An Electronic Clinical Decision Support System for the Management of Low Back Pain in Community Pharmacy: Development and Mixed Methods Feasibility Study

Background People with low back pain (LBP) in the community often do not receive evidence-based advice and management. Community pharmacists can play an important role in supporting people with LBP as pharmacists are easily accessible to provide first-line care. However, previous research suggests that pharmacists may not consistently deliver advice that is concordant with guideline recommendations and may demonstrate difficulty determining which patients require prompt medical review. A clinical decision support system (CDSS) may enhance first-line care of LBP, but none exists to support the community pharmacist–client consultation. Objective This study aimed to develop a CDSS to guide first-line care of LBP in the community pharmacy setting and to evaluate the pharmacist-reported usability and acceptance of the prototype system. Methods A cross-platform Web app for the Apple iPad was developed in conjunction with academic and clinical experts using an iterative user-centered design process during interface design, clinical reasoning, program development, and evaluation. The CDSS was evaluated via one-to-one user-testing with 5 community pharmacists (5 case vignettes each). Data were collected via video recording, screen capture, survey instrument (system usability scale), and direct observation. Results Pharmacists’ agreement with CDSS-generated self-care recommendations was 90% (18/20), with medicines recommendations was 100% (25/25), and with referral advice was 88% (22/25; total 70 recommendations). Pharmacists expressed uncertainty when screening for serious pathology in 40% (10/25) of cases. Pharmacists requested more direction from the CDSS in relation to automated prompts for user input and page navigation. Overall system usability was rated as excellent (mean score 92/100, SD 6.5; 90th percentile compared with similar systems), with acceptance rated as good to excellent. Conclusions A novel CDSS (high-fidelity prototype) to enhance pharmacist care of LBP was developed, underpinned by clinical practice guidelines and informed by a multidisciplinary team of experts. User-testing revealed a high level of usability and acceptance of the prototype system, with suggestions to improve interface prompts and information delivery. The small study sample limits the generalizability of the findings but offers important insights to inform the next stage of system development. </jats:sec

Efficacy, safety, and tolerability of antidepressants for pain in adults : overview of systematic reviews

Objective To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition. Design Overview of systematic reviews. Data sources PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022. Eligibility criteria for selecting studies Systematic reviews comparing any antidepressant with placebo for any pain condition in adults. Data extraction and synthesis Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework. Results 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference −5.3, 95% confidence interval −7.3 to −3.3), postoperative pain (−7.3, −12.9 to −1.7), neuropathic pain (−6.8, −8.7 to −4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons). Conclusions Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews—seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions. Systematic review registration PROSPERO CRD42022311073

A lesson in mental health stigma

There is little evidence that knowledge and attitudes toward mental health are improving. This is of particular concern in medical students who must treat patients who are mentally ill with compassion and respect. There is also little evidence for any interventions that are effective in reducing mental health stigma in medical students

The effects of a brief educational intervention on medical students' knowledge, attitudes and beliefs towards low back pain

Background and aims Knowledge, attitudes and beliefs towards low back pain (LBP) can significantly impact a health care provider's clinical decision making. Several studies have investigated interventions designed to change practitioner attitudes and beliefs towards LBP, however no such studies involving medical students have been identified. Methods This study explored medical students' knowledge, attitudes and beliefs towards LBP before and after a brief educational intervention on LBP. Responses from medical students (n = 93) were evaluated before and after a 15-min educational video on back pain. The intervention was developed using Camtasia™ video editor and screen recorder. Knowledge, attitudes and beliefs were measured using the “Modified Back Beliefs Questionnaire“, with items from two previously reported questionnaires on back beliefs. The questionnaire asks participants to indicate their agreement with statements about LBP on a 5-point Likert scale. Preferred responses were based on guidelines for the evidence-based management of LBP. The primary analysis evaluated total score on the nine-inevitability items of the Back Beliefs Questionnaire (“inevitability score”). Results Following the brief intervention there was a significant improvement in the inevitability score (post-workshop mean [SD] 20.8 [4.9] vs pre-workshop mean [SD] 26.9 [4.2]; mean difference (MD) 6.1, p < 0.001; lower score more favourable1) and large improvements in the proportion of students providing correct responses to items on activity (pre: 49% vs post: 79%), bed rest (41% vs 75%), imaging (44% vs 74%) and recovery (25% vs 66%). Conclusions After watching the educational video students' knowledge, beliefs and attitudes towards LBP improved and thus aligned more closely with evidence-based guidelines. Implications Medical doctors are at the forefront of managing low back pain in the community, however there is a need to strengthen musculoskeletal education in medical training programmes. The results from this research suggest educational interventions on back pain do not need to be extensive in order to have favourable outcomes on medical students' knowledge, attitudes and beliefs towards back pain. The translational effects of these changes into clinical practice are not known

Moderators of treatment effect of non-steroidal anti-inflammatory drugs for patients with (sub) acute low back pain:Protocol for a systematic review with individual participant data meta-analysis

A Cochrane review found that non-steroidal anti-inflammatory drugs (NSAIDs) are slightly more effective than placebo on acute and subacute low back pain (LBP) outcomes (pain intensity, disability, and global improvement). Our objectives are: (1) to assess the overall treatment effect of NSAIDs in adults with acute and subacute LBP; (2) to identify the moderation of baseline patients’ characteristics on treatment effect. We will conduct a systematic search of RCTs on effectiveness of NSAIDs compared with placebo in adults with non-chronic LBP in Medline ALL, Embase, Cochrane Central Register of Controlled Trials*. We will screen the records after January 2020, and include eligible RCTs before January 2020 screened by the Cochrane review mentioned above. Our primary outcomes are pain intensity, disability, and health-related quality of life, secondary outcomes are adverse events. Our IPD dataset will consist of the information on each eligible trial characteristics and included variables according to a predefined coding scheme. We will assess risk-of-bias of included RCTs with the Cochrane Risk Of Bias (RoB)-2 assessment tool. We will perform power calculations with closed-form solutions and prioritize a one-stage approach for IPD-MA. For reporting the results, we will adhere to the PRISMA-IPD statement.</p

Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection

Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery

Deprescribing interventions for gabapentinoids in adults: A scoping review

The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non-randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3 months), intermediate (\u3e3 but \u3c12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose-reducing protocols, education and/or pharmacological-based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focused psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area

Adverse outcomes following the provision of opioid therapy for musculoskeletal pain in the emergency department: a systematic review and meta-analysis protocol

Clinical practice guidelines consistently discourage opioid therapy in people with musculoskeletal pain related to any cause. Adverse outcomes related to opioid therapy for pain management have been reported in the literature. The main aim of this review is to summarise the prevalence of continued opioid use, opioid overdose, and serious adverse events following the provision of opioid therapy in or at discharge from emergency departments for the management of musculoskeletal pain