Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada.

Objective: Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers). Methods: A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain. Results: 1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models. Discussion: There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

Changing society, changing research: integrating gender to better understand physical and psychological treatments use in chronic pain management.

ABSTRACT: Treatment of chronic pain should be multimodal and include pharmacological, physical, and psychological treatments. However, because various barriers to physical and psychological treatments (PPTs) exist, a better understanding of biopsychosocial factors leading to their use is relevant. This study aimed to explore the association between gender identity, gender-stereotyped personality traits, and the use of PPTs in chronic pain management. The ChrOnic Pain trEatment cohort, a self-reported data infrastructure resulting from a web-based recruitment of 1935 people living with chronic pain (Quebec, Canada) was analyzed. Gender identity was operationalized as women, men, and nonbinary. Gender-stereotyped personality traits were measured using the Bem Sex-Role Inventory (feminine, masculine, androgynous, undifferentiated). A checklist of 31 types of PPTs that can be used for chronic pain management was presented to participants (yes/no). From the 1433 participants, 85.5% reported using at least one PPT. Hot-cold therapies (43.4%), exercise (41.9%), and meditation (35.2%) were the most frequently used PPTs, but most popular PPTs were not the same among women and men. Women reported a significantly higher use of PPTs in general (87.2% vs 77.2%; P < 0.001). Multivariable and interaction analyses showed that identifying as a man decreased the odds of reporting the use of PPTs (odds ratio: 0.32, 95% confidence interval: 0.11-0.92) but only among participants who scored high on both masculine and feminine personality traits (those classified as androgynous). The high prevalence of PPTs use found in our study is positive. Our results are relevant for a more personalized promotion of PPTs for chronic pain management.

Prevalence of cannabis use for pain management in Quebec: A post-legalization estimate among generations living with chronic pain.

Background: Medical cannabis has been legal in Canada since 2001, and recreational cannabis was legalized in October 2018, which has led to a widespread increase in the accessibility of cannabis products. Aims: This study aimed to estimate the prevalence of cannabis use among adults living with chronic pain (CP) and investigate the relationship between age and cannabis use for CP management. Methods: A cross-sectional analysis of the COPE Cohort data set, a large Quebec sample of 1935 adults living with CP, was conducted. Participants completed a web-based questionnaire in 2019 that contained three yes/no questions about past-year use of cannabis (i.e., for pain management, management of other health-related conditions, recreational purposes). Results: Among the 1344 participants who completed the cannabis use section of the questionnaire, the overall prevalence of cannabis use for pain management was 30.1% (95% confidence interval 27.7-32.7). Differences were found between age groups, with the highest prevalence among participants aged ≤26 years (36.5%) and lowest for those aged ≥74 years (8.8%). A multivariable logistic model revealed that age, region of residence, generalized pain, use of medications or nonpharmacological approaches for pain management, alcohol/drug consumption, and smoking were associated with the likelihood of using cannabis for pain management. Conclusions: Cannabis is a common treatment for the management of CP, especially in younger generations. The high prevalence of use emphasizes the importance of better knowledge translation for people living with CP, rapidly generating evidence regarding the safety and efficacy of cannabis, and clinicians' involvement in supporting people who use cannabis for pain management.

Contexte: Le cannabis médical est légal au Canada depuis 2001 et le cannabis récréatif a été légalisé en octobre 2018, ce qui a conduit à une augmentation généralisée de l'accessibilité des produits du cannabis. Objectifs: Cette étude visait à estimer la prévalence de la consommation de cannabis chez les adultes vivant avec la douleur chronique et à étudier l'association entre l'âge et la consommation de cannabis pour la prise en charge de la douleur chronique. Méthodes: Une analyse transversale de l'ensemble de données de la cohorte COPE, un grand échantillon québécois de 1 935 adultes vivant avec la douleur chronique, a été menée. En 2019, les participants ont rempli un questionnaire en ligne qui contenait trois questions oui/non sur la consommation de cannabis au cours de l'année écoulée (c.-à-d., pour la prise en charge de la douleur, la prise en charge d'autres affections liées à la santé, à des fins récréatives). Résultats: Parmi les 1 344 participants qui ont rempli la section du questionnaire portant sur la consommation de cannabis, la prévalence globale de la consommation de cannabis pour la prise en charge de la douleur était de 30,1 % (intervalle de confiance à 95 %, 27,7-32,7). Des différences ont été constatées entre les groupes d'âge, avec la prévalence la plus élevée chez les participants âgés de ≤ 26 ans (36,5 %) et la plus basse chez les participants âgés de ≥ 74 ans (8,8 %). Un modéle logistique multivariable a révélé que l'âge, la région de résidence, la douleur généralisée, l'utilisation de médicaments ou approches non pharmacologiques pour la prise en charge de la douleur, la consommation d'alcool/de drogue et le tabagisme étaient associés à la probabilité d'utiliser le cannabis pour la prise en charge de la douleur. Conclusions: Le cannabis est un traitement courant pour la prise en charge de la douleur chronique, en particulier chez les jeunes générations. La prévalence élevée de l'utilisation souligne l'importance d'un meilleur transfert des connaissances pour les personnes vivant avec la douleur chronique, en générant rapidement des donnant probantes concernant l'innocuité et l'efficacité du cannabis, ainsi que l'implication des cliniciens dans le soutien aux personnes qui consomment du cannabis pour la prise en charge de la douleur.

The importance of chronic pain education and awareness amongst occupational safety and health professionals.

Purpose: Occupational safety and health (OSH) professionals are often the point of contact for health and safety policies derived in the workplace, and the handling of incidents in their aftermath. As chronic pain affects 20% of people, many pain-awareness campaigns and educational activities target healthcare professionals. However, initiatives directed toward OSH professionals are also important to aid in prevention and rehabilitation efforts. The objective of this study was to describe knowledge and attitudes of OSH students with regard to chronic pain. Methods: A web-based cross-sectional study was conducted amongst a convenience sample of 88 students enrolled in the distance learning OSH undergraduate certificate program at the Université du Québec en Abitibi-Témiscamingue (Quebec, Canada). Results: Although 30% of students were already employed within OSH or human resources and 40% reported intervening in cases involving chronic pain in their line of work, 56% of respondents had received no training on chronic pain and its treatment in the past five years. Only 14% chose to take the optional 45 hr course dedicated to pain within the program. OSH students also exhibited poorer knowledge and more negative attitudes toward people suffering from chronic pain when compared to other groups assessed in the province of Quebec, including healthcare professionals, chronic pain patients, and people not suffering from chronic pain (p≤0.0002). Half of the respondents (51.9%) were not aware that chronic pain affects 1 in 5 adults. Conclusion: Our study demonstrates a need for pain education within OSH training programs and through continuing education.

Review of chronic non-cancer pain research among Aboriginal people in Canada.

PURPOSE: Aboriginal people in Canada are disproportionately affected by chronic illnesses, compared to non-Aboriginal Canadians. The purpose of this review was to determine whether differences exist between the two groups with respect to chronic non-cancer pain (CNCP) in order to better inform clinical practice and to identify research gaps. DATA SOURCES: Four electronic databases were searched for the period of 1990-2015. STUDY SELECTION: Only English and French language original studies that examined CNCP prevalence, assessment tools and beliefs among Aboriginal people in Canada were considered. DATA EXTRACTION: Data extracted included Aboriginal group, geographic location, study setting and pain definition (for prevalence studies only). RESULTS OF DATA SYNTHESIS: A total of 11 studies matched the selection criteria: 10 reported estimates of chronic pain prevalence among Aboriginal people in Canada, 1 was about a culturally adapted pain assessment tool, and no study was found about CNCP beliefs within Aboriginal people. CONCLUSION: CNCP among Aboriginal people is still a largely unexplored research field. The limited evidence available so far does not allow us to conclude that CNCP affects a higher proportion of Aboriginal than non-Aboriginal people in Canada. However, arthritis, a specific condition associated with chronic pain, is more prevalent in Aboriginal than non-Aboriginal people. Additional research is needed on other CNCP types and conditions. Furthermore, pain assessment tools are not culturally adapted and clinicians should inquire more about the beliefs of Aboriginal patients to make them feel safer and to better target interventions.

Prevalence and determinants of cannabinoid prescription for the management of chronic noncancer pain: a postal survey of physicians in the Abitibi-Témiscamingue region of Quebec.

BACKGROUND: Few studies have been conducted to explore physicians' prescription practices and attitudes toward the use of cannabinoids in Canada.We measured the prevalence and identified determinants of cannabinoid prescription for the management of chronic noncancer pain among physicians in southwestern Quebec. METHODS: In February 2013, we conducted a postal survey using a modified Dillman method that involved physicians practising in the Abitibi-Témiscamingue region of Quebec. We used multivariate logistic regression models to identify determinants of cannabinoid prescription. RESULTS: A total of 166 physicians of 318 practising in the region participated in the survey (response rate 52.2%). The prevalence of cannabinoid prescription was 27.3% (45/165) for any indication and 23.0% (38/165) for the management of chronic noncancer pain; 91.1% (41/45) of the physicians prescribed cannabinoids to 5 or fewer patients. Of the 38 physicians who prescribed cannabinoids for chronic noncancer pain, 35 (92.1%) prescribed nabilone, 7 (18.4%) medical marijuana and 2 (5.3%) nabiximols. The principal determinant of cannabinoid prescription was the physician's level of comfort with prescribing cannabinoids (adjusted odds ratio 1.25, 95% confidence interval 1.01-1.55, per 1-point increase in comfort level measured on 10-point scale). Respondents reported that continuing medical education (CME) activities could increase their comfort level. They also indicated a need for guidelines or algorithms that included cannabinoid use as well as more studies about the efficacy and safety of cannabinoids for the management of chronic noncancer pain. INTERPRETATION: We found that cannabinoids were not often prescribed for the management of chronic noncancer pain and that survey respondents were not comfortable with prescribing this drug class. This degree of discomfort could be addressed by CME activities, more effective dissemination of guidelines and more evidence regarding cannabinoid use for the management of chronic noncancer pain.

Traditional use of medicinal plants in the boreal forest of Canada: review and perspectives.

BACKGROUND: The boreal forest of Canada is home to several hundred thousands Aboriginal people who have been using medicinal plants in traditional health care systems for thousands of years. This knowledge, transmitted by oral tradition from generation to generation, has been eroding in recent decades due to rapid cultural change. Until now, published reviews about traditional uses of medicinal plants in boreal Canada have focused either on particular Aboriginal groups or on restricted regions. Here, we present a review of traditional uses of medicinal plants by the Aboriginal people of the entire Canadian boreal forest in order to provide comprehensive documentation, identify research gaps, and suggest perspectives for future research. METHODS: A review of the literature published in scientific journals, books, theses and reports. RESULTS: A total of 546 medicinal plant taxa used by the Aboriginal people of the Canadian boreal forest were reported in the reviewed literature. These plants were used to treat 28 disease and disorder categories, with the highest number of species being used for gastro-intestinal disorders, followed by musculoskeletal disorders. Herbs were the primary source of medicinal plants, followed by shrubs. The medicinal knowledge of Aboriginal peoples of the western Canadian boreal forest has been given considerably less attention by researchers. Canada is lacking comprehensive policy on harvesting, conservation and use of medicinal plants. This could be explained by the illusion of an infinite boreal forest, or by the fact that many boreal medicinal plant species are widely distributed. CONCLUSION: To our knowledge, this review is the most comprehensive to date to reveal the rich traditional medicinal knowledge of Aboriginal peoples of the Canadian boreal forest. Future ethnobotanical research endeavours should focus on documenting the knowledge held by Aboriginal groups that have so far received less attention, particularly those of the western boreal forest. In addition, several critical issues need to be addressed regarding the legal, ethical and cultural aspects of the conservation of medicinal plant species and the protection of the associated traditional knowledge.

Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study.

The main goal of this project was to identify the presence of fibromyalgia (FM) subgroups using a simple and frequently used clinical tool, the Fibromyalgia Impact Questionnaire (FIQ). A total of 61 women diagnosed with FM participated in this study. FM subgroups were created by applying a hierarchical cluster analysis on selected items of the FIQ (pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms). We also tested for group differences on experimental pain, psychosocial functioning and demographic characteristics. Two cluster profiles best fit our data. FM-Type I was characterized by the lowest levels of anxiety, depressive and morning tiredness symptoms, while FM-Type II was characterized by elevated levels of pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms. Both FM subgroups showed hyperalgesic responses to experimental pain. These results suggest that pain and stiffness are universal symptoms of the disorder but that psychological distress is a feature present only in some patients.

Changes in pain perception and descending inhibitory controls start at middle age in healthy adults.

OBJECTIVES: Previous studies have shown a reduction of diffuse noxious inhibitory controls (DNICs) in elderly adults compared with younger adults. Unfortunately, little is known regarding the developmental course of DNIC deficits and so it is still unclear whether middle-aged adults also show a DNIC deficit. The aims of the present study were to better characterize the developmental time course of the change in DNIC response by adding a middle-aged group. The role of expectations was also investigated. METHODS: The pain thresholds (PTs) of 20 young, 20 middle-aged, and 20 healthy elderly volunteers were assessed before and during a cold pressor task (water at 7 degrees C). Acute nociceptive stimuli were administered using a thermode and consisted of a range of painless and painful heat pulses. RESULTS: Analyses showed that thermal PTs increase by middle age but that the DNIC-induced increase in PT dampens progressively with advancing age. DNIC response was negatively correlated with advancing age, however, expectations regarding DNIC efficacy did not vary with age. This suggests that age-related changes in the size of the DNIC response are not best explained by an age-related change in expectation. DISCUSSION: The findings tell us that changes in pain perception and endogenous pain modulation arrive earlier than previously suggested. Studies on aging and pain should include a middle-aged group when comparing pain measures across the adult lifespan.

Endogenous pain inhibitory systems activated by spatial summation are opioid-mediated.

We previously developed a spatial summation model and demonstrated that spatial summation of pain involves the activation of both excitatory and inhibitory systems. The aim of this study was to determine whether the endogenous pain inhibitory systems recruited by the spatial summation model are opioid-mediated by verifying if they could be blocked by the opioid antagonist naloxone. Twenty healthy volunteers (10 men, 10 women) participated in a randomized, four-session, cross-over study. Each session consisted of pain perception ratings (visual analog scale) taken during the immersion of different surfaces of the arm in circulating noxious cold water (12 degrees C). The arm was arbitrarily divided into eight segments from fingertips to shoulder. Two sessions were increasing (from fingertips to shoulder) and two sessions were decreasing (from shoulder to fingertips). All sessions consisted of eight consecutive 2-min immersions separated by 5-min resting periods. Intravenous injections of naloxone hydrochloride (0.14 mg/kg) or saline (NaCl, 0.9%) were administered under double-blind conditions. We found that during the control session (saline injection) there was a significant difference in pain intensity ratings between the increasing and decreasing sessions. The decreasing session resulted in lower pain intensity. As previously demonstrated, this lowering of the perception curve seems to be due to a large recruitment of inhibitory systems at the beginning of the decreasing session as opposed to a gradual recruitment during the increasing session. However, during the opioid inhibition session (naloxone injection) no differences were found between the increasing and decreasing sessions. Naloxone inhibited the endogenous pain inhibitory systems activated by the spatial summation model, suggesting that these systems have an opioid-mediated component, as previously reported for diffuse noxious inhibitory controls.

Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition.

A deficit of endogenous pain inhibitory systems has been suggested to contribute to some chronic pain conditions, one of them being fibromyalgia. The aim of the investigation was to test whether endogenous pain inhibitory systems were activated by a spatial summation procedure in 30 fibromyalgia, 30 chronic low back pain, and 30 healthy volunteers who participated in a cross-over trial (two sessions). Each session consisted of visual analog scale ratings of pain during the immersion of different surfaces of the arm in circulating noxious cold (12 degrees C) water. The arm was arbitrarily divided into eight segments from the fingertips to the shoulder. One session was ascending (from the fingertips to the shoulder) and the other was descending (from the shoulder to the fingertips); they included eight consecutive 2-min immersions separated by 5-min resting periods. For healthy and low back pain subjects, pain was perceived differently during the ascending and descending sessions (P=0.0001). The descending session resulted in lower pain intensity and unpleasantness. This lowering of the perception curve seems to be due to a full recruitment of inhibitory systems at the beginning of the descending session as opposed to a gradual recruitment during the ascending session. For fibromyalgia subjects, no significant differences were found between the increasing and decreasing sessions (P>0.05). These data support a deficit of endogenous pain inhibitory systems in fibromyalgia but not in chronic low back pain. The treatments proposed to fibromyalgia patients should aim at stimulating the activity of those endogenous systems.