EFICACIA DE LOS OPIOIDES EN EL TRATAMIENTO DE DOLOR NO ONCOLOGICO. EXISTE EVIDENCIA?

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1 EFICACIA DE LOS OPIOIDES EN EL TRATAMIENTO DE DOLOR NO ONCOLOGICO. EXISTE EVIDENCIA? Oscar A. de Leon-Casasola, MD Professor of Anesthesiology and Medicine Senior Vice-Chair Dept. of Anesthesiology, The Jacobs School of Medicine Chief, Pain Medicine and Professor of Oncology Roswell Park Cancer Institute Buffalo, NY

2 Conflictos de Interes Ninguno

3 Papyrus Ebers the goddess Isis gave the juice of the poppy to Ra, the sun god, to treat his headache 1552 BC

4 Chronic Pain: Prevalence Across Conditions 1 Back Pain Arthritis Pain 28% 26% Diabetic Neuropathy Rheumatoid Arthritis Pain Cancer Pain HIV/AIDS Pain 1.6% 1% 4.5% Prevalence in % 1. CDC and NCHS, 2010

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7 Problem? No differential diagnosis!!! Assumes all conditions that result in low back pain are opioid sensitive.

8 Back Pain Mechanical (somatic) Neuropathic Mixed

9 Back Pain Mechanical (somatic) ú Axial: Bone: osteoporotic Fxs Disc: IDD -> High Risk Vertebral body Disc interface degeneration ú Lateral: Facet arthropathy Muscle: myofascial pain Ligaments: strain Neuropathic ú Disc herniation with nerve root compression Mixed ú Spinal Stenosis

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14 Back Pain- Clinical Approach Back Pain Yes No, or mild Axial? Lateral? Leg Pain below the knee? MRI/CT Negative Leg Pain below the knee? Leg Pain, ONLY Above Knee Radicular v. Radiculopathy Consider IDD Patient may need Prov. Discography Spinal Stenosis Consider Piriformis Syndrome Facet, SI Joint, Myofascial

15 Back Pain Mechanical (somatic) ú Axial: Bone: osteoporotic Fxs -> APAP + NSAIDs/COX-2 + Opioids Disc: IDD -> High Risk - > APAP + NSAIDs/COX-2 + Opioids Vertebral body Disc interface degeneration ->? ú Lateral: Facet arthropathy -> NSAIDs/COX-2 + Opioids + RF MBB Muscle: myofascial pain -> APAP + NSAIDs/COX-2 + patches + PT Ligaments: strain -> PT Neuropathic ú Disc herniation with nerve root compression -> PT -> epidural steroid -> surgery v. pharmacological Rx Mixed ú Spinal Stenosis -> APAP + NSAIDs/COX-2 + Antineuropathics + Opioids + epidural steroid

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19 Chronic Low Back Pain

20 Chronic Low Back Pain

21 FDA Strengthens NSAID Warning for Heart, Stroke Risks July, 2015

22 Chronic Low Back Pain Consequently, based on the evidence, are duloxetine and/or tramadol the only viable options for these patients when considering pharmacological therapy?

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24 Results

25 Results

26 Conclusions from this analysis We did not find substantial differences in effects according to type of opioid, analgesic potency, route of administration, daily dose, methodological quality of trials, and type of funding. Trials with treatment durations of four weeks or less showed larger pain relief than trials with longer treatment duration (P value for interaction = 0.001) The small mean benefit of non-tramadol opioids are contrasted by significant increases in the risk of adverse events. For the pain outcome in particular, observed effects were of questionable clinical relevance since the 95% CI did not include the minimal clinically important difference of 0.37 SMDs, which corresponds to 0.9 cm on a 10-cm VAS.

27 Why do we have this uncoupling from clinic studies and clinical experience?

28 Three situations at play: 1. All these opioid studies evaluated them in a monotherapy format. We do not treat patients like that. 2. The presence of central sensitization makes therapy with opioids not very effective 3. The placebo effect is very strong in pain studies

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30 What can we do?

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34 How about Hip OA The jury is still out

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36 Conclusions There is little evidence the strong-opioids are effective in the treatment of low back pain Caveat, the studies were not clear on the diagnosis that led to the use of opioids AND all of them used opioids as monotherapy However, there is evidence that tramadol may provide some therapeutic benefit There is little evidence that strong-opioids are effective in the treatment of knee or hip osteoarthritis We will need to re-evaluate the use of interventional techniques in light of these findings.