What's important in a contract beyond the salary? A primer for pain physicians and trainees.

This manuscript is designed to complement the previously published primer on salary structures for new pain physicians. The previous manuscript "Employment Contract Financial Models for the Pain Physician: A Primer" had a goal of increasing understanding of financial models by pain fellows when preparing for contract negotiations. This manuscript illustrates the many equally important considerations of "non-monetary" values that are a significant part of contract negotiation outside of salary. It contributes to the overall education for trainees and pain physicians on benefits and job responsibilities.

Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice?

Chronic pain is becoming increasingly prevalent and burdensome both worldwide and in the United Kingdom. Due to the complexity of chronic pain and the therapeutic challenge associated, management is often difficult and requires multidisciplinary care encompassing a combination of pharmacological and non-pharmacological strategies. Conventional analgesic treatments, such as opioids and anticonvulsants, are effective in less than half of chronic pain sufferers and are typically limited to short-term use to prevent complications associated with long-term use such as tolerance and dependence. Consequently, research and clinical interest in alternative management options for chronic pain have increased in recent years, with ketamine being one example under investigation. However, since ketamine has been licensed as an anaesthetic for decades, it has bypassed the traditional scrutinous drug development sequence that is typically seen for therapeutics marketed for pain. As such, data supporting the unlicensed administration of ketamine for chronic pain management is lacking and is being outpaced by the rates of off-label use in pain clinics. Recent limited evidence suggests that ketamine, when given as an intravenous infusion in subanaesthetic doses for refractory pain patients, may provide modest analgesic effects in nearly all aetiologies of chronic pain, with side effects common but typically mild. However, there are concerns over the safety of this practice due to the paucity of robust supportive evidence and the accompanying lack of clinical guidelines or standardised protocols. This review shall summarise the literature examining the use of subanaesthetic-dose ketamine infusions for chronic pain to comment on the current level of evidence, with limitations of existing research and future recommendations discussed.

"It has changed my picture of myself": how did females living with chronic pain perceive the impact of the standard pain rehabilitation, including the occupational therapy lifestyle intervention REVEAL(OT)?

PURPOSE: This study investigated patient perceptions of multidisciplinary chronic pain rehabilitation, including the occupational therapy lifestyle management program REVEAL(OT), on everyday life with chronic pain. METHODS: Individual interviews were conducted using video conferencing after completing multidisciplinary chronic pain rehabilitation. The interviews followed a semi-structured interview guide and investigated patient experiences with occupational therapy-supported health behavior transformation. The interviews were transcribed verbatim and analyzed iteratively using an inductive semantic data-driven approach inspired by Braun & Clarke's methodology. RESULTS: Five females, 34 to 58 years old, revealed three common themes: To discover oneself anew; Increased energy and calmness; and Look into the future. The themes reflected transformations towards a healthier lifestyle through enhanced self-control, developing meaningful and secure everyday activities, and gaining reaffirmed dignity. The study also identified the participants' need for professional assistance to cope with the pain after discharge. CONCLUSIONS: Chronic pain rehabilitation that included an occupational therapy intervention supported health behavior transformation and chronic pain self-management in females, where meaningful daily occupations and physical activity played an important role. Individually tailored support, also available after chronic pain rehabilitation, would benefit the transformation process towards improved pain coping in females.Implications for rehabilitationPersonal gains for health and well-being may develop over a shorter or longer time after chronic pain rehabilitation.Targeting daily occupations and physical activity during chronic pain rehabilitation appears meaningful for females living with chronic pain.Progression from an individual to group approach can be relevant in planning chronic pain rehabilitation, but the individual capacities shall be considered.Male perspectives on chronic pain rehabilitation that includes focus on daily occupations and lifestyle need further investigation.

Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia.

Background: Providing cultural education to health professionals is essential in improving the quality of care and outcomes for Aboriginal and Torres Strait Islander patients. This study reports the evaluation of a novel training workshop used as an intervention to improve communication with Aboriginal and Torres Strait Islander patients of persistent pain services. Methods: In this single-arm intervention study, health professionals undertook a one-day workshop, which included cultural capability and communication skills training based on a clinical yarning framework. The workshop was delivered across three adult persistent pain clinics in Queensland. At the end of the training, participants completed a retrospective pre/post evaluation questionnaire (5 points Likert scale, 1 = very low to 5 = very high), to rate their perceived importance of communication training, their knowledge, ability and confidence to communicate effectively. Participants also rated their satisfaction with the training and suggested improvements for future trainings. Results: Fifty-seven health professionals were trained (N = 57/111; 51% participation rate), 51 completed an evaluation questionnaire (n = 51/57; 90% response rate). Significant improvements in the perceived importance of communication training, knowledge, ability and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients were identified (p < 0.001). The greatest increase was in the perceived confidence pre-training mean of 2.96 (SE = 0.11) to the post-training mean of 4.02 (SE = 0.09). Conclusion: This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants' perceived competence. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

Is England facing an opioid epidemic?

The opioid crisis in the United States (US) is one of the most high-profile public health scandals of the 21st century with millions of people unknowingly becoming dependent on opioids. The United Kingdom (UK) had the world's highest rate of opioid consumption in 2019, and opiate-related drug poisoning deaths have increased by 388% since 1993 in England and Wales. This article explores the epidemiological definitions of public health emergencies and epidemics in the context of opioid use, misuse, and mortality in England, to establish whether England is facing an opioid crisis.

Patient experiences of remote care in a pain service during a pandemic.

Background: In March 2020, Pain Management Services were obliged to cease face-to-face consultations. This abrupt change, in line with recommendations from the British Pain Society, aimed to protect patients and staff and allowed resource re-allocation. Pain services were obliged to switch to remote consultations using Video Tele-Conferencing Technology (VTC) and Remote Consultations (RC) either through telephone or video calls using a variety of media and software applications. Little is known about the patient experience of remotely delivered pain care especially when alternatives are removed. The aim of this work was to understand the patient experience of this necessary switch regarding pain self-management interventions during the initial stages of the COVID-19 pandemic. Methods: A mixed-methods evaluation of the patient experience from three pain self-management interventions, taking place in a large community-based pain rehabilitation service along the South Coast of England, was performed. Experience-Based Design (EBD) methods were used to map patient experience at touch points through two interventions that were delivered in a structured format. Semi-structured recorded interviews were transcribed and analysed using thematic analysis for the third. Findings: Fifty-eight patients took part covering the scope of the service. In general, educational and psychological sessions were well received, with physical rehabilitation components being less easy to convey remotely. Attrition rates were high for the pain management programme. Group pain education worked particularly well in an online format with hope being the predominant emotion experienced. Clear limitations were technical failures and the lack of ability to form relationships in a virtual world. Conclusions: Remote digitalised interventions were acceptable to most patients. Attention should be paid to access and improving social aspects of delivery when considering such interventions. Physiotherapy may require more face-to-face necessitating a hybrid model and needs further investigation. EBD proved a highly suitable approach.

Inequalities and inequities in the types of chronic pain services available in areas of differing deprivation across England.

OBJECTIVES: In England, the prevalence of chronic pain is higher in more deprived compared to less deprived areas. Patients in such areas also experience more severe and disabling pain than those in less deprived areas. However, little is known about whether the distribution of services for chronic pain reflect these ranging levels of need. This study examines how the types of services available for chronic pain patients vary between healthcare providers in England, serving areas of differing deprivation. METHODS: National guidelines regarding primary as well the 8 commonest causes of secondary chronic pain (in the United Kingdom) were used to compile a list of services that have been recommended for supporting chronic pain patients. After searching the websites of 63 randomly selected National Health Service (NHS) Trusts and contacting their pain receptionists and/or secretaries, it was recorded whether the Trusts were providing each of these recommended chronic pain services. Mean Index of Multiple Deprivation 2019 scores were used to compare deprivation levels of areas covered by each NHS Trust. RESULTS: There was no significant difference in the overall number of types of chronic pain services provided by NHS Trusts serving areas of differing deprivation, but deprived areas were being disadvantaged with regards to specific services. These areas were significantly (p<0.05) less likely to have occupational therapy, return-to-work programmes, and hand therapy services. Areas with fewer types of professionals (≤3) in their pain multidisciplinary team were also significantly (p<0.05) more deprived than those with more types (>3). CONCLUSION: There are significant differences in the provision of certain types of chronic pain services between areas of differing deprivation. Similar research across Europe is recommended to inform policy to combat the widespread chronic pain related health inequalities.

Ultrasound-guided lumbar erector spinae plane block versus caudal block for postoperative analgesia in pediatric hip and proximal femur surgery: a randomized controlled study.

BACKGROUND: According to previous research, 20% of infants experience prolonged postsurgical pain 6-12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries. METHODS: Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia. RESULTS: The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups. CONCLUSIONS: The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.

Use of High-Resolution Ultrasound to Guide Alcohol Neurolysis for Chronic Pain.

BACKGROUND: The diagnosis and treatment of neuropathic pain is often clinically challenging, with many patients requiring treatments beyond oral medications. To improve our percutaneous treatments, we established a clinical pathway that utilized ultrasound (US) guidance for steroid injection and alcohol ablation for patients with painful neuropathy. OBJECTIVES: To describe a collaborative neuropathy treatment pathway developed by a neurosurgeon, pain physicians, and a sonologist, describing early clinical experiences and patient-reported outcomes. STUDY DESIGN: A retrospective case series was performed. METHODS: Patients that received percutaneous alcohol ablation with US guidance for neuropathy were identified through a retrospective review of a single provider's case log. Demographics and treatment information were collected from the electronic medical record. Patients were surveyed about their symptoms and treatment efficacy. Descriptive statistics were expressed as medians and the interquartile range ([IQR]; 25th and 75th data percentiles). Differences in the median follow-up pain scores were assessed using a Wilcoxon signed-rank test. RESULTS: Thirty-five patients underwent US-guided alcohol ablation, with the average patient receiving one treatment (range: 1 to 2), having a median duration of 4.8 months until reinjection (IQR: 2.9 to 13.1). The median number of steroid injections that individuals received before US-guided alcohol ablation was 2 (IQR: 1 to 3), and the median interval between steroid injections was 3.7 months (IQR: 2.0 to 9.6). Most (20/35 [57%]) patients responded to the survey, and the median pain scores decreased by 3 units (median: -3, IQR: -6 to 0; P < 0.001) one week following the alcohol ablation. This pain reduction remained significant at one month (P < 0.001) and one year (P = 0.002) following ablation. Most (12/20 [60%]) patients reported that alcohol ablation was more effective in improving their pain than oral pain medications. LIMITATIONS: Given the small sample size, treatment efficacy for alcohol neurolysis cannot be generalized to the broader population. CONCLUSIONS: US-guided percutaneous treatments for neuropathic pain present a growing opportunity for interprofessional collaboration between neurosurgery, clinicians who treat chronic pain, and sonologists. US can provide valuable diagnostic information and guide accurate percutaneous treatments in skilled hands. Further studies are warranted to determine whether a US-guided treatment pathway can prevent unnecessary open surgical management.

Aplicación y seguimiento del tratamiento del dolor neuropático periférico con capsaicina 179 mg realizado por enfermeras / Application and follow-up of the peripheral neuropathic pain treatment with capsaicin 179 mg conducted by nurses

Objetivo: evaluar la efectividad del tratamiento con parches de capsaicina 179 mg en personas con dolor neuropático periférico aplicado y en seguimiento realizado por enfermeras. Método: serie de casos longitudinal retrospectiva efectuada en la Unidad de Dolor del Hospital Universitario Son Llàtzer (Palma) entre 2018 y 2020. La población de estudio fue de 163 personas con ese tratamiento. Se llevó a cabo medición basal al mes, a los tres y a los seis meses. Se midieron sexo, edad, tiempo de evolución, aplicaciones realizadas, mejora en intensidad (NPRS: 0 a 10 puntos) y extensión del dolor, calidad de vida relacionada con la salud (EQ-5D-3L: 0 peor a 1 mejor), impresión de mejoría global del paciente (PGI-I: mejora; empeora o no mejora), uso de fármacos adyuvantes y efectos secundarios. Se llevó a cabo estadística descriptiva. Resultados: se incluyeron 133 pacientes con registros completos (= 57 años; = 30,2 meses de evolución; = 1,6 aplicaciones por persona). Se redujo la zona de dolor [Sí reduce (Mes 1: 67%; Mes 3: 41%; Mes 6: 20%)] y la intensidad del dolor pasó de = 7,35 a 6,32 al sexto mes. La calidad de vida fue superior a la media basal (0,37 sobre 1) en todas las mediciones. Mejoró la PGI [Mejora (Mes 1: 64,6%: Mes 3: 58,9%; Mes 6: 53,6 %)]. Disminuyó el uso de medicación adyuvante [Sí reduce (Mes 1: 28%; Mes 3: 30%; Mes 6: 67%)]. Los efectos adversos fueron dolor (78,9%), eritema (67,7%) y prurito (63,9%). Conclusión: el tratamiento aplicado por enfermeras fue eficaz y seguro. El seguimiento debe ser prolongado para detectar necesidades y cambios.(AU)

Objective: to evaluate the efficacy of the treatment with capsaicin 179mg patches applied and on follow-up by nurses in persons with peripheral neuropathic pain. Method: a longitudinal retrospective series of cases conducted at the Pain Unit of the Hospital Universitario Son Llàtzer between 2018 and 2020. The study population consisted of 196 persons with that treatment. Basal measurement was conducted at one month, at three and six months. The following were measured: gender, age, time of evolution, applications conducted, improvement in intensity (NPRS scale: 0 to 10 points) and extent of pain, health-related quality of life (EQ-5D-3L: 0=the worst to 1=the best), patient global impression of improvement (PGI-I: improvement, worsening or no improvement), use of adjuvant drugs and side effects. Descriptive statistics was applied. Results: 133 patients were included with complete records(= 57 years; = 30.2 months of evolution; = 1.6 applications per person). There was a reduction in the pain area [Reduced (Month 1: 67%; Month 3: 41%; Month 6: 20%)] and pain intensity moved from = 7.35 to 6.32 at month six. Quality of life was superior to the mean baseline (0.37 of 1) in all measurements. There was improvement in PGI [Improvement (Month 1: 64.6%: Month 3: 58.9%; Month 6: 53.6 %)]. There was a reduction in the use of adjuvant medication [Reduced (Month 1: 28%; Month 3: 30%; Month 6: 67%)]. The adverse effects were pain (78.9%), erythema (67.7%) and itching (63.9%). Conclusion: the treatment applied by nurses was effective and safe. There must be follow-up at long term in order to detect any needs and changes.(AU)

Feasibility and efficacy of erector spinae plane block versus transversus abdominis plane block in laparoscopic bariatric surgery: a randomized comparative trial.

BACKGROUND: Overweight and obesity are growing public health concerns worldwide. Bariatric surgery is a modality of weight reduction; however, postoperative pain can increase the length of hospital stay, with all the associated consequences. While regional anesthesia is an available option, the feasibility of performing abdominal wall blocks on patients with obesity is questionable. METHODS: Sixty adult patients with a body mass index of 40-50 kg/m2 undergoing laparoscopic bariatric surgery were randomly assigned to receive either an ultrasound-guided transversus abdominis plane (TAP) or erector spinae plane (ESP) block. The primary outcome was the analgesic effect in the first 24 h postoperatively, assessed using the mean visual analog scale (VAS) score. Secondary outcomes were the time required for a successful block, incidence of complications, time to first rescue analgesia, time to flatus or stool passage, and total opioid consumption. RESULTS: The mean VAS score during the first 24 h was higher with the TAP block than with the ESP block (2.78 ± 0.34 vs. 2.32 ± 0.12, P < 0.001). Additionally, the time to first rescue analgesia was greater with the ESP block (P = 0.001) and the time required for a successful block was higher with the TAP block (P = 0.001). However, the incidence of complications, total opioid consumption, and other secondary outcomes was similar between the groups. CONCLUSIONS: Compared with the TAP block, the bilateral ESP block is a more feasible and effective method for intra- and postoperative analgesia in patients undergoing laparoscopic bariatric surgery.

Experiences of Pediatric Pain Professionals Providing Care during the COVID-19 Pandemic: A Qualitative Study.

Chronic pain affects 1 in 5 youth, many of whom manage their pain using a biopsychosocial approach. The COVID-19 pandemic has impacted the way that healthcare is delivered. As part of a larger program of research, this study aimed to understand the impact of the pandemic on pediatric chronic pain care delivery including impact on patients' outcomes, from the perspective of pediatric healthcare providers. A qualitative descriptive study design was used and 21 healthcare providers from various professional roles, clinical settings, and geographic locations across Canada were interviewed. Using a reflexive thematic analysis approach 3 themes were developed: (1) duality of pandemic impact on youth with chronic pain (i.e., how the pandemic influenced self-management while also exacerbating existing socioeconomic inequalities); (2) changes to the healthcare system and clinical practices (i.e., triaging and access to care); (3) shift to virtual care (i.e., role of institutions and hybrid models of care). These findings outline provider perspectives on the positive and negative impacts of the pandemic on youth with chronic pain and highlight the role of socioeconomic status and access to care in relation to chronic pain management during the pandemic in a high-income country with a publicly funded healthcare system.

Participants' experiences from group-based treatment at multidisciplinary pain centres - a qualitative study.

OBJECTIVES: The aim of the study was to explore the experiences of participants in non-pharmacological group-based treatments delivered as part of a randomised controlled trial at Norwegian tertiary care pain centres. METHODS: Individual semi-structured interviews with 15 persons were conducted. The data were analysed with a descriptive thematic cross-case analysis based on the method of systematic text condensation. RESULTS: All participants talked about some aspects of the group-based treatments as a positive experience, but mainly the outcome was in line with their expectations; they hoped it would reduce their pain but did not expect it. There were no clear-cut differences in the experiences between the participants from the two different intervention groups. The content was experienced as both relevant and interesting but also to introduce concepts that were difficult to grasp and understand. Similarly, the experiences of participating in a group-based treatment were mostly stimulating but could also be challenging because of an expectancy of sharing personal stories. Although experiencing few changes to their pain they came away with techniques and lessons that were valuable to them. CONCLUSIONS: In this study, taking part in group-based treatment was perceived as giving positive and valuable lessons, due to relevant content and learning from the professionals and fellow participants, but without any clear indication of reduced pain. Approval from ethical committee number 10260 REK Midt. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04057144.

Perfil algológico del paciente con enfermedad del sistema musculoesquelético / Algological profile of the patient with musculoskeletal system disease

Resumen: Introducción: Se estima que del total de personas que refieren dolor crónico, uno de cada cuatro presenta dolor de origen musculoesquelético. El objetivo del estudio fue analizar el perfil demográfico y clínico del paciente con patología musculoesquelética que acude por primera vez a un centro especializado en tratamiento del dolor. Material y métodos: Se realizó un estudio transversal, descriptivo y retrospectivo que consistió en la revisión de la historia clínica algológica de los expedientes archivados del 2009 al 2017 del Centro Interdisciplinario para el Estudio y Tratamiento del Dolor y Cuidados Paliativos de la UMAE «Dr. Victorio de la Fuente Narváez¼. Resultados: Se incluyeron 4,518 expedientes. La mediana de la edad de los pacientes fue de 59 años (RIQ 47:72), consultando con mayor frecuencia el género femenino (62%). El dolor crónico se presentó en 83% de los pacientes con una intensidad media valorada por la escala visual analógica (EVA) de 6 (± 2.4). El síndrome doloroso mixto (somático y neuropático) se presentó con mayor frecuencia (41%). Conclusiones: La progresión de las enfermedades crónico degenerativas sobre el sistema musculoesquelético impacta en el origen y evolución de dolor crónico. El momento en el que los pacientes son remitidos a un centro especializado y reciben tratamiento específico del dolor podría modificar la evolución y consecuencias de éste.

Abstract: Introduction: It is estimated that of the total number of people who report chronic pain, one in every four presents pain of musculoskeletal origin. The objective of the study was to analyze the demographic and clinical profile of the patient with musculoskeletal pathology who visits a specialized pain treatment center for the first time. Material and methods: A cross-sectional, descriptive and retrospective study consisting of the review of the clinical history of the records archived from 2009 to 2017 of the Interdisciplinary Center for the Study and Treatment of Pain and Palliative Care of the UMAE «Dr. Victorio de la Fuente Narváez¼. Results: 4,518 records were included. The median age of patients was 59 years (IQR 47:72), with more frequent consultation for the female gender (62%). Chronic pain occurred in 83% of patients with an intensity assessed by the average visual analog scale (VAS) of 6 (± 2.4). Mixed pain syndrome (somatic and neuropathic) occurred more frequently (41%). Conclusions: The progression of chronic degenerative diseases on the musculoskeletal system impacts on the origin and evolution of chronic pain. The moment in which patients are referred to a clinic of pain and receive specific treatment could modify its evolution and consequences.

Radiofrequency denervation of the lumbar facet joints: guidelines for the RADICAL randomised controlled trial.

BACKGROUND AND AIM: The RADICAL trial has been funded by the National Institute for Health Research (NIHR) to evaluate the clinical and cost-effectiveness of radiofrequency denervation (RFD) for low back pain. Recommendations have been published which aim to standardise selection of patients and RFD technique. However, it is important to ensure these recommendations are acceptable to clinicians within the context of the trial. The aim of this work was to develop standardised criteria for the trial entry and RFD technique for implementation within the RADICAL trial. METHODS: Fourteen pain clinicians completed a survey, which involved reviewing the current recommendations and indicating whether they disagreed with any of the recommendations and if so why. Responses were collated and presented at a half-day workshop with 14 attendees. During the workshop, the National Low Back and Radicular Pain Pathway (NLBRPP) guidelines for patient selection and an article by Eldabe and colleagues presenting recommendations on the RFD technique were reviewed. Attendees discussed whether each component of the recommendations should be mandatory, mandatory with alteration or clarification or optional within the RADICAL trial. RESULTS: Attendees agreed during the workshop that 5 of the 10 criteria for patient selection described in the NLBRPP should be mandatory within the RADICAL trial. Three were agreed as mandatory criteria but required further clarification, one of which involved defining a positive response to a diagnostic medial branch block as ⩾60% pain relief. Two criteria had optional components. After reviewing the recommendations on the RFD technique from Eldabe and colleagues, seven components were agreed as mandatory, three were mandatory with alterations and three were optional. CONCLUSION: When evaluating complex interventions, such as RFD, it is important to ensure agreement and clarity on the clinical protocol, so that the intervention can be reproduced, if found to be effective.

COVID-19 Pandemic Impact and Response in Canadian Pediatric Chronic Pain Care: A National Survey of Medical Directors and Pain Professionals.

Background: The COVID-19 pandemic presents one of the greatest threats to pediatric pain care seen in generations. Due to public health restrictions, many pediatric pain clinics halted in-person appointments, delaying and disrupting access to care. There is no existing research on the impacts of COVID-19 on pediatric chronic pain care in Canada or the challenges experienced by health care professionals and pain clinics. Aims: The aim of this study was to evaluate the impact of COVID-19 on Canadian pediatric chronic pain care by documenting how health care professionals provided care during the first six months of the pandemic. Methods: Two Canadian online cross-sectional surveys were conducted: one among Canadian pediatric pain clinic directors (Study 1) and another among multidisciplinary pediatric pain health care professionals (Study 2). Results: Responses from 13/13 Canadian pediatric pain clinics/rehabilitation programs indicated that all clinics provided virtual care during the pandemic. No significant changes were reported on the frequency of appointment requests. Most clinics reported no perceived change in patient pain levels (n = 9/13, 69%) or occurrence of pain flares (n = 10/13, 77%). Results from 151 individual health care professionals indicated that the majority (90%) of non-emergency department respondents were providing virtual care. The main challenges of virtual care included technological barriers, financial concerns, infrastructure and logistics, privacy, and clinical challenges. Conclusions: This study documented the impact of the COVID-19 pandemic on pediatric chronic pain care in Canada and highlighted the rapid shift to using virtual solutions. Simultaneously, respondents outlined current challenges and potential solutions to consider in the development of virtual care guidelines and policy in Canada.

Contexte: La pandémie de COVID-19 représente l'une des plus grandes menaces pour les soins de la douleur pédiatrique jamais connue depuis des générations. En raison de restrictions de santé publique, de nombreuses cliniques pédiatriques de la douleur ont interrompu les rendez-vous en personne, occasionnant ainsi des retards et des perturbations dans l'accès aux soins. Il n'existe pas de recherche sur les répercussions de la COVID-19 sur les soins pédiatriques de la douleur chronique au Canada ou sur les défis rencontrés par les professionnels des soins de santé et les cliniques de la douleur.Objectifs: L'objectif de cette étude était d'évaluer les répercussions de la COVID-19 sur les soins pédiatriques de la douleur chronique au Canada en documentant la façon dont les professionnels de la santé ont prodigué les soins au cours des six premiers mois de la pandémie.Méthodes: Deux enquêtes transversales canadiennes en ligne ont été menées : l'une auprès des directeurs de cliniques pédiatriques de la douleur canadiennes (Étude 1) et l'autre auprès de professionnels des soins de santé de la douleur pédiatriques multidisciplinaires (étude 2).Résultats: Les réponses obtenues de la part de 13 / 13 cliniques pédiatriques de la douleur / programmes de réadaptation ont indiqué que toutes les cliniques avaient fourni des soins virtuels pendant la pandémie. Aucun changement significatif n'a été rapporté sur la fréquence des demandes de rendez-vous. La plupart des cliniques n'ont signalé aucun changement perçu dans les niveaux de douleur des patients (n = 9/13, 69 %) ou la survenue de poussées douloureuses (n = 10/13, 77 %). Les résultats obtenus de 151 professionnels de la santé ont indiqué que la majorité (90 %) des répondants de département autres que les urgences fournissaient des soins virtuels. Les principaux défis des soins virtuels comprenaient les barrières technologiques, les préoccupations financières, l'infrastructure et la logistique, la confidentialité et les défis cliniques.Conclusions: Cette étude a documenté les répercussions de la pandémie de COVID-19 sur les soins pédiatriques de la douleur chronique au Canada et a mis en lumière le passage rapide à l'utilisation de solutions virtuelles. Simultanément, les répondants ont décrit les défis actuels et les solutions potentielles devant être tenues en compte dans l'élaboration de lignes directrices et de politiques sur les soins virtuels au Canada.

Spatiotemporal Analysis of the Association Between Pain Management Clinic Laws and Opioid Prescribing and Overdose Deaths.

Pain management clinic (PMC) laws were enacted by 12 states to promote appropriate opioid prescribing, but their impact is inadequately understood. We analyzed county-level opioid overdose deaths (National Vital Statistics System) and patients filling long-duration (≥30 day) or high-dose (≥90 morphine milligram equivalents per day) opioid prescriptions (IQVIA, Inc.) in the United States in 2010-2018. We fitted Besag-York-Mollié spatiotemporal models to estimate annual relative rates (RRs) of overdose and prevalence ratios (PRs) of high-risk prescribing associated with any PMC law and 3 provisions: payment restrictions, site inspections, and criminal penalties. Laws with criminal penalties were significantly associated with reduced PRs of long-duration and high-dose opioid prescriptions (adjusted PR = 0.82, 95% credible interval (CrI): 0.82, 0.82, and adjusted PR = 0.73, 95% CI: 0.73, 0.74 respectively) and reduced RRs of total and natural/semisynthetic opioid overdoses (adjusted RR = 0.86, 95% CrI: 0.80, 0.92, and adjusted RR = 0.84, and 95% CrI: 0.77, 0.92, respectively). Conversely, PMC laws were associated with increased relative rates of synthetic opioid and heroin overdose deaths, especially criminal penalties (adjusted RR = 1.83, 95% CrI: 1.59, 2.11, and adjusted RR = 2.59, 95% CrI: 2.22, 3.02, respectively). Findings suggest that laws with criminal penalties were associated with intended reductions in high-risk opioid prescribing and some opioid overdoses but raise concerns regarding unintended consequences on heroin/synthetic overdoses.

Feasibility assessment of an occupational therapy lifestyle intervention added to multidisciplinary chronic pain treatment at a Danish pain centre: a qualitative evaluation from the perspectives of patients and clinicians.

Purpose: As part of intervention feasibility evaluation before conducting a clinical trial, this study aimed to investigate perspectives of patients and clinicians involved in the occupational therapy lifestyle-oriented programme REVEAL(OT) [Redesign your EVEveryday Activities and Lifestyle with Occupational Therapy] which was added to multidisciplinary chronic pain treatment.Methods: We conducted three focus group interviews, two with eight voluntarily selected patients and one with four clinicians. Data were analysed using Braun & Clarke's semantic data-driven analysis.Results: Patients reported satisfaction with the intervention and a greater acceptance of living with chronic pain through increased understanding of pain mechanisms, more effective daily planning and improved social interaction. Patients felt empowered to change lifestyle habits by restarting habitual interests, prioritizing joyful occupations for improved occupational balance, and lifestyle modifications. Contact to occupational therapists and peer support were important empowering factors for working with lifestyle goals. Patients and clinicians expressed their views on further improvement of the REVEAL(OT).Conclusions: Patients and clinicians found the lifestyle-oriented occupational therapy programme relevant as an add-on to the multidisciplinary chronic pain treatment. A need was expressed for a reduced information and treatment load and a higher degree of communication and cooperation among the clinicians involved in the intervention.

Correlates of Manual Therapy and Acupuncture Use Among Rural Patients Seeking Conventional Pain Management: A Cross-sectional Study.

OBJECTIVE: In this cross-sectional study, we examined correlates of manual therapy (spinal manipulation, massage therapy) and/or acupuncture use in a population engaging in conventional pain care in West Virginia. METHODS: Participants were patients (aged 18+ years) from 4 Appalachian pain and rheumatology clinics. Of those eligible (N = 343), 88% completed an anonymous survey including questions regarding health history, pain distress (Short Form Global Pain Scale), prescription medications, and current use of complementary health approaches for pain management. We used age-adjusted logistic regression to assess the relation of sociodemographic, lifestyle, and health-related factors to use of manual therapies and/or acupuncture for pain (complete-case N = 253). RESULTS: The majority of participants were white (92%), female (56%), and middle aged (mean age, 54.8 ± 13.4 years). Nearly all reported current chronic pain (94%), and 56% reported ≥5 comorbidities (mean, 5.6 ± 3.1). Manual therapy and/or acupuncture was used by 26% of participants for pain management (n = 66). Current or prior opioid use was reported by 37% of those using manual therapies. Manual therapy and/or acupuncture use was significantly elevated in those using other complementary health approaches (adjusted odds ratio, 3.0; 95% confidence interval, 1.5-5.8). Overall Short Form Global Pain Scale scores were not significantly associated with use of manual therapies and/or acupuncture after adjustment (adjusted odds ratio per 1-point increase, 1.01; 95% confidence interval, 1.00-1.03). CONCLUSION: We found no evidence for an association of pain-related distress and use of manual therapies and/or acupuncture, but identified a strong association with use of dietary supplements and mind-body therapies. Larger studies are needed to further examine these connections in the context of clinical outcomes and cost-effectiveness in rural adults given their high pain burden and unique challenges in access to care.