Treatment of chronic non-cancer pain

Complementary treatment comparison for chronic pain management: A randomized longitudinal study

Background

In chronic pain, it seems that the effect of cognitive-behavioral therapy (CBT) is boosted when it is combined with hypnosis. The aim of this study was to assess the efficacy of self-hypnosis combined with self-care (i.e., a type of CBT) compared to music/self-care, self-care and psychoeducation/CBT and to evaluate their long-term effects.

Methods

An open label randomized clinical trial enrolled patients with chronic pain and was carried out at the University Hospital of Liège (Belgium). Patients were randomized into four groups: self-hypnosis/self-care, music/self-care, self-care, psychoeducation/CBT (7 monthly sessions of 2 hours). Two follow-up sessions were delivered at 6- and 12-month. Levels of pain, fatigue intensity, anxiety, depression, insomnia severity, disability, health locus of control, mental and physical quality of life and attitudes (control, disability, harm, emotion, medical cure, medication, solicitude) towards pain were assessed before and after the treatments, and at follow-up.

Results

203 patients were randomized: 52 in self-hypnosis/self-care, 59 in music/self-care, 47 in self-care, and 45 in psychoeducation/CBT. No group effect was found. A significant time effect was showed. Directly after the treatment, all groups decreased in pain attitudes and physical quality of life. Perceived control increased. At 6-month, all patients kept their levels of physical quality of life and perceived control, and showed decrease in pain intensity, harm, emotion and medical cure. At 12-month, scores that had change previously remained ameliorated, a decrease in insomnia severity and an increase in internal locus of control were observed.

Conclusions

The present findings are encouraging as they display long-term beneficial effects of complementary biopsychosocial-based treatments in chronic pain. It seems that patients continued to apply the learnt strategies as improvements were observed one year after the treatments had ended.

Are positive psychology interventions efficacious in chronic pain treatment? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Although positive psychology interventions are increasingly popular in chronic pain treatment their efficacy is still unclear. The objective is to summarize evidence on the effect of positive psychology interventions (PPIs) on pain, physical functioning, and emotional functioning in adults with chronic pain.

METHODS

Four electronic databases and additional references were searched for randomized controlled trials published between 1990 and 2020. Findings from included studies were qualitatively and quantitatively synthesized, and study quality was assessed for risk of bias. A random effects meta-analysis model was applied for outcomes with more than four findings.

RESULTS

Of 16 included randomized controlled trials, almost half delivered positive psychology interventions as self-help online interventions, and half conducted guided face-to-face interventions which lasted mostly eight weeks. Results from meta-analysis showed beneficial effects of positive psychology interventions compared to the control group on pain intensity and emotional functioning (i.e., less depressive symptoms, pain catastrophizing, negative affect; more positive affect) post-intervention. At 3-month follow-up, beneficial effects were maintained for depressive symptoms and positive and negative affect, but not for pain catastrophizing. However, the evidence on the long-term efficacy of PPIs and the efficacy of PPIs on physical functioning remains limited.

CONCLUSION

This review supports the notion that positive psychology interventions are beneficial to chronic pain treatment, although further, high quality research is needed to support this conclusion.

Cognitive Change and Relaxation as Key Mechanisms of Treatment Outcome in Chronic Pain: Evidence From Routine Care

Despite effective treatment approaches within the cognitive behavioral framework general treatment effects for chronic pain are rather small to very small. Translation from efficacy trials to naturalistic settings is questionable. There is an urgent need to improve the effectiveness of well-established treatments, such as cognitive-behavior therapy (CBT) and the investigation of mechanisms of change is a promising opportunity. We performed secondary data analysis from routine data of 1,440 chronic pain patients. Patients received CBT in a multidisciplinary setting in two inpatient clinics. Effect sizes and reliable change indices were computed for pain-related disability and depression. The associations between changes in the use of different pain coping skills (cognitive restructuring, activity despite pain, relaxation techniques and mental distraction) and changes in clinical outcomes were analyzed in structural equation models. Pre-post effect sizes range from g = 0.47 (disability) to g = 0.89 (depression). Changes in the use of cognitive restructuring, relaxation and to a lesser degree mental distraction were associated with changes in disability and depression. Effects from randomized trials can be translated to naturalistic settings. The results complement experimental research on mechanisms of change in the treatment of chronic pain and indicate an important role of cognitive change and relaxation as mechanisms of change. Our findings cautiously suggest that clinicians should optimize these processes in chronic pain patients to reduce their physical and emotional disability.

The relationships between chronic pain and changes in health with cannabis consumption patterns

BACKGROUND

Pain is the most common reason endorsed by patients seeking medical cannabis. Given the nature of chronic pain, it is particularly important to understand consumption patterns for patients who use cannabis for chronic health conditions to evaluate how frequency of use might impact overall health and functioning. This analysis examines whether levels of chronic pain were associated with cannabis consumption patterns, after controlling for patient-level differences in demographics.

METHODS

Our sample included 295 medical cannabis patients. Logistic regression models were fit to evaluate the association between pain (low, moderate and high) and dichotomous measures of cannabis consumption (daily vs. nondaily; ≥3 times per day vs. <3 times per day). Additionally, two ordered logit models were fit to evaluate the association between past-year health status change (better, same, or worse) and cannabis consumption.

RESULTS

A significantly higher proportion of respondents in the high pain category used cannabis 3 or more times per day, compared to lower pain categories. Pain level was not significantly associated with daily cannabis use. However, pain level was significantly associated with log odds of using cannabis ≥3 times per day, such that respondents with both high pain and moderate pain had significantly higher log odds of consuming cannabis ≥3 times per day compared to low pain group.

CONCLUSION

While the efficacy of cannabis for various medical conditions continues to be evaluated, the best available evidence suggests a possible benefit for the treatment of chronic pain. The results of this study indicate that individuals with high pain are more likely to consume cannabis multiple times a day, but this use may not be related to better health. Our results point to a need for more research on the health impacts of frequency of cannabis use among medical cannabis dispensary patients.

Long-term follow-up of patients with chronic musculoskeletal pain attending interdisciplinary pain rehabilitation: outcomes and predictive factors

The long-term outcomes of interdisciplinary pain rehabilitation (IPR) in patients with chronic musculoskeletal pain (CMP) and its predictors has been studied to a limited extent. In this historical cohort study, functioning, satisfaction with life domains, and pain were assessed at baseline, discharge, and at 6-15 years follow-up. At follow-up, most patients (77%) rated the effects of the IPR as temporarily or persistently positive. The gains in functioning, satisfaction with life domains, and pain made during IPR remained for 6-15 years after the IPR. Patients who were single, retired, or not in work, and those having higher pain and lower functioning at baseline, had lower functioning at follow-up, while patients with traumatic pain disorders had higher functioning at follow-up. Gains made during IPR, particularly gains in social and mental functioning and in pain predicted functioning at follow-up. Treatments and events between discharge and follow-up also influenced the long-term outcome. In conclusion, on average, outcomes achieved during IPR persisted at long-term follow-up. Predictors of a better long-term outcome were mainly baseline characteristics.

Evaluating Baseline and Sensitised Heat Nociception in Adult Drosophila

Chronic pain is a complex disease that affects a large proportion of the population. With little to no effective treatments currently available for patients, this malady presents a large burden to society. Drosophila melanogaster has been previously used to describe conserved molecular components of nociception in larvae and adults. However, adult assays tend to rely on avoidance behaviours, and whilst larval acute thermal avoidance assays exist, larvae are not best suited to a chronic pain scenario as the condition must be long-term. Therefore, an adult thermal nociception response assay was required to study injury-evoked changes in heat nociception threshold (allodynia and hyperalgesia) over time, and we describe such a protocol here. Following leg amputation, flies display increased thermal sensitivity (allodynia) to innocuous temperatures but not an increase in magnitude of response (hyperalgesia) to noxious heat. Our method allows for individualised analysis of both allodynia and hyperalgesia.

"I'm empowered to look after myself" - Mindfulness as a way to manage chronic pain: An interpretative phenomenological analysis of participant experiences in Scotland

BACKGROUND AND PRIMARY AIM

Chronic pain is a common problem that can impact on psychological and social wellbeing and activity levels. Despite pharmacological treatments, there is often a lack of improvement in physical and emotional functioning and health-related quality of life. Mindfulness meditation has become an increasingly popular self-management technique. The aim of the study was to explore the experiences of patients with chronic pain who took part in a mindfulness programme.

METHODS

A mixed-methods feasibility study was carried out. Participants were aged 18 years or over with non-malignant chronic pain recruited from general medical practices in Fort William, Scotland. In 2013 participants undertook an eight-week mindfulness programme based on Mindfulness-Based Stress Reduction (MBSR) and were interviewed immediately post-programme and at eight-months' post-programme. Analysis of qualitative data involved Interpretative Phenomenological Analysis (IPA).

FINDINGS

Thirty-four patients consented to take part in the study; twenty-four took part in the programme (14 attended four or more sessions, 10 attended one to three). Twenty-three were interviewed. Participant experiences of the programme were themed under: factors affecting experience (influence of earlier life events; the process of taking part in, and of relating to, the programme); and effects of the programme (impact on emotions, mental health, adverse events and a process of change). The process of change, resulting after better understanding the relationship between mindfulness and pain, involved learning to 'listen to the body', gaining a sense of community, learning to accept pain, and approaching life with more self-care, awareness, appreciation and empowerment.

CONCLUSION

Participants reported a variety of experiences. For some, these included undergoing a process of change which may have supported them in living with their painful condition. This contributes to our understanding of how mindfulness could benefit people with chronic pain.

Differential expression of cerebrospinal fluid neuroinflammatory mediators depending on osteoarthritis pain phenotype

Supplemental Digital Content is Available in the Text.

Distinct cerebrospinal fluid neuroinflammatory profiles may be associated with different objective characteristics of persistent pain in osteoarthritis patients undergoing total hip arthroplasty.

Neuroinflammation is implicated in the development and maintenance of persistent pain states, but there are limited data linking cerebrospinal fluid (CSF) inflammatory mediators with neurophysiological pain processes in humans. In a prospective observational study, CSF inflammatory mediators were compared between patients with osteoarthritis (OA) who were undergoing total hip arthroplasty due to disabling pain symptoms (n = 52) and pain-free comparison controls (n = 30). In OA patients only, detailed clinical examination and quantitative sensory testing were completed. Cerebrospinal fluid samples were analyzed for 10 proinflammatory mediators using Meso Scale Discovery platform. Compared to controls, OA patients had higher CSF levels of interleukin 8 (IL-8) (P = 0.002), intercellular adhesion molecule 1 (P = 0.007), and vascular cell adhesion molecule 1 (P = 0.006). Osteoarthritis patients with central sensitization possibly indicated by arm pressure pain detection threshold <250 kPa showed significantly higher CSF levels of Fms-related tyrosine kinase 1 (Flt-1) (P = 0.044) and interferon gamma-induced protein 10 (IP-10) (P = 0.024), as compared to subjects with PPDT above that threshold. In patients reporting pain numerical rating scale score ≥3/10 during peripheral venous cannulation, Flt-1 was elevated (P = 0.025), and in patients with punctate stimulus wind-up ratio ≥2, CSF monocyte chemoattractant protein 1 was higher (P = 0.011). Multiple logistic regression models showed that increased Flt-1 was associated with central sensitization, assessed by remote-site PPDT and peripheral venous cannulation pain, and monocyte chemoattractant protein-1 with temporal summation in the area of maximum pain. Multiple proinflammatory mediators measured in CSF are associated with persistent hip OA-related pain. Pain phenotype may be influenced by specific CSF neuroinflammatory profiles.

Patients' perspectives of pain in dialysis: systematic review and thematic synthesis of qualitative studies

ABSTRACT

Pain is a severe and common symptom in patients receiving dialysis but remains inadequately managed in clinical practice. Understanding patient experiences of pain can inform strategies to address this patient-important symptom. We aimed to describe patients' perspectives on causes, experiences, and impacts of dialysis-associated pain. MEDLINE, Embase, PsycINFO, and CINAHL were searched to August 2019 for all qualitative studies that described the perspectives of pain in adults aged 18 years or older receiving dialysis. Findings from the primary studies were analyzed using thematic synthesis. We included 60 studies across 14 countries involving 1343 participants (1215 receiving hemodialysis and 128 receiving peritoneal dialysis), and identified 6 themes: gripped by an all-consuming agony (draining cognitive capacity, exacerbating other symptoms); suffering in silence (surrendering to the inevitable, ignored or dismissed, hiding symptoms to protect others); provoking fear of treatment (resistance to cannulation, avoiding dialysis, anxious from witnessing other patients in pain); preventing life participation (preventing fulfilment of valued roles, depleting the will to live); coping aided by connection with others (shared understanding among patients, comforted and supported by others); and developing awareness, assertiveness, and self-reliance (procedural vigilance, finding strategies to minimize pain, bodily understanding and knowing thresholds, positive thinking). Struggling with pain in dialysis involved a progression of agony, fear, avoidance, and despair. However, support from others and self-management strategies were used to cope with pain. Strategies to empower patients to report and minimize pain and its consequences in dialysis are needed.

Treatment satisfaction mediates the association between perceived physician empathy and psychological distress in a community sample of individuals with chronic pain

OBJECTIVE

While the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.

METHODS

A community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.

RESULTS

Results revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.

CONCLUSION

Chronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.

PRACTICE IMPLICATIONS

Clinical training and practice should promote empathetic components of health communication within chronic pain treatment.

Systematic evaluation of content and quality of English and German pain apps in European app stores

BACKGROUND AND OBJECTIVE

Pain spans a broad spectrum of diseases and types that are highly prevalent and cause substantial disease burden for individuals and society. Up to 40% of people affected by pain receive no or inadequate treatment. Providing a scalable, time-, and location-independent way for pain diagnostic, management, prevention and treatment mobile health applications (MHA) might be a promising approach to improve health care for pain. However, the commercial app market is rapidly growing and unregulated, resulting in an opaque market. Studies investigating the content, privacy and security features, quality and scientific evidence of the available apps are highly needed, to guide patients and clinicians to high quality MHA.Contributing to this challenge, the present study investigates the content, quality, and privacy features of pain apps available in the European app stores.

METHODS

An automated search engine was used to identify pain apps in the European Google Play and Apple App store. Pain apps were screened and checked for systematic criteria (pain-relatedness, functionality, availability, independent usability, English or German). Content, quality and privacy features were assessed by two independent reviewers using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality on four objectives (engagement, functionality, aesthetics, information quality) and two subjective scales (perceived impact, subjective quality).

RESULTS

Out of 1034 identified pain apps 218 were included. Pain apps covered eight different pain types. Content included basic information, advice, assessment and tracking, and stand-alone interventions. The overall quality of the pain apps was average M = 3.13 (SD = 0.56, min = 1, max = 4.69). The effectiveness of less than 1% of the included pain apps was evaluated in a randomized controlled trial. Major problems with data privacy were present: 59% provided no imprint, 70% had no visible privacy policy.

CONCLUSION

A multitude of pain apps is available. Most MHA lack scientific evaluation and have serious privacy issues, posing a potential threat to users. Further research on evidence and improvements privacy and security are needed. Overall, the potential of pain apps is not exploited.

Dropout associated with osteopathic manual treatment for chronic noncancerous pain in randomized controlled trials

CONTEXT

Reviews exploring harm outcomes such as adverse effects (AE), all cause dropouts (ACD), dropouts due to inefficacy, and dropouts due to AE associated with osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are scant.

OBJECTIVES

To explore the overall AE, ACD, dropouts due to inefficacy, and AE in chronic noncancerous pain (CNCP) patients receiving OMTh through a systematic review of previous literature.

METHODS

For this systematic review and meta-analysis, the authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), EMCare, and Allied and Complementary Medicine Database (AMED), and Ostmed.Dr, as well as the bibliographical references of previous systematic reviews evaluating OMTh for pain severity, disability, quality of life, and return to work outcomes. Randomized controlled trials with CNCP patients 18 years or older with OMTh as an active or combination intervention and the presence of a control or combination group were eligible for inclusion. In this sub-study of a previous, larger systematic review, 11 studies (n=1,015) reported data that allowed the authors to perform meta-analyses on ACD and dropouts due to AE. The risk of bias (ROB) was assessed with the Cochrane ROB tool and the quality of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The pooled analysis showed that ACD was not significantly different for visceral OMTh (vOMTh) vs. OMTh control (odds ratio [OR]=2.66 [95% confidence interval [[CI]], 0.28, 24.93]) or for OMTh vs. standard care (OR=1.26 [95% CI, 0.84, 1.89]; I²=0%). Single study analysis showed that OMTh results were nonsignificant in comparison with chemonucleolysis, gabapentin, and exercise. OMTh in combination with gabapentin (vs. gabapentin alone) and OMTh in combination with exercise (vs. exercise alone) showed nonsignificant ACD. Dropouts due to AE were not significantly different, but the results could not be pooled due to an insufficient number of studies.

CONCLUSIONS

Most articles did not explicitly report AEs, ACD rates, or dropouts due to AEs and inefficacy. The limited data available on dropouts showed that OMTh was well tolerated compared with control interventions, and that the ACD and dropouts due to AEs were not significantly different than comparators. Future trials should focus on explicit reporting of dropouts along with beneficial outcomes to provide a better understanding of OMTh efficacy.

Construct validity and reproducibility of the Prescription Opioid Misuse And Abuse Questionnaire (POMAQ)

OBJECTIVE

The Prescription Opioid Misuse and Abuse Questionnaire was developed to identify prescription opioid abuse and misuse among patients with chronic pain, however, evidence of construct validity and reproducibility is needed.

METHODS

Chronic pain patients were recruited from five Department of Defense Military Health System clinics across the United States. Construct validity was examined using subjective clinician-reported and patient-reported measures as well as objective information (e.g. hair/urine drug screens and electronic medical records). Test-retest reliability was assessed across 2 timepoints among a subgroup of patients with stable chronic pain.

RESULTS

Of 3,263 screened patients, 938 (28.7%) met eligibility and were enrolled; 809 (86.2%) completed the Prescription Opioid Misuse and Abuse Questionnaire. Construct validity was supported by comparison to other validated questionnaires and hair and urine screens which yielded high agreements with patient reports on the Prescription Opioid Misuse and Abuse Questionnaire. Electronic medical record data supported patients' Prescription Opioid Misuse and Abuse Questionnaire responses regarding physician and emergency room visits and opioid refills. The Prescription Opioid Misuse and Abuse Questionnaire had excellent test-retest reliability; the percentage agreement between the two Prescription Opioid Misuse and Abuse Questionnaire administrations was high (>90%) for most questions.

DISCUSSION

Results suggest that the Prescription Opioid Misuse and Abuse Questionnaire is a valid and reproducible tool that can be used to assess the presence of prescription opioid misuse and abuse among patients with chronic pain.

ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.

OBJECTIVE

ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.

METHODS

The study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.

RESULTS

The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.

CONCLUSION

The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

Pregabalin prescribing patterns in Australian general practice, 2012-2018: a cross-sectional study

BACKGROUND

In 2013 pregabalin was subsidised by Australia's Pharmaceutical Benefits Scheme (PBS) for neuropathic pain. Since the subsidy, pregabalin prescribing has been increasing in Australia and so has related harm. There are concerns it is being prescribed for indications other than neuropathic pain, which have little evidence of efficacy.

AIM

To describe pregabalin prescribing in Australian general practice.

DESIGN & SETTING

A cross-sectional study of patients attending 445 general practice sites in the national MedicineInsight database from March 2012-February 2018.

METHOD

The following aspects were calculated: the proportion of prescriptions that were for pregabalin per year; the prevalence of pain conditions in patients prescribed pregabalin; and same-day prescribing of pregabalin with opioids or benzodiazepines.

RESULTS

Prescribing increased from 13 per 10 000 to 104 per 10 000 prescriptions between 2012-2013 and 2017-2018. A total of 1 891 623 patients were identified of whom 114 123 (6.0%) were prescribed pregabalin; 49.7% (n = 56 772) had a recorded diagnosis of neuropathic pain. Among people prescribed pregabalin without a recorded diagnosis of neuropathic pain, 43.5% (n = 24 927) had a diagnosis of back problems, 8.8% (n = 5073) chronic pain, and 26.4% (n = 30 146) had no pain diagnosis. Pregabalin was prescribed the same day as an opioid to 38.1% of patients (95% confidence interval [CI] = 37.1% to 39.1%) and a benzodiazepine to 13.1% of patients (95% CI = 12.5% to 13.7%). Patients with a diagnosis of chronic pain had the highest rate of same-day prescribing of pregabalin with an opioid (70.4%, 95% CI = 68.9% to 71.9%) or a benzodiazepine (25.8%, 95% CI = 24.2% to 27.4%) CONCLUSION: Substantial increases in pregabalin prescribing were identified in Australian general practice, but only half of patients had a neuropathic pain diagnosis recorded, the only approved indication for subsidy. High rates of same-day prescribing with opioids and benzodiazepines may put patients at increased risk of harm.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.

Objectives:

To determine the prevalence and severity of chronic pain in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.

Patients:

Adults with glomerular filtration rate (GFR) category 3 to 5 CKD including dialysis patients and those managed conservatively without dialysis.

Measurements:

Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of pain, and severity of pain.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain and the I² statistic was computed to measure heterogeneity. Random effects models were used to account for variations in study design and sample populations and a double arcsine transformation was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.

Results:

Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.

Limitations:

Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.

Conclusions:

Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.

Trial registration:

PROSPERO Registration number CRD42020166965

Bicyclic Diazepinones as Dual Ligands of the α2δ-1 Subunit of Voltage-Gated Calcium Channels and the Norepinephrine Transporter

The synthesis and pharmacological activity of a new series of bicyclic diazepinones with dual activity toward the α2δ-1 subunit of voltage-gated calcium channels (Ca_vα2δ-1) and the norepinephrine transporter (NET) are reported. Exploration of the positions amenable for substitution on a nonaminoacidic Ca_vα2δ-1 scaffold allowed the identification of favorable positions for the attachment of NET pharmacophores. Among the patterns explored, attachment of the 2-ethylamino-9-methyl-6-phenyl-6,7,8,9-tetrahydro-5H-pyrimido[4,5-e][1,4]diazepin-5-one framework to the meta-position of the phenyl ring of the 3-methylamino-1-phenylpropoxy and 3-methylamino-1-thiophenylpropoxy moieties provided dual compounds with excellent NET functionality. Alternative bicyclic frameworks were also explored, and some lead molecules were identified, which showed a balanced dual profile and exhibited good ADMET properties.

Quality of life and treatment satisfaction with pharmacological interventions in Chinese adults with chronic pain due to osteoarthritis

Background

Aim of this multicenter, observational, cross-sectional study was to evaluate health-related quality of life (HRQoL) and treatment satisfaction of current medications in Chinese knee OA patients.

Methods

Brief Pain Inventory (BPI), Treatment Satisfaction Questionnaire (TSQM-1.4), and HRQoL (EQ-5D-5L) were assessed in total of 601 OA of knee patients. Impact on QoL (EQ-5D-5L) and treatment satisfaction (TSQM-1.4) by BPI-Severity score (< 4 and ≥ 4) were presented using mean standard deviations (SDs) and were compared using a t-test. For each of self-assessed health EQ-5D-5L and TSQM, a linear regression model was used to estimate the regression coefficient along with corresponding 95% confidence interval (CI) for BPI-Severity.

Results

Mean score of EQ-5D-5L of patients with BPI-Severity ≥4 was significantly lower than those with BPI-Severity < 4. All the scores of TSQM in 4 dimensions were lower in patients with BPI-Severity ≥4 than in those with BPI-Severity < 4. Both HRQoL scores and TSQM scores showed a statistically significant decreasing trend with increasing BPI-Severity pain score.

Conclusion

Chronic knee OA pain has a significant impact on patients’ HRQoL. More severe patients with OA were less satisfied with current treatments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04012-2.

Effectiveness of Perineural Injections Combined with Standard Postoperative Total Knee Arthroplasty Protocols in the Management of Chronic Postsurgical Pain After Total Knee Arthroplasty

Background

Despite increased experience and technical developments in total knee arthroplasty (TKA), chronic postsurgical pain (CPSP) remains one of physicians’ biggest challenges. The aim of the present study was to evaluate the effectiveness of perineural injection therapy (PIT) in the management of CPSP after TKA.

Material/Methods

A total of 60 patients who had been surgically treated with TKA because of advanced knee osteoarthritis was included in the present study. The study included 2 groups. Group A consisted of patients who received 3 rounds of PIT combined with standard postoperative TKA protocol during the same period. Group B received standard postoperative TKA protocols (rehabilitation programs, oral and intravenous analgesics). Clinical effectiveness was evaluated via Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Visual Analog Scale (VAS) at baseline and 1-, 3-, and 6-month follow-ups.

Results

All repeated measures showed significant improvements (P<0.001) in both groups for VAS and WOMAC scores. These scores were significantly better in group A in all follow-up periods compared with group B (P<0.001). Twenty-nine patients (93.5%) in group A reported excellent or good outcomes compared with 26 patients (89.6%) in group B.

Conclusions

PIT is a promising approach in CPSP with minimal cost, simple and secure injection procedures, minimal side effects, and higher clinical efficacy.

Autobiographical Memory and Future Thinking Specificity and Content in Chronic Pain

Chronic pain is associated with high levels of mental health issues and alterations in cognitive processing. Cognitive-behavioral models illustrate the role of memory alterations (e.g., autobiographical memory and future thinking) in the development and maintenance of chronic pain as well as in mental health disorders which frequently co-occur with chronic pain (e.g., anxiety and mood disorders). This study aims to expand our understanding of specific cognitive mechanisms underlying chronic pain which may in turn shed light on cognitive processes underlying pain-related psychological distress. Individuals (N = 84) who reported a history of chronic pain and individuals who reported no history of chronic pain (N = 102) were recruited from MTurk to complete an online survey including standardized measures of anxiety and depression and two sentence completion tasks that assessed autobiographical memory and future thinking specificity and content. Chi square analyses revealed that participants who endorsed experiencing chronic pain were significantly more likely to recall at least one painful and negative event and to imagine at least one anticipated painful event in their future. Two ANCOVAs were performed to examine the degree to which chronic pain endorsement influenced specificity in memory and future imagining. Individuals with a history of chronic pain and higher levels of depression symptom severity generated autobiographical memories with significantly less specificity; whereas, individuals with a history of chronic pain also generated future autobiographical events with significantly less specificity. In addition, individuals with a history of chronic pain were more likely to generate episodes related to pain when asked to recall the past or imagine the future. Further research is needed to improve our understanding of the etiology of autobiographical memory and future thinking specificity and content in the pathogenesis of mental health conditions in the context of chronic pain.

Bibliometric Analysis of Research on the Comorbidity of Cancer and Pain

BACKGROUND

Pain is the most common symptom in patients with neoplasm. It is a distressing experience that seriously destructs the quality-of-life of patients, with a high prevalence in clinical observations. However, only a few studies have applied bibliometric methods to analyze systematic works on the comorbidity of cancer and pain.

PURPOSE

The aim of this work was to conduct a systematic analysis of the scientific studies worldwide on the comorbidity of cancer and pain in 2010-2019.

METHODS

The Web of Science databases were searched for publications related to the comorbidity of cancer and pain from 2010 to 2019.

RESULTS

A total of 3,423 papers met the inclusion criteria in this research. The increase in the quantity of papers presented a significant growth from 2010 to 2019 (P<0.001) by linear regression analysis. The research subject categories of the 3,423 papers mainly concentrated on oncology (28.57%), clinical neurology (25.62%), and healthcare science services (15.89%). The US had the highest number of published papers, followed by the People's Republic of China, and England. According to scientific statistics, breast cancer (20.36%) was by far the most predominant topic in the papers related to the comorbidity of cancer and pain.

CONCLUSION

This bibliometric research provided a framework for visual and quantitative research to management scholars in favor of exploring a potential field related to hot issue and research frontiers.

Opioid Management in CKD

Patients with chronic kidney disease (CKD) experience a high pain and symptom burden. Concurrently, opioid prescription and use in patients with CKD continues to increase, leading to concern for opioid-related risks. Nephrologists increasingly face challenging clinical situations requiring further evaluation and treatment of pain, for which opioid use may be indicated. However, nephrologists are not commonly trained in pain management and may find it difficult to compile the necessary information and tools to effectively assess and treat potentially multidimensional pain. In these situations, they may benefit from using an evidence-based stepwise approach proposed in this article. We address current approaches to opioid use for pain management in CKD and offer a stepwise approach to individualized opioid assessment, focusing on kidney-specific concerns. This includes thorough evaluation of the pain experience, opioid use history, and treatment goals. We subsequently discuss considerations when initiating opioid therapy, strategies to reduce opioid-related risks, and recommended best practices for opioid stewardship in CKD. Using this sequential approach to opioid management, nephrologists can thereby gain a broad overview of key patient considerations, the foundation for understanding implications of opioid use, and a patient-tailored plan for opioid therapy.

A cost-utility analysis of multimodal pain rehabilitation in primary healthcare

OBJECTIVES

Multimodal rehabilitation programs (MMRPs) have been shown to be both cost-effective and an effective method for managing chronic pain in specialist care. However, while the vast majority of patients are treated in primary healthcare, MMRPs are rarely practiced in these settings. Limited time and resources for everyday activities alongside the complexity of chronic pain makes the management of chronic pain challenging in primary healthcare and the focus is on unimodal treatment. In order to increase the use of MMRPs incentives such as cost savings and improved health status in the patient group are needed. The aim of this study was to evaluate the cost-effectiveness of MMRPs for patients with chronic pain in primary healthcare in two Swedish regions. The aim of this study was to evaluate the cost-effectiveness of MMRPs at one-year follow-up in comparison with care as usual for patients with chronic pain in primary healthcare in two Swedish regions.

METHODS

A cost-utility analysis was performed alongside a prospective cohort study comparing the MMRP with the alternative of continuing with care as usual. The health-related quality of life (HRQoL), using EQ5D, and working situation of 234 participants were assessed at baseline and one-year follow-up. The primary outcome was cost per quality-adjusted life year (QALY) gained while the secondary outcome was sickness absence. An extrapolation of costs was performed based on previous long-term studies in order to evaluate the effects of the MMRP over a five-year time period.

RESULTS

The mean (SD) EQ5D index, which measures HRQoL, increased significantly (p<0.001) from 0.34 (0.32) to 0.44 (0.32) at one-year follow-up. Sickness absence decreased by 15%. The cost-utility analysis showed a cost per QALY gained of 18 704 € at one-year follow-up.

CONCLUSIONS

The results indicate that the MMRP significantly improves the HRQoL of the participants and is a cost-effective treatment for patients with chronic pain in primary healthcare when a newly suggested cost-effectiveness threshold of 19 734 € is implemented. The extrapolation indicates that considerable cost savings in terms of reduced loss of production and gained QALYs may be generated if the effects of the MMRP are maintained beyond one-year follow-up. The study demonstrates potential benefits of MMRPs in primary healthcare for both the patient with chronic pain and the society as a whole. The cost-effectiveness of MMRPs in primary healthcare has scarcely been studied and further long-term studies are needed in these settings.

Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services' reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids. Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases. This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.

Isolation and Pharmacological Characterization of Six Opioidergic Picralima nitida Alkaloids

The seeds of the akuamma tree (Picralima nitida) have been used as a traditional treatment for pain and fever. Previous studies have attributed these effects to a series of indole alkaloids found within the seed extracts; however, these pharmacological studies were significantly limited in scope. Herein, an isolation protocol employing pH-zone-refining countercurrent chromatography was developed to provide six of the akuamma alkaloids in high purity and quantities sufficient for more extensive biological evaluation. Five of these alkaloids, akuammine (1), pseudo-akuammigine (3), akuammicine (4), akuammiline (5), and picraline (6), were evaluated against a panel of >40 central nervous system receptors to identify that their primary targets are the opioid receptors. Detailed in vitro investigations revealed 4 to be a potent kappa opioid receptor agonist, and three alkaloids (1-3) were shown to have micromolar activity at the mu opioid receptor. The mu opioid receptor agonists were further evaluated for analgesic properties but demonstrated limited efficacy in assays of thermal nociception. These findings contradict previous reports of the antinociceptive properties of the P. nitida alkaloids and the traditional use of akuamma seeds as analgesics. Nevertheless, their opioid-preferring activity does suggest the akuamma alkaloids provide distinct scaffolds from which novel opioids with unique pharmacologic properties and therapeutic utility can be developed.

Nonpharmacologic Treatments for Opioid Reduction in Patients With Advanced Chronic Kidney Disease

Opioid analgesics carry risk for serious health-related harms in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease. In the general population with chronic noncancer pain, there is some evidence that opioid reduction or discontinuation is associated with improved pain outcomes; however, tapering opioids abruptly or without providing supportive interventions can lead to physical and psychological harms and relapse of opioid use. There is emerging evidence that nonpharmacologic treatments such as psychosocial interventions, acupuncture, and interdisciplinary pain management programs are effective approaches to support opioid dose reduction in patients experiencing persistent pain, but research in this area still is relatively new. This review describes the current evidence for nonpharmacologic interventions to support opioid reduction in non-CKD patients with pain and discusses the application of the available evidence to patients with advanced CKD who are prescribed opioids to manage pain.

Nonopioid Approaches to Pain Management in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) and end-stage renal disease experience high pain and symptom burden, but management of chronic pain in this population remains challenging. Recent studies have shown a high rate of opioid prescription and use in patients with kidney disease. However, the concern for opioid-related morbidity and mortality suggests a need to reconsider the safety and efficacy of opioid use in patients with CKD. In this review, we describe the current approaches to pain management in CKD, highlight the evolving opioid-related risks and kidney-specific concerns, and offer both pharmacologic and nonpharmacologic nonopioid strategies for pain management in patients with kidney disease, emphasizing the importance of using a multimodal approach to optimize pain control.

Evaluation of patients suffered from burning mouth syndrome and persistent idiopathic facial pain using Japanese version PainDETECT questionnaire and depression scales

BACKGROUND/PURPOSE

Various questionnaires have been validated as methods for screening of neuropathic pain, but none have been established for the orofacial region. Although chronic pain and depression are likely to comorbid, few studies have examined the relationship between orofacial chronic pain and depression. Therefore, we evaluated the potential of the Japanese Version of PainDETECT as an assessment tool for neuropathic pain associated with burning mouth syndrome (BMS) and persistent idiopathic facial pain (PIFP). We also evaluated the depression scale such as Beck's Depression Inventory (BDI: a subjective index) and Hamilton Depression Rating Scale (HDRS: an objective index) with BMS or PIFP.

MATERIALS AND METHODS

As a target, we administered the Japanese version of the PainDETECT questionnaire to the BMS (29 patients) and PIFP (17 patients). As a control, patients with post-extraction pain (typical nociceptive pain, (EXT) 16 patients) were also participated. We performed BDI and HDRS with BMS or PIFP.

RESULTS

Although PainDETECT final score was significantly higher in BMS [median: 10] compared with PIFP [6] and EXT [5] (p < 0.05), PainDETECT final scores for all groups were lower than the cutoff value for the possibility of neuropathic pain. HDRS was significantly higher in the BMS than the PIFP. There were no significant differences between the BMS and PIFP in BDI.

CONCLUSION

Under the limitations of current research design, the Japanese version of the PainDETECT questionnaire does not show sufficient potential as pain assessment tool for patients with BMS and PIFP. BMS is comorbid with depression objectively when compared with PIFP.

Site, frequency, and duration of pain in young children with spina bifida

PURPOSE

To investigate the: (1) percent of children with spina bifida (SB) complaining of pain, (2) frequency, duration, and cause of pain by sex, level of lesion type of SB, and ambulation status, (3) body sites reported to hurt, by variables in objective 2, and (4) associations between physical and mental/emotional health between caregiver and child.

METHODS

Cross-sectional study of 101 caregivers of children (3 to 6 years old) with SB. Survey data and information from medical records were included. Pearson chi-square, one-way ANOVA, Fisher's exact test, logistic regressions, and bivariate correlations were used.

RESULTS

Seventy percent reported that their child complained of pain, which did not significantly differ by sex, level of lesion, type of SB, or ambulation status. Most (86%) were reported to have experienced pain for less than 24 hours. The most frequently reported pain site was the head, followed by the abdomen and the lower body. Number of pain sites was moderately correlated with frequency of pain complaints. Correlations between how caregivers reported their own physical/mental/emotional health and how they rated that of their children ranged from weak (r = 0.22) to moderate (r = 0.55).

CONCLUSION

Almost seven of ten children reportedly complained of pain ranging from at least once a month to everyday. Pain needs to be routinely assessed and treated in this population.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

The Effects of Psychological Interventions on Diabetic Peripheral Neuropathy: A Systematic Review and Meta-Analysis

BACKGROUND

Psychological interventions are effective at ameliorating the experience of pain in conditions such as rheumatoid arthritis and chronic back pain. However, their effect on diabetic peripheral neuropathy (DPN) pain has yet to be established AIM: To assess the effectiveness of psychological interventions on pain and related outcomes in adults with DPN.

DESIGN

Systematic review.

SETTINGS

Community, hospital in-patient and out-patient.

PARTICIPANTS/SUBJECTS

Adults with diabetic peripheral neuropathy.

METHODS

Medline, Embase, PsychInfo, and CINAHL databases together with grey literature and trial registers were searched. A meta-analysis and narrative synthesis of included studies were undertaken.

RESULTS

Nine studies were selected from 1610 citations. At short-term follow-up psychological therapies showed a large effect on pain severity (SMD = -0.94, 95%CI [-1.50, -0.37], p = .001), a small effect on pain interference (SMD = -0.39, 95%CI [-0.73, -0.05], p = .02), and a moderate effect on depressive symptoms (SMD = -0.58, 95%CI [-0.95, -0.21], p = .002). Quality of life significantly improved in experimental subjects, (MD = -2.35, 95%CI [-3.99, -0.71], p = .005). At medium-term follow-up there was a large effect on pain severity (SMD = -1.26, 95%CI [-1.76, -0.77], p < .00001) and on pain interference (SMD = -0.91, 95%CI [-1.61, -0.21], p = .01) and a moderate effect on depressive symptoms (SMD = -0.76, 95%CI [-1.48, -0.05], p = .04). At long-term follow-up, improvements in pain interference, mood, and self-care behaviors were reported.

CONCLUSIONS

These findings demonstrate that the relationship between pain and perceived control identified in other groups who experience chronic pain may also be replicated in the DPN population. This is an important outcome that can guide further research and associated service developments.

EST64454: a Highly Soluble σ1 Receptor Antagonist Clinical Candidate for Pain Management

The synthesis and pharmacological activity of a new series of pyrazoles that led to the identification of 1-(4-(2-((1-(3,4-difluorophenyl)-1H-pyrazol-3-yl)methoxy)ethyl)piperazin-1-yl)ethanone (9k, EST64454) as a σ1 receptor (σ1R) antagonist clinical candidate for the treatment of pain are reported. The compound 9k is easily obtained through a five-step synthesis suitable for the production scale and shows an outstanding aqueous solubility, which together with its high permeability in Caco-2 cells will allow its classification as a BCS class I compound. It also shows high metabolic stability in all species, linked to an adequate pharmacokinetic profile in rodents, and antinociceptive properties in the capsaicin and partial sciatic nerve ligation models in mice.

Involvement of relatives in chronic non-malignant pain rehabilitation at multidisciplinary pain centres: part one - the patient perspective

OBJECTIVES

Chronic non-malignant pain (CNP) is a significant healthcare problem with considerable consequences for patients, relatives and society. CNP is a lifelong condition that calls for acceptance and self-management. Existing research indicates that the involvement of relatives improves patients' and relatives' management of CNP, but the area is, at present, scarcely described. Research is required to obtain knowledge about the patients' experiences, needs and preferences concerning the involvement of their relatives within the frame of CNP rehabilitation, which is the aim of this study.

METHODS

The study applied a qualitative phenomenological-hermeneutic design conducting individual interviews with 10 patients with CNP from three selected Multidisciplinary Pain Centres (MPC). The analysis was guided by Paul Ricoeur's philosophy of interpretation of the text.

RESULTS

The findings illuminated the patients' perspectives on the involvement of relatives within three key themes, each having two or three sub-themes. The analysis revealed that patients in CNP rehabilitation had various interpretations of the substance of involving relatives, reflecting their sparse experiences. It seemed arbitrary, who during the rehabilitation actually experienced the involvement of their relatives, leaving the impression of an area short of structure. This shortage was troublesome, due to a heartrending impact of CNP. Patients' reduced functional level, combined with their surroundings difficulties in grasping the magnitude of CNP led to a loss of relationships and a risk of social isolation. Patients' close relationships became essential but were under pressure as well. Patients living with a spouse/cohabitant experienced that the relationship was affected by a disrupted balance and pain-related emotional outbursts. The patients experienced a profound need for being understood, but the text also revealed a need for mutual understanding to acknowledge the relatives' strain as well. Particular patients with children living at home experienced to be under great strain, complicated by a deep concern for long-term consequences for their children growing up influenced by parental CNP. Experienced involvement of relatives, even to a minor extend was perceived as beneficial for the patients, who experienced increased understanding and support from the relatives. However, due to the lack of a structured service, the patients' access to the involvement of relatives became dependent on their ability to define their need and pick it out. Thus the patients also expressed a general preference for mandatory and structured involvement, yet tailored to the specific patient.

CONCLUSIONS

The study showed an overwhelming need for the involvement of relatives among patients with CNP, indicating that increased attention and investigation of relevant interventions are required. Despite differences between the MPC, our primary impression was that the involvement of relatives reached a minimal level of what was expected, which might entail desertion of patients scarce of resources. Individualised adjusted involvement of relatives is assumed to improve patient's management of CNP in everyday life. A family systems nursing (FSN) approach is a relevant proposal for intervention, useful in other illness areas. Still, research needs to shed light on the appropriateness of FSN when involving relatives in the rehabilitation of CNP.

Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review

BACKGROUND

Opioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management.

OBJECTIVE

This systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders' opinions about role of pharmacists in optimising opioid therapy.

METHODS

We conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990-June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized.

RESULTS

Fourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed.

CONCLUSION

This systematic review gives an overview of pharmacist intervention feasibility, stakeholders' opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management.

Psychosocial resources and chronic pain in individuals with spinal cord injury: evidence from the second Swiss national community survey

STUDY DESIGN

Cross-sectional.

OBJECTIVE

To investigate the associations of a set of psychosocial resources with pain and pain-related factors in individuals with spinal cord injury (SCI) and chronic pain.

SETTING

Community, Switzerland.

METHODS

Data from 1,064 individuals with chronic pain who participated in the second community survey of the Swiss Spinal Cord Injury Cohort Study (Survey 2017) were analyzed. Multiple linear regression modeling was performed to test the hypotheses that higher levels of psychosocial resources (self-efficacy, self-esteem, purpose in life, optimism, hope, social support, sense of belonging) are negatively associated with pain intensity, pain interference and depressive symptoms.

RESULTS

Higher self-esteem, optimism and hope were related to less pain interference and all psychosocial resources under study were negatively associated with depressive symptoms in final models. However, neither of the psychosocial resources was related to pain intensity when models were adjusted for pain interference and depressive symptoms.

CONCLUSIONS

These findings strengthen the evidence that psychosocial resources can have an impact on pain interference and depressive symptoms as pain-related factors, and support the notion that psychosocial resources might be promising targets for pain interventions in individuals with SCI.

Screening to identify postoperative pain and cross-sectional associations between factors identified in this process with pain and function, three months after total knee replacement

Objective

To describe the screening and recruitment process of a randomized trial and evaluate associations with knee pain and function 3 months after total knee replacement (TKR).

Methods

In order to screen for a multicenter trial, a total of 5,036 patients were sent the Oxford Knee Score (OKS) questionnaire 10 weeks post‐TKR. Patients who reported pain in their replaced knee (score of ≤14 on the OKS pain component) completed a second OKS questionnaire 12 weeks post‐TKR. Those patients who were still experiencing pain 12 weeks post‐TKR completed a detailed questionnaire 13 weeks post‐TKR. These data were used to characterize pain in a cross‐sectional analysis. Multivariable regression was performed in order to identify factors associated with pain and function at 13 weeks post‐TKR.

Results

We received OKS questionnaires from 3,058 of 5,063 TKR patients (60%), and 907 of the 3,058 (30%) reported pain in their replaced knee 10 weeks post‐TKR. By 12 weeks, 179 of 553 patients (32%) reported improved pain (score of >14 on the OKS pain component). At 13 weeks, 192 of 363 patients (53%) who completed a detailed questionnaire reported neuropathic pain, 94 of 362 (26%) reported depression symptoms, and 95 of 363 (26%) anxiety symptoms. More severe pain at 13 weeks postoperatively was associated with poorer general health, poorer physical health, more pain worry, and lower satisfaction with surgery outcome. More severe functional limitation was associated with higher levels of depression, more pain worry, lower satisfaction with surgery outcome, and higher pain acceptance.

Conclusion

Screening after TKR identified individuals with pain. We identified several potential targets (physical and mental health outcomes, acceptance of pain, and quality of life) for tailored intervention to improve outcomes for patients. Future trials of multidisciplinary interventions warranted.

Pain Across the Menstrual Cycle: Considerations of Hydration

Chronic pain – pain that persists for more than 3 months – is a global health problem and is associated with tremendous social and economic cost. Yet, current pain treatments are often ineffective, as pain is complex and influenced by numerous factors. Hypohydration was recently shown to increase ratings of pain in men, but studies in this area are limited (n = 3). Moreover, whether hypohydration also affects pain in women has not been examined. In women, changes in the concentrations of reproductive hormones across menstrual phases may affect pain, as well as the regulation of body water. This indicates potential interactions between the menstrual phase and hypohydration on pain, but this hypothesis has yet to be tested. This review examined the literature concerning the effects of the menstrual phase and hypohydration on pain, to explore how these factors may interact to influence pain. Future research investigating the combined effects of hypohydration and menstrual phase on pain is warranted, as the findings could have important implications for the treatment of pain in women, interpretation of previous research and the design of future studies.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

In Vivo, In Vitro and In Silico Studies of the Hybrid Compound AA3266, an Opioid Agonist/NK1R Antagonist with Selective Cytotoxicity

AA3266 is a hybrid compound consisting of opioid receptor agonist and neurokinin-1 receptor (NK1R) antagonist pharmacophores. It was designed with the desire to have an analgesic molecule with improved properties and auxiliary anticancer activity. Previously, the compound was found to exhibit high affinity for μ- and δ-opioid receptors, while moderate binding to NK1R. In the presented contribution, we report on a deeper investigation of this hybrid. In vivo, we have established that AA3266 has potent antinociceptive activity in acute pain model, comparable to that of morphine. Desirably, with prolonged administration, our hybrid induces less tolerance than morphine does. AA3266, contrary to morphine, does not cause development of constipation, which is one of the main undesirable effects of opioid use. In vitro, we have confirmed relatively strong cytotoxic activity on a few selected cancer cell lines, similar to or greater than that of a reference NK1R antagonist, aprepitant. Importantly, our compound affects normal cells to smaller extent what makes our compound more selective against cancer cells. In silico methods, including molecular docking, molecular dynamics simulations and fragment molecular orbital calculations, have been used to investigate the interactions of AA3266 with MOR and NK1R. Insights from these will guide structural optimization of opioid/antitachykinin hybrid compounds.

Spezielle Schmerztherapie bei rheumatischen Erkrankungen

Schmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.

"Tobacco Is the Chief Medicinal Plant in My Work": Therapeutic Uses of Tobacco in Peruvian Amazonian Medicine Exemplified by the Work of a Maestro Tabaquero

Introduction

Harmful usage of tobacco is a public health problem of global concern and, in many countries, the main risk factor for non-communicable diseases. Yet, in the Peruvian Amazon, the geographical region believed to be tobacco’s historical birthplace, this plant is associated with a strikingly different usage and repute: Tobacco (especially Nicotiana rustica L.) in this area is described as a potent medicinal plant, used topically or via ingestion to treat a variety of health conditions. The goal of this transdisciplinary field study was to investigate clinical applications of the tobacco plant as per Amazonian medicine exemplified in the practice of a reputed Maestro Tabaquero, an Amazonian traditional healer whose medical specialization focuses on tobacco-based treatments.

Methods

Using a transdisciplinary clinical approach, we conducted in-depth interviews with the tabaquero applying the systematizing expert interview method, in order to map modes of preparation and administration, indications, contraindications, effects, risks, adverse effects, and systemic aspects of tobacco-based remedies.

Results

The informant’s descriptions revealed refined knowledge on this plant’s therapeutic properties and scope, safety profile, and application techniques. The main indications mentioned included “problems of the mind,” of the respiratory system, parasitic illnesses (intestinal/skin), gout, and Amazonian epistemic conditions described as spiritual-energetic in nature. A liquid remedy taken orally was his most commonly used preparation, with acute/sub-acute effects involving a pronounced psychoactive component (altered state of consciousness) and physiological response (emesis, nausea). A skilled tabaquero that knows how to dose, administer, and intervene in case of adverse effects was considered imperative for safe treatment delivery.

Conclusions

To our knowledge, this is the first study employing a transdisciplinary clinical approach to examine therapeutic applications of tobacco by an Amazonian tabaquero. Our findings significantly contribute to the growing research literature on Amazonian medicine and emergent psychedelic-assisted therapies and could, in the long-term, open new treatment avenues in several domains. Forthcoming studies should assess toxicity/safety and clinical outcomes of patients receiving Amazonian tobacco-based treatment.

Motivational nondirective resonance breathing versus transcutaneous vagus nerve stimulation in the treatment of fibromyalgia: study protocol for a randomized controlled trial

BACKGROUND

Chronic widespread pain (CWP), including fibromyalgia (FM), affects one in every ten adults and is one of the leading causes of sick leave and emotional distress. Due to an unclear etiology and a complex pathophysiology, FM is a condition with few, if any, effective and safe treatments. However, current research within the field of vagal nerve innervation suggests psychophysiological and electrical means by which FM may be treated. This study will investigate the efficacy of two different noninvasive vagal nerve stimulation techniques for the treatment of FM.

METHODS

The study will use a randomized, single-blind, sham-controlled design to investigate the treatment efficacy of motivational nondirective resonance breathing (MNRB™) and transcutaneous vagus nerve stimulation (Nemos® tVNS) on patients diagnosed with FM. Consenting FM patients (N = 112) who are referred to the Department of Pain Management and Research at Oslo University Hospital, in Oslo, Norway, will be randomized into one of four independent groups. Half of these participants (N = 56) will be randomized to either an experimental tVNS group or a sham tVNS group. The other half (N = 56) will be randomized to either an experimental MNRB group or a sham MNRB group. Both active and sham treatment interventions will be delivered twice per day at home, 15 min/morning and 15 min/evening, for a total duration of 2 weeks (14 days). Participants are invited to the clinic twice, once for pre- and once for post-intervention data collection. The primary outcome is changes in photoplethysmography-measured heart rate variability. Secondary outcomes include self-reported pain intensity on a numeric rating scale, changes in pain detection threshold, pain tolerance threshold, and pressure pain limit determined by computerized pressure cuff algometry, blood pressure, and health-related quality of life.

DISCUSSION

The described randomized controlled trial aims to compare the efficacy of two vagal nerve innervation interventions, MNRB and tVNS, on heart rate variability and pain intensity in patients suffering from FM. This project tests a new and potentially effective means of treating a major public and global health concern where prevalence is high, disability is severe, and treatment options are limited.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03180554 . Registered on August 06, 2017.

Antihypernociceptive, Anxiolytic, and Antidepressant Properties of Aqueous and Ethanol Extracts of Dissotis thollonii Cogn. (Melastomataceae) in Mice

Diabetic neuropathy, which affects 7 to 9% of the world's population and that is usually accompanied by anxiety and depression, is chronic pain that results from impaired function of the central or peripheral nervous system. This study aimed at evaluating the antihypernociceptive, antiallodynic, anxiolytic, and antidepressant effects of Dissotis thollonii extracts. Diabetic neuropathy was induced by intraperitoneal injection of streptozotocin (200 mg/kg) in mice. The aqueous and ethanol extracts (250 and 500 mg/kg) were administered orally. Hyperalgesia (thermal and chemical), allodynia (mechanical and thermal), anxiety (high plus labyrinth, light-dark box, and social interaction), and depression (open field test, suspension test tail, and forced swimming test) were evaluated, and then the levels of some cytokines and growth factors were determined. The aqueous and ethanol extracts of Dissotis thollonii demonstrated significant antihypernociceptive (inhibition of hyperalgesia and allodynia), anxiolytic, and antidepressant activities in mice made diabetic by STZ. The extracts also significantly inhibited (p < 0.001) the levels of TNF-α, IL-1β, and IL-6 in the blood as well as the levels of TNF-α, IL-1β, IL-6, IGF, and NGF in the sciatic nerve. This study shows that the extracts of Dissotis thollonii have antihypernociceptive and neuroprotective effects which could be linked to the inhibition of proinflammatory cytokines and growth factors in the blood and the sciatic nerve.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Chronic non-cancer pain management by nurses in specialist pain clinics

BACKGROUND

Chronic non-cancer pain (CNCP) is one of the major causes of disability globally, and patients who suffer from it are a complex population, which makes it difficult to provide effective care. Specialist pain clinics and nursing professionals in them are the main care providers, but there is little research conducted in this field.

AIM

To explore the attitudes and knowledge of nurses working in specialist pain clinics regarding care of CNCP patients.

METHODS

Qualitative phenomenological approach. Sixteen semi-structured interviews were conducted in 2017 with nurses who worked in specialist pain clinics in six hospitals in southern Spain.

RESULTS

Data analysis led to the formation of two categories, 'being trained and improving knowledge in CNCP' and 'the challenge of caring for patients with CNCP', and five subcategories.

CONCLUSION

The need for care in CNCP is not covered by nurses in all the areas it requires. Lack of time, staffing issues, and specific training in this area makes it difficult to provide care. However, some areas for improvement are proposed, such as psychological interventions, group workshops, continuous training, and multidisciplinary teams.

Telemonitoring in Chronic Pain Management Using Smartphone Apps: A Randomized Controlled Trial Comparing Usual Assessment against App-Based Monitoring with and without Clinical Alarms

BACKGROUND

The usefulness of mHealth in helping to target face-to-face interventions for chronic pain more effectively remains unclear. In the present study, we aim to test whether the Pain Monitor mobile phone application (app) is well accepted by clinicians, and can help improve existent medical treatments for patients with chronic musculoskeletal pain. Regarding this last goal, we compared three treatment conditions, namely usual treatment, usual treatment with an app without alarms and usual treatment with an app with alarms. All treatments lasted one month. The three treatments were compared for all outcomes, i.e., pain severity and interference, fatigue, depressed mood, anxiety and anger.

METHODS

In this randomized controlled trial, the usual monitoring method (i.e., onsite; n = 44) was compared with daily ecological momentary assessment using the Pain Monitor app-both with (n = 43) and without alarms (n = 45). Alarms were sent to the clinicians in the presence of pre-established undesired clinical events and could be used to make treatment adjustments throughout the one-month study.

RESULTS

With the exception of anger, clinically significant changes (CSC; 30% improvement) were greater in the app + alarm condition across outcomes (e.g., 43.6% of patients experienced a CSC in depressed mood in the app + alarm condition, which occurred in less than 29% of patients in the other groups). The clinicians were willing to use the app, especially the version with alarms.

CONCLUSIONS

The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.