SummaryBackgroundBack pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control).Methods1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406.Findings851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 [SD 5·9] vs 3·0 [5·9], between-group difference 1·81 [95% CI 1·06–2·57]) and at 12 months (4·3 [6·4] vs 3·3 [6·2], 1·06 [0·25–1·86]), equating to effect sizes of 0·32 (0·19–0·45) and 0·19 (0·04–0·33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0·039 additional QALYs) and cost savings (£240·01 vs £274·40) compared with the control group.InterpretationThe results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care.FundingArthritis Research UK.

Background Chronic opioid therapy for chronic non-cancer pain (CNCP) is increasingly common in community practice. Concomitant with this practice change, rates of fatal opioid overdose have increased. It is not known to what extent overdose risks are elevated among patients receiving medically prescribed chronic opioid therapy. Objective To estimate rates of opioid overdose and their association with average prescribed daily opioid dose among patients receiving medically prescribed chronic opioid therapy. Design Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at time of overdose. Setting Health maintenance organization. Patients Individuals (n=9940) who received 3+ opioid prescriptions within 90-days for CNCP between 1997 and 2005. Measurements Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes, non-fatal and fatal overdoses, were identified through diagnostic codes from inpatient and outpatient care and death certificates and confirmed by medical record review. Results Fifty-one opioid-related overdoses were identified, including six deaths. Compared to patients receiving 1-20mg of opioids per day (0.2% annual overdose rate), patients receiving 50-99 mg had a 3.7 fold increase in overdose risk (95% C.I. 1.5, 9.5) and a 0.7% annual overdose rate. Patients receiving 100mg or more per day had an 8.9 fold increase in overdose risk (95% C.I. 4.0, 19.7) and a 1.8% annual overdose rate. Limitations Increased overdose risk among patients on higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. Conclusions Patients receiving higher doses of prescribed opioids are at increased risk of opioid overdose, underscoring the need for close supervision of these patients.

Objective. To develop and validate a tool that screens for back pain prognostic indicators relevant to initial decision making in primary care. Methods. The setting was UK primary care adults with nonspecific back pain. Constructs that were independent prognostic indicators for persistence were identified from secondary analysis of 2 existing cohorts and published literature. Receiver operating characteristic curve analysis identified single screening questions for relevant constructs. Psychometric properties of the tool, including concurrent and discriminant validity, internal consistency, and repeatability, were assessed within a new development sample (n ‫؍‬ 131) and tool score cutoffs were established to enable allocation to 3 subgroups (low, medium, and high risk). Predictive and external validity were evaluated within an independent external sample (n ‫؍‬ 500). Results. The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0 -3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk. Conclusion. We validated a brief screening tool, which is a promising instrument for identifying subgroups of patients to guide the provision of early secondary prevention in primary care. Further work will establish whether allocation to treatment subgroups using the tool, linked with targeting treatment appropriately, improves patient outcomes.

These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Study objective-To investigate the association of sexual problems with social, physical, and psychological problems. Design-An anonymous postal questionnaire survey. Setting-Four general practices in England. Participants-789 men and 979 women responding to a questionnaire sent to a stratified random sample of the adult general population (n=4000). Main results-Strong physical, social, and psychological associations were found with sexual problems. In men, erectile problems and premature ejaculation were associated with increasing age. Erectile problems were most strongly associated with prostate trouble, with an age adjusted odds ratio of 2.6 (95% confidence intervals 1.4, 4.7), but hypertension and diabetes were also associated. Premature ejaculation was predominantly associated with anxiety (age adjusted odds ratio 3.1 (95% confidence intervals 1.7, 5.6)). In women, the predominant association with arousal, orgasmic, and enjoyment problems was marital diYculties, all with odds ratios greater than five. All female sexual problems were associated with anxiety and depression. Vaginal dryness was found to increase with age, whereas dyspareunia decreased with age. Conclusions-This study indicates that sexual problems cluster with self reported physical problems in men, and with psychological and social problems in women. This has potentially important consequences for the planning of treatment for sexual problems, and implies that eVective therapy could have a broad impact on health in the adult population.

Understanding the course of back pain is important for clinicians and researchers, but analyses of longitudinal data from multiple time points are lacking. A prospective cohort study of consecutive back pain consulters from five general practices in the United Kingdom was carried out between 2001 and 2003 to identify groups defined by their pain pathways. Patients were sent monthly questionnaires for a year. Longitudinal latent class analysis was performed by using pain intensity scores for 342 consulters. Analysis yielded four clusters representing different pathways of back pain. Cluster 1 ("persistent mild"; n = 122) patients had stable, low levels of pain. Patients in cluster 2 ("recovering"; n = 104) started with mild pain, progressing quickly to no pain. Cluster 3 ("severe chronic"; n = 71) patients had permanently high pain. For patients in cluster 4 ("fluctuating"; n = 45), pain varied between mild and high levels. Distinctive patterns for each cluster were maintained throughout follow-up. Clusters showed statistically significant differences in disability, psychological status, and work absence (p< 0.001). This is the first time, to the authors' knowledge, that latent class analysis has been applied to longitudinal data on back pain patients. Identification of four distinct groups of patients improves understanding of the course of back pain and may provide a basis of classification for intervention.

Among responders there was a high level of reported sexual problems. The most frequently reported problems (vaginal dryness, erectile problems) may be amenable to physical treatment in practice, and yet few had sought or received help. However, many said that they would like to receive help. These figures suggest that there may be an important burden of potentially reversible sexual problems in the general population.

The evidence concerning the association of back pain prevalence with age is more sparse than currently believed and this association seems to be modified by the severity of the problem. This knowledge could have important public health implications, as the proportion of older people will increase considerably in the coming years in most industrialised societies.