Post-surgical discharge opioid prescribing, use and handling after introduction of a stewardship program.

SummaryOpioids are often used to provide postsurgical analgesia but may cause harm if used inappropriately. We introduced an opioid stewardship program in three Melbourne hospitals to reduce the inappropriate use of opioids after patient discharge. The program had four pillars: prescriber education, patient education, a standardised quantity of discharge opioids, and general practitioner (GP) communication. Following introduction of the program, we undertook this prospective cohort study. The study aimed to describe post-program discharge opioid prescribing, patient opioid use and handling, and the impact of patient demographics, pain and surgical treatment factors on discharge prescribing. We also evaluated compliance with the program components. We recruited 884 surgical patients from the three hospitals during the ten-week study period. Discharge opioids were dispensed to 604 (74%) patients, with 20% receiving slow-release opioids. Junior medical staff undertook 95% of discharge opioid prescribing, which was guideline-compliant for 78% of patients. Of the patients discharged with opioids, a GP letter was sent for only 17%. Follow-up at two weeks was successful in 423 (70%) patients and in 404 (67%) at three months. At the three-month follow-up, 9.7% of patients reported ongoing opioid use; in preoperatively opioid naïve patients, the incidence was 5.5%. At the two-week follow-up, only 5% reported disposal of excess opioids, increasing to 26% at three months. Ongoing opioid therapy at three months in our study cohort (9.7%; 39/404) was associated with preoperative opioid consumption and higher pain scores at the three-month follow-up. The introduction of the opioid stewardship program resulted in highly guideline-compliant prescribing, but hospital-to-GP communication was uncommon and opioid disposal rates were low. Our findings suggest that opioid stewardship programs can improve postoperative opioid prescribing, use and handling, but the realisation of these gains will require effective program implementation.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project).

STUDY DESIGN: Multiround wiki-based Delphi expert panel survey. OBJECTIVE: To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." METHODS: Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. RESULTS: From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. CONCLUSION: These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process.

BACKGROUND: Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed. METHODS: Using a multistage modified Delphi process, twenty global experts across nine countries developed consensus-based recommendations on how to dose and administer medical cannabis in patients with chronic pain. RESULTS: There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed. A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC. A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every 7 days until a maximum daily dose of 40 mg/day of THC. A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day. CONCLUSIONS: In summary, using a modified Delphi process, expert consensus-based recommendations were developed on how to dose and administer medical cannabis for the treatment of patients with chronic pain.

Waiting in Pain II: An Updated Review of the Provision of Persistent Pain Services in Australia.

OBJECTIVE: To provide an update on Australian persistent pain services (number, structure, funding, wait times, activity). METHODS: An updated national search was conducted. Of those identified, 74 persistent pain services provided detailed responses between July 2016 and February 2018 (64 adult, seven pediatric, two pelvic pain, and one cancer pain). A similar structure to the original Waiting in Pain (WIP) survey was used, and participants chose online or telephone completion. RESULTS: Pediatric pain services had more than doubled but remained limited. Adult services had also increased, with a concurrent decrease in median wait times and an increase in the number of new referrals seen each year. Despite this, some lengthy wait times (≥3 years) persisted. Wait times were longest at clinics using public or combined funding models and offering pain management group programs (PMGPs). Although clinical activity had increased, medical staffing had not, suggesting that clinics were operating differently. Privately funded clinics performed more procedures than publicly funded services. Use of PMGPs had increased, but program structure remained diverse. CONCLUSIONS: Specialist pain services have expanded since the original WIP survey, facilitating treatment access for many. However, wait time range suggested that the most disadvantaged individuals still experienced the longest wait times, often far exceeding the recommended 6-month maximum wait. More needs to be done. Numerous developments (e.g., National Strategic Action Plan for Pain Management, health system changes as a result of the COVID-19 pandemic) will continue to influence the delivery of pain services in Australia, and repeated analysis of service structures and wait times will optimize our health system response to the management of this condition.

Can adequate analgesia be achieved in patients with cirrhosis without precipitating hepatic encephalopathy? A prospective study.

AIM OF THE STUDY: Analgesic use in patients with liver cirrhosis can be associated with increased morbidity and mortality and presents clinicians with a significant and challenging management issue. We evaluated the efficacy of opiate analgesia in patients with cirrhosis, while closely monitoring the side effect profile. MATERIAL AND METHODS: This prospective cohort pilot study compared inpatients with cirrhosis who required regular opiate analgesia to non-cirrhotic patients requiring opiates and patients with cirrhosis who did not require opiates. Participants completed daily surveys to assess for analgesic efficacy and encephalopathy. RESULTS: Fifty-two patients were initially recruited, of whom 50 patients were analysed in three groups (40 male, 10 female, median age 52 years). These included 13 cirrhotic patients (69% Child-Pugh B or C) requiring regular opiate analgesia, 18 cirrhotic patients (67% Child-Pugh B or C) not receiving regular opiate analgesia, and 19 non-cirrhotic controls. Two patients were excluded due to past stroke and acquired brain injury. All cirrhotic patients received regular lactulose. There was no statistical difference in the adequacy of analgesia between the three groups. The modified orientation log score for encephalopathy remained in the normal range in all but two cirrhotic patients receiving regular opiate analgesia. CONCLUSIONS: Effective pain control is achievable with opiate analgesia in most patients with advanced liver disease without precipitating hepatic encephalopathy.

Severe acute pain and persistent post-surgical pain in orthopaedic trauma patients: a cohort study.

BACKGROUND: We conducted a cohort study of adult patients presenting for orthopaedic trauma surgery at a statewide trauma centre, with the aims of determining (i) the incidence and risk factors for severe acute pain in the PACU, and (ii) the incidence and risk factors for persistent post-surgical pain at 3 months. METHODS: Data were collected before operation, in the PACU, 72 h after surgery and 3 months after surgery, and included numerical rating scale (NRS) scores for pain, and modified Brief Pain Inventory-Short Form, Kessler Psychological Distress Scale, World Health Organization Disability Assessment Schedule, and Pain Catastrophizing Scale scores. RESULTS: Severe acute pain in the PACU was reported by 171 (56%; 95% confidence interval [CI]: 51%, 62%) of the 303 included patients. Female sex (odds ratio [OR]: 1.86; 95% CI: 1.06, 3.26) and prior post-injury surgery (OR: 2.21; 95% CI: 1.11, 4.41) remained associated with severe acute pain after multivariable adjustment. Persistent post-surgical pain at 3 months was reported by 149 (65%; 95% CI: 59%, 71%) of the 229 included patients. The preoperative NRS score (OR: 1.17; 95% CI: 1.03, 1.32) remained associated with persistent pain after multivariable adjustment. CONCLUSIONS: We identified three easy-to-measure risk factors: female sex, prior post-injury surgery for severe acute pain, and preoperative NRS scores for persistent pain. Further research is required to identify pain management strategies and psychosocial interventions to reduce the burden of pain, disability, and distress in these patients.

Effects of Electroacupuncture on Opioid Consumption in Patients with Chronic Musculoskeletal Pain: A Multicenter Randomized Controlled Trial.

OBJECTIVES: To evaluate the efficacy and safety of electroacupuncture in reducing opioid consumption in patients with chronic musculoskeletal pain. DESIGN: A randomized, participant-assessor-blinded, three-arm trial. SETTING: Participants from three pain clinics and from the public. SUBJECTS: One hundred and eight adults with chronic pain who were taking opioids. METHODS: All participants received pain and medication management education. Participants were randomly allocated to electroacupuncture (N = 48), sham electroacupuncture (N = 29), or education alone (N = 31) to receive relevant treatment for 12 weeks. The last group received electroacupuncture during the three-month follow-up. Analysis of covariance and paired t tested were used. RESULTS: Opioid dosage, that is, the primary outcome measure, was reduced by 20.5% (P < 0.05) and 13.7% (P < 0.01) in the two acupuncture groups and by 4.5% in the education group at the end of the treatment phase, but without any group difference. Intensity of pain of all three groups did not change over time. No group differences were found in dosage of nonopioid analgesics, pain intensity, function, and opioid-related adverse events. During follow-up, the education group had a 47% reduction of opioids after a course of electroacupuncture. Adverse events to electroacupuncture were minor. CONCLUSION: It is safe to reduce opioid medication use in patients with chronic pain. Due to the small sample size, we could not confirm if electroacupuncture offers extra benefit in addition to education. This nondrug therapy could be a promising adjunct to facilitate opioid tapering in patients who are willing to reduce opioids.

Comparative Plasma and Cerebrospinal Fluid Pharmacokinetics of Paracetamol After Intravenous and Oral Administration.

BACKGROUND: We compared plasma and cerebrospinal fluid (CSF) pharmacokinetics of paracetamol after intravenous (IV) and oral administration to determine dosing regimens that optimize CSF concentrations. METHODS: Twenty-one adult patients were assigned randomly to 1 g IV, 1 g oral or 1.5 g oral paracetamol. An IV cannula and lumbar intrathecal catheter were used to sample venous blood and CSF, respectively, over 6 hours. The plasma and CSF maximum concentrations (Cmax), times to maximum concentrations (Tmax), and area under the plasma and CSF concentration-time curves (AUCs) were calculated using noncompartmental techniques. Significance was defined by P < .0167 (Bonferroni correction for 3 comparisons for each parameter). Probability (X < Y) (p″) with Bonferroni corrected 95% confidence intervals (CIs) were calculated (CIs including 0.5 meet the null hypothesis). Results are presented as median (range) or p″ (CI). P values are listed as 1 g IV vs 1 g orally, 1 g IV vs 1.5 g orally and 1 g orally vs 1.5 g orally, respectively. RESULTS: Wide variation in measured paracetamol concentrations was observed, especially in the oral groups. The median plasma Cmax in the 1 g IV group was significantly greater than the oral groups. In contrast, the median CSF Cmax was not different between groups. The median plasma Tmax in the 1 g IV group was 105 and 75 minutes earlier than in the 1 and 1.5 g oral groups. The median CSF Tmax was not significantly different between groups. The median plasma AUC (total) was not significantly different between groups; however, in the first hour, the median plasma AUC was significantly greater in the IV group than in the oral groups. In the second hour, there was no difference between groups. The median CSF AUC (total) did not significantly differ between groups; however, in the first hour, the median CSF AUC was significantly greater in the IV compared with the orally groups. In the second hour, there was no difference between groups. Our analysis indicated that the median Cmax, Tmax, and AUC values lacked precision because of small sample sizes. CONCLUSIONS: Peak plasma concentrations were greater and reached earlier after IV than oral dosing. Evidence for differences in CSF Cmax and Tmax was lacking because of the small size of this study.

Resisting Prescribed Opioids: A Qualitative Study of Decision Making in Patients Taking Opioids for Chronic Noncancer Pain.

BACKGROUND: Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible. OBJECTIVE: To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients. DESIGN: A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking." SETTING AND PARTICIPANTS: A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options. FINDINGS: Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence. CONCLUSIONS: Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making. SUMMARY: Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making.

Using Social Media While Waiting in Pain: A Clinical 12-Week Longitudinal Pilot Study.

BACKGROUND: Chronic pain places an enormous burden on health care systems. Multidisciplinary pain management services are well documented as an effective means to improve patient outcomes. However, waiting lists to access these services are long and outcomes deteriorate. Innovative solutions such as social media are gaining attention as a way to decrease this burden and improve outcomes. It is a challenge to design research that demonstrates whether social media are acceptable to patients and clinically effective. OBJECTIVE: The aim was to conduct a longitudinal pilot study to understand what aspects of research design are key to the success of running a larger-scale study of social media use in the clinical management of chronic pain. METHODS: A 12-week study examined social media use by patients on the waiting list for the Royal Melbourne Hospital Pain Management Service. Selected social media resources were suggested for use by patients waiting for an appointment at the clinic. Patients filled out measures for pain interference and pain self-efficacy before and after the study. Follow-up was conducted at monthly intervals via telephone semistructured interviews to discuss engagement and garner individual perceptions towards social media use. A social media-use instrument was also administered as part of the after-study questionnaire. RESULTS: Targeted recruitment refined 235 patient referrals to 138 (58.7%) suitable potential participants. Contact was made with 84 out of 138 (60.9%) patients. After a further exclusion of 54 out of 84 (64%) patients for various reasons, this left 30 out of 84 (36%) patients fitting the inclusion criteria and interested in study participation. A final study cohort of 17 out of 30 (57%) was obtained. Demographics of the 17 patients were mixed. Low back pain was the primary condition reported as leading to chronic pain. Semistructured interviews collected data from 16 out of 17 (94%) patients who started the trial, and at final follow-up 9 out of 17 (53%) patients completed questionnaires. Low specificity of the resources to one's condition and time poorness may have been barriers to engagement. CONCLUSIONS: Results suggest that with refinements, this study design can be implemented successfully when conducting a larger social media study. At present, comment cannot be made on what effect using social media can have on patients on hospital waiting lists, nor whether those who use social media while waiting in pain achieve better outcomes from eventual participation in a chronic pain program. Long-term follow-up should be included in future studies to answer this. Future research should focus on multicenter randomized controlled trials, involving patients in the intervention design for improved participation and outcomes and for evidence to be sound.

An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services.

OBJECTIVE: To document staffing (medical, nursing, allied health [AH], administrative) in Australian multidisciplinary persistent pain services and relate them to clinical activity levels. METHODS: Of the 68 adult outpatient persistent pain services approached (Dec'08-Jan'10), 45 agreed to participate, received over 100 referrals/year, and met the contemporaneous International Association for the Study of Pain criteria for Level 1 or 2 multidisciplinary services. Structured interviews with Clinical Directors collected quantitative data regarding staff resources (disciplines, amount), services provided, funding models, and activity levels. RESULTS: Compared with Level 2 clinics, Level 1 centers reported higher annual demand (referrals), clinical activity (patient numbers) and absolute numbers of medical, nursing and administrative staff, but comparable numbers of AH staff. When staffing was assessed against activity levels, medical and nursing resources were consistent across services, but Level 1 clinics had relatively fewer AH and administrative staff. Metropolitan and rural services reported comparable activity levels and discipline-specific staff ratios (except occupational therapy). The mean annual AH staffing for pain management group programs was 0.03 full-time equivalent staff per patient. CONCLUSIONS: Reasonable consistency was demonstrated in the range and mix of most disciplines employed, suggesting they represented workable clinical structures. The greater number of medical and nursing staff within Level 1 clinics may indicate a lower multidisciplinary focus, but this needs further exploration. As the first multidisciplinary staffing data for persistent pain clinics, this provides critical information for designing and implementing clinical services. Mapping against clinical outcomes to demonstrate the impact of staffing patterns on safe and efficacious treatment delivery is required.

Persistent disability is a risk factor for late-onset mental disorder after serious injury.

BACKGROUND: Most of what we know about the psychiatric consequences of injury is limited to the first year. Determining the prevalence of and risk factors for psychiatric morbidity beyond one year will aid service development and facilitate timely diagnosis and treatment. The aim of this prognostic study was to determine the prevalence of mental disorders in the three years following serious injury and to identify risk factors for the onset of new disorders after 1 year. METHODS: Of 272 patients assessed in hospital following serious injury, 196 (72.1%) were reassessed at 3 years. Assessment involved gold standard semi-structured interviews for psychiatric diagnoses, risk factors for mental disorder, injury measures and pain scores. RESULTS: More than a quarter of all patients were diagnosed with at least one mood or anxiety disorder at some stage during the three years following their injury. The most common diagnoses were major depression (20.0%), generalised anxiety disorder (6.7%) and panic disorder (6.7%). For a third of these patients, the disorder appeared after 12 months, for which persistent physical disability was an independent risk factor. CONCLUSION: Although there is a necessary focus on the early detection and treatment of mental disorders after injury, attention to later onset disorders is also required for those with persistent pain and physical disability.

Chaos to hope: a narrative of healing.

AIMS: To investigate the progression of the illness and opioid journeys of people who are taking opioids for chronic non-cancer pain. METHODS: In-depth qualitative interviews were conducted with 20 people who were taking opioids for non-cancer pain. A purposive sample was drawn from patients attending two pain clinics in Melbourne, Australia. Transcripts were analyzed within case, as individual narratives, and across case, as a thematic analysis. Conceptual explanatory variables were developed. RESULTS: The experience of taking opioids for chronic non-cancer pain varies greatly between individuals and these diverse narratives-chaos, restitution, and quest narratives-raise questions about why and how some individuals find a way forward, while others remain in situations of chaotic and worsening ill health. We offer an explanation for this variability in terms of four key influences: support from individual health professionals and the health system; medical explanation or solutions; social support and social responsibilities; and the use of non-pharmaceutical interventions and self-help strategies. A unifying theme was the importance of maintaining hope. CONCLUSION: The four key factors influencing the progress of people taking opioids for chronic non-cancer pain are rooted in the provisions made by society for caring for this patient group and involve relationships between patient and provider, between patients and their social world, and between different providers and their professional knowledge. In our patient sample, effective support involved the provision and maintenance of hope, and professionals who are knowledgeable about opioids and chronic pain, good communicators, and cognizant with their patients' social support and responsibilities.

Determinants of chronic pain 3 years after moderate or serious injury.

OBJECTIVE: Patients with pain 3 years after injury are at risk of lifetime pain. It is not known if the predictors of chronic pain at 3 years are the same as those for earlier time points or whether other factors become important. Clarifying these factors will aid our understanding of the development of long-term pain and further inform the development of models for screening and early intervention for pain in the aftermath of injury. DESIGN: Patients admitted to two trauma centers underwent a comprehensive physical and psychological assessment of known and potential risk factors for chronic pain during their index admission. Three years after injury, these patients were assessed for the presence of chronic pain (score was ≥5 on an 11-point numerical rating scale during the last episode of pain, and present in the last month and at least two times in the past week) and pain-related disability. Logistic regression was used to identify independent risk factors for the presence of chronic pain and disability. RESULTS: Two hundred and twenty patients (75.9% of the original cohort) were assessed at 3 years. Of these, 146 (66.7%) reported some pain and 52 (23.7%) reported chronic pain. Factors (present at the time of injury) that predicted chronic pain were lower socioeconomic status, pain severity, and injury severity. The predictive power of these combined factors was modest. CONCLUSIONS: Three years after serious injury, almost a quarter of patients report chronic pain, and more than a third report at least moderate pain-related disability. The predicative power of measures taken in the acute setting is not enough to support discharge screening alone as a method of triaging high-risk patients to early intervention.

Effect of electroacupuncture on opioid consumption in patients with chronic musculoskeletal pain: protocol of a randomised controlled trial.

BACKGROUND: Chronic musculoskeletal pain is common and has been increasingly managed by opioid medications, of which the long-term efficacy is unknown. Furthermore, there is evidence that long-term use of opioids is associated with reduced pain control, declining physical function and quality of life, and could hinder the goals of integrated pain management. Electroacupuncture (EA) has been shown to be effective in reducing postoperative opioid consumption. Limited evidence suggests that acupuncture could assist patients with chronic pain to reduce their requirements for opioids.The proposed research aims to assess if EA is an effective adjunct therapy to standard pain and medication management in reducing opioids use by patients with chronic musculoskeletal pain. METHODS: In this multicentre, randomised, sham-acupuncture controlled, three-arm clinical trial, 316 patients regularly taking opioids for pain control and meeting the defined selection criteria will be recruited from pain management centres and clinics of primary care providers in Victoria, Australia. After a four-week run-in period, the participants are randomly assigned to one of three treatment groups to receive EA, sham EA or no-EA with a ratio of 2:1:1. All participants receive routine pain medication management delivered and supervised by the trial medical doctors. Twelve sessions of semi-structured EA or sham EA treatment are delivered over 10 weeks. Upon completion of the acupuncture treatment period, there is a 12-week follow-up. In total, participants are involved in the trial for 26 weeks. Outcome measures of opioid and non-opioid medication consumption, pain scores and opioid-related adverse events are documented throughout the study. Quality of life, depression, function, and attitude to pain medications are also assessed. DISCUSSION: This randomised controlled trial will determine whether EA is of significant clinical value in assisting the management of debilitating chronic pain by reducing opioids consumption and their associated adverse events, as well as improving the quality of life for those with chronic pain. Such an outcome will provide the rationale for including EA into multidisciplinary programmes for effective management of chronic musculoskeletal pain. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12609000676213)http://www.anzctr.org.au/trial_view.aspx?ID=308008.

Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia.

OBJECTIVES: To document and describe outpatient persistent pain management services in Australia. DESIGN, PARTICIPANTS AND SETTING: Systematic survey conducted between 1 December 2008 and 31 January 2010 of 57 services providing outpatient care to adult clients with persistent pain, plus five specialised paediatric services throughout Australia. MAIN OUTCOME MEASURES: Service structure, including funding processes; activity, including client numbers, access to specialised services (inpatient care, pain relief interventions); waiting times; and use of allied-health-professional-based pain management programs. RESULTS: Of 68 services identified, 57 participated in the study. The median waiting time from referral receipt to initial clinical assessment for a publicly funded outpatient adult pain management service was 150 days, compared with 38.5 days for a privately funded service (P<0.05). There was substantial variability among providers in range of services offered, including provision and duration of allied-health pain management programs. The level of service provision for children and rural patients is notably lower than that reported for urban adult constituents. CONCLUSIONS: Persistent pain management services are currently unable to meet service requirements adequately, and waiting times are more prolonged for publicly funded than privately funded services. Greater service provision is required in rural areas and for children.

Predictors of pain 12 months after serious injury.

OBJECTIVE: The majority of patients will report pain 12 months after a serious injury. Determining the independent risk factors for pain after serious injury will establish the degree to which high-risk patients can be detected in the acute setting and the viability of early triage to specialist pain services. DESIGN: A prospective cohort study of patients following serious injury was conducted. The initial assessment comprised a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed at 12 months for pain severity and for the presence of chronic pain. RESULTS: Two hundred ninety patients underwent an initial assessment of whom 238 (82%) were followed up at 12 months. At 12 months, 171 (72%) patients reported some pain over the past 24 hours. Thirty-five patients (14.7%) reported chronic pain. Five factors independently predicted the 24-hour pain severity: preinjury physical role function, preinjury employment status, initial 24 hours pain score, higher beliefs in the need for medication, and compensable injury (R(2) = 0.21, P < 0.0001). Four factors predicted the presence of chronic pain at 12 months: not working prior to injury, total Abbreviated Injury Scale, initial pain severity, and initial pain control attitudes (pseudo R(2) = 0.24, P = 0.0001). CONCLUSIONS: Factors present at the time of injury can allocate patients into high- or low-risk groups. The majority of cases of chronic pain emerging from the high-risk group warrant more intense clinical attention. We recommend recording these factors in discharge documentation as indicators of persistent pain.

Predictors of pain severity 3 months after serious injury.

OBJECTIVE: Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN: A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS: Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS: Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.