Permanent End To Chronic Pain

Natural Pain Management

Natural Pain Management

Do You Suffer From Chronic Pain? Do You Feel Like You Might Be Addicted to Pain Killers For Life? Are You Trapped on a Merry-Go-Round of Escalating Pain Tolerance That Might Eventually Mean That No Pain Killer Treats Your Condition Anymore? Have you been prescribed pain killers with dangerous side effects?

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Erase Chronic Pain

The Ease Chronic Pain Program is a complete how to guide for permanently curing even the worse cases of chronic pain. Youll be given a comprehensive list of different foods and supplements which, when combined in the specific way. Every single food or supplement youll find inside The Erase Chronic Pain Program is 100% natural. The Key to why this works is that for each evil neurotransmitter in your brain, there are other natural organic chemicals that, when introduced into your body, immediately break down those pain-causing agents and bansih them from your body. Scientific study after scientific study has already shown that the different chemical compounds, included inside this guide counteract these biological pain amplifiers.

Erase Chronic Pain Overview

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Chronic Pain in Canada and Alberta

The situation has been no different in Canada as study methods and findings have also varied. Millar - 23 presents a portrait of chronic pain in Canada based upon responses to the 1994 National Population Health Survey. The National Population Health Survey (NPHS) is a major longitudinal health survey conducted by Statistics Canada. The NPHS is comprehensive in scope, and includes questions relevant to an examination of the prevalence of chronic pain and the characteristics of chronic pain sufferers. Two questions measure pain states. They ask about pain intensity on a three point scale and about degree of activity limitation or prevention on a four category scale. While it is emphasized that questions are being asked about individuals' usual abilities rather than short term states, there is no specific temporal criterion for duration and persistence, so the questions do not strictly meet the IASP definitions of pain. In addition, a wide variety of questions about health status are...

Direct Costs of Chronic Pain

The extent of the chronic pain problem poses a significant economic burden for patients, the health services and society as a whole in Canada. In a study that estimated the prevalence of chronic pain in Alberta from the National Population Health Survey (NPHS) 4 , described in the previous chapter, various self report measures of health system utilization were also collected. Compared to individuals reporting no pain, those suffering from severe Chronic Pain reported In Canada administrative data is collected on each patient visit to hospital, outpatient clinic, or doctor's office. This information is used for payment ofmedical professionals as well as for statistical purposes. Unfortunately, administrative data sources are unable to provide direct estimates of the prevalence of chronic pain because the International Classification of Diseases ninth Revision (ICD-9-CM) diagnostic system is not organized by symptoms such as pain. Furthermore, chronic pain can be a symptom of a large...

The Wider Impact of Chronic Pain

The estimates of the burden associated with pain fail to do justice to the extent of suffering and reduced quality of life experienced by patients. It is not merely the economic impact, but rather the tremendous human suffering resulting from chronic pain that warrants pain relief being regarded as a universal human right 8 . Pain affects all of us to varying degrees. For some it may be the briefest of acute sensations, but for others it is a permanent feature of life and has a profound impact on the quality of life. Without adequate treatment, these people are often unable to work or even sometimes to carry out the simplest of tasks. This often leads to problems such as depression or stress which then compound the problems caused by the physical pain. Using the World Health Organization estimate of prevalence of chronic pain 26 of 22 , there would be 2400 million chronic pain days in Canada, which translates into over 250000 working lives. These pain days have a profound impact on...

The Evidence for Prescription Drug Use in the Management of Chronic Pain

Despite significant developments in pharmacological technology over time, very little has changed with regards to drug options for the management of pain. Derivatives of the poppy and the bark of the willow continue to play a prominent role. Cannabinoids have continued to be used as traditional remedies in many parts of the world and, with increasing evidence for analgesic and other therapeutic effects, are now receiving increased attention in Europe and North America 2-5 . The main additions to the pain therapists ' drug armamentarium include members of the antidepressant and anticonvulsant groups of drugs, and topical preparations (applied directly to the painful part), the latter supported by evidence identifying peripheral mechanisms of chronic pain. Recent reviews have identified several key groups of medication for which there is high quality evidence supporting efficacy in the management of chronic pain 6-9 . This evidence has been used to develop recommendations and treatment...

Motivation For Cell Transplantation Therapies In Chronic Pain And

Chronic Pain Despite improvements (1) in surgical management, physical therapy, and the availability of pharmacological agents with a variety of delivery systems, many patients following peripheral and central neural injuries continue to suffer from intractable chronic pain (2). Although opioids are the most commonly used agent to control pain, only about 32 of patients receive any significant relief with long-term use (3). This often leads to untoward effects associated with tolerance, tolerability, drug diversion, and other side effects (4), including opioid-induced neurotoxicity. Nonopioid medications can attenuate some types of neuropathic pain but seldom remove the painful sensation completely (5). Recent attempts at classification of neuropathic, nociceptive, and other pain, aided by an IASP Taskforce (6), has helped the understanding of mechanisms and improvement of better treatments for chronic pain. Yet, with the frequency of inadequate or failed clinical trials, especially...

What Constitutes Multidisciplinary Care for Chronic Pain

There is no one formula for multidisciplinary or multimodal therapy for chronic pain but in general it involves collaboration between clinical professionals who have complementary training and skills to address a multifaceted problem. It is more than a clinical involvement with multiple professionals. In most cases it involves a psychological model (behavioral, cognitive behavioral, psychoeduca-tion or coping skills training) combined with active exercise. It may also involve a rehabilitation model with ergonomics assessment, work hardening, and work reentry management. In this chapter the focus is on multidisciplinary treatment for chronic pain management (i.e. comprehensive pain programs). Because multidisciplinary programs usually include behavioral treatments, active exercise, and patient education, we will also consider briefly what is known about these individual modalities that are usually included in multidisciplinary treatment, but we will give main attention to the efficacy...

The Chronic Pain Self Management Program

LeFort 22 developed the Chronic Pain Self-Management Program (CPSMP) in 1995 by adapting the ASMP in order to make it more directly applicable to people with chronic pain. Modifications were made with respect to (i) myths and information about chronic pain, (ii) understanding acute and chronic pain, (iii) pacing activity and rest, (iv) exercise, (v) communicating about chronic pain, (vi) breathing and body awareness, and (viii) medications. 14.3 The Chronic Pain Self-Management Program 171 What Is chronic pain Figure 14.1 Chronic pain self-management program overview. Figure 14.1 Chronic pain self-management program overview. Like the ASMP, the CPSMP was designed to enhance self-efficacy via a standardized small-group intervention format (7-9 patients per group), delivered by a nurse facilitator, in two - hour weekly sessions, over six weeks. Figure 14.1 provides a detailed overview of the program content and format. During the first week's session, there is detailed discussion of...

Is There Evidence for Chronic Pain Patient Improvements

We did not find published studies explicitly studying the impact of changes made in the healthcare system in France on the mental and physical health of chronic pain patients, with the exception of a recent investigation by Allaria-Lapierre et al. 48 . This study specifically aimed to address the national program objective of increasing access to specialized services, in the context of outpatient management of chronic pain. A cohort of 172 chronic pain patients being treated in GPs' offices in five regions were examined and asked to complete questionnaires 109 (63 ) who had not previously received specialized treatment for chronic pain were followed over three to six months. Sixty-five patients initiated specialized treatment (administered by the GP for over 50 ), whereas 20 had no specific pain therapy over the six months. The treated patients showed a significant decrease (p 0.027) in their pain intensity score, from an average of 6.54 at three months to 5.97 at six months (on a...

Improving Chronic Pain Management in Alberta Policy Considerations

A clear health policy is needed to guide and implement specific measures. Such a policy must emphasize the importance of appropriate support for and treatment of people in chronic pain, and demand professional accountability for adequate and evidence-based services in the field. There are several ways to start Continue to build awareness by convening a Consensus Conference to further explore the evidence surrounding interventions to treat and manage chronic pain. Such a Consensus Conference could be modeled on previous successful Consensus Conferences in Alberta 1, 2 . Recognize chronic pain as a public health problem, and initiate a Chronic Pain Strategy modeled on other Alberta Health and Wellness Strategies such as the Alberta Diabetes Strategy 3 . Subsequently, or as an immediate alternative, we suggest that the Minister of Health of Alberta establish a provincial Chronic Pain Steering Commitee (CPSC) and commission it to Develop a comprehensive proposal for improved services for...

The Prevalence of Psychopathology with Chronic Pain

Pain is both an emotional and a physical experience, and a range of expected emotional responses to chronic pain may arise, including anxiety, depressed mood, anger, bereavement, frustration, irritation, and isolation. These symptoms may or may not reach the threshold for the diagnosis of a mental disorder. There are a variety of characteristics of patients with chronic pain 7 The psychological comorbidities found in chronic pain patients are 8 15.2 The Prevalence of Psychopathology with Chronic Pain 187 Emotional disorders associated with chronic pain syndrome 7 are Suffering from a condition for which the medical profession may not find a suitable solution may be associated with a sense of anger, hostility, confusion, fear, despair, hopelessness, and other symptoms of significant subjective distress. If no objectively demonstrable tissue damage is apparent to explain the chronic pain, care providers may erroneously attribute it to a mental condition, indirectly contributing to a...

Two Jurisdictions That Have Prioritized Management of Chronic Pain

Jurisdictions (i.e. countries, states provinces or specific health systems) differ with regard to how they administer and finance services for patients with chronic pain. In the following section we provide a description of the commitment made to the management of chronic pain in the two example jurisdictions, selected because (i) they have made a clear commitment to chronic pain health services and their quality control (ii) they provide services to all members of a specific region or group (iii) they have published or placed documents on the Internet in English or French which allowed us to examine their initiatives and (iv) we found evidence of attempts to study patient outcomes or monitor implementation. For more than a decade, pain, and chronic pain in particular, have been a national priority for France 8 . Through the establishment of Phase I (1998-2002) of a National fight against pain, the Minister of Health committed to improving the overall management and treatment of...

Chronic Pain

There are a number of chronic pain syndromes commonly seen in pediatric offices and clinics. Chronic pain is traditionally defined as pain existing recurrently or consistently in the previous 3 months (8). The American Pain Society has added to that definition that chronic pain, in contrast to acute pain, rarely is accompanied by autonomic arousal (90). Chronic pain is a remarkably frequent occurrence in children and has an overall prevalence ranging between 15 and 25 . Girls tend to have more chronic pain than boys (30 vs 19 ). Chronic pain in childhood seems to peak between 12 and 15 years, but it is still significant in children as late as 16-18 years (91). Typical chronic problems are headache, abdominal pain, and limb pain. Of children who report chronic pain, 50 have pain in multiple sites, and the incidence of multiple pain sites increases with age. In children who have multiple pain sites, the most common combination is headache and abdominal pain, which occurs in 25 of all...

Dealing with the Evidence

What strategies will help healthcare providers and policy makers appreciate the role of lived experience in effective programming for chronic pain We have identified diverse sources for gaining access to the patient' s voice. What remains is knowledge translation -developing healthcare workers' and policy makers' receptivity to and awareness oflived experience. Knowledge translation strategies make explicit the benefits of the evidence available through qualitative inquiry. For example, the University of Alberta' s Arts and Humanities in Health and Medicine (AHHM) Program offers healthcare providers a broader socio-cultural perspective on issues of illness and wellbeing. The newly revised Core Curriculum for Professional Education in Pain produced by the International Association for the Study of Pain (www.iasp-pain.org), and the expanding range of publications in journals like the BMJ that stress the value of listening to the patient's narrative as a critical component of healthcare...

Transient Receptor Potential Channel Receptors

The TRPV1 does appear to contribute to both acute and chronic pain. The TRP channels of the vanilloid family (TRPV1, TRPV2, TRPV3, and TRPV4) undergo stimulation by heat stimuli, although TRPV8 and ANKTM1 (a TRP-like channel expressed in nociceptive neurons activated by cold temperatures) are responsive to cold. Both TRPV1 and ANKTM1 mediate the pungency of nociceptor-specific chemicals including capsaicin and mustard oil. The resulting sensitization of TRPV1 is an important mechanism for heat hyperalgesia and enables the symptoms of chronic pain (46).

Pain Management Strategies

The burden of suffering that pain imposes on individuals, and the enormous costs which societies have to bear as a result, clearly demonstrate that policy makers and health care decision- makers need to adopt a broad, strategic and coherent perspective in determining issues relating to service provision and resource allocation. Fragmented, budgetary-based interventions and programs based on, at best, inadequate evidence do little to alleviate chronic pain and suffering, and also deprive patients of those services that would have a positive impact. It has therefore

Summary and Conclusion

The aims of this chapter therefore have been to assess the economic impact of chronic pain on the health service and more widely on the Canadian economy and propose a coherent and integrated approach to the management of pain, based on the notions of effectiveness, efficiency, and equity of service provision. It is clear that chronic pain imposes an enormous burden on individuals, their families and society as a whole. This provides a sound rationale for greater emphasis to be given to pain management. Chronic pain is a complex syndrome that demands a broad strategic perspective for decision-making. Analgesic therapy is only one part of the treatment. It is increasingly evident that, in relation to chronic pain, other factors may contribute to the intensity and persistence of the pain 55 and simple pharmacological interventions, in themselves, are insufficient and need to be located within the context of an overall pain management strategy geared to the needs of the individual patient...

Justice and Social Responsibility

Fair opportunity says that no persons should receive services on the basis of undeserved advantageous attributes (because no persons are responsible for having these attributes) and that no persons should be denied services on the basis of undeserved disadvantageous attributes (because they similarly are not responsible for having these attributes). Given the positive value attached to courage, cooperativeness, resignation, and will power, those patients with chronic pain who fail to measure up to these stoic attributes are very likely to be underserved. Conversely, those patients who bear their pain without complaint and unquestioningly follow medical advice are very likely to be granted special moral standing and professional and personal favors 3, 4 . Patients with chronic pain who also have a history of substance abuse are particularly prone to being denied effective pain treatment 17 .

Pain Public Policy and Ethics

The main health policy needs arising out of this discussion are (i) protocols for determining appropriate treatment and compensation in light of the inherently subjective nature of pain, (ii) a need for guidance as to the responsible use of opioids for treating chronic pain, and (iii) recognition of relief of suffering due to chronic pain as an important healthcare goal. Patient-centered principles ought to guide efforts to relieve chronic pain, including accepting all patient pain reports as valid while negotiating treatment goals early in care, avoiding harming patients, and incorporating opioids as one part of the treatment plan if they improve the patient' s overall health -related quality of life 6 .

Chemical Mediators of Pain

These are but examples of what is a chemical correlate to the intricate anatomical and morphological complexities that contribute to nociception. Slight disturbances or prolonged synaptic input can generate long-term or even permanent plastic changes in these neurones and these changes may account for some types of chronic pain.

Basic Science Contributions to Pain Management

Thus, while we know much and there are emerging leads that may be useful in developing novel approaches to management of chronic pain, there remains much to learn. Oversimplified theories of sensory processing mechanisms impede our ability to understand fully these mechanisms. We see the pain system now as multiple pathways, with multiple synaptic junctions and an elaborate network of local and remote control systems acting at each junction and a fathomless capacity for neuroplastic change 9 . If we are to begin to match mechanisms with clinical conditions and to exploit knowledge of mechanisms to develop novel approaches to pain management, we must commit ourselves to the long and difficult task of accumulating a vast amount of scientific knowledge.

Impact of Policy on Knowledge Generation

There is ample reason to be optimistic that these developments and others will eventually lead to new types of treatment for pain, given adequate support and time. In this context, it is sad to note that the Canadian Institutes of Health Research does not have a review process that specifically addresses pain, either for the basic or for the clinical sciences, and that funding for knowledge generation in pain is not commensurate with its impact on the individual and society. The European parliament has declared chronic pain to be a disease in and of itself. This highlights the need for increased knowledge generation. The U.S. House of Representatives has declared this to be the Decade of Pain Care and Research. This was backed up by a 10 - step approach and by a major influx of funding for pain care and research. Benefits of this policy change will not be seen immediately, yet in the long run Americans will benefit from this influx of funding. As Canadians, we justifiably pride...

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is an important source of musculoskeletal pain. It is also one of the most common sources of chronic pain. Clinically, MPS involves a localized or regional pain complaint that is associated with tender trigger points with referred pain upon palpation, which are located in taut banks of skeletal muscle.

Complex Regional Pain Syndrome

CRPS is characterized by chronic pain, usually in a limb, associated with local changes in sweating, skin color, skin sensitivity, skin temperature, swelling, muscle spasm, wasting of muscles, and changes in hair and nail growth. Patients do not necessarily present with all the symptoms and signs.

Evidencebased Medicine Reviews

One review tried to evaluate the effectiveness of TENS in chronic pain. Nineteen RCT (randomized controlled trials) from 107 were evaluated. The results of this review are inconclusive the published trials do not provide information on the stimulation parameters which are not likely to provide optimum pain relief, nor do they answer questions about long term effectiveness (38). Larger randomized studies were suggested.

Fatigue ExhaustionSleep Disorders

In addition, coping with pain is emotionally draining. This reduces any reserves of energy that they have and commonly leads patients to experience significant tiredness and fatigue. This can be accentuated by fatigue from lack of restorative sleep, which usually accompanies chronic pain. Almost invariably patients with chronic pain give a history of significant interference with sleep 34 . This is usually both initiation as well as maintenance of sleep. Inactivity and depressed mood can also contribute to poor sleep. Non-restorative sleep itself can lead to chronic fatigue, difficulties in concentration, irritability and may also increase pain. Patients have usually tried various tranquillizers and sleep medications. At best, these provide short-term help, but rarely do they help in the long term. In addition, many of the currently available tranquillizers have a significant risk of addiction. Thus sleep is probably one of the most difficult secondary problems to treat...

Physical Social Functioning

Chronic pain patients, as a group, are known to be some of the most disabled patients 35 . Although limiting activity does help control the pain a little, the patient becomes progressively unfit and deconditioned. This leads to the patient becoming less physically capable of performing physical activities, irrespective of their pain, and to being more prone to minor injuries when they attempt to improve their activity level.

Psychological Treatment

There is absolutely no one-size-fits-all psychological approach to the chronic pain patient. Although many clinicians feel that a behavioral management program is appropriate, utilizing the Fordyce (40) paradigm of behavior modification by not rewarding pain behaviors, most now favor cognitive behavioral therapy (CBT).

Why Do Patients Consult

Although chronic pain is very common, not everyone with chronic pain consults his or her family physician. Many seem to manage with over-the-counter medications and minimal use of healthcare. Some patients have undoubtedly been bruised by their previous experiences of the healthcare system, particularly if they have not been believed or have been treated dismissively.

Problem Medication

FPs recommend and prescribe a wide range of medications for both acute and chronic pain. Some of these have the potential for addiction. Although the risk of addiction is small, a number of patients develop problem medication use. This is exemplified by an apparent loss of control. The patient may begin to use more than the recommended dose and often escalates the dose without any major benefit (see Chapter 15) . Helping these patients manage this situation requires skill and time, often with assistance from a number of professionals in a specialized clinic.

Help with Patient Management

Patients with chronic pain can be intellectually and emotionally challenging, even for the most seasoned physicians. Sometimes the family physician needs moral support if they continue to manage the patient in the community. It is important to offer such support to primary care physicians to prevent burnout.

Other Obstacles to Managing Pain in the Community

Some FPs simply don't like working with patients with chronic pain. There is no simple answer to the patient' s problem. The physician finds him herself constantly under pressure from the patient. Each consultation seems to be a battle, either to achieve the impossible (cure the pain) or to try and retain some control over prescribing. The patient demands steadily more medication and the physician worries about coming into conflict with regulatory bodies about his prescribing. Trying to deal with patients with complex problems in the time available may seem impossible. There are also significant problems with reimbursement. In many areas there is no additional fee for looking after patients with chronic pain or funding mechanisms to allow more time to be spent with the patient. Some jurisdictions allow additional fees if the patient has already been assessed in a multidisciplinary pain clinic. Finally some physicians recognize the need for a more broad-based approach to managing...

Tricyclic Antidepressants

This class of medications was originally developed for the treatment of depression, for which there are now better choices available. However, several systematic reviews and meta-analyses have concluded that tricyclic antidepressants are effective in relieving pain in a number of chronic pain conditions, in doses that are much lower than would have been used for mood elevation 8, 13-15 . The number needed to treat (NNT)1 is generally in the range of 2.1-2.6 (Table 9.1). TCAs are

Cognitive Behavioral Therapy with Bruce Dick

Cognitive behavioral therapy (CBT) is a psychological treatment based on the premise that a person's thoughts, mood affect, and behavior exert a considerable influence upon each other 6 It follows that any adopted treatment or strategy that affects one of those factors will affect the other two. Traditionally, CBT has been used as a means of improving negative mood. Within the context of chronic pain management, CBT is often administered within a multidisciplinary environment. In such an environment, medical and physical therapies are accompanied by psychological interventions that target negative feelings such as depression and anxiety that co exist with the pain. The psychological treatment often aims to change negative and unhelpful thought patterns that are related to or are a consequence of the chronic pain. Additional behavioral patterns that are also frequently targeted include the reduction of activity avoidance, reducing pain-related fear and distress, and pain behavior. The...

Manipulation and Mobilization

Manipulation is movement of short amplitude and high velocity that moves a joint beyond where a patient's muscles could move it by themselves but that does not cause ligament rupture. Mobilization is movement administered by the clinician within normal joint range in order to increase the overall range of motion. Manipulation is considered to have a higher complication rate compared to mobilization due to the velocity and movement of the joint. There is very limited information about the effectiveness of manipulation and mobilization in conditions associated with chronic pain. Neither mobilization nor manipulation was superior when compared to each other. There is little evidence in mechanical neck disorders that manipulation or mobilization used in isolation or with other passive physical medicine modalities is beneficial (although some benefits when used in association with exercise were seen 20 ). In chronic low back pain, manipulation was beneficial, but only reduced pain by less...

Cervical and Lumbar Epidural Injections

In summary, the weight of evidence does not support the use of epidural steroid injections for chronic pain. However, our clinical experience suggests that selected patients with primarily radicular pain can benefit from epidural injections as a part of a multidisciplinary multimodal treatment plan. Patients should be made aware of the very rare but potentially catastrophic complications that may occur.

Spinal Cord Stimulation

There is limited evidence from systematic reviews in favor of spinal cord stimulation (SCS) for failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) in follow-up of 6-12 months. There is insufficient evidence to assess the benefits and harms of SCS for the relief of other types of chronic pain 39, 40 . A recent RCT of FBSS versus conventional medical management demonstrated better pain relief and improved health-related quality of life and functional capacity for SCS 41 .

Various Behavioral and Cognitive Behavioral Treatments

A review 22 of controlled trials concerning cognitive behavioral therapy and behavior therapy for chronic pain in adults, excluding headache, found that CBT resulted in significantly greater improvements in pain experience, positive cognitive coping and appraisal, and reduced behavioral pain expression. There was no significant change in measures of mood, catastrophizing, and social functioning.

Cost Effectiveness of Multidisciplinary Pain Management Programs

Gatchel and Okifuji 27 conducted a narrative review of studies reporting treatment outcomes using comprehensive programs for chronic pain. They estimated work return rates for comprehensive programs compared to outcomes of control conditions, noting that, on average, 66 of patients in the comprehensive pain programs versus 27 in the control programs returned to work. They estimated significant saving on disability and health care costs as a result of these comprehensive programs. Weir et al. 28 identified an historical cohort and conducted a telephone interview-based survey and mailed questionnaire, with economic analysis of 571 patients referred to a specialty pain clinic. The measures included demographic, economic and health care utilization variables, and validated psychosocial adjustment and coping measures. Using these measures, 81 were fairly adjusted or poorly adjusted psychosocially before treatment. Poor adjustment was correlated with lack of intimate caring social...

Based ori the History and i

Figure 12.1 Principles of multidisciplinar chronic pain rehabilitation, 1 Fordyce, W., Fowler, R., Lehmann, J. and de Lateur, B. (1968) Some implications of learning in problems of chronic pain. Journal of Chronic Diseases, 21, 179-90. 17 Eccleston, C., Morley, S., Williams, A., Yorke, L. and Mastroyannopoulou, K. (2002) Systematic review of randomized controlled trials of psychological therapy for chronic pain in children and adolescents, with a subset meta-analysis of pain relief. Pain, 99, 157-65. 18 Turner, J., Holtzman, S. and Mancl, L. (2007) Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain, 127, 276-86. 20 Malone, M.D. and Strube, M.J. (1988) Meta-analysis of non-medical treatments for chronic pain. Pain, 34, 231-44. 22 Morley, S., Eccleston, C. and Williams, A. (1999) Systematic review and meta-analysis of randomized controlled trials of cognitive behavior and behavior therapy for chronic pain in adults,...

Pharmacological Treatment of Associated Syndromes

This is a common problem for FMS patients (127,128). It may be associated with poor memory and concentration and lead to problems with employment. It appears to be related to the effects of chronic pain, depression, mental fatigue, and sleep disorder. Treatment of these various problems is needed. In some patients medication treatment of fatigue may be helpful with this problem, which appears to be the result of one or more other FMS-associated problem(s).

Towards an Integrative Pain Medicine

Should safe and effective CAM therapies be integrated into pain clinic services Are they cost effective A 2005 survey of 39 US academic health centers found that while 23 offered CAM services (particularly acupuncture, massage, dietary supplements, mind-body therapies, and music therapy), none had written policies concerning malpractice liability or credentialing practices 61 Nothing is currently known of the policy issues regarding integration of such practices in chronic pain centers in Canada. The mechanics of providing integrated (CAM plus conventional) care in Canada deserve to be further explored.

The Systemic Barriers to Access

Like other disenfranchised and marginalized populations, persons with mental illness appear to have inequitable access to medically necessary services 5 , and specialized pain management options are no exception. Conversely, persons with chronic pain infrequently have optimal access to specialized mental health services and such referrals are often reserved for those with the most marked psychopathol-ogy. Individuals with severe and persistent mental illness may be especially prone to experiencing these disparities in services, in part related to the very nature of the illness. Cognitive deficits and psychotic features in particular may result in suboptimal skills in advocating for equity in their own management. Putative safety concerns may rank higher on the hierarchy of priorities than chronic pain. those with chronic pain, may help to remove the existing disparities in access to integrated pain and mental health care.

Pharmacotherapeutic Considerations

The development of pragmatic solutions and effective protocols for managing chronic pain in the mentally ill is imperative. An integral part of mental health care and pain management is a longitudinal integrated psychosocial focus combined with pharmacotherapy. Considerations for medication management of pain in persons with mental illness include (i) Risk of abuse, (ii) addictive potential of a drug, (iii) the potential of the drug to exacerbate existing psychopathology and (iv) the potential of the drug to improve existing psychopathology. The risk of addiction in persons with mental illness is elevated, and the lifetime prevalence of addiction in those with mental illness has been estimated as almost one in two 17 . The evidence for pharmacotherapy for pain management in chronic pain patients with concurrent mental illness is considerably weaker than that for the non-mentally ill population because research protocols typically exclude mentally ill persons. The existing range of...

Proposed Systems Level Changes

In a universal health care system that is free at the point of delivery, like that of Canada, disparities in management of comorbid chronic pain and psychopathol-ogy may contribute to excess morbidity and healthcare spending. Further research into the association between pain and psychopathology may eventually contribute to remedying such disparity. Advocating for increased efforts in psychopathology screening and management in pain clinic settings, and for optimal pain management in mental health settings appears prudent.

Psychologically Based Interventions

As discussed earlier in this section, psychosocial variables can play a significant role in the initiation and maintenance of chronic pain. Yet, psychosocial variables are complex, embedded in a larger social context, and often highly unique to individual patients. For this reason, most traditional clinic- based treatments aimed at alleviating pain have been found to be of only marginal benefit 47 .

Overview Review of the Literature

As in many fields of study, as our understanding of chronic pain in children has expanded, so has our realization that complex interactions of many factors underlie the effects of pain. Children present with unique features that make the assessment and treatment of their pain especially challenging. For example, due to the subjective nature of pain, it can be difficult even for adults to describe their pain. Factors such as a child's developmental level and ability to communicate information about pain exacerbates the challenge of adequately assessing pain 6-8 . Sex differences have also been found to exist in children's coping style and reaction to pain 9 . Recurrent pain problems are a common complaint in children 10 and tend to increase in prevalence with age 11 . Estimates of the occurrence of some common chronic pain problems have been found to be as high as 10-19 of children reporting recurrent abdominal pain 12 and as many as 28 of adolescents reporting chronic headaches 13 ....

What Public Health Policies Would Enable Better Care Outcomes for Patients Families and Communities

Proposed that education during training and continuing education programs for healthcare professionals be active and interactive, citing research suggesting that passive didactic sessions on pain management are often not effective at changing clinical practice 33, 34 . They also suggest that public advertising campaigns using media, including billboards, the lay press, and electronic and visual media, have the potential to inform the public regarding the need and benefits of adequate pain management and encourage public support of these initiatives. Second, as chronic pain is a multifactorial problem, it is unlikely that a professional from a single discipline could adequately address and manage the many challenges that arise for children with chronic pain. Multidisciplinary program management of chronic pain is another key element of adequate health care for this population. Research has shown that these services have the potential to provide valuable clinical services, research...

Neuropathic Lowback Pain

Approach was looked at, essentially a model of chronic pain which was more or less neuropathic. They looked at 200 patients (100 each of nociceptive and neuropathic) and used the LANSS pain scale and the Neuropathic Pain Scale. They felt that their data supported the theoretical construct that pain can be more or less neuropathic or predominantly neuropathic in origin.

Complex Regional Pain Syndromes As Neuropathic Pain

This may explain why TENS and spinal cord stimulation, which produce a low-threshold, tingling sensation characteristic of large fiber afferent activation, may be effective in chronic pain states, particularly neuropathic pain. Tactile allodynia should be differentiated from thermal allodynia, which appears to be mediated by nonmyelinated C fibers and amplified by pathologic spinal dynorphin.

Health Technology Assessment and Knowledge Translation

A fresh approach to disseminating HTA-derived evidence was pioneered by the Swedish Council on Technology Assessment in Health Care (SBU) (http www. sbu.se www index.asp). SBU engaged senior clinicians representing each of the health councils to serve as HTA ambassadors to facilitate uptake of HTA reports by health councils in Sweden. The ambassadors met regularly with HTA researchers in Stockholm to learn about ongoing or recently completed HTA research projects. Upon returning to their health councils, the ambassadors arranged presentations at administrative meetings, clinical rounds, and local conferences to inform colleagues about current HTA research evidence that was relevant to local practice environments. The Alberta Chronic Pain Ambassador Program built upon the idea of using senior clinicians as HTA ambassadors.

Description of the Program

The Alberta Chronic Pain Ambassador Program involved an interactive case-based workshop delivered locally to clinical practitioners who were known to have a special interest in chronic pain management. These workshops combined several crucial dissemination strategies, including bringing the workshop to the participants, inviting multidisciplinary participation, and using highly credible facilitators. The interactive case-based, small-group learning approach ensured the active engagement of the participants, and education credits were available for the family physicians and pharmacists who participated. main components the clinical question, a description and categorical assessment of the quality and strength of the best evidence available for the intervention, and implications for practice. The last component, implications for practice, outlined what is known and unknown about the intervention and provided pragmatic recommendations from the clinical ambassadors about its utility. The...

What Were the Outcomes

Nearly all of the participants (99 ) indicated that the workshops were a useful way of linking research to practice. In most areas relating to content and presentation, satisfaction scores were high. The Evidence in Brief summaries were particularly well received. The effect of the workshops on the knowledge of participants in five sample topic areas in chronic pain management was assessed. The participants recorded an increase in perceived knowledge in each area. Nearly a third (30 ) of the respondents reported that the workshop had changed the way they manage chronic pain. This percentage is very encouraging, given that the participants were local opinion leaders in chronic pain management and had established interest and expertise in the area.

Initial Symptom Management

The clinician should also keep in mind that successful management of chronic pain often requires treating neuropathic pain as well as pain associated with tissue injury, because both conditions may coexist and interact to maintain the painful condition. Chronic pain syndromes are often a product of integrated nociceptive and neuropathic mechanisms, and as such require consideration of both types for any pain lasting greater than three to six months.

Mechanistic Basis Of Neuropathic Pain Management

Management of neuropathic pain is a complicated endeavor and often is frustrating to patient and physician alike. This stems from our relatively poor understanding of mechanisms and the limited efficacy of currently available analgesics. Therapeutic approaches vary greatly among physicians, which reflects the paucity of randomized clinical trials, particularly those comparing different drug regimens. Given our current level of understanding of neuropathic pain mechanisms and the limitations of available drugs, nonpharmacologic methods may be as effective as pharmacologic approaches. Recalcitrant chronic pain syndromes warrant an interdisciplinary approach, which may include attempts to treat the underlying disease (e.g., causes of the peripheral neuropathy) as well as formulation of a rational approach to medications, interventions such as nerve blocks, and psychologic and physical therapies.

Health System Organization and Care Pathways

In the study of health system organization for a particular condition, structure refers to how services are organized, and includes such elements as types and sizes of facilities, human resources, infrastructure, and equipment. Process refers to how services are delivered, including coordination of care, communication, and care pathways. Healthcare systems are generally structured according to a hierarchy of levels at which care is delivered, ordered with increasing specialization in terms of human resources, facilities, and equipment as one moves up the hierarchy. A hierarchy of services does not imply, however, that patient care pathways are unidirectional - in fact, patients may need to move from one level of service to another and back over the course of time - nor does it imply that one level is more important than another. Ideally, referral protocols are put in place to coordinate the movement of patients through the care levels. We begin this chapter with a brief introduction...

Treatment Of Comorbid Depression And Anxiety

It is crucial that psychosocial and emotional factors be explored, because there is a high comorbidity of depression and anxiety disorders in patients with chronic pain. Moreover, given the similarities between the pharmacology of mood and depression and pain transmission (e.g., serotonin and norepinephrine), patients with concomitant systemic illness and stress may be at risk for depression and development of an abnormal chronic pain state. Pharmacologic management of depression may improve neuropathic pain by addressing overlapping, but distinct mechanisms.

Inter Discipline and Inter Level Communication

A consistent problem in many healthcare systems is lack of communication, both between healthcare professionals (e.g. between GP and physiotherapist) and between levels of care (e.g. between GP and medical specialist). This problem can negatively impact patient outcomes if diagnostic test results are not received in a timely manner, or if no one is tracking the various professionals a patient has seen, and the treatments tried, when making referrals or treatment decisions. In France, communication between the various levels of the healthcare system is considered indispensable for the management of chronic pain 26 . In the VHA, information is relayed back to the referring physician for patients treated in comprehensive multidisciplinary outpatient clinics 22 .

Use of Innovative Technology

In the VHA system the use of videoconferencing to deliver clinic follow-up services was recently tested in a small group of 36 consecutive, stable chronic pain patients over a 29-month period 35 . Both patients and staff (a pain medicine physician, a behavioral medicine psychologist and a clinical nurse specialist) completed questionnaires pertaining to their satisfaction with this means of providing pain management. The majority of both groups found it to be a very good or excellent means of receiving or providing follow-up care. The viability of this approach was further supported by the fact that patients found the technology easy to manage and almost all were able to communicate adequately. The VHA Care Coordination Home Telehealth project in Florida uses an in-home messaging device for chronic pain patients to communicate with care coordinators 36 .

Program Implementation

A survey of the structures in place was conducted across France during phase II, including 207 structures, 20 interviews with physicians, and 28 interviews with chronic pain patients 39 . With a response rate of 72 , it was found that about half of the patients received multidisciplinary care and integration of chronic pain structures within institutions was relatively good, in terms of having access to hospital beds. The success of a program often depended on an institution. based champion of the need for chronic pain services. Multidisciplinary team meetings were considered indispensable for the functioning of pain structures. In the VHA, the National Pain Management Strategy Coordinating Committee is mandated to establish target goals, mechanisms for accountability, and a timeline for implementation of the strategy 15 . The 2007 Military and Veterans Pain Care Act reinforces this committee's mandate through its recognition of the importance of acute and chronic pain and its...

Monitoring Patient Outcomes

The guide for implementation of the French national pain program promotes the use and regular analysis of discharge questionnaires in health establishments that include patient satisfaction surveys 12 . In the small survey of 28 patients from five structures (representing centers, units, and consultations) during phase II, patients indicated that they were satisfied with how they were treated and with the information received, and that the doctors were responsive to their needs 39 . It is unknown, however, if the sample is representative of chronic pain patients in general given the limited number interviewed. Patient outcome data from the Tampa Chronic Pain Rehabilitation Program (CPRP) are available on-line for the years 2004-2005. 46 Generally, these outcomes look favorable in terms of reductions in pain and disability. A related slide presentation available on the Internet also shows decreases in healthcare visits and associated costs 47 . This appears to be the most relevant...

Elements That Helped to Germinate the Qubec Strategy

Several factors converged and provided an argument for recognizing the importance of addressing the issue of chronic pain in Quebec. First, citizens wrote letters to the Ministry, relating their problems and requesting that action be taken to help them find relief for their pain. These letters sowed the seeds for an early awareness that chronic pain is an issue. This awareness was subsequently augmented by requests from hospitals and clinicians to the Ministry for funding to bring in the new expensive pain treatment technologies (e.g. intrathecal pumps and neurostimulators). These separate events thus instilled an initial recognition within the Ministry's administrative services of the broader problem surrounding the treatment of chronic pain and fostered the informal opening of a file on this issue. This led to the appointment of a professional who would be responsible for the issue, who would thereafter consolidate the pertinent information originating from inside or outside the...

Validate this Vision with the Various Stakeholders to Ensure Its Relevance Practicality and Accuracy

This validation exercise showed there was a very broad consensus on the relevance of taking action to address chronic pain. In addition, the feedback proved to be supportive of the proposed form of organization (a hierarchical approach to service delivery) and the importance of discussing the training and support to be given to the primary care workers in order to prevent the transition from acute to chronic pain.

Prepare an Operational Plan to Progressively Systematically and Carefully Implement The Vision and Selected

First, the Minister is authorized by the Act respecting health services and social services to determine the supra-regional mission, and mandate of an institution with regard to certain highly specialized services it offers or limit to certain institutions the function of offering certain services or dispensing certain medicines he determines. It is therefore up to the Minister to formally designate which expert centers are to supply highly specialized chronic pain services, based on the recommendations of an expert panel that has evaluated the services offered by these centers.

Observations and Avenues for Future Action

Although we are still early in the operational phase, which will shortly give birth to the expert centers for chronic pain, some mobilization is already observable among the universities and institutions shortlisted to become expert centers. Additionally, Qu bec's Health Research Fund5) (FRSQ) has flagged pain research, and more particularly chronic pain research, as one of its priorities in its latest strategic development plan. This has led to the creation of a Quebec network for pain research (RQRD6)) comprised of researchers active in the four Qu bec universities with a faculty of medicine. There are plans in the current process to develop a large clinical research component centered on the emerging service network. Although still unfinished, Quebec's program for the evaluation, treatment, and management of chronic pain will unquestionably be called upon to become an effective and efficient network of services that by its very nature is able to continually improve itself.

Conclusion The Way Forward

In the opening chapter of this volume we were introduced to the voices of people in pain voices that are all around us but rarely heard. In addition to expressions of suffering inherent in the pain experience we also heard a distinct message that our interactions as providers can add a further burden when people in pain feel unheard. Let us now return to the patients, and hear the voices of those who have had successful healthcare encounters for their chronic pain. The following are extracts of feedback from patients who participated in the multidisciplinary chronic pain program in Calgary, Alberta, Canada. This program is a service offered by the Calgary Health Region, the public healthcare provider for this geographic area. Patients cared for through this program report that they have been in chronic pain for an average of eight years and that their average pain intensity is in the moderate to severe range. Upon completing the program, these patients participated in a focus group...

Limbically Augmented Pain Syndrome

The Rome brothers described a hypothesis that would tie the biopsychosocial aspects of the problem of chronic pain together in a way that would encompass all aspects of chronic soft-tissue pain and other forms of chronic pain in at least a subset of such patients (20). The question of the relationship between depression and chronic pain has long been debated. It is known that nociceptive sensory information, after reaching the thalamus, goes to the limbic system where any emotional significance to such input is assessed this will result in the type and degree of CNS, endocrine, immune system, and neuropeptide response (21). Research has shown, from brain-imaging studies, limbic system abnormalities in previously traumatized individuals (22). Linkages between the various sensory, emotional affective, and cognitive aspects of chronic pain have been explained via the gate control mechanisms in the spinal cord dorsal horn (23) factors mediating cognitive and behavioral activities It was...

Voltagegated Channels

Potassium channels appear to play an important role in the development of neuronal excitability. There are four families of potassium channels that have different structures, neuropharmacological sensitivities, and functional characteristics the voltage-gated (KV), calcium activated K (Ca) , inward rectifier K (ir) , and the two-pore channels K (2P) K (+) (80). Antinociception has been associated with the opening of some forms of these K (+) channels induced by agonists of multiple G-protein coupled receptors, including alpha(2)-adrenoceptors, opioid, GABA(B), muscarinic, serotonin 5HT-1A, nonsteroidal anti inflammatory drugs (NSAIDs), tricyclic antidepressants, and cannabinoid receptors (80). New research indicates that drugs that directly open K (+) channels produce antinociceptive effects in various models of acute and chronic pain (80).

Environment

In this book, information of this type and scope is organized and presented in four sections. In the first, information and evidence are presented to contextualize the dilemmas (personal, societal, economic, ethical, scientific) surrounding chronic pain. In the second, evidence about treatments (medical and non-medical) is reviewed. The focus is on what is known about treatment effectiveness from the most stringent medical research. The third section describes some additional challenges in the management of chronic pain presented by populations with special characteristics and circumstances. The final section concentrates upon broader issues such as the prevention of chronic pain, the optimal organization of health care service delivery for the management of chronic pain, and processes that might hasten our arrival at that optimal organization. While rigorous evidence of effectiveness is much less plentiful, and the scale of these activities makes them complex and time consuming to...

Unfiltered Voices

So if I go to a GP and I'm not being understood or I'm not being . . . thinking Okay here comes another one you know, or whatever, whatever they don't know about chronic pain, I'll try and be different and say Well actually it . . .you know, and go overboard to try and make them understand a little more of what my situation is like.

The Visual Arts

Of particular interest are two projects that show how we can directly access people ' s pain expression through visual art. Debra Padfield's Perceptions of Pain started when people from a pain clinic worked with an artist to create images of their pain. The resulting exhibition was published as a book with the assistance of Novartis Pharma AG and is now owned by Napp Educational Foundation' in Cambridge, UK. Selected images from the project (see Figure 1.1) are available through a research project for healthcare providers in primary care to use with patients attending doctors' appointments. Perhaps when words fail, as they often do for people with pain, images can be used to give pain a presence accessible to others. The images in Perceptions of Pain were created in an effort to express the multilayered experience of living with chronic pain. As one participant said 14

Recent Studies

Breivik and colleagues 21 conducted a two stage telephone survey about chronic pain across 15 European countries and Israel. A total of46 394 (of 67 733 contacted) participated in the first questionnaire. 19 of adults aged 18yrs and older (with a mean age of 49.9) experienced moderate to severe CP lasting more than six months, as defined by ratings of 5 or greater on a 10 point numeric rating scale rating the severity of pain. Countries varied quite widely (range Spain 12 to Norway 30 ).

Effectiveness

The evidence-base for the effectiveness of interventions and strategies in managing pain is large 36-38 although the issue of what works, where and when remains inconclusive 39-41 . While the evidence base is continuously being updated, incorporating potential new therapeutic areas, interventions and management programs 25, 42-46 , questions remain relating to the quality of studies and their relevance for policy and practice 47, 48 . Further, the nature and extent of adverse events associated with some interventions have also resulted in debate as to what actually constitutes effectiveness when efficacy and safety are combined. For example, a systematic review of over 5000 patients confirmed that most patients would experience at least one adverse event resulting from opioid use in chronic pain, and that substantial minorities would experience common adverse events of dry mouth, nausea, and constipation, and would not continue treatment because of intolerable adverse events 49 .

Equity

The availability and accessibility of good quality services for all patients is highly desirable and should form part of the decision-making process. However, a survey of 105 hospitals from 17 European countries showed that only 34 of hospitals had an organized acute pain service, very few hospitals used quality assurance measures and over 50 of anesthesiologists were dissatisfied with post-operative pain management on surgical wards 53 . Similarly, it has been argued that, in selected populations, patients managed through multidisciplinary programs have lower costs, return to work more frequently and experience greater pain control than those who are managed with more traditional methods 43 . However, the availability of such facilities is sketchy and some populations have no local access to services for patients with long-lasting pain-a situation likely to deteriorate, as demographic factors intensify the demand for chronic pain services for the foreseeable future 54 .

Scope and Context

Chronic pain represents a particularly troubling health circumstance from an ethical perspective. Because pain is inherently subjective, the experience of pain is influenced by the meaning and values attributed to it by the person in pain 1 Chronic Pain A Health Policy Perspective and the observer 2 . This may result in ambivalence toward pain on the part of healthcare professionals and society at large, whereby medicine is seen as having a duty to relieve the pain and suffering of patients, while patients are expected to be willing and able to endure pain without complaint 2 . Thus, the values of healthcare staff and policy makers deeply affect the quality and quantity of care provided 3, 4 . making ethics of central concern when considering the health policy implications of chronic pain. The very nature of chronic pain -pain that persists disproportionate to objective disease - puts the person who suffers from it at odds with the healthcare system. Chronic pain is often undertreated...

Beneficence

The principle of beneficence places a high value on acting for the benefit of others. The primary focus is benefit to patient, but healthcare decisions may also provide benefits to family members, employers, a variety of others, or even society as a whole, provided that they are also in the best interest of the patient. The most obvious and direct benefit of pain management is the alleviation of suffering, and other benefits may include improved physical, psychological, and social function, reduced demands on caregivers, or more productive work life. The ethical obligation to manage pain and relieve the patient's suffering is at the core of the health professional' s commitment and a fundamental responsibility 2, 9 . Yet chronic pain tends to be undertreated as a result of focus on diagnosis and cure of disease 5, 10 and fear of opioid addiction 6, 11 and regulatory action 12 .

Nonmaleficence

Moreover, doubt concerning the reality of patients' unrelieved chronic pain has allowed concerns about addiction - which appear to be largely unfounded 17 (though contested 18, 19 )-to dominate discussions of treatment, rather than effectiveness 6, 11 . Under the rubric of nonmaleficence, many patients are under-medicated, on the theory that a dosage high enough to produce analgesia will either produce discomfort from side effects that exceeds the discomfort of unrelieved pain, sedation that will undermine quality of life, or respiratory depression that may be life-threatening 2 .

Autonomy

The anxieties generated by being totally at the mercy of others with regard to pain relief are often overwhelming and these anxieties tend to magnify the patient's suffering. The other side of this coin is that such anxieties and amplifications may be largely avoided by allowing the patient to make his own properly informed decisions concerning the quantity and timing of pain relief medication. The possibility of patient abuse in this area is considerably less than many have feared, especially since being in control diminishes pain. Among ethics scholars there is agreement that pain -chronic pain in particular-is undertreated 2, 20 .

Case Study

Psychological stressors are of equal importance in terms of perpetuating a myofascial problem. Although the other perpetuating factors noted in this section may be found on examination or via laboratory testing, psychological problems may not come out easily, as a patient may have no understanding of the ability of such problems to be part of a psychophysiological muscle pain problem. This is one important reason for the utilization of an interdisciplinary treatment team needed to deal with chronic myofascial and other forms of chronic pain.

Summary

Taken together, the studies reviewed above indicate that the transition of acute pain to chronic pain is a complex and poorly understood process. Figure 7.1 illustrates this in the surgical context. The noxious effects of surgery (e.g. incision, retraction, inflammatory response, ectopic activity following nerve injury) in conjunction with the competing, beneficial effects of perioperative, preventive multimodal analgesia interact with pre-existing and concurrent pain, psychological and emotional factors (e.g. catastrophizing, pain coping strategies) as well as the social environment (e.g. solicioutousness, social support) to determine the nature, severity, frequency and duration of CPSP. We are a long way from being able to predict with certainty who will recover uneventfully and who will go on to develop debilitating, chronic pain. Figure 7.1 Proposed model of the process of the transition of acute post surgical pain to chronic pain. Figure 7.1 Proposed model of the process of the...

The Typical Patient

Chronic Pain A Health Policy Perspective Chronic Pain Centre, 2006). She will most likely be in her late forties. She will most likely have completed high school nearly half will have completed further education. She is likely married or in a common law relationship (60 ).

Sadness Depression

Patients with chronic pain suffer losses. Their life is no longer normal. They may no longer obtain enjoyment out of life. They may lose contact with their workmates they may lose their place as an active contributor to family life they may lose intimacy with their partner they may lose self-worth they may lose the future they had planned.

Coping

For most patients with chronic pain there is no cure, so they have to cope with their pain. Some patients seem to cope well despite their pain problem and others clearly do not. Those who cope well may not consult the healthcare system very much, if at all. It is those who appear not to cope well who consult and require

Opioids

There is a growing body of evidence that controlled release opioid analgesics have a role to play in a subset of patients with chronic pain. A recent meta-analysis of 41 randomized controlled trials involving 6019 patients found that opioids were more effective than placebo for both pain and functional outcomes in both noci-ceptive and neuropathic pain -57 , Guidelines for the use of opioid analgesics in chronic pain have been established by the Canadian Pain Society 58 and details regarding treatment using opioids for chronic pain are presented in a recent review 8 . The main message is that opioids are a reasonable and efficacious treatment for people with chronic pain 8 . The average duration of trials was only 5 weeks (range 1-16 weeks) and there is a need for longer term trials examining efficacy and safety parameters. Recommended front line agents include codeine, hydromorphone, morphine, oxycodone, and tramadol used orally on a time contingent basis. Additional options include...

Massage Therapy

Various types of massage (deep transverse friction massage, classical massage and acupressure massage) are advocated for the treatment of chronic pain. Deep transverse friction is a specific type of connective tissue massage and is applied by the finger(s) directly to the painful area, across the direction of the muscle fibers. It can be used after an injury or for mechanical overuse in muscles, tendons and ligaments. In acupressure massage, points on the body are massaged using finger or thumb in a rapid circular motion with medium pressure. Massages last between 5 and 15 minutes. Classical (also known as Swedish) massage includes a variety of techniques specifically designed to relax muscles by applying pressure to them against deeper muscles and bones, and rubbing in the same direction as the flow of blood returning to the heart. It employs five different movements long gliding

Pathophysiology

While FMS is recognized as a chronic pain disorder with the common multiple dimensions of all chronic pain problems it is also associated with CS, neuroendocrine, and autonomic nervous system (ANS) dysfunction. It appears that the main problem is central in origin. Brain-imaging techniques that can detect neuronal activation after nociceptive stimulation also give evidence for abnormal central pain mechanisms in FMS. Brain images corroborated augmented pain experienced by FMS patients during experimental pain stimuli. Thalamic activity, for example, which contributes to pain processing, is found to be decreased in FMS patients (48). It has also been demonstrated that dysfunction of central pain mechanisms is not only secondary to neuronal activation, but also, possibly, neuroglial cell activation, which appears to have an important role in the induction and maintenance of chronic pain (48).

Conclusion

Many different non-drug modalities are used to treat chronic pain. Many have short-term benefit but few have any evidence of long-term benefit and some have no evidence of benefit at all. Often, results appear to be better if modalities are combined and this is particularly so when exercise is combined with other modalities. Generally, most studies are of low quality and small numbers and there is a need to perform high quality studies. Understandably perhaps, many patients with chronic pain are willing to try modality treatments whether or not there is scientific justification for their use and whether or not they are required to pay out of pocket for doing so. There is a wide range of such treatments available. Many of their practitioners make extravagant claims of success and charge high fees. Research studies need to be undertaken to determine whether modalities not covered by this review should be considered when deciding what care to provide to individuals with conditions that...

Recommendations

This does not address all chronic pain sufferers. An analogous process should be considered for those who are eligible for accident benefits under no-fault insurance. The challenge would be bringing together the insurance, primary healthcare, rehabilitation, and attorney stakeholders, with common agreement on a common model. The present accident-benefits model is still inclined toward the tort system which undermines the comprehensiveness and timeliness demonstrated in the Sherbrooke model. Chronic pain patients who are not employed and or who are disabled at the time of first attendance at a specialty clinic represent another challenge. These may yet benefit from clinic-based tertiary care multidisciplinary chronic pain services. Both for community based clinics and for university based clinics that identify themselves as offering pain management, there is a lack of coherence in terms of the treatment model, comprehensiveness, pain interventionist versus rehabilitation focus, waiting...

Background

Chronic pain frequently coexists with a range of emotional symptoms, varying degrees of psychopathology and with mental disorders, and may be an associated symptom of a number of psychiatric illnesses. Pain is widely recognized 1, 2 to have both psychological and physical components, and one of the early pioneers of psychiatry, Sigmund Freud, elaborated on the existence of a mind-body connection at a time when it was not widely endorsed 3 . Chronic pain patients with pronounced psychopathology tend to be complicated and difficult to manage -4 - and furthermore, mentally ill persons are often dis- Chronic Pain A Health Policy Perspective 1. The prevalence and scope of psychiatric illness in chronic pain patients.

Conclusions

To those seen in this group of patients is of great interest, as the LAPS gives a neuro-biological construct that takes into account not only the various clinical hypotheses that account for the physiological nociceptive aspects of FMS and other chronic painful disorders, but also the questions of past history, pre-existing and concurrent psychiatric morbidity, and the close association of the biological, psychological, and sociological (including environmental) aspects of chronic pain. Central sensitization or sensitivity secondary to nociceptive neuroplastic changes (secondary to nociceptive changes in the dorsal horn) as a primary pain mechanism is not an isolated etiology in the production of the various aspects of chronic pain. Recalling that the nociceptive and antinociceptive pathways have a very close anatomical relationship in the CNS with the limbic system, whether one looks at the concept of neuromodules in Melzack's neuromatrix hypothesis or the possibly more encompassing...

Referral

Within healthcare systems in general, a chronic pain patient who wishes to access a specialist or be admitted to a pain clinic must be referred by a GP. Several management issues arise with the referral process, whether for diagnostic testing or treatment. One relates to the primary healthcare provider knowing when and where to refer a patient. A second relates to timely patient access to the next level of care, which can be problematic. For some types of chronic pain (e.g. back pain, complex regional pain syndrome), waiting too long for appropriate diagnosis and treatment contributes to the development of long-term disability. Ideally, a referring GP will explicitly commit to continuing to treat the patient once he she is discharged from specialty care.

Coordination of Care

Care coordination plays an important role in stepped care, an approach to disease management in which patients progressively receive more complex, specialized and, often, costly interventions according to need 29 . We found little specific information pertaining to this aspect of management of chronic pain in the documents reviewed from France. In the VHA, an Office of Care Coordination was established in 2003 to support system-wide implementation of case management and to ensure the right care at the right place at the right time 30 . The home is recognized as the preferred place of care when possible, and services incorporate the use of computerized patient records, telehealth technologies and an emphasis on patient self-management 31 . The 2005-2009 care coordination strategic plan focuses on elderly veterans and those with mental health problems, as well as care coordination training and program evaluation 32 . The Care Coordination Home Telehealth program in one service region in...

Process

An interdisciplinary approach-in which health professionals from different disciplines work together to provide care, as needed for the individual case -is ideal for management of chronic pain at all levels of the healthcare system. This includes links between primary care physicians and physical medicine rehabilitation practitioners, as well as collaboration between multiple care providers in specialized clinics. Chronic pain patients need to be viewed as part of the solution in that they require education about pain, including self-management strategies.

Outcomes

As for all other types of patients, it is important that outcomes experienced by chronic pain patients are systematically assessed. Outcomes that should be considered in the case of chronic pain may be different to those traditionally used for other patient groups where cure is more likely. When chronic pain structures and processes of care are altered, there is a need to collect relevant baseline and follow-up data in order to monitor program implementation and examine the impact of these elements on outcomes for patients and care providers.

Context

In comparison, health conditions such as chronic pain, which at first glance do not seem to have a visible impact on the life or health of individuals, and which do not receive sufficient media coverage to provoke a society-wide reaction, are faced with greater difficulty from the outset as regards being recognized as a health problem that needs a solution. For the public decision makers concerned, who in all likelihood hold this view as well, the need to tackle the phenomenon of chronic pain is not immediately evident. Additionally, because the advances in effective treatments for chronic pain

Capsaicin

Capsaicin is a C-fiber-specific neurotoxin and is one of the components of hot peppers that produces a burning sensation on contact with mucous membranes. Topical preparations are available over the counter and are widely used for chronic pain syndromes. Capsaicin is a vanilloid receptor agonist and activates ion channels on C fibers that are thermotransducers of noxious heat (> 43 C) (316). With repeated application in sufficient quantities, capsaicin can inactivate primary afferent

Cannabinoids

The potent anti- nociceptive and antihyperalgesic effects of cannabinoid agonists in animal models of acute and chronic pain, the presence of cannabinoid receptors in pain- processing areas of the brain, spinal cord and periphery and evidence supporting endogenous modulation of pain systems by cannabinoids, provide support that cannabinoids exhibit significant potential as analgesics. Fifteen of eighteen randomized controlled trials examining cannabinoids in the treatment of pain have demonstrated a significant analgesic effect. Table 9.3 presents further detail. Cannabinoid agents tested included synthetic analogs as well as cannabis and cannabis-based extracts. These agents were tested in a number of pain conditions. Taken together, the evidence supports that cannabinoids exhibit a moderate analgesic effect in neuropathic pain and cancer pain with preliminary evidence for action in other types of pain such as spinal pain and headache. In Canada there are four cannabinoid agents...

Psychophysical Studies Of Visceral Sensation

To determine whether uncontrolled clinical observations are indeed representative of responses evoked by visceral pain rather than a nonspecific characterization of chronic pain, psychophysical studies have been performed using controlled visceral and nonvisceral stimuli in both healthy subjects and those with clinical diagnoses of painful visceral disorders. Visceral stimuli have included chemical, electrical, thermal, and mechanical stimuli (15). Most studies have not attempted to compare responses to visceral stimuli with those evoked by cutaneous stimuli in a side-by-side comparison. An exception to this is a study by Strigo et al. (16), which directly compared sensations evoked by balloon distension of the esophagus with sensations evoked by thermal stimulation of the midchest skin. Using graded intensities of both distending and thermal stimuli, it was possible to match the intensity of evoked sensations produced at the two different sites. Consistent with clinical lore,...

Principles of Pediatric Pain Management

Third, give analgesics by pain intensity. Mild-to-moderate pain should be managed with nonsteroidal anti-inflammatory drugs (NSAIDs) and oral weak opioids. Severe pain is managed by oral strong opioids or intravenous opioids and regional blockade techniques. Transdermal systems of opioids have little application in acute pain but are continued if the patient with chronic pain receiving this technique is admitted for acute exacerbation of pain.

Use in Prevention and Therapy

Because thiamin deficiency can reduce pain tolerance, supplemental thiamin may ease chronic pain. Thiamin may be effective in peripheral neuropathy,5 particularly in inflammatory nerve disorders (such as trigeminal neuralgia). It may also be effective in diabetic neuropathy.

Pain Measurement by Methods Other Than Self Report

One of the formal behavioral observation tools is the Gauvain-Piquard scale developed for the measurement of chronic pain in children 2-6 years old with cancer. Fifteen items have a 0-4 scale with nine items specific to pain assessment, six indicative of psychomotor retardation, and four relating to anxiety are included in the revised version. A score greater than 12 of a possible maximum score of 60 is indicative of pain (22).