NEW YORK—Use of a class of nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase 2 inhibitors (COX-2), such as rofecoxib, before and after knee replacement surgery significantly reduces pain, the consumption of pain killers, and sleep disturbances, and increases the postoperative range of motion of the knee, according to an article in the November 12 issue of the Journal of the American Medical Association (JAMA), a theme issue on pain management.

Lead author Asokumar Buvanendran, M.D., from the Department of Anesthesiology, at Rush University Medical Center, Chicago, presented the findings of the research today at a JAMA media briefing on pain management in New York.

According to background information in the article, controlling postoperative pain after knee arthroplasty (replacement) while reducing opioid (pain medication)-induced adverse effects and improving outcomes remains an important challenge to both anesthesiologists and surgeons.

This study tested the hypothesis that preoperative administration of an inhibitor of COX-2 (an enzyme that causes inflammation and pain), followed by continued postoperative administration, reduces opioid requirements and improves clinical outcomes after total knee arthroplasty (TKA). Patients were randomly assigned to receive 50 mg of oral rofecoxib at 24 hours and 2 hours before TKA, 50 mg daily for 5 days postoperatively, and 25 mg daily for another 8 days, or matching placebo at the same times.

The study, conducted from June 2001 through September 2002, was a randomized, placebo-controlled, double-blind trial at a university hospital that included 70 patients (aged 44 to 77) undergoing TKA.

The researchers found that total analgesic consumption and in-hospital opioid consumption were less in the group receiving rofecoxib compared with the group receiving placebo. According to the authors, "Mean pain score achieved for the knee was lower in the rofecoxib group compared with the placebo group during hospital stay and 1 week after discharge. There was less postoperative vomiting in the rofecoxib group (6 percent) compared with the placebo group (26 percent), as well as a decrease in sleep disturbances compared with the placebo group on the night of surgery and on the first and second days postoperatively." Use of a conventional NSAID during orthopedic surgery may lead to increased bleeding, but with the COX-2 selective inhibitors "there was no intergroup difference in surgical blood loss in this study."

"Knee flexion is an important outcome after TKA. The range of motion was increased in the rofecoxib group compared with the placebo group at discharge and at one month postoperatively, with shorter time in physical therapy to achieve effective joint range of motion. These beneficial effects have important economic implications for reducing the costs". The patients in the "rofecoxib group were more satisfied with analgesia at discharge compared with the placebo group, and the differences persisted at 2-week and at 1-month follow-up."

NEW YORK—Elderly patients with depression can reduce their pain and disability from arthritis by receiving treatment for depression, according to an article in the November 12 issue of the Journal of the American Medical Association (JAMA), a theme issue on pain management.

Lead author Elizabeth H. B. Lin, M.D., M.P.H., of the Center for Health Studies, Group Health Cooperative, Seattle, presented the findings of the research today at a JAMA media briefing on pain management in New York.

Depression and arthritis are disabling and common health problems in late life, according to background information in the article. Depression, with a prevalence of about 16 percent among older persons, is also a risk factor for functional disability and poor health outcomes among arthritis patients. Osteoarthritis is the most common type of arthritis among older adults, with about one-third of individuals older than 65 years experiencing osteoarthritis of the knee, and almost 80 percent of persons having degenerative joint disease after age 70 years. Arthritis is a leading cause of disability for older persons, reduces quality of life, and accounts for one-eighth of all restricted activity days. The combined medical and economic costs associated with arthritis pose a significant public health problem.

This randomized controlled trial (Improving Mood-Promoting Access to Collaborative Treatment [IMPACT]) was performed to assess the effects of improving depression treatment for older adults in primary care settings. The study included 1,801 depressed older adults (60 years or older) and was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1,001 (56 percent) reported coexisting arthritis at baseline.

Participants were randomly assigned to receive usual care or an intervention designed to enhance care for depression using antidepressant medications and/or 6 to 8 sessions of a psychotherapy program called Problem Solving Treatment in Primary Care.

The researchers found that in addition to reduction in depressive symptoms, the intervention group, compared with the usual care group at 12 months, had lower average scores for pain intensity, interference with daily activities due to arthritis, and interference with daily activities due to pain. Overall health and quality of life were also enhanced among intervention patients relative to usual care patients at 12 months.

"From a clinical perspective, current medical treatments cannot cure osteoarthritis nor eliminate arthritis-related pain and disability entirely. Therefore, arthritis management needs to be aimed at decreasing pain, improving function, and enhancing quality of life," the authors write.

NEW YORK—Nearly 13 percent of the U.S. workforce experiences a loss in productive time due to common pain conditions, according to an article in the November 12 issue of the Journal of the American Medical Association (JAMA), a theme issue on pain management. This loss in productive time costs U.S. employers an estimated $61.2 billion per year.

Lead author Walter F. Stewart, Ph.D., M.P.H., Director, Center for Health Research and Rural Advocacy, Geisinger Health System, Danville, Pa., presented the findings of the research today at a JAMA media briefing on pain management in New York. Dr. Stewart was Director of the AdvancePCS Center for Work and Health in Hunt Valley, Maryland, at the time the research was conducted.

Pain is a common human malady that spares no group and often impairs function, according to Dr. Stewart. Pain occurs in a variety of forms, including one-time events such as from injuries, chronic episodic conditions (e.g., migraine headache), and chronic persistent problems (e.g., persistent pain from arthritis, back pain). Common pain conditions appear to have an adverse effect on work, but no comprehensive estimates exist on the amount of productive time lost in the U.S. workforce due to pain.

Stewart and colleagues estimated pain-related lost productive time (absence and reduced performance due to common pain conditions) during a 2-week period and the associated costs due to headache, back pain, arthritis, and other musculoskeletal pain in the U.S. workforce in aggregate and individually for each pain disorder. The researchers used data from the American Productivity Audit (a telephone survey that uses the Work and Health Interview) of working adults between August 1, 2001, and July 30, 2002. The study included a random sample of 28,902 working adults in the United States.

The researchers found that, "Thirteen percent of the total workforce experienced a loss in productive time during a 2-week period due to a common pain condition. Headache was the most common (5.4 percent) pain condition resulting in lost productive time. It was followed by back pain (3.2 percent), arthritis pain (2.0 percent), and other musculoskeletal pain (2.0 percent). Workers who experienced lost productive time from a pain condition lost a mean of 4.6 h/wk. Workers who had a headache had a mean loss in productive time of 3.5 h/wk. Workers who reported arthritis or back pain had mean lost productive times of 5.2 h/wk."

Other common pain conditions resulted in an average loss in productive time of 5.5 h/wk. The majority (76.6 percent) of the lost productive time was explained by reduced performance while at work and not by work absence.

NEW YORK—Progress has been made in understanding pain in infants and children, however these youngest patients do not always receive the pain management they need, according to an article in the November 12 issue of the Journal of the American Medical Association (JAMA), a theme issue on pain management.

Author Richard F. Howard, M.B., F.R.C.A., from the Great Ormond Street Hospital for Children NHS Trust, London, presented his article today at a JAMA media briefing on pain management in New York.

"Although much more about the safe and effective management of pain in children is now known, this knowledge has not been widely or effectively translated into routine clinical practice," Dr. Howard writes. For this report, he analyzed original research studies and reviews that he found through a search of the medical literature from 1966 to 2003. "There is a lack of comparable randomized controlled trials of children's pain management, and consequently there are relatively few published meta-analyses or systematic reviews."

"Commonly used definitions of pain emphasize its personal sensory, emotional, and contextual nature, placing much reliance on an individual's ability to express what he or she feels when in pain. Children, particularly those who are preverbal or with limited cognitive capability, are clearly disadvantaged by this approach." Dr. Howard notes that "a subject of considerable interest recently is the discovery that the experience of pain in early life may lead to long-term consequences. ... Timing, degree of injury, and administered analgesia and its nature may be important determinants of the long-term outcome of infant pain. Chronic pain, including neuropathic pain, is far more common in children than was thought."

"Parents are increasingly recognized as important participants in pain management in hospital settings and as primary caregivers at home. Parents may underestimate and undertreat pain, a particular concern because outpatient surgery is prevalent. Pain assessment tools for use by parents have been designed to help parents recognize pain and guide pain management. Better communication with parents can improve subsequent pain management."

U.S. EMPLOYERS LOSE $61 BILLION A YEAR TO COMMON PAIN CONDITIONS AMONG WORKERS