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1.
Br J Anaesth ; 123(5): 655-663, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31558315

RESUMO

BACKGROUND: The Korean National Health Insurance Service (NHIS) was developed to provide population data for medical research. The aim of this study was to estimate trends in prescription opioid use in South Korea, and to determine the association between chronic opioid use and 5-yr mortality in cancer and non-cancer patients. METHODS: A population-based cohort study was conducted amongst the South Korean adult population using data from the NHIS. Those prescribed a continuous supply of opioids for ≥90 days were defined as chronic opioid users. Multivariable Cox regression analysis was used to assess the association between chronic opioid use and 5-yr mortality. RESULTS: The proportion of chronic weak opioid users increased from 1.03% in 2002 to 9.62% in 2015. The proportion of chronic strong opioid users increased from 0.04% in 2002 to 0.24% in 2015. In the 2010 cohort (n=822 214), compared with non-users, chronic weak opioid users had a significantly lower 5-yr mortality (hazard ratio [HR]: 0.93; 95% confidence interval [CI]: 0.89-0.96; P<0.001), and chronic strong opioid users had a significantly higher 5-yr mortality (HR: 1.45; 95% CI: 1.28-1.63; P<0.001). Similar results were observed in non-cancer patients, but chronic weak opioid users were not significantly associated with 5-yr mortality in cancer patients (P=0.063). CONCLUSIONS: In South Korea, chronic opioid use has increased since 2002. Chronic strong opioid use was associated with a higher 5-yr mortality, and chronic weak opioid use was associated with a slightly lower 5-yr mortality. However, the findings regarding chronic weak opioid users should be interpreted carefully because there might be residual confounders in this study. Further study is needed to confirm these retrospective findings.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/mortalidade , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/mortalidade , Modelos de Riscos Proporcionais , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores Socioeconômicos
2.
Artigo em Inglês | MEDLINE | ID: mdl-31004724

RESUMO

Chronic pain is highly prevalent among older adults where it is associated with significant suffering, disability, social isolation, and greater costs and burden to health care systems. Pharmaceutical treatment of chronic pain in older adults is usually only partially effective and is often limited by side effects including urinary retention, constipation, sedation, cognitive impairment, and increased risk of falls. Since older adults are underrepresented in clinical trials testing treatments for chronic pain, the potential impacts of polypharmacy and frailty on reported outcomes and side effect profiles are largely unknown. Thus, for current treatments, providers and patients must balance anticipated benefits of pain reduction with the known and unknown risks of treatment. Chronic pain is also a risk factor for premature death as well as accelerated cognitive decline, suggesting potential shared mechanisms between persistent pain (or its treatment) and dementia. Cognitive decline and dementia may also impact pain perception and the ability to report pain, complicating treatment decisions. Associations between persistent pain and the risks of premature death and accelerated cognitive decline make estimates for chronic pain in these populations particularly challenging. Future research is needed to improve estimates for chronic pain in older adults, to elucidate underlying mechanisms of pain with aging, and to develop and advance safer, more effective treatment options for chronic pain in older adults.


Assuntos
Dor Crônica/epidemiologia , Fatores Etários , Idoso , Dor Crônica/complicações , Dor Crônica/mortalidade , Demência/complicações , Epidemias , Humanos , Manejo da Dor , Qualidade de Vida , Fatores de Risco
3.
Scand J Pain ; 19(1): 93-99, 2019 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-30205653

RESUMO

Background and aims Almost 20% of the adult population suffers from chronic pain. Chronic pain may be linked to an elevated mortality; however, results from previous studies are inconsistent. Some studies find similar mortality levels in chronic pain patients and pain-free controls while other studies show elevated mortality levels among chronic pain patients, primarily with respect to cancer, diseases of the circulatory and respiratory systems, and suicide. These conflicting results are potentially due to different population samples and different operational definitions of chronic pain. Further research on overall and cause-specific mortality in patients with severe chronic pain is needed to inform clinical practice. The objective of this register-linkage study was to investigate whether patients with severe chronic pain referred to multidisciplinary pain treatment have higher cause-specific mortality rates than the general population. Methods In this register-linkage cohort study, data from 6,142 chronic pain patients (female: n=3,941, male: n=2,201, mean age: 48.2±14.2; range: 16-97 years) attending an interdisciplinary Pain Center in Odense, Denmark from 2005 to 2014 were linked to the Danish Register of Causes of Death. Age and gender standardized mortality ratios (SMRs) with their 95% confidence intervals (CI) were calculated and compared with those of the general population. Data from the general population was extracted from the Danish Register of Causes of Death, and Causes of death were classified according to national Classification of Disease (ICD-10). Results In all, 276 deaths (women: n=152, men: n=124) were observed among the chronic pain patients, and a six-fold higher overall mortality rate was found [SMR: 6.2 (95% CI: 5.5-7.0)] compared with the general population. Elevated cause-specific mortality rates were noted for chronic patients with respect to cancer and neoplasms [4.7 (95% CI: 3.7-5.9)], diseases of the circulatory system [5.7 (95% CI: 4.3-7.3)], diseases of the respiratory system [8.7 (95% CI: 6.2-11.9)], and suicide [7.3 (95% CI: 2.7-15.9)]. Conclusions The overall mortality rate of patients with severe chronic pain in this study was six-fold higher than the rate of the general population in this region. This was reflected in select specific causes of death (cancer and neoplasms, diseases of the circulatory system, diseases of the respiratory system, and suicide). The results are in agreement with previous studies and emphasize the need to understand which factors causally affect this increased mortality allowing for targeted interventions in similar chronic pain populations. Implications Potential reasons for the excess mortality should be adequately addressed by future studies in order to better target this in the management of these patients. The chronic pain population included in this study may have several comorbidities contributing to the increased mortality. To better address these aspects, complete medical profiles are needed in future studies. In addition, implementation of management strategies towards potential risk factors such as poor diet, low levels of physical activity, smoking, and high BMI as well as sleep deprivation and morphine use previously shown associated with having pain may reduce the excess mortality ratio.


Assuntos
Dor Crônica/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/epidemiologia , Dor Crônica/complicações , Estudos de Coortes , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Clínicas de Dor , Encaminhamento e Consulta , Índice de Gravidade de Doença , Suicídio/estatística & dados numéricos , Adulto Jovem
5.
Transplantation ; 102(6): 994-1004, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29319627

RESUMO

BACKGROUND: Centers for Disease Control and Prevention guidelines recommend caution in prescribing opioids for chronic pain. The characteristics of opioid prescription (OpRx) among kidney transplant (KTx) recipients have not been described in a national population. METHODS: We assessed OpRx prevalence among prevalent KTx recipients, and associated duration (long-term, defined as ≥90 days in a year) and dosing (in morphine milligram equivalents per day of <50, 50-89, and ≥90) with outcomes, death and graft loss, among incident KTx recipients using 2006-2010 US Renal Data System files, including Medicare Part D for medication ascertainment. Cox models controlled for recipient factors. RESULTS: Of 36,486 KTx recipients in the 2010 prevalent cohort, approximately 14.6% had long-term OpRx. The strongest association with long-term OpRx after KTx was long-term OpRx before KTx (64%; adjusted odds ratio, 95% confidence interval, 95.2, 74.2-122.1). Incident KTx recipients with long-term OpRx had increased risk of mortality and graft loss compared with those without OpRx or short-term OpRx after KTx. This risk was highest among recipients with long-term OpRx doses of ≥90 morphine milligram equivalents or higher per day (adjusted hazard ratio, 95% confidence interval, 1.61, 1.24-2.10 for death, and 1.33, 1.05-1.67 for graft loss, respectively). CONCLUSIONS: In contrast to either no or short-term OpRx, long-term, and especially long-term high-dose OpRx, is associated with increased risk of death and graft loss in US KTx recipients. Causal relationships cannot be inferred, and OpRx may be an illness marker. Nevertheless, efforts to treat pain effectively in KTx recipients with less toxic interventions and decrease OpRx deserve consideration.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Transplante de Rim/efeitos adversos , Transplantados , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Dor Crônica/diagnóstico , Dor Crônica/mortalidade , Prescrições de Medicamentos , Feminino , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Incidência , Transplante de Rim/mortalidade , Masculino , Medicare Part D , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
6.
PLoS One ; 12(9): e0183966, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28910309

RESUMO

Multimorbidity is increasingly the primary concern of healthcare systems globally with substantial implications for patient outcomes and resource cost. A critical knowledge gap exists as to the magnitude of multimorbidity in primary care practice in low and middle income countries with available information limited to prevalence. In India, primary care forms the bulk of the health care delivery being provided through both public (community health center) and private general practice setting. We undertook a study to identify multimorbidity patterns and relate these patterns to severity among primary care attendees in Odisha state of India. A total of 1649 patients attending 40 primary care facilities were interviewed using a structured multimorbidity assessment questionnaire. Multimorbidity patterns (dyad and triad) were identified for 21 chronic conditions, functional limitation was assessed as a proxy measure of severity and the mean severity score for each pattern, was determined after adjusting for age. The leading dyads in younger age group i.e. 18-29 years were acid peptic disease with arthritis/ chronic back ache/tuberculosis /chronic lung disease, while older age groups had more frequent combinations of hypertension + arthritis/ chronic lung disease/vision difficulty, and arthritis + chronic back ache. The triad of acid peptic disease + arthritis + chronic backache was common in men in all age groups. Tuberculosis and lung diseases were associated with significantly higher age-adjusted mean severity score (poorer functional ability). Among men, arthritis, chronic backache, chronic lung disease and vision impairment were observed to have highest severity) whereas women reported higher severity for combinations of hypertension, chronic back ache and arthritis. Given the paucity of studies on multimorbidity patterns in low and middle income countries, future studies should seek to assess the reproducibility of our findings in other populations and settings. Another task is the potential implications of different multimorbidity clusters for designing care protocols, as currently the protocols are disease specific, hardly taking comorbidity into account.


Assuntos
Artrite/mortalidade , Dor nas Costas/mortalidade , Dor Crônica/mortalidade , Assistência à Saúde , Hipertensão/mortalidade , Úlcera Péptica/mortalidade , Atenção Primária à Saúde , Tuberculose Pulmonar/mortalidade , Adolescente , Adulto , Fatores Etários , Doença Crônica , Comorbidade , Feminino , Humanos , Índia/epidemiologia , Masculino
8.
Ann Rheum Dis ; 76(11): 1815-1822, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28733474

RESUMO

OBJECTIVE: It is uncertain whether persons with chronic widespread pain (CWP) experience premature mortality. Using the largest study conducted, we determine whether such a relationship exists, estimate its magnitude and establish what factors mediate any relationship. METHODS: UK Biobank, a cohort study of 0.5 million people aged 40-69 years, recruited throughout Great Britain in 2006-2010. Participants reporting 'pain all over the body' for >3 months were compared with persons without chronic pain. Information on death (with cause) was available until mid-2015. We incorporated these results in a meta-analysis with other published reports to calculate a pooled estimate of excess risk. RESULTS: 7130 participants reported CWP and they experienced excess mortality (mortality risk ratio 2.43, 95%CI 2.17 to 2.72). Specific causes of death in excess were cancer (1.73adjusted age and sex, 95% CI 1.46 to 2.05), cardiovascular (3.24adjusted age and sex, 95% CI 2.55 to 4.11), respiratory (5.66adjusted age and sex, 95% CI 4.00 to 8.03) and other disease-related causes (4.04adjusted age and sex, 95% CI 3.05 to 5.34). Excess risk was substantially reduced after adjustment for low levels of physical activity, high body mass index, poor quality diet and smoking. In meta-analysis, all studies showed significant excess all-cause (combined estimate 1.59 (95% CI 1.05 to 2.42)), cardiovascular and cancer mortality. CONCLUSIONS: Evidence is now clear that persons with CWP experience excess mortality. UK Biobank results considerably reduce uncertainty around the magnitude of excess risk and are consistent with the excess being explained by adverse lifestyle factors, which could be targeted in the management of such patients.


Assuntos
Bancos de Espécimes Biológicos/estatística & dados numéricos , Dor Crônica/mortalidade , Mortalidade Prematura , Adulto , Idoso , Causas de Morte , Estudos de Coortes , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Reino Unido
9.
Cochrane Database Syst Rev ; 4: CD011279, 2017 04 24.
Artigo em Inglês | MEDLINE | ID: mdl-28436583

RESUMO

BACKGROUND: Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure. OBJECTIVES: To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions. METHODS: We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively. MAIN RESULTS: We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance. AUTHORS' CONCLUSIONS: The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.


Assuntos
Dor Crônica/terapia , Terapia por Exercício/métodos , Adulto , Dor Crônica/mortalidade , Dor Crônica/psicologia , Terapia por Exercício/efeitos adversos , Necessidades e Demandas de Serviços de Saúde , Humanos , Mialgia/etiologia , Medição da Dor , Cooperação do Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como Assunto
11.
Musculoskeletal Care ; 15(2): 104-113, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27430167

RESUMO

BACKGROUND: Chronic widespread musculoskeletal complaints (CWMSC) are a prevalent condition with a large impact on quality of life and with a large burden on society. Studies investigating the relationship between CWMSC and mortality have yielded inconsistent results. The present study aimed to clarify this relationship through a systematic review of the existing literature, including meta-analyses, to estimate pooled results and heterogeneity. METHODS: The MEDLINE, EMBASE and Science Citation Index Expanded databases were searched in February 2016. Broad search terms were used to identify as many observational studies as possible that investigated the association between CWMSC and mortality. The identified studies were evaluated according to predetermined inclusion criteria. RESULTS: Six studies fulfilled the inclusion criteria. In pooled unadjusted analyses of three studies evaluating CWMSC, a non-significant tendency of increased overall mortality was found [mortality risk ratio (MRR) 1.69, 95% confidence interval (CI) 0.91-3.14]. However, in pooled analyses of all six studies reporting adjusted results, the non-significant tendency for higher mortality rates in those with CWMSC was nearly eliminated (MRR 1.13, 95% CI 0.95-1.34). Heterogeneity between studies was moderate to high, particularly regarding the use of confounding factors. CONCLUSIONS: In this systematic review, based on a limited number of studies, pooled data gave no evidence of a higher mortality rate among individuals with CWMSC. The non-significant tendency for a higher mortality rate in unadjusted pooled analyses was nearly eliminated in the adjusted pooled analyses, considering lifestyle factors such as physical activity smoking. In population-based studies evaluating the relationship between CWMSC and mortality rates, we recommend that both unadjusted and adjusted analyses should be presented. Copyright © 2016 John Wiley & Sons, Ltd.


Assuntos
Dor Crônica/mortalidade , Doenças Musculoesqueléticas/mortalidade , Doença Crônica/mortalidade , Humanos
12.
Neuromodulation ; 19(8): 857-863, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27730706

RESUMO

OBJECTIVES: The Implantable Systems Performance Registry (ISPR) was created to monitor the product performance of Medtronic Spinal Cord Stimulation (SCS) and implanted intrathecal drug infusion systems available in the United States. MATERIALS AND METHODS: Data were collected on 2605 patients from 44 centers from various geographic regions across the United States implanting and following patients with SCS systems between June 25, 2004 and January 31, 2014. Actuarial life table methods are used to estimate device performance over time. Of the 2605 patients, 1490 (57.2%) were female, 1098 (42.1%) were male and 17 (0.7%) did not provide gender data. The average age at enrollment was 56.3 years (range: 4-97, SD = 14.3) and average follow-up time was 20.1 months (SD = 22.5). RESULTS: Currently the estimates of device survival from neurostimulator-related events exceed 97% for all neurostimulator models across the applicable follow-up time points and all applicable extension models had greater than 95% survival from extension events. The majority of product performance events were lead-related. At 5 years of follow-up, all applicable lead families, with the exception of the Pisces-Quad LZ family, had greater than 75% survival from lead events. CONCLUSIONS: The ISPR is designed to serve as an ongoing source of system and device-related information with a focus on "real-world" safety and product performance. ISPR data continue to be used to guide future product development efforts aimed at improving product reliability and quality.


Assuntos
Dor Crônica/terapia , Eletrodos Implantados , Sistema de Registros , Estimulação da Medula Espinal/métodos , Resultado do Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Dor Crônica/mortalidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Medição da Dor , Análise de Sobrevida , Estados Unidos , Adulto Jovem
14.
JAMA ; 315(22): 2415-23, 2016 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-27299617

RESUMO

IMPORTANCE: Long-acting opioids increase the risk of unintentional overdose deaths but also may increase mortality from cardiorespiratory and other causes. OBJECTIVE: To compare all-cause mortality for patients with chronic noncancer pain who were prescribed either long-acting opioids or alternative medications for moderate to severe chronic pain. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study between 1999 and 2012 of Tennessee Medicaid patients with chronic noncancer pain and no evidence of palliative or end-of-life care. EXPOSURES: Propensity score-matched new episodes of prescribed therapy for long-acting opioids or either analgesic anticonvulsants or low-dose cyclic antidepressants (control medications). MAIN OUTCOMES AND MEASURES: Total and cause-specific mortality as determined from death certificates. Adjusted hazard ratios (HRs) and risk differences (difference in incidence of death) were calculated for long-acting opioid therapy vs control medication. RESULTS: There were 22,912 new episodes of prescribed therapy for both long-acting opioids and control medications (mean [SD] age, 48 [11] years; 60% women). The long-acting opioid group was followed up for a mean 176 days and had 185 deaths and the control treatment group was followed up for a mean 128 days and had 87 deaths. The HR for total mortality was 1.64 (95% CI, 1.26-2.12) with a risk difference of 68.5 excess deaths (95% CI, 28.2-120.7) per 10,000 person-years. Increased risk was due to out-of-hospital deaths (154 long-acting opioid, 60 control deaths; HR, 1.90; 95% CI, 1.40-2.58; risk difference, 67.1; 95% CI, 30.1-117.3) excess deaths per 10,000 person-years. For out-of-hospital deaths other than unintentional overdose (120 long-acting opioid, 53 control deaths), the HR was 1.72 (95% CI, 1.24-2.39) with a risk difference of 47.4 excess deaths (95% CI, 15.7-91.4) per 10,000 person-years. The HR for cardiovascular deaths (79 long-acting opioid, 36 control deaths) was 1.65 (95% CI, 1.10-2.46) with a risk difference of 28.9 excess deaths (95% CI, 4.6-65.3) per 10,000 person-years. The HR during the first 30 days of therapy (53 long-acting opioid, 13 control deaths) was 4.16 (95% CI, 2.27-7.63) with a risk difference of 200 excess deaths (95% CI, 80-420) per 10,000 person-years. CONCLUSIONS AND RELEVANCE: Prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose, with a modest absolute risk difference. These findings should be considered when evaluating harms and benefits of treatment.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Dor Crônica/mortalidade , Analgésicos Opioides/uso terapêutico , Anticonvulsivantes/uso terapêutico , Antidepressivos/uso terapêutico , Doenças Cardiovasculares/mortalidade , Causas de Morte , Overdose de Drogas/mortalidade , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fentanila/efeitos adversos , Fentanila/uso terapêutico , Humanos , Masculino , Metadona/efeitos adversos , Metadona/uso terapêutico , Pessoa de Meia-Idade , Morfina/efeitos adversos , Morfina/uso terapêutico , Oxicodona/efeitos adversos , Oxicodona/uso terapêutico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco
17.
Pain Physician ; 18(3): E307-22, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26000678

RESUMO

BACKGROUND: Available data have shown steady increases of drug overdose deaths between 1992 and 2011. We review evidenced-based recommendations provided by a few prominent North American pain societies and suggest ways on how health providers might help reduce opioid analgesic deaths by implementing these practices. OBJECTIVE: To identify health care providers' roles in reducing opioid analgesic deaths. STUDY DESIGN: A comprehensive review of current literature. METHODS: The review included relevant literature identified through searches of MEDLINE, Cochran reviews, and Google Scholar, PubMed and EMBASE from January 1998 to January 2014. The level of evidence was classified as I (good), II (fair), and III (limited) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). RESULTS: Several practices such as too high doses overall, giving too high doses to opioid naive patients, too fast opioid titration, insufficient use and knowledge of urine drug testing, not updating knowledge of drug metabolism/interactions, and inadequate patient monitoring are associated with higher risks of opioid analgesic deaths. Suboptimal risk stratification of patients, rotation practices, and use of opioids analgesics in chronic noncancer pain are also associated factors. LIMITATIONS: There were a paucity of good evidence studies which show recommendations reduce death. CONCLUSION: Providers should be aware of all associated factors with opiate analgesic deaths and apply the available evidence in reducing opioid analgesic deaths.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Dor Crônica/mortalidade , Overdose de Drogas/mortalidade , Pessoal de Saúde , Analgésicos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/prevenção & controle , Pessoal de Saúde/normas , Humanos , Dor/tratamento farmacológico , Dor/mortalidade , Detecção do Abuso de Substâncias/métodos , Detecção do Abuso de Substâncias/mortalidade , Detecção do Abuso de Substâncias/normas , Estados Unidos/epidemiologia
18.
Curr Pain Headache Rep ; 18(11): 460, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25249422

RESUMO

Deaths from prescription opioid use continue to rise in North America. The main focus to date has been developing strategies to prevent nonintentional (accidental) fatalities, which constitute the majority of opioid deaths across all jurisdictions. Often overlooked is the complex group of individuals whose cause of death was suicide by opioid overdose. Although most opioid prescribing tools focus on identifying risk factors for potential abuse, diversion, and propensity for opioid addiction, physicians who consider prescribing opioids should also screen and optimize chronic pain treatment for patients at risk for suicide.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Suicídio/prevenção & controle , Dor Crônica/mortalidade , Dor Crônica/psicologia , Depressão/complicações , Depressão/etiologia , Overdose de Drogas/mortalidade , Overdose de Drogas/psicologia , Prescrições de Medicamentos , Humanos , América do Norte/epidemiologia , Transtornos Relacionados ao Uso de Opioides/mortalidade , Transtornos Relacionados ao Uso de Opioides/psicologia , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Medição de Risco , Suicídio/psicologia
19.
World J Gastroenterol ; 20(27): 9154-61, 2014 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-25083089

RESUMO

AIM: To systematically characterize specific pain patterns in the most frequent pancreatic diseases. METHODS: Pain in patients with chronic pancreatitis (n = 314), pancreatic cancer (n = 469), and other pancreatic tumors (n = 249) including mucinous (n = 20) and serous cystadenoma (n = 31), invasive (n = 37) and non-invasive intraductal papillary mucinous neoplasia (IPMN; n = 48), low stage (n = 18) and high stage neuroendocrine neoplasia (n = 44), and ampullary cancer (n = 51) was registered and correlated with clinicopathological data. Survival times were estimated by the Kaplan-Meier method. Patients alive at the follow-up time were censored. Survival curves were compared statistically using the log-rank test. RESULTS: Forty-nine point one percent of pancreatic cancer patients revealed no pain, whereas in chronic pancreatitis only 18.3% were pain free. In contrary, moderate/severe pain was registered in 15.1% in pancreatic cancer patients that was increased in chronic pancreatitis with up to 34.2%. Serous cystadenoma was asymptomatic in most cases (58.1%), whereas 78.9% of all mucinous cystadenoma patients suffered pain. In neuroendocrine neoplasia pain was not a key clinical symptom since 64% of low stage neuroendocrine neoplasia and 59% of high stage neuroendocrine neoplasia patients were pain free. Cancer localization in the pancreatic body and patients with malignant pancreatic neoplasms were associated with more severe pain. Tumor grading and stage did not show any impact on pain. Only in pancreatic cancer, pain was directly associated with impaired survival. CONCLUSION: Pancreatic pain depicts different patterns of abdominal pain sensation according to the respective pancreatic disorder and does not allow a unification of the term pancreatic pain.


Assuntos
Dor Abdominal/etiologia , Dor Crônica/etiologia , Limiar da Dor , Neoplasias Pancreáticas/complicações , Pancreatite Crônica/complicações , Dor Visceral/etiologia , Dor Abdominal/diagnóstico , Dor Abdominal/mortalidade , Dor Abdominal/fisiopatologia , Dor Abdominal/psicologia , Distribuição de Qui-Quadrado , Dor Crônica/diagnóstico , Dor Crônica/mortalidade , Dor Crônica/fisiopatologia , Dor Crônica/psicologia , Humanos , Estimativa de Kaplan-Meier , Medição da Dor , Percepção da Dor , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreatite Crônica/diagnóstico , Pancreatite Crônica/mortalidade , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Dor Visceral/diagnóstico , Dor Visceral/mortalidade , Dor Visceral/fisiopatologia , Dor Visceral/psicologia
20.
Transplant Proc ; 46(6): 1978-9, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25131087

RESUMO

For patients with chronic pancreatitis (CP), standard surgical procedures (eg, partial or total resections, drainage procedures) are inadequate treatment options, because they do not confer pain relief and they leave patients prone to brittle diabetes and hypoglycemia. The combination of total pancreatectomy and islet autotransplantation (TP-IAT), however, can create insulin-independent and pain-free states. At our center, from August 2009 through August 2013, 61 patients with CP underwent either open or robot-assisted TP-IAT. The 30-day mortality rate was 0%. The transplanted islet equivalents per body weight ranged from 10,000 to 17,770. In all, 19% of the patients became insulin independent (after a range of 1-24 months); 27% of patients required <10 units of insulin. Moreover, at 12 months after surgery, 71% of the patients were pain free and no longer required analgesics. Our metabolic outcomes could have been even better if most patients had been referred at an earlier disease stage; instead, ∼80% had already undergone surgical procedures, and 91% had abnormal results on preoperative continuous glucose monitoring tests. Only if patients with CP are referred early for a TP-IAT-rather than being subjected to additional inadequate endoscopic and surgical procedures-can insulin-independent and pain-free states be accomplished in most.


Assuntos
Dor Crônica/prevenção & controle , Diabetes Mellitus Tipo 1/cirurgia , Transplante das Ilhotas Pancreáticas , Pancreatectomia , Pancreatite Crônica/cirurgia , Procedimentos Cirúrgicos Robóticos , Adulto , Idoso , Dor Crônica/etiologia , Dor Crônica/mortalidade , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/mortalidade , Feminino , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Pancreatite Crônica/complicações , Pancreatite Crônica/mortalidade , Estudos Retrospectivos , Transplante Autólogo
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