Clinical ScienceCross-Country Differences in Pain Medication Before and After Spinal Cord Stimulation: A Pooled Analysis of Individual Patient Data From Two Prospective Studies in the United Kingdom and Belgium
Introduction
Pain and pain-related conditions are recognized as prominent causes of disability worldwide by the Global Burden of Disease Studies.1, 2, 3 Chronic pain is estimated to affect approximately 37% of the population in Belgium4 and 43% in the United Kingdom5 and has a large impact on the economies of every country worldwide. The cost of back pain alone has been estimated at around one-fifth of the total healthcare expenditure in a country or 1.5% of the annual gross domestic product.6 The costs of analgesic medication prescription and pain-related primary care appointments for the management of chronic pain in the United Kingdom have been estimated at approximately £580 million per year,7 while annual costs associated with loss of productivity due to chronic pain have been reported to total £11 billion.8
The pharmaceutical management of pain commonly follows the steps on the World Health Organization (WHO) analgesic ladder.9 The WHO ladder was initially developed for the treatment of cancer pain, but it is applicable to most pain conditions, among which chronic pain management. In brief, step 1 consists of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs). If the pain persists or increases, weak opioids such as codeine would be provided for mild-to-moderate pain (ie, step 2) followed by strong opioids (eg, morphine) for moderate-to-severe pain (ie, step 3). Paracetamol and some NSAIDs can be obtained over the counter (ie, without a prescription) in the United Kingdom, but in Belgium, a prescription is required. Opioids are only available upon receipt of a prescription, except for small doses of weak opioids such as codeine with paracetamol (8/500), which are accessible over the counter in the United Kingdom.10
Spinal cord stimulation (SCS) has been shown to be an effective and cost-effective intervention for the management of chronic pain with neuropathic features.11, 12, 13, 14 Reduction or cessation in the use of opioids following SCS has been reported in several studies.15,16 However, there has been limited research on the role of SCS in facilitating reductions in the use of pharmaceutical therapies in addition to opioids.
The aims of this study are to investigate the use of pharmaceutical agents commonly employed for the management of chronic pain following SCS, explore potential differences in prescription practices between Belgium and UK settings and factors that may affect the use of oral analgesics after implantation of the SCS device.
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Study Design
For this study, individual patient data from two prospective, multicenter studies were used; namely the TRIAL-STIM study (ISRCTN, ISRCTN60778781)17 and DISCOVER study (Clinicaltrials.gov NCT02787265).18 The TRIAL-STIM study was approved by the UK Health Research Authority North East Research Ethics Committee (17/NE/0056). The DISCOVER study protocol was approved by the ethics committee of Universitair Ziekenhuis Brussel (B.U.N. 143201629180). In both studies, written informed consent was
Results
In total, data of 180 patients were analyzed in this study (99 females, 81 males). Baseline characteristics of the patients from the TRIAL-STIM study and DISCOVER study are presented in Table 1.
Discussion
For more than a decade, physicians have been confronted with the negative long-term impact of opioids in terms of analgesic tolerance, hyperalgesia, or drug dependence.22 Additionally, the use of other types of pain medication is not without risk either since misuse and dependency problems with benzodiazepines or gabapentinoids have been reported.23,24 Awareness has increased of the risk of gastrointestinal and cardiac adverse events caused by NSAIDs use in the chronic pain setting.25 Moreover,
Conclusions
Our combined analysis revealed differences in prescription practices between Belgium and the United Kingdom, in patients scheduled for SCS implantation. More specifically, NSAIDs and neuropathic mood agents are more frequently used in the United Kingdom compared to Belgium, while the reverse is observed for benzodiazepines. A possible explanation for the increased use of NSAIDs in the United Kingdom can be found in the “self-care strategy” with direct access to this type of medication without
Authorship Statements
Lisa Goudman, Rui V. Duarte, Sam Eldabe, and Maarten Moens were responsible for the conceptualization of the study. All authors were responsible for the data collection, formal analysis, methodology and writing, and reviewing and editing of the manuscript. All authors approved the final version of the manuscript.
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Neuropathic pain: From actual pharmacological treatments to new therapeutic horizons
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2024, American Journal of Hospice and Palliative Medicine
Source(s) of financial support: The TRIAL-STIM study was funded by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) program (project number: PB-PG-0815-20028). DISCOVER was funded by Medtronic Europe SARL that provided a research grant.
Conflict of Interest: Rui V. Duarte has received consultancy fees from Medtronic Ltd, Boston Scientific Corp, Mainstay Medical, and Saluda Medical. Sam Eldabe has received consultancy fees from Medtronic Ltd, Mainstay Medical, Boston Scientific Corp, and Abbott. His department received research funding from the National Institute of Health Research, Medtronic Ltd, and Nevro Corp. Maarten Moens has received speaker fees from Medtronic and Nevro. STIMULUS received independent research grants from Medtronic. The remaining authors have no conflicts of interest to report.
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These authors contributed equally to this study.