Begin forwarded message:

From: “Joule – a CMA Company” <cma.ca>

Subject: POEM: Nonopioids equivalent to opioids for severe chronic back, hip, or knee pain with fewer adverse outcomes

Date: May 15, 2018 at 4:00:03 AM PDT

To: “Joris Anton Josef Wiggers” <joriswiggers>

Reply-To: cma.ca

View the Web version POEMs Research Summaries Your daily update for the latest Patient Oriented Evidence that Matters Nonopioids equivalent to opioids for severe chronic back, hip, or knee pain with fewer adverse outcomes Clinical question Are opioid medications preferable for improving pain-related function in adults with severe chronic back, hip, or knee pain? Bottom line Nonopioid medications were at least as effective as opioid medications for improving pain-related function over 12 months in adults with severe chronic back pain or knee or hip osteoarthritis pain. The evidence that opioids are NOT superior to nonopioid medications for both chronic and acute pain continues to mount. The tough job will be getting patients and their clinicians to believe the evidence. (LOE = 1b) Reference Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain. The SPACE randomized clinical trial. JAMA 2018;319(9):872-882. Study design Randomized controlled trial (double-blinded) Funding Government Allocation Concealed Setting Outpatient (primary care) Synopsis For decades both patients and clinicians have believed/assumed that opioids are superior for reducing pain and improving function in patients with severe chronic pain. These investigators identified adults with chronic back pain or hip or knee osteoarthritis pain that rated at least moderately severe on a standard pain rating scale and persisted every day for at least 6 months. Patients with severe depression or posttraumatic stress disorder symptoms were NOT excluded. Study participants (N = 240) randomly received assignment (concealed allocation) to either an opioid or nonopioid pain management group. Patients in the opioid group started taking immediate release (IR) oral opioids with escalation to sustained-released (SA) oral opioids and finally to transdermal fentanyl, if needed. Titration continued to a maximum daily dose of 100 morphine-equivalent milligrams. Patients in the nonopioid medication group started with acetaminophen and nonsteroidal anti-inflammatory drugs, with step-up as needed to adjuvant oral medications (eg, amitriptyline, gabapentin) and topical analgesics (eg, capsaicin, lidocaine), and finally to pregabalin, duloxetine, and/or tramadol, if needed. Medication adherence was monitored by urine drug testing and with regular checking of a state prescription monitoring program. Individuals who assessed outcomes remained masked to treatment group assignment. Follow-up rates ranged from 90% to 98% of patients at 12 months. Mean age was 58.3 years (range = 21 – 80 years) and 13% were women. Using intention-to-treat analyses, there was no significant group difference in pain-related function over 12 months based on standard rating scales. Overall, pain intensity was significantly better in the nonopioid group over 12 months. Drop-outs due to adverse medication-related symptoms were significantly higher in the opioid group than in the nonopioid group (19% vs 8%, respectively). No deaths or diversions were detected in either group. Tramadol was dispensed to 11% of patients in the nonopioid group over the 12 months of follow-up. Earn CME Credits Discuss this POEM About Joule • Archives • More CME/CPD • My CME Activities • Ask a Librarian • Send us your comments POEMs stands for Patient-Oriented Evidence that Matters. POEMs is a publication of John Wiley and Sons, Inc. and distributed by Joule as a CMA Member service. All content is provided for information and education and not as a substitute for the advice of a physician. Joule assumes no responsibility or liability arising from any error or omission or from the use of any information contained herein. This email was sent to joriswiggers. POEMs is a daily email newsletter from Joule™, a Canadian Medical Association Company. Unsubscribe from this list. Ensure delivery: Please add cma.ca to your address book or safe-senders list. Privacy Policy | Contact Us Joule.cma.ca Tel (toll free): 1-888-855-2555 Copyright © 1995-2018 John Wiley & Sons, Inc. or related companies. All Rights Reserved. Copyright © 2018 Joule Inc. or its licensors. CMA and Joule are trademarks of the Canadian Medical Association used under licence. Daily POEMs is a trademark of John Wiley & Sons, Inc. used under license.