Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research.

Background: Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy. Aim: The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature. Methods: Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded. Results: Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation). Conclusions: Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.

Contexte: L'équilibre entre les avantages et les inconvénients de l'utilisation d'opioïdes pour la prise en charge de la douleur chronique non cancéreuse (CNCP) doit être soigneusement examiné au cas par cas. Il n'existe pas d'approche uniforme pouvant être adoptée par les prescripteurs et les cliniciens lorsqu'ils envisagent cette thérapie.Objectif: L'objectif de cette étude était de recenser les obstacles et les facilitateurs pour la prescription d'opioïdes pour la douleur chronique non cancéreuse par une revue systématique de la littérature qualitative.Méthodes: Six bases de données ont été consultées pour la période allant de leur création jusqu'en juin 2019 afin d'y repérer les rapports d'études qualitatives sur les connaissances, les attitudes, les croyances ou les pratiques des prestataires en matière de prescription d'opioïdes pour la douleur chronique non cancéreuse en Amérique du Nord. Les données ont été extraites, le risque de biais a été évalué et la confiance envers les données probantes a été notée.Résultats: Vingt-sept études faisant état de données provenant de 599 prestataires de soins de santé ont été incluses. Dix thèmes influençant la prise de décision clinique lors de la prescription d'opioïdes ont émergé. Les prestataires étaient plus à l'aise pour prescrire des opioïdes lorsque (1) les patients étaient activement engagés dans la prise en charge de la douleur, (2) des politiques de prescription institutionnelles claires et des programmes de surveillance des médicaments d'ordonnance étaient en place, (3) des relations de longue date et une alliance thérapeutique forte étaient présentes, et (4) du soutien interprofessionnel était disponible. Les facteurs qui réduisaient la probabilité de la prescription d'opioïdes comprenaient (1) l'incertitude à l'égard de la subjectivité de la douleur et de l'efficacité des opioïdes, (2) une préoccupation pour le patient (p. ex., effets indésirables) et la collectivité (p. ex., détournement), (3) des expériences négatives antérieures (p. ex., recevoir des menaces), (4) des difficultés à adopter des lignes directrices et (5) des obstacles organisationnels (p. ex., durée insuffisante des rendez-vous et longueur de la documentation).Conclusions: La compréhension des obstacles et des facilitateurs qui influencent les pratiques de prescription d'opioïdes permet d'avoir un aperçu des cibles modifiables pour les interventions qui peuvent aider les prestataires à fournir des soins conformes aux directives de pratique.

A formal evaluation of The Ottawa Hospital Pain Clinic orientation session: A quality improvement project.

Background: Chronic pain affects approximately one in every five Canadians and has a substantial impact on psychological well-being, relationships, ability to attend work or school, and overall functioning.The Ottawa Hospital Pain Clinic introduced orientation sessions, with the aim of providing new patients with pain education to help prepare patients for engagement with multimodal pain management strategies. This report summarizes the results of a formative evaluation of the orientation session at The Ottawa Hospital Pain Clinic to determine whether patients perceived the orientation session as beneficial. Methods: Interviews were conducted, transcribed, and then thematically analyzed to understand patients' perspectives on the orientation session. Coding was done by two team members using the constant comparison analyses method with key ideas, concepts, and patterns identified and compared to identify similarities. Results: Between September 6 and October 18, 2019, 18 patients attended an orientation session and 12 consented to participation and completed telephone interviews. The six themes identified included (1) feeling of community, (2) participants feeling heard by providers, (3) appreciation of the holistic approach, (4) availability of community resources, (5) barriers to access, and (6) discordant feelings of preparedness for the physician appointment. Conclusion: Results from this evaluation indicate that the orientation session offered at The Ottawa Hospital Pain Clinic improves chronic pain literacy, reduces feeling of isolation, and instills hope. As such, it appears to be a valuable component of pain clinic programs.

Contexte: La douleur chronique touche environ un Canadien sur cinq et a des répercussions sur le bien-être psychologique, les relations, la capacité à aller au travail ou à l'école, et l'ensemble du fonctionnement. La Clinique de la douleur de l'Hôpital d'Ottawa a lancé des séances d'orientation, dans le but de fournir aux nouveaux patients une formation sur la douleur pour les aider à se préparer à adopter des stratégies multimodales de prise en charge de la douleur. Ce rapport résume les résultats d'une évaluation formative de la séance d'orientation à la Clinique de la douleur de l'Hôpital d'Ottawa visant à déterminer si les patients perçoivent la session d'orientation comme bénéfique.Méthodes: Les entrevues ont été menées, transcrites, puis analysées de maniére thématique pour comprendre les points de vue des patients sur la séance d'orientation. Le codage a été effectué par deux membres de l'équipe à l'aide d'une méthode d'analyse par comparaison constante avec des idées, des concepts et des modéles clés répertoriés et par rapport à l'identification de similitudes.Résultats: Entre le 6 septembre et le 18 octobre 2019, 18 patients ont assisté à une séance d'orientation. Parmi ceux-ci, 12 ont accepté de participer et ont complété des entrevues téléphoniques. Les six thémes répertoriés comprenaient (1) le sentiment de communauté, (2) le sentiment des participants d'étre entendus des prestataires, (3) l'appréciation de l'approche holistique, (4) la disponibilité des ressources communautaires, (5) les obstacles à l'accés, et (6) des sentiments discordants de préparation pour le rendez-vous chez le médecin.Conclusion: Les résultats de cette évaluation indiquent que la séance d'orientation offerte à la Clinique de la douleur de l'Hôpital d'Ottawa améliore la littératie en matiére de douleur chronique, réduit le sentiment d'isolement et suscite l'espoir. Ainsi, elle semble étre un élément précieux des programmes de la Clinique de la douleur.

What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map.

ABSTRACT: Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark.

OBJECTIVES: Patient and stakeholder engagements in research have increasingly gained attention in healthcare and healthcare-related research. A common and rigorous approach to establish research priorities based on input from people and stakeholders is the James Lind Alliance Priority Setting Partnership (JLA-PSP). The aim of this study was to establish research priorities for chronic musculoskeletal (MSK) pain by engaging with people living with chronic MSK pain, relatives to people living with chronic MSK pain, healthcare professionals (HCP), and researchers working with chronic MSK pain. METHODS: This JLA-PSP included a nation-wide survey in Denmark, an interim prioritisation, and an online consensus building workshop. The information gained from this was the basis for developing the final list of specific research priorities within chronic MSK pain. RESULTS: In the initial survey, 1010 respondents (91% people living with chronic MSK pain/relatives, 9% HCPs/researchers) submitted 3121 potential questions. These were summarised into 19 main themes and 36 sub-themes. In the interim prioritisation exercise, 51% people living with pain/relatives and 49% HCPs/researchers reduced the list to 33 research questions prior to the final priority setting workshop. 23 participants attended the online workshop (12 people/relatives, 10 HCPs, and 1 researcher) who reached consensus for the most important research priorities after two rounds of discussion of each question. CONCLUSIONS: This study identified several specific research questions generated by people living with chronic MSK pain, relatives, HCPs, and researchers. The stakeholders proposed prioritization of the healthcare system's ability to support patients, focus on developing coherent pathways between sectors and education for both patients and HCP. These research questions can form the basis for future studies, funders, and be used to align research with end-users' priorities.

Extension for Community Healthcare Outcomes (ECHO) Chronic Pain & Opioid Stewardship in Northwestern Ontario: A Thematic Analysis of Patient Cases.

Background: Chronic pain (CP) is a debilitating disease that reduces quality of life, decreases productivity, and has become a primary cause of health care resource consumption. Despite this, many Canadian family physicians have received little formal education in managing CP, making it one of the most challenging areas of practice in primary care. Project Extension for Community Healthcare Outcomes Chronic Pain & Opioid Stewardship St. Joseph's Care Group (Project ECHO-SJCG) is an evidence-based educational program connecting community-based health care providers (HCPs) with an interprofessional team by videoconference to learn about management of CP in rural, remote, and underserved areas. Aims: To explore key learning points from cases presented at Project ECHO-SJCG, identify and analyze themes and improve future sessions of continuing professional development for HCPs. Methods: We completed a thematic analysis of forty cases and key learning points using the constant comparison method. We also summarized descriptive statistics for patient and provider characteristics. Results: Forty cases were presented by 31 HCPs, who received suggestions focused on assessment and diagnosis, pharmacological and non-pharmacological pain symptom management, interventional management, attention to biopsychosocial factors, and appropriate referral to other HCPs. Conclusion: Project ECHO-SJCG cases allow HCPs to gain a broad knowledge base to evaluate and manage CP in their practice. Identified themes highlight common gaps in HCPs' knowledge and will guide future sessions.

Contexte: La douleur chronique est une maladie débilitante qui réduit la qualité de vie et diminue la productivité. En outre, elle est devenue une cause principale de consommation des ressources en soins de santé. Malgré cela, de nombreux médecins de famille canadiens ont reçu peu d'éducation conventionnelle sur la prise en charge de la douleur chronique, ce qui en fait l'un des domaines de pratique les plus difficiles en soins primaires.Le Projet de vulgarisation pour des résultats de santé communautaires ­ Gestion des opioïdes et de la douleur chronique du St. Joseph' s Care Group (projet ECHOSJCG) est un programme éducatif fondé sur les données probantes qui met les prestataires de soins de santé communautaires en relation avec une équipe interprofessionnelle par vidéoconférence pour en apprendre davantage sur la prise en charge de la douleur chronique dans les zones rurales, éloignées et mal desservies.Objectifs: Explorer les principaux points d'apprentissage à partir des cas présentés au projet ECHO-SJCG, recenser et analyser les thèmes et améliorer les futures sessions de développement professionnel continu pour les professionnels de la santé.Méthodes: Nous avons effectué une analyse thématique de quarante cas et points d'apprentissage clés à l'aide de la méthode de comparaison constante. Nous avons également résumé les statistiques descriptives pour le patient et le prestataire.Résultats: Quarante cas ont été présentés par 31 professionnels de la santé ayant reçu des suggestions axées sur l'évaluation et le diagnostic, la prise en charge des symptômes de douleur pharmacologique et non pharmacologique, la prise en charge interventionnelle, l'attention aux facteurs biopsychosociaux et l'orientation appropriée vers d'autres professionnels de la santé.Conclusions: Les cas du projet ECHO-SJCG permettent aux professionnels de la santé d'acquérir une large base de connaissances pour l'évaluation et la prise en charge de la douleur chronique dans leur pratique. Les thèmes recensés mettent en évidence les lacunes communes dans les connaissances des professionnels de la santé et orienteront les sessions futures.

Mindfulness-Based Stress Reduction in Breast Cancer Survivors with Chronic Neuropathic Pain: A Randomized Controlled Trial.

Objectives: The purpose of this study was to compare the effects of group-delivered mindfulness-based stress reduction as compared to a waitlist control group among breast cancer survivors living with CNP. Methods: A randomized controlled trial design was applied, and outcomes collected included pain, emotional function, quality of life, and global impression of change. Results: A total of 98 women were randomized and included in analyses. The sample included 49 women in the mindfulness-based stress reduction group, and 49 women in the waitlist control group. The intervention group participants (mean age 51.3 years, standard deviation = 11.4) and waitlist participants (mean age 55.1 years, standard deviation = 9.6) reported an average pain duration of approximately three years. No significant differences were found on the primary outcome of the proportions of women with reduced pain interference scores from the time of randomization to 3 months after the intervention was received. No significant changes were found among secondary outcomes. Conclusion: Our randomized clinical trial did not find significant benefits of group-based mindfulness-based stress reduction for the management of CNP. The current study findings should be replicated and are important to consider given ongoing concerns that nonsignificant results of mindfulness-based stress reduction are often unpublished.

Mindfulness-based stress reduction and cognitive function among breast cancer survivors: A randomized controlled trial.

BACKGROUND: Breast cancer (BC) survivors frequently report changes in cognition after chemotherapy. Mindfulness may benefit survivors by mitigating cancer-related cognitive impairment. As part of a larger study investigating the effects of mindfulness-based stress reduction (MBSR) for BC survivors living with neuropathic pain, the authors assessed whether MBSR would have an effect on cognitive outcomes. METHODS: Participants were randomized to an MBSR intervention group (n = 30) or a waitlist control group (n = 30). Cognitive assessments were administered at 3 time points: at baseline, 2 weeks, and 3 months post-MBSR in the intervention group and at equivalent time intervals for the control group. Multilevel models were used to assess whether MBSR significantly improved task performance at each time point. RESULTS: MBSR participants showed a significantly greater reduction in prospective and retrospective memory failures at 2 weeks postintervention. No effects of MBSR were noted for objective assessments. CONCLUSIONS: These results suggest that MBSR training reduces subjective (but not objective) memory-related impairments in BC survivors who receive treatment with chemotherapy. This study provides insight into a noninvasive intervention to ameliorate memory difficulties in BC survivors.

Evaluating the efficacy of intranasal oxytocin on pain and function among individuals who experience chronic pain: a protocol for a multisite, placebo-controlled, blinded, sequential, within-subjects crossover trial.

INTRODUCTION: Current treatments for chronic pain (eg, opioids) can have adverse side effects and rarely result in resolution of pain. As such, there is a need for adjuvant analgesics that are non-addictive, have few adverse side effects and are effective for pain management across several chronic pain conditions. Oxytocin is a naturally occurring hormone that has gained attention for its potential analgesic properties. The objective of this trial is to evaluate the efficacy of intranasal oxytocin on pain and function among adults with chronic pain. METHODS AND ANALYSIS: This is a placebo-controlled, triple-blind, sequential, within-subject crossover trial. Adults with chronic neuropathic, pelvic and musculoskeletal pain will be recruited from three Canadian provinces (British Columbia, Alberta and Newfoundland and Labrador, respectively). Enrolled patients will provide one saliva sample pretreatment to evaluate basal oxytocin levels and polymorphisms of the oxytocin receptor gene before being randomised to one of two trial arms. Patients will self-administer three different oxytocin nasal sprays twice daily for a period of 2 weeks (ie, 24 IU, 48 IU and placebo). Patients will complete daily diaries, including standardised measures on day 1, day 7 and day 14. Primary outcomes include pain and pain-related interference. Secondary outcomes include emotional function, sleep disturbance and global impression of change. Intention-to-treat analyses will be performed to evaluate whether improvement in pain and physical function will be observed posttreatment. ETHICS AND DISSEMINATION: Trial protocols were approved by the Newfoundland and Labrador Health Research Ethics Board (HREB #20227), University of British Columbia Clinical Research Ethics Board (CREB #H20-00729), University of Calgary Conjoint Health Research Ethics Board (REB20 #0359) and Health Canada (Control # 252780). Results will be disseminated through publication in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04903002; Pre-results.

Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis.

CONTEXT: This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain. EVIDENCE ACQUISITION: Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation. EVIDENCE SYNTHESIS: A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs. CONCLUSIONS: Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses.

BACKGROUND: Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. METHODS: A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. RESULTS: Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. CONCLUSIONS: This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. TRIAL REGISTRATION: PROSPERO registration CRD42018090761.

Systematic scoping review of interactions between analgesic drug therapy and mindfulness-based interventions for chronic pain in adults: current evidence and future directions.

Most patients with chronic pain do not find adequate pain relief with a single treatment, and accumulating evidence points to the added benefits of rational combinations of different treatments. Given that psychological therapies, such as mindfulness-based interventions (MBIs), are often delivered in conjunction with concomitant analgesic drug therapies (CADTs), this systematic scoping review examines the evidence for any interactions between MBIs and CADTs. The protocol for this review has been published and registered. MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and PsycINFO databases were searched until July 2019. We included randomized controlled trials that evaluated the efficacy of MBIs for the treatment of chronic pain. A total of 40 randomized controlled trials (2978 participants) were included. Thirty-nine of 40 (97.5%) included mindfulness-based clinical trials allowed the use of CADTs. However, only 6 of these 39 (15.4%) trials provided adequate details of what these CADTs were, and only 4 (10.3%) trials controlled for CADTs. Of great relevance to this review, none of the included trials analyzed the interactions between MBIs and the CADTs to determine whether they have an additive, synergistic, or antagonistic effect on chronic pain. Adverse events were inconsistently reported, and no judgment could be made about safety. Future trials assessing the interactions between MBIs and CADTs, with better harms reporting, are needed to better define the role of MBIs in the management of chronic pain.

Exploring Cancer Patients' Experiences of an Online Mindfulness-Based Program: A Qualitative Investigation.

OBJECTIVE: Chronic neuropathic pain (CNP) is a common condition cancer survivors experience. Mindfulness training may be one approach to address the psychosocial factors associated with CNP. The purpose of this study was to understand patients' experiences in an 8-week online mindfulness-based program (MBP), including techniques and skills learned and applied, barriers to practice, and research experiences. METHODS: Nineteen participants who were part of a randomized controlled trial consented to participate in a telephone interview or submit written responses via email post-course. Interviews were transcribed and analyzed using the principles of Applied Thematic Analysis (ATA). RESULTS: Predominant themes identified in participant interviews included (1) common humanity, (2) convenience, (3) teacher resonance, (4) perceived relaxation and calm, (5) pain and stress management, (6) half-day session, and (7) mindful breathing. Participants also identified helpful strategies learned and implemented from the course, as well as barriers to practice, and key components of their experiences in a randomized controlled trial, including a sense of disconnection post-course and needing continued ongoing sessions, and the importance of the facilitators' skills in creating a comfortable and supportive space. CONCLUSIONS: An online group-based MBP may offer a more accessible resource and form of psychosocial intervention and support for cancer survivors living with CNP. Furthermore, the need and consideration for implementing ongoing group maintenance sessions to minimize participants' feelings of disconnect and abandonment post-course and post-study are warranted in future MBP development.

Characteristics of frequent users of the emergency department with chronic pain.

OBJECTIVES: To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain. METHODS: We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related. RESULTS: We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain. CONCLUSIONS: Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

Prescriber adherence to guidelines for chronic noncancer pain management with opioids: Systematic review and meta-analysis.

OBJECTIVE: This review quantified prescriber adherence to opioid prescribing guidelines for chronic noncancer pain (CNCP). METHOD: We searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and the Joanna Briggs Institute EBP Database from inception until June 3, 2019. Studies that focused on provider adherence to opioids guidelines for CNCP in North America were eligible. Four reviewers screened studies, extracted data, and assessed study quality. RESULTS: Thirty-eight studies were eligible, comprising 17 cross-sectional studies (n = 11,835 providers) and 22 chart reviews (n = 22,512 patients). Survey data indicated that adherence was 49% (95% CI [40, 59]) for treatment agreements, 33% (95% CI [19%, 47%]) for urine drug testing, 48% (95% CI [26%, 71%]) for consultation with drug monitoring program, 57% (95% CI [35%, 79%]) for assessing risk of aberrant medication-taking behavior, and 61% (95% CI [35%, 87%]) for mental health screening. Chart review data indicated that the proportion of patients with documentation was 40% (95% CI [29, 51]) for treatment agreements, 41% (95% CI [32%, 50%]) for urine drug testing, 40% (95% CI [2%, 78%]) for consultation with drug monitoring program, 41% (95% CI [20%, 64%]) for assessing risk of aberrant medication-taking behavior, and 22% (95% CI [9%, 33%]) for mental health screening. Year of publication, practice guideline referenced, and risk of bias explained significant heterogeneity. No study evaluated whether nonadherence to recommendations reflected well-justified deviations to care. CONCLUSIONS: Adherence to guideline recommendations for opioids for CNCP is low. It is unclear whether nonadherence reflects thoughtful deviations in care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Implementation of the Ottawa Hospital Pain Clinic stepped care program: A preliminary report.

BACKGROUND: Access to multidisciplinary pain management treatment in Canada is limited, with wait times up to 4 years. Stepped care approaches to mental health treatment have led to substantial reduction and elimination of wait times and may be applicable to chronic pain settings. There is no unifying framework for stepped care chronic pain programs. A systematic review of the efficacy of stepped care in chronic pain management conducted by the Canadian Agency for Drugs and Technologies reported varied results that may be due to heterogeneous stepped care models across facilities. AIM: We propose a unifying framework for multidisciplinary stepped care chronic pain programs and present its application at The Ottawa Hospital Pain Clinic. The Ottawa Hospital stepped care framework is an eight-tiered approach that allows patients the opportunity to decide collaboratively with a health care professional which treatment program will best suit their needs for the management of chronic pain. As levels of stepped care increase, the time and resource commitment to each step will also increase. Treatment is stepped up or down, depending on patient needs. METHOD: This is a descriptive case study. RESULTS: Implementing the interprofessional model of care with the stepped care program has eliminated wait times for access to The Ottawa Hospital Pain Clinic Interprofessional Chronic Pain Management Program and has improved communication between professions of the interprofessional team, resulting in better care for patients. CONCLUSION: More research is needed to further develop and evaluate the clinical efficacy of stepped care to manage chronic pain.

Contexte: L'accès à la prise en charge multidisciplinaire de la douleur au Canada est limité, avec des délais d'attente pouvant aller jusqu'à quatre ans. Les approches de soins de santé mentale par paliers ont donné lieu à une réduction et une élimination des temps d'attente et peut être applicable aux contextes de soins pour la douleur chronique. Il n'existe pas de cadre unificateur pour les programmes de soins par paliers pour la douleur chronique. Un examen systématique de l'efficacit' des soins par paliers dans la prise en charge de la douleur chronique menée par l'Agence canadienne des médicaments et des technologies de la santé a fait état de résultats variés qui peuvent être attribuables à l'hétérogénéité des modèles de soins par paliers dans les vtablissements.Objectifs: Nous proposons un cadre unificateur pour les programmes de soins multidisciplinaires par paliers pour la douleur chronique et présentons son application à la Clinique de la douleur de l'Hôpital d'Ottawa. Le cadre de soins par paliers de l'Hôpital d'Ottawa est une approche à huit niveaux qui donne aux patients la possibilité de décider, en collaboration avec un professionnel de la santé, du programme de traitement qui répondra le mieux à leurs besoins pour la prise en charge de leur douleur chronique. À mesure que les niveaux de soins par paliers augmentent, le temps et les ressources nécessaires à chaque palier augmentent également. Le traitement est intensifié ou réduit, en fonction des besoins du patient.Méthodes: Il s'agit d'une étude de cas descriptive.Résultats: La mise en œuvre du modèle interprofessionnel de soins avec le programme de soins par paliers a éliminé les délais d'attente pour l'accès au programme de prise en charge interprofessionnelle de la douleur chronique de la clinique de la douleur de l'Hôpital d'Ottawa et a amélioré la communication entre les professions de l'équipe interprofessionnelle, ce qui a donné lieu à une meilleure prise en charge des patients.Conclusions: Des recherches supplémentaires sont nécessaires pour développer et évaluer davantage l'efficacité clinique des soins par paliers pour la prise en charge de la douleur chronique.

Mediators and moderators of change in mindfulness-based stress reduction for painful diabetic peripheral neuropathy.

Painful diabetic peripheral neuropathy (PDPN) is a chronic pain condition with modest response to pharmacotherapy. Participation in mindfulness-based stress reduction (MBSR) leads to improvements in pain-related outcomes but the mechanisms of change are unknown. The present study examined the mediators and moderators of change in 62 patients with PDPN who participated in a randomized controlled trial comparing MBSR to waitlist. Changes in mindfulness and pain catastrophizing were tested simultaneously as mediators. Increased mindfulness mediated the association between participation in MBSR and improved pain severity, pain interference, and the physical component of health-related quality of life (HRQoL) 3 months later. The mediation effect of pain catastrophizing was not significant. Linear moderated trends were also found. Post-hoc moderated mediation analyses suggested that MBSR patients with longer histories of diabetes might increase their mindfulness levels more, which in turn leads to improved pain severity and physical HRQoL. These results allow for a deeper understanding of pathways by which MBSR benefits patients with PDPN.

Understanding the High Frequency Use of the Emergency Department for Patients With Chronic Pain: A Mixed-Methods Study.

INTRODUCTION: Chronic pain (CP) is a common driver of emergency department (ED) visits despite the ED not being the ideal setting for CP because of increased risk of adverse events and high costs. PURPOSE: The purpose of this study is to understand factors contributing to CP-related ED visits, patients' care experiences, and patients' perspectives on alternatives to the ED. METHODS: We used a mixed-methods design combining semi-structured interviews and questionnaires with 12 patients with CP who had 12 or more ED visits over 1 year. We analyzed test scores using descriptive statistics and interviews using applied thematic analysis. RESULTS: Four themes emerged. Factors contributing to ED visits included the following: fear (e.g., pain and its impact); inability to cope with pain; family suggestions to go to the ED; and access to other services and resources. Patients had validating and invalidating experiences in the ED: needs were met or not met; and feeling acknowledged or unacknowledged. Patients' experiences with their family physician included feeling supported or unsupported. Alternatives to the ED included working with an interdisciplinary team, developing personalized care plans, and increased community-based resources. CONCLUSIONS: Patients with CP and frequent ED use present with complex pain and care experiences, requiring careful attention to management strategies and the patient-provider relationship.

Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis.

QUESTION: This review compares mindfulness-based stress reduction (MBSR) to cognitive-behavioural therapy (CBT) in its ability to improve physical functioning and reduce pain intensity and distress in patients with chronic pain (CP), when evaluated against control conditions. STUDY SELECTION AND ANALYSIS: Ovid MEDLINE, EmbaseClassic+Embase, PsycINFO and the Cochrane Library were searched to identify randomised controlled trials. The primary outcome measure was physical functioning. Secondary outcomes were pain intensity and depression symptoms. We used random and fixed effects (RE and FE) network meta-analyses (NMA) to compare MBSR, CBT and control interventions on the standardised mean difference scale. FINDINGS: Twenty-one studies were included: 13 CBT vs control (n=1095), 7 MBSR vs control (n=545) and 1 MBSR vs CBT vs control (n=341). Of the 21 articles, 12 were determined to be of fair or good quality. Findings from RE NMA for change in physical functioning, pain intensity and depression revealed clinically important advantages relative to control for MBSR and CBT, but no evidence of an important difference between MBSR and CBT was found. CONCLUSIONS: This review suggests that MBSR offers another potentially helpful intervention for CP management. Additional research using consistent measures is required to guide decisions about providing CBT or MBSR.

Understanding the Impact of Chronic Pain in the Emergency Department: Prevalence and Characteristics of Patients Visiting the Emergency Department for Chronic Pain at an Urban Academic Health Sciences Centre.

Background: Canadians make approximately 16 million visits to the emergency department (ED) each year. ED visits for non-urgent reasons contribute to suboptimal patient care and ineffective resource use. Aims: To estimate the proportion of ED visits related to chronic pain at our institution. Methods. We conducted a retrospective review of 1000 randomly selected ED visits at TOH during the 2012-2013 fiscal year (April 1, 2012 to March 31, 2013). Visits for chronic pain were identified using pre-defined criteria. Demographic and medical data were extracted from medical charts. Results: 104 visits during this time period were related to chronic pain (10.4%; 95% CI: 8.2-12.6). All visits were from unique patients (i.e., no patients contributed more than 1 visit). Patients were predominantly women (71%), with a mean age of 45.9 years. Seventy-eight percent of patients had a primary care provider. The most common location of pain included the abdomen (24%), the head or face (21%), and the low back (21%). Only 5% of patients had consultation with a pain medicine specialist while 78% were awaiting a consultation. More than 2/3 of patients (71%) reported using opioids for their pain. Conclusion: Presenting to the ED for chronic pain was found to occur among a sample of ED visits reviewed. This can result in ineffective care for patients with chronic pain. Cost-effective solutions to improve clinical outcomes and reduce ED use for chronic pain may yield significant improvements in health outcomes of patients and benefits for the health care system.

Contexte: Les Canadiens font approximativement 16 millions de visites aux urgences chaque année. Les visites aux urgences pour des raisons non urgentes contribuent à ce que les soins aux patients soient sous-optimaux et que les ressources soient utilisées de manière inefficace.Objectifs: Estimer la proportion de visites aux urgences liées à la douleur chronique à notre institution.Méthodes: Nous avons fait un examen rétrospectif de 1 000 visites aux urgences de l'Hôpital d'Ottawa sélectionnées de manière aléatoire qui avaient eu lieu au cours de l'exercice financier 2012-2013 (1er avril 2012 au 31 mars 2013). Les visites en raison d'une douleur chronique ont été repérées à l'aide de critères prédéfinis. Les données démographiques et médicales ont été extraites des dossiers médicaux.Résultats: Au cours de la période à l'étude, 104 visites étaient liées à la douleur chronique (10,4 %; IC 95% : 8,2 ­ 12,6). Toutes les visites étaient le fait de patients uniques (i.e. aucun patient n'a contribué pour plus d'une visite). Les patients étaient en majeure partie des femmes (71 %), dont l'âge moyen était de 45,9 ans. Soixante-dix huit pour cent des patients avaient un prestataire de soins primaires. L'endroit où la douleur se manifestait le plus fréquemment était l'abdomen (24 %), la tête ou le visage (21 %) et le bas du dos (21 %). Seulement 5 % des patients avaient consulté un médecin spécialiste de la douleur tandis que 78 % étaient en attente d'une consultation. Plus de 2/3 des patients (71 %) ont déclaré avoir utilisé des opioïdes pour leur douleur.Conclusion: Il a été constaté que parmi l'échantillon de visites à l'étude, des patients s'étaient présentés aux urgences en raison d'une douleur chronique. Cette situation peut avoir pour conséquence que les soins prodigués aux patients souffrant de douleur chronique soient inefficaces. La mise en place de solutions efficientes pour améliorer les résultats cliniques et diminuer le recours aux urgences pour de la douleur chronique pourrait grandement améliorer les résultats de santé des patients tout en étant avantageux pour le système de santé.

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review.

BACKGROUND: Evidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations-a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain. METHODS: An experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach. DISCUSSION: The ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP's ability to select the most appropriate treatment for an individual patient. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018091640 .