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      Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists

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          Abstract

          Purpose

          Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction.

          Methods

          A cohort study was conducted in Quebec (Canada). Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0–10 scale (10= worst possible pain) and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information on pharmacotherapy was based on an administrative provincial database and pharmacies’ charts. Determinants of patients’ satisfaction were identified using multivariate linear regression models.

          Results

          Four hundred and eighty six patients participated. Their mean age was 58.4 years and they had had pain for a mean of 11.7 years (standard deviation, ±11.1) at an average pain intensity of 6.5 in the past week. Although 90% reported adverse gastrointestinal effects, 36.4% and 54.4% of these patients took no over-the-counter or prescribed medication for constipation or nausea, respectively. On a scale from 0–100, the mean overall satisfaction score was 64.7 (95% confidence interval [CI] =63.5–65.9). Patient satisfaction was low, particularly regarding the “information about pain and its treatment” (mean 50.6; 95% CI =47.6–53.7) and “treatment efficacy” (mean 53.6; 95% CI =51.5–55.6) subscales. The overall treatment satisfaction score decreased with more pain disability, probable depression and anxiety, more barriers to pain treatment, higher incidence of nausea, and use of over-the-counter analgesics.

          Conclusion

          In primary care, patients’ level of satisfaction with their pain treatment is not optimal. This study underlines how the expanded scope of practice of community pharmacists may allow them to play a pivotal role in providing information, discussing barriers to pain treatment, and monitoring pain disability, and by appropriately managing pharmacotherapy to optimize effectiveness while minimizing adverse effects.

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          Most cited references 43

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          Treatment of neuropathic pain: an overview of recent guidelines.

          A number of different treatments for neuropathic pain have been studied, but the literature is sizable, rapidly evolving, and lacks important information about practical aspects of patient management. Under the auspices of the International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), a consensus process was used to develop evidence-based guidelines for the pharmacologic management of neuropathic pain that take into account clinical efficacy, adverse effects, impact on health-related quality of life, convenience, and costs. On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha(2)-delta ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications that generally would be used as third-line treatments include certain other antidepressant and antiepileptic medications, topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists. Two other national and international associations recently published pharmacologic treatment guidelines for neuropathic pain, which are summarized and contrasted with the NeuPSIG recommendations. Recent guidelines for the use of neurostimulation for the treatment of neuropathic pain also are summarized. For all treatments for neuropathic pain, long-term studies, head-to-head comparisons, and studies of treatment combinations are a priority for future research.
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            Long-term opioid management for chronic noncancer pain.

            Opioid therapy for chronic noncancer pain (CNCP) is controversial due to concerns regarding long-term effectiveness and safety, particularly the risk of tolerance, dependence, or abuse. To assess safety, efficacy, and effectiveness of opioids taken long-term for CNCP. We searched 10 bibliographic databases up to May 2009. We searched for studies that: collected efficacy data on participants after at least 6 months of treatment; were full-text articles; did not include redundant data; were prospective; enrolled at least 10 participants; reported data of participants who had CNCP. Randomized controlled trials (RCTs) and pre-post case-series studies were included. Two review authors independently extracted safety and effectiveness data and settled discrepancies by consensus. We used random-effects meta-analysis' to summarize data where appropriate, used the I(2) statistic to quantify heterogeneity, and, where appropriate, explored heterogeneity using meta-regression. Several sensitivity analyses were performed to test the robustness of the results. We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Opioids were administered orally (number of study treatments groups [abbreviated as "k"] = 12, n = 3040), transdermally (k = 5, n = 1628), or intrathecally (k = 10, n = 231). Many participants discontinued due to adverse effects (oral: 22.9% [95% confidence interval (CI): 15.3% to 32.8%]; transdermal: 12.1% [95% CI: 4.9% to 27.0%]; intrathecal: 8.9% [95% CI: 4.0% to 26.1%]); or insufficient pain relief (oral: 10.3% [95% CI: 7.6% to 13.9%]; intrathecal: 7.6% [95% CI: 3.7% to 14.8%]; transdermal: 5.8% [95% CI: 4.2% to 7.9%]). Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies. Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies. Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.
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              Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial.

              Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients. To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis. Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline. Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months. In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P =.009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P =.004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P =.002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months. In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2014
                24 March 2014
                : 7
                : 163-173
                Affiliations
                [1 ]Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
                [2 ]Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, Quebec, Canada
                [3 ]Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
                [4 ]Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
                [5 ]Sanofi-Aventis Endowment Research Chair in Optimal Drug Use, Université de Montréal, Montreal, Quebec, Canada
                [6 ]Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada
                [7 ]Division of Geriatric Medicine and Alan-Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada
                [8 ]Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
                [9 ]Department of Family Medicine and Emergency, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
                [10 ]Sanofi-Aventis Endowment Research Chair in Ambulatory Pharmaceutical Care, Université de Montréal and Centre de santé et de services sociaux de Laval, Quebec, Canada
                Author notes
                Correspondence: Lyne Lalonde, Centre de recherche du Centre hospitalier de l’Université de Montréal, 850 Saint-Denis Street, Tour Saint-Antoine, Room S03.436, Montreal, Quebec, H2X 0A9, Canada, Tel +1 514 890 8000 ext 15491, Fax +1 514 412 7038, Email lyne.lalonde@ 123456umontreal.ca
                Article
                jpr-7-163
                10.2147/JPR.S56884
                3969347
                © 2014 Jouini et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

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