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Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis Publisher Pubmed



Busse JW1, 2, 3, 4 ; Wang L1, 2, 5 ; Kamaleldin M6 ; Craigie S3 ; Riva JJ3, 7 ; Montoya L8 ; Mulla SM3, 9 ; Lopes LC10 ; Vogel N11 ; Chen E12 ; Kirmayr K13 ; De Oliveira K14 ; Olivieri L15 ; Kaushal A1, 3, 16 Show All Authors
Authors
  1. Busse JW1, 2, 3, 4
  2. Wang L1, 2, 5
  3. Kamaleldin M6
  4. Craigie S3
  5. Riva JJ3, 7
  6. Montoya L8
  7. Mulla SM3, 9
  8. Lopes LC10
  9. Vogel N11
  10. Chen E12
  11. Kirmayr K13
  12. De Oliveira K14
  13. Olivieri L15
  14. Kaushal A1, 3, 16
  15. Chaparro LE17
  16. Oyberman I17
  17. Agarwal A3, 18
  18. Couban R1
  19. Tsoi L19
  20. Lam T20
  21. Vandvik PO21
  22. Hsu S3
  23. Bala MM22
  24. Schandelmaier S3, 23, 24
  25. Scheidecker A2, 25
  26. Ebrahim S3
  27. Ashoorion V1, 26
  28. Rehman Y1, 27
  29. Hong PJ28
  30. Ross S3
  31. Johnston BC3, 29
  32. Kunz R24
  33. Sun X3, 5
  34. Buckley N1, 2
  35. Sessler DI30
  36. Guyatt GH3

Source: JAMA - Journal of the American Medical Association Published:2018


Abstract

Importance: Harms and benefits of opioids for chronic noncancer pain remain unclear. Objective: To systematically review randomized clinical trials (RCTs) of opioids for chronic noncancer pain. Data Sources and Study Selection: The databases of CENTRAL, CINAHL, EMBASE, MEDLINE, AMED, and PsycINFO were searched from inception to April 2018 for RCTs of opioids for chronic noncancer pain vs any nonopioid control. Data Extraction and Synthesis: Paired reviewers independently extracted data. The analyses used random-effects models and the Grading of Recommendations Assessment, Development and Evaluation to rate the quality of the evidence. Main Outcomes and Measures: The primary outcomes were pain intensity (score range, 0-10 cm on a visual analog scale for pain; lower is better and the minimally important difference [MID] is 1 cm), physical functioning (score range, 0-100 points on the 36-item Short Form physical component score [SF-36 PCS]; higher is better and the MID is 5 points), and incidence of vomiting. Results: Ninety-six RCTs including 26169 participants (61% female; median age, 58 years [interquartile range, 51-61 years]) were included. Of the included studies, there were 25 trials of neuropathic pain, 32 trials of nociceptive pain, 33 trials of central sensitization (pain present in the absence of tissue damage), and 6 trials of mixed types of pain. Compared with placebo, opioid use was associated with reduced pain (weighted mean difference [WMD], -0.69 cm [95% CI, -0.82 to -0.56 cm] on a 10-cm visual analog scale for pain; modeled risk difference for achieving the MID, 11.9% [95% CI, 9.7% to 14.1%]), improved physical functioning (WMD 2.04 points [95% CI, 1.41 to 2.68 points] on the 100-point SF-36 PCS; modeled risk difference for achieving the MID, 8.5% [95% CI, 5.9% to 11.2%]), and increased vomiting (5.9% with opioids vs 2.3% with placebo for trials that excluded patients with adverse events during a run-in period). Low- to moderate-quality evidence suggested similar associations of opioids with improvements in pain and physical functioning compared with nonsteroidal anti-inflammatory drugs (pain: WMD -0.60 cm [95% CI, -1.54 to 0.34 cm]; physical functioning: WMD -0.90 points [95% CI, -2.69 to 0.89 points]), tricyclic antidepressants (pain: WMD -0.13 cm [95% CI, -0.99 to 0.74 cm]; physical functioning: WMD -5.31 points [95% CI, -13.77 to 3.14 points]), and anticonvulsants (pain: WMD -0.90 cm [95% CI, -1.65 to -0.14 cm]; physical functioning: WMD 0.45 points [95% CI, -5.77 to 6.66 points]). Conclusions and Relevance: In this meta-analysis of RCTs of patients with chronic noncancer pain, evidence from high-quality studies showed that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. Comparisons of opioids with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality. © 2018 American Medical Association. All rights reserved.
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