Patient-Reported Wait Times and the Impact of Living with Chronic Pain on their Quality of Life: A Waiting Room Survey in Chronic Pain Clinics in Ontario, Manitoba, and Quebec.

Background: Wait times at Canadian multidisciplinary pain clinics have been reported as excessive for nearly 2 decades. Aims: The aim of this study was to gain insight into the patient experience of waiting for chronic pain specialty care. Methods: A cross-sectional survey of new patients waiting for an appointment was conducted in six multidisciplinary pain clinics, including one pediatric clinic, in Ontario, Quebec, and Manitoba between February 2020 and October 2022. Participants were asked about the length of time they waited for their appointment since being referred, their quality of life, health care professionals seen while waiting, and an open-ended question, "Is there anything else you'd like to tell us?" Results: Among the 493 adult and 100 pediatric respondents, 53% of adults and 82% of children reported wait times under 6 months, whereas 22% of adults and 4% of children waited longer than a year. Between 52% and 63% of adults and 29% to 48% of children reported being affected by chronic pain "quite a bit" or "extremely" on measures of quality of life. The most visited health care professionals while waiting for a pain clinic appointment were family doctors/nurse practitioners for adults and physiotherapists for children. Qualitative analysis of open-ended question responses revealed eight themes: system navigation issues, administrative issues, decreased quality of life, distress, self-advocacy, coping strategies, communication, and distrust. Conclusions: Our findings provide real-time regional snapshots into the impact of long wait times experienced by Canadians living with chronic pain. There is an urgent need to better support patients during the waiting period. Expanding technologies such as electronic consultation hold great promise.

Contexte: Les temps d'attente dans les cliniques multidisciplinaires de traitement de la douleur au Canada sont jugés excessifs depuis près de deux décennies.Objectifs: L'objectif de cette étude était de mieux comprendre l'expérience des patients en attente de soins spécialisés pour la douleur chronique.Méthodes: Une enquête transversale sur les nouveaux patients en attente d'un rendez-vous a été menée dans six cliniques multidisciplinaires de traitement de la douleur, dont une clinique pédiatrique, en Ontario, au Québec et au Manitoba, entre février 2020 et octobre 2022. Les participants ont été interrogés sur le temps d'attente pour leur rendez-vous depuis qu'ils avaient été référés, sur leur qualité de vie, sur les professionnels de la santé qu'ils avaient consultés pendant qu'ils attendaient, et sur une question ouverte : « Y a-t-il autre chose que vous aimeriez nous dire? ¼Résultats: Parmi les 493 adultes et les 100 enfants interrogés, 53 % des adultes et 82 % des enfants ont déclaré des temps d'attente inférieurs à six mois, tandis que 22 % des adultes et 4 % des enfants ont attendu plus d'un an. Entre 52 % et 63 % des adultes et 29 % à 48 % des enfants ont déclaré être affectés par la douleur chronique « assez ¼ ou « extrêmement ¼ sur les mesures de la qualité de vie. Les professionnels de la santé les plus consultés pendant l'attente d'un rendez-vous à la clinique de la douleur étaient les médecins de famille/infirmières praticiennes pour les adultes et les physiothérapeutes pour les enfants. L'analyse qualitative des réponses aux questions ouvertes a révélé huit thèmes : les problèmes de navigation dans le système; les problèmes administratifs; la diminution de la qualité de vie; la détresse; l'autonomie; les stratégies d'adaptation; la communication et la méfiance.Conclusions: Nos résultats offrent des instantanés régionaux en temps réel des répercussions des longs temps d'attente sur les Canadiens souffrant de douleur chronique. Il est urgent de mieux soutenir les patients pendant la période d'attente. Les technologies en expansion, telles que la consultation électronique, sont très prometteuses.

Treatment for patients with sleep apnea on opioids for chronic pain: results of the OpSafe trial.

STUDY OBJECTIVES: Approximately 20% of North Americans are afflicted with chronic pain with 3% being opioid users. The objective was to determine whether patients on opioids for chronic pain with newly diagnosed sleep apnea attended sleep clinic review and followed treatment recommendations. METHODS: The study was a post hoc analysis from a multicenter perspective cohort study. Inclusion criteria included adults taking opioid medications for chronic pain for >3 months. Demographic data and daily opioid dose were collected. Sleep apnea was diagnosed via level 1 polysomnography. Patients who attended sleep clinic review were grouped based on the types of treatment they received. RESULTS: A total of 204 patients completed polysomnography and 58.8% were diagnosed to have sleep apnea (apnea-hypopnea index ≥5 events/h). Of those with sleep apnea, 58% were recommended to have an evaluation by a sleep physician. Body mass index and age were 29.5 ± 6 kg/m² and 56 ± 12 years, respectively. Of those with newly diagnosed sleep apnea, 25% received treatment, with the majority being treated with positive airway pressure therapy, whereas the rest received positional therapy and opioids/sedative reduction. The adherence rate of positive airway pressure therapy was 55% at 1 year. Over 50% of participants on opioids for chronic pain with newly diagnosed sleep apnea declined attendance for sleep clinic review or treatment. CONCLUSIONS: There was a high refusal rate to attend clinic for treatment. Adherence to positive airway pressure therapy was low at 55%. This sheds light on the high rate of treatment nonadherence and the need for further research. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Opioid Safety Program in Pain Clinics (Op-Safe); URL: https://www.clinicaltrials.gov/ct2/show/NCT02513836; Identifier: NCT02513836.

Concomitant benzodiazepine and opioids decrease sleep apnoea risk in chronic pain patients.

BACKGROUND: The concurrent use of sedating centrally acting drugs and opioids by chronic pain patients occurs routinely despite concerns of negative impacts on respiration during sleep. The effects of centrally acting drugs and opioids on sleep apnoea have not been well characterised. The objective of this study was to assess the effect of concomitant centrally acting drugs and opioids on the prevalence and severity of sleep apnoea in chronic pain patients. METHODS: We conducted a prospective cohort study at five chronic pain clinics. Each participant underwent an in-laboratory polysomnography and daily morphine milligram equivalents were calculated. Participants were grouped into centrally acting drugs and opioid users versus sole opioid users. RESULTS: Of the 332 consented participants, 204 underwent polysomnography and 120 (58.8%) had sleep apnoea (72% obstructive, 20% central, and 8% indeterminate sleep apnoea). Overall, 35% (71 of 204) were taking opioids alone, and 65% (133 of 204) were taking centrally acting drugs and opioids. There was a 69% decrease in the odds of having sleep apnoea (apnoea-hypopnoea index ≥5 events·h-1) in participants taking benzodiazepine/opioids versus sole opioid users (OR 0.31, 95% CI:0.12-0.80, p=0.015). Additionally, concomitant benzodiazepine/opioids versus sole opioid use was associated with a decrease in respiratory arousal index scores (p=0.03). Mean overnight S pO2 was approximately 1% lower in the concomitant benzodiazepine/opioids group versus sole opioid users (93.1±2.5 versus 94.4±2.1%, p=0.01). CONCLUSION: In chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold.

Predictive factors for sleep apnoea in patients on opioids for chronic pain.

Background: The risk of death is elevated in patients taking opioids for chronic non-cancer pain. Respiratory depression is the main cause of death due to opioids and sleep apnoea is an important associated risk factor. Methods: In chronic pain clinics, we assessed the STOP-Bang questionnaire (a screening tool for sleep apnoea; Snoring, Tiredness, Observed apnoea, high blood Pressure, Body mass index, age, neck circumference and male gender), Epworth Sleepiness Scale, thyromental distance, Mallampati classification, daytime oxyhaemoglobin saturation (SpO2) and calculated daily morphine milligram equivalent (MME) approximations for each participant, and performed an inlaboratory polysomnogram. The primary objective was to determine the predictive factors for sleep apnoea in patients on chronic opioid therapy using multivariable logistic regression models. Results: Of 332 consented participants, 204 underwent polysomnography, and 120 (58.8%) had sleep apnoea (AHI ≥5) (72% obstructive, 20% central and 8% indeterminate sleep apnoea), with a high prevalence of moderate (23.3%) and severe (30.8%) sleep apnoea. The STOP-Bang questionnaire and SpO2 are predictive factors for sleep apnoea (AHI ≥15) in patients on opioids for chronic pain. For each one-unit increase in the STOP-Bang score, the odds of moderate-to-severe sleep apnoea (AHI ≥15) increased by 70%, and for each 1% SpO2 decrease the odds increased by 33%. For each 10 mg MME increase, the odds of Central Apnoea Index ≥5 increased by 3%, and for each 1% SpO2 decrease the odds increased by 45%. Conclusion: In patients on opioids for chronic pain, the STOP-Bang questionnaire and daytime SpO2 are predictive factors for sleep apnoea, and MME and daytime SpO2 are predictive factors for Central Apnoea Index ≥5. Trial registration number: NCT02513836.

Can women in labor give informed consent to epidural analgesia?

There are reasons to believe that decision-making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women's decisional capacity. Decision-making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to 'understanding' alone. A systematic literature search identified a total of 20 empirical studies focused on women's decision-making about epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women's autonomy. To fill in the significant gap in clinical knowledge about laboring women's decision-making capacity, well-designed prospective and retrospective studies may be required.

Postoperative pain management in patients with chronic kidney disease.

Chronic kidney disease (CKD) is a health care problem with increasing prevalence worldwide. Pain management represents one of the challenges in providing perioperative care for this group of patients. Physicians from different specialties may be involved in pain management of CKD patients, especially in advanced stages. It is important to understand the clinical staging of kidney function in CKD patients as the pharmacotherapeutic pain management strategies change as kidney function becomes progressively impaired. Special emphasis should be placed on dose adjustment of certain analgesics as well as prevention of further deterioration of renal function that could be induced by certain classes of analgesics. Chronic pain is a common finding in CKD patients which may be caused by the primary disease that led to kidney damage or can be a direct result of CKD and hemodialysis. The presence of chronic pain in some of the CKD patients makes postoperative pain management in these patients more challenging. This review focuses on the plans and challenges of postoperative pain management for patient at different stages of CKD undergoing surgical intervention to provide optimum pain control for this patient population. Further clinical studies are required to address the optimal medication regimen for postoperative pain management in the different stages of CKD.

Use of near infrared spectroscopy to detect impaired tissue oxygen saturation in patients with complex regional pain syndrome type 1.

PURPOSE: Deep tissue hypoxia has been hypothesized in the pathogenesis of complex regional pain syndrome type 1 (CRPS 1) for some patients. The purpose of this study was to determine if near-infrared spectroscopy (NIRS) could detect differences in deep tissue oxygen saturation (StO2) and microcirculatory function in the hands of patients with CRPS 1. METHODS: Tissue oxygen saturation was evaluated at baseline and during an ischemia reperfusion challenge using vascular occlusion testing (VOT) in affected vs unaffected hands of patients with unilateral upper limb CRPS 1. A non-randomized experimental study design was used with baseline StO2 as the primary outcome measure. Secondary outcome measures were occlusion and reperfusion slopes from VOT. Values were compared with the unaffected, contralateral hand and with the dominant and non-dominant hands of sex and age-matched volunteers. Correlations between values derived from NIRS and measures of pain and function from the Brief Pain Inventory (BPI) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaires were explored. RESULTS: Independent of handedness, the baseline StO2 of the affected hands of ten CRPS 1 patients was significantly lower than that of their unaffected hands (-5.8%; 95% confidence interval [CI] -10.6 to -1.0; P = 0.02). The baseline StO2 of affected CRPS 1 hands was also significantly lower than the non-dominant hands of ten volunteers (-7.3%; 95% CI -12.4 to -2.3; P = 0.007). Differences in VOT occlusion and reperfusion slopes did not reveal changes that could be uniquely attributed to CRPS 1. No significant correlations were detected between values derived from VOT and values for pain and function obtained from BPI and DASH questionnaires for patients with CRPS 1. CONCLUSIONS: Hands of patients affected by CRPS 1 of the upper limb showed significantly lower StO2 compared with their unaffected contralateral hand as well as the hands of control subjects. This trial was registered at: ClinicalTrials.gov: NCT01586377.

Intake assessment of problematic use of medications in a chronic noncancer pain clinic.

BACKGROUND: The present article outlines the process of instituting an assessment of risk of problematic use of medications with new patients in an ambulatory chronic noncancer pain (CNCP) clinic. It is hoped that the authors' experience through this iterative process will fill the gap in the literature by setting an example of an application of the 'universal precautions' approach to chronic pain management. OBJECTIVES: To assess the feasibility and utility of the addition of a new risk assessment process and to provide a snapshot of the risk of problematic use of medications in new patients presenting to a tertiary ambulatory clinic treating CNCP. METHODS: Charts for the first three months following the institution of an intake assessment for risk of problematic medication use were reviewed. Health care providers at the Wasser Pain Management Centre (Toronto, Ontario) were interviewed to discuss the preliminary findings and provide feedback about barriers to completing the intake assessments, as well as to identify the items that were clinically relevant and useful to their practice. RESULTS: Data were analyzed and examined for completeness. While some measures were considered to be particularly helpful, other items were regarded as repetitive, problematic or time consuming. Feedback was then incorporated into revisions of the risk assessment tool. DISCUSSION: Overall, it is feasible and useful to assess risk for problematic use of medications in new patients presenting to CNCP clinics. CONCLUSION: To facilitate the practice of assessment, the risk assessment tool at intake must be concise, clinically relevant and feasible given practitioner time constraints.

Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance.

BACKGROUND: Although fluoroscopy is an established imaging modality for pudendal nerve block, ultrasound (US) technique allows physicians better visualization of anatomic structures. This study aimed to compare the effectiveness and safety between the US- and fluoroscopy-guided techniques. METHODS: A randomized, single-blind, split-plot design was used to conduct the study. Twenty-three patients undergoing bilateral pudendal nerve blocks received US-guided injections to either the left or right side, whereas the contralateral side received a fluoroscopic-guided injection in randomized sequence. Injections consisted of 4 mL of 0.5% bupivacaine and 40 mg methylprednisone. The primary outcome was the success of the block in the distribution of the pudendal nerve along the perineum, rated as either absent, moderate, or strong. Secondary outcomes were the time to administer the blocks, quality of visualization of anatomic structures using US and fluoroscopy, distance of the final US-guided needle position from the ischial spine, and incidence of adverse effects. RESULTS: No differences in the degree of neural blockade were noted between US- or fluoroscopic-guided techniques for either temperature or pinprick blockade. Time to complete the procedure was significantly longer using US compared with fluoroscopy (219 [SD, 65] and 428 [SD, 151] secs, P < 0.0001). No significant differences were noted regarding the occurrence of adverse effects between the 2 techniques. CONCLUSIONS: Ultrasound-guided pudendal nerve blockade is as accurate as fluoroscopically guided injections when performed by an experienced clinician. However, the former took a longer time to perform.

A low-cost ultrasound phantom of the lumbosacral spine.

BACKGROUND AND OBJECTIVES: This report describes the production of a low-cost ultrasound phantom of the lumbosacral spine. The phantom should be a very useful tool to teach the basic skills for ultrasound-guided procedures of the lumbosacral spine. METHODS: A lumbosacral spine model is secured to the bottom of a microwave-safe container and is immersed in a concentrated gelatin solution. After the gelatin hardens, the model can be used for scanning practice as well as needle placement. The phantom can be recovered after use by melting the gelatin in a microwave to "erase" any needle track marks. RESULTS: A transparent and durable gelatin block is produced. This allows trainees to have direct visual access to the lumbosacral spine model to correlate with the ultrasound images as well as to confirm proper needle placement. Disadvantages of the model include lack of simulated soft tissue structures and an absence of simulated haptic feedback during needle placement. Metamucil can be added to the gelatin to simulate the appearance of soft tissue, although this increases the opacity and thus decreases the visual access of the gelatin. CONCLUSIONS: This teaching tool can provide trainees with an opportunity to familiarize themselves with sonoanatomy of the lumbosacral spine in addition to practicing probe handling techniques and needle placement.

Duloxetine: a review of its pharmacology and use in chronic pain management.

Duloxetine is a serotonin and norepinephrine reuptake inhibitor that possesses antidepressant and pain-relieving properties. Compared with other antidepressants, it has a high affinity for both norepinephrine and serotonin reuptake transporters, which are relatively balanced. Analgesic onset has been observed within the first week of administration in randomized controlled trials and is likely obtained by enhancing the tone of the descending pain inhibition pathways of the central nervous system. Randomized trials have documented significant analgesic effects for managing chronic pain associated with fibromyalgia and diabetic peripheral neuropathic pain. Studies have also suggested that pain associated with major depressive disorder can be reduced with this medication. Modest effects for headache, osteoarthritic pain, and pain secondary to Parkinson disease have also been documented, but data are obtained from single-blinded or open-label trials that require further corroboration with larger randomized studies. Duloxetine has not yet been directly compared with other antidepressants or anticonvulsants for the treatment of pain syndromes.

Ultrasound-guided suprascapular nerve block: a correlation with fluoroscopic and cadaveric findings.

PURPOSE: Previous work on the ultrasound-guided injection technique and the sonoanatomy of the suprascapular region relevant to the suprascapular nerve (SSN) block suggested that the ultrasound scan showed the presence of the suprascapular notch and transverse ligament. The intended target of the ultrasound-guided injection was the notch. The objective of this case report and the subsequent cadaver dissection findings is to reassess the interpretation of the ultrasound images when locating structures for SSN block. CLINICAL FEATURES: A 45-yr-old man with chronic shoulder pain received an ultrasound-guided SSN block using the suprascapular notch as the intended target. The position of the needle was verified by fluoroscopy, which showed the tip of the needle well outside the suprascapular notch. Similar ultrasound-guided SSN blocks were performed in two cadavers. Dissections were performed which showed that the needle tips were not at the suprascapular notch but, more accurately, were close to the SSN but at the floor of the suprascapular fossa between the suprascapular and spinoglenoid notch. CONCLUSION: Our fluoroscopic and cadaver dissection findings both suggest that the ultrasound image of the SSN block shown by the well-described technique is actually targeting the nerve on the floor of the suprascapular spine between the suprascapular and spinoglenoid notches rather than the suprascapular notch itself. The structure previously identified as the transverse ligament is actually the fascia layer of the supraspinatus muscle.

Proximal splenic artery embolization in the management of splenic rupture.

OBJECTIVE: To report the use of proximal splenic artery embolization for management of spontaneous splenic rupture. DESIGN: Case report and literature review. SETTING: A tertiary pediatric critical care unit in a university teaching hospital. INTERVENTIONS: Proximal splenic artery embolization. MEASUREMENTS AND MAIN RESULTS: An 8-yr-old boy presented with abdominal pain radiating to the left shoulder 9 days after completing induction chemotherapy for acute lymphoblastic leukemia. Imaging revealed a splenic rupture with parenchymal and subcapsular hematomas, with no evidence of active extravasations. The patient was admitted to the pediatric critical care unit for close hemodynamic monitoring and frequent measurements of hemoglobin. His lowest recorded hemoglobin and hematocrit were 63 g/L and 0.19 L/L, respectively. Posttransfusion of packed red blood cells, he was taken to interventional radiology for proximal splenic artery embolization under moderate sedation. Several coils were successfully placed in the proximal splenic arterial system resulting in a marked reduction of splenic blood flow without disruption of collaterals. The patient recovered well from proximal splenic artery embolization in the pediatric critical care unit and experienced short lasting abdominal pain and fever for 1 day. He was discharged home 4 days after the procedure and follow-up imaging showed resolving hematomas with preserved splenic blood flow. CONCLUSION: Proximal splenic artery embolization in children may be a safe therapeutic alternative to either conservative or surgical management in spontaneous splenic rupture. Preservation of splenic tissue with a reduced risk of repeated hemorrhage can be obtained with proximal splenic artery embolization.

Case report: retroperitoneoscopic pheochromocytoma removal in an adult with Eisenmenger's syndrome.

PURPOSE: Patients with uncorrected or palliated, complex congenital heart lesions requiring surgery can benefit from laparoscopic techniques, but retroperitoneal insufflation may render them hemodynamically unstable. Alterations in cardiopulmonary physiology during retroperitoneal insufflation have been studied, yet there are no cases detailing this approach in patients with congenital heart lesions. We present a case of a pheochromocytoma removal via retroperitoneoscopy in a patient with a palliated, complex heart lesion. CLINICAL FEATURES: A 28-yr-old woman was admitted for removal of a pheochromocytoma through retroperitoneoscopy. The main feature of her heart disease was a complete atrioventricular canal defect. She eventually developed Eisenmenger's syndrome and became chronically cyanotic. Retroperitoneal insufflation with CO2 gas did not change hemodynamic variables. Significant increases in peak airway pressures were encountered, possibly due to the distending effects of insufflation, or due to increasing the minute ventilation to reduce exogenous CO2. Arterial CO2 remained stable, but a significant increase between end-tidal and arterial levels became apparent with insufflation. Tumour manipulation led to systemic (and possibly pulmonary) hypertension, which exacerbated ventricular dysfunction. This condition resulted in atrioventricular valve regurgitation, as seen on transesophageal echocardiography, and diminished pulmonary blood flow with subsequent desaturation. These changes resolved with antihypertensive medications. The patient's trachea was extubated four hours postoperatively, and she recovered uneventfully. CONCLUSION: Patients with altered cardiopulmonary physiology may tolerate retroperitoneoscopic insufflation with relative hemodynamic stability. Appropriate use of short-acting, vasoactive drugs and aggressive monitoring of PaCO2 and hemodynamic variables is required.