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Developing a minimum standard of care for treating people with osteoarthritis of the hip and knee.
March L, Amatya B, Osborne RH, Brand C.
Best Pract Res Clin Rheumatol. 2010;24(1):121-45.
We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of interventions, that should be offered to all patients with OA of the hip and/or knee. Eight core recommendations emerged where it is recommended that health-care professionals: Provide advice about, and offer access to appropriate information for OA self-management and lifestyle change; Provide advice about weight loss if patient is overweight or obese and refer to services as required; Provide advice for land-based exercises incorporating aerobic and strengthening components and refer to services as required; Recommend adequate paracetamol for pain relief; Make patients aware that non-steroid anti-inflammatory drugs (NSAIDs) or coxibs can improve symptoms in majority but this comes with potential for harm and that risk potential varies--be aware of and minimise the individual's risk potential; Offer intra-articular steroids for short-term relief of a flare or acute deterioration in symptoms; Offer stronger analgesic relief if prolonged severe symptoms; Offer access to assessment for arthroplasty for consumers with severe symptomatic OA not responding to conservative therapy. An integrated, chronic disease model of care is proposed to best implement OA management and a check list of clinical indicators/performance measures is provided. Copyright 2009. Published by Elsevier Ltd.
March L, Amatya B, Osborne RH, Brand C.
Best Pract Res Clin Rheumatol. 2010;24(1):121-45.
We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of interventions, that should be offered to all patients with OA of the hip and/or knee. -
Cortical thickness and pain sensitivity in zen meditators.
Grant JA, Courtemanche J, Duerden EG, et al.
Emotion. 2010;10(1):43-53.
Zen meditation has been associated with low sensitivity on both the affective and the sensory dimensions of pain. Given reports of gray matter differences in meditators as well as between chronic pain patients and controls, the present study investigated whether differences in brain morphometry are associated with the low pain sensitivity observed in Zen practitioners. Structural MRI scans were performed and the temperature required to produce moderate pain was assessed in 17 meditators and 18 controls. Meditators had significantly lower pain sensitivity than controls. Assessed across all subjects, lower pain sensitivity was associated with thicker cortex in affective, pain-related brain regions including the anterior cingulate cortex, bilateral parahippocampal gyrus and anterior insula. Comparing groups, meditators were found to have thicker cortex in the dorsal anterior cingulate and bilaterally in secondary somatosensory cortex. More years of meditation experience was associated with thicker gray matter in the anterior cingulate, and hours of experience predicted more gray matter bilaterally in the lower leg area of the primary somatosensory cortex as well as the hand area in the right hemisphere. Results generally suggest that pain sensitivity is related to cortical thickness in pain-related brain regions and that the lower sensitivity observed in meditators may be the product of alterations to brain morphometry from long-term practice.
Grant JA, Courtemanche J, Duerden EG, et al.
Emotion. 2010;10(1):43-53.
Zen meditation has been associated with low sensitivity on both the affective and the sensory dimensions of pain. Given reports of gray matter differences in meditators as well as between chronic pain patients and controls, the present study investigated whether differences in brain morphometry are associated with the low pain sensitivity observed in Zen practitioners. Structural MRI scans were performed and the temperature required to produce moderate pain was assessed in 17 meditators and 18 controls. Meditators had significantly lower pain sensitivity than controls. Assessed across all subjects, lower pain sensitivity was associated with thicker cortex in affective, pain-related brain regions including the anterior cingulate cortex, bilateral parahippocampal gyrus and anterior insula. -
Urine drug testing in the treatment of chronic noncancer pain: implications of recent Medicare policy changes in Kentucky.
Gilbert JW, Wheeler GR, Mick GE, et al.
Pain Physician. 2010;13(2):167-86.
BACKGROUND: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. OBJECTIVE: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. DISCUSSION: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. CONCLUSION: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse.
Gilbert JW, Wheeler GR, Mick GE, et al.
Pain Physician. 2010;13(2):167-86.
BACKGROUND: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. OBJECTIVE: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. -
Chronic low back pain analgesic studies - A methodological minefield.
Moore RA, Straube S, Derry S, et al.
Pain. 2010 Mar 19.
Moore RA, Straube S, Derry S, et al.
Pain. 2010 Mar 19.
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Reducing patient barriers to pain and fatigue management.
Borneman T, Koczywas M, Sun VC, et al.
J Pain Symptom Manage. 2010;39(3):486-501.
CONTEXT: Pain and fatigue are recognized as critical symptoms that impact the quality of life of cancer patients. The barriers to pain and fatigue relief have been classified into three categories: patient, professional, and system barriers. OBJECTIVES: The overall objective of this trial as to test the effects of the "Passport to Comfort" intervention on reducing barriers to pain and fatigue management for ambulatory care cancer patients. METHODS: This quasi-experimental, comparative study uses a Phase 1 control group of usual care followed sequentially by a Phase 2 intervention group in which educational and system-change efforts were directed toward improved pain and fatigue management. A sample of 187 cancer patients with breast, lung, colon, or prostate cancers, and a pain and/or fatigue rating of 4 or more (moderate to severe), were recruited. Patients in the intervention group received four educational sessions on pain/fatigue assessment and management, whereas patients in the control group received usual care. Pain and fatigue barriers and patient knowledge were measured at baseline, one month, and three months post-accrual. RESULTS: Patients in the intervention group experienced significant improvements in pain and fatigue measures immediately postintervention, and these improvements were sustained over time. CONCLUSION: The "Passport to Comfort" intervention was effective in reducing patient barriers to pain and fatigue management as well as in increasing patient knowledge regarding pain and fatigue. This intervention demonstrates innovation by translating the evidence-based guidelines for pain and fatigue as developed by the National Comprehensive Cancer Network into practice. (c) 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Borneman T, Koczywas M, Sun VC, et al.
J Pain Symptom Manage. 2010;39(3):486-501.
CONTEXT: Pain and fatigue are recognized as critical symptoms that impact the quality of life of cancer patients. The barriers to pain and fatigue relief have been classified into three categories: patient, professional, and system barriers. OBJECTIVES: The overall objective of this trial as to test the effects of the "Passport to Comfort" intervention on reducing barriers to pain and fatigue management for ambulatory care cancer patients. METHODS: This quasi-experimental, comparative study uses a Phase 1 control group of usual care followed sequentially by a Phase 2 intervention group in which educational and system-change efforts were directed toward improved pain and fatigue management. A sample of 187 cancer patients with breast, lung, colon, or prostate cancers, and a pain and/or fatigue rating of 4 or more (moderate to severe), were recruited. -
Ultrasound-guided interventional procedures in pain management: Evidence-based medicine.
Narouze SN.
Reg Anesth Pain Med. 2010;35(2 Suppl):S55-8.
Recently, there has been a growing interest in the application of ultrasonography in pain medicine because ultrasound provides direct visualization of various soft tissues and real-time needle advancement and avoids exposing the health care provider and the patient to the risks of radiation. The machine itself is more affordable and transferrable than a fluoroscopy, computed tomography scan, or magnetic resonance imaging machine. These factors make ultrasonography an attractive adjunct to other imaging modalities in interventional pain management especially when those modalities are not available or feasible.The present article reviews the existing evidence that evaluates the role of ultrasonography in spine interventional procedures in pain management.
Narouze SN.
Reg Anesth Pain Med. 2010;35(2 Suppl):S55-8.
Recently, there has been a growing interest in the application of ultrasonography in pain medicine because ultrasound provides direct visualization of various soft tissues and real-time needle advancement and avoids exposing the health care provider and the patient to the risks of radiation. The machine itself is more affordable and transferrable than a fluoroscopy, computed tomography scan, or magnetic resonance imaging machine. These factors make ultrasonography an attractive adjunct to other imaging modalities in interventional pain management especially when those modalities are not available or feasible.The present article reviews the existing evidence that evaluates the role of ultrasonography in spine interventional procedures in pain management. -
The effect of music on postoperative pain and anxiety.
Allred KD, Byers JF, Sole ML.
Pain Manag Nurs. 2010 Mar;11(1):15-25. Epub 2009 Mar 18.
The purpose of this study was to determine if listening to music or having a quiet rest period just before and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients who underwent a total knee arthroplasty. Fifty-six patients having a total knee arthroplasty were randomly assigned to either a music intervention group or a quiet rest group. A visual analog scale was used to measure pain and anxiety. Physiologic measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Statistical findings between groups indicated that the music group's decrease in pain and anxiety was not significantly different from the comparison rest group's decrease in pain (F = 1.120; p = .337) or anxiety (F = 1.566; p = .206) at any measurement point. However, statistical findings within groups indicated that the sample had a statistically significant decrease in pain (F = 6.699; p = .001) and anxiety (F = 4.08; p = .013) over time. Results of this research provide evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety. The interventions pose no risks and have the benefits of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with confidence, knowing there is evidence to support its efficacy. Copyright 2010 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Allred KD, Byers JF, Sole ML.
Pain Manag Nurs. 2010 Mar;11(1):15-25. Epub 2009 Mar 18.
The purpose of this study was to determine if listening to music or having a quiet rest period just before and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients who underwent a total knee arthroplasty. Fifty-six patients having a total knee arthroplasty were randomly assigned to either a music intervention group or a quiet rest group. A visual analog scale was used to measure pain and anxiety. Physiologic measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Statistical findings between groups indicated that the music group's decrease in pain and anxiety was not significantly different from the comparison rest group's decrease in pain (F = 1.120; p = .337) or anxiety (F = 1. -
Evaluation of the Acceptability and Usability of a Decision Support System to Encourage Safe and Effective Use of Opioid Therapy
Trafton J, Martins S, et al.
Pain Med. 2010 Mar 1. [Epub ahead of print]
Abstract Objective. To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. Design. CDSS development and iterative evaluation using the analysis, design, development, implementation, and evaluation process including simulation-based and in-clinic assessments of usability for providers followed by targeted system revisions. Results. Volunteers provided detailed feedback to guide improvements in the graphical user interface, and content and design changes to increase clinical usefulness, understandability, clinical workflow fit, and ease of completing guideline recommended practices. Revisions based on feedback increased CDSS usability ratings over time. Practice concerns outside the scope of the CDSS were also identified. Conclusions. Usability testing optimized the CDSS to better address barriers such as lack of provider education, confusion in dosing calculations and titration schedules, access to relevant patient information, provider discontinuity, documentation, and access to validated assessment tools. It also highlighted barriers to good clinical practice that are difficult to address with CDSS technology in its current conceptualization. For example, clinicians indicated that constraints on time and competing priorities in primary care, discomfort in patient-provider communications, and lack of evidence to guide opioid prescribing decisions impeded their ability to provide effective, guideline-adherent pain management. Iterative testing was essential for designing a highly usable and acceptable CDSS; however, identified barriers may limit the impact of the ATHENA-Opioid Therapy system and other CDSS on clinical practices and outcomes unless CDSS are paired with parallel initiatives to address these issues.
Trafton J, Martins S, et al.
Pain Med. 2010 Mar 1. [Epub ahead of print]
Abstract Objective. To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. Design. CDSS development and iterative evaluation using the analysis, design, development, implementation, and evaluation process including simulation-based and in-clinic assessments of usability for providers followed by targeted system revisions. Results. Volunteers provided detailed feedback to guide improvements in the graphical user interface, and content and design changes to increase clinical usefulness, understandability, clinical workflow fit, and ease of completing guideline recommended practices. Revisions based on feedback increased CDSS usability ratings over time. -
Consistent and Clinically Relevant Effects with Fentanyl Buccal Tablet in the Treatment of Patients Receiving Maintenance Opioid
Zeppetella G, Messina J, Xie F, Slatkin NE.
Pain Pract. 2010 Mar 3. [Epub ahead of print]
Abstract Fentanyl buccal tablet (FBT) has shown efficacy and tolerability in patients with cancer-related persistent pain treated with maintenance opioids. We conducted a combined analysis of two similarly designed, randomized, placebo-controlled studies to further evaluate the consistency and clinical relevance of analgesia outcomes. Of the 252 patients enrolled, 150 fulfilled the criteria for efficacy analysis and experienced 1,417 breakthrough pain episodes. A consistently greater effect was noted with FBT vs. placebo on the following measures: improvements from baseline of >/=33% and >/=50% in pain intensity (PI), a >/=2-point reduction in PI, and a score of >/=2 for pain relief. Improvements in these clinically meaningful efficacy measures were seen with FBT at 15 minutes (earliest common evaluation) and remained evident at 60 minutes (final common evaluation). They were also reflected in a more favorable global medication performance assessment for FBT over placebo. FBT was generally well tolerated; most adverse events were typical of potent opioid use in a cancer population. Application-site (buccal) abnormalities were infrequent and led to withdrawal of three patients. There were no serious adverse events or deaths attributable to FBT. This analysis suggests that FBT provides an analgesic effect that is consistent across multiple clinically relevant efficacy measures
Zeppetella G, Messina J, Xie F, Slatkin NE.
Pain Pract. 2010 Mar 3. [Epub ahead of print]
Abstract Fentanyl buccal tablet (FBT) has shown efficacy and tolerability in patients with cancer-related persistent pain treated with maintenance opioids. We conducted a combined analysis of two similarly designed, randomized, placebo-controlled studies to further evaluate the consistency and clinical relevance of analgesia outcomes. Of the 252 patients enrolled, 150 fulfilled the criteria for efficacy analysis and experienced 1,417 breakthrough pain episodes. A consistently greater effect was noted with FBT vs. placebo on the following measures: improvements from baseline of >/=33% and >/=50% in pain intensity (PI), a >/=2-point reduction in PI, and a score of >/=2 for pain relief. -
Does Screening for Pain Correspond to High Quality Care for Veterans?
Zubkoff L, Lorenz KA, et al.
J Gen Intern Med. 2010 Mar 14. [Epub ahead of print]
BACKGROUND: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. OBJECTIVE: To assess adherence to measures of pain management quality and identify associated patient and provider factors. DESIGN: A cross-sectional visit-based study. PARTICIPANTS: One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. MEASUREMENT AND MAIN RESULTS: We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. CONCLUSIONS: Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.
Zubkoff L, Lorenz KA, et al.
J Gen Intern Med. 2010 Mar 14. [Epub ahead of print]
BACKGROUND: Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. OBJECTIVE: To assess adherence to measures of pain management quality and identify associated patient and provider factors. DESIGN: A cross-sectional visit-based study. PARTICIPANTS: One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.
