Analgesic efficacy of opioids in chronic pain: recent meta-analyses

Opioids are regularly administered in acute and cancer pain. In chronic non-cancer pain (CNCP), however, their use is controversial. Previous meta-analyses and randomized controlled trials (RCTs) lack methodological homogeneity and comparable data. Here we analysed the maximum analgesic efficacies of opioids and non-opioids compared with placebo, and of physiotherapy and psychotherapy compared with active or waiting-list controls. We screened 3647 citations and included RCTs if treatment duration was at least 3 weeks, data were sufficient for meta-analysis, and criteria for high quality were met. Only 46 studies (10 742 patients) met the criteria. Weighted and standardized mean differences (WMD, SMD) between pain intensities were pooled to conduct separate meta-analyses for each treatment category. At the end of treatment the WMD for pain reduction (100-point scale) was 12.0 for ‘strong’ opioids, 10.6 for ‘weak’ opioids, 8.4 for non-opioids (each vs. placebo), 5.5 for psychotherapy and 4.5 for physiotherapy (each vs. active controls). Dropout rates were high in pharmacological studies. The 95% confidence intervals using the outcomes of control groups did not indicate statistical differences between efficacies of the five interventions. Because not enough eligible head-to-head trials were available, our analysis is limited to adjusted indirect comparisons. The heterogeneity of pre-post pain differences in control groups did not allow the definition of a common comparator. In conclusion, although there were statistically significant differences between maximum treatment efficacies, no intervention per se produced clinically important improvements in average pain intensity. Thus, opioids alone are inappropriate and multimodal treatment programmes may be required for CNCP.

LINKED ARTICLES

This article is part of a themed section on Opioids: New Pathways to Functional Selectivity. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2015.172.issue-2     

Current Therapeutic Approaches to Anorexia Nervosa: State of the Art

Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.     

Attachment and Object Relations in Patients With Narcissistic Personality Disorder: Implications for Therapeutic Process and Outcome

This article presents a therapeutic approach for patients with severe personality disorders, transference‐focused psychotherapy (TFP), a manualized evidence‐based treatment, which integrates contemporary object relations theory with attachment theory and research. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate the tactics and techniques of TFP and how they have been refined for treatment of individuals with NPD. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the interpretation of devalued and idealized representations of self and others, both of which are key components of the compensatory grandiose self that defensively protects the individual from an underlying sense of vulnerability and imperfection.     

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury:design and methodology of a pilot study

Background:Selective serotonergic reuptake inhibitors(SSRIs)are first-line pharmacologic treatments for patients with posttraumatic stress disorder(PTSD),but must be given over extended period of time before the onset of action.The use of SSRIs in PTSD patients with mild traumatic brain injury(mTBI)is problematic since SSRIs could exacerbate post-concussion syndrome(PCS)symptoms.VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD,but overall effectiveness is limited by reduced levels of patient engagement and retention.A previous study from this research group suggested that quetiapine monotherapy,but not risperidone or valproate,could increase engagement in trauma-focused psychotherapy.Methods:We report the study protocol of a pilot study funded under the South-Central Mental Illness Research,Education,and Clinical Center pilot study program from the U.S.Department of Veterans Affairs.This randomized,open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs.treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.Discussion:We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial.Positive efficacy results in a full-scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.     

Palliative and supportive care needs of patients with high-grade glioma and their carers: A systematic review of qualitative literature

Objective

Patients diagnosed with Primary Malignant Glioma (PMG) face substantial challenges with poor prognosis, high symptom burden and care needs. This study aims to collate current literature detailing the supportive and palliative care needs of patients with PMG and their carers, and to subject it to a novel approach of formal evaluation.

Methods

Medline, EMBASE, CINAHL, PsychInfo were searched with core concepts: (1) glioma, (2) high-grade disease, and (3) palliative and supportive care needs. A narrative synthesis approach was undertaken including a quality appraisal of the 21 included studies.

Results

Key themes related to the need for consistent well-delivered information around disease sequelae, treatment, and resources available; health service needs including a key professional identified to coordinate care; the need for psychological and social supports, and clear avenues of communication with treating professionals.

Conclusion

The literature remains limited in the number and quality of evidence with two Level I, eight Level II, and eleven Level III studies. The findings call for improved information, communication and support practices to address the complexity and breadth of needs.

Practice implications

Specialised and individually tailored information, attention to clear, consistent communication and support practices should be incorporated into a future needs-based model of care.     

Comparison of cerebral activation between motor execution and motor imagery of self-feeding activity

Motor imagery is defined as an act wherein an individual contemplates a mental action of motor execution without apparent action. Mental practice executed by repetitive motor imagery can improve motor performance without simultaneous sensory input or overt output. We aimed to investigate cerebral hemodynamics during motor imagery and motor execution of a self-feeding activity using chopsticks. This study included 21 healthy right-handed volunteers. The self-feeding activity task comprised either motor imagery or motor execution of eating sliced cucumber pickles with chopsticks to examine eight regions of interest: pre-supplementary motor area, supplementary motor area, bilateral prefrontal cortex, premotor area, and sensorimotor cortex. The mean oxyhemoglobin levels were detected using near-infrared spectroscopy to reflect cerebral activation. The mean oxyhemoglobin levels during motor execution were significantly higher in the left sensorimotor cortex than in the supplementary motor area and the left premotor area. Moreover, significantly higher oxyhemoglobin levels were detected in the supplementary motor area and the left premotor area during motor imagery, compared to motor execution. Supplementary motor area and premotor area had important roles in the motor imagery of self-feeding activity. Moreover, the activation levels of the supplementary motor area and the premotor area during motor execution and motor imagery are likely affected by intentional cognitive processes. Levels of cerebral activation differed in some areas during motor execution and motor imagery of a self-feeding activity. This study was approved by the Ethical Review Committee of Nagasaki University(approval No. 18110801) on December 10, 2018.     

How narrative source impacts convergence of ratings from the Social Cognition and Object Relations Scale–Global Rating Method with psychotherapy process measures

This study examines the construct validity of the Social Cognition and Object Relations Scale–Global Rating Method (SCORS-G; Westen, 1995; see also Stein & Mulford, 2018) by exploring the degree of convergence across different narrative sources (i.e., early memories [EM] and psychotherapy narratives [PT]) in relation to patient- and therapist-rated psychotherapy process measures. Using a university-based outpatient sample (n = 81), we found limited convergence for SCORS-G ratings across narrative type. First, paired t tests showed that the means for six of the eight SCORS-G dimensions differed significantly between the EM and PT narratives with the majority having a large magnitude of effect. Moreover, despite 29 significant correlations between a SCORS-G dimension and either an alliance or session quality variable, only two of the eight SCORS-G dimensions significantly correlated with the same process variable across narrative type (e.g., patient-rated session depth with SCORS-G Self Esteem [SE] and Identity and Coherence of Self [ICS]). Importantly, the high degree of theoretical coherence in the associations that emerged between the SCORS-G dimensions and the process variables suggest that the lack of convergence was not due to limited validity of the SCORS-G. Instead, the results underscore the importance of multi-method assessment techniques by highlighting that the manner in which a narrative is elicited will impact the object relational content patients provide. Future research and clinical implications related to the SCORS-G, alliance and psychotherapy process are discussed.