Articles: chronic-pain.
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Randomized Controlled Trial Comparative Study
A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain.
The use of opioid medications for treating chronic noncancer pain is growing; however, there is a lack of good evidence regarding their long-term effectiveness, association with substance abuse, and proper prescribing guidelines. The current study directly compares for the first time in a randomized trial the effectiveness of a conservative, hold the line (Stable Dose) prescribing strategy for opioid medications with a more liberal dose escalation (Escalating Dose) approach. This 2-arm, parallel, randomized pragmatic clinical trial followed 135 patients referred to a specialty pain clinic at a Veterans Affairs Hospital for 12 months (94% male and 74% with musculoskeletal pain). Primary outcomes included monthly or quarterly evaluations of pain severity, pain relief from medications, pain-related functional disability, and opioid misuse behaviors. All subjects received identical pain treatment except for the application of treatment group specific strategies for opioid prescriptions. No group differences were found for primary outcomes of usual pain or functional disability although the Escalating Dose group did show a small but significantly larger increase in self-rated pain relief from medications. About 27% of patients were discharged over the course of the study due to opioid misuse/noncompliance, but there were no group differences in rate of opioid misuse. ⋯ The results of this study demonstrate that even in carefully selected patients there is a significant risk of problematic opioid misuse. Although in general there were no statistically significant differences in the primary outcomes between groups, the escalating dose strategy did lead to small improvements in self-reported acute relief from medications without an increase in opioid misuse, compared to the stable dose strategy.
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Western studies document the prevalence of chronic pain in the general adult population to be between 2 and 55%. Knowing the prevalence of chronic pain among Chinese populations provides important comparative perspective: To determine the prevalence of chronic pain in the general population of Hong Kong; evaluate the relationship of chronic pain with sociodemographic and lifestyle factors; and describe the pain characteristics among chronic pain sufferers. A total of 5,001 adults aged ≥ 18 years (response rate 58%) drawn from the general population of Hong Kong completed the Chronic Pain Grade (CPG) questionnaire, providing information on chronic pain and sociodemographic status using telephone interviews. Overall 34.9% reported pain lasting more than 3 months (chronic pain), having an average of 1.5 pain sites; 35.2% experienced multiple pain sites, most commonly of the legs, back, and head with leg and back being rated as the most significant pain areas among those with multiple pain problems. The CPG criteria classified 21.5% of those with chronic pain symptoms as Grade III or above. Fully adjusted stepwise regression analyses identified being female, older age, divorced/separated, having part-time employment, existing long-term health problems, higher HADS Anxiety scores, poor QoL (mental health component), and low self-perceived health to be significantly associated with chronic pain. ⋯ Our data evidenced that chronic pain is common in the general population of Hong Kong, and the prevalence is highest among women and middle-aged adults.
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Methadone HCl is used for the management of opioid addiction and chronic pain. Published reports indicate that methadone can be associated with a prolonged corrected QT (QTc) interval, especially at daily doses greater than 100 mg. The risk of this adverse effect is not always considered by health care pain specialists, who sometimes use lower doses. The objectives of this case series were to evaluate the effects of methadone on the QTc interval in patients being treated for chronic pain and to determine whether there was a correlation between dosing and the degree of QTc prolongation. ⋯ Our case series suggested that QTc intervals should be routinely monitored in patients receiving methadone and that patients should be screened before therapy is initiated. Ideally, the QTc interval should be monitored before treatment begins and during repeated intervals thereafter. On the basis of the analysis, a protocol was developed at our facility for monitoring ECGs in patients being treated with methadone for chronic pain.