The Medication Quantification Scale 4.0: An Updated Index Based on Prescribers' Perceptions of the Risk Associated With Chronic Pain Medications.

To quantify risks associated with drug utilization in the real world for the treatment of chronic pain (CP), an index called the Medication Quantification Scale (MQS) was developed in 1992 in the United States and last updated in 2003. This study aimed to update, adapt to the contemporary Canadian context, and validate a revised version of the MQS (the MQS-4.0). Step 1: An expert committee adapted the MQS to the Canadian clinical practice context. Step 2: An update of risk weights given to medication subclasses was achieved using a prescriber survey (weights were derived from median 0-10 scores given to each subclass). Step 3: Construct validity of the MQS-4.0 was assessed after applying risk weights to the medication use profile of persons living with CP covered by public drug insurance plan. Thirty-six medication subclasses were included in the MQS-4.0. A total of 207 prescribers (physicians, pharmacists, and nurse practitioners) participated in the perception survey; 10.63% identified as pain specialists. When risk weights were applied to prescription claims (n = 9,122), the MQS-4.0 score was associated (P < .05) with the MQS-III score and variables associated with polypharmacy (eg, Charlson Comorbidity Index, number of prescribers or health care visits). This study provides an updated index intended for adult populations based on prescribers' perceptions of the risk associated with CP medications that can be useful for clinical practice and research among persons living with CP in Canada. It will, however, be relevant to verify whether similar risk weights are obtained in future pain specialist surveys. PERSPECTIVE: The MQS-4.0 is an update of the MQS used for quantifying the risk associated with the use of analgesics/coanalgesics. Adequate psychometrics properties were found.

Pain Medications Used by Persons Living With Fibromyalgia: A Comparison Between the Profile of a Quebec Sample and Clinical Practice Guidelines.

Background: Pharmacological management of fibromyalgia is complex. Chronic pain management is characterized by off-label prescribing and use, multimorbidity, and polypharmacy. Aims: This study aimed to describe pain medications use and perceived risk among people living with fibromyalgia and compare this use to evidence-based recommendations. Methods: Directive telephone interviews were conducted with 63 individuals self-reporting a diagnosis of fibromyalgia (Quebec, Canada). The questionnaire addressed specific questions about their pain and pharmacological treatments currently used for pain management (prescribed and over-the-counter). Collected data were compared to the Canadian Fibromyalgia Clinical Practice Guidelines and to evidence reports published by recognized organizations. Results: Despite a lack of robust scientific evidence to support opioids use to manage pain in fibromyalgia, 33% of our sample reported using them. Nonsteroidal anti-inflammatory drugs were used by 54.0% of participants, although this medication is not recommended due to lack of efficacy. Tramadol, which is recommended, was used by 23.8% of participants. Among the medications strongly recommended, anticonvulsants were used by 36.5%, serotonin norepinephrine reuptake inhibitor antidepressants by 55.6%, and tricyclic antidepressants by 22.2%. Cannabinoids (17.5%) and medical cannabis (34.9%) use were also reported. For all of these medication subclasses, no differences were found between participants not reporting (n = 35) or reporting (n = 28) more than one pain diagnosis (P < 0.05). Medication subclasses considered most at risk of adverse effects by participants were the least used. Conclusions: Results reveal discordance between evidence-based recommendations and medications use, which highlights the complexity of pharmacological treatment of fibromyalgia.

Contexte: La prise en charge pharmacologique de la fibromyalgie est complexe. La prise en charge de la douleur chronique est caractérisée par la prescription et l'utilisation non conforme de médicaments, la multimorbidité et la polypharmacothérapie.Objectifs: Cette étude visait à décrire l'utilisation de médicaments contre la douleur et le risque perçu chez les personnes atteintes de fibromyalgie, et à comparer cette utilisation aux recommandations fondées sur des données probantes.Méthodes: Des entretiens téléphoniques directifs ont été menés auprès de 63 personnes ayant déclaré avoir reçu un diagnostic de fibromyalgie (Québec, Canada). Le questionnaire abordait des questions précises sur leur douleur et les traitements pharmacologiques actuellement utilisés pour la prise en charge de leur douleur (prescrits et vendus sans ordonnance). Les données recueillies ont été comparées aux Lignes directrices canadiennes sur la fibromyalgie et aux rapports de données probantes publiés par des organisations reconnues.Résultats: Malgré l'absence de données probantes robustes à l'appui de l'utilisation des opioïdes pour la prise en charge la douleur chez les personnes atteintes de fibromyalgie, 33 % de notre échantillon a déclaré les utiliser. Les anti-inflammatoires nonstéroïdiens étaient pour leur part utilisés par 54,0 % des participants, bien que ce médicament ne soit pas recommandé en raison d'un manque d'efficacité. Le tramadol, recommandé, était utilisé par 23,8 % des participants. Parmi les médicaments fortement recommandés, les anticonvulsivants étaient utilisés par 36,5 % desparticipants, les antidépresseurs inhibiteurs de la recapture de la sérotonine et de la noradrénaline par 55,6 % des participants, et les antidépresseurs tricycliques par 22,2 % d'entre eux. La consommation de cannabinoïdes (17,5 %) et de cannabis médical (34,9 %) ont également été signalées. Pour toutes ces sous-classes de médicaments, aucune différence n'a été trouvée entre les participants ne signalant pas (n = 35) ou signalant (n = 28) plus d'un diagnostic de douleur (P < 0,05). Les sous-classes de médicaments considérées par les participants comme les plus à risque d'effets indésirables étaient les moins utilisées.Conclusions: Les résultats révèlent une discordance entre les recommandations fondées sur des données probantes et l'utilisation de médicaments, ce qui met en évidence la complexité du traitement pharmacologique de la fibromyalgie.

French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC.

OBJECTIVE: The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings. METHODS: The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence. RESULTS: Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version. CONCLUSIONS: A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study.

PURPOSE: A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs. METHODS: We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures. RESULTS: A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff. CONCLUSIONS: Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

RéSUMé: OBJECTIF: Une approche multidisciplinaire est recommandée pour les patients souffrant de douleur chronique (DC) complexe. De nombreux centres multidisciplinaires de traitement de la douleur (CMTD) utilisent des critères d'exclusion des patients, mais on ne sait que peu de choses sur leurs caractéristiques. L'objectif de cette étude était de décrire la fréquence et les caractéristiques des critères d'exclusion dans les CMTD publics canadiens. MéTHODE: Nous avons mené une étude transversale dans laquelle nous avons défini un CMTD comme une clinique composée de professionnels de trois disciplines ou plus (y compris au moins une spécialité médicale) et dont les services étaient intégrés à l'établissement. En 2017-2018, nous avons fait parvenir un questionnaire en ligne aux responsables administratifs des CMTD partout au pays. Ils ont été invités à remplir le questionnaire sur les caractéristiques de leurs établissements. Les données ont été analysées à l'aide de statistiques descriptives et de mesures de corrélation. RéSULTATS: Au total, 87 CMTD ont été inclus dans les analyses. La moitié d'entre eux (52 %) ont déclaré utiliser trois critères d'exclusion ou plus. Il n'y avait pas d'association significative entre le nombre de critères d'exclusion et le temps d'attente pour un premier rendez-vous ou le nombre de nouvelles consultations au cours de la dernière année. La fibromyalgie et la migraine étaient les syndromes douloureux les plus fréquemment exclus (10 % et 7 % des CMTD, respectivement). Plus d'un CMTD sur quatre excluait les patients atteints de troubles de santé mentale (30 %) et/ou de troubles liés à l'utilisation de substances (29 %), y compris les CMTD comptant des spécialistes dans leur personnel. CONCLUSION: Les critères d'exclusion des centres multidisciplinaires de traitement de la douleur sont plus susceptibles d'affecter les patients atteints de douleur chronique vivant avec des problèmes de douleur complexes et des vulnérabilités psychosociales. Des efforts au niveau des politiques sont nécessaires pour aider les CMTD canadiens à favoriser un accès équitable à la prise en charge de la douleur.

Qualitative Study of Health Care Providers' Uptake of the Project Extension for Community Health Outcomes for Chronic Pain.

INTRODUCTION: There is an enormous need for pain education among all health care professions before and after licensure. The study goal was to explore generic and chronic pain-specific factors that influenced uptake of a continuous education program for chronic pain, the Project Extension for Community Health Outcomes (ECHO) CHUM Douleur chronique. METHODS: The study team conducted 20 semistructured virtual interviews among participants of the program. Interviews were transcribed verbatim, and two analysts used a reflexive thematic analysis approach to generate study themes. RESULTS: Five aspects facilitating engagement, continued participation, and uptake of the Project ECHO were identified: rapid access to reliable information, appraising one's knowledge, cultivating meaningful relationships, breaking the silos of learning and practice, and exponential possibilities of treatment orchestrations for a complex condition with no cure. Although participants' experiences of the program was positive overall, some obstacles to engagement and continued participation were identified: heterogeneity of participants' profiles, feelings of powerlessness and discouragement in the face of complex incurable pain conditions, challenges in applying recommendations, medical hierarchy, and missed opportunity for advocacy. DISCUSSION: Many disease-specific and contextual factors contributed to an increased motivation to participate in the ECHO program. Some elements, such as the complexity of diagnosis and treatment, and the multidisciplinary requirements to manage cases were identified as elements motivating one's participation in the program but also acting as a barrier to knowledge uptake. These must be understood in the broader systemic challenges of the current health care system and lack of resources to access allied health care.

Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in Canada.

BACKGROUND: Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006. METHODS: This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities. RESULTS: Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed. CONCLUSION: Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.

Opioid Poisoning and Opioid Use Disorder in Older Trauma Patients.

BACKGROUND: Patients hospitalized following a traumatic injury will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (<3 months) opioid use after discharge and the risk of opioid poisoning or use disorder in older trauma patients. METHODS: In a retrospective multicenter cohort study conducted on registry data, we included all patients ≥65 years admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for opioid poisoning and opioid use disorder from ICD-9 to ICD-10 code diagnosis after their initial injury. Patients that filled an opioid prescription within a 3-month period after sustaining the trauma were compared to those who did not, using Cox proportional hazards regressions. RESULTS: A total of 70,314 admissions were retained for analysis; median age was 82 years (IQR: 75-87), 68% were women, and 34% of the patients filled an opioid prescription within 3 months of the initial trauma. During a median follow-up of 2.6 years (IQR: 1-5), 192 participants (0.27%; 95% CI: 0.23%-0.31%) were hospitalized for opioid poisoning and 73 (0.10%; 95% CI: 0.08%-0.13%) were diagnosed with opioid use disorder. Having filled an opioid prescription within 3 months of injury was associated with an increased hazard ratio of opioid poisoning (2.8; 95% CI: 2.1-3.8) and opioid use disorder (4.2; 95% CI: 2.4-7.4) after the injury. However, history of opioid poisoning (2.6; 95% CI: 1.1-5.8), of substance use disorder (4.3; 95% CI: 2.4-7.7), or of the opioid prescription filled (2.8; 95% CI: 2.2-3.6) before the trauma, was also related to opioid poisoning or opioid use disorder after the injury. CONCLUSION: Opioid poisoning and opioid use disorder are rare events after hospitalization for trauma in older patients. However, opioids should be used cautiously in patients with a history of substance use disorder, opioid poisoning or opioid use.

French-Canadian translation of a self-report questionnaire to monitor opioid therapy for chronic pain: The Opioid Compliance Checklist (OCC-FC).

Context: Chronic noncancer pain (CNCP) is a frequent condition among Canadians. The psychosocial and economic costs of CNCP for individuals, their families, and society are substantial. Though opioid therapy is often used to manage CNCP, it is also associated with risks of misuse. The Opioid Compliance Checklist (OCC) was developed to monitor opioid misuse in patients taking opioids for CNCP. The objective of the present study was to provide a French-Canadian translation of the eight-item OCC, the OCC-FC. Methods: The eight-item OCC was translated for use in Québec using published guidelines for the translation and adaptation of self-report measures, including an expert committee and a double forward-backward translation process. A pretest of the adapted eight-item OCC was also conducted among 30 patients with CNCP. Results: A French-Canadian version of the OCC was generated. When ambiguity in the items was detected during expert committee consultation or pretest administration, modifications made were kept to a strict minimum to facilitate future comparisons across studies using the original English and translated French-Canadian version. Discussion: This study provides a culturally adapted tool that will contribute to identifying French-Canadian patients with CNCP who misuse opioids over the course of opioid therapy. This translation of the OCC has the strong potential to be useful in research and clinical settings.

Contexte: La douleur chronique non cancéreuse est une affection fréquente chez les Canadiens. Les coûts psychosociaux et économiques de la douleur chronique non cancéreuse pour les individus, leurs familles et la société sont considérables. Si le traitement opioïde est souvent utilisé pour la prise en charge de la douleur chronique non cancéreuse, il est également associé à des risques de mauvais usage. La liste de vérification de l'observance du traitement opioïde (OCC) a été élaborée pour surveiller le mauvais usage des opioïdes chez les patients prenant des opioïdes pour la douleur chronique non cancéreuse. L'objectif de la présente étude était de fournir une traduction canadienne-française de l'OCC en 8 points, le OCC-FC.Méthodes: L'OCC en 8 points a été traduit pour être utilisé au Québec selon les lignes directrices publiées pour la traduction et l'adaptation des mesures autorapportées, y compris un comité d'experts et un double processus de traduction - rétrotraduction. Un prétest de l'OCC en 8 points adapté a également été réalisé auprès de trente patients atteints de douleur chronique non cancéreuse.Résultats: Une version canadienne française de l'OCC a été produite. Lorsqu'une ambiguïté dans les énoncés a été détectée par 'lors de la consultation avec le comité d'experts ou de l'administration du prétest, les modifications apportées ont été maintenues au strict minimum afin de faciliter les comparaisons futures entre les études utilisant la version originale anglaise et la version canadienne-française traduite.Discussion: Cette étude fournit un outil culturellement adapté qui contribuera à répertorier les patients canadiens français atteints de douleur chronique non cancéreuse qui font un mauvais usage des opioïdes au cours de leur traitement. Cette traduction de l'OCC présente un grand potentiel d'utilité dans la recherche et les milieux cliniques.

Early Factors Associated with the Development of Chronic Pain in Trauma Patients.

Objective: To identify factors, available at the time of trauma admission, associated with the development of chronic pain to allow testing of preventive approaches. Methods: In a retrospective observational cohort study, we included all patients ≥ 18 years old admitted for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Chronic pain was defined as follows: treated in a chronic pain clinic, diagnosed with chronic pain, or received at least 2 prescriptions of chronic pain medications 3 to 12 months postinjury. Results: A total of 95,134 patients were retained for analysis. Mean age was 59.8 years (±21.7), and 52% were men. The causes of trauma were falls (63%) and motor vehicle accidents (22%). We identified 14,518 patients (15.3%; 95% CI: 15.1-15.5) who developed chronic pain. After controlling for confounding factors, the variables associated with chronic pain were spinal cord injury (OR = 3.9; 95% CI: 3.4-4.6), disc-vertebra trauma (OR = 1.6; 95% CI: 1.5-1.7), history of alcoholism (OR = 1.4; 95% CI: 1.2-1.7), history of anxiety (OR = 1.4; 95% CI: 1.2-1.5), history of depression (OR = 1.3; 95% CI: 1.1-1.4), and being female (OR = 1.3; 95% CI: 1.2-1.3). The area under the receiving operating characteristic curve derived from the model was 0.80. Conclusions: We identified risk factors present on hospital admission that can predict trauma patients who will develop chronic pain. These factors should be prospectively validated.

Recent opioid use and fall-related injury among older patients with trauma.

BACKGROUND: Evidence for an association between opioid use and risk of falls or fractures in older adults is inconsistent. We examine the association between recent opioid use and the risk, as well as the clinical outcomes, of fall-related injuries in a large trauma population of older adults. METHODS: In a retrospective, observational, multicentre cohort study conducted on registry data, we included all patients aged 65 years and older who were admitted (hospital stay > 2 d) for injury in 57 trauma centres in the province of Quebec, Canada, between 2004 and 2014. We looked at opioid prescriptions filled in the 2 weeks preceding the trauma in patients who sustained a fall, compared with those who sustained an injury through another mechanism. RESULTS: A total of 67 929 patients were retained for analysis. Mean age was 80.9 (± 8.0) years and 69% were women. The percentage of patients who had filled an opioid prescription in the 2 weeks preceding an injury was 4.9% (95% confidence interval [CI] 4.7%-5.1%) for patients who had had a fall, compared with 1.5% (95% CI 1.2%-1.8%) for those who had had an injury through another mechanism. After we controlled for confounding variables, patients who had filled an opioid prescription within 2 weeks before injury were 2.4 times more likely to have a fall rather than any other type of injury. For patients who had a fall-related injury, those who used opioids were at increased risk of in-hospital death (odds ratio 1.58; 95% CI 1.34-1.86). INTERPRETATION: Recent opioid use is associated with an increased risk of fall and an increased likelihood of death in older adults.

Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry study.

OBJECTIVE: The objective of this study was to investigate in a real-life context the effectiveness of long-term opioid therapy for reducing pain intensity and interference and improving health-related quality of life (QOL) in patients with chronic noncancer pain. METHODS: Participants were 893 patients (age = 52.4 ± 14.1, female = 62.4%) enrolled in the Quebec Pain Registry (2008-2011) who completed questionnaires before their first visit at one of three multidisciplinary pain management clinics and 6 and 12 months thereafter. Based on their opioid use profile (OUP), patients were categorized as nonusers, non-lasting users, or lasting users. Data were analyzed using generalized estimating equations. RESULTS: More than 60% of patients newly initiated on opioid therapy stopped their medication mainly because of adverse effects and/or lack of pain relief. OUP significantly predicted pain intensity and interference and physical QOL (pQOL; P values < 0.001). Lasting users of opioids reported higher levels of pain intensity and interference and poorer pQOL than nonusers and/or non-lasting users over the 12-month follow-up (P values < 0.001). However, all effect sizes were small, thus questioning the clinical significance of these group differences. Among lasting users, more than 20% of patients experienced a meaningful amelioration in pain intensity and interference as well as mental QOL (mQOL), whereas only 8% exhibited improved pQOL. DISCUSSION: A significant subgroup of patients may benefit from long-term opioid therapy in terms of pain severity and mQOL but the majority do not. The challenge facing clinicians is how to identify who the responders will be.

Objectif: L'objectif de cette étude était d'investiguer dans un contexte de vraie vie l'efficacité à long terme des opioïdes pour réduire l'intensité et l'interférence de la douleur et améliorer la qualité de vie reliée à la santé (QDV) des patients souffrant de douleur chronique non cancéreuse.Méthodes: Les participants à cette étude étaient 893 patients (âge = 52.4 ± 14.1, femmes = 62,4%) enrôlés dans le Registre Québec Douleur (2008­2011) et qui avaient complété des questionnaires avant leur premiére visite dans l'un des trois centres multidisciplinaires de gestion de la douleur ainsi qu'à 6 et 12 mois plus tard. Selon leur profil d'utilisation d'opioïdes (PUO), les patients ont été classés en non-utilisateurs, utilisateurs non continus, ou utilisateurs continus. Les données ont été analysées à l'aide de modéles d'équation d'estimation généralisée.Résultats: Plus de 60% des patients nouvellement initiés à une thérapie à base d'opioïdes en avaient cessé la prise principalement à cause des effets indésirables et/ou d'un manque de soulagement de leur douleur. Le PUO prédisait d'une maniére significative l'intensité de la douleur et son interférence ainsi que la QDV physique (QDVp; valeurs p < 0.001). Comparés aux non-utilisateurs et/ou utilisateurs non continus, les utilisateurs continus rapportaient des niveaux plus élevés d'intensité et d'interférence de la douleur ainsi qu'une moins bonne QDVp au cours des 12 mois de suivi (valeurs p < 0.001). Cependant, la magnitude de ces effets était de petite taille, remettant ainsi en question la signification clinique des différences observées entre ces groupes. Parmi les utilisateurs continus, plus de 20% d'entre eux montraient une amélioration significative de leur condition douloureuse en termes d'intensité et d'interférence ainsi que de la QDV mentale (QDVm), alors que seulement 8% présentaient une amélioration de leur QDVp.Discussion: Un sous-groupe important de patients peut bénéficier d'un traitement à long terme à base d'opioïdes en termes de sévérité de la douleur et de QDVm, mais ce n'est pas le cas pour la majorité des patients. Le défi auquel les cliniciens doivent faire face est de déterminer les patients les plus susceptibles de bénéficier de ce type de traitement.

Opioid Prescribing Practices and Training Needs of Québec Family Physicians for Chronic Noncancer Pain.

AIM: To examine medical practices and training needs of Québec family physicians with respect to pain management and opioid prescription for chronic noncancer pain (CNCP). METHODOLOGY: An online survey was carried out in 2016. RESULTS: Of 636 respondents (43.0% men; 54.3% ≥ 50 years old), 15.2% and 70.9% felt very or somewhat confident that they could properly prescribe opioids for CNCP. Concerns related to abuse (72.5% strongly/somewhat agree), dependence (73.2%), and lack of support (75.4%) were the main barriers reported. Only 19.7% always/often screened their patients for risks of abuse and dependence using a screening tool. About two-thirds of participants (65.7%) had recently (last five years) taken part in continuing education programs on opioid use for CNCP and 73.4% on CNCP management. Patient evaluation and differential diagnoses of chronic pain syndromes were rated as a top priority for further training. CONCLUSIONS: This study provides insights into Québec family physicians' concerns, practices, and needs with respect to the management of CNCP. Physicians' difficulties around the application of strategies to mitigate the problem of opioid abuse and addiction are worrying. The need to better train physicians in the field of pain and addiction cannot be emphasized enough.

Medical cannabis: considerations for the anesthesiologist and pain physician.

PURPOSE: New regulations are in place at the federal and provincial levels in Canada regarding the way medical cannabis is to be controlled. We present them together with guidance for the safe use of medical cannabis and recent clinical trials on cannabis and pain. SOURCE: The new Canadian regulations on the use of medical cannabis, the provincial regulations, and the various cannabis products available from the Canadian Licensed Producers were reviewed from Health Canada, provincial licensing authorities, and the licensed producers website, respectively. Recent clinical trials on cannabis and pain were reviewed from the existing literature. PRINCIPAL FINDINGS: Health Canada has approved a new regulation on medical marijuana/cannabis, the Marihuana for Medical Purposes Regulations: The production of medical cannabis by individuals is illegal. Health Canada, however, has licensed authorized producers across the country, limiting the production to specific licenses of certain cannabis products. There are currently 26 authorized licensed producers from seven Canadian provinces offering more than 200 strains of marijuana. We provide guidance for the safe use of medical cannabis. The recent literature indicates that currently available cannabinoids are modestly effective analgesics that provide a safe, reasonable therapeutic option for managing chronic non-cancer-related pain. CONCLUSION: The science of medical cannabis and the need for education of healthcare professionals and patients require continued effort. Although cannabinoids work to decrease pain, there is still a need to confirm these beneficial effects clinically and to exploit them with acceptable benefit-to-risk ratios.

Accuracy of Self-reported Prescribed Analgesic Medication Use: Linkage Between the Quebec Pain Registry and the Quebec Administrative Prescription Claims Databases.

OBJECTIVES: The validity of studies conducted with patient registries depends on the accuracy of the self-reported clinical data. As of now, studies about the validity of self-reported use of analgesics among chronic pain (CP) populations are scarce. The objective of this study was to assess the accuracy of self-reported prescribed analgesic medication use. This was attained by comparing the data collected in the Quebec Pain Registry (QPR) database to those contained in the Quebec administrative prescription claims database (Régie de l'assurance maladie du Québec [RAMQ]). METHODS: To achieve the linkage between the QPR and the RAMQ databases, the first 1285 patients who were consecutively enrolled in the QPR between October 31, 2008 and January 27, 2010 were contacted by mail and invited to participate in a study in which they had to provide their unique RAMQ health insurance number. Using RAMQ prescription claims as the reference standard, κ coefficients, sensitivity, specificity, and their respective 95% confidence intervals were calculated for each therapeutic class of prescribed analgesic drugs that the participants reported taking currently and in the past 12 months. RESULTS: A total of 569 QPR patients responded to the postal mailing, provided their unique health insurance number, and gave informed consent for the linkage (response proportion=44%). Complete RAMQ prescription claims over the 12 months before patient enrollment into the QPR were available for 272 patients, who constituted our validated study population. Regarding current self-reported prescribed analgesic use, κ coefficients measuring agreement between the 2 sources of information ranged from 0.66 to 0.78 for COX-2-selective nonsteroidal anti-inflammatory drugs, anticonvulsants, antidepressants, skeletal muscle relaxants, synthetic cannabinoids, opiate agonists/partial agonists/antagonists, and antimigraine agents therapeutic classes. For the past 12-month self-reported prescribed analgesic use, QPR patients were less accurate regarding anticonvulsants (κ=0.59), opiate agonists/partial agonists/antagonists (κ=0.57), and antimigraine agents use (κ=0.39). DISCUSSION: Information about current prescribed analgesic medication use as reported by CP patients was accurate for the main therapeutic drug classes used in CP management. Accuracy of the past year self-reported prescribed analgesic use was somewhat lower but only for certain classes of medication, the concordance being good on all the others.

Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society.

BACKGROUND: Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians. OBJECTIVE: To review the randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence-based consensus statement on its management. METHODS: RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment were based on the degree of evidence of analgesic efficacy, safety and ease of use. RESULTS: Analgesic agents recommended for first-line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled-release opioid analgesics are recommended as second-line treatments for moderate to severe pain. Cannabinoids are now recommended as third-line treatments. Recommended fourth-line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacosamide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions. CONCLUSIONS: These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Additional studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes and treatment of pediatric, geriatric and central NeP.

The Canadian STOP-PAIN project: the burden of chronic pain-does sex really matter?

OBJECTIVES: The Canadian STOP-PAIN Project assessed the human and economic burden of chronic pain (CP) in individuals on waitlists of Canadian multidisciplinary pain treatment facilities. This article focuses on sex differences. Objectives were to (1) determine the pain characteristics and related biopsychosocial factors that best differentiated women and men with CP; and (2) examine whether public and private costs associated with CP differed according to sex. MATERIALS AND METHODS: Sample consisted of 441 women and 287 men who were evaluated using self-administered questionnaires and a structured interview protocol. A subsample (233 women and 137 men) recorded all pain-related expenditures in a comprehensive diary over 3 months. RESULTS: Results revealed that the burden of illness associated with CP was comparable in both sexes for average and worst pain intensity, pain impact on daily living, quality of life, and psychological well-being. The same was true for pain-related costs. The results of a hierarchical logistic regression analysis, in which sex was treated as the dependent variable, showed that factors that differentiated men and women were: work status, certain circumstances surrounding pain onset, present pain intensity, intake of particular types of pain medication, use of certain pain management strategies, pain beliefs, and utilization of particular health care resources. DISCUSSION: This study suggests that women and men who are referred to multidisciplinary pain treatment facilities do not differ significantly in terms of their pain-related experience. However, the aspects that differ may warrant further clinical attention when assessing and managing pain.

Anatomy of the Pain Centre waiting list at the Centre hospitalier de l'Université de Montréal (CHUM).

BACKGROUND: Waiting list management at chronic pain clinics has become a serious problem throughout Canada. We analyzed the waiting list at the Centre hospitalier de l'Université de Montréal (CHUM) Pain Centre. METHODS: The present study is an observational, prospective study. We used a specifically designed survey questionnaire. Survey findings were analyzed with descriptive statistical methods. RESULTS: A total of 270 patients were contacted; only 146 were included. Of these, 93 were women and 53 men. The average age was 55.9 years. Fifty-two percent of the patients were referred by a medical specialist; 34% by family physicians; 3% for emergency; and 11% unknown. The mean for pain score was 6.7/10. Seventy-three percent were taking pain killers with an average improvement on their pain score of 52%. Ten percent of respondents were not taking any type of analgesic medication, while 17% were taking over-the-counter drugs. Fifty-three percent of the patients had been suffering from chronic pain for 5 years or less, while 10% had been suffering and awaiting specialized pain treatment for more than 20 years. CONCLUSION: Our data suggests that accessibility to specialized health care is not the sole obstacle to the timely and effective management of chronic pain. Seventy-three percent of the patients were taking some form of pharmaceutical treatment for pain and reported an average improvement rate of 52% on their pain score under medication. Such inconsistency may be attributable to patients' lack of compliance with their treatment. The World Health Organization Working Group recommended in chronic patients a novel approach to health care, based on patient therapeutic education. Our results show that patients need to acquire self-management skills regarding their chronic conditions.

Further validation of the BDI-II among people with chronic pain originating from musculoskeletal disorders.

OBJECTIVE: One criticism of the BDI-II for assessing depressive symptoms in people experiencing chronic pain has been the potential overlap between the physical or psychological origins of some of the symptoms. Furthermore, previous studies have reported both two-factor and three-factor solutions, so that the factor solution of the instrument in this population remains unclear. The main objective of the present study was to validate the BDI-II with a chronic pain population experiencing musculoskeletal disorders. Three specific objectives were: (1) to modify the BDI-II for people with musculoskeletal disorders by adding sub-questions to better identify the perceived cause of the depressive symptoms, (2) to assess the validity and reliability of this modified version of the BDI-II, and (3) to explore the perceptions of the causes/origins of symptoms reported on the BDI-II. Results of the confirmatory factor analysis supported the presence of three dimensions within the BDI- : Cognitive, Affective and Somatic. METHODS: A total of 206 participants experiencing chronic pain answered a modified version of the BDI-II, the CES-D and a sociodemographic questionnaire. RESULTS: Results confirmed the three-dimensional factorial structure of the BDI for this population. Overall, participants experienced higher levels of somatic symptoms compared to symptoms belonging to other dimensions. The percentages of answers to the sub-questions were also similarly distributed between "pain", and "pain and state of mind", regardless of the dimension. DISCUSSION: The importance of assessing somatic symptoms of depression in pain patients and of thoroughly examining the underlying perceived cause of symptoms, regardless of the dimension, are discussed.

Buprenorphine transdermal system in adults with chronic low back pain: a randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase.

BACKGROUND: Buprenorphine is a mixed-activity, partial mu-opioid agonist. Its lipid solubility makes it well suited for transdermal administration. OBJECTIVE: This study assessed the efficacy and safety profile of a 7-day buprenorphine transdermal system (BTDS) in adult (age >18 years) patients with moderate to severe chronic low back pain previously treated with > or =1 tablet daily of an opioid analgesic. METHODS: This was a randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. After a 2- to 7-day washout of previous opioid therapy, eligible patients were randomized to receive BTDS 10 microg/h or matching placebo patches. The dose was titrated weekly using 10- and 20-microg/h patches (maximum, 40 microg/h) based on efficacy and tolerability. After 4 weeks, patients crossed over to the alternative treatment for another 4 weeks. Patients who completed the double-blind study were eligible to enter the 6-month open-label phase. Rescue analgesia was provided as acetaminophen 325 mg to be taken as 1 or 2 tablets every 4 to 6 hours as needed. The primary outcome assessments were daily pain intensity, measured on a 100-mm visual analog scale (VAS), from no pain to excruciating pain, and a 5-point ordinal scale, from 0 = none to 4 = excruciating. Secondary outcome assessments included the Pain and Sleep Questionnaire (100-mm VAS, from never to always), Pain Disability Index (ordinal scale, from 0 = no disability to 11 = total disability), Quebec Back Pain Disability Scale (categorical scale, from 0 = no difficulty to 5 = unable to do), and the 36-item Short Form Health Survey (SF-36). Patients and investigators assessed overall treatment effectiveness at the end of each phase; they assessed treatment preference at the end of double-blind treatment. After implementation of a precautionary amendment, the QTc interval was measured 3 to 4 days after randomization and after any dose adjustment. All assessments performed during the double-blind phase were also performed every 2 months during the open-label extension. Adverse events were collected by non-directed questioning throughout the study. RESULTS: Of 78 randomized patients, 52 (66.7%) completed at least 2 consecutive weeks of treatment in each study phase without major protocol violations (per-protocol [PP] population: 32 women, 20 men; mean [SD] age, 51.3 [11.4] years; mean weight, 85.5 [19.5] kg; 94% white, 4% black, 2% other). The mean (SD) dose of study medication during the last week of treatment was 29.8 (12.1) microg/h for BTDS and 32.9 (10.7) microg/h for placebo (P = NS). During the last week of treatment, BTDS was associated with significantly lower mean (SD) pain intensity scores compared with placebo on both the VAS (45.3 [21.3] vs 53.1 [24.3] mm, respectively; P = 0.022) and the 5-point ordinal scale (1.9 [0.7] vs 2.2 [0.8]; P = 0.044). The overall Pain and Sleep score was significantly lower with BTDS than with placebo (177.6 [125.5] vs 232.9 [131.9]; P = 0.027). There were no treatment differences on the Pain Disability Index, Quebec Back Pain Disability Scale, or SF-36; however, BTDS was associated with significant improvements compared with placebo on 2 individual Quebec Back Pain Disability Scale items (get out of bed: P = 0.042; sit in a chair for several hours: P = 0.022). Of the 48 patients/physicians in the PP population who rated the effectiveness of treatment, 64.6% of patients (n = 31) rated BTDS moderately or highly effective, as did 62.5% of investigators (n = 30). Among the 50 patients in the PP population who answered the preference question, 66.0% of patients (n = 33) preferred the phase in which they received BTDS and 24.0% (n = 12) preferred the phase in which they received placebo (P = 0.001), with the remainder having no preference; among investigators, 60.0% (n = 30) and 28.0% (n = 14) preferred the BTDS and placebo phases, respectively (P = 0.008), with the remainder having no preference. The mean placebo-adjusted change from baseline in the QTc interval ranged from -0.8 to +3.8 milliseconds (P = NS). BTDS treatment was associated with a significantly higher frequency of nausea (P < 0.001), dizziness (P < 0.001), vomiting (P = 0.008), somnolence (P = 0.020), and dry mouth (P = 0.003), but not constipation. Of the 49 patients completing 8 weeks of double-blind treatment, 40 (81.6%) entered the 6-month, open-label extension study and 27 completed it. Improvements in pain scores achieved during the double-blind phase were maintained in these patients. CONCLUSIONS: In the 8-week, double-blind portion of this study, BTDS 10 to 40 microg/h was effective compared with placebo in the management of chronic, moderate to severe low back pain in patients who had previously received opioids. The improvements in pain scores were sustained throughout the 6-month, open-label extension. (Current Controlled Trials identification number: ISRCTN 06013881).