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Pain Medicine 2014; 15: 425–431 Wiley Periodicals, Inc.
PRIMARY CARE & HEALTH SERVICES SECTION Review Article Update in Pain Medicine for Primary Care Providers: A Narrative Review, 2010–2012 Joseph W. Frank, MD, MPH,* Matthew J. Bair, MD, MS,† William C. Becker, MD,‡ Erin E. Krebs, MD, MPH,§ Jane M. Liebschutz, MD, MPH,¶** and Daniel P. Alford, MD, MPH¶ *Denver VA Medical Center, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado,
English-language studies related to the management of chronic noncancer pain in adult patients in primary care settings. One investigator reviewed all eligible studies for relevance, and 47 studies were reviewed by all authors and rated according to their impact on 1) primary care clinical practice, 2) policy, 3) research, and 4) quality of study methods. Through iterative discussion, nine articles were selected for detailed review and discussion.
†
Roudebush VA Medical Center, Indiana University School of Medicine, Indianapolis, Indiana, ‡
VA Connecticut Healthcare System, Yale University School of Medicine, New Haven, Connecticut, §
Minneapolis VA Medical Center, University of Minnesota Medical School, Minneapolis, Minnesota, ¶
Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, **Boston University School of Public Health, Boston, Massachusetts, USA Reprint requests to: Joseph W. Frank, MD, MPH, Division of General Internal Medicine, University of Colorado School of Medicine, 8th floor, Academic Office 1, Mailstop B180, 12631 E. 17th Avenue, Aurora, CO 80045, USA. Tel: (317) 509-0071; Fax: (303) 724 2270; E-mail: [email protected]. Disclosure: The authors report no potential conflicts of interest. Abstract Objective. This manuscript reviews peer-reviewed literature published from 2010–2012 relevant to the management of chronic pain in the primary care setting. Design. Narrative literature.
review
of
Results. We present articles in six topic areas: interventional pain management; opioid dose and risk of overdose death; neuropathic pain; yoga for chronic low back pain; cognitive behavioral therapy; and systematic approaches to treating back pain. We discuss implications for pain management in primary care. Conclusions. There is growing evidence for the risks, benefits, and limitations of the multiple modalities available to primary care providers for the management of chronic pain. The dissemination and implementation of the evidence from these studies as well as novel system-level interventions warrant additional study and support from clinicians, educators, and policy makers. Key Words. Pain Management; Primary Care; Interventional; Opioids; Neuropathic Pain; Exercise; Psychotherapy; Physical Therapy
Introduction Chronic pain affects about 100 million American adults and costs the nation up to $635 billion each year in medical treatment and lost productivity [1]. Chronic pain is a common complaint in general medical settings [2]. Analgesics account for 11% of all prescriptions in ambulatory care and 35% of all prescriptions in emergency department settings [3,4]. Our aims were to review recent pain medicine studies and their key findings and to discuss the implications of these findings in the primary care setting.
peer-reviewed
Methods. We searched MEDLINE, PubMed, and reference lists and queried expert contacts for
We searched for peer-reviewed articles published from January 1, 2010 through December 31, 2012 with the aim of identifying studies that could potentially change primary care-based management of patients with chronic pain.
Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
425
Frank et al.
Table 1
Summary of reviewed articles and their key findings
Interventional Pain Management Pinto et al. Ann Intern Med
2012
Meta-analysis of epidural corticosteroid injection for sciatica showed short-term improvements but no significant long-term effects.
Opioid Dose and Overdose Risk Dunn et al. Ann Intern Med
2010
Three observational studies showed increasing opioid overdose risk at increased opioid dose in three distinct patient populations.
Bohnert et al. Gomes et al.
JAMA Arch Intern Med
2011 2011
Neuropathic Pain Finnerup et al.
Pain
2010
Updated meta-analysis found large increase in published trials, but tricyclic antidepressants remain first-line for neuropathic pain.
Yoga Tilbrook et al.
Ann Intern Med
2011
Two randomized trials of yoga found small-to-moderate improvements in back pain-related function compared with self-care.
Arch Intern Med
2011
Sherman et al.
Cognitive Behavioral Therapy (CBT) Lamb et al. Lancet
2010
Randomized trial of group-based CBT for back pain found reductions in pain-related disability and pain severity at 12 months.
Systematic Approaches Hill et al. Lancet
2011
Randomized trial of a risk stratification tool and physical therapy treatment algorithm found improvements in back pain-related disability and decreased costs compared with usual care.
We searched MEDLINE and PubMed using the medical subject heading (MeSH) terms Pain, Pain Measurement, Pain Management, Analgesia or Analgesics, excluding acute pain, postoperative pain, cancer pain, chest pain and pediatrics, and limiting to humans, English language and study type (trial, epidemiologic, review, meta-analysis, or guideline). This project is a part of an ongoing initiative of the Pain Medicine Interest Group of the Society of General Internal Medicine (SGIM) to present the prior 2 years’ most relevant pain medicine articles in workshop format at the Society’s annual meeting [5,6]. We supplemented the above search strategy by inviting members of the Pain Medicine Interest Group to suggest candidate articles. This search strategy produced 2,738 references. We specified the following selection criteria to identify articles for in-depth discussion by the entire authorship team: Potential impact on 1) primary care clinical practice, 2) clinical policy, 3) research, and 4) the quality of study methods. One investigator (JWF) reviewed all 2,738 article abstracts. Guided by the above selection criteria, two investigators (JWF, DPA) narrowed down the article list to 47 articles. The full authorship team reviewed these 47 articles and rated each according to our prespecified selection criteria. In a series of conference calls, we achieved consensus on the nine articles with the highest ratings for detailed review and discussion (Table 1). 426
Interventional Pain Management Pinto RZ, Maher CG, Ferreira ML et al. Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis. Ann Intern Med 2012; 157:865–877 [7]. Sciatica is a common condition that sometimes resolves spontaneously but may progress to chronic pain refractory to pharmacotherapy [8]. Epidural corticosteroid injection (ECI) is an increasingly used interventional treatment for sciatica; however, the authors of this study contend that given the predominance of small studies with heterogeneous comparators and outcomes, the evidence base for ECI is unclear. Therefore, the authors performed a systematic review and meta-analysis of the literature, including randomized controlled trials (RCTs) comparing ECI to inert placebo injection. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to evaluate study quality [9]; the authors also investigated the relationship between trial characteristics (intention-to-treat analysis, therapist blinding, and allocation concealment) and outcomes. The meta-analysis included only studies reporting continuous outcomes, which were converted to a 0–100 scale and grouped by duration of follow-up (short vs long term), pain type (leg pain, back pain), and disability. Twenty-three trials were included. The pooled results
Update in Pain Medicine demonstrated a significant but small effect of ECI compared with placebo; reduced leg pain (mean difference, −6.2 [95% CI, −9.4 to −3.0]) and disability (mean difference, −3.1 [CI, −5.0 to −1.2]) in the short term (>2 weeks but ≤3 months). The long-term (≥12 months) pooled effects were not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high; trial characteristics—including anatomical approach—did not influence the results.
studies, increasing opioid dose was associated with an increasing risk of opioid-related overdose. This association was statistically significant at opioid doses above 50 mg/day MED in all three studies. There was no active opioid prescription (i.e., expired or never prescribed) on the day of overdose in 12–63% of overdose events. Each study advised close monitoring of patients receiving opioids for chronic pain, particularly those receiving high doses (>100 mg/day).
Implications for Practice
Implications for Practice
The results of this study should help primary care providers (PCPs) counsel patients about ECI treatment for sciatica. In this meta-analysis, ECI did not show benefit in the long term and showed small benefit of questionable clinical significance in the short term regardless of anatomical approach (caudal vs interlaminar vs transforaminal). The study did not review safety aspects of ECI. With recently publicized fungal meningitis from contaminated steroids [10], if patients wish to pursue ECI despite these efficacy data, clinicians should counsel patients that major harms (i.e., meningitis and spinal infarction) are rare [11], but minor harms are relatively common (i.e., transient headache, transient numbness, and vascular entry of the needle) [12]. While this study demonstrated only modest efficacy for ECI for two short-term outcomes, patients with sciatica refractory to conservative measures may still warrant referral [13]. Clinicians should also be aware that the use of ECI for nonspecific low back pain is not recommended [14].
These three studies identified a robust association between opioid dose and risk of opioid-related overdose that has important implications for PCPs as well as pain specialists. First, while causality cannot be established from these observational data, high-dose opioids are strongly correlated with overdose risk. Opioid dose should be incorporated into efforts to better target risk mitigation resources such as patient education and monitoring, particularly at the clinician panel or population level. Second, as overdose rates appear to increase with increasing opioid dose, so too does the risk/benefit analysis change with dosing adjustments. Providers should use these opportunities to reassess patients’ goals and ensure that benefits (i.e., relief of pain, improved quality of life) continue to justify the risks of opioids. Finally, as a significant proportion of overdose events occurred among patients not currently prescribed an opioid, these studies highlight the need for further studies of other approaches to overdose prevention such as use of prescription monitoring programs, safe disposal of unused medications, and increased availability of intranasal naloxone in the community.
Opioid Dose and Risk of Overdose Death Dunn KM, Saunders KW, Rutter CM et al. Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study. Ann Intern Med 2010;152:85–92 [15]. Bohnert ASB, Valenstein M, Bair MJ et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA 2011;305 [13]:1315– 1321 [16]. Gomes T, Mamdani MM, Dhalla IA et al. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. Arch Intern Med 2011;171 [7]:686–691 [17]. Prescription of opioids for chronic noncancer pain has increased over the past decade as have rates of opioidrelated overdose [18]. The factors influencing overdose risk are incompletely understood. Three separate studies, published in 2010 and 2011, examined the relationship between opioid dose and opioid-related overdose. The authors analyzed observational data from distinct patient populations in the United States and Canada. Each study measured prescribed daily opioid dose converted to morphine equivalent doses (MED) and compared the risk of confirmed opioid-related overdose across opioid dose categories (i.e., 1-
Pain Medicine 2014; 15: 425–431 Wiley Periodicals, Inc.
PRIMARY CARE & HEALTH SERVICES SECTION Review Article Update in Pain Medicine for Primary Care Providers: A Narrative Review, 2010–2012 Joseph W. Frank, MD, MPH,* Matthew J. Bair, MD, MS,† William C. Becker, MD,‡ Erin E. Krebs, MD, MPH,§ Jane M. Liebschutz, MD, MPH,¶** and Daniel P. Alford, MD, MPH¶ *Denver VA Medical Center, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado,
English-language studies related to the management of chronic noncancer pain in adult patients in primary care settings. One investigator reviewed all eligible studies for relevance, and 47 studies were reviewed by all authors and rated according to their impact on 1) primary care clinical practice, 2) policy, 3) research, and 4) quality of study methods. Through iterative discussion, nine articles were selected for detailed review and discussion.
†
Roudebush VA Medical Center, Indiana University School of Medicine, Indianapolis, Indiana, ‡
VA Connecticut Healthcare System, Yale University School of Medicine, New Haven, Connecticut, §
Minneapolis VA Medical Center, University of Minnesota Medical School, Minneapolis, Minnesota, ¶
Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, **Boston University School of Public Health, Boston, Massachusetts, USA Reprint requests to: Joseph W. Frank, MD, MPH, Division of General Internal Medicine, University of Colorado School of Medicine, 8th floor, Academic Office 1, Mailstop B180, 12631 E. 17th Avenue, Aurora, CO 80045, USA. Tel: (317) 509-0071; Fax: (303) 724 2270; E-mail: [email protected]. Disclosure: The authors report no potential conflicts of interest. Abstract Objective. This manuscript reviews peer-reviewed literature published from 2010–2012 relevant to the management of chronic pain in the primary care setting. Design. Narrative literature.
review
of
Results. We present articles in six topic areas: interventional pain management; opioid dose and risk of overdose death; neuropathic pain; yoga for chronic low back pain; cognitive behavioral therapy; and systematic approaches to treating back pain. We discuss implications for pain management in primary care. Conclusions. There is growing evidence for the risks, benefits, and limitations of the multiple modalities available to primary care providers for the management of chronic pain. The dissemination and implementation of the evidence from these studies as well as novel system-level interventions warrant additional study and support from clinicians, educators, and policy makers. Key Words. Pain Management; Primary Care; Interventional; Opioids; Neuropathic Pain; Exercise; Psychotherapy; Physical Therapy
Introduction Chronic pain affects about 100 million American adults and costs the nation up to $635 billion each year in medical treatment and lost productivity [1]. Chronic pain is a common complaint in general medical settings [2]. Analgesics account for 11% of all prescriptions in ambulatory care and 35% of all prescriptions in emergency department settings [3,4]. Our aims were to review recent pain medicine studies and their key findings and to discuss the implications of these findings in the primary care setting.
peer-reviewed
Methods. We searched MEDLINE, PubMed, and reference lists and queried expert contacts for
We searched for peer-reviewed articles published from January 1, 2010 through December 31, 2012 with the aim of identifying studies that could potentially change primary care-based management of patients with chronic pain.
Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
425
Frank et al.
Table 1
Summary of reviewed articles and their key findings
Interventional Pain Management Pinto et al. Ann Intern Med
2012
Meta-analysis of epidural corticosteroid injection for sciatica showed short-term improvements but no significant long-term effects.
Opioid Dose and Overdose Risk Dunn et al. Ann Intern Med
2010
Three observational studies showed increasing opioid overdose risk at increased opioid dose in three distinct patient populations.
Bohnert et al. Gomes et al.
JAMA Arch Intern Med
2011 2011
Neuropathic Pain Finnerup et al.
Pain
2010
Updated meta-analysis found large increase in published trials, but tricyclic antidepressants remain first-line for neuropathic pain.
Yoga Tilbrook et al.
Ann Intern Med
2011
Two randomized trials of yoga found small-to-moderate improvements in back pain-related function compared with self-care.
Arch Intern Med
2011
Sherman et al.
Cognitive Behavioral Therapy (CBT) Lamb et al. Lancet
2010
Randomized trial of group-based CBT for back pain found reductions in pain-related disability and pain severity at 12 months.
Systematic Approaches Hill et al. Lancet
2011
Randomized trial of a risk stratification tool and physical therapy treatment algorithm found improvements in back pain-related disability and decreased costs compared with usual care.
We searched MEDLINE and PubMed using the medical subject heading (MeSH) terms Pain, Pain Measurement, Pain Management, Analgesia or Analgesics, excluding acute pain, postoperative pain, cancer pain, chest pain and pediatrics, and limiting to humans, English language and study type (trial, epidemiologic, review, meta-analysis, or guideline). This project is a part of an ongoing initiative of the Pain Medicine Interest Group of the Society of General Internal Medicine (SGIM) to present the prior 2 years’ most relevant pain medicine articles in workshop format at the Society’s annual meeting [5,6]. We supplemented the above search strategy by inviting members of the Pain Medicine Interest Group to suggest candidate articles. This search strategy produced 2,738 references. We specified the following selection criteria to identify articles for in-depth discussion by the entire authorship team: Potential impact on 1) primary care clinical practice, 2) clinical policy, 3) research, and 4) the quality of study methods. One investigator (JWF) reviewed all 2,738 article abstracts. Guided by the above selection criteria, two investigators (JWF, DPA) narrowed down the article list to 47 articles. The full authorship team reviewed these 47 articles and rated each according to our prespecified selection criteria. In a series of conference calls, we achieved consensus on the nine articles with the highest ratings for detailed review and discussion (Table 1). 426
Interventional Pain Management Pinto RZ, Maher CG, Ferreira ML et al. Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis. Ann Intern Med 2012; 157:865–877 [7]. Sciatica is a common condition that sometimes resolves spontaneously but may progress to chronic pain refractory to pharmacotherapy [8]. Epidural corticosteroid injection (ECI) is an increasingly used interventional treatment for sciatica; however, the authors of this study contend that given the predominance of small studies with heterogeneous comparators and outcomes, the evidence base for ECI is unclear. Therefore, the authors performed a systematic review and meta-analysis of the literature, including randomized controlled trials (RCTs) comparing ECI to inert placebo injection. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to evaluate study quality [9]; the authors also investigated the relationship between trial characteristics (intention-to-treat analysis, therapist blinding, and allocation concealment) and outcomes. The meta-analysis included only studies reporting continuous outcomes, which were converted to a 0–100 scale and grouped by duration of follow-up (short vs long term), pain type (leg pain, back pain), and disability. Twenty-three trials were included. The pooled results
Update in Pain Medicine demonstrated a significant but small effect of ECI compared with placebo; reduced leg pain (mean difference, −6.2 [95% CI, −9.4 to −3.0]) and disability (mean difference, −3.1 [CI, −5.0 to −1.2]) in the short term (>2 weeks but ≤3 months). The long-term (≥12 months) pooled effects were not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high; trial characteristics—including anatomical approach—did not influence the results.
studies, increasing opioid dose was associated with an increasing risk of opioid-related overdose. This association was statistically significant at opioid doses above 50 mg/day MED in all three studies. There was no active opioid prescription (i.e., expired or never prescribed) on the day of overdose in 12–63% of overdose events. Each study advised close monitoring of patients receiving opioids for chronic pain, particularly those receiving high doses (>100 mg/day).
Implications for Practice
Implications for Practice
The results of this study should help primary care providers (PCPs) counsel patients about ECI treatment for sciatica. In this meta-analysis, ECI did not show benefit in the long term and showed small benefit of questionable clinical significance in the short term regardless of anatomical approach (caudal vs interlaminar vs transforaminal). The study did not review safety aspects of ECI. With recently publicized fungal meningitis from contaminated steroids [10], if patients wish to pursue ECI despite these efficacy data, clinicians should counsel patients that major harms (i.e., meningitis and spinal infarction) are rare [11], but minor harms are relatively common (i.e., transient headache, transient numbness, and vascular entry of the needle) [12]. While this study demonstrated only modest efficacy for ECI for two short-term outcomes, patients with sciatica refractory to conservative measures may still warrant referral [13]. Clinicians should also be aware that the use of ECI for nonspecific low back pain is not recommended [14].
These three studies identified a robust association between opioid dose and risk of opioid-related overdose that has important implications for PCPs as well as pain specialists. First, while causality cannot be established from these observational data, high-dose opioids are strongly correlated with overdose risk. Opioid dose should be incorporated into efforts to better target risk mitigation resources such as patient education and monitoring, particularly at the clinician panel or population level. Second, as overdose rates appear to increase with increasing opioid dose, so too does the risk/benefit analysis change with dosing adjustments. Providers should use these opportunities to reassess patients’ goals and ensure that benefits (i.e., relief of pain, improved quality of life) continue to justify the risks of opioids. Finally, as a significant proportion of overdose events occurred among patients not currently prescribed an opioid, these studies highlight the need for further studies of other approaches to overdose prevention such as use of prescription monitoring programs, safe disposal of unused medications, and increased availability of intranasal naloxone in the community.
Opioid Dose and Risk of Overdose Death Dunn KM, Saunders KW, Rutter CM et al. Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study. Ann Intern Med 2010;152:85–92 [15]. Bohnert ASB, Valenstein M, Bair MJ et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA 2011;305 [13]:1315– 1321 [16]. Gomes T, Mamdani MM, Dhalla IA et al. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. Arch Intern Med 2011;171 [7]:686–691 [17]. Prescription of opioids for chronic noncancer pain has increased over the past decade as have rates of opioidrelated overdose [18]. The factors influencing overdose risk are incompletely understood. Three separate studies, published in 2010 and 2011, examined the relationship between opioid dose and opioid-related overdose. The authors analyzed observational data from distinct patient populations in the United States and Canada. Each study measured prescribed daily opioid dose converted to morphine equivalent doses (MED) and compared the risk of confirmed opioid-related overdose across opioid dose categories (i.e., 1-
