Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada

Identifying competencies for an advanced practice physiotherapy role within an interprofessional chronic pain clinic

BACKGROUND

Advanced practice physiotherapy (APP) models of care have shown success in access, safety, satisfaction, and care quality for musculoskeletal pain conditions in various settings. Yet, there is a gap in defining competencies for physiotherapists to be the initial point of contact for people with chronic pain. This study aims to identify and agree upon the competencies necessary for a physiotherapist to fulfill the role of an APP in an interprofessional chronic pain clinic.

METHODS

Three focus groups were conducted using a Nominal Group Technique and a modified Delphi process. Consensus on the competency, defined as agreement by ≥ 75% of participants, was sought.

RESULTS

Twenty-three experts (17 healthcare providers and six individuals with chronic pain) participated in the focus group discussions. Twenty completed the follow-up Delphi surveys. Ten essential competencies for an APP role in interprofessional chronic pain clinics were identified and achieved consensus: 1) use an evidence-based approach to practice; 2) communicate effectively with the patient; 3) perform a comprehensive assessment; 4) determine pain-related diagnoses; 5) develop therapeutic relationships; 6) provide appropriate care; 7) support patients through transitions in care; 8) collaborate with members of the interprofessional team; 9) advocate for the needs of the patients; and 10) use a reflective approach to practice.

CONCLUSION

This study identified ten competencies essential for physiotherapists to fulfill an APP role within interprofessional chronic pain clinics. These competencies serve as a foundation for informing a training program and future research evaluating the effectiveness of the APP model in this setting.

Health Care Utilization and Direct Costs Prior to Subspecialty Care in Children with Chronic Pain Compared with Other Chronic Childhood Diseases: A Cohort Study

OBJECTIVES

To understand the burden associated with pediatric chronic pain (CP) on the health care system compared with other costly chronic diseases prior to subspecialty care.

STUDY DESIGN

In this retrospective cohort study, we assessed all-cause health care utilization and direct health care costs associated with pediatric CP (n = 91) compared with juvenile arthritis (n = 135), inflammatory bowel disease (n = 90), type 1 diabetes (n = 475) or type 2 diabetes (n = 289), anxiety (n = 7193), and controls (n = 273) 2 and 5 years prior to patients entering subspecialty care in Manitoba, Canada. Linked data from physician encounters, emergency department visits, hospitalizations, and prescriptions were extracted from administrative databases. Differences in health care utilization and direct health care costs associated with CP vs the other conditions were tested using negative binomial and zero-inflated negative binomial regression models, respectively.

RESULTS

After adjustment for age at diagnosis, sex, location of residence, and socioeconomic status, CP continued to be associated with the highest number of consulted physicians and subspecialists and the highest number of physician billings compared with all other conditions (P < .01, respectively). CP was significantly associated with higher physician costs than juvenile arthritis, inflammatory bowel disease, type 1 diabetes, type 2 diabetes, or controls (P < .01, respectively); anxiety was associated with the highest physician and prescription costs among all cohorts (P < .01, respectively).

CONCLUSION

Compared with chronic inflammatory and endocrinologic conditions, pediatric CP and anxiety were associated with substantial burden on the health care system prior to subspecialty care, suggesting a need to assess gaps and resources in the management of CP and mental health conditions in the primary care setting.

Accessing care within team-based models of primary care for the management of chronic low back pain in Ontario, Canada: a qualitative study of patient experiences

PURPOSE

To understand experiences accessing care within team-based primary care models among adults with chronic low back pain (LBP).

MATERIALS & METHODS

We conducted an interpretive description qualitative study and collected data using one-to-one semi-structured interviews. Participants were recruited from publicly funded, team-based primary care models in Ontario, Canada.

RESULTS

We completed interviews with 16 adults with chronic LBP (9 women; median age of 66). Participants expressed a desire to access care from team-based models of primary care in hopes of alleviating pain and its impacts on daily life. Due to no direct out-of-pocket costs, co-location of healthcare providers, and the use of technology and virtual care, participants described an ease of accessing interprofessional care within team-based primary care models. Finally, participants described experiences with and expectations for timely access to care, being heard and understood by healthcare providers, and receiving coordinated care by an interprofessional team.

CONCLUSIONS

Adults living with chronic LBP described overall positive experiences and specific expectations when accessing care within team-based models of primary care, whereby they experienced an ease of accessing interprofessional care with the hope of alleviating pain and its impacts. Results may be transferable to other chronic pain conditions and health system contexts.

Cultivating Comfort: Examining Participant Satisfaction with Hypnotic Communication Training in Pain Management

Context

One in four Canadians experiences chronic pain, yet insufficient services and restrictions surrounding prevailing treatments result in inadequate management and significant negative consequences for these individuals. Previous work indicates that hypnotic communication represents a promising complementary treatment; however, training protocols for healthcare professionals are underdeveloped and understudied.

Aim

To evaluate the level of satisfaction for a training program on hypnotic communication in pain management clinics.

Design

Qualitative study.

Methods

Six health professionals who first completed the hypnotic communication training participated in 30 minutes virtual semi-structured interviews. These testimonials allowed them to elaborate on their user experience and potential areas for improvement. Thematic analysis using qualitative data management software NVIVO was conducted on the interview data.

Results

Two themes emerged from the interviews. 1) Satisfaction: Participants expressed satisfaction on various structural aspects of the training, including the provided materials, atmosphere, training structure, presentation modalities, practical workshops, acquired knowledge, trainer quality, and training duration. 2) Areas for Improvement: Five main improvement suggestions were identified (providing more material; more practical workshops, more concrete and adapted; testimonials from former patients; follow-up training meeting; and continuing education).

Implications for the Profession and/or Patient Care and Conclusion

The results improved the training program to help minimized inherent biases related to this technique, cut associated costs, and identify reasons that would explain its underutilization among medical professionals in Quebec. Our work highlights that healthcare professionals in chronic pain management clinics (eg, respiratory therapists, nurses) can incorporate this simple hypnotic communication technique into their usual care and contribute to the well-being of patients.

Impact

This study aimed to address the lack of training protocols for healthcare professionals, that are underdeveloped and understudied. The main findings on participant' satisfaction and the areas of improvement for the training will help the refinement of the training to better suit healthcare professional's needs in hospitals and chronic pain facilities.

Integrated pain care models and the importance of aligning stakeholder values

Sustained widespread deployment of clinically and cost-effective models of integrated pain care could be bolstered by optimally aligning shared stakeholder values.

Waiting in Pain II: An Updated Analysis of the Multidisciplinary Staffing Levels and Clinical Activity in Australian Specialist Persistent Pain Services

This study provides an update on multidisciplinary staffing and clinical activity in Australian specialist persistent pain services. Of the 109 services identified, 57 responded, met inclusion criteria and completed a study-specific questionnaire detailing service characteristics, staff resources, and clinical activities. Where possible, data were compared between the 'Waiting in Pain' (WIP) investigations (WIP-I: Dec'08-Jan'10, WIP-II: Jul'16-Feb'18). WIP-II found more pain services (Level 1 centres, rural services) and more full-time equivalent (FTE) staffing (overall, psychiatry, psychology, occupational therapy) than WIP-I. Although Level 1 centres employed more FTE staff (overall, medical) than Level 2 clinics, staffing was comparable when considered relative to clinical activity and this was stable over time for most disciplines. Clinical activity in metropolitan and rural services also remained stable, as did rural service staffing (type, FTE), suggesting that newer clinics replicated existing models. WIP-II highlighted greater diversity in group structures than WIP-I and an associated mean .02FTE allied health staff/patient seen (WIP-I = .03 FTE). Staffing (amounts, types) did not change significantly over time when considered relative to clinical activity, supporting the conclusion that these are workable clinical structures. However, changes in group format (duration, staffing) suggest a shift towards lower-intensity programmes that require less allied health staffing to deliver. PERSPECTIVE: This article presents updated data regarding multidisciplinary staffing profiles, clinical activity, and group programme structures within Australian specialist persistent pain services and examines changes since the original investigation. As the only published staffing profile for multidisciplinary pain services, this project provides critical information to inform service (re)design and care delivery.

"Keep trying": a qualitative investigation into what patients with chronic pain gain from Project ECHO

Objective

The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain.

Introduction

Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation.

Methods

Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them.

Results

Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation.

Conclusions

Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain.

Assessing the Feasibility and Preliminary Effects of a Web-Based Self-Management Program for Chronic Noncancer Pain: Mixed Methods Study

BACKGROUND

In Canada, adults with chronic noncancer pain face a persistent insufficiency of publicly funded resources, with the gold standard multidisciplinary pain treatment facilities unable to meet the high clinical demand. Web-based self-management programs cost-effectively increase access to pain management and can improve several aspects of physical and emotional functioning. Aiming to meet the demand for accessible, fully automated resources for individuals with chronic noncancer pain, we developed a French web- and evidence-based self-management program, Agir pour moi (APM). This program includes pain education and strategies to reduce stress, practice mindfulness, apply pacing, engage in physical activity, identify and manage thinking traps, sleep better, adapt diet, and sustain behavior change.

OBJECTIVE

This study aims to assess the APM self-management program's feasibility, acceptability, and preliminary effects in adults awaiting specialized services from a center of expertise in chronic pain management.

METHODS

We conducted a mixed methods study with an explanatory sequential design, including a web-based 1-arm trial and qualitative semistructured interviews. We present the results from both phases through integrative tables called joint displays.

RESULTS

Response rates were 70% (44/63) at postintervention and 56% (35/63) at 3-month follow-up among the 63 consenting participants who provided self-assessed information at baseline. In total, 46% (29/63) of the participants completed the program. We interviewed 24% (15/63) of the participants. The interview's first theme revolved around the overall acceptance, user-friendliness, and engaging nature of the program. The second theme emphasized the differentiation between microlevel and macrolevel engagements. The third theme delved into the diverse effects observed, potentially influenced by the macrolevel engagements. Participants highlighted the features that impacted their self-efficacy and the adoption of self-management strategies. We observed indications of improvement in self-efficacy, pain intensity, pain interference, depression, and catastrophizing. Interviewees described these and various other effects as potentially influenced by macrolevel engagement through behavioral change.

CONCLUSIONS

These findings provided preliminary evidence that the APM self-management program and research methods are feasible. However, some participants expressed the need for at least phone reminders and minimal support from a professional available to answer questions over the first few weeks of the program to engage. Recruitment strategies of a future randomized controlled trial should focus on attracting a broader representation of individuals with chronic pain in terms of gender and ethnicity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05319652; https://clinicaltrials.gov/study/NCT05319652.

Patient-Reported Wait Times and the Impact of Living with Chronic Pain on their Quality of Life: A Waiting Room Survey in Chronic Pain Clinics in Ontario, Manitoba, and Quebec

Background

Wait times at Canadian multidisciplinary pain clinics have been reported as excessive for nearly 2 decades.

Aims

The aim of this study was to gain insight into the patient experience of waiting for chronic pain specialty care.

Methods

A cross-sectional survey of new patients waiting for an appointment was conducted in six multidisciplinary pain clinics, including one pediatric clinic, in Ontario, Quebec, and Manitoba between February 2020 and October 2022. Participants were asked about the length of time they waited for their appointment since being referred, their quality of life, health care professionals seen while waiting, and an open-ended question, "Is there anything else you'd like to tell us?"

Results

Among the 493 adult and 100 pediatric respondents, 53% of adults and 82% of children reported wait times under 6 months, whereas 22% of adults and 4% of children waited longer than a year. Between 52% and 63% of adults and 29% to 48% of children reported being affected by chronic pain "quite a bit" or "extremely" on measures of quality of life. The most visited health care professionals while waiting for a pain clinic appointment were family doctors/nurse practitioners for adults and physiotherapists for children. Qualitative analysis of open-ended question responses revealed eight themes: system navigation issues, administrative issues, decreased quality of life, distress, self-advocacy, coping strategies, communication, and distrust.

Conclusions

Our findings provide real-time regional snapshots into the impact of long wait times experienced by Canadians living with chronic pain. There is an urgent need to better support patients during the waiting period. Expanding technologies such as electronic consultation hold great promise.

Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada

Objective

Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers).

Methods

A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain.

Results

1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models.

Discussion

There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

Improving access to chronic pain care with central referral and triage: The 6-year findings from a single-entry model

Background

Despite the established efficacy of multidisciplinary chronic pain care, barriers such as inflated referral wait times and uncoordinated care further hinder patient health care access.

Aims

Here we describe the evolution of a single-entry model (SEM) for coordinating access to chronic pain care across seven hospitals in Toronto and explore the impact on patient care 6 years after implementation.

Methods

In 2017, an innovative SEM was implemented for chronic pain referrals in Toronto and surrounding areas. Referrals are received centrally, triaged by a clinical team, and assigned an appointment according to the level of urgency and the most appropriate care setting/provider. To evaluate the impact of the SEM, a retrospective analysis was undertaken to determine referral patterns, patient characteristics, and referral wait times over the past 6 years.

Results

Implementation of an SEM streamlined the number of steps in the referral process and led to a standardized referral form with common inclusion and exclusion criteria across sites. Over the 6-year period, referrals increased by 93% and the number of unique providers increased by 91%. Chronic pain service wait times were reduced from 299 (±158) days to 176 (±103) days. However, certain pain diagnoses such as chronic pelvic pain and fibromyalgia far exceed the average.

Conclusions

The results indicate that the SEM helped reduce wait times for pain conditions and standardized the referral pathway. Continued data capture efforts can help identify gaps in care to enable further health care refinement and improvement.

A Journey Through Tapering

Living with rheumatoid arthritis (RA) for almost 40 years has not been an easy journey. My disease has been severe and difficult to manage; from the beginning there were challenges getting a diagnosis and in finding medications that were effective long term. Thirty years ago, unable to cope with the extreme pain and with 3 children aged 8, 11, and 13 who needed a functioning mother, my doctor prescribed an opioid. This medication gave me back some quality of life but taking opioids is not without significant risks. No one discussed the challenges I would face if and when the time came to stop taking them. With the opioid crisis there has been more pressure from government and medical licensing bodies to implement policies to restrict access for patients prescribed opioids and to encourage tapering. With the change in policy additional funding and resources are needed to help patients through the process but those supports do not exist across Canada.

Interventional pain blocks in Ontario: a population-based cross-sectional study on 2019 procedural volumes, clustering, and physician billings

PURPOSE

Multidisciplinary chronic pain management includes pharmacologic, psychological, and interventional strategies. In Canada, the use of interventional pain blocks (PBs) has increased in recent years. We sought to determine the distribution and clustering of PBs among physicians in Ontario, and to examine differences in the patient and physician characteristics by volume of PBs administered.

METHODS

We conducted a population-based cross-sectional study of PBs administered for chronic pain to Ontario residents between 1 January and 31 December 2019. Our primary outcome was the total number of PBs administered in an outpatient setting for chronic pain by eligible physicians. We used Lorenz curves, overall and stratified by PB type and physician specialty, to examine clustering of PBs among physicians, and compared patient and physician characteristics using standardized differences.

RESULTS

Among physicians who provided PBs, provision was highly clustered, with the top 1% of physicians providing 39% of blocks. In these high-volume PB providers, the majority of whom were general practitioners (88.4%), PBs made up the vast majority (median [interquartile range (IQR)], 87% [84-89]) of their billings, with the majority of the patients in their practices (63.0%) receiving at least one PB in 2019. Patients who received a PB from a high-volume provider had a higher annual frequency of visit for PBs (median [IQR], 10 [3-23]) and number of PBs administered per visit (median [IQR], 5 [4-6]).

CONCLUSION

Pain block administration is highly clustered in Ontario, with many patients receiving PBs in ways that are not supported by best evidence. Further research is required to determine whether the Ontario fee-for-service model of billing has created a suboptimal use of these health care resources.

Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era

BACKGROUND

Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation.

METHODS

A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey.

RESULTS

The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options.

CONCLUSIONS

Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.

Delivering Team-Based Primary Care for the Management of Chronic Low Back Pain: An Interpretive Description Qualitative Study of Healthcare Provider Perspectives

Background

Chronic low back pain (LBP) is a prevalent and disabling health issue. Team-based models of primary care are ideally positioned to provide comprehensive care for patients with chronic LBP. A better understanding of primary care team perspectives can inform future efforts to improve how team-based care is provided for patients with chronic LBP in this practice setting.

Aims

The aim of this study was to understand health care providers' experiences, perceived barriers and facilitators, and recommendations when providing team-based primary care for the management of chronic LBP.

Methods

We conducted an interpretive description qualitative study based on focus group discussions with health care providers from team-based primary care settings in Ontario, Canada. Data were analyzed using thematic analysis.

Results

We conducted five focus groups with five different primary care teams, including a total of 31 health care providers. We constructed four themes (each with subthemes) related to experiences, perceived barriers and facilitators, and recommendations to providing team-based primary care for the management of chronic LBP, including (1) care pathways and models of service delivery, (2) team processes and organization, (3) team culture and environment, and (4) patient needs and readiness.

Conclusions

Primary care teams are implementing diverse care pathways and models of service delivery for the management of patients with chronic LBP, which can be influenced by patient, team, and organizational factors. Results have potential implications for future research and practice innovations to improve how team-based primary care is delivered for patients with chronic LBP.

Sex and gender differences in healthcare utilisation trajectories: a cohort study among Quebec workers living with chronic pain

OBJECTIVES

Chronic pain (CP) is a poorly recognised and frequently inadequately treated condition affecting one in five adults. Reflecting on sociodemographic disparities as barriers to CP care in Canada was recently established as a federal priority. The objective of this study was to assess sex and gender differences in healthcare utilisation trajectories among workers living with CP.

DESIGN

Retrospective cohort study.

PARTICIPANTS

This study was conducted using the TorSaDE Cohort which links the 2007-2016 Canadian Community Health Surveys and Quebec administrative databases (longitudinal claims). Among 2955 workers living with CP, the annual number of healthcare contacts was computed during the 3 years after survey completion.

OUTCOME

Group-based trajectory modelling was used to identify subgroups of individuals with similar patterns of healthcare utilisation over time (healthcare utilisation trajectories).

RESULTS

Across the study population, three distinct 3-year healthcare utilisation trajectories were found: (1) low healthcare users (59.9%), (2) moderate healthcare users (33.6%) and (3) heavy healthcare users (6.4%). Sex and gender differences were found in the number of distinct trajectories and the stability of the number of healthcare contacts over time. Multivariable analysis revealed that independent of other sociodemographic characteristics and severity of health condition, sex-but not gender-was associated with the heavy healthcare utilisation longitudinal trajectory (with females showing a greater likelihood; OR 2.6, 95% CI 1.6 to 4.1).

CONCLUSIONS

Our results underline the importance of assessing sex-based disparities in help-seeking behaviours, access to healthcare and resource utilisation among persons living with CP.

Assessing the feasibility of a clinical trial to evaluate an advanced practice physiotherapy model of care in chronic pain management: a feasibility study

BACKGROUND

Chronic pain management is challenging for health systems worldwide. Clinical practice guidelines recommend interprofessional chronic pain management, but chronic pain clinics often have lengthy wait-lists. Advanced practice physiotherapists (APP) in orthopedic clinics and emergency departments have provided effective care and reduced wait times. The purpose of this study is to determine the feasibility of a clinical trial to evaluate the effects of integrating an APP into a chronic pain clinic setting. The primary objectives are as follows: (1) determine the feasibility of implementing trial methods by evaluating participant recruitment rates, retention, and assessment completion; (2) determine the feasibility of implementing the APP model of care by monitoring care provided and treatment fidelity; and (3) assess contextual factors that may influence implementation of the APP model of care by exploring the perspectives of patient participants and healthcare providers related to the model of care.

METHODS

This will be a single-arm feasibility study with embedded qualitative interviews to assess contextual factors influencing implementation by exploring participant and provider perspectives. Approximately 40 adults with chronic musculoskeletal pain referred for care at an interprofessional chronic pain clinic will be invited to participate in the feasibility study. Approximately 10-12 patient participants and 5-10 health professionals from the interprofessional team will be interviewed using an interpretive description approach. The APP model of care will involve participants seeing a physiotherapist as the first point of contact within the interprofessional team. The APP will complete an initial assessment and make care recommendations. Outcome measures planned for the full trial will be reported descriptively, including pain severity, pain interference, health-related quality of life, psychosocial risk factors for chronic pain, treatment satisfaction, perceived change, healthcare utilization, and healthcare costs over one year.

DISCUSSION

This study will inform plans to implement a full-scale study to evaluate the impact of an APP model of care in an interprofessional chronic pain management program. The results of the full study are intended to inform stakeholders considering this model to improve patient-centered and health system outcomes in interprofessional pain management program settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05336903 (Registered April 5, 2022).

Continuing professional development needs in pain management for Canadian health care professionals: A cross sectional survey

Background

Continuing professional development is an important means of improving access to effective patient care. Although pain content has increased significantly in prelicensure programs, little is known about how postlicensure health professionals advance or maintain competence in pain management.

Aims

The aim of this study was to investigate Canadian health professionals' continuing professional development needs, activities, and preferred modalities for pain management.

Methods

This study employed a cross-sectional self-report web survey.

Results

The survey response rate was 57% (230/400). Respondents were primarily nurses (48%), university educated (95%), employed in academic hospital settings (62%), and had ≥11 years postlicensure experience (70%). Most patients (>50%) cared for in an average week presented with pain. Compared to those working in nonacademic settings, clinicians in academic settings reported significantly higher acute pain assessment competence (mean 7.8/10 versus 6.9/10; P < 0.002) and greater access to pain specialist consultants (73% versus 29%; P < 0.0001). Chronic pain assessment competence was not different between groups. Top learning needs included neuropathic pain, musculoskeletal pain, and chronic pain. Recently completed and preferred learning modalities respectively were informal and work-based: reading journal articles (56%, 54%), online independent learning (44%, 53%), and attending hospital rounds (43%, 42%); 17% had not completed any pain learning activities in the past 12 months. Respondents employed in nonacademic settings and nonphysicians were more likely to use pocket cards, mobile apps, and e-mail summaries to improve pain management.

Conclusions

Canadian postlicensure health professionals require greater access to and participation in interactive and multimodal methods of continuing professional development to facilitate competency in evidence-based pain management.

Fractured system, fractured care: The experiences of Canadian women with chronic pelvic pain waiting for interprofessional pain care

Background:

Chronic pelvic pain (CPP) is a common disorder in women that includes complex interactions between biological, psychological, and social factors. Accessibility to interprofessional, biopsychosocial CPP care remains a challenge for many patients. There is a lack of knowledge regarding the experiences of women using health services for CPP care and the impact of waiting for interprofessional CPP care. This study explores the perceptions and experiences of Canadian women with CPP interacting with the health system while waiting for interprofessional CPP care.

Methods:

Our qualitative study included women with CPP waiting for interprofessional care in Ontario, Canada. Data were obtained through semi-structured interviews which were transcribed verbatim and analyzed inductively using established methods for thematic analysis.

Results:

Ten women (median age of 38.5 years, age range 28–57) participated in in-depth semi-structured interviews. Three main themes were identified: (1) feeling adrift in the health system, (2) feeling “On hold,” uncertain, and in need of guidance, and (3) feeling reliant on a system that does not understand. Within these themes, women with CPP describe tangible strategies and recommendations for improving health system navigation and care.

Conclusion:

Our study highlights the need for improved access to interprofessional CPP programs, enhanced and targeted training for health professionals in CPP management, and better health system navigation support. Specific recommendations were provided from the perspectives of women with CPP and included providing information on what to expect and prepare for their appointment and engaging patients in education resources while they wait.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center

Background

Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain.

Methods

We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores).

Results

The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant.

Conclusion

Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research

Background

Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy.

Aim

The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature.

Methods

Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded.

Results

Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation).

Conclusions

Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.

Chronic pain in children and adolescents in Manitoba: A retrospective chart review to inform the development of a provincial service for pediatric chronic pain

Background

In the absence of an interdisciplinary service for pediatric chronic pain in Manitoba, pain management has been offered through a single provider outpatient setting with consultative services from physiotherapy, occupational therapy, and psychiatry since October 2015.

Aims

The aim of this study was to characterize the patient population of this clinic to understand needs and inform future service development for pediatric chronic pain.

Methods

Demographics and disease characteristics of all patients seen in this clinic between October 1, 2015, and February 28, 2019, were analyzed retrospectively from electronic medical records.

Results

A total of 157 patients, mean age 13.1 (sd ±3.0) years, 75.2% female, with a median duration of pain of 20.5 (interquartile range [IQR] = 10.0–45.8) months at their first visit were included in the study. At baseline, 74.0% of patients experienced insomnia, 76.6% fatigue, 86.5% symptoms of anxiety, and 58.69% symptoms of depression; 80.1% showed withdrawal from physical activity, 67.1% missed school, and 10.2% reported opioid usage. Throughout their care in clinic, 83.4% of patients received physiotherapy, 17.8% occupational therapy, 49.7% mental health support, and 51.6% care from multiple services. The clinic experienced a significant increase in median referrals from 1.0 to 5.0 (IQR = 2.0–9.0) per month and wait time from 35.0 to 97.0 (IQR = 88.0–251.0) days during the observation period.

Conclusions

Developing an interdisciplinary service for pediatric chronic pain will provide an opportunity to improve access, coordination, and comprehensiveness of care and to employ culturally sensitive services to improve care for children and youth living with chronic pain in Manitoba and possibly other jurisdictions with similar demographics and needs.

The Geography of Pain in the United States and Canada

Pain epidemiologists have, thus far, devoted scant attention to geospatial analyses of pain.  Both cross-national and, especially, subnational variation in pain have been understudied, even though geographic comparisons could shed light on social factors that increase or mitigate pain. This study presents the first comparative analysis of pain in the U.S. and Canada, comparing the countries in aggregate, while also analyzing variation across states and provinces. Analyses are based on cross-sectional data collected in 2020 from U.S. and Canadian adults 18 years and older (N = 4,113). The focal pain measure is a product of pain frequency and pain interference. We use decomposition and regression analyses to link socioeconomic characteristics and pain, and inverse-distance weighting spatial interpolation to map pain levels. We find significantly and substantially higher pain in the U.S. than in Canada. The difference is partly linked to Americans' worse economic conditions. Additionally, we find significant pain variability within the U.S. and Canada. U.S. states in the Deep South, Appalachia, and parts of the West stand out as pain 'hotspots' with particularly high pain levels. Overall, our findings identify areas with a high need for pain prevention and management; they also urge further scholarship on geographic factors as important covariates in population pain. PERSPECTIVE: This study documents the high pain burden in the U.S. versus Canada, and points to states in the Deep South, Appalachia, and parts of the West as having particularly high pain burden. The findings identify geographic areas with a high need for pain prevention and management.

Patterns of patient outcomes following specialist pain management in Australasia: a latent class analysis using the ePPOC database

ABSTRACT

The increasing demand for pain management and limited resources available highlight the need to measure treatment effectiveness. We analysed data collected at 75 specialist persistent pain services located in Australia and New Zealand to calculate overall treatment outcome for patients receiving care during 2014-2020. Socio-demographic and clinical information was provided for 23,915 patients, along with patient-reported measures assessing pain, pain interference, depression, anxiety, stress, pain catastrophizing and pain self-efficacy. Latent Class Analysis identified four distinct outcomes based on patients' pattern of responses across the assessment tools at treatment end. Group 1 (n=8,369, 35%) reported low/mild severity across all clinical domains at the end of care, while Group 4 (n= 7,081, 30%) were more likely to report moderate/high severity on all domains. Group 2 (n=1,991, 8%) reported low/mild pain with moderate/high psychological distress at treatment end, and Group 3 (n=6,474, 27%) reported moderate/high pain with low/mild psychological distress. Multi-variable logistic regression identified those factors associated with the different groups. In particular, factors most predictive of a poor (Group 4) vs. good outcome (Group 1) were unemployment (due to pain or other reasons), requiring an interpreter, widespread pain, pain of longer duration and attributing the pain to an injury at work. The results may allow identification of those most likely to benefit from the services currently provided, and inform development of alternative or enhanced services for those at risk of a poor outcome.

Definition and refinement of HYlaDO, a self-hypnosis training program for chronic pain management: A qualitative exploratory study

One in four Canadians is affected by chronic pain, frequently treated with opioids, which present a risk of addiction and overdose. The development of non-pharmacological interventions is therefore crucial. In a pilot project, a self-hypnosis training program showed encouraging results in improving breast cancer patients' quality of life. Based on this program, we developed a new self-hypnosis program for chronic pain patients: HYlaDO (Hypnosis of pain in French, HYpnose de la DOuleur). To structure the process of adapting an existing program to a new context, we used the ORBIT model (Obesity-Related Behavioral Intervention Trials), which consists of four development phases. This study aimed to collect patients' opinions and recommendations, and to refine HYlaDO (ORBIT Phase Ib). Fifteen participants took part in individual semi-structured interviews about this program. Two analysts coded the verbatims, and a thematic categorization was performed. Six themes emerged: practice training, expected vs. perceived effects, chronic pain management, individual practice, satisfaction, and participants' recommendations. Improvements to be considered in this type of program were finally discussed.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study

PURPOSE

A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs.

METHODS

We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures.

RESULTS

A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff.

CONCLUSIONS

Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Time series-based bibliometric analysis of a systematic review of multidisciplinary care for opioid dose reduction: exploring the origins of the North American opioid crisis

Bibliometric analyses of systematic reviews offer unique opportunities to explore the character of specific scientific fields. In this time series-based analysis, dynamics of multidisciplinary care for chronic pain and opioid prescribing are analyzed over a forty-four year time span. Three distinct periods are identified, each defined by distinct research areas, as well as priorities regarding the use of opioids and the appropriate management of chronic pain. These scientometrically defined periods align with timelines identified previously by narrative historical accounts. Through cross-correlation with a mortality time series, a significant two-year lag between opioid overdose mortality and citation dynamics is identified between 2004 and 2019. This analysis demonstrates a bidirectional relationship between the scientific literature and the North American opioid overdose crisis, suggesting that the scientific literature is both reflective and generative of an important health and social phenomenon. A scientometric phenomenon of memory lapse, namely an overt and prolonged failure to cite older relevant literature, is identified using a metric of mean time to citation. It is proposed that this metric can be used to analyze changes in emerging literature and thus predict the nature of clinical and policy responses to the opioid crisis, and thus potentially to other health and social phenomena.

Use of bisphosphonates in a retrospective case series of children and adolescents with complex regional pain syndrome

BACKGROUND

There is increasing evidence for the use of bisphosphonates to treat Complex Regional Pain Syndrome in adults. However, there are scarce data for their use in children with Complex Regional Pain Syndrome.

AIM

This retrospective case series aimed to analyze the effects of intravenous bisphosphonate use in children and adolescents with Complex Regional Pain Syndrome enrolled in a multidimensional pain treatment program.

METHODS

We analyzed the data of 16 patients (15 females and 1 male, mean age 14 ± 3 years) who received infusions of zoledronic acid (0.015 ± 0.0044mg/kg), pamidronate (0.72 ± 0.17mg/kg), or both depending on their initial response between October 2014 and December 2019. The primary endpoint of the study was the patient's global impression of change. Secondary outcomes included pain intensity, physical function, role function (school attendance), need for pain medications, and adverse effects.

RESULTS

Nine of 16 patients reported meaningful improvements (global impressions of change of 84% or higher) at a median follow-up time of 16 (8-21) months after their last infusion of bisphosphonates. There were also meaningful reductions in pain intensity and the need for pain medications. There was an increase in the proportion of patients with minimal or without physical disability, and almost all patients normalized their school activities. Thirteen patients (81%) reported adverse effects, mostly flu-like symptoms, for a few days after the infusion.

CONCLUSION

The use of bisphosphonate infusions may represent an effective treatment option for children with Complex Regional Pain Syndrome, not responding to multidisciplinary pain treatment programs.

Transnasal Sphenopalatine Ganglion Block for the Preventive Treatment of Chronic Daily Headache in Adolescents

Chronic headaches are a major source of morbidity in the pediatric population, affecting physical function, school attendance, social capacity, mood, and sleep. In adults, repetitive sphenopalatine ganglion (SPG) blockade has been studied as a preventive treatment for chronic migraines. This case series aims to evaluate the SPG block for the preventive treatment of chronic daily headache (CDH) in adolescents. We prospectively evaluated 17 adolescents (14 females, 14 ± 1 year) with CDH not responding to cognitive behavioral therapy (CBT), physiotherapy, and standard medications. Each patient received 10 SPG blocks (two blocks/week) using the Tx360® device. At the end of treatment, 10 patients (59%) reported a Patient's Global Impression of Change (PGIC) score ≥ 67%, and 3 months after the end of treatment, nine patients (53%) sustained a PGIC ≥ 67%. There was also a statistically significant reduction in the depression subscale of the Revised Children's Anxiety and Depression Scale (RCADS) at the end of treatment and 3 months post-treatment compared with baseline. The procedure was well tolerated with no adverse effects. In our study, the use of repeat SPG blockade was associated with sustained benefits on the PGIC and the depression subscale of the RCADS when used as preventive headache treatment in adolescents with refractory CDH.

A national survey of publicly funded chronic pain management services in Ireland

Background

Chronic pain management services have historically been under-resourced in Ireland. There is no agreed model of care for chronic pain management services in Ireland. Previous studies have assessed the extent of services in Ireland without examining waiting times for access to services.

Aims

This study aimed to quantify the extent of, geographical distribution of and waiting times for access to publicly funded chronic pain management services in Ireland.

Methods

Using the British Pain Society’s Core Standards for Pain Management Services in the UK (2015) and International Association for the Study of Pain (IASP) recommendations, a questionnaire was devised. Publically funded departments in Ireland were contacted and questionnaires completed. Waiting list data was publicly available and obtained from the National Treatment Purchase Fund website.

Results

There was a 100% response rate. Sixteen publicly funded chronic pain management services were identified. There are 27 chronic pain management consultants (16.6 whole time equivalents (WTE)) practicing chronic pain management, amounting to 0.55 specialists (0.34 WTEs)/100,000 of the population. There are 21 WTE for non-consultant hospital doctors (NCHDs), 26.5 WTEs for nursing, 8 WTEs for physiotherapy and 6.2 WTEs for psychology, nationally. A percentage of 93.75% of departments (n = 15) provide interventional therapies, 37.5% (n = 6) provide advanced neuromodulation and 43.75% (n = 7) are managing intrathecal pump therapies. There are five pain management programmes nationally. As of January 2020, ~ 25% patients on waiting lists for outpatient appointments were waiting > 18 months, with ~ 17% patients on waiting lists for interventional treatments waiting > 12 months.

Conclusions

Shortage of multidisciplinary staff is of particular concern for Irish services. Patient access is limited as evidenced by significant waiting lists. In order to improve access to care and bring services in line with international recommendations, increased resources are needed.