Gabapentin as part of a multimodal pain protocol for selective dorsal rhizotomy does not impact percentage of rootlets transected.

PURPOSE: We aim to determine whether preoperatively initiated gabapentin for pain control impacts the percentage of rootlets cut during monitored, limited laminectomy selective dorsal rhizotomy (SDR) procedure. METHODS: This retrospective cohort study includes participants with cerebral palsy who had SDR for treatment of spasticity between 2010 and 2019 at a single-institution tertiary care center. One-level laminectomy SDR aimed to evaluate the cauda equina roots from levels L2-S1 with EMG monitoring. Gabapentin titration began 3 weeks prior to SDR. Data was analyzed using simple linear regression. Thirty-one individuals met inclusion criteria. Mean age was 7 years, 4 months. Eighteen participants (58%) identified as male, 12 (39%) female, and one (3%) non-binary. Thirty (97%) had bilateral CP. Sixteen (52%) were GMFCS II, four (13%) GMFCS III, five (16%) GMFCS IV, and six (19%) GMFCS V. RESULTS: Mean percentage of rootlets transected was 50.75% (SD 6.00, range 36.36-60.87). There was no relationship between the dose of gabapentin at time of SDR and percentage of rootlets cut with a linear regression slope of - 0.090 and an R2 of 0.012 (P = 0.56). CONCLUSION: Results indicate that preoperative initiation of gabapentin did not impact the percentage of rootlets transected. Thus, gabapentin can be initiated prior to SDR at moderate dosages without impacting SDR surgical outcomes.

Long-Term Outcomes in the Management of Central Neuropathic Pain Syndromes: A Prospective Observational Cohort Study.

BACKGROUND: Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, traumatic spinal cord injury, or multiple sclerosis. These syndromes are distinctly less common than peripheral neuropathic pain, and less is known regarding the underlying pathophysiology, appropriate pharmacotherapy, and long-term outcomes. The objective of this study was to determine the long-term clinical effectiveness of the management of central neuropathic pain relative to peripheral neuropathic pain at tertiary pain centers. METHODS: Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified for analysis from a prospective observational cohort study of patients with chronic neuropathic pain recruited from seven Canadian tertiary pain centers. Data regarding patient characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome measure was the composite of a reduction in average pain intensity and pain interference. Secondary outcome measures included assessments of function, mood, quality of life, catastrophizing, and patient satisfaction. RESULTS: At 12-month follow-up, 13.5% (95% confidence interval [CI], 5.6-25.8) of patients with central neuropathic pain and complete data sets (n=52) achieved a ≥30% reduction in pain, whereas 38.5% (95% CI, 25.3-53.0) achieved a reduction of at least 1 point on the Pain Interference Scale. The proportion of patients with central neuropathic pain achieving both these measures, and thus the primary outcome, was 9.6% (95% CI, 3.2-21.0). Patients with peripheral neuropathic pain and complete data sets (n=463) were more likely to achieve this primary outcome at 12 months (25.3% of patients; 95% CI, 21.4-29.5) (p=0.012). CONCLUSION: Patients with central neuropathic pain syndromes managed in tertiary care centers were less likely to achieve a meaningful improvement in pain and function compared with patients with peripheral neuropathic pain at 12-month follow-up.

Long-Term Outcomes in the Management of Painful Diabetic Neuropathy.

BACKGROUND: Painful diabetic neuropathy (PDN) is a frequent complication of diabetes mellitus. Current treatment recommendations are based on short-term trials, generally of ≤3 months' duration. Limited data are available on the long-term outcomes of this chronic disease. The objective of this study was to determine the long-term clinical effectiveness of the management of chronic PDN at tertiary pain centres. METHODS: From a prospective observational cohort study of patients with chronic neuropathic non-cancer pain recruited from seven Canadian tertiary pain centres, 60 patients diagnosed with PDN were identified for analysis. Data were collected according to Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials guidelines including the Brief Pain Inventory. RESULTS: At 12-month follow-up, 37.2% (95% confidence interval [CI], 23.0-53.3) of 43 patients with complete data achieved pain reduction of ≥30%, 51.2% (95% CI, 35.5-66.7) achieved functional improvement with a reduction of ≥1 on the Pain Interference Scale (0-10, Brief Pain Inventory) and 30.2% (95% CI, 17.2-46.1) had achieved both these measures. Symptom management included at least two medication classes in 55.3% and three medication classes in 25.5% (opioids, antidepressants, anticonvulsants). CONCLUSIONS: Almost one-third of patients being managed for PDN in a tertiary care setting achieve meaningful improvements in pain and function in the long term. Polypharmacy including analgesic antidepressants and anticonvulsants were the mainstays of effective symptom management.

Incidence of Nonsynostotic Plagiocephaly and Developmental Disorders.

Importance: This is the first population-based study quantifying the incidence of nonsynostotic positional plagiocephaly and/or brachycephaly (PPB) in infancy and its association with developmental disorders. Objective: To report the incidence of PPB before age 1 year, the incidence of craniosynostosis, and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years. Design, Setting, and Participants: This was a retrospective, population-based cohort study of children in the Rochester Epidemiology Project (REP) born in Olmsted County, Minnesota, from January 1, 2008, through December 31, 2012, with follow-up through age 7 years. Data were analyzed from March 2021 to April 2024. Exposure: Physical examination detecting cranial deformity. Main Outcomes and Measures: The primary outcome was the incidence of PPB. Secondary outcomes were the incidence of craniosynostosis and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years. Results: Of 9909 infants (5084 [51.3%] male; 9205 [92.9%] born at term and 704 [7.1%] born preterm) included in the study, 575 had PPB, for a PPB incidence of 5.8% (95% CI, 5.3%-6.3%). The incidence of PPB was 5.3% (95% CI, 4.8%-5.8%) in term infants vs 11.8% (95% CI, 9.4%-14.6%) in preterm infants. The incidence of craniosynostosis was 0.16% (95% CI, 0.09%-0.26%). A developmental disorder was known or suspected in 4.2% (95% CI, 2.7%-6.2%) of infants at the time of PPB diagnosis; among 402 infants with PPB and follow-up through age 7 years, 30 (7.5%; 95% CI, 5.0%-10.7%) had a confirmed developmental disorder by 7 years of age. The prevalence of autism spectrum disorder (ASD) in children with a history of PPB who were followed up to age 7 years was 2.2% (9 of 402 children). Conclusions and Relevance: This study found that only a small percentage of the infants had positional head deformity significant enough to be documented and/or referred for subspecialty evaluation, and only a small subset of these children went on to have a developmental disorder in childhood. This information is helpful for counseling families about their child's developmental risk at time of PPB diagnosis.

Understanding specific effects of prenatal alcohol exposure on brain structure in young adults.

Prenatal alcohol exposure (PAE) is associated with various adverse effects on human brain and behavior. Recently, neuroimaging studies have begun to identify PAE effects on specific brain structures. Investigation of such specific PAE effects is important for understanding the teratogenic mechanism of PAE on human brain, which is critical for differentiating PAE from other disorders. In this structural MRI study with young adults, PAE effects on the volumes of automatically segmented cortical and subcortical regions of interest (ROIs) were evaluated both through a group difference approach and a parametric approach. In the group difference approach (comparing among two PAE and a control groups), a disproportionate PAE effect was found in several occipital and temporal regions. This result is inconsistent with previous studies with child samples. Moreover, a gender difference in PAE effect was shown in some cortical ROIs. These findings suggest that sampling and gender may be important factors for interpreting specific PAE effects on human brain. With the parametric approach, it was demonstrated that the higher the PAE level, the smaller the entire brain, the lower the IQ. Several cortical and subcortical ROIs also exhibited a negative correlation between the PAE level and ROI volume. Furthermore, our data showed that the PAE effect on the brain could not be interpreted by the PAE effect on general physical growth until the young adult age. This study provides valuable insight into specific effects of PAE on human brain and suggests important implications for future studies in this field.

Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials.

Effective therapeutic options for patients living with chronic pain are limited. The pain relieving effect of cannabinoids remains unclear. A systematic review of randomized controlled trials (RCTs) examining cannabinoids in the treatment of chronic non-cancer pain was conducted according to the PRISMA statement update on the QUORUM guidelines for reporting systematic reviews that evaluate health care interventions. Cannabinoids studied included smoked cannabis, oromucosal extracts of cannabis based medicine, nabilone, dronabinol and a novel THC analogue. Chronic non-cancer pain conditions included neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain. Overall the quality of trials was excellent. Fifteen of the eighteen trials that met the inclusion criteria demonstrated a significant analgesic effect of cannabinoid as compared with placebo and several reported significant improvements in sleep. There were no serious adverse effects. Adverse effects most commonly reported were generally well tolerated, mild to moderate in severity and led to withdrawal from the studies in only a few cases. Overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis. The context of the need for additional treatments for chronic pain is reviewed. Further large studies of longer duration examining specific cannabinoids in homogeneous populations are required.

The Canadian STOP-PAIN project - Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities?

PURPOSE: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This article presents the patients' bio-psycho-social profile. METHODS: A sample of 728 patients was recruited from waitlists of eight university-affiliated MPTFs across Canada. Subjects completed validated questionnaires to: 1) assess the characteristics and impact of their pain; and 2) evaluate their emotional functioning and quality of life (QoL). Follow-up questionnaires were completed by a subgroup of 271 patients three months later. RESULTS: Close to 2/3 of the participants reported severe pain (> or = 7/10) that interfered substantially with various aspects of their daily living and QoL. Severe or extremely severe levels of depression were common (50.0%) along with suicidal ideation (34.6%). Patients aged > 60 yr were twice as likely to experience severe pain (> or = 7/10) as their younger counterparts (P = 0.002). Patients with frequent sleep problems were more at risk of reporting severe pain (P < or = 0.003). Intense pain was also associated with a greater tendency to catastrophize (P < 0.0001) severe depressive symptoms (P = 0.003) and higher anger levels (P = 0.016). Small but statistically significant changes in pain intensity and emotional distress were observed over a three-month wait time (all P < 0.05). CONCLUSION: This study highlights the severe impairment that patients experience waiting for treatment in MPTFs. Knowing that current facilities cannot meet the clinical demand, it is clear that effective prevention/treatment strategies are needed earlier in primary and secondary care settings to minimize suffering and chronicity.

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.

COVID-19 impact and response by Canadian pain clinics: A national survey of adult pain clinics.

Background: As the result of public health authority responses to the COVID-19 pandemic, pain clinics have had to cease providing in-person appointments to reduce contact between patients and staff. Over the past decade, Canadians living with chronic pain have faced long waiting times for care within multidisciplinary pain clinics. We are concerned that ceasing in-person pain services exacerbates the daily hardships already faced by Canadians living with chronic pain. Aims: The aim of this study was to evaluate the impact of the COVID-19 pandemic on Canadian pain clinics, their responses, and changes to clinic practices that might be maintained when the pandemic is over. Methods: A survey of Canadian adult multidisciplinary pain clinics was conducted to determine impacts on medical and allied health care services and the strategies used to deliver care to patients during the COVID-19 pandemic. Results: Responses received from 17 adult pain clinics across Canada showed that adult multidisciplinary pain clinics had to cease or significantly reduce in-person patient contacts during the COVID-19 pandemic and responded by offering telehealth options. Despite their efforts, patients are waiting longer and have lost access to usual care. Increased levels of pain, stress, and medication use, particularly opioids and cannabinoids, were reported. Conclusions: Access to adaptable and innovative technologies, such as telehealth, can assist in the care of the one in five Canadians living with chronic pain during times of crises and must be included as a vital component of a comprehensive Canadian pain strategy.

Contexte: Suite aux mesures prises par les autorités de santé publique en réponse à la pandémie de COVID-19, les cliniques antidouleur ont dû cesser de proposer des rendez-vous en personne afin de réduire les contacts entre les patients et le personnel. Au cours de la dernière décennie, les Canadiens vivant avec la douleur chronique ont dû faire face à de longs délais d'attente pour obtenir des soins dans les cliniques antidouleur multidisciplinaires. Nous sommes préoccupés par le fait que l'arrêt des services antidouleur en personne exacerbe les difficultés quotidiennes auxquelles sont déjà confrontés les Canadiens qui vivent avec la douleur chronique.Objectifs: Cette étude visait à évaluer les repercussions de la pandémie de COVID-19 sur les cliniques antidouleur au Canada, leurs réactions et les changements dans leurs pratiques qui pourraient être maintenus en raison de la pandémie.Méthodes: Une enquête a été menée auprès des cliniques antidouleur multidisciplinaires pour adultes au Canada afin de determiner les répercussions sur les services médicaux et les services paramédicaux, ainsi que les strategies utilisées pout fournir des soins de santé aux patients pendant la pandémie de COVID-19.Résultats: Les réponses reçues de 17 cliniques antidouleur pour adultes au Canada ont montré que les cliniques antidouleur multidisciplinaires pour adultes avaient dû cesser ou réduire considérablement les contacts en personne avec les patients pendant la COVID-19 et qu'elles ont réagi en proposant des options de télésanté. Malgré leurs efforts, les patients attendent plus longtemps et n'ont plus accès aux soins habituels. L'augmentation des niveaux de douleur, de stress et de médication, en particulier les opioïdes et les cannabioïdes, a été signalée.Conclusion: L'accès à des technologies adaptables et innovantes, telles que la télésanté, peut contribuer aux soins des 20 % de Canadiens vivant avecla douleur chronique en période de crise et doit constituer un élément essentiel d'une stratégie canadienne globale de lutte contre la douleur.

Pediatric telerehabilitation medicine: Making your virtual visits efficient, effective and fun.

The COVID-19 pandemic has accelerated many changes in medicine including the transition from providing care in person to providing care via technology enabled telemedicine. The benefits of telemedicine visits with a Pediatric Rehabilitation Medicine (PRM) provider, also known as telerehabilitation medicine visits, are numerous. Telerehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distance and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers. Telerehabilitation medicine also allows for access to PRM care in rural areas or areas without medical specialty, virtual in-home equipment evaluation, and reduced travel burden. Because of these and many other benefits, telerehabilitation medicine will likely become part of our ongoing model of care if barriers to telemedicine continue to be lowered or removed. This paper is intended to establish a foundation for pediatric telerehabilitation medicine visit efficiency and effectiveness in our current environment and into the future.

Child catastrophizing about parent chronic pain: A potential child vulnerability factor.

Objective Robust evidence suggests children's catastrophizing about their own pain is a risk factor for poor child pain-related outcomes. In children of parents with chronic pain, child catastrophizing about their parents' pain might be a unique predictor of child pain-related outcomes given their increased exposure to parental chronic pain and disability. The objective of this study was to examine associations between child and parent catastrophizing about their own and each other's pain and child and parent pain-related outcomes. Methods Seventy-two parents with chronic pain and their children (ages 8-15) completed questionnaires assessing their trait catastrophizing about their own and each other's pain, their own pain, and the child's internalizing symptoms. Children completed the cold pressor task (CPT) in the presence of their parent. Parents and children rated children's worst pain intensity and their own anxiety during the task. Analyses were guided by the Actor-Partner Interdependence Model. Results Greater child catastrophizing about parent pain was associated with children's and parents' increased catastrophizing about their own pain. Child catastrophizing about parent pain was associated with greater child- and parent-reported child internalizing symptoms and greater CPT pain intensity for the child, but not parent/child usual pain or CPT anxiety, over and above the influence of parent and child catastrophizing about their own pain. Conclusions Child catastrophizing about parent pain is a potential vulnerability factor associated with poor pain-related outcomes in children of parents with chronic pain that should be considered in future research and clinical settings. Statement of contribution What is already known on this subject? Higher rates of pain and internalizing symptoms are observed in offspring of parents with vs. without chronic pain. Greater child and parent pain catastrophizing are associated with poorer pain-related outcomes in children. Child catastrophizing about parent chronic pain and its association with child outcomes has not been examined. What does this study add? Greater child catastrophizing about parent chronic pain is associated with greater child internalizing and CPT pain. These effects were seen beyond the association of child and parent catastrophizing about their own pain.

Research funding for pain in Canada.

Chronic pain is an escalating public health problem. There are inadequate resources to assist patients suffering with pain in Canada. Therefore, it is important that research examining novel and appropriate treatment for chronic pain is conducted. To determine the current level of research funding for pain in Canada, the Canadian Pain Society conducted a survey. Of 79 active researchers performing pain-related studies, 65 received funding in the past five years amounting to a total of approximately $80.9 million. This is less than 1% of the total funding from the Canadian Institutes of Health Research and 0.25% of the total funding for health research.

Compound heterozygosity in sodium channel Nav1.7 in a family with hereditary erythermalgia.

Hereditary erythermalgia is a painful and debilitating genetic disorder associated with mutations in voltage-gated sodium channel Nav1.7. We have previously reported a Canadian family segregating erythermalgia consistently with a dominant genetic etiology. Molecular analysis of the proband from the family detected two different missense mutations in Nav1.7. In the present study we have performed a long-term follow-up clinical study of disease progression in three affected family members. A more extensive molecular study has also been completed, analyzing the segregation of the two missense variants in the family. The two variants (P610T, L858F) segregate independently with respect to clinical presentation. Detailed genotype/phenotype correlation suggests that one of the two variants (L858F) is causal for erythermalgia. The second variant (P610T) may modify the phenotype in the proband. This is the second reported study of potential compound heterozygosity for coding polymorphisms in Nav1.7, the first being in a patient with paroxysmal extreme pain disorder.

The utility of universal urinary drug screening in chronic pain management.

BACKGROUND: A recent systematic review found few studies that assessed the value of urinary drug screening (UDS) in the management of chronic pain. The Pain Management Unit in Halifax, Nova Scotia, has recently implemented tandem mass spectrometry (TMS) UDS for all new patients. AIMS: To study the prevalence of unexpected TMS UDS results at a hospital-based chronic pain center, to assess which drugs are most likely to contribute to an unexpected result and to assess the clinical utilization of unexpected results by pain physicians. METHODS: From June 2014 to June 2016, a total of 664 patients with chronic non-cancer pain (CNCP) were seen for initial consult. Charts were reviewed and used to create a database containing sex, age, UDS result, physician, and medication/illicit drug history. For all unexpected UDS results, an interview was conducted with the treating physician to determine its clinical implications. RESULTS: For the general pain specialists, the overall percentage of patients with an unexpected UDS result was 16.67%. Excluding codeine, at most 4.47% of patients tested unexpectedly positive for a strong opioid. Although eight out of nine physicians found UDS helpful in general, only 29.58% of unexpected results were helpful in the management of their patients and directly influenced their care. CONCLUSIONS: The prevalence of an unexpected UDS result in patients with CNCP is significant. Most physicians agree that UDS is helpful but in only a limited number of cases did the unexpected result provide helpful information that significantly influenced patient care.

Contexte: Une revue systématique récente a démontré que peu d'études évaluaient la valeur du dépistage urinaire de drogue dans la prise en charge de la douleur chronique. L'Unité de prise en charge de la douleur d'Halifax, en Nouvelle-Écosse, a récement instauré le dépistage urinaire de drogue par spectrométrie de masse en tandem pour tous ses nouveaux patients.But: Éudier la prévalence de résultats inattendus lors du dépistage urinaire de drogue par spectométrie de masse en tandem dans un centre de la douleur chronique en milieu hospitalier, afin d'évaluer quelle drogues sont les plus susceptibles de donner lieu à un résultat inattendu et à la fois évaluer l'utilisation clinique des résultats inattendus par les médecins spécialisés dans le traitement de la douleur.Méthodes: De juin 2014 à juin 2016, 664 patients souffrant de douleur chronique non cancéreuse ont été vus pour une consultation initiale. Leurs dossiers ont été étudiés et utilisés pour créer une base de données contenant leur sexe, leur âge, le résultat obtenu lors du dépistage urinaire de drogue, leur médecin traitant et leurs antécédents en matière de médication ou de drogues illicites. Pour tous les résultats de dépistage urinaire de drogue inattendus, une entrevue a eu lieu avec le médecin traitant afin d'en déterminer les implications cliniques.Résultats: Pour les spécialistes de la douleur générale, le pourcentage global de patients ayant obtenu un résultat inattendu lors du dépistage urinaire de drogue était de 16,67 %. À l'exclusion de la codéine, tout au plus 4,47% des patients ont obtenu un résultat positif inattendu pour un opioïde puissant. Bien que huit médecins sur neuf aient trouvé le dépistage urinaire de drogue utile en général, seulement 29,58% des résultats inattendus ont été utiles dans la prise en charge de leurs patients et ont influencé directements les soins prodigués.Conclusions: La prévalence d'un résultat inattendu lors du dépistage urinaire de drogue chez les patients souffrant de douleur chronique non cancéreuse est élevée. La plupart des médecins sont d'accord pour dire que le dépistage urinaire de drogue est utile, mais que le résultat inattendu a fourni de l'information utile ayant influencé les soins aux patients de manière significative seulement dans un nombre limité de cas.

A prospective observational study of problematic oral cannabinoid use.

BACKGROUND: Despite evidence supporting the benefits of cannabinoids for symptom control across a wide range of medical conditions, concerns have been raised regarding the potential misuse and/or problematic use of cannabinoids (CBs). OBJECTIVE: The first objective of this study was to examine the incidence of problematic prescription cannabinoid use (PPCBU) over a 12-month period among patients initiating cannabinoid therapy. The second objective was to examine the factors associated with PPCBU. A total of 265 patients who were prescribed oral cannabinoid therapy as part of usual medical practice were enrolled into this prospective observational study. Patients first completed a series of baseline questionnaires assessing demographic, clinical, and substance use variables. Three measures designed to assess PPCBU were then administered at 3, 6, and 12 months after initiation of cannabinoid therapy. RESULTS: At each of the follow-up assessment time points, a significantly greater number of patients scored below (vs above) cutoff scores on the three main PPCBU outcomes (all p's < .001). At any follow-up time point, a maximum of roughly 25% of patients demonstrated PPCBU. Heightened odds of PPCBU were observed among patients with a history of psychiatric problems, tobacco smokers, and recreational cannabis users (all p's < .05). Results indicated that past-year substance abuse, assessed using the DAST-20, was the strongest predictor of PPCBU (p < .005). CONCLUSION: Findings from the present study could have implications for clinicians considering the use of cannabinoids for the management of patients with medical conditions. Although results indicated that the majority of patients included in this study did not reach cutoff scores on the three main PPCBU outcomes, our findings suggest that PPCBU should be routinely assessed and monitored over the course of cannabinoid therapy, particularly among patients with a history of psychiatric or substance use problems.

Waiting for treatment for chronic pain - a survey of existing benchmarks: toward establishing evidence-based benchmarks for medically acceptable waiting times.

As medical costs escalate, health care resources must be prioritized. In this context, there is an increasing need for benchmarks and best practices in wait time management. In December 2005, the Canadian Pain Society struck a Task Force to identify benchmarks for acceptable wait times for treatment of chronic pain. The task force mandate included a systematic review and survey to identify national or international wait time benchmarks for chronic pain, proposed or in use, along with a review of the evidence upon which they are based. An extensive systematic review of the literature and a survey of International Association for the Study of Pain Chapter Presidents and key informants has identified that there are no established benchmarks or guidelines for acceptable wait times for the treatment of chronic pain in use in the world. In countries with generic guidelines or wait time standards that apply to all outpatient clinics, there have been significant challenges faced by pain clinics in meeting the established targets. Important next steps are to ensure appropriate additional research and the establishment of international benchmarks or guidelines for acceptable wait times for the treatment of chronic pain. This will facilitate advocacy for improved access to appropriate care for people suffering from chronic pain around the world.

Qigong and Fibromyalgia circa 2017.

Qigong is an internal art practice with a long history in China. It is currently characterized as meditative movement (or as movement-based embodied contemplative practice), but is also considered as complementary and alternative exercise or mind-body therapy. There are now six controlled trials and nine other reports on the effects of qigong in fibromyalgia. Outcomes are related to amount of practice so it is important to consider this factor in overview analyses. If one considers the 4 trials (201 subjects) that involve diligent practice (30-45 min daily, 6-8 weeks), there are consistent benefits in pain, sleep, impact, and physical and mental function following the regimen, with benefits maintained at 4-6 months. Effect sizes are consistently in the large range. There are also reports of even more extensive practice of qigong for 1-3 years, even up to a decade, indicating marked benefits in other health areas beyond core domains for fibromyalgia. While the latter reports involve a limited number of subjects and represent a self-selected population, the marked health benefits that occur are noteworthy. Qigong merits further study as a complementary practice for those with fibromyalgia. Current treatment guidelines do not consider amount of practice, and usually make indeterminate recommendations.

A case series of patients using medicinal marihuana for management of chronic pain under the Canadian Marihuana Medical Access Regulations.

The Canadian Marihuana Medical Access Regulations (MMAR) program allows Health Canada to grant access to marihuana for medical use to those who are suffering from grave and debilitating illnesses. This is a report on a case series of 30 patients followed at a tertiary care pain management center in Nova Scotia who have used medicinal marihuana for 1-5 years under the MMAR program. Patients completed a follow-up questionnaire containing demographic and dosing information, a series of 11-point numerical symptom relief rating scales, a side effect checklist, and a subjective measure of improvement in function. Doses of marihuana ranged from less than 1 to 5g per day via the smoked or oral route of administration. Ninety-three percent of patients reported moderate or greater pain relief. Side effects were reported by 76% of patients, the most common of which were increased appetite and a sense of well-being, weight gain, and slowed thoughts. Limitations of the study include self-selection bias, small size, and lack of a control group. The need for further study using controlled trials is discussed along with an overview of the MMAR program.