Beyond the needle: expanding the role of anesthesiologists in the management of chronic non-malignant pain.

Chronic pain and narcotics: a dilemma for primary care.

Issues in Long-term Opioid Therapy: Unmet Needs, Risks, and Solutions

Clinical Associate Professor of Anesthesiology; University of Calgary; Department of Anaesthesia; Foothills Hospital; 1403 29th Street NW; Calgary, Alberta; Canada T2N 2T9 (Lang)Clinical Assistant Professor of Anesthesiology; University of Calgary; Department of Anaesthesia; Foothills Hospital; Calgary, Alberta, Canada (Arraf)Acting Assistant Professor; Department of Anesthesiology; University of Washington; Multidisciplinary Pain Center; Seattle, Washington (Tumber)Clinical Assistant Professor of Anesthesiology; Department of Anaesthesia; University of Saskatchewan; Royal University Hospital; Saskatoon, Saskatchewan, Canada (Shah)To the Editor:-After reading the letters by Erjavec [1]and Khan [2]and the accompanying response by Jacobson, [3]we felt obliged to share some of our ideas regarding chronic pain management. As anesthesiologists involved in the management of chronic pain we share the points of view expressed by Jacobson et al. [4]Their emphasis on a biopsychosocial model of chronic non-malignant pain that also embraces a biomedical approach when appropriate seems ideal.We would like to comment on the “training” of anesthesiologists in the subject of chronic pain. It is our belief that we are failing our residents, our profession, and patients with the current approach used in many anesthesiology residency and chronic pain fellowship programs. We concur with Jacobson et al. that the focus of “current pain training is on regional anesthesia, interventional techniques, and medication management.” We further agree that “anesthesiologists training in chronic pain management need more biopsychosocial instruction.”However, there are issues important to the recruitment and training of anesthesiologists in the area of chronic pain management that are just as important as the lack of “biopsychosocial training.” Although physicians can be trained to communicate more effectively, it is equally likely that a physician's personality may limit his or her effectiveness as a biopsychosocial healer while allowing the physician to function appropriately in a traditional biomedical environment. Therefore, when recruiting physicians into anesthesia residency programs more attention needs to be paid to recruitment of people who are more likely to be effective and happy as biopsychosocial healers if, ultimately, we expect them to treat patients with chronic pain. This is especially true in Canada where true multidisciplinary pain clinics are few and anesthesiologists must assume multiple roles.We agree that anesthesiologists are in an excellent position to contribute to the management of chronic pain. However, anesthesiologists graduating from “traditional” anesthesiology residencies often think that a chronic pain fellowship is simply a ticket to a job, which often leads to job dissatisfaction. Further discontent is created by the failure of traditional training programs to adequately prepare residents for their role in treating patients with chronic non-malignant pain, and which is compounded by the lack of acceptance regarding the importance of this role by anesthesiologists serving in more traditional venues. Add to this the “financial penalty” perpetuated and maintained by “traditional” fee schedules and the necessity to provide “continuity of care”(a concept foreign to most “traditional” anesthesiologists), and the discontent grows.If “anesthesiologists” are to continue to participate in the treatment of these patients, these “problems” need to be addressed by our leaders. If not, other disciplines will quickly take on the leadership role by training their own in the science and art of biopsychosocial healing. Biomedical interventions requiring technical expertise may occasionally require the assistance of a proficient anesthesiologist, but many of these skills can be readily learned by physicians in other disciplines (e.g., interventional radiologists).In summary, although anesthesiologists have an opportunity to make an important contribution in the management of chronic non-malignant pain, there are many obstacles hindering progress in this area.Scott A. Lang, M.D.Clinical Associate Professor of Anesthesiology; University of Calgary; Department of Anaesthesia; Foothills Hospital; 1403 29th Street NW; Calgary, Alberta; Canada T2N 2T9John Arraf, M.D.Clinical Assistant Professor of Anesthesiology; University of Calgary; Department of Anaesthesia; Foothills Hospital; Calgary, Alberta, CanadaPaul Tumber, M.D., C.C.F.P., F.R.C.P.C.Acting Assistant Professor; Department of Anesthesiology; University of Washington; Multidisciplinary Pain Center; Seattle, WashingtonMisbah Shah, M.D.Clinical Assistant Professor of Anesthesiology; Department of Anaesthesia; University of Saskatchewan; Royal University Hospital; Saskatoon, Saskatchewan, Canada(Accepted for publication August 4, 1998.)

Opioids for the treatment of acute pain and the pain of malignancy have been strongly encouraged for more than 25 years.1 In the past 2 decades, the treatment of chronic noncancer pain using long-term opioid therapy has become more common. However, recent studies have revealed the astonishing rapidi

The OPENMinds Primary Care group is a group of European primary care physicians (PCPs) with an interest in pain management, formed to improve the understanding and management of chronic pain in primary care. A survey was conducted to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs. A questionnaire was developed for online use by PCPs in 13 European countries (Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, and the UK). A total of 1309 PCPs completed the questionnaire, approximately 100 from each country. Most PCPs (84%) perceived CNMP to be one of the most challenging conditions to treat, yet a low priority within healthcare systems. Only 48% of PCPs used pain assessment tools, and 81% considered chronic pain and its impact on quality of life to be underassessed in primary care. PCPs were less confident about prescribing strong opioids for CNMP than for use in cancer pain. Most PCPs (84%) considered their initial training on CNMP was not comprehensive, with 89% recognizing a need for more education on the topic. These findings reveal that PCPs in Europe find CNMP a challenge to treat. Areas to address with training include underuse of pain assessment tools and lack of confidence in use of opioid therapy. Guidelines on CNMP management in primary care would be welcomed. The insights gained should provide the basis for future initiatives to support primary care management of chronic pain.

Opioid Agreement or Patient-Centric Action Plan?

ABSTRACTChronic pain is one of the most common reasons for patients to seek medical care. Chronic pain results in substantial economic losses and remains one of the most costly conditions in modern western society. In 1991, costs were estimated to be approximately $65 billion annually, comparable to the cost of treating diabetes. Persistent chronic pain and the use of advanced interventional and pharmacological treatments often leads to complex social and psychological maladaptations, health care overutilization, as well as many other substantial direct and indirect costs. Thus, the proper treatment of chronic pain involves intense multidisciplinary management, including pharmacological, behavioral, and psychological interventions. Few studies have assessed the total economic cost of chronic pain. However, many of the chronic pain treatments do not alleviate pain symptoms for most patients and lead to unsuccessful application of resources. The economic consequences of inadequately treated chronic pain translates into lost work days, overutilization of health care resources (excess hospitalizations, and surgical procedures and inappropriate medications) and other out-of-pocket patient expenses. Increasing emphasis on diagnosis and treatment of chronic pain places more importance on the need for efficient and coordinated management of patient with chronic pain. The management of chronic pain is remarkably complex and resource intensive. Therefore, a clear need exists for intensive pharmacoeconomic investigations, specifically evaluating costs related to chronic pain and the associated treatment modalities. Additionally, evaluation of the costs related to chronic pain would measure the economic burden of chronic pain, including an estimate of the amount that could potentially be saved if chronic pain patients are optimally managed.

Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt

Background & Objectives: Chronic non-malignant neuropathic pain management is a major challenge for the clinicians despite a wide range of analgesics and pain treatment protocols. First, second, and third line drug treatments for neuropathic pain include the use of anticonvulsants, tricyclic antidepressants, mixed serotonin and norepinephrine reuptake inhibitors, opioids and other various treatment opportunities. However, the results of these treatment protocols for neuropathic pain management are heterogeneous and sometimes with short term outcomes. Although nerve blocks have been recognized as a major modality in chronic pain management, they are not included in guidelines for chronic non-malignant neuropathic pain management. The aim of our study was to investigate whether administration of peripheral nerve blocks with local anesthetic and corticosteroid significantly reduced pain in patients with chronic non-malignant neuropathic pain resistant to standard treatment, based on guidelines for chronic neuropathic pain management. Materials & Methods: 55 patients with chronic non-malignant neuropathic pain that was resistant to standard treatment based on guidelines for neuropathic pain were included in our study. The mixture of local anesthetic (0.125% levobupivacaine) and corticosteroid (betamethasone) was used to perform the blocks of peripheral nerves. Pain was assessed by the use of numeric pain rating scale (NPRS), with range 0-10 (0-no pain to 10-worst possible pain). Pain was evaluated before the application of peripheral nerve blocks and 3 weeks after. Differences between groups of patients were assessed by Wilcoxon signed rank test. All P-values were two-sided and statistical significance (p) was set at a value of 0.01. Results: A Wilcoxon signed rank test revealed a statistically significant reduction in pain, assessed on NPRS, following administration of peripheral nerve blocks, z= –6.47, p< 0.01, with a large effect size (r= 0.62). The median score on NPRS decreased from pre-peripheral nerve block administration (Median= 9; interquartile range (8-10)) to post-peripheral nerve block administration (Median= 3; interquartile range (2-5)). Conclusion: Our results suggest that peripheral nerve blocks improve pain management in patients with chronic non-malignant neuropathic pain and that these interventions could be used as therapeutic approach for patients with neuropathic pain resistant to other treatment alternatives.

Navigating the complexities of pain management

A persistent pain

To investigate the prevalence and current approaches to clinical management of chronic nonmalignant pain in patients referred to palliative care services. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42021205432). Six databases were searched on 25 August 2020 and again on 11 July 2022: PubMed and Ovid MEDLINE, Elsevier Scopus, PsychINFO, the Cochrane Library, and CINAHL. Search included prevalence or intervention studies with patients who had chronic nonmalignant pain and were referred to palliative care services. Screening was undertaken independently by 2 reviewers. The searches returned 417 titles; subsequent screening identified 5 eligible studies, 4 from the USA and 1 from Hong Kong, including 2 cohort and 3 cross-sectional studies. Sample sizes ranged from 137 to 323, with a total of 1,056 patients. The prevalence of chronic nonmalignant pain ranged from 14% to 34% across different palliative care settings. There was significant crossover of pain types; 54% of patients with chronic no-malignant pain had additional cancer-related pain or cancer treatment-related pain. Opioids were used to manage stand-alone chronic nonmalignant pain for 39% of patients compared to 58% with mixed chronic nonmalignant pain and other pain diagnoses. Five studies have documented the prevalence of chronic nonmalignant pain of 14-34% in palliative care. Further research including prevalence and treatment studies would provide clearer evidence for best practice management of chronic nonmalignant pain in the palliative care setting.

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

Management of cancer pain: ESMO Clinical Practice Guidelines

We explore the attitudes and experience of urology residents toward acute and chronic pain management during their training. A convenience sample of Canadian Urology chief residents were invited to complete an anonymous questionnaire involving both open and closed-ended questions using a 5-point Likert scale. Descriptive and quantitative statistics were used to analyze the attitudes toward pain management, including their experience and training issues. The response rate was 97%. Most residents agreed or strongly agreed that more formal training in acute pain (77% agreement, mean 4.03 ± 0.98 SD) and chronic pain (68%, 3.97 ± 0.95) management would be valuable in urology residency with only 1 respondent disagreeing that training should be mandatory. There was a significant difference of training experience in chronic versus acute pain management, with only 13% agreement (2.99 ± 0.67) that their training in chronic pain was adequate. Most residents agreed (74%, 3.84 ± 1.00) that most of their training in pain management came from their senior residents or fellows. Many of the residents (65%, 3.61 ± 0.84) felt that they could manage their patients' acute pain issues independently, even in the absence of an acute pain service, although apparent knowledge of opioids was poor. The results of this survey suggest that urology residents attain their knowledge of pain management experientially with what may be insufficient formal training, particularly in chronic pain. These observations are limited by the relatively small number of respondents and by the nature of a cross-sectional, self-reported survey; however, they would appear to underscore a need to redouble efforts in residency education.