Pain Management Services Research Articles

The Clinical Impact of a False-Positive Urine Cocaine Screening Result on a Patient's Pain Management

The urine of a patient admitted for chest and epigastric pain tested positive for cocaine using an immunoassay-based drug screening method (positive/negative cutoff concentration 150 ng/mL). Despite the patient's denial of recent cocaine use, this positive cocaine screening result in conjunction with a remote history of drug misuse impacted the patient's recommended pain therapy. Specifically, these factors prompted the clinical team to question the appropriateness of opioids and other potentially addictive therapeutics during the treatment of cancer pain from previously undetected advanced pancreatic carcinoma. After pain management and clinical pathology consultation, it was decided that the positive cocaine screening result should be confirmed by gas chromatography-mass spectrometry (GC-MS) testing. This more sensitive and specific analytical technique revealed that both cocaine and its primary metabolite benzoylecgonine were undetectable (i.e., less than the assay detection limit of 50 ng/mL), thus indicating that the positive urine screening result was falsely positive. With this confirmation, the pain management service team was reassured in offering intrathecal pump (ITP) therapy for pain control. ITP implantation was well tolerated, and the patient eventually achieved excellent pain relief. However, ITP therapy most likely would not have been utilized without the GC-MS confirmation testing unless alternative options failed and extensive vigilant monitoring was initiated. As exemplified in this case, confirmatory drug testing should be performed on specimens with unexpected immunoassay-based drug screening results. To our knowledge, this is the first report of a false-positive urine cocaine screening result and its impact on patient management.

Knocking out pain: Hospital pharmacists launch new approach to pain management

Although the adage pain, no gain might be true when it comes to meeting physical fitness goals, a trio of pharmacists at a hospital in California's Central Valley has developed and launched an innovative pain management service and opioid stewardship program designed to help patients control their pain on the lowest possible dose. In addition to improved patient outcomes and satisfaction, the pain program has saved the hospital millions of dollars in indirect costs.

Abdominal cutaneous nerve entrapment syndrome

Chronic abdominal pain is a frequently presenting condition in the pain clinics. Patients have often undergone a plethora of investigations, including diagnostic surgery and psychiatric review, before referral to Pain Management Services. Ongoing pain leads to development of central sensitization, which is heightened sensitivity to pain and touch, because of the effect of persistent pain on the neuroplasticity of the central nervous system. It can result in significant anxiety, distress, and loss of work days for the patient. Up to 30% of patients with chronic abdominal pain have pain originating in the abdominal wall 1,2 and abdominal cutaneous nerve entrapment syndrome (ACNES) is the most frequent cause of pain in these cases. 3 This diagnosis can be established from the patient’s history, physical examination, and positive response to local anaesthetic injection. 4 More awareness among clinicians of the abdominal cutaneous nerve entrapment syndrome could lead to earlier diagnosis and prevent the consequences of prolonged investigation and pain.

Pain Management Programmes for Non-English-Speaking Black and Minority Ethnic Groups With Long-Term or Chronic Pain.

Increasing ethnic diversity in the UK means that there is a growing need for National Health Service care to be delivered to non-English-speaking patients. The aims of the present systematic review were to: (1) better understand the outcomes of chronic pain management programmes (PMPs) for ethnic minority and non-English-speaking patients and (2) explore the perspectives on and experiences of chronic pain for these groups. A systematic review identified 26 papers meeting the inclusion criteria; no papers reported on the outcomes of PMPs delivered in the UK. Of the papers obtained, four reported on PMPs conducted outside the UK; eight reported on ethnic differences in patients seeking support from pain management services in America; and the remaining papers included literature reviews, an experimental pain study, a collaborative enquiry, and a survey of patient and clinician ratings of pain. The findings indicate a lack of research into UK-based pain management for ethnic minorities and non-English-speaking patients. The literature suggests that effective PMPs must be tailored to meet cultural experiences of pain and beliefs about pain management. There is a need for further research to explore these cultural beliefs in non-English-speaking groups in the UK. Culturally sensitive evaluations of interpreted PMPs with long-term follow-up are needed to assess the effectiveness of current provision. Copyright © 2015 John Wiley & Sons, Ltd.

Polypharmacy and Chronic Pain: Harm Exposure Is Not All about the Opioids

Individuals seeking treatment for chronic pain in multidisciplinary pain management services are typically already on high doses of pain medications. This cross-sectional cohort study of patients with long-term chronic pain examined profiles of polypharmacy and pain medication-related harm exposure. Multidisciplinary pain management service. The cohort comprised 224 patients taking medications for their pain (1-9 medications; mean = 3.19) with an average pain duration of 10.33 years. The Medication Quantification Scale III (MQS-III) was used to examine potential harm exposure. We generated detriment scores for simple analgesics, adjunctive therapies (e.g., anticonvulsants), opioids, and benzodiazepines. The total MQS-III score was correlated with the total number of medications, but not with age. Almost 10% of patients took medications from all four categories, with most taking medications from two (37%) to three (35%) classes. Eighty percent of patients were taking opioids, accounting for 41% of total MQS scores. Five primary profiles of potential medication-related harms were identified: high harm from all medication categories (N = 12); above average harm from single category-simple analgesics (N = 76), adjunctive analgesics (N = 59), or opioids (N = 46); and above average opioid and benzodiazepine harm (N = 31). While treatment with multiple medications for synergistic or adjunctive effects may assist in medical management of chronic pain, this approach generates increased potential harm exposure. We show that the majority of detriment comes from medications other than opioids and highlight the importance of profiling all pain medications contributing to polypharmacy in clinical pain studies.

TelePain: A Community of Practice for Pain Management.

Comprehensive pain management services are primarily located in urban areas, limiting specialist consultation opportunities for community healthcare providers. A community of practice (CoP) for pain management could create opportunities for consultation by establishing professional relationships between community healthcare providers and pain management specialists. A CoP is a group of people with a common concern, set of problems, or a passion for something they do. Members of a CoP for pain management increase their knowledge of evidence-based pain management strategies in a way that is meaningful and relevant. In this article, we provide evidence that TelePain, an interdisciplinary, case-based pain management teleconference consultation program through the University of Washington, qualifies as a CoP and present preliminary evidence of TelePain's effectiveness as a CoP for pain management. Specific behaviors and conversations gathered through participant observation during TelePain sessions were analyzed based on the 14 indicators Wegner developed to evaluate the presence of a CoP. To demonstrate preliminary effectiveness of TelePain as a CoP for pain management, descriptive statistics were used to summarize TelePain evaluation forms. TelePain is an example of a successful CoP for pain management as demonstrated by the presence of Wegner's 14 indicators. Additionally, evaluation forms showed that TelePain enhanced community healthcare providers' knowledge of pain management strategies and that continued participation in TelePain lead to community healthcare providers' increased confidence in their ability to provide pain management. TelePain, a CoP for pain management, facilitates multidisciplinary collaboration and allows members to develop interdisciplinary care plans for complex pain patients through case study discussions. Evidence-based pain management strategies gained through CoP membership could be disseminated to other healthcare providers in members' clinics, which has the potential of improving the care of chronic pain patients.

The Scottish model for chronic pain management services

This article outlines how Scotland's approach to improving chronic pain services has evolved over the last seven years and where it stands currently. Successive reports have highlighted patchy provision of chronic pain management services. The Scottish Service Model for Chronic Pain clearly sets out how services need to be organised and delivered across the whole patient pathway. Establishing a nationally resourced initiative has provided clear direction, support and drive to improve clinical services locally.

The clinical nurse specialist's role in chronic pain management services

Clinical nurse specialists (CNSs) are valuable members of the multidisciplinary chronic pain team. This article will discuss the role of the CNS, who is required to undertake a range of activities and possess a wide portfolio of skills to support individuals to live with chronic pain. In addition, it will focus on how, in times of economic uncertainty and financial constraints, clinical nurse specialists within the field must articulate and demonstrate the value of their role and the service they provide.

Competing patient and professional agendas in service development.

The purpose of this paper is to engage stakeholders in the development of a community based chronic pain-management service and identify their different agendas for service design and delivery. Data were collected using the Nominal Group Technique (NGT), a ten-step process that generates qualitative and quantitative data. Seven NGT groups were conducted in the south-west region of the UK, three with General Practitioners and nurses, three with chronic pain patients, and one with Healthcare Commissioners. The patient agenda for service development focused on process of care issues particularly the need for deep- empathy and emotional support from providers, while professionals prioritised cost-effectiveness. While there was some overlap between agendas they were largely discrete and often contradictory. - The findings imply service planners will need to make trade-offs between cost-containment and patient satisfaction. The methodology did not allow trade-offs to be put to participants in a structured form. However, such techniques are available, for example, Conjoint Analysis. There may also be value in bringing together patients and professionals in joint focus groups, to see if the gap between their different agendas can be bridged through discussion. The findings provide a novel insight into the competing agendas of patients and professionals regarding service development and design which will be of value to service planners and managers as they strive to reconcile these differences.

Preoperative predictors of postoperative opioid usage, pain scores, and referral to a pain management service in total knee arthroplasty.

Little is known about preoperative predictors of postoperative pain and referral to a recuperative pain management service after total knee arthroplasty (TKA). We sought to identify the preoperative predictors of postoperative pain scores, referral to a pain management service, and narcotic usage in patients undergoing primary total knee arthroplasty. We performed a prospective cohort study of 97 TKAs from a single surgeon. Pre and 6-week postoperative WOMAC, visual analog pain scale (VAS) scores, narcotic usage, and catastrophizing pain scores were collected. After adjusting for all other variables, higher age and catastrophizing pain scores were associated with lower odds of postoperative opioid usage. Increasing age and BMI were associated with lower odds of being referred to pain management. There was no relationship between self-reported preoperative pain tolerance and postoperative change in WOMAC or VAS pain scores. This information may help surgeons advise their patients preoperatively and set expectations during the recovery period.

Pain Management for Children during Bone Marrow and Stem Cell Transplantation

Pain management for children during bone marrow and stem cell transplantation is a significant clinical challenge for the health care team. Pain management strategies vary by institution. This paper reports on the use of a pediatric pain management service and patient- and caregiver-controlled analgesia for children undergoing transplant. This 2-year retrospective chart review examined the pain management practices and outcomes of children undergoing bone marrow and stem cell transplants in a large urban teaching hospital during 2008 and 2009. We concluded that patient- and caregiver-controlled analgesia is a well-tolerated modality for pain control during hospitalization for transplantation at this institution.

Appendix: Educational gaps among healthcare providers: An institution needs assessment to improve pain management for postsurgical patients

Objective: Nurses should be educated in pain management because they are more likely than other healthcare professionals to educate patients about their pain. The authors sought to identify the knowledge gaps in postoperative pain management among postsurgical nursing staff and the existence of institutional policies and educational programs to support them in delivering optimal pain management services.
 Setting: Academic hospital.
 Participants: Two hundred seventy-seven registered nurses, nurse practitioners, nurse managers, physician assistants, and other health professionals.
 Interventions: Nurses participated in an online, anonymous survey that consisted of 43 questions in two broad categories: (1) knowledge and attitudes about pain management and (2) institutional pain management and assessment. 
 Main Outcome Measure: Knowledge base of surgical nursing staff regarding postoperative pain management.Results: The overall mean knowledge score was 44.84 percent, with the highest percent of correct answers in the cancer pain category (54.03 percent). Recognition of signs and symptoms of pain had the lowest correct response rate (40.91 percent). Forty-nine percent of respondents reported that pain management protocols tailored to the specific population treated were available, 42 percent reported that patient pain education was always performed, 29 percent reported that they received regular training about pain management, and 17 percent had access to national pain management guidelines.
 Conclusion: The survey results demonstrate general gaps in pain management knowledge among nurses, particularly in recognizing signs and symptoms of pain. This work may guide the development of programs that improve postoperative pain management by increasing the frequency of nurses' pain education and improving the availability of pain-related policies and protocols.

Longitudinal assessment of pain in patients with knee osteoarthritis (OA): using data from the Study of Real World Therapies (SORT)

Longitudinal assessment of pain in patients with knee osteoarthritis (OA): using data from the Study of Real World Therapies (SORT)

An Anomalous Pattern of Superficial Branch of Radial Nerve: A Cadaveric Case Report

In the present case study, there is an anomalous pattern of superficial branch of radial nerve (SBRN) that can be recognized as an anatomical variant of the left upper limb of a 60 years old donated embalmed male cadaver in the Department of Human Anatomy, Universiti Putra Malaysia, in which the superficial branch of radial nerve supplies the extensor carpi radialis longus and extensor carpi radialis brevis muscle. The superficial branch of radial nerve gave off branch to supply the proximal fusion part of extensor carpi radialis longus and extensor carpi radialis brevis muscles immediately after bifurcation of the radial nerve into the superficial branch of radial nerve and deep branch of radial nerve. This variation is very important to the surgeon as the presence of the variant will make them more careful in dealing with nerve entrapment surgery, reconstructive surgery and in the pain management services, the variation giving indications for treatment.

Implementation of a Chest Pain Management Service Improves Patient Care and Reduces Length of Stay

Chest pain is one of the most common complaints in patients presenting to an emergency department. Delays in management due to a lack of readily available objective tests to risk stratify patients with possible acute coronary syndromes can lead to an unnecessarily lengthy admission placing pressure on hospital beds or inappropriate discharge. The need for a co-ordinated system of clinical management based on enhanced communication between departments, timely and appropriate triage, clinical investigation, diagnosis, and treatment was identified. An evidence-based Chest Pain Management Service and clinical pathway were developed and implemented, including the introduction of after-hours exercise stress testing. Between November 2005 and March 2013, 5662 patients were managed according to a Chest Pain Management pathway resulting in a reduction of 5181 admission nights by more timely identification of patients at low risk who could then be discharged. In addition, 1360 days were avoided in high-risk patients who received earlier diagnosis and treatment. The creation of a Chest Pain Management pathway and the extended exercise stress testing service resulted in earlier discharge for low-risk patients; and timely treatment for patients with positive and equivocal exercise stress test results. This service demonstrated a significant saving in overnight admissions.

Acute pain services following surgery for colorectal cancer

This paper evaluates the pain management provided to patients following surgery for colorectal cancer. These patients were part of an enhanced recovery after surgery (ERAS) programme, which among other goals, aims to reduce length of hospital stay. The aim of the service evaluation was to investigate the success of the pain service in meeting the needs of the patients in relation to provision of analgesia for their postoperative recovery, ensuring that the ERAS programme wasn't compromising patient satisfaction. Findings demonstrate high levels of satisfaction with pain management and the approach of staff. The study also reinforces findings that there is a paradoxical link between pain intensity and patient satisfaction. However, despite advances in care, treatments and services, patients continue to experience high levels of pain after surgery and recommendations are made on how pain management services provided to patients after surgery might be enhanced.

Assessment of Community Pharmacists Willingness and Barriers of Medication Therapy Management (MTM) focused on Pain Management and Mental Health

Objectives: To determine the willingness and barriers of community pharmacists to provide pain management and depression MTM services.
 Methods: An anonymous, self-administered survey was distributed electronically to 350 licensed pharmacists in a supermarket pharmacy chain. The survey consisted of a 40 question, Likert-type scale, where strongly disagree was assigned a value of one and strongly agree a value of seven. Constructs measured included: MTM interest, comfort with MTM, confidence with appropriate medication use and adjustment, educational needs, training required, time constraints, and work-related factors. Demographic data was also collected.
 Results: A total of 186 (53%) community pharmacists completed the survey. These pharmacists worked in an environment where MTM was currently being provided. Ninety percent of respondents averaged 0-5 MTM sessions per 4 week period. Pharmacists agreed that patients would benefit from MTM focused on pain (median 6 IR[5-7]) and/or depression (median 6 IR[5-7]) and agreed pharmacists can have positive interventions in these situations (pain: median 6 IR[5-7]; depression: median 6 IR[5-7]). Pharmacists surveyed were interested in continuing education and live presentation as preferred methods to improve knowledge of pain management and depression.
 Conclusion: Pharmacists are interested in and believe patients would benefit from MTM specifically for pain management and depression. Barriers to MTM focused on pain and depression were pharmacist training and workflow issues with the MTM process.
 
 Type: Original Research

The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care.

BackgroundChronic pain is common in Europe and elsewhere and its under treatment confers a substantial burden on individuals, employers, healthcare systems and society in general. Indeed, the personal and socioeconomic impact of chronic pain is as great as, or greater, than that of other established healthcare priorities. In light of review of recently published data confirming its clinical and socioeconomic impact, this paper argues that chronic pain should be ranked alongside other conditions of established priority in Europe. We outline strategies to help overcome barriers to effective pain care resulting in particular from deficiencies in education and access to interdisciplinary pain management services. We also address the confusion that exists between proper clinical and scientific uses of opioid medications and their potential for misuse and diversion, as reflected in international variations in the access to, and availability of, these agents.DiscussionAs the economic costs are driven in part by the costs of lost productivity, absenteeism and early retirement, pain management should aim to fully rehabilitate patients, rather than merely to relieve pain. Accredited education of physicians and allied health professionals regarding state-of-the-art pain management is crucial. Some progress has been made in this area, but further provision and incentivization is required. We support a tiered approach to pain management, whereby patients with pain uncontrolled by non-specialists are able to consult a physician with a pain competency or a specialist in pain medicine, who in turn can recruit the services of other professionals on a case-by-case basis. A fully integrated interdisciplinary pain service should ideally be available to patients with refractory pain. Governments and healthcare systems should ensure that their policies on controlled medications are balanced, safeguarding public health without undue restrictions that compromise patient care, and that physician education programmes support these aims.SummaryStrategic prioritization and co-ordinated actions are required nationally and internationally to address the unacceptable and unnecessary burden of uncontrolled chronic pain that plagues European communities and economies. An appreciation of the ‘return on investment’ in pain management services will require policymakers to adopt a long-term, cross-budgetary approach.

Implementation of a pain medication stewardship program

Pain medication stewardship is important to pharmacy practice because of its impact on quality patient care and medication safety. The Joint Commission recently published a Sentinel Event Alert on opioid safety suggesting that hospitals create and implement policies and procedures for a second-level review of pain management plans with high-risk opioids by pain specialists or pharmacists.1 A pain medication stewardship pharmacist would fulfill this role and enhance patient safety. In this article, we describe our experience with the development of such a program, which was created to bridge the gaps between pain management services provided by multiple disciplines within our institution, an academic medical center with more than 600 staffed beds. In November 2009, an interdisciplinary pain steering committee was created to identify barriers to improving patient satisfaction with pain management. The committee comprised representatives from various departments, including anesthesia, physical medicine and rehabilitation, surgical services, inpatient pain management consultation team, palliative medicine, pharmacy, and nursing. One of the major health care gaps identified was that while our institution had five consultation services for different types of pain management, there was no accountability for any one service to address the needs of the patient population as a whole. The committee championed recommendations to restructure the pain management services under the coordination of a medical director and through collaboration with other departments, including nursing and pharmacy. Recommendations specific to pharmacy included monitoring analgesic medications for safe use and providing evidenced-based prescribing guidelines through the enhancement of order sets and clinical services.

Managing a Chronic Pain Patient in the Perioperative Period

ABSTRACTThe chronic pain patient with and without chronic opioid medication is at risk for under- and overtreatment perioperatively. Careful planning of the perioperative period by the anesthesiologist, the pain service and the surgeon is crucial. Epidural analgesia requires reduction of preoperative opioid doses to a maximum of 50% to avoid withdrawal as well as continuous postanesthesia care unit-monitoring for the first 24 hours. Brief cognitive behavioral interventions pre- and postoperatively contribute to successful pain management. The perioperative period may be used to re-evaluate the patient's opioid requirements. A follow-up by an experienced pain management service should be available after discharge of the chronic pain patient. Individualized assessment by a pain management team is necessary for this increasing group of patients.This report is adapted from paineurope 2013; Issue 2, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD. and is distributed free of charge to healthcare professionals in Europe. Archival issues can be accessed via the website: http://www.paineurope.com at which European health professionals can register online to receive copies of the quarterly publication.