Therapies For Management Of Chronic Pain Research Articles

Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management.

Chronic pain is a common condition affecting almost one in five Canadians. One of the methods used to treat chronic pain is injection therapies. While they are considered relatively safe procedures, they do carry inherent risk that can result in adverse events. Our goal was to investigate these patient safety events to identify themes that could be used to shape practice guidelines and standards and improve patient safety. We looked at closed civil legal actions and regulatory college complaints associated with injection therapies for chronic pain in the Canadian Medical Protection Association database from 2015 to 2019. Injury was defined as that arising from, or associated with, plans or actions taken during the provision of health care, rather than an underlying disease or injury. Of the 91 cases identified, the most common reported complications were neurologic-related symptoms, injury, and infection. Fifty-eight percent (53/91) of patients experienced health care-related harm that had a negative effect on their health or quality of life. Peer experts were critical of the clinical care provided in 74% (67/91) of the cases. Provider-related (60%, 40/67), team-related (75%, 50/67), and system-related factors (21%, 14/67) were identified as contributing factors in these cases. Common examples of provider-related factors were deficiencies in clinical decision-making (48%, 19/40), failure to follow established procedures (43%, 17/40), and situational awareness (38%, 15/40). Common examples of team-related factors were deficiencies in medical record keeping (80%, 40/50) and communication breakdowns (56%, 28/50). All system-related factors were related to inadequate office procedures. We recommend that clinicians conduct appropriate physical examinations, keep up-to-date with clinical standards, and ensure their documentation reflects their assessment, the patient's condition, and the treatment rationale.

Mindfulness-Based Group Therapy for Chronic Pain Management in Older Adults

ABSTRACT Objectives There were two quality improvement goals for this project: (1) to evaluate the outcomes of an 8-week geriatric-focused mindfulness-based group therapy program for chronic pain management called “Mindfulness-based Chronic Pain Care” offered at a senior community center affiliated with a geriatric primary care clinic, and (2) to obtain feedback from participants to make relevant modifications for future groups. Methods The program consisted of eight 150-minute weekly sessions. Thirteen community-dwelling older adults aged 60 and older participated in the program. The study utilized a non-randomized control-group pretest-posttest design. Participants completed pre- and post-program evaluations measuring pain and related psychosocial outcomes and were also asked to evaluate the importance of the group. Intervention and control groups were compared by t-test, chi-square likelihood ratio, Fischer’s exact test, and multivariate analysis of variance with repeated measures. Results There were statistically significant improvements in three areas: 1) increased activity level, 2) increased “pain willingness,” and 3) decreased generalized anxiety symptoms. Qualitative analysis highlighted how this intervention was important to participants. Conclusions The results of this pilot program indicate promising outcomes for older adults suffering from chronic pain. Clinical Implications The Mindfulness-based Chronic Pain Care program was a practical, feasible, and acceptable approach for pain management among program participants.

Interactive music therapy for chronic pain management in people with advanced cancer: A mechanistic study.

e24119 Background: Chronic pain is one of the most feared symptoms in people with cancer. Although music therapy is frequently used for pain management in cancer care, there is a lack of knowledge of underlying mechanisms. Yet, it is well accepted that knowledge of mediators is essential for optimization of psychosocial treatment interventions. We conducted a multi-site randomized controlled trial to examine mediators hypothesized to account for the pain-reducing effects of interactive music therapy (IMT) in adults with advanced cancer. Methods: This study included adults with advanced cancer (stage III/IV) who had moderate to severe chronic pain caused by 1) locally advanced cancer that had extended to other organs/soft tissue or was impinging on/eroding the bone, 2) bone metastasis, or 3) soft tissue metastasis. We excluded adults with primary central nervous system (CNS) tumor, CNS metastatic disease, or hematologic malignancies. We randomized 92 participants to 6 individual IMT ( n = 45) or social attention control (SAC) ( n = 47) sessions. The mediators (anxiety, mood, pain-related self-efficacy and emotional support) and pain outcomes (pain intensity and pain interference) were measured at baseline, week 4, and week 6 using self-report measures. We included treatment expectancy, music reward, and adult playfulness as moderators. Follow-up interviews were conducted to examine congruence between the hypothesized mediation model and participants’ explanations of how IMT impacted their pain experience. Our target sample size was 100 to achieve 80% power to detect a medium effect at α = 0.05 and 28% attrition. We used ITT analyses and the mediation model per Preacher and Hayes to estimate the total and specific indirect effects of each hypothesized mediator individually. Interview transcripts were analyzed using thematic analysis. Results: Participants were 56±12 years old. Most were female (72%), white (44%) or Black (39%), and had stage IV cancer (75%). The most common types of cancer were breast (46%) and lung (13%). Self-efficacy was found to be a significant mediator for the effect of IMT on pain intensity (indirect effect ab = 0.79, 95% CI 0.01 to 1.82) and pain interference (indirect effect ab = 1.16, 95% CI 0.02 to 2.51), while anxiety, mood, and perceived support were not. The quantitative results were supported by the qualitative findings. None of the proposed moderators were found to be significant. However, we found that the mediating effect of pain-related self-efficacy on pain intensity and pain interference was significantly moderated by baseline pain interference. Conclusions: This study suggests that the impact of music therapy on chronic pain management is mediated through self-efficacy. This knowledge can help further optimize music therapy interventions for chronic pain management in people with advanced cancer by capitalizing on teaching music-based self-management techniques. Clinical trial information: NCT03432247 .

ID: 208161 Intrathecal Pump Refill With a Different Concentration - A Routine Thing or Is it?

Intrathecal drug delivery device is an FDA-approved therapy for chronic pain management. The therapy is generally safe, but few serious complications have been reported. The complications related to implantation, device mechanical failure, and during reservoir refill are well described but issues related to refill when drug concentration has changed is less well described. We described a case of potential drug overdose during reservoir refill despite following all safety protocol.

An individualized digital twin of a patient for transdermal fentanyl therapy for chronic pain management

Fentanyl transdermal therapy is a suitable treatment for moderate-to-severe cancer-related pain. The inter-individual variability of the patients leads to different therapy responses. This study aims to determine the effect of physiological features on the achieved pain relief. Therefore, a set of virtual patients was developed by using Markov chain Monte Carlo (MCMC) based on actual patient data. The members of this virtual population differ by age, weight, gender, and height. Tailored digital twins were developed using these correlated, individualized parameters to propose a personalized therapy for each patient. It was shown that patients of different ages, weights, and gender have significantly different fentanyl blood uptake, plasma fentanyl concentration, pain relief, and ventilation rate. In the digital twins, we included the virtual patients’ response to the treatment, namely, pain relief. Therefore, the digital twin was able to adjust the therapy in silico to have more efficient pain relief. By implementing digital-twin-assisted therapy, the average pain intensity decreased by 16% compared to conventional therapy. The median time without pain increased by 23 h over 72 h. Therefore, the digital twin can be successfully used in individual control of transdermal therapy to reach higher pain relief and maintain steady pain relief.Graphical (Created with BioRender.com)

Patients’ Beliefs in Optimal Pain Management: A Pilot Study

Opioids are commonly prescribed for chronic pain despite potential adverse side effects, risks of misuse and abuse, and limited evidence for improved outcomes. Patients’ perspectives and understanding of pain management may impact treatment approaches and the success of therapies. Yet, few studies have investigated how patients’ beliefs in optimal pain management may influence their care. We prospectively surveyed 200 patients with chronic pain with the aim of assessing patients’ beliefs on the optimal management of their chronic pain. The following significant findings were made: 1) most responders agreed that opioid medication was the best way to control pain (p<0.05), especially those currently taking opioids (p<0.0001); 2) those who received injections for pain disagreed that opioids were the best way to control pain (p<0.0001); 3) most participants were aware of other options to control pain (p<0.05), but patients on opioids were significantly less aware of other options for pain control (p<0.05). This study demonstrated that most patients with chronic pain surveyed in our clinic believed that opioids were the best option for treating their chronic pain, but this finding did not hold true for those who were exposed to other interventions for their pain, such as injections. Pain physicians may encounter resistance when attempting to incorporate non-opioid and or non-pharmacological therapies for chronic pain management. Further research may help determine whether patient education and exposure to such therapies can help combat these challenges.

Frontal alpha asymmetry: A potential biomarker of approach-withdrawal motivation towards pain.

Pain-related catastrophising is a maladaptive coping strategy known to have a strong influence on clinical pain outcomes and treatment efficacy. Notwithstanding, little is known about its neurophysiological correlates. There is evidence to suggest catastrophising is associated with resting-state EEG frontal alpha asymmetry (FAA) patterns reflective of greater relative right frontal activity, which is known to be linked to withdrawal motivation and avoidance of aversive stimuli. The present study aims to investigate whether such a relationship occurs in the situational context of experimental pain. A placebo intervention was also included to evaluate effects of a potential pain-relieving intervention on FAA. 35 participants, including both chronic pain patients and healthy subjects, completed the Pain Catastrophising Scale (PCS) questionnaire followed by EEG recordings during cold pressor test (CPT)-induced tonic pain with or without prior application of placebo cream. There was a negative correlation between FAA and PCS-subscale helplessness scores, but not rumination or magnification, during the pre-placebo CPT condition. Moreover, FAA scores were shown to increase significantly in response to pain, indicative of greater relative left frontal activity that relates to approach-oriented behaviours. Placebo treatment elicited a decrease in FAA in low helplessness scorers, but no significant effects in individuals scoring above the mean on PCS-helplessness. These findings suggest that, during painful events, FAA may reflect the motivational drive to obtain reward of pain relief, which may be diminished in individuals who are prone to feel helpless about their pain. This study provides valuable insights into biomarkers of pain-related catastrophising and prospects of identifying promising targets of brain-based therapies for chronic pain management.

Nonpharmacologic management of chronic pain in the United States' Medicare population: a scoping review protocol.

ABSTRACTObjective:This objective of this review is to describe the scope of the literature on the access to and use of nonpharmacologic therapies to manage chronic pain among people with disabilities and older adults.Introduction:Clinical guidelines recommend nonpharmacologic interventions as first-line therapy for chronic pain management. The importance of nonpharmacologic management is magnified in populations with a high pain burden and multiple chronic conditions, such as people living with a disability and/or older adults, many of whom are enrolled in Medicare. Understanding the utilization of nonpharmacologic therapies for pain is critical to guide effective pain management delivery and policy.Inclusion criteria:This scoping review will consider studies of Medicare beneficiaries and Medicare-eligible individuals who have chronic pain. Noninvasive and nonpharmacologic treatments for pain identified in clinical guidelines will be included. We will exclude studies exclusively focused on acute pain, cancer pain, palliative care and hospice settings, cannabis-based treatment, and pharmacologic therapies. Studies conducted outside the United States will be excluded.Methods:The proposed scoping review will be conducted in accordance with JBI methodology. The search strategy has been developed in consultation with a public health librarian and will be carried out in MEDLINE, CINAHL, and SocINDEX, Web of Science, and the Cochrane Library. The search will be limited to results published in English since January 1, 1990. Two independent reviewers will screen all titles and abstracts and then full-text articles. Data will be extracted and summarized in diagrammatic, tabular, and narrative formats.Scoping review registration:Open Science Framework (https://osf.io/h7bwc/)

Cognitive Behavioural Therapy for Chronic Pain Management: A Narrative Review

Chronic pain is disabling and impacts an individual’s psychosocial and functioning in multiple areas. Cognitive Behavioural Therapy (CBT) appears to be one of the psychotherapies that has good potential of prominent efficacy in managing chronic pain. This narrative review aims to provide the necessary information and latest development on the delivery, results efficacy and barriers of CBT in chronic pain management. A search was conducted at Pubmed and Web of Science in April 2021 yielding a total of 251 articles. After careful screening and filtration, a total of 21 articles was selected for this review. Of these 21 articles, CBT was observed to be commonly delivered through online, which helped to preserving cost, promoting adherence, having good efficacy and also safer during the time of the Covid-19 pandemic. Most of the articles showed significant efficacy of CBT in chronic pain management. In order to improve CBT for better efficacy, understanding and consideration towards mediators that affect pain outcome and barriers in implementation are crucial in developing modules in CBT for chronic pain management. As such, CBT can be improved by integrating customised components in the modules to target mediators specifically, and training can be provided for psychotherapist to combat the barrier of online communication and time management. For future research, direction can be focused on development of CBT modules that are specific to chronic pain management.

Novel bivalent ligands carrying potential antinociceptive effects by targeting putative mu opioid receptor and chemokine receptor CXCR4 heterodimers

The functional interactions between opioid and chemokine receptors have been implicated in the pathological process of chronic pain. Mounting studies have indicated the possibility that a MOR-CXCR4 heterodimer may be involved in nociception and related pharmacologic effects. Herein we have synthesized a series of bivalent ligands containing both MOR agonist and CXCR4 antagonist pharmacophores with an aim to investigate the functional interactions between these two receptors. In vitro studies demonstrated reasonable recognition of designed ligands at both respective receptors. Further antinociceptive testing in mice revealed compound 1a to be the most promising member of this series. Additional molecular modeling studies corroborated the findings observed. Taken together, we identified the first bivalent ligand 1a showing promising antinociceptive effect by targeting putative MOR-CXCR4 heterodimers, which may serve as a novel chemical probe to further develop more potent bivalent ligands with potential application in analgesic therapies for chronic pain management.

Evaluation of Chronic, Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic

BackgroundChronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016). AimsThe aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids. MethodsA retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic. ResultsParticipants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy. ConclusionsAPRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.

High Frequency 10 kHz Spinal Cord Stimulation as a First Line Programming Option for Patients With Chronic Pain: A Retrospective Study and Review of the Current Evidence.

IntroductionNeuromodulation is an evolving and increasingly popular therapy for chronic pain management. Recent data suggest that novel waveforms have demonstrated greater benefit over traditional spinal cord stimulation (SCS). The authors conducted a retrospective review of patients undergoing high-frequency 10 kHz SCS at a single tertiary medical center for the purpose of contributing further evidence to this growing body of data. The literature of high-frequency SCS published to date was also reviewed.MethodsA retrospective chart review was performed for patients with chronic pain syndrome, including failed back surgery syndrome and sciatica alone, who underwent high-frequency SCS at 10 kHz. This data was analyzed using R software (R Foundation for Statistical Computing, Vienna, Austria) for statistical analysis. The PubMed database was searched for relevant articles using the search terms “high frequency,” “10 kHz,” and “spinal cord stimulation.” All relevant studies conducted to date were included in this literature review.ResultsTwenty-one patients had complete follow-up data and were included in this study. Of the 21 patients, 85.7% subjectively reported post-operative pain relief while 71.4% of the total patients reported pain relief by ≥ 50%. There was a statistically significant decrease in mean VAS scores from pre-operative to 12-months post-operative (8.52 vs 4.37, p < 0.001). Additionally, 76.5% of patients subjectively reported improvements in sleep and activities of daily living. Recent studies indicate that high-frequency SCS appears to be a viable option for delivering quality pain relief in patients for chronic regional pain syndrome, failed back surgery syndrome, sciatica, and also pain in the upper cervical region of the spine.ConclusionThis article provides evidence both with the authors’ own institutional data and from the currently published literature for the efficacy of using high-frequency SCS at 10 kHz as a first-line programming option for patients undergoing SCS.

Comparison between acupuncture therapy and gabapentin for chronic pain: a pilot study.

We examined whether the effect of true electroacupuncture on pain and functionality in chronic pain participants can be differentiated from that of medication (gabapentin) by analyzing quantitative sensory testing (QST). We recruited chronic back and neck pain participants who received six sessions (twice weekly) of true electroacupuncture versus sham electroacupuncture or 3 weeks of gabapentin versus placebo treatment. QST profiles, pain scores, and functionality profile were obtained at baseline (visit 1) and after three sessions (visit 4) or six sessions (visit 7) of acupuncture or 3 weeks of gabapentin or placebo. A total of 50 participants were analyzed. We found no differences in QST profile changes (p = 0.892), pain reduction (p = 0.222), or functionality (p = 0.254) between the four groups. A major limitation of this pilot study was the limited number of study participants in each group. This pilot study suggests that a large-scale clinical study with an adequate sample size would be warranted to compare acupuncture and medication therapy for chronic pain management. NCT01678586 (ClinicalTrials.gov).

A Comprehensive Review of Alternative Therapies for the Management of Chronic Pain Patients: Acupuncture, Tai Chi, Osteopathic Manipulative Medicine, and Chiropractic Care.

IntroductionNon-pharmacologic alternative therapies for pain have been around for a long time, some for hundreds of years. They have been used throughout history to treat many issues.Recent FindingsCurrently, alternative medicine is most frequently used to treat musculoskeletal pain, and between 59 and 90% of patients utilizing alternative therapies for chronic pain claimed they were helpful and can serve as an effective adjunctive for the treatment of chronic pain. Some examples of alternative therapies that will be discussed in this review include acupuncture, tai chi, osteopathic manipulation, and chiropractic care. Acupuncture, traditionally a Chinese practice, is becoming more popular across the world to attempt to relieve pain. It involves the placement of thin needles at various points in the body. The efficacy of acupuncture for pain is heavily debated. More research and discussion are necessary to determine the exact role it plays in the treatment of chronic pain. Tai chi is also a traditional Chinese practice that is often used as a form of meditation and for potential health benefits. Tai chi involves a series of complex movements such as squatting combined with deep breathing to achieve relaxation and pain reduction. Osteopathic manipulative treatment (OMT) is a technique used by both osteopathic physicians (DO) as well as other health professionals to manage a wide range of conditions in any given patient. The technique involves utilization and manipulation of the musculoskeletal system to achieve potential health benefits. OMT has been used as therapy for many issues but is commonly used for pain conditions.SummaryAlternative therapies may serve as an effective adjunctive treatment modality for the management of chronic pain conditions. There has been a tremendous amount of research dictating the effectiveness of alternative therapies for chronic pain management. The purpose of this review is to provide a comprehensive evidence-based update of alternative therapy used for the management of chronic pain conditions.

Use of complementary therapies for chronic pain management in patients with reported Ehlers-Danlos syndrome or hypermobility spectrum disorders.

Ehlers-Danlos Syndromes (EDS) and related Hypermobility Spectrum Disorders (HSD) are debilitating connective tissue disorders that feature a prominent pain component for which there are limited therapeutic options for pain management. Consequently, many patients try various non-prescribed treatments, including complementary and alternative therapies that have not been well studied in the EDS/HSD patient population. We surveyed over 500 individuals through the EDS Society who reported having been diagnosed with EDS or HSD to ascertain what complementary and alternative therapies were used and their reported effectiveness in alleviating pain and improving quality of life. Specifically, we focused on the use of traditional Chinese therapies, herbal medications, and marijuana. The most commonly reported therapies, used by 70-92% of participants, were non-steroidal anti-inflammatory drugs, acetaminophen, opioids, and physical therapy. Therapies rated by participants as most efficacious were opioids, physical therapy, and marijuana with 10-24% of those using these therapies rating them as extremely helpful. Patient-initiated complementary therapy use in EDS/HSD patients is widespread at 56%. Complementary therapies were largely utilized by EDS/HSD patients with higher reported pain levels. Providers caring for EDS/HSD patients should be aware of these data showing broad usage of predominantly non-prescribed therapies and be prepared to consider such usage in working collaboratively with these patients to develop comprehensive treatment plans to manage their chronic pain complications.

Nurses' experiences of providing nonpharmacological pain management in palliative care: A qualitative study.

To explore the experiences and views of nurses who provide nonpharmacological therapies for chronic pain management in palliative care. Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses' attitudes, views and experiences regarding pain therapies in this context. A qualitative descriptive design was chosen. Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist. The analysis yielded four categories, as follows: "building and sustaining favourable therapeutic relationships" involved the creation of trust and a solid relationship; in "recognising the diversity of patients' needs," person-centred care is expressed as being vital for individualised nonpharmacological pain management; "incorporating significant others" describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in "recognising the existence of barriers," nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management. The unique knowledge that nurses gain about the patient through the nurse-patient relationship is central and crucial for successful nonpharmacological pain management. This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients' descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

Preliminary evaluation of the clinical implementation of cognitive-behavioral therapy for chronic pain management in pediatric sickle cell disease

ObjectivesEvaluate the implementation of cognitive-behavioral therapy (CBT) for chronic pain in a clinical setting by comparing youth with sickle cell disease (SCD) who initiated or did not initiate CBT. DesignYouth with SCD (ages 6–18; n = 101) referred for CBT for chronic pain were compared based on therapy attendance: Established Care; Early Termination; or Comparison (i.e., did not initiate CBT). SettingOutpatient pediatric psychology and comprehensive SCD clinics in 3 locations at a southeastern children’s hospital. InterventionsCBT delivery was standardized. Treatment plans were tailored to meet individualized needs.Main Outcome Measures: Healthcare utilization included pain-related inpatient admissions, total inpatient days, and emergency department reliance (EDR) at 12-months pre-post CBT. Patient-reported outcomes (PROs) included typical pain intensity, functional disability, and coping efficacy pre-post treatment. ResultsAdjusting for age, genotype, and hydroxyurea, early terminators of CBT had increased rates of admissions and hospital days over time relative to comparisons; those who established care had faster reduction in admissions and hospital days over time relative to comparisons. EDR decreased by 0.08 over time for Established Care and reduced by 0.01 for every 1 completed session. Patients who completed pre- and post-treatment PROs reported decreases in typical pain intensity, functional disability, and improved coping efficacy. ConclusionsEstablishing CBT care may support reductions in admissions for pain, length of stay, and EDR for youth with chronic SCD pain, which may be partially supported by patient-reported improvements in functioning, coping, and lower pain intensity following CBT. Enhancing clinical implementation of multidisciplinary treatments may optimize the health of these youth.

Behavioral and Molecular Basis of Cholinergic Modulation of Pain: Focus on Nicotinic Acetylcholine Receptors.

Nicotinic acetylcholine receptors (nAChRs) have emerged as a novel therapeutic strategy for pain and inflammatory disorders. In particular, α4β2∗, α7, and α9α10 nAChR subtypes have been investigated as potential targets to treat pain. The nAChRs are distributed on the pain transmission pathways, including central and peripheral nervous systems and immune cells as well. Several agonists for α4β2∗ nAChR subtypes have been investigated in multiple animal pain models with promising results. However, studies in human indicated a narrow therapeutic window for α4β2∗ agonists. Furthermore, animal studies suggest that using agonists for α7 nAChR subtype and antagonists for α9α10 nAChR subtypes are potential novel therapies for chronic pain management, including inflammatory and neuropathic pain. More recently, alternative nAChRs ligands such as positive allosteric modulators and silent agonists have shown potential to develop into new treatments for chronic pain.

Engagement in Cognitive-Behavioral Therapy for Chronic Pain Management Is Associated with Reductions in Healthcare Utilization in Pediatric Sickle Cell Disease

Introduction: Chronic pain in sickle cell disease (SCD) is a multifactorial complication that can contribute to high healthcare utilization. Multidisciplinary treatments going beyond medication alone are needed for the most effective chronic pain management. Cognitive-behavioral therapy (CBT) is effective for youth with chronic pain and focuses on improving daily functioning and coping, but the clinical effectiveness for chronic SCD pain has not been evaluated. This study examined changes in healthcare use over time for youth with chronic SCD pain who participated in CBT compared to controls with chronic SCD pain who never initiated CBT. Methods: Youth receiving care at comprehensive SCD clinics at three tertiary care locations at Children's Healthcare of Atlanta were included if they were aged 6-18 years, any SCD genotype, and referred to a pediatric psychology outpatient clinic for chronic pain management from November 2014-March 2018. Youth were excluded if they received bone marrow transplantation during the study period, had ongoing CBT past the study period, or were not actively followed for ≥1 year of medical care pre- or post-CBT. Patients were grouped based on therapy attendance: Established Care (i.e., attended ≥3 CBT sessions within 3 consecutive months); Early Termination (i.e., attended &amp;lt;3 CBT sessions within 3 consecutive months); or Control (i.e., did not attend any CBT visits). Patient-reported outcomes included typical pain intensity, functional disability, and coping efficacy at pre- and post-treatment. Healthcare utilization outcomes were abstracted from electronic medical records including: number of inpatient admissions for pain, total inpatient days for pain, and emergency department dependency ratio (EDR; ratio of ED visits to sum of ED and outpatient visits). For the treatment groups, utilization outcomes were calculated from 12-months prior to the first CBT visit, and from 12-months following the last CBT visit. For the control group, outcomes were calculated for 12-months prior to the referral date, and from 12-months following the average duration of CBT for treatment groups (i.e., 3.5 months) to account for passage of time. Changes over time in inpatient admissions, hospital days, and EDR were evaluated separately using linear mixed effect models with a random effect for person-specific intercepts and slopes, which were retained based on model contribution determined by Bayesian Information Criterion. Time, patient characteristics, SCD-modifying treatments, therapy attendance, number of CBT sessions, and interaction effects were initially included in the models; the most parsimonious models were chosen based on backward selection. Results: At time of referral, youth (n=101) were on average (M) 13.4 years old (SD=2.92), 56.4% female, 68.1% HbSS or HbSβ0, 63.9% prescribed hydroxyurea, and 12.6% received chronic transfusions. The Control (n=44) and Treatment Groups (n=57) did not significantly differ by age, sex, genotype, or treatment with hydroxyurea or chronic transfusion. Based on therapy attendance, 36.1% Established Care, 21.8% were Early Termination, and 42% Controls. Adjusting for age, genotype, and hydroxyurea, patients who terminated CBT early had increased admissions and total hospital days over time compared to controls; those who established care had a reduction in admissions and hospital days over time compared to controls (F's=3.27-3.61, p's&amp;lt;.05). EDR decreased by 0.1 over time for Established Care; for every 1 completed CBT session, EDR was further reduced by 0.01 (p&amp;lt;.05). Patients who completed CBT (n=18) reported decreases in typical pain intensity (Mpre= 5.47, SD=2.24; Mpost=3.76, SD=2.84; p&amp;lt;.01), functional disability (Mpre=26.24, SD=8.45; Mpost=15.18, SD=10.85; p&amp;lt;.001), and improved coping efficacy (Mpre=8.0, SD=2.21; Mpost=9.65, SD=2.94; p&amp;lt;.05) from pre- to post-treatment. Conclusions: Establishing care in CBT may support reductions in admissions for pain, length of stay, and ED dependency for youth with chronic SCD pain beyond the potential effects of age, genotype, and SCD-modifying treatments. Reductions in utilization may be partially supported by patient-reported improvements in functioning, coping, and lower pain intensity following CBT. Reducing barriers to access and enhancing clinical implementation of multidisciplinary treatments may optimize the health of youth with chronic SCD pain. Disclosures Lane: NHLBI: Research Funding; CDC: Research Funding; GA Dept: Other: Contract for newborn screeninjg follow-up services services; Bio Products Laboratory: Other: Sickle Cell Advisory Board; FORMA Therapeutics: Other: Clinical Advisory Board. Dampier:Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Micelle BioPharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Global Blood Therapeutics: Consultancy; Epizyme: Consultancy; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Katz Foundation: Research Funding; Modus Therapeutics: Consultancy; NIH: Research Funding; Merck: Research Funding.

Medical cannabis for chronic pain: can it make a difference in pain management?

Globally, chronic pain is a major therapeutic challenge and affects more than 15% of the population. As patients with painful terminal diseases may face unbearable pain, there is a need for more potent analgesics. Although opioid-based therapeutic agents received attention to manage severe pain, their adverse drug effects and mortality rate associated with opioids overdose are the major concerns. Evidences from clinical trials showed therapeutic benefits of cannabis, especially delta-9-tetrahydrocannabinol and cannabinoids reduced neuropathic pain intensity in various conditions. Also, there are reports on using combination cannabinoid therapies for chronic pain management. The association of cannabis dependence and addiction has been discussed much and the reports mentioned that it can be comparatively lower than other substances such as nicotine and alcohol. More countries have decided to legalise the medicinal use of cannabis and marijuana. Healthcare professionals should keep themselves updated with the changing state of medical cannabis and its applications. The pharmacokinetics and safety of medical cannabis need to be studied by conducting clinical research. The complex and variable chemically active contents of herbal cannabis and methodological limitations in the administration of cannabis to study participants, make the clinical research difficult.