systematic reviews of common chronic pain medications and interventions trang nguyen md, phd masi...
TRANSCRIPT
![Page 1: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/1.jpg)
1
Systematic Reviews of Common Chronic pain
Medications and InterventionsTrang Nguyen MD, PhD
MASI 09.24.15
![Page 2: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/2.jpg)
2
Long acting opioids: Pain & Function2. Systemic review of 16 randomized controlled trials and 8
observational studies studying efficacy and safety of long-acting opioids in CNCP
n=2617
Studies examined the use of long-acting opioids (taken ≤ twice a day) in CNCP patients –transdermal fentanyl and long acting oral oxycodone, morphine, codeine, and dihydrocodeine
Efficacy regarding reducing pain and improve function
Adverse Effects
Subgroup analysis- which long acting opioid is more effective
Chou R, et al. J Pain and Symptom Management.2003; 26:1026-1048
![Page 3: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/3.jpg)
3
Long acting opioids: Pain & Function
Conclusions:
Comparing 1 long acting opioid to another long acting opioid (2 trials)
Insufficient evidence from head to head comparison studies.
Comparing long acting opioids to other types of drugs or placebo (14 trials- mostly placebo, one trial with Darvocet, one trial with Cogentin)
There is insufficient evidence to suggest that long-acting opioid is superior to another in terms of efficacy.
Pain scales varied between trials.
Comparing long acting opioids to short acting opioids in improving pain and function (7 trials)
There is insufficient evidence
Chou R, et al. J Pain and Symptom Management.2003; 26:1026-1048; Review Article
![Page 4: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/4.jpg)
4
Efficacy: Oral Opioids1. Meta-analysis of 11 randomized, placebo controlled trials
comparing oral opioids to placebo n=1025
Length 4 days-8 weeks
388/1025 (38%) had open label f/u beyond 8 weeks Only 170 (44%) were on opioids after therapy for 7-24 months
Kalso E, et al. Pain. 2004: 372-380. Systematic Review
![Page 5: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/5.jpg)
5
Function: Oral Opioids
Function
5/11 studies reported no significant difference in either self reported overall activity or ADL
1/11 reported improved in disability (Maier, 2002)
2/11 reported lower disability scores during treatment (Watson 1998 and 2003)
Kalso E, et al. Pain. 2004: 372-380. Systemic Review
![Page 6: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/6.jpg)
6
Efficacy: Oral Opioids Mean decrease in pain intensity in most studies was
at least 30% with the use of opioids compare to placebo
Effectiveness was comparable in neuropathic and nociceptive pain
However… Tolerance: occurred in 6% patients at one year. Most
patients required increased doses of opioids
Lower doses (Morphine 30 mg and Oxycodone 20 mg PO qd) were not effective
Side effects prevented from increasing dose
Only 3/11 trials used a validated quality of life questionnaire (SF-36 or Sickness Impact Profile) Only 1/11 reported a + difference in quality of life with opioids
We don’t know if opioids improved quality of life
Kalso E, et al. Pain. 2004: 372-380. Systemic Review
![Page 7: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/7.jpg)
7
Opioids -Efficacy
Furlan A. Opioids for chronic noncancer pain: a meta-analysis of
effectiveness and side effects. CMAJ. May 23,2006. 174(11) p. 1589-94.
Meta-analysis
Methods:
Literature search up to May 2005
Results
Total- 6019 patients with CNCP
80% nociceptive pain, 12% neuropathic & others
Ages – 40-71 years; average 58 years
63% female and 85% white
Duration of therapy 1 week to 16 weeks
![Page 8: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/8.jpg)
8
Results
90% of the studies funded or had > 1 author affiliated with pharmaceutical industry.
17/41 RCTs have adequate randomization 30/39 trials have adequate “double-
blinded” Drop out rate 33% - 38% (cases & controls-
side effects or inadequate pain relief) Not all RCTs have adequate data for meta-
analysis
![Page 9: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/9.jpg)
9
Efficacy- Pain relief
Opioids vs. PLACEBO
28 RCTs data available for meta-analysis
Results in favor of opioids
SMD -0.60, 95% CI -0.69 to -0.50
Standard mean difference
SMD = Mean (case) – Mean (controls)
pooled standard deviation
Conclusion persist with subgroup analysis of different opioids and methodological quality
![Page 10: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/10.jpg)
10
Efficacy- functional outcomes
Opioids vs. PLACEBO 20 RCTs Results favor opioids
SMD -0.31, 95% CI -0.41 to -0.22
Subgroup analysis Long acting morphine compared to
placebo was not statistically significant Mixed pain subjects also do not have
statistically significant functional relief with opioids
![Page 11: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/11.jpg)
11
Efficacy- Pain relief
Opioids vs. other ANALGESICS 8 RCTs Pain relief NOT statistically significant SMD – 0.05, 95% CI -0.32 to 0.21 Subgroup analysis did not change
conclusions NSAIDs, TCAs or methodological quality
Strong opioids (oxycodone and morphine) compared to NSAIDs or TCAs Subgroup analysis was significant for pain relief SMD- 0.34, 95% CI -0.67 to -0.01)
![Page 12: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/12.jpg)
12
Efficacy- functional outcomes
Opioids vs. other analgesics
Other analgesics more effective
SMD 0.16, 95% CI 0.03 to 0.30
![Page 13: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/13.jpg)
13
Efficacy
Martell B. “Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction” Ann Intern Med. 2007; 146: 116-27.
Meta-analysis Methods
Literature search up to March 2005
Chronic low back pain (> 3 months)
Oral, topical or transdermal opioids
![Page 14: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/14.jpg)
14
Efficacy
Results 18 studies
15 studies for final analysis- 3 excluded quality score poor
1008 patients
8/15 studies used randomized, double blind trial
4/15 studies had placebo controlled
11/15 trials sponsored by pharmaceutical companies
![Page 15: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/15.jpg)
15
Efficacy- Pain relief
Results
Opioids vs. Nonopioids or Placebo
4 RCTs- quality score “excellent”
Study duration- mean 64 days (7-16 weeks)
Patient retention- 67%-99%
Average morphine dose- 73mg/day (30-232mg/day)
(most trials do not have pretrial analgesia)
Nonsignificant pooled data
![Page 16: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/16.jpg)
16
Efficacy- Pain relief
Conclusions:
Meta-analysis (opioids vs. nonopioids or placebo) no significant effect
SMD- -0.199; 95% CI -0.49 to 0.11; P= 0.136
Sensitivity analysis- (study quality, sample size, study duration, and opioid dose) did not change SMD
Not more effective compared to other analgesics (NSAIDs or TCA)
Opioids have limited efficacy in treatment of CLBP
![Page 17: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/17.jpg)
17
Conclusions
Efficacy
Comparing one opioids to another opioids- no significant effect
![Page 18: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/18.jpg)
18
Opioids
Opioids in the Management of Chronic
Non-Cancer Pain: An Update of American
Society of the Interventional Pain Physicians’ (ASIPP) Guidelines
Pain Physician 2008: Opioids Special Issue: 11:S5-S62.
![Page 19: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/19.jpg)
19
Summary of Evidence- Opioid Effectiveness
Based on the review of multiple systematic reviews
and the available literature, the evidence for
the effectiveness of long-term opioids (specifically
transdermal Fentanyl and sustain release morphine) in reducing pain and improving the functional status for 6 months or longer is available but weak.
Noble M. J. Pain Symptom Manage 2008; 35:214-228. Systematic Review.
Trescot AM. Pain Physician 2008; 11: S181-S200.
![Page 20: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/20.jpg)
20
Opioid Effectiveness
For Oxycodone, the level of evidence is limited.
For Hydrocodone and Methadone, the level of evidence is non-existent (opinions- no published evidence regarding effectiveness with long term therapy)
![Page 21: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/21.jpg)
21
Hydrocodone
There were no studies evaluating the effectiveness of hydrocodone even though this is the most commonly used drug.
![Page 22: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/22.jpg)
22
RecommendationsOpioids
Based on the review of multiple systematic reviews
and the available literature, there is insufficient data for long term opioids with regards to efficacy and improve function.
Patients withdrew from clinical trials secondary to side effects (32% for oral therapy, 17% for transdermal) and insufficient pain relief (12% oral therapy and 5% transdermal)
Substantial heterogeneity among oral studies
Many trials have removal of patients who do not respond leading to high drop out rate. Validity of the trials is questionable.
![Page 23: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/23.jpg)
23
Opioid Therapy
G u i d e l i n e f o r t he Use of Chronic Opioid Therapy in Chronic Noncancer Pain-Evidence Review
The American Pain Society in Conjunction with the American Academy of Pain Medicine February 2009
Recommended Reading***
![Page 24: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/24.jpg)
24
Comparing Long Acting Opioids
There is insufficient evidence from eight head-to-head trials (three higher-quality) and three observational studies to conclude that any long-acting opioid (sustained-release formulation or transdermal fentanyl) is more beneficial or less harmful than others.
Level of evidence: moderate
![Page 25: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/25.jpg)
25
Comparing sustained-release andimmediate-release formulations of opioids
Seven trials (two higher-quality) found no clear differences in benefits or harms between sustained- and immediate-release opioids (level of evidence: high).
Chou, 2003 systematic review.
![Page 26: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/26.jpg)
26
Comparisons between different Tramadols
Six trials (three higher-quality) found no clear differences in benefits or harms between extended-release (once/day), sustained-release (twice/day), and immediate release Tramadol (level of evidence: high).
![Page 27: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/27.jpg)
27
Comparisons between Tramadol versus opioids
Three trials (one higher-quality) found no clear difference in efficacy between tramadol and different opioids. (level of evidence: moderate). Evidence of differences in harms was inconclusive.
Jensen, 1994- OA- f/u 2 weeks, n= 264
*Mullican, 2001- OA or LBP- f/u 22 days, n= 462
Wilder-Smith, 2001- OA- f/u 1month, n= 57
![Page 28: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/28.jpg)
28
Anticonvulsants
Cochrane Review- 2009, Issue 4
RCTs only
Trigeminal neuralgia, post herpetic, diabetic neuropathy, central pain post stroke, IBS, TMJ dysfunction
Mostly oral medication
Carbamazepine
Clonazepam
Gabapentin
Phenytoin
Sodium Valproate
![Page 29: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/29.jpg)
29
Anticonvulsants
Results:
23 trials of 6 anticonvulsants
Acute pain- one trail – placebo vs. sodium valproate- no evidence of effectiveness
![Page 30: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/30.jpg)
30
Anticonvulsants
Chronic Pain- anti-convulsant is not first line medication
(except for trigeminal neuralgia).
Trigeminal Neuralgia
3 trials of carbamazepine- NNT for effectiveness of 2.5
Post Herpetic Neuralgia
1 trial of Gabapentin – NNT 3.2
Diabetic Neuropathy (1 trial each)
Carbamazepine- NNT 2.3
Gabapentin – NNT 3.8
Phenytoin – NNT 2.1
![Page 31: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/31.jpg)
31
Antidepressants
Meta-analyses of randomized controlled trials indicate that tricyclic antidepressants provide effective pain relief for a variety of chronic pain etiologies for assessment periods ranging from 2 to 8 weeks (Category A1
evidence).
In addition, meta-analyses of randomized controlled trials indicate that selective serotonin–norepinephrine reuptake inhibitors provide effective pain relief for a variety of chronic pain etiologies for assessment periods ranging from 3 to 6 months (Category A1 evidence).
A meta-analysis of randomized placebo-controlled trials is equivocal
regarding the efficacy of selective serotonin reuptake inhibitors
in providing effective pain relief for diabetic neuropathy
(Category C1 evidence).
![Page 32: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/32.jpg)
32
Benzodiazepines:
One case report indicates that benzodiazepines can provide pain relief for up to 2 months for neuralgic pain syndrome.
![Page 33: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/33.jpg)
33
Skeletal muscle relaxants
The literature is insufficient to evaluate
the efficacy of skeletal muscle relaxants in providing pain relief for patients with chronic pain.
![Page 34: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/34.jpg)
34
NSAIDs
Randomized controlled trials indicate that NSAIDs compared with placebo provide effective pain relief
for patients with back pain for assessment periods ranging from 2 to 12 weeks.
![Page 35: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/35.jpg)
35
Topical agents
Randomized, placebo-controlled controlled
trials of topical agents (e.g., capsaicin, lidocaine, and ketamine) are equivocal regarding relief of peripheral pain for patients with neuropathic pain (e.g., diabetic neuropathy and postherpetic neuralgia).
![Page 36: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/36.jpg)
36
Opioids for Chronic Non-Cancer Pain
Washington State Department of Labor and Industries. Guidelines for outpatient prescription of oral opioids for injured workers with chronic, noncancer pain.
Olympia (WA): Washington State Department of Labor and Industries; 2002 Aug.
21 p. [28 references]
Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: 2010 Update
![Page 37: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/37.jpg)
37
What is New in this Revised Guideline
New data, including scientific evidence to support the 120mg MED dosing threshold
Tools for calculating dosages of opioids during treatment and when tapering
Validated screening tools for assessing substance abuse, mental health, and addiction
![Page 38: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/38.jpg)
38
Recommended Principles for prescribing chronic opioids
Single prescriber
Single pharmacy
Patient and prescriber sign opioid agreement
Lowest possible effective dose should be used
Be cautious when using opioids with conditions that may potentiate opioid adverse effects (including COPD, CHF, sleep apnea, current or past alcohol or substance abuse, elderly, or history of renal or hepatic dysfunction).
Do not combine opioids with sedative-hypnotics, benzodiazepines or barbiturates for chronic non-cancer pain unless there is a specific medical and/or psychiatric indication for the combination and increased monitoring is initiated
![Page 39: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/39.jpg)
39
Recommended Principles for prescribing chronic opioids
Routinely assess function and pain status
Monitor for medication misuse Random urine drug testing to
objectively assure compliance
![Page 40: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/40.jpg)
40
Injection Therapy
Updated Cochrane Review. Staal JB, de Bie RA. Spine. Vol. 34, No.1, pp 49-59. 2009
Injection therapy for subacute and CLBP
18 RCTs (ESI, facet injections, trigger points)
No statistical pooling secondary to heterogeneity of the trials
Conclusion: “There is insufficient evidence to support the use of injection therapy in subacute and CLBP”.
![Page 41: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/41.jpg)
41
Injection Therapy
Injection therapy for subacute and CLBP- An
Updated Cochrane Review. Staal JB, de Bie RA. Spine. Vol. 34, No.1, pp 49-59. 2009
ESI vs. Placebo Injections
2 trials evaluate short term effects
One high quality and one low quality study
No significant result for pain relief or other outcomes
![Page 42: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/42.jpg)
42
Injection Therapy
Facet Injections vs. Placebo Injections
2 trials (1 high quality and 1 low quality)
Moderate evidence that facet joint injections are not significantly different from placebo injections for short-term pain relief and improvement of disability
Limited evidence that facet joint injections are not significantly different from placebo injections on work attendance.
![Page 43: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/43.jpg)
43
Spinal Injection Procedures
Spinal Injection Procedures: A Review of Concepts, Controversies, and Complications. Heran MK, Smith AD. Radiol Clin N. Am 46(2008) 487-514.
Long term efficacy of ESIs has not been shown with lack of a preferred method for administration of medications. The number and frequency of ESIs is arbitrary. Patients should not receive more than 3 injections in total.
![Page 44: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/44.jpg)
44
Spinal Injection Procedures
Intra-articular facet blocks and medial branch blocks are equivalent when assessing a patient for facet denervation procedures. However, the false positive rates for both procedures are too high for them to be useful.
Rhizotomy procedures for facet-mediated pain do not provide sufficient long term relief to justify their use. The methods for evaluating which patients will benefit form these procedures are flawed, with no uniformity in how these procedures are performed.
![Page 45: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/45.jpg)
45
Spinal Injection Procedures
Complications
Spinal injection procedures can be associated with potentially devastating complications and should not be performed because there are limited data to support their efficacy as diagnostic and therapeutic procedures.
![Page 46: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/46.jpg)
46
Spinal Injection Procedures
Potential complications from facet denervation procedures
Infection Bleeding Painful cutaneous dysesthesia Pain caused by neurogenic inflammation Pneumothorax Damage to spinal nerve or motor branches
![Page 47: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/47.jpg)
47
Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for LBP
Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for LBP: An Evidence Based Clinical Practice Guideline from the American Pain Society. SPINE. V. 34, No. 10, pp 1066-1077. 2009
Surgery for Low Back Pain: A Review for the Evidence for an American Pain Society Clinical Practice Guideline. Chou R, Baisden J, Carragee EJ. SPINE V. 34, No. 10, pp 1094-1109. 2009
Recommended
![Page 48: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/48.jpg)
48
Prolotherapy
Condition: NS LBP Level of Evidence: Good: consistent results
from well designed, well conducted studies; at least 2 higher quality trials.
Net Benefit: No benefit
Grade: Panel recommends against the intervention.
![Page 49: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/49.jpg)
49
Intradiscal steroid injection
Condition: Presumed discogenic pain Level of Evidence: Good: consistent results
from well designed, well conducted studies; at least 2 higher quality trials.
Net Benefit: No benefit
Grade: Panel recommends against the intervention.
![Page 50: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/50.jpg)
50
Facet injection
Condition: Presumed facet pain Level of Evidence: Fair: at least 1 higher
quality trial, >2 higher quality trials with some inconsistency, or >2 lower quality trials with consistent results, or multiple consistent cohort studies.
Net Benefit: No benefit
Grade: Panel recommends against the intervention.
![Page 51: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/51.jpg)
51
Botulinum toxin injection
Condition: NS LBP Level of Evidence: poor- large and unexplained
inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 52: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/52.jpg)
52
ESI
Condition: NS LBP Level of Evidence: poor- large and
unexplained inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 53: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/53.jpg)
53
Medial Branch Block (therapeutic)
Condition: Presumed Facet joint pain Level of Evidence: poor- large and unexplained
inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 54: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/54.jpg)
54
Radiofrequency denervation
Condition: Presumed facet joint pain Level of Evidence: poor- large and
unexplained inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 55: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/55.jpg)
55
Radiofrequency denervation
Condition: Presumed discogenic pain Level of Evidence: poor- large and unexplained
inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 56: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/56.jpg)
56
Percutaneous Intradiscal Radiofrequency thermocoagulation
Condition: Presumed Facet joint pain Level of Evidence: poor- large and unexplained
inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 57: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/57.jpg)
57
Coblation Nucleoplasty
Condition: Presumed discogenic pain Level of Evidence: NO trials
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 58: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/58.jpg)
58
Spinal cord Stimulation
Condition: NS LBP Level of Evidence: NO trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 59: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/59.jpg)
59
Intrathecal therapy
Condition: NS LBP Level of Evidence: NO trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 60: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/60.jpg)
60
RF Denervation
Condition: Radiculopathy Level of Evidence: poor- large and
unexplained inconsistency between higher quality trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 61: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/61.jpg)
61
Coblation Nucleoplasty
Condition: Radiculopathy with prolapsed lumbar disc
Level of Evidence: NO trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 62: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/62.jpg)
62
Spinal cord Stimulation
Condition: Radiculopathy with prolapsed lumbar disc
Level of Evidence: NO trials;
Net Benefit: Unable to estimate
Grade: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
![Page 63: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/63.jpg)
63
ESI Condition: Radiculopathy with prolapsed lumbar disc
Level of Evidence: Fair: at least 1 higher quality trial, >2 higher quality trials with some inconsistency, or >2 lower quality trials with consistent results, or multiple consistent cohort studies.
Net Benefit: MODERATE for SHORT TERM only ( 3 months) Mean 10-20 point improvement of VAS pain scale Mean 10-20 point improvement of ODI scale, 2-5 points on
RDQ, or equivalent
Grade: Panel recommends the intervention. +at least fair evidence that intervention improves health outcomes, benefits moderately outweigh harms OR
Benefits are small but there are no significant harms, costs or burden associated with the intervention.
![Page 64: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/64.jpg)
64
SCS
Condition: FBSS with persistent radiculopathy
Level of Evidence: Fair: at least 1 higher quality trial, >2 higher quality trials with some inconsistency, or >2 lower quality trials with consistent results, or multiple consistent cohort studies.
Net Benefit: MODERATE Mean 10-20 point improvement of VAS pain scale Mean 10-20 point improvement of ODI scale, 2-5 points on
RDQ, or equivalent
Grade: Panel recommends the intervention. +at least fair evidence that intervention improves health outcomes, benefits moderately outweigh harms OR
Benefits are small but there are no significant harms, costs or burden associated with the intervention.
![Page 65: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/65.jpg)
65
Intradiscal steroid injection
Condition: Radiculopathy with prolapsed lumbar disc
Level of Evidence: Fair: at least 1 higher quality trial, >2 higher quality trials with some inconsistency, or >2 lower quality trials with consistent results, or multiple consistent cohort studies.
Net Benefit: NO effect vs. chemonucleolysis (NO TRIALS VS. PLACEBO)
Grade: Benefits only slightly outweigh harms, or the balance of benefits and harms are too close to justify a general recommendations
![Page 66: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/66.jpg)
66
Lumbar Fusion Outcomes Among Ohio Workers’ Compensation Subjects
Trang Nguyen M.D., Ph.D.
David C. Randolph M.D, Ph.D. M.P.H.
James Talmage MD
Paul Succop PhD
Russell Travis MD
Spine - 2011 Feb 15;36(4):320-31
![Page 67: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/67.jpg)
67
Failed Fusion
![Page 68: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/68.jpg)
68
Lumbar Fusion Volumes by Diagnoses
![Page 69: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/69.jpg)
Lumbar Fusion by Age & Diagnoses
69
![Page 70: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/70.jpg)
70
Overview of study design
Historical Cohort 725 lumbar fusion cases, 725 computer randomized non-surgical
controls
The primary outcome was return to work status. The secondary outcomes were permanent disability status,
complications, re-operations, and opiate utilization.
Ohio Workers’ Compensation Database
![Page 71: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/71.jpg)
71
3,138Injured Workers with Lumbar
Fusionwith Injury dates 01/01/99 -
12/31/2001
2,413 Excluded:
1,001 had lumbar fusion after the cut off date of 7/31/03 and 1,412 have injuries to other body parts in addition to the lumbar spine
725 Final Surgical Subjects
78 ALIF One Level34 ALIF Multi-Level
30 AP 360 One Level39 AP 360 Multi-Level
310 PLIF One Level 68 PLIF Multi-Level
26 Post Uninstr. One Level 5 Post Uninstr. Multi Level
47 Post w/ Instr. One Level 88 Post w/ Instr. Multi Level
![Page 72: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/72.jpg)
72
Results: Return to Work, Rehabilitation and Disabled Status
RTW no RTW
Cases 188(25.93%) 367(50.62%)
Controls 483(66.62%) 163(22.48%)
Rehab
Cases 64(8.83%)
Controls 43(5.93%)
PTD
Cases 82 (11.31%)
Controls 11 (1.52%)
7 cases and 14 controls with no RTW status
Loss to follow up = 1.45%
![Page 73: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/73.jpg)
Results: Duration of Time Off
Cases Controls
Total number of days off:
1140+ 735 316+463
Number of days from DOI to DOS:597 + 330
Number of days off work from DOI to DOS:337 + 277 73
![Page 74: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/74.jpg)
74
Results: Re-operations
194 cases have re-operations (26.76%)
Re-operations no.(%)
Once 158/194 (81.44%)
Twice 28/194 (14.43%)
> Three 08/194 (4.12%)
No re-operation 531/725 (73.24%)
![Page 75: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/75.jpg)
75
Results: Complications
Category no.(%)
264 cases (36.4%)
Early major systemic 45(6.21%) Implant complications 34(4.69%) Late spinal complications 183(25.24%) Neurologic complications 18(2.48%) Wound complications 27(3.72%)
No complications 461(63.59%)
![Page 76: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/76.jpg)
76
Results: Mortality
Post op (no.-%) <6 weeks 0/725 (0%) <3months 1/725 (0%) >3 months 16/725(2.2%)
Controls Mortality 11(1.52%)
P value: .26
![Page 77: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/77.jpg)
77
Results: Daily amount of Morphine Average daily MEQ (Mean + SD)
Cases Controls P Value 48.06 + 43.88 65.57 + 70.66 <.001
Number of subjects taking opioids
614 (84.69%) 354 (48.83%) <.001
Average daily MEQ before surgery 44.23 + 33.57
Average daily MEQ after surgery 62.31 + 70.80
Maximum daily MEQ 585.00 (controls)
Before surgery 276.00
After surgery 878.00
![Page 78: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/78.jpg)
Patient Characteristic All subjects Adjusted OR
(95% CI) P Value
CasesAdjusted OR
(95%CI) P Value
Controls Adjusted OR
(95%CI) P Value
Current smoker 0.65(0.42-1.01)
.05
Total days off a 0.93(0.92-0.94)
<.001 0.85(0.82-0.88)
<.001
Weekly Wages b 1.09(1.01-1.18)
.02 1.12(1.03-1.21)
.008 1.16(1.02-1.32) .02
Complications c .007
No complications (Reference)
Early Major Systemic 0.25(0.07-0.90)
.03
Implant 0.13(0.02-1.08)
.06
Late Spinal 0.50(0.29-0.87)
.01
Neurologic 0.65(0.12-3.45)
.61
Wound Complications 2.72(0.69-10.66)
.15
78
Multivariate Logistic Regression
![Page 79: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/79.jpg)
Patient Characteristic All subjects Adjusted OR
(95% CI) P Value
CasesAdjusted OR
(95%CI) P Value
Controls Adjusted OR
(95%CI) P Value
Days off work prior to surgery d
0.94(0.92-0.97)
<.001
Legal representation 3.43(1.58-7.41)
.002
Morphine(daily) e 0.83(0.71-0.98)
.03
Re-operation 0.42(0.26-0.69)
<.001
79
Multivariate Logistic Regression
![Page 80: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/80.jpg)
80
Total Days off as Predictor of RTW status
![Page 81: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/81.jpg)
Daily Morphine Equivalents as Predictor of RTW status
81
![Page 82: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/82.jpg)
Daily Morphine Equivalents as Predictor of RTW status
Cases’ OR of RTW at 100 MEQ units 0.25, p<.001
Controls’ OR of RTW at 100 MEQ units 0.93, p<.65
82
![Page 83: Systematic Reviews of Common Chronic pain Medications and Interventions Trang Nguyen MD, PhD MASI 09.24.15 1](https://reader036.vdocuments.us/reader036/viewer/2022062518/56649ee45503460f94bf2b4b/html5/thumbnails/83.jpg)
83
The End..
Thank you for your time!