JB, Sparks DA.
Neuromodulation. 2011 Sep;14(5):423-7.
Spinal cord stimulation (SCS) may reduce pain scores and improve function in patients with various chronic abdominal pain syndromes including chronic pancreatitis. Here described is a large clinical experience in SCS for severe chronic pancreatitis. Methods: SCS was trialed in 30 patients with chronic pancreatitis. SCS trials lasted 7-14 days (median 9 days). SCS lead tips were mostly positioned at the T5 (N= 10) or T6 (N= 10) vertebral level. Results: Twenty-four patients (80%) reported at least 50% pain relief on completion of the trial. Among these, pre-trial visual analog scale (VAS) pain scores averaged 8 ± 1.6 (standard deviation) and opioid use averaged 165 ± 120 mg morphine sulfate equivalents. During the trial, VAS pain scores decreased to 3.67 ± 2 cm (p < 0.001, Mann-Whitney Rank Sum Test) and opioid use decreased to 105 ± 101 mg morphine equivalent a day. Six patients failed the trial; one was lost to follow-up; in three patients after the implantation, the system had to be removed due to infection or lead migration; and 20 were followed for the whole year. For 20 patients followed for the whole year, VAS pain scores remained low (3.6 ± 2 cm; p < 0.001) at one year, as did opioid use (48.6 ± 58 mg morphine equivalents). Conclusions: SCS may be a useful therapeutic option for patients with severe visceral pain from chronic pancreatitis. Prospective trial is warranted.
Spinal cord stimulation (SCS) may reduce pain scores and improve function in patients with various chronic abdominal pain syndromes including chronic pancreatitis.
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The relationship of demographic and psychosocial variables to pain-related outcomes in a rural chronic pain population.
Day MA, Thorn BE.
Pain. 2010 Nov;151(2):467-74.
Rural residency and low socioeconomic status (SES) are associated with increased likelihood of chronic pain. Other demographics are also differentially associated with the experience of pain. This study examines the relations between demographic and pain-related variables in a virtually unstudied population of rural Alabama chronic pain patients. One hundred and fifteen patients completed validated measures of pain catastrophizing, depression, pain intensity, pain interference, perceived disability, and life satisfaction. Average age of study participants was 52-years, 79% were female, 74% were African-American, 72% reported annual income between 00,000-12,999, and 61% were unemployed. Although average years of reported education was 12.26, reading level percentile (primary literacy indicant) was 17.33. Cross-sectional multivariate and univariate analyses were conducted to examine associations among demographic and psychosocial variables in relation to various pre-treatment pain-related variables. The mediating role of pain catastrophizing and depression was investigated. Results indicate that race was significantly associated with pain intensity and pain interference, such that African-Americans reported higher scores than White-Americans. Pain catastrophizing was uniquely associated with pain intensity, pain interference, and perceived disability; depression was uniquely associated with pain interference and life satisfaction. Pain catastrophizing mediated the relation between primary literacy and pain intensity; age effects were differentially mediated by either pain catastrophizing or depression. These analyses provide an insight into the specific demographic and psychosocial factors associated with chronic pain in a low-literacy, low-SES rural population.
Rural residency and low socioeconomic status (SES) are associated with increased likelihood of chronic pain. Other demographics are also differentially associated with the experience of pain.
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The Opioid Emperor Has No Clothes.
Keane M.
Am J Bioeth. 2010 Nov;10(11):25-7.
Keane M.
Am J Bioeth. 2010 Nov;10(11):25-7. -
Is Primary Care Providers' Trust in Socially Marginalized Patients Affected by Race?
Moskowitz D, Thom DH, Guzman D, Penko J, Miaskowski C, Kushel M.
J Gen Intern Med. 2011 Mar 11.
BACKGROUND: Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white patients are perceived negatively by clinicians.
OBJECTIVE: To examine whether clinicians' trust in patients differed by patients' race/ethnicity in a socially marginalized cohort.
DESIGN: Cross-sectional study of patient-clinician dyads.
PARTICIPANTS: 169 HIV infected indigent patients recruited from the community and their 61 primary care providers (PCPs.)
MAIN MEASURES: The Physician Trust in Patients Scale (PTPS), a validated scale that measures PCPs' trust in patients.
KEY RESULTS: The mean PTPS score was 43.2 (SD 10.8) out of a possible 60. Reported current illicit drug use and prescription opioid misuse were similar across patients' race or ethnicity. However, both patient illicit drug use and patient non-white race/ethnicity were associated with lower PTPS scores. In a multivariate model, non-white race/ethnicity was independently associated with PTPS scores 6.3 points lower than whites (95% CI: -9.9, -2.7). Current illicit drug use was associated with PTSP scores 5.5 lower than no drug use (95% CI -8.5, -2.5).
CONCLUSION: In a socially marginalized cohort, non-white patients were trusted less than white patients by their PCPs, despite similar rates of illicit drug use and opioid analgesic misuse. The effect was independent of illicit drug use. This finding may reflect unconscious stereotypes by PCPs and may underlie disparities in chronic pain management.
BACKGROUND: Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white...
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Biologic Drugs for Analgesia: Redefining the Opportunity
Hughes J, Hatcher JP, Chessell IP.
Curr Pharm Biotechnol. 2011 Apr 5.
Chronic pain conditions present a huge burden on modern society. Both inflammatory and neuropathic pain is poorly treated in man; the majority of patients do not benefit from adequate pain relief, and side effects of currently used treatments are common. Discovery and development of novel therapies remains an imperative, but the ability to genuinely test the efficacy of novel therapies is often limited by effects at targets other than intended, particularly with novel small molecule approaches. Approaches which limit these off-target activities, and thus avoid the commonest cause of terminating development of new therapeutics may provide a greater ability to genuinely test targets of choice clinically, and here, biologic therapeutics provide such an opportunity; in the major class of biologic therapies, monoclonal antibodies, inherent exquisite selectivity is intrinsic to their nature. Antibody therapeutics have been developed successfully in the immunology and cancer fields, and recent progress in analgesia suggests that these therapeutics may transform treatment paradigms in a similar manner to that observed within, for example, the rheumatoid arthritis space. In addition, opportunities with other biologic approaches, such as peptides, further broadens the potential to bring forward genuinely novel approaches to pain. In this review, the current status of biologic therapies, as well as future opportunities are reviewed.
Chronic pain conditions present a huge burden on modern society. Both inflammatory and neuropathic pain is poorly treated in man; the majority of patients do not benefit from adequate pain relief, and side effects of currently used treatments are...
