Expect analgesic failure; pursue analgesic success

Moore, Andrew; Derry, Sheena; Eccleston, Christopher; Kalso, Eija

doi:10.1136/bmj.f2690

Cited by 245 publications

(150 citation statements)

References 22 publications

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“…29,31 These are of a similar to the numbers needed to treat found with antidepressant or anti-epileptic drugs used to treat chronic painful disorders. 32 The cost per quality adjusted life year (QALY) for some of these treatments are well within cost-effectiveness thresholds usually used by NICE. In spite of this evidence access to such treatments within the National Health Service (NHS) remains patchy.…”

Section: Effectiveness and Cost Effectiveness Of Treatments For Low Bmentioning

confidence: 99%

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Patel

Hee

Mistry

et al. 2016

Programme Grants Appl Res

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Total word count including appendix: 93,499 ii ABSTRACT BackgroundThere is good evidence that therapist delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority. Aim and objectivesOverall aim was to improve the clinical and cost-effectiveness of LBP treatment by providing patients, their clinical advisors, and health service purchasers with better information about which participants are most likely to benefit from which treatment To achieve these objectives required substantial methodological work including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse main effect of interventions and no such interpretations should be made.iii MethodsFirstly, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with >179 participants to share their data with us; some further smaller trials offered to us were also included. Using these trials we developed a repository of individual participant data of therapist delivered interventions for LBP. Using this dataset we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical and cost effectiveness outcomes.We did an ANCOVA to identify potential moderators to apply in our main analyses.Subsequently we developed and applied three methods of subgroup identification; recursive partitioning (interaction trees and subgroup identification based on a differential effect search), adaptive risk group refinement, and an individual participant data indirect network meta-analysis to identify sub-groups defined by multiple parameters. ResultsWe included data from 19 randomised controlled trials with 9,328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small, and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of sub-group identification that we identified. Additionally we explored the application of Bayesian indirect network metaanalysis. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile. ConclusionThese data lack clinical or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas.iv The pooled repository database will serve as a valuable resource to the LBP research community. FundingFunding from the NIHR Programme Grants for Ap...

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Section: Effectiveness and Cost Effectiveness Of Treatments For Low Bmentioning

confidence: 99%

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Patel

Hee

Mistry

et al. 2016

Programme Grants Appl Res

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“…In a one-year cross-sectional, open trial study of 24 unscreened subjects, using an oral KB220Z variant, the following beneficial outcomes occurred: decreased stress; sleep improvement; increased energy; universal well-being; decreased cravings (sugar/carbohydrates); enhancement in mental focus/memory; enhancement in blood sugar levels; decreased food intake; decreased waist circumference; weight loss; decreased blood pressure; enhanced exercise performance; decreased drug-seeking; decreased hyperactivity; and decreased cholesterol levels (Blum, Chen et al, 2006). Although opioid medications effectively treat acute pain and help relieve chronic pain for some patients (Moore, Derry, Eccleston, & Kalso, 2013), their addiction risk presents a dilemma for healthcare providers seeking to relieve suffering, while preventing drug abuse and addiction. Little is currently known about the risk for addiction among patients treated for chronic pain or about how basic pain mechanisms interact with prescription opioids to influence addiction potential.…”

Section: Have We Hatched Dnacustomized Nutrition?mentioning

confidence: 99%

Invited Commentary: In a Genomic Era, Should We Promote Dopamine Homeostasis to Treat Opiate/ Opioid Abuse, Instead of Blocking Brain Dopamine Function?

Blum

Modestino

Waite

et al. 2017

MRAJ

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“…This openness to the ontology of pain and to the insufficiencies of scientific knowledge in total pain was supplemented by a commitment to the emotional accompaniment of patients -'being there' as Saunders so often put it -especially when attempts at analgesic pain relief failed, as they still often do (see Moore et al 2013). And although empathic and intersubjective connection was advocated as a goal of care, its achievement was by no means assumed.…”

Section: Hybridity and Total Pain In Palliative Carementioning

confidence: 99%

Morbid mixtures: Hybridity, pain and transnational dying

Gunaratnam

2014

Subjectivity

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Three stories about diseased and dying migrants in the United Kingdom are at the heart of this paper. Working with these narratives, I investigate the neurobiological, subjective and sociocultural entanglements of disease, pain and dying and the challenges these hybridisations present for attempts to recognise and alleviate suffering. My aim is to show the differential workings of hybridising forces with regard to assumed correspondences and time, as well as the indeterminate and liminal states of subjective experience that disease can amplify. The paper engages with the growing literature on 'social pain' and suggests that social pain is the mortar rather than merely a reflection of the affects and neurology of transnational migrations, loss and social violation. Keywords:Bodies, care, ethics, migrants, neurology, temporality.In the early stages of an on-going project, I sent out a call through palliative care networks in the UK, for stories about transnational dying and care. The first story that I received came from Errol, a music therapist, who described his work with Tony, a Rastafarian and migrant from Jamaica. Tony was in his late sixties and was nearing the end of his life in an urban hospice (all names are pseudonyms). Errol explained how Tony 'on the basis of his beliefs, had refused conventional cancer treatment such as chemotherapy and radiotherapy' and 'was adamant that he did not wish any opiates or western medical painkillers'. When Errol met him for the first time -taking a tambourine, a guitar and a small hand drum to the single-bedded room -Tony was writhing in 'silent agony' in his bed. Errol continued I immediately began playing the guitar trying to match the intensity of his movements and mood with the intention of providing a musical focus that called his attention to the music and away from the pain. Upon hearing this, Tony responded by indicating he wanted the hand drum. For the next hour the sound of improvised rhythmic grooves, Reggae rhythms and various Bob Marley songs could be heard to the delight of staff, floating down the ward as Tony, who proved to be a consummate drummer, played himself into a state of musical transcendence -music, used therapeutically had helped him tap into his own resources of pain management. The session ended and Tony asked for the drum to be left. As I exited, promising to return the following day, he thanked me and smiled saying he felt better…"more like me old self". There was a similar event of shared musical improvisation the next day with Tony's release from pain through music. Because it was a Friday, Errol left the instruments with Tony for the weekend. On his return to the hospice on Monday, a nurse told him that Tony had died on Sunday morning, peacefully and without pain. He had spent much of the previous day singing and playing the drums with his family and friends.Errol's story opens up three crucial matters for my discussion of hybridity at the migrant deathbed in the UK. First, there is the underlying mixing that characterises transna...

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Expect analgesic failure; pursue analgesic success

Abstract: Most analgesic drugs work well but in only a small percentage of people. Andrew Moore and colleagues argue that we need to move away from a focus on average response and seek out what works for each patient

Cited by 245 publications

References 22 publications

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials

Invited Commentary: In a Genomic Era, Should We Promote Dopamine Homeostasis to Treat Opiate/ Opioid Abuse, Instead of Blocking Brain Dopamine Function?

Morbid mixtures: Hybridity, pain and transnational dying

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