Identification and Management of Chronic Pain in Primary Care: a Review

Comparing the efficacy of two E-learning programs on physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management: A randomized trial

BACKGROUND

Physiotherapists play a crucial role in managing patients with musculoskeletal pain. However, their training often lacks focus on pain management.

OBJECTIVES

This randomized controlled trial evaluated the effects of two e-learning programs on physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management.

METHODS

Eligible participants had active professional registration, treated patients with musculoskeletal pain, and had internet access. Participants were randomized into two groups (video-based and booklet-based), with interventions lasting 5 weeks. Assessments were conducted at baseline, 6 weeks (T1), and 12 weeks (T2) using the Neurophysiology of Pain Questionnaire, a pain attitude survey, and self-reported confidence.

RESULTS

A total of 211 physiotherapists were randomized (video = 106; booklet = 105). Both groups improved pain neurophysiology knowledge, with the booklet group scoring higher at T1 (adjusted mean difference = 1.25, 95%CI = 0.93 to 1.58) and T2 (adjusted mean difference = 1.30, 95%CI = 0.97 to 1.63). Attitudes varied: the booklet group improved in emotion (adjusted mean difference = -0.19, 95%CI = -0.35 to -0.03) and control (adjusted mean difference = -0.20, 95%CI = -0.37 to -0.03) at T2, while the video group improved in solicitude (adjusted mean difference = -0.37, 95% CI: 0.55 to -0.19) and disability at T1 and T2. No significant effects were found in the medical cure domain, and no interaction effects were observed in the physical harm domain. Confidence increased in both groups, with no between-group differences.

CONCLUSION

Both e-learning programs effectively enhanced physiotherapists' knowledge, attitudes, and confidence in musculoskeletal pain management, demonstrating the value of e-learning for continuing education.

Application of a Nociceptive Test Battery to Assess Potential Synergy between Two Analgesics in Healthy Subjects

Chronic pain management remains a major challenge due to the risks associated with conventional treatments, such as opioids and NSAIDs, which carry significant risks, including addiction, tolerance, and adverse side effects, particularly with prolonged use. Combining opioid with nonopioid drugs offer a potential solution, as it may minimize opioid-related side effects by reducing the required opioid dose. We performed a study to compare the analgesic effects and safety of a pregabalin-morphine combination to each drug alone and placebo in healthy volunteers. A randomized, double-blind, placebo-controlled crossover design was used, with subjects receiving 300 mg of pregabalin combined with 3 and 7 mg of morphine, morphine only, pregabalin only, or a double placebo. Analgesic effects and CNS side effects were assessed up to 10 h postdose using nociceptive and neurocognitive test batteries. Results demonstrated that the pregabalin-morphine combination significantly increased pain tolerance compared to either drug alone on several pain tests (cold pressor, electrical burst, electrical stair, and pressure pain) with only minimal additional CNS side effects compared to monotherapy and placebo. This study indicates that validated nociceptive and CNS test batteries were suitable to assess the potential of opioid-sparing combination therapies in an experimental setting.

A discrete choice experiment: Understanding patient preferences for managing chronic non-cancer pain

BACKGROUND

The management of chronic non-cancer pain (CNCP) is complex. Concerns about adverse effects associated with opioid pain medications and a lack of funding for holistic programs present challenges for decision-making among clinicians and patients. Discrete choice experiments (DCE) are one way of assessing and valuing patient treatment preferences.

METHOD

DCE attributes and levels were generated through qualitative research and included number of medicines, side effects from medicines, pain interference, care management, risk of addiction, activity goals, preferred source of information on pain management and willingness to pay. The survey was administered to participants with CNCP recruited through an existing cohort study (n = 442) and a sample of people living with CNCP recruited through Australia's leading pain advocacy body (Painaustralia) (n = 256).

RESULTS

The median age of participants was 58 years (SD 12.0), the majority were female. The analysis revealed two latent demographic classes: a younger group with higher levels of private health insurance and an older group with lower levels of private health insurance coverage. There were notable differences in preference. The younger cohort exhibited a greater willingness-to-pay to reduce pain interference, whereas the older group prioritized GP management, preferred more medicines and expressed fewer addiction concerns.

CONCLUSION

Patients' treatment preferences diverged based on age and insurance status, underscoring the importance of understanding patient perspectives in treatment communication and care coordination. These findings provide insight into patient decision-making, which is important for promoting access to quality healthcare and engagement with evidence-based treatment of CNCP.

SIGNIFICANCE STATEMENT

A discrete choice experiment identified two groups: younger, with more private insurance, and older, with less private health insurance, each with unique pain management preferences. Clinicians should be aware that age and private health insurance may have an impact on a patient's preferences for CNCP management.

Recognition at the Heart of the Complex Situations Experienced by People With Chronic Musculoskeletal Pain

OBJECTIVE

Chronic musculoskeletal pain (CMSP) is frequent in chronic diseases, decreasing the quality of life of these patients. In a survey conducted in Belgium in 2019, chronic pain was named by patients as the main factor of complexity in their lives. The objective of our research was to provide elements to understand why and how CMSP contributes to the complexity of these people's lives.

DESIGN

Qualitative study through semi-structured interviews.

SETTING

The study was conducted in Belgium with French-speaking individuals. The interviews took place at the university, in a teaching hospital, in private clinics or in individuals' homes.

PARTICIPANTS

We included 24 individuals with CMSP and living complex situations. The recruitment was made in two phases in agreement with the grounded theory methodology and to reach the saturation of ideas.

RESULTS

The complexity experienced by people with CMSP turns around the notion of recognition, which can be broken down into 3 spheres: intimate, social and legal. The poor quality of listening and the fragmented vision of aid and care professionals generate a feeling of loneliness and incomprehension in the face of illness. The unsuitability of the world of work, the opacity of protocols and the attitude of medical experts reveal inequalities in access to recognition for immigrants and people of low socio-professional status.

CONCLUSION

The complexity of the situations experienced could be reduced by implementing health policies that facilitate: legal recognition of this illness; adaptability in the workplace; raising awareness about pain mechanisms; the risks of stigmatization and the need of interprofessional collaboration.

PATIENT OR PUBLIC CONTRIBUTION

Patients and the public participated in the dissemination of our research and were able to help us with recruitment through social networks (call for participation published on Facebook by the association 'Aidants proches') or word of mouth. The presentation of preliminary results at conferences as well as the publication of a public article in Belgian journals (http://www.lejournaldumedecin.com/magazine/douleurs-chroniques-un-veritable-parcours-du-combattant/article-normal-63055.html?cookie_check=1671467500%22) facilitated the contact with the public.

Which Patients With Chronic Pain Do The Primary Care Refers to a Tertiary Hospital in a Developing Country? Experience From a University Hospital

PURPOSE

The study aimed to profile patients with uncontrolled chronic pain referred from primary care to a tertiary hospital in a developing country, and identify factors associated with pain intensity, interference, and its link with mental health.

DESIGN

Cross-sectional design.

METHODS

Data from 906 adult patients with nonmalignant chronic pain during their first visit to the multidisciplinary pain center at the State University of Rio de Janeiro in 2019 were used. The brief pain inventory and the Hospital Anxiety and Depression Scale questionnaire assessed pain intensity, its impact on daily activity, and symptoms of anxiety and depression.

RESULTS

The population was predominantly female (68.8%), over 50 (66.3%), with less than 11 years of education (86.5%), and 75.2% were overweight or obese. Most (81.9%) reported moderate or severe pain, significantly interfering with daily activities (>50%). The lower back was the most commonly affected site. Widespread pain was present in 43.6% of patients. High scores for anxiety (67.4%) and depression (52.2%) were observed. Severe pain was predominantly seen in middle-aged women and individuals with high levels of anxiety and depression.

CONCLUSION

Patients with uncontrolled chronic pain referred from primary care to a tertiary hospital were predominantly female, overweight or obese, and exhibited a high prevalence of depression and anxiety. Their pain significantly interfered with daily activities.

CLINICAL IMPLICATIONS

The study provides valuable insight into the biopsychosocial characteristics of uncontrolled chronic pain patients in primary care, emphasizing the importance of implementing multidisciplinary approaches to manage chronic pain effectively within primary care settings.

Understanding General Practitioner and Patient Perceptions Regarding Integration of Non-Pharmacological Interventions in Chronic Non-Cancer Pain Management-A Cross-Sectional Mixed-Methods Study in the RELIEF Project

Background: Chronic non-cancer-related pain is an independent condition with a multicausal genesis. Guidelines highlight the need for holistic treatment based on the bio-psycho-social model. While prescribing medication is common, it remains unclear how and to what extent non-pharmacological interventions are considered and recommended in general practice pain management. The project RELIEF explored the integration of non-pharmacological interventions in general practices in Germany from both physician and patient perspectives. Methods: A mixed-methods study collected data with patients and general practitioners via semi-structured telephone interviews and self-developed questionnaires. Qualitative data were analyzed in a reflexive thematic analysis. Survey data were analyzed descriptively. Results: N = 383 questionnaires (n = 131 general practitioners, n = 252 patients) and n = 61 interviews (n = 21 general practitioners, n = 40 patients) were analyzed. Patient and physician perceptions regarding the integration of non-pharmacological interventions differed. Patients felt pharmacological therapy was recommended primarily, applied non-pharmacological interventions based on their own initiative, and were aware of bio-psycho-social interrelations. Physicians perceived that they often recommended physiotherapy and psychotherapy alongside analgesics, and asked about non-pharmacological interventions (79.4%), explained the bio-psycho-social chronic pain genesis (55.7%), and provided information on physical (48.9%) and social (35.9%) activity, relaxation techniques (42%), topical applications (31.9%), and support groups (25.2%). Conclusions: The integration of holistic pain management and communication between patients and general practitioners appear to need strengthening.

Pharmacodynamic characteristics and influencing factors of tapentadol for chronic pain relief under dose titration

Objective

The aim of this study was to establish a pharmacodynamic model of tapentadol analgesia under dose titration conditions, to quantitatively analyze the time-effect relationship of the drug, and to identify relevant influencing factors. This model is intended to provide a pharmacodynamic reference for designing rational tapentadol dose titration schemes in clinical research.

Methods

Randomized controlled trials assessing the efficacy of tapentadol in the management of chronic pain were retrieved from public databases (PubMed and EMBASE). A time-effect relationship model of the percent change in Numerical Rating Scale (NRS) scores post-tapentadol intervention from baseline was constructed, along with a covariate model to identify factors significantly impacting the analgesic effects of tapentadol. Potential influencing factors that were clinically significant but not included in the final covariate model were examined for their impact trends on tapentadol analgesia through subgroup analysis.

Results

A total of 16 studies involving 4,508 participants were included in the analysis. Covariate analysis indicated that age significantly affected the maximum reduction in NRS scores following tapentadol treatment, with the reduction rate being 40.9% for patients aged 45 and 60.7% for those aged 65, suggesting that older patients have a higher demand for pain relief. Furthermore, studies published after 2014 and placebo-controlled trials showed a slower rate of NRS reduction, indicating a more cautious approach to tapentadol dosing titration post the U.S. opioid crisis and in placebo-controlled contexts. Additionally, subgroup analysis suggested that higher titration doses, higher baseline NRS levels, the use of extended-release tapentadol, and a smaller proportion of male participants were trends associated with better analgesic effects, although the differences were not statistically significant. Moreover, the study found that tapentadol was significantly more effective in treating lower back pain compared to non-lower back pain.

Conclusion

This research successfully developed a pharmacodynamic model for dose-titrated tapentadol administration, which can simulate the temporal changes in analgesic effects of tapentadol across different clinical scenarios. This model can guide the formulation of dosing titration protocols for tapentadol in clinical research.

Systematic Review Registration

https://inplasy.com/inplasy-2024-5-0014/.

Use of acupuncture among chronic disease patients attending primary healthcare facilities: a cross-sectional study in Korea

BACKGROUND

Given the crucial role of integrating acupuncture treatment into primary care for managing chronic diseases, this study endeavors to identify the utilization of acupuncture among chronic disease patients seeking primary care services in Korea. Additionally, it aims to evaluate their knowledge level and perceptions related to acupuncture use.

METHODS

A descriptive cross-sectional study was conducted among chronic disease patients attending a primary care clinic in Korea. A self-reported questionnaire comprising 37 items was employed to evaluate the utilization of acupuncture treatment. These items covered socio-demographic information, respondents' health status, levels of acupuncture knowledge, and patterns of acupuncture use. Using the SPSS Statistics 26.0 Network Version program, descriptive statistics, a chi-square test, and a logistic regression analysis were performed to identify factors associated with acupuncture treatment.

RESULTS

Out of 370 respondents, 44.3% reported utilizing acupuncture treatment. The most popular reason for the utilization of acupuncture was to enhance the effectiveness of the current treatment. The patients with musculoskeletal disease had the highest utilization rate of 53.2%. The main source of information for acupuncture use was family and friends. The average score for the level of knowledge on acupuncture treatment among the respondents was 65.4%, and the knowledge level of the acupuncture group was high. Potential predictors of acupuncture use included musculoskeletal disease, and intention to recommend acupuncture.

CONCLUSION

This study highlights the widespread acceptance of acupuncture use among patients with chronic diseases in primary healthcare context. Integration of acupuncture into primary care emerges as a viable avenue for effective chronic disease management, and fostering a comprehensive and holistic approach to healthcare.

CLINICAL TRIAL NUMBER

Not applicable.

Exploring the Characteristics and Utilization of General Practice Healthcare by Adults With Cerebral Palsy: A Systematic Review

BACKGROUND

Individuals with cerebral palsy (CP) experience acute and chronic health issues requiring lifespan primary care. This review aimed to investigate characteristics and utilization of general practitioner (GP) access by adults with CP. Secondary aims included exploring reasons prompting access, identifying interventions provided, and personal features affecting access.

METHODS

Using systematic review methodology, 5 databases were searched using keywords relating to adults, CP, and primary care, relating to quantitative studies (January 2000-July 2024). Data was extracted, collated, and analyzed descriptively, with additional meta-analyses to estimate proportion of GP visits.

RESULTS

Fifteen studies were included describing GP access by 6231 adults with CP. The proportion annually accessing a GP was 78% (95% CI = 69%-85%). The frequency of GP access ranged from 1.76 to 11.7 visits per year, increased with advancing age and disability severity. Comorbid intellectual disability and pain also increased GP attendance. Limited data was available reporting healthcare needs prompting GP access, and no interventions were described.

CONCLUSIONS

Advancing age, greater disability severity, comorbid intellectual disability, and pain may prompt increased GP access by adults with CP. Identification of reasons for seeking primary care, and interventions provided are required through data linkage studies to enhance lifespan care.

Management of pain in cancer patients - an update

Pain is one of the most detrimental symptoms exhibited by cancer patients, being an indication for opioid therapy in up to half of the patients receiving chemotherapy and even more for those with advanced cancer. This article aims to briefly overview current knowledge on cancer-related pain with a focus on assessment and new approaches and trends. We will also provide some insight on the lower- and middle-income countries context.

Data sources

A narrative review of the literature was conducted including relevant guidelines and recommendations from scientific societies and WHO.

Data summary

Data on the approach and assessment of cancer pain as well as current and novel approaches have been displayed with the help of tables and figures.

Conclusion

Since the initial recommendations of the WHO analgesic ladder method, new insights have emerged. Scientific progress reaches its maximum social sense when populations and governments prioritise the value of relief and compassion, and concrete actions are implemented with the aim of relieving cancer pain.

The WHO guidelines: the new and the old

PURPOSE OF THE REVIEW

The original World Health Organisation (WHO) cancer pain guidelines were published in 1986 and used globally. Updated guidance was released in 2018. This review compares the 'old' with the 'new' with a closer look at the relevance of the WHO analgesic ladder in the current climate.

RECENT FINDINGS

The new guidelines provide a more evidence based, rigorously developed document including recommendations relating to radiotherapeutic management. There is a more detailed focus on safe opioid prescribing, opioid stewardship and the importance of integrating pain management expertise early on in the cancer journey. There remains a lack of evidence for certain therapies despite their widespread use particularly in relation to adjuvants. The pitfalls of the original renowned analgesic ladder are highlighted including a recognition that omitting 'step 2' is safe, feasible and cost effective.

SUMMARY

The new guidelines offer more detailed recommendations relevant to clinical practice with a strong focus on safety of opioid prescribing making it relevant in the current climate. The original WHO analgesic ladder is no longer recommended as a strict protocol for cancer pain management.

The unmet mental health needs of U.S. adults living with chronic pain

ABSTRACT

Previous research suggests that individuals with mental health needs and chronic pain may be less likely to use mental health treatment compared with those with mental health needs only. Yet, few studies have investigated the existence of population-level differences in mental health treatment use. We analyzed data from the National Health Interview Survey (n = 31,997) to address this question. We found that chronic pain was associated with end-to-end disparities in the mental health journeys of U.S. adults: (1) Those living with chronic pain are overrepresented among U.S. adults with mental health needs; (2) among U.S. adults with mental health needs, those living with chronic pain had a lower prevalence of mental health treatment use; (3) among U.S. adults who used mental health treatment, those living with chronic pain had a higher prevalence of screening positive for unremitted anxiety or depression; (4) among U.S. adults living with both chronic pain and mental health needs, suboptimal mental health experiences were more common than otherwise-just 44.4% of those living with mental health needs and co-occurring chronic pain reported use of mental health treatment and screened negative for unremitted anxiety and depression, compared with 71.5% among those with mental health needs only. Overall, our results suggest that U.S. adults with chronic pain constitute an underrecognized majority of those living with unremitted anxiety/depression symptoms and that the U.S. healthcare system is not yet adequately equipped to educate, screen, navigate to care, and successfully address their unmet mental health needs.

The impact of dipeptidyl peptidase 4 inhibitors on health-related quality of life in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

PURPOSE

To evaluate the impact of dipeptidyl peptidase 4 (DPP-4) inhibitors on Health-related quality of life (HRQOL) in patients with type 2 diabetes mellitus (T2DM) compared with other hypoglycemic agents.

METHODS

A systematic review and meta-analysis based on randomized controlled trials was conducted following the Cochrane Handbook and PRISMA. Studies were identified by searching PubMed (MEDLINE), EMBASE, Web of Science, CNKI, WANGFANG DATA, VIP DATABASE, Google Scholar, and Cochrane Central Register of Controlled Trials from database inception to Dec 30, 2023. The main result was HRQOL scores. The outcomes were extracted using the mean difference (MD) from each study. Sensitivity analysis and subgroup analysis were also performed.

RESULTS

Forty studies (4,579 participants) were included, with 32 pooled for meta-analysis. DPP-4 inhibitors alongside conventional treatment significantly enhanced HRQOL compared to conventional treatment alone (MD = 9.85, 95% CI [7.98-11.71], P < 0.001; heterogeneity, I2 = 94%, P < 0.001), as assessed by SF-36 using a random-effects model. No additional benefit was found when measured by DTR-QOL using a fixed-effects model (MD = 2.29, 95% CI [-0.06-4.64], P = 0.06; heterogeneity, I2 = 49%, P = 0.1) and compared to SGLT-2 inhibitors. Subgroup analysis indicated that DPP-4 inhibitors favored patients ≥ 60 years old on medication for ≥ 6 months.

CONCLUSIONS

DPP-4 inhibitors were superior for T2DM HRQOL improvement. More long-term, multicenter evidence is needed to generalize findings and compare them with newer hypoglycemic agents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42023440134.

Barriers and facilitators for physical activity in people living with chronic pain: a systematic review and combined analysis

ABSTRACT

Chronic pain is a prevalent and complex health issue associated with physical, emotional, and social consequences. Management of pain is multifactorial and challenging; however, physical activity (PA) has consistently been shown to be beneficial. Despite this, PA levels among people with chronic pain are low. This study aimed to identify facilitators and barriers to PA among adults with chronic pain and analyse these using the structure of a validated behaviour change model: the capability, opportunity, and motivation behaviour change model (COM-B). We performed a systematic review of 6 databases and subsequent combined analysis including peer-reviewed primary research published in English up to November 15, 2023. Search terms consisted of 3 components: pain, PA, and facilitators/barriers. Quality appraisal of studies was conducted using appropriate tools. The systematic search yielded 40 eligible studies with a total of 2164 participants. The studies represented various chronic pain conditions, locations, and study designs. The key barriers to engagement in PA were the impact of pain severity, comorbidities, lack of knowledge about PA benefits, and time constraints. Key facilitators were a personalised approach, social support, and awareness of the benefits. The findings were categorised according to the COM-B model, allowing for the identification of modifiable factors. Person-centred approaches, education, and accessible environments were identified as important aspects to consider for successful PA promotion among people with chronic pain. Utilising the factors identified in the COM-B model is crucial for successful future interventions to increasing PA uptake and adherence in this population.

Evaluation of chiropractic students' knowledge and attitudes following pain interventions: A randomized educational trial at 2 institutions

OBJECTIVE

To examine chiropractic students' attitudes regarding knowledge of pain neuroscience, chronic pain, and patient-centered care before and after educational interventions. Secondarily, this study aimed to compare measures of these skills between cohorts at different timepoints throughout training programs.

METHODS

Using stratified randomization, 281 Year 3 chiropractic students at 2 institutions were allocated into 1 of 3 educational interventions and served as active-control comparison groups: pain neuroscience education, chronic pain education, or patient-centered care. Participants completed validated surveys regarding their experience with the education interventions immediately pre- and post-lecture and 12 weeks after completion. For further comparison, surveys were also completed by 160 Year 1 students and 118 Year 2 students at 1 of the institutions. Independent sample t tests and 1-way analysis of variance were used for data analysis.

RESULTS

All Year 3 lecture groups showed immediate improvements (pain neuroscience education: 3.99 + 3.09/100, p = .18 [95% CI: 10.10 to -1.77]; chronic pain education: 0.42 + 0.74/7, p = .02 [95% CI: 0.72 to 0.07]; patient-centered care: 0.25 + 0.12/6, p = .05 [95% CI: 0.12-0.51]), but these were not sustained at the 12-week follow-up (pain neuroscience education: -6.25 + 4.36/100, p = .15 [95% CI: 14.93 to -2.42]; chronic pain education: 0.33 + 0.16/7, p = .19 [95% CI, 0.66 to 0.01]; patient-centered care: 0.13 + 0.13/6, p = .30 [95% CI: 0.41 to -0.13]). Compared to active controls, only the patient-centered care group showed an immediate statistically significant difference.

CONCLUSIONS

While this study found that immediate improvement in targeted competencies is possible with focused interventions, they were not sustained long term.

The perpetual evidence-practice gap: addressing ongoing barriers to chronic pain management in primary care in three steps

Background

Most management of chronic pain, a serious illness affecting the physical and psychological wellbeing of millions, occurs in primary care settings. Primary care practitioners (PCPs) attempt to provide evidence-based practices to treat chronic pain. However, there continues to be a gap between the care people receive and the evidence. The objectives for this study were to (1) explore determinants of evidence-based chronic pain management and (2) develop a novel approach to using implementation science to address the evidence-practice gap.

Method

A convenience sample of twenty-one Pennsylvania PCPs participated in one-time semi-structured telephone interviews. Interviews were transcribed verbatim and both deductive and inductive approaches were used during analysis. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) to inform our analysis and findings.

Results

We identified determinants of evidence-based chronic pain management across the CFIR domains of Intervention Characteristics, Characteristics of Individuals, and the Outer Setting and reported implementation strategies. Based on identified themes, we developed a three-step process to support the ongoing and pragmatic implementation of evidence-based chronic pain management in primary care settings.

Conclusions

Previous efforts exist to integrate implementation science into chronic pain management; yet a gap persists. Implementation approaches should prioritize the needs of people living with chronic pain and their families. Further, future approaches or strategies used should build on the current three-step model to include the fourth step of tailoring existing implementation strategies to the specific needs of chronic pain in the clinical context.

Comparing cognitive behavioral therapy and social prescribing in patients with loneliness on long-term opioid therapy to reduce opioid misuse: protocol for a randomized controlled trial

BACKGROUND

Patients with chronic pain on opioids frequently experience loneliness, which is associated with poorer health outcomes and higher risk for opioid misuse and opioid use disorder. Given that almost half of opioids are prescribed in primary care, a critical need exists for the development and testing of interventions to reduce loneliness in primary care patients at risk for opioid misuse. Cognitive behavioral therapy and social prescribing have been shown to be efficacious in reducing loneliness and improving outcomes in other populations but have not been tested in patients at risk for substance use disorder. The overall objective of our study is to reduce opioid misuse and opioid use disorder by addressing loneliness in patients on long-term opioid therapy in real-world primary care settings.

METHODS

We will conduct a 3-arm pragmatic, randomized controlled trial to compare the effectiveness of two group-based, telehealth-delivered interventions with treatment as usual: (1) cognitive behavioral therapy to address maladaptive thought patterns and behaviors around social connection and (2) a social prescribing intervention to connect participants with social opportunities and develop supportive social networks. Our primary outcome is loneliness as measured by the UCLA Loneliness Scale and our dependent secondary outcome is opioid misuse as measured by the Common Opioid Misuse Measure. We will recruit 102 patients on long-term opioid therapy who screen positive for loneliness from 2 health care systems in Washington State. Implementation outcomes will be assessed using the RE-AIM framework.

DISCUSSION

Our study is innovative because we are targeting loneliness, an under-addressed but critical social risk factor that may prevent opioid misuse and use disorder in the setting where most patients are receiving their opioid prescriptions for chronic pain. If successful, the project will have a positive impact in reducing loneliness, reducing opioid misuse, improving function and preventing substance use disorder.

TRIAL REGISTRATION

NCT06285032, issue date: February 28, 2024, original.

Non-hallucinogenic compounds derived from iboga alkaloids alleviate neuropathic and visceral pain in mice through a mechanism involving 5-HT2A receptor activation

The aim of this study was to determine the anti-hypersensitivity activity of novel non-hallucinogenic compounds derived from iboga alkaloids (i.e., ibogalogs), including tabernanthalog (TBG), ibogainalog (IBG), and ibogaminalog (DM506), using mouse models of neuropathic (Chronic Constriction Injury; CCI) and visceral pain (dextrane sulfate sodium; DSS). Ibogalogs decreased mechanical hyperalgesia and allodynia induced by CCI in a dose- and timeframe-dependent manner, where IBG showed the longest anti-hyperalgesic activity at a comparatively lower dose, whereas DM506 displayed the quickest response. These compounds also decreased hypersensitivity induced by colitis, where DM506 showed the longest activity. To understand the mechanisms involved in these effects, two approaches were utilized: ibogalogs were challenged with the 5-HT2A receptor antagonist ketanserin and the pharmacological activity of these compounds was assessed at the respective 5-HT2A, 5-HT6, and 5-HT7 receptor subtypes. The behavioral results clearly demonstrated that ketanserin abolishes the pain-relieving activity of ibogalogs without inducing any effect per se, supporting the concept that 5-HT2A receptor activation, but not inhibition, is involved in this process. The functional results showed that ibogalogs potently activate the 5-HT2A and 5-HT6 receptor subtypes, whereas they behave as inverse agonists (except TBG) at the 5-HT7 receptor. Considering previous studies showing that 5-HT6 receptor inhibition, but not activation, and 5-HT7 receptor activation, but not inhibition, relieved chronic pain, we can discard these two receptor subtypes as participating in the pain-relieving activity of ibogalogs. The potential involvement of 5-HT2B/2 C receptor subtypes was also ruled out. In conclusion, the anti-hypersensitivity activity of ibogalogs in mice is mediated by a mechanism involving 5-HT2A receptor activation.

Management of chronic non-cancer pain by primary care physicians: A qualitative study

Chronic non-cancer pain is a highly prevalent health issue with personal and societal consequences. Patients suffering from chronic non-cancer pain are mainly cared for by primary care physicians, but research shows that the latter perceive treating chronic pain as difficult. This qualitative descriptive study aimed to explore how primary care physicians in Switzerland manage patients with chronic non-cancer pain and what factors influence patient management. Data were collected through semi-structured interviews amongst primary care physicians in the German speaking part of Switzerland. A thematic analysis of the interviews allowed to identify four main themes: Investigation of chronic pain; patient-provider relationship; patient characteristics, and medical recommendations. These themes were closely interconnected and influenced each other. Physicians not only enquired about the origin of pain but also about the patients' beliefs and expectations towards it. They stressed the role of communication in fostering a good patient-physician relationship and to help patients cope with their pain. In addition to purely medical considerations, the psychological, social and economic situation of their patients and their possible impacts on the management of chronic non-cancer pain played a crucial role when recommending a treatment. This study highlighted the complexity of chronic pain management, which entails that primary care physicians need to figure out a unique strategy for each patient. By integrating patients' values and beliefs, as well as socioeconomic aspects, primary care physicians are in a position to take the lead in chronic non-cancer pain management. However, considering the burden of this disease, more continuous medical education on chronic pain is needed for primary care physicians, especially to better take into account the social determinants of pain.

"They really trust us!": Medical Interpreter's Roles and Experiences in an Integrated Primary Care Clinic

This study describes medical interpreters' experiences with behavioral health (BH) services in a primary care clinic. Focus group data with medical interpreters representing multiple languages was analyzed using hybrid inductive-deductive thematic analysis. Themes related to interpreter roles were: (1) case management, (2) patient-interpreter relationship, and (3) patient-provider liaison. Themes related to barriers and facilitators to interpreter-mediated BH care were: (1) cultural factors, (2) patient-provider interactions, (3) BH-specific considerations, and (4) clinic factors. Results illustrate ways that interpreters directly (e.g., interpreter-mediated services) and indirectly (e.g., relationship building) support care. The interpreter-patient relationship reportedly helped improve patient attitudes and buy-in for BH.

A control study on pain characteristics and influencing factors in patients with depressive disorders-based on a 5-year follow-up report from the epidemiological survey of mental disorders in Shandong Province, China

BACKGROUND

This study extends from the 2015 Shandong Province Epidemiological Survey of Mental Disorders in adults aged 18 and above. Over five years, it investigates pain characteristics and influencing factors in individuals with depressive disorders in Shandong Province.

METHODS

The study encompasses 871 individuals who met DSM-IV criteria for depressive disorders in 2015. Using 1:1:1 matching by gender, age, and residence, 825 non-afflicted individuals were selected as high-risk controls, and 825 screening-negative individuals became low-risk controls. A follow-up study in 2020 involved 1848 participants. Survey tools included a general information questionnaire, General Health Questionnaire-12 (GHQ-12), SCID-I/P, Global Pain Scale (GPS), Quality of Life Questionnaire (QLQ), PSQI, MoCA, and clinical data questionnaire.

RESULTS

GPS scores in the current depressive group were higher than in non-current depressive group (Z = 14.36, P < 0.01). GPS scores in study group exceeded those in high-risk and low-risk control groups (H = 93.71, P < 0.01). GPS scores in non-remission group were higher than in the remission group (Z = 8.90, P < 0.01). Regression analysis revealed positive correlations between GPS scores and physical illnesses, current depression, incumbency, GHQ-12 total score, and PSQI total score. Negative correlations were observed with QLQ total score and MoCA total score.

LIMITATIONS

The study could not assess pain during the 2015 survey, limiting controlled pain analysis before and after five years.

CONCLUSION

Depression sufferers may experience prolonged heightened pain, potentially relieved when depression subsides. Individual pain is influenced by depression, physical illnesses, sleep quality, quality of life, cognitive function, gender, residence, and occupation.

Psychometric properties and domains covered by patient-reported outcome measures used in trials assessing interventions for chronic pain

OBJECTIVES

To identify the patient-reported outcome measures (PROMs) used in clinical trials assessing interventions for chronic pain, describe their psychometric properties, and the clinical domains they cover.

STUDY DESIGN AND SETTING

We identified phase 3 or 4 interventional trials: on adult participants (aged >18 years), registered in clinicaltrials.gov between January 1, 2021 and December 31, 2022, and which provided "chronic pain" as a keyword condition. We excluded diagnostic studies and phase 1 or 2 trials. In each trial, one reviewer extracted all outcomes registered and identified those captured using PROMs. For each PROM used in more than 1% of identified trials, two reviewers assessed whether it covered the six important clinical domains from the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT): pain, emotional functioning, physical functioning, participant ratings of global improvement and satisfaction with treatment, symptoms and adverse events, and participant disposition (eg, adherence to medication). Second, reviewers searched PubMed for both the initial publication and latest review reporting the psychometric properties of each PROM and assessed their content validity, structural validity, internal consistency, reliability, measurement error, hypotheses testing, criterion validity, and responsiveness using published criteria from the literature.

RESULTS

In total, 596 trials assessing 4843 outcomes were included in the study (median sample size 60, interquartile range 40-100). Trials evaluated behavioral (22%), device-based (21%), and drug-based (10%) interventions. Of 495 unique PROMs, 55 were used in more than 1% trials (16 were generic pain measures; 8 were pain measures for specific diseases; and 30 were measures of other symptoms or consequences of pain). About 50% PROMs had more than 50% of psychometric properties rated as sufficient. Scales often focused on a single clinical domain. Only 25% trials measured at least three clinical domains from IMMPACT.

CONCLUSION

Half of PROMs used in trials assessing interventions for chronic pain had sufficient psychometric properties for more than 50% of criteria assessed. Few PROMs assessed more than one important clinical domain. Only 25% of trials measured more than 3/6 clinical domains considered important by IMMPACT.

Unraveling the Tapestry of Pain: A Comprehensive Review of Ethnic Variations, Cultural Influences, and Physiological Mechanisms in Pain Management and Perception

The medical management of pain is a nuanced challenge influenced by sociocultural, demographic, and ethical factors. This review explores the intricate interplay of these dimensions in shaping pain perception and treatment outcomes. Sociocultural elements, encompassing cultural beliefs, language, societal norms, and healing practices, significantly impact individuals' pain experiences across societies. Gender expectations further shape these experiences, influencing reporting and responses. Patient implications highlight age-related and socioeconomic disparities in pain experiences, particularly among the elderly, with challenges in managing chronic pain and socioeconomic factors affecting access to care. Healthcare provider attitudes and biases contribute to disparities in pain management across racial and ethnic groups. Ethical considerations, especially in opioid use, raise concerns about subjective judgments and potential misuse. The evolving landscape of placebo trials adds complexity, emphasizing the importance of understanding psychological and cultural factors. In conclusion, evidence-based guidelines, multidisciplinary approaches, and tailored interventions are crucial for effective pain management. By acknowledging diverse influences on pain experiences, clinicians can provide personalized care, dismantle systemic barriers, and contribute to closing knowledge gaps, impacting individual and public health, well-being, and overall quality of life.

Chronic nonspecific multiple-sites pain [CNMSP] of unknown etiology: Biopsychosocial method of evaluation for the primary care level

Background

Understanding and dealing with chronic nonspecific pain (CNP) is the important entity at primary care hospital. Chronic nonspecific multiple-site pain [CNMSP] of unknown etiology creates diagnostic and therapeutic challenges for primary care physicians due to lack of guidance regarding evaluation and treatment.

Aims and Objectives

To classify and formulate the evaluation, treatment strategies, and prediction of prognosis of patients with CNMSP of unknown etiology.

Methods

Patients present with CNMSP of more than 3-month duration without any obvious medical cause. The biopsychosocial [BPS] model with 3P model was applied to see the biological, psychological, and social factors behind persistence. Finally, patients were classified into four groups for evaluation response to treatment and relapse rates in 12-month follow-up.

Results

Of the total 243 patients of CNMSP, 243 [96.3%] were females. Sixty [24.7%] patients had short duration, and 183 [75.3%] had long duration. Headache was in 115 [47%], low back pain ± leg pain in 96 [39.4%], cervical pain ± shoulder/arm pain in 83 [34.1%], and diffuse body pain in 50 [20.5%] in various combinations. A total of 155 [63.8%] patients had high somatization-sensitization index (SSI), and 144 [59.3%] had low ferritin level. Group 1 [high SSI and low ferritin] had 37.9% of patients, group 2 [high SSI and normal ferritin] had 25.9% of patients, group 3 [low to medium SSI with low ferritin] had 21.4% of patients, and group 4 [low to medium SSI with normal ferritin] had 14.8% of patients. Response to pain symptoms was better in group 1, and relapse rate was higher in group 2.

Conclusion

CNMSP of unknown etiology itself is a heterogeneous entity, and assessment based on the BPS model can be very useful to understand the treatment plan and outcome of these patients.

Exercise effect on pain is associated with negative and positive affective components: A large-scale internet-based cross-sectional study in Japan

Pain is a global health problem that leads to sedentary behavior and tends to cause negative emotion. In contrast, exercise is widely recommended for a health promotion, while pain often worsens with physical activity. Although exercise therapy is often prescribed to people with pain, the mechanisms of exercise effect on pain remains unclear. In this study, we tried to identify a universal association factor between regular exercise and pain intensity utilizing a cross-sectional web-based survey involving 52,353 adult participants from a large national study conducted in Japan. Using principal component analysis, we uncovered a mediation model of exercise effect on pain through psychological components. Analyses were performed in half of the population with pain (n = 20,330) and validated in the other half (n = 20,330), and showed that high-frequency exercise had a significant association with reduction in pain intensity. We also found Negative Affect and Vigor, two psychological components, are fully associating the exercise effect on pain (indirect effect =  - 0.032, p < 0.001; association proportion = 0.99) with a dose-dependent response corresponding to the frequency of exercise. These findings were successfully validated (indirect effect of high-frequency exercise =  - 0.028, p < 0.001; association proportion = 0.85). Moreover, these findings were also identified in subpopulation analyses of people with low back, neck, knee pain, and the tendency of the exercise effect on pain was increased with older people. In conclusion, the effect of exercise on pain is associated with psychological components and these association effects increased in parallel with the frequency of exercise habit regardless pain location.

Efficacy of chronic neck pain self-treatment using press needles: a randomized controlled clinical trial

Background

Chronic neck pain is common among Japanese individuals, but few receive treatment. This randomized controlled trial aimed to evaluate the efficacy of acupuncture using press needles in the self-treatment of chronic neck pain and preliminarily identify the characteristics of patients likely to benefit from this treatment.

Methods

Fifty participants with chronic neck pain were allocated to receive either press needle or placebo treatment for 3 weeks. The visual analogue scale (VAS) and motion-related VAS (M-VAS) scores for neck pain, Neck Disability Index score, and pressure pain threshold were measured at baseline, after the first session, at the end of the last session, and 1 week after the last session. Changes in the outcomes were analyzed using analysis of variance, and the relationships between the variables were evaluated using structural equation modeling.

Results

Intervention results as assessed by VAS score revealed no significant differences in the ANOVA. A between-groups comparison of M-VAS scores at the end of the last session and baseline showed a significant difference (press needle: -21.64 ± 4.47, placebo: -8.09 ± 3.81, p = 0.025, d = -0.65). Structural equation modeling revealed a significant pain-reducing effect of press needle treatment (β = -0.228, p = 0.049). Severity directly affected efficacy (β = -0.881, p < 0.001). Pain duration, baseline VAS and Neck Disability Index scores were variables explaining severity, while age and occupational computer use were factors affecting severity.

Conclusion

Self-treatment with press needles for chronic neck pain did not significantly reduce the VAS score compared to placebo but reduced the motion-related pain as assessed by M-VAS score. A direct association was observed between pain severity and the effectiveness of press needles, and the impact of age and computer were indirectly linked by pain severity.

Clinical Trial Registration

Identifier UMIN-CTR, UMIN000044078.

Professional-Facing Digital Health Solutions for the Care of Patients With Chronic Pain: Protocol for a Systematic Scoping Review

BACKGROUND

Chronic pain is a highly prevalent condition and one of the most common reasons why people seek health care. As a result, chronic pain has a significant personal and economic burden. The COVID-19 pandemic has aggravated the situation for patients with chronic pain through increased risk factors (eg, anxiety or depression) as well as decreased access to health care. Digital health solutions to support people with chronic pain are becoming increasingly popular. Most of the research has focused on patient-facing digital health solutions, although it is clear that the involvement of health and care professionals is crucial in chronic pain care. Certainly, digital health solutions intended for the use of health and care professionals in the care of patients with chronic pain (ie, professional facing) exist, for example, for clinical decision support; however, no review has investigated the studies reporting these interventions.

OBJECTIVE

The overall aim of this scoping review is to identify the available professional-facing digital health solutions for the purpose of chronic pain management. The objectives of this review are to investigate the components, target populations, and user settings of the available professional-facing digital solutions; health and care professionals' perspectives on using digital health solutions (if reported); the methods in which the digital health solutions are developed; and the outcomes of using professional-facing digital health solutions.

METHODS

Databases including MEDLINE, Embase, CINAHL, PsycInfo, and Inspec will be searched for studies reporting professional-facing digital health solutions for chronic pain care, using a comprehensive search strategy developed for each of the specific databases. A total of 2 independent reviewers will screen the titles and abstracts for review inclusion and then conduct full-text screening. Any conflicts in study inclusion will be resolved by a third reviewer at each stage of the screening process. Following data extraction and quality assessment, a qualitative content analysis of the results will be conducted. This review will identify the available professional-facing digital health solutions for chronic pain management. The results of this review are likely to be heterogeneous in terms of content (ie, the digital solutions will serve a variety of purposes, settings, target populations, etc) and methods (ie, experimental and nonexperimental designs).

RESULTS

The review is expected to finish in March 2024 and published in the summer of 2024.

CONCLUSIONS

This protocol outlines the need for a scoping review to identify professional-facing digital health solutions for the management of chronic pain. Results from this review will contribute to the growing field of research into the utility of digital health for chronic pain management.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51311.

Endorsing a Biopsychosocial Perspective of Pain in Individuals With Chronic Pain: Development and Validation of a Scale

OBJECTIVES

Patients' beliefs about pain play an important role in their readiness to engage with chronic pain self-management. The central aim of this study was to validate a self-report instrument to assess a specific set of pain beliefs, patients' endorsement of a biopsychosocial model of chronic pain Patients' Endorsement of a Biopsychosocial Model of Chronic Pain Scale (PEB).

METHODS

Interdisciplinary experts in the field of pain were involved in creating an instrument, the PEB Scale, to operationalize patients' endorsement of a biopsychosocial pain model. A sample of 199 patients with chronic pain was recruited to evaluate the factorial structure (principal axis factoring), the internal consistency (Cronbach alpha), the convergent and discriminant validity (correlational analyses), incremental validity (multiple, hierarchical regression analyses), and construct validity (differential population analysis) of the instrument.

RESULTS

The factor analysis resulted in a unidimensional, 11-item instrument that explained 51.2% of the total variance. Cronbach alpha (=0.92) indicated high internal consistency of the created set of pain-related beliefs. Regression analyses demonstrated that PEB is a strong predictor of patients' engagement with pain self-management ( P < 0.001) after controlling for demographic variables, anxiety, depression, and other pain-related beliefs.

DISCUSSION

Our results show that the PEB Scale is a highly reliable self-report instrument that has the potential to predict patients' readiness to adopt pain self-management. Future research should focus on revalidating the scale to operationalize PEB. Moreover, the PEB Scale should be implemented in longitudinal study designs to investigate its ability to predict the transition from acute to chronic pain and patients' long-term pain management.

Association of Risk Factors and Comorbidities With Chronic Pain in the Elderly Population

INTRODUCTION/OBJECTIVE

Chronic pain disorders affect about 20% of adults in the United States, and it disproportionately affects individuals living in the neighborhoods of extreme socioeconomic disadvantage. In many instances, chronic pain has been noted to arise from an aggregation of multiple risk factors and events. Therefore, it is of importance to recognize the modifiable risk factors. The aim of this study was to investigate the comorbid medical conditions and risk factors associated with chronic pain disorders in patients aged 65 years and older.

METHODS

Our team retrospectively reviewed medical records of elderly patients (65 years and older) who were evaluated in our outpatient medicine office between July 1, 2020 and June 30, 2021 for acute problems, management of chronic medical problems, or well visits. We divided our patients into a group who suffered from chronic pain disorder, and another group who did not have chronic pain disorder. The association of variables were compared between those groups.

RESULTS

Of the 2431 patients, 493 (20.3%) had a chronic pain disorder. A higher frequency of females in the group with chronic pain disorder was found compared to the group without a chronic pain disorder (60.6% vs 55.2%; P = .033). The mean ages between the two groups were similar in the group with a chronic pain disorder compared to the group without (76.35 ± 7.5 year vs 76.81 ± 7.59 year; P = .228). There were significant associations of certain comorbidities in the group with a chronic pain disorder compared to the group without a chronic pain disorder, such as depression (21.9% vs 15.2%; P < .001), anxiety (27.0% vs 17.1%; P < .001), chronic obstructive pulmonary disease (8.7% vs 6.1%; P = .036), obstructive sleep apnea (16.8% vs 11.6%; P = .002), gastroesophageal reflux disease (40.8% vs 29.0%; P < .001), osteoarthritis (49.3% vs 26.1%; P < .001), other rheumatologic diseases (24.9% vs 19.4%; P = .006), and peripheral neuropathy (14.4% vs 5.3%; P < .001).

CONCLUSION

Female sex, depression, anxiety, chronic obstructive pulmonary disease, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, other rheumatologic diseases, and peripheral neuropathy were significantly associated with chronic pain disorder in elderly patients, while BMI was not associated with chronic pain disorder.

Overlap of pain-related and general measures of disability among adults with chronic pain

PURPOSE

Chronic pain is known to be correlated with disability. We aimed to determine the overlap between a general self-reported measure of disability and a measure of disability due to pain problems among adults with chronic pain.

MATERIALS AND METHODS

We used data from the National Health Interview Survey (NHIS) and analyzed respondents with chronic pain in the past 3 months. General disability was defined as being limited in the kind or amount of work one can do due to any physical, mental, or emotional problem. Pain-related disability was defined as pain limiting one's activity on "most days" or "every day."

RESULTS

Based on a sample of 6874 respondents with chronic pain, 58% had either kind of disability, including 9% who reported only pain-related, but not general disability; and 27% who reported both types of disability. Respondents reporting only pain-related, but not general disability tended to be younger and had lower rates of obesity, smoking, diabetes, and hypertension than respondents reporting both pain-related and general disability.

DISCUSSION

Among people with chronic pain, most people with disability are experiencing limitations related to pain problems. Assessment of disability without addressing pain interference has likely underestimated the disability burden in this population.

Clinical Diagnosis and Treatment of Chronic Pain

More than 600 million people globally are estimated to be living with chronic pain. It is one of the most common complaints seen in an outpatient setting, with over half of patients complaining of pain during a visit. Failure to properly diagnose and manage chronic pain is associated with substantial morbidity and mortality, especially when opioids are involved. Furthermore, it is a tremendous financial strain on the healthcare system, as over USD 100 billion is spent yearly in the United States on healthcare costs related to pain management and opioids. This exceeds the costs of diabetes, heart disease, and cancer-related care combined. Being able to properly diagnose, manage, and treat chronic pain conditions can substantially lower morbidity, mortality, and healthcare costs in the United States. This review will outline the current definitions, biopsychosocial model, subclassifications, somatosensory assessments, imaging, clinical prediction models, and treatment modalities associated with chronic pain.

Multicentre cross-sectional study assessing content validity of the International Classification of Functioning, disability and health core set for post-acute musculoskeletal conditions in primary care physiotherapy services

OBJECTIVE

To assess content validity of the comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for post-acute musculoskeletal conditions in primary care physiotherapy services.

DESIGN

Multicentre cross-sectional study.

SUBJECTS

Patients with musculoskeletal disorders referred to primary care physiotherapy services.

METHODS

Structured interviews were conducted using categories from the ICF Core Set, and their relevance was assessed using a visual analogue scale. An ICF category had to represent a problem for at least 5% of the sample in order to be validated.

RESULTS

The study sample comprised 274 patients. All categories in the ICF Core Set were confirmed. Body functions related to pain and movement were the most commonly impaired, with ICF categories "b280 Sensation of pain" and "b710 Mobility of joint functions" having the highest prevalence (87.2% and 84.7%, respectively). Activity limitations and participation restrictions were concentrated in chapters "d4 Mobility" (63.5% for "d430 Lifting and carrying objects") and "d2 General tasks and demands" (59.5% for "d240 Handling stress and other psychological demands"). The most relevant environmental factors were "e225 Climate" (55.8%) and "e580 Health services, systems and policies" (39.4%).

CONCLUSION

The ICF Core Set for post-acute musculoskeletal conditions shows appropriate content validity for primary care physiotherapy services.

A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing

OBJECTIVES

To explore the continuum of pain and addiction for patients with chronic pain (CP) who used opioids during a time of restrictive opioid prescribing in West Virginia.

DESIGN

This qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed.

SETTING

West Virginia.

PARTICIPANTS

Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists.

INTERVENTION

Semistructured interviews.

MAIN OUTCOME MEASURE

To better understand the impact of restrictive prescribing measures on people who used opioids for CP.

RESULTS

Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a "life saver."

CONCLUSIONS

Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to "get high" but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management.

KEY MESSAGE

Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress

BACKGROUND

Chronic pain conditions impose significant burdens worldwide. Pharmacological treatments like opioids have limitations. Non-invasive non-pharmacological therapies (NINPT) encompass diverse interventions including physical, psychological, complementary and alternative approaches, and other innovative techniques that provide analgesic options for chronic pain without medications.

MAIN BODY

This review elucidates the mechanisms of major NINPT modalities and synthesizes evidence for their clinical potential across chronic pain populations. NINPT leverages peripheral, spinal, and supraspinal mechanisms to restore normal pain processing and limit central sensitization. However, heterogeneity in treatment protocols and individual responses warrants optimization through precision medicine approaches.

CONCLUSION

Future adoption of NINPT requires addressing limitations in standardization and accessibility as well as synergistic combination with emerging therapies. Overall, this review highlights the promise of NINPT as a valuable complementary option ready for integration into contemporary pain medicine paradigms to improve patient care and outcomes.

Involvement of Oxidative Stress and Nutrition in the Anatomy of Orofacial Pain

Pain is a very important problem of our existence, and the attempt to understand it is one the oldest challenges in the history of medicine. In this review, we summarize what has been known about pain, its pathophysiology, and neuronal transmission. We focus on orofacial pain and its classification and features, knowing that is sometimes purely subjective and not well defined. We consider the physiology of orofacial pain, evaluating the findings on the main neurotransmitters; in particular, we describe the roles of glutamate as approximately 30-80% of total peripheric neurons associated with the trigeminal ganglia are glutamatergic. Moreover, we describe the important role of oxidative stress and its association with inflammation in the etiogenesis and modulation of pain in orofacial regions. We also explore the warning and protective function of orofacial pain and the possible action of antioxidant molecules, such as melatonin, and the potential influence of nutrition and diet on its pathophysiology. Hopefully, this will provide a solid background for future studies that would allow better treatment of noxious stimuli and for opening new avenues in the management of pain.

Effects of interdisciplinary pain rehabilitation programs on neuropathic and non-neuropathic chronic pain conditions - a registry-based cohort study from Swedish Quality Registry for Pain Rehabilitation (SQRP)

BACKGROUND AND AIM

Neuropathic pain arises as a direct consequence of a lesion or disease affecting the somatosensory system. Pharmacological treatments for neuropathic pain often fail despite following guidelines. Interdisciplinary Pain Rehabilitation Programs (IPRP) are an effective intervention for chronic pain conditions. Little research has investigated whether IPRP can benefit patients with chronic neuropathic pain compared to other chronic pain conditions. This study assesses the real-world effects of IPRP on patients with chronic neuropathic pain compared to non-neuropathic patients using Patient-Reported Outcome Measures (PROMs) available in the Swedish Quality Registry for Pain Rehabilitation (SQRP).

METHODS

A neuropathic group of patients (n = 1,654) were identified in two steps. This group was compared to a non-neuropathic group (n = 14,355) composed of common diagnoses (low back pain, fibromyalgia, whiplash associated disorders, and Ehlers-Danlos Syndrome) in relation to background variables, three overall outcome variables, and mandatory outcome variables (pain intensity, psychological distress symptoms, activity/participation aspects and health-related quality of life variables). Of these patients 43-44% participated in IPRP.

RESULTS

At assessment, the neuropathic group reported significantly (with small effect sizes (ES)) more physician visits the previous year, older age, shorter pain durations, and less spatial extent of the pain (moderate ES). Moreover, for the 22 mandatory outcome variables, we found only clinically insignificant differences according to ESs between the groups. For patients participating in IPRP, the neuropathic group displayed equal or in some cases slightly superior results compared to the non-neuropathic group.

DISCUSSION AND CONCLUSION

After assessing the real-world effects of IPRP, this large study found that neuropathic pain patients can benefit from the IPRP intervention. Both registry studies and RCTs are needed to better understand which patients with neuropathic pain are most suitable for IPRP and to what extent special considerations need to be made for these patients within the framework of IPRP.

Implementation of an online pain science education for chronic musculoskeletal pain in Brazilian public health system: protocol for a hybrid type III randomised controlled trial with economic evaluation

BACKGROUND

Although clinical practice guidelines recommend pain education as the first-line option for the management of chronic musculoskeletal pain, there is a lack of pain education programmes in healthcare. Thus, digital health programmes can be an effective tool for implementing pain education strategies for public health. This trial will aim to analyse the implementation and effectiveness outcomes of three online pain science education strategies in the Brazilian public health system (SUS) for individuals with chronic musculoskeletal pain.

METHODS

We will conduct a hybrid type III effectiveness-implementation randomised controlled trial with economic evaluation. We will include adult individuals with chronic musculoskeletal pain, recruited from primary healthcare in the city of Guarapuava, Brazil. Individuals will be randomised to three implementation groups receiving a pain science education intervention (EducaDor) but delivered in different modalities: group 1) synchronous online; group 2) asynchronous videos; and group 3) interactive e-book only. Implementation outcomes will include acceptability, appropriateness, feasibility, adoption, fidelity, penetration, sustainability, and costs. We will also assess effectiveness outcomes, such as pain, function, quality of life, sleep, self-efficacy, and adverse effects. Cost-effectiveness and cost-utility analyses will be conducted from the SUS and societal perspectives. The evaluations will be done at baseline, post-intervention (10 weeks), and 6 months.

DISCUSSION

This study will develop and implement a collaborative intervention model involving primary healthcare professionals, secondary-level healthcare providers, and patients to enhance self-management of chronic pain. In addition to promoting better pain management, this study will also contribute to the field of implementation science in public health by generating important insights and recommendations for future interventions.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05302180; 03/29/2022).

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Transcranial direct current stimulation combined with peripheral stimulation in chronic pain: a systematic review and meta-analysis

INTRODUCTION

The combination of Transcranial Direct Current Stimulation (tDCS) with peripheral stimulation may optimize their effects and bring positive results in treatment of people with chronic pain.

AREAS COVERED

A systematic review with meta-analysis of randomized and non-randomized trials was performed to investigate the combination of tDCS with peripheral stimulation in adults with chronic pain. The primary outcome was pain intensity. Six studies were included in this review (sample of 228 participants), which investigated the combination of tDCS and transcutaneous electrical nerve stimulation, peripheral electrical stimulation, breathing-controlled electrical stimulation and intramuscular electrical stimulation. The conditions studied were knee osteoarthritis, spinal cord injury, chronic low back pain, and neurogenic pain of the arms. Pain intensity, measured by visual analog scale or numerical rating scale, was reduced in all included studies when at least one of the interventions was active, regardless they were combined or alone, with or without tDCS. However, meta-analysis showed superiority of tDCS used in combination with peripheral stimulation.

EXPERT OPINION

This systematic review and meta-analysis suggests positive effects of tDCS combined with peripheral stimulation in chronic pain conditions. However, the evidence of the primary outcome was classified as low quality due to the limited number of studies.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusions

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

The state of the art in telerehabilitation for musculoskeletal conditions

BACKGROUND

Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future.

MAIN BODY

Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users.

CONCLUSIONS

Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Multimodal Chronic Pain Therapy for Adults via Smartphone: Randomized Controlled Clinical Trial

BACKGROUND

Combination therapies delivered remotely via the internet or mobile devices are increasingly being used to improve and promote the self-management of chronic conditions. However, little is known regarding the long-term effects of these interventions.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a multimodal intervention program that measures associated variables such as catastrophizing, pain acceptance, and quality of life using a mobile device in people with chronic pain in an outpatient setting.

METHODS

A randomized controlled clinical trial was performed using parallel treatment groups. A total of 209 patients with chronic musculoskeletal pain were randomly assigned to one of the two study arms. The intervention group received a standard web-based psychosocial therapy-type program of activities through a smartphone for 6 weeks. The control group only had access to the Find out more section of the app, which contained audiovisual material for pain management based on a self-help approach. The primary outcome was catastrophizing measured using the Pain Catastrophizing Scale (PCS). Secondary outcomes were pain acceptance measured using the Chronic Pain Acceptance Questionnaire and health-related quality of life measured using the EuroQol Visual Analogue Scale. Assessments were conducted at baseline (T1), after treatment (T2), and at the 3-month follow-up (T3). The variations between the different phases were assessed using the percentage change rescaled with log base 2. The Cohen d was calculated based on the results of the linear mixed model. The investigators of the study who evaluated the results were not involved in patient recruitment and were blinded to the group assignment.

RESULTS

Positive effects were found in the intervention group (T2-T1) in catastrophizing between the baseline and posttreatment phases (P<.001) and in helplessness (-0.72 vs 0.1; P=.002), rumination (-1.59 vs -0.53; P<.001), acceptance (0.38 vs 0.05; P=.001), and quality of life (0.43 vs -0.01; P=.002), although no significant changes were found for magnification (0.2 vs 0.77; P=.14) and satisfaction with health (0.25 vs -0.27; P=.13). Three months after treatment, significant differences were observed in the intervention group for the outcome variable of catastrophizing (PCS; -0.59 vs 0.2; P=.006) and the PCS subscales of helplessness (-0.65 vs 0.01; P=.07), rumination (1.23 vs -0.59; P=.04), and magnification (0.1 vs 0.86; P=.02).

CONCLUSIONS

The results of our study suggest that app-based mobile multidimensional treatments for adults with chronic pain improve catastrophizing, quality of life, and psychological flexibility immediately after treatment and that the effects are maintained for the primary outcome of catastrophizing for at least 3 months following treatment. Moreover, they promote self-management and can be used to complement face-to-face pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04509154; https://clinicaltrials.gov/ct2/show/NCT04509154.

Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials

BACKGROUND

Current pain management recommendations emphasize leveraging interdisciplinary teams. We aimed to identify key features of interdisciplinary team structures and processes associated with improved pain outcomes for patients experiencing chronic pain in primary care settings.

METHODS

We searched PubMed, EMBASE, and CINAHL for randomized studies published after 2009. Included studies had to report patient-reported pain outcomes (e.g., BPI total pain, GCPS pain intensity, RMDQ pain-related disability), include primary care as an intervention setting, and demonstrate some evidence of teamwork or teaming; specifically, they needed to involve at least two clinicians interacting with each other and with patients in an ongoing process over at least two timepoints. We assessed study quality with the Cochrane Risk of Bias tool. We narratively synthesized intervention team structures and processes, comparing among interventions that reported a clinically meaningful improvement in patient-reported pain outcomes defined by the minimal clinically important difference (MCID).

RESULTS

We included 13 total interventions in our review, of which eight reported a clinically meaningful improvement in at least one patient-reported pain outcome. No included studies had an overall high risk of bias. We identified the role of a care manager as a common structural feature of the interventions with some clinical effect on patient-reported pain. The team processes involving clinicians varied across interventions reporting clinically improved pain outcomes. However, when analyzing team processes involving patients, six of the interventions with some clinical effect on pain relied on pre-scheduled phone calls for continuous patient follow-up.

DISCUSSION

Our review suggests that interdisciplinary interventions incorporating teamwork and teaming can improve patient-reported pain outcomes in comparison to usual care. Given the current evidence, future interventions might prioritize care managers and mechanisms for patient follow-up to help bridge the gap between clinical guidelines and the implementation of interdisciplinary, team-based chronic pain care.

The 2021 NICE guidelines for assessment and management of chronic pain: A cross-sectional study mapping against a sample of 1,000* in the community

Objectives

To characterise the prevailing pharmacological and non-pharmacological pain management strategies among adults with chronic pain, comparing these against the newly published NICE guidelines NG-193, and examine these pre-NG-193 pain management strategies in relation to pain severity, pain interference, sleep quality and mental health outcomes.

Design

This study was conducted using a cross-sectional online survey study design.

Setting

This study was conducted on a community-dwelling cohort.

Participants

Adults aged 18+, living in the UK, with diagnosis of chronic pain by a health care professional.

Main outcome measures

Primary outcomes were characterisation of the pain management strategies utilised. Secondary outcomes were related to pain severity, pain interference, sleep quality, depression and anxiety via validated self-report measures.

Results

Several strategies were employed by respondents to manage their chronic pain condition including physical therapy, exercise, psychological therapy and pharmacological therapy. The data also indicated a high level of joint-care planning among patients and their clinicians. Some group differences were found in relation to pain, sleep and mental health outcomes.

Conclusion

This study set a comparative starting baseline to which the efficacy of the NG-193 may be compared in future years. There is evidence that NICE recommendations are being followed for the management of chronic primary pain conditions; however, pharmacological use of opioid drugs is still reported by 47%. Despite the confirmed evidence in this study of small efficacy of chronic pain by pharmacological agent, the reduction in the use of pain relief medications be it over the counter medications or prescription opioids, as recommended by NG-193, may be slow to be adopted. The data suggest that more care provision is needed to meet the recommendations around pharmacological management and review.

Patients' Experiences of Using an eHealth Pain Management Intervention Combined With Psychomotor Physiotherapy: Qualitative Study

Background

Chronic pain is a major health challenge to those affected. Blended care with psychomotor physiotherapy (PMP) combined with eHealth self-management might be beneficial.

Objective

This study aims to explore how patients with chronic pain experience the combination of PMP and the use of EPIO, an eHealth self-management intervention for chronic pain.

Methods

Individual semistructured interviews were conducted with 5 adult patients with chronic pain (ie, participants) who used EPIO in combination with PMP over a period of 10 to 15 weeks. Interviews explored participants’ experiences using this treatment combination in relation to their pain and analyzed their experiences using systematic text condensation.

Results

Participants described having benefited from using EPIO in combination with PMP in terms of increased awareness of bodily signals and how pain was related to stress and activity. They also described changes in the relationship to themselves in terms of increased self-acceptance, self-assertion, and hope and their relationship to their pain in terms of seeing pain as less harmful and engaging in more active coping strategies.

Conclusions

Results indicate that a blended care approach combining eHealth self-management interventions such as EPIO with PMP may be of value to patients living with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104