Malcolm Hogg

Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia.

Objectives: To document and describe outpatient persistent pain management services in Australia.

Predictors of Pain 12 Months after Serious Injury

OBJECTIVE The majority of patients will report pain 12 months after a serious injury. Determining the independent risk factors for pain after serious injury will establish the degree to which high-risk patients can be detected in the acute setting and the viability of early triage to specialist pain services. DESIGN A prospective cohort study of patients following serious injury was conducted. The initial assessment comprised a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed at 12 months for pain severity and for the presence of chronic pain. RESULTS Two hundred ninety patients underwent an initial assessment of whom 238 (82%) were followed up at 12 months. At 12 months, 171 (72%) patients reported some pain over the past 24 hours. Thirty-five patients (14.7%) reported chronic pain. Five factors independently predicted the 24-hour pain severity: preinjury physical role function, preinjury employment status, initial 24 hours pain score, higher beliefs in the need for medication, and compensable injury (R(2) = 0.21, P < 0.0001). Four factors predicted the presence of chronic pain at 12 months: not working prior to injury, total Abbreviated Injury Scale, initial pain severity, and initial pain control attitudes (pseudo R(2) = 0.24, P = 0.0001). CONCLUSIONS Factors present at the time of injury can allocate patients into high- or low-risk groups. The majority of cases of chronic pain emerging from the high-risk group warrant more intense clinical attention. We recommend recording these factors in discharge documentation as indicators of persistent pain.

Predictors of Pain Severity 3 Months after Serious Injury

OBJECTIVE Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.

Determinants of Chronic Pain 3 Years after Moderate or Serious Injury

OBJECTIVE Patients with pain 3 years after injury are at risk of lifetime pain. It is not known if the predictors of chronic pain at 3 years are the same as those for earlier time points or whether other factors become important. Clarifying these factors will aid our understanding of the development of long-term pain and further inform the development of models for screening and early intervention for pain in the aftermath of injury. DESIGN Patients admitted to two trauma centers underwent a comprehensive physical and psychological assessment of known and potential risk factors for chronic pain during their index admission. Three years after injury, these patients were assessed for the presence of chronic pain (score was ≥5 on an 11-point numerical rating scale during the last episode of pain, and present in the last month and at least two times in the past week) and pain-related disability. Logistic regression was used to identify independent risk factors for the presence of chronic pain and disability. RESULTS Two hundred and twenty patients (75.9% of the original cohort) were assessed at 3 years. Of these, 146 (66.7%) reported some pain and 52 (23.7%) reported chronic pain. Factors (present at the time of injury) that predicted chronic pain were lower socioeconomic status, pain severity, and injury severity. The predictive power of these combined factors was modest. CONCLUSIONS Three years after serious injury, almost a quarter of patients report chronic pain, and more than a third report at least moderate pain-related disability. The predicative power of measures taken in the acute setting is not enough to support discharge screening alone as a method of triaging high-risk patients to early intervention.

Effect of electroacupuncture on opioid consumption in patients with chronic musculoskeletal pain: protocol of a randomised controlled trial.

AbstractBackgroundChronic musculoskeletal pain is common and has been increasingly managed by opioid medications, of which the long-term efficacy is unknown. Furthermore, there is evidence that long-term use of opioids is associated with reduced pain control, declining physical function and quality of life, and could hinder the goals of integrated pain management. Electroacupuncture (EA) has been shown to be effective in reducing postoperative opioid consumption. Limited evidence suggests that acupuncture could assist patients with chronic pain to reduce their requirements for opioids.The proposed research aims to assess if EA is an effective adjunct therapy to standard pain and medication management in reducing opioids use by patients with chronic musculoskeletal pain.MethodsIn this multicentre, randomised, sham-acupuncture controlled, three-arm clinical trial, 316 patients regularly taking opioids for pain control and meeting the defined selection criteria will be recruited from pain management centres and clinics of primary care providers in Victoria, Australia. After a four-week run-in period, the participants are randomly assigned to one of three treatment groups to receive EA, sham EA or no-EA with a ratio of 2:1:1. All participants receive routine pain medication management delivered and supervised by the trial medical doctors. Twelve sessions of semi-structured EA or sham EA treatment are delivered over 10 weeks. Upon completion of the acupuncture treatment period, there is a 12-week follow-up. In total, participants are involved in the trial for 26 weeks. Outcome measures of opioid and non-opioid medication consumption, pain scores and opioid-related adverse events are documented throughout the study. Quality of life, depression, function, and attitude to pain medications are also assessed.DiscussionThis randomised controlled trial will determine whether EA is of significant clinical value in assisting the management of debilitating chronic pain by reducing opioids consumption and their associated adverse events, as well as improving the quality of life for those with chronic pain. Such an outcome will provide the rationale for including EA into multidisciplinary programmes for effective management of chronic musculoskeletal pain.Trial registrationAustralian New Zealand Clinical Trial Registry (ACTRN12609000676213) http://www.anzctr.org.au/trial_view.aspx?ID=308008

Persistent disability is a risk factor for late-onset mental disorder after serious injury

Background: Most of what we know about the psychiatric consequences of injury is limited to the first year. Determining the prevalence of and risk factors for psychiatric morbidity beyond one year will aid service development and facilitate timely diagnosis and treatment. The aim of this prognostic study was to determine the prevalence of mental disorders in the three years following serious injury and to identify risk factors for the onset of new disorders after 1 year. Methods: Of 272 patients assessed in hospital following serious injury, 196 (72.1%) were reassessed at 3 years. Assessment involved gold standard semi-structured interviews for psychiatric diagnoses, risk factors for mental disorder, injury measures and pain scores. Results: More than a quarter of all patients were diagnosed with at least one mood or anxiety disorder at some stage during the three years following their injury. The most common diagnoses were major depression (20.0%), generalised anxiety disorder (6.7%) and panic disorder (6.7%). For a third of these patients, the disorder appeared after 12 months, for which persistent physical disability was an independent risk factor. Conclusion: Although there is a necessary focus on the early detection and treatment of mental disorders after injury, attention to later onset disorders is also required for those with persistent pain and physical disability.

Effects of Electroacupuncture on Opioid Consumption in Patients with Chronic Musculoskeletal Pain: A Multicenter Randomized Controlled Trial

Objectives To evaluate the efficacy and safety of electroacupuncture in reducing opioid consumption in patients with chronic musculoskeletal pain. Design A randomized, participant-assessor-blinded, three-arm trial. Setting Participants from three pain clinics and from the public. Subjects One hundred and eight adults with chronic pain who were taking opioids. Methods All participants received pain and medication management education. Participants were randomly allocated to electroacupuncture (N = 48), sham electroacupuncture (N = 29), or education alone (N = 31) to receive relevant treatment for 12 weeks. The last group received electroacupuncture during the three-month follow-up. Analysis of covariance and paired t tested were used. Results Opioid dosage, that is, the primary outcome measure, was reduced by 20.5% (P < 0.05) and 13.7% (P < 0.01) in the two acupuncture groups and by 4.5% in the education group at the end of the treatment phase, but without any group difference. Intensity of pain of all three groups did not change over time. No group differences were found in dosage of nonopioid analgesics, pain intensity, function, and opioid-related adverse events. During follow-up, the education group had a 47% reduction of opioids after a course of electroacupuncture. Adverse events to electroacupuncture were minor. Conclusion It is safe to reduce opioid medication use in patients with chronic pain. Due to the small sample size, we could not confirm if electroacupuncture offers extra benefit in addition to education. This nondrug therapy could be a promising adjunct to facilitate opioid tapering in patients who are willing to reduce opioids.

Time to reconsider steroid injections in the spine

MJA 199 (11) · 16 December 2013 754 Before impeaching facet joint injections and medial branch blocks, and thereby medial branch neurotomies, as well as lumbar transforaminal epidural steroid injections, Harris and Buchbinder should consider: • interprofessional patient-centred approaches are key; • pharmacological management is often ineffective; • their view does not reflect the current practice of Australian pain medicine physicians; • these procedures help people struggling to continue in social roles and maintain quality of life, so they help to reduce the economic impact of spinal pain on Australian society. We support education to improve evidence-based practice of interventional procedures.