Experiences and Perceptions of Medical Cannabis among People Living with Chronic Pain and Community Pharmacists: A Qualitative Study in Canada.

Background: The use of cannabis to treat chronic pain is under debate despite high expectations from patients. Qualitative data obtained by exploring both patients' and health professionals' perspectives are scarce. Aims: This study aimed to understand the experiences and perceptions of people living with chronic pain and community pharmacists regarding the role of cannabis in chronic pain treatment in the Canadian context where both medical and recreational cannabis are legal. Methods: We conducted 12 online focus groups (July 2020-February 2021) with 26 patients and 19 community pharmacists using semistructured discussion guides. All discussions were audio recorded and transcribed verbatim were analyzed using a reflexive thematic approach. Results: We developed three themes related to patients' perspectives and three themes related to pharmacists' perspectives. Patients' perspectives included (1) cannabis as an alternative to other pain medications, (2) a new treatment with potential health-related risks, and (3) a therapy rather than a recreational drug. Pharmacists' perspectives included (1) challenges in monitoring drug interactions with cannabis in the context of scarce research data, (2) informing and treating patients self-medicating with cannabis amid its growing popularity, and (3) financial costs and legal constraints for patients. Conclusions: This study highlights patients' and pharmacists' urgent need for reliable information regarding the benefits and risks of cannabis. Training tailored to pharmacists' needs and evidence-based information for patients should be developed to support pharmacists' practice, improve patients' experiences, and promote safe cannabis use.

Contexte: L'utilisation du cannabis pour traiter la douleur chronique fait l'objet d'un débat, malgré les fortes attentes des patients. Les données qualitatives issues de l'exploration des perspectives à la fois des patients et des professionnels de la santé, demeurent rares.Objectifs: Cette étude visait à comprendre les expériences et les perceptions des personnes vivant avec une douleur chronique et des pharmaciens communautaires concernant le rôle du cannabis dans le traitement de la douleur chronique dans le contexte canadien, où le cannabis médical et récréatif est légal.Méthodes: Nous avons mené 12 groupes de discussion en ligne entre juillet 2020 et février 2021, réunissant 26 patients et 19 pharmaciens communautaires, à l'aide de guides de discussion semi-structurés. Toutes les discussions ont été enregistrées et transcrites mot à mot, puis analysées à l'aide d'une approche thématique réflexive.Résultats: Nous avons développé trois thèmes liés aux perspectives des patients et trois thèmes liés aux perspectives des pharmaciens. Le point de vue des patients incluait (1) le cannabis comme option de rechange à d'autres médicaments contre la douleur, (2) un nouveau traitement avec des risques potentiels pour la santé, et (3) un traitement plutôt qu'une drogue récréative. Le point de vue des pharmaciens portait sur (1) les défis liés à la surveillance des interactions médicamenteuses avec le cannabis dans le contexte de la rareté des données de recherche, (2) l'information et le traitement des patients qui s'auto-médicamentent avec du cannabis dans un contexte de popularité croissante, et (3) les coûts financiers et les contraintes légales pour les patients.Conclusions: Cette étude met en évidence le besoin urgent des patients et des pharmaciens de disposer d'informations fiables sur les avantages et les risques du cannabis. Une formation adaptée aux besoins des pharmaciens et des informations fondées sur des données probantes pour les patients devraient être développées pour soutenir la pratique des pharmaciens, améliorer l'expérience des patients et promouvoir une utilisation sûre du cannabis.

Swallowing the pill of adverse effects: A qualitative study of patients' and pharmacists' experiences and decision-making regarding the adverse effects of chronic pain medications.

INTRODUCTION: Pharmacological treatments of chronic pain can lead to numerous and sometimes serious adverse effects. Drawing on a social science approach to chronic illness, this study aimed to understand the experiences of people living with chronic pain and community pharmacists regarding the definition, prevention and management of analgesic adverse effects. METHODS: This qualitative study proceeded through 12 online focus groups (FGs) with people living with chronic pain (n = 26) and community pharmacists (n = 19), conducted between July 2020 and February 2021 in the province of Quebec, Canada. The semistructured discussion guides covered participants' definitions of adverse effects and decision-making regarding their prevention and management. Discussions were audio-recorded, transcribed verbatim and analysed using grounded theory. RESULTS: Both people with chronic pain and pharmacists provided varying definitions of analgesic adverse effects depending on patients' social and clinical characteristics. Present quality of life and serious long-term risks related to treatment were described as key dimensions influencing adverse effect appraisal. Dilemmas and discrepancies occurred between patients and pharmacists when choosing to prioritize pain relief or adverse effect prevention. Some patients lacked information about their medications and wanted to be more involved in decisions, while many pharmacists were concerned by patients' self-management of adverse effects. Preventing opioid-related overdoses often led pharmacists to policing practices. Despite most pharmacists wishing they could have a key role in the management of pain and adverse effects face organizational and financial barriers. CONCLUSION: Defining, preventing and managing adverse effects in the treatment of chronic pain requires a person-centred approach and shared decision-making. Clinical training improvements and healthcare organization changes are needed to support pharmacists in providing patients with community-based follow-up and reliable information about the adverse effects of chronic pain treatments. PATIENT OR PUBLIC CONTRIBUTION: A person with lived experience of chronic pain was involved as a coinvestigator in the study. He contributed to shaping the study design and objectives, including major methodological decisions such as the choice of pharmacists as the most appropriate professionals to investigate. In addition, 26 individuals with chronic pain shared their experiences extensively during the FGs.

The Impact of Pain Invisibility on Patient-Centered Care and Empathetic Attitude in Chronic Pain Management.

Objectives: The use of interdisciplinary patient-centered care (PCC) and empathetic behaviour seems to be a promising avenue to address chronic pain management, but their use in this context seems to be suboptimal. Several patient factors can influence the use of PCC and empathy, but little is known about the impact of pain visibility on these behaviours. The objective of this study was to investigate the influence of visible physical signs on caregiver's patient-centered and empathetic behaviours in chronic pain context. Methods: A convenience sample of 21 nurses and 21 physicians participated in a descriptive study. PCC and empathy were evaluated from self-assessment and observer's assessment using a video of real patients with chronic pain. Results: The results show that caregivers have demonstrated an intraindividual variability: PCC and empathetic behaviours of the participants were significantly higher for patients who have visible signs of pain (rheumatoid arthritis and complex regional pain syndrome) than for those who have no visible signs (Ehler-Danlos syndrome and fibromyalgia) (p < 0.001). Participants who show a greater difference in their patient-centered behaviour according to pain visibility have less clinical experience. Discussion: The pain visibility in chronic pain patients is an important factor contributing to an increased use of PCC and empathy by nurses and physicians, and clinical experience can influence their behaviours. Thus, pain invisibility can be a barrier to quality of care, and these findings reinforce the relevance to educating caregivers to these unconscious biases on their behaviour toward chronic pain patients.

Evaluation of Nurse Empathy Perceived by the Standardized Patient in Simulation: A French Validation of the Jefferson Scale of Patient Perceptions of Physician Empathy.

PURPOSE: The aim is to validate a French version of the Jefferson Scale of Patient Perceptions of Physician Empathy (F-JSPPPE). METHODS: Twenty-six intensive care nurses took part in a standardized clinical simulation (SCS). For each nurse, a standardized simulated patient completed the F-JSPPPE and three observers filled the French version of the Reynolds Empathy Scale (F-RES). RESULTS: The expert committee concluded that the F-JSPPPE has a good content validity. The internal consistency was good. A positive correlation was observed between the F-JSPPPE and the F-RES, suggesting good convergent validity. CONCLUSIONS: The F-JSPPPE validated with a standardized patient in SCS is the first reliable and valid instrument available in French to measure patient's perception of intensive care unit (ICU) nurse's empathy. Future study is needed to evaluate test-retest reliability.

Validity of the French Version of the Reynolds Empathy Scale Among Intensive Care Nurses.

BACKGROUND AND PURPOSE: Empathy is an important part of the nurse-patient relationship. The aim was to validate the French version of the Reynolds Empathy Scale (F-RES) for assessing empathy in nurses during standardized clinical simulations (SCS). METHODS: A series of steps recommended for the translation and validation of an instrument was carried out. Then the F-RES was used to assess empathy during SCS sessions with 26 nurses. RESULTS: The results showed good internal consistency and inter-rater reliability of the F-RES. The expert panel was satisfied with the content and face validity of the instrument. Convergent validity was confirmed using the French version of the Jefferson Scale of Patient Perceptions of Physician Empathy. CONCLUSIONS: The F-RES has good psychometric qualities and potential for future research in French populations.

Assessing patient-centred care for chronic pain: Validation of a new research paradigm.

BACKGROUND: Chronic pain is a complex phenomenon resulting from biological, psychological and social factors, and the use of patient-centred care (PCC) appears to be a promising avenue for its treatment. Various methods have been used for measuring PCC in nurses and physicians (caregivers); however, methodological problems have been raised following the observation of real clinical encounters or standardized patient simulations. The development of new strategies is required. OBJECTIVE: To develop and validate an observation scale for the assessment of PCC in caregivers, using standardized videos of real patients with chronic pain. METHODS: An expert panel developed five videos and the Sherbrooke Observation Scale of Patient-Centered Care (SOS-PCC), which were tested in a sample of 21 nurses and 21 physicians working with chronic pain patients. The content validity, internal consistency and inter-rater reliability of the SOS-PCC were assessed. RESULTS: The expert panel was satisfied with the content validity of the SOS-PCC. Results revealed good internal consistency (Cronbach's alpha = 0.88) and inter-rater reliability (intraclass coefficient = 0.93) for this scale. CONCLUSIONS: To the authors' knowledge, the SOS-PCC is the first instrument available in French to assess PCC behaviour of caregivers using videos of real patients with chronic pain. The psychometric qualities of these instruments are good. Future studies will need to assess this instrument with other populations of caregivers.

Relationship Between Empathy and Well-Being Among Emergency Nurses.

INTRODUCTION: A large number of patients who are in pain upon arriving at the emergency department are still in pain when they are discharged. It is suggested that nurses' personal traits and their level of empathy can explain in part this issue in pain management. The purpose of this study was to better understand the shortfalls in pain management provided by emergency nurses by considering nurses' characteristics. METHODS: A cross-sectional descriptive correlational design was used for this pilot study. French validated self-administrated questionnaires (sociodemographic characteristics, empathy, psychological distress, and well-being) were presented to 40 emergency nurses. Thirty emergency nurses completed all questionnaires during work hours. Descriptive statistics, group comparisons, and correlation analyses were used for the data analysis. RESULTS: Emergency nurses appear to have low levels of empathy. High levels of psychological distress and low levels of well-being were also observed in our sample. Among these variables, only empathy and well-being appear to be related, because we found higher empathy scores in nurses with higher well-being. DISCUSSION: The poor mental health we found among emergency nurses is alarming. A clear need exists for supportive interventions for nurses. Finally, well-being was the only variable related to empathy. To our knowledge, this is the first study to report this relationship in nurses.

Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth.

OBJECTIVE: As pain during childbirth is very intense, several educational programs exist to help women prepare for the event. This study evaluates the efficacy of a specific pain management program, the Bonapace Method (BM), to reduce the perception of pain during childbirth. The BM involves the father, or a significant partner, in the use of several pain control techniques based on three neurophysiological pain modulation models: (1) controlling the central nervous system through breathing, relaxation, and cognitive structuring; (2) using non-painful stimuli as described in the Gate Control Theory; and (3) recruiting descending inhibition by hyperstimulation of acupressure trigger points. METHODS: A multicenter case control study in Quebec on pain perception during labor and delivery compared traditional childbirth training programs (TCTPs) and the BM. Visual analog scales were used to measure pain perception during labor. In all, 25 women (TCTP: n = 12; BM: n = 13) successfully reported their perceptions of pain intensity and unpleasantness every 15 minutes. RESULTS: A POSITIVE CORRELATION BETWEEN THE PROGRESSION OF LABOR AND PAIN WAS FOUND (PAIN INTENSITY: P < 0.01; pain unpleasantness: P < 0.01). When compared to TCTP, the BM showed an overall significant lower pain perception for both intensity (45%; P < 0.01) and unpleasantness (46%; P < 0.01). CONCLUSION: These significant differences in pain perception between TCTP and the BM suggest that the emphasis on pain modulation models and techniques during labor combined with the active participation of a partner in BM are important variables to be added to the traditional childbirth training programs for childbirth pain management.

Is the deficit in pain inhibition in fibromyalgia influenced by sleep impairments?

It has been proposed that a deficit in inhibitory conditioned pain modulation (ICPM) underlies the pathophysiology of fibromyalgia (FM), but there is high variability in ICPM efficacy in this syndrome that remains poorly understood. Based on emerging data showing that age, anxiety, depression and sleep can modulate ICPM efficacy, the main objective of this study was to determine the clinical correlates of experimentally-induced pain perception in FM. Fifty FM patients and 39 healthy controls (HC) were tested. Anxiety, depression, sleep and FM symptoms were measured with questionnaires or interview-type scales. Experimental pain testing consisted of two tonic heat pain stimulations separated by a 2-minute cold pressor test (CPT). Thermal pain thresholds and tolerance were higher in HC compared to FM patients. Pain ratings during the CPT were lower in HC relative to FM patients. ICPM efficacy was stronger in HC compared to FM patients. Finally, sleep quality was the only factor significantly related to ICPM efficacy. To our knowledge, this is the first study to report this association in FM. Future studies will need to replicate this finding, to determine whether impaired sleep is primary or secondary to deficient pain inhibition, and to characterize the neurobiological mechanisms underlying this association.

Temporal summation of pain is not amplified in a large proportion of fibromyalgia patients.

Background. Recently, it has been proposed that fibromyalgia (FM), a chronic widespread pain syndrome, results from overactive endogenous excitatory pain mechanisms. Experimental studies using temporal summation paradigms have confirmed this hypothesis but have included small samples of patients, prompting our group to perform a large-scale study. Methods. Seventy-two female FM patients and 39 healthy females participated in the study. The temporal summation test consisted of a 2-minute continuous and constant heat pulse administered with a thermode on the participants' left forearm. Experimental temperature was set at a value individually predetermined to induce a 50/100 pain rating. Results. Relative to controls, FM patients had lower thermal pain thresholds and lower temporal summation of pain. However, 37 FM patients required experimental temperatures lower than the minimal temperature used in controls (45°C). Nevertheless, temporal summation was not increased in the other FM subgroup, relative to controls, despite equivalent experimental temperatures. Discussion. Our results suggest that temporal summation of pain is normal, rather than increased, in a large proportion of FM patients. Future studies on temporal summation in FM will need to be careful since some FM patients require abnormally low experimental temperatures that may confound results and make necessary to separate patients into subgroups.

Procedural pediatric sedation by nurses: available, competent, and safe.

Sedation and/or analgesia are standard of care for pediatric patients during painful intervention or medical imaging requiring immobility. Physician availability is frequently insufficient to allow for all procedural sedation. A nurse-led sedation program was created at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) to address this problem. Objective. To evaluate the effectiveness and the safety of our program. Methods. A retrospective study of all the procedural sedations done over one year was performed. Complications were separated in four categories: (1) major complications (call for help; unexpected admission, aspiration, and code); (2) reportable sedation events (oxygen saturation <90%, bradycardia (more than 2 SD below normal for the age of the child), and hypotension (more than 2 SD below normal for the age of the child); (3) difficult sedation (agitation, inadequate sedation, and failure to perform the procedure), (4) minor complications. Results. 448 patients, 249 boys and 199 girls; received sedation for 555 procedures. Overall, 78% (432) of interventions were successfully accomplished: 0% of major complications, 8% of reportable sedation events; 5% of difficult sedation; 9% of minor complications. Conclusion. Our nurse-led sedation program compares favorably to other similar systems.

A deficit in peripheral serotonin levels in major depressive disorder but not in chronic widespread pain.

OBJECTIVES: It has been proposed that serotonin dysfunctions underlie the pathophysiology of various mood disorders (including major depressive disorder, MDD) and chronic pain conditions characterized by deficient pain inhibition, such as fibromyalgia (FM). There is reliable data showing that serotonin disturbances are involved in the pathophysiology of MDD. However, in the case of FM, results published so far are less consistent. Therefore, the current cross-sectional study sought to measure plasma serotonin levels in FM patients, MDD patients, and healthy controls (HC). METHODS: Twenty-nine FM patients, 17 MDD patients, and 57 HC were recruited who did not differ in terms of age, sex, and the presence or absence of a regular menstrual cycle. Plasma samples were analysed with mass spectrometry. RESULTS: Serotonin levels were decreased in MDD patients, relative to FM patients and HC. Post hoc analyses showed that serotonin levels were decreased in FM patients taking antidepressants, relative to HC, but not in drug-free FM patients. Moreover, serotonin levels were negatively correlated with mood symptoms across groups. DISCUSSION: Our results further confirm that MDD is associated with decreased serotonin levels, but that serotonin levels are not altered in FM per se, and suggest that 5-Hydroxytryptamine is related to mood symptoms in these patient groups. Our results also suggest that the taking of antidepressant is a major confound to consider when studying serotonin functioning in FM. The long-term use of antidepressants in FM may lead to serotonin depletion. Conversely, serotonin depletion may be before the taking of antidepressants in FM.