Timely and Relevant Articles

Below are our initial offerings:

1. Update on Fibromyalgia and Chronic Widespread Pain
   Hsu, Michael C, MD and Clauw, Daniel J, MD
   Advances in Pain Management
   Vol 1, No 2, 2007
   Pages 38-45
   Text and free CME available at: www.advancesinpainmanagement.com
2. Post-herpetic Neuralgia in
   Selected Topics in Pain Management
   Text and free CME available at: www.clevelandclinicmeded.com/online/topic.htm
3. Rational Use of Sublingual Opioids in Palliative Medicine
   Reisfield, Gary M., MD and Wilson, George R., MD
   Journal of Palliative Medicine
   Volume 10, Number 2, 2007
   Pages 465-477
4. Post-herpetic Neuralgia in
   Selected Topics in Pain Management
   Text and free CME available at: www.clevelandclinicmeded.com/online/topic.htm

Abrahm, J. L. (2000). "Advances in pain management for older adult patients." Clin Geriatr Med 16(2): 269-311.
Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.

Dworkin, R. H., M. Backonja, et al. (2003). "Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations." Arch Neurol 60(11): 1524-34.
Chronic neuropathic pain, caused by lesions in the peripheral or central nervous system, comes in many forms. We describe current approaches to the diagnosis and assessment of neuropathic pain and discuss the results of recent research on its pathophysiologic mechanisms. Randomized controlled clinical trials of gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants provide an evidence-based approach to the treatment of neuropathic pain, and specific recommendations are presented for use of these medications. Continued progress in basic and clinical research on the pathophysiologic mechanisms of neuropathic pain may make it possible to predict effective treatments for individual patients by application of a pain mechanism-based approach.

Gatchel, R. J. and A. Okifuji (2006). "Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain." J Pain 7(11): 779-93.
Chronic pain is one of the most prevalent and costly problems in the United States today. Traditional medical treatments for it, though, have not been consistently efficacious or cost-effective. In contrast, more recent comprehensive pain programs (CPPs) have been shown to be both therapeutically efficacious and cost-effective. The present study reviews available evidence demonstrating the therapeutic efficacy and cost-effectiveness of CPPs, relative to conventional medical treatment. Searches of the chronic pain treatment literature during the past decade were conducted for this purpose, using MEDLINE and PSYCHLIT. Studies reporting treatment outcome results for patients with chronic pain were selected, and data on the major outcome variables of self-reported pain, function, healthcare utilization and cost, medication use, work factors, and insurance claims were evaluated. When available, conventional medical treatments were used as the benchmark against which CPPs were evaluated. This review clearly demonstrates that CPPs offer the most efficacious and cost-effective, evidence-based treatment for persons with chronic pain. Unfortunately, such programs are not being taken advantage of because of short-sighted cost-containment policies of third-party payers. PERSPECTIVE: A comprehensive review was conducted of all studies in the scientific literature reporting treatment outcomes for patients with chronic pain. This review clearly revealed that CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment.

Nguyen, M., C. Ugarte, et al. (2005). "Access to care for chronic pain: racial and ethnic differences." J Pain 6(5): 301-14.
Access to medical care is a major national issue, and several surveys suggest that racial and ethnic differences influence access to care for chronic pain problems. To evaluate the influence of race and ethnicity on access to treatment for chronic pain, a cross-sectional telephone survey was performed in a nationally representative sample of 454 white, 447 African-American, and 434 Hispanic subjects with pain for > or =3 months. Questions explored demographics, pain and its treatment, and perceived access to care. A composite "access" variable combined actual consultation with perceived access. Hispanics were younger, least likely to be insured, and had the least education and lowest income; 61% spoke Spanish at home. Hispanics were significantly less likely to have consulted a primary care practitioner for pain (70%) than whites (84%) or African-Americans (85%). A lower likelihood of consultation also was associated with speaking Spanish, being male, being relatively young (18-34 years old) or single, having limited education, and not being employed. Low "access" to care was associated with being Hispanic and speaking Spanish, being younger or male, having low income or limited education, being employed, and agreeing that financial concerns prevented pain treatment. High "access" was associated with being white or African-American; being older or female or living in a suburban area; having insurance, higher income, or college education; and being unemployed. In multivariate models, low "access" was associated with Hispanic ethnicity and agreement that financial concerns prevented pain treatment. High "access" was associated with more severe pain, having insurance or an income of US 25,000 dollars to US 74,000 dollars, and agreeing that "A doctor or other health care provider is the first person I would go to to discuss my pain." These data suggest that race/ethnicity, other demographic characteristics, and socioeconomic factors influence access to pain care. Hispanic ethnicity predicts limited access. PERSPECTIVE: The influence of race and ethnicity on access to health care is a major issue in the United States. A national telephone survey suggests that race and ethnicity, along with other demographic and socioeconomic factors, influence access to care for chronic pain.

Passik, S. D. and K. L. Kirsh (2004). "Assessing aberrant drug-taking behaviors in the patient with chronic pain." Curr Pain Headache Rep 8(4): 289-94.
Tremendous progress has been made in the study and treatment of pain in the past two decades. The growing problem of prescription drug abuse has forced the field to take a new look at opioid prescribing and to seek balance between its risks and benefits. Every pain clinician must become better acquainted with the principles of addiction medicine as they apply to pain management. The assessment of aberrant behaviors in patients with chronic pain is one key aspect of mastering these principles.

Passik, S. D., K. L. Kirsh, et al. (2004). "A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy." Clin Ther 26(4): 552-61.
BACKGROUND: Opioid analgesics are the cornerstone of management for malignant pain. Their use in managing chronic, nonmalignant pain, albeit controversial, has increased in recent years. The decisions about whether to initiate opioid therapy or continue it over time should be guided by a comprehensive patient assessment. During long-term treatment, this assessment should focus on a broad range of outcomes, each of which should be documented in the medical record. OBJECTIVE: The goal of this study was to develop an instrument, the Pain Assessment and Documentation Tool (PADT), to focus on key outcomes and provide a consistent way to document progress in pain management therapy over time. METHODS: Items that assess 4 domains (pain relief, patient functioning, adverse events, and drug-related behaviors) were generated with input from a MEDLINE literature search and experts in pain and addiction management. The original tool was field tested by clinicians who applied it to the assessment of patients receiving long-term opioid therapy for the management of chronic, nonmalignant pain. Data analysis and debriefing telephone interviews with a formalized set of questions were then used to rephrase, delete, and refine items to create the final tool. RESULTS: A 6-member expert panel contributed to the initial development of the PADT. Twenty-seven clinicians completed the preliminary version of PADT for 388 patients. The original 59-item tool was modified to create a 41-item tool. The revised PADT was formatted for use as a chart note designed to assist clinicians in assessing and documenting 4 main outcome domains during long-term opioid use. CONCLUSIONS: In this study, the PADT appeared to be a useful tool for clinicians to guide the evaluation of several important outcomes during opioid therapy and provide a simple means of documenting patient care.

Portenoy, R. K., U. Sibirceva, et al. (2006). "Opioid use and survival at the end of life: a survey of a hospice population." J Pain Symptom Manage 32(6): 532-40.
Concern that opioids hasten death may be among the reasons that pain is treated inadequately in populations with advanced illness. Studies that assess the true risks are needed. To determine whether survival after last opioid dose change is associated with opioid dosing characteristics and other factors, data from the National Hospice Outcomes Project, a large prospective cohort study involving 13 U.S. hospice programs, were analyzed. Of 1,306 patients, 725 received opioids and underwent at least one dose change before death. Subsamples based on maximum opioid dose compared patients receiving usual doses with those receiving high-dose therapy. Spearman rank correlations examined bivariate associations between survival after final dose change and other variables, including dose in morphine equivalent mg and percentage dose increase. Multivariate least squares regression analyses determined associations between survival and other variables, including those significant in bivariate analyses. The mean+/-SD number of days between final dose change and death was 12.46+/-23.11. Multivariate models demonstrated a significant association between shorter survival and higher opioid dose, a cancer diagnosis, unresponsiveness, and pain of <5 on a 0-10 scale, but none of these models explained >10% of the variance in time till death. Analyses of subsamples did not reveal additional effects of dose. This analysis revealed that opioid dosing was associated with time till death, but this factor would explain very little of the variation in survival. In a hospice population, survival is influenced by complex factors, many of which may not be measurable. Based on these findings, concern about hastening death does not justify withholding opioid therapy.

Portenoy, R. K., C. Ugarte, et al. (2004). "Population-based survey of pain in the United States: differences among white, African American, and Hispanic subjects." J Pain 5(6): 317-28.
A cross-sectional telephone survey was conducted in nationally representative probability sample of non-Hispanic white subjects, non-Hispanic African American subjects, and Hispanic subjects of any race to explore relationships between chronic pain and race or ethnicity. Approximately one third in each group reported "frequent or persistent pain" for 3 months or longer during the past year, and approximately one third of the 454 white subjects, 447 African American subjects, and 434 Hispanic subjects in the final sample experienced "disabling pain" (defined as both high severity and high functional interference). White subjects had pain longer but with lesser intensity than the other groups, and pain-related life interference did not vary. Significantly fewer Hispanic subjects (68%) than white subjects (82%) or African American subjects (85%) had visited a physician for pain, and African American subjects (81%) were more likely than white subjects (75%) or Hispanic subjects (63%) to have used prescription medications. Disabling pain was positively associated with female sex (odds ratio [OR], 1.45), income of $25,000 or less (OR, 1.71), less than a high school education (OR, 1.72), and divorce (OR, 1.69) and was negatively associated with younger age (18-34 years; OR, 0.68), income between $25,000 and $74,999 (OR, 0.64) or $75,000 or more (OR, 0.37), being employed (OR, 0.48), suburban residence (OR, 0.64), and having a college (OR, 0.51) or graduate (OR, 0.32) degree. Multivariate logistic regression found that income of $25,000 or less (OR, 2.54), less than a high school education (OR, 1.59), and being unemployed (OR, 1.50) remained significant when other factors were controlled. Neither race nor ethnicity predicted disabling pain, but the minorities had more characteristics identified as predictors. The data suggest that race and ethnicity contribute to clinical diversity, but socioeconomic disadvantage is the more important predictor of disabling pain. PERSPECTIVE: Race and ethnicity influence the presentation and treatment of chronic pain. This study evaluated community-dwelling white, African American, and Hispanic subjects by using a sophisticated telephone survey methodology. Pain was highly prevalent across groups, and there were racial and ethnic differences in pain experience and treatment preferences. Race and ethnicity were not independently associated with severe pain, but both minorities were more likely to possess the socioeconomic and educational characteristics that were associated.