Orthopedic Postoperative Pain
Scope
Report Highlights
Reasons to Purchase
Table of Contents
- ABOUT DATAMONITOR HEALTHCARE - page 2
- About the CNS, Arthritis and Pain pharmaceutical analysis team - page 2
- CHAPTER 1 EXECUTIVE SUMMARY - page 3
- Scope of the analysis - page 3
- Datamonitor insight into the orthopedic postoperative pain market - page 4
- Key metrics - page 5
- CHAPTER 2 INTRODUCTION - page 14
- Coverage of the Stakeholder Insight Survey - page 14
- Section 1 - Epidemiology - page 14
- Section 2 - Treatment trends for postoperative pain - page 14
- Section 3 - Involvement of the varying healthcare professionals - page 14
- Section 4 - Utilization of diagnostic tools - page 14
- Section 5 - Preferred treatment options upon discharge - page 15
- Section 6 - Pipeline drug therapies - page 15
- Coverage of the Stakeholder Insight Survey - page 14
- CHAPTER 3 COUNTRY TREATMENT TREES - page 16
- Similar treatments for mild and moderate pain - page 16
- Morphine popularity varies by country - page 16
- Implications for the pharmaceutical industry - page 17
- US treatment of mild, moderate and severe postoperative pain - page 18
- Japan's treatment of mild, moderate and severe postoperative pain - page 20
- France's treatment of mild, moderate and severe postoperative pain - page 22
- Germany's treatment of mild, moderate and severe postoperative pain - page 24
- Italy's treatment of mild, moderate and severe postoperative pain - page 26
- Spain's treatment of mild, moderate and severe postoperative pain - page 28
- UK treatment of mild, moderate and severe postoperative pain - page 30
- CHAPTER 4 EPIDEMIOLOGY AND PATIENT SEGMENTATION - page 32
- Postoperative pain definitions and classification - page 32
- What is postoperative pain? - page 32
- Under-treatment of postoperative pain - page 32
- Current management trends - page 33
- Epidemiology of orthopedic postoperative pain - page 34
- US - page 34
- Japan - page 35
- Europe - page 36
- France - page 36
- Germany - page 36
- Italy - page 37
- Spain - page 38
- UK - page 39
- Key patient segmentations - page 41
- Surgery type by age - page 41
- Gender difference in prevalence - page 41
- Postoperative pain definitions and classification - page 32
- CHAPTER 5 STAKEHOLDERS IN ASSESSING AND TREATING POSTOPERATIVE PAIN - page 43
- Pre-surgery pain assessment is dominated by surgeons across all markets - page 43
- Post-surgery pain assessment is also governed by surgeons - page 45
- Surgeons play cardinal role in the initiation of post-surgery pain treatment except in the German market - page 47
- Surgeons continue to manage postoperative pain relief after initiation - page 49
- Japan and Germany deviating from the norm in respect to pain treatment following discharge - page 51
- Country differentiations of the treating healthcare professional - page 52
- Management and referral of patients - page 54
- Surgeons involvement decreases significantly from 12 hours post-surgery - page 54
- Healthcare provider receiving and making referrals in first two hours post-surgery - page 57
- Surgeons in the first two hours - page 57
- Anesthetists in the first two hours - page 58
- Healthcare providers receiving and making referrals in the two- to 12-hour period following surgery - page 58
- Surgeons in the two- to 12-hour time period post-surgery - page 58
- Anesthetists in the two- to 12-hour time period post-surgery - page 58
- Healthcare providers receiving and making referrals in the 12-24 hour period following surgery - page 59
- Surgeons role in 12-24 hour period - page 59
- Anesthetist role in the 12-24 hour period - page 59
- Healthcare providers receiving and making referrals during the one- to five-day period post-surgery - page 59
- Surgeons and anesthetists role in the one- to five-day period following surgery - page 59
- CHAPTER 6 DIAGNOSIS AND PAIN ASSESSMENT - page 60
- Patient management guidelines - page 60
- American Society of Anesthesiologists (ASA) - page 60
- The Agency for Healthcare Research and Quality (AHRQ) - page 61
- Department of Defense, Veterans Health Administration (VHA) - The management of postoperative pain - page 61
- Opioids are considered safe and effective - page 62
- Acetaminophen and NSAIDs not recommended as sole agent for pain after major surgery - page 62
- PROSPECT guidelines - European society of anesthesiologists & European society of regional anesthesiology and pain - page 62
- ASA guidelines are the most widely known - page 63
- Pain management planning and advice - page 65
- Advice from anesthetists and surgeons - page 65
- Commencing pain management programs - page 68
- Presentation and assessment of pain - page 70
- The vast majority of patients receive pain assessment regularly during the hours and days following surgery - page 70
- Market analysis for pain assessment in first two hours post-surgery - page 71
- Surgeons and anesthetists share in pain assessment during the first two hours following surgery - page 71
- The role of ward physicians increases in pain assessment during the two to 12 hours following surgery - page 72
- Nurses become more involved in pain assessment during the 12-24 hours following surgery - page 73
- No change in pattern of assessing physician is seen after 24 hours - page 74
- Presentation and diagnostic tools for pain assessment - page 75
- Numerous pain scales are available to aid assessment - page 75
- Discussion with patient - page 75
- Visual Analogue Scale (VAS) - page 76
- Faces Pain Rating Scale (FPRS) - page 76
- Verbal Descriptive Scale (VDS) - page 76
- Numerical Rating Scale (NRS) - page 76
- Edmonton Symptom Assessment Scale (ESAS) - page 77
- Objective Pain Score (OPS) - page 77
- Brief Pain Inventory (BPI) - page 77
- Discussion, not a single diagnostic tool dominates assessment - page 77
- The most favored diagnostic tool in pain measurement - page 80
- Numerous pain scales are available to aid assessment - page 75
- Differentiating between the different degrees of pain - page 82
- Level of pain in the first two hours - page 82
- Level of pain reported during the later periods - page 84
- Patient management guidelines - page 60
- CHAPTER 7 TREATMENT TRENDS - page 85
- Early pain treatment prevents later suffering for patients - page 85
- Pharmacological versus non-pharmacological treatments - page 87
- Pharmacological therapy is the foundation of treatment - page 87
- Non-pharmacological methods of pain treatment - page 88
- Transcutaneous electrical nerve stimulation (TENS) - page 88
- Cold/heat - page 88
- Exercise - page 88
- Positioning - page 88
- Immobilization/rest - page 89
- Massage - page 89
- Acupuncture - page 89
- Other - page 89
- Pharmacological treatment for postoperative pain - page 91
- Treatment of mild and moderate postoperative pain is dominated by NSAIDs - page 91
- The use of NSAIDs and other non-opioid analgesics for postoperative pain treatment - page 91
- Acetaminophen is most popular first-line product to treat mild pain - page 91
- Naproxen is most popular first-line product to treat moderate pain - page 92
- Diclofenac second most stated drug for mild postoperative pain relief - page 93
- Piroxicam in top three for use in moderate postoperative pain - page 94
- Ibuprofen fourth most frequent first choice for both mild and moderate postoperative pain - page 95
- Ketoprofen fifth most frequent first choice for both mild and moderate postoperative pain - page 96
- Treatment of severe postoperative pain sees increase in opioid use - page 97
- The use of opioids for postoperative pain treatment - page 97
- Tramadol is respondents' most popular choice for the treatment of severe postoperative pain - page 98
- Morphine similar in popularity to tramadol for severe postoperative pain - page 99
- Oxycodone third most frequent first choice for severe postoperative pain - page 99
- Fentanyl fourth most frequent first choice for severe postoperative pain - page 100
- Codeine fifth most frequent first choice for severe postoperative pain - page 101
- Progression to a second-line therapy - page 102
- Patients progress to second-line therapy up to five days following surgery - page 102
- Progression on to third-line therapy - page 103
- Patients on Patient Controlled Analgesia (PCA) - page 103
- Inadequately treated pain affects all severities and may become an issue at discharge - page 106
- Half of postoperative pain patients receive drug therapy upon final discharge from hospital - page 109
- Treatment at hospital discharge is not known by hospital practitioners for milder cases - page 110
- Duration of postoperative pain is generally less than five days - page 114
- Treatment of mild and moderate postoperative pain is dominated by NSAIDs - page 91
- CHAPTER 8 UNMET NEEDS AND FUTURE THERAPIES - page 115
- Treatment attributes - page 115
- No single therapy addresses the key attributes - page 116
- Physician assessment of changes in the market - page 117
- Complications with treatment - page 118
- New product development for postoperative pain - page 120
- Bicifadine (SR) - page 122
- ALGRX-4975 - page 122
- Morphine-6-glucuronide - page 122
- APF-112 - page 123
- ORG-41793/DPI-3290 - page 123
- Lidocaine patch - page 123
- Morphine (intranasal) - page 124
- REN-213/nalbuphine + naloxone - page 124
- Fentanyl (transdermal spray) - page 124
- Dyloject (injectable diclofenac) - page 124
- Treatment attributes - page 115
- APPENDIX A: BIBLIOGRAPHY - page 125
- Bibliography - page 125
- APPENDIX B - page 129
- Epidemiology calculation methodology - page 129
- Physician research methodology - page 129
- Physician sample breakdown - page 129
- Contributing experts - page 130
- APPENDIX C - page 131
- The survey questionnaire - page 131
- Treating healthcare professional - page 131
- Pharmacological vs. non-pharmacological treatments - page 136
- Non-pharmacological - page 137
- Pharmacological therapy - page 138
- Inadequately treated pain - page 142
- Complications - page 144
- Guidelines - page 145
- Unmet needs - page 145
- Pipeline products - page 147
- Disclaimer - page 148
- The survey questionnaire - page 131
- List of Tables
- Table 1: Estimated number of orthopedic surgeries, by country, 2005 - page 5
- Table 2: Patient postoperative pain survey, UK, 1994 - page 33
- Table 3: Estimated number of orthopedic surgeries, by country, 2005 - page 34
- Table 4: Number of operations on the musculoskeletal system, short-stay hospitals, by age - page 35
- Table 5: OECD data for French surgical discharges by ICD-9 code and surgical procedure, 1998-2001 - page 36
- Table 6: OECD data for Italian surgical discharges by ICD-9 code and surgical procedure, 2000-02 - page 37
- Table 7: OECD data for Spanish surgical discharges by ICD-9 code and surgical procedure, 1998-2001 - page 38
- Table 8: Main orthopedic operations in England, 2003-04 - page 39
- Table 9: OECD data for UK surgical discharges by ICD-9 code and surgical procedure, 2000-02 - page 40
- Table 10: Percentage of respondents that identified the following healthcare professional as responsible for pre-surgery pain assessment in all markets (%), 2005 - page 44
- Table 11: Percentage of respondents that identified the following healthcare professionals as being responsible for post-surgery pain assessment in all markets, 2005 - page 46
- Table 12: Percentage of respondents that identified the following healthcare professionals to be responsible for initiation of post-surgery pain treatment in all markets, 2005 - page 48
- Table 13: Percentage of respondents that identified the following healthcare professional to be responsible for the management of pain relief following treatment initiation, by country, 2005 - page 50
- Table 14: Percentage of respondents that identified the following healthcare professionals as responsible for the management of patient's pain treatment upon hospital discharge (%), 2005 - page 51
- Table 15: Mean number of healthcare professionals that are responsible for the varying stages of pain assessment/treatment, by country, 2005 - page 53
- Table 16: Percentage of respondents (surgeons) that make decisions on pain management during the different time frames following surgery, across all major markets 2005 - page 55
- Table 17: Percentage of respondents (anesthetists) that make decisions in the different time frames following surgery, 2005 - page 56
- Table 18: The percentage of respondents that are aware of the following treatment guidelines, by country, 2005 - page 64
- Table 19: Percentage of respondents that adhere to treatment guidelines on a scale of 1-10 (10=high adherence), by country, 2005 - page 65
- Table 20: Mean percentage of patients given advice during all stages leading up to and after surgery, by country, 2005 - page 66
- Table 21: Mean percent of patients that have pain management programs commenced before, during and after surgery, by country, 2005 - page 69
- Table 22: Mean % of patients that receive pain assessment during different time periods following surgery, 2005 - page 70
- Table 23: Total % of respondents using the diagnostic tools to measure severity of postoperative pain, 2005 - page 78
- Table 24: Total % of physicians using diagnostic tools used to measure postoperative pain in all markets, 2005 - page 80
- Table 25: Percentage of respondents highlighting best diagnostic method used, by country, 2005 - page 81
- Table 26: Mean percentage of patients that report pain within two hours post-surgery, across all major markets, 2005 - page 83
- Table 27: Mean number of patients experiencing pain in the two hours following surgery that have received pain relief during or immediately after surgery - page 86
- Table 28: Mean percentage of patients with mild, moderate and severe pain receiving pharmacological, non-pharmacological or both treatments, across all markets, 2005 - page 87
- Table 29: Mean percentage of patients that use non-pharmacological methods for the relief of postoperative pain, by country, 2005 - page 90
- Table 30: Mean percentage of patients that receive second line treatment following failure of first-line treatment, 2005 - page 102
- Table 31: Mean time (days) patients are on first-line therapy before progression to second line treatment, 2005 - page 103
- Table 32: Mean percentage of patients that progress on to third-line treatment following failure of second-line treatment, in all markets, 2005 - page 103
- Table 33: Mean percentage of patients that are treated with PCA only for postoperative pain, 2005 - page 104
- Table 34: Mean percentage of patients treated with PCA and fixed scheduled drug for postoperative pain, 2005 - page 105
- Table 35: Mean percentage of patients that have inadequately treated postoperative pain, by country, 2005 - page 106
- Table 36: Mean percentage of inadequately treated patients who suffer mild, moderate or severe pain, by country, 2005 - page 106
- Table 37: Percentage of patients experiencing inadequately managed pain following surgery and following patient discharge in all markets, 2005 - page 108
- Table 38: Mean percentage of patients that volunteer information regarding inadequately treated pain to physicians, 2005 - page 109
- Table 39: Mean percentage of patients that receive drug therapy at final discharge from hospital, by country, 2005 - page 110
- Table 40: Percentage of respondents that carry out the following actions in addition to drug treatment by first preference, by country, 2005 - page 111
- Table 41: Percentage of respondents that rate actions in terms of preference for patients experiencing pain associated with surgery at time of discharge, 2005 - page 113
- Table 42: Mean percentage of patients that suffer from varied postoperative complications, by country, 2005 - page 119
- Table 43: Mean percentage of patients that suffer complications where this is attributed to drug therapy, by country, 2005 - page 120
- Table 44: Total % of respondents spontaneous or prompted awareness or lack of awareness for pipeline drugs in postoperative pain, in all markets, 2005 - page 121
- Table 45: Estimated number of orthopedic surgeries, by country - page 129
- List of Figures
- Figure 1: Overview of what postoperative pain report covers, 2005 - page 15
- Figure 2: The percentage and number of US patients that undergo orthopedic surgery that suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 18
- Figure 3: Percentage of physicians in the US that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 19
- Figure 4: The percentage and number of patients in Japan that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 20
- Figure 5: Percentage of physicians in Japan that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 21
- Figure 6: The percentage and number of patients in France that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 22
- Figure 7: Percentage of physicians in France that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 23
- Figure 8: The percentage and number of patients in Germany that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 24
- Figure 9: Percentage of physicians in Germany that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 25
- Figure 10: The percentage and number of patients in Italy that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 26
- Figure 11: Percentage of physicians in Italy that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 27
- Figure 12: The percentage and number of patients in Spain that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 28
- Figure 13: Percentage of physicians in Spain that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 29
- Figure 14: The percentage and number of patients in UK that undergo orthopedic surgery and suffer either no pain or mild, moderate or severe postoperative pain, 2005 - page 30
- Figure 15: Percentage of physicians in the UK that choose as their first-choice, first-line therapy each drug for the treatment of mild, moderate and severe postoperative pain - page 31
- Figure 16: Number of orthopedic operations (ICD-9 codes 76-84) in the US, according to age, 2003 - page 41
- Figure 17: Number of orthopedic operations, by gender, 2003 - page 42
- Figure 18: Factors influencing pain perception, 2005 - page 43
- Figure 19: Percentage of respondents that identified the following healthcare professionals as responsible for pre-surgery pain assessment across all major markets, 2005 - page 45
- Figure 20: Percentage of respondents that identified the following healthcare professionals as being responsible for post-surgery pain assessment across all major markets, 2005 - page 47
- Figure 21: Percentage of respondents that identified the following healthcare professionals to be responsible for initiation of post-surgery pain treatment, in all major markets, 2005 - page 49
- Figure 22: Percentage of respondents that identified each healthcare professionals to be responsible for the management of pain relief following treatment initiation, 2005 - page 50
- Figure 23: Percentage of respondents that identified stated healthcare professionals as responsible for managing pain treatment upon hospital discharge, 2005 - page 52
- Figure 24: Mean number of healthcare professionals that are responsible for the varying stages of pain assessment/treatment, by country, 2005 - page 54
- Figure 25: Percentage of respondents (surgeons) that make decisions in the different time frames following surgery, across all major markets, 2005 - page 56
- Figure 26: Percentage of respondents (anesthetists) that make decisions in the different time frames following surgery, 2005 - page 57
- Figure 27: Mean percentage of patients advice is given to during all stages leading up to and after surgery, by country, 2005 - page 67
- Figure 28: Total mean % of patients given advice through all stages before and after surgery in all markets, 2005 - page 67
- Figure 29: Total mean % of patients given pain management advice by surgeons and anesthetists through the stages of postoperative pain management - page 68
- Figure 30: Mean percent of patients that have pain management programs initiated before, during and after surgery, by country, 2005 - page 69
- Figure 31: Mean % of patients that receive pain assessment during different time periods following surgery, 2005 - page 71
- Figure 32: The primary physicians that assess pain management during the first two hours following surgery by percentage of respondents stating, 2005 - page 72
- Figure 33: The primary physicians that assess pain management during the two- to 12-hour period following surgery by percentage of respondents stating, 2005 - page 73
- Figure 34: The primary physicians that assess pain management during the 12-24 hour time period following surgery by percentage of respondents stating, 2005 - page 74
- Figure 35: The primary physicians that assess pain management during the one-to five-day period following surgery by percentage of respondents stating, 2005 - page 75
- Figure 36: Total % of respondents using the diagnostic tools to measure severity of postoperative pain, 2005 - page 79
- Figure 37: Total percentage of respondents highlighting their choice of the best diagnostic tool, 2005 - page 82
- Figure 38: Mean percentage of patients that report pain within two hours post-surgery, across all major markets, 2005 - page 83
- Figure 39: Mean number of patients experiencing pain in the two hours following surgery that have received pain relief during or immediately after surgery - page 86
- Figure 40: Mean percentage of patients that use non-pharmacological methods for the relief of postoperative pain, by country, 2005 - page 90
- Figure 41: Percentage of physicians that prescribe acetaminophen according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 92
- Figure 42: Percentage of physicians that prescribe naproxen according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 93
- Figure 43: Percentage physicians that prescribe diclofenac according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 94
- Figure 44: Percentage of physicians that prescribe piroxicam according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 95
- Figure 45: Percentage of physicians that prescribe ibuprofen according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 96
- Figure 46: Percentage of physicians that prescribe ketoprofen according to administration route, combination therapy and reasons for switching to another drug, for mild and moderate postoperative pain, in all markets, 2005 - page 97
- Figure 47: Percentage of physicians that prescribe tramadol according to administration route, combination therapy and reasons for switching to another drug, for severe postoperative pain, in all markets, 2005 - page 98
- Figure 48: Percentage of physicians that prescribe morphine according to administration route, combination therapy and reasons for switching to another drug, for severe postoperative pain, in all markets, 2005 - page 99
- Figure 49: Percentage of physicians that prescribe oxycodone according to administration route, combination therapy and reasons for switching to another drug, for severe postoperative pain, in all markets, 2005 - page 100
- Figure 50: Percentage of physicians that prescribe fentanyl according to administration route, combination therapy and reasons for switching to another drug, for severe postoperative pain, in all markets, 2005 - page 101
- Figure 51: Percentage of physicians that prescribe codeine according to administration route, combination therapy and reasons for switching to another drug, for severe postoperative pain, in all markets, 2005 - page 101
- Figure 52: Mean percentage of patients treated with PCA alone or in combination with a fixed scheduled drug for postoperative pain, 2005 - page 105
- Figure 53: Mean percentage of inadequately treated patients who suffer mild, moderate or severe pain, by country, 2005 - page 107
- Figure 54: Percentage of patients experiencing inadequately managed pain following surgery and following patient discharge in all markets, 2005 - page 108
- Figure 55: Total percentage of respondents that carry out the following actions in addition to drug treatment in the first instance, by country, 2005 - page 112
- Figure 56: Total percentage of respondents that carry out the following actions in order of preference, 2005 - page 113
- Figure 57: Total % of respondents that state number of days that patients experience pain related to surgery, 2005 - page 114
- Figure 58: Key attributes in postoperative pain treatment - page 115
- Figure 59: Percentage of physicians that state product as most closely fitting their chosen key attributes - page 116
- Figure 60: Physician perception of improvements in postoperative pain management in the last five years - page 117
- Figure 61: Respondents stating the mean percentage of patients that suffer from varied postoperative complications, by country, 2005 - page 119
- Figure 62: Total percentage of respondent's spontaneous or prompted awareness for pipeline drugs in postoperative pain, in all markets, 2005 - page 122
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