Evidence-Based Guidance on Safe, Effective Use of Analgesics

June 3, 2013

New in the non-specialty journals: Major reviews on pain relief (NSAIDs and opioids) and further reflections on judging some procedures unnecessary and overused.

Last week's articles on rheumatology topics in the major nonspecialty journals


Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trialsLancet, May 30, 2013, online first, Free

High-dose non-steroidal anti-inflammatories: painful choicesLancet, May 30, 2013, online first, $31.50

This meta-analysis examined 754 trials of NSAIDs versus placebo or another NSAID, with outcomes of major vascular events, major coronary events, stroke, mortality, heart failure, and upper GI complications. For every 1,000 patients taking a coxib or diclofenac for a year, it concluded, three more had major vascular events, one of which was fatal, than among the same number taking placebo.

A commentary says that naproxen seems like a good choice for patients at high risk of cardiovascular disease, but that the concomitant use of antiplatelet agents or warfarin would increase bleeding risks. It favors offering patients non-drug options(heat and cold, exercise, and weight los)s, and reserving NSAIDs for those who receive significant benefit and understand the risks.

Therapeutics: Opioids for chronic non-cancer painBMJ, May 29, 2013, $30

For patients at high risk of complications with NSAIDs, opioids may actually have fewer risks, say the German and Australian clinicians who review the latest evidence on opioids, including osteoarthritis and other orthopedic pain. Proponents claim that opioids are underused, they say, but lack of good scientific data has hindered the formulation of evidence-based guidelines. (Most randomized trials were funded by industry, and were of short duration.) Opioids have some effectiveness, particularly in neuropathic pain, but the risk/benefit profile has usually relegated them to second- or third-line treatment. For non-neuropathic pain, the data are “even less encouraging.” Physician error in starting patients on high doses, or rapid escalation, are notable causes of death.

Practice Standards

Overuse of Health Care Services: When Less Is More . . . More or LessJAMA Intern Med, May 27, 2013, $30

The American College of Rheumatology contributed “Five Things Physicians and Patients Should Question” to the Choosing Wisely campaign, which is trying to prevent overuse of health care services. For example, it advised not to repeat routine DXA scans more often than every two years. These lists, however, are “a loose collection of services joined only by the broad notion that they should not be delivered,” says this article. The authors suggest red flags for “overuse”:

1. Harms exceed benefits.

2. Costs exceed benefits. (For instance, DXA costs $70 per scan but has no benefit for low-risk women.)

3.  Patients don't judge that the the increase in survival or other benefit is sufficient to justify the cost in reduced quality of life.