Specialty Pain Research Articles

Assessing Quality of Referrals to a Community-Based Chronic Pain Clinic

ABSTRACT Introduction Because patients with chronic pain are complex, with significant medical and psychiatric comorbidities, referrals to specialty pain clinics are often necessary. The present study explores the quality of information submitted and the profile of referring physicians associated with rejected patient referrals by a community pain clinic. Methods A retrospective cross-sectional study was conducted on a series of consecutive new patient referrals rejected by a noninterventional community pain clinic (November 2021–June 2022). Data were collected on the reasons for rejected referrals and physicians responsible for these referrals using the public database of the College of Physicians and Surgeons of Ontario. Results During the study period, 120 new referrals made by 99 physicians (88% primary care providers, or PCPs; male : female ratio 1:1.2; 53% Canadian university graduates) were rejected because of inadequate information (62%) or because they were inappropriate (38%). Only 46% of the rejected referrals were resubmitted within a median of 7 days (range 0–96 days) and accepted. Half of the non-resubmitted referrals could have been accepted if the referring provider had sent in the missing information. Conclusion A significant number of referrals to our pain clinic (primarily from PCPs) are rejected for mainly avoidable reasons. The process of rejected referrals and resubmissions requires 92 to 126 h of additional staff time/year. Without additional health care resources, our study highlights simple but effective improvements in the referral process that could facilitate patient care, avoid unnecessary delays, and decrease possible sources of patient complaints.

Mindfulness-Oriented Recovery Enhancement: Implementing an evidence-based intervention for chronic pain, opioid use, and opioid addiction in clinical settings.

The opioid crisis emerged in part due to the overprescribing of opioid analgesics for chronic pain. Although not the only source of the current epidemic of opioid use disorder (OUD), the prescription of opioids for chronic pain remains one vector for the development of opioid misuse and OUD. However, opioid tapering is not appropriate for all patients, and some patients may need to remain on opioid therapy for the long term. To reduce the risk of opioid-related harm among people with chronic pain and to treat incipient or entrenched addictive behaviours, new interventions are needed. This review discusses the clinical outcomes, biobehavioural mechanisms and implementation considerations for a novel, evidence-based intervention for chronic pain, opioid use and OUD called Mindfulness-Oriented Recovery Enhancement (MORE). MORE unites complementary aspects of mindfulness training, cognitive behavioural therapy and principles from positive psychology to simultaneously address addictive behaviour, emotion dysregulation and chronic pain by targeting brain reward and stress systems. MORE has been tested in 13 completed randomized clinical trials, including over 1300 patients, and has demonstrated efficacy against a range of active control conditions for reducing opioid dosing, opioid misuse, illicit drug use, depression, post-traumatic stress symptoms and chronic pain. Opportunities for implementing MORE include facilitating opioid tapering and promoting safe opioid use in primary care and specialty pain clinics, decreasing opioid misuse and enhancing medication-assisted treatment for OUD. Given evidence of MORE's efficacy, it is now time to consider disseminating this evidence-based treatment in the United States, the United Kingdom and worldwide.

Predictors of response in PROMIS-global in a chronic low back pain specialty clinic: STarTBack and chronic overlapping pain conditions.

Tools, such as the STarTBack Screening Tool (SBT), have been developed to identify risks of progressing to chronic disability in low back pain (LBP) patients in the primary care population. However, less is known about predictors of change in function after treatment in the specialty care population. We pursued a retrospective observational cohort study involving LBP patients seen in a multidisciplinary specialty clinic to assess which features can predict change in function at follow-up. The SBT was administered at initial visit, and a variety of patient characteristics were available in the chart including the presence of chronic overlapping pain conditions (COPCs). Patient Reported Outcomes Measurement Information System-10 (PROMIS-10) global physical health (PH) and global mental health (MH) were measured at baseline and at pragmatic time points during follow-up. Linear regression was used to estimate adjusted associations between available features and changes in PROMIS scores. 241patients were followed for a mean of 17.0 ± 7.5months. Mean baseline pain was 6.7 (SD 2.1), PROMIS-10 global MH score was 44.8 (SD 9.3), and PH score was 39.4 (SD 8.6). 29.7% were low-risk on the SBT, 41.8% were medium-risk, and 28.5% were high-risk. Mean change in MH and PH scores from baseline to the follow-up questionnaire were 0.86 (SD 8.11) and 2.39 (SD 7.52), respectively. Compared to low-risk patients, high-risk patients had a mean 4.35points greater improvement in their MH score (p= 0.004) and a mean 3.54points greater improvement in PH score (p= 0.006). Fewer COPCs also predicted greater improvement in MH and PH. SBT and the presence of COPC, which can be assessed at initial presentation to a specialty clinic, can predict change in PROMIS following treatment. Effort is needed to identify other factors that can help predict change in function after treatment in the specialty care setting.

Prevalence of Depression in Patients with Chronic Pain

Background: Chronic pain is a distressing health crisis with a profound physical and emotional impacts. There is an association between chronic pain and depression. This study aimed at examining prevalence of depression in patients with chronic pain and determining the link between medications used in chronic pain and depression. Methods: In a cross-sectional study, 201 participants who fit the criteria of chronic pain and attended the pain management clinic, Salmaniya Medical Complex, Bahrain over a period of five months were included. Data about depression was collected from participants using validated Patient Health Questionnaire (PHQ-9). Results: The prevalence of 44.3% of depression was detected in patients with chronic pain. Males to females represented a proportion of 49.3% vs 50.7%, majority of them had sickle cell disease (74.1%). Bivariate analysis expressed that none of the examined variables was significantly different among depressed and non-depressed patients (P>0.05). Univariate analysis found that increased age, male patients, and absence of limitation in daily activity were less prone to severe depression, however, opioid-treated patients, and rarely or intermittently drug intake are more liable to increased depression severity (P<0.05). Conclusions: Adult patients with chronic pain treated at specialty pain clinics were observed to have high levels of depression, with a negative association between the opioids use and depression. Thus, the recognition of the psychological burden of chronic pain emphasizes the necessity of taking action. Reducing the burden of chronic pain on healthcare systems and enhancing patient health and function are two benefits of effective depression treatment.

Herpes Simplex Virus-1 Complicated by Postherpetic Neuralgia: A Case Report

BACKGROUND: The following case describes management of severe persistent vulvar pain from postherpetic neuralgia through a ganglion impar block. CASE REPORT: A 21-year-old female patient initially presented with genital lesions consistent with herpes simplex virus-1 (HSV-1) and antibody testing suggestive of primary HSV-1 infection. After her genital lesions resolved, she continued to have severe persistent vulvar pain and was diagnosed with postherpetic neuralgia, approximately one year after initial presentation. After unsuccessful medical management with her gynecologist and primary care physician, she was referred to a specialty pain management clinic, where a ganglion impar block was performed and provided significant pain relief. CONCLUSIONS: Genital HSV-1 is a rare cause of postherpetic neuralgia which can cause debilitating pain. Its management requires a multidisciplinary approach, including gynecology, pain management, physiatry, and if appropriate, behavioral health. KEY WORDS: Vulvar pain, postherpetic neuralgia, ganglion impar block, genital pain, case report

Use of patient-reported global assessment measures in clinical trials of chronic pain treatments: ACTTION systematic review and considerations.

Establishing clinically meaningful changes in pain experiences remains important for clinical trials of chronic pain treatments. Regulatory guidance and pain measurement initiatives have recommended including patient-reported global assessment measures (eg, Patient-Global Impression of Change [PGIC]) to aid interpretation of within-patient differences in domain-specific clinical trial outcomes (eg, pain intensity). The objectives of this systematic review were to determine the frequency of global assessment measures inclusion, types of measures, domains assessed, number and types of response options, and how measures were analyzed. Of 4172 abstracts screened across 6 pain specialty journals, we reviewed 96 clinical trials of chronic pain treatments. Fifty-two (54.2%) studies included a global assessment measure. The PGIC was most common (n = 28; 53.8%), with relatively infrequent use of other measures. The majority of studies that used a global assessment measure (n = 31; 59.6%) assessed change or improvement in an unspecified domain. Others assessed overall condition severity (n = 9; 17.3%), satisfaction (n = 8; 15.4%), or overall health status/recovery (n = 5; 9.6%). The number, range, and type of response options were variable and frequently not reported. Response options and reference periods even differed within the PGIC. Global assessment measures were most commonly analyzed as continuous variables (n = 24; 46.2%) or as dichotomous variables with positive categories combined to calculate the proportion of participants with a positive response to treatment (n = 18; 34.6%). This review highlights the substantial work necessary to clarify measurement and use of patient global assessment in chronic pain trials and provides short- and long-term considerations for measure selection, reporting and analysis, and measure development.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

Background and ObjectiveCOVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.Design and ParticipantsThis was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19–2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18–2/28–19; n = 1,536,954).Main MeasuresWe assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.Key ResultsPrior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.ConclusionsDisparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Improving Access to Oral Medicine and Orofacial Pain Specialty Care

Improving Access to Oral Medicine and Orofacial Pain Specialty Care

Increasing buprenorphine access for patients with chronic pain: a quality improvement initiative.

Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. Eight primary care clinics within a Veterans Health Administration health care system. A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed.

Myofascial Trigger Point Identification in B-Mode Ultrasound: Texture Analysis Versus a Convolutional Neural Network Approach.

Myofascial pain syndrome (MPS) is one of the most common causes of chronic pain and affects a large portion of patients seen in specialty pain centers as well as primary care clinics. Diagnosis of MPS relies heavily on a clinician's ability to identify the presence of a myofascial trigger point (MTrP). Ultrasound can help, but requires the user to be experienced in ultrasound. Thus, this study investigates the use of texture features and deep learning strategies for the automatic identification of muscle with MTrPs (i.e., active and latent MTrPs) from normal (i.e., no MTrP) muscle. Participants (n=201) were recruited from Toronto Rehabilitation Institute, and ultrasound videos of their trapezius muscles were acquired. This new data set consists of 1344 images (248 active, 120 latent, 976 normal) collected from these videos. For texture analysis, several features were investigated with varying parameters (i.e., region of interest size, feature type and pixel pair relationships). Convolutional neural networks (CNN) were also applied to observe the performance of deep learning approaches. Performance was evaluated based on the classification accuracy, micro F1-score, sensitivity, specificity, positive predictive value and negative predictive value. The best CNN approach was able to differentiate between muscles with and without MTrPs better than the best texture feature approach, with F1-scores of 0.7299 and 0.7135, respectively. The results of this study reveal the challenges associated with MTrP identification and the potential and shortcomings of CNN and radiomics approaches in detail.

An Evaluation of the Clinical Tools Used to Monitor Illicit Methamphetamine Use Among Chronic Pain Patients: A Cross Sectional Retrospective Study.

Purpose: Illicit drug use continues to be a concern for adults on opioid therapy for chronic pain. Prescribers use tools such as urine screening and confirmatory testing with mass spectrometry to monitor adherence to chronic opioid therapy contracts. Design: A cross sectional retrospective study was conducted using electronic medical records. Methods: Data was analyzed from 6558 urine samples of adult outpatients receiving opioid therapy at an urban pain specialty clinic who consented to urine drug tests. Results: From October 18, 2021, to October 21, 2022, 569 were positive amphetamine with immunoassay testing. 310 (54%) of those samples were absent amphetamine with or without methamphetamine while 259 (45.5%) were true positive amphetamine proven by confirmation testing. Analysis of confirmatory testing results identified 281 samples positive for amphetamine with or without methamphetamine. 71 samples confirmed positive for methamphetamine with or without amphetamine. 37 (52.1%) of those methamphetamine samples screened positive for amphetamine and 34 (47.9%) samples screened negative for amphetamine. 48 of the methamphetamine samples were sent for chiral confirmation testing. 45 (93.8%) samples were positive for D-methamphetamine while 3 (6.2%) samples were positive for L-methamphetamine. Only 5 (11.1%) of the 45 patients whose samples were positive for d-methamphetamine reported the use of illicit drugs before their urine sample was tested. Discussion: Confirmatory testing with mass spectrometry can detect illicit drugs, such as methamphetamine, with high sensitivity and specificity and should be used with all samples given the low sensitivity of screening immunoassay. It is of utmost importance that opioid pain medicine prescribers know the many possible interpretations of these results so that they are equipped to make appropriate clinical decisions to ensure the safety of the patient, prescriber, and practice.

Feasibility and Acceptability of the Pain Profile, a Clinical Questionnaire Aimed at Improving Pain Care.

Despite being one of the most common medical complaints, chronic pain is difficult to manage due to ineffective communication between providers and patients and time restraints during appointments. Patient-centered questionnaires have the potential to optimize communication by assessing a patient's pain history, prior treatments, and associated comorbidities to develop an effective treatment plan. This study aimed to analyze the feasibility and acceptability of a pre-visit clinical questionnaire aimed at improving communication and pain care. The "Pain Profile" questionnaire was piloted across two specialty pain clinics in a large academic medical center. Patient and provider surveys were conducted with patients who completed the Pain Profile questionnaire and providers who use it in practice. Surveys consisted of multiple-choice and open-ended questions regarding the helpfulness, usability, and implementation of the questionnaire. Descriptive analyses of patient and provider surveys were conducted. Qualitative data were analyzed using matrix framework-based coding. A total of 171 patients and 32 clinical providers completed the feasibility and acceptability surveys. 77% of patients (N= 131) found the Pain Profile helpful in communicating their pain experiences and 69% of providers (N= 22) found it helpful in guiding clinical decisions. The section that assessed the impact of pain was rated most helpful by patients (4/5) while the open-ended section asking patients to describe their pain history was rated least helpful by patients and providers (3.7/5 and 4.1/5, respectively). Both patients and providers provided suggestions to future iterations of the Pain Profile, including the addition of opioid risk and mental health screening tools. The Pain Profile questionnaire was feasible and acceptable in a pilot study at a large academic site. Future testing in a large-scale, fully powered trial is needed to assess the effectiveness of the Pain Profile in optimizing communication and pain management.

Genetic Testing for Opioid Risk and Drug Metabolism: A Pain Clinic's Retrospective Cohort Study

Background/PurposePharmacogenetics hold promise as an important clinical tool to individualize chronic pain treatment. Prescribing based on drug metabolism and other unique genetic characteristics can potentially decrease inherent risks of chronic opioid therapy. This IRB-approved retrospective study addressed the primary research question: Is there a significant association between genetic test results evaluating drug metabolism and clinical decision-making six months after the initial genetic test results? MethodsA retrospective study was conducted using clinical data gathered from electronic medical records of 99 outpatients with voluntary genetic tests completed from 2015-2016 at an urban pain specialty clinic. Included were adults prescribed any opioid for a pain condition who agreed to a dry buccal swab to determine their metabolism of drugs known to be associated with common chronic pain medications. The genetic test used an algorithm to determine low, moderate, and high risk of adverse opioid effects. Chi-square tests of independence and Kendall's Tau correlation tests were conducted to analyze relationships between genetic test results and clinical data. Results85 patients had documented medication changes, including nonopioid and opioid pain medications. No significant associations were observed between the opioid risk level and increased or decreased opioid dose or urine drug screen inconsistencies. A significant positive correlation was found between decreased drug metabolism and non-steroidal anti-inflammatory (NSAID) medication change. ConclusionsThe results of the genetic testing did not indicate an association with clinical decision-making when prescribing opioid medications or any captured data indicative of opioid misuse. This could be due to multiple factors in the complex nature of prescribing opioid medications such as insurance coverage, patient willingness, and the intricacy of rotating opioid medicines. Future research may aim to examine whether adding clinical guidelines to assist prescribers can maximize the usefulness of genetic results and result in clinical changes that improve patient outcomes.

The association between the problem list and chronic pain management

BackgroundRoughly a quarter of the US population suffers from moderate to severe chronic pain for at least six months in any given year. The complexity of managing chronic pain has encouraged providers to use innovative methods to address it. Research has shown that problem lists are potential tools that support the care of patients with diabetes and chronic kidney disease.ObjectivesTo examine the extent to which the inclusion of chronic pain in a problem list is associated with follow-up specialty pain care.MethodsThe association between chronic pain documentation on the problem list and specialty pain care was investigated in this retrospective cohort study using 4531 patient records.ResultsChronic pain documentation in the problem list was associated with higher odds of receiving specialty pain care. The most common diagnosis was chronic pain (69.7%). A migraine diagnosis was associated with decreased odds of receiving specialty care, and chronic pain syndrome was associated with increased odds of receiving specialty care compared with the other chronic pain groups.ConclusionDocumenting chronic pain on the problem list was associated with a higher likelihood of patients receiving specialty pain care.

Pain Widespreadedness, and Not Primary Pain Location, is Associated With Comorbid Symptoms in Children With Chronic Pain

Pediatric chronic pain represents heterogeneous diagnoses; often, primary pain location informs research classifications and treatment. In contrast, recent research has highlighted the role of widespread pain and this perspective has been adopted in assessments in specialty pediatric pain clinics. The lack of direct comparison between these 2 methods of categorizing pediatric chronic pain may hinder the adoption of evidence-based practices across the spectrum of care. Therefore, this study aimed to compare whether primary pain location or pain widespreadedness is more informative for pain-related symptoms in pediatric chronic pain. Youth (n=223) between the ages of 8 to 23 years (M=15.93, SD=2.11, 83% female) completed surveys upon intake at the pediatric chronic pain clinic. Free-text entries of primary pain location were coded into categories: headache, abdominal pain, and musculoskeletal pain. Additional domains assessed included widespread pain, pain interference, kinesiophobia, catastrophizing, anxiety, depression, sleep, and fatigue. Differences based on primary pain location only emerged for kinesiophobia, F(2150)=8.20, P<0.001, with the highest scores among those with musculoskeletal pain. In contrast, controlling for sex, age, and pain intensity, pain widespreadedness was associated with pain interference, pain catastrophizing, fatigue, anxiety, and depression (P<0.05). Pain widespreadedness was more consistently associated with pain-related outcomes among pediatric chronic pain patients than primary pain location, and body maps may be useful in determining a nociplastic pain mechanism to inform treatment. Improved assessment of pediatric pain mechanisms may help advance more precise treatment delivery.

Survey on Prevalance &amp; Comparison of Back Pain Among Surgeons

The objective was to determine the prevalence of lower back pain (LBP) and comparison of lower back pain among surgeons of different specialties. METHODS: For this research 100 surgeons sample size was estimated. A self-prepared questionnaire having 25 items was distributed in respondents to gather data about the prevalence of lower back pain in surgeons of different specialties. Using SPSS V-19 data was analyzed having quantitative and qualitative variables. RESULT: It was noted that out of 10, general (4), cardiac (2), plastic (2), ENT(4), trauma(6), pediatric(4), and orthopedic(7), neuro (2), urology(2) and gynecology (6) specialty felt lower back pain during surgeries. Out of 100 surgeons of diverse specialty 43 surgeons have lower back pain during the surgery. Out of 100 diverse specialty surgeons’ 25 surgeons have LBP in region of lumbar, thoracic region (2 surgeons) and 29 in their region of lower lumbar. CONCLUSIONS: It was concluded that Gyne &amp; Obs and ENT surgeons are more prone to lower back pain (LBP) as compare to the surgeons of other specialties. The reason of the lower back pain was tough routine, lengthy standing time during surgeries of patients, adaptation of abnormal postures and due to less rest time.

Survey on Prevalance &amp; Comparison of Back Pain Among Surgeons

The objective was to determine the prevalence of lower back pain (LBP) and comparison of lower back pain among surgeons of different specialties. METHODS: For this research 100 surgeons sample size was estimated. A self-prepared questionnaire having 25 items was distributed in respondents to gather data about the prevalence of lower back pain in surgeons of different specialties. Using SPSS V-19 data was analyzed having quantitative and qualitative variables. RESULT: It was noted that out of 10, general (4), cardiac (2), plastic (2), ENT(4), trauma(6), pediatric(4), and orthopedic(7), neuro (2), urology(2) and gynecology (6) specialty felt lower back pain during surgeries. Out of 100 surgeons of diverse specialty 43 surgeons have lower back pain during the surgery. Out of 100 diverse specialty surgeons’ 25 surgeons have LBP in region of lumbar, thoracic region (2 surgeons) and 29 in their region of lower lumbar. CONCLUSIONS: It was concluded that Gyne &amp; Obs and ENT surgeons are more prone to lower back pain (LBP) as compare to the surgeons of other specialties. The reason of the lower back pain was tough routine, lengthy standing time during surgeries of patients, adaptation of abnormal postures and due to less rest time.

Rurality impacts pain care for female veterans similarly to male veterans.

Rural disparities exist in access to multidisciplinary pain care with higher rates of opioid prescribing in rural regions. Among Veterans, who have prevalent rates of chronic pain, women often evidence complex presentations, multiple comorbidities, and dissatisfaction with care. This study investigates the impact of rurality on pain care for women specifically, and whether this varies from the impact of rurality for men. A cohort of Veterans with chronic pain in 2018 was built utilizing VA administrative data. Variables of interest included: demographic, comorbidities, medications, and health care utilization for chronic pain. The cohort included 2,261,030 Veterans; 11% (n = 248,977) were women. Significantly fewer women (7%) compared to men (10.7%) received long-term opioids (adjusted OR = 0.77, 95% CI: 0.75-0.78). Men, relative to women, were also more likely to receive gabapentinoids and nonsteroidal ant-inflammatory drugs, whereas women, relative to men, were more likely to receive muscle relaxants and duloxetine. Women were more likely to receive most psychiatric medications. Rural women received more primary care visits compared to urban women (adjusted OR = 1.19, 95% CI: 1.15-1.22), but fewer women's clinic visits (a subset of primary care visits: adjusted OR = 0.69, 95% CI:0.67-0.71) and fewer pain specialty care visits (physical therapy, pain clinic, and mental health visits with pain codes). Rural effects did not vary substantially between women and men. Rural-dwelling Veterans received more pain and psychiatric medications compared to urban Veterans and fewer specialty care visits. Rural Veterans may benefit from increased access to specialty chronic pain care.

Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change

ABSTRACT Background Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%–79.8% reported “yes, for every child”), with tertiary/quaternary children’s hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants “somewhat agreed” that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.

Pain coping skills training un-locks patient-centered pain care during the COVID- 19 lockdown

BackgroundIn 2020, the COVID-19 virus sparked a crisis constituting a nationwide public health emergency that rapidly altered the provision of healthcare services for all Americans. Infectious disease mitigation led to widespread lockdowns of perceived nonessential services, programs, and non-emergent healthcare interventions. This lockdown exacerbated the public health dyad of uncontrolled pain and the opioid epidemic, which was already in a crisis state. Current literature supports the management of uncontrolled pain with a biopsychosocial approach, empowering patients to explore self-care to enhance activities of daily living. Pain Coping Skills Training (PCST) delivers real-life strategies that improve quality of life and strengthen self-efficacy. Self-efficacy has been identified as a patient outcome measure that demonstrates improved patient-perceived function and quality of life despite pain intensity. Studies have shown that nurse practitioners (APRN) are well-positioned to provide PCST to chronic pain sufferers. MethodsA pretest-posttest design was utilized for this project to enhance pain self- efficacy through an APRN-led community-based intervention. InterventionCommunity-dwelling adults treated in a specialty pain management practice were self-selected to participate in a 6-week telehealth delivered PCST Program. This APRN delivered program presented basic pain education and a broad range of evidence-based nonpharmacologic pain management self-care tools. The primary outcome was improved Pain Self-efficacy measured with the pain self-efficacy questionnaire (PSEQ), with secondary outcomes of improved perceived pain intensity and function measured with the pain, enjoyment, and general activity (PEG) scale tracked weekly. ResultsBaseline PSEQ and weekly PEG scores were obtained and compared to scores after the program. Collateral data points included confidence in using complementary and alternative nonpharmacologic interventions, satisfaction with the program, and a qualitative patient statement regarding pre-and post-intervention participation. ConclusionsThis project concluded that a Nurse Practitioner delivered PCST program via telehealth technology could provide community-dwelling adults with an intervention that improves pain self-efficacy, enhances self-reported PEG measures, and meets the social distancing requirements that continue to impact patients during the COVID-19 pandemic.