Transitional Pain Care in Quebec: Did We Forget Our Youths? A Brief Research Report.

Adolescents and young adults (AYAs) represent a unique population with distinct psycho-social risks and care needs. About 10% of AYAs live with chronic pain (CP) and transition to adult pain care between 16 and 25 years of age. These transitions in care happen simultaneously with other bio-psycho-social changes and require flexible multi-disciplinary support models. As it stands, transitional pain care appears suboptimal, fragmented, and opportunistic in Quebec (Canada). The objective of this Brief Report is, therefore, to present our study findings and propose a multi-disciplinary transitional framework vision applicable to AYAs living with CP. Data were collected using a sequential-consensual qualitative design with a longitudinal participatory component. The consecutive stages of this work included an exploratory stage, semi-structured interviews with primary care providers, and inter-disciplinary deliberative stakeholder consultation groups. The deductive inductive thematic approach and the three-level Health Care Transition Research Consortium's theoretical framework were used to analyze the data. A representative group of stakeholders discussed findings from the first two steps, made fifteen actionable recommendations and formulated their vision of a transitional pain care model that can be further adapted in other settings. The study results present important insights into various psycho-social factors associated with transitional pain care for AYAs.

Chronic pain-related consultations to the emergency department of children with complex pain conditions: A retrospective analysis of healthcare utilization and costs.

Background: There is limited information regarding the effects of pediatric chronic pain management on the number and cost of chronic pain-related emergency department (ED) consultations. Aim: This retrospective study aimed to evaluate the number and costs of chronic pain-related ED consultations of children and adolescents with chronic pain conditions at the Montreal Children's Hospital (MCH). Methods: Charts of patients followed by the Edwards Family Interdisciplinary Center for Complex Pain (CCP) of the MCH between April 2017 and December 2018 were reviewed. ED consultations, specialist consultations, medication prescriptions, hospital admissions, and outpatient consultation referrals were assessed for the period of 1 year before and after the patients' first consultation with the CCP. Associated costs were also calculated. Results: One-hundred sixty-eight patients were included in the analysis. Fifty-one percent consulted the ED and had 151 chronic pain-related ED consultations within 1 year before their initial CCP consultation. In the year following their first CCP consultation, 52 patients (31%) consulted the ED, of which 24 consultations were chronic pain-related (84% reduction). There was an 81% reduction in the costs associated with chronic pain-related ED consultations within 1 year after CCP management. In addition, there was a significant reduction in ED interventions within 1 year after CCP management, though there was no change in medication prescriptions, hospital admissions, or subspecialist consultations. Conclusion: Children and adolescents with chronic pain conditions had fewer chronic pain-related ED consultations within 1 year after the first evaluation by an interdisciplinary center for complex pain, contributing to reduced ED costs.

Contexte : L'information sur les effets de la prise en charge de la douleur chronique pédiatrique sur le nombre et le coût des consultations liées à la douleur chronique au service des urgences est limitée.Objectif : Cette étude rétrospective visait à évaluer le nombre et le coût des consultations liées à la douleur chronique des enfants et des adolescents souffrant de douleur chronique au service des urgences de l'Hôpital de Montréal pour enfants.Méthodes : Les dossiers de patients suivis par le Centre interdisciplinaire de la famille Edwards pour la douleur complexe (CCP) de l'Hôpital de Montréal pour enfants entre avril 2017 et décembre 2018 ont été examinés. Les consultations au service des urgences, les consultations de spécialistes, les ordonnances de médicaments, les admissions à l'hôpital et les références pour consultation externe ont été évaluées pour la période d'un an avant et après la première consultation des patients auprés du CCP. Les coûts associés ont également été calculés.Résultats : Cent soixante-huit patients ont été inclus dans l'analyse. Cinquante et un pour cent ont consulté le service des urgences dans le cadre de 151 consultations liées à la douleur chronique au service des urgences au cours de l'année précédant leur première consultation au CCP. Dans l'année suivant leur première consultation au CCP, 52 patients (31 %) ont consulté le service des urgences. Vingt-quatre de ces consultations étaient liées à la douleur chronique (une réduction de 84 %). Une réduction de 81 % des coûts associés aux consultations liées à la douleur chronique au service des urgences a été observée dans l'année suivant la prise en charge par le CCP. En outre, une réduction significative des interventions du services des urgences dans l'année suivant la prise en charge par le CCP a été observée, bien quéil néy ait pas eu de changement dans les ordonnances de médicaments, les admissions à léhôpital ou les consultations de sous-spécialistes.Conclusion : Les enfants et les adolescents souffrant de douleur chronique ont consulté le service des urgences pour la douleur chronique moins souvent dans l'année suivant la première évaluation par un centre interdisciplinaire pour la douleur complexe, contribuant ainsi à réduire les coûts du service des urgences.

An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain.

This ecological momentary assessment (EMA) study examined the extent of pain intensity variability among 140 individuals with chronic low back pain and explored predictors of such variability and psychosocial and health care utilization outcomes. Individuals completed momentary pain intensity reports (0-10 numeric rating scale) several times daily for two periods of seven consecutive days, one month apart. Participants also completed online questionnaires at baseline which tapped into pain characteristics, pain-related catastrophization, kinesiophobia, activity patterns, and depression and anxiety symptoms. Questionnaires assessing quality of life and health care utilization were administered online one month after completion of the last EMA report. Data were analyzed using linear hierarchical location-scale models. Results showed that pain intensity fluctuated over the course of a week as shown by an average standard deviation of 1.2. The extent of variability in pain intensity scores was heterogeneous across participants but stable over assessment periods. Patients' baseline characteristics along with psychosocial and health care utilization outcomes were not significantly associated with pain intensity variability. We conclude that pain intensity variability differs across patients yet correlates remain elusive. There is an important gap in our knowledge of what affects this variability. Future EMA studies should replicate and extend current findings. PERSPECTIVE: This study provides evidence indicating that there is substantial variability in momentary reports of pain intensity among individuals living with chronic low back pain. However, risk and protective factors for greater lability of pain are elusive as is evidence that greater pain intensity variability results in differential health care utilization.

"They think you're trying to get the drug": Qualitative investigation of chronic pain patients' health care experiences during the opioid overdose epidemic in Canada.

Background: The opioid overdose epidemic has led health care providers to increased vigilance for opioid-related risks in the treatment of chronic non-cancer pain (CNCP). Media have conveyed stigmatizing representations of opioid analgesics. Aims: This study aimed to understand how the opioid overdose epidemic has impacted health care experiences among people living with CNCP in two Canadian provinces (British Columbia, Quebec). Methods: This qualitative study proceeded through 22 semi-structured interviews conducted in 2019. Participants were recruited from a cross-sectional survey examining the effects of the opioid overdose epidemic on individuals with CNCP. We collected in-depth narratives that we analyzed using a thematic framework. The sample included 12 women and 10 men aged 20 to 70 years, with 11 from each province. Results: Several participants described increased difficulty in accessing medical services for pain since the onset of the opioid overdose epidemic. They reported that some physicians urged them to taper opioids regardless of their pain severity and functional limitations. Some participants reported facing discrimination and care denials as they were labeled "drug-seeking," especially in hospital. Depending on their educational resources, they were unequally able to counter providers' stigmatizing behaviors. However, participants described empathetic relationships with providers with whom they had a long-term relationship. Some participants drew distinctions between themselves and the stigmatized status of "addict" in ways that reinforced stigma toward people who are dependent on opioids. Conclusions: Health policies and provider education programs aimed at reducing opioid-related stigma are needed to counter detrimental consequences of the opioid overdose epidemic for people living with CNCP.

Contexte: L'épidémie de surdose d'opioïdes a conduit les prestataires de soins de santé à une vigilance accrue des risques liés aux opioïdes dans le traitement de la douleur chronique non cancéreuse (DCNC). Les médias ont véhiculé des représentations stigmatisantes des analgésiques opioïdes.Objectifs: Cette étude visait à comprendre comment l'épidémie de surdose d'opioïdes a eu un impact sur les expériences avec les soins de santé des personnes vivant avec la DCNC dans deux provinces canadiennes (Colombie-Britannique, Québec).Méthodes: Cette étude qualitative a été réalisée au moyen de 22 entretiens semi-structurés menés en 2019. Les participants ont été recrutés à partir d'une enquête transversale examinant les effets de l'épidémie de surdose d'opioïdes sur les personnes atteintes de DCNC. Nous avons recueilli des récits approfondis que nous avons analysés en utilisant un cadre thématique. L'échantillon comprenait 12 femmes et 10 hommes âgés de 20 à 70 ans, parmi lesquels 11 provenaient de chacune des deux provinces.Résultats: Plusieurs participants ont décrit une difficulté accrue à avoir accès aux services médicaux pour la douleur depuis le début de l'épidémie de surdose d'opioïdes. Ils ont déclaré que certains médecins les avaient incités à réduire les opioïdes, quelle que soit la gravité de leur douleur et leurs limitations fonctionnelles. Certains participants ont déclaré être confrontés à de la discrimination et au refus de soins car ils ont été qualifiés de « chercheurs de drogue ¼, en particulier à l'hôpital. En fonction de leurs ressources éducatives, ils ont été inégalement capables de contrer les comportements stigmatisants des prestataires. Cependant, les participants ont décrit des relations d'empathie avec les prestataires avec lesquels ils avaient une relation à long terme. Certains participants ont établi des distinctions entre eux-mêmes et le statut stigmatisé de « toxicomane ¼ d'une manière qui renforce la stigmatisation des personnes dépendantes aux opioïdes.Conclusions: Les politiques de santé et les programmes d'éducation des prestataires visant à réduire la dépendance aux opioïdes et la stigmatisation liée aux opioïdes est nécessaire afin de contrer les conséquences néfastes de l'épidémie de surdose d'opioïdes pour les personnes vivant avec la DCNC.

Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada.

BACKGROUND: Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006. METHODS: This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities. RESULTS: Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed. CONCLUSION: Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.

Prevalence, Characteristics, and Management of Chronic Noncancer Pain Among People Who Use Drugs: A Cross-Sectional Study.

INTRODUCTION: Most studies on chronic noncancer pain (CNCP) in people who use drugs (PWUD) are restricted to people attending substance use disorder treatment programs. This study assessed the prevalence of CNCP in a community-based sample of PWUD, identified factors associated with pain, and documented strategies used for pain relief. METHODS: This was a cross-sectional study nested in an ongoing cohort of PWUD in Montreal, Canada. Questionnaires were administered to PWUD seen between February 2017 and January 2018. CNCP was defined as pain lasting three or more months and not associated with cancer. RESULTS: A total of 417 PWUD were included (mean age = 44.6 ± 10.6 years, 84% men). The prevalence of CNCP was 44.8%, and the median pain duration (interquartile range) was 12 (5-18) years. The presence of CNCP was associated with older age (>45 years old; odds ratio [OR] = 1.8, 95% CI = 1.2-2.7), male sex (OR = 2.3, 95% CI = 1.2-4.2), poor health condition (OR = 1.9, 95% CI = 1.3-3.0), moderate to severe psychological distress (OR = 2.9, 95% CI = 1.8-4.7), and less frequent cocaine use (OR = 0.5, 95% CI = 0.3-0.9). Among CNCP participants, 20.3% used pain medication from other people, whereas 22.5% used alcohol, cannabis, or illicit drugs to relieve pain. Among those who asked for pain medication (N = 24), 29.2% faced a refusal from the doctor. CONCLUSIONS: CNCP was common among PWUD, and a good proportion of them used substances other than prescribed pain medication to relieve pain. Close collaboration of pain and addiction specialists as well as better pain assessment and access to nonpharmacological treatments could improve pain management in PWUD.

The Quebec Low Back Pain Study: a protocol for an innovative 2-tier provincial cohort.

INTRODUCTION: The neurobiological mechanisms underlying recovery from or persistence of low back pain (LBP) remain misunderstood, limiting progress toward effective management. We have developed an innovative two-tier design to study the transition from acute to chronic LBP. The objective of the first tier is to create a provincial web-based infrastructure to recruit and monitor the trajectory of individuals with acute LBP. The objective of the second tier is to fuel hypothesis-driven satellite data collection centers with specialized expertise to study the role of biomechanical, epigenetic, genetic, neuroanatomical, ontological, physiological, psychological, and socioeconomic factors in LBP chronicity. METHODS: This article describes the first tier of the protocol: establishment of the Core Dataset and Cohort. Adults with acute LBP will be recruited through networks, media, and health care settings. A web-based interface will be used to collect self-reported variables at baseline and at 3, 6, 12, and 24 months. Acute LBP will be defined according to the Dionne 2008 consensus. Measurements will include the Canadian minimum data set for chronic LBP research, DN4 for neuropathic pain, comorbidities, EQ-5D-5L for quality of life, and linkage with provincial medico-administrative databases. The primary outcome will be the transition to chronic LBP, as defined by Deyo 2014. Secondary outcomes include health care resource utilization, disability, sick leave, mood, and quality of life. PERSPECTIVE: This study brings together diverse research expertise to investigate the transition from acute to chronic LBP, characterize the progression to recovery or chronicity, and identify patterns associated with that progression.

Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis.

BACKGROUND: In Canada, the rise in prescription opioid (PO) overdoses and addiction is a major public health concern. Various health authorities have recently recommended that physicians use caution when prescribing opioids, especially to people with histories of substance use. As a result, fewer therapeutic options are available for people who use drugs (PWUD) and suffer from chronic non-cancer pain (CNCP). This paper examines how PWUD describe their experiences with CNCP management in the context of the opioid crisis. METHODS: This qualitative study is based on in-depth interviews with Montreal (Canada) PWUD experiencing CNCP for 3 months or more. RESULTS: Most of the 25 participants (27-61 years; 10 women, 15 men) were polysubstance users (cocaine, opioids, amphetamine, etc.) suffering from CNCP for several years, with multiple additional health and social problems. The majority were unsatisfied with their CNCP management. They felt labelled as "addicts" and stigmatized within the healthcare system. Many participants had been denied PO, even those with severe CNCP and those who were not opioid-dependent. Participants expressed a desire to access non-pharmacological CNCP therapies, but these were often too expensive. Some PWUD were offered methadone to relieve CNCP and found this inappropriate. As a last resort several participants reported self-medicating CNCP with street drugs, increasingly known to be laced with fentanyl. CONCLUSION: PWUD with CNCP are affected by two opioid crises: the PO crisis and the street-opioid crisis. The lack of a coherent policy that addresses their pain management produces reoccurring problems when seeking CNCP relief. Restrictive prescription measures implemented in response to the PO crisis may have consequences similar to prohibitionist policies: they heighten overdose risks for PWUD by increasing exposure to street drugs laced with fentanyl. Improving access to diverse CNCP management options for PWUD can help reduce harms related to street-opioid use.

Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study.

INTRODUCTION: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not. METHODS AND ANALYSES: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score. ETHICS AND DISSEMINATION: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals. TRIAL REGISTRATION NUMBER: NCT01842568.

Just how much does it cost? A cost study of chronic pain following cardiac surgery.

OBJECTIVE: The study objective was to determine use of pain-related health care resources and associated direct and indirect costs over a two-year period in cardiac surgery patients who developed chronic post-surgical pain (CPSP). METHODS: This multicentric observational prospective study recruited patients prior to cardiac surgery; these patients completed research assistant-administered questionnaires on pain and psychological characteristics at 6, 12 and 24 months post-operatively. Patients reporting CPSP also completed a one-month pain care record (PCR) (self-report diary) at each follow-up. Data were analyzed using descriptive statistics, multivariable logistic regression models, and generalized linear models with log link and gamma family adjusting for sociodemographic and pain intensity. RESULTS: Out of 1,247 patients, 18%, 13%, and 9% reported experiencing CPSP at 6, 12, and 24 months, respectively. Between 16% and 28% of CPSP patients reported utilizing health care resources for their pain over the follow-up period. Among all CPSP patients, mean monthly pain-related costs were CAN$207 at 6 months and significantly decreased thereafter. More severe pain and greater levels of pain catastrophizing were the most consistent predictors of health care utilization and costs. DISCUSSION: Health care costs associated with early management of CPSP after cardiac surgery seem attributable to a minority of patients and decrease over time for most of them. Results are novel in that they document for the first time the economic burden of CPSP in this population of patients. Longer follow-up time that would capture severe cases of CPSP as well as examination of costs associated with other surgical populations are warranted. SUMMARY: Economic burden of chronic post-surgical pain may be substantial but few patients utilize resources. Health utilization and costs are associated with pain and psychological characteristics.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma.

PURPOSE: Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma). METHODS: Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients. RESULTS: The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery. CONCLUSION: This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.

Fibromyalgia-related costs and loss of productivity: a substantial societal burden.

BACKGROUND: This study aimed at describing pain-related health care resource use, direct costs, and productivity loss among patients suffering from fibromyalgia syndrome (FMS). METHODS: A cost-of-illness study with a sample of 57 adults having a diagnosis of FMS was conducted in the province of Quebec (Canada). Data regarding FMS-related direct costs and productivity loss from paid and unpaid work over a three-month period were collected using a standardized structured telephone interview protocol. Direct costs were valued in 2009 Canadian dollars using a societal perspective. RESULTS: Results showed that average direct costs over a three-month period added up to $951 per patient (SD: $710), which could be translated in a mean annual cost of $3804. The purchase of prescribed medications led to the highest costs (mean: $329, SD: $321), followed by consultations to health care professionals other than physicians (mean: $129, SD: $222) and physicians consultations (mean: $98, SD: $116). Results further showed a high economic burden for patients themselves, aside from costs covered by public or private insurers. Among the subsample of participants who had a paid job (45.6%), an average of 5.6 days (SD: 13.2) were lost due to pain during the past three months. Among those who were not employed (54.4%), an average of 25.1 days in household productivity (SD: 24.8) were lost. CONCLUSIONS: FMS is associated with a substantial socioeconomic burden. Further research is clearly needed to improve the management of this type of disorder and make better decisions regarding resource allocation.

Costs of moderate to severe chronic pain in primary care patients - a study of the ACCORD Program.

BACKGROUND: The economic burden of chronic noncancer pain (CNCP) remains insufficiently documented in primary care. PURPOSE: To evaluate the annual direct health care costs and productivity costs associated with moderate to severe CNCP in primary care patients taking into account their pain disability. MATERIALS AND METHODS: Patients reporting noncancer pain for at least 6 months, at a pain intensity of 4 or more on a 0 (no pain) to 10 (worst possible pain) intensity scale, and at a frequency of at least 2 days a week, were recruited from community pharmacies. Patients' characteristics, health care utilization, and productivity losses (absenteeism and presenteeism) were documented using administrative databases, pharmacies' renewal charts, telephone, and self-administered questionnaires. Patients were stratified by tertile of pain disability measured by the Brief Pain Inventory questionnaire. RESULTS: Patients (number =483) were, on average, 59 years old, mainly women (67.5%), and suffered from CNCP for a mean of 12 years at an average pain intensity of 6.5±1.9. The annual direct health care costs and productivity costs averaged CAD $9,565 (±$13,993) and CAD $7,072 (±$11,716), respectively. The use of complementary health care services accounted for almost 50% of the direct health care costs. The mean adjusted total direct health care costs (considering pain-related hospitalizations only) and productivity costs increased with more pain disability: low disability, CAD $12,118; moderate, CAD $18,278; and severe, CAD $19,216; P=0.001. CONCLUSION: The economic burden of CNCP is substantial and increases with the level of pain disability, which suggests the need for and potential benefits of improving CNCP management through specific and adapted treatment plans targeting the impact of pain on daily functioning.

Can fluctuations in vital signs be used for pain assessment in critically ill patients with a traumatic brain injury?

Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants (N = 45) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations (P < 0.05) in diastolic (F = 6.087), HR (F = 3.566), SpO2 (F = 5.740), and ICP (F = 3.776) were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (t = 3.933; P < 0.001) and was correlated to participants' self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC.

The Canadian STOP-PAIN project: the burden of chronic pain-does sex really matter?

OBJECTIVES: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain (CP) in individuals on waitlists of Canadian multidisciplinary pain treatment facilities. This article focuses on sex differences. Objectives were to (1) determine the pain characteristics and related biopsychosocial factors that best differentiated women and men with CP; and (2) examine whether public and private costs associated with CP differed according to sex. MATERIALS AND METHODS: Sample consisted of 441 women and 287 men who were evaluated using self-administered questionnaires and a structured interview protocol. A subsample (233 women and 137 men) recorded all pain-related expenditures in a comprehensive diary over 3 months. RESULTS: Results revealed that the burden of illness associated with CP was comparable in both sexes for average and worst pain intensity, pain impact on daily living, quality of life, and psychological well-being. The same was true for pain-related costs. The results of a hierarchical logistic regression analysis, in which sex was treated as the dependent variable, showed that factors that differentiated men and women were: work status, certain circumstances surrounding pain onset, present pain intensity, intake of particular types of pain medication, use of certain pain management strategies, pain beliefs, and utilization of particular health care resources. DISCUSSION: This study suggests that women and men who are referred to multidisciplinary pain treatment facilities do not differ significantly in terms of their pain-related experience. However, the aspects that differ may warrant further clinical attention when assessing and managing pain.

Educational needs of health care providers working in long-term care facilities with regard to pain management.

BACKGROUND: The prevalence of chronic pain ranges from 40% to 80% in long-term care facilities (LTCF), with the highest proportion being found among older adults and residents with dementia. Unfortunately, pain in older adults is underdiagnosed, undertreated, inadequately treated or not treated at all. A solution to this problem would be to provide effective and innovative interdisciplinary continuing education to health care providers (HCPs). OBJECTIVE: To identify the educational needs of HCPs working in LTCF with regard to pain management. METHODS: A qualitative research design using the nominal group technique was undertaken. Seventy-two HCPs (21 physicians/pharmacists, 15 occupational/physical therapists, 24 nurses and 21 orderlies) were recruited from three LTCF in Quebec. Each participant was asked to provide and prioritize a list of the most important topics to be addressed within a continuing education program on chronic pain management in LTCF. RESULTS: Forty topics were generated across all groups, and six specific topics were common to at least three out of the four HCP groups. Educational need in pain assessment was ranked the highest by all groups. Other highly rated topics included pharmacological treatment of pain, pain neurophysiology, nonpharmacological treatments and how to distinguish pain expression from other behaviours. CONCLUSION: The present study showed that despite an average of more than 10 years of work experience in LTCF, HCPs have significant educational needs in pain management, especially pain assessment. These results will help in the development of a comprehensive pain management educational program for HCPs in LTCF.

The Canadian STOP-PAIN project - Part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?

PURPOSE: The Canadian STOP-PAIN Project was designed to document the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This paper describes the societal costs of their pain. METHODS: A subgroup of 370 patients was selected randomly from The Canadian STOP-PAIN Project. Participants completed a self-administered costing tool (the Ambulatory and Home Care Record) on a daily basis for three months. They provided information about publicly financed resources, such as health care professional consultations and diagnostic tests as well as privately financed costs, including out-of-pocket expenditures and time devoted to seeking, receiving, and providing care. To determine the cost of care, resources were valued using various costing methods, and multivariate linear regression was used to predict total cost. RESULTS: Overall, the median monthly cost of care was $1,462 (CDN) per study participant. Ninety-five percent of the total expenditures were privately financed. The final regression model consisted of the following determinants: educational level, employment status, province, pain duration, depression, and health-related quality of life. This model accounted for 35% of the variance in total expenditure (P < 0.001). CONCLUSION: The economic burden of chronic pain is substantial in patients on waitlists of MPTFs. Consequently, it is essential to consider this burden when making decisions regarding resource allocation and waitlist assignment for a MPTF. Resource allocation decision-making should include the economic implications of having patients wait for an assessment and for care.

Challenges in accessing multidisciplinary pain treatment facilities in Canada.

PURPOSE: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs. METHODS: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities. RESULTS: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities CONCLUSION: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.

Pain and quality of life assessment after endovascular versus open repair of abdominal aortic aneurysms in patients at low risk.

PURPOSE: To compare functional autonomy, quality of life (QOL), and pain control after endovascular and open repair (OR) of abdominal aortic aneurysms. MATERIALS AND METHODS: Forty patients with a low surgical risk profile and anatomic compatibility for stent-graft therapy were randomized to receive OR or endovascular aneurysm repair (EVAR). Technical and clinical success as well as mortality were assessed in both groups and compared by Kaplan-Meier analysis. Functional autonomy and QOL were assessed by Karnofsky score and Short Form 36 (SF-36) questionnaire. Pain control was assessed by a numeric rating scale and Brief Pain Inventory questionnaire. QOL outcomes by means of the SF-36 and pain questionnaires were compared with use of mixed-effects models for repeated-measures analysis. RESULTS: All procedures were technically successful in both groups. Three late clinical failures requiring surgical conversion or repeated intervention were observed in the EVAR group and one was observed in the OR group. There was no significant difference between groups in terms of functional autonomy or QOL. No difference in pain level was evident during the early postoperative period, whereas the pain level was lower in the OR group after 1 month. Opioid analgesic drug consumption was significantly greater in the OR group during the postoperative period. Mean hospitalization duration was shorter in the EVAR group than in the OR group (4.5 days +/- 2.4 vs 11.5 days +/- 8.1; P= .001). CONCLUSION: EVAR has no advantage over OR in patients at low risk in terms of functional autonomy, QOL, and pain control. However, EVAR was associated with shorter hospitalization durations compared with OR.

Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries.

In order to provide burn patients with adequate pain relief, the nurses must be able to accurately evaluate the patients' pain levels and to assess whether sufficient analgesia is achieved or not. The present study examined this issue by comparing the pain ratings in 42 patients hospitalized for burn injuries and 42 nurses. The patient and the attending nurse were asked to rate, independently of each other, the intensity of the pain felt by the patient during a therapeutic procedure and at rest. When analgesic medication was given prior to the procedure, both the patients and the nurses were asked to estimate the degree of pain relief. All ratings were obtained using visual analogue and verbal scales. The results revealed significant but small correlations between the nurses' and patients' ratings. Frequently, the nurses underestimated or overestimated the patients' pain. Discrepancies were also observed in the evaluation of pain medication efficacy, the nurses showing a tendency to overestimate the degree of pain relief. The accuracy of the nurses' perception did not vary as a function of the patients' age, socioeconomic status or burn severity. However, the number of years of experience in burn-nursing had a significant influence on the nurses' estimation of the patients' pain during therapeutic procedures. Theoretical and clinical implications of these results are discussed with a particular emphasis on the need to implement systematic procedures to assess pain and success of analgesia. Additional recommendations to optimize pain management in burn patients are also made.