Are we missing the opioid consumption in low- and middle-income countries?

OBJECTIVES: The rise in opioid prescriptions with a parallel increase in opioid use disorders remains a significant challenge in some developed countries (opioid epidemic). However, little is known about opioid consumption in low- and middle-income countries (LMICs). In this short report, we aim to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil. METHODS: We analyzed opioid sales on the publicly available Brazilian Health Regulatory Agency (ANVISA) database from 2015 to 2020. RESULTS: In Brazil, opioid sales increased 34.8 %, from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020, this represents an increase from 44 to 56 prescriptions for every 1,000 inhabitants. Codeine phosphate combined with paracetamol and tramadol hydrochloride were the most common opioids prescribed with an increase each year. CONCLUSIONS: The results suggest that opioid prescriptions are rising in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies and guidelines to better educate patients and prescribers and to prevent an opioid crisis.

Opioids compared to placebo or other treatments for chronic low-back pain.

BACKGROUND: The use of opioids in the long-term management of chronic low-back pain (CLBP) has increased dramatically. Despite this trend, the benefits and risks of these medications remain unclear. This review is an update of a Cochrane review first published in 2007. OBJECTIVES: To determine the efficacy of opioids in adults with CLBP. SEARCH METHODS: We electronically searched the Cochrane Back Review Group's Specialized Register, CENTRAL, CINAHL and PsycINFO, MEDLINE, and EMBASE from January 2006 to October 2012. We checked the reference lists of these trials and other relevant systematic reviews for potential trials for inclusion. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that assessed the use of opioids (as monotherapy or in combination with other therapies) in adults with CLBP that were at least four weeks in duration. We included trials that compared non-injectable opioids to placebo or other treatments. We excluded trials that compared different opioids only. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias and extracted data onto a pre-designed form. We pooled results using Review Manager (RevMan) 5.2. We reported on pain and function outcomes using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (95% CI). We used absolute risk difference (RD) with 95% CI to report adverse effects. MAIN RESULTS: We included 15 trials (5540 participants). Tramadol was examined in five trials (1378 participants); it was found to be better than placebo for pain (SMD -0.55, 95% CI -0.66 to -0.44; low quality evidence) and function (SMD -0.18, 95% CI -0.29 to -0.07; moderate quality evidence). Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD -2.47, 95%CI -2.69 to -2.25; very low quality evidence), but no difference compared to placebo for function (SMD -0.14, 95%CI -0.53 to 0.25; very low quality evidence). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), examined in six trials (1887 participants), were better than placebo for pain (SMD -0.43, 95%CI -0.52 to -0.33; moderate quality evidence) and function (SMD -0.26, 95% CI -0.37 to -0.15; moderate quality evidence). One trial (1583 participants) demonstrated that tramadol may make little difference compared to celecoxib (RR 0.82, 95% CI 0.76 to 0.90; very low quality evidence) for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for either pain (SMD 0.21, 95% CI -0.03 to 0.45; very low quality evidence), or function (SMD -0.11, 95% -0.63 to 0.42; very low quality evidence). The included trials in this review had high drop-out rates, were of short duration, and had limited interpretability of functional improvement. They did not report any serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism). In general, the effect sizes were medium for pain and small for function. AUTHORS' CONCLUSIONS: There is some evidence (very low to moderate quality) for short-term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non-steroidal anti-inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-RCTs supporting the effectiveness and safety of long-term opioid therapy for treatment of CLBP.

A randomized controlled trial of acupuncture added to usual treatment for fibromyalgia.

OBJECTIVE: To evaluate the effectiveness of acupuncture for fibromyalgia. METHODS: Fifty-eight women with fibromyalgia were allocated randomly to receive either acupuncture together with tricyclic antidepressants and exercise (n=34), or tricyclic antidepressants and exercise only (n=24). Patients rated their pain on a visual analogue scale. A blinded assessor evaluated both the mean pressure pain threshold value over all 18 fibromyalgia points and quality of life using SF-36. RESULTS: At the end of 20 sessions, patients who received acupuncture were significantly better than the control group in all measures of pain and in 5 of the SF-36 subscales. After 6 months, the acupuncture group was significantly better than the control group in numbers of tender points, mean pressure pain threshold at the 18 tender points and 3 subscales of SF-36. After one year, the acupuncture group showed significance in one subscale of the SF-36; at 2 years there were no significant differences in any outcome measures. CONCLUSION: Addition of acupuncture to usual treatments for fibromyalgia may be beneficial for pain and quality of life for 3 months after the end of treatment. Future research is needed to evaluate the specific effects of acupuncture for fibromyalgia.

Evidence-informed management of chronic low back pain with massage.

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-informed management of chronic low back pain without surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Em busca de evidência para a prática médica diária / Searching of evidence for the daily medical practice

O médico näo tem tempo para estudar e manter-se atualizado na medida que seria necessário. No entanto, a medicina tem evoluçäo com uma velocidade espantosa e práticas atuais säo substituídas por novas muito mais rapidamente nos últimos anos. O que fazer diante de problemas clínicos e questionamentos sobre eficácias de tratamentos? O médico tem várias opçöes, e uma delas é procurar as respostas em revisöes de literatura. Entretanto, nem todas as revisöes da literatura säo bem-feitas ou têm resultados confiáveis. A maioria representa a opiniäo pessoais dos autores e näo há uma metodologia para a sua realizaçäo. Ultimamente, têm sido publicadas revisöes sistemáticas da literatura, em que os autores delimitam uma questäo específica para, entäo, buscar todos os estudos que respondam a essa pergunta. Uma revisäo sistemática da literatura deve conter: objetivos, métodos , análise de qualidade de cada estudo incluído, resultados, conclusöes e discussäo. O médico precisa ter acesso a esses tipos de revisäo e aprender a avaliar a sua qualidade. Um dos critérios recomendados é o que foi desenvolvido por Oxman e Guyatt. A Cochrane Collaboration tem desevolvido métodos e técnicas para a realizaçäo de revisöes com o mínimo de erros e opiniöes pessoais, sendo, portanto, uma das maiores fontes de revisöes da literatura de boa qualidade.

Tipóia de Gaylord Adaptada: Uso na subluxaçäo do ombro do paciente hemiplégico / Adapted Gaylord Splint: Use in shoulder subluxation of hemiplegic patient

O presente estudo tem por objetivo avaliar os benefícios do uso da tipóia de Gaylord adaptada em 30 pacientes hemiplégicos com subluxaçäo de ombro associado à dor. Analisamos aspectos referentes à melhora da dor, grau de dependência, dificuldade na sua colocaçäo e conforto durante seu uso. Consideramos melhora expressiva da dor quando esta ocorreu em pelo menos 75 por cento. Resultados, após pelo menos 2 meses de uso, mostraram que 66.7 por cento dos pacientes obtiveram melhora expressiva da dor, 93.3 por cento eram dependentes na sua colocaçäo, 83.3 por cento referem que esta era fácil de ser colocada e 100 por cento que ela era confortável. Frente aos resultados obtidos, verificamos que a tipóia de Gaylord pode ser um recurso ortésico benéfico na subluxaçäo de ombro dos pacientes hemiplégicos.