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Eur J Anaesthesiol 2014; 31:3540

ORIGINAL ARTICLE

Intravenous nonopioid analgesic drugs in chronic low


back pain patients on chronic opioid treatment
A crossover, randomised, double-blinded, placebo-controlled
study
Leonore Wetzel, Markus Zadrazil, Tatjana Paternostro-Sluga, Georg Authried,
Sibylle Kozek-Langenecker and Gisela Scharbert

BACKGROUND Addition of nonopioid analgesic drugs MAIN OUTCOME MEASURES Primary outcome was as
reduces pain and opioid requirements in acute low back pain. follows: VAS pain intensity (0 to 100 mm) at inclusion,
In noncancer chronic low back pain (CLBP), the efficacy of a before and within 30 min after infusion. Secondary outcomes
combined regimen to reduce breakthrough pain has not were as follows: RolandMorris questionnaire, McGill pain
been proven so far. questionnaire and a test panel of physical functioning for
spinal mobility, muscular endurance, balance and coordina-
OBJECTIVE Evaluation of the effects of intravenous (i.v.)
tion. The differences in means of the above assessments
nonopioid analgesic drugs on pain intensity and lumbar
among the groups were analysed.
mobility in CLBP patients on chronic opioid therapy.
RESULTS We found an improvement in VAS from the day of
DESIGN Randomised, placebo-controlled, double blinded,
inclusion to the day of each appointment. We observed no
crossover study.
improvement in pain intensity (VAS) or in any of the physical
SETTING Vienna General Hospital, Austria, from December functioning tests immediately before versus after adminis-
2002 to May 2004. tration of the four i.v. drugs. Reductions in sensory, affective
and cognitive dimensions of the McGill pain questionnaire
PATIENTS Thirty-six adults with CLBP on chronic opioid
were statistically significant in the diclofenac group. A trend
therapy. Inclusion criteria are as follows: American Society
of McGill pain questionnaire improvement existed in the other
of Anesthesiologists physical status less than 3, visual
groups.
analogue scale (VAS) more than 4 and no known allergy to
any of the used drugs. CONCLUSION The present data show that the anti-
cipation of an i.v. infusion of nonopioid analgesic drug
INTERVENTION After written informed consent and VAS
improves VAS significantly, probably through expectation-
assessment, any oral nonopioid analgesic drug (NSAIDs,
related mechanisms. However, single dose i.v. infusions of
metamizol, paracetamol) was replaced by placebo 10 days
nonopioid analgesic drugs fail to improve pain intensity and
before the first test infusion as a washout period.
spinal mobility in CLBP patients on chronic opioid treatment,
Coanalgesics (anticonvulsants, antidepressants) were main-
even immediately after the infusion.
tained. Each patient received randomly four i.v. test infusions
of diclofenac 75 mg (and orphenadrine 30 mg), parecoxib Published online 17 October 2013
40 mg, paracetamol 1 g and isotonic saline. A washout time
of 72 h was allowed between each infusion.

From the Department of Anaesthesia, Intensive Care and Pain Management (LW, MZ, GA, GS), Department of Physical Medicine and Rehabilitation, Medical University
Vienna (TP-S), Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna (SK-L), Vienna, Austria
Correspondence to Leonore Wetzel, MD, Department of Anaesthesia, Intensive Care and Pain Management, Vienna, Austria
E-mail: leonore.wetzel@meduniwien.ac.at

0265-0215 2013 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e328365ae28

Copyright European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.


This Article Has Been Retracted
36 Wetzel et al.

Background assessed at inclusion. The pain intensity on VAS at


Chronic low back pain (CLBP) is a complex bio-psycho- inclusion was the baseline value.
social problem requiring multidisciplinary and multi-
General exclusion criteria were any additional
modal treatment that includes nonpharmacological
treatment (psychotherapy, orthopaedic aids, physio-
therapy, drugs and self-care.1 In the pharmacological
therapy, acupuncture, use of depot steroids in the last
part of the treatment, rational combinations of
three months), cancer-related pain, positive pregnancy
analgesic drugs with different mechanisms of action
test, American Society of Anesthesiologists (ASA)
are proposed to achieve improved efficacy and safety
physical status at least 3, allergy or contraindications to
compared with equianalgesic doses of single drugs.24
the tested substances, specific inflammatory or progress-
Addition of nonopioid analgesic drugs (NSAIDs, meta-
ive metabolic disorders, fibromyalgia, autoimmune dis-
mizol, paracetamol) reduces pain and opioid requirement
eases, inflammatory rheumatic disorders, radiculopathy,
in cancer pain patients and in acute back pain.57
spinal trauma or vertebral fracture caused by osteoporosis
This approach was adopted for noncancer chronic pain
in the past 6 months, relevant cardiopulmonary restric-
patients.
tions, severe kidney or liver function disorders, acute
Breakthrough pain is highly prevalent in opioid-treated duodenal or ventricular ulcer or psychiatric disorder.
patients with noncancer CLBP compared with cancer
Preexisting nonopioid analgesic drugs (NSAIDs, meta-
groups.7 In the primary care setting in Europe,
mizol, paracetamol) were replaced by oral placebo 10 days
this breakthrough pain in CLBP patients is commonly
before the first test infusion as a washout period and
managed with a series of intravenous infusions of
were maintained until 1 week after the last test infu-
nonopioid analgesics. Patients receive intravenous
sion. Coanalgesics (anticonvulsants, antidepressants) and
infusions over 30 min, for example. During the proce-
opioids were maintained. Medication for the treatment of
dure of intravenous access, patients probably feel
internal comorbidity remained unchanged.
increased attention from the medical staff in comparison
to a normal consultation. After inclusion, four appointments for the study were
fixed. At every appointment, each patient received
Nonopioid analgesic drugs are heterogeneous in pharma-
randomly the test infusions of 250 ml administered over
cology and include nonselective cyclooxygenase (COX)-I
30 min consisting of diclofenac 75 mg (and orphenadrine
and COX-II inhibitors, selective isoenzyme COX-II
30 mg; Neodolpasse; Fresenius Kabi Austria GmbH,
inhibitors, nonselective inhibitors of prostaglandin syn-
Graz, Austria), parecoxib 40 mg (Dynastat; Bristol-Myers
thesis and other mostly unknown mechanisms such as
Squibb, Wien, Austria), paracetamol 1 g (Paracetamol;
paracetamol (acetaminophen).8 The aim of the present
Bristol-Myers Squibb, Wien, Austria; acetaminophen)
study was to evaluate the effect of nonopioid analgesic
and normal saline (placebo). The sequence of test
drugs on breakthrough pain intensity and lumbar
infusions was assigned randomly using a computer-
mobility in CLBP patients on chronic oral sustained-
generated table. The time interval between test infusions
release opioid therapy.
was 72 h. The elimination half-life for the chosen drugs
are 1 to 2 h for diclofenac and paracetamol, 8 h for
parecoxib and 17 h for the muscle relaxant orphenadrine.
Materials and methods
After four times the half-life value, more than 90% of the
Ethics
drugs are eliminated and so we calculated elimination as
Ethical approval for this study (Ethical Committee N8
four times the longest half-life of 17 h; this equals 68 h.
411/2002) was provided by the Ethical Committee of the
To make the planning easier, we waited 3 days between
Medical University of Vienna, Austria on 9 December
each infusion. Patients and observers were blinded to the
2002.
test infusion. The doses of diclofenac, parecoxib and
paracetamol represent the manufacturers recommended
Data collection was at the pain clinic of the Vienna
dose for single rescue injection. The duration of the test
University Hospital, Austria. After written informed
infusion was standardised at 30 min in order to guarantee
consent, 40 adult male and female consecutive out-
study blinding. This infusion speed represents common
patients were included. The patients were referred from
clinical practice. A pilot study in 10 patients confirmed
their primary care doctor or specialist to our pain manage-
no difference in efficacy between parecoxib infusions
ment department. The patients were aged more than
administered over 30 and 10 min.
19 and less than 65 years with CLBP (at least 6 months) of
intensity at least 4 on a visual analogue scale (VAS) At every appointment, pain intensity on the VAS
according to the Quebec Task Force definition9 on stable and lumbar mobility (tests are described below) were
WHO class II or III medication (at least 4 months). The investigated immediately before and within 30 min after
study design was crossover, randomised, double-blinded each test infusion. Patients assessed their pain intensity
and placebo-controlled. The increase of pain intensity at on VAS (10-cm line, 0 no pain, 10 worst pain imagin-
least VAS 4 was regarded as breakthrough pain and was able) as a primary outcome. A validated German version

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This Article Has Been Retracted
Intravenous nonopioid analgesic drugs in chronic low back pain 37

of the McGill pain questionnaire was used to assess values before each test infusion were assessed using
cognitive, affective and sensory dimensions of pain analysis of variance for repeated measures. Post-hoc
(PRI pain rating index, total number of words chosen comparisons were made by a paired t-test. Differences
to describe pain sensation).10 The cross-cultural between preinfusion and postinfusion values were
adaptation of the RolandMorris questionnaire for assessed using the paired t-test. Data are expressed as
German-speaking patients was used to assess long-term mean  standard deviation (SD); P <0.05 was considered
mean score changes in the functional status (values 0 to statistically significant. Power analysis was performed
24 items chosen).11 based on a two-sided significance level of 5% and a power
of 90%. Forty patients were required to demonstrate a
Patients underwent a clinical examination assessing tests
clinically relevant difference of pain intensity of at least
of physical functioning for spinal mobility, muscular
1.5 cm, which means 15% on VAS between oral WHO
endurance, balance and coordination by the use of the
I medication and pausing of this therapy (0.05 a,
fingertip-to-floor test, lumbar flexibility by the modified
two-tailed; 0.1 b, one-tailed). For the statistical analysis
Schobers test, endurance by the 6-min walk test, coordi-
program, SPSS version 16.0 was used.
nation by the timed up-and-go test and balance by the
functional reach test.
Results
Fingertip-to-floor test Forty patients with a mean (SD) age of 55  12 years, a
The distance from the middle finger to the floor is mean weight of 82  14 kg and a mean height of
determined with a tape during forward bending with 173  9 cm were included. Patients received either weak
the knees, arms and fingers fully extended (normal opioids (n 31) or potent opioids (n 9) on a stable basis
values: maximum 10 cm).12 (at least 4 months). Four patients dropped out without
giving reasons. Personal data are shown in Table 1.
Modified Schobers test
One line is marked in the standing position 5 cm below Table 1 Personal data and the distribution of treatment of chronic
the cranial margin of the sacrum and another line 15 cm low back pain patients by our pain management department
above the first line. The change in the distance between Number of patients
the two lines is measured before and after maximal Men 22
forward bending with the knees extended (normal range: Women 18
5 cm).13 Mean age in years (min to max)  SD 57.2 (25 to 83)  12.8
Antidepressants 17
Anticonvulsant 8
Six-minute walk test Tramadol 31
For the 6-min walk test, patients were asked to walk Morphine 9
Pain diagnosis
rapidly up and down a corridor in our hospital of known
Pseudoradicular lumboischialgia 24
length (30 m) for exactly 6 min. The maximum distance Radicular lumboischialgia 6
achieved was determined. The mean 6-min walk Failed back surgery 8
distance in women was 367 m (range: 249 to 479 m) Scoliosis 1
Vertebral endplate compression 1
and 400 m in men (range: 280 to 532 m).14 Treatment time in our department
1 year 12
Timed up-and-go test 2 years 11
3 years 12
This test measures the time taken to stand up from 5 years 3
a chair, walk around a marker on the floor at a distance 7 Years 2
of 3 m, return to the chair, and sit down (normal Duration of illness (low back pain)
values: 10 s).15 The test assesses spinal mobility and 2 years 4
3 years 8
coordination. 4 years 10
5 years 9
Functional reach test 7 years 5
15 years 4
This test measures the difference between arms length Daily tramadol dose at inclusion date
and maximal forward reach using a fixed base of 200 mg 4
support and is determined with a yardstick (normal range 300 mg 3
depending on age and sex between 30 and 45 cm).16 The 400 mg 14
600 mg 10
test assesses balance and coordination. Mean values of Daily morphine dose at inclusion date
three measurements for each test were determined. 30 mg 1
60 mg 3
120 mg 3
Statistics 180 mg 2
All data were tested for normal distribution using
the KolmogorovSmirnov test. Differences in baseline Twenty five percent of patients were treated with WHO III and 75% with WHO II.

Eur J Anaesthesiol 2014; 31:3540


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This Article Has Been Retracted
38 Wetzel et al.

Fig. 1 an improvement in the VAS score between the day


of inclusion and before drug infusions of 17% for
VAS at inclusion day NaCl, 16% for paracetamol, 19% for parecoxib and
VAS before infusion 19% for diclofenac orphenadrine. As shown in Fig. 1,
VAS after infusion the improvement in pain intensity on the VAS after
the nonopioid administration is insignificant. Table 2
10 shows the data of the functional tests for spinal mobility,
** * ** * ** ** ** **
9
muscular endurance, balance and coordination. None of
8
the tests improved significantly after the administration
7
of the infusions. A significant improvement in the total
number of words chosen (PRI) to describe pain sensation
VAS (cm)

6
in sensory, affective and cognitive dimensions of the
5
McGill pain questionnaire was found in the diclofenac
4
group as shown in Fig. 2. As also shown in Fig. 2, there
3
was only an insignificant trend of sensory pain improve-
2
ment in the other groups. The RolandMorris disability
1
questionnaire showed no statistically significant change
0
Diclofenac+
in functional outcome over time (13.6  5.1 before and
NaCI Paracetamol Parecoxib orphenadrine 14.8  5.2 after four cross-over infusions).

Pain intensity on visual analogue scale (VAS) at inclusion day, and


before and after the test infusions. The figure shows statistically Discussion
significant improvements in pain intensity between values at the We found a highly significant improvement in pain
inclusion day and administration days, but not between the values intensity on VAS from baseline (at inclusion) to all days
immediately before and after administration of infusions. Statistically
significant compared with baseline (P <0.001). Statistically significant of infusion. This indicates that the anticipation of getting
compared with baseline (P <0.01). an intravenous infusion improved VAS significantly,
probably through expectation-related mechanisms as
described in a work of Benedetti et al.17 These expec-
Test infusions were administered intravenously for tations of additional care activate endogenous opioids and
30 min without any complications such as pain at the change the pain modulation network. Benedetti et al.17
intravenous injection site or along the vein. The mean showed that destruction of the prefrontal lobes in
treatment time in our department and the time of illness Alzheimer patients leads to a loss of endogenous
are shown in Table 1. expectation and placebo mechanisms. These losses make
an analgesic treatment less effective and more difficult.
The mean baseline value of pain intensity of the Several other studies have demonstrated a positive effect
study population at inclusion was 6.5  1.3 cm on VAS. of placebo and expectation in irritable bowel syndrome,
Immediately before infusion of the first analgesic chronic neuropathic pain and psychiatric patients.1820
drug, the mean VAS value was 4.8  2.0 cm for NaCl, If the appointment itself improves the patients pain
4.9  2.0 cm for paracetamol, 4.6  2.0 cm for parecoxib intensity, it should be used as part of the treatment rather
and 4.6  2.0 cm for diclofenac orphenadrine. After the than giving additional NSAID infusions. Side-effects of
test infusions, pain intensity on the VAS scale was nonopioids are well known.
5.1  2.1 cm for NaCl, 5.1  2.1 cm for paracetamol,
4.5  2.0 cm for parecoxib and 4.5  2.0 cm for diclofe- Our data also show that additional nonopioids do not
nac orphenadrine. This is shown in Fig. 1. The relieve breakthrough pain as expected. All infusions
significant improvement in pain intensity on the VAS failed to improve pain intensity on VAS, spinal mobility
scale is clearly visible in the boxplot graph. There was and physical functioning in CLBP patients on stable

Table 2 Functional tests before and after the test infusions

Diclofenac R
NaCl Paracetamol Parecoxib orphenadrine
Before After Before After Before After Before After
Fingertip-to-floor 26.7  12.0 27.9  13.0 29.6  11.4 27.3  2.5 28.3  12.4 28.4  13.3 27.0  10.8 27.0  12.3
distance (cm)
Schobers test (cm) 19.9  1.7 19.7  1.9 20.1  1.8 20.2  2.4 19.9  1.7 19.9  1.9 20.3  1.7 20.3  1.8
Timed up-and-go test (s) 11.9  4.8 11.4  4.5 11.1  3.9 11.2  4.1 12.1  4.8 11.7  4.6 11.3  3.9 11.3  3.8
Functional reach test (cm) 85.0  12.0 84.5  11.8 84.9  11.0 85.4  11.4 84.9  11.4 85.4  10.8 83.4  8.3 84.4  9.6
Six-minute walk test (m) 383  117 398  120 379  116 376  128 374  132 390  127 398  120 381  109

Data are mean  SD. There were no statistically significant differences.

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Intravenous nonopioid analgesic drugs in chronic low back pain 39

Fig. 2 patient-oriented questionnaires may be the most


important tools clinicians have at their disposal to identify
PRI before infusion the effectiveness of different low back pain therapies.25,26
PRI after infusion Furthermore, tests of physical functioning may help
25
patients to focus on their functional ability rather than
* symptoms when attempting to document progress.
At the same time, interaction between the patient and
20
the medical staff is more intense when functional tests
and questionnaires are used and could have a benefit
15
on the patients psychological well being. The set of
PRI

validated tests used in the present study proved


10 useful to measure spinal mobility, muscular endurance,
balance and coordination. Performance of these physical
5 examinations and questionnaires was completed within
20 min. The present data show a statistically significant
0 improvement in the total number of words chosen in the
Diclofenac+ McGill Pain Questionnaire (PRI) only after diclofenac
NaCI Paracetamol Parecoxib
orphenadrine
administration. We observed an insignificant improve-
Total number of items/words chosen in the McGill pain Questionnaire ment in psychological well being after the other
(PRI pain rating index) before and after the test infusions. nonopioid infusions (Table 1). We do not have any
Statistically significant (P <0.05).
explanation for the improvement only in the diclofenac
group.
One limitation of our study is the sample size. A larger
sample would allow subgroup analyses for differences
opioid therapy (Table 2). Even repeated administration
between patients with either weak or strong opioids.
of nonopioid analgesics after three cross-over sessions
Without subgroup analysis, the inclusion of patients with
showed no benefit (Table 2). Sometimes, the pain on
strong and weak opioids is a shortcoming of this study.
VAS increased after infusion as in the NaCl and
In addition, we did not perform tests of physical func-
paracetamol groups (Fig. 1). There is no explanation
tioning at the date of inclusion, which is also a limitation
for an increase in VAS after infusion, but the pain relief
of this study. However, our primary goal was not to
of the expectations lasted for the full study period.
analyse any expectation-related mechanisms. We only
Back pain is a common and very costly condition found this interesting outcome at the end of our evalua-
associated with disability and absence from work.2,21 tion.
Chapman et al.2 even call it the Sisyphus of challenges
for the clinician. National guidelines for the manage- Conclusion
ment of low back pain recommend the use of NSAIDs as Our study enforces the theory that CLBP is a complex
one option for symptomatic relief in the early stage to bio-psycho-social problem requiring multidisciplinary
prevent disability and to support early return to normal and multimodal treatment. The positive effect of the
activities.1,7,22 There is strong evidence that various expectation-related mechanisms could be a helpful
types of NSAIDs are equally effective in acute pain.22,23 tool in the treatment of CLBP patients to reduce
However, there is low-quality evidence that NSAIDs are pain intensity. Further studies need to confirm these
more effective than placebo.24 In a recent review, Roelofs placebo and expectation-related mechanisms. Our find-
et al.23 suggest that NSAIDs are effective for short-term ings challenge the usefulness of repetitive intravenous
symptomatic relief in patients with acute and CLBP infusions with nonopioid analgesic drugs in CLBP
without sciatica. requiring stable long-term opioid therapy.
This Sisyphus of challenges often leads to the
practice of giving a patient infusions that are not always Acknowledgements relating to this article
evidence-based. Nonopioid analgesic drugs remain the Assistance with the study: Dr Paul Nilges, Chair of the Pain Center
most frequently prescribed medications worldwide and in Mainz, helped the authors with some literature and inter-
are widely used for patients with low back pain at various pretation.
stages of the disease.22 Financial support and sponsorship: this work was financially
supported by the Department of Anesthesiology, General Intensive
The goals of pain treatment in CLBP are to relieve pain Care and Pain Control, Vienna Medical University, Vienna, Austria.
and to enable patients to start physiotherapy and
Conflicts of interest: none.
rehabilitation, work and normal activities.1,2 Pain syn-
drome-specific tests of physical functioning together with Presentation: none.

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40 Wetzel et al.

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