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Schatman ME, Shapiro H. Chronic Pain Patient "Advocates" and Their Focus on Opiophilia: Barking Up the Wrong Tree? J Pain Res 2021; 14:3627-3630. [PMID: 34880670 PMCID: PMC8646865 DOI: 10.2147/jpr.s349631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael E Schatman
- Division of Medical Ethics, NYU School of Medicine, New York, NY, USA.,Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA.,School of Social Work, North Carolina State University, Raleigh, NC, USA
| | - Hannah Shapiro
- School of Social Work, North Carolina State University, Raleigh, NC, USA.,McLean Hospital, Division of Alcohol, Drugs, and Addiction, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Rollin M Gallagher
- Center for Health Equities Research and Promotion (CHERP), Michael J. Crescenz VA Medical Center, Philadelphia, United States.
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Abstract
The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.
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Affiliation(s)
- Rollin M Gallagher
- Pain Service, Michael Crescenz VA Medical Center, University and Woodland, Philadelphia, PA 19035, USA; Penn Pain Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Gallagher RM, Gallagher RM. VHA Pain Research Working Group and VHA Pain Care. JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT 2016; 53:xv-xvi. [PMID: 26934166 DOI: 10.1682/jrrd.2015.10.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Thomson S, Raso L, Burton A, DeAndres J, Buchser E, Buvanendran A, Liem L, Kumar K, Rizvi S, Feler C, Abejon D, Anderson J, Eldabe S, Kim P, Leong M, Hayek S, McDowell G, Poree L, Brooks ES, McJunkin T, Lynch P, Kapural L, Foreman RD, Caraway D, Alo K, Narouze S, Levy RM, North R. The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:571-97; discussion 597-8. [PMID: 25112891 DOI: 10.1111/ner.12206] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/24/2013] [Accepted: 12/14/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. METHODS The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. RESULTS The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. CONCLUSIONS The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.
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Peppin JF, Cheatle MD, Kirsh KL, McCarberg BH. The Complexity Model: A Novel Approach to Improve Chronic Pain Care. PAIN MEDICINE 2015; 16:653-66. [DOI: 10.1111/pme.12621] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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High-frequency transcutaneous electrical nerve stimulation attenuates postsurgical pain and inhibits excess substance P in rat dorsal root ganglion. Reg Anesth Pain Med 2015; 39:322-8. [PMID: 24781287 DOI: 10.1097/aap.0000000000000091] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transcutaneous electrical nerve stimulation (TENS) is a common therapeutic modality for pain management, but its effectiveness in skin/muscle incision and retraction (SMIR)-evoked pain is unknown. We aimed to examine the effects of TENS on postoperative pain and the levels of substance P (SP), N-methyl-D-aspartate receptor 1 (NR1), and interleukin 1β (IL-1β) in rat dorsal root ganglion (DRG). METHODS High-frequency (100 Hz) TENS was administered daily beginning on postoperative day 1 (POD1) and continued until animal subjects were killed for tissues. Mechanical sensitivity to von Frey stimuli (6g and 15g) and the levels of NR1, SP, and IL-1β in DRG were assessed in the sham-operated, SMIR-operated, TENS after SMIR surgery, and placebo-TENS after SMIR surgery groups. RESULTS Skin/muscle incision and retraction rats exhibited a significant hypersensitivity to von Frey stimuli on POD3. In contrast with SMIR rats, SMIR-operated rats receiving TENS therapy demonstrated a rapid recovery of mechanical hypersensitivity. The SMIR-operated rats showed an up-regulation of NR1, SP, and IL-1β in DRG on PODs 14 and 28, whereas the SMIR-operated rats after TENS administration reversed this up-regulation. By contrast, the placebo-TENS after SMIR operation did not alter postsurgical pain nor the levels of NR1, SP, and IL-1β. CONCLUSIONS Our data demonstrated that TENS intervention reduced persistent postoperative pain caused by SMIR operation. Up-regulation of NR1, SP, and IL-1β in DRG, activated after SMIR surgery, is important in the development of prolonged postincisional pain. The TENS pain relief may be related to the suppression of NR1, SP, and IL-1β in DRG of SMIR rats.
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Transcutaneous electrical nerve stimulation attenuates postsurgical allodynia and suppresses spinal substance P and proinflammatory cytokine release in rats. Phys Ther 2015; 95:76-85. [PMID: 25212520 DOI: 10.2522/ptj.20130306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transcutaneous electrical nerve stimulation (TENS) is often used for management of chronic pain. OBJECTIVE The purpose of this study was to investigate whether TENS altered postincisional allodynia, substance P, and proinflammatory cytokines in a rat model of skin-muscle incision and retraction (SMIR). DESIGN This was an experimental study. METHODS High-frequency (100-Hz) TENS therapy began on postoperative day 3 and was administered for 20 minutes daily to SMIR-operated rats by self-adhesive electrodes delivered to skin innervated via the ipsilateral dorsal rami of lumbar spinal nerves L1-L6 for the next 27 days. The expressions of substance P, tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and interleukin-1beta (IL-1β) in the spinal cord and mechanical sensitivity to von Frey stimuli (4g and 10g) were evaluated. RESULTS The SMIR-operated rats displayed a marked hypersensitivity to von Frey stimuli on postoperative day 3. In contrast to the SMIR-operated rats, SMIR-operated rats after TENS administration showed a quick recovery of mechanical hypersensitivity. On postoperative days 3, 16, and 30, SMIR-operated rats exhibited an upregulation of substance P and cytokines (TNF-α, IL-6, and IL-1β) in the spinal cord, whereas SMIR-operated rats after TENS therapy inhibited that upregulation. By contrast, the placebo TENS following SMIR surgery did not alter mechanical hypersensitivity and the levels of spinal substance P, TNF-α, IL-6, and IL-1β. LIMITATIONS The experimental data are limited to animal models and cannot be generalized to postoperative pain in humans. CONCLUSIONS The results revealed that TENS attenuates prolonged postoperative allodynia following SMIR surgery. Increased levels of spinal substance P and proinflammatory cytokines, activated after SMIR surgery, are important in the processing of persistent postsurgical allodynia. The protective effect of TENS may be related to the suppression of spinal substance P and proinflammatory cytokines in SMIR-operated rats.
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Brooks EA, Unruh A, Lynch ME. Exploring the lived experience of adults using prescription opioids to manage chronic noncancer pain. Pain Res Manag 2015; 20:15-22. [PMID: 25562838 PMCID: PMC4325885 DOI: 10.1155/2015/314184] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic noncancer pain (CNCP) and prescription opioid use is a highly complex and growing health care issue in Canada. Many quantitative research studies have investigated the effectiveness of opioids for chronic pain; however, gaps remain in the literature regarding the personal experience of using opioids and their impact on those experiencing CNCP. OBJECTIVE To explore the lived experience of adults using prescription opioids to manage CNCP, focusing on how opioid medication affected their daily lives. METHODS In-depth qualitative interviews were conducted with nine adults between 40 and 68 years of age who were using prescription opioids daily for CNCP. Interviews were audiorecorded and transcribed, and subsequently analyzed using interpretive phenomenological analysis. RESULTS Six major themes identified positive and negative aspects of opioid use associated with social, physical, emotional and psychological dimensions of pain management. These themes included the process of decision making, and physical and psychosocial consequences of using opioids including pharmacological side effects, feeling stigmatized, guilt, fears, ambivalence, self-protection and acceptance. CONCLUSION Although there were many negative aspects to using opioids daily, the positive effects outweighed the negative for most participants and most of the negative aspects were socioculturally induced rather than caused by the drug itself. The present study highlighted the complexities involved in using prescription opioids daily for management of CNCP for individuals living with pain.
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Affiliation(s)
- Erica A Brooks
- School of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia
| | - Anita Unruh
- School of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia
| | - Mary E Lynch
- Departments of Anesthesia and Psychiatry, Dalhousie University, Halifax, Nova Scotia
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Deer T, Pope J, Hayek S, Narouze S, Patil P, Foreman R, Sharan A, Levy R. Neurostimulation for the Treatment of Axial Back Pain: A Review of Mechanisms, Techniques, Outcomes, and Future Advances. Neuromodulation 2014; 17 Suppl 2:52-68. [DOI: 10.1111/j.1525-1403.2012.00530.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/01/2012] [Accepted: 10/01/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Salim Hayek
- University Hospitals Case Medical Center-Anesthesiology; Cleveland OH USA
| | - Samer Narouze
- Center for Pain Medicine-Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | - Parag Patil
- Taubman Health Care Center; Ann Arbor MI USA
| | - Robert Foreman
- University of Oklahoma Health Sciences Center-Physiology; Oklahoma City OK USA
| | - Ashwini Sharan
- Thomas Jefferson University-Neurosurgery; Philadelphia PA USA
| | - Robert Levy
- Shands Jacksonville Neuroscience Institute; University of Florida College of Medicine; Jacksonville FL USA
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Tauben DJ, Loeser JD. Pain education at the University of Washington School of Medicine. THE JOURNAL OF PAIN 2013; 14:431-7. [PMID: 23523022 DOI: 10.1016/j.jpain.2013.01.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 10/19/2012] [Accepted: 01/02/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED Contemporary medical education is inadequate to prepare medical students to competently assess and design care plans for patients with acute and chronic pain. The time devoted to pain education in most medical school curricula is brief and not integrated into case-based clinical experiences, and it is frequently nonexistent during clinical clerkships. Medical student pain curricula have been proposed for over 30 years and are commonly agreed upon, though rarely implemented. As a consequence of poor undergraduate pain education, postgraduate trainees and practicing physicians struggle with both competency and practice satisfaction; their patients are similarly dissatisfied. At the University of Washington School of Medicine, a committee of multidisciplinary pain experts has, between 2009 and 2011, successfully introduced a 4-year integrated pain curriculum that increases required pain education teaching time from 6 to 25 hours, and clinical elective pain courses from 177 to 318 hours. It is expected that increased didactic and case-based multidisciplinary clinical training will increase knowledge and competency in biopsychosocial measurement-based pain narrative and risk assessment, improve understanding of persistent pain as a chronic complex condition, and expand the role of patient-centered interprofessional treatment for medical students, residents, and fellows, leading to better prepared practicing physicians. PERSPECTIVE Strategies for improving multidisciplinary pain education at the University of Washington School of Medicine are described and the preliminary results demonstrated.
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Affiliation(s)
- David J Tauben
- Department of Medicine, University of Washington, School of Medicine, Seattle, Washington, USA.
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Exercise Training Attenuates Postoperative Pain and Expression of Cytokines and N-methyl-D-aspartate Receptor Subunit 1 in Rats. Reg Anesth Pain Med 2013; 38:282-8. [PMID: 23640243 DOI: 10.1097/aap.0b013e31828df3f9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: research findings and mechanistic considerations. Psychol Bull 2012; 137:1065-93. [PMID: 21967450 DOI: 10.1037/a0025544] [Citation(s) in RCA: 237] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tobacco addiction and chronic pain represent 2 highly prevalent and comorbid conditions that engender substantial burdens upon individuals and systems. Interrelations between pain and smoking have been of clinical and empirical interest for decades, and research in this area has increased dramatically over the past 5 years. We conceptualize the interaction of pain and smoking as a prototypical example of the biopsychosocial model. Accordingly, we extrapolated from behavioral, cognitive, affective, biomedical, and social perspectives to propose causal mechanisms that may contribute to the observed comorbidity between these 2 conditions. The extant literature was 1st dichotomized into investigations of either effects of smoking on pain or effects of pain on smoking. We then integrated these findings to present a reciprocal model of pain and smoking that is hypothesized to interact in the manner of a positive feedback loop, resulting in greater pain and increased smoking. Finally, we proposed directions for future research and discussed clinical implications for smokers with comorbid pain disorders. We observed modest evidence that smoking may be a risk factor in the multifactorial etiology of some chronically painful conditions and that pain may come to serve as a potent motivator of smoking. We also found that whereas animal studies yielded consistent support for direct pain-inhibitory effects of nicotine and tobacco, results from human studies were much less consistent. Future research in the emerging area of pain and smoking has the potential to inform theoretical and clinical applications with respect to tobacco smoking, chronic pain, and their comorbid presentation. (PsycINFO Database Record (c) 2011 APA, all rights reserved).
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Affiliation(s)
- Joseph W Ditre
- Department of Psychology, Texas A&M University, College Station, USA.
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Gallagher RM. ChronificationtoMaldynia: Biopsychosocial Failure of Pain Homeostasis. PAIN MEDICINE 2011; 12:993-5. [DOI: 10.1111/j.1526-4637.2011.01186.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Davies SJ, Hayes C, Quintner JL. System plasticity and integrated care: informed consumers guide clinical reorientation and system reorganization. PAIN MEDICINE 2010; 12:4-8. [PMID: 21143757 DOI: 10.1111/j.1526-4637.2010.01016.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
SETTING Two Australian public hospital multidisciplinary pain centers (MPCs) situated on opposite sides of the country. OBJECTIVE Restructuring our services to become patient-centred and patient-driven by enabling entry to our MPCs through an education portal, inclusive of both knowledge and self-management skills, and to then be free to select particular treatment options on the basis of evidence of known efficacy (risk/benefit). DESIGN Group-based education to inform our patients of the current state of uncertainty that exists in Pain Medicine, both in regard to diagnostic and therapeutic practices. Using an interprofessional team approach, we aimed to present practical and evidence-based advice on techniques of pain self-management and existing traditional medical options. RESULTS Early, resource efficient, group intervention provides many patients with sufficient information to make informed decisions and enables them to partner us in engaging a whole person approach to their care. We have implemented routine comprehensive audits of clinical services to better inform the planning and provision of health care across health services. CONCLUSIONS System plasticity is as important to the process of integrated health care as it is to our understanding of the complexity of the lived experience of pain. Better-informed consumers partnered with responsive health professionals drive the proposed paradigm shift in service delivery. The changes better align the needs of consumers with the ability of health care providers to meet them, thus achieving the twin goals of patient empowerment and system efficiency.
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Affiliation(s)
- Stephanie J Davies
- School of Physiotherapy, Curtin University, Bentley, Western Australia, Australia.
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Ditre JW, Heckman BW, Butts EA, Brandon TH. Effects of expectancies and coping on pain-induced motivation to smoke. JOURNAL OF ABNORMAL PSYCHOLOGY 2010; 119:524-33. [PMID: 20677841 DOI: 10.1037/a0019568] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The prevalence of tobacco smoking among persons with recurrent pain is approximately twice that observed in the general population. Smoking has been associated with the development and exacerbation of several chronically painful conditions. Conversely, there is both experimental and cross-sectional evidence that pain is a potent motivator of smoking. A recent study provided the first evidence that laboratory-induced pain could elicit increased craving and produce shorter latencies to smoke (Ditre & Brandon, 2008). To further elucidate interrelations between pain and smoking, and to identify potential targets for intervention, in the current study, we tested whether several constructs derived from social-cognitive theory influence the causal pathway between pain and increased motivation to smoke. Smokers (N = 132) were randomly assigned to 1 of 4 conditions in this 2 x 2 between-subjects experimental design. Results indicated that manipulations designed to (a) challenge smoking-related outcome expectancies for pain reduction and (b) enhance pain-related coping produced decreased urge ratings and increased latencies to smoke, relative to controls. An unexpected interaction effect revealed that although each manipulation was sufficient to reduce smoking urges, the combination was neither additive nor synergistic. These findings were integrated with those of the extant literature to conceptualize and depict a causal pathway between pain and motivation to smoke as moderated by smoking-related outcome expectancies and mediated by the use of pain coping behaviors.
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Affiliation(s)
- Joseph W Ditre
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 4115 East Fowler Avenue, Tampa, FL 33617, USA
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Buckley DI, Calvert JF, Lapidus JA, Morris CD. Chronic opioid therapy and preventive services in rural primary care: an Oregon rural practice-based research network study. Ann Fam Med 2010; 8:237-44. [PMID: 20458107 PMCID: PMC2866721 DOI: 10.1370/afm.1114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE For clinicians, using opioid therapy for chronic noncancer pain (CNCP) often gives rise to a conflict between treating their patients' pain and fears of addiction, diversion of medication, or legal action. Consequent stresses on clinical encounters might adversely affect some elements of clinical care. We evaluated a possible association between chronic opioid therapy (COT) for CNCP and receipt of various preventive services. METHODS We conducted a retrospective cohort study in 7 primary care clinics within the Oregon Rural Practice-based Research Network (ORPRN). Using medical records of 704 patients, aged 35 to 85 years, seen during a 3-year period, we compared the receipt of 4 preventive services between patients on COT for CNCP and patients not on chronic opioid therapy (non-COT). We used multivariate log-binomial regression analyses to estimate the relative risk of receipt of each preventive service. RESULTS After adjustment for plausible confounders, we found that patients using COT had a statistically significantly lower relative risk (RR) of receipt of cervical cancer screening (RR = 0.60; 95% confidence interval [CI], 0.47-0.76) and colorectal cancer screening (RR = 0.42; 95% CI, 0.22-0.80) when compared with non-COT patients. The RR was reduced, without statistical significance, for lipid screening (RR = 0.77; 95% CI, 0.54-1.10), and not notably reduced for smoking cessation counseling (RR = 0.95; 95% CI, 0.78-1.15). CONCLUSIONS Patients using COT for CNCP were less likely to receive some preventive services. Research is needed to better understand barriers to and improved methods for providing preventive services for these patients.
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Affiliation(s)
- David I Buckley
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Dobkin PL, Boothroyd LJ. Organizing health services for patients with chronic pain: when there is a will there is a way. PAIN MEDICINE 2009; 9:881-9. [PMID: 18950443 DOI: 10.1111/j.1526-4637.2007.00326.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SETTING Due to its magnitude as a health problem, its associated burden, and the viability of modes of intervention, chronic pain (CP) should be considered a priority within health care systems. The lives of many patients with CP are devastated by this problem and health care professionals have a responsibility to assist them in reducing their suffering. Countries, regions, and systems differ considerably with regard to how they organize, administer, and finance services for CP patients. OBJECTIVE In this review, we highlight initiatives in three jurisdictions--France, Australia, and the Veterans' Health Administration in the United States--which demonstrate that when there is a will there is a way to change health care services for patients with CP. This work is a synopsis of a health technology assessment report we completed on behalf of the Quebec Health Services and Technology Assessment Agency (http://www.aetmis.gouv.qc.ca) at the request of the Ministry of Health and Social Services in Quebec, Canada, to inform policymakers at various levels of the health care system. DESIGN A literature search of published and unpublished "gray" literature was used to identify organizational themes according to structure, process, and outcome elements of health care services. For each theme, literature was reviewed in a qualitative manner; in addition, "real world" information was sought from example jurisdictions that have prioritized management of CP. Our conclusions point to key issues to consider when organizing health services for CP patients.
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Affiliation(s)
- Patricia L Dobkin
- Quebec Health Services and Technology Assessment Agency, Agence d'évaluation des technologies et des modes d'intervention en santé, Montreal, Quebec, Canada.
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Bair MJ. Primary care and health services section: an opportunity for pain medicine and primary care to come together. PAIN MEDICINE 2008; 9:487-9. [PMID: 18755010 DOI: 10.1111/j.1526-4637.2008.00489.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fleming MF, Davis J, Passik SD. Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. PAIN MEDICINE (MALDEN, MASS.) 2008; 9:1098-106. [PMID: 18721174 PMCID: PMC2779534 DOI: 10.1111/j.1526-4637.2008.00491.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this report is to determine the frequency of aberrant drug behaviors and their relationship to substance abuse disorders in a large primary sample of patients receiving opioids for chronic pain. METHODS The data utilized for this report was obtained from 904 chronic pain patients receiving opioid therapy from their primary care physician. A questionnaire was developed based on 12 aberrant drug behaviors reported in the clinical literature. The diagnosis of a current substance use disorder was determined using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition(DSM-IV) criteria. RESULTS The average duration of chronic pain in the sample was 16 years and for opioid therapy, 6.4 years. Of the patients, 80.5% reported one or more lifetime aberrant drug behaviors. The most frequent behaviors reported included early refills (41.7%), increase dose without physician consent (35.7%), and felt intoxicated from opioids (32.2%). Only 1.1% of subjects with 1-3 aberrant behaviors (N = 464, 51.2%) met DSM-IV criteria for current opioid dependence compared with 9.9% of patients with four or more behaviors (N = 264, 29.3%). Persons with positive urine toxicology tests for cocaine were 14 times more likely to report four or more behaviors than no behaviors (14.1% vs 1.1%). A logistic model found that subjects who reported four or more aberrant behaviors were more likely to have a current substance use disorder (odds ratio [OR] 10.14; 3.72, 27.64), a positive test for cocaine (odds ratio [OR] 3.01; 1.74, 15.4), an Addiction Severity Index (ASI) psychiatric composite score >0.5 (OR 2.38; 1.65, 3.44), male gender (OR 2.08: 1.48, 2.92), and older age (OR 0.69; 0.59, 0.81) compared with subjects with three or fewer behaviors. Pain levels, employment status, and morphine equivalent dose do not enter the model. CONCLUSIONS Patients who report four or more aberrant drug behaviors are associated with a current substance use disorder and illicit drug use, whereas subjects with up to three aberrant behaviors have a very low probability of a current substance abuse disorder. Four behaviors--oversedated oneself, felt intoxicated, early refills, increase dose on own--appear useful as screening questions to predict patients at greatest risk for a current substance use disorders.
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Affiliation(s)
- Michael F Fleming
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Wisconsin, USA.
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Meghani SH, Gallagher RM. Disparity vs Inequity: Toward Reconceptualization of Pain Treatment Disparities. PAIN MEDICINE 2008; 9:613-23. [DOI: 10.1111/j.1526-4637.2007.00344.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Miller DA, Dinunzio JC, Williams RO. Advanced formulation design: improving drug therapies for the management of severe and chronic pain. Drug Dev Ind Pharm 2008; 34:117-33. [PMID: 18302030 DOI: 10.1080/03639040701542200] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic pain is a condition affecting a vast patient population and resulting in billions of dollars in associated health care costs annually. Sufferers from severe chronic pain often require [correction of requite] twenty-four hour drug treatment through intrusive means and/or repeated oral dosing. Although the oral route of administration is most preferred, conventional immediate release oral dosage forms lead to inconvenient and suboptimal drug therapies for the treatment of chronic pain. Effective drug therapies for the management of chronic pain therefore require advanced formulation design to optimize the delivery of potent analgesic agents. Ideally, these advanced delivery systems provide efficacious pain therapy with minimal side effects via a simple and convenient dosing regime. In this article, currently commercialized and developing drug products for pain management are reviewed with respect to dosage form design as well as clinical efficacy. The drug delivery systems reviewed herein represent advanced formulation designs that are substantially improving analgesic drug therapies.
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Affiliation(s)
- Dave A Miller
- College of Pharmacy, University of Texas at Austin, Austin, Texas 78712, USA
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Gallagher RM, Rosenthal LJ. Chronic Pain and Opiates: Balancing Pain Control and Risks in Long-Term Opioid Treatment. Arch Phys Med Rehabil 2008; 89:S77-82. [DOI: 10.1016/j.apmr.2007.12.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 12/06/2007] [Indexed: 11/16/2022]
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Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. PAIN MEDICINE 2007; 8:573-84. [PMID: 17883742 DOI: 10.1111/j.1526-4637.2006.00254.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To measure the impact of a structured opioid renewal program for chronic pain run by a nurse practitioner (NP) and clinical pharmacist in a primary care setting. PATIENTS AND SETTING Patients with chronic noncancer pain managed with opioid therapy in a primary care clinic staffed by 19 providers serving 50,000 patients at an urban academic Veterans hospital. DESIGN Naturalistic prospective outcome study. INTERVENTION Based on published opioid prescribing guidelines and focus groups with primary care providers (PCPs), a structured program, the Opioid Renewal Clinic (ORC), was designed to support PCPs managing patients with chronic noncancer pain requiring opioids. After training in the use of opioid treatment agreements (OTAs) and random urine drug testing (UDT), PCPs worked with a pharmacist-run prescription management clinic supported by an onsite pain NP who was backed by a multi-specialty Pain Team. After 2 years, the program was evaluated for its impact on PCP practice and satisfaction, patient adherence, and pharmacy cost. RESULTS A total of 335 patients were referred to the ORC. Of the 171 (51%) with documented aberrant behaviors, 77 (45%) adhered to the OTA and resolved their aberrant behaviors, 65 (38%) self-discharged, 22 (13%) were referred for addiction treatment, and seven (4%) with consistently negative UDT were weaned from opioids. The 164 (49%) who were referred for complexity including history of substance abuse or need for opioid rotation or titration, with no documented aberrant drug-related behaviors, continued to adhere to the OTA. Use of UDT and OTAs by PCPs increased. Significant pharmacy cost savings were demonstrated. CONCLUSION An NP/clinical pharmacist-run clinic, supported by a multi-specialty team, can successfully support a primary care practice in managing opioids in complex chronic pain patients.
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Affiliation(s)
- Nancy L Wiedemer
- Philadelphia VA Medical Center, Philadelphia, Pennsylvania 19104, USA.
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Bair MJ. Overcoming Fears, Frustrations, and Competing Demands: An Effective Integration of Pain Medicine and Primary Care to Treat Complex Pain Patients. PAIN MEDICINE 2007; 8:544-5. [PMID: 17883738 DOI: 10.1111/j.1526-4637.2007.00384.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cheatle MD, Gallagher RM. Chronic pain and comorbid mood and substance use disorders: a biopsychosocial treatment approach. Curr Psychiatry Rep 2006; 8:371-6. [PMID: 16968617 DOI: 10.1007/s11920-006-0038-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic pain is a colossal health care problem that is devastating to the individual afflicted with unremitting pain and frustrating to the beleaguered health care provider attempting to adequately manage this multifaceted disease. The biopsychosocial model of pain management is a promising approach that emphasizes evidence-based medication management in conjunction with cognitive-behavioral therapy and a graded exercise program. The patient with chronic pain and concomitant mood and/or substance use disorders is exceptionally challenging. Effective pharmacologic management of pain and comorbid mood disorders, including the thoughtful use of opioids, can have a dramatic effect in improving the quality of life in patients with chronic pain. The high prevalence of chronic pain in our society and the scarcity of experienced pain medicine physicians necessitate the development of a community-based systems approach to this complex patient population.
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Affiliation(s)
- Martin D Cheatle
- Behavioral Medicine Center, The Reading Hospital and Medical Center, P.O. Box 16052, Reading, PA 19612-6052, USA.
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Olsen Y, Daumit GL, Ford DE. Opioid prescriptions by U.S. primary care physicians from 1992 to 2001. THE JOURNAL OF PAIN 2006; 7:225-35. [PMID: 16618466 DOI: 10.1016/j.jpain.2005.11.006] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Revised: 11/03/2005] [Accepted: 11/03/2005] [Indexed: 01/22/2023]
Abstract
UNLABELLED Little is known about primary care physicians' (PCPs) prescribing of opioids. We describe trends and factors associated with opioid prescribing during PCP visits over the past decade. Using the National Ambulatory Medical Care Survey, we found an opioid prescribed in 2,206 (5%) PCP visits from 1992 to 2001. The prevalence of visits where an opioid was prescribed increased from a low of 41 per 1000 visits in 1992-1993 to a peak of 63 per 1000 in 1998-1999 (P < .0001 for trend) and then stabilized (59 per 1000 in 2000-2001). Several factors increased the odds of receiving an opioid: having Medicaid (odds ratio [OR] 2.09 [95% confidence interval (CI) 1.82-2.40]) or Medicare (OR 2.00 [95% CI 1.68-2.39]); having a visit between 15 and 35 minutes (OR 1.16 [95% CI 1.05-1.27]); and receiving an NSAID (OR 2.27 [95% CI 2.04-2.53]). Patients of hispanic (OR .67 [95% CI .56-.81]) or other race/ethnicity (OR .68 [95% CI .52-.90]), patients in health maintenance organizations (OR .74 [95% CI .66-.84]), and those living in the northeast (OR .60 [95% CI .51-.69]) or midwest (OR .75 [95% CI .66-.85]) had lower odds of receiving an opioid. Substantial variation exists in opioid prescribing by PCPs. Now that pain management standards are advocated, understanding the dynamics of opioid prescribing is necessary. PERSPECTIVE This study describes a decade-long increase in opioid prescribing by U.S. primary care physicians and identifies important geographic-, racial/ethnic-, and insurance-related differences in who receives these medications. Several underlying factors, including regulatory and legal pressures, attitudes and knowledge of opioids, and publicized opioid-related events, may contribute to these differences.
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Affiliation(s)
- Yngvild Olsen
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Bloomberg School of Public Health, Baltimore, Maryland 21287, USA.
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Mossey JM, Kerr NDS, Welz-Bosna M, Gallagher RM. Preliminary Evaluation of the Health Background Questionnaire for Pain and Clinical Encounter Form for Pain. PAIN MEDICINE 2005; 6:443-51. [PMID: 16336481 DOI: 10.1111/j.1526-4637.2005.00075.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The principal aims of this study were to evaluate the extent to which patients completed, understood, and were satisfied with the Health Background Questionnaire for Pain (HBQ-P), a health and pain history questionnaire that includes a modification of the Medical Outcome Study Short Form-36, the Treatment Outcomes in Pain Survey, and to examine the degree to which the questionnaire produced reliable and valid responses. A secondary aim was to determine the length of time for a physician to complete the Clinician Evaluation Form for Pain (CEF-P), a brief questionnaire designed to obtain key elements resulting from clinical assessment and management decisions. METHODS This cross-sectional study utilized data from consecutive new patients seen from January to December 2001 in Drexel University College of Medicine's Pain Medicine and Comprehensive Rehabilitation Center at Graduate Hospital in Philadelphia, PA. The HBQ-P and an accompanying brief satisfaction inventory were completed at home by the patient prior to the individual's initial office visit. The CEF-P was completed by the physician after seeing the patient. RESULTS Ten of 11 comparisons of patient responses to similar questions on the HBQ-P showed significant consistency. Of eight comparisons between the CEF-P and HBQ-P, two pain duration comparisons showed moderate agreement and one depression comparison showed significant association. Patients consistently had difficulty in answering six single questions and two question sets. Overall patient satisfaction was high. The mean time for the physician to complete the CEF-P was 90 seconds. CONCLUSIONS Analyses indicate patient responses to similar HBQ-P questions have sufficient reliability to support the use of the Health Background Questionnaire for clinically related data collection and for outcome evaluation of treatments for chronic and recurring pain. The consistently missed questions on the HBQ-P should be revised.
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Affiliation(s)
- Jana M Mossey
- School of Public Health and College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
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Koleva D, Krulichova I, Bertolini G, Caimi V, Garattini L. Pain in primary care: an Italian survey. Eur J Public Health 2005; 15:475-9. [PMID: 16150816 DOI: 10.1093/eurpub/cki033] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pain is a universal symptom of various pathologies and largely affects human well-being. Pain is therefore commonly observed by general practitioners (GPs) and its management is a useful indicator of quality. In our study we investigated the epidemiology and management of pain in Italian general practice. METHODS Participating GPs were asked to record the first out of every two contacts with pain during two working weeks between November 2000 and February 2001. They entered information on type of pain, pain-related diagnosis, certainty of diagnosis and types of prescription. RESULTS 89 GPs participated in the study. About one third of all reported contacts were with pain. The number of contacts analysed was 1432. Nearly half the cases were diagnosed as acute. The main complaints were of musculoskeletal and abdominal origin. Pain was 1.5 times more frequent in women than men and the female to male ratios for acute and chronic pain were 1.2:1 and 1.8:1 respectively. The most frequent site of pain was the limbs. 'Arthropathies and related disorders', 'dorsopathies' and 'rheumatism excluding the back' were the commonest groups of diagnoses. Approximately two thirds of contacts with pain led to a drug prescription. CONCLUSIONS The study identified a high proportion of contacts with pain in Italian general practice, with widespread use of drugs. The distribution of chronic and acute pain was rather similar and musculoskeletal pain was the most frequent form. Most types of prescriptions were closely related to certainty of diagnosis.
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Affiliation(s)
- Daniela Koleva
- CESAV, Centre for Health Economics, Mario Negri Institute for Pharmacological Research, Ranica, Italy
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Gallagher RM. The clinical art of pain medicine: balancing evidence, experience, ethics, and policy. PAIN MEDICINE 2005; 6:277-9. [PMID: 16083455 DOI: 10.1111/j.1526-4637.2005.00055.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. PAIN MEDICINE 2005; 5:335-48. [PMID: 15563319 DOI: 10.1111/j.1526-4637.2004.04041.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the longitudinal course of depressive symptoms and pain experienced by continuing care retirement community (CCRC) residents and to investigate the impact of comorbid chronic activity-limiting pain and chronic high depressive symptoms on physical functioning and health service use. METHODS This longitudinal study of 169 CCRC residents involved five assessments (baseline and four in-person interviews at 6-month intervals). The Geriatric Depression Scale (GDS), questions drawn from the McGill Pain Questionnaire, and self-report data on physical functioning and health care use were assessed. Individuals reporting activity-limiting pain and those with GDS scores > or =11 at three or more assessments were considered to have chronic pain or chronic depression, respectively. The analysis sample included 169 CCRC residents. Multivariate logistic regression was used to test hypotheses. RESULTS Pain and depressive symptoms were characterized by longitudinal stability. Of the sample, 37% met the criteria for chronic activity-limiting pain, 21% met the criteria for chronic high depressive symptoms, and 13% were comorbid. Adjusting for age and health conditions, those with chronic activity-limiting pain were five times more likely than those in the lowest pain group to persistently be in the worst two quartiles of physical functioning, as were those with even one GDS score >5. The odds of poor physical functioning were 11.2 times greater in those with comorbid chronic pain and depression. Comparable greater odds were seen in this sample for frequency of medical care visits (adjusted odds ratio AOR]=12.4) and consistently high use of all medical services (AOR=3.5). CONCLUSIONS Pain and depressive symptoms were both common and appeared remarkably stable over time. Depressive symptoms contributed significantly to the prediction of impairment associated with pain, and identification and treatment of such symptoms, even minor symptoms, could reduce pain-related impairment and health care costs in the elderly.
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Affiliation(s)
- Jana M Mossey
- Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Mail Stop 660, 1505 Race Street, Philadelphia, PA 19102-1192, USA.
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Rational Integration of Pharmacologic, Behavioral, and Rehabilitation Strategies in the Treatment of Chronic Pain. Am J Phys Med Rehabil 2005. [DOI: 10.1097/01.phm.0000154910.01200.0b] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
This article reviews how emotions, behavior, and psychiatric comorbidity influence the course and outcome of chronic pain disorders and addresses methods of identifying and managing these problems in clinical practice. Successful medical rehabilitation for patients with chronic pain requires (1) appreciating the effects of biopsychosocial factors in the onset, course, and outcomes of pain disorders; (2) understanding neurobiologic mechanisms linking mind, brain, and body in the functions of pain perception and modulation; and (3) being able to review critically and use selectively the plethora of new medications and interventional technologies that are proposed in the literature. Deficits in these skills now are recognized as hazardous to the public health so that medical school education and post residency training in pain medicine is now mandatory in some states.
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Affiliation(s)
- Rollin M Gallagher
- Pain Management, Philadelphia VA Medical Center, University and Woodland, Philadelphia, PA 19104, USA.
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Abstract
There has been increasing awareness concerning the problem of acute pain in ED patients. There has, however, been little attention devoted to chronic pain in ED patients. Our purpose was to determine the extent and severity of chronic pain in adult ED patients. Adult noncritical patients were interviewed to determine if they had chronic pain. The Chronic Pain Grade scale was used to grade the severity of the pain. Four hundred seventy-six patients were enrolled. One hundred ninety-three (40.6%) had chronic pain. Sixty-five (13.7%) identified their chronic pain as the reason for the ED visit. The spine and abdomen were the most common sites of chronic pain. Those with chronic pain were more likely to be unemployed (relative risk [RR], 1.77; 95% confidence interval [CI], 1.34-2.34), disabled (RR, 3.24; 95% CI, 1.95-5.40), and have had four or more ED visits in the past year (RR, 2.47; 95% CI, 1.76-3.47). A total of 32.1% had class 3 pain (high disability, moderately limiting) and 58.0% had class 4 pain (high disability, severely limiting). Many noncritical ED patients have chronic pain. They are high users of ED services and most have not been seen in a pain clinic. Further studies are indicated to further delineate the demographics of this population and determine which patients would best be served in other healthcare settings. In an effort to improve care, ED physicians should be educated in diagnosing and treating chronic pain.
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Abstract
Pain Medicine has its roots in multiple primary specialties and has developed into a discrete specialty with disparate practice styles. Its identity is in flux and is threatened by forces that may fragment this new field before it can set firm roots. The public health crisis of under treated pain parallels medicine's struggle to adequately classify Pain Medicine as a specialty. We review the case for Pain Medicine as a discrete discipline, with specialized knowledge, treatments, training and education. Without recognition of the specialty of Pain Medicine, and resolution of the fragmentation of the field throughout healthcare, medicine's approach to the current problem of under treated pain is likely to continue to be inadequate.
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Affiliation(s)
- Scott M Fishman
- Division of Pain Medicine, Department of Anesthesiology & Pain Medicine, University of California, Davis, Sacramento, California 95817, USA.
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Gammaitoni AR, Gallagher RM, Welz M, Gracely EJ, Knowlton CH, Voltis-Thomas O. Palliative pharmaceutical care: a randomized, prospective study of telephone-based prescription and medication counseling services for treating chronic pain. PAIN MEDICINE 2004; 1:317-31. [PMID: 15101878 DOI: 10.1046/j.1526-4637.2000.00043.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effects of providing a unique telephone-based pharmaceutical care program to a sample of patients enrolled at a university pain clinic in Philadelphia, Pa. We hypothesized that in comparison to routine pharmaceutical care, the telephone-based pharmaceutical care program would have a positive impact on delivery of medication, quality of life, and overall satisfaction with the pain clinic program. PATIENTS One hundred seven pain clinic patients were randomly assigned to the control and intervention groups. Seventy-four patients (control group, n = 36; intervention group, n = 38) met inclusion criteria. METHOD The control group continued to receive care and prescription services through the same means as prior to the study. There were 2 components to the pharmaceutical care program offered to the intervention group. The first component consisted of a palliative care pharmacy company, PainRxperts, providing specialized prescription services tailored to the needs of a pain medicine clinical practice. The second component involved the palliative-trained pharmacist's proactive monitoring of patient pharmacotherapy for potential or actual drug related problems (DRPs). RESULTS Intervention patients perceived that they had better access to medication, more efficient processing of prescriptions, and fewer stigmatizing experiences. They also endorsed pharmacists' behavioral interventions such as medication counseling, availability to answer medication-related questions, and non-judgmental attitudes when managing opioid prescriptions. CONCLUSION This study suggests that the palliative-trained pharmacist can play an important collaborative role in managing chronic pain. Application of the pharmaceutical care model in pain medicine centers can improve satisfaction and remove some of the barriers to good pharmaceutical care facing patients with chronic pain disorders
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Affiliation(s)
- A R Gammaitoni
- PainRxperts, MCP Hahnemann School of Medicine, Philadelphia, Pennsylvania, USA
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Gallagher RM. Intrathecal Drug Delivery for Chronic Back Pain: Better Science for Clinical Innovation. PAIN MEDICINE 2004; 5:1-3. [PMID: 14996230 DOI: 10.1111/j.1526-4637.2004.04014.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cook L, Sefcik E, Stetina P. Pain Management in the Addicted Population: A Case Study Comparison of Prescriptive Practice. J Addict Nurs 2004. [DOI: 10.1080/jan.15.1.11.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Baumann TJ. Introduction. J Pharm Pract 2003. [DOI: 10.1177/0897190003258506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Turner GH, Weiner DK. Essential Components of a Medical Student Curriculum on Chronic Pain Management in Older Adults: Results of a Modified Delphi Process. PAIN MEDICINE 2002; 3:240-52. [PMID: 15099259 DOI: 10.1046/j.1526-4637.2002.02030.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this study was to develop expert-based guidelines for a medical student curriculum on chronic pain evaluation and management in older adults. METHODS A modified Delphi approach was used to survey an interdisciplinary panel (N = 12) with expertise in pain assessment, pharmacological and nonpharmacological pain management, and medical student education. A list of core knowledge/attitudes/skills (KAS) competency items was developed based upon a comprehensive literature review and clinical experience. The expert panel was then asked to consider the degree to which each item should be included in a pain education curriculum, using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree with inclusion of item). Items with a mean>4.0 (agree) and a standard deviation (SD) <1 were retained, while others were discarded. Retained items were refined, and new items were added based upon panel suggestions. The new KAS list was again scored by the expert panel, and items with a mean <4.0 and SD <1 were discarded. RESULTS The original KAS list contained eight pain assessment knowledge, seven pain management knowledge, 12 pain attitudes, and 14 skills/abilities items. The final list, presented in this paper, consisted of 11 pain assessment knowledge, seven pain management knowledge, 12 pain attitudes, and 12 skills/abilities items. DISCUSSION We have developed curriculum content guidelines for educating medical students about the evaluation and management of chronic pain in older adults. Once curricula are developed, their efficacy, in particular their influence on patient outcomes, must be evaluated.
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Affiliation(s)
- Gregory H Turner
- School of Education, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
OBJECTIVE To document the health resource utilization of patients who repeatedly use emergency department services for headache care. BACKGROUND Patients with headache who frequently use emergency department services may differ from patients with more typical, episodic migraine. Previous studies of health resource utilization have often failed to distinguish the high utilizer as a specific subset of the migraine population. DESIGN Retrospective review of urgent care/emergency department charts, clinic charts, and pharmacy rosters. PATIENTS AND METHODS Patients who made three or more visits for headache to an urgent care/emergency department (UC/ED) facility for headache over a 6-month study period were identified and designated as "repeaters" for this study. Pharmacy profiles and appointment histories of 52 of the 54 repeaters whose records were available were reviewed for the 12 months prior to the study period. RESULTS Over the 6-month study period, 518 patients visited the UC/ED 1004 times for primary headache complaints. Fifty-four (10%) repeaters made 502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months prior to the study period, 52 of these repeaters made 1832 visits to the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated 12-month cost for all visits was $183,760. Pharmacy rosters showed use of narcotics in 41 of the 52 patients (annual mean +/- SD, 613 +/- 670 tablets), benzodiazepines in 30 patients (500 +/- 486 tablets), and butalbital products in 27 patients (395 +/- 590 tablets). Mean daily use of all symptomatic medications combined was 3.9 +/- 3.2 doses/day. CONCLUSION Health resource utilization of emergency department headache repeaters is predominantly headache-related acute care. Associated medication overuse is frequently present. Efforts to improve care for patients with headache will benefit from distinguishing the high utilizer as a subset of the migraine population.
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Affiliation(s)
- Morris Maizels
- Department of Family Practice, Kaiser Permanente, Woodland Hills, Calif 91367, USA
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Abstract
Pain is unnecessary. Effective tools are available to help doctors evaluate pain in their patients. Unrelieved pain should be treated just like any other vital sign: with aggressive measures. Effective therapies are available to treat pain. Use guidelines to develop a rational plan to relieve pain. Side effects are manageable. Anticipate side effects and treat aggressively. Addiction rarely occurs. Trust your patient when they report pain. Tolerance and physical dependence can occur. Plan and you will succeed. Take the initiative and focus on relieving pain at your hospital. Your patients depend on it.
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Affiliation(s)
- Joseph Ming Wah Li
- Hospital Medicine Program, Beth Israel Deconess Medical Center, Harvard Medical School, One Deaconess Road, Palmer 212, Boston, MA 02215, USA.
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Gallagher RM. Pain Management in Primary Care: What Is the Role for Pain Medicine? PAIN MEDICINE 2002; 3:81-2. [PMID: 15102152 DOI: 10.1046/j.1526-4637.2002.02028.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O'Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med 2002; 17:173-9. [PMID: 11929502 PMCID: PMC1495018 DOI: 10.1046/j.1525-1497.2002.10435.x] [Citation(s) in RCA: 255] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To define the spectrum of chronic noncancer pain treated with opioid medications in 2 primary care settings, and the prevalence of psychiatric comorbidity in this patient population. We also sought to determine the proportion of patients who manifested prescription opioid abuse behaviors and the factors associated with these behaviors. DESIGN A retrospective cohort study. SETTING A VA primary care clinic and an urban hospital-based primary care center (PCC) located in the northeastern United States. PATIENTS A random sample of VA patients ( n=50) and all PCC patients ( n=48) with chronic noncancer pain who received 6 or more months of opioid prescriptions during a 1-year period (April 1, 1997 through March 31, 1998) and were not on methadone maintenance. MEASUREMENTS Information regarding patients' type of chronic pain disorder, demographic, medical, and psychiatric status, and the presence of prescription opioid abuse behaviors was obtained by medical record review. MAIN RESULTS Low back pain was the most common disorder accounting for 44% and 25% of all chronic pain diagnoses in the VA and PCC samples, respectively, followed by injury-related (10% and 13%), diabetic neuropathy (8% and 10%), degenerative joint disease (16% and 13%), spinal stenosis (10% and 4%), headache (4% and 13%) and other chronic pain disorders (8% and 22%). The median duration of pain was 10 years (range 3 to 50 years) in the VA and 13 years in the PCC sample (range 1 to 49 years). Among VA and PCC patients, the lifetime prevalence rates of psychiatric comorbidities were: depressive disorder (44% and 54%), anxiety disorder (20% and 21%), alcohol abuse/dependence (46% and 31%), and narcotic abuse/dependence (18% and 38%). Prescription opioid abusive behaviors were recorded for 24% of VA and 31% of PCC patients. A lifetime history of a substance use disorder (adjusted odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4 to 10.8) and age (adjusted OR, 0.94; 95% CI, 0.89 to 0.99) were independent predictors of prescription opioid abuse behavior. CONCLUSIONS A broad spectrum of chronic noncancer pain disorders are treated with opioid medications in primary care settings. The lifetime prevalence of psychiatric comorbidity was substantial in our study population. A significant minority of patients manifested prescription opioid abusive behaviors, and a lifetime history of a substance use disorder and decreasing age were associated with prescription opioid abuse behavior. Prospective studies are needed to determine the potential benefits as well as risks associated with opioid use for chronic noncancer pain in primary care.
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Affiliation(s)
- M Carrington Reid
- Clinical Epidemiology Unit, VA Connecticut Healthcare System, West Haven Conn. 06516, USA.
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Mossey JM, Gallagher RM, Tirumalasetti F. The Effects of Pain and Depression on Physical Functioning in Elderly Residents of a Continuing Care Retirement Community. PAIN MEDICINE 2000; 1:340-50. [PMID: 15101880 DOI: 10.1046/j.1526-4637.2000.00040.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED OBJECTIVE. Explore the relationships between pain, depression, and functional disability in elderly persons. DESIGN A cross-sectional, observational study of 228 independently living retirement community residents. METHODS Self-report measures of pain (adaptation of McGill Pain Questionnaire), depression (Geriatric Depression Scale [GDS]) and physical functioning (Physical performance difficulties, activities of daily living [ADL], independent activities of daily living [IADL], and 3-meter walking speed) were employed. OUTCOME MEASURES Physical functioning variables were dichotomized. Individuals in the lowest quartiles of functional performance and of walking speed were contrasted to all others; for ADL and IADL, those needing some help were compared with those independent in activities. RESULTS Pain and depression levels were strongly related to physical performance; depression levels were related to ADL and walking speed. In multivariate analyses, an interaction effect was observed where the effects of pain were a function of level of depression. Individuals reporting activity-limiting pain and slightly elevated depressive symptom levels, sub-threshold depression, or major depression were significantly more likely (AOR 7.8; 95% CI, 3.07-20.03) than non-depressed persons to be in the lowest quartile of self-reported physical performance. CONCLUSIONS While both pain and depression level affect physical performance, depressive symptoms rather than pain appear the more influential factor. When seeing elderly patients, identifying, evaluating, and treating both pain complaints and depressive symptoms and disorders may reduce functional impairment.
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Affiliation(s)
- J M Mossey
- Center for Epidemiology and Biostatistics, School of Public Health, MCP Hahnemann University, Philadelphia, Pennsylvania 19102-1192, USA.
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Gallagher RM. Treatment planning in pain medicine. Integrating medical, physical, and behavioral therapies. Med Clin North Am 1999; 83:823-49, viii. [PMID: 10386127 DOI: 10.1016/s0025-7125(05)70136-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article addresses a systematic approach to the treatment of chronic pain. The first section presents a biopsychosocial model of pain. The second section presents an application of the biopsychosocial approach to the clinical assessment and management of clinical cases with chronic pain.
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Affiliation(s)
- R M Gallagher
- Comprehensive Pain and Rehabilitation Center, MCP/Hahnemann School of Medicine, Philadelphia, Pennsylvania, USA
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