Jane C. Ballantyne

Core competencies for pain management: Results of an interprofessional consensus summit

Objective The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported. Methods An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached. Results The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain. Conclusions These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

Intensity of Chronic Pain — The Wrong Metric?

Borrowing treatment principles from acute and end-of-life pain care, particularly a focus on pain intensity, has had harmful consequences for patients with chronic pain. Multimodal therapy, by contrast, aims to reduce pain-related distress, disability, and suffering.

Personalized medicine and opioid analgesic prescribing for chronic pain: opportunities and challenges.

UNLABELLEDnUse of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. There is currently no well-validated objective means of accurately identifying patients likely to experience good analgesia with low side effects and abuse risk prior to initiating opioid therapy. This paper discusses the concept of data-based personalized prescribing of opioid analgesics as a means to achieve this goal. Strengths, weaknesses, and potential synergism of traditional randomized placebo-controlled trial (RCT) and practice-based evidence (PBE) methodologies as means to acquire the clinical data necessary to develop validated personalized analgesic-prescribing algorithms are overviewed. Several predictive factors that might be incorporated into such algorithms are briefly discussed, including genetic factors, differences in brain structure and function, differences in neurotransmitter pathways, and patient phenotypic variables such as negative affect, sex, and pain sensitivity. Currently available research is insufficient to inform development of quantitative analgesic-prescribing algorithms. However, responder subtype analyses made practical by the large numbers of chronic pain patients in proposed collaborative PBE pain registries, in conjunction with follow-up validation RCTs, may eventually permit development of clinically useful analgesic-prescribing algorithms.nnnPERSPECTIVEnCurrent research is insufficient to base opioid analgesic prescribing on patient characteristics. Collaborative PBE studies in large, diverse pain patient samples in conjunction with follow-up RCTs may permit development of quantitative analgesic-prescribing algorithms that could optimize opioid analgesic effectiveness and mitigate risks of opioid-related abuse and mortality.

Must we reduce pain intensity to treat chronic pain

The idea that physicians have a duty to relieve human suffering dates back to antiquity. However, the notion that suffering can be quantified and monitored as a pain level is a much more recent development. A corollary to this quantitative approach to pain assessment is the notion that pain treatment should be “titrated to effect” on a measured pain intensity level. The titrate to effect principle was developed for treating acute and cancer pain, but was then extended to outpatient treatment of chronic noncancer pain. Because opioids have no strict ceiling dose and may produce rapid and marked reductions in pain intensity, they are uniquely suitable for titrating to effect. The idea that opioids should be used at whatever dose produces a satisfactory reduction in pain intensity, and especially the extension of this principle to chronic pain treatment, has led to dramatic increases in opioid prescribing in many developed countries. Unfortunately, this increased use has been accompanied by increases in opioid abuse, overdose, and death without any significant easing of the population burden of chronic pain. In this article, we will argue that focusing on pain intensity for the assessment and care of patients with chronic pain (1) establishes the wrong goal for care, (2) results in the selection of the wrong patients for the strongest analgesics, and (3) retards our understanding of chronic pain. Let us consider our duty toward the following patient: Mr. Harris is a 41-year-old man who has had axial low back pain for 1 year. He has just moved into town and comes for his first appointment with you, his new primary care physician. A previous lumbar magnetic resonance imaging showed a disk bulge at L5–S1 and some degenerative changes at the other levels, but there is no evidence on physical examination for nerve root irritation. He rates his average pain intensity as 10/10. He takes oxycodone sustained-release 20 mg b.i.d, which used to provide him significant relief, but no longer does. He wants his opioids increased until they relieve his pain. He explains that this was the treatment goal that he agreed onwith his previous physician, who had called it the titrate to effect principle.When you express doubt as to whether an opioid dose increase is the right treatment, he responds, “Don’t you believe I am in pain? Don’t you believe that I deserve relief? Do you just want me to suffer?” You are confused. You do believe Mr. Harris is in pain and deserves relief, but you doubt that escalating his opioid dosewill provide him a lasting and overall benefit. 1. Establishing the right to pain relief

“Safe and Effective When Used As Directed”: The Case of Chronic Use of Opioid Analgesics

Opioid analgesics have been used increasingly over the past 20xa0years for the management of chronic non-cancer pain in the USA under the assumption that they were safe and effective when used as directed. The accuracy of that assumption has not been tested against accumulated evidence. The safety of opioids used on a long-term basis has not been tested in clinical trials. Epidemiologic evidence from examinations of such use in the general population indicates that the risk of overdose increases in a dose–response manner. Such evidence also suggests increased risk of fractures and acute myocardial infarctions among elderly users of opioids for chronic pain. Experimental evidence supports short-term use of opioids, but trials of long-term use for chronic pain have not been conducted. Epidemiologic evidence suggests that long-term use does not result in improvement in function or quality of life while being associated with significant dropout rates and a high prevalence of adverse drug effects. Substantial fractions of patients are not using opioid analgesics as directed, while millions of US residents are using them without a prescription for nonmedical reasons. A prudent treatment approach consistent with the available evidence would be to reserve chronic opioid therapy for serious pain-related problems for which the effectiveness of opioids has been demonstrated and for patients whose use as directed is assured through close monitoring and for whom an explicit, informed calculation has been made that the benefits of opioids outweigh the risks.

Opioid Dependence vs Addiction: A Distinction Without a Difference?

A Distinction Without a Difference? B IOLOGICALLY, OPIOID addiction can be understood in terms of neuroadaptations that arise when exog-enous opioids are taken continuously and long-term. 1 Tolerance and dependence are 2 such central adaptations. Tolerance is the need to increase dose to achieve the same effect , and dependence is the physi-ologic response either to an uncom-pensated increase in tolerance or to the withdrawal of a drug. 2 Tolerance may develop for both the eu-phoric and the analgesic effects of opioids and can be produced by psychological as well as pharmacological factors. Dependence is manifest as withdrawal symptoms (eg, sweating , anxiety, insomnia) that are caused by rebound at central nor-adrenergic nuclei, and the less well-understood effects of hyperalgesia (increased pain sensation) and an-hedonia (inability to feel pleasure). 3,4 Withdrawal hyperalgesia and anhe-donia may explain the worsening of pain and mood that is seen during an opioid taper or after detoxifica-tion. Withdrawal symptoms are powerful drivers of opioid seeking, which in turn can be induced by factors that change tolerance (Figure). Addiction is further defined by aberrant opioid-seeking behaviors that, when persistent, result in irreversible changes in the brain. 1 Standard drug addiction criteria have long been unsatisfactory when attempting to characterize iatro-genic addiction. 5 For the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, tolerance and withdrawal (physical dependence) will be specifically excluded from the diagnostic criteria for substance use disorder that arises during medical drug treatment, so that the diagnosis will be based solely on aberrant behaviors. 6 For pain patients , drug-seeking behaviors are different from behaviors that are listed by standard criteria and are fo-cused on obtaining opioids from pre-scribers. Aberrancy in pain patients may include doctor shopping, frequent lost prescriptions, and repeated requests for early prescriptions , while the behaviors listed in the fourth or fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, eg, failure to fulfill major role obligations at work, school or home, tend to be attributed to pain rather than to addiction. In fact, pain patients who are treated continuously with opioids may not manifest any aberrant behaviors because they are effectively receiving maintenance therapy, which suppresses craving. However , when opioids are suddenly not available, tolerance occurs, or attempts are made to taper, craving and addiction behaviors emerge. Recent teaching has been that this should be thought of as pseudoad-diction, a misleading …

WHO analgesic ladder: a good concept gone astray

Our mistake is to treat chronic pain as if it were acute or end of life pain

Opioid Therapy in Chronic Pain

Opioids remain the strongest and most effective analgesics available. The downside is that they are addictive and potentially dangerous. Throughout history, although recognizing the value of opioids in treating serious pain, especially acute pain and pain at the end of life, there has been caution about using opioids to treat chronic pain. This article presents how opioids should be used to treat chronic pain considering recent concerns about their efficacy and safety.

Research design considerations for single-dose analgesic clinical trials in acute pain: IMMPACT recommendations

This article summarizes the results of a meeting convened by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) on key considerations and best practices governing the design of acute pain clinical trials. We discuss the role of early phase clinical trials, including pharmacokinetic-pharmacodynamic (PK-PD) trials, and the value of including both placebo and active standards of comparison in acute pain trials. This article focuses on single-dose and short-duration trials with emphasis on the perioperative and study design factors that influence assay sensitivity. Recommendations are presented on assessment measures, study designs, and operational factors. Although most of the methodological advances have come from studies of postoperative pain after dental impaction, bunionectomy, and other surgeries, the design considerations discussed are applicable to many other acute pain studies conducted in different settings.

Assessing the prevalence of opioid misuse, abuse, and addiction in chronic pain.

In their systematic review, Vowles et al. 16 tackle the debatably impossible task of estimating the prevalence of opioid misuse, abuse, and addiction in chronic pain. Theymake their assessments utilizing rate estimates from the literature (this literature happens to bemostly aUnitedStates literature).Why impossible—because it is hard to understand what addiction actually is when it arises during pain treatmentwith opioids. Rather sensibly, the authors use broad categories where “misuse” is using opioid not as prescribed, “abuse” is intentional use for nonmedical purpose, and “addiction” is compulsive use (see article for more complete descriptions). These definitions are based on recent consensus statements from expert panels and additional expert opinion. The authors do not get bogged down in language used in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and International Classification of Diseases where “abuse” and “dependence” carried different meanings to those generally understood and confused people’s understanding of addiction, as well confounding efforts to quantify addiction prevalence. Perhaps not surprisingly, given the difficulty we have with agreeing on definitions or understanding what addiction is when it arises during the treatment of pain with opioids, rates of problematic use extracted from studies are broad ranging (from,1% to 81%). Abuse is reported in only one study, while average rates of misuse range from 21% to 29% and average rates of addiction range from 8% to 12%. This is useful information in terms of understanding the scale of misuse and addiction. But, could rates of addiction have been underestimated because there cannot be clear distinctions between misuse and addiction, despite the apparent clarity of the definitions? The neural processes of opioid addiction have been learned from animal and human studies in subjects that are receiving opioids not as pain treatment, but for other purposes. In the case of human studies, subjects have generally been using opioids for recreational purposes. What is known from such studies is that adaptations in the rewardcenter in thebrain (themesocorticolimbic system) and in central noradrenergic nuclei result in the state of dependence whereby unpleasant psychological and physical symptoms result in a need to obtain opioid should levels decline or needs increase. Dependence is known to be a powerful driver of opioid-seeking behavior. In fact, established opioid addicts seek opioids not to provide euphoria but to avoid dysphoria and other unpleasant symptoms. What turns opioid seeking for the relief of withdrawal into the state of compulsive opioid seeking that defines addiction is not fully understood, but irreversibility is a feature, and is believed to be due to the secondary process of memory formation (memory, ie, of obtaining or procuring drug) in structures such as the amygdala, hippocampus, and cerebral cortex. In the case of recreational or illicit use of opioids, dependence without addiction does not arise because the progression in this case is fairly clear from occasional use involving procurement but without dependence, through repeated procurement, to addiction with dependence. Because in the case of recreational or illicit use, the user must obtain or procure the drug, the clinical picture and the underlying drivers of addiction are relatively straightforward and well established. Not so in the case of opioid treatment of chronic pain. While there are similarities in that dependencewill developwith continued use and will similarly be a powerful driver of opioid seeking (in fact dependence will be responsible for the state aptly described by patients themselves whereby they believe that they need opioids even when they have stopped providing good pain relief: “you see, they work, when I stop them, I get worse”). But in the case of chronic pain treatment, there are many other drivers of opioid seeking.Not least, of course, is seekingpain relief, but patientswith pain could alsobe looking for relief of anxiety, depression, stress, or existential suffering. Patients having pain are typically prescribed opioids; therefore, they do not need to procure them. This has 2 implications: one that dependence may develop without addiction because there may be long-term use without aberrant behaviors; and second that the progression toward and the factors underlying addiction when it does occur are extremely complex. In fact, do we really know when the dependence that arises in opioid-treated pain patients becomes addiction? Does the absence of the defining characteristics of impaired control over drug use, compulsive use, continued use despite harm and craving mean asmuch in a person essentially maintained on opioids, as it does in a person needing to procure drug? And where in the large gray zone between clearly addicted and clearly not addicted, can a line be drawn that not only clearly defines addiction but would also define who is suitable for addiction treatment, or at least addictiontype treatment? Rather than trying to identify such a line or to distinguish betweenmisuse, abuse, and addiction, itmay be better to accept that the state of dependence (which could variously be manifest asmisuse, abuse, or addiction), or what has been termed “complex persistent dependence” (a state of dependence that, like addiction, does not easily reverse), is akin to addiction and worthy of addiction-type treatment. Vowles et al. end their article with the comment that it is not certain whether the unclear benefits derived from opioids compensate for the additional burden of the “unintended” consequences to patients and health care systems. Adaptations Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.