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      Reflections on the role of opioids in the treatment of chronic pain: a shared solution for prescription opioid abuse and pain

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          Abstract

          ‘The Role of Opioids in the Treatment of Chronic Pain’ was the title of a recent workshop (September 29–30, 2014) supported by the National Institutes of Health (NIH) Office of Disease Prevention that highlights the relevance and urgency of the topic. High‐quality research presently does not exist to definitively answer questions about opioid safety, efficacy and abuse potential with long‐term use 1. However, prescriptions for opioids increased from 76 million in 1991 to 207 million in 2013, which were associated with parallel increases in opioid‐related morbidity and mortality 2. Currently, in the U.S., close to 100 million Americans suffer from chronic pain and may be given prescription opioids, along with close to two million Americans who abuse opioid analgesics 3, with over 16 000 overdose deaths attributed to prescription opioids 4. This situation reflects both the challenge to effectively treat the complex condition of chronic pain and the lack of understanding about opioid abuse potential and the risk of addiction in healthcare settings. The medical needs of so many people in chronic pain overwhelm much of our healthcare system, and this problem continues to worsen. Inadequate provider education of how to treat chronic pain compounds the problem. U.S. medical students get a median of only 9 h of training that relate in some way to pain over their 4 years of medical school 5, resulting in inadequate training for many physicians on the effective use of opioids. This is further compounded by the minimal training that medical students get regarding substance use disorders 6, resulting in many of them being unprepared to recognize and monitor risks or signs of addiction in their patients. Furthermore, the structure of the American healthcare system may hinder access to adequate pain management. Opioids are frequently used as the first and only option for treating chronic pain, which is partly explained by a medical treatment reimbursement system that generally does not cover the multimodal treatment approaches for effective management of chronic pain 7. As the Pathways to Prevention workshop report identifies, there is a necessity to focus on developing a rigorous research base to inform clinical and policy decision‐making. Research funders and pharma should increase support for studies to establish better data on the utility of opioids in the treatment of chronic pain. Specifically, studies are needed to understand the efficacy of long‐term opioid use in the treatment of chronic pain; efficacy of opioid treatment for individuals who might have had prior problems with prescription opioids or other drugs of abuse, and what might be the best treatment course for this population; the potential for misuse, abuse and addiction in the long‐term use of opioids for pain; and potential individual differences that could predict who might respond best to which treatments (e.g. pharmacogenetics, pain/drug history, pain subtypes, length of chronic pain). Whilst providing funding for additional research is one strategy, the NIH (and the National Institute on Drug Abuse, in particular) also supports additional approaches to reducing opioid misuse, abuse and addiction. Expanding curriculum for education on chronic pain management in medical, nursing, pharmacy, dental and other professional schools is being addressed by the NIH Pain Consortium (a multi‐institute consortium that deals with pain issues across the NIH) through the Centers of Excellence in Pain Education programme (http://painconsortium.nih.gov/NIH_Pain_Programs/CoEPES.html). Another strategy for an effective pain management focuses on the development and use of nonopioid pain medications, complementary and alternative medical treatments, other medications, physical therapy, stress management and cognitive/behavioural therapy 8. Systematic reviews of acupuncture have revealed benefits for pain management in postoperative patients and in tension headache treatment 9, 10. There is also evidence that cognitive‐behavioural therapy helped individuals with chronic pain 11, 12. A meta‐analysis of interdisciplinary pain management programmes that included physical therapy showed both intensity of pain and consumption of pain medication decreased significantly 13. These options may offer pain patients treatments that could improve pain, function and quality of life and decrease the reliance on opioid medications. More comprehensive systems for treating pain are needed, for the current options fail to deliver significant relief for individuals with severe chronic pain 7. Dersh et al. 14 concluded that treatments without a biopsychosocial approach will most likely put a great number of chronic pain patients at a higher risk for prolonged disability. Existing data on multidisciplinary pain management show consistently effective benefits for chronic back pain relief that exceed surgical results, enabling patients to return to work and live more active and productive lives 15. Yet, these more integrative and individualized therapies may not be reimbursed by health insurance, making them less accessible to patients 7. Importantly, individualized care for chronic pain may still involve prescription opioids. Because their role will vary from patient to patient, potentially changing during the scope of treatment, individualized therapy for chronic pain should also include careful prescription drug monitoring. Especially when integrated into electronic healthcare records, such information will help healthcare providers better detect opioid misuse, abuse and diversion. Including prescription drug monitoring in individualized treatment for chronic pain could help identify those struggling with addiction and lead to their treatment for this problem. More careful monitoring can also aid in determining exactly what treatments for pain management an individual receives, and what works for that patient. The provider can then use this information to adjust individualized treatment plans for chronic pain. Even with careful monitoring of prescription opioid use, overdose may still occur with misuse, abuse and also with ordinary use of opioids in pain patients. Therefore, strategies that minimize the risks of overdose should be emphasized as well. For example, naloxone, an opioid antagonist that can reverse the life‐threatening effects of an overdose, saves lives when made more accessible 16. As overdoses are more likely to occur in patients that receive higher doses of opioid medication and in those using benzodiazepines, special care should be given to properly monitor these patients and educate their relatives or caregivers on the proper use of naloxone. In summary, a critical need exists for better and more comprehensive chronic pain treatment in the United States. Required research must determine the efficacy of various treatment options for chronic pain, including the role of opioids. In addition to having an in‐depth understanding of the physical nature of this condition, healthcare professionals treating chronic pain should also have a keen clinical understanding of the psychosocial, emotional and affective aspects of this condition. Furthermore, treatment systems may need to be modified to make available the intensive, interprofessional/integrative and much more individualized treatment requirements of the most complex of these patients. The growing numbers of patients with chronic pain, along with the increases in the abuse and overdoses from prescription opioids in the U.S., highlight the urgency to instate better education for healthcare providers in the management of chronic pain and addiction, but also the need to develop better systems for managing and treating chronic pain. Conflict of interest statement No conflict of interest was declared.

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          Meta-analysis of psychological interventions for chronic low back pain.

          The purpose of this meta-analysis of randomized controlled trials was to evaluate the efficacy of psychological interventions for adults with noncancerous chronic low back pain (CLBP). The authors updated and expanded upon prior meta-analyses by using broad definitions of CLBP and psychological intervention, a broad data search strategy, and state-of-the-art data analysis techniques. All relevant controlled clinical trials meeting the inclusion criteria were identified primarily through a computer-aided literature search. Two independent reviewers screened abstracts and articles for inclusion criteria and extracted relevant data. Cohen's d effect sizes were calculated by using a random effects model. Outcomes included pain intensity, emotional functioning, physical functioning (pain interference or pain-specific disability, health-related quality of life), participant ratings of global improvement, health care utilization, health care provider visits, pain medications, and employment/disability compensation status. A total of 205 effect sizes from 22 studies were pooled in 34 analyses. Positive effects of psychological interventions, contrasted with various control groups, were noted for pain intensity, pain-related interference, health-related quality of life, and depression. Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious. Multidisciplinary approaches that included a psychological component, when compared with active control conditions, were also noted to have positive short-term effects on pain interference and positive long-term effects on return to work. The results demonstrated positive effects of psychological interventions for CLBP. The rigor of the methods used, as well as the results that reflect mild to moderate heterogeneity and minimal publication bias, suggest confidence in the conclusions of this review.
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            Major increases in opioid analgesic abuse in the United States: concerns and strategies.

            The problem of abuse of and addiction to opioid analgesics has emerged as a major issue for the United States in the past decade and has worsened over the past few years. The increases in abuse of these opioids appear to reflect, in part, changes in medication prescribing practices, changes in drug formulations as well as relatively easy access via the internet. Though the use of opioid analgesics for the treatment of acute pain appears to be generally benign, long-term administration of opioids has been associated with clinically meaningful rates of abuse or addiction. Important areas of research to help with the problem of opioid analgesic abuse include the identification of clinical practices that minimize the risks of addiction, the development of guidelines for early detection and management of addiction, the development of opioid analgesics that minimize the risks for abuse, and the development of safe and effective non-opioid analgesics. With high rates of abuse of opiate analgesics among teenagers in the United States, a particularly urgent priority is the investigation of best practices for treating pain in adolescents as well as the development of prevention strategies to reduce diversion and abuse.
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              Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials.

              Postoperative pain management remains a significant challenge for all healthcare providers. The objective of this systematic review was to quantitatively evaluate the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management. We searched the databases of Medline (1966-2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials (RCTs) using acupuncture for postoperative pain management. We extracted data about postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects. Combined data were analysed using a random effects model. Fifteen RCTs comparing acupuncture with sham control in the management of acute postoperative pain were included. Weighted mean difference for cumulative opioid analgesic consumption was -3.14 mg (95% confidence interval, CI: -5.15, -1.14), -8.33 mg (95% CI: -11.06, -5.61), and -9.14 mg (95% CI: -16.07, -2.22) at 8, 24, and 72 h, respectively. Postoperative pain intensity (visual analogue scale, 0-100 mm) was also significantly decreased in the acupuncture group at 8 and 72 h compared with the control group. The acupuncture treatment group was associated with a lower incidence of opioid-related side-effects such as nausea (relative risk, RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation (RR: 0.78; 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention (RR: 0.29; 95% CI: 0.12, 0.74). Perioperative acupuncture may be a useful adjunct for acute postoperative pain management.
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                Author and article information

                Journal
                J Intern Med
                J. Intern. Med
                10.1111/(ISSN)1365-2796
                JOIM
                Journal of Internal Medicine
                John Wiley and Sons Inc. (Hoboken )
                0954-6820
                1365-2796
                02 February 2015
                July 2015
                : 278
                : 1 ( doiID: 10.1111/joim.2015.278.issue-1 )
                : 92-94
                Affiliations
                [ 1 ] Division of Clinical Neuroscience and Behavioral ResearchNational Institute on Drug Abuse Bethesda MDUSA
                [ 2 ] Office of Behavior and Social Sciences ResearchNational Institutes of Health Bethesda MDUSA
                [ 3 ] Office of the DirectorNational Institute on Drug Abuse Bethesda MDUSA
                [ 4 ] Office of the DirectorNational Institute of Neurological Disorders and Stroke Bethesda MDUSA
                [ 5 ] Office of the DirectorNational Center for Complementary and Integrative Health Bethesda MDUSA
                [ 6 ] Office of the DirectorNational Institute of Nursing Research Bethesda MDUSA
                [ 7 ] Office of the DirectorNational Institute of Dental and Craniofacial Research Bethesda MDUSA
                Author notes
                [*] [* ] Correspondence: David A. Thomas, National Institute on Drug Abuse ‐ Division of Clinical Neuroscience and Behavioral Research, 6001 Executive Blvd, Bethesda, Maryland 20892, USA.

                (fax: +1‐301‐443‐6814; e‐mail: dthomas1@ 123456nida.nih.gov ).

                Article
                JOIM12345
                10.1111/joim.12345
                4964933
                25556772
                53c6fae9-a07e-459d-9273-68c1ee1d00f4
                Published [2014]. This article is a U.S. Government work and is in the public domain in the USA.

                This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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                Pages: 3
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                2.0
                joim12345
                July 2015
                Converter:WILEY_ML3GV2_TO_NLMPMC version:4.9.2 mode:remove_FC converted:28.07.2016

                Internal medicine
                Internal medicine

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