Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

PICOT Question

Research question posed: In patients with chronic pain, how does prescribing antidepressants and non-steroidal anti-inflammatory drugs (NSAIDs) compared to opiates affect pain relief within 1 year?

Population:

Patients with chronic pain

Intervention:

Antidepressants and NSAIDs

Comparison:

Opiates

Outcome:

Pain relief

Time:

1 year

Review of Literature Overview

Search Terms: “chronic pain,” “opiates,” “NSAIDs,” and “antidepressants.”

Databases: CINAHL, PubMed, SciELO, Embase, and Cochrane.

Total Number of Articles Obtained: 356 articles.

Number of Articles Excluded Based on Abstract: 150 articles.

Number of Articles Excluded Based on Criteria: 170 articles.

Number of Articles Reviewed: 10 articles.

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Inclusion Criteria: Published in English, current within the last seven years, full text article. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Exclusion Criteria: Non-English article, abstract only, published more than seven years ago.

Introduction

Pain can fall under many categories that include neuropathic pain, nociceptive pain, inflammatory pain, and radicular pain amongst others (Beaumont Health, 2023; Chisholm-Burns et al., 2022). This pain can also be described as either acute or chronic. Acute pain is characterized by its briefness—it can last anywhere from a few minutes to approximately six months. Acute pain frequently results from a soft tissue injury or a transient infection, and as a result, it usually goes away after the damage or illness recovers. If an injury does not heal properly or if the pain signals are not processed properly, acute pain from the injury may become chronic pain. The duration of chronic discomfort is greater. It could be continuous or irregular (Beaumont Health, 2023). For instance, even though the pain does not always exist, headaches that last for several months or years can be categorized as chronic pain. A medical issue like arthritis, fibromyalgia, or a problem with the spine is frequently the cause of persistent pain. Pharmacotherapy for pain usually involves non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, or opioid analgesics. The purpose of this paper is to conduct a literature review of evidence supporting the use of antidepressants and NSAIDs as alternatives compared to opioids. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Review of Literature

A database search of current literature was conducted and out of the 36 articles that were found to specifically address the PICOT question, ten (10) are reviewed here. Nine of these were published five years ago or earlier; while only one was published six years ago. Thus the articles are some of the most current that one can retrieve at this point in time. The studies are of quite high value in terms of the levels of evidence because half of them are systematic reviews and meta-analyses that give the highest level of evidence at level I. the rest are randomized controlled trials, cross-sectional studies, and other experimental studies falling at level II or second best evidence. The least number of them are what would be called expert opinion s with low evidentiary value. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

The Future of Pain Treatment and the Wisdom or Not of using Opioid Analgesics

Bhatia et al. (2020) have given their expert opinion on what they believe is the future of pharmacotherapy for back pain, which is usually chronic in nature. Low back pain (LBP) is defined as discomfort that extends from the horizontal gluteal fold to the lower posterior margin of the rib cage. Chronic pain is defined as pain that has persisted for at least three months on most days. They assert that chronic LBP, which affects more than 500,000,000 people worldwide at any given moment, is the main contributor to handicap worldwide. According to these specialists, some of the major causes of LBP include aging, sedentary lifestyles, rising body mass index, smoking, a high co-prevalence of psychosocial dysfunction, and low socioeconomic level. They claim that LBP is a significant driver of health-care expenses and calculate that in the US, this amount exceeds $100 billion yearly.

Da Costa et al. (2021) carried out a systematic review and meta-analysis of randomized clinical trials (RCTs) on the effectiveness of NSAIDs and opioids in treating pain of chronic origin. The goal of the study was to compare the pain-relieving and safety profiles of paracetamol, non-steroidal anti-inflammatory medications (NSAIDs), and opioids for the treatment of knee and hip osteoarthritis. They also had to make sure that these medications could be used safely and effectively at the lowest dosage possible. They looked at major randomised trials that evaluated NSAIDs, opioids, paracetamol (acetaminophen), or placebo for the pharmacological therapy of osteoarthritis pain in people with knee or hip osteoarthritis. Their secondary outcome was physical function, but their primary outcome was pain. The researchers came to the conclusion that the therapeutic benefit of opioid therapy, in any form or dosage, did not justify the potential risks it poses for individuals with osteoarthritis. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Tackling the Opioid Crisis by Reducing Opioid Use

An observational cohort study by Duncan et al. (2018) sought to determine whether the prescription by emergency room clinicians of alternative analgesia to opioids could reduce opioid use. This was in appreciation of the fact that the opioid crisis in the US has reached epidemic proportions and alternatives to opioids need to be used more and more. The aim of this research was to evaluate the usage of opioids in an emergency room after an alternative pain treatment strategy was developed and put into practice. The study examined the impact of implementation on patient satisfaction ratings. The investigation’s final finding was that involved professionals were able to dramatically reduce the usage of IV opioids in the emergency department by adopting an alternative to opioids-first approach and a multimodal therapy approach to pain management. After execution, the patient ratings of happiness continued to be unaltered.

Ostling et al. (2018) looked at the rising opioid crisis in the United States and how it can be mitigated by prescribing less opioids and using alternatives. Their sis an expert opinion that presents hard facts about the opioid crisis and measures practitioners can take. Since the 1990s, overdose deaths from heroin, prescription opiates, and illicitly made fentanyl have tripled in the USA. Several states where there is a higher percentage of synthetic opiate use have been labeled as “high-burden” abuse states. The national fentanyl pandemic occurred at the same time as prescription restrictions were initially put in place across the nation. States started limiting access to FDA-approved opioid drugs as a result of data showing an almost fourfold increase in overdose deaths from over a period of nine years up to 2008. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

The cost of all naloxone formulations has climbed dramatically over the past few years, which, in the opinion of the experts, is another factor aggravating the opioid crisis. In conclusion, they claim that stronger prescribing guidelines and prescription-monitoring mechanisms have been put in place to tackle the opioid pandemic. Additionally, the FDA is focusing heavily on developing abuse-deterrent tactics for all opioid formulations that can contribute to the safety of these drugs.

A systematic review and meta-analysis by Migliorini et al. (2020) examined the drug management of chronic LBP. They claim that the purpose of their current systematic study was to look into the use of pharmacological treatment for persistent LBP. According to the results of their current investigation, baclofen, duloxetine, NSAIDs, and opiates exerted statistically significant benefits for persistent LBP among all tested medications. Thus, they draw the conclusion that, in light of the evidence from the available RCTs, opioids, NSAIDs, and baclofen all reduce pain and impairment in LBP patients. The results must be read carefully and in light of any potential side effects associated with the usage of these medications because the demographics of the patients are varied. They advise conducting another research with a longer follow-up to look into the long-term effectiveness and safety of these drugs. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

NSAIDs and Gabapentinoids for Chronic Lumbar Pain

Yet another systematic review and meta-analysis by Migliorini et al. (2021) investigated the role and effectiveness of NSAIDS and gabapentinoids in relieving lumbar back pain. The researchers claim that there is controversy around the effectiveness as well as safety of gabapentinoids and non-steroidal anti-inflammatory medications (NSAIDs) for persistent LBP. The most efficient and secure class of medications has not yet been identified, and several clinical investigations produced contentious findings. Access was granted to all randomized clinical trials (RCTs) examining the use of NSAIDs and/or gabapentinoids for chronic LBP. Articles written in English, German, Italian, French, or Spanish were acceptable, based on the authors’ language proficiency. Results showed that in selected patients with chronic LBP, selective NSAID outperformed non-selective NSAID and gabapentinoids. These findings are consistent with earlier research that backed the effectiveness of NSAIDs in the treatment of LBP. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Ushida et al. (2020) examined through a cross-sectional observational investigation if there would be patient satisfaction with medications taken orally for chronic pain relief. They carried out a cross-sectional observational study with dispensing pharmacists. 781 individuals who received one NSAID or neuropathic pain (NeP) medication for at least 90 days straight participated in a patient satisfaction survey. Patient satisfaction with analgesics was the main outcome. The improvement of activities of daily living (ADL) and doctor-patient communication were the secondary objectives. In the NSAID and NeP medication groups, the percentages of patients who responded “satisfied if anything” or better for patient satisfaction were 70.0% and 65.2%, respectively. In contrast, 43.3% and 29.4% of patients respectively responded “satisfied”. In comparison to individuals who responded “satisfied if anything” or better, the proportions of patients with improved pain alleviation, improved ADLs, and effective doctor-patient communication were statistically greater. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

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Adjuvant Non-Opioid Analgesia to Reduce Opioid Use

The systematic review and meta-analysis by Zhao et al. (2019) investigated the viability and efficacy of combining opioids with non-opioid analgesics for analgesia in patients in intensive care. They sought to determine the effects of non-opioid analgesics used as adjuvants to opioids on the consumption of opioids and their side effects, as well as the efficacy of analgesics in adult patients in the intensive care unit. For analgesia in the ICU, only randomized clinical trials utilizing non-opioid analgesics were included. In their initial search, 2,271 publications and abstracts were found. 2,256 publications were screened based on their titles and abstracts after duplicates were eliminated. The eligibility of 31 articles’ entire texts was evaluated. Twelve RCTs with a combined subject count of 910 were included. The researchers came to the conclusion that combining non-opioid analgesics with opioid drugs reduced opioid use and negative effects. This would potentially mitigate the opioid crisis.

Another systematic review by Zobdeh et al. (2022) looks at the role that antidepressants and NSAIDs play in pain management. The systematic review provides an overview of the influence of pharmacogenetics on the effectiveness and safety of antidepressants and non-steroidal anti-inflammatory medications (NSAIDs) when used to treat pain. Concerning the human in vivo safety and effectiveness of NSAIDs and antidepressants in pain management strategies that take pharmacogenetic variables into account, a systematic literature search was conducted in accordance with the PRISMA guidelines. Databases from PubMed, Scopus, and Web of Science were used to gather studies. Of the 6,547 entries that were originally discovered, 25 articles were found to be appropriate for consideration. According to the review, NSAIDs and CYP2C9 poor metabolizers are more likely to experience mild to moderate adverse effects. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Cancer Pain

The last systematic review and meta-analysis in this review is by Kane et al. (2017). It was published six years ago looked at the management of cancer pain with opioids that are combined with antidepressants. The goal was to ascertain whether there is an added benefit to using opioids in conjunction with antidepressants or antiepileptic medications to treat cancer pain. The researchers found that when used for neuropathic pain in non-cancer diseases, combining antidepressant or antiepileptic medications with opioids enhanced pain alleviation. However, there isn’t enough evidence to back up their effectiveness in treating cancer pain. There was a need for randomized control trials contrasting opioid analgesia with antidepressant or antiepileptic medications with opioid monotherapy. Data on negative experiences and discomfort were taken out. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

Divergence was evaluated when data were combined using DerSimonian-Laird random-effects meta-analyses. The evaluation comprised seven randomized controlled studies with a total of n=605 subjects. Neuropathic cancer pain, cancer bone pain, and non-specific cancer pain were used to describe the patients’ agony. The meta-analysis included four randomized controlled studies that compared opioid monotherapy to opioid combination treatment with either gabapentin or pregabalin. There was no discernible difference in the groups’ ability to relieve pain, according to the pooled standardized mean difference. In the combo arms, adverse events were more common. Amitriptyline, fluvoxamine, and phenytoin had conflicting information.

Discussion of Resources

The ten resources used to make a case for using NSAIDs and antidepressants compared to opioid analgesics are of a combine high evidentiary value. This is because half of them alone are all systematic reviews and meta-analyses. These provide the highest and best level of evidence according to the pyramid of evidence. The rest are level II evidence articles with only two being expert opinions of low evidentiary value. The resources are also very current with nine of them having been published just five years ago or later. This means the information contained in the articles is still fresh and far from obsolete. The importance of this is that the evidence can then be used without reservations to inform evidence-based practice or EBP.  Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

The resources have also clearly demonstrated that they are addressing with precision the PICOT question posed at the beginning of the clinical inquiry. The question was whether using non-opioid analgesics compared to opioid analgesics affected pain relief (as scored by the patient using scales such as the numerical rating scale or NRS). All of the resources have addressed this in one way or another and in very specific terms. Thus all the resources used in this review are befitting and relevant for the PICOT question.

Conclusion

That practitioners are taking a different approach in pain management for the reason that the opioid crisis is ravaging the US is not in question. A lot of efforts have been put in place to try and forestall opioid addiction, and this includes avoiding prescribing it readily to patients in pain. Currently, enough evidence-based practice approaches are in place to use alternatives to opioids in pain relief and still get the same patient satisfaction rates.  This literature review has evaluated a total of ten articles of quite high combined evidentiary value. The PICOT question set out to establish if indeed there is evidence for the use of NSAIDS and antidepressants as non-opioid alternatives compared to opioid use in pain relief. Indeed, the evidence unearthed in the review show that these can be effective; but that they can also reduce opioid use by being combined with them. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

 References

Beaumont Health (2023). Types of pain. https://www.beaumont.org/services/pain-management-services/types-of-pain

Bhatia, A., Engle, A., & Cohen, S. P. (2020). Current and future pharmacological agents for the treatment of back pain. Expert Opinion on Pharmacotherapy, 21(8), 857-861. https://doi.org/10.1080/14656566.2020.1735353

Chisholm-Burns, M.A., Schwinghammer, T.L., Malone, P.M., Kolesar, J.M., Bookstaver, P.B., & Lee, K.C. (Eds) (2022). Pharmacotherapy principles and practice, 6^th ed. McGraw-Hill Medical.

Da Costa, B.R., Pereira, T.V., Saadat, P., Rudnicki, M., Iskander, S.M., Bodmer, N.S., Bobos, P., Gao, L., Kiyomoto, H.D., Montezuma, T., Almeida, M.O., Cheng, P.S., Hincapié, C.A., Hari, R., Sutton, A.J., Tugwell, P., Hawker, G.A., & Jüni, P. (2021). Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: Network meta-analysis. BMJ, 375(n2321), 1-16.  https://doi.org/10.1136/bmj.n2321

Duncan, R.W., Smith, K.L., Maguire, M., & Stader III, D.E. (2018). Alternatives to opioids for pain management in the emergency department decrease opioid usage and maintains patient satisfaction. The American journal of emergency medicine, 37(1), 38-44. https://doi.org/10.1016/j.ajem.2018.04.043

Kane, C.M., Mulvey, M.R., Wright, S., Craigs, C., Wright, J.M., & Bennett, M.I. (2017). Opioids combined with antidepressants or antiepileptic drugs for cancer pain: Systematic review and meta-analysis. Palliative Medicine, 32(1), 276–286. https://doi.org/10.1177/0269216317711826

Migliorini, F., Maffulli, N., Eschweiler, J., Betsch, M., Catalano, G., Driessen, A., Tingart, M., & Baroncini, A. (2020). The pharmacological management of chronic lower back pain. Expert Opinion on Pharmacotherapy, 22(1), 109–119. https://doi.org/10.1080/14656566.2020.1817384

Migliorini, F., Maffulli, N., Eschweiler, J., Tingart, M., & Baroncini, A. (2021). Non-steroidal anti-inflammatory drugs and gabapentinoids for chronic lumbar pain: A Bayesian network meta-analysis of randomized controlled trials. British Medical Bulletin, 138(0), 85–95 https://doi.org/10.1093/bmb/ldab003

Ostling, P.S., Davidson, K.S., Anyama, B.O., Helander, E.M., Wyche, M.Q., & Kaye, A.D. (2018). America’s opioid epidemic: A comprehensive review and look into the rising crisis. Current Pain and Headache Reports, 22(5), 1-7. https://doi.org/10.1007/s11916-018-0685-5

Ushida, T., Inoue, T., Matsui, D., Yokoyama, M., Shiosakai, K., Takeda, K., Fukuoka, K., Nakagawa, O., & Okuizumi, K. (2020). Cross-sectional study of patient satisfaction with oral analgesics in patients with chronic pain in japan. Expert Opinion on Pharmacotherapy, 21(8), 983-991. https://doi.org/10.1080/14656566.2020.1743267

Zhao, H., Yang, S., Wang, H., Zhang, H., & An, Y. (2019). Non-opioid analgesics as adjuvants to opioids for pain management in adult patients in the ICU: A systematic review and meta-analysis. Journal of critical care, 54, 136-144. -analysis. Journal of Critical Care, 54, 136-144. https://dx.doi.org/10.1016/j.jcrc.2019.08.022

Zobdeh, F., Eremenko, I.I., Akan, M.A., Tarasov, V.V., Chubarev, V.N., Schiöth, H.B., & Mwinyi, J. (2022). Pharmacogenetics and pain treatment with a focus on non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressants: A systematic review. Pharmaceutics, 14(6), 1190 Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

MSN 630 Capstone: Review of Literature Fall 2nd 7weeks 2019
Review of Literature
Components 10 points 5 points 1-2 points

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Introduction to the ROL 10 points
Provide a succinct overview of review of literature.
Orients the reader to what topics will be addressed in this ROL.
Identifies key words and databased used to search the topic.
Does not provide a clear overview of the project. No direction as to what will be accomplished in project. Few to no key words identified. Does not include an introduction; no search words identified, nor any databases used in the search.
Components 20 points 10 points 3 points
Articles
20 points
Identifies the most appropriate current studies to support the proposed project. Current refers to resources in the last 5-7 years with limited exception; includes primary sources
Utilizes out of date references or does not identify seminal research related to topic. Information gathered from a single source
Coverage of Content

20 points Appropriate resources examined and covered in depth; significance of research critiqued.
Major works included but not covered in adequate depth; significance of selected resources discussed. Major works omitted; significance to field not clear;
Analysis of ideas Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper

20 points Clear analysis and synthesis presented; demonstrated insight into problems; conclusions strongly supported Does not succinctly summarize the literature findings. Describes individual studies and does not provide an overall view of the literature findings or recommendations (i.e presents an annotated bibliography rather than a review of the literature); some analysis and synthesis of ideas; discussed the history and relationships among key points found in the literature Did not attempt to synthesize the information or discuss the topic in the broader context of the scholarly literature
Scholarly Writing Components 10 points 5 points 1-2 points
Organization- 10 points
Good organization with clear focus and excellent transition between paragraphs; logical order to presentation of information; paragraphs are well-organized; easy to understand and makes sense. ROL goes from general to specific Adequate organizational style, although flow is somewhat choppy and may wander occasionally; somewhat confusing due to organization of paper or paragraphs. Basic flow of ideas but not all sections follow a logical order Incoherent structure; logic is unclear; paragraph transition is weak; difficult to understand; must re-read parts to figure out what is being said. ROL has no clear direction and subtopics not connected.
Mechanics-10 Skillful use of language; varied, accurate vocabulary; well-developed sentence structure with minimal errors in punctuation, spelling or grammar; appropriate margins, font; correct application of research style format; use of professional active voice; very well-written paper. Some problems with sentence structure, grammar, punctuation, and/or spelling; may have several run-on sentences or comma splices; some errors in citation style; format does not fully comply with assignment guidelines; somewhat difficult to read due to mistakes. 1 point: Many difficulties in sentence structure, grammar, citation style, punctuation, spelling and/or misused words; proper format not used consistently; many errors in citation style very difficult to understand.
0 points: Not written at a graduate level; many mistakes; proper format not used consistently; many errors in citation style; difficult to read and understand.
References-10 Uses sources effectively and documents sources accurately with minimal errors; limited use of direct quotes (No more than 2 or 3); meets reference requirements for assignment; reference list is in correct format. References: minimum of 10 references from peer reviewed sources are required (preferably research based) Some quotes not integrated smoothly into text; several errors with in-text citations or reference list; omitted in-text citations infrequently; missing 2 required references; overuse of direct quotes Quotes are not well integrated into narrative or are significantly overused; paraphrasing is too close to original work. (Minimal errors only; more significant errors will be considered plagiarism – Plagiarism – source material not adequately paraphrased; direct quotes not identified; source material not referenced. Antidepressants And Non-Steroidal Anti-Inflammatory Drugs Discussion Paper