Pain medicine: The case for an independent medical specialty and training programs

The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Shifts in Students' Attitudes Towards Pain Patients, Pain, and Opioid Management Following a Dedicated Medical School Pain Curriculum

Objective

To examine the immediate effects of a comprehensive pain course on medical students' pre-existing perceptions and attitudes toward pain patients and opioid management.

Methods

First-year medical students at a major academic medical center enrolled in a required pre-clerkship pain course in June 2020 and completed pre- and post-course online surveys with Likert-scale questions about their attitudes toward pain management and opioid-related issues. Additionally, the surveys included a free-text question where the students listed the first five words that came to mind when hearing the word "opioids". These words were categorized as "professional" or "lay" words and further as having "positive", "negative", or "neutral" connotations. Data analyses included descriptive statistics, as well as non-parametric and parametric tests.

Results

Fifty-four of the 119 students responded to pretest and posttest surveys and were included in paired analyses. There was a significant difference between the number of professional words used before (M=1.21, SD=0.97) and after the course (M=2.40 SD=1.33); t(52)=-6.39, P<0.001. Students also used more lay-positive words after the course (M=0.81, SD=0.63) than they used pre-course (M=0.23, SD=0.43); t(51)=-5.98, P<0.001. Students' post-course responses to several key Likert-scale questions showed significant shifts toward more positive attitudes about caring for patients with pain. For example, students acknowledged greater comfort in providing opioids for chronic pain (P<0.001) where appropriate, and enhanced interest in handling complex pain cases (P<0.001).

Conclusion

Results showed that a comprehensive, multi-disciplinary pain course could greatly enhance first-year medical students' attitudes toward pain management, chronic pain patients, and the complex issues surrounding opioids.

Practical approaches for clinicians in chronic pain management: Strategies and solutions

Effective management of chronic pain necessitates multidisciplinary approaches including medical treatment, physical therapy, lifestyle interventions, and behavioral or mental health therapy. Medical providers regularly report high levels of stress and challenge when treating patients with chronic pain, which recur in part due to improper education on contributors to pain and misalignment in patient and provider goals and expectations for treatment. The current paper reviews common challenges and misconceptions in the setting of chronic pain management as well as strategies for effective patient education and goal setting related to these issues. The paper also outlines key aspects of provider burnout, its relevance for medical providers in chronic pain management, and recommendations for burnout prevention in navigating issues of patient education and treatment planning.

A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Introduction/Aim

Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain.

Methods

The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted.

Results

The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs.

Discussion/Conclusions

This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.

Effectiveness and Dissemination of the Interprofessional Pediatric Pain PRN Curriculum

INTRODUCTION

Cultural transformation is needed for health care to be sensitive to children's pain. The Pediatric Pain Practice Registered Nurses (PRN) Curriculum is the first free, open access, downloadable, interprofessional pain continuing education (IPPCE) curriculum developed to empower health care professionals to translate evidence-based pain care into clinical practice. To evaluate the curriculum and its experiential flipped-learning strategies, we used a mixed methods approach.

METHODS

Interprofessional pediatric teams from eight health care systems evaluated the curriculum after attending Pediatric Pain PRN Courses in the Fall of 2017 (N = 90). Qualitative methods were used to evaluate the acceptability, feasibility, and utility of the curriculum and IPPCE strategies. Pain knowledge and attitudes were measured pre-IPPCE/post-IPPCE with the Pediatric Healthcare Provider's Knowledge & Attitude Survey Regarding Pain (PHPKAS). Web analytics were used to describe dissemination for the first year after the curriculum's webpage launch.

RESULTS

Learners rated their achievement of course objectives as moderate-great. PHPKAS scores significantly increased (P < .0005); but significant differences in physician and nurse PHPKAS question responses pre-IPPCE/post-IPPCE were found. Within 2 years of the IPPCE, three health care systems were certified as Childkind Hospitals, five Pediatric Pain PRN Programs were established, and various practice changes and improved patient outcomes, such as decreased hospital lengths of stay and emergency department returns for pain, were realized. Curriculum dissemination was global.

DISCUSSION

Results support the acceptability, effectiveness, feasibility, utility, and global dissemination of the curriculum and IPPCE strategies. More rigorous patient outcome data are needed; however, this study demonstrated the benefit of a free, open-access, downloadable, interprofessional health care provider continuing education curriculum.

Influence of provider type on chronic pain prescribing patterns A systematic review

BACKGROUND

Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues.

OBJECTIVE

Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist.

DATA SOURCES

Searches within PubMed, Embase, CINAHL, and Web of Science.

CONCLUSIONS

Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines.

IMPLICATIONS FOR PRACTICE

Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.

Qualitative Needs Assessment for the Development of Chronic Pain Group Medical Visits

Group medical visits (GMVs) for patients with chronic pain are becoming more accessible and have been shown to be successful in furthering patient education on multidisciplinary, nonopioid interventions. Unfortunately, evidence suggests that many group visit models lack sustainability due to recruitment issues and retention rates. Additionally, most of the studies surrounding GMVs are located in primarily urban health centers, potentially limiting their generalizability. This study aims to identify patient interest in and barriers to GMVs for chronic pain and to explore how chronic pain impacts daily lives for GMV content optimization in a nonurban population. Nineteen participants age 18 to 65 years participated in semistructured phone interviews to generate a thematic analysis. Participants received their care from family practitioners at a suburban multiclinic academic medical group and were being prescribed at least 50 morphine milligram equivalents (MME) at the time of recruitment. Analysis generated two themes: (1) Participants expressed specific interest in GMVs with few barriers identified, and (2) Pain has a negative impact on mental health and most aspects daily life, creating a foundation for discussion in GMVs. Findings support significant patient interest in group medical visits for chronic pain, but careful planning is necessary to address patient needs, expectations, and barriers in order to ensure GMV sustainability.

Medical Cannabis for Headache Pain: a Primer for Clinicians

PURPOSE OF REVIEW

Public acceptance of Cannabis sativa L. (cannabis) as a therapeutic option grows despite lags in both research and clinician familiarity. Cannabis-whether as a medical, recreational, or illicit substance-is and has been commonly used by patients. With ongoing decriminalization efforts, decreased perception of harms, and increased use of cannabis in the treatment of symptoms and disease, it is critical for clinicians to understand the rationale for specific therapies and their medical and practical implications for patients. In view of the opioid crisis, overall patient dissatisfaction, and lack of adherence to current chronic pain and headache therapies, this review provides up-to-date knowledge on cannabis as a potential treatment option for headache pain.

RECENT FINDINGS

Research into the use of cannabinoids for disease treatment have led to FDA-approved drugs for seizures, nausea, and vomiting caused by cancer chemotherapy; and for decreased appetite and weight loss in people with HIV/AIDS. For a wide variety of conditions and symptoms (including chronic pain), cannabis has gained increasing acceptance in society. The effects of cannabidiol (CBD) and tetrahydrocannabinol (THC) in pain pathways have been significantly elucidated. An increasing number of retrospective studies have shown a decrease in pain scores after administration of cannabinoids, as well as long-term benefits such as reduced opiate use. Yet, there is no FDA-approved cannabis product for headache or other chronic pain disorders. More is being done to determine who is likely to benefit from cannabis as well as to understand the long-term effects and limitations of the treatment. Cannabis can refer to a number of products derived from the plant Cannabis sativa L. Relatively well-tolerated, these products come in different configurations, types, and delivery forms. Specific formulations of the plant have been shown to be an effective treatment modality for chronic pain, including headache. It is important for clinicians to know which product is being discussed as well as the harms, benefits, contraindications, interactions, and unknowns in order to provide the best counsel for patients.

Understanding the Psychological, Physiological, and Genetic Factors Affecting Precision Pain Medicine: A Narrative Review

PURPOSE

Precision pain medicine focuses on employing methods to assess each patient individually, identify their risk profile for disproportionate pain and/or the development of chronic pain, and optimize therapeutic strategies to target specific pathological processes underlying chronic pain. This review aims to provide a concise summary of the current body of knowledge regarding psychological, physiological, and genetic determinants of chronic pain related to precision pain medicine.

METHODS

Following the Scale for the Assessment of Narrative Review Articles (SANRA) criteria, we employed PubMed/Medline to identify relevant articles using primary database search terms to query articles such as: precision medicine, non-modifiable factors, pain, anesthesiology, quantitative sensory testing, genetics, pain medicine, and psychological.

RESULTS

Precision pain medicine provides an opportunity to identify populations at risk, develop personalized treatment strategies, and reduce side effects and cost through elimination of ineffective treatment strategies. As in other complex chronic health conditions, there are two broad categories that contribute to chronic pain risk: modifiable and non-modifiable patient factors. This review focuses on three primary determinants of health, representing both modifiable and non-modifiable factors, that may contribute to a patient's profile for risk of developing pain and most effective management strategies: psychological, physiological, and genetic factors.

CONCLUSION

Consideration of these three domains is already being integrated into patient care in other specialties, but by understanding the role they play in development and maintenance of chronic pain, we can begin to implement both precision and personalized treatment regimens.

Practical Opportunities for Biopsychosocial Education Through Strategic Interprofessional Experiences in Integrated Primary Care

Even with the expansion of primary care teams to include behavioral health and other providers from a range of disciplines, providers are regularly challenged to deliver care that adequately addresses the complex array of biopsychosocial factors underlying the patient's presenting concern. The limits of expertise, the ever-changing shifts in evidence-based practices, and the difficulties of interprofessional teamwork contribute to the challenge. In this article, we discuss the opportunity to leverage the interprofessional team-based care activities within integrated primary care settings as interactive educational opportunities to build competencies in biopsychosocial care among primary care team members. We argue that this approach to learning while providing direct patient care not only facilitates new provider knowledge and skills, but also provides a venue to enhance team processes that are key to delivering integrated biopsychosocial care to patients. We provide three case examples of how to utilize strategic planning within specific team-based care activities common in integrated primary care settings-shared medical appointments, conjoint appointments, and team huddles-to facilitate educational objectives.

Unmet needs in the management of functional impairment in patients with chronic pain: a multinational survey

Background: A survey of European Pain Federation 2019 attendees was conducted to identify unmet needs in chronic pain patients. Materials & methods: Four questions were asked focusing on functional impairment in chronic pain, including who are at increased risk and ways to better identify and manage these patients. Results: In total 143 respondents indicated that key issues were lack of knowledge, lack of resources/time to assess and manage chronic pain and lack of sufficient tools to identify patients at risk for functional impairment. Education and training of primary care physicians, simplified guidelines and practical tools for assessment and use of multidisciplinary teams to treat chronic pain were recommended. Conclusion: There are many unmet needs in the management of functional impairment in chronic pain patients.

The Interaction Between Chronic Pain and PTSD

PURPOSE OF REVIEW

Post-traumatic stress disorder (PTSD) and chronic pain often co-occur. Understanding the shared mechanisms, signs to identify PTSD, and treatment options is integral in allowing providers to better serve their patients.

RECENT FINDINGS

Individuals with comorbid PTSD and chronic pain report greater PTSD symptoms, pain, anxiety, depression, disability, and opioid use than those with only one of these conditions. There are several empirically supported therapies for chronic pain, and for PTSD, as well as pilot data for a treatment of comorbid pain and PTSD. The purpose of this paper is to review and synthesize current literature investigating the interaction between chronic pain and PTSD, and provide treatment recommendations for providers treating patients with chronic pain and PTSD.

Project ECHO Chronic Pain: A Qualitative Analysis of Recommendations by Expert Faculty and the Process of Knowledge Translation

INTRODUCTION

Previous studies of the same Project ECHO Chronic Pain cohort demonstrated that recommendations to primary care providers (PCPs) by expert faculty follow CDC Guidelines for Prescribing Opioids and that participating PCPs change their practice accordingly. The purpose of this study was to identify how expert faculty translates knowledge, so that PCPs can act on it.

METHODS

One hundred ninety-seven PCPs from 82 practices in 14 states attended at least one Project ECHO Chronic Pain session over 10 months, hosted by a large federally qualified health center. Expert faculty was a multidisciplinary panel of six clinicians. Recommendations for 25 randomly selected case presentations were transcribed, yielding 406 discrete units of data. A thematic analysis contributed to a concept map for knowledge translation.

RESULTS

Expert faculty addressed psychosocial issues in 40% of recommendations. Three themes represented a familiar clinical decision-making process: recommendations for treatment accounted for risk factors and patient engagement and behavior. A concept map placed the recommendations for selected cases in the first phase of the action cycle in the Knowledge-to-Action framework, where knowledge is shared but not yet acted on.

DISCUSSION

Project ECHO Chronic Pain is an example of iterative guided practice, wherein expert faculty use published guidelines and professional experience to make recommendations for patient care to PCPs. This occurs using shared social-cultural-historical language and context consistent with social constructivist theories of learning.

Liquid Chromatography-Tandem Mass Spectrometry: An Emerging Technology in the Toxicology Laboratory

In the last decade, liquid chromatography-tandem mass spectrometry (LC-MS/MS) has seen enormous growth in routine toxicology laboratories. LC-MS/MS offers significant advantages over other traditional testing, such as immunoassay and gas chromatography-mass spectrometry methodologies. Major strengths of LC-MS/MS include improvement in specificity, flexibility, and sample throughput when compared with other technologies. Here, the basic principles of LC-MS/MS technology are reviewed, followed by advantages and disadvantages of this technology compared with other traditional techniques. In addition, toxicology applications of LC-MS/MS for simultaneous detection of large panels of analytes are presented.

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

Chronic pain is a common, complex, and challenging condition, where understanding the biological, social, physical and psychological contexts is vital to successful outcomes in primary care. In managing chronic pain the focus is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. Recent screening tools and brief intervention techniques can be effective in helping clinicians identify, stratify and manage both patients already living with chronic pain and those who are at risk of developing chronic pain from acute pain. Frequent assessment and re-assessment are key to ensuring treatment is appropriate and safe, as well as minimizing and addressing side effects. Primary care management should be holistic and evidence-based (where possible) and incorporates both pharmacological and non-pharmacological approaches, including psychology, self-management, physiotherapy, peripheral nervous system stimulation, complementary therapies and comprehensive pain-management programmes. These may either be based wholly in primary care or supported by appropriate specialist referral.