[Therapeutic alliance and cognitive behavioral group therapy]. / Alliance thérapeutique et thérapie cognitivo-comportementale de groupe.

In cognitive-behavioral group therapy, the therapeutic alliance with the psychotherapists and between the patients in the group, allows patients to develop coping strategies. These include cognitive and behavioral efforts aimed to control, reduce or tolerate specific demands, whether internal or external, experienced as threatening, exhausting or exceeding the patient's resources. This adaptive mechanism lowers the intensity of anxiety, favors control of fear and reinforces the motivation and energy invested in the process of change. We describe the importance of therapeutic alliance in group therapy with patients suffering from chronic pain. These processes will be illustrated with clinical vignettes.

Lors de thérapie cognitivo-comportementale de groupe, l'alliance thérapeutique, avec les psychothérapeutes et entre les patients, permet à ces derniers de développer leurs capacités de coping, c'est-à-dire l'ensemble des efforts cognitifs et comportementaux destinés à maîtriser, réduire ou tolérer des demandes spécifiques internes et/ou externes, vécues par le sujet comme menaçantes, épuisantes ou dépassant ses ressources. Cette alliance fonctionne en tant que mécanisme adaptatif permettant de diminuer l'intensité de l'anxiété, favoriser le contrôle des peurs et renforcer la motivation et l'énergie investies dans le processus de changement. Nous décrivons l'importance de cette alliance thérapeutique dans le processus groupal réunissant des thérapeutes et des patients souffrant de douleurs chroniques. Ces mouvements seront illustrés par des vignettes cliniques.

[Monoaminergic opioids: which one should we choose?] / Opioïdes monoaminergiques : lequel choisir ?

Tapentadol shares with tramadol a mixed mechanism of action. It has no identified analgesically active metabolite and is not significantly metabolised by CYP450, thus overcoming some limitations of tramadol, including potential for pharmacokinetic drug-drug interactions and inter-individual variability due to genetic polymorphisms of CYP450. It is likely to expose less to serotoninergic adverse effects (nausea, vomiting, hypoglycaemia) and more to opioid adverse effects (constipation, respiratory depression, abuse) than tramadol. The level of evidence on the efficacy of both tramadol and tapentadol for the treatment of chronic pain is globally low. As a conclusion, tapentadol represents an additional analgesic which some patients may benefit from after careful examination of their clinical situation, comorbidities and comedications.

Le tapentadol partage avec le tramadol un mode d'action mixte. Il n'a pas de métabolite actif identifié et n'est pas significativement métabolisé par le cytochrome P450 (CYP450), ce qui lui permet de contourner certaines limites du tramadol (interactions pharmacocinétiques, variabilité due aux polymorphismes génétiques du CYP450). Il expose potentiellement moins aux effets indésirables sérotoninergiques (nausées, vomissements, hypoglycémie) et davantage aux effets opioïdergiques (constipation, dépression respiratoire, abus) que le tramadol. Le niveau de preuve des données disponibles sur l'efficacité du tramadol et du tapentadol dans les douleurs chroniques est globalement faible. Le tapentadol représente un antalgique supplémentaire dont certains patients peuvent bénéficier après un examen attentif de leurs comorbidités, de leurs comédications et de la situation clinique.

[Activity, decentration and cognitive restructuring in cognitive-behavioural therapy - practice-based aspects]. / Activité, décentration et restructuration cognitive dans la thérapie cognitivocomportementale - Éléments pour la pratique clinique.

Decentration and cognitive restructuring are used in cognitive-behavioural therapy (CBT) with patients suffering from chronic pain and are reinforced by group work. They can also be useful to the general practitioner. Clinical vignettes summarize the role of group CBT in identifying realistic and meaningful activities. They stress decentration and cognitive restructuring as key therapeutic tools in group CBT. Using them with patients suffering from chronic pain is complex and challenging when it comes to allow the patients to overcome the impossibility to function 'as before' while figuring out how to cope 'as for now'.

La décentration et la restructuration cognitive sont utilisées dans les thérapies cognitivocomportementales (TCC) chez les patients souffrant de douleurs chroniques et sont renforcées par le travail en groupe. Elles peuvent également être utilisées par les praticiens dans leurs cabinets. Des vignettes cliniques résument leur rôle dans l'identification d'activités réalistes et significatives et posent la décentration et la restructuration cognitive en tant qu'outils d'intérêt pour la TCC de groupe. Leur utilisation avec des patients douloureux chroniques peut permettre aux patients de surmonter l'impossibilité à faire « comme avant ¼ pour s'imaginer parvenir à gérer « comme maintenant ¼.

[Use of hypnosis in chronic pain : a setting in motion]. / Utilisation de l'hypnose lors de douleurs chroniques : une mise en mouvement.

The biopsychosocial complexity of chronic pain requires a multimodal approach of which hypnosis is one. Its effectiveness is increasingly proven by studies using functional neuroimaging, as well as clinical studies in various etiologies of chronic pain. The goal of hypnosis is to restore the patient to an active role where, during the sessions, he will discover his creative capacities allowing him to temporarily modify or even significantly reduce painful sensations. Regular practice of self-hypnosis amplifies and anchors these changes. Gradually, hypnosis allows patients to regain both physical and mental mobility.

La complexité biopsychosociale des douleurs chroniques impose une approche multimodale dont l'hypnose fait partie. Son efficacité est de plus en plus prouvée par des études utilisant la neuro-imagerie fonctionnelle, ainsi que des études cliniques dans diverses étiologies de douleurs chroniques. Le but de l'hypnose est de redonner au patient un rôle actif où, au cours des séances, il découvrira ses capacités créatrices lui permettant de modifier, voire de nettement réduire temporairement les sensations douloureuses. La pratique régulière de l'autohypnose amplifie et ancre ces modifications. Progressivement, l'hypnose permet aux patients de retrouver une mobilité tant physique que psychique.

[Mobile applications and self-management of chronic pain]. / Applications mobiles et autogestion des douleurs chroniques.

Self-management of chronic pain should enable patients to regain an acceptable quality of life, autonomy, and reduce the number of consultations. These strategies are increasingly available on mobile applications, which have been evaluated for their content and effectiveness in several reviews. The vast majority of applications offer only one self-management strategy, few opportunities for interactions, and have not involved patients and healthcare professionals in their development. It is therefore still difficult to determine their effectiveness in the self-management of chronic pain. However, mobile applications should not be neglected. On the contrary, it is necessary to develop validated applications in French considering the five criteria classically recommended for self-management. Then such applications can be prescribed by health professionals as part of the multimodal management of chronic pain.

L'autogestion des douleurs chroniques doit permettre aux patients de retrouver une qualité de vie acceptable, une autonomie, et de diminuer les consultations. Ces stratégies sont de plus en plus disponibles sur des applications mobiles dont plusieurs revues ont évalué le contenu et l'efficacité. Il en ressort que la grande majorité des applications ne proposent qu'une seule stratégie d'autogestion, offrent peu de possibilités d'interactions, et n'ont pas impliqué dans leur développement patients ou professionnels de la santé. Il est ainsi encore difficile de déterminer leur efficacité dans l'autogestion des douleurs chroniques. Cependant, les applications mobiles ne sont pas un moyen à négliger, il faut au contraire développer des applications validées en français tenant compte des cinq critères classiquement recommandés pour l'autogestion. Alors de telles applications pourront être prescrites par les professionnels de la santé dans le cadre de la prise en charge multimodale des douleurs chroniques.

[Why propose cognitive-behavioural therapy for chronic pain patients†?] / Pourquoi proposer la thérapie cognitivo-comportementale dans les douleurs chroniques ?

Cognitive and behavioral techniques (CBT) are used in the approach of chronic pain, based on the assumption that pain and disability are not (only) influenced by somatic issues but also by psychosocial factors. CBT aim to improving quality of life while targeting disability. Psychoeducation, activity-centered and cognitive techniques are central, drawing on the identification of an activity that is not only important and meaningful for the patient but also realistic. This should allow the patient to overcome the impossibility to function «â€…as before ¼ while figuring out how to cope «â€…as for now ¼. The ways to explore possible alternative options during the group therapy is presented and discussed.

Les techniques cognitives et comportementales (TCC) sont utilisées dans l'approche des douleurs chroniques, sur la base du postulat que douleur et handicap ne sont pas (uniquement) influencés par la pathologie somatique, mais aussi par des facteurs psychosociaux. Les TCC visent à l'amélioration de la qualité de vie, au-travers d'une réduction du handicap. La dimension psychoéducative, les techniques centrées sur l'activité et les techniques cognitives y tiennent une place centrale, reposant sur le choix d'une activité importante et qui fasse du sens pour le patient, autour d'objectifs réalistes, et qui permettent au patient de dépasser l'impossibilité de faire «â€…comme avant ¼ pour imaginer des façons de faire «â€…comme maintenant ¼. La manière dont l'exploration du champ des possibles est abordée au fil des séances est présentée et discutée.

[Demoralization and meaning in life in suicidal ideation†: a role for patients suffering from chronic pain?] / Démoralisation et sens dans la vie dans l'idéation suicidaire†: un role chez les patients douloureux chroniques†?

Chronic pain is strongly related to the emotional state of the individual and may be associated with suicidal ideation. The concepts of demoralization and meaning in life may have a role in suicidal ideation as a factor of crisis and resilience, respectively. Demoralization, and especially one of its elements, hopelessness, predisposes to suicidal behavior and is often associated with chronic pain conditions. In addition, the meaning that a patient with chronic pain attributes to his or her existence may also influence suicidal behavior. Follow-ups focused on demoralization and meaning in life may be a promising psychotherapeutic approach for patients suffering from chronic pain.

La douleur chronique est fortement liée à l'état émotionnel de l'individu et peut être associée à l'idéation suicidaire. Les concepts de démoralisation et de sens dans la vie peuvent avoir un rôle sur l'idéation suicidaire respectivement en tant que facteur de crise et de résilience. La démoralisation, et surtout l'un de ses éléments, le désespoir, prédispose au comportement suicidaire et est souvent associée à des états douloureux chroniques. En outre, le sens qu'un patient souffrant de douleurs chroniques peut attribuer à son existence peut également influencer le comportement suicidaire. Une prise en charge centrée sur la démoralisation et le sens dans la vie pourrait constituer une approche psychothérapeutique prometteuse pour les patients souffrant de douleurs chroniques.

[Opioids prescription in the vulnerable populations : the children and the elderly. Practical guidelines]. / Prescription des opioïdes chez les patients vulnérables : les enfants et les personnes âgées. Recommandations pratiques.

Pain management in ambulatory care regularly requires the prescription of opioids. These drugs allow adequate analgesia achievement in many patients, but inefficiency and/or intolerable side effects may limit their use. Factors related to physiological particularities, comorbidities and comedication, as well as difficulties related to drug intake and pain assessment, make children and the elderly more vulnerable to variability in opioid response and problems of safety and efficacy profile. The purpose of this article is to remain the specificities of these two populations and to propose recommendations for the good use of opioids for ambulatory care.

La prise en charge de la douleur en médecine de ville nécessite régulièrement le recours à la prescription d'opioïdes. Une antalgie adéquate est obtenue chez de nombreux patients, mais une inefficacité et/ou des effets indésirables intolérables peuvent limiter leur utilisation. Les facteurs liés aux particularités physiologiques, aux comorbidités et aux comédications, les difficultés liées à la prise médicamenteuse et l'évaluation de la douleur, rendent l'enfant et le sujet âgé plus vulnérables à la variabilité de réponse aux opioïdes et aux problèmes de sécurité et d'efficacité. Le présent article a pour but de rappeler les spécificités de ces deux populations aux extrêmes de l'âge et de proposer des recommandations de bon usage des opioïdes pour la médecine ambulatoire.

[Pain management in adult medico-surgical wards : practical guidelines]. / Antalgie dans les services médico-chirurgicaux adultes. Recommandations pratiques du réseau douleur des Hôpitaux Universitaires de Genève.

Guidelines for pain management in the medical and surgical departments of the Geneva University Hospitals (GUH) have been systematically developed using a multidisciplinary approach. These guidelines are aimed towards improving healthcare quality. We point to the ways the pain network of the GUH has elected to deal with the ever-increasing progression of concepts regarding pain management. This is of importance at a time when the risks related to the patients' transitions between the different departments, to the specificities of the clinical practices, and to the need for personalized care have never been so high.

Les recommandations pratiques (RP) pour l'antalgie dans les services médico-chirurgicaux des Hôpitaux Universitaires de Genève (HUG) ont été développées de façon systématique et interdisciplinaire. Les RP représentent un outil d'amélioration de la qualité des soins. Nous montrons de quelle manière le réseau douleur des HUG a décidé de faire face à l'évolution croissante des concepts en matière de prise en charge de la douleur. Ceci alors que les risques liés aux transferts des patients entre les services cliniques, aux spécificités des pratiques, ainsi qu'au besoin d'individualisation des soins n'ont jamais été aussi grands.

[It is not only about cost ... when it comes to generic medication]. / Le coût, ce n'est pas tout ... à propos des médicaments génériques.

The aim of this qualitative study was to explore patients' representations regarding generics in patients suffering from non-specific disabling chronic musculoskeletal pain, as these patients are confronted with the issue of the prescription and/or substitution of original formulations with generics. Patients' representations suggest that they might be confident in taking a generic medication: when the generic medication is prescribed by the physician and each prescription is discussed, i.e., the patient is prescribed the generic version of a given medication and not a generic medication. Economic arguments are not sufficient to accept substitution. Negative representations require attention and need be considered.

Assessing the affective load in the narratives of women suffering from fibromyalgia: the clinicians' appraisal.

OBJECTIVE: Fibromyalgia is characterized by chronic widespread pain and various associated symptoms, including psychological distress. This study presents a secondary analysis of the interviews of patients with fibromyalgia to appraise the affective load of the patient narratives as assessed by independent clinicians. SETTING AND PARTICIPANTS: Three clinicians, an internist, a psychiatrist and a psychologist, who were experienced in chronic pain reviewed the interview transcripts of 56 women eliciting their views regarding fibromyalgia onset. A Clinical Global Impression (CGI) scale was used (0 = no affective load to 5 = maximum affective load) to provide a subjective appraisal of the intensity of the affective impact, as suggested in the transcripts and from the clinician perspectives. RESULTS: The mean affective load was 3.6 (SD = ±1), indicating the perception of a high affective load in the clinicians. Values indicating a high or very high affective load (≥4 points on the CGI scale) were more frequent than those in the lower range [23 narratives (41%) vs. 3 (5%)]. The inter-rater agreement of the affective load of the narratives was high (K > 0.85). These results of the clinician perspectives parallel those of the patient narratives, emphasizing disruptive circumstances, psychological distress and hopelessness surrounding symptom onset. CONCLUSION: The affective load in the narratives of these patients with fibromyalgia was high and had a negative undertone when considered from the clinicians' perspective. This study highlights the importance of considering the affective resonance in the context of therapeutic relationships that are often emotionally laden and highly challenging for the clinician.

Volunteers trained in palliative care at the hospital: an original and dynamic resource.

OBJECTIVE: Volunteers trained in palliative care are increasingly present in acute care units in general hospitals. Nevertheless, there still are few available data on this topic, especially concerning the integration of volunteers outside the palliative structures. Our present study aimed to describe the experience of volunteers trained in palliative care in the context of a primary care hospital. In particular, the difficulties and the benefits of this specific position were evaluated according to volunteers' own perceptions and words. METHOD: We employed a qualitative method. Various aspects of the volunteer's role were explored by means of semistructured questions, addressing their activity, their motivations, and their feelings. Participants were volunteers (n = 19) trained in palliative care and working at a university hospital. After giving written consent, they completed the semistructured questionnaire at home. Content analysis was used to identify the main categories of answers and the principal themes reported by the volunteers. RESULTS: The main difficulties were related to uncertainty of the context. As every situation is different, volunteers could not define their role once and for all. However, they derived great satisfaction from their activity. A supporting frame and a good balance between constraints and autonomy were facilitating factors. Besides, the complexity related to the context contributed to make the position valuable and challenging. SIGNIFICANCE OF RESULTS: Integrating a voluntary service in a primary care hospital is partly based on active participation of the volunteers in developing their position in a more adequate way. In return, this relative autonomy implies a rigorous and supportive attitude from the institution.

[Prescription of antidepressants in the treatment of pain: role of pharmacogenetics]. / Prescription d'antidépresseurs dans le traitement de la douleur: rôle de la pharmacogénétique.

Antidepressants, mainly tricyclic and non-selective reuptake inhibitors of serotonin antidepressants, are part of the treatment of chronic pain. The management is complicated by a large interindividual variability of efficacy and tolerance. Important part of this variability is associated with nucleotide polymorphisms of genes encoding enzymes involved in the pharmacokinetics and pharmacodynamics of these molecules. Identification of these genetic variants could to predict clinical consequences and allowed individualized adjustments in medication or dosage. This article presents the current knowledge on the influence of genetics on the efficacy and adverse effects of antidepressants used in chronic pain treatment.

[Analgesia in patients with hepatic impairment]. / Antalgie chez les patients avec une atteinte hépatique.

The lack of clear recommendations makes optimal pain management difficult in patients with hepatic function impairment. This article reviews the evidence on commonly used analgesics (paracetamol, NSAIDs, opiates). Paracetamol can be safely used at low doses (2-3 grams per day) for a period not exceeding a few days. NSAIDs should be avoided because of their direct hepatic toxicity and an increased risk of life-threatening side-effects (hemorrhagic, renal). Glucuronoconjugated opiates should be preferred but all must be used carefully because of the risk of side effects. Dosage reduction and/or increased dose interval are often required.

[The use of transdermal opioids in patients in oncological remission suffering from chronic pain]. / Utilisation des patchs d'opioïdes dans les douleurs chroniques chez les patients en rémission oncologique.

Today, oncological patients in remission are becoming more numerous and about a third have chronic pain from various etiologies. In the objective of a comprehensive management plan for chronic pain in these patients, therapeutic goals, conditions and terms of prescription of opioids in the long-term should be discussed. The transdermal route may be an attractive alternative when analgesic treatment of moderate to severe pain is balanced. It provides increased comfort in selected patients in whom oral administration is difficult or a polypharmacy troublesome. Risks/benefits of a prescription of opioids in the treatment of chronic pain in patients in oncological remission should be re-evaluated and included in a multimodal support.

[Chronic noncancer pain and patient education: a place for e-learning?]. / DouIeurs chroniques non, cancéreuses et éducation thérapeutique du patient: une place pour le e-learning?

Chronic non cancerous pain considerably limits the patients' quality of life. Yet, chronic non cancerous pain has a prevalence as high as 25% to 35%, Therapeutic education allows to work on the knowledge and know-how about the disease, the treatment, the management of health resources and health behaviors. E-learning uses new technologies of communication to improve the quality of learning by facilitating access to the resources and favoring the interactivity. It is attractive by its wide accessibility and its limited logistic needs. The level of proof of its efficacy is weak, mainly because of methodological limitations. Some good quality studies are promising, with a positive effect of e-learning programs on pain intensity, disability, autonomy and medication misuse.

[Clinical pharmacology of medical cannabinoids in chronic pain]. / Cannabinoïdes médicaux dans les douleurs chroniques: aspects pharmacologiques.

In Switzerland, medical cannabinoids can be prescribed under compassionate use after special authorization in justified indications such as refractory pain. Evidence of efficacy in pain is limited and the clinical benefit seems to be modest. Their drug-drug interactions (DDI) profile is poorly documented. Cytochromes P450 (CYP) 2C9 and 3A4 are involved in the metabolism of tetrahydrocannabinol and cannabidiol, which implies possible DDI with CYP450 inhibitor and inducer, such as anticonvulsivants and HIV protease inhibitors, which may be prescribed in patients with neuropathic pain.

[Efficient treatment of breakthrough pain in adults: the importance of timing and medication choice]. / Traiter efficacement la douleur incidente chez l'adulte: donner le bon antalgique au bon moment!

Diagnostic or therapeutic procedures can lead to breakthrough pain. Thanks to a wise choice of analgesic medication started in due time, this type of pain can be avoided or decreased. The therapeutic options of this preventive approach are presented according to the expected breakthrough pain type and intensity. Specific situations are presented through case discussions. The main pharmacokinetic information needed to prescribe the right analgesic at the right time is summarized in a convenient table. When associated to non-pharmacological measures such as empathy, patient positioning and high quality procedures, preventive analgesia provides patients the best possible relief from breakthrough pain.

Representations of symptom history in women with fibromyalgia vs chronic low back pain: a qualitative study.

OBJECTIVE: To compare fibromyalgia (FM) and chronic non-specific low back pain (LBP) patients' narratives about symptom onset. This investigation aimed to better understand how patients with FM relate to their pain problem and the physicians in charge of making the diagnosis. DESIGN: Qualitative study. SUBJECTS AND METHODS: We included 56 female patients with FM and 29 with LBP. Semi-structured interviews were conducted, eliciting patients' representations of symptom onset. Interviews were tape-recorded and transcribed, and content analysis was performed. RESULTS: Patients with FM and LBP were comparable for socio-demographic characteristics and pain duration. Content analysis identified five dimensions: psychological issues, somatic concerns, occupational problems, diagnostic issues, and issues related to chronicity. FM patients emphasized psychological issues, as single events and long-lasting distress. Regarding somatic concerns, gynecological events were prominent in FM while LBP patients emphasized accidents, awkward movements, and physical work conditions. Both groups expressed pessimistic views about pain evolution. FM patients reported diagnosis as an area of major uncertainty in an illness perceived as spreading all over the body. CONCLUSIONS: The narratives of patients with FM expressed high psychological loads and dramatic connotations and emphasized legitimacy issues. In contrast, patients with LBP stressed overload, wear and tear, and treatment inefficacy. The combination of chronicity and lack of specificity may render FM and LBP prone to raise skepticism in the therapists. Investigating and discussing patients' perceptions allows overcoming the apparent uniformity of patients' complaints. It contributes defining realistic and shared treatment goals and help therapists cope with pain chronicity.

[Pain medication during pregnancy]. / Antalgie médicamenteuse et grossesse.

To treat pain that does not respond to non-pharmacological approaches in a pregnant woman represents a challenge for the primary care physician. He is often the first health professional to be consulted and finds himself confronted to not only one but two patients:the mother and the fetus. His knowledge on pain treatment and the practical approach that he is used to, will have to be adapted to this new equation. He will have to weigh the benefit for the mother against the risk for the fetus, while creating a true relationship with his patient. Although only a few drugs are considered compatible with pregnancy, the data available from the literature allow nowadays to better understand the nature of the risk when exposing the fetus to a given drug and to elaborate evidence-based recommendations.