During 2011, we posted 145 News/Research UPDATES articles, which were viewed in total more than 115,000 times by 67,000 visitors; a third of those persons were regular repeat visitors to the UPDATES site. And, we thank each and every one of you.
Which were the most popular, frequently visited UPDATES this past year? Here is a recap of the Top 10 in our “Hit Parade” of articles that visitors found of greatest interest. So, take a look at any that you missed.
Part 10 – Interpreting Effect Sizes in Research Data
One of the greatest and most frequent failings of pain research reports is authors presenting the statistical significance of outcome results, but not assessing the clinical importance of those findings. This is especially vexing when pain therapies are compared with each other or against placebo and there are differences between groups, as is commonly the case. What do the differences, when considered as effect sizes, mean for patients?
As statistician Darrell Huff stated more than half a century ago, “A difference is a difference only if it makes a difference” [Huff 1954]. When research demonstrates that one treatment or intervention might be better than another, healthcare providers and their patients want to know whether the differences can be trusted as being valid and also if they are of any consequence for better patient care; that is, what is the clinical significance?
Chronic noncancer-related abdominal pain is a frequent reason for outpatient healthcare visits and can be difficult to treat. A recently reported study found that during a 12-year period, through 2008, there was an increasing trend of opioid analgesic prescribing for this ailment. Although opioids have not been adequately assessed for this purpose and may complicate or worsen abdominal pain, the validity of this present research and needs for further clarification should be considered before reaching any conclusions.
Many patients with pain justifiably want to purchase prescribed medications online, for convenience and/or to save money. However, the Internet can be a hazardous place to buy medicines unless the source is legitimate and follows high standards for product quality and delivery. There are a number of resources available to help select suitable online pharmacies that healthcare professionals and patients should know about.
In a recent UPDATE [here] we noted that, as access to prescribed opioid analgesics and other pain medications is becoming more difficult in some areas, patients are turning to Internet-based pharmacies of questionable caliber and reputation. Many of these operate outside the laws of the United States, or even regulations of the countries in which they operate, and their products can be of low quality and harmful in some cases. Patients need to be warned of the hazards and steered in the direction of more reliable sources.
Correspondent: Thomas Sachy, MD, MSc
As mentioned in my first installment in this series [here], I will continue to comment on my personal experiences and knowledge regarding the continuing war on pain. Of course the Internet has made monitoring this conflict infinitely easier; similar to the general who, while safely removed from harm, is able to monitor the pitched battles taking place a world away with an all-seeing eye while perched high above the fray.
However, in my case, I am no armchair general. I am clearly in the fight, struggling against the enemy called “chronic pain.” This battle has its host of dangers, including the possibility of so-called “friendly fire” from the very “weapons” used to fight pain.
Even before new rules governing opioid prescribing in Washington state go into effect next month, in January 2012, access to adequate pain care is becoming scarce in the state. And, there are signs that this could be a harbinger of trouble and bad times ahead for persons with pain in other parts of the United States.
Aggressive new laws for the management of chronic noncancer pain, intended to curb rising opioid overdose deaths in Washington state, have been discussed in previous UPDATES [here] and [here]. Last September 2011 — concerned about reports that access to any type of pain care was becoming more difficult for the 1.7 million persons in the state with chronic pain conditions — the American Pain Foundation (APF) conducted a special survey to evaluate what seemed to be a mushrooming crisis.
Swearing can help to relieve acute pain, investigators have reported for a second time. Such is the state of research in the pain management field, that research of questionable importance is not only worth doing, but doing again. And, why it would merit a lengthy article in a supposedly sagacious pain journal is perplexing. Was this a joke?
More than two years ago, in an UPDATE [here], we first described a study that investigated the benefits of swearing to help relieve the pangs of acute pain. It was a rather novel experiment that attracted much news media attention at the time. Richard Stephens and colleagues from Keele University in the United Kingdom had 64 college student volunteers hold their hands in a tub of ice water (a cold-pressor pain test) for as long as possible while repeating a swear word of their choice; each then repeated the experiment but using a commonplace word they would use to describe a table.
We have long advocated for the potential benefits of supplementation with vitamin D3, not D2, in persons with musculoskeletal pain. While some authors claim the formulation of vitamin D does not make that much difference, recent feedback from an UPDATES reader, plus a research summary by two experts, point toward D3 as the definite choice. In fact, prescribing D2 supplements should be reconsidered.
First, the letter, e-mailed to us from Susan Gray of Little Rock, Arkansas [name used with permission]:
Two new surveys in the U.S. have found that nearly 45% of patients with acute pain may receive inadequate analgesia and a quarter of persons with cancer pain are not taking analgesics at all. Various factors contribute to insufficient pain relief, such as patient age, side effects of medications, fear of addiction, and inability to pay for analgesics. And, the problems are of worldwide crisis proportions.
Moderate-to-Severe Acute Pain Undertreated
Writing in the Journal of Opioid Management, Bruce L. Moskovitz, MD, and fellow researchers from Ortho-McNeil Janssen Scientific Affairs assessed data from the Physicians Partnering Against Pain (P3) survey to evaluate patients’ perceptions of the adequacy of analgesia for moderate-to-severe acute pain and the influence of opioid-related side effects [Moskovitz et al. 2011]. This largest survey of its kind involved 5,982 physicians — mainly primary care practitioners — who recruited 50,869 patients with acute pain to complete questionnaires between September and November 2008. All were ≥18 years of age, with 16% ≥65 years old (including 6% ≥ age 75), and 57% were female.
Correspondent: Thomas Sachy, MD, MSc
Although I practice child, adolescent, adult, and forensic neuropsychiatry, the majority of my clinical practice is in the field of pain management, and I am a strong supporter of using opioids for the treatment of chronic noncancer pain. I have come to this position after approximately 11 years of face-to-face patient interaction, along with ongoing intensive review of the medical and scientific literature dealing with opioids, and the other forms of analgesic medication, as well as the neuroscience behind chronic pain disorders.
For several years now, and especially over the past several months, there has been an ongoing barrage of news media attention focusing on the fact that overdose deaths due to prescription opioids have reached “dangerous” or “alarming” levels of epidemic proportions. In response to these statistics has come an almost mob-like crusade to track down and punish incompetent, unethical, “pill mill” physicians and their practices, which is justified and one would think this could be easily attainable. Inexplicably, these objectives do not seem to be that easy to accomplish. Why?
Featured Items: bupivacaine liposome injectable suspension (Exparel) approved for postsurgical pain; onabotulinumtoxinA (BOTOX) approved for chronic migraine prophylaxis; TNF Blockers, azathioprine, and/or mercaptopurine - FDA safety update; duloxetine (Cymbalta) approval denied in Europe for chronic musculoskeletal pain. — All brand names are trademarks of their respective manufacturers. Compiled by: Winnie Dawson, MA, RN, BSN.
Bupivacaine Liposome Injectable Suspension (Exparel™) — FDA Approval for Postsurgical Pain
Pacira Pharmaceuticals announced an October 2011 U.S. Food and Drug Administration approval for Exparel — a single-dose liposome injection of bupivacaine, an amide local anesthetic. When administered into the surgical site during or soon after surgery, a single infiltration provides analgesia for several days. FDA approval was based on 10 randomized, double-blind clinical trials in more than 800 patients who had various surgical procedures. The results of one placebo-controlled hemorrhoidectomy trial that was considered pivotal, demonstrated significant reductions in cumulative pain scores plus decreased opioid consumption for up to 72 hours in patients receiving Exparel. The safety of the product was evaluated in more than 1300 patients in a total of 21 clinical trials. The most commonly reported adverse effects were vomiting, nausea, and constipation. Pacira cautions healthcare providers that other formulations of bupivacaine must be withheld until 96 hours after administration of Exparel. This single-dose injectable product is contraindicated for paracervical block anesthesia in obstetrical patients. See the prescribing information [PDF here] for further administration and safety instructions.
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