Benign Pain Research Articles

Insights in the use of health care services in chronic benign pain in childhood and adolescence

The utilization of health care services in children and adolescents with chronic benign pain was studied in a Dutch population sample of 254 chronic pain sufferers aged 0–18 years. Children and adolescents who had reported chronic pain (continuous or recurrent pain >3 months) in our previous prevalence study were asked to keep a 3-week diary on their pain and to fill out questionnaires on background factors, health care use and the impact of pain. Parent ratings were used for children aged 0–11 years, self-report was used in adolescents (12–18 years). In a 3-month period, in 53.4% of the cases medication was used for pain, and general practitioners and specialists were consulted for pain in 31.1% and 13.9% of subjects, respectively. Physiotherapists, psychologists and alternative health providers were visited by 11.5, 2.8, and 4.0%, respectively. In the preceding year, 6.4% had been hospitalized due to pain. The most important factors linked to utilizing medical services were gender, various pain characteristics, school absenteeism and disability. Although consulters reported to be less physically fit and less satisfied with health, their parents were better adapted to the pain, by talking and sharing, mutual support, normalization of the child and heightened self-esteem, than non-consulters. Prospective studies are needed to test causality of coping on care-seeking behavior.

A method for research programming in the field of evidence-based medicine.

This paper presents the method we used in programming research on the efficacy of therapeutic interventions for nine chronic benign pain disorders. We started with an inventory to identify commonly applied interventions. For these interventions we searched the literature to identify gaps in evidence. First, we searched for recent reviews, of which we assessed the methodologic quality. If only reviews of poor or moderate quality were found, a new systematic review was recommended. When we found no recent reviews, we searched for randomized controlled trials (RCTs). If there was insufficient or inconsistent evidence, the performance of a new RCT was advised. This structured procedure resulted in a list with topics for which new systematic reviews were recommended and topics for which new RCTs were needed. These lists were the starting points for priority setting by four Centers for Pain Management and Research. All members of the centers were asked to state the priority of each topic. The resulting hierarchy of topics for their own center was discussed in a meeting in each center, giving participants the opportunity to elucidate their views and considerations. The final result was a robust priority list for the need of research (systematic reviews and RCTs) on chronic benign pain syndromes. The strength and weaknesses of this approach are discussed. This method of priority setting is by no means restricted to treatments for chronic pain; it is also a useful approach for programming research to enable evidence-based medicine in other fields of interest.

The management of chronic pain in Switzerland: A comparative survey of Swiss medical specialists treating chronic pain

Chronic pain management by Swiss specialist physicians with the primary hypothesis that pain clinic practitioners conform better to good practice (interdisciplinarity, diagnostic/therapeutic routines, quality control, education) than other specialists treating chronic pain was surveyed.Management of all types of chronic pain by pain clinic practitioners and rheumatologists, oncologists or neurologists was compared via a mailed questionnaire survey (n=125/group).Two hundred and twenty-nine (46%) of 500 mailed questionnaires were returned with similar group return rates. Eighty-six percent of responders find chronic pain therapy very difficult/difficult; they estimate only 45% of these patients achieve good outcomes. Twenty-three per cent of responders belong to an interdisciplinary pain centre, but 72% of chronic pain patients are treated by responders alone. Fifty-nine percent never/only occasionally use therapeutic algorithms, 38% use formal pain diagnostic procedures, 20% have a pain quality control programme. Fifty-one percent lack past pain education, 37% do not attend continuing pain education, 69% agree that pain education is their greatest need. Pain clinic practitioners are more interdisciplinary and use more pain diagnostics than other specialists. They are matched by oncologists in education and success in therapeutic escalation, and bettered by them in algorithm use.Pain clinic practitioners and oncologists bring particular—differing—skills to chronic pain management compared to rheumatologists and neurologists. Chronic pain management diversity may result from differences in malignant and benign pain, and its generally being provided by the speciality treating the underlying cause. This survey identifies targets for improvement in areas fundamental to good chronic pain practice: interdisciplinarity, diagnostic/therapeutic tools, quality management and education.

Setting a New Gold Standard

Setting a New Gold Standard

Intravenous infusion of lidocaine is not associated with changes in cardiovascular parameters: a study of 15 patients

Aim: to assess if intravenous infusion of 900 mg of lidocaine over 6 hours is associated with Subjects : 15 adult patients with chronic benign pain. Method: all subjects received an intravenous infusion of 900 mg lidocaine intravenously over 6 hours. Supine blood pressure and heart rate were recorded prior to infusion and at 15 minute intervals for 7 hours, while erect blood pressure and heart rate were recorded prior to infustion and at hourly intervals for 7 hours. Continous EKG monitoring was also employed. Results: No patient experienced side effects during or after the infusion period. There were no changes from baseline levels in either supine or erect blood pressure or heart rates. There were no new cardiac arrhythmias observered during the infusion period. Conclusion : the intravenous infusion of 900 mg lidocaine over 6 hours is not associated with overt evidence of myocardial depression or cardiac arrhythmia.

Presleep cognitions in patients with insomnia secondary to chronic pain.

This study had two primary objectives: (1) characterize the content of presleep cognitions of chronic pain patients and (2) evaluate the association between presleep cognitions and sleep disturbance. Thirty-one outpatients with benign chronic pain completed the Beck Depression Inventory, pain and sleep diaries and participated in an in vivo, presleep thought sampling procedure for 1 week in their homes. The three most frequently reported presleep cognitions were general pain-related thoughts (36%), thoughts about the experimental procedure (27%), and negative sleep-related thoughts (26%). Stepwise multiple regression analyses found the presleep thoughts pertaining to pain and environmental stimuli were significantly associated with sleep continuity, independent from the effects of depression and nightly pain severity. Pain severity was found to be positively associated with Wake After Sleep Onset Time. These results are consistent with cognitive-behavioral models of primary insomnia and suggest the content of presleep cognitive arousal may contribute to sleep disturbance secondary to pain.

Medical help-seeking by different types of chronic pain patients

This paper reports on a study of the use of health services by different types of patients with chronic benign pain. The purpose of the study was to identify differences in medical consumption between different types of pain patients. In the course of one year 586 patients were selected by 45 general practitioners: they included patients who had had almost daily chronic pain symptoms for at least six months, without a medical diagnosis (such as cancer or arthritis) to explain the pain. Patients were categorized according to the Multidimensional Pain Inventory which distinguishes four categories: the dysfunctional, who perceive severe pain and gain social support; the interpersonally distressed, who combine pain with affective and relational distress; adaptive copers, who cope with their pain in a number of ways; the average type, with characteristics of all three other types. It was hypothesised that adaptive copers would make less use of health services and would be more involved in self-help activities than dysfunctional or interpersonally distressed patients. Frequent use of psychological services by the interpersonally distressed group was expected. It was predicted that difference in health services use would continue during the subsequent year. No differences were found between the four groups in location, temporal characteristics, or possible medical causes of the pain symptoms. Dysfunctional patients used more services than the others. Adaptive copers used the least. The four groups did not differ in self-care activities. Group-membership as well as pain severity are related to the use of health services. None of the groups showed a significant decline in the use of health services during the year. It is concluded that chronic pain is invalidating, but that not all patients are equally excessive in their use of medical services.

842 Long-term Effectiveness of Continuous Intrathecal Opioid Treatment in Alleviating Malignant and Chronic Benign Pain

842 Long-term Effectiveness of Continuous Intrathecal Opioid Treatment in Alleviating Malignant and Chronic Benign Pain

Review: Injection therapy is not better than placebo for relieving pain in benign chronic low-back pain

Review: Injection therapy is not better than placebo for relieving pain in benign chronic low-back pain

Multidisciplinary treatment of benign chronic pain syndrome in substance abusing patients

This article presents a model for combined treatment of benign chronic pain and substance abuse. The combined treatment program illustrated draws resources from a comprehensive pain treatment center and an addictions program, which affiliated to better serve these challenging patients. Three illustrative cases are presented. Potentially divisive conceptual issues, such as lack of understanding of the biopsychosocial model of benign chronic pain, and the debate over the role of long-term opioid medication in the treatment of addiction and chronic pain disorders, are discussed.

Coeliac plexus block using computed tomography guidance.

Coeliac plexus blocks have been used successfully in the treatment of abdominal pain in advanced cancer and in benign chronic abdominal pain. However, concern remains about occasional potentially serious complications. One possible way to reduce the risks of this procedure may be to improve imaging during the procedure. We report a series of 38 coeliac plexus blocks carried out under computer tomographic (CT) guidance, mostly using the anterior approach. The technique is described. Effectiveness and side-effect rates were similar to other reported series. There were no major complications. Analysis of contrast spread would indicate that anterior preaortic or bilateral contrast spread is necessary to obtain pain relief. Our experience would indicate that routine CT guidance can be a simple aid to coeliac plexus block, and can be achieved easily in a district general hospital. Improved imaging allows accurate needle placement, while avoiding vital structures such as the aorta and pleura. Accurate placement may also allow the use of reduced volumes of neurolytic drugs.

The Neurotoxicity of Drugs Given Intrathecally (Spinal)

The Neurotoxicity of Drugs Given Intrathecally (Spinal)

The Cholecystokinin Antagonist Proglumide Enhances the Analgesic Efficacy of Morphine in Humans with Chronic Benign Pain

The analgesic efficacy of morphine is sometimes only partial in patients with chronic benign pain. Among the possible factors contributing to this limitation are increased levels of cholecystokinin (CCK). We performed this prospective, placebo-controlled, double-blind, cross-over study to examine the effect of proglumide, a nonspecific CCK agonist, on analgesia in patients taking morphine on a chronic basis. Forty patients with intractable pain who were taking sustained-release morphine were recruited, and we obtained results from 36 of these patients. Median visual analog scale scores before the study were 8 and 7 after the addition of placebo for 2 wk (P = 0.16), and 6 after proglumide for 2 wk (P = 0.002). Mobility was unchanged by proglumide or placebo. Of the 36 patients, 13 elected to continue receiving proglumide after the study. We conclude that proglumide enhances the analgesia produced by morphine in some, but not all, patients with chronic benign pain. The pain-killing effect of morphine is incomplete in some patients. Increasing doses may be needed to maintain the initial effect. The peptide cholecystokinin may be partially responsible for this. In this study, we demonstrated that the cholecystokinin antagonist proglumide increases the analgesic effect of morphine in some patients with chronic benign pain.

The Cholecystokinin Antagonist Proglumide Enhances the Analgesic Efficacy of Morphine in Humans with Chronic Benign Pain

The analgesic efficacy of morphine is sometimes only partial in patients with chronic benign pain.Among the possible factors contributing to this limitation are increased levels of cholecystokinin (CCK). We performed this prospective, placebo-controlled, double-blind, cross-over study to examine the effect of proglumide, a nonspecific CCK agonist, on analgesia in patients taking morphine on a chronic basis. Forty patients with intractable pain who were taking sustained-release morphine were recruited, and we obtained results from 36 of these patients. Median visual analog scale scores before the study were 8 and 7 after the addition of placebo for 2 wk (P = 0.16), and 6 after proglumide for 2 wk (P = 0.002). Mobility was unchanged by proglumide or placebo. Of the 36 patients, 13 elected to continue receiving proglumide after the study. We conclude that proglumide enhances the analgesia produced by morphine in some, but not all, patients with chronic benign pain. Implications: The pain-killing effect of morphine is incomplete in some patients. Increasing doses may be needed to maintain the initial effect. The peptide cholecystokinin may be partially responsible for this. In this study, we demonstrated that the cholecystokinin antagonist proglumide increases the analgesic effect of morphine in some patients with chronic benign pain. (Anesth Analg 1998;87:1117-20)

Is there a bilateral block of the thoracic sympathetic chain after unilateral intrapleural analgesia?

This study was designed to ascertain, by telethermography and clinical observation, the effect of injecting anesthetic solutions into the intrapleural space on thoracic sympathetic chains and splanchnic nerves. We studied 15 patients with neoplastic (n = 8) or benign (n = 7) pain, divided into three groups of 5 patients each. The first group received 20 mL of bupivacaine 0.25% in the intrapleural space, the second received 20 mL of bupivacaine 0.5%, and the third received 20 mL of isotonic sodium chloride solution. Each patient was examined telethermographically 30, 60, 90, and 120 min after the blockade. Visceral pain intensity was measured in eight patients using a visual analog scale. Patients receiving bupivacaine had a uniform bilateral increase of cutaneous temperature (+2 degrees C). In those with diffuse visceral pain, the mean value of the pain score decreased from 82 +/- 10 mm at the time of injection to 16 +/- 5 at 120 min. We conclude that intrapleural bupivacaine 0.25% and 0.5% results in bilateral blockade of the thoracic sympathetic chain and also of the splanchnic nerves, which pass in front of the spinal column between the two thoracic sympathetic chains. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves. We subjected 10 patients to monolateral intrapleural analgesia. Five other patients served as controls. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain.

Complications of opioids and nonsteroidal antiinflammatories in chronic nonmalignant pain

Chronic pain patients often require maintenance medication for ongoing symptom relief. Two of the most common classes of drugs used in this setting are opioids and nonsteroidal antiinflammatories. Both types of medication are being prescribed with increasing frequency and consequently complications and side-effects are being encountered more often. A role for opioids is beginning to emerge in the chronic benign pain patient population. Choosing appropriate patients, setting ground rules for medication use, and being aware of potential problems are all critical in minimizing complications. Nonsteroidal antiinflammatories are used both with and without physician supervision. The consumption of these medications is widespread despite potentially serious complications. Awareness of the pitfalls encountered with these medications should lead to safer outcomes and increased physician and patient satisfaction.

Psychosocial and Behavioural Assessment of Chronic Pain: Recommendations for Clinicians and Researchers

A variety of methods have been developed for the assessment of chronic benign pain. In research or in clinical practise, choosing an adequate measurement technique can be a laborious task. This article has two main purposes: to report on some basic features to consider when selecting assessment instruments, and to present a review of some psychosocial and behavioural measurement methods for the assessment of chronic benign pain. The selected methods have, with one exception, been evaluated on Swedish chronic pain populations and are used in international pain research. In conclusion, we recommend the use of psychometrically sound instruments, and that the purposes for use of a measure have to be thoroughly considered in advance. We also emphasize that in clinical practise, each separate measure must be interpreted in a wider context, where clinical findings and judgements are considered as a whole. In addition, none of the single reviewed assessment techniques can replace the communication between the patient and the clinician.

Meta-analysis: A time for closer scrutiny in applications to pain research?

After reading our Focus article herein and the Commentaries one may very well ask: What then do I use as a yardstick by which to judge meta-analysis for clinical decision-making purposes? Is meta-analysis equivalent to “mega-silliness” [6]? Can meta-analysis be used to resolve scientific brouhahas [14]? Or, does it actually create such brouhahas? Some guidance, then, for caution in the interpretation of meta-analysis for the reader of the pain literature may be of utility. Several clear caveats can be offered. A caution should be stated regarding publication bias—that is, significant results are more likely to be published—an issue that is greater for trials with a smaller sample size. Results that seem “too good to be true” probably are. Always examine the quality of the trials included in the review and evaluate the consistency of the results. A reader should also examine whether both clinical and statistical criteria were offered for the inclusion of trials for analysis from the larger set of trials screened for entry. When the results are on the same side of the “no difference between groups” line, then more confidence may be taken in the reported metaanalysis result [5]; however, although it is more time consuming, we would recommend separate evaluation of each trial by the reader, as does Horwitz [9]. Finally, any subgroup analyses should be examined carefully. Although subgroup analyses can help define a response surface, lack of sufficient data and appropriate analytic techniques can vitiate this approach. The broader area of meta-analytic review of the analgesic effects of antidepressants for chronic, benign pain syndromes has largely shown significant effects for the antidepressants, though the size of the effects reported has been more modest in recent reviews. Hence, it might be concluded that our interpretation of the results of trials conducted in this area to date are nihilistic in that we have stated that no effect can clearly be demonstrated, with the exception of headache; however, we emphasize that a well-justified conclusion (that we largely do not know the effect of this treatment) is not equivalent to a decrease in knowledge or a denial of knowledge of the experts in the field [1]. In fact, in this or any area of research, such a conclusion may well represent an actual increase in scientific knowledge. That is, we could conclude that trial quality assessment and the extent of heterogeneity in antidepressant medications tested and in pain syndromes investigated may account for our differential results. Stating that there is currently insufficient evidence to conclude that all antidepressants have analgesic effects in all chronic, benign pain syndromes is different from stating that selected antidepressant medications may well demonstrate analgesic effects in specific chronic, benign pain syndromes. It is the latter statement with which we are in accord and believe merits further research.

Altered cardiovascular/pain regulatory relationships in chronic pain

In healthy individuals, there is an inverse relationship between resting blood pressure (BP) and pain sensitivity. This study examined possible dysregulation of this adaptive relation in chronic pain patients, and tested whether the extent of this dysregulation is a function of pain duration. Continuous resting BP's were assessed for 5 min after a 5-min rest period in 121 chronic benign pain patients. Unlike the inverse relationship observed previously in normals, mean resting diastolic. BPs during the assessment period were correlated positively with ratings of pain severity. A Pain Duration x Systolic BP interaction emerged (p < .05) such that the magnitude of the BP-pain relation was greatest in patients with the longest duration of pain, r(38) = .50, p < .001. A hypothesized progressive alteration in endogenous pain regulatory systems in chronic pain patients was supported. A possible role of endogenous opioid dysfunction in accounting for these alterations is discussed.

Meta-analysis and the need for study quality control

Meta-analysis has become widely popularized as a method for determining the answer to a scientific question based on multiple different sources of data. Recently, pitfalls in the application of meta-analysis have been identified in areas outside of pain research. A major focus of these pitfalls has been variance in methods for incorporating the effect of trial quality. The issue of trial quality in meta-analyses of pain research is discussed herein. The specific example of antidepressant trials for pain reduction in chronic, benign pain syndromes is used as an illustration of this issue. Recommendations for addressing the issue of trial quality specific to pain research are promulgated, and the issues with incorporating the results of prior meta-analytic reviews in specific pain research areas are addressed.