[Comment] Why do people not take life-saving medications? The case of statins

Several clinical trials have shown that statins reduce myocardial infarction, strokes, revascularisation procedures, and deaths from cardiovascular causes,1 with only a small excess in muscle pain or weakness.2 On the basis of a retrospective analysis of a database, Zhang and colleagues3 reported that about 20% of individuals taking a statin stopped because of suspected side-effects. Of these, 35% restarted statin treatment and more than 90% tolerated statins,3 indicating that the reasons for stopping medications were unrelated to statins in most cases.

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[Correspondence] Titrated doses are optimal for opioids in pain trials

We read with interest the study by Sameer Pathan and colleagues (May 14, p 1999),1 which compared the non-steroidal anti-inflammatory drug (NSAID) diclofenac, intravenous morphine (0·1 mg/kg), and paracetamol in patients with renal colic. The investigators concluded that diclofenac offered the most effective analgesia. However, the way that opioids were administered was far from optimal and created a clear disadvantage in the morphine group, which precludes any definite conclusion. The choice of the appropriate dose of NSAID is simple because there is a ceiling effect; lower doses are recognised to be as efficient as higher doses.

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[Correspondence] Titrated doses are optimal for opioids in pain trials – Authors' reply

Bruno Riou and Frédéric Aubrun accurately summarised the key advantages of intramuscular non-steroidal anti-inflammatory drugs (NSAIDs) over intravenous opioids, as shown by the results of our randomised clinical trial.1 A standardised single dose of NSAID provides a ceiling effect, does not have a cumulative dose effect, and is associated with minimal adverse effects. By contrast, opioids are associated with enormous variability in their effect between individuals, demanding a personalised tailored approach to analgesia.

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Comparison of Clinical and Radiographic Outcomes in Patients Receiving Single-Level Transforaminal Lumbar Interbody Fusion With Removal of Unilateral or Bilateral Facet Joints

Study Design. A retrospective cohort study. Objective. The objective of this study is to compare the radiographic and clinical outcomes of transforaminal lumbar interbody fusion (TLIF) with bilateral facetectomy (BF) versus unilateral facetectomy (UF). Summary of Background Data. BF is a surgical technique utilized with the intent of creating a greater degree of segmental lordosis than UF alone. However, the clinical benefits of this technique have not been defined. We seek to determine whether a difference exists between bilateral versus UF during TLIF by utilizing both clinical and radiographic outcome measures. Methods. The electronic medical records of 57 patients who underwent single-level TLIF with either a UF (n = 28) or BF (n = 29) were reviewed. Clinical outcomes were measured through Patient Health Questionnaire-9 (PHQ-9), Pain Disability Questionnaire (PDQ), EuroQol 5 Dimensions (EQ-5D) Health State, and Quality Adjusted Life Year (QALY). Radiographic parameters including disc height and sagittal balance were measured on plain radiographs at 1 year following operation. Results. All radiographic parameters showed no significant differences between the UF and BF cohorts. Segmental lordosis increased significantly in both cohorts. However, there was no significant difference in the increase of segmental lordosis between cohorts. Overall lumbar lordosis did not increase significantly in either cohort. Perioperative complications were also similar between cohorts. PDQ and EQ-5D scores improved significantly in both cohorts at 1 year postoperatively. The BF cohort showed a significantly greater improvement in both EQ-5D (0.1 ± 0.2 vs. 0.3 ± 0.2, P = 0.01) and PHQ-9 scores (-0.8 ± 4.6 vs. 4.6 ± 5.2, P = 0.03) than the UF cohort. The PDQ score improved over the minimally clinical important difference (MCID) of 26 in only the BF cohort. Conclusion. The findings in the present study demonstrate that BF during single-level TLIF improves clinical outcomes to a greater degree than UF without any notable differences in perioperative complications or radiographic measurements. Level of Evidence: 3

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Illicit Substance Use in US Adults With Chronic Low Back Pain

Study Design. A population-based cross-sectional survey. Objective. The aim of this study was to compare the prevalence of illicit drug use among US adults with and without chronic low back pain (cLBP). Summary of Background Data. Although addictive medications, such as opioids and benzodiazepines, are frequently prescribed to patients with cLBP, little is known about illicit drug use among Americans with cLBP. Methods. We used data from the back pain survey, administered to a representative sample of US adults aged 20 to 69 years (N = 5103) during the 2009 to 2010 cycle of the National Health and Nutrition Examination Survey (NHANES). Participants with pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold for at least 3 months were classified as having cLBP (N = 700). The drug use questionnaire was self-administered in a private setting, and included data on lifetime and current use of marijuana or hashish, cocaine, heroin, and methamphetamine. Chi-square tests, one-way analysis of variance, and logistic regression, adjusted for age, gender, race, and level of education, were used for comparisons. Results. About 46.5% of US adults with cLBP used marijuana versus 42% of those without cLBP [Adjusted odds ratio (aOR) 1.36, 95% confidence interval (95% CI) 1.06–1.74]. About 22% versus 14% used cocaine (aOR 1.80, 95% CI 1.45–2.24), 9% versus 5% used methamphetamine (aOR 2.03, 95% CI 1.30–3.16), and 5% versus 2% used heroin (aOR 2.43, 95% CI 1.44–4.11). Subjects with cLBP who reported lifetime illicit drug use were more likely to have an active prescription for opioid analgesics than those without illicit drug use history: 22.5% versus 15.3%, P = 0.018. Conclusion. cLBP in community-based US adults was associated with higher odds of using marijuana, cocaine, heroin, and methamphetamine. Prescription opioid analgesic use was more common in cLBP sufferers with a history of illicit drug use. Level of Evidence: 2

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Is There an Association Between Pain and Magnetic Resonance Imaging Parameters in Patients With Lumbar Spinal Stenosis?

Study Design. A prospective multicenter cohort study. Objective. The aim of this study was to identify an association between pain and magnetic resonance imaging (MRI) parameters in patients with lumbar spinal stenosis (LSS). Summary of Background Data. At present, the relationship between abnormal MRI findings and pain in patients with LSS is still unclear. Methods. First, we conducted a systematic literature search. We identified relationships of relevant MRI parameters and pain in patients with LSS. Second, we addressed the study question with a thorough descriptive and graphical analysis to establish a relationship between MRI parameters and pain using data of the LSS outcome study (LSOS). Results. In the systematic review including four papers about the associations between radiological findings in the MRI and pain, the authors of two articles reported no association and two of them did. Of the latters, only one study found a moderate correlation between leg pain measured by Visual Analog Scale (VAS) and the degree of stenosis assessed by spine surgeons. In the data of the LSOS study, we could not identify a relevant association between any of the MRI parameters and buttock, leg, and back pain, quantified by the Spinal Stenosis Measure (SSM) and the Numeric Rating Scale (NRS). Even by restricting the analysis to the level of the lumbar spine with the most prominent radiological “stenosis,” no relevant association could be shown. Conclusion. Despite a thorough analysis of the data, we were not able to prove any correlation between radiological findings (MRI) and the severity of pain. There is a need for innovative “methods/techniques” to learn more about the causal relationship between radiological findings and the patients’ pain-related complaints. Level of Evidence: 2

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Codeine shopping behavior in a retrospective cohort of chronic non-cancer pain patients: incidence and risk factors

Codeine is a widely used opioid analgesic but studies on its misuse in chronic non-cancer pain (CNCP) are still lacking. The aim of this study was to assess the incidence of codeine shopping behavior in CNCP patients and to identify the associated risk factors. This was a population-based retrospective cohort study from the French health insurance claims database from 2004 to 2014. The main outcome was the one-year incidence of codeine shopping behavior defined as ≥1 day of overlapping prescriptions written by ≥2 different prescribers and filled in ≥3 different pharmacies.

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