ArticlePDF Available

Severe chronic low back pain: patient journey from onset of symptoms to strong opioid treatments in Europe

Authors:
  • Institute for Neurosciences, Algesiology and Pediatrics

Abstract and Figures

Aim: We report the first patient roadmap in severe chronic low back pain (cLBP) in Europe, assessing the views of cLBP patients and general practitioners (GPs) who treat cLBP with regard to current cLBP management. Methodology: Patient journey mapping was conducted in four European countries to assess the views of cLBP patients (n = 20) and GPs (n = 40). Results: Four broad phases of cLBP, subdivided into eight individual steps, were identified as part of the patient journey, showing a disconnect between patients’ and physicians’ treatment goals, and expectations regarding pain relief levels for some patients. Conclusion: Improved communication, with greater involvement of patients in multimodal management decisions, might benefit the GP–patient relationship and overall outcomes for cLBP patients.
Content may be subject to copyright.
Short Communication
For reprint orders, please contact: reprints@futuremedicine.com
Severe chronic low back pain: patient
journey from onset of symptoms to strong
opioid treatments in Europe
Bart Morlion*,1 , Gabriele Finco2, Dominic Aldington3, Michael ¨
Uberall4&Ravi
Karra,5
1Leuven Centre for Algology & Pain Management, University Hospitals Leuven, KU Leuven, Leuven, Belgium
2Department of Medical Science & Public Health, University of Cagliari, Cagliari, Italy
3The Pain Team Ltd. c/o BMI Hampshire Clinic, Basingstoke, UK
4IFNAP – Private Institute of Neurological Sciences, N ¨
urnberg, Germany
5Gr ¨
unenthal GmbH, Zieglerstr. 6, 52058 Aachen 4, 90411, N¨
urnberg, Germany
*Author for correspondence: bart.morlion@uzleuven.be
Afliation at the time of the study and during preparation of the manuscript
Aim: We report the rst patient roadmap in severe chronic low back pain (cLBP) in Europe, assessing the
views of cLBP patients and general practitioners (GPs) who treat cLBP with regard to current cLBP man-
agement. Methodology: Patient journey mapping was conducted in four European countries to assess
the views of cLBP patients (n =20) and GPs (n =40). Results: Four broad phases of cLBP, subdivided into
eight individual steps, were identied as part of the patient journey, showing a disconnect between pa-
tients’ and physicians’ treatment goals, and expectations regarding pain relief levels for some patients.
Conclusion: Improved communication, with greater involvement of patients in multimodal management
decisions, might benet the GP–patient relationship and overall outcomes for cLBP patients.
First draft submitted: 5 February 2021; Accepted for publication: 30 March 2021; Published online:
13 April 2021
Keywords: chronic pain low back pain opioids pain management patient journey mapping
Chronic low back pain (cLBP) is the most prevalent chronic disease across the globe and a leading cause of disability
adjusted life-years (DALYs) worldwide [1,2]. The estimated point prevalence for cLBP (duration 3 months) was
13.1% in adults aged 20–69 years [3], with increasing prevalence with age: 4.2% in adults aged 24–39 years and
19.6% in 20–59 year-olds [4].
Numerous studies worldwide have shown that cLBP negatively impacts quality of life (QoL) and functionality [5–
9], and the condition impacts on individuals, their families, communities, businesses and healthcare systems [10].
cLBP is associated with high societal costs due to both direct healthcare costs and indirect costs from missing work
or reduced productivity [10–15]. In the USA, the cost of low back pain exceeds $100 billion per year with most due
to indirect costs [13]; in Australia, chronic back problems accounted for around 1.8% of total healthcare expenditure
for 2008–2009 [9]; in Japan, the total annual medical cost for work-related low back pain in 2011 was estimated to
be 82 billion yen (680 million) [16]; and in Sweden, the total economic burden of LBP in 2011 was estimated
as 740 million [14].
Patient journey mapping is a commonly used qualitative method for assessing the overall patient experience,
and enables gathering of actionable insights that may lead healthcare to be more patient-centered and improve
the patient pathway [17–19]. It allows an understanding of the patient’s experience via a series of consecutive events
or steps (activities, interventions or staff interactions, for example) and helps identify breaking points sensitive to
interventions aimed at improving such a journey [20].
The data provided by patient journey mapping may be used to redesign the patient pathway to improve the
quality/efficiency of clinical management by focusing care toward outcomes most valued by the patient and reducing
administrative stress [19,21]. Patient journey mapping also promotes opportunities for staff engagement, training and
innovation within their own work environment [21,22]. The patient’s experience (including functionality and overall
Pain Manag. (Epub ahead of print) ISSN 1758-186910.2217/pmt-2021-0009 C
2021 Future Medicine Ltd
Short Communication Morlion, Finco, Aldington, ¨
Uberall & Karra
wellbeing) along with clinical effectiveness and safety, are key measures for assessing the quality of healthcare [23].
This mapping, which reports the first patient roadmap in severe cLBP in Europe, assessed the views of patients
with cLBP and general practitioners (GPs) who treat cLBP with regard to current cLBP management. The main
objective of this exercise was to enhance the understanding of the severe cLBP patient journey from the onset of
symptoms through to the point where strong opioids, including tapentadol (Palexia R
), are prescribed.
Methods
Patient journey mapping was conducted in the UK, Germany, Italy and Spain and involved experienced GPs actively
treating cLBP patients (n = 40) and adults with severe cLBP (n = 20). GPs were recruited through a panel approach
and severe cLBP patients were recruited through referrals from GPs. The main criteria for selecting GPs were: 3
years working as a GP, 70% of time spent managing patients, seeing more than five patients with severe cLBP
per month, the GPs were selected from a panel including tapentadol prescribers as a proxy to identify prescribers
of strong opioids. The main criteria for patient selection were: aged 18–75 years old, and diagnosed with severe
cLBP for greater than 12 months and must be receiving treatment with a strong opioid including tapentadol.
The selected GPs and patients participated in a series of in-depth qualitative, one-to-one interviews, telephone
interviews and small-group discussions, which were conducted in the local language and were designed to ascertain
the following:
The experience and suitability of the GP screeners and details of the treatments they prescribe for severe cLBP
(Supplementary data: Appendix 1.1);
The demographics of patients, severe cLBP history and any treatments received (Supplementary data: Appendix
1.2);
GPs completed anonymized Patient Record Forms detailing real clinical cases for two patient types: a patient
currently receiving a strong analgesic/opioid and a patient not receiving a strong analgesic/opioid. Details
collected included clinical characteristics, nonclinical characteristics (demography/co-morbidities, etc.) and
treatment goals (Supplementary data: Appendix 2.1);
Detailed discussion guide with GPs (Supplementary data: Appendix 3.1):
Perceptions of treating severe cLBP;
Patient journey overview and understanding decision-making;
Deep discussion of patient journey involving real cases;
Understanding drivers and barriers to prescribing opioids.
Detailed discussion guide with patients (Supplementary data: Appendix 3.2):
Build rapport;
Patient experience living with severe cLBP;
Patient journey exploration;
The circumstances for opioid prescription and if the treatments helped meet goals of patients;
Advice to other patients and GPs.
Results
Based on this research, four phases of a cLBP patient journey were identified combining the results from both the
patients and the GPs interviews and discussions. These four phases identify different touch points, which reflect
the differences in severity of the disease and may enable GPs to tailor the management of patients as needed. The
four phases are: Phase 0 – Onset of Symptoms; Phase I – Simple Problem; Phase II – Complex Puzzle; and Phase
III – Unsolvable Frustration. Phases I, II and III are subdivided into a total of eight steps: Phase I was subdivided
into four steps: Step 1 – Initial Presentation - Quick Fix; Step 2 – Movement Therapies; Step 3 – Underlying
Cause? and Step 4 – No Easy Fix. Phase II was subdivided into two steps: Step 5 – Shifting Focus to Lifestyle
& Psychology and Step 6 – Exploring Unfamiliar Treatment Options, while Phase III was subdivided into two
steps: Step 7 – Unsolvable Frustration and Step 8 – Resigned to the Problem (Table 1 &Figure 1). These phases
were organized based on the main patterns of thinking and behavior that emerged during the course of the patient
journey mapping. This break-up of the journey into different phases may enable us to highlight certain key aspects
10.2217/pmt-2021-0009 Pain Manag. (Epub ahead of print) future science group
Severe cLBP: patient journey from onset of symptoms to strong opioid treatments Short Communication
Table 1. Steps and phases of the chronic low back pain patient journey.
Phase Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8
0, Onset of
symptoms
1, Simple
problem
Initial
presentation –
quick x
Movement
therapies
Underlying
cause?
No easy x
2, Complex
puzzle
Shifting focus to
lifestyle
and psychology
Exploring
unfamiliar
treatment
options
3, Unsolvable
frustration
Unsolvable
frustration
Resigned to the
problem
Figure 1. Severe chronic low back pain: the patient journey.
future science group 10.2217/pmt-2021-0009
Short Communication Morlion, Finco, Aldington, ¨
Uberall & Karra
that may contribute to better outcomes for patients when addressed in a timely and adequate manner, for example,
the role of physical therapy in the early stages of cLBP.
Phase 0, following the onset of symptoms, LBP was self-managed with over-the-counter analgesics and/or visits
to a private physiotherapist or chiropractor. Phase 0 had a variable time span, lasting from 2 weeks to 12 months.
In Phase I (‘Simple Problem’), the initial presentation involved a physical examination, circumstances and
history and exclusion of a ‘sinister’ cause. Treatment in Step 1 was nonsteroidal anti-inflammatory drugs
(NSAIDs)/paracetamol (acetaminophen), heat/gels and advising patients to be more active. In Step 2, the role of
posture and muscle imbalance was considered with referral to a physiotherapist, although it was recognized that this
approach was not beneficial for all patients. GPs prescribed NSAID dose escalation for patients still experiencing
uncomfortable pain levels. In Step 3, a physical underlying cause was checked by x-ray examination and, if present,
the patient was referred for surgery. GPs indicated that they would consider prescribing weak opioids such as
tramadol/tilidine to help improve functionality in patients with severe cLBP. The main caveat was the short-term
use of these drugs to minimize the risk of dependency. In Step 4, the dose of tramadol was increased and add-on
therapies (e.g., neuropathic treatments) were considered. However, no simple fix was identified, and tramadol was
considered not to be providing pain relief. This marked the end of Phase I, which lasted for up to 6 months, with
a few patients who experienced extremely severe pain/significant functional impairment progressing to Phase II in
around 1 month.
The ‘Complex Puzzle’ of Phase II lasted from 6 months to over 2 years. The focus of Step 5 was helping the cLBP
patient to live with chronic pain. GP management of patients included encouraging activity/lifestyle changes, with
a renewed focus on physiotherapy, and referrals for psychological support or to a specialist and/or pain clinic. GPs
sought to manage expectations, provide coping strategies and share the burden of discomfort. Pharmacological
options included dose escalation of the strong opioid initiated in Steps 3/4, or switching/adding therapies. In Step
6, there was no standard approach in the selection of a strong opioid, and the decision was often subjective and
ad hoc. Opioids prescribed included oxycodone, oral morphine and fentanyl patches. There was also some use of
multiple add-on therapies including selective serotonin-reuptake inhibitors, serotonin- and noradrenaline-reuptake
inhibitors, benzodiazepines, tricyclic antidepressants and gabapentinoids.
In Phase III (‘Unsolvable Frustration’), GPs provided regular medication reviews and strong opioids were
continued with a general preference for switching rather than escalating to high drug doses. The treatment goal of
Step 7 was to deliver a degree of functionality and QoL while managing side effects. In the final stage (Step 8),
GPs looked for a drug treatment that reduces the frequency of patient visits while minimizing the risk of long-term
dependency. This phase of the patient journey is open-ended.
Physician and patient attitudes changed during the patient journey.
In early Phase I (Step 1), GPs were generally positive and optimistic about treatment outcomes with comments
exemplified by ‘I am very experienced at understanding the patient’s problem quickly in order to fix it’ and ‘Initially
I am optimistic and hopeful that we can reverse the situation’. GPs noted that with the exclusion of ‘sinister’ causes,
treatment for the majority of patients is relatively straightforward. In Step 2, GPs were hopeful but pragmatic
regarding potential outcomes of movement therapies. By Step 3, GPs were confident in their prescribing decision,
while recognizing the risks of their limited treatment options. However, by Step 4, the lack of success in treating
severe cLBP resulted in some GPs feeling frustrated. GPs indicated that patients were not fully engaging with their
health (e.g., inactivity and overweight).
In Phase II (Step 5), GPs considered pain to be one element of a complex problem, with a combination of
psychological, lifestyle and physical issues. There was also a suspicion that the pain may be exaggerated in some
patients in order to avoid work. In Step 6, concern about high-dose opioid dependency was first voiced by GPs, who
considered that the pain was unlikely to be resolved until there was a change in attitude and lifestyle. Expectations
were limited, but they wanted to be seen to be ‘doing something’.
In Phase III (Step 7), there was a growing disconnect between patients and their GPs. The GPs expressed
frustration that the patient was not learning to live with the pain, exemplified by the comment that ‘some cLBP
patients are just depressed or unhappy and have a lower pain threshold than others’. By the final step (Step 8), GPs
expressed concerns about the perceived ‘overuse’ of opioids and about long-term high-dose opioid use (especially
for younger patients). The patient was added to their mental list of ‘problem patients’ – ‘my heart sinks when I see
their name on the appointment list’.
Triggers that prompted patients to seek help from GPs (Phase 0) included emotional impact (‘fed-up’), an acute
episode of LBP and an impact on work and/or household responsibilities. At the initial consultation (Step 1), some
10.2217/pmt-2021-0009 Pain Manag. (Epub ahead of print) future science group
Severe cLBP: patient journey from onset of symptoms to strong opioid treatments Short Communication
patients indicated that they felt the consultation was too hurried and superficial with comments such as ‘I felt like
I was being cut into pieces’. In Step 2, some patients considered that physiotherapy could be challenging, painful
and not always beneficial. Furthermore, some patients believed that GPs failed to understand the extent of the
problem – ‘the hardest thing was that she was not aware of the level of pain I was suffering, there were times when
she would release you without asking many questions’. Patients began to lose confidence in their care because of the
continued pain, and some reported that they felt like they were not being listened to and, worse, not being taken
seriously. These individuals were often desperate for pain relief, and consequently not initially concerned about
the risks associated with taking opioid medications. By Step 4, patients were frustrated because they were still in
pain and this led to some saying that they felt vulnerable. Also, they were concerned that the cause of the pain and
potential solutions for its management had not yet been identified.
In Phase II (Step 5), patients indicated that their lifestyle was becoming increasingly limited, with diminished
functionality and QoL. Depression and anxiety were raised as concerns by some patients, and many noted that
they had stopped working, and their ability to perform household chores and participate socially had become
restricted. At a later stage (Step 6), patients became increasingly withdrawn in all aspects of life, and they felt
frustrated and unheard. In addition, adverse effects such as confusion, forgetfulness and dizziness were becoming
more troublesome.
In Phase III (Step 7), patients were becoming increasingly depressed and withdrawn as the pain experienced was
unchanged. In the final stage (Step 8), some patients accepted their limited and restricted life and developed their
own personalized strategy to cope with pain and manage opioid use. They considered opioids to be ‘essential’ to
control their pain.
Discussion
This patient journey shows the pathway of trial and error taken by GPs in the treatment of cLBP, which may lead to
suboptimal patient management and complexification of the problem due to untimely/suboptimal control. There
is scope for improvement, especially at the earlier stages of the disease when appropriate multimodal management
including physical (e.g., electrotherapy [24]) and rehabilitation therapies and control of pain may lead to better patient
outcomes. There is also a tendency toward indiscriminate and long-term use of nonspecific pharmacotherapies
like NSAIDs in patients, some of whom may not respond to such treatments that do not address the underlying
pathology of cLBP like the neuropathic component. In addition, such therapies may also expose some patients
with high-risk factors to gastrointestinal or cardiovascular adverse effects. Patient and GP perceptions about cLBP
management change over time as chronic pain persists and the opportunities and available options for treatment
decrease; potentially leading to a frustrated patient and GP relationship. Timely intervention plays an important
role in preventing pain chronification and, as key influencers in the management of patients with pain, it is critical
that GPs are equipped with the necessary awareness, education and skills to manage pain patients appropriately [25].
It is also imperative that clear treatment goals related to pain and function should be agreed with the patient [26–29].
A recent systematic review of guidelines for neck and low back pain across Europe revealed a broad European
consensus on treatment and referral recommendations [30]. Opioids should not be considered for chronic primary
musculoskeletal pain syndromes, including LBP [31,32]. However, daily care for patients with cLBP is mostly not in
line with existing guidelines, as clearly illustrated by the results of this study. Nonconcordant management leads to
suboptimal treatment outcomes [33].
Patients should be carefully selected and regularly monitored to ensure that, when prescribed, opioids are
monitored appropriately [26–29]. Patients should also be made aware of potential opioid adverse effects, and the
possibility of misuse, abuse and addiction [26,27,29]. It is therefore imperative that physicians monitor and manage
patients carefully to reassess the benefits and risks of continued therapy. If benefits do not outweigh risks, treatments
must be titrated to appropriate therapeutic range and treatment plans and doses of opioids should be reconsidered
and tapered down or discontinued as needed [26–29].
This qualitative mapping provides an insight into the management and views of patients and GPs during the
cLBP patient journey. There is no definitive guide to sample size in qualitative research, although sufficiency of
thematic saturation is considered by many experts to be the ‘gold standard’ in qualitative inquiry [34].Although
the sample size in our study was small, highlighting a key limitation and may have a significant impact on the
representativeness and generalizability of the results, the current mapping helps to provide an insight into the patient
journey for individuals with cLBP, both from the patient’s and GP’s point of view. While acknowledging that the
current work is restricted to the views of patients and GPs, rather than the wider multidisciplinary team involved
future science group 10.2217/pmt-2021-0009
Short Communication Morlion, Finco, Aldington, ¨
Uberall & Karra
in the management of cLBP, our research highlights that a disconnect sometimes develops between treatment goals
and the level of pain relief obtained for some patients and this can lead to a frustrated GP–patient relationship.
Comments provided by both GPs and their patients indicate a certain level of distrust develops in both groups as
pain continues to be a problem.
Conclusion
Across the whole journey, some factors worth considering to reduce any conflicts and improve outcomes might
include: empowering patient’s self-management through proper education on the disease and physical activities to
overcome further functional decline, better communication and shared decision-making between GPs and patients
in disease management; setting of common goals between patients and GPs relating to their functional status and
consideration of a multimodal team approach for management including a physiotherapist, psychologist and pain
specialist; and in select cases the introduction of an appropriate analgesic in a timely manner.
Summary points
Chronic low back pain (cLBP) is the most prevalent chronic disease globally, and a leading cause of disability
adjusted life-years worldwide.
In this study, we report a patient roadmap in severe cLBP in Europe, assessing the views of patients with cLBP and
general practitioners (GPs) who treat cLBP with regard to current cLBP management.
The main objective of this qualitative exercise was to enhance the understanding of the severe cLBP patient
journey from onset of symptoms through to the point where strong opioids are prescribed including tapentadol.
As part of the patient journey, four broad phases of cLBP, subdivided into a total of eight individual steps, were
identied.
The study identied a disconnect between the treatment goals of patients and physicians, as well as the
expectation on the level of pain relief for some patients.
As a result of uncontrolled severe cLBP, some frustrations may develop in patients due to their suffering and their
GPs due to the inability to help, which may have an implication for the overall management of cLBP.
Improved communication, with greater involvement of patients in multimodal management decisions, might
benet the GP–patient relationship and overall outcomes for patients with cLBP.
Supplementary data
To view the supplementary data that accompany this paper please visit the journal website at: www.futuremedicine.com/doi/sup
pl/10.2217/pmt-2021- 0009
Author contributions
All the authors critically reviewed the draft manuscript and approved the nal version of the manuscript for publication.
Financial & competing interests disclosure
This study was sponsored by Gr ¨
unenthal GmbH, Aachen, Germany. B Morlion received honoraria for speaker’s activities for Med-
scape and Krka and consultancy activities for Reckitt Benckiser, Gr ¨
unenthal, and Pzer Belgium. D Aldington received honoraria for
participation in Advisory Boards and the Change Pain project both with Gr ¨
unenthal. G Finco and M ¨
Uberall have received funding
for a variety of projects from Gr ¨
unenthal not related to this publication. At the time of the study and during preparation of the
manuscript, R Karra was employed by Gr ¨
unenthal GmbH.
Medical writing support was provided by Content Ed Net, with funding from Gr ¨
unenthal GmbH, Aachen, Germany.
References
Papers of special note have been highlighted as: of interest
1. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and
injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet
388(10053), 1603–1658 (2016).
2. GBD 2017 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and
injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of
Disease Study 2017. Lancet 392(10159), 1859–1922 (2018).
3. Shmagel A, Foley R, Ibrahim H. Epidemiology of chronic low back pain in US adults: data from the 2009–2010 National Health and
Nutrition Examination Survey. Arthritis Care Res. (Hoboken) 68(11), 1688–1694 (2016).
10.2217/pmt-2021-0009 Pain Manag. (Epub ahead of print) future science group
Severe cLBP: patient journey from onset of symptoms to strong opioid treatments Short Communication
4. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev. Saude Publica. 49, 1 (2015).
5. H¨
aggO,BurckhardtC,FritzellPet al. Quality of life in chronic low back pain: a comparison with fibromyalgia and the general
population. J. Musculoskelet. Pain 11(1), 31–38 (2003).
6. Husky MM, Ferdous Farin F, Compagnone P et al. Chronic back pain and its association with quality of life in a large French population
survey. Health Qual. Life Outcomes 16(1), 195 (2018).
7. Wettstein M, Eich W, Bieber C et al. Pain intensity, disability, and quality of life in patients with chronic low back pain: does age matter?
Pain Med. 20(3), 464–475 (2019).
8. Raczkiewicz D, Owoc A, Sarecka-Hujar B et al. Impact of spinal pain on daily living activities in postmenopausal women working in
agriculture. Ann. Agric. Environ. Med. 24(1), 134–140 (2017).
9. Australian Institute of Health and Welfare. Impacts of chronic back problems. Bulletin 137. Cat. No. 204. Canberra: AIHW, 2016.
www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/impacts- of-chronic- back-problems/data
10. Hoy D, Brooks P, Blyth F et al. The Epidemiology of low back pain. Best Pract. Res. Clin. Rheumatol. 24(6), 769–781 (2010).
11. Dutmer AL, Schiphorst Preuper HR, Soer R et al. Personal and societal impact of low back pain: the Groningen Spine Cohort. Spine
(Phila Pa 1976) 44(24), E1443–E1451 (2019).
12. Mutubuki EN, Luitjens MA, Maas ET et al. Predictive factors of high societal costs among chronic low back pain patients. Eur. J. Pain
24(2), 325–337 (2020).
Recent study highlighting the significant personal and societal burden of low back pain.
13. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J. Bone Joint Surg. Am. 88(Suppl. 2), 21–24
(2006).
A US study highlighting that the cost of low back pain exceeds $100 billion per year.
14. Olafsson G, Jonsson E, Fritzell P et al. Cost of low back pain: results from a national register mapping in Sweden. Eur. Spine J. 27(11),
2875–2881 (2018).
15. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 84(1), 95–103 (2000).
16. Itoh H, Kitamura F, Yokoyama K. Estimates of annual medical costs of work-related low back pain in Japan. Ind. Health 51(5), 524–529
(2013).
17. Coulter A, Fitzpatrick R, Cornwell J. The point of care: measures of patients’ experience in hospital: purpose, methods and uses. The
King’s Fund. 2009; 1–32.
www.kingsfund.org.uk/sites/def ault/f iles/Point-of-Care-Measures-of -patients- experience-in- hospital-Kings- Fund-July- 2009 0.pdf
18. Mould G, Bowers J, Ghattas M. The evolution of the pathway and its role in improving patient care. Qual. Saf. Health Care 19(5), e14
(2010).
19. Grocott MP. Pathway redesign: putting patients ahead of professionals. Clin.Med.(Lond.)19(6), 468–472 (2019).
20. Ben-Tovim DI, Dougherty ML, O’Connell TJ et al. Patient journeys: the process of clinical redesign. Med. J. Aust. 188(S6), S14–S17
(2008).
21. The Health Foundation. No. 19. Improving patient flow across organisations and pathways. (2013).
www.health.org.uk/publications/improving-patient-f low-across-organisations-and-pathways
22. petesaunders.com. The benefits of patient experience and journey mapping in health care. (2018).
www.petesaunders.com/the-benef its-of -patient-experience-and-journey-mapping-in-health-care/
23. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness.
BMJ Open 3(1), 1–18 (2013).
24. Albornoz-Cabello M, Maya-Mart´
ın J, Dom´
ınguez-Maldonado G et al. Effect of interferential current therapy on pain perception and
disability level in subjects with chronic low back pain: a randomized controlled trial. Clin. Rehabil. 31(2), 242–249 (2017).
25. Morlion B, Coluzzi F, Aldington D et al. Pain chronification: what should a non-pain medicine specialist know? Curr.Med.Res.Opin.
34(7), 1169–1178 (2018).
26. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm.
Rep. 65(1), 1–49 (2016).
27. Faculty of Pain Medicine of the Royal College of Anaesthetists. Opioids aware: a resource for patients and healthcare professionals to
support prescribing of opioid medicines for pain. https://www.fpm.ac.uk/opioids-aware
28. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci. Pract. Perspect. 1, 13–20 (2002).
29. Manchikanti L, Kaye AM, Knezevic NN et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain:
American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician 20(2S), S3–S92 (2017).
30. Corp N, Mansell G, Stynes S et al. Evidence-based treatment recommendations for neck and low back pain across Europe: a systematic
review of guidelines. Eur. J. Pain 25(2), 275–295 (2021).
future science group 10.2217/pmt-2021-0009
Short Communication Morlion, Finco, Aldington, ¨
Uberall & Karra
31. Tucker HR, Scaff K, McCloud T et al. Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a
systematic review. Br.J.SportsMed.54(11), 664 (2020).
32. H¨
auser W, Morlion B, Vowles KE et al. European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1:
role of opioids in the management of chronic noncancer pain. Eur. J. Pain doi:10.1002/ejp.1736 (2021). (Epub ahead of print).
33. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet 389(10070), 736–747 (2017).
34. Vasileiou K, Barnett J, Thorpe S et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis
of qualitative health research over a 15-year period. BMC Med. Res. Methodol. 18(1), 148 (2018).
10.2217/pmt-2021-0009 Pain Manag. (Epub ahead of print) future science group
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC). Methods: The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment. Results: The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation. Conclusions: Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.
Article
Full-text available
Background and objective This systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe. Databases and Data Treatment Comprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up‐to‐date evidence‐based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines. Results Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain‐specific subgroups—work‐based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain. Conclusions This review of European CPGs identified a range of mainly non‐pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe. Significance Consensus regarding evidence‐based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non‐pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back‐UP research team will transfer these evidence‐based treatment options to an accessible clinician decision support tool for first contact clinicians.
Article
Full-text available
Background: Societal costs of low back pain are high, yet few studies have been performed to identify predictive factors of high societal costs among chronic low back pain patients. This study aimed to determine which factors predict high societal costs in patients with chronic low back pain. Methods: Data of 6,316 chronic low back pain patients were used. In the main analysis high societal costs were defined as patients in the top 10% of cost outcomes. Sensitivity analyses were conducted using patients in the top 5% and top 20% of societal costs. Potential predictive factors included patient expectations, demographic factors (e.g. age, gender, nationality), socioeconomic factors (e.g. employment, education level), and health-related factors (e.g. body mass index, general health, mental health). The final prediction models were obtained using backward selection. The model's prognostic accuracy (Hosmer-Lemeshow X2 , Nagelkerke's R2 ) and discriminative ability (area under the receiver operating curve [AUC]) were assessed, and the models were internally validated using bootstrapping. Results: Poor physical health, high functional disability, low health-related quality of life, high impact of pain experience, non-Dutch nationality, and decreasing pain were found to be predictive of high societal costs in all models, and were therefore considered robust. After internal validation, the models' fit was good, their explained variance was relatively low (≤14.1%), and their AUCs could be interpreted as moderate (≥0.71). Conclusion: Future studies should focus on understanding the mechanisms associated with the identified predictors for high societal costs in order to design effective cost reduction initiatives.
Article
Full-text available
Study design: Cross-sectional study. Objective: The aim of this study was to study the personal and societal impact of low back pain (LBP) in patients admitted to a multidisciplinary spine center. Summary of background data: The socioeconomic burden of LBP is very high. A minority of patients visit secondary or tertiary care because of severe and long-lasting complaints. This subgroup may account for a major part of disability and costs, yet could potentially gain most from treatment. Currently, little is known about the personal and societal burden in patients with chronic complex LBP visiting secondary/tertiary care. Methods: Baseline data were acquired through patient-reported questionnaires and health insurance claims. Primary outcomes were LBP impact (Impact Stratification, range 8-50), functioning (Pain Disability Index, PDI; 0-70), quality of life (EuroQol-5D, EQ5D; -0.33 to 1.00), work ability (Work Ability Score, WAS; 0-10), work participation, productivity costs (Productivity Cost Questionnaire), and healthcare costs 1 year before baseline. Healthcare costs were compared with matched primary and secondary care LBP samples. Descriptive and inferential statistics were applied. Results: In total, 1502 patients (age 46.3 ± 12.8 years, 57% female) were included. Impact Stratification was 35.2 ± 7.5 with severe impact (≥35) for 58% of patients. PDI was 38.2 ± 14.1, EQ5D 0.39 (interquartile range, IQR: 0.17-0.72); WAS 4.0 (IQR: 1.0-6.0) and 17% were permanently work-disabled. Mean total health care costs (&OV0556;4875, 95% confidence interval [CI]: 4309-5498) were higher compared to the matched primary care sample (n = 4995) (&OV0556;2365, 95% CI: 2219-2526, P < 0.001), and similar to the matched secondary care sample (n = 4993) (&OV0556;4379, 95% CI: 4180-4590). Productivity loss was estimated at &OV0556;4315 per patient (95% CI: 3898-4688) during 6 months. Conclusion: In patients seeking multidisciplinary spine care, the personal and societal impact of LBP is very high. Specifically, quality of life and work ability are poor and health care costs are twice as high compared to patients seeking primary LBP care. Level of evidence: 3.
Article
Full-text available
Background: Choosing a suitable sample size in qualitative research is an area of conceptual debate and practical uncertainty. That sample size principles, guidelines and tools have been developed to enable researchers to set, and justify the acceptability of, their sample size is an indication that the issue constitutes an important marker of the quality of qualitative research. Nevertheless, research shows that sample size sufficiency reporting is often poor, if not absent, across a range of disciplinary fields. Methods: A systematic analysis of single-interview-per-participant designs within three health-related journals from the disciplines of psychology, sociology and medicine, over a 15-year period, was conducted to examine whether and how sample sizes were justified and how sample size was characterised and discussed by authors. Data pertinent to sample size were extracted and analysed using qualitative and quantitative analytic techniques. Results: Our findings demonstrate that provision of sample size justifications in qualitative health research is limited; is not contingent on the number of interviews; and relates to the journal of publication. Defence of sample size was most frequently supported across all three journals with reference to the principle of saturation and to pragmatic considerations. Qualitative sample sizes were predominantly – and often without justification – characterised as insufficient (i.e., ‘small’) and discussed in the context of study limitations. Sample size insufficiency was seen to threaten the validity and generalizability of studies’ results, with the latter being frequently conceived in nomothetic terms. Conclusions: We recommend, firstly, that qualitative health researchers be more transparent about evaluations of their sample size sufficiency, situating these within broader and more encompassing assessments of data adequacy. Secondly, we invite researchers critically to consider how saturation parameters found in prior methodological studies and sample size community norms might best inform, and apply to, their own project and encourage that data adequacy is best appraised with reference to features that are intrinsic to the study at hand. Finally, those reviewing papers have a vital role in supporting and encouraging transparent study-specific reporting.
Article
Full-text available
Background How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years. Methods We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Findings Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1–7·8), from 65·6 years (65·3–65·8) in 1990 to 73·0 years (72·7–73·3) in 2017. The increase in years of life varied from 5·1 years (5·0–5·3) in high SDI countries to 12·0 years (11·3–12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1–33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8–15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9–6·7), from 57·0 years (54·6–59·1) in 1990 to 63·3 years (60·5–65·7) in 2017. The increase varied from 3·8 years (3·4–4·1) in high SDI countries to 10·5 years (9·8–11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4–1·7) in Saint Vincent and the Grenadines (62·4 years [59·9–64·7] in 1990 to 63·5 years [60·9–65·8] in 2017) to 23·7 years (21·9–25·6) in Eritrea (30·7 years [28·9–32·2] in 1990 to 54·4 years [51·5–57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6–2·3) in Algeria to 11·9 years (10·9–12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4–78·7]) and males (72·6 years [69·8–75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7–50·2] for females and 42·8 years [40·1–45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8–43·5) for communicable diseases and by 49·8% (47·9–51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8–43·0), although age-standardised DALY rates decreased by 18·1% (16·0–20·2). Interpretation With increasing life expectancy in most countries, the question of whether the additional years of life gained are spent in good health or poor health has been increasingly relevant because of the potential policy implications, such as health-care provisions and extending retirement ages. In some locations, a large proportion of those additional years are spent in poor health. Large inequalities in HALE and disease burden exist across countries in different SDI quintiles and between sexes. The burden of disabling conditions has serious implications for health system planning and health-related expenditures. Despite the progress made in reducing the burden of communicable diseases and neonatal disorders in low SDI countries, the speed of this progress could be increased by scaling up proven interventions. The global trends among non-communicable diseases indicate that more effort is needed to maximise HALE, such as risk prevention and attention to upstream determinants of health.
Article
Full-text available
Background: Chronic back pain is associated with significant burden, yet few epidemiological studies have provided data on chronic back pain, its predictors and correlates in France. Methods: Data were drawn from a cross-sectional survey conducted in France (n = 17,249) using computer-assisted telephone interviews. Sample age ranges from 18 to 98 with a mean of 46.39 years (SD = 17.44), and was 56.7% female. Medical conditions were assessed using the CIDI, quality of life was assessed using both the physical and mental component scores of the SF-36. Results: Overall, 38.3% of adults reported chronic back pain. Female gender, older age, lower education, manual labor occupation, and population density were significantly associated with the distribution of chronic back pain. Chronic back pain was associated with lower scores on all SF-36 mean scores and on the Physical Composite Score and Mental Composite Score controlling for comorbid medical conditions including other types of chronic pain. Conclusion: The study highlights the burden of chronic back pain in the general population and underscores its correlation with quality of life. Such data contribute to raise awareness among clinicians and health policy makers on the necessity of prevention, early diagnosis, proper management and rehabilitation policies in order to minimize the burden associated with chronic pain.
Article
Full-text available
Purpose To estimate the societal costs of low back pain with/without radiating leg pain (LBP). LBP is a major burden in terms of both personal suffering and societal costs. Methods Patients visiting healthcare providers with a LBP-diagnosis in the Western region of Sweden (Västra Götaland) in 2008–2011 were identified in national registers and an administrative patient database. Direct healthcare costs and indirect costs in terms of sick leave and early retirement were summarized over time periods called LBP episodes, starting with a LBP-related healthcare contact or work absence due to LBP and ended when 6 months had elapsed without any LBP-related healthcare contact or work absence. Results The mean total cost per episode was estimated at €2753 with a mean duration of 51 days. There was a sharp increase in total cost the first month after the LBP episode started and a marked decrease from the second month. Total cost leveled off at a higher level during the 2 years after episode start compared with the 2 years before episode start. The total economic burden of LBP in Sweden including all LBP episodes that started in 2011 was estimated at €740 million, or €78 per capita. Conclusions LBP has an apparent impact on the overall resource use and work loss. The results indicate that there is a high short-term cost increase at the beginning of an LBP episode, but also that the costs decrease in the long term after the LBP symptoms have come to clinical attention. Graphical abstract These slides can be retrieved under Electronic Supplementary Material. Open image in new window
Article
Background: Consequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline. Objective: Our primary purpose was to improve overall understanding of the harms and benefits associated with oral opioid interventions prescribed for treatment of acute or chronic back pain. Our second goal was to evaluate pain intensity and to compare and contrast these data with the harms. Our last objective was to evaluate conflicts of interest among the study authors and the findings. Design/data/eligibility criteria: Studies incorporating oral prescription opioid management of non-surgical LBP were evaluated. After systematic assessment, no studies that met inclusion included participants with specifically acute LBP. Therefore, extracted data reflects only populations with subacute and chronic LBP. Data on reported harms, severe harms, pain outcomes and withdrawal rates were extracted and meta-analyses were completed for opioid versus placebo trials and opioids versus non-opioid trials. Results: Fourteen studies met inclusion/exclusion requirements. All trials involved short-term management with limited follow-up. A high percentage of harms were identified across most studies. Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms). Conclusion: This review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of subacute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of subacute or chronic LBP. Trial registration number: CRD42017070914.
Article
Many perioperative clinical pathways, and therefore patient journeys, are focused around provider, rather than patient, convenience. Business process re-engineering (BPRE) offers a framework for transformative process-change with the aim of improving 'consumer experience' and efficiency and may be an effective driver for improving patient experience and value within healthcare. Involvement of patients in service and pathway design, through experience-based codesign, is increasingly prevalent and may be an effective complement to BPRE. The elective perioperative pathway offers an opportunity to rethink the patient journey with the aim of maximising opportunities for effective shared decision making and improving preparation for surgery through prehabilitation and management of long-term conditions (comorbidity/multimorbidity management). Additional opportunities include improved management of transitions of care and effective medicines management to minimise polypharmacy. Pathway mapping, deconstruction and reconstruction enables such changes and is a method of service transformation that may have relevance for a spectrum of other elective/scheduled pathways.