Chronic Non-cancer Pain Patients Research Articles

Pharmaceuticalization to Opioid Pharmacovigilance: A Qualitative Investigation of the Impact of Opioid-related Policy Changes and the Perspectives of Residents and Chronic Non-cancer Pain Patients

As a result of the pharmaceuticalization of chronic pain over the past three decades, opioid therapy became a common form of treatment for chronic pain patients. However, the overprescribing of opioids led to the opioid overdose epidemic in the United States. In response, the Centers for Disease Control and Prevention implemented guidelines reducing the number of opioid prescriptions—better known as opioid pharmacovigilance. Little is known about the sociocultural challenges during the transition to opioid pharmacovigilance for the resident/patient relationship. Using a thematic analysis, we analyzed 20 semi-structured interviews of residents and chronic non-cancer pain (CNCP) patients in a family medicine residency practice. Findings suggest that due to the pharmaceuticalization of CNCP and the transition to opioid pharmacovigilance, residents develop a wariness to prescribe opioids, which leads to prejudice against patients. Patients report constrained care and a lack of alternative treatments for chronic pain, which inevitably leads to duplicitous behavior.

Long‐term observational studies with cannabis‐based medicines for chronic non‐cancer pain: A systematic review and meta‐analysis of effectiveness and safety

This systematic review evaluated the effectiveness, tolerability and safety of cannabis-based medicines (CbMs) for chronic non-cancer pain (CNCP) in long-term observational studies. CENTRAL, EMBASE and MEDLINE were searched until December 2021. We included prospective observational studies with a study duration ≥26 weeks. Pooled estimates of event rates of categorical data and standardized mean differences (SMD) of continuous variables were calculated using a random effects model. Six studies were included with 2686 participants, with study duration ranging between 26 and 52 weeks. Pain conditions included nociceptive, nociplastic, neuropathic and mixed pain mechanisms. The certainty of evidence for every outcome was very low. The weighted mean difference of mean pain reduction was 1.75 (95% confidence interval [CI] 0.72 to 2.78) on a 0-10 scale. 20.8% (95% CI 10.2% to 34.0%) of patients reported pain relief of 50% or greater. The effect size for sleep problems was moderate and for depression and anxiety was low. Study completions was reported for 53.3% (95% CI 26.8% to 79.9%) of patients, with dropouts of 6.8% (95% CI 4.3% to 9.7%) due to adverse events. Serious adverse events occurred in 3.0% (95 CI 0.02% to 12.8%) and 0.3% (95% CI 0.1% to 0.6%) of patients died. Information included in observational studies should be regarded with caution. Within the context of observational studies. CbMs had positive effects on multiple symptoms for some CNCP patients and were generally well tolerated and safe. There is very low quality evidence for the long-term effectiveness (pain, sleep, mood, health-related quality of life), tolerability and safety of medical cannabis for chronic non-cancer pain (CNCP) according to reports of prospective observational studies. Predefined criteria of a large magnitude of effect size in these types of studies were not met. Nevertheless, long-term medical cannabis therapy can be considered in some carefully selected and monitored patients with CNCP.

Self-Reported Practices and Emotions in Prescribing Opioids for Chronic Noncancer Pain: A Cross-Sectional Study of German Physicians.

Background: The pressure on physicians when a patient seeks pain relief and their own desire to be self-effective may lead to the prescription of strong opioids for chronic noncancer pain (CNCP). This study, via physician self-reporting, aims to identify and measure (i) physician adherence to national opioid prescribing guidelines and (ii) physician emotions when a patient seeks a dosage increase of the opioid. Methods: Within a cross-sectional survey—conducted as part of a randomized controlled online intervention trial (ERONA)—600 German physicians were queried on their opioid prescribing behavior (choice and formulation of opioid, indications) for CNCP patients and their emotions to a case vignette describing a patient seeking an opioid dosage increase without signs of objective deterioration. Results: The prescription of strong opioids in this study was not always in accordance with current guidelines. When presented with a scenario in which a patient sought to have their opioid dose increased, some physicians reported negative feelings, such as either pressure (25%), helplessness (25%), anger (23%) or a combination. The risk of non-guideline-compliant prescribing behavior using the example of ultrafast-acting fentanyl for CNCP was increased when negative emotions were present (OR: 1.7; 95%-CI: 1.2–2.6; p = 0.007) or when sublingual buprenorphine was prescribed (OR: 15.4; 95%-CI: 10.1–23.3; p < 0.001). Conclusions: Physicians’ emotional self-awareness represents the first step to identify such direct reactions to patient requests and to ensure a responsible, guideline-based opioid prescription approach for the long-term well-being of the patient.

Health-related quality of life in patients with chronic orofacial pain compared with other chronic pain patients.

BackgroundHealth‐related quality of life (HRQoL) of orofacial pain patients is lower than that of the general population and impaired in multiple dimensions. The aim of the present study was to investigate HRQoL of orofacial pain patients in comparison with patients suffering from other chronic pain disorders.Materials and MethodsOne hundred and fifty‐one tertiary care facial pain patients (mean age, 50 years; standard deviation [SD], 15; 119 females), were compared with 312 other non‐cancer chronic pain patients (mean age, 46 years; SD, 13; 204 women), recruited from three multidisciplinary pain clinics in Finland. The groups were compared using the 15D, and pain‐related measures such as pain interference, pain acceptance, anxiety, depression, and sleep. Statistical comparisons between groups were done using t test, χ 2 test, or analysis of covariance. Multivariate linear regression analysis was used to study whether pain‐related aspects influencing HRQoL are similar between the patient groups.ResultsThe 15D score was significantly higher in facial pain patients (0.823; SD, 0.114) indicating better HRQoL in comparison with other chronic pain patients (0.732; SD, 0.107) (p < .001). The 15D profiles of studied populations resembled each other but orofacial pain patients showed significantly higher scores for most individual 15D dimensions. Dimensions regarding discomfort and symptoms and sleep were most affected in both groups. Orofacial pain patients showed less psychosocial disability and better acceptance of their pain. Pain acceptance was a weaker explanatory factor of HRQoL in orofacial pain patients.ConclusionCompared to other non‐cancer chronic pain, chronic pain in the orofacial area causes less impairment in HRQoL. Orofacial pain patients showed less psychosocial disability and better pain acceptance.

Transcultural validation of a French-European version of the Prescription Opioid Misuse Index Scale (POMI-5F).

The Prescription Opioid Misuse Index scale (POMI) is a brief questionnaire used to assess opioid prescription misuse. In view of the increase in the prescription of opioid analgesics for chronic noncancer pain (CNCP), this tool is particularly useful during medical consultations to screen opioid misuse in patients using opioids. We sought to generate and validate a French-European translation of the POMI. We conducted an observational, longitudinal, and multicenter psychometric study with crosscultural validation. All adult CNCP patients who were treated with opioids for at least three months, were followed in pain clinics, and spoke French were eligible. From September 2015 to November 2017, we included 163 patients and analyzed 154. We performed a pretest on a sample of representative patients to evaluate acceptability and understanding of translation. Study patients completed the POMI scale at a pain clinic (test phase), and we assessed test-retest reliability after two to four weeks by a second completion of the POMI scale at home by patients (retest phase). We subsequently explored psychometric properties of the POMI (acceptability, internal consistency, reproducibility, and external validity). Due to poor internal consistency and reproducibility, items 4, 7, and 8 of the original POMI scale were removed, and we proposed a five-question French-European version (POMI-5F). The internal consistency of POMI-5F was good (Cronbach's α = 0.71), as was test-retest reliability (r = 0.65 [0.55-0.67]). The external validity of POMI-5F, compared with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was moderate but significant (r = 0.45; P < 0.001). The optimal POMI-5F cut-off score to indicate misuse was 2/5 (sensitivity = 0.95 and specificity = 0.54). We generated and validated a French-European translation of the POMI scale, POMI-5F, for use by French researchers and physicians to identify opioid misuse in CNCP patients.

Update on the role of naldemedine in opioid-induced constipation in patients with chronic noncancer pain.

Chronic noncancer pain (CNCP) affects up to 20% of adults and can interfere with activities of daily living. Up to 4% of adults in the United States receive chronic opioid therapy and up to 57% of patients on long-term opioids for CNCP report opioid-induced constipation (OIC). OIC is essentially constipation occurring after starting opioid treatment. While laxatives are traditionally the first-line therapy for OIC, 81% of patients taking daily laxatives and opioids still reported OIC and considered that it negatively affected their quality of life. Naldemedine is a peripherally acting µ-opioid receptor antagonists (PAMORA) approved for the treatment of OIC in patients with CNCP. This article reviews the mechanism of action, efficacy, and safety of naldemedine in CNCP patients. Naldemedine improves OIC in patients with CNCP by acting as an opioid receptor antagonist in the gastrointestinal tract. It does not interfere with the analgesic properties of opioids or cause withdrawal symptoms since these effects are centrally mediated, and naldemedine does not cross the blood brain barrier. Naldemedine showed significant and sustained improvement in frequency of bowel movements, quality of life, and constipation-related symptoms. It is generally well tolerated with a higher incidence of gastrointestinal adverse events of mild or moderate severity such as diarrhea, abdominal pain, or vomiting compared to placebo. While there are no randomized, controlled trials that compare head-to-head pharmacological therapies used for treatment of OIC, network meta-analysis shows that naldemedine has an overall good benefit-risk profile compared to the other approved medications.

Monitoring Pharmacological Treatment in Patients With Chronic Noncancer Pain.

Chronic pain has been not recognized as a chronic illness, and its far-reaching impacts are often ignored. Chronic noncancer pain (CNCP) is a chronic disease and health care professionals need recommendations on how to monitor treatments, patients and long-term side effects of the different medications used to control CNCP.CNCP patients make up a vulnerable population due to the various associated pathologies and the challenging socio-economic conditions experienced by many of these patients. CNCP is more common among older adults, females, cancer survivors, indigenous peoples, veterans, and populations affected by social inequities and discrimination. These social determinants can lead to a complex interplay between chronic pain, mental illness, and substance use disorders. Given these realities, long-term pharmacological and side effect surveillance is more complex.Follow-up of patients with CNCP is a challenge for physicians, and thus it is important to provide recommendations on how to monitor treatments and long-term side effects of the different medications used to control CNCP.

The role of simulated-experience and descriptive formats on perceiving risks of strong opioids: A randomized controlled trial with chronic noncancer pain patients

ObjectivesOpioid prescription rates worldwide suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive science show that risk perceptions can differ systematically depending on whether people learn about risks by description or experience. We investigated the effects of descriptive and simulated experience risk formats on patients’ risk perceptions and behavior regarding long-term strong opioid use. Methods300 German patients with chronic noncancer pain were randomly assigned in an exploratory randomized controlled trial to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary endpoints were subjective and objective risk perceptions and intended intake behavior. ResultsBoth formats significantly improved patients’ objective risk perception; patients who saw the fact box estimated some outcomes more accurately (p = .031). Formats were equally effective in improving patients’ subjective risk perception in terms of opioids’ harms; however, patients receiving the simulation showed a greater reduction and termination of their opioid intake (p = .030) and a higher uptake of alternative therapies. ConclusionsDescriptive and simulated experience risk formats improve risk perceptions and behavior regarding potent but highly risky drugs. Practice implicationsTo eliminate risky behavior, simulated experience formats may be superior to descriptive formats.

An Italian Expert Consensus on the Use of Opioids for the Management of Chronic Non-Oncological Pain in Clinical Practice: Focus on Buprenorphine.

PurposeThe aim of the present work was to evaluate the knowledge and prescriptive habits of clinicians involved in the management of chronic non cancer pain (CNCP), with a special focus on the use of opioids.MethodsA Delphi method was used. A Board of specialists elaborated and discussed a series of statements, based on available literature and personal clinical expertise, about particularly controversial topics on pain pathophysiology and treatment. A Panel of experts in the field of pain management, selected by the Board, was invited to vote the proposed statements, indicating the level of agreement on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: partially agree; 4: agree; 5: strongly agree). The threshold for consensus was set at minimum 66.6% of the number of respondents with a level of agreement ≥4 (Agree or Strongly agree).ResultsThe Board included 5 pain therapists, 1 pharmacologist and 1 methodology expert and drew up a total of 36 statements (for a total of 40 requested answers)”. A total of 100 clinicians were included in the Expert Panel. Respondents were 89 (89%). Consensus was achieved for 32 out of 40 answers. Most of the lack of consensus was recorded for statements regarding opioids use, and resulted from a low level of agreement (3 on the Likert scale), suggesting a neutral position deriving from a lack of knowledge rather than a strong contrary opinion.ConclusionMost of the proposed items reached consensus, suggesting a generally homogeneous approach to CNCP management. However, the lack of consensus recorded for several items regarding opioid use confirms the need to fill important gaps in the knowledge of available agents. A clear explanation of the peculiar pharmacological properties of drugs associated with potential clinical advantages (such as buprenorphine) will help optimize pain treatment in both primary care and hospital settings and improving pain control in CNCP patients.

Kritische Auseinandersetzung mit neuen Daten zur Prävalenz von Opioidgebrauchsstörungen bei Patienten mit chronischen Schmerzen in Deutschland

HintergrundEs gibt keine Opioidkrise in Deutschland. Neue Studien mit Nichttumorpatienten mit chronischen Schmerzen (CNTS) in Deutschland zeigen jedoch eine unerwartet hohe Prävalenz von Opioidgebrauchsstörungen nach Diagnostic and Statistical Manual for Psychiatric Diseases 5 (DSM-5).Ziel der ArbeitKritische Diskussion neuer Studienergebnisse zur Prävalenz von Opioidgebrauchsstörungen bei Schmerzpatienten in Deutschland.Material und MethodenSelektive Literaturrecherche und multiprofessionelle Einordnung der Ergebnisse durch Expertenrunde (Schmerztherapie, Neurologie, Psychiatrie, Palliativmedizin, Allgemeinmedizin und Suchttherapie).ErgebnisseDie Kriterien für die Diagnose „Opioidgebrauchsstörung“ des DSM‑5 sind auf Patienten mit CNTS nur eingeschränkt anwendbar, können aber für problematisches Verhalten sensibilisieren. Hierbei ist die Diagnose Opioidgebrauchsstörung nicht mit der Diagnose einer Substanzabhängigkeit nach ICD-10 gleichzusetzen, da die Diagnose nach DSM‑5 ein deutlich breiteres Spektrum abdeckt (mild, moderat, schwer). Risikofaktoren für eine Opioidgebrauchsstörung sind jüngeres Alter, depressive Störungen, somatoforme Störungen und hohe Opioidtagesdosen. Die interdisziplinäre Leitlinie zur Langzeitanwendung von Opioiden bei chronischen nichttumorbedingten Schmerzen (LONTS) enthält Empfehlungen, welche das Risiko für eine Opioidgebrauchsstörung reduzieren sollen.DiskussionEine Anpassung der DSM-5-Diagnosekriterien der Opioidgebrauchsstörung an die besondere Situation von Patienten mit CNTS und eine Validierung dieser Kriterien könnte helfen, in der Zukunft genauere Daten zu Opioidgebrauchsstörungen von Patienten mit chronischen Schmerzen in Deutschland zu erheben. Verordner sollten für diese Problematik sensibilisiert werden, ohne die Patienten zu pathologisieren oder gar zu stigmatisieren. Weitere Forschung zur Einordnung dieses bisher unterschätzten Phänomens ist notwendig.

Doctor shopping among chronic noncancer pain patients treated with opioids in the province of Quebec (Canada): incidence, risk factors, and association with the occurrence of opioid overdoses.

Prescription opioids continue to be involved in the opioid crisis, and a better understanding of factors associated with problematic opioid use is needed. The aim of this study was to assess the incidence of opioid doctor shopping, a proxy for problematic opioid use, to identify associated risk factors, and to assess its association with the occurrence of opioid overdoses. This was a retrospective cohort study of people living with chronic noncancer pain (CNCP) and treated with opioids for at least 6 months between 2006 and 2017 in the province of Quebec (Canada). Data were drawn from the Quebec health administrative databases. Doctor shopping was defined as overlapping prescriptions written by ≥ 2 prescribers and filled in ≥3 pharmacies. A total of 8,398 persons with CNCP were included. The median age was 68.0 (Q1: 54; Q3: 82) years, and 37.1% were male. The 1-year incidence of opioid doctor shopping was 7.8%, 95% confidence interval (CI): 7.2-8.5. Doctor shopping was associated with younger age (hazard ratio [HR] 18-44 vs ≥65 years: 2.22, 95% CI: 1.77-2.79; HR 45-64 vs ≥65 years: 1.34, 95% CI: 1.11-1.63), male sex (HR = 1.20, 95% CI: 1.01-1.43), history of substance use disorder (HR = 1.32, 95% CI: 1.01-1.72), and anxiety (HR = 1.41, 95% CI: 1.13-1.77). People who exhibited doctor shopping were 5 times more likely to experience opioid overdoses (HR = 5.25, 95% CI: 1.44-19.13). Opioid doctor shopping is a marginal phenomenon among people with CNCP, but which is associated with the occurrence of opioid overdoses. Better monitoring of persons at high risk to develop doctor shopping could help prevent opioid overdoses.

Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder.

Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.

Demographics, Pain Characteristics and Diagnostic Classification Profile of Chronic Non-Cancer Pain Patients Attending a Canadian University-Affiliated Community Pain Clinic.

IntroductionLittle information exists regarding the characteristics of patients with chronic non-cancer pain (CNCP) attending Canadian pain clinics. The study describes the demographics, pain characteristics and the diagnostic classification profile of such patients attending a university-affiliated community-based pain clinic in the Greater Toronto Area.MethodsRetrospective descriptive study based on 644 unique consecutive CNCP patients assessed between January 2016 and December 2017.ResultsThe female/male ratio was 1.6:1; 80% were younger than 65 years; 43% held some form of employment (full-time, part-time or self employment); median pain duration was 3 years; car accidents and medical conditions accounted for 28 and 27% of pain onset, respectively; 34% had four or more distinct areas of pain; and low back pain (LBP) was the most prevalent site (66%), but was the sole site of pain in less than a third of these patients. Age was positively associated with LBP prevalence. Self-reported health service utilization (visits to the emergency room, pain physician or psychologist) increased with patient psychopathology. Cannabis was used by 15% of the cohort and opioids by 34.5%, with only one in six opioid users exceeding 90 mg of morphine equivalent dose per day. Comparison of our data to three previously published studies from other Canadian pain clinics demonstrated both similarities and substantial differences between the populations.ConclusionOur study highlights regional differences between CNCP population phenotypes. Recognition of biomedical, psychological and socio-environmental factors affecting pain should be considered for patient stratification and rational approaches to treatment, as “one size treatment does not fit all”.

Risk and benefit of cannabis prescription for chronic non-cancer pain

Objectives We investigated whether cannabis usage was associated with reduced opioid usage, and the rates of opioid and cannabis use disorders among chronic pain patients who had been prescribed medical cannabis. Methods A random sample of chronic pain patients who had license for cannabis use were interviewed by telephone about their lifetime opioid and cannabis usage. Cannabis and opioid use disorders were assessed with Portenoy’s criteria. Results Of the 100 participants aged 18–70 years (compliance 67% (aged >40) and 33% (aged ≤ 40y)), 76 ever used opioids. Of them, 93% decreased or stopped opioids following cannabis initiation. Ten patients (10%), 17.4% of the ≤40 y age group, met the criteria for cannabis use disorder. Compared to those who did not meet the criteria, their lifetime depression was higher (80% vs. 43.2%, respectively, P=.042), and they were less educated (12.2 ± 0.6y vs. 13.5 ± 2.1y, p = 0.05). Conclusions Cannabis usage was associated with reduced opioid usage. The prevalence of cannabis use disorder was high among the younger participants who also had a lower study compliance rate, suggesting the higher actual prevalence of cannabis use disorder. While medical cannabis may help reduce opioid use in chronic non-cancer pain patients, younger age, depression, and other risk factors should be carefully evaluated before cannabis is prescribed.

Long-term opioid treatment and endocrine measures in chronic non-cancer pain patients: A systematic review and meta-analysis.

Long-term opioid treatment (L-TOT) of chronic non-cancer pain (CNCP) patients has been suspected to alter the endocrine system. This systematic review and meta-analysis aimed at investigating the published evidence of L-TOT effects on the endocrine system in adult CNCP patients. A systematic search of the literature in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and the CINAHL was performed. Studies examining measures of endocrine function of the hypothalamic-pituitary-gonadal, -adrenal, -thyroid, -somatotropic and -prolactin axis in adult CNCP patients in L-TOT (≥4weeks of use) were included. Outcomes and the level of evidence were analyzed (The Cochrane Collaboration Tool, modified version of the Newcastle-Ottawa Scale and Rating of Recommendations Assessment, Development and Evaluation working group). A total of 2,660 studies were identified; 1981 excluded and finally thirteen studies (one randomized controlled trial (RCT), three longitudinal- and nine cross-sectional studies) were analyzed. L-TOT was associated with low insulin, suppression of the hypothalamic-pituitary-gonadal axis and alterations of the hypothalamic-pituitary-adrenal axis in both men and women with CNCP compared to different control groups (CNCP or healthy pain-free). No other significant differences were reported. The studies had a high risk of bias and the overall quality of evidence was low. There seems to be an impact of L-TOT in CNCP patients on several components of the endocrine system, but the level of evidence is weak. Given the high prevalence of L-TOT use systematic studies of larger patient populations are urgently needed. This systematic review and meta-analysis suggested that long-term opioid treatment may suppress the hypothalamic-pituitary-gonadal axis, and result in lower insulin levels and alter the glucocorticoid adrenal axis in adult chronic non-cancer pain patients. This adds to the need of more research of both clinical and paraclinical outcomes and their association when initiating and maintaining long-term opioid treatment.

Impact of the Opioid Epidemic and Associated Prescribing Restrictions on People Who Live With Chronic Noncancer Pain in Canada.

Little is known about the consequences of the opioid epidemic on people living with chronic noncancer pain (CNCP). This study examined this issue in people who lived in the most impacted province by opioid overdoses in Canada (British Columbia [BC]) or one of the least impacted (Quebec [QC]), and examined the factors associated with opioid use. This cross-sectional study was carried out in adults living in BC (N=304) and QC (N=1071) who reported CNCP (≥3 months) and completed an online questionnaire that was tailored to their opioid status. Almost twice as many participants in BC as in QC were proposed to cease their opioid medication in the past year (P<0.001). The proportion who reported having hoarded opioids in fear of not being able to get more in the future was also significantly higher in BC (P<0.001) compared with QC. In addition, they were significantly more likely to have had their opioid dose decreased than those in QC (P=0.001). No significant association was found between opioid discontinuation and province of residence. Two-thirds of the BC participants felt that the media coverage of the opioid crisis was very to extremely detrimental to CNCP patients in general, this percentage being significantly higher than in QC (P<0.001). The opioid epidemic and associated prescribing restrictions have had harmful effects on Canadians with CNCP. The clinical community, the general public, and the media need to be aware of these negative consequences to decrease patients' stigmatization and minimize inadequate treatment of CNCP.

679 Prevalence of Sleep Disturbances in Patients with Chronic Non-cancer Pain: A Systematic Review and Meta-Analysis

Abstract Introduction In individuals with chronic pain, sleep disturbances have been suggested to increase suffering, perception of pain, and to negatively affect long-term prognosis. This systematic review and meta-analysis aims to determine the pooled prevalence of sleep disturbances in chronic non-cancer pain patients with no other sleep disorders, using the patient-rated questionnaires Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI). Methods Multiple databases were searched for studies reporting the prevalence of sleep disturbances in chronic pain patients. Chronic pain was defined as pain &amp;gt;3 months. Comorbid sleep disorders such as sleep disordered breathing and restless leg syndrome were excluded. Sleep disturbances were defined using the PSQI cutoff of &amp;gt; 5 (poor sleep quality) and ISI ≥ 8 (subthreshold to clinical insomnia). The meta-analysis was conducted to examine the pooled prevalence of PSQI and ISI data using the inverse-variance random-effects model and to examine mean differences in PSQI scores. Results The systematic search resulted in 25,486 articles and 20 were included for analysis. In 12 studies using PSQI, the pooled prevalence of sleep disturbance was 75.3% among 3,597 chronic pain patients (mean age 53 ± 12 years; 74% female). In eight studies using ISI, the pooled prevalence was 72.9% among 2,578 chronic pain patients (mean age 63 ± 12 years; 57% female). The meta-analysis showed a significant mean difference of 2.75 (p &amp;lt; 0.001) in the global PSQI score between the chronic pain group versus the non-chronic pain group. The meta-analysis also showed a significant mean difference in the scores of four of seven PSQI components: sleep latency, sleep efficiency, sleep duration, and sleep disturbances (p &amp;lt; 0.05). Conclusion In chronic pain patients, the pooled prevalence of sleep disturbances as measured by PSQI (75.3%) and ISI (72.9%) studies was much higher than those reported for the general population. The relatively high prevalence of sleep disturbances in chronic pain patients emphasizes the importance of further characterizing the relationship between sleep and chronic pain. Support (if any):

Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain.

Background: Chronic non-cancer pain (CNCP) is estimated to affect 20% of the adult population. Current United States and Canadian Chronic non-cancer pain guidelines recommend careful reassessment of the risk-benefit ratio for doses greater than 90 mg morphine equivalent dose (MED), due to low evidence for improved pain efficacy at higher morphine equivalent dose and a significant increase in morbidity and mortality. There are a number of human studies demonstrating cannabis opioid synergy. This preliminary evidence suggests a potential role of cannabis as an adjunctive therapy with or without opioids to optimize pain control. Methods: In 2017, the Canadian Opioid Guidelines Clinical Tool was created to encourage judicious opioid prescribing for CNCP patients and to reevaluate those who have been chronically using high MED. Mirroring this approach, we draw on our clinical experiences and available evidence to create a clinical tool to serve as a foundational clinical guideline for the initiation of medical cannabis in the management of CNCP patients using chronic opioid therapy. Findings: Following principles of harm reduction and risk minimization, we suggest cannabis be introduced in appropriately selected CNCP patients, using a stepwise approach, with the intent of pain management optimization. We use a structured approach to focus on low dose cannabis (namely, THC) initiation, slow titration, dose optimization and frequent monitoring. Conclusion: When low dose THC is introduced as an adjunctive therapy, we observe better pain control clinically with lower doses of opioids, improved pain related outcomes and reduced opioid related harm.

Depression Among Non-Cancer Chronic Pain Patients at a Tertiary Hospital in Malaysia

INTRODUCTION: Pain is as important public health concern. Chronic pain patients most frequently present with depression, and this needed to be treated. The aim of the study was to find the prevalence of depression among non-cancer chronic pain patients attending a Pain Clinic in Malaysia, and discuss possible treatment methods to help these patients. MATERIAL AND METHODS: Inclusion criteria were all non- cancer chronic pain patients who visited the Pain Clinic of Queen Elizabeth Hospital (QEH), Kota Kinabalu, Sabah from 2013 till 2017. All patients were required to fill a PainDetect form and a Patient Health Questionnaire-9 (PHQ-9). RESULTS: Two hundred and fifty-four patient’s case notes were analysed. The results show that 29.6 % patients had mild depression, with 34.4% of patients had moderate to severe depression. There was a significant correlation between pain scores and depression. There was also a significant correlation between PainDetect scores and depression. CONCLUSION: There is a high prevalence of depression among non-cancer chronic pain patients. This study shows that psychological treatment for all chronic pain patients is needed.

Efficacy of a combination of hypnosis and transcutaneous electrical nerve stimulation for chronic non-cancer pain: A randomized controlled trial.

BackgroundChronic non‐cancer pain, which persists for at least three months, seriously affects quality of life. Chronic non‐cancer pain patients are usually managed by a multidisciplinary team using pharmacological and non‐pharmacological strategies. Nurses perform transcutaneous electrical nerve stimulation (TENS) and hypnosis, which are widely used in France for the treatment of chronic pain in pain departments.ObjectiveTo assess pain relief at three months, comparing a simultaneous combination of hypnosis and TENS (intervention) with TENS alone (control).DesignRandomized controlled trial.MethodsPatients aged 18–80 years, suffering from chronic peripheral neuropathic and/or nociceptive non‐cancer pain were included (September 2013 to May 2017) and followed for six months. The primary outcome was the pain intensity difference (by visual analog scale score) between month 3 and baseline. The secondary outcomes, assessed at months 3 and 6, were SF36 score, analgesics consumption and number of TENS sessions performed at home (last seven days).ResultsSeventy‐two patients were included, suffering from a combination of chronic non‐cancer nociceptive and neuropathic pain, with a mean pain intensity of about sixty out of a hundred. The results show an important pain reduction (forty percent) in both groups at 3 months. No significant difference was observed between the control and intervention groups. Similarly, SF36 score, change in analgesic intake and patient compliance did not differ significantly between groups.ConclusionsThis is the first randomized controlled study showing a decrease of pain intensity and a high level of compliance with transcutaneous electrical nerve stimulation alone or associated to hypnosis. The combination does not seem to be more efficient than transcutaneous electrical nerve stimulation alone. Chronic non‐cancer pain remains a major issue and a substantial proportion of patients do not appear to benefit from interventions.ImpactThis study increases our understanding of the combination of two non‐pharmacological methods in chronic non‐cancer pain patients. The combination of the two non‐pharmacological strategies did not appear to be more efficient than one alone. Further research on non‐pharmacological treatments targeting to patient's characteristics are needed to find appropriate strategies in patients with complex multidimensional pain conditions. Clinical Trial Number: NCT01944150 (Sept. 17, 2013).