British Journal of Pain最新文献

Background: Pain from rib fractures often requires inpatient management with opioid medication. The need for ongoing opioid prescriptions following hospital discharge is poorly understood. Harms associated with long-term opioid use are generally accepted. However, a deeper understanding of current prescribing patterns in this population at-risk is required.

Methods: A retrospective cohort of adult patients hospitalised in Queensland, Australia between 2014 and 2015 with rib fractures (ICD-10-AM: S22.3, S22.4, S22.5), was obtained from the Community Opioid Dispensing after Injury (CODI) study, which includes person-linked hospitalisation, mortality and community opioid dispensing data. Data were extracted 90-days prior to the index-hospitalisation and 720-days after discharge. Factors associated with long-duration (>90 days cumulatively) and increased end-dose were examined using multivariable logistic regressions, odds ratios (OR), and 95% confidence intervals (95% CI).

Results: In total, 4306 patients met the inclusion criteria, and 58.8% had opioids dispensed in the community within 30 days of hospital discharge. 23.6% had long-duration dispensing and 13.7% increased opioid end-doses. Pre-injury opioid use was most associated with long-duration (OR = 12.00, 95% CI 8.99-16.01) and increased end-dose (OR = 9.00, 95% CI 6.75-12.00). Females and older persons had higher odds of long-duration dispensing (Females OR = 1.75, 95% CI 1.38-2.22; Age 65+ OR = 1.86, 95% CI 1.32-2.61). Injury severity and presence of concurrent injuries were not statistically significantly associated with duration or dose (p > .05). Subsequent hospitalisations and death during the follow-up period had statistically significant associations with long-duration and increased end-dose (p < .001).

Conclusion: Opiate prescribing following rib fractures is prolonged in older, and female patients, beyond the traditionally reported recovery time frames requiring analgesia. Previous opioid use (without dependence) is associated with long-duration opioid use and increased end-dose in rib fracture patients. These results support the need for a collaborative health system approach and individualised strategies for high-risk patients with rib fractures to reduce long-term opiate use.

Level of evidence: Level III, Prognostic/Epidemiological.

Background: Some patients with postoperative hip fractures (HF) experience persistent severe pain. In this longitudinal study, we examined the characteristics of patients with persistent pain after HF surgery, and the factors influencing pain intensity.

Methods: We conducted an 8-week prospective study in patients with postsurgical HF. Verbal rating scale (VRS), and multifaceted outcomes, including pressure pain threshold (PPT) (affected site and biceps), were evaluated at 2, 4, and 8 weeks postoperatively. Patients were divided into mild (VRS ≤1) and severe (VRS ≥2) groups according to pain intensity at 8 weeks postoperatively. Statistical analyses were performed using two-way ANOVA and decision-tree analysis.

Results: VRS, PPT at the affected site and biceps, and physical activity (PA) time were significantly lower in the severe group than in the mild group 2 weeks postoperatively. VRS, PPT at the affected site, pain catastrophizing (PCS)-13, and the Tampa Scale for Kineshiophobia (TSK)-11 did not show significant improvements in the severe group. Decision tree analysis revealed that the VRS and PCS-13 at 4 weeks, PA time at 2 weeks, and TSK-11 change between 4 weeks and 2 weeks were factors influencing severe pain intensity at 8 weeks after HF surgery.

Conclusion: Persistent severe pain after HF surgery was characterised by high peripheral and central sensitisation, pain catastrophizing, and reduced PA at 2 weeks after HF surgery. In addition, early pain intensity, pain catastrophizing, and PA may be hierarchically influential factors for persistent pain 8 weeks after HF surgery.

Objectives: To 1) estimate the utilization and costs of physician and diagnostic imaging (DI) services for shoulder, knee, and low-back pain (LBP) conditions; and 2) examine determinants of the utilization and costs of these services.

Methods: All patients visiting a physician for shoulder, knee, or LBP conditions (identified by the ICD-9 codes) in Alberta, Canada, in fiscal year (FY) 2022/2023 were included. Interested outcomes included numbers and costs of physician visits and DI exams stratified by condition, physician specialty, DI modality, and patients' sex and age. Multivariate regressions were used to examine determinants of the outcomes.

Results: In FY 2022/2023, 10.4%, 7.0%, and 6.7% of the population saw physicians for shoulder, knee, and LBP conditions, respectively. This costs Alberta $307.04 million ($67.93 per capita), of which shoulder accounted for 41%, knee 28%, and LBP 31%. In the same FY, 17,734 computed tomography (CT), 43,939 magnetic resonance imaging (MRI), 686 ultrasound (US), and 170,936 X-ray exams related to shoulder/knee/LBP conditions were ordered for these patients, costing another $29.07 million, of which CT accounted for 14%, MRI 48%, US 0%, and X-ray 37%. Female, older age, comorbidity scores, and capital zone used physician services more frequently. Patients with a higher comorbidity index scores or more physician visits were more likely being referred for CT or MRI.

Conclusion: Musculoskeletal conditions are common and result in patients seeking healthcare services. Visits to family physicians, specialists, and the ordering of DI contribute to extensive utilization of health services, contributing to considerable health system costs.

Objective: To assess the feasibility and possible impacts of implementation of systematic non-pharmacological interventions to reduce the level of prescribing of opioid and gabapentinoid analgesics for chronic non-cancer pain (CNCP), particularly high-dose prescriptions, through a proof-of-concept study in a deprived area (second lowest decile) primary care practice in North-East England.

Participant: Twenty-five primary care staff (clinical and non-clinical) of which 18 clinicians received the intervention.

Intervention used in this study practice known as gott gabapentinoid and opioid toolkit: All clinicians received an educational skills programme to support patient pain self-management, tailored on the clinicians' self-assessment of their learning needs, embedding both clinician skill learning and patient self-care resources for rapid access within consultations into a GP clinical management computer system.

Outcome measures: Clinical staff completed questionnaires before and after the GOTT intervention to assess levels of knowledge and confidence in their own skills to support chronic pain self-management across several domains. Prescription data were used to measure changes in opioid and gabapentinoid prescribing at the practice across the 12-month intervention and 30-month follow-up period.

Results: Prescribing of opioid and gabapentinoid/pregabalin decreased substantially in the practice across the intervention period (c. 90% in high-dose opioid [p = .0118], and 15% gabapentin/pregabalin prescriptions, respectively), over a one-year period during the COVID-19 pandemic. Follow-up analysis showed 100% and c.50% reductions, respectively, in December 2022. The questionnaire data showed an increase in clinician confidence in skills to enable self-management over the intervention period, overall (p = .044) and, specifically across three of the five domains measured: supporting behavioural change (p = .028), supporting self-care (p = .008), and managing difficult consultations (p = .011).

Conclusion: The GOTT intervention program provided some initial evidence of a proof-of-concept for the implementation of a systematic non-pharmacological pain management skills and resources programme addressing lack of confidence in skills to introduce and support self-management and reduce use of strong opioids and gabapentinoids.

Background: Multicomponent treatment is commonly used. However, there are no studies that included graded motor imagery and therapeutic neuroscience education to multicomponent treatment for patients with fibromyalgia This study aims to compare the short-term effects (at 12 weeks) of a multicomponent treatment combined with graded motor imagery and therapeutic neuroscience education versus standard treatment in patients with FM.

Methods: The study was a single-blinded randomized controlled trial. Sixty-five women with a clinical diagnosis of FM were randomly allocated (1:1) into two groups. The experimental group (n = 33) received a novel multicomponent treatment combined with graded motor imagery and neuroscience education. The control group (n = 32) received a standard treatment including pharmacotherapy and standard physician education. The primary outcome was pain intensity assessed with the Numeric Pain Rating Scale (NPRS). The secondary outcomes were changes in the Fibromyalgia Impact Questionnaire (FIQ), the Pain Catastrophizing Scale (PCS), the Tampa Scale of Kinesiophobia (TSK-17), and the Pittsburgh Sleep Quality Index (PSQI) scores. All outcomes were assessed at baseline and 12 weeks.

Results: All of the participants completed the trial. The between-group mean differences at 12 weeks were: NPRS-1.18 points (95% confidence interval [CI] -0.4 to -1.8; η² = 0.47; p < .001); FIQ-16.21 points (95% CI -10.9 to -22.1; η² = 0.58; p < .001); PCS total domain -12.5 points (95% CI -7.2 to -17.8; η² = 0.61; p < .001); TSK-17-6.15 points (95% CI -3.5 to -8.7; η² = 0.52; p < .001); and PSQI-2.74 points (95% CI -1.4 to 4.0; η² = 0.54; p < .001). All differences were statistically significant in favor of the novel multicomponent treatment group and had a large effect size.

Conclusions: In the short term, a novel multicomponent treatment, including graded motor imagery and neuroscience education, was an effective therapeutic intervention for improving clinical outcomes compared with standard treatment in women with FM. Additional studies are needed to support long-term clinical effectiveness in these patients.

Background: Chronic pain is common and associated with disruptions in quality of life (QoL) and psychosocial functioning. These issues are particularly pronounced in veterans, although data in this regard primarily come from the United States Veterans Affairs System, meaning less is known regarding veterans of other countries and regions. The present study evaluated veterans living in Northern Ireland (NI), a region with historic high rates of both chronic pain and psychosocial difficulties associated with the decades-long period of civil and military conflict preceding the 1999 armistice (the Good Friday Agreement). Unique to the Northern Ireland military operation was the initiation of Home Service battalions comprised of local recruits, a role with increased risk due to the conflict's nature and the fact that they were serving as a military and security presence in their home region.

Methods: A cross-sectional assessment of veterans living in Northern Ireland (N = 722) provided details of service type (Home Service vs other service), current health conditions (including chronic pain), and current psychosocial functioning (including physical and mental health QoL, anxiety, depression, and post-traumatic stress disorder [PTSD] symptoms).

Results: Findings indicated that those with chronic pain had worse QoL, anxiety, depression, and PTSD. Those with chronic pain were also more likely to have served in the Home Services, be unemployed, and be receiving disability payment. Contrary to hypotheses, there was no interaction between chronic pain and service type.

Conclusions: These results extend previous work with veterans to the unique circumstances of a post-conflict military that engaged in operations within its own country and underscore the need for coordinated, efficacious interventions for co-morbid chronic pain and anxiety, depression, and PTSD.

Background: More sex-specific pain sensitivity normative values from population-based cohorts in pain-free older adults are required. The aims of this study were (1) to provide sex- and age-specific normative values of pressure and cold pain thresholds in older pain-free adults and (2) to examine the association of potential correlates of pain sensitivity with pain threshold values.

Methods: This study investigated sex-specific pressure (lumbar spine, tibialis anterior, neck and dorsal wrist) and cold (dorsal wrist) pain threshold estimates for older pain-free adults aged 41-70 years. This cross-sectional study used participants (n = 212) from the Raine Study Gen1-26 year follow-up. The association of pain thresholds, with correlates including sex, test site, ethnicity, waist-hip ratio, smoking status, health-related quality of life, depression, anxiety and stress symptoms, sleep quality, socioeconomic status and physical activity levels, was examined.

Results: Values for pressure and cold pain thresholds for older pain-free adults are provided, grouped by vicennium, sex and test site (pressure). Statistically significant independent correlates of increased pressure pain sensitivity were test site, ethnicity and sex. Only lower waist/hip ratio was a statistically significant, independent correlate of increased cold pain sensitivity.

Conclusions: This study provides robust sex- and age-specific normative values for pressure pain threshold and cold pain threshold for an older adult pain-free population. Combined with existing values, these data provide an important resource in assisting interpretation of pain sensitivity in clinical pain disorders and provide insights into the complex association of pain sensitivity with correlates that can be used in research.

Introduction: Currently there are few opioid prescribing guidelines for orthopaedic fractures. Long-term post-surgical analgesia requirements, understandably, vary between orthopaedic cases. Our study aims to provide detailed information to clinicians and policy makers, on the opioid requirement associations for patients sustaining tibial fractures.

Methods: This study reviewed all patients sustaining an isolated tibial fracture at a major trauma centre that were operated on within 1 month of injury, from 2015 to 2022. The total opioid dosage used each month in morphine milligrams equivalents (MME) and the number of days opioids were used each month, within the first-year post-surgery were collected, representing the strength and coverage of opioid analgesia in the post-operative stage, respectively. We compared opioid strength and coverage requirements with types of definitive fracture fixations, location, fracture type and concurrent patient medical comorbidities to assess for any trends.

Results: A total of 1814 patients sustaining a combined of 1970 fractures were included in the study. Tibial plateau fractures had the highest opioid strength and coverage requirements in each month and the entire year (p < .05). Across all fracture locations, Ex Fix frame showed higher opioid strength and coverage requirements compared to both IM nailing and plate ORIF. With regard to opioid coverage in the presence of specific comorbidities, only chronic kidney disease (quotient: 1.37, 95% Confidence interval [95%CI] = 1.19-1.55, p = .002) and hypertension (quotient: 1.34, 95%CI = 1.14-1.53, p = .009) showed significance at the 1-year overall level. For opioid strength, Chronic Kidney Disease (quotient: 1.72, 95%CI = 1.41-2.03 p = .005) and COPD (quotient: 1.90, 95%CI = 1.44-2.36, p = .014), show significance at the 1-year overall level.

Conclusion: Our study details opioid requirements post-surgery amongst tibial fractures with subgroup analysis assessing opioid needs amongst specific fracture locations, types, surgical techniques and medical comorbidities. This framework aids clinicians in anticipating rehabilitation and assists in risk stratifying patients at injury onset.