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      Journal of Pain Research (submit here)

      This international, peer-reviewed Open Access journal by Dove Medical Press focuses on reporting of high-quality laboratory and clinical findings in all fields of pain research and the prevention and management of pain. Sign up for email alerts here.

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      Tapentadol in the management of chronic low back pain: a novel approach to a complex condition?

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          Abstract

          Chronic pain affects approximately 1 in 5 people in Europe, and around half of sufferers receive inadequate pain management. The most common location is the lower back. Pharmacological treatment of this condition is challenging because of the range of causative mechanisms and the difficulty of balancing analgesic efficacy and tolerability. An international panel of clinical pain specialists met in September, 2009, to discuss the treatment of chronic low back pain, and to review preclinical and clinical data relating to the new analgesic, tapentadol. A lack of consensus exists on the best treatment for low back pain. The range of regularly prescribed pharmacological agents extends from nonopioids (paracetamol, NSAIDs, and COX-2 inhibitors) to opioids, antidepressants and anticonvulsants. Pain relief may be compromised, however, by an undetected neuropathic component or intolerable side effects. Treatment is potentially life-long and effective analgesics are urgently needed, with demonstrable long-term safety. Combining separate agents with different mechanisms of action could overcome the limitations of present pharmacological therapy, but clinical evidence for this approach is currently lacking. Tapentadol combines μ-opioid agonism with noradrenaline reuptake inhibition in a single molecule. There is strong evidence of synergistic antinociception between these two mechanisms of action. In preclinical and clinical testing, tapentadol has shown efficacy against both nociceptive and neuropathic pain. Preclinical data indicate that tapentadol’s μ-opioid agonism makes a greater contribution to analgesia in acute pain, while noradrenaline reuptake inhibition makes a greater contribution in chronic neuropathic pain models. Tapentadol also produces fewer adverse events than oxycodone at equianalgesic doses, and thus may have a ‘μ-sparing effect’. Current evidence indicates that tapentadol’s efficacy/tolerability ratio may be better than those of classical opioids. However, further research is needed to establish its role in pain management.

          Most cited references45

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          Lost productive time and cost due to common pain conditions in the US workforce.

          Common pain conditions appear to have an adverse effect on work, but no comprehensive estimates exist on the amount of productive time lost in the US workforce due to pain. To measure lost productive time (absence and reduced performance due to common pain conditions) during a 2-week period. Cross-sectional study using survey data from the American Productivity Audit (a telephone survey that uses the Work and Health Interview) of working adults between August 1, 2001, and July 30, 2002. Random sample of 28 902 working adults in the United States. Lost productive time due to common pain conditions (arthritis, back, headache, and other musculoskeletal) expressed in hours per worker per week and calculated in US dollars. Thirteen percent of the total workforce experienced a loss in productive time during a 2-week period due to a common pain condition. Headache was the most common (5.4%) pain condition resulting in lost productive time. It was followed by back pain (3.2%), arthritis pain (2.0%), and other musculoskeletal pain (2.0%). Workers who experienced lost productive time from a pain condition lost a mean (SE) of 4.6 (0.09) h/wk. Workers who had a headache had a mean (SE) loss in productive time of 3.5 (0.1) h/wk. Workers who reported arthritis or back pain had mean (SE) lost productive times of 5.2 (0.25) h/wk. Other common pain conditions resulted in a mean (SE) loss in productive time of 5.5 (0.22) h/wk. Lost productive time from common pain conditions among active workers costs an estimated 61.2 billion dollars per year. The majority (76.6%) of the lost productive time was explained by reduced performance while at work and not work absence. Pain is an inordinately common and disabling condition in the US workforce. Most of the pain-related lost productive time occurs while employees are at work and is in the form of reduced performance.
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            Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.

            The prevalence, efficacy, and risk for addiction for persons receiving opioids for chronic back pain are unclear. To determine the prevalence of opioid treatment, whether opioid medications are effective, and the prevalence of substance use disorders among patients receiving opioid medications for chronic back pain. English-language studies from MEDLINE (1966-March 2005), EMBASE (1966-March 2005), Cochrane Central Register of Controlled Clinical Trials (to 4th quarter 2004), PsychInfo (1966-March 2005), and retrieved references. Articles that studied an adult, nonobstetric sample; used oral, topical, or transdermal opioids; and focused on treatment for chronic back pain. Two investigators independently extracted data and determined study quality. Opioid prescribing varied by treatment setting (range, 3% to 66%). Meta-analysis of the 4 studies assessing the efficacy of opioids compared with placebo or a nonopioid control did not show reduced pain with opioids (g, -0.199 composite standardized mean difference [95% CI, -0.49 to 0.11]; P = 0.136). Meta-analysis of the 5 studies directly comparing the efficacy of different opioids demonstrated a nonsignificant reduction in pain from baseline (g, -0.93 composite standardized mean difference [CI, -1.89 to -0.03]; P = 0.055). The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%. Retrieval and publication biases and poor study quality. No trial evaluating the efficacy of opioids was longer than 16 weeks. Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (> or =16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.
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              Opioid therapy for chronic pain.

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                Author and article information

                Journal
                J Pain Res
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2011
                21 July 2011
                : 4
                : 203-210
                Affiliations
                [1 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;
                [2 ]Universitätsspital Zurich, Switzerland;
                [3 ]Universitätsklinikum Schleswig-Holstein, Kiel, Germany;
                [4 ]Fondazione Salvatore Maugeri, Pavia, Italy;
                [5 ]Zakład Badania i Leczenia Bólu, Kraków, Poland;
                [6 ]Hospital Universitario Virgen de las Nieves, Granada, Spain;
                [7 ]Aarhus University, Denmark;
                [8 ]Medical University of Vienna, Austria;
                [9 ]Maastricht University Medical Center and University of Muenster, Maastricht, The Netherlands;
                [10 ]University Hospitals Leuven, Belgium;
                [11 ]Hôpital Dieu, Paris, France;
                [12 ]Ruprecht-Karls-University, Heidelberg, Germany
                Author notes
                Correspondence: Joseph Pergolizzi, Naples Anesthesia and Pain Associates, 4840 Sycamore Drive, Naples, FL 34119, USA, Tel +1 239 597 3564, Fax +1 239 597 7566, Email jpjmd@ 123456msn.com
                Article
                jpr-4-203
                10.2147/JPR.S19625
                3160833
                21887117
                e707901c-7a5a-4deb-bcb8-a128c2fb1f6c
                © 2011 Pergolizzi et al, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                History
                : 20 July 2011
                Categories
                Expert Opinion

                Anesthesiology & Pain management
                chronic low back pain,neurophysiological changes,neuropathic component,multimechanistic approach,efficacy/side effect ratio,tapentadol

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