Intravenous nonopioid analgesic drugs in chronic low back pain patients on chronic opioid treatment

Wetzel, Léonore; Zadrazil, Markus; Paternostro-Sluga, Tatjana; Authried, Georg; Kozek‐Langenecker, Sibylle A.; Scharbert, Gisela

doi:10.1097/eja.0b013e328365ae28

Cited by 18 publications

(15 citation statements)

References 23 publications

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“…The median treatment duration in included trials was 7 (IQR, 5–7) days. NSAIDs were mostly administered orally, but five trials used intravenous or intramuscular injection,35 37–39 59 and three used a topical formulation, such as a gel, patch or cream 51 53 56. Nine trials had a three-arm parallel design and two were randomised crossover trials.…”

Section: Resultsmentioning

confidence: 99%

Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

et al. 2017

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Section: Resultsmentioning

confidence: 99%

Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

et al. 2017

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“…While the efficacy of acetaminophen in spinal pain was statistically significant in a recent meta‐analysis, the greatest observed effect size of −3.7 points in a 0–100 point VAS scale falls short of the minimal clinically relevant change of −9.0 points . However, unlike our study, this review included patients presenting acute pain conditions , and studies using single‐dose regimens . Extrapolating data from single‐dose or intermediate duration treatment regimens (treatment duration less than 3 months) to that of chronic use (more than 6 months continuous treatment) is questionable as earlier studies have shown loss of analgesic efficacy during long‐term follow‐up .…”

Section: Discussionmentioning

confidence: 88%

Acetaminophen for Chronic Pain: A Systematic Review on Efficacy

Ennis

Dideriksen

Vægter

et al. 2015

Basic Clin Pharma Tox

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Acetaminophen (paracetamol) is the most commonly used analgesic worldwide and recommended as first-line treatment in all pain conditions by WHO. We performed a systematic literature review to evaluate the efficacy of acetaminophen when used for chronic pain conditions. Applying three broad search strategies for acetaminophen use in chronic pain in both Embase and PubMed, 1551 hits were obtained. After cross-reference searches of both trials and 38 reviews, seven studies comparing acetaminophen in continuous dosing regimens of more than 2 weeks with placebo were included. The review was conducted according to the PRISMA guidelines. All studies were conducted in patients with hip-or knee osteoarthritis and six of seven studies had observation periods of less than 3 months. All included studies showed no or little efficacy with dubious clinical relevance. In conclusion, there is little evidence to support the efficacy of acetaminophen treatment in patients with chronic pain conditions. Assessment of continuous efficacy in the many patients using acetaminophen worldwide is recommended.Acetaminophen (paracetamol) has been widely endorsed as a first-line analgesic and is currently the most commonly used analgesic worldwide (1). As an example, 9.6% of all Danes obtained acetaminophen via prescription in 2013, with the prevalence rising to an astonishing 23% among 65-to 79-yearolds and 45% among octogenarians (2). The recommendation of using acetaminophen has been generalized by the World Health Organization (WHO), suggesting acetaminophen as the first step in any pharmacological pain treatment (3). Similarly, acetaminophen is recommended as first-line treatment in many chronic pain conditions such as osteoarthritis (4) and for geriatric patients in general (5). The wide endorsement of acetaminophen is primarily attributable to a favourable safety profile compared with other treatment options (6), and the notion that acetaminophen has an efficacy comparable with non-steroid anti-inflammatory drugs (NSAIDs) -the latter primarily based on a highly cited study from 1991 by Bradley et al. (7).While a solid evidence base exists for the use of acetaminophen in acute pain states such as dental and post-operative pain (8), post-partum pain (9) and migraine (10), the evidence supporting its use in chronic pain conditions is less obvious. In a pivotal and often cited study from 1983, Amadio and Cummings showed that acetaminophen was superior to placebo in patients with osteoarthritis (OA) (11). While this cross-over study was only based on 25 patients, it has served as a basis for subsequent investigations, and as such, later studies often compare acetaminophen directly to NSAIDs (12) or COX2 inhibitors (12), without including an arm receiving placebo.Considering the widespread and often long-term use of acetaminophen, it is of major public health importance to ensure that this use is founded on solid evidence regarding efficacy. To this end, we conducted a systematic literature review to assess the efficacy of acetamin...

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“…For example, pre-emptive diclofenac resulted in favorable analgesia immediately following spinal surgery but those patients that received diclofenac also required a greater quantity of analgesic drugs at significantly higher doses during the post-operative period than patients who received only a continuous infusion of morphine [47]. More recently, administration of diclofenac was shown to provide minimal enhancement in pain relief in patients that were treated with opioids for non-cancer chronic lower back pain even when diclofenac was infused at the same time as morphine [48]. These clinical observations underscore the importance of our present study, which was designed to establish a mechanistic basis for drug-drug interactions between NSAIDs and opioid analgesic drugs.…”

Section: Discussionmentioning

confidence: 99%

P-glycoprotein Modulates Morphine Uptake into the CNS: A Role for the Non-steroidal Anti-inflammatory Drug Diclofenac

et al. 2014

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Our laboratory has previously demonstrated that peripheral inflammatory pain (PIP), induced by subcutaneous plantar injection of λ-carrageenan, results in increased expression and activity of the ATP-dependent efflux transporter P-glycoprotein (P-gp) that is endogenously expressed at the blood-brain barrier (BBB). The result of increased P-gp functional expression was a significant reduction in CNS uptake of morphine and, subsequently, reduced morphine analgesic efficacy. A major concern in the treatment of acute pain/inflammation is the potential for drug-drug interactions resulting from P-gp induction by therapeutic agents co-administered with opioids. Such effects on P-gp activity can profoundly modulate CNS distribution of opioid analgesics and alter analgesic efficacy. In this study, we examined the ability of diclofenac, a non-steroidal anti-inflammatory drug (NSAID) that is commonly administered in conjunction with the opioids during pain therapy, to alter BBB transport of morphine via P-gp and whether such changes in P-gp morphine transport could alter morphine analgesic efficacy. Administration of diclofenac reduced paw edema and thermal hyperalgesia in rats subjected to PIP, which is consistent with the known mechanism of action of this NSAID. Western blot analysis demonstrated an increase in P-gp expression in rat brain microvessels not only following PIP induction but also after diclofenac treatment alone. Additionally, in situ brain perfusion studies showed that both PIP and diclofenac treatment alone increased P-gp efflux activity resulting in decreased morphine brain uptake. Critically, morphine analgesia was significantly reduced in animals pretreated with diclofenac (3 h), as compared to animals administered diclofenac and morphine concurrently. These novel findings suggest that administration of diclofenac and P-gp substrate opioids during pain pharmacotherapy may result in a clinically significant drug-drug interaction.

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Intravenous nonopioid analgesic drugs in chronic low back pain patients on chronic opioid treatment

Cited by 18 publications

References 23 publications

Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

Acetaminophen for Chronic Pain: A Systematic Review on Efficacy

P-glycoprotein Modulates Morphine Uptake into the CNS: A Role for the Non-steroidal Anti-inflammatory Drug Diclofenac

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