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PURPOSE OF REVIEW: As artificial intelligence (AI) and machine learning (ML) are becoming more pervasive in medicine, understanding their ethical considerations for chronic pain and headache management is crucial for optimizing their safety. RECENT FINDINGS: We reviewed thirty-eight editorial and original research articles published between 2018 and 2023, focusing on the application of AI and ML to chronic pain or headache. The core medical principles of beneficence, non-maleficence, autonomy, and justice constituted the evaluation framework. The AI applications addressed topics such as pain intensity prediction, diagnostic aides, risk assessment for medication misuse, empowering patients to self-manage their conditions, and optimizing access to care. Virtually all AI applications aligned both positively and negatively with specific medical ethics principles. This review highlights the potential of AI to enhance patient outcomes and physicians' experiences in managing chronic pain and headache. We emphasize the importance of carefully considering the advantages, disadvantages, and unintended consequences of utilizing AI tools in chronic pain and headache, and propose the four core principles of medical ethics as an evaluation framework.
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Inteligência Artificial , Dor Crônica , Cefaleia , Humanos , Inteligência Artificial/ética , Dor Crônica/terapia , Cefaleia/terapia , Ética Médica , Manejo da Dor/ética , Manejo da Dor/métodosRESUMO
PURPOSE OF REVIEW: This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. RECENT FINDINGS: Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.
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PURPOSE OF REVIEW: Chronic headaches are a significant source of disability worldwide. Despite the development of conventional strategies, a subset of patients remain refractory and/or experience side effects following these treatments. Hence, occipital nerve stimulation (ONS) should be considered as an alternative strategy for intractable chronic headaches. This review aims to provide a comprehensive overview of the effectiveness, safety, mechanisms and practical application of ONS for the treatment of headache disorders. RECENT FINDINGS: Overall response rate of ONS is 35.7-100%, 17-100%, and 63-100% in patients with cluster headache, chronic migraine and occipital neuralgia respectively. Regarding the long-term effectivity in all groups, 41.6-88.0% of patients remain responders after ≥ 18.3 months. The most frequently reported adverse events include lead migration/fracture (13%) and local pain (7.3%). Based on our results, ONS can be considered a safe and effective treatment for chronic intractable headache disorders. To support more widespread application of ONS, additional research with larger sample sizes should be conducted.
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PURPOSE OF REVIEW: This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape. RECENT FINDINGS: Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.
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COVID-19 , Dor Crônica , Telemedicina , Realidade Virtual , Humanos , Dor Crônica/terapia , Telemedicina/métodosRESUMO
PURPOSE OF REVIEW: This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations. RECENT FINDINGS: Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.
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Physician reviews influence how patients seek care, but dishonest reviews can be detrimental to a physician practice. It is unclear if reviews can be challenged, and processes differ and are not readily apparent. The objective of this observational study was to determine the ability to challenge dishonest negative reviews online. Commonly used websites for physician reviews as of August 2021 were utilized: Healthgrades, Vitals, RateMDs, Zocdoc, Yelp, and Google Business. Each review platform's website was tested for leaving a physician review and process of appeal and possible removal of a negative review. The process for appeal and the steps involved in posting and appealing a review were determined, whether individuals are verified patients and criteria for verification, how physicians can respond, and the process of appealing false or defamatory reviews.Any individual can leave reviews by searching for a physician's name or practice and visiting their profile page and can then provide a rating and written review of their experience with the physician. Many require verification to prevent suspicious activity but not proof of a medical visit, allowing significant potential for inaccurate review postings. Posting a review can be done by anyone without verification of a visit. It is challenging for physicians to remove negative online reviews, as most review platforms have strict policies against. This review concludes that physicians should be aware of their online presence and the steps that can be taken to address issues to mitigate adverse effects on their practices.
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Médicos , Mídias Sociais , Humanos , Comércio , Estudos Observacionais como Assunto , Internet , Competência Clínica , DifamaçãoRESUMO
PURPOSE OF REVIEW: Appropriate use of opioid analgesics is a key concern within the field of pain medicine. Several methods exist to discourage abuse and facilitate effective treatment regimens. Pill counting is often cited as one such method and frequently employed in varying fashions within clinical practice. However, to date, there is no published review of the evidence to support this practice. This was a comprehensive review of the available literature that was conducted with analysis of the efficacy and practical application of pill counting during treatment of chronic pain conditions. RECENT FINDINGS: There is paucity in data regarding pill count importance in pain management. Pill count is a very important tool to monitor compliance of opioids use which in turn can prevent several complications associated with opioid misuse. Pill counting may be used in conjunction with other abuse deterrents, although increased support for this practice requires standardized methods of pill counting and further analysis of its effectiveness.
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Dor Crônica , Transtornos Relacionados ao Uso de Opioides , Humanos , Dor Crônica/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Doença Crônica , Manejo da Dor/métodosRESUMO
OBJECTIVES: Post-thoracotomy pain syndrome (PTPS) is defined as persistent pain following a thoracotomy and has an incidence of 21-61%. Dorsal root ganglion stimulation (DRG-S) is a form of neuromodulation that modulates pain signal transmission to the spinal cord. The aims of this study were to investigate the efficacy of DRG-S for the management of PTPS and to assess the role of thoracic paravertebral blocks (t-PVB) as a tool for prediction of success of DRG-S. MATERIALS AND METHODS: In this prospective study, we included all patients undergoing thoracic surgery, with PTPS not responding to pharmacotherapy and treated with DRG-S from September 2018 to February 2019. t-PVB followed by a percutaneous DRG-S trial was performed on all patients. Pain intensity was assessed through a numeric rating scale (NRS) and Douleur Neuropathique en 4 Questions (DN4) at baseline, post-trial, at 14 days, 90 days, and at one year after DRG-S implantation. Data summarized as continuous variables were expressed as means and standard deviations (SDs), and categorical variables were expressed as raw numbers and percentages. RESULTS: Four patients out of 51 who underwent thoracic surgery at our institution surveyed were included (mean age ± SD, 56 ± 16 years old). Mean NRS and DN4 were, respectively, 7.2 ± 0.96 SD and 8.2 ± 0.5 SD at baseline, 2.5 ± 0.6 SD and 3.2 ± 0.5 SD after t-PVB, 2.2 ± 0.5 SD and 2.2 ± 0.5 SD at 14 days, 90 days, and at one year after DRG-S implantation. No complications or side effects were reported. CONCLUSIONS: Our preliminary results show that DRG-S is an effective therapy for PTPS after thoracic surgery. In addition, thoracic paravertebral blocks performed prior to DRG-S correlated with a positive outcome with treatment.
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Dor Crônica , Cirurgia Torácica , Dor Crônica/etiologia , Dor Crônica/terapia , Gânglios Espinais , Humanos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Projetos Piloto , Estudos ProspectivosRESUMO
OBJECTIVE: To determine the relationship between opioid dose change, pain severity, and function in patients with chronic pain. DESIGN: Retrospective cohort study. SETTING: Community interdisciplinary pain management practice. SUBJECTS: A total of 778 patients with chronic pain prescribed opioids for three or more consecutive months between April 1, 2013, and March 1, 2015. METHODS: Changes in opioid dose, pain severity rating, modified Roland Morris Disability Questionnaire score, and opioid risk data were extracted from medical records and analyzed for associations. RESULTS: Two hundred forty-three subjects (31.2%) had an overall dose decrease, 223 (28.7%) had a dose increase, and 312 (40.1%) had no significant change in dose (<20% change). There was a weak negative correlation between change in opioid dose and change in pain severity (r = -0.08, P = 0.04) but no association between change in disability scores and dose change (N = 526, P = 0.13). There was a weak positive correlation between change in pain severity rating and change in disability scores (r = 0.16, P < 0.001). CONCLUSIONS: The results suggest that escalating opioid doses may not necessarily result in clinically significant improvement of pain or disability. Similarly, significant opioid dose reductions may not necessarily result in worsened pain or disability. This exploratory investigation raised questions of possible subgroups of patients who might demonstrate improvement of pain and disability with opioid dose adjustments, and further research should prospectively explore this potential, given the limitations inherent in retrospective analyses. Prescribers should still consider reduction of opioid doses as recommended by current guidelines, in an effort to mitigate the potential risks associated with high-dose treatment.
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Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Manejo da Dor , Adulto , Pessoas com Deficiência/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Medição da Dor/métodos , Estudos RetrospectivosRESUMO
Objective: Health care providers are likely to see an increase in the concomitant use of cannabis and opioids, particularly with the increased liberalization and ongoing research into the possible role of medical marijuana for chronic pain. Recent literature reports a prevalence of concurrent use ranging from 8.9% to 31.8%. The primary aim of this study was to determine the relationship between cannabis use and aberrant drug behaviors in noncancer pain patients receiving chronic opioid therapy. Design: Retrospective chart review. Setting: Community-based, interdisciplinary pain management center. Subjects: Data from 209 patients who were evaluated for a medication management program between October 1, 2011, and January 1, 2014, and met inclusion criteria. Forty-four were positive for cannabis in their initial random urine drug toxicology. Methods: Data from electronic health records, including demographics, urine drug toxicology, disability, opioid dose, opioid risk assessment data, and pain severity were analyzed to examine differences among cannabis users and noncannabis users. Results: Subjects with cannabis in their initial urine drug toxicology were more likely to have a future occurrence of an opioid-related aberrancy (P < 0.001), be male (P = 0.047), have a history of substance abuse (P = 0.013), and be enrolled into a higher level of clinical monitoring of opioid medication use (P = 0.008). No other associations with demographic and clinical variables reached statistical significance. Conclusions: Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate higher risk for opioid misuse. Closer monitoring for opioid-related aberrancy is indicated for this group of patients.
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Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Uso da Maconha/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Clínicas de Dor , Estudos Retrospectivos , Fatores de RiscoRESUMO
In recent decades, there has been a revision of the role of institutional review boards with the intention of protecting human subjects from harm and exploitation in research. Informed consent aims to protect the subject by explaining all of the benefits and risks associated with a specific research project. To date, there has not been a review published analyzing issues of informed consent in research in the field of genetic/Omics in subjects with chronic pain, and the current review aims to fill that gap in the ethical aspects of such investigation. Despite the extensive discussion on ethical challenges unique to the field of genetic/Omics, this is the first attempt at addressing ethical challenges regarding Informed Consent Forms for pain research as the primary focus. We see this contribution as an important one, for while ethical issues are too often ignored in pain research in general, the numerous arising ethical issues that are unique to pain genetic/Omics suggest that researchers in the field need to pay even greater attention to the rights of subjects/patients. This article presents the work of the Ethic Committee of the Pain-Omics Group (www.painomics.eu), a consortium of 11 centers that is running the Pain-Omics project funded by the European Community in the 7th Framework Program theme (HEALTH.2013.2.2.1-5-Understanding and controlling pain). The Ethic Committee is composed of 1 member of each group of the consortium as well as key opinion leaders in the field of ethics and pain more generally.
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Genômica/ética , Genômica/tendências , Consentimento Livre e Esclarecido/ética , Dor Crônica/terapia , Comitês de Ética em Pesquisa , Humanos , Manejo da Dor/ética , Manejo da Dor/métodos , Manejo da Dor/tendênciasRESUMO
Background: Evidence regarding the frequency and timing of treatment for lumbar spinal stenosis (LSS) fails to offer clear consensus. We describe the LSS care journey from initial diagnosis to first surgical intervention. Methods: Using Medicare claims database from 2009 through 2020, we identified patients who were diagnosed with LSS. The use and timing of conservative and surgical treatments during the entire follow-up from the initial diagnosis were reported. Results: Of the 143,849 patients identified, 68% received conservative care within 8.4 months and 25.3% received a surgical or minimally invasive intervention over 5.7 years following initial diagnosis, with 12.6% undergoing open decompression alone, 10.2% undergoing open decompression with fusion, and 5.1% undergoing fusion surgery alone. Fewer than 1% were provided with interspinous spacers or a percutaneous image-guided lumbar decompression. Conclusion: Approximately three-quarters of patients in the study received no surgical or non-invasive interventions for approximately six years following diagnosis with LSS.
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Could it be possible that we should give some weight to the contribution of biological differences as contributors to the greater fentanyl mortality in males than in females? Most current explanations for a sex difference are based largely on psychosocial and other non-physiologic contributions. Our recent findings suggest a biological contribution. This could have broad implications for the interpretation and prevention of fentanyl overdose deaths.
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The last decade has seen a boom in pain medicine, basic science and interventional pain management. Concomitantly, there is a need to educate trainees, young attendings, and seasoned attendings on these innovations. There has been a growth in the number of societies that represent pain medicine physicians, each with its own philosophy and guiding principles. The variety of thought within pain management, within the various groups that practice this field, and amongst the societies which protect those missions inherently creates divergence and isolation within these different communities. There is the enormous opportunity for our field to grow, but we need the voices of all different specialties and sub-specialties which practice pain medicine to collectively design the future of our emerging field. The explosion of revolutionary percutaneous surgeries, medications, psychotherapy, and research and development in our field has outpaced the ability of payers to fully embrace them. There is an increased number of pain practitioners using novel therapies, postgraduate training programs do not adequately train users in these techniques thereby creating a potential for sub-optimal outcomes. In part, this is a reason why payers for many of our more novel treatments have decreased patient access or eliminated remuneration for some of them. We believe that society-based collaborative regulation of education, research, and treatment guidelines is needed to improve visibility for payers and end users who provide these treatments. Furthermore, postgraduate chronic pain fellowship education has been deemed by many to be insufficient to educate on all of the necessary requirements needed for the independent practice of pain medicine, especially the consummation of newer technologies. Here, we draw comparison with this tenuous stage in pain management history with the last United States recession to remind us of how poor institutional regulation and neglect for long-term growth hampers a community.
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Background: Chronic abdominal pain (CAP) is a common and challenging to treat condition with a global prevalence of up to 25%. Despite extensive evaluation, approximately 40% of patients with CAP have an unknown diagnosis. Medications may be ineffective, and surgery is rarely indicated. Interventional treatment including sympathetic blocks, sympathetic neurolysis, and transversus abdominal plane (TAP) blocks may be an option, but their efficacy can wane over time. Neuromodulation has emerged as an option for these patients, as there is evidence of success with dorsal column spinal cord and dorsal root ganglion (DRG) stimulation. Peripheral nerve stimulation (PNS) may be an alternative option, particularly in higher risk patients or in patients for whom neuraxial access may be unsafe or too technically challenging. Thoracoabdominal nerve peripheral nerve stimulation via a TAP approach may be more specifically targeted in comparison to dorsal column or DRG stimulation. In this short report, we detail a technique that the authors have successfully used for thoracoabdominal nerve PNS via a TAP approach for management of CAP. Methods: This article describes a novel medial to lateral ultrasound guided thoracoabdominal nerve PNS via a TAP approach technique for lead placement and implantation. Results: A medial to lateral ultrasound guided TAP approach as described to successfully implant percutaneous thoracoabdominal nerve PNS leads for management of CAP. Conclusion: The thoracoabdominal nerve PNS via a TAP approach lead placement technique noted in this report has been used as a means for management of CAP utilizing peripheral neuromodulation. Here, we present a short report detailing a potential technique for PNS utilization for management of CAP. Further studies are needed to validate the safety and efficacy of this therapy modality, although the authors have found it to be a viable management option for patients with medically refractory neuropathic CAP.
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Introduction: Amid a lack of effective chronic pain treatments, psychedelics have gained attention as a potential solution, although their Schedule 1 classification poses challenges. Psychedelics, such as lysergic acid diethylamide (LSD) and psilocybin, have gained popularity as alternatives and adjuncts for chronic pain treatment. Studies suggest that they may modulate pain processing through agonism primarily at the serotonin receptor, 5-HT2A. One of the first of its nature, we present an artificial intelligence (AI)-powered scoping review primarily focusing on evaluating psychedelics for chronic pain conditions such as cluster headache, phantom limb pain, and fibromyalgia. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we used an AI-powered comprehensive search strategy utilizing the ChatGPT4.0 Bing chat to search Medline, Embase, Cochrane, and Google Scholar for articles addressing chronic pain. The query was performed on June 1, 2023, focusing on psychedelics for chronic, non-cancer pain including headache disorders. Inclusion criteria were English-only, peer-reviewed articles involving human participants >18 years, focusing on chronic pain conditions (eg, phantom limb pain and cluster headache), using LSD, 2.5-dimethoxy-4-bromophenethylamine (2C-B), N, N-dimethyltryptamine (DMT), psilocybin, or mescaline. Exclusion criteria were reviews, editorials, and opinion articles and studies focusing on tetrahydrocannabinol/cannabis and/or ketamine. Results: A total of 186 unique database entries were retrieved, of which nine studies were included in the scoping review. These included four case reports/series, an open-label study, a cohort study, two online surveys, and a randomized, double-blind, placebo-controlled trial. They comprised three studies addressing phantom limb pain, four addressing cluster headaches, and two addressing fibromyalgia, spinal cord injury, complex regional pain syndrome, and lumbar radiculopathy. Conclusion: Psychedelics may have potential in alleviating pain symptoms secondary to a multitude of chronic pain conditions. However, further randomized, double-blind, placebo-controlled trials are needed to further explore and evaluate the role of psychedelics in chronic, non-cancer pain.
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Aim: Visceral pain, characterized by pain that is diffuse and challenging to localize, occurs frequently and is difficult to treat. In cases where the pain becomes intractable despite optimal medical management, it can affect patients' Quality of Life (QoL). Spinal Cord Stimulation (SCS) has emerged as a potential solution for intractable visceral pain. Purpose: In this narrative review, we collected all evidence regarding the efficacy of SCS for visceral pain across various underlying conditions. Methods: A comprehensive literature search was conducted in PubMed, Embase, and Web of Science in which articles published from October 1st, 1963 up to March 7th, 2023 were identified. Results: Seventy articles were included in this review of which most were retrospective cohort studies, case series and case reports. The studies, often with a small number of participants, reported on SCS for chronic pancreatitis, anorectal pain and bowel disorders, gynaecological diagnoses, visceral pelvic pain, urological disorders and finally general visceral pain. They found positive effects on pain and/or symptom relief, opioid consumption, anxiety and depression and QoL. Complications occurred frequently but were often minor and reversible. Conclusion: Better screening and selection criteria need to be established to optimally evaluate eligible patients who might benefit from SCS. A positive outcome of a sympathetic nerve block appears to be a potential indicator of SCS effectiveness. Additionally, women receiving SCS for endometriosis had a better outcome compared to other indications. Finally, SCS could also relief functional symptoms such as voiding problems and gastroparesis. Complications could often be resolved with revision surgery. Since SCS is expensive and not always covered by standard health insurance, the incorporation of cost-analyses is recommended. In order to establish a comprehensive treatment plan, including selection criteria for SCS, rigorous prospective, possibly randomized and controlled studies that are diagnosis-oriented, with substantial follow-up and adequate sample sizes, are needed.