Long term outcomes of chronic pain patients attending a publicly funded community-based interdisciplinary pain program in the Greater Toronto area: results of a practice-based audit.

BACKGROUND: Chronic pain management multi/interdisciplinary programs attempt to address all elements of the biopsychosocial model. The primary objective of this retrospective study (based on practice-based audit) was to determine the effectiveness of a patient-centered, comprehensive and intense interdisciplinary pain management program in a publicly funded community-based pain clinic in the Greater Toronto Area. METHOD: This retrospective longitudinal study was conducted on 218 carefully selected sequential chronic pain patients, with 158 completing a 3-4-month interdisciplinary program between January 2016 and December 2018. Data collected upon exit, at 6 months and 12 months post-discharge included demographic information, pain characteristics, emotional/functional status obtained by validated instruments and global impression of change (GIC). Additionally, social health outcomes (return to work or school) were retrieved through retrospective chart review. Means of pre-and post-program variables were compared to assess changes of each patient's "journey". RESULTS: Physical and mental/ emotional health outcomes at exit, 6 months and 12 months post-discharge, showed initial and sustained, statistically and clinically significant improvement from pre-treatment levels, with GIC (much/very much improved) reported as 77%, 58% and 76%, respectively. Additionally, a substantial positive change in social health outcomes was noted particularly in patients on disability (29%), part time workers gaining full time employment (55%), and students (71%) who improved their level of schooling. CONCLUSION: The study showed that careful patient selection in a community-based publicly funded interdisciplinary pain management program can produce significant improvement in pain, physical, mental/emotional health and social function, with sustained long-term outcomes.

Demographics, Pain Characteristics and Diagnostic Classification Profile of Chronic Non-Cancer Pain Patients Attending a Canadian University-Affiliated Community Pain Clinic.

INTRODUCTION: Little information exists regarding the characteristics of patients with chronic non-cancer pain (CNCP) attending Canadian pain clinics. The study describes the demographics, pain characteristics and the diagnostic classification profile of such patients attending a university-affiliated community-based pain clinic in the Greater Toronto Area. METHODS: Retrospective descriptive study based on 644 unique consecutive CNCP patients assessed between January 2016 and December 2017. RESULTS: The female/male ratio was 1.6:1; 80% were younger than 65 years; 43% held some form of employment (full-time, part-time or self employment); median pain duration was 3 years; car accidents and medical conditions accounted for 28 and 27% of pain onset, respectively; 34% had four or more distinct areas of pain; and low back pain (LBP) was the most prevalent site (66%), but was the sole site of pain in less than a third of these patients. Age was positively associated with LBP prevalence. Self-reported health service utilization (visits to the emergency room, pain physician or psychologist) increased with patient psychopathology. Cannabis was used by 15% of the cohort and opioids by 34.5%, with only one in six opioid users exceeding 90 mg of morphine equivalent dose per day. Comparison of our data to three previously published studies from other Canadian pain clinics demonstrated both similarities and substantial differences between the populations. CONCLUSION: Our study highlights regional differences between CNCP population phenotypes. Recognition of biomedical, psychological and socio-environmental factors affecting pain should be considered for patient stratification and rational approaches to treatment, as "one size treatment does not fit all".

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients.

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

From (Ontario Ministry of Health and Long-Term Care) policy to implementation: A retrospective look at a community-based patient-centered model of care for chronic pain.

Background: Chronic pain is one of the most widely recognized, disabling, and expensive health problems in Canada. Interdisciplinary multimodal pain management is effective in helping chronic pain patients lessen symptoms and reclaim functionality, but most patients lack access to such treatments. Aim: The aim of this study was to describe the development and implementation of a publicly funded and patient-centered model of care in the community. Methods: The study was set in the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic in Ontario funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as a demonstration project of a template for similar future community clinics. The study is descriptive, including a brief review of the Ontario comprehensive pain strategy framework and an overview of the PWC and the process involved in the development of an interdisciplinary pain program (IDP), based on the biopsychosocial model of chronic pain management. Results: During a 2.5-year period, the PWC has offered 1055 new patient medical consultations and 1921 follow-up visits and admitted 242 patients in the IDP program (demonstrating significant success in patient outcomes at the 3-month exit from the program). It established robust outcomes research, organized educational programs for pain trainees, and cultivated a collaborative relationship with the Toronto Academic Pain Medicine (TAPMI) network and the community at large. Conclusions: This demonstration program has shown the feasibility and applicability of the principles of the MOHLTC comprehensive pain strategy, providing an effective, evidence-based, and accountable approach to chronic pain diagnosis and management in the community.

Contexte: La douleur chronique est l'un des problèmes de santé les plus reconnus, invalidants et coûteux au Canada. La prise en charge multimodale interdisciplinaire est efficace pour aider les patients souffrant de douleur chronique à diminuer leurs symptômes et à recouvrer leur fonctionnalité, mais la plupart des patients n'ont pas accès à de tels traitements.But: Le but de cette étude était de décrire l'élaboration et la mise oeuvre d'un modèle communautaire de soins axé sur le patient, financé par des fonds publics.Méthodes: L'étude s'est déroulée au Pain and Wellness Centre à Vaughan, la seule clinique de la douleur chronique communautaire en Ontario. Elle était financée par le MSSLD en tant que projet de démonstration pouvant servir de modèle pour des cliniques communautaires semblables dans l'avenir. L'étude est descriptive et comprend notamment un survol du cadre stratégique global pour la douleur de l'Ontario et un aperçu du Pain & Wellness Centre, de même que du processus menant à l'élaboration d'un programme interdisciplinaire de la douleur fondé sur le modèle bio-psycho-social de la prise en charge de la douleur chronique.Résultats: Au cours d'une période de 2,5 ans, le PWC a offert des consultations médicales à 1055 nouveaux patients et 1921 visites de suivi, en plus d'accueillir 242 patients dans le programme interdisciplinaire de la douleur (tout en démontrant un important succès dans les résultats des patients trois mois après leur sortie du programme). Il a obtenu des résultats de recherche robustes, organisé des programmes de formation pour des stagiaires et cultivé une relation de collaboration avec le réseau du Toronto Academic Pain Medicine, ainsi qu'avec la collectivité dans son ensemble.Conclusions: Ce programme a démontré la faisabilité et l'applicabilité des principes de la stratégie globale du ministère de la Santé et ds Soins de longue durée de l'Ontario en matière de douleur, offrant ainsi une approche communautaire efficace, fondée sur des données probantes, ainsi que sur une approche responsable du diagnostic et de la prise en charge de la douleur chronique.

Differences in physical activity, eating habits and risk of obesity among Kuwaiti adolescent boys and girls: a population-based study.

The study aimed to assess gender differences among Kuwaiti adolescents in healthy living choices that impact the risk of obesity. A cross-sectional multistage cluster design was employed with a representative sample of 2672 students aged 13-15 years who completed a self-administered Global School-based Student Health (GSHS) survey. The study found that around 48.0% of adolescents were overweight and obese. More boys than girls were obese (28.2% vs. 22.3%, p < 0.0001). However, boys were more likely than girls to report healthy food choices regarding fruit (38.1% vs. 33.2%), and vegetables (21.8% vs. 16.7%). Only 20.7% of adolescents reported physical activity for more than 60 min/day, predominately by boys rather than girls (30.8% vs. 10.5%, respectively, p < 0.0001). Multivariate analysis revealed that male gender, skipping breakfast and physical inactivity were significantly correlated with the risk of overweight and obesity among adolescents. These results suggest that lifestyle education for promoting healthy body masses targeting adolescents should take gender into account.

Chronic Non-Cancer Pain Management Capacity in Karachi.

Chronic non-cancer pain (CNCP) affects people everywhere in the world, but people in developing countries have far less access to therapies that provide relief. There are often missed opportunities to implement these therapies. Karachi shares many characteristics with megacities of the global south and represents Pakistan in the global city league. This review informs readers about the availability of health management and pain services for CNCP in Karachi, and their comparability to those found in other global cities. The literature about CNCP and its management in Karachi and Pakistan is scarce. Nevertheless, some conclusions can be made. In order to inform readers based in other global cities, a brief review of the current health system and pain services in Karachi and Pakistan are discussed together with barriers that impede pain service outputs. The present review employs vignettes to illustrate typical experiences of CNCP patients seeking pain management services in three sectors: public, charitable, and private institutions.

Health Services for Management of Chronic Non-Cancer Pain in Kuwait: A Case Study Review.

The experience of chronic pain is universal, yet pain management services delivered by health professionals vary substantially, depending on the context and patient. This review is a part of a series that has examined the issue of chronic non-cancer pain services and management in different global cities. The review is structured as a case study of the availability of management services for people living with chronic non-cancer pain within the context of the Kuwaiti health systems, and the cases are built from evidence in the published literature identified through a comprehensive review process. The evolution of the organizational structure of the public and private health systems in Kuwait is described. These are discussed in terms of their impact on the delivery of comprehensive chronic pain management service by health professionals in Kuwait. This review also includes a description of chronic pain patient personas to highlight expected barriers as well as compliance issues with services likely to be encountered in Kuwait. The case study analysis and persona descriptions illustrate a need to move beyond pain symptom management towards considering the entire person and his/her individual experience of pain such that health care success is judged by enhancement of patient well-being rather than access to services. A road map for improving integrative chronic pain management in Kuwait is discussed.

Efficacy of Low-Dose Oral Liquid Morphine for Elderly Patients with Chronic Non-Cancer Pain: Retrospective Chart Review.

INTRODUCTION: The use of medications among older persons can often be challenging as physiological changes may affect metabolism and cognitive abilities. Several studies show that the elderly with chronic pain are seriously undertreated or inappropriately treated, particularly with respect to opioids. OBJECTIVE: To determine whether very low doses of oral liquid morphine (LM) in patients over 65 years of age with chronic non-cancer pain provides meaningful pain improvement. METHODS: A retrospective chart review was conducted for ten carefully selected older patients seen at a tertiary care pain clinic in Toronto Ontario (2009-2011) with serious biomedical painful conditions and intolerance to other opioid analgesics. Data collected included demographics, LM dosing, diagnosis and average Numeric Rating Scale (NRS) pain ratings pre- and post-administration of LM. RESULTS: Of the ten eligible patients, the female/male ratio was 4:1, mean age 75.5 years and mean pain duration 7.9 years. The initial dose of LM for all patients was 1-3 mg three times/day and the maintenance dose ranged from 5 to 30 mg/day. Overall, pain ratings dropped from 6.35 to 2.95 (3.4 point drop on the NRS score) with a mean follow-up of 14 months (range 10-21). CONCLUSION: The case series showed that carefully selected elderly patients with biomedical pathology can benefit from very low doses of LM. Future larger and well-designed studies need to focus on the use of LM for elderly patients.

Referring patients with chronic noncancer pain to pain clinics: survey of Ontario family physicians.

OBJECTIVE: To examine the factors associated with FPs' referrals of patients with chronic noncancer pain to a tertiary care pain clinic. DESIGN: A questionnaire-based survey; data were analyzed using univariate methods. SETTING: A tertiary care pain clinic in Toronto, Ont. Participants All FPs who referred patients to the clinic between 2002 and 2005. MAIN OUTCOME MEASURES: Variables explored included FPs' sex, age, and ethnic background, ethnicity of patient groups seen, and FPs' rationale or barriers influencing referrals to specialized pain clinics. RESULTS: The response rate was 32% (47 of 148 FPs). There were no statistically significant differences between respondents and non-respondents in sex, age, duration of practice, and university of graduation, or between the variables of interest and the referral patterns of those who did respond. The mean age of respondents was 50 years; 47% of the FPs identified themselves as Canadian; and one-third of the respondents indicated that they referred more than 30 patients to pain clinics each year. The 3 most frequently cited reasons prompting referral to pain clinics were requests for nerve blocks or other injections, desire for the expertise of the program, and concerns about opioids; the 3 most prevalent barriers were long waiting lists, patient preference for other treatments, and distance from the clinic. CONCLUSION: Although the results of our survey of FPs identify certain barriers to and reasons for referring patients to pain clinics, the results cannot be generalized owing to the small sample of FPs in our study. Larger studies of randomly selected FPs, who might or might not refer patients to pain clinics, are needed to provide a better understanding of chronic noncancer pain management needs at the primary care level.

Chronic noncancer pain: characteristics of patients prescribed opioids by community physicians and referred to a tertiary pain clinic.

OBJECTIVE: To describe the characteristics of patients with chronic noncancer pain (CNCP) prescribed opioids by community physicians and referred to a tertiary pain clinic. DESIGN: Cross-sectional, descriptive study. SETTING: A tertiary care, hospital-based pain clinic in Toronto, Ont. PARTICIPANTS: A total of 455 consecutive patients newly referred to the pain clinic by community physicians. MAIN OUTCOME MEASURES: Data on demographic characteristics, pain ratings, and medication intake were obtained using standardized collection forms and retrospective chart review. Patients were classified by diagnosis: group 1 patients had biomedical disorders only, group 2 patients had biomedical disorders and psychological factors, and group 3 patients had psychological factors only. Patients were also categorized based on opioid use: no opioid use (NOU); low opioid use (LOU), with a daily morphine-equivalent dosage (MED) of 200 mg or less; or high opioid use (HOU), with a daily MED of more than 200 mg. RESULTS: In the general study population, 63% of patients were taking opioids, with 1 in 5 exceeding an MED of 200 mg daily. In group 1, 59% of patients used opioids and 10% had HOU; 66% of patients in groups 2 and 3 were taking opioids, with 21% and 26% classified as having HOU. The mean (SD) daily MED for groups 2 and 3 HOU patients combined was significantly higher than that of group 1 HOU patients: 575.7 (472.9) mg/d versus 284.9 (74.6) mg/d, respectively. Men were twice as likely as women to have HOU; Canadian-born patients were 3 times as likely as foreign-born patients to have HOU. Psychoactive drugs were coprescribed in 61% of LOU patients and 76% of HOU patients. Greater opioid use was associated with group 2 and 3 diagnoses, male sex, Canadian-born origin, and high pain scores. CONCLUSION: Our results indicate that male, Canadian-born CNCP patients presenting with psychological morbidity or comorbidity and reporting higher pain severity ratings were more likely to receive opioids. Additionally, many CNCP patients referred to our tertiary care pain clinic were receiving opioids in excess of a 200-mg/d MED. More studies are needed to determine which factors lead to high-dose opioid prescribing in a subset of this CNCP population.