Opioids for low back pain Deyo, Richard A; Von Korff, Michael; Duhrkoop, David
BMJ,
01/2015, Letnik:
350, Številka:
jan05 10
Journal Article, Book Review
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Back pain affects most adults, causes disability for some, and is a common reason for seeking healthcare. In the United States, opioid prescription for low back pain has increased, and opioids are ...now the most commonly prescribed drug class. More than half of regular opioid users report back pain. Rates of opioid prescribing in the US and Canada are two to three times higher than in most European countries. The analgesic efficacy of opioids for acute back pain is inferred from evidence in other acute pain conditions. Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care. For chronic back pain, systematic reviews find scant evidence of efficacy. Randomized controlled trials have high dropout rates, brief duration (four months or less), and highly selected patients. Opioids seem to have short term analgesic efficacy for chronic back pain, but benefits for function are less clear. The magnitude of pain relief across chronic non-cancer pain conditions is about 30%. Given the brevity of randomized controlled trials, the long term effectiveness and safety of opioids are unknown. Loss of long term efficacy could result from drug tolerance and emergence of hyperalgesia. Complications of opioid use include addiction and overdose related mortality, which have risen in parallel with prescription rates. Common short term side effects are constipation, nausea, sedation, and increased risk of falls and fractures. Longer term side effects may include depression and sexual dysfunction. Screening for high risk patients, treatment agreements, and urine testing have not reduced overall rates of opioid prescribing, misuse, or overdose. Newer strategies for reducing risks include more selective prescription of opioids and lower doses; use of prescription monitoring programs; avoidance of co-prescription with sedative hypnotics; and reformulations that make drugs more difficult to snort, smoke, or inject.
The objective of this study was to identify barley leaf proteins differentially regulated in response to drought and heat and the combined stresses in context of the morphological and physiological ...changes that also occur. The Syrian landrace Arta and the Australian cultivar Keel were subjected to drought, high temperature, or a combination of both treatments starting at heading. Changes in the leaf proteome were identified using differential gel electrophoresis and mass spectrometry. The drought treatment caused strong reductions of biomass and yield, while photosynthetic performance and the proteome were not significantly changed. In contrast, the heat treatment and the combination of heat and drought reduced photosynthetic performance and caused changes of the leaf proteome. The proteomic analysis identified 99 protein spots differentially regulated in response to heat treatment, 14 of which were regulated in a genotype-specific manner. Differentially regulated proteins predominantly had functions in photosynthesis, but also in detoxification, energy metabolism, and protein biosynthesis. The analysis indicated that de novo protein biosynthesis, protein quality control mediated by chaperones and proteases, and the use of alternative energy resources, i.e. glycolysis, play important roles in adaptation to heat stress. In addition, genetic variation identified in the proteome, in plant growth and photosynthetic performance in response to drought and heat represent stress adaption mechanisms to be exploited in future crop breeding efforts.
The objective of the present study was to identify favourable exotic Quantitative Trait Locus (QTL) alleles for the improvement of agronomic traits in the BC2DH population S42 derived from a cross ...between the spring barley cultivar Scarlett and the wild barley accession ISR42-8 (Hordeum vulgare ssp. spontaneum). QTLs were detected as a marker main effect and/or a marker x environment interaction effect (M x E) in a three-factorial ANOVA. Using field data of up to eight environments and genotype data of 98 SSR loci, we detected 86 QTLs for nine agronomic traits. At 60 QTLs the marker main effect, at five QTLs the M x E interaction effect, and at 21 QTLs both the effects were significant. The majority of the M x E interaction effects were due to changes in magnitude and are, therefore, still valuable for marker assisted selection across environments. The exotic alleles improved performance in 31 (36.0%) of 86 QTLs detected for agronomic traits. The exotic alleles had favourable effects on all analysed quantitative traits. These favourable exotic alleles were detected, in particular on the short arm of chromosome 2H and the long arm of chromosome 4H. The exotic allele on 4HL, for example, improved yield by 7.1%. Furthermore, the presence of the exotic allele on 2HS increased the yield component traits ears per m2 and thousand grain weight by 16.4% and 3.2%, respectively. The present study, hence, demonstrated that wild barley does harbour valuable alleles, which can enrich the genetic basis of cultivated barley and improve quantitative agronomic traits.
KEY MESSAGE : Spring growth in barley controlled by natural variation at Vrn-H1 and Vrn-H2 improved yield stability in marginal Syrian environments. The objective of the present study was to identify ...QTL influencing agronomic performance in rain-fed Mediterranean environments in a recombinant inbred line (RIL) population, ARKE derived from the Syrian barley landrace, Arta and the Australian feed cultivar, Keel. The population was field tested for agronomic performance at two locations in Syria for 4 years with two sowing dates, in autumn and winter. Genotypic variability in yield of the RIL population was mainly affected by year-to-year variation presumably caused by inter-annual differences in rainfall distribution. The spring growth habit and early flowering inherited from the Australian cultivar Keel increased plant height and biomass and improved yield stability in Syrian environments. QTL for yield and biomass coincided with the map location of flowering time genes, in particular the vernalisation genes Vrn-H1 and Vrn-H2. In marginal environments with terminal drought, the Vrn-H1 allele inherited from Keel improved final biomass and yield. Under changing climate conditions, such as shorter winters, reduced rainfall, and early summer drought, spring barley might thus outperform the traditional vernalisation-sensitive Syrian landraces. We present the ARKE population as a valuable genetic resource to further elucidate the genetics of drought adaptation of barley in the field.
The relationship between mental and physical disorders is well established, but there is less consensus as to the nature of their joint association with disability, in part because additive and ...interactive models of co-morbidity have not always been clearly differentiated in prior research.
Eighteen general population surveys were carried out among adults as part of the World Mental Health (WMH) Survey Initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). Chronic physical conditions (arthritis, heart disease, respiratory disease, chronic back/neck pain, chronic headache, and diabetes) were ascertained using a standard checklist. Severe disability was defined as on or above the 90th percentile of the WMH version of the World Health Organization Disability Assessment Schedule (WHODAS-II).
The odds of severe disability among those with both mental disorder and each of the physical conditions (with the exception of heart disease) were significantly greater than the sum of the odds of the single conditions. The evidence for synergy was model dependent: it was observed in the additive interaction models but not in models assessing multiplicative interactions. Mental disorders were more likely to be associated with severe disability than were the chronic physical conditions.
This first cross-national study of the joint effect of mental and physical conditions on the probability of severe disability finds that co-morbidity exerts modest synergistic effects. Clinicians need to accord both mental and physical conditions equal priority, in order for co-morbidity to be adequately managed and disability reduced.
To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches.
A probability sample of US adults (n = 5,692) was ...interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers. Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning.
Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio OR 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches.
Comorbidity is an important factor in understanding disability among persons with headache.
Both effective and ineffective interventions used treatment guidelines, patient education, and screening for depression. The interventions that consistently improved patient outcomes incorporated ...some form of case management with specialist support.
Summary
Aim To provide estimates of actual costs to deliver health care to patients with functional bowel disorders, and to assess the cost impact of symptom severity, recency of onset, and ...satisfaction with treatment.
Methods We enrolled 558 irritable bowel (IBS), 203 constipation, 243 diarrhoea and 348 abdominal pain patients from primary care and gastroenterology clinics at a health maintenance organization within weeks of a visit. Costs were extracted from administrative claims. Symptom severity, satisfaction with treatment and out‐of‐pocket expenses were assessed by questionnaires.
Results Average age was 52 years, 27% were males, and 59% participated. Eighty percent were seen in primary care clinics. Mean annual direct health care costs were $5049 for IBS, $6140 for diarrhoea, $7522 for constipation and $7646 for abdominal pain. Annual out‐of‐pocket expenses averaged $406 for treatment of IBS symptoms, $294 for diarrhoea, $390 for constipation and $304 for abdominal pain. Lower gastrointestinal costs comprised 9% of total costs for IBS, 9% for diarrhoea, 6.5% for constipation and 9% for abdominal pain. In‐patient care accounted for 17.5% of total costs (15.2% IBS).
Conclusion Costs were affected by disease severity (increased), recent exacerbation of bowel symptoms (increased), and whether the patient was consulting for the first time (decreased).
CONTEXT.— There is little information on the extent of persistent pain across
cultures. Even though pain is a common reason for seeking health care, information
on the frequency and impacts of ...persistent pain among primary care patients
is inadequate. OBJECTIVE.— To assess the prevalence and impact of persistent pain among primary
care patients. DESIGN AND SETTING.— Survey data were collected from representative samples of primary care
patients as part of the World Health Organization Collaborative Study of Psychological
Problems in General Health Care, conducted in 15 centers in Asia, Africa,
Europe, and the Americas. PARTICIPANTS.— Consecutive primary care attendees between the age of majority (typically
18 years) and 65 years were screened (n=25916) and stratified random samples
interviewed (n=5438). MAIN OUTCOME MEASURES.— Persistent pain, defined as pain present most of the time for a period
of 6 months or more during the prior year, and psychological illness were
assessed by the Composite International Diagnostic Interview. Disability was
assessed by the Groningen Social Disability Schedule and by activity-limitation
days in the prior month. RESULTS.— Across all 15 centers, 22% of primary care patients reported persistent
pain, but there was wide variation in prevalence rates across centers (range,
5.5%-33.0%). Relative to patients without persistent pain, pain sufferers
were more likely to have an anxiety or depressive disorder (adjusted odds
ratio OR, 4.14; 95% confidence interval CI, 3.52-4.86), to experience
significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41-1.89), and
to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49).
The relationship between psychological disorder and persistent pain was observed
in every center, while the relationship between disability and persistent
pain was inconsistent across centers. CONCLUSIONS.— Persistent pain was a commonly reported health problem among primary
care patients and was consistently associated with psychological illness across
centers. Large variation in frequency and the inconsistent relationship between
persistent pain and disability across centers suggests caution in drawing
conclusions about the role of culture in shaping responses to persistent pain
when comparisons are based on patient samples drawn from a limited number
of health care settings in each culture.
(1) To investigate whether there is an association between obesity and mental disorders in the general populations of diverse countries, and (2) to establish whether demographic variables (sex, age, ...education) moderate any associations observed.
Thirteen cross-sectional, general population surveys conducted as part of the World Mental Health Surveys initiative.
Household residing adults, 18 years and over (n=62 277).
DSM-IV mental disorders (anxiety disorders, depressive disorders, alcohol use disorders) were assessed with the Composite International Diagnostic Interview (CIDI 3.0), a fully structured diagnostic interview. Obesity was defined as a body mass index (BMI) of 30 kg/m(2) or greater; severe obesity as BMI 35+. Persons with BMI less than 18.5 were excluded from analysis. Height and weight were self-reported.
Statistically significant, albeit modest associations (odds ratios generally in the range of 1.2-1.5) were observed between obesity and depressive disorders, and between obesity and anxiety disorders, in pooled data across countries. These associations were concentrated among those with severe obesity, and among females. Age and education had variable effects across depressive and anxiety disorders.
The findings are suggestive of a modest relationship between obesity (particularly severe obesity) and emotional disorders among women in the general population. The study is limited by the self-report of BMI and cannot clarify the direction or nature of the relationship observed, but it may indicate a need for a research and clinical focus on the psychological heterogeneity of the obese population.
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