Edward A. Shipton

Psychosocial adjustment and physical health of children living with maternal chronic pain

Aim:  There is limited research examining the functioning of children living with parental chronic pain and illness. The aim of this study was to examine the psychosocial adjustment and physical health of children living with a mother experiencing chronic pain.

POST‐SURGICAL NEUROPATHIC PAIN

Surgeons and anaesthetists are involved in Pain Medicine, as they have a responsibility to contribute to postoperative pain management and are often consulted about longer‐term pain problems as well. A large component of persistent pain after surgery can be defined as neuropathic pain (NP). Nerves are injured during surgery and pain can persist after the surgical wound has healed. NP is because of a primary lesion or dysfunction of the peripheral or central nervous system. Prevalence estimates indicate that 2–3% of the population in the developed world experience NP. Persistent post‐surgical NP is a mostly unrecognized clinical problem. The chronicity and persistence of post‐surgical NP is often severely debilitating and impinges on the psychosocial, physical, economic and emotional well‐being of patients. Options for treatment of any neuropathic factors are based on understanding the pain mechanisms involved. The current understandings of the mechanisms involved are presented. There is reasonable evidence for the efficacy of pharmacological management for NP. The aim of this article was to appraise the prevention, diagnostic work‐up, the physical and particularly the pharmacological management of post‐surgical NP and to provide a glimpse of advances in the field. It is a practical approach to post‐surgical NP for all surgeons and anaesthetists. The take‐home message is that prevention is better than waiting for post‐surgical NP to become persistent.

Potential Risk Factors for the Onset of Complex Regional Pain Syndrome Type 1: A Systematic Literature Review

Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.

Vitamin D Deficiency and Pain: Clinical Evidence of Low Levels of Vitamin D and Supplementation in Chronic Pain States

IntroductionA number of studies suggest a link between low levels of 25-hydroxy vitamin D and incidence of acute and chronic pain. Clinical studies of vitamin D supplementation in patients with known vitamin D deficiency have shown mixed results in improving pain scores.MethodsIn this article, vitamin D deficiency risk factors are observed and adequate levels of 25-hydroxy vitamin D defined. Clinical supplementation with vitamin D is explored, including the schedules used in published clinical trials. Evidence of the effectiveness of vitamin D supplementation for the treatment of chronic pain conditions from double-blind randomized controlled trials (RCTs) is examined.ResultsThe scientific evidence for vitamin D as a treatment option for chronic pain is limited due to lack of RCTs. It cannot be stated conclusively that vitamin D deficiency is directly linked to the etiology or maintenance of chronic pain states.ConclusionThere remains a growing body of both clinical and laboratory evidence pointing to a potential relationship between low levels of 25-hydroxy vitamin D and a variety of chronic pain states. More focused research involving large RCTs is necessary.

New formulations of local anaesthetics-part I.

Part 1 comments on the types of local anaesthetics (LAs); it provides a better understanding of the mechanisms of action of LAs, and their pharmacokinetics and toxicity. It reviews the newer LAs such as levobupivacaine, ropivacaine, and articaine, and examines the newer structurally different LAs. The addition of adjuvants such as adrenaline, bicarbonate, clonidine, and corticosteroids is explored. Comment is made on the delivery of topical LAs via bioadhesive plasters and gels and controlled-release local anaesthetic matrices. Encapulation matrices such as liposomes, microemulsions, microspheres and nanospheres, hydrogels and liquid polymers are discussed as well. New innovations pertaining to LA formulations have indeed led to prolonged action and to novel delivery approaches.

Vitamin D and Pain: Vitamin D and Its Role in the Aetiology and Maintenance of Chronic Pain States and Associated Comorbidities.

The emergence of new data suggests that the benefits of Vitamin D extend beyond healthy bones. This paper looks at Vitamin D and its role in the aetiology and maintenance of chronic pain states and associated comorbidities. The interfaces between pain and Vitamin D and the mechanisms of action of Vitamin D on pain processes are explored. Finally the association between Vitamin D and pain comorbidities such as sleep and depression is investigated. The paper shows that Vitamin D exerts anatomic, hormonal, neurological, and immunological influences on pain manifestation, thereby playing a role in the aetiology and maintenance of chronic pain states and associated comorbidities. More research is necessary to determine whether Vitamin D is useful in the treatment of various pain conditions and whether or not the effect is limited to patients who are deficient in Vitamin D.

Demographic Characteristics, Psychosocial Measures, and Pain in a Sample of Patients with Persistent Pain Referred to a New Zealand Tertiary Pain Medicine Center

OBJECTIVE Little is known on epidemiology of chronic pain in New Zealand. Its management has been based on data and models in North American/European studies. This project evaluated demographic and psychosocial correlates of pain severity, duration, and disability (PSDD) in chronic pain patients for assessment at a New Zealand tertiary care Pain Medicine Center. DESIGN AND SETTING This study was a retrospective, cross-sectional analysis on existing clinical assessment data (audit) collected over an 18-month period. METHODS Pre-admission data were collected on a consecutive series of 874 patients presenting for assessment. ASSESSMENT TOOLS This included demographic (gender, educational attainment, ethnicity) and psychosocial data. Pain severity was measured by numerical rating scale and present pain intensity using McGill Pain Questionnaire. Duration was measured in months. Disability was measured by using Pain Disability Index and depression using the Center for Epidemiological Studies Depression Scale. Distress was measured using the Kessler Psychological Distress Scale and self-efficacy using the Pain Self-Efficacy Questionnaire. Catastrophizing was measured by Coping Strategies Questionnaire and pain acceptance by the Pain Solutions Questionnaire. RESULTS No difference was found in mean values of all PSDD between genders and between ethnicities. Years of education did not form an important correlate of PSDD. Catastrophizers experienced more pain and were more disabled. Patients with severe pain experienced greater distress. Depressed patients were more disabled. Patients presenting with a high degree of self-efficacy were likely to have lower pain levels and to be less disabled. Level of acceptance of pain was positively associated with reported duration of pain and negatively associated with total disability. CONCLUSION Through this study, more is now known about effects of chronic pain on New Zealanders. The use of validated psychometric testing enables proper assessment and informs clinical management for chronic pain patients.

Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain.

There are no comparative randomised controlled trials of physiotherapy modalities for chronic low back and radicular pain associated with multilevel fusion. Physiotherapy-based rehabilitation to control pain and improve activation levels for persistent pain following multilevel fusion can be challenging. This is a case report of a 68-year-old man who was referred for physiotherapy intervention 10 months after a multilevel spinal fusion for spinal stenosis. He reported high levels of persistent postoperative pain with minimal activity as a consequence of his pain following the surgery. The physiotherapy interventions consisted of three phases of rehabilitation starting with pool exercise that progressed to land-based walking. These were all combined with transcutaneous electrical nerve stimulation (TENS) that was used consistently for up to 8 hours per day. As outcome measures, daily pain levels and walking distances were charted once the pool programme was completed (in the third phase). Phase progression was determined by shuttle test results. The pain level was correlated with the distance walked using linear regression over a 5-day average. Over a 5-day moving average, the pain level reduced and walking distance increased. The chart of recorded pain level and walking distance showed a trend toward decreased pain with the increased distance walked. In a patient undergoing multilevel lumbar fusion, the combined use of TENS and a progressive walking programme (from pool to land) reduced pain and increased walking distance. This improvement was despite poor medication compliance and a reported high level of postsurgical pain.

Deaths from Opioid Overdosing: Implications of Coroners’ Inquest Reports 2008–2012 and Annual Rise in Opioid Prescription Rates: A Population-Based Cohort Study

IntroductionIn the late 1990s multiple physicians and advocacy organizations promoted increased use of opioids for the treatment of acute, chronic and cancer pain. There has been an exponential growth in opioid prescribing in the last 20 years in the United States of America, in Australia, and in other developed Western countries. There are negative consequences associated with the liberal use of opioids. The primary aim of this population-based cohort study is to investigate the opioid-related death rate in New Zealand between 1 January 2008 and 31 December 2012. The secondary aims of this cohort study are: (1) to compare the opioid-related death rate per population in New Zealand in 2001/2002 with that between 2011/2012; (2) to investigate the number of opioid prescriptions in New Zealand between 2001 and 2012; (3) to compare the opioid-related death rate per population in New Zealand between 2001 and 2012 with the number of opioid prescriptions in New Zealand between 2001 and 2012.MethodsPermission to access records from the Coronial Services Office in Wellington for 2008–2012 was acquired. Permission to access records for prescriptions containing opioids (dose and formulation) was obtained from the Pharmaceutical Collection.ResultsThe rate of opioid-related deaths in New Zealand has increased by 33% from 2001 to 2012. More than half of the opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses. Opioid analgesic deaths were most likely due to methadone, morphine and codeine prescribed by healthcare professionals. That 179 of these opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses, and thus could have been avoided, is tragic. This study shows that there was a steady annual increases in opioid prescriptions in New Zealand from 2001 to 2012. This rise in opioid analgesic deaths was associated with the increases in the numbers of opioid prescriptions.ConclusionA multifaceted national public health approach is needed to bring together the various stakeholders involved with pain management, opioid dependence, opioid availability and opioid diversion. There needs to be a targeted approach to educate current and future medical practitioners regarding the appropriate use of opioid prescriptions for the management of pain, as well as a strengthening of primary, secondary and tertiary resources to support medical practitioners managing their patients who suffer with pain.

Should doctors be allowed to prescribe cannabinoids for pain in Australia and New Zealand

Clarification is needed around the use of cannabis in chronic pain. In Australia and New Zealand, general practitioners are routinely faced with patients who smoke cannabis for ‘so called’ medicinal reasons. Criminal drug laws in all Australian States continue to prohibit the possession, cultivation and supply of cannabis – even for medical purposes. In Australia, a parliamentary committee is recommending that the New South Wales Government amend legislation to allow the medical use of cannabis by patients with a terminal illness and those who have moved from HIV infection to AIDS (Legislative Council, 2013). The recommendation, if adopted by the Government, will allow patients with specific medical conditions certified by their specialist treating medical practitioner to possess and use up to 15 grams of dry cannabis or the equivalent amount of other cannabis products and equipment (Legislative Council, 2013). The inquiry by the Legislative Council’s General Purpose Standing Committee No. 4 was established in November 2012 to examine the efficacy and safety of cannabis for medical purposes. The Committee believed that people who are at the end of their life and take measures to either relieve their severe pain or stimulate their appetite should not be criminalised (Legislative Council, 2013). The medicinal use of cannabis has been much debated in New Zealand. It has been estimated that 13.4% of those between the ages of 16 and 64 years in New Zealand use cannabis (United Nations Office on Drugs and Crime, 2006). In New Zealand, the use of cannabis is governed by the Misuse of Drugs Act 1975. Unauthorised possession of any amount of cannabis is illegal. In 2006, Metiria Turei from the New Zealand Green Party proposed the ‘Misuse of Drugs (Medicinal Cannabis) Amendment Bill’, whereby cannabis would be allowed for medicinal use (New Zealand Parliament, 2009). The bill was defeated. Calls are being made for the legalisation of cannabis, citing its compassionate use for alleviation of a number of ailments. The Law Commission’s Issues Paper on ‘Controlling and Regulating Drugs’ recommends those suffering from chronic or debilitating illnesses be able to use cannabis under medical supervision, particularly where conventional treatment options have proven ineffective (Law Commission, 2010). Pressure is being placed on the judicial system to condone its medicinal use. In March 2012, Victoria Davis was discharged without conviction by Judge Tony Zohrab on charges of cultivating cannabis. She grew the plants to help her husband cope with phantom pain. The New Zealand Medical Association does not oppose partial decriminalisation of the use of small amounts for medical purposes, provided it can be shown that no harm would result. In New Zealand, all injured patients are covered by accident compensation insurance. The Accident Compensation Corporation in New Zealand has been requested to fund synthetic cannabis (nabiximols or Sativex®) for chronic pain, where conventional treatments have failed or are not tolerated. At present, Sativex® is approved for use as an add-on treatment for symptom improvement in unresponsive patients with spasticity due to multiple sclerosis under strict medical supervision after ministerial approval has been granted. The types of synthetic cannabinoids used are shown in Table 1.