A common theme in recent reporting by the National Pain Report has been the lack of research devoted to chronic pain issues.
While a study in the Clinical Journal of the American Society of Nephrology highlights chronic pain from early stage chronic kidney disease (CKD) and what it calls “the inappropriate use of pain medications”, buried in the press release was this nugget.
More research is needed.
“Given the prevalence of chronic pain and analgesic use in CKD patients, greater attention should be given to devising optimal pain management strategies as a means to improve medication safety and effectively address the health needs of this population,” said lead study author Jeffrey Fink, MD, from the Department of Medicine, University of Maryland School, Baltimore.
An accompanying editorial by Sara Davison, MD, professor, Department of Medicine, University of Alberta, Edmonton, Canada, supports these conclusions. “Currently little is known about the use and safety of analgesics, including opioids, in CKD and the impact of analgesic use on clinically relevant outcomes such as analgesic effect, [health-related quality of life], physical function or adverse events is essentially unexplored,” she notes.
“This work (the research) is an important step in understanding the patterns of analgesic use and misuse [in CKD],” Dr Davison writes.
Pain control in CKD should be handled with a comprehensive approach that includes physical, psychological, and behavioral therapies, according to Dr Davison. Further research on the effectiveness of analgesics for chronic pain in CKD is also needed.
What did the study show?
“We demonstrated that there is a link between pain and patient safety in CKD and that the CKD population warrants closer attention to their pain management such that practitioners can avert clinically significant adverse safety events,” added Dr. Fink.
Although chronic pain is common in end-stage renal disease, less is known about pain in pre-dialysis CKD, and safety may be an issue. Some prescription and over-the-counter analgesics require renal dosing. In addition, non-steroidal anti-inflammatory medications (NSAIDs) are nephrotoxic but may be frequently used for pain in CKD, the authors note.
Dr Fink and colleagues analyzed data from 308 pre-dialysis patients enrolled between 2011 and 2013 in the Safe Kidney Care cohort in Baltimore, Maryland. They assessed pain and analgesic use over the course of 12 months, using self-reported questionnaires. Analgesics were categorized as “drug-related problems” on the basis of their potential for nephrotoxicity and whether the dose was appropriate to the participants’ estimated glomerular filtration rate. NSAIDs were considered drug-related problems regardless of estimated glomerular filtration rate.
Analyses revealed the following statistics.:
- 7% of participants reported chronic pain,
- 72% of them had pain three to four times per week
- Patients with arthritis were more likely to report severe pain as were patients taking 12 or more medications
- Patients aged 65 years and older had lower odds of reporting severe pain
Across the population, the adjusted per patient rate for use of an analgesics with a drug-related problem increased with increasing pain. In addition the likelihood a patient would use an analgesic with a drug-related problem increased as pain increased. Specifically, patients with mild chronic pain were more than three times as likely to receive an inappropriate analgesic.
Participants most commonly used acetaminophen (34%), tramadol (15%), strong opioids (12%), NSAIDs (5%), and codeine (3%). Ibuprofen was the most commonly used NSAID.