What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map.

ABSTRACT: Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark.

OBJECTIVES: Patient and stakeholder engagements in research have increasingly gained attention in healthcare and healthcare-related research. A common and rigorous approach to establish research priorities based on input from people and stakeholders is the James Lind Alliance Priority Setting Partnership (JLA-PSP). The aim of this study was to establish research priorities for chronic musculoskeletal (MSK) pain by engaging with people living with chronic MSK pain, relatives to people living with chronic MSK pain, healthcare professionals (HCP), and researchers working with chronic MSK pain. METHODS: This JLA-PSP included a nation-wide survey in Denmark, an interim prioritisation, and an online consensus building workshop. The information gained from this was the basis for developing the final list of specific research priorities within chronic MSK pain. RESULTS: In the initial survey, 1010 respondents (91% people living with chronic MSK pain/relatives, 9% HCPs/researchers) submitted 3121 potential questions. These were summarised into 19 main themes and 36 sub-themes. In the interim prioritisation exercise, 51% people living with pain/relatives and 49% HCPs/researchers reduced the list to 33 research questions prior to the final priority setting workshop. 23 participants attended the online workshop (12 people/relatives, 10 HCPs, and 1 researcher) who reached consensus for the most important research priorities after two rounds of discussion of each question. CONCLUSIONS: This study identified several specific research questions generated by people living with chronic MSK pain, relatives, HCPs, and researchers. The stakeholders proposed prioritization of the healthcare system's ability to support patients, focus on developing coherent pathways between sectors and education for both patients and HCP. These research questions can form the basis for future studies, funders, and be used to align research with end-users' priorities.

A Cognitive Functional Therapy+ Pathway Versus an Interdisciplinary Pain Management Pathway for Patients With Severe Chronic Low Back Pain (CONFeTTI Trial): Protocol for a Pragmatic Randomized Controlled Trial.

OBJECTIVE: Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care). METHODS: This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D. IMPACT: The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.

Preliminary validity and test-retest reliability of two depression questionnaires compared with a diagnostic interview in 99 patients with chronic pain seeking specialist pain treatment.

Objectives Depression symptomatology is highly prevalent in patients with chronic pain, but accurate identification of major depression may be challenged due to time constraints and diagnostic interviews are therefore not routinely performed in clinical practice. Assessment of depression may be facilitated through the use of full-length depression screening questionnaires with acceptable construct validity and test-retest reliability. However, as previously indicated screening questionnaires may overestimate depression in patients with chronic pain, possibly due to overlapping symptoms. However, the failure to screen for depression may raise a concern for missing relevant cases with depression. The objectives of this study were to (1) quantify the validity of the 9-items Patient-Health Questionnaire (PHQ9) and the Major Depression Inventory (MDI) compared with a diagnostic interview in patients with chronic pain seeking specialist pain treatment, and (2) assess the relative test-retest reliability of PHQ9 and MDI over two weeks. Methods Responses to the PHQ9 and MDI were compared with a Present-State-Examination (PSE) interview in 99 patients with chronic pain referred to interdisciplinary pain treatment. PHQ9 and MDI were completed twice over two weeks. Construct validity were assessed with the area under the curve (AUC) analysis, and performance characteristics derived from 2 × 2 contingency tables in which scores on the screening questionnaires were dichotomized and compared with the classification of clinical depression based on the diagnostic interview. Relative test-retest reliability was assessed with intraclass correlation coefficients (ICC). Results Based on the PSE interview, the prevalence of depression was 22.2%, and according to the PHQ9 and MDI questionnaires the prevalence was 26.3 and 34.3%, respectively. Compared with the diagnostic PSE, the PHQ9 and MDI questionnaires had areas under the curve of 0.83 and 0.88, respectively. Both questionnaires had high negative predictive values (PHQ9: cut-off of 11; MDI: cut-off of 26), but low positive predictive values for all possible scores. ICC values were excellent. Conclusions The PHQ9 and MDI questionnaires reliably identified chronic pain patients unlikely to have clinical depression, but showed limited validity identifying patients with clinical depression. These preliminary results may have clinical implications in depression screening in patients with chronic pain seeking specialist pain treatment. Clinicians in a specialty care pain clinic can use these screening questionnaires to identify patients without depression, but caution should be used when positive cases are identified by PHQ9 or MDI due to the risk of false positives.

Cause-specific mortality of patients with severe chronic pain referred to a multidisciplinary pain clinic: a cohort register-linkage study.

Background and aims Almost 20% of the adult population suffers from chronic pain. Chronic pain may be linked to an elevated mortality; however, results from previous studies are inconsistent. Some studies find similar mortality levels in chronic pain patients and pain-free controls while other studies show elevated mortality levels among chronic pain patients, primarily with respect to cancer, diseases of the circulatory and respiratory systems, and suicide. These conflicting results are potentially due to different population samples and different operational definitions of chronic pain. Further research on overall and cause-specific mortality in patients with severe chronic pain is needed to inform clinical practice. The objective of this register-linkage study was to investigate whether patients with severe chronic pain referred to multidisciplinary pain treatment have higher cause-specific mortality rates than the general population. Methods In this register-linkage cohort study, data from 6,142 chronic pain patients (female: n=3,941, male: n=2,201, mean age: 48.2±14.2; range: 16-97 years) attending an interdisciplinary Pain Center in Odense, Denmark from 2005 to 2014 were linked to the Danish Register of Causes of Death. Age and gender standardized mortality ratios (SMRs) with their 95% confidence intervals (CI) were calculated and compared with those of the general population. Data from the general population was extracted from the Danish Register of Causes of Death, and Causes of death were classified according to national Classification of Disease (ICD-10). Results In all, 276 deaths (women: n=152, men: n=124) were observed among the chronic pain patients, and a six-fold higher overall mortality rate was found [SMR: 6.2 (95% CI: 5.5-7.0)] compared with the general population. Elevated cause-specific mortality rates were noted for chronic patients with respect to cancer and neoplasms [4.7 (95% CI: 3.7-5.9)], diseases of the circulatory system [5.7 (95% CI: 4.3-7.3)], diseases of the respiratory system [8.7 (95% CI: 6.2-11.9)], and suicide [7.3 (95% CI: 2.7-15.9)]. Conclusions The overall mortality rate of patients with severe chronic pain in this study was six-fold higher than the rate of the general population in this region. This was reflected in select specific causes of death (cancer and neoplasms, diseases of the circulatory system, diseases of the respiratory system, and suicide). The results are in agreement with previous studies and emphasize the need to understand which factors causally affect this increased mortality allowing for targeted interventions in similar chronic pain populations. Implications Potential reasons for the excess mortality should be adequately addressed by future studies in order to better target this in the management of these patients. The chronic pain population included in this study may have several comorbidities contributing to the increased mortality. To better address these aspects, complete medical profiles are needed in future studies. In addition, implementation of management strategies towards potential risk factors such as poor diet, low levels of physical activity, smoking, and high BMI as well as sleep deprivation and morphine use previously shown associated with having pain may reduce the excess mortality ratio.

Brief Psychological Screening Questions Can be Useful for Ruling Out Psychological Conditions in Patients With Chronic Pain.

OBJECTIVES: Psychological symptoms are highly prevalent in chronic pain patients. Timely and accurate identification may enable individualized treatment and improve outcomes. The aims of this study were to (1) investigate the concurrent validity of brief psychological screening questions assessing anxiety, fear of movement, stress, pain catastrophization, and depression in chronic pain patients, and (2) to determine screening question cut-points at which the likely probability of having these psychological states was <10%. MATERIALS AND METHODS: Responses to 1-item or 2-item screening questions within each of these 5 psychological constructs were compared with those of validated full-length questionnaires in 894 patients with diverse chronic pain conditions. RESULTS: Compared with scores from full-length questionnaires, brief screening question scores had correlations between 0.54 and 0.66, and area under the curve between 0.79 and 0.83. At the dichotomized threshold scores that we chose, the posttest probability after a negative test result ranged from 6.5% to 8.6% for all these psychological constructs, except fear of movement. The pretest probability was so high (70%) for fear of movement that no threshold resulted in a posttest probability (negative test result) that was below 10%. DISCUSSION: Use of these screening tests and scoring thresholds would have correctly identified that between 38.5% and 60.5% of the sample were unlikely to have these psychological states (true negatives), with a false-negative rate between 3.4% and 5.3%. This would allow clinicians to focus on whether there are other patient attributes in those patients requiring more thorough investigation using comprehensive validated questionnaires or structured clinical interviews.

[Pharmacological treatment of chronic non-cancer pain].

19% of the grown-up Danish population suffer from a chronic pain condition. Most patients are treated by general practi-tioners (GPs), and only a smaller group need specialist treatment. This article goes through the pharmacological possibilities available with a special focus on treatment by GPs. For chronic pain as fibromyalgia and low back pain non-steroidal anti-inflammatory drugs and paracetamol are not recommended on a regular basis. The main pharmacological treatment is tricyclic antidepressants and gabapentinoids. If opioids are needed, long acting drugs are preferred.

[Psychosocial treatment of pain at general practitioners and in specialist pain treatment units].

Patients with complex chronic pain conditions are often difficult to treat with analgesia alone. Psychosocial intervention is needed to help them gain control and find an appropriate level of activity. This article summarizes the possibilities of psychosocial treatment of pain patients at the general practitioners and in specialist units of multidisciplinary pain treatment. The theoretical frame used is cognitive behavioural therapy. In practice, psychoeducation, mindfulness, and relaxation exercises are introduced to the patients to help them with daily life activity and work.

Preoperative Hypoalgesia After Cold Pressor Test and Aerobic Exercise is Associated With Pain Relief 6 Months After Total Knee Replacement.

OBJECTIVES: Chronic pain after total knee replacement (TKR) is not uncommon. Preoperative impaired conditioning pain modulation (CPM) has been used to predict chronic postoperative pain. Interestingly, exercises reduce pain sensitivity in patients with knee osteoarthritis (KOA). This pilot study investigated the association between exercise-induced hypoalgesia (EIH) and CPM on post-TKR pain relief. METHODS: Before and 6 months post-TKR, 14 patients with chronic KOA performed the cold pressor test on the nonaffected leg and 2 exercise conditions (bicycling and isometric knee extension), randomized and counterbalanced. Before and during the cold pressor test and after exercises test stimuli were applied to extract the pain sensitivity difference: computer-controlled cuff inflation on the affected lower leg until the participants detected the cuff pain threshold (cPPT) and subsequently the cuff pain tolerance (cPTT) and manual pressure pain thresholds (PPTs) at the legs, arm, and shoulder. Clinical pain intensity (numerical rating scale [NRS]) and psychological distress (questionnaires) were assessed. RESULTS: Clinical pain intensity, psychological distress, cPPT, and PPT at the affected leg improved post-TKR compared with pre-TKR (P<0.05). Preoperatively, the CPM and bicycling EIH assessed by the increase in cPTT correlated with reduction in NRS pain scores post-TKR (P<0.05). Improved CPM and EIH responses after TKR were significantly correlated with reduction in NRS pain scores post-TKR (P<0.05). DISCUSSION: In KOA patients, hypoalgesia after cold pressor stimulation and aerobic exercise assessed preoperatively by cuff algometry was associated with pain relief 6 months after TKR. EIH as a novel preoperative screening tool should be further investigated in larger studies.

Acetaminophen for Chronic Pain: A Systematic Review on Efficacy.

Acetaminophen (paracetamol) is the most commonly used analgesic worldwide and recommended as first-line treatment in all pain conditions by WHO. We performed a systematic literature review to evaluate the efficacy of acetaminophen when used for chronic pain conditions. Applying three broad search strategies for acetaminophen use in chronic pain in both Embase and PubMed, 1551 hits were obtained. After cross-reference searches of both trials and 38 reviews, seven studies comparing acetaminophen in continuous dosing regimens of more than 2 weeks with placebo were included. The review was conducted according to the PRISMA guidelines. All studies were conducted in patients with hip- or knee osteoarthritis and six of seven studies had observation periods of less than 3 months. All included studies showed no or little efficacy with dubious clinical relevance. In conclusion, there is little evidence to support the efficacy of acetaminophen treatment in patients with chronic pain conditions. Assessment of continuous efficacy in the many patients using acetaminophen worldwide is recommended.

Hypoalgesia After Exercise and the Cold Pressor Test is Reduced in Chronic Musculoskeletal Pain Patients With High Pain Sensitivity.

OBJECTIVES: In chronic pain patients, impaired conditioned pain modulation (CPM) and exercise-induced hypoalgesia (EIH) have been reported. No studies have compared CPM and EIH in chronic musculoskeletal pain patients with high pain sensitivity (HPS) and low pain sensitivity (LPS). MATERIALS AND METHODS: On 2 days, manual pressure pain thresholds (PPTs) were recorded at the legs, arm, and shoulder in 61 chronic pain patients and they performed the cold pressor test, 2 exercise conditions (bicycling and isometric contraction), and a control condition in a randomized and counterbalanced order. PPTs, pain tolerance, pain tolerance limit, and temporal summation of pain were assessed with cuff algometry before and after the tests. On the basis of a median split of the average PPTs for women and men, respectively, low (LPS; N=30) and high (HPS; N=31) pain-sensitivity groups were created. RESULTS: At baseline, cuff PPT and pain tolerance were decreased and temporal summation of pain was increased in the HPS group (P<0.02). Cuff PPT increased and pain tolerance limit decreased after the cold pressor test and exercises in LPS (P<0.001). Temporal summation of pain was increased after bicycling in HPS (P<0.005). Pain tolerance increased after the cold pressor test and exercise in both groups (P<0.001). DISCUSSION: CPM and EIH were partly impaired in chronic pain patients with high versus less pain sensitivity, suggesting that the CPM and EIH responses depend on the degree of pain sensitivity. This has clinical implications as clinicians should evaluate pain sensitivity when considering treatment options utilizing the descending modulatory pain control.

[Low dose naltrexone for treatment of pain]. / Lavdosisnaltrexon til smertebehandling

Recent years have seen an increasing interest in the use of low dose naltrexone (LDN) for off-label treatment of pain in diseases as fibromyalgia, multiple sclerosis and morbus Crohn. The evidence is poor, with only few randomized double-blind placebo-controlled studies. The studies currently available are reviewed in this paper. LDN could be a potentially useful drug in the future for the treatment of pain in fibromyalgia, but more studies are needed to verify that it is superior to placebo, and currently it cannot be recommended as first-line therapy.

Opioid prescriptions before and after high-energy trauma.

OBJECTIVE: To describe the legal use of opioids in adult patients before and after high-energy trauma. DESIGN: The study was a retrospective database study. SETTING: Clinical care outside hospitals. PATIENTS: All patients who suffered high-energy trauma and were brought to Odense University Hospital (OUH), Denmark, in 2007 and 2008 were retrieved from the trauma database. These patients were linked with data on opioid use from the regional prescription database. In all, 938 patients were included. MAIN OUTCOME MEASURE: Redemption of opioid prescription during the 6 months prior to a multitrauma or redemption of two or more prescriptions for opioids 6 months or later after a multitrauma. RESULTS: Of the 938 patients brought to OUH with severe trauma within the study period, 61 patients died (7 percent) and six of these had redeemed prescriptions for opioids within 6 months prior to the trauma (10 percent) compared to 65 patients of the 877 survivors (7 percent) (odds ratio 1.4, nonsignificant). In all, 62 patients (7 percent) redeemed opioid prescriptions later than 6 months after their trauma and in a multivariable analysis, severe injury itself and severe injuries of the lower extremities were associated with redemption of opioid prescription after the trauma. CONCLUSIONS: The authors did not find any correlation between death by trauma and redemption of opioid prescriptions within the 6 months before the trauma. More severe traumas and especially severe traumas to the lower extremities were associated with redemption of opioid prescriptions after multitrauma.

Assessment of musculoskeletal pain sensitivity and temporal summation by cuff pressure algometry: a reliability study.

Chronic musculoskeletal pain is linked with sensitization, and standardized methods for assessment are needed. This study investigated (1) the test-retest reliability of computer-controlled cuff-pressure algometry (pain thresholds and temporal pain summation) on the arm and leg and (2) conditioned pain modulation (CPM) assessed by cuff algometry. The influences of age and gender were evaluated. On 2 different days, cuff pain threshold (cPPT), cuff pain tolerance (cPTT), and temporal summation of pain (TSP) by visual analog scale scores to 10 repeated cuff stimulations at cPTT intensity, as well as pressure pain threshold with handheld pressure algometry, were assessed in 136 healthy subjects. In one session, cuff pain sensitivity was also assessed before and after cold pressor-induced CPM. Good-to-excellent intraclass correlations (0.60-0.90) were demonstrated for manual and cuff algometry, and no systematic bias between sessions was found for cPPT, cPTT, and TSP on the leg and for cPTT and TSP on the arm. Cuff pressure pain threshold and cPTT were higher in men compared with women (P < 0.05). Middle-aged subjects had higher pressure pain threshold, but lower cPPT and cPTT, compared with younger subjects (P < 0.05). Temporal summation of pain was increased in women compared with men (P < 0.05). Cuff algometry was sensitive to CPM demonstrated as increased cPPT and cPTT and reduced TSP (P < 0.05). Reliability and sensitivity of computer-controlled cuff algometry for pain assessment is comparable with manual pressure algometry and constitutes a user-independent method for assessment of pain. Difference in age-related pain sensitivity between manual and cuff algometry should be further investigated.

Aerobic exercise and cold pressor test induce hypoalgesia in active and inactive men and women.

BACKGROUND: Physical inactivity is a risk factor for chronic pain. Several mechanisms play a role in pain chronification including impairment of pain inhibition. OBJECTIVE: This study compared the efficiency of pain inhibitory systems between physical active and inactive healthy subjects. It was hypothesized that active subjects had more efficient pain inhibition compared with inactive subjects. DESIGN: A randomized, crossover study with 2 days of data collection. METHODS: Fifty-six (28 females) subjects participated in this study. Subjects were subgrouped into active (n = 30) and inactive (n = 26). Conditioned pain modulation (CPM) was assessed by cold pressor testing. Exercise-induced hypoalgesia (EIH) was assessed after 15 minutes bicycling at a heart rate corresponding to 75% VO2max. A control session of 15 minutes quiet rest was also included. Pressure pain thresholds (PPTs) were recorded at the dominant arm and leg before, immediately after, and 15 minutes after conditioning and exercise as well as before and after rest. PPTs were also recorded during conditioning. RESULTS: At baseline, PPTs in inactive men were increased compared with inactive women (P < 0.003). During cold pressor test and after exercise, PPTs increased to the same degree in active and inactive subjects, and the CPM and EIH responses were correlated (P < 0.05). The CPM response immediately after cold pressor test was maintained in women but not in men. CONCLUSIONS: Cold pressor stimulation and aerobic exercise caused comparable multisegmental increases in PPT in active and inactive men and women. The CPM and EIH responses were correlated, but they have different temporal manifestation of hypoalgesia.

Prevalence of neuropathic pain according to the IASP grading system in patients with chronic non-malignant pain.

OBJECTIVE: The primary objective was to determine the prevalence of neuropathic pain according to the new International Association for the Study of Pain (IASP) grading system. The secondary objective was to compare the system classification of neuropathic pain with the classification of neuropathic pain according to a patient-administered screening questionnaire. SETTING: A Multidisciplinary Pain Center. SUBJECTS: One hundred twenty patients with a variety of chronic pain conditions referred to a multidisciplinary pain center. METHODS: Consecutively referred patients filled out the PainDETECT Questionnaire before the first consultation. During the first consultation, patients had pain history taken and bedside examination performed by a pain specialist. Patients were classified according to the score on the PainDETECT Questionnaire and graded according to the IASP grading system about the certainty of neuropathic pain. RESULTS: According to the IASP grading system, 22 patients (18.3%) classified as probable or definite neuropathic pain and 90 patients (75%) as unlikely neuropathic pain. According to the PainDETECT Questionnaire, 55 patients (45%) were classified as likely neuropathic pain and 13 patients (10.8%) as unlikely neuropathic pain. Eleven patients (20%) who were classified as neuropathic pain according to PainDETECT were also classified as probable or definite neuropathic pain by the new IASP grading system. CONCLUSIONS: According to the new IASP grading system, less than 20% of the patients referred to a multidisciplinary pain center fulfilled the criteria for neuropathic pain. The classification of neuropathic pain with the IASP system varies from the classification of neuropathic pain with the use of a self-administered screening questionnaire.

Suicide attempts in chronic pain patients. A register-based study.

Background There are several studies about the relationship between depression and chronic non-malignant pain. These studies have shown that up to 50% of chronic pain patients are suffering from depression. It is, therefore, reasonable to expect that pain patients would also have an increased risk of suicidal behaviour. This problem is not well studied. Since 1990 the Centre for Suicide Research, Odense, Denmark has registered all suicide attempts in patients residing in the Region of Funen, Denmark. The Pain Clinic, Odense University Hospital receives patients with chronic pain from the entire Region of Southern Denmark. Purpose The purpose of the study has been: To investigate, whether patients treated in the Pain Clinic during the period from 1 January 2004 to 31 December 2009 had an increased risk of suicide attempts compared with the background population. Materials and methods The Register for Suicide Attempts (RSA) is a product of the WHO research programme WHO/EURO Multicentre Study on Para suicide. The RSA is a longitudinal person-based register. It contains information about people who have been in contact with the health care system in the County of Funen as a result of a suicide attempt. The Pain Clinic, Odense University Hospital receives patients with non-malignant chronic pain from the Region of Southern Denmark with 1,194,659 inhabitants. Data about age, sex, and time of treatment for patients treated in the Pain Clinic during the period were registered. Time and method of the suicide attempts were registered in the RSA. By registry linkages between the patient registers it was possible to calculate any excess risk of suicide attempts in chronic pain patients in the study period. We used a cohort design and calculated incidence rates (IR) and incidence rate ratios (IRRs) for suicide attempts, based on data from RSA. Poisson Regression analyses were used for calculation of IR and IRR for suicide attempts. Results In the study period from 1 January 2004 to 31 December 2009 1871 patients residing in the Region of Funen in Denmark were referred to The Pain Clinic. In the patient group 258 suicide attempts in 110 persons were registered. In all 6% of the patient group had attempted suicide. An increased risk of suicide attempts was found in the pain population as the incidence rate ratio (IRR) was 3.76 95% CI (3.22; 4.40). No statistical significant differences between men and women were found. Conclusion In a chronic non-malignant pain population, referred to a pain clinic, the risk of suicide attempts was increased. Implications It is important to be aware of risk factors for suicidal behaviour, i.e. pain history, depression, anxiety, abuse problems, and social problems when caring for patients with chronic pain. More knowledge and training of the staff caring for chronic pain patients are needed to decrease the risk of suicidal behaviour.

Similarities between exercise-induced hypoalgesia and conditioned pain modulation in humans.

Pain inhibitory mechanisms are often assessed by paradigms of exercise-induced hypoalgesia (EIH) and conditioned pain modulation (CPM). In this study it was hypothesized that the spatial and temporal manifestations of EIH and CPM were comparable. The participants were 80 healthy subjects (40 females), between 18 and 65 years of age in this randomized, repeated-measures cross-over trial that involved data collection on 2 different days. CPM was assessed by 2 different cold pressor tests (hand and foot). EIH was assessed by 2 intensities of aerobic bicycling exercises and 2 intensities of isometric muscle contraction exercises (arm and leg). Pressure pain thresholds (PPTs) were recorded before, during, after, and 15 minutes after conditioning/exercise at sites local to and remote from the extremity used for cold pressor stimulation and exercise. PPTs increased at local as well as at remote sites during both cold pressor tests and after all of the exercise conditions except low-intensity bicycling. EIH after bicycling was higher in women than in men. CPM and the EIH responses after isometric exercises were comparable in men and women and were not affected by age. The EIH response was larger in the exercising body part compared with nonexercising body parts for all exercise conditions. High-intensity exercise produced greater EIH responses than did low-intensity exercise. The change in PPTs during cold pressor tests and the change in PPTs after exercises were not correlated. The CPM response was not dominated by local manifestations, and the effect was seen only during the stimulation, whereas exercise had larger local manifestations, and the effects were also found after exercise.

Health care costs, work productivity and activity impairment in non-malignant chronic pain patients.

This study explores the costs of non-malignant chronic pain in patients awaiting treatment in a multidisciplinary pain clinic in a hospital setting. Health care costs due to chronic pain are particular high during the first year after pain onset, and remain high compared with health care costs before pain onset. The majority of chronic pain patients incur the costs of alternative treatments. Chronic pain causes production losses at work, as well as impairment of non-work activities.

[Opioids for chronic pain patients. What are the consequences of following the Nordic recommendations?]. / Opioider til kroniske smertepatienter. Hvad er konsekvenserne af at følge de nordiske anbefalinger?

INTRODUCTION: In this study the consequences of following the Nordic recommendation for treating chronic pain patients with opioids are illustrated with regard to how many patients started and how many ended opioid treatment, what was the success rate for going from short-acting to long-acting opioids and what were the consequences for the daily doses of going from short-acting to long-acting opioids. MATERIALS AND METHODS: During the study period patients revisited the Pain Centre 6 months after treatment had ended. It was documented whether each patient was treated with opioids initially as well as any changes in the opioid prescription during their treatment. RESULTS: 2/3 of the patients were initially in opioid treatment, 1 patient began while 25% were weaned off opioids during treatment. 88% percent of the patients initially on opioids were changed from short-acting to long-acting opioids. The number of patients who had their opioid doses increased with this change was approximately the same as the number of patients who had their doses reduced and the percent of changes was almost identical. CONCLUSION: Following the Nordic recommendations for treating chronic pain patients with opioids can help to minimise the number of opioid users. The recommendation for going from short-acting to long-acting opioids can be accomplished in daily routine and in this study there is no indication that changing from short-acting to long-acting opioids per se increases daily doses.