Mark A. Ware

The Canadian STOP-PAIN project - Part 1: Who are the patients on the waitlists of multidisciplinary pain treatment facilities?

PurposeThe Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This article presents the patients’ bio-psycho-social profile.MethodsA sample of 728 patients was recruited from waitlists of eight university-affiliated MPTFs across Canada. Subjects completed validated questionnaires to: 1) assess the characteristics and impact of their pain; and 2) evaluate their emotional functioning and quality of life (QoL). Follow-up questionnaires were completed by a subgroup of 271 patients three months later.ResultsClose to 2/3 of the participants reported severe pain (≥xa07/10) that interfered substantially with various aspects of their daily living and QoL. Severe or extremely severe levels of depression were common (50.0%) along with suicidal ideation (34.6%). Patients agedxa0>xa060xa0yr were twice as likely to experience severe pain (≥xa07/10) as their younger counterparts (Pxa0=xa00.002). Patients with frequent sleep problems were more at risk of reporting severe pain (Pxa0≤xa00.003). Intense pain was also associated with a greater tendency to catastrophize (Pxa0<xa00.0001) severe depressive symptoms (Pxa0=xa00.003) and higher anger levels (Pxa0=xa00.016). Small but statistically significant changes in pain intensity and emotional distress were observed over a three-month wait time (all Pxa0<xa00.05).ConclusionThis study highlights the severe impairment that patients experience waiting for treatment in MPTFs. Knowing that current facilities cannot meet the clinical demand, it is clear that effective prevention/treatment strategies are needed earlier in primary and secondary care settings to minimize suffering and chronicity.RésuméObjectifLe projet canadien STOP-PAIN a évalué le fardeau humain et économique que représentait la douleur chronique des personnes se trouvant sur les listes d’attente des établissements pluridisciplinaires de traitement de la douleur (MPTF – Multidisciplinary Pain Treatment Facilities). Cet article présente le profil bio-psycho-social de ces patients.MéthodeUn échantillon de 728 patients a été recruté à partir des listes d’attente de huit MPTF affiliés à des universités partout au Canada. Les participants ont rempli des questionnaires validés afin dexa0: 1) évaluer les caractéristiques et l’impact de leur douleur; et 2) évaluer leur fonctionnement émotionnel et leur qualité de vie (QdV). Des questionnaires de suivi ont été remplis trois mois plus tard par un sous-groupe de 271 patients.RésultatsPrès de 2/3 des participants ont fait état d’une douleur grave (≥xa07/10) qui entravait considérablement différents aspects de leur vie quotidienne et de leur QdV. Des niveaux graves ou extrêmement graves de dépression étaient fréquents (50,0xa0%), tout comme les idées suicidaires (34,6xa0%). Les patients âgés dexa0>xa060 ans couraient un risque deux fois plus élevé de ressentir des douleurs graves (≥xa07/10) que les participants plus jeunes (Pxa0=xa00,002). Les patients ayant souvent des problèmes de sommeil couraient un risque plus élevé de faire état de douleur grave (Pxa0≤xa00,003). Une douleur intense était également associée à une tendance plus prononcée à la dramatisation (Pxa0<xa00,0001), à des symptômes de dépression grave (Pxa0=xa00,003) et à des niveaux plus élevés de colère (Pxa0=xa00,016). Des changements petits mais significatifs au niveau de l’intensité de la douleur et de la détresse émotionnelle ont été observés sur une période d’attente de trois mois (tous Pxa0<xa00,05).ConclusionCette étude met en évidence le handicap grave que les patients ressentent pendant qu’ils attendent d’être traités dans un MPTF. Sachant que les établissements actuels ne peuvent répondre à la demande clinique, il est clair que des stratégies de prévention et de traitement efficaces sont nécessaires plus tôt dans les cadres de soins primaires et secondaires afin de minimiser la souffrance et la chronicité.

Study of Natural Health Product Adverse Reactions (SONAR): Active Surveillance of Adverse Events Following Concurrent Natural Health product and Prescription Drug Use in Community Pharmacies

Background Many consumers use natural health products (NHPs) concurrently with prescription medications. As NHP-related harms are under-reported through passive surveillance, the safety of concurrent NHP-drug use remains unknown. To conduct active surveillance in participating community pharmacies to identify adverse events related to concurrent NHP-prescription drug use. Methodology/Principal Findings Participating pharmacists asked individuals collecting prescription medications about (i) concurrent NHP/drug use in the previous three months and (ii) experiences of adverse events. If an adverse event was identified and if the patient provided written consent, a research pharmacist conducted a guided telephone interview to gather additional information after obtaining additional verbal consent and documenting so within the interview form. Over a total of 112 pharmacy weeks, 2615 patients were screened, of which 1037 (39.7%; 95% CI: 37.8% to 41.5%) reported concurrent NHP and prescription medication use. A total of 77 patients reported a possible AE (2.94%; 95% CI: 2.4% to 3.7%), which represents 7.4% of those using NHPs and prescription medications concurrently (95%CI: 6.0% to 9.2%). Of 15 patients available for an interview, 4 (26.7%: 95% CI: 4.3% to 49.0%) reported an AE that was determined to be “probably” due to NHP use. Conclusions/Significance Active surveillance markedly improves identification and reporting of adverse events associated with concurrent NHP-drug use. Although not without challenges, active surveillance is feasible and can generate adverse event data of sufficient quality to allow for meaningful adjudication to assess potential harms.

The Canadian STOP-PAIN project – Part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?

PurposeThe Canadian STOP-PAIN Project was designed to document the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This paper describes the societal costs of their pain.MethodsA subgroup of 370 patients was selected randomly from The Canadian STOP-PAIN Project. Participants completed a self-administered costing tool (the Ambulatory and Home Care Record) on a daily basis for three months. They provided information about publicly financed resources, such as health care professional consultations and diagnostic tests as well as privately financed costs, including out-of-pocket expenditures and time devoted to seeking, receiving, and providing care. To determine the cost of care, resources were valued using various costing methods, and multivariate linear regression was used to predict total cost.ResultsOverall, the median monthly cost of care was

The abuse potential of the synthetic cannabinoid nabilone

1,462 (CDN) per study participant. Ninety-five percent of the total expenditures were privately financed. The final regression model consisted of the following determinants: educational level, employment status, province, pain duration, depression, and health-related quality of life. This model accounted for 35% of the variance in total expenditure (Pxa0<xa00.001).ConclusionThe economic burden of chronic pain is substantial in patients on waitlists of MPTFs. Consequently, it is essential to consider this burden when making decisions regarding resource allocation and waitlist assignment for a MPTF. Resource allocation decision-making should include the economic implications of having patients wait for an assessment and for care.RésuméObjectifLe projet canadien STOP-PAIN a été élaboré afin de documenter le fardeau humain et économique que représentait la douleur chronique pour les personnes se trouvant sur les listes d’attente des établissements pluridisciplinaires de traitement de la douleur (MPTF – Multidisciplinary Pain Treatment Facilities). Cet article décrit les coûts sociétaux de leur douleur.MéthodeUn sous-groupe de 370 patients a été aléatoirement choisi parmi les participants au projet canadien STOP-PAIN. Les participants ont rempli quotidiennement un outil auto-administré de calcul des coûts (le fichier de soins ambulatoires et à domicile - Ambulatory and Home Care Record) pendant trois mois. Ils ont fourni des renseignements concernant les ressources financées par le secteur public, comme par exemple les consultations auprès de professionnels de la santé et les tests diagnostiques, ainsi que les coûts privés, notamment les sorties effectives d’argent et le temps consacré à chercher, recevoir et fournir des soins. Afin de déterminer le coût des soins, les ressources ont été estimées à l’aide de plusieurs méthodes de calcul des coûts, et une analyse par régression linéaire multivariée a été appliquée afin d’estimer le coût total.RésultatsGlobalement, le coût mensuel moyen des soins était de 1462xa0

Dietary fat and protein interact in suppressing neuropathic pain-related disorders following a partial sciatic ligation injury in rats

(CDN) par participant à l’étude. Quatre-vingt-quinze pour cent des dépenses totales étaient prises en charge de façon privée. Le modèle de régression final était composé des déterminantes suivantesxa0: niveau d’éducation, situation d’emploi, province, durée de la douleur, dépression, et qualité de vie par rapport à la santé. Ce modèle a justifié 35xa0% de la variance des dépenses totales (Pxa0<xa00,001).ConclusionLe fardeau économique que représente la douleur chronique est substantiel pour les patients sur les listes d’attente des MPTF. Pour cette raison, il est nécessaire de tenir compte de ce fardeau lors de la prise de décision concernant l’attribution des ressources et l’affectation à la liste d’attente d’un MPTF. La prise de décision concernant l’attribution des ressources devrait inclure les implications économiques liées à l’attente des patients pour une évaluation de leur état et pour les soins.

Association of herbal cannabis use with negative psychosocial parameters in patients with fibromyalgia

AIMnNabilone is a synthetic cannabinoid prescription drug approved in Canada since 1981 to treat chemotherapy-induced nausea and vomiting. In recent years, off-label use of nabilone for chronic pain management has increased, and physicians have begun to express concerns about nabilone becoming a drug of abuse. This study evaluates the evidence for abuse of nabilone, which is currently ill-defined.nnnSTUDY DESIGNnScientific literature, popular press and internet databases were searched extensively for evidence of nabilone abuse. Focused interviews with medical professionals and law enforcement agencies across Canada were also conducted.nnnFINDINGSnThe scientific literature and popular press reviews found very little reference to nabilone abuse. Nabilone is perceived to produce more undesirable side effects, to have a longer onset of action and to be more expensive than smoked cannabis. The internet review revealed rare and isolated instances of recreational use of nabilone. The database review yielded little evidence of nabilone abuse, although nabilone seizures and thefts have occurred in Canada in the past few years, especially in Ontario. Most law enforcement officers reported no instances of nabilone abuse or diversion, and the drug has no known street value. Medical professionals reported that nabilone is not perceived to be a matter of concern with respect to its abuse potential.nnnCONCLUSIONSnReports of nabilone abuse are extremely rare. However, follow-up of patients using nabilone for therapeutic purposes is prudent and should include assessment of tolerance and dependence. Prospective studies are also needed to definitively address the issue of nabilone abuse.

Pharmacy study of natural health product adverse reactions (SONAR): a cross-sectional study using active surveillance in community pharmacies to detect adverse events associated with natural health products and assess causality.

Abstract Chronic neuropathic sensory disorders (CNSD) of rats receiving a partial sciatic nerve ligation injury (the PSL model) are suppressed by dietary soy protein. Although previously shown to modify nociceptive behavior in acute pain models, dietary fat has never been tested for its putative analgesic properties in chronic pain states. Here we tested the role of dietary fat, protein and fat/protein interactions in the development of tactile allodynia and heat hyperalgesia in PSL‐injured rats. Male Wistar rats were fed nine different diets, comprising of three proteins (soy, casein and albumin) and three fats (corn, soy and canola) for a week preceding PSL injury and for 2 weeks thereafter. Rats responses to tactile and noxious heat stimuli were tested before surgery and 3, 7 and 14 days afterwards. Tactile and heat sensory abnormalities following PSL injury were significantly different among the nine dietary groups. Consumption of corn and soy fats suppressed the levels of tactile and heat allodynia and hyperalgesia, whereas consumption of soy and casein proteins was associated with lower levels of heat hyperalgesia but not tactile allodynia. A significant fat/protein interaction was found for the heat but not tactile stimuli. We conclude that dietary fat is a significant independent predictor of levels of neuropathic sensory disorders in rats and that this effect is accentuated by dietary protein. The mechanisms by which fat suppresses neuropathic disorders have yet to be determined.

Intradialytic clearance of opioids: Methadone versus hydromorphone

Patients with chronic pain, including fibromyalgia (FM), may seek treatments outside of mainstream medicine. Medicinal cannabinoids are popularly advocated for pain relief but with limited evidence for efficacy in FM. The extent of use of cannabinoids in FM is unknown.

A survey of cannabis (marijuana) use and self-reported benefit in men with chronic prostatitis/chronic pelvic pain syndrome

Objectives To investigate the rates and causality of adverse event(s) (AE) associated with natural health product (NHP) use, prescription drug use and concurrent NHP-drug use through active surveillance in community pharmacies. Design Cross-sectional study of screened patients. Setting 10 community pharmacies across Alberta and British Columbia, Canada from 14 January to 30 July 2011. Participants The participating pharmacy staff screened consecutive patients, or agents of patients, who were dropping or picking up prescription medications. Primary outcome measures Patients were screened to determine the proportions of them using prescription drugs and/or NHPs, as well as their respective AE rates. All AEs reported by the screened patients who took a NHP, consented to, and were available for, a detailed telephone interview (14%) were adjudicated fully to assess for causality. Results Over a total of 105 pharmacy weeks and 1118 patients screened, 410 patients reported taking prescription drugs only (36.7%; 95% CI 33.9% to 39.5%), 37 reported taking NHPs only (3.3%; 95% CI 2.4% to 4.5%) and 657 reported taking prescription drugs and NHPs concurrently (58.8%; 95% CI 55.9% to 61.6%). In total, 54 patients reported an AE, representing 1.2% (95% CI 0.51% to 2.9%), 2.7% (95% CI 0.4% to 16.9%) and 7.3% (95% CI 5.6% to 9.6%) of each population, respectively. Compared with patients who reported using prescription drugs, the patients who reported using prescription drugs and NHPs concurrently were 6.4 times more likely to experience an AE (OR; 95% CI 2.52 to 16.17; p<0.001). Combined with data from Ontario, Canada, a national proportion was calculated, which found that 45.4% (95% CI 43.8% to 47.0%) of Canadians who visit community pharmacies take NHPs and prescription drugs concurrently, and of those, 7.4% (95% CI 6.3% to 8.8%) report an AE. Conclusions A substantial proportion of community pharmacy patients use prescription drugs and NHPs concurrently; these patients are at a greater risk of experiencing an AE. Active surveillance provides a means of detecting such AEs and collecting high-quality data on which causality assessment can be based.

Prevalence and determinants of cannabinoid prescription for the management of chronic noncancer pain: a postal survey of physicians in the Abitibi-Témiscamingue region of Quebec

Summary Methadone plasma concentrations are more stable during hemodialysis compared to hydromorphone. Abstract Opioids are commonly prescribed to patients with chronic pain associated with end‐stage renal disease requiring hemodialysis. The stability of opioid analgesia during dialysis may vary among different opioids. No studies to date have corroborated this clinical observation by directly comparing plasma concentrations of different opioids during dialysis. We compared changes in peridialysis plasma concentrations of 2 pharmacokinetically distinct opioids, methadone and hydromorphone (HM). Fourteen dialysis patients with chronic pain received either methadone or HM for at least 2 weeks before beginning the study. Blood samples were obtained immediately before, during, and after hemodialysis in 2 separate dialysis sessions, 1 week apart, and were analyzed for opioid concentrations. Methadone plasma concentrations were more stable during hemodialysis compared to HM: the mean percent change of methadone plasma levels was 14.9% ± 8.2% (±SD) compared with 55.1% ± 8.1% in the HM treatment group, a difference of 40.2% (95% confidence interval 17.14 to 63.14). The mean plasma clearance of methadone was 19.9 ± 8.5 mL/min (±SD) compared with 105.7 ± 8.3 mL/min for HM, a difference of 85.7 mL/min (95% confidence interval 61.9 to 109.1). There were no differences between the 2 opioid groups in pain scores, side effect profile, and quality of life. Methadone therapy was not associated with an increased rate of adverse events. If confirmed by larger clinical studies, methadone could be considered as one of the opioids of choice in dialysis patients.