Specialty Pain Research Articles

Evaluation of a telementoring intervention for pain management in the Veterans Health Administration.

Half of all Veterans experience chronic pain yet many face geographical barriers to specialty pain care. In 2011, the Veterans Health Administration (VHA) launched the Specialty Care Access Network-ECHO (SCAN-ECHO), which uses telehealth technology to provide primary care providers with case-based specialist consultation and pain management education. Our objective was to evaluate the pilot SCAN-ECHO pain management program (SCAN-ECHO-PM). This was a longitudinal observational evaluation of SCAN-ECHO-PM in seven regional VHA healthcare networks. We identified the patient panels of primary care providers who submitted a consultation to one or more SCAN-ECHO-PM sessions. We constructed multivariable Cox proportional hazards models to assess the association between provider SCAN-ECHO-PM consultation and 1) delivery of outpatient care (physical medicine, mental health, substance use disorder, and pain medicine) and 2) medication initiation (antidepressants, anticonvulsants, and opioid analgesics). Primary care providers (N = 159) who presented one or more SCAN-ECHO-PM sessions had patient panels of 22,454 patients with chronic noncancer pain (CNCP). Provider consultation to SCAN-ECHO-PM was associated with utilization of physical medicine [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05-1.14] but not mental health (HR 0.99, 95% CI 0.93-1.05), substance use disorder (HR 0.93, 95% CI 0.84-1.03) or specialty pain clinics (HR 1.01, 95% CI 0.94-1.08). SCAN-ECHO-PM consultation was associated with initiation of an antidepressant (HR 1.09, 95% CI 1.02-1.15) or anticonvulsant medication (HR 1.13, 95% CI 1.06-1.19) but not an opioid analgesic (HR 1.05, 0.99-1.10). SCAN-ECHO-PM was associated with increased utilization of physical medicine services and initiation of nonopioid medications among patients with CNCP. SCAN-ECHO-PM may provide a novel means of building pain management competency among primary care providers.

Longitudinal associations between depression, anxiety, pain, and pain-related disability in chronic pain patients.

The current study sets out to examine the longitudinal relationship between pain, pain-related disability, and symptoms of depression and anxiety. The latter symptoms are highly prevalent in chronic pain and seriously impede functioning and quality of life. Nevertheless, the direction of the relationship involving these variables among individuals with chronic pain is still unclear. Four-hundred twenty-eight individuals with chronic pain (238 women, mean age 54.84 years, mean pain duration 85.21 months) treated at two pain clinics completed questionnaires regarding their pain (Short-Form McGill Pain Questionnaire), depression (Center for Epidemiological Studies-Depression Scale), state anxiety (State-Trait Anxiety Inventory), and pain-related disability (Pain Disability Index) at four time points, with an average of 5 months between measurements. Cross-lagged, structural equation modeling analyses were performed, enabling the examination of longitudinal associations between the variables. Significant symptoms of both depression and anxiety were reported by more than half of the sample on all waves. A latent depression/anxiety variable longitudinally predicted pain (β = .27, p < .001) and pain-related disability (β = .38, p < .001). However, neither pain (β = .10, p = .126) nor pain-related disability (β = -.01, p = .790) predicted depression/anxiety. Among adult patients with chronic pain treated at specialty pain clinics, high levels of depression and anxiety may worsen pain and pain-related disability.

(499) Provider perspectives on the potential utility of technology-based tools in the treatment of chronic pain

Although there is a recognized need for behavioral approaches in the treatment of chronic pain, a number of systemic barriers, such as limited payer reimbursement, have hindered their widespread implementation. Technology-based tools are a promising means to help address this need, yet sustaining user engagement with e-Health tools remains a persistent challenge, and there is a need for research to identify new ways of increasing patients' uptake of and engagement with these tools. A pilot study was conducted to explore the perspectives of pain specialty providers regarding how to optimize pain patients' engagement with technology-based behavioral interventions and promote broader implementation of such tools in chronic pain care.

Integrating interdisciplinary pain management into primary care: development and implementation of a novel clinical program.

The aims of this study were to develop and implement an interdisciplinary pain program integrated in primary care to address stakeholder-identified gaps. Program development and evaluation project utilizing a Plan-Do-Study-Act (PDSA) approach to address the identified problem of insufficient pain management resources within primary care. A large Healthcare System within the Veterans Health Administration, consisting of two academically affiliated medical centers and six community-based outpatients clinics. An interprofessional group of stakeholders participated in a Rapid Process Improvement Workshop (RPIW), a consensus-building process to identify systems-level gaps and feasible solutions and obtain buy-in. Changes were implemented in 2012, and in a 1-year follow-up, we examined indicators of engagement in specialty and multimodal pain care services as well as patient and provider satisfaction. In response to identified barriers, RPIW participants proposed and outlined two readily implementable, interdisciplinary clinics embedded within primary care: 1) the Integrated Pain Clinic, providing in-depth assessment and triage to targeted resources; and 2) the Opioid Reassessment Clinic, providing assessment and structured monitoring of patients with evidence of safety, efficacy, or misuse problems with opioids. Implementation of these programs led to higher rates of engagement in specialty and multimodal pain care services; patients and providers reported satisfaction with these services. Our PDSA cycle engaged an interprofessional group of stakeholders that recommended introduction of new systems-based interventions to better integrate pain resources into primary care to address reported barriers. Early data suggest improved outcomes; examination of additional outcomes is planned.

Health Care Utilization Among Veterans with Pain and Posttraumatic Stress Symptoms

To examine health care utilization among veterans with both chronic pain and posttraumatic stress symptoms. Retrospective cohort study of 40,716 veterans in a VA regional network from January 1, 2002 to January 1, 2007. Veterans were categorized into pain-only, posttraumatic stress disorder symptoms (PTSD)-only, and pain plus PTSD (pain+PTSD) comparison groups. Negative binomial models were used to compare adjusted rates of primary care, mental health, and specialty pain service use, as well as opioids, benzodiazepines, nonopioid analgesics, and antidepressant prescriptions. Rates of clinic visits were calculated by days per year, and rates of medication use were calculated by prescription months per year. Participants were followed for a mean duration of 47 months. Participants were 94.7% men and had a mean age of 58.9 years. Nearly all used primary care (99.2%), 37.1% used pain-related specialty care, and 33.8% used mental health services. Nonopioid and opioid analgesics were the most commonly used medications (63.7% and 53.8%, respectively). Except for mental health visits, which did not differ between PTSD-only and pain+PTSD groups, the pain+PTSD group used significantly more of all categories of health care services than the pain-only and PTSD-only groups. For example, the pain+PTSD group had 7% more primary care visits (rate ratio [RR]=1.07; 95% confidence interval [CI]: 1.05, 1.09) than the pain-only group and 46% more primary care visits than the PTSD-only group (RR=1.46; 95% CI: 1.40, 1.52). Adjusted rates of opioid, benzodiazepine, nonopioid analgesic, and antidepressant prescriptions were higher for the pain+PTSD group than either of the comparison groups. Our findings support our expectation that veterans with both pain and PTSD symptoms use more health care services than those with pain or PTSD symptoms alone. Research is needed to assess the health care costs associated with increases in health care utilization among these veterans.

The Cognitive Fusion Questionnaire

Acceptance and Commitment Therapy and the psychological flexibility model on which it is based are growing interests for those researching and treating chronic pain. One part of this model is a therapeutic process called cognitive defusion. Cognitive defusion is a process of experiencing a distinction between thoughts and the events or people they describe. This process is intended to reduce the dominating psychological influence of thoughts without necessarily changing the content or frequency of the thoughts. There are recently developed measures of this process but little study of it in people with chronic pain. This study explored the reliability and validity of the Cognitive Fusion Questionnaire (CFQ) within a chronic pain population. A total of 326 adults with chronic pain completed this measure and a set of other standard clinical measures at the start of treatment in a specialty chronic pain service in the United Kingdom. An exploratory factor analysis revealed an interpretable 2-factor structure within the items of the CFQ. Internal consistency reliability was good (α=0.87). In the analyses of validity the CFQ significantly correlated with general psychological acceptance and pain-related acceptance as expected. In multiple regression analyses, which included relevant patient background variables, pain, and acceptance of pain, cognitive fusion contributed significantly to the explained variance in the prediction of 5 of 6 dependent variables tested. The CFQ may be a useful measure for further research and treatment development.

Prevalence of Suicidal Ideation in Patients with Chronic Non-Cancer Pain Referred to a Behaviorally Based Pain Program

Background: Patients with chronic pain often experience co-occurring depression and in some cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient population. Objective: To assess the prevalence of suicidal ideation and identify potential risk factors in patients with chronic non-cancer pain. Study Design: Retrospective chart review. Setting: Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally based pain program in a community health system. Methods: Data collected included pain intensity and level of pain interference (Brief Pain Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance use disorder history, level of isolation, and demographic data. Univariate and logistic regression analyses were performed. Results: Results showed a high rate of suicidal ideation in this patient population (28%). Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal ideation) revealed statistically significant group differences on pain location (extremity P = 0.046, generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P &lt; 0.001), pre-pain history of depression (P &lt; 0.001), family history of depression (P &lt; 0.001), and history of sexual/physical abuse (P &lt; 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825; P = 0.020; OR = 2.657 [95% CI = 1.447 – 4.877]), family history of depression (Beta = 0.471; P = 0.006; OR = 1.985 [95% CI = 1.234 – 3.070]), and being socially withdrawn (Beta = 0.482; P &lt; 0.001; OR = 2.226 [95% CI = 1.431 – 3.505]) were predictive of suicidal ideation. Limitations: Measure of depression was not included in data analysis to reduce effect of colinearity. Also the study population was a specialty pain clinic allowing for possible subject selection bias. Conclusions: Results of this study are consistent with the prevailing literature on pain and suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel predictive variables were also identified that will provide the basis for developing a risk stratification model that can be further tested prospectively in chronic pain patients. Key words: Chronic pain, suicide, depression

Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post‐lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis

The increase in the number of interventions for the management of chronic pain and associated escalation of healthcare costs has captured the attention of health policymakers, in no small part due to the lack of documentation of efficacy, cost-effectiveness, or cost utility analysis. A recent cost utility analysis of caudal epidural injections in managing chronic low back pain of various pathologies showed a high cost utility with improvement in quality of life years, competitive with various other modalities of treatments. However, there are no analyses derived from high-quality controlled studies related to the cost utility of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome or lumbar central spinal stenosis. This analysis is based on 2 previously published controlled studies. To assess the cost utility of percutaneous adhesiolysis procedures in managing chronic low back and lower extremity pain secondary to post-lumbar surgery syndrome and lumbar central spinal stenosis. A private, specialty referral interventional pain management center in the United States. Two controlled studies were conducted assessing the clinical effectiveness of percutaneous adhesiolysis for post-lumbar surgery syndrome and lumbar central spinal stenosis in an interventional pain management setting utilizing contemporary interventional pain management practices. A cost utility analysis was performed with direct payment data for a total of 130 patients in treatment groups over a 2-year period. Various outcome measures were included with significant improvement, defined as at least 50% improvement with reduction in pain and disability status. The results of 2 controlled studies of low back pain with 60 and 70 patients and a 2-year follow-up with the actual reimbursement data showed cost utility for 1year of quality-adjusted life year (QALY) of USD $2,652 for post-lumbar surgery syndrome and USD $2,649 for lumbar central spinal stenosis. The results of this assessment show that the cost utility of managing chronic, intractable low back pain with percutaneous adhesiolysis at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, spinal cord stimulation, and surgery. The limitations of this cost utility analysis are that it is a single-center evaluation, with the inclusion of costs of adhesiolysis procedures in an ambulatory surgery center and physician visits, rather than all related costs including drug therapy and costs of disability in multiple settings. This cost utility analysis of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome and lumbar central spinal stenosis shows the clinical effectiveness and cost utility of these procedures at USD $2,650 per one year of QALY when performed in an ambulatory surgery center.

Exploring Rates of Abnormal Pharmacogenetic Findings in a Pain Practice

ABSTRACTPharmacogenetic testing (PGT) is part of increasing efforts to personalize medicine, hopefully leading to better medication selection with more effective, less toxic therapies. Pharmacogenetic testing has relevance for chronic pain treatment, given the frequent comorbidities and polypharmacy. This retrospective study explored the prevalence of polymorphisms in a specialty pain practice in Louisiana. Pharmacogenetic testing was conducted for the cytochrome P450 (CYP) enzymes CYP2B6, CYP2C19, and CYP2D6, or the uridine diphosphate-glucuronosyltransferase 2 family polypeptide B15 (UGT2B15) enzyme utilizing a noninvasive, saliva-based test based on clinical decision-making. The sample consisted of 61 men (58.7%) and 41 women (39.4%), with an average age of 46.7 years (range = 23–83, SD = 11.5 years). Across all tests, 164 (42.3%) were extensive, 99 (25.5%) were intermediate, 28 (7.2%) were ultrarapid, and 27 (7%) were poor metabolizers. Only three patients who had been tested were found to be extensive (normal) for all four genes. These data demonstrate that genetic polymorphisms were frequently encountered. Consideration should be given to obtaining PGT as an aspect of evaluation and treatment planning when working with patients in need of specialty pain consultation and care. Caution is needed, as this brief report encompasses results from a single pain practice in one geographic location with a potentially distinct prevalence of genetic polymorphisms. Further prospective study is needed.

Predictors of self-management for chronic low back pain

Aims(a) Identify variables that predict self-management (SM) of chronic low back pain (CLBP), and (b) evaluate differences in these variables between participants in specialty pain centers (SPCs) and primary care clinics (PCCs). BackgroundChronic low back pain is highly prevalent in various healthcare settings. Self-management strategies are recommended in pain care guidelines to help address CLBP. However, the evidence of SM effectiveness in CLBP remains unclear. Self-management may be effective for only certain patients. Hence, identifying the predictors to SM of CLBP is essential to help recognize the best responders to SM programs. MethodSecondary analysis was conducted on data collected from two CLBP primary research studies in SPCs (N=110) and PCCs (N=120). General linear modeling was utilized for the combined sample of 230 participants and for each practice setting. ResultsOverall, in SPCs and PCCs combined, five variables were found to be predictors of SM: age, SM support, education, overall health, and helpfulness of pain management. In SPCs, SM support, support received from other than healthcare providers, religion or spirituality, and overall health were identified as significant predictors to SM. In PCCs, both SM support and overall health were also significant predictors. In addition, those with higher income scored better in SM. ConclusionsFindings provide essential information to healthcare providers in intervening appropriately toward engaging CLBP patients in SM. Other strategies need to be identified for those who do not respond effectively to SM strategies.

Changes in Opioid Prescribing for Chronic Pain in Washington State

To conduct a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in Washington State (WA) focused on changes in practice patterns and use of support tools in the prescription of opioids for the treatment of chronic noncancer pain (CNCP). A convenience sample of primary care providers in WA was obtained from diverse geographic regions and health care organizations. The web-based anonymous survey was conducted in March-August 2011. Among 856 provider respondents, 623 reported treating patients with CNCP and served as the analysis sample. Most providers (72%) reported concern about opioid overdose, addiction, dependence, or diversion. Only 25% indicated concern about regulatory scrutiny. Only a small proportion of providers overall (3.3%) reported that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians (MDs and osteopaths) (2.1%) reported this. A greater proportion of physicians (70.9%) than ARNPs (40.1%) reported familiarity with the Washington State opioid dosing guidelines. Physicians in a large health plan with substantial infrastructure support reported less concern about opioids compared with providers in other settings. Of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation. The vast majority of providers reported a need to access more efficient, innovative means of support and education related to treating patients with CNCP, such as telemedicine consultation. Overall, prescribing providers in WA reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a health care organization with opioid prescribing guidelines and access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.

The influence of patient's sex, race and depression on clinician pain treatment decisions

Pain treatments often vary across patients' demographic and mental health characteristics. Most research on this topic has been observational, has focused on opioid therapy exclusively and has not examined individual differences in clinician decision making. The current study examined the influence of patient's sex, race and depression on clinicians' chronic pain treatment decisions. We used virtual human technology and lens model methodology to enhance study realism and facilitate a richer understanding of treatment decisions. Clinicians and trainees (n = 100) made treatment decisions (opioid, antidepressant, pain specialty referral, mental health referral) for 16 computer-simulated patients with chronic low back pain. Patients' sex, race and depression status were manipulated across vignettes (image and text). Individual- and group-level analyses indicated that patient's depression status had the strongest and most consistent influence on treatment decisions. Although less influential overall, patient's sex and race were significantly influential for a subset of participants. Furthermore, the results indicated that participants who were influenced by patient's race had less experience in treating chronic pain than those who were not influenced by patient's race [t(11.59) = 4.75; p = 0.001; d = 1.20]. The results of this study indicated considerable variability in participants' chronic pain treatment decisions. These data suggest that interventions to reduce variability in treatment decision making and improve pain care should be individually tailored according to clinicians' decision profiles.

Cost Utility Analysis of Caudal Epidural Injections in the Treatment of Lumbar Disc Herniation, Axial or Discogenic Low Back Pain, Central Spinal Stenosis, and Post Lumbar Surgery Syndrome

Background: In this era of escalating health care costs and the questionable effectiveness of multiple interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine, and has an influence coverage decisions. Even though multiple cost effectiveness analysis studies have been performed over the years, extensive literature is lacking for interventional techniques. Cost utility analysis studies of epidural injections for managing chronic low back pain demonstrated highly variable results including a lack of cost utility in randomized trials and contrasting results in observational studies. There has not been any cost utility analysis studies of epidural injections in large randomized trials performed in interventional pain management settings. Objectives: To assess the cost utility of caudal epidural injections in managing chronic low back pain secondary to lumbar disc herniation, axial or discogenic low back pain, lumbar central spinal stenosis, and lumbar post surgery syndrome. Study Design: This analysis is based on 4 previously published randomized trials. Setting: A private, specialty referral interventional pain management center in the United States. Methods: Four randomized trials were conducted assessing the clinical effectiveness of caudal epidural injections with or without steroids for lumbar disc herniation, lumbar discogenic or axial low back pain, lumbar central spinal stenosis, and post surgery syndrome. A cost utility analysis was performed with direct payment data for a total of 480 patients over a period of 2 years from these 4 trials. Outcome included various measures with significant improvement defined as at least a 50% improvement in pain reduction and disability status. Results: The results of 4 randomized controlled trials of low back pain with 480 patients with a 2 year follow-up with the actual reimbursement data showed cost utility for one year of quality-adjusted life year (QALY) of $2,206 for disc herniation, $2,136 for axial or discogenic pain without disc herniation, $2,155 for central spinal stenosis, and $2,191 for post surgery syndrome. All patients showed significant improvement clinically and showed positive results in the cost utility analysis with an average cost per one year QALY of $2,172.50 for all patients and $1,966.03 for patients judged to be successful. The results of this assessment show a better cost utility or lower cost of managing chronic, intractable low back pain with caudal epidural injections at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, and surgery in most cases. Limitations: The limitations of this cost utility analysis include that it is a single center evaluation, even though 480 patients were included in the analysis. Further, only the costs of interventional procedures and physician visits were included. The benefits of returning to work were not assessed. Conclusion: This cost utility analysis of caudal epidural injections in the treatment of disc herniation, axial or discogenic low back pain, central spinal stenosis, and post surgery syndrome in the lumbar spine shows the clinical effectiveness and cost utility of these injections at less than $2,200 per one year of QALY. Key words: Caudal epidural injections, chronic low back pain, lumbar disc herniation, lumbar discogenic pain, lumbar spinal stenosis, lumbar post surgery syndrome, cost utility analysis, cost effectiveness analysis, quality-adjusted life years

Shear wave elastography for characterizing muscle tissue in myofascial pain syndrome

Myofascial pain syndrome (MPS) affects 85% of chronic pain sufferers in a specialty pain center. Neck and low-back are commonly affected by MPS. Myofascial trigger points (MTrPs) are characteristic findings of MPS and are palpable tender nodules in the muscles of symptomatic subjects. Mechanical characterization of MTrPs and surrounding tissue can offer important insight about the pathophysiology of the MPS, which is currently poorly understood. In this study, we propose an inexpensive technique, based on ultrasound shear wave elastography, to objectively measure mechanical properties of MTrPs and surrounding tissue in the upper trapezius. In an ongoing clinical study, we recruited 34 subjects: 12 healthy controls, 10 with not spontaneously painful MTrPs (latent) and 12 with symptomatic chronic neck pain (&amp;gt;3 months) and active (spontaneously painful) MTrPs. Shear wave elastography was performed on the upper trapezius of all subjects using the Ultrasonix RP system and an external vibrator. Voigt’ s model was used to estimate shear modulus G and viscosity μ of the interrogated tissue. Preliminary analysis demonstrates that symptomatic muscle tissue in subjects with neck pain is stiffer (G = 8.40 ± 8.31 kPa, mean ± standard deviation) compared to muscle in control subjects (G = 2.86 ± 2.48 kPa) (p &amp;lt; 0.05), and that active MTrPs are more viscous (μ = 17.10 ± 9.46 Pa*s) than surrounding tissue (μ = 10.59 ± 5.96 Pa*s). Latent MTrPs (μ = 24.31 ± 12.72 Pa*s) and surrounding tissue (μ = 20.09 ± 7.48 Pa*s) are more viscous than normal tissue (μ = 10.96 ± 4.17 Pa*s).

Does provider sexism contribute to sex/gender disparities in pain treatment decisions?

There is conflicting evidence of sex/gender disparities in pain treatment. Provider sexism is one factor that may account for these inconsistencies. The current study investigated sex differences in providers’ pain treatment decisions and the extent to which providers’ sexist attitudes play a role in this context. Ninety-eight healthcare trainees and providers made assessment (pain, psychological distress) and treatment (opioid, antidepressant, mental health referral, pain specialty referral) recommendation ratings for 16 computer-simulated patients with chronic low back pain.

A Prospective Evaluation of Psychotherapeutic and Illicit Drug Use in Patients Presenting with Chronic Pain at the Time of Initial Evaluation

Background: Reports of chronic pain and associated opioid use, abuse, and fatalities continue to increase at an alarming rate, not only in the United States but also across the globe. In light of the many resultant fatalities, multiple authors and authorities have cautioned against the excessive use of opioids. Consequently, the Food and Drug Administration, Drug Enforcement Administration, and multiple state authorities have been proposing and implementing a plethora of regulations to curb opioid overuse and abuse. In the majority of cases, pain physicians have been portrayed as the perpetrators responsible for escalating use and abuse and resultant fatalities. Objectives: To assess the patterns of psychotherapeutic drug use and illicit drug use at the time of initial evaluation. Study Design: A prospective evaluation. Setting: A private, specialty referral interventional pain management clinic in the United States. Methods: Participants were all new patients presenting to interventional pain management evaluated by one physician. Inclusion criteria was patients over 18 years of age with chronic spinal pain of at least one year duration. Results: The results of this evaluation indicate that 94% of patients were on long-term opioids prior to presenting to interventional pain management. Illicit drug use is also common, although it has declined significantly. While a large proportion of individuals (45.7%) have used illicit drugs at some point in the past, current illicit drug use is present in only 7.9% of patients, both past and current use are similar to that of the general population. More importantly, a significant proportion of patients have been on opioids (high doses of more than 40 mg equivalents of morphine 48.8%) on a long-term basis, initiated and maintained by primary care physicians, prior to presenting to interventional pain management. Further, 35% were on benzodiazepines, and 9.2% on carisoprodol prior to presenting to interventional pain management. Limitations: The limitations of this evaluation include that it is a prospective, single center evaluation by one physician that is partially dependent on subjective recall of the patient. Conclusion: This study shows an overwhelming majority of patients were initiated and maintained with opioids in managing chronic noncancer pain. They were frequently on high doses over a long period of time with multiple drug combinations prescribed by primary care physicians. Key Words: Chronic pain, persistent pain, noncancer pain, controlled substances, substance abuse, prescription drug abuse, opioids, prescriptions, urine drug testing, fatalities, regulations

Correlates of Higher-Dose Opioid Medication Use for Low Back Pain in Primary Care

Factors associated with high-dose opioid therapy for noncancer pain are poorly understood. We documented the prevalence of high-dose opioid use as well as associated demographic, clinical, and health service utilization correlates among low back pain patients. Patients prescribed higher doses of opioids (≥100 mg/day morphine equivalent at last dispensing; n = 453) and receiving opioids for 90+ consecutive days were compared to 2 groups: lower-dose opioid group (1–99 mg/day; n = 4,815) or no-opioid group (n = 10,184). Higher-dose opioid use occurred in 2.9% of patients who received any opioids and in 8.6% of patients who received opioids long-term. The median dose in the higher-dose group was 180.0 mg/day. Compared to the no-opioid group, higher-dose users reported poorer health. Compared to either comparison group, patients in the higher-dose group had higher rates of mental health and substance use disorders, concurrent sedative-hypnotic use (60.5%; n = 274), and health service utilization. After adjusting for select covariates, male gender (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.37–2.06), higher comorbidity, Medicare coverage (OR = 1.65, 95% CI = 1.22–2.23), any mental health or substance use diagnosis (OR = 1.58, 95% CI = 1.28–1.95), co-prescriptions of sedative-hypnotics (OR = 1.75, 95% CI = 1.42–2.16), and more emergency department and specialty pain clinic visits were associated with higher likelihood of high-dose prescriptions. PerspectiveHigher-dose opioid therapy is being prescribed to 8.6% of back pain patients who receive long-term opioids. These patients had higher mental health and medical comorbidities and co-prescriptions of sedative-hypnotics, raising potential safety concerns.

Does War Hurt? Effects of Media Exposure After Missile Attacks on Chronic Pain

This study focused on the effects of exposure to terrorist missile attacks on the physical and mental well being of chronic pain patients. In this prospective and longitudinal design, 55 chronic pain patients treated at a specialty pain clinic completed self-report questionnaires regarding their pain, depression and anxiety pre- and post a three week missile attack on the southern region of Israel. In addition, levels of direct and indirect exposure to the attacks were measured. Results of regression analyses showed that exposure to the attacks through the media predicted an increase in pain intensity and in the sensory component of pain during the pre-post war period, but did not predict depression, anxiety or the affective component of pain. These findings contribute to the understanding of the effects of terrorism on physical and emotional distress and identify chronic pain patients as a vulnerable population requiring special attention during terrorism-related stress.

Evoked Pain Analgesia in Chronic Pelvic Pain Patients Using Respiratory-Gated Auricular Vagal Afferent Nerve Stimulation

Previous vagus nerve stimulation (VNS) studies have demonstrated antinociceptive effects, and recent noninvasive approaches, termed transcutaneous-vagus nerve stimulation (t-VNS), have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS. Counterbalanced, crossover study. Patients with chronic pelvic pain (CPP) due to endometriosis in a specialty pain clinic. INTERVENTIONS/OUTCOMES: We evaluated evoked pain analgesia for respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) compared with nonvagal auricular stimulation (NVAS). RAVANS and NVAS were evaluated in separate sessions spaced at least 1 week apart. Outcome measures included deep-tissue pain intensity, temporal summation of pain, and anxiety ratings, which were assessed at baseline, during active stimulation, immediately following stimulation, and 15 minutes after stimulus cessation. RAVANS demonstrated a trend for reduced evoked pain intensity and temporal summation of mechanical pain, and significantly reduced anxiety in N = 15 CPP patients, compared with NVAS, with moderate to large effect sizes (η(2) > 0.2). Chronic pain disorders such as CPP are in great need of effective, nonpharmacological options for treatment. RAVANS produced promising antinociceptive effects for quantitative sensory testing (QST) outcomes reflective of the noted hyperalgesia and central sensitization in this patient population. Future studies should evaluate longer-term application of RAVANS to examine its effects on both QST outcomes and clinical pain.

A Comprehensive Review of Telehealth for Pain Management: Where We Are and The Way Ahead

Pain is generally undertreated in the United States, owing to a number of barriers including geographic distance from specialty treatment providers; functional disability that limits mobility; treatment-related stigma; economic limitations; and educational barriers. Pain undertreatment exacerbates pain chronicity and emotional disruption that can significantly erode a pain patient's quality of life, and there is widespread agreement that pain care must evolve to address this significant problem. The growing field of telehealth (defined for the purposes of this paper as technology that allows for distance interaction between providers and/or patients) offers a novel opportunity to expand pain assessment, consultation, and treatment services beyond the walls of the specialty pain clinic, but there is limited availability of resources describing how to best use this technology to improve access to care. A recent literature review (September 2011) using universally endorsed MeSH search criteria revealed only 32 MEDLINE references focusing on telehealth for pain. This is surprising in light of the very large number of references covering telehealth (14,164 references) and pain (104,564 references), respectively. Of the studies available, there are very few randomized trials of telehealth pain care and only one general overview of e-health and chronic pain, which dedicates just a few paragraphs to telehealth. This manuscript represents one of the first comprehensive reviews of the current state of telehealth and pain management research and practice. The goals are to provide a rationale for the potential benefit of telehealth-based pain management services; describe the various applications of telehealth technology for pain management; orient the reader to cost models for telehealth; present examples of services in place; and offer recommendations for future research based on the current state of knowledge.