Make a CHANGE: optimising communication and pain management decisions

Percutaneous endoscopic interlaminar discectomy with patients' participation : better postoperative rehabilitation and satisfaction

OBJECT

Evaluation of the impact of patients' participation on postoperative recovery and satisfaction who underwent the Percutaneous Endoscopic Interlaminar Discectomy(PEID).

METHODS

We collected data from sixty-nine patients who underwent PEID surgery at Chuzhou Chinese and Western Medicine Hospital between January 2020 and December 2022. All patients had L5/S1 lumbar disc herniation and met the inclusion and exclusion criteria. The patients were divided into two groups: non-communication group (n = 33) and communication group (n = 36). The division was made based on whether the patients had preoperative surgical video viewing and intraoperative communication. We compared the baseline data, surgical time, VAS score, lumbar JOA score, surgical complications, and patient satisfaction between the two groups.

RESULT

The communication group showed better pain control and functional recovery in the early postoperative period. The communication group had better VAS scores on the first day and month after surgery, as well as JOA scores on the first week and month after surgery, with statistically significant differences (P < 0.05). There was no significant difference in hospital stay, VAS score, JOA score, and postoperative complications between the two groups of patients at 3 and 6 months after surgery. The communication group had higher patient satisfaction (P < 0.05).

CONCLUSION

Preoperative surgical video viewing and intraoperative communication by PEID patients can alleviate pain, accelerate functional recovery, improve symptoms, and increase patients' satisfaction. We need to do more work to develop this new model.

Pathophysiologic Approach to Pain Therapy for Complex Pain Entities: A Narrative Review

Pain management is challenging for both clinicians and patients. In fact, pain patients are frequently undertreated or even completely untreated. Optimal treatment is based on targeting the underlying mechanisms of pain and tailoring the management modality for each patient using a personalized approach. This narrative review deals with pain conditions that have a complex underlying mechanism and need an individualized and frequently multifactorial approach to pain management. The research is based on previously conducted studies, and does not contain any studies with human participants or animals performed by any of the authors. This is not an exhaustive review of the current evidence. However, it provides the clinician with a perspective on pain therapy targeting the underlying pain mechanism(s). When dealing with complex pain conditions, the prudent physician benefits from having a deep knowledge of various underlying pain mechanisms in order to provide a plan for optimal pharmacological pain relief to patients.

Clinical Validation of the Nursing Outcome "Pain: Disruptive Effects" in People With Chronic Pain in Spain

BACKGROUND AND PURPOSE

The measurement of the effects of chronic pain on the patients is a challenge for nurses. The purpose was to translate into Spanish and to assess the psychometrics of the indicators of the nursing outcome "Pain: disruptive effects."

METHODS

A three-stage study: (a) translation and cultural adaptation, (b) content validation, (c) clinical validation in 10 healthcare centers.

RESULTS

The Spanish version of the outcome "Pain: disruptive effects" has high content validity (CVI = .90) with 17 indicators organized into three factors. The Inter-observer agreement was good (kappa = .66) and the internal consistency high (alpha = .90).

CONCLUSIONS

The 17 indicators of the outcome "Pain: disruptive effects" has evidence of reliability and validity for assessing the harmful effects of chronic pain.

Psychometric Evaluation of the Nursing Outcome "Pain: Adverse Psychological Response" in Patients With Chronic Pain

PURPOSE

To culturally adapt into Spanish and validate the outcome "Pain: Adverse psychological response" (code 1306) in patients with chronic pain.

METHODS

A three-stage study was conducted: (a) translation and cultural adaptation, (b) content validation, and (c) clinical validation.

FINDINGS

The Spanish version of the outcome "Pain: Adverse psychological response" has high content validity ( 0.91). Fourteen indicators were organized into two factors. This version offers good reliability in both inter-observer agreement (kappa = 0.72) and internal consistency (alpha = 0.89).

CONCLUSIONS

The Spanish adaptation of "Pain: Adverse psychological response" is a reliable and valid instrument for the measurement of emotional aspects of chronic pain.

IMPLICATIONS FOR NURSING PRACTICE

The Spanish adaptation of this outcome offers nurses a set of structured indicators to measure the adverse emotional impact of chronic pain.

The impact of contextual factors on nursing outcomes and the role of placebo/nocebo effects: a discussion paper

INTRODUCTION

Placebo and nocebo effects represent one of the most fascinating topics in the health care field.

OBJECTIVES

the aims of this discussion paper were (1) to briefly introduce the placebo and nocebo effects, (2) to elucidate the contextual factors able to trigger placebo and nocebo effects in the nursing field, and (3) to debate the impact of contextual factors on nursing education, practice, organisation, and research.

METHODS

a narrative review was conducted based on the available evidence.

RESULTS

Placebo responses (from Latin "I shall please") are a beneficial outcome(s) triggered by a positive context. The opposite are the nocebo effects (from Latin "I shall harm"), which indicates an undesirable outcome(s) caused by a negative context. Both are complex and distinct psychoneurobiological phenomena in which behavioural and neurophysiological changes arise subsequent to an interaction between the patient and the health care context.

CONCLUSION

Placebo and nocebo concepts have been recently introduced in the nursing discipline, generating a wide debate on ethical issues; however, the impact on nursing education, clinical practice, nursing administration, and research regarding contextual factors triggering nocebo and placebo effects has not been debated to date.

Addressing the barriers related with opioid therapy for management of chronic pain in India

India has a high prevalence of chronic disorders which may be associated with persistent pain. Despite the availability of multiple treatment options, chronic pain is largely untreated and contributes to disability and mortality. Medical consumption of opioids remains low due to various barriers that prevent access to opioids for patients and healthcare practitioners. Stringent regulatory provisions outlined in the Narcotic Drugs and Psychotropic Substances Act (1985) have been major deterrents to adequate opioid use. Although multiple amendments to the act have ensured ease of opioid access for medicinal purposes, concerns such as lack of awareness and prescribing practices and attitudes of physicians/patients still need to be addressed. This review aims to identify these barriers and suggest recommendations to overcome them.

Management of postoperative pain in Spain: a nationwide survey of practice

BACKGROUND

Although the need for structured assessment and management of acute postoperative pain has been recognized, practices and responsibilities vary between and within hospitals and countries. We sought to determine current pain management practices in Spanish hospitals with and without acute pain services (APSs) or acute pain management programmes (APMPs) and compare them to practices reported for 1997-1998.

METHODS

Members of the Spanish Pain Society and APS/APMP heads were asked to respond to a survey. Responses were stratified by hospital size (< 200 or ≥ 200 beds) and APS/APMP presence or not. Categorical variables were described by percentages and the 95% confidence interval and continuous ones by the median and interquartile range.

RESULTS

Responses were received from 42.4% of hospitals with ≥ 200 beds (vs. 9.6% of the smaller ones). We fully analysed only data for the larger hospitals, 57.7% of which had an APS or APMP. Full-time pain physicians were on staff in 28.6% of large hospitals; 25% had full-time nurses. Patients received written information about postoperative pain in 34.8% of APS/APMP hospitals, and 72% of them recorded pain assessments routinely. Protocols reflected interdepartmental consensus in 80.8%; training in postoperative pain was organised in 54%. Respondents thought pain was well or very well managed in 46.4%. In APS/APMP hospitals the following results had improved: provision of written information for patients (58.5% vs. 0%), the recording of pain assessments (93% vs. 43.8%), consensus on a pain scale (92.5% vs. 41.9%), use of protocols (99.7% vs. 55.2%), analysis of quality indicators (52.8% vs. 15.4%), training (73% vs. 26.9%), and respondents' satisfaction with pain management in their hospital (68.6% vs. 9.5%).

CONCLUSIONS

The presence of an APS or APMP is associated with better results on indicators of quality of acute postoperative pain management.

Chronic Pain Features Relate to Quality of Life More than Physiopathology: A Cross-Sectional Evaluation in Pain Clinics

OBJECTIVE

To compare the impact of chronic pain physiopathology on health-related quality of life (HR-QoL), considering the influence of pain features and psychosocial adjustment (intensity, interference, psychological comorbidities, and sleep quality).

DESIGN

A cross-sectional study involving 1,025 noncancer patients with predominantly neuropathic, nociceptive, or mixed chronic pain conditions was conducted in 88 pain clinics within Spain. The EuroQol-5 Dimensions instrument (EQ-5D) was used to measure HR-QoL. The Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS), and sleep scale developed for the MOS study (MOS-SQ) were used to measure pain features and psychosocial adjustment. Multivariate analyses were used to model HR-QoL measures.

RESULTS

All patients reported very low HR-QoL. The mean EQ-5D index scores were 0.33, 0.36, and 0.37 in the mixed, neuropathic, and nociceptive pain groups, respectively. The differences did not reach statistical significance (P = 0.057). Patients with nociceptive pain had less pain (least pain intensity score: 4.7 vs. 5.2 in the other groups; P = 0.006), less interference with daily activities (BPI average interference score: 6.3 vs. 6.6 and 6.7 in the neuropathic and mixed pain groups, respectively; P = 0.013), less anxiety (HADS score: 8.5 vs. 9.6 and 9.7 in the same respective groups; P = 0.001), and fewer sleep problems (MOS-SQ sleep problems index: 46.8 vs. 52.2 and 50.2 in the same respective groups; P = 0.005). In the adjusted analyses, HR-QoL measures were explained by pain intensity, anxiety, and sleep quality, but not by physiopathological pain type.

CONCLUSIONS

Pain features, particularly intensity, have a greater impact than pain physiopathology on HR-QoL. Distinct physiopathological mechanisms give rise to different pain features that, in turn, may mediate the HR-QoL of patients with chronic pain. This could be used to improve pain management strategies.

Change Pain: Ever Evolving-An Update for 2016

Since 1986, the pharmacological management of pain was mainly based on the WHO "analgesic ladder", with very few drugs available. The huge development of the basic knowledge on pain and its therapy, especially in the past 15 years, has made the "guidelines" of WHO obsolete. That's why, during the presidency of EFIC of one of the authors (GV), an international advisory board was proposed to review the document, but mainly to ameliorate the approach to the pain patients.

Ultralow Dose of Naloxone as an Adjuvant to Intrathecal Morphine Infusion Improves Perceived Quality of Sleep but Fails to Alter Persistent Pain: A Randomized, Double-blind, Controlled Study

Supplemental Digital Content is available in the text.

Introduction:

This randomized, cross-over, double-blind, controlled study of continuous intrathecal morphine administration in patients with severe, long-term pain addresses whether the supplementation of low doses of naloxone in this setting is associated with beneficial clinical effects.

Methods:

All of the study subjects (n=11) provided informed consent and were recruited from a subset of patients who were already undergoing long-term treatment with continuous intrathecal morphine because of difficult-to-treat pain. The patients were (in a randomized order) also given intrathecal naloxone (40 ng/24 h or 400 ng/24 h). As control, the patients’ ordinary dose of morphine without any additions was used. The pain (Numeric Rating Scale, NRS) during activity, perceived quality of sleep, level of activity, and quality of life as well as the levels of several proinflammatory and anti-inflammatory cytokines in the blood were assessed. The prestudy pain (NRS during activity) in the study group ranged from 3 to 10.

Results:

A total of 64% of the subjects reported improved quality of sleep during treatment with naloxone at a dose of 40 ng per 24 hours as compared with 9% with sham treatment (P=0.024). Although not statistically significant, pain was reduced by 2 NRS steps or more during supplemental treatment with naloxone in 36% of subjects when using the 40 ng per 24 hours dose and in 18% of the subjects when using naloxone 400 ng per 24 hours dose. The corresponding percentage among patients receiving unaltered treatment was 27%.

Conclusions:

To conclude, the addition of an ultralow dose of intrathecal naloxone (40 ng/24 h) to intrathecal morphine infusion in patients with severe, persistent pain improved perceived quality of sleep. We were not able to show any statistically significant effects of naloxone on pain relief, level of activity, or quality of life.

Improving the management of post-operative acute pain: priorities for change

Poor management of post-operative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. It is therefore important that all patients undergoing surgery should receive adequate pain management. However, evidence suggests this is not currently the case; between 10% and 50% of patients develop chronic pain after various common operations, and one recent US study recorded >80% of patients experiencing post-operative pain. At the first meeting of the acute chapter of the Change Pain Advisory Board, key priorities for improving post-operative pain management were identified in four different areas. Firstly, patients should be more involved in decisions regarding their own treatment, particularly when fateful alternatives are being considered. For this to be meaningful, relevant information should be provided so they are well informed about the various options available. Good physician/patient communication is also essential. Secondly, better professional education and training of the various members of the multidisciplinary pain management team would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain at different points along pain pathways, more widespread adoption of patient-controlled analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational change could provide similar benefits; introducing acute pain services and increasing their availability towards the 24 hours/day ideal, greater adherence to protocols, increased use of patient-reported outcomes, and greater receptivity to technological advances would all help to enhance performance and increase patient satisfaction. It must be acknowledged that implementing these recommendations would incur a considerable cost that purchasers of healthcare may be unwilling or unable to finance. Nevertheless, change is under way and the political will exists for it to continue.

Patients' recall of diagnostic and treatment information improves with use of the Pain Explanation and Treatment Diagram in an outpatient chronic pain clinic

Educating patients about their condition and treatment plan is an essential component of successful treatment. Patients need to understand their condition, recall treatment suggestions and comply with the treatment protocol. Unfortunately, the method of patient education most commonly used by physicians is verbal teaching and discussion, which leads to poor patient recall. The authors of this article developed the Pain Explanation and Treatment Diagram, a worksheet that the clinician completes with the patient during their first consultation to function as a record of their diagnosis, pain risk factors and an action plan for when pain occurs. In this study, patient recall, among other variables, was assessed as a function of time since first appointment.

BACKGROUND:

To maximize the benefit of therapies, patients must understand their condition, recall treatment suggestions and comply with treatments. The Pain Explanation and Treatment Diagram (PETD) is a one-page worksheet that identifies risk factors (health-related habits, sleep, exercise, ergonomics and psychosocial factors) involved in chronic pain. Clinician and patient complete the PETD together, and the clinician notes recommended treatments and lifestyle changes.

OBJECTIVES:

To examine the effect of use of the PETD on patient recall of diagnostic and treatment information on the sheet.

METHODS:

The present study was a cross-sectional analysis. Patients with chronic musculoskeletal pain seen by one physiatrist at an outpatient pain clinic in a university-affiliated hospital between 2009 and 2012 (all of whom received the PETD) were eligible. A structured telephone interview lasting approximately 1 h was used to determine recall of PETD diagnostic and treatment information.

RESULTS:

Of the 84 eligible patients, 46 were contacted and 29 completed the telephone interview. Participants recalled an average of 12.2% (95% CI 7.8% to 17.4%) of items without prompting and 48.5% (95% CI 42.0% to 53.5%) when prompted. Participants who referred to the PETD at home (n=13) recalled significantly more items than those who did not (n=15) (17.6% [95% CI 11.1% to 23.9%] versus 5.2% [95% CI 3.0% to 14.5%], P=0.004); when prompted, the rates increased to 54.3% (95% CI 48.3% to 61.2%) and 41.2% (95% CI 34.7% to 50.7%), respectively (P=0.032).

CONCLUSIONS:

The PETD is a promising, feasible and inexpensive tool that can improve patients’ recall of diagnostic- and treatment-related information.

Lasting Prolonged-Release Tapentadol for Moderate/Severe Non-Cancer Musculoskeletal Chronic Pain

Introduction

Despite opioids’ recognized role in the treatment of moderate/severe musculoskeletal chronic pain, their long-term benefits need investigation. We explored the lasting analgesic efficacy, tolerability, influence on life quality, and chronicity stage of the novel prolonged release (PR) opioid, tapentadol, in 30 outpatients.

Methods

We evaluated patients’ pain intensity and relief (Numerical Rating Scale; NRS), adverse effects, sleep quality, treatment satisfaction, health status (12-questions Health-Survey; SF-12), chronicity stage (Italian Mainz Pain-Staging System; I-MPSS) at 10, 30, 60, and 90 days after tapentadol prescription.

Results

At follow-ups, the investigated outcomes showed an overall statistically significant (Wilcoxon signed-rank test) improvement and remained stable over time, as did the health status and chronicity stage. Adverse effects were limited, transitory, and tolerable.

Conclusions

Twelve weeks of PR tapentadol in outpatients with moderate/severe chronic musculoskeletal pain showed satisfactory analgesic efficacy and tolerability, and had a positive influence on life quality and chronicity stage. The results are robust enough to warrant a subsequent study with a larger sample and a longer observation period.

A holistic approach to chronic pain management that involves all stakeholders: change is needed

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.

Impact of a Script-based Communication Intervention on Patient Satisfaction with Pain Management

Pain is a common complaint among hospitalized patients no matter the diagnosis. Pain has a negative effect on many aspects of a patient's life, including quality of life, sleep, and activities of daily living as well as increased health care expenses. The aim of this study was to evaluate the effectiveness of an intervention (script-based communication, use of white boards, and hourly rounding) related to pain management on patient satisfaction with nurses' management of pain. A prospective, quasi-experimental pretest-posttest design was used. Data were collected from two units that provided care for patients with a variety of medical-surgical diagnoses in a hospital located in an academic health sciences center in the southern United States. When nurses used clear and consistent communication with patients in pain, a positive effect was seen in patient satisfaction with pain management over time. This intervention was simple and effective. It could be replicated in a variety of health care organizations.

Comparison of anterior cingulate vs. insular cortex as targets for real-time fMRI regulation during pain stimulation

Real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback allows learning voluntary control over specific brain areas by means of operant conditioning and has been shown to decrease pain perception. To further increase the effect of rt-fMRI neurofeedback on pain, we directly compared two different target regions of the pain network, notably the anterior insular cortex (AIC) and the anterior cingulate cortex (ACC). Participants for this prospective study were randomly assigned to two age-matched groups of 14 participants each (7 females per group) for AIC and ACC feedback. First, a functional localizer using block-design heat pain stimulation was performed to define the pain-sensitive target region within the AIC or ACC. Second, subjects were asked to down-regulate the BOLD activation in four neurofeedback runs during identical pain stimulation. Data analysis included task-related and functional connectivity analysis. At the behavioral level, pain ratings significantly decreased during feedback vs. localizer runs, but there was no difference between AIC and ACC groups. Concerning neuroimaging, ACC and AIC showed consistent involvement of the caudate nucleus for subjects that learned down-regulation (17/28) in both task-related and functional connectivity analysis. The functional connectivity toward the caudate nucleus is stronger for the ACC while the AIC is more heavily connected to the ventrolateral prefrontal cortex. Consequently, the ACC and AIC are suitable targets for real-time fMRI neurofeedback during pain perception as they both affect the caudate nucleus, although functional connectivity indicates that the direct connection seems to be stronger with the ACC. Additionally, the caudate, an important area involved in pain perception and suppression, could be a good rt-fMRI target itself. Future studies are needed to identify parameters characterizing successful regulators and to assess the effect of repeated rt-fMRI neurofeedback on pain perception.

Pain in the cancer patient: different pain characteristics CHANGE pharmacological treatment requirements

Twenty years ago, the main barriers to successful cancer pain management were poor assessment by physicians, and patients' reluctance to report pain and take opioids. Those barriers are almost exactly the same today. Cancer pain remains under-treated; in Europe, almost three-quarters of cancer patients experience pain, and almost a quarter of those with moderate to severe pain do not receive any analgesic medication. Yet it has been suggested that pain management could be improved simply by ensuring that every consultation includes the patient's rating of pain, that the physician pays attention to this rating, and a plan is agreed to increase analgesia when it is inadequate. After outlining current concepts of carcinogenesis in some detail, this paper describes different methods of classifying and diagnosing cancer pain and the extent of current under-treatment. Key points are made regarding cancer pain management. Firstly, the pain may be caused by multiple different mechanisms and therapy should reflect those underlying mechanisms - rather than being simply based on pain intensity as recommended by the WHO three-step ladder. Secondly, a multidisciplinary approach is required which combines both pharmacological and non-pharmacological treatment, such as psychotherapy, exercise therapy and electrostimulation. The choice of analgesic agent and its route of administration are considered, along with various interventional procedures and the requirements of palliative care. Special attention is paid to the treatment of breakthrough pain (particularly with fast-acting fentanyl formulations, which have pharmacokinetic profiles that closely match those of breakthrough pain episodes) and chemotherapy-induced neuropathic pain, which affects around one third of patients who receive chemotherapy. Finally, the point is made that medical education should place a greater emphasis on pain therapy, both at undergraduate and postgraduate level.

[Long-term treatment of chronic pain with low-dose 7-day buprenorphine transdermal patch. Observational data from elderly patients of pain relief and quality of life]

BACKGROUND

Six-months analysis of non-interventionally collected observation data of effectiveness of long-term treatment with low-dose 7-day buprenorphine transdermal patch in elderly patients with chronic pain.

METHODS

Analysis of data regarding pain intensity, pain-related impairments of daily life and quality of life documented by 321 pain patients in German primary care (age 72.4 +/- 13.8 years; 67.3% female; musculoskeletal pain 85.4%; mean pain intensity 6.1 +/- 1.2, for 90% > or = 5 NRS11) using standardised self-report instruments (German Pain Questionnaire/German Pain Diary).

RESULTS

After initiation with 5/10 microg/h buprenorphine (89.7%/10.3%), treatment was maintained in 57.1/39.1/3.8% patients with stable doses of 5/10/20 microg/h after 6 months. The average pain intensity decreased by 5.1 +/- 1.0 (absolute) to 1.0 +/- 1.0 NRS11 (83.5%), pain-related impairments and burden of pain were reduced by 86.0% and 87.9%, respectively, and pain-related quality of life improved by 97.3% to nearly normalvalues.

CONCLUSIONS

Pain treatment of elderly persons with 7-day low-dose transdermal buprenorphine patch on a stable dose regimen resulted in fast, effective and sustained pain relief accompanied by marked improvements in daily life participation and quality of life.

Managing chronic pain in elderly patients requires a CHANGE of approach

In many countries, the number of elderly people has increased rapidly in recent years and this is expected to continue; it has been predicted that almost a quarter of the population in the European Union will be over 65 years of age in 2035. Many elderly people suffer from chronic pain but it is regularly under-treated, partly because managing these patients is often complex. This paper outlines the extent of untreated pain in this population and the consequent reduction in quality of life, before articulating the reasons why it is poorly or inaccurately diagnosed. These include the patient's unwillingness to complain, atypical pain presentations, multiple morbidities and cognitive decline. Successful pain management depends upon accurate diagnosis, which is based upon a complete history and thorough physical examination, as well as an assessment of psychosocial functioning. Poor physician/patient communication can be improved by using standardized instruments to establish individual treatment targets and measure progress towards them. User-friendly observational instruments may be valuable for patients with dementia. In line with the widely accepted biopsychosocial model of pain, a multidisciplinary approach to pain management is recommended, with pharmacotherapy, psychological support, physical rehabilitation and interventional procedures available if required. Declining organ function and other physiological changes require lower initial doses of analgesics and less frequent dosing intervals, and the physician must be aware of all medications that the patient is taking, in order to avoid drug/drug interactions. Non-adherence to treatment is common, and various strategies can be employed to improve it; involving the elderly patient's caregivers and family, using medication systems such as pill-boxes, or even sending text messages. In the long term, the teaching of pain medicine needs to be improved--particularly in the use of opioids--both at undergraduate level and after qualification.

Cognitive functioning, emotional processing, mood, and personality variables before and after stereotactic surgery: a study of 8 cases with chronic neuropathic pain

BACKGROUND

Stereotactic central lateral thalamotomy (CLT) has been applied as a treatment for chronic intractable neuropathic pain. However, it is not clear whether this intervention influences the emotional and cognitive impairments observed in patients who have chronic neuropathic pain.

OBJECTIVE

To investigate neuropsychological functions and emotional processing in patients with chronic neuropathic pain compared with healthy volunteers and to explore the neuropsychiatric effect of the CLT.

METHODS

We investigated pain ratings, cognitive functions, emotional processes, and personality variables before and after surgery in 8 patients with intractable neuropathic pain. Patients were tested before and 3 months after CLT by the use of neuropsychological tests; clinical scales for depression, anxiety, anhedonia, and anger regulation; a personality test; and 2 experimental tasks testing the theory of mind as well as the ability to recognize facial emotional expressions. Nine age- and sex-matched control subjects were tested once using the same procedure.

RESULTS

The comparison of the patient group before surgery with the control group evidenced significant differences on the cognitive assessments, the depression and anxiety scores, as well as on the somatic complaint subscale of the personality test. Three months after CLT, patients experienced a significant improvement in their depression scores. There were no additional postsurgical cognitive impairments.

CONCLUSION

For our patients with chronic neuropathic pain, CLT provided pain relief and reduction of their depression scores without causing postsurgical cognitive impairments.

The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment

Chronic pain is currently under-diagnosed and under-treated, partly because doctors' training in pain management is often inadequate. This situation looks certain to become worse with the rapidly increasing elderly population unless there is a wider adoption of best pain management practice. This paper reviews current knowledge of the development of chronic pain and the multidisciplinary team approach to pain therapy. The individual topics covered include nociceptive and neuropathic pain, peripheral sensitization, central sensitization, the definition and diagnosis of chronic pain, the biopsychosocial model of pain and the multidisciplinary approach to pain management. This last section includes an example of the implementation of a multidisciplinary approach in Belgium and describes the various benefits it offers; for example, the early multidimensional diagnosis of chronic pain and rapid initiation of evidence-based therapy based on an individual treatment plan. The patient also receives continuity of care, while pain relief is accompanied by improvements in physical functioning, quality of life and emotional stress. Other benefits include decreases in catastrophizing, self-reported patient disability, and depression. Improved training in pain management is clearly needed, starting with the undergraduate medical curriculum, and this review is intended to encourage further study by those who manage patients with chronic pain.

[Pain treatment decisions--relevance of health-related quality of life in family medicine]

BACKGROUND

The reduction of pain is no longer regarded as the predominant objective of pain therapy. Pain-related impairments in quality of life or daily activities, and anxietyand depression--all of which worsen with progressing pain chronification--increasingly gain importance. Impairments in quality of life in particular often have a greater impact on patients afflicted by pain than by other chronic diseases.

METHOD

The present overview explains the importance of the parameter health-related quality of life in the treatment of pain patients in family medicine; in addition, a variety of tools forthe initial and follow-up assessment of pain and pain-related impairments are introduced.

RESULTS AND CONCLUSION

In addition to a mandatory comprehensive pain diagnostic work-up, pain-related restrictions in daily activities and in quality of life should be documented in primary care facilities and considered in pain management approaches. In a multimodal therapy setting, family practitioners have a key role in thediagnosis of pain and in particularalso in the diagnosis of additional symptoms and impairments accompanying pain.

Survey of European patients assessing their own noncancer chronic pain: results from Spain

OBJECTIVE

As part of the CHANGE PAIN international health campaign to improve pain management, patient surveys are being undertaken to explore how patients perceive their noncancer chronic pain and how they deal with it.

RESEARCH DESIGN AND METHODS

In Spain, 8695 patients completed this survey. The cross-sectional data were provided during routine visits to 893 physicians from different specialties. Pain intensity was assessed on two scales: a 5-point verbal rating scale (VRS) and an 11-point numerical rating scale (NRS).

RESULTS

Most patients were women (57%) in their late adulthood (45-64 years; 34%) or elderly (65 years or older; 53%). Pain duration of one year or longer was frequent (65%). Combined pharmacological treatment (51%) was more common than monotherapy (33%). The most frequently prescribed agents were nonsteroidal anti-inflammatory drugs, to be taken alone (18%) or together with weak opioids (15%), followed by weak (7%) or potent (6%) opioids in monotherapy; but there were many different treatments prescribed. Most patients had moderate (47%) or severe/extreme (34%) VRS rated pain. The mean intensity in the NRS was of 5.7 over 10. Many patients had pain above the level they could tolerate (38%) and most (55%) were not satisfied with their therapy. Their main goals were pain relief and reduction of side effects.

KEY LIMITATIONS

Causal inductions are not possible in a cross-sectional research like this. Other clinically meaningful outcome measures in patients with chronic pain, such as patients' quality of life, were not gathered.

CONCLUSIONS

Chronic noncancer pain management is poor. The uncoupling of VRS and NRS pain ratings reveals the high subjectivity of the pain experience, whilst the wide variation in treatment choices indicates that an optimal management strategy remains to be defined. Advances might be attained by boosting communication to tailor treatments to individual patients' perceptions.

Tramadol/Paracetamol fixed-dose combination for chronic pain management in family practice: a clinical review

The family practitioner plays an important role in the prevention, diagnosis, and early management of chronic pain. He/she is generally the first to be consulted, the one most familiar with the patients and their medical history, and is likely the first to be alerted in case of inadequate pain control or safety and tolerability issues. The family practitioner should therefore be at the center of the multidisciplinary team involved in a patient's pain management. The most frequent indications associated with chronic pain in family practice are of musculoskeletal origin, and the pain is often multimechanistic. Fixed-dose combination analgesics combine compounds with different mechanisms of action; their broader analgesic spectrum and potentially synergistic analgesic efficacy and improved benefit/risk ratio might thus be useful. A pain specialist meeting held in November 2010 agreed that the fixed-dose combination tramadol/paracetamol might be a useful pharmacological option for chronic pain management in family practice. The combination is effective in a variety of pain conditions with generally good tolerability. Particularly in elderly patients, it might be considered as an alternative to conventional analgesics such as NSAIDs, which should be used rarely with caution in this population.

What is quality improvement and why should child neurologists care?

In this article, the authors discuss the 6 domains of care identified by the Institute of Medicine report, Crossing the Chasm, with examples and questions that are especially relevant to physicians caring for children who have neurologic disorders and their families.

The chronic pain conundrum: should we CHANGE from relying on past history to assessing prognostic factors?

BACKGROUND

Despite limited empirical support, chronic pain has traditionally been defined mainly on the basis of its duration, which takes no account of the causative mechanisms or its clinical significance.

SCOPE

For this commentary on current pain management practice, the CHANGE PAIN Advisory Board considered the evidence for adopting a prognostic definition of chronic pain. The rationale underlying this approach is to take psychological and behavioural factors into account, as well as the multidimensional nature of pain. Measures of pain intensity, interference with everyday activities, role disability, depression, duration and number of pain sites are used to calculate a risk score, which indicates the likelihood of a patient having pain in the future. The consistency of a prognostic definition with the concept of integrated patient care was also considered.

FINDINGS

When this method was compared with the number of pain days experienced over the previous 6 months--in patients with back pain, headache or orofacial pain--it was a better predictor of clinically significant pain 6 months later for all three pain conditions. Further evidence supporting this approach is that several factors other than the duration of pain have been shown to be important prognostic indicators, including unemployment, functional disability, anxiety and self-rated health. The use of a multifactorial risk score may also suggest specific measures to improve outcomes, such as addressing emotional distress. These measures should be undertaken as part of an integrated pain management strategy; chronic pain is a biopsychosocial phenomenon and all aspects of the patient's pain must be dealt with appropriately and simultaneously for treatment to be effective.

CONCLUSION

The implementation of a prognostic definition and wider adoption of integrated care could bring significant advantages. However, these measures require improved training in pain management and structural revision of specialist facilities, for which political support is essential.

European survey of chronic pain patients: results for Germany

OBJECTIVES

This ongoing pan-European patient survey is being conducted to explore how chronic pain patients perceive their condition and the coping strategies they use to help deal with the pain.

METHODOLOGY

Participating doctors - general practitioners (GPs), pain specialists and orthopaedists - selected patients suffering from chronic pain who routinely visited their practices. Doctors provided details of individual pain diagnoses and treatment which were entered into a questionnaire. Each patient then answered additional questions about pain experience, pain therapy, possible areas for improvement and any coping strategies used. Completed questionnaires were sent to a healthcare-focused global consultancy for analysis and evaluation.

RESULTS

The most common diagnosis was chronic back pain, in 61% of the 6435 patients. Using a five-point verbal rating scale (VRS), 70% of participants rated the intensity of their pain as moderate or severe. Approximately half were receiving monotherapy. The more intense the pain was, the higher the percentage of patients receiving combination therapy. The most frequently used combinations were NSAIDs/non-opioids with weak or strong opioids. Approximately two out of three patients received non-pharmacological treatment in addition to their pain medication. Almost all the patients (90%) perceived their pain intensity to be higher than it should be under successful pain management, and 30% were dissatisfied with their current treatment. Insufficient pain relief was the reason in most cases, but 29% of dissatisfied responders cited the side effects of medication. About half the patients identified a medium to high need for improvement in their ability to work, sleep and carry out general activities. For each specialisation, the more severe the pain, the fewer patients who were satisfied with their current pain treatment. More patients with severe and extreme pain were satisfied with treatment by a pain specialist than with a GP or orthopaedist. For all three specialisations, the most frequent combination used was NSAIDs/non-opioids with weak opioids, but pain specialists prescribed more strong opioids and fewer NSAIDS/non-opioids than the other groups. Overall, 35% of the survey subjects took pain medication not prescribed by their doctor, and coping strategies included reading, participating in sports and listening to music.

CONCLUSION

High levels of dissatisfaction, which increase proportionately with the intensity of pain, could adversely affect the chances of successful outcomes.

Proceedings of the CHANGE PAIN Expert Summit in Rome, June 2010

Chronic non-cancer pain - unlike acute pain, which can be regarded as a symptom of disease or injury - is gaining recognition as a disease in its own right. It is a burden for the individual sufferer that has a severe impact on physical and social functioning. Chronic back pain, in particular, is a highly prevalent condition that has a considerable economic impact on society. However, treatment approaches for severe chronic non-cancer pain differ widely. The CHANGE PAIN initiative aims to enhance the understanding of patients who suffer from severe chronic pain and to improve pain management. The following special supplement, consisting of 10 commentaries, describes the proceedings from the first international Expert Meeting of the CHANGE PAIN initiative, which was held in Rome on June 20th and 21st, 2010.

Management of chronic pain among older patients: inside primary care in the US

Under-treatment of pain is a worldwide problem. We examine how often pain was addressed and the factors that influence how much time was spent on treating pain. We analyzed 385 videotapes of routine office visits in several primary care practices in the Southwest and Midwest regions of the United States. We coded the visit contents and the time spent on pain and other topics. Logistic regression and survival analyses examined the effects of time constraint, physician's supportiveness, patient's health, and demographic concordance. We found that discussion of pain occurred in 48% of visits. A median of 2.3 min was spent on addressing pain. The level of pain, physician's supportiveness, and gender concordance were significantly associated with the odds of having a pain discussion. Time constraints and racial concordance significantly influenced the length of discussion. We conclude that despite repeated calls for addressing under-treatment for pain, only a limited amount of time is used to address pain among elderly patients. This phenomenon could contribute to the under-treatment of pain.

Emerging therapies in metastatic bone pain

INTRODUCTION

Current treatment for metastatic bone pain is mainly palliative. Recent insights into the molecular mechanisms involved in bone metastases have led to the identification of promising therapeutic targets. This review offers an update of preclinical and clinical data on new drugs for metastatic bone pain.

AREAS COVERED

Biphosphonates are the gold standard of bone-targeted therapy in bone metastases, for their anti-resorptive and analgesic effects. New drugs aim at breaking the 'vicious cycle' of bone metastatic disease, due to the bidirectional interaction between cancer cells and bone microenvironment. Osteoprotegerin, RANK/RANKL interaction, cathepsin K, the Wnt/beta-catenin pathway and sclerostin are emerging targets for modulation of cancer-induced bone desorption. Other promising targets are those expressed in cancer cells that metastasize to bone, including Src, nerve growth factor, endothelin A, TGF-beta and CXCR4. Interesting therapeutic options include targets on nociceptors that innervate the bone, such as TPRV1, Trk and cannabinoid receptors.

EXPERT OPINION

Emerging therapies promise, in the next 10 years, a significant expansion in the array of therapeutic options for bone metastases. Most of these drugs are still in an early phase of development. Further clinical trials are needed to support the evidence of their efficacy and tolerability profile.