Clinical Journal of Pain最新文献

Objectives: Chronic pain is a significant health concern that adversely affects all aspects of life, including emotional well-being. Opioids are prescribed for the management of refractory, severe chronic pain, although they have been associated with adverse effects, including addiction and overdose. The aim of this study was to examine factors that predict thoughts of self-harm among adults with chronic pain who are prescribed opioids.

Materials and methods: Seven hundred sixty-five (N=765) persons with opioid-treated chronic lower back pain completed the Current Opioid Misuse Measure (COMM) and other validated questionnaires as part of a larger study. Response to 1 question from the COMM ("How often have you seriously thought about hurting yourself?") was used to assess suicide risk on a 5-point scale (0=never; 4=very often).

Results: Participants were categorized into 3 groups according to their responses to the self-harm question: never (N=628; 82.1%), seldom or sometimes (N=74; 9.7%), and often or very often (N=63; 8.2%). Multivariate adjusted odds ratio (aOR) analyses indicated that reports of alcohol or drug overuse within the past month (aOR=1.41,[95% CI 1.11-1.78]), posttraumatic stress (PTSD; aOR=1.24,[1.07 to 1.44]), pain catastrophizing (aOR=1.03,[1.01 to 1.05]), not loving oneself (aOR=0.99,[.98-1.00]) and poor perceived mental health (aOR=0.94,[.92 to 97]) were most associated with thoughts of self-harm. Importantly, the ideation frequency of self-harm was highest among individuals treated with higher daily doses of opioids.

Discussion: These results support the need for continued monitoring of adults treated with opioids for chronic pain, particularly among those on high-dose opioids who present with increased negative affect and concerns of substance misuse.

Objective: Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk).

Methods: This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up.

Results: There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids.

Discussion: Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.

Objective: Chronic pain has economic costs on par with cardiovascular disease, diabetes, and cancer. Despite this impact on the health care system and increasing awareness of the relationship between pain and mortality, efforts to identify simple symptom-based risk factors for the development of pain, particularly in children, have fallen short. This is critically important as pain that manifests during childhood often persists into adulthood. To date, no longitudinal studies have examined symptoms in pain-free children that presage a new, multisite manifestation of pain in the future. We hypothesized that female sex, sleep problems, and heightened somatic symptoms complaints at baseline would be associated with the risk of developing new multisite pain 1 year later.

Methods: Symptom assessments were completed by parents of youth (ages 9 to 10) enrolled in the Adolescent Brain Cognitive Development study. Multivariate logistic regression models focused on children who developed multisite pain 1 year later (n=331) and children who remained pain free (n=3335).

Results: Female sex (odds ratio [OR]=1.35; 95% CI, 1.07, 1.71; P =0.01), elevated nonpainful somatic symptoms (OR=1.17; 95% CI, 1.06, 1.29; P <0.01), total sleep problems (OR=1.20; 95% CI, 1.07, 1.34; P <0.01), and attentional issues (OR=1.22; 95% CI, 1.10, 1.35; P <0.001) at baseline were associated with new multisite pain 1 year later. Baseline negative affect was not associated with new multisite pain.

Discussion: Identifying symptom-based risk factors for multisite pain in children is critical for early prevention. Somatic awareness, sleep and attention problems represent actionable targets for early detection, treatment, and possible prevention of multisite pain in youth.

Objective: This study aimed to determine the effectiveness of pregabalin for the control of symptoms in mild to moderate idiopathic Carpal tunnel syndrome (CTS).

Methods: In this randomized, placebo-controlled trial, 146 mild to moderate idiopathic CTS patients were randomized into pregabalin (n=74) and placebo groups (n=72). Per protocol, analysis was conducted with 131 patients; pregabalin (n=65) and placebo (n=66). The drug titration dose was 50 mg once daily for the first week, twice daily for the second week and thrice daily for the next 6 weeks. The primary outcome included a change in the Symptom Severity Scale and Functional Status Scale (FSS) of the Boston Carpal Tunnel Questionnaire after the eighth week. The secondary outcome was the change in clinical and electrophysiological grading after 8 weeks of therapy.

Results: There was a statistically significant improvement in the mean Symptom Severity Scale (14.92±3.72 vs. 16.55±4.45; P =0.025) and FSS (10.77±2.64 vs. 12.0±2.55; P =0.007) in the pregabalin group after 8 weeks. Mean clinical and electrophysiological grading changed significantly from 2.3±0.7 to 2.1±0.8 ( P =0.001) and 1.9±0.7 to 1.8±0.8 ( P =0.020), respectively in the pregabalin group but not in the placebo group.

Discussion: The results of this study demonstrates that pregabalin is effective in ameliorating symptoms and improving functional outcomes in mild to moderate idiopathic CTS.

Objective: To determine the impact of mobile-phone telemonitoring on patients' adherence and satisfaction with posttrauma pain treatment.

Materials and methods: We conducted a prospective randomized clinical trial including patients with minor trauma discharged from the emergency department (ED) with analgesic treatment. Patients were randomized to one of 3 groups, the control group, where patients received a phone call on day-7, the short message service (SMS) group, where patients received a daily text message to remind them to take their treatment during 7 days, and the mobile-phone based telemonitoring (TLM) group. Patients' adherence to analgesic treatments using the Morisky Medication Adherence Scale, current pain by using a visual analogue scale, and patients' satisfaction were assessed. For the TLM group, the assessment was performed at day-2, 4 and 7.

Results: Good adherence was observed in 418 patients (92.9%) in the TLM group versus 398 patients (88.6%) in the SMS group and 380 patients (84.8%) in the control group ( P <0.001). The factor mostly associated with adherence was telemonitoring (OR 2.40 95% CI 1.55-3.71). The decrease in pain visual analogue scale was highest in the TLM group compared with SMS and control groups ( P <0.001). The percentage of patients' satisfaction at 7 days post-ED discharge was 93% in the TLM group versus 88% in the SMS group and 84% in the standard group ( P =0.02).

Discussion: Our findings suggest that mobile-phone-based telemonitoring is beneficial in the treatment of pain in trauma patients after ED discharge. This approach improved patients' adherence and satisfaction.

Objectives: Prolonged postoperative opioid use increases the risk for new postsurgical opioid use disorder. We evaluated preoperative phenotypic factors predicting prolonged postoperative opioid use.

Methods: We performed a secondary analysis of a prospective observational cohort (n=108) undergoing total knee arthroplasty (TKA) for osteoarthritis with 6-week and 6-month follow-up. Current opioid use and psychosocial, pain, and opioid-related characteristics were assessed at preoperative baseline. Primary outcomes were days/week of opioid use at follow-up.

Results: At 6 weeks, preoperative opioid use and greater cumulative opioid exposure, depression, catastrophizing, anxiety, pain interference, sleep disturbance, and central sensitization were significantly associated with more days/week of opioid use after controlling for contemporaneous pain intensity. Prior euphoric response to opioids were also significant predictors at 6 months. All 6-week predictors except anxiety remained significant after controlling for preoperative opioid use; at 6 months, cumulative opioid exposure, catastrophizing, pain interference, and sleep disturbance remained significant after this adjustment ( P <0.05). In multivariable models, a psychosocial factor reflecting negative affect, sleep, and pain accurately predicted 6-week opioid use (area under the curve=0.84). A combined model incorporating psychosocial factor scores, opioid-related factor scores, and preoperative opioid use showed near-perfect predictive accuracy at 6 months (area under the curve=0.97).

Discussion: Overall, preoperative psychosocial, pain-related, and opioid-related phenotypic characteristics predicted prolonged opioid use after total knee arthroplasty.

Objectives: Depression is prevalent among patients with chronic pain and may impact pain management. An accurate assessment is, however, complicated by overlapping symptoms. This study investigated how patients with high-impact chronic pain interpreted and responded to the Patient Health Questionnaire 9 (PHQ-9) to identify problematic items and causes hereof.

Materials and methods: Cognitive interviews using the Three-Step Test-Interview procedure were conducted during the completion of the PHQ-9 in 33 patients with high-impact chronic pain referred to interdisciplinary treatment. Responses were analyzed using 4 coding categories: (1) "congruent" (response consistent with intention); (2) "incongruent" (response not consistent intention); (3) "ambiguous" (response both congruent and incongruent or insufficient to evaluate congruency); and (4) "confused" (response with confused or misunderstood statements). Next, the content of responses to problematic items was analyzed to identify causes for noncongruency, and encountered response difficulties were identified across all items.

Results: Three items (items 2, 6, and 9) performed as intended (>97% congruent responses), while 7 items (items 1, 3, 4, 5, 7, 8, and 10) were identified as problematic (<50% congruent responses). Problematic items had 1 or more issues: Responses were based on (1) pain-related issues or (2) other (non-pain) factors unrelated to depression, or item structure caused response difficulties due to wordings, reversion, or having 2 questions in 1.

Discussion: Problematic items limit the construct validity of the PHQ-9, leaving an increased risk of inflated depression scores in high-impact chronic pain. Identified problems should guide future revisions to enhance validity and screening accuracy for the benefit of both research and clinical practice.

Objectives: The effectiveness of Evoke closed-loop spinal cord stimulation (CL-SCS), a novel modality of neurostimulation, has been demonstrated in a randomized controlled trial (RCT). The objective of this cost-utility analysis was to develop a de novo economic model to estimate the cost-effectiveness of Evoke CL-SCS when compared with open-loop SCS (OL-SCS) for the management of chronic back and leg pain.

Methods: A decision tree followed by a Markov model was used to estimate the costs and outcomes of Evoke CL-SCS versus OL-SCS over a 15-year time horizon from the UK National Health Service perspective. A "high-responder" health state was included to reflect improved levels of SCS pain reduction recently reported. Results are expressed as incremental cost per quality-adjusted life year (QALY). Deterministic and probabilistic sensitivity analysis (PSA) was conducted to assess uncertainty in the model inputs.

Results: Evoke CL-SCS was estimated to be the dominant treatment strategy at ~5 years postimplant (ie, it generates more QALYs while cost saving compared with OL-SCS). Probabilistic sensitivity analysis showed that Evoke CL-SCS has a 92% likelihood of being cost-effective at a willingness to pay threshold of £20,000/QALY. Results were robust across a wide range of scenario and sensitivity analyses.

Discussion: The results indicate a strong economic case for the use of Evoke CL-SCS in the management of chronic back and leg pain with or without prior spinal surgery with dominance observed at ~5 years.

Objectives: Anti-calcitonin gene-related peptide (CGRP) agents are some of the newest preventive medications for migraine. There is limited literature comparing the efficacy of the most recent CGRP antagonist, atogepant, to CGRP monoclonal antibodies for migraine prevention. In this network meta-analysis, the efficacy and safety of migraine treatments including different doses of atogepant and CGRP monoclonal antibodies were evaluated to provide a reference for future clinical trials.

Materials and methods: A search using PubMed, Embase, and Cochrane Library identified all randomized controlled trials published through May 2022 and including patients diagnosed with episodic or chronic migraine and treated with erenumab, fremanezumab, eptinezumab, galcanezumab, atogepant, or placebo. The primary outcomes were the reduction of monthly migraine days, 50% response rate, and the number of adverse events (AEs). The Cochrane Collaboration tool was used to assess the risk of bias.

Results: In this study, 24 articles were considered for analysis. Regarding efficacy, all interventions were superior to placebo with a statistically significant difference. The most effective intervention was monthly fremanezumab 225 mg in change from baseline of migraine days (standard mean difference = -0.49, 95% CI: -0.62, -0.37) and 50% response rate (risk ratio = 2.98, 95% CI: 2.16,4.10), while the optimal choice for reducing acute medication days was monthly erenumab 140 mg (standard mean difference = -0.68, 95% CI: -0.79, -0.58). In terms of AEs, all therapies and placebo did not achieve statistical significance except for monthly galcanezumab 240 mg and quarterly fremanezumab 675 mg. There was no significant difference in discontinuation due to AEs between interventions and placebo.

Discussion: All anti-CGRP agents were more effective than placebo in migraine prevention. Overall, monthly fremanezumab 225 mg, monthly erenumab 140 mg, and daily atogepant 60 mg were effective interventions with fewer side effects.

Objectives: The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs).

Methods: "PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not.

Results: Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline.

Discussion: We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.