Spiritual Pain: A Symptom in Search of a Clinical Definition.

We conducted a literature search to identify and compare definitions of the experiential dimension of spiritual pain. Key databases were searched, up to the year 2021 inclusive, for papers with a definition of "spiritual" or "existential" pain/distress in a clinical setting. Of 144 hits, seven papers provided theoretical definitions/descriptions; none incorporated clinical observations or underlying pathophysiological constructs. Based on these findings, we propose a new definition for "spiritual pain" as a "self-identified experience of personal discomfort, or actual or potential harm, triggered by a threat to a person's relationship with God or a higher power." Our updated definition can inform future studies in pain assessment and management.

Deconstructing One Medical School's Pain Curriculum: II. Partnering with Medical Students on an Evidence-Guided Redesign.

Objective: To reshape medical education about pain to present it as a population-based public health process as well as a neuron-centered phenomenon. Design: Collaborate with students to apply a recent inventory of pain-related preclinical curricular content and clinical training in order to modify the current multiyear presentation and offer a broadened social perspective on pain. Appraise fourth-year medical students' pain-related educational needs by surveying their knowledge, attitudes, experience with the curriculum, and self-reported assessment of pain-related competencies. Setting and subjects: University-affiliated medical school and its fourth-year medical students. Methods: Analysis of a detailed inventory of first- and second-year curricula. Survey of graduating medical students assessing attitudes, skills, and confidence. Construction of a fourth-year pain education elective and collaboration with enrollees to better integrate pain throughout the four-year curriculum. Results: This student-faculty collaboration produced an evidence-guided proposal to reorganize pain-related content across the longitudinal medical curriculum. An attitudes/skills/confidence survey of graduating medical students (104 respondents of 200 polled) found that 70% believed chances for successful outcomes treating chronic pain were low. Self-evaluated competency was high for evaluating (82%) and managing (69%) acute pain; for chronic pain, both were lower (evaluating = 38%; managing = 6%). Self-evaluated knowledge of pain physiology and neurobiology was poor (14%), fair (54%), or good (30%), but rarely excellent (2%). Conclusions: To meet graduating students' desire for increased competency in pain, pain-related curricula can and should be reorganized to include pain as a disease state and a widespread public health burden, not merely a symptom.

Deconstructing One Medical School's Pain Curriculum: I. Content Analysis.

Objective: Inventory one medical school's first- and second-year pain-related curriculum in order to explore opportunities to teach about pain both as a social, population-based process and as a neuron-centered phenomenon. Design: Deconstruction of pain-related curricular content through a detailed content inventory and analysis by students and faculty. Setting and Subjects: University-affiliated US medical school. Methods: Detailed inventory and content analysis of first- and second-year curricular materials. Results: The inventory of pain content showed fragmentation, mostly presenting it as a symptom without an underlying framework. Conclusion: Analysis of one medical school's pain-related curricular materials reveals opportunities for a more unified perspective that includes pain as a widespread disease state (not merely a symptom) and to provide an emphasis in the curriculum consistent with pain's public health burden.

Intravenous Ketamine for Rapid Opioid Dose Reduction, Reversal of Opioid-Induced Neurotoxicity, and Pain Control in Terminal Care: Case Report and Literature Review.

OBJECTIVE: We report a case of opioid-induced neurotoxicity (OIN) in an actively dying hospice patient, its reversal and improved analgesia that followed opioid dosage reduction made possible after addition of IV ketamine. We briefly review the diagnosis and treatment of OIN. SETTING: OIN, particularly when associated with high dose opioid therapy in palliative care, may pose difficult diagnostic and treatment challenges. Few publications from end-of-life settings provide systematic approaches to management of OIN. PATIENTS: We describe a case of OIN in a hospice patient receiving medical care at home while actively dying. INTERVENTION: Addition of IV ketamine and reduction of the patient's high-dose opioid regimen. RESULTS: The patient's pain was controlled within 24 hours of initiation of IV ketamine while the total opioid dose was reduced. His symptoms of OIN (delirium, tremor, myoclonus, and hallucinations) also rapidly subsided. CONCLUSION: OIN should be considered as an etiology of CNS dysfunction occurring with prolonged, high-dose opioid therapy. This case highlights the opioid-sparing and analgesic properties of low-dose ketamine, allowing reversal of OIN in the home hospice setting.

Durations of Opioid, Nonopioid Drug, and Behavioral Clinical Trials for Chronic Pain: Adequate or Inadequate?

OBJECTIVES: A recent US federal review and clinical guideline on opioids for chronic pain asserted that the literature contributes no evidence on efficacy because all trials had "inadequate duration." To explore the evidence, we examined durations of studies on opioid, nonopioid drug, and behavioral therapies for chronic pain. METHODS: We retrieved Cochrane reviews of anticonvulsants, antidepressants, NSAIDs, opioids, or behavioral interventions for chronic pain. We also examined all opioid treatment studies retrieved for the federal evidence report but excluded due to "inadequate duration." RESULTS: Of 378 Cochrane reviews retrieved, 72 evaluated one of the five therapies. Six of these 72 were excluded because they were proposals without data or investigated acute pain. Fourteen addressed multiple interventions, leaving 52 for analysis. We graphed numbers of trials vs duration for the five treatments reviewed in the Cochrane Library, compared with durations of opioid trials dropped from the federal evidence report. Most graphs were overdispersed Poisson distributions. Nearly all trials had active treatment durations of 12 weeks or less. CONCLUSIONS: No common nonopioid treatment for chronic pain has been studied in aggregate over longer intervals of active treatment than opioids. To dismiss trials as "inadequate" if their observation period is a year or less is inconsistent with current regulatory standards. The literature on major drug and nondrug treatments for chronic pain reveals similarly shaped distributions across modalities. Considering only duration of active treatment in efficacy or effectiveness trials, published evidence is no stronger for any major drug category or behavioral therapy than for opioids.

Communicating the experience of chronic pain and illness through blogging.

BACKGROUND: Although more individuals are sharing their experiences with chronic pain or illness through blogging (writing an Internet web log), research on the psychosocial effects and motivating factors for initiating and maintaining a blog is lacking. OBJECTIVE: The objective was to examine via online questionnaire the perceived psychosocial and health benefits of blogging among patients who use this media to communicate their experience of chronic pain or illness. METHODS: A 34-item online questionnaire was created, tested, and promoted through online health/disease forums. The survey employed convenience sampling and was open from May 5 to July 2, 2011. Respondents provided information regarding demographics, health condition, initiation and upkeep of blogs, and dynamics of online communication. Qualitative data regarding respondents' blogging experiences, expectations for blogging, and the perceived effects from blogging on the blogger's health, interpersonal relationships, and quality of life were collected in the form of written narrative. RESULTS: Out of 372 respondents who started the survey, 230 completed the entire questionnaire. Demographic data showed survey respondents to be predominantly female (81.8%) and highly educated (97.2% > high school education and 39.6% with graduate school or professional degrees). A wide spectrum of chronic pain and illness diagnoses and comorbidities were represented. Respondents reported that initiating and maintaining an illness blog resulted in increased connection with others, decreased isolation, and provided an opportunity to tell their illness story. Blogging promoted accountability (to self and others) and created opportunities for making meaning and gaining insights from the experience of illness, which nurtured a sense of purpose and furthered their understanding of their illness. CONCLUSIONS: Results suggest that blogging about chronic pain and illness may decrease a sense of isolation through the establishment of online connections with others and increases a sense of purpose to help others in similar situations. Further study involving a larger sample size, a wider range of education levels, and respondents with different types and magnitudes of illnesses will be needed to better elucidate the mechanism of the observed associations in this understudied area.

Comparison of the Impacts of Under-Treated Pain and Opioid Pain Medication on Cognitive Impairment.

PURPOSE: To guide clinicians in balancing the risks and benefits of opioids when treating pain, we conducted two systematic reviews: 1) the impact of pain on cognitive function, and 2) the impact of opioids on cognitive function. METHODS: Part one addressed the impact of pain on cognitive impairment; Part two considered the impact of opioids on cognitive impairment. PubMed was used to search for eligible articles. For part one, 1786 articles were identified, of which 23 met our eligibility criteria. For part two, among 584 articles, 18 were found eligible. RESULTS: For part one, 16 studies concluded that patients with chronic pain showed impaired cognitive function; six studies found that chronic pain does not worsen cognitive function; one study concluded that the impact of pain on cognitive function differs based on the underlying cognitive status. For part two, 15 studies found that using opioids to control pain did not cause significant cognitive impairment, while three studies concluded the opposite. Studies evaluating older subjects did not observe different results from those in the whole population for both reviews. CONCLUSION: The published literature indicates that moderate to severe pain can impair cognitive function, and that careful use of opioid analgesics in such subjects does not necessarily worsen cognition. Although our results are insufficient to support clear guidance due to heterogeneity of cohorts and outcomes, this study may assist primary care providers by rendering explicitly the factors to be considered by providers caring for this population with pain when opioids are considered.

Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study.

Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction; two others included substantial discussion which was not evidently directed at the patient's changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.

Scoping Review of Off-Label Topical Analgesia in Palliative, Hospice and Cancer Care: Towards Flexibility in Evidence-Based Medicine.

PURPOSE: Scoping reviews address the nature of the literature per se rather than inferring evidence-based treatment guidelines. Scoping reviews of the published literature are intended to describe the aggregated nature of the evidence surrounding some agent or intervention, in contrast to systematic reviews that seek when possible to guide clinical practice. We conducted a scoping review to identify reports of potential clinical utility of off-label topical analgesics and adjuvants when FDA-approved treatments have proven inadequate. METHODS: We performed a comprehensive search of three databases (PubMed, Web of Science and Embase) for articles dating from 1947 to the present. Mindful that FDA-approved and WHO-recommended analgesic medications often prove inadequate for individual patients in extremis with palliative, hospice or cancer pain, we used broad, structured inclusion criteria to retrieve articles. RESULTS: We retrieved 12,100 articles; after screening, we had 39 reports addressing 19 different topical agents out of the 32 chemical entities. Our scoping review disclosed evidence about agents that might not have met inclusion criteria for clinical practice guidelines. DISCUSSION: Although generally considered lower quality evidence, case reports or series present suggestions for diverse topical medications to manage pain in challenging circumstances when high-quality evidence for agents and routes of administration is lacking. CONCLUSION: Patients with the greatest need for evidence to identify and guide lesser-used agents during aggressive pain management are the most difficult to enroll and follow in standardized, controlled and/or blinded clinical trials. This scoping review identifies medications, dosages, and routes of topical agents reported to be effective in these often-challenging circumstances. Until larger and higher quality studies are completed, we must rely on the best available evidence even if of lower quality.

How do I ask about your disability? An examination of interpersonal communication processes between medical students and patients with disabilities.

Medical student behaviors were examined through digital recordings of interpersonal skills communication training framed around a brief curriculum on disability within a family medicine clerkship. This analysis focuses on interpersonal communication processes and ways medical students ask standardized patient educators about visually apparent disability (N = 142). Primary themes of asking about or avoiding disability were identified with regard to language and nonverbal communication in how medical students asked and whether they integrated chronic disability with new musculoskeletal pain complaints. Secondary themes related to timing and communication further contextualized the primary themes. Seventy-four percent of students asked about the disability. Analysis of feedback sessions immediately following the interactions revealed that more than half the students who did not ask about disability spontaneously recognized that they avoided disability language. Results suggest that some ways of asking about disability may inhibit patient disclosure and restrict relationship building. In particular, asking about disability, but then avoiding integrating disability disclosure into the treatment plan, or responding to disability-related disclosure with overly positive, infantilizing-type communication, may pose more difficult dilemmas than never asking about the disability. On the contrary, students who ignored disability altogether often also recognized they missed disability cues, thus providing a learning experience of considerable value. Underlying student attitudes and possibilities for integrating biomedical concerns with social-psychological impacts of disability are addressed.

The Internet as a health information source: findings from the 2007 Health Information National Trends Survey and implications for health communication.

A wealth of health information is available online, but we do not fully understand the implications for health communication. This study examined whether health information seekers who turn to the Internet first differ from those who turn elsewhere. Data from the 2,338 respondents to the mail portion of the National Cancer Institute's Health Information National Trends Survey (HINTS) 2007 who reported looking for health information for themselves were analyzed. Logistic regression was used to examine whether health information seekers turning to the Internet first differed in terms of demographics, information preferences and seeking confidence, and communication with providers from those using other sources. In the final model, Internet users were younger, more educated, higher income, preferred numbers rather than words to describe chance, and think it is very important to get personal medical information electronically. There were no differences in terms of gender, health status, confidence seeking health information, or communication with providers. Health information seekers who turn to the Internet first are different, both in terms of demographics and information preferences. As the use of communication technologies increases, health communicators need to be attentive to the potential for communication inequalities.

Topical Ketamine with Other Adjuvants: Underutilized for Refractory Cancer Pain? A Case Series and Suggested Revision of the World Health Organization Stepladder for Cancer Pain.

Background: Uncontrolled cancer pain is a significant problem in palliative medicine. Opioids are often first-line treatment that increase risks of analgesic tolerance and hyperalgesia. Topical ketamine with other adjuvant pain medications is an often-overlooked treatment, yet may be most effective in difficult-to-treat cancer pain. Objective: We report a case series of hospice patients with uncontrolled cancer pain who were suboptimally treated with opioids and nerve blocks, whose symptoms responded to topical ketamine with other adjuvants. We review the pronociceptive properties of opioids and how topical multimodal treatment of cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks. We discuss the shortcomings of the World Health Organization (WHO) stepladder for the treatment of cancer pain and suggest an adjuvant treatment algorithm, directing physicians to appropriate adjuvant pain agents based on pain type and distinct receptor actions. Design: This is a retrospective case series of patients who responded to topical multimodal pain treatment with implementation of findings into an addendum to the WHO stepladder. Subjects: Subjects were from a case series of community-based hospice patients with previously uncontrolled cancer pain. Measurement: Measurement was made by self-report of pain levels using the 10-point numeric pain rating scale. Results: Patients' pain was controlled with topical adjuvant medications with return to previously lost function and prevention of otherwise escalating opioid dosing. Conclusions: These patient cases reveal how ketamine-based topical treatment for cancer pain can be more effective than standard opioids, other topical adjuvant medications, and nerve blocks with no noted side effects and observed reduction in opioid consumption.

What can I learn from this interaction? A qualitative analysis of medical student self-reflection and learning in a standardized patient exercise about disability.

Patients with disabilities receive fewer health services than the general population, yet they have greater health needs. Similarly, physicians report limited training in disability. The current project examines medical students' learning about disability in a project using individuals with disabilities as medical educators. Family medicine clerkship students (N = 138) across an academic year were videotaped during interviews with standardized patient educators with disabilities and during feedback sessions following the interactions. Qualitative analysis of feedback transcripts identifies three primary areas of integrating learning, reflective practice, and disability: (1) learning how disability impacts the treatment plan, (2) self-reflection and recognizing attitudes about disability, and (3) learning about the practice of medicine generally from the disability exercise. Themes are identified within each of the primary learning areas. Medical student reflection provides evidence of learning to connect disability with pain, everyday life, and treatment. Medical students learned to recognize patients' expertise in their own condition and in health care navigation. Medical students also examined how their language implies attitude. The current investigation provided evidence of the ways examining disability can serve as a cornerstone for building relationship-centered patient care and encouraging reflective practice overall.

Respiratory hygiene in the emergency department.

The emergency department (ED) is an essential component of the public health response plan for control of acute respiratory infectious threats. Effective respiratory hygiene in the ED is imperative to limit the spread of dangerous respiratory pathogens, including influenza, severe acute respiratory syndrome, avian influenza, and bioterrorism agents, particularly given that these agents may not be immediately identifiable. Sustaining effective respiratory control measures is especially challenging in the ED because of patient crowding, inadequate staffing and resources, and ever-increasing numbers of immunocompromised patients. Threat of contagion exists not only for ED patients but also for visitors, health care workers, and inpatient populations. Potential physical sites for respiratory disease transmission extend from out-of-hospital care, to triage, waiting room, ED treatment area, and the hospital at large. This article presents a summary of the most current information available in the literature about respiratory hygiene in the ED, including administrative, patient, and legal issues. Wherever possible, specific recommendations and references to practical information from the Centers for Disease Control and Prevention are provided. The "Administrative Issues" section describes coordination with public health departments, procedures for effective facility planning, and measures for health care worker protection (education, staffing optimization, and vaccination). The patient care section addresses the potentially infected ED patient, including emergency medical services concerns, triage planning, and patient transport. "Legal Issues" discusses the interplay between public safety and patient privacy. Emergency physicians play a critical role in early identification, treatment, and containment of potentially lethal respiratory pathogens. This brief synopsis should help clinicians and administrators understand, develop, and implement appropriate policies and procedures to address respiratory hygiene in the ED.

Lessons from an acupuncture teaching clinic: patient characteristics and pain management effectiveness.

OBJECTIVES: To understand the following about patients using an acupuncture teaching clinic: (1) sociodemographic characteristics and main complaints and (2) self-reported level of patient-centered outcomes regarding pain management. METHODS/DESIGN: Retrospective chart review. SUBJECTS: A total of 458 new patients at NESA clinic during October 1, 2009 to July 31, 2010 were enrolled in the study. INTERVENTIONS: A variety of styles of Oriental medicine, primarily Chinese and Japanese style acupuncture and also heat treatments (MOXA or heat lamps) and Tui Na (Asia bodywork). RESULTS: Results from Objective 1 were descriptive (n = 421). Objective 2 focused on the 59 patients from the larger sample who completed both an initial and a follow-up Measure Your Medical Outcome Profile (MYMOP) form and who used acupuncture for pain management of (1) diseases of the musculoskeletal system and/or connective tissue or (2) migraine/headache. Both the symptom severity and activity of daily living/well-being scales of the MYMOP showed over 15.8% improvement from baseline to at least six weeks of treatment: 28.6% for Symptom 1, 19.4% for Symptom 2, 35.7% for activities of daily living, and 25.0% for well-being. The relative majority for each sociodemographic trait investigated were as follows: female, about 40 years old, white, not Hispanic or Latino, married, highly educated, and employed. Most patients were confident in acupuncture treatment. Out of the 421 acupuncture patients, 68.2% wanted acupuncture in order to manage pain. Overall, 20.6% of the patients (59, N = 287) who used acupuncture for pain management for diseases of the musculoskeletal system and/or connective tissue or migraine or headache completed the sixth-week follow-up MYMOP form. Of these patients, 57.6% (34, N = 59) returned during week 6 of the semester for acupuncture treatment and reported clinical improvement in at least one MYMOP severity score, and no score got worse. CONCLUSIONS: The information about sociodemographic characteristic and patient-centered outcomes of pain management can be used for service provision, future study planning, and marketing. Future studies should address the low follow-up rate, the quality of self-reported clinic data, and the reasons that patients chose acupuncture treatments and teaching clinics.

When rapport building extends beyond affiliation: communication overaccommodation toward patients with disabilities.

INTRODUCTION: Physician rapport with patients is described as a vital component of relationship-centered care, but rapport-building communication behaviors may exceed boundaries and instead indicate patronizing behavior toward patients with disabilities. This paper addresses the types of communication behaviors and contexts for interpreting when rapport building extends beyond boundaries toward patients with disabilities. METHODS: Videotaped interactions between third- and fourth-year medical students (N = 142) and standardized patient educators with physical disabilities were qualitatively analyzed. RESULTS: Results suggest six primary themes of exceeding expected rapport boundaries, including baby talk (ie, exaggerated nonverbal gestures and "we" language to indicate "you"), kinesic movement (ie, stiff posture and awkward handshakes), vocalics (ie, volume or pitch that interfered with the flow of conversation), relationship assumptions (ie, communicating assumptions that relationships were grounded in care-receiving), emotional divergence from patient disclosure (ie, minimizing or embellishing disability), and inconsistency with patient emotional cues (ie, responding to negative or neutral disclosure by overly accentuating positive interpretation). DISCUSSION: This study suggests that communication behaviors generally described as positive, rapport-building behaviors can pose negative implications when they exceed the expected quantity or duration, when they are inconsistent with patient verbal disclosure, or when verbal and nonverbal messages are inconsistent. Identified themes serve as examples to understand when rapport building exceeds beyond affiliation and instead appears to indicate patronizing behavior toward patients with disabilities. Suggestions for interpreting communication behaviors within the context of patient disclosure and building capacity to distinguish attitudes and biases limiting communication are addressed.