A Systematic Review and Meta-Analysis of the Global Burden of Chronic Pain Without Clear Etiology in Low- and Middle-Income Countries

Intervention delivery complexity and adaptations for implementation of non-pharmacologic pain interventions

Background

Delivering evidence-based interventions remains challenging, particularly for complex conditions like chronic musculoskeletal pain. Non-pharmacologic treatments are recommended for many pain conditions, but implementing these can be difficult due to their complexity and resource demands. Pragmatic trials, especially embedded designs, provide a method to see how interventions are being implemented and adapted in real-world settings throughout the trial process. This study explored how intervention delivery complexity and adaptations differ between non-pharmacologic pain trials and non-pain trials to provide guidance on future treatment delivery and implementation.

Methods

From July to October 2023, an online survey was distributed to members of three NIH Trial Collaboratories to assess intervention delivery complexity and adaptations during their pragmatic trials. Participants rated their trial's intervention delivery complexity using a 7-item tool and reported any adaptations to intervention delivery throughout the trial process. Data analysis compared complexity and adaptations between the two trial types to explore differences and relationships between intervention delivery complexity and adaptations.

Results

We analyzed 12 pain and 12 non-pain trials and found that intervention delivery complexity was not discernibly different between the two trial types, however, pain trials did have a slightly higher average intervention delivery complexity, overall. Pain trials also had more adaptations in the workflow domain compared to non-pain trials, while adaptations across other domains were similar between the two types. Workflow emerged as the most challenging domain for adaptation among all trials.

Conclusion

Intervention delivery complexity may be higher for pragmatic trials that are investigating non-pharmacologic pain interventions versus non-pain trials, but only in very specific areas.

Mendelian Randomization Analysis Identifies Causal Effects of Multi-Site Chronic Pain on Obstructive Sleep Apnea

Background

Observational studies have suggested an association between obstructive sleep apnea (OSA) and chronic pain disorders, but causal evidence have not been confirmed.

Methods

Here we performed Mendelian randomization (MR) study to explore the potential causal association and mediating roles of modifiable factors between multi-site chronic pain (MCP) and OSA. Independent single nucleotide polymorphisms (SNPs) (N=26) from MCP GWAS (n=387,649) in the UK Biobank were used as instrumental variables to test associations with OSA from the FinnGen consortium, which encompassed 16,761 individuals with OSA cases and 201,194 individuals without OSA.

Results

MR analyses provide genetic evidence to predict MCP on the risk of OSA. Specifically, a per-site increase in multi-site chronic pain was linked to a 184% higher risk of OSA (ORIVW = 1.84, 95% CI = 1.29-2.63, p = 7.24×10-4). However, we also performed reverse association analyses and found no significant casual effect of OSA on MCP. MR estimates were in agreement regardless of the method used, such as MR-egger, weighted median and weighted mode, thereby demonstrating the accuracy of the causal associations. Through mediation analyses, we found that body mass index (BMI), waist circumference, and educational attainment explained a substantial proportion of the association between MCP and OSA (proportion mediated=21.13%; 26.57% and 9.66% respectively).

Conclusion

Our findings suggest that both pain management interventions, prevention of obesity and health education are likely to be effective strategies to reduce OSA risk in individuals with MCP.

Enhanced Analgesic Efficacy and Reduced Side Effects of Morphine by Combination with PD-1 Agonist

Chronic pain is a debilitating disease and remains challenging to treat. Morphine serves as the most commonly used drug for the treatment of pathological pain. However, detrimental side effects (e.g., hyperalgesia and tolerance) manifest during chronic administration, thus counteracting morphine analgesia. Investigators have sought methods to widen the therapeutic window of morphine in the management of chronic pain. Programmed cell death protein 1 (PD-1) is a recently validated analgesic target and is coexpressed with the mu opioid receptor (μOR) in dorsal root ganglion (DRG) sensory neurons. Here, we present evidence that PD-1 regulates the expression of μOR mRNA and influences μOR-mediated analgesia. Notably, the concomitant administration of PD-1 agonist H-20 greatly reduces the dosage of morphine needed for analgesia, thereby significantly decreasing opioid-related side effects. This new combination therapy may provide a solution for managing chronic pain in patients who require morphine.

Bariatric Surgery as an Adjunctive Treatment for Failed Back Surgery Syndrome: A Case Report Highlighting a Multidisciplinary Approach

Failed back surgery syndrome (FBSS) poses a significant challenge in chronic pain management, particularly in patients with obesity, where excess weight exacerbates spinal strain and pain. Bariatric surgery has been explored as a potential adjunctive treatment for pain relief by reducing mechanical stress and systemic inflammation. We report the case of a 42-year-old woman with a history of FBSS, chronic back pain, narcolepsy, rheumatoid arthritis, and obesity, who underwent laparoscopic sleeve gastrectomy as part of a multidisciplinary pain management strategy. Despite having a spinal cord stimulator for pain control, she remained dependent on opioids, gabapentin, and amitriptyline. Following an uneventful surgery, postoperative pain was effectively managed with a ketamine infusion, leading to significant pain score reduction. The patient was discharged with an optimized pain regimen and demonstrated early improvements in mobility and overall well-being. This report highlights the potential role of bariatric surgery in managing chronic pain in patients with FBSS and obesity. It underscores the importance of a multidisciplinary approach, preoperative planning, and tailored postoperative pain management in optimizing outcomes. Further research is warranted to evaluate the long-term impact of bariatric surgery on chronic pain management and functional recovery in this patient population.

Association of Pain With Falls and Fractures Among Middle-Aged Korean Community-Dwelling Adults

BACKGROUND

The relationship between pain and falls remains controversial. Therefore, this study explored the associations between pain and fall-related outcomes in 5 340 middle-aged (45-65 years) adults residing in the communities in Korea.

METHODS

Pain was defined as pain at any location, pain-related activity restriction, and persistent pain. The outcome measures included fall injuries, recurrent falls, injurious falls, and fall-related hip fractures. A multivariate logistic regression model was used to examine the relationship between pain and fall outcome.

RESULTS

Among the study participants, 54.0% reported having experienced pain. During a follow-up period of up to 14 years, those who reported pain and pain-related activity restriction at baseline exhibited a positive association with the occurrence of fall injury (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.27-2.53) and injurious falls (OR 1.72, 95% CI: 1.20-2.48) but not with recurrent falls (OR 1.90, 95% CI: 0.80-4.54). We also observed a positive association between persistent pain and the risk of fall injury (OR 1.41, 95% CI: 1.13-1.91), whereas no consistent conclusions were drawn regarding the risk of recurrent falls and injurious falls. We also did not identify any correlation between pain and hip fractures resulting from falls.

CONCLUSIONS

In conclusion, our findings of the positive correlations of pain and pain-related activity restriction at baseline with fall injuries and injurious falls but not recurrent falls during follow-up suggest that public health initiatives should prioritize pain screening, especially for participants reporting ankle and toe pain, and implement suitable interventions to mitigate the risk of falls and the associated adverse outcomes among middle-aged adults.

Nociplastic pain: controversy of the concept

Classically, pain can be of a nociceptive or neuropathic nature, which refers to non-neural or neural tissue lesions, respectively. Chronic pain in conditions such as migraine, fibromyalgia, and complex regional pain syndrome (CRPS), is thought to perpetuate without a noxious input. Pain in such patients can be assigned neither to the nociceptive nor neuropathic category. Therefore, a third pain descriptor, named "nociplastic pain", has been adopted by the International Association for the Study of Pain. The current controversy-focused narrative review updates littledebated aspects of the new pain concept. The most disputable feature of nociplastic pain is its autonomous persistence, i.e., existence without causative tissue damage, presumably because of a malfunction of pain pathways and processing. This contradicts the fact that nociplastic pain is accompanied by persistent central sensitization that has been shown to require a continuing noxious input, e.g ., nerve injury. Even if sensitization occurs without a lesion, e.g ., in psychogenic and emotional pain, peripheral stimulus is necessary to produce pain. A logical weakness of the concept is that the word "plastic" in biology refers to adaptation rather than to maladaptation. The pathophysiologic mechanism of nociplastic pain may, in fact, be associated with background conditions that elude diagnosis because of the limitations of current diagnostic means. Misapplication of the nociplastic pain category may weaken diagnostic alertness toward occult causes of pain. Possible diagnostic errors could be avoided by understanding that nociplastic pain is a mechanism of pain rather than a diagnosis. Clinical use of this pain descriptor deserves a wider critical discussion.

Association between chronic pain and cognitive frailty among middle-aged and elderly individuals: evidence from the China Health and Retirement Longitudinal Study

Background

Frailty, particularly cognitive frailty, is an escalating public health issue. Cognitive frailty is defined by the simultaneous presence of physical frailty and cognitive impairment, without a confirmed diagnosis of dementia, and has become a significant geriatric syndrome. This study aimed to explore the association between chronic pain and the risk of cognitive frailty.

Methods

We utilized data from two waves (2011 and 2015) of the China Health and Retirement Longitudinal Study (CHARLS), conducting both cross-sectional and longitudinal analyses involving 17,705 Chinese adults aged 45 years and older. Chronic pain was defined as pain reported at both time points. Cognitive function was evaluated using a questionnaire adapted from the Telephone Interview for Cognitive Status. The frailty index (FI) was derived from a 30-item assessment. Cognitive frailty was characterized by the co-occurrence of cognitive impairment and physical frailty.

Results

Among the 14,285 participants, 5.39% exhibited cognitive frailty at baseline. Both cross-sectional and longitudinal analyses indicated that individuals suffering from chronic pain faced a higher likelihood of developing cognitive frailty compared to those without pain. After adjusting for potential confounders, multivariate models also indicated a higher odds of cognitive frailty for participants with chronic pain.

Conclusion

Chronic pain is significantly associated with an elevated risk of cognitive frailty among middle-aged and elderly individuals. These findings highlight the importance of managing chronic pain to mitigate the risk of cognitive frailty, thereby potentially enhancing the quality of life for the aging population and alleviating the economic burden on families and society.

Effectiveness and Safety of Sublingual Fentanyl in the Treatment of Breakthrough Cancer Pain in Older Patients with Cancer: Results from a Retrospective Observational Study

The study assessed sublingual fentanyl citrate (SFC) effectiveness and safety for breakthrough cancer pain (BtCP) in older patients. A multicenter, retrospective, observational study was conducted in three subgroups of cancer patients aged over 65 years with BtCP. The reports were collected by 20 oncologists across 12 hospitals. The primary goal was to measure changes in BtCP intensity with SFC treatment over 30 days; secondary objectives included pain relief onset and adverse events. A total of 127 patients with long-term cancer (mean: 3.3 years) were recruited. All of them had BtCP, mostly of mixed origin (62.5%). A significantly lower dose was needed in the high-age group at the final visit compared to baseline (212.90 ± 200.45 mcg vs. 206 ± 167.08 mcg; p = 0.000). Pain intensities at the beginning of the flare and at 30 min after SFC administration were significantly lower when the last and first visits were compared (1.9 vs. 2.3, p = 0.000; and 6.2 vs. 6.8 p = 0.006, respectively). The onset of analgesia was significantly more rapid for half of the patients ≥75 years, compared with 65-69 and 70-74 age groups. SFC appears then to be effective, well-tolerated, and safe to treat BtCP in older cancer patients.

Burden of chronic pain among adult pastoralists in Ethiopia: a cross-sectional household survey

ABSTRACT

Chronic pain is a major global health problem. Untreated pain causes particular suffering in marginalized communities. Most studies investigating chronic pain in sub-Saharan Africa stem from South Africa and Nigeria. Pastoralists are particularly underrepresented in pain research. The main objective of this study is to investigate the burden of chronic pain in adult pastoralists in the Somali Regional State of Ethiopia. We conducted a cross-sectional household survey among adult pastoralists (aged 18 years or older, N = 299) by face-to-face interviews. To randomly select households, we applied GPS-based household localization and recruitment. Chronic pain was self-reported by 17.0% (95% CI: 10.8-25.7) of male and 34.7% (95% CI: 28.4-41.5) of female adult pastoralists. The prevalence of chronic pain increased with age from 5.4% (95% CI: 0.8-30.1; 18-34 years) to 27.1% (95% CI: 15.1-43.7; 35-54 years) to 69.1% (95% CI: 53.7-81.1; 55 years and older). The body sites most commonly affected among those with chronic pain were knees (37.2%), followed by lower back (33.7%) and head (23.3%). The data for the first time provide insights into the burden of chronic pain among Somali pastoralists and reveal associated risk factors. The results support the planning of locally adapted health interventions for pastoralist-specific pain management considering the effects of chronic pain on pastoralists' daily lives.

Causal impacts of smoking on pain conditions and the mediating pathways: a mendelian randomization study

Smoking is a risk factor for multiple diseases. We performed mendelian randomization (MR) analyses to investigate the causal association of smoking initiation on pain conditions and the potential mediating pathways. Genetic associated with smoking initiation at the genome-wide significance level were selected as instrumental variables. Genetic associations with 10 pain conditions were derived from the FinnGen and UK Biobank study. Multivariable MR analysis was conducted to explore the mediation effects of depression, insomnia and sedentary behavior. A series of sensitivity analyses were conducted to assess the stability of our research findings. Genetic liability to smoking initiation was associated with an increased risk of angina pectoris, dorsalgia, low back pain, pain in limb, pain in joint, pain in thoracic spine and sciatica in both FinnGen and UK Biobank study. These causal associations were largely mediated by major depression (2.9- 39.5%), sedentary behavior (13.0- 31.2%), insomnia (10.3- 33.1%) and combination of all three mediators (30.2- 65.3%). The effects of smoking on outcomes were partly attenuated after adjusting for depression, sedentary behavior and insomnia respectively, and the direct effect of smoking initiation on pain was diminished toward null after adjusting for combined three mediators. These results were robust to sensitivity analyses. Our findings illustrated the causal effect of smoking and a broad range of pain conditions, and major depression, sedentary behavior and insomnia mediate many of these associations.

Implementation of a Virtual Reality Intervention in Outpatient Physiotherapy for Chronic Pain: Protocol for a Pilot Implementation Study

BACKGROUND

Chronic pain is a global health issue that causes physical, psychological, and social disabilities for patients, as well as high costs for societies. Virtual reality (VR) is a new treatment that provides an opportunity to narrow the gap between clinical practice and recommended care in the use of patient education and behavioral interventions in the outpatient physiotherapy setting. However, there is currently no implementation strategy to integrate VR treatments into this setting.

OBJECTIVE

This protocol outlines a pilot implementation study that aims to (1) identify barriers and facilitators for implementing a VR intervention in outpatient physiotherapy care for people with chronic pain and (2) develop and pilot test an implementation strategy in 5 practices in Germany.

METHODS

The study consists of 4 phases. The first phase involves adapting the treatment protocol of the VR intervention to the local context of outpatient physiotherapy practices in Germany. The second phase includes the collection of barriers and facilitators through semistructured interviews from physiotherapists and the development of a theory-driven implementation strategy based on the Theoretical Domains framework and the Behavior Change Wheel. This strategy will be applied in the third phase, which will also include a 6-month span of using VR interventions in practices, along with a process evaluation. The fourth phase consists of semistructured interviews to evaluate the developed implementation strategy.

RESULTS

The recruitment process and phase 1, including the adaptation of the treatment protocol, have already been completed. We recruited 5 physiotherapy practices in Lower Saxony, Germany, where the VR intervention will be implemented. The collection of barriers and facilitators through semistructured interviews is scheduled to begin in February 2024.

CONCLUSIONS

This pilot implementation study aims to develop a theory-driven implementation strategy for integrating a VR intervention into outpatient physiotherapy care for people with chronic pain. The identified barriers and facilitators, along with the implementation strategy, will serve as a starting point for future randomized controlled implementation studies in different settings to refine the implementation process and integrate VR interventions into the outpatient care of people with chronic pain.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00030862; https://tinyurl.com/3zf7uujx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58089.

Innovative Applications of Telemedicine and Other Digital Health Solutions in Pain Management: A Literature Review

Since the COVID-19 pandemic, healthcare systems are facing extraordinary challenges. Our approaches to medicine have changed and created a whole new generation of people who have chronic pain. Various medical services were postponed. The pandemic significantly impacted the bio-psychosocial model of pain and the management of chronic pain. These new challenges affected millions of patients worldwide, with more burden on patients with chronic pain. Telemedicine and digital health rather than traditional office visits have become essential tools for communications, resulting in an unmatched surge in telehealth adoption. This new approach facilitated the remote treatment and follow-up of patients who have difficulty to access the healthcare services, particularly patients with chronic pain and those who were receiving regular controlled medications. An extensive computer search was conducted, during the period (from January 2014 to March 2024), and included literature from PubMed, Scopus, MEDLINE, and Google scholar. According to preset inclusion and exclusion criteria, a total of 38 articles have been included in this review article. This literature review focuses on the innovation of telemedicine and digital health in pain management, especially in the context of the challenges posed by the COVID-19 pandemic. The manuscript provides a comprehensive overview of telemedicine and digital communications, their evolution, and their significance in healthcare. It also emphasizes the benefits, challenges, limitations, and the ethical concerns of telemedicine in pain management after the COVID-19 pandemic. Furthermore, the document explores the different modes of the telecommunications and discusses the future directions of the digital health technology.

Lumbar braces and other assistive devices for treatment of chronic low back pain

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of assistive technologies (i.e. non-rigid and rigid lumbar braces, belts, supports, and devices to assist mobility and gait) for improving pain and function (and consequently reducing disability) in adults with chronic low back pain.

What Predicts a Longer Period of Pain in Patients Referred to an Interdisciplinary Center for Pain Care?

Chronic musculoskeletal pain (CMP) is a global health condition that affects thousands of people. CMP can substantially affect the functional capacity and quality of life of the people impacted, resulting in high costs for health care and social security systems. Sociodemographic factors may play a significant role in pain chronification prevention and control programs. Thus, current risk factors for CMP must be seriously considered as part of an interdisciplinary management strategy. The purpose of the study was to identify the primary sociodemographic characteristics of CMP patients at a multidisciplinary and specialized center for chronic pain. This is a retrospective investigation based on a review of medical records. Age, gender, income, and the time of onset of pain symptoms were among the variables included in the analyzed data. To analyze variables related to the duration of discomfort, a multiple regression model was utilized. Sociodemographic factors explained 37.94% of experiencing prolonged pain, according to the study's findings. Being female and having a family income above the minimum wage were variables that were directly proportional to discomfort duration. Age was not associated with a prolonged duration of pain perception.

Anxiety and depression in patients with non-site-specific cancer symptoms: data from a rapid diagnostic clinic

Background

Rapid diagnostic clinics (RDCs) provide a streamlined holistic pathway for patients presenting with non-site specific (NSS) symptoms concerning of malignancy. The current study aimed to: 1) assess the prevalence of anxiety and depression, and 2) identify a combination of patient characteristics and symptoms associated with severe anxiety and depression at Guy's and St Thomas' Foundation Trust (GSTT) RDC in Southeast London. Additionally, we compared standard statistical methods with machine learning algorithms for predicting severe anxiety and depression.

Methods

Patients seen at GSTT RDC between June 2019 and January 2023 completed the General Anxiety Disorder Questionnaire (GAD-7) and Patient Health Questionnaire (PHQ-8) questionnaires, at baseline. We used logistic regression (LR) and 2 machine learning (ML) algorithms (random forest (RF), support vector machine (SVM)) to predict risk of severe anxiety and severe depression. The models were constructed using a set of sociodemographic and clinical variables.

Results

A total of 1734 patients completed GAD-7 and PHQ-8 questionnaires. Of these, the mean age was 59 years (Standard Deviation: 15.5), and 61.5% (n:1067) were female. Prevalence of severe anxiety (GAD-7 score ≥15) was 13.8% and severe depression (PHQ-8 score≥20) was 9.3%. LR showed that a combination of previous mental health condition (PMH, Adjusted Odds Rario (AOR) 3.28; 95% confidence interval (CI) 2.36-4.56), symptom duration >6 months (AOR 2.20; 95%CI 1.28-3.77), weight loss (AOR 1.88; 95% CI 1.36-2.61), progressive pain (AOR 1.71; 95%CI 1.26-2.32), and fatigue (AOR 1.36; 95%CI 1.01-1.84), was positively associated with severe anxiety. Likewise, a combination PMH condition (AOR 3.95; 95%CI 2.17-5.75), fatigue (AOR 2.11; 95%CI 1.47-3.01), symptom duration >6 months (AOR 1.98; 95%CI 1.06-3.68), weight loss (AOR 1.66; 95%CI 1.13-2.44), and progressive pain (AOR 1.50; 95%CI 1.04-2.16), was positively associated with severe depression. LR and SVM had highest accuracy levels for severe anxiety (LR: 86%, SVM: 85%) and severe depression (SVM: 89%, LR: 86%).

Conclusion

High prevalence of severe anxiety and severe depression was found. PMH, fatigue, weight loss, progressive pain, and symptoms >6 months emerged as combined risk factors for both these psychological comorbidities. RDCs offer an opportunity to alleviate distress in patients with concerning symptoms by expediting diagnostic evaluations.

Shared comorbidity of depression, migraine, insomnia, and fibromyalgia in a population-based sample

BACKGROUND

Depression, migraine, insomnia, and fibromyalgia are reportedly comorbidities. Nevertheless, no study has evaluated the comorbidity of all four of these disorders. This study aimed to investigate the comorbidity of these four disorders.

METHODS

Cross-sectional analyses were performed using data of the Circannual Change in Headache and Sleep study, an online nationwide population-based survey. Validated questionnaires were used to diagnose the disorders and measure quality of life. The change of clinical characteristics by addition of any comorbidity was analyzed using the Jonckheere-Terpstra trend test.

RESULTS

The prevalence rates of depression, migraine, insomnia, and fibromyalgia were 7.2 %, 5.6 %, 13.3 %, and 5.8 %, respectively. Among the 3030 included participants, 494 (16.3 %), 164 (5.4 %), 40 (1.3 %), and 6 (0.2 %) had one, two, three, and four of these conditions, respectively. The number of headache days per 30 days (Jonckheere-Terpstra trend test, p = 0.011) and migraine-related disability (migraine disability assessment score, p = 0.021) increased with an increase in the number of comorbidities but not with the intensity of headache (visual analog scale, p = 0.225) among participants with migraine. The severity of insomnia (Insomnia Severity Index, p < 0.001) and fibromyalgia (fibromyalgia severity score, p = 0.002) increased with additional comorbidities; however, depression (Patient Health Questionnaire-9, p = 0.384) did not show such an increase.

LIMITATIONS

The diagnoses of conditions were based on self-reported questionnaires.

CONCLUSIONS

The findings confirmed significant comorbidity between depression, migraine, insomnia, and fibromyalgia. Health professionals should be aware of the probable comorbidity of depression, migraine, insomnia, and fibromyalgia when caring for individuals with any of these four disorders.

Prevalence and associations of temporomandibular disorders in older Brazilian adults

OBJECTIVE

The objective of the study was to estimate the prevalence of temporomandibular disorders (TMD) and describe associations in a representative sample of community-dwelling older Brazilian adults.

BACKGROUND

TMD cause recurrent or chronic pain and dysfunction with substantial impacts on quality of life, but little is known of their occurrence and associated factors among older adults.

MATERIALS AND METHODS

This was a cross-sectional study using data from the second wave of the Brazilian Longitudinal Study of Aging, a nationally representative sample of older Brazilian adults aged 50 or older. The presence of temporomandibular disorder symptoms was measured by the Fonseca Anamnestic Index. Independent variables included sociodemographic characteristics, general health conditions and self-reported oral health measures. The association between the independent variables and TMD symptoms was evaluated using logistic regression models.

RESULTS

Complete information for the variables of interest was available for 9391 individuals. The overall prevalence of TMD symptoms was 18.0% (95% CI 14.4-22.1). Relative to older adults aged 50-59 those in all age categories had lower odds of TMD symptoms. Individuals with depression, pain, sleep problems and self-reported poor general health had higher odds of reporting TMD symptoms. None of the oral health measures were related to TMD.

CONCLUSION

The prevalence of TMD symptoms among Brazilian older adults is associated with demographic and general health conditions, but not with dentition status.

Comparative benefits and harms of perioperative interventions to prevent chronic pain after orthopedic surgery: a systematic review and network meta-analysis of randomized trials

BACKGROUND

Chronic postsurgical pain (CPSP) is common following musculoskeletal and orthopedic surgeries and is associated with impairment and reduced quality of life. Several interventions have been proposed to reduce CPSP; however, there remains uncertainty regarding which, if any, are most effective. We will perform a systematic review and network meta-analysis of randomised trials to assess the comparative benefits and harms of perioperative pharmacological and psychological interventions directed at preventing chronic pain after musculoskeletal and orthopedic surgeries.

METHODS

We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to present, without language restrictions. We will include randomised controlled trials that as follows: (1) enrolled adult patients undergoing musculoskeletal or orthopedic surgeries; (2) randomized them to any pharmacological or psychological interventions, or their combination directed at reducing CPSP, placebo, or usual care; and (3) assessed pain at 3 months or more after surgery. Screening for eligible trials, data extraction, and risk-of-bias assessment using revised Cochrane risk-of-bias tool (RoB 2.0) will be performed in duplicate and independently. Our main outcome of interest will be the proportion of surgical patients reporting any pain at ≥ 3 months after surgery. We will also collect data on other patient important outcomes, including pain severity, physical functioning, emotional functioning, dropout rate due to treatment-related adverse event, and overall dropout rate. We will perform a frequentist random-effects network meta-analysis to determine the relative treatment effects. When possible, the modifying effect of sex, surgery type and duration, anesthesia type, and veteran status on the effectiveness of interventions will be investigated using network meta-regression. We will use the GRADE approach to assess the certainty evidence and categorize interventions from most to least beneficial using GRADE minimally contextualised approach.

DISCUSSION

This network meta-analysis will assess the comparative effectiveness of pharmacological and psychological interventions directed at preventing CPSP after orthopedic surgery. Our findings will inform clinical decision-making and identify promising interventions for future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023432503.

Multimodal automatic assessment of acute pain through facial videos and heart rate signals utilizing transformer-based architectures

Accurate and objective pain evaluation is crucial in developing effective pain management protocols, aiming to alleviate distress and prevent patients from experiencing decreased functionality. A multimodal automatic assessment framework for acute pain utilizing video and heart rate signals is introduced in this study. The proposed framework comprises four pivotal modules: the Spatial Module, responsible for extracting embeddings from videos; the Heart Rate Encoder, tasked with mapping heart rate signals into a higher dimensional space; the AugmNet, designed to create learning-based augmentations in the latent space; and the Temporal Module, which utilizes the extracted video and heart rate embeddings for the final assessment. The Spatial-Module undergoes pre-training on a two-stage strategy: first, with a face recognition objective learning universal facial features, and second, with an emotion recognition objective in a multitask learning approach, enabling the extraction of high-quality embeddings for the automatic pain assessment. Experiments with the facial videos and heart rate extracted from electrocardiograms of the BioVid database, along with a direct comparison to 29 studies, demonstrate state-of-the-art performances in unimodal and multimodal settings, maintaining high efficiency. Within the multimodal context, 82.74% and 39.77% accuracy were achieved for the binary and multi-level pain classification task, respectively, utilizing 9.62 million parameters for the entire framework.

Musculoskeletal disorders and pain in agricultural workers in Low- and Middle-Income Countries: a systematic review and meta-analysis

Agricultural workers constitute two-thirds of the population of Low- and Middle-Income Countries (LMIC) and are at increased risk of developing musculoskeletal disorders (MSD) due to high-risk activities. This systematic review and meta-analysis aim to synthesise the prevalence, predictors, and outcomes of musculoskeletal pain amongst agricultural workers to identify priority areas for prevention and development of early interventions. This systematic review and meta-analysis included Studies published from the inception of global electronic databases until 30 September 2022 were included. Prevalence estimates for MSDs among agricultural workers aged over 18 years in LMIC were extracted. Narrative synthesis summarized study findings and pooled estimates for 12-month pain prevalence were calculated. 7502 potential studies were identified. 64 studies (68,684 participants from 23 countries) were included in the systematic review; 33 studies were included in the meta-analysis. Low back pain was the most widely investigated symptom. The 12-month pooled prevalence of low back pain was highest in Africa [61.96% (45.69-76.22)] compared to Asia [54.16% (47.76-60.50)] and South/Central America [28.52%(10.91-50.33)]. Narrative synthesis found associations between MSDs, particular activities including heavy lifting and repetitive movements, and outcomes including reduced productivity. MSDs are common in agriculture workers in LMIC. Global prevalence of low back pain in farmers, particularly in Africa, is greater than in previously reported global prevalence in the general population. This may be attributed to environmental factors and high-risk activities which could be targeted for prevention and early intervention strategies to support individuals, prevent disability, and reduce loss of productivity.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Evaluation of low back pain status and affecting factors in drivers in Turkey: A cross-sectional study1

BACKGROUND

Low back pain (LBP) is a common public health problem resulting in workforce loss.

OBJECTIVE

This study aims to evaluate the LBP status and its affecting factors among drivers in a city in southeast Turkey.

METHODS

This cross-sectional questionnaire survey study was conducted among 323 drivers. The chi-square test and logistic regression analysis were used to analyze the data.

RESULTS

The mean age of the drivers was 41.7±11.5 years (min: 19, max: 70), and 83.9% were married, and all were men. LBP was found in 59.4% of drivers. It was significantly higher in drivers with poor socioeconomic status, dissatisfied with their life, having a chronic illness, physically inactive, having sleep disorders, exposed to bad road conditions, prolonged vibration, high physical- psychological workload, and a family history of LBP (p < 0.05). There was no significant association between age, education level, and BMI with LBP (p > 0.05).

CONCLUSION

There is limited study on this subject in Turkey. Further studies can raise awareness about this issue and create an educational plan.

Examining the Efficacy of a Brief Cognitive-Behavioral Therapy for Chronic Pain (Brief CBT-CP) Group Delivered via VA Video Connect (VVC) Among Older Adult Veterans

OBJECTIVES

To evaluate the effectiveness of a Brief CBT-CP Group delivered via VA Video Connect (VVC) among different age groups of Veterans with chronic noncancer pain being seen in primary care. A secondary aim was to evaluate participant characteristics of patients who completed vs. did not complete the group.

METHODS

Single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels pre- and post-treatment. Dependent variables included generalized anxiety, quality of life, disability, physical health, and pain outcomes.

RESULTS

Following a 2 × 3 mixed-model ANCOVA, a main effect of time was found for all outcome variables, demonstrating significant improvements in disability rating, physical health, quality of life, generalized anxiety, and pain outcomes from pre- to post-treatment. There were no significant main effects for age group for any outcome variable, suggesting that patients of all ages reported improvements.

CONCLUSIONS

Accommodations and adaptations to telehealth treatment for older adults are proposed and discussed.

CLINICAL IMPLICATIONS

The Brief CBT-CP Group via VVC is an effective and accessible treatment for older adults with chronic noncancer pain who are being managed in the primary care setting. Certain Veterans are less likely to complete the Brief CBT-CP Group via VVC.

A global comparative study of wealth-pain gradients: Investigating individual- and country-level associations

Pain is a significant yet underappreciated dimension of population health. Its associations with individual- and country-level wealth are not well characterized using global data. We estimate both individual- and country-level wealth inequalities in pain in 51 countries by combining data from the World Health Organization's World Health Survey with country-level contextual data. Our research concentrates on three questions: 1) Are inequalities in pain by individual-level wealth observed in countries worldwide? 2) Does country-level wealth also relate to pain prevalence? 3) Can variations in pain reporting also be explained by country-level contextual factors, such as income inequality? Analytical steps include logistic regressions conducted for separate countries, and multilevel models with random wealth slopes and resultant predicted probabilities using a dataset that pools information across countries. Findings show individual-level wealth negatively predicts pain almost universally, but the association strength differs across countries. Country-level contextual factors do not explain away these associations. Pain is generally less prevalent in wealthier countries, but the exact nature of the association between country-level wealth and pain depends on the moderating influence of country-level income inequality, measured by the Gini index. The lower the income inequality, the more likely it is that poor countries experience the highest and rich countries the lowest prevalence of pain. In contrast, the higher the income inequality, the more nonlinear the association between country-level wealth and pain reporting such that the highest prevalence is seen in highly nonegalitarian middle-income countries. Our findings help to characterize the global distribution of pain and pain inequalities, and to identify national-level factors that shape pain inequalities.

Effectiveness of m-health-based core strengthening exercise and health education for public safety workers with chronic non-specific low back pain: study protocol for a superiority randomized controlled trial (SAFEBACK)

BACKGROUND

Low back pain (LBP) is the leading cause of years lived with disability worldwide. Public safety workers are highly exposed to physically demanding activities and inappropriate postures, increasing the risk of experiencing LBP. Smartphone app-based self-managed interventions may be an alternative for chronic non-specific LBP (CNSLBP) treatment. This study aims to evaluate the effectiveness of a smartphone app-based self-managed exercise program plus health education, compared to a health education program alone, on neuromuscular and perceptual outcomes in police officers and firefighters with CNSLBP.

METHODS

This is a parallel, two-armed, blinded evaluator randomized clinical trial. Police officers and firefighters (from public safety institutions in the Rio Grande do Sul state, Brazil) will be randomly assigned to a m-health self-managed exercise program (twice a week) plus health education or health education alone. Self-management exercise program components are mobility and core resistance exercises, available on the app. Follow-ups will be conducted post-treatment (8 weeks) and 16 weeks after randomization. The co-primary outcomes will be pain intensity and disability post-treatment (8 weeks). Secondary outcomes will be biopsychosocial factors related to CNSLBP.

DISCUSSION

We hypothesize that the effects of a smartphone app-based self-managed exercise program on co-primary and secondary outcomes will be superior, compared to the health education only in public safety workers with CNSLBP.

TRIAL REGISTRATION

The study was prospectively registered at ClinicalTrials.gov (NCT05481996. Registered on August 01, 2022).

The burden of rheumatoid arthritis and low back pain in North Africa and Middle East from 1990 to 2019: Results from the Global Burden of Disease Study 2019

BACKGROUND

Rheumatoid arthritis (RA) and low back pain (LBP) are among the most prevalent musculoskeletal disorders (MSDs). The need for investigation of regional and local patterns of these two MSDs seems inevitable for better policy-making. The current study presents updated results of the Global Burden of Disease (GBD) Study 2019 and reports the burden of RA and LBP in North Africa and Middle East (NAME) countries from 1990 to 2019.

METHODS

Incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and risk factors, including high body mass index, occupational ergonomic factors, and smoking, were extracted based on the GBD 2019 data.

RESULTS

The age-standardized prevalence and mortality of RA were 120.6 (95% uncertainty interval [95% UI] 107.0-135.7) and 0.1 (95% UI 0.1-0.2) per 100 000 population in 2019 with 28.3% (95% UI 25.5%-30.9%) increase and 7.5% (95% UI -37.5% to 32.5%) decrease since 1990, respectively. Turkey had the highest age-standardized incidence, prevalence, and DALYs of RA in 2019. All RA burden measures were higher for women; however, the incidence was almost the same at ages greater than 65 years. The age-standardized prevalence and DALYs of LBP were 7668.2 (95% UI 6798.0-8636.3) and 862 (95% UI 605.5-1153.3) in 2019, which had decreased by 5.8% (95% UI -7.4% to -4.3%) and 6.0% (95% UI -7.7% to -4.2%) since 1990, respectively. Moreover, although Turkey had the highest incidence and prevalence in 1990, Iran was at the top in 2019. The regional age-standardized DALY rates due to RA and LBP attributed to smoking were 1.7 (95% UI 0.5-3.2) and 139.4 (95% UI 87.3-198.8) in 2019, respectively, which had decreased 2.2% (95% UI -19.2% to 13.7%) and 15.4% (95% UI -19.4% to -10.5%) since 1990, respectively.

CONCLUSION

RA still imposes a significant burden in the NAME region as the burden measures have increased from 1990 to 2019. On the other hand, regarding LBP, a decreasing pattern was observed. Differences among the countries and between ages and genders can have implications, and the results of this study may be helpful for policy-makers in the NAME countries.

Pain management in cancer surgery: Global inequities and strategies to address them

Among patients undergoing surgical oncologic operations, patients in low- and middle-income countries are at particularly high risk for inadequate perioperative analgesia. This article reviews some of the guiding pillars of pain management for cancer surgery, including use of regional analgesia and acute pain service consultation, multimodal adjunctive analgesia, and judicious opioid use while presenting data on international disparities for each pillar and proposing strategies to address these inequities.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa

BACKGROUND

Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA).

METHODS

The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training.

RESULTS

6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical.

CONCLUSIONS

Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.

Prevalence of musculoskeletal disorders among dental students: A systematic review and meta-analysis

Objectives

This study aimed to determine the prevalence of work-related musculoskeletal disorders (WMSDs) in dental students and analyze the potential associated risk factors.

Methods

This review was registered in PROSPERO with the number CRD42022349864. We performed a meta-analysis calculating event rates with relative 95% confidence intervals for each body region. Two investigators systematically searched Cochrane, Pubmed, Scopus, and EBSCO databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Results

Sixteen studies, with 3761 dental students, were included. The highest 7-day prevalence was in the lower back (27.2%; 95% CI 20-35), neck (27%; 95% CI 19.1-35.8), and upper back (24.2%; 95% CI 17.2-32). Yearly occurrence was mainly in the neck (51%; 95% CI 41-61), followed by shoulders (45.3%; 95% CI 37.6-53.1) and lower back (42%; 95% CI 34.1-50.2) and a fraction of these reported that symptoms in lower-back (15.2%; 95% CI 12.1-18.5), neck (13.9%; 95% CI 10.6-17.5) and shoulders (12.2%; 95% CI 8.7-16.3) affected work or normal activities. Associated contributing factors include female sex, poor posture habits, inadequate ergonomics knowledge, sedentary lifestyle, high physical activity levels, poor quality of life, and smoking. In contrast, engaging in physical exercise has positively impacted mitigating the risk of musculoskeletal disorders.

Conclusions

WMSDs have a high prevalence among dental students, particularly in the cervicothoracic, lumbar, and shoulder regions, having a significant impact since training years. Further research with a multidimensional approach with psychosocial and physical assessments is recommended to understand this issue thoroughly.

The invisible cost of pain management by the current International Classification of Diseases coding system: a study in a tertiary care inpatient setting

ABSTRACT

The International Classification of Diseases ( ICD ) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD ( ICD-10 ), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11 . The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.

Psychiatric disorders, personality traits, and childhood traumatic events predicting incidence and persistence of chronic pain: results from the CoLaus|PsyCoLaus study

ABSTRACT

Chronic pain (CP) is often accompanied by mental disorders (MDs). However, little is known concerning the long-term effect of MDs, personality traits, and early-life traumatic events (ETEs) on CP course. Accordingly, we aimed to prospectively assess the associations of major depressive disorders (MDDs), anxiety disorders, personality traits, and ETEs with the incidence and the persistence of CP in middle-aged and older community dwellers. Data stemmed from the 3 first follow-up evaluations of CoLaus|PsyCoLaus, a prospective cohort conducted in the general population of Lausanne (Switzerland). Diagnostic criteria for MDs and ETEs were elicited using semistructured interviews. CP and personality traits were assessed by self-rating questionnaires. Follow-up intervals were subdivided into 2 groups: those without (n = 2280) and those with (n = 1841) CP initially. The associations between the psychological variables and the occurrence or persistence of CP 5 years later were assessed using serially adjusted logistic regression models. Higher neuroticism (odds ratio [95% confidence interval] 1.21 [1.08; 1.36]) and extraversion (1.18 [1.06; 1.32]) were associated with higher 5-year CP incidence, whereas current (2.14 [1.34; 3.44]) and remitted MDD (1.29 [1.00; 1.66]) as well as lower extraversion (0.83 [0.74; 0.94]) were associated with persistence of CP. By contrast, ETEs and anxiety disorders were not associated with the incidence or persistence of CP. Our results suggest that personality traits are associated with both CP occurrence and persistence, whereas the MDDs may be more associated with CP persistence. Both personality and MDD are accessible to psychotherapy, and MDD is also accessible to pharmacotherapy. Hence, these therapeutic measures might decrease the risk of CP and its persistence.

Looking Back, Moving Forward in Pain Medicine

Pain is an ancient medical complaint and a clinical riddle that has never been entirely solved. Looking back into history was the springboard to a look into the future of pain medicine. This article was based on a series of presentations given in a recent congress (May 2023) and represents the research, views, and opinions of the authors. Opium has been used for millennia to treat pain, but when it gained broad use in the United States in the 1980s and 1990s, it was so vastly overprescribed and mis-prescribed that it led to a public health crisis. This, in turn, led to the reaction where opioids at times were under-prescribed, leaving out many patients who may have benefited from opioids while leaving many legacy pain patients to manage withdrawal on their own and with few analgesic options. Cannabinoids (CB) were likewise widely used for various conditions, including pain, but were outlawed in the 20th century, only to be brought back as a potential analgesic agent. Interventional pain medicine is a developing discipline and has reinforced the concept of the interdisciplinary pain clinic. It plays an increasingly important part in modern medicine overall, especially with the support of ultrasound, for both diagnosis and therapy. Today, the views about pain have changed. Anyone has accepted that pain is not purely a physical phenomenon but a biopsychosocial phenomenon that occurs within a cultural context. Pain management remains a small but vitally important medical subspecialty that is critical from a functional enablement and population health perspective, which is helping to navigate new therapeutic targets, new drugs and routes of administration, greater understanding of pain psychology, and new technologies. Pain control today means early intervention, functional enablement through pain alleviation, educating patients about pain management, and minimizing the transition from acute to chronic pain.

Low Back Pain and Its Risk Factors Among Nurses Working in East Bale, Bale, and West Arsi Zone Government Hospitals, Oromia Region, South East Ethiopia, 2021 -Multicenter Cross-Sectional Study

Background

Hospital nursing staff are particularly susceptible to low back pain (LBP) a widespread health issue worldwide. There was little available data on the prevalence of LBP and risk factors related to it in this population.

Objective

Assessed the prevalence of LBP and risk factors in nurses working in South-East Ethiopia's Oromia region in the East Bale, Bale, and West Arsi zone government hospitals.

Methods

A cross-sectional study was carried out within an institution in the East Bale, Bale, and West Arsi zone government hospitals; 440 nurses were chosen to use a process of systematic random sampling, and data was gathered between June 1 and July 30, 2021. Using pre-designed questionnaires, I interrogated participants. After being verified as complete, the gathered data was entered into Epi-data version 3.1 and exported to SPSS version 25 for analysis. Bi variate and multivariate logistic regressions with 95% confidence intervals and crude and adjusted odd ratios were generated and interpreted as necessary. To deem a result statistically significant, a p-value of 0.05 or lower was required.

Results

A total of 427 nurses engaged in the interview out of the 440 participants that wanted to take part in the study, yielding a response rate of 97.1%. Low back pain was 42.6% more common over a year [95% CI: (0.384, 0.476)]. According to the multivariate analysis, females [AOR = 1.791; 95% CI: (1.121, 2.861)], age higher than forty [AOR=2.388, 95% CI: (1.315, 4.337)], age grouped 31-40 years [(AOR=2.064, 95% CI: 1.233, 3.455)], divorced [(AOR=10.288, 95% CI: (3.063, 34.553)], married [(AOR=1.676 (1.675, 16.999)].

Conclusion

The study suggests that implementing preventive measures and offering ergonomic training can help reduce LBP among nurses in these hospitals.

Causal Associations between Dietary Habits and Chronic Pain: A Two-Sample Mendelian Randomization Study

Chronic pain is a prevalent and debilitating condition with significant impacts on individuals and society. While the role of diet in chronic pain is well-known, the relationship between special dietary choices and chronic pain remains unclear. This study investigates the causal associations between 20 dietary habits and chronic pain using a Mendelian randomization (MR) approach. Publicly available genome-wide association study data from the UK Biobank dataset were utilized for secondary analysis, and genetic instrumental variables strongly correlated with 20 different dietary habits were selected. Multisite chronic pain (MCP) scores were used as the primary outcome, with site-specific chronic pain (SSCP) including back pain, headache, knee pain, neck pain, and hip pain as secondary outcomes. The inverse-variance-weighted (IVW) method was the primary method used in the MR. The weighted median (WM) and Mendelian randomization pleiotropy residual sum and outlier test (MR-PRESSO) methods were used as sensitivity analyses. This study identified causal associations between specific dietary habits and chronic pain. A high intake of cheese, cereal, dried fruits, and fresh fruits was associated with lower MCP scores. Conversely, high alcohol, salt, pork, and poultry intakes were associated with higher MCP scores. Similar associations between special dietary habits and some types of SSCP, such as back and neck pain, were also observed. The findings were consistent across different statistical methods, and sensitivity analyses confirmed the reliability of the results. In conclusion, our study provides evidence of a causal relationship between various dietary habits and different types of chronic pain based on secondary analysis of the UK Biobank dataset. Adhering to an anti-inflammatory diet, including increased consumption of fruits and cereal while reducing salt and pork intake, may potentially alleviate chronic pain symptoms.

Chronic non-cancer pain management - insights from Australian general practitioners: a qualitative descriptive study

BACKGROUND

The study explored the experiences and perceptions of GPs regarding the management of chronic non-cancer pain (CNCP). Specifically, participants were asked to identify perceived enablers and barriers to CNCP care and how the care of patients with CNCP may be improved.

METHODS

The study utilised a qualitative descriptive methodology. General practice in Western Australia. The sample was purposive with 12 Australian GPs from predominantly metropolitan locations and with experience in managing CNCP. Semi structured interviews were conducted. Each interview was of 45-60min duration. All interviews were audio recorded and transcribed using a secure transcription service. Thematic analysis developed themes inductively and deductively.

RESULTS

Themes emerged regarding: the importance of a holistic and personalised approach; the important role of a coordinating GP; the need for an evidence-based approach to opioid management; concerns relating to access to multidisciplinary services; the importance of clinician and patient education regarding CNCP; and an acknowledgement of the challenges for doctors and patients in managing CNCP.

CONCLUSIONS

Currently, the management of CNCP in Australia is challenging. Notable challenges include: difficulties with continuity of patient care; challenges with patient expectations of treatment, in particular opioid medications; difficulty with access to the health services required to enable holistic care; and the need for improved pain education in the community. The breadth of these challenges suggests there is a need for supportive organisational and structural considerations in the healthcare system to enable optimal care of CNCP in the community.

Exploring the bidirectional relationship between pain and mental disorders: a comprehensive Mendelian randomization study

BACKGROUND

The close relationship between pain and mental health problems is well-known, and psychological intervention can provide an effective alternative to medication-based pain relief. However, previous studies on the connection between pain and psychological problems, the findings thus far have been inconclusive, limiting the potential for translating psychological interventions into clinical practice. To complement the gap, this study utilized genetic data and Mendelian randomization (MR) to examine the potential relationship between pain in different parts and common mental disorders.

METHODS

Based on the instrumental variables selected from the Genome-wide association study summary statistics of localized pain and mental disorders, we conducted bidirectional two-sample MR analyses to infer bidirectional causal associations between pain and mental disorders. The inverse-variance weighted MR method and MR-Egger were used as the primary statistical method according to the horizontal pleiotropy and heterogeneity level. We reported the odds ratio to infer the causal effect between pain and mental disorders. F statistic was calculated to measure the statistical efficacy of the analyses.

RESULTS

Insomnia is causally related to the genetic susceptibility of multisite pain including head (OR = 1.09, 95% CI: 1.06-1.12), neck/shoulder (OR = 1.12, 95% CI: 1.07-1.16), back (OR = 1.12, 95% CI: 1.07-1.18) and hip (OR = 1.08, 95% CI: 1.05-1.10). Reversely, headache (OR = 1.14, 95% CI: 1.05-1.24), neck/shoulder pain (OR = 1.95, 95% CI: 1.03-3.68), back pain (OR = 1.40, 95% CI: 1.22-1.60), and hip pain (OR = 2.29, 95% CI: 1.18-4.45) promote the genetic liability of insomnia. Depression is strongly associated with the predisposition of multisite pain including headache (OR = 1.28, 95% CI: 1.08-1.52), neck/shoulder pain (OR = 1.32, 95% CI: 1.16-1.50), back pain (OR = 1.35, 95% CI: 1.10-1.66) and stomach/abdominal pain (OR = 1.14, 95% CI: 1.05-1.25), while headache (OR = 1.06, 95% CI: 1.03-1.08), neck/shoulder (OR = 1.09, 95% CI: 1.01-1.17), back (OR = 1.08, 95% CI: 1.03-1.14), and stomach/abdominal pain (OR = 1.19, 95% CI: 1.11-1.26) are predisposing factors for depression. Additionally, insomnia is associated with the predisposition of facial, stomach/abdominal, and knee pain, anxiety was associated with the predisposition of neck/shoulder and back pain, while the susceptibilities of hip and facial pain are influenced by depression, but these associations were unidirectional.

CONCLUSIONS

Our results enhance the understanding of the complex interplay between pain and mental health and highlight the importance of a holistic approach to pain management that addresses both physical and psychological factors.

The influence of cultural and religious factors on cross-national variations in the prevalence of chronic back and neck pain: an analysis of data from the global burden of disease 2019 study

Introduction

Low back pain and neck pain are among the most commonly reported forms of chronic pain worldwide, and are associated with significant distress, disability and impairment in quality of life. Though these categories of pain can be analyzed and treated from a biomedical perspective, there is evidence that they are both related to psychological variables such as depression and anxiety. The experience of pain can be significantly influenced by cultural values. For example, cultural beliefs and attitudes can influence the meaning attached to the experience of pain, the responses of others to a sufferer's pain, and the likelihood of seeking medical care for particular symptoms. Likewise, religious beliefs and practices can influence the both experience of pain and the responses to it. These factors have also been associated with variations in the severity of depression and anxiety.

Methods

In the current study, data on the estimated national prevalence of both low back pain and neck pain, obtained from the 2019 Global Burden of Disease Study (GBD 2019), is analyzed in relation to cross-national variations in cultural values, as measured using Hofstede's model (n =115 countries) and in religious belief and practice, based on the most recent Pew Research Center survey (n = 105 countries). To address possible confounding factors, these analyses were adjusted for variables known to be associated with chronic low back or neck pain, namely smoking, alcohol use, obesity, anxiety, depression and insufficient physical activity.

Results

It was found that the cultural dimensions of Power Distance and Collectivism were inversely correlated with the prevalence of chronic low back pain, and Uncertainty Avoidance was inversely correlated with the prevalence of chronic neck pain, even after adjustment for potential confounders. Measures of religious affiliation and practice were negatively correlated with the prevalence of both conditions, but these associations were not significant after adjusting for cultural values and confounders.

Discussion

These results highlight the existence of meaningful cross-cultural variations in the occurrence of common forms of chronic musculoskeletal pain. Psychological and social factors that could account for these variations are reviewed, along with their implications for the holistic management of patients with these disorders.

Prevalence of chronic pain in Brazil: A systematic review and meta-analysis

OBJECTIVE

This review synthesized existing studies on the prevalence of chronic pain in Brazil and its associated factors to produce a recent estimation to guide public health politics.

METHODS

A search was carried out in the Ovid Medline, Embase, Web of Science, and BVS Regional/Lilacs databases to identify population-based cross-sectional studies from 2005 to 2020, which reported the prevalence of benign chronic pain in Brazil (more than three months). The risk of bias was assessed using design, sample size determination, and random selection as essential issues. Pooled prevalence estimates were calculated for chronic pain in the general and elderly populations. The protocol was registered on Prospero (CRD42021249678).

RESULTS

Of the 682 identified, 15 macheted the authors' inclusion criteria. Chronic pain prevalence in the general adult population ranged from 23.02% to 41.4% (pooled estimate 35.70%, 95% Cis 30.42 to 41.17) and was described as moderate to intense. It was associated with female sex, old age, lower education, intense professional activity, excessive alcohol consumption, smoking, central obesity, mood disorder, and sedentarism. The Southeastern and Southern regions presented a higher prevalence. The prevalence in the elderly population ranged from 29.3% to 76.2% (pooled estimate 47.32%, 95% Cis 33.73 to 61.11). In addition, this population visited doctors more frequently, had more sleep disorders, and was more dependent on daily living activities. Almost fifty percent of both populations with chronic pain reported pain-induced disability.

CONCLUSION

Chronic Pain is highly prevalent in Brazil and associated with significant distress, disability, and poorly controlled.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis

Background

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care.

Methods

A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated.

Results

Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey.

Conclusion

Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

Automatic assessment of pain based on deep learning methods: A systematic review

BACKGROUND AND OBJECTIVE

The automatic assessment of pain is vital in designing optimal pain management interventions focused on reducing suffering and preventing the functional decline of patients. In recent years, there has been a surge in the adoption of deep learning algorithms by researchers attempting to encode the multidimensional nature of pain into meaningful features. This systematic review aims to discuss the models, the methods, and the types of data employed in establishing the foundation of a deep learning-based automatic pain assessment system.

METHODS

The systematic review was conducted by identifying original studies searching digital libraries, namely Scopus, IEEE Xplore, and ACM Digital Library. Inclusion and exclusion criteria were applied to retrieve and select those of interest, published until December 2021.

RESULTS

A total of one hundred and ten publications were identified and categorized by the number of information channels used (unimodal versus multimodal approaches) and whether the temporal dimension was also used.

CONCLUSIONS

This review demonstrates the importance of multimodal approaches for automatic pain estimation, especially in clinical settings, and also reveals that significant improvements are observed when the temporal exploitation of modalities is included. It provides suggestions regarding better-performing deep architectures and learning methods. Also, it provides suggestions for adopting robust evaluation protocols and interpretation methods to provide objective and comprehensible results. Furthermore, the review presents the limitations of the available pain databases for optimally supporting deep learning model development, validation, and application as decision-support tools in real-life scenarios.

Prevalence of pain and use of prescription opioids among older adults: results from the Brazilian Longitudinal Study of Aging (ELSI-Brazil)

Background

Pain has a significant impact on people's quality of life. The use of prescription opioids to treat pain is associated with an increased risk of opioid use disorders and overdose death. We measured the prevalence of recurrent pain, prescription opioid use, and associations between chronic conditions and prescription opioid use among Brazilian older adults.

Methods

We used data from the first population-based longitudinal study of aging in Brazil (ELSI-Brazil), 2019-2020 (mean age = 63.3; 54.4% female). Outcomes were: (1) experience of recurrent pain and (2) use of opioid analgesics in the past three months among those who experience pain. Exposures included selected health conditions, history of falls, and hospitalizations.

Findings

Prevalence of pain (n = 9234) was 36.9% (95% CI: 32.6-41.1). Pain was reported more frequently by female participants, low-income individuals, and those with a previous diagnosis of arthritis, chronic back pain, depressive symptoms, history of falls, and hospitalizations. Prevalence of opioid use among those reporting pain (n = 3350) was 30% (95% CI: 23.1-38.0). Prevalence of opioid use was higher among female and single individuals. In adjusted models, arthritis, chronic back pain, and presence of depressive symptoms were associated with prescription opioid use.

Interpretation

Prescription opioid use was reported by a sizable portion of the older adults who suffer from pain in Brazil. In a context of growing consumption of prescription opioids, opioid misuse has the potential to increase in the future. Surveillance of prescription opioid use is critical to prevent their harmful consequences.

Funding

ELSI-Brazil was funded by the Brazilian Ministry of Health.

Investigating the shared genetic architecture and causal relationship between pain and neuropsychiatric disorders

Pain often occurs in parallel with neuropsychiatric disorders. However, the underlying mechanisms and potential causality have not been well studied. We collected the genome-wide association study (GWAS) summary statistics of 26 common pain and neuropsychiatric disorders with sample size ranging from 17,310 to 482,730 in European population. The genetic correlation between pair of pain and neuropsychiatric disorders, as well as the relevant cell types were investigated by linkage disequilibrium (LD) score regression analyses. Then, transcriptome-wide association study (TWAS) was applied to identify the potential shared genes by integrating the gene expression information and GWAS. In addition, Mendelian randomization (MR) analyses were conducted to infer the potential causality between pain and neuropsychiatric disorders. Among the 169 pairwise pain and neuropsychiatric disorders, 55 pairs showed positive correlations (median r_g = 0.43) and 9 pairs showed negative correlations (median r_g =  -0.31). Using MR analyses, 26 likely causal associations were identified, including that neuroticism and insomnia were risk factors for most of short-term pain, and multisite chronic pain was risk factor for neuroticism, insomnia, major depressive disorder and attention deficit/hyperactivity disorder, and vice versa. The signals of pain and neuropsychiatric disorders tended to be enriched in the functional regions of cell types from central nervous system (CNS). A total of 19 genes shared in at least one pain and neuropsychiatric disorder pair were identified by TWAS, including AMT, NCOA6, and UNC45A, which involved in glycine degradation, insulin secretion, and cell proliferation, respectively. Our findings provided the evidence of shared genetic structure, causality and potential shared pathogenic mechanisms between pain and neuropsychiatric disorders, and enhanced our understanding of the comorbidities of pain and neuropsychiatric disorders.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Multisite chronic pain and the risk of autoimmune diseases: A Mendelian randomization study

Background

Accumulating evidence has demonstrated that an association between chronic pain and autoimmune diseases (AIDs). Nevertheless, it is unclear whether these associations refer to a causal relationship. We used a two-sample Mendelian randomization (MR) method to determine the causal relationship between chronic pain and AIDs.

Methods

We assessed genome-wide association study (GWAS) summary statistics for chronic pain [multisite chronic pain (MCP) and chronic widespread pain (CWP)], and eight common AIDs, namely, amyotrophic lateral sclerosis (ALS), celiac disease (CeD), inflammatory bowel disease (IBD), multiple sclerosis (MS), rheumatoid arthritis (RA), systemic lupus Erythematosus (SLE), type 1 diabetes (T1D) and psoriasis. Summary statistics data were from publicly available and relatively large-scale GWAS meta-analyses to date. The two-sample MR analyses were first performed to identify the causal effect of chronic pain on AIDs. The two-step MR and multivariable MR were used to determine if mediators (BMI and smoking) causally mediated any connection and to estimate the proportion of the association mediated by these factors combined.

Results

With the utilization of MR analysis, multisite chronic pain was associated with a higher risk of MS [odds ratio (OR) = 1.59, 95% confidence interval (CI) = 1.01-2.49, P = 0.044] and RA (OR = 1.72, 95% CI = 1.06-2.77, P = 0.028). However, multisite chronic pain had no significant effect on ALS (OR = 1.26, 95% CI = 0.92-1.71, P = 0.150), CeD (OR = 0.24, 95% CI = 0.02-3.64, P = 0.303), IBD (OR = 0.46, 95% CI = 0.09-2.27, P = 0.338), SLE (OR = 1.78, 95% CI = 0.82-3.88, P = 0.144), T1D (OR = 1.15, 95% CI = 0.65-2.02, P = 0.627) or Psoriasis (OR = 1.59, 95% CI = 0.22-11.26, P = 0.644). We also found positive causal effects of MCP on BMI and causal effects of BMI on MS and RA. Moreover, there were no causal connections between genetically predicted chronic widespread pain and the risk of most types of AIDs disease.

Conclusion

Our MR analysis implied a causal relationship between MCP and MS/RA, and the effect of MCP on MS and RA may be partially mediated by BMI.

Cannabis use for pain relief in the context of health service barriers: Accounts of street-involved Nigerian women suffering chronic pain

INTRODUCTION

This study explored cannabis use for pain relief among socially marginalised Nigerian women in the context of barriers to pain management.

METHODS

The study was designed as a qualitative exploratory study of pain experience and management. Sixteen in-depth, individual interviews were conducted with street-involved women who use drugs and had chronic pain. Transcripts were coded and analysed thematically.

RESULTS

Pain was experienced as a pervasive feature of everyday life that disrupted daily routines, affected economic activities, strained social relationships and had adverse effects on health and wellbeing. Participants sought treatment in health facilities, but faced social and health system barriers to service utilisation including financial cost of services, dismissal of symptoms by providers, stigma due to physical appearance, substance use and lack of social support. These barriers encouraged disengagement from services and reliance on cannabis (along with heroin and diverted prescription opioids) for pain management. Cannabis use relieved pain and improved daily functioning, enabling participants to undertake economic activities. However, using cannabis to enhance the effects of opioids and heavy and long-term use owing to pain chronicity and disability generated concerns about harms.

DISCUSSION AND CONCLUSIONS

Findings show the therapeutic benefits of cannabis in the face of barriers to pain management. This support calls to explore the potentials of cannabis for pain management for socially marginalised populations and to develop medical guidelines to reduce the risk of adverse health consequences. Therapeutic cannabis, provided based on medical guidance, could improve pain management for socially marginalised populations.

The burden of low back pain and its association with socio-demographic variables in the Middle East and North Africa region, 1990-2019

BACKGROUND

Low back pain (LBP) is the most common musculoskeletal disorder globally. Providing region- and national-specific information on the burden of low back pain is critical for local healthcare policy makers. The present study aimed to report, compare, and contextualize the prevalence, incidence and years lived with disability (YLDs) of low back pain in the Middle East and North Africa (MENA) region by age, sex and sociodemographic index (SDI), from 1990 to 2019.

METHODS

Publicly available data were obtained from the Global Burden of Disease (GBD) study 2019. The burden of LBP was reported for the 21 countries located in the MENA region, from 1990 to 2019. All estimates were reported as counts and age-standardised rates per 100,000 population, together with their corresponding 95% uncertainty intervals (UIs).

RESULTS

In 2019, the age-standardised point prevalence and incidence rate per 100,000 in MENA were 7668.2 (95% UI 6798.0 to 8363.3) and 3215.9 (95%CI 2838.8 to 3638.3), which were 5.8% (4.3 to 7.4) and 4.4% (3.4 to 5.5) lower than in 1990, respectively. Furthermore, the regional age-standardised YLD rate in 2019 was 862.0 (605.5 to 1153.3) per 100,000, which was 6.0% (4.2 to 7.7) lower than in 1990. In 2019, Turkey [953.6 (671.3 to 1283.5)] and Lebanon [727.2 (511.5 to 966.0)] had the highest and lowest age-standardised YLD rates, respectively. There was no country in the MENA region that showed increases in the age-standardised prevalence, incidence or YLD rates of LBP over the measurement period. Furthermore, in 2019 the number of prevalent cases were highest in the 35-39 age group, with males having a higher number of cases in all age groups. In addition, the age-standardised YLD rates for males in the MENA region were higher than the global estimates in almost all age groups, in both 1990 and 2019. Furthermore, the burden of LBP was not associated with the level of socio-economic development during the measurement period.

CONCLUSION

The burden attributable to LBP in the MENA region decreased slightly from 1990 to 2019. Furthermore, the burden among males was higher than the global average. Consequently, more integrated healthcare interventions are needed to more effectively alleviate the burden of low back pain in this region.

Logic model for opioid safety in chronic non-malignant pain management, an in-depth qualitative study

BACKGROUND

Opioids are commonly used for the management of chronic non-malignant pain in Pakistan; but there is a lack of literature around precursors or motivators in the use of opioids.

AIM

The study holistically explored factors contributing towards the unsafe use of opioids and identifies strategies to overcome them.

METHOD

Exploratory qualitative methods using interviews, focus groups and non-participant observational case studies were used. Interviews and focus groups were carried out face-to-face as well as virtually and observations were conducted in community pharmacies in Islamabad and Khyber Pukhtoon Khuwa province, Pakistan. Data were collected from 4 stakeholder groups; pharmacy policy makers (n = 11), people with chronic non-malignant pain (n = 14), doctors (n = 31) and community pharmacists (n = 36) by purposive critical case sampling method. Data were analysed inductively using reflexive thematic analysis and then deductively mapped to a social ecological framework. Non-participant observations were analysed using a cross case synthesis using explanation building technique. Data from all three methods were triangulated to develop a logic model.

RESULTS

Identified factors at macro (regulation), meso (social perceptions of pain and opioids) and micro levels (uncontrolled pain, self-medication, health literacy) and strategies are presented holistically and were used to develop a logic model for the prevention and mitigation of factors currently causing unsafe use of opioids.

CONCLUSION

The study provides an in-depth view of factors contributing towards diversion of pharmaceutical opioids and can help guide national and international policy makers in their future initiatives to promote safe use of opioids in the management of chronic non-malignant pain in Pakistan.

Pharmacokinetics and tissue distribution of five bioactive components in the Corydalis yanhusuo total alkaloids transdermal patch following Shenque acupoint application in rats assessed by ultra-performance liquid chromatography-tandem mass spectrometry

The purpose of this study was to evaluate the pharmacokinetics and tissue distribution of the Corydalis yanhusuo total alkaloids transdermal patch (CTTP) following Shenque acupoint application in rats. The concentrations of corydaline, tetrahydropalmatine, tetrahydrocolumbamine, protopine, and dehydrocorydaline in rat plasma and various tissues were simultaneously detected by ultra-performance liquid chromatography-tandem mass spectrometry after Shenque acupoint administration of CTTP. Plasma, heart, liver, spleen, lung, and kidney tissue samples were collected at specific times and separated by gradient elution on an ACQUITY UPLC HSS T3 column (1.8 μm, 100 mm × 2.1 mm) with a mobile phase of 0.01% formic acid aqueous solution and acetonitrile-0.01% formic acid. The methodological results showed that the selectivity, linear range, accuracy, precision, stability, matrix effect, and extraction recovery of the established method met the requirements of biological sample analysis. The results indicated that CTTP following Shenque acupoint administration rapidly delivered adequate drug into rat blood and maintained an effective plasma level for a significantly longer time than non-acupoint administration. Furthermore, CTTP effectively reached the liver through Shenque acupoint administration and showed tissue selectivity. The data obtained could provide a prospect for the treatment of chronic pain with CTTP following Shenque acupoint application.