Improving Quality of Life for Patients With Chronic Pain
This excellent review considers how chronic pain may be managed, not by simply increasing administration of analgesics, but rather by a shift in clinical approach and redirection of focus to self-managing pain. Because pharmacologic therapy only helps a proportion of patients, and often results in tolerance, addiction, and unpleasant side effects, patients can develop substantial functional disability and poor quality of life, as well as substantial health-related economic burden.
The authors of this review differentiate between helpful and unhelpful strategies and messages. For example, although patients may seek an explanation for their pain, repeated investigations are not helpful; however, an explanation that chronic pain may exist without overt pathology may indeed be helpful to them in understanding and coping with their conditions.
The authors note that removing medication is as important as adding new drugs. A self-management approach, as with structured pain management programs (PMP), is better than simply telling patients to "live with it."
Such an approach is not easy to realize, but pain management practitioners can teach the skills to improve the quality of life, even if the patients' pain remains poorly controlled by medicines. Patients should be introduced to self-management philosophy relatively early, rather than waiting for pharmacologic failure. (See Gauntlett-Gilbert J, Brook P. Living well with chronic pain: The role of pain-management programmes. BJA 2018:18(1): 3-7.)
Selective COX-2 Inhibitors After Rotator Cuff Repair
A recent study evaluated the efficacy of a selective COX-2 inhibitor in managing early postoperative pain control, patient satisfaction, and incidence of systemic adverse effects in 180 patients undergoing arthroscopic rotator cuff repair.
Patients were randomly assigned to receive celecoxib, ibuprofen, or tramadol (n = 60 each). Visual analog scale (VAS) scores for pain intensity and satisfaction with medication, incidence of adverse effects, and use of rescue medication were recorded and compared between the 3 groups at 3 days after surgery, and again at 2 weeks after surgery. Magnetic resonance and ultrasonography images of 82 patients were retrospectively reviewed at least 24 months after surgery, along with the range of motion and pain VAS and functional scores.
No significant differences among the 3 groups were evident for pain intensity, incidence of adverse effects, or dosage of rescue medication at 3 days or 2 weeks after surgery. Pain VAS and functional scores at the final follow-up were also comparable. However, the re-tear rate in the celecoxib group (11/30 [37%]) was significantly higher than those in the ibuprofen (2/27 [7%]) and tramadol (1/25 [4%]) groups (P = .009).
The authors concluded that selective COX-2 inhibitors should not be used for postoperative analgesia due to a negative effect on tendon-to-bone healing after surgical repair.
http://ClinicalTrials.gov identifier: NCT02850211. (See Oh JH, Seo HJ, Lee YH, et al. Do selective COX-2 inhibitors affect pain control and healing after arthroscopic rotator cuff repair? A preliminary study. Am J Sports Med. 2017 Dec 1:363546517744219. doi: 10.1177/0363546517744219.)
Gabapentin and Postoperative Opioid Dependence
The authors studied 410 patients over 2 years to determine the effect of gabapentin in reducing postoperative pain, as well as the time to opioid cessation. In group 1, 208 patients received gabapentin, 1200 mg preoperatively, and 600 mg 3 times a day postoperatively. Group 2 (202 patients) received an active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours.
The primary outcome considered was time to pain resolution (5 consecutive reports of 0 of 10 levels of average pain on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year.
Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in group 1. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in any other adverse events, nor in the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]).
The authors concluded that perioperative administration of gabapentin had no effect on postoperative pain resolution, but did help in promoting opioid cessation after surgery, and thus may prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin were not addressed.
http://Clinicaltrials.gov Identifier: NCT01067144. (See Hah J, Mackey SC, Schmidt P, et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort: A randomized clinical trial. JAMA Surg. 2017; Dec 13. pii: 2664958. doi: 10.1001/jamasurg.2017.4915.)