Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution: A Case Series.

Purpose: Low-dose naltrexone (LDN) has increased in popularity as a non-opioid medication that may decrease chronic pain symptoms. LDN is most commonly used to treat fibromyalgia, complex regional pain syndrome (CRPS), and painful diabetic neuropathy. Other studies suggest that LDN provides general symptom reduction in inflammatory conditions such as Crohn's disease and multiple sclerosis. We reviewed our experience with patients to whom we have prescribed LDN to see what types of painful conditions were most responsive to LDN in our patient population. Patients and Methods: Charts from patients who came to the Pain Center between 2014 and 2021 were reviewed. Results: Of the n = 137 patients who were prescribed LDN, 44% had no evidence of ever filling the prescription, and 4.4% of the responses were not charted. Of the remaining who took LDN (n = 70), 64% had some relief and were designated as 'Responders'. The most common pain diagnosis was neuropathic pain which, when added to the diagnosis of complex regional pain syndrome, accounted for 51% of responders to LDN. Patients who experienced greater than 50% pain relief from LDN were more likely to have the diagnosis of neuropathic pain or complex regional pain syndrome (p = 0.038, Fisher's Exact Test). There was a significant difference in the diagnosis of patients who responded to LDN. Patients with spondylosis were much less likely to respond to LDN when compared with other diagnoses (p = 0.00435, Chi-Square Test). Conclusion: Patients with all types of neuropathic pain, including CRPS, were significantly more likely to have pain relief from LDN than patients with spondylosis (p=0.018). The diagnosis of spondylosis was more often associated with a lack of response to LDN than any other diagnosis. Patients may need to have a trial of several weeks before analgesic effects are seen with LDN.

Pain Medicine Milestones 2.0: a step into the future.

OBJECTIVE: To describe the process of revising the Pain Medicine Milestones 1.0 and implementing changes into the Pain Medicine Milestones 2.0 along with implications for pain medicine trainees. BACKGROUND: Competency-based medical education has been implemented in graduate medical education, including pain medicine. Milestones 1.0, introduced by the Accreditation Council for Graduate Medical Education (ACGME), has been used to assess learners in six competencies and respective sub-competencies. Recognizing areas for improvement in Milestones 1.0, the ACGME initiated the process of Milestones 2.0 and a working group was created to execute this task for pain medicine. The working group discussed revisions; consensus was sought when changes were introduced. Final milestones were agreed upon and made available for public comment prior to publication. RESULTS: Redundant sub-competencies were either merged or eliminated, reducing the number of sub-competencies. A maximum of three rows representing skill, knowledge, behavior and attitude were included for each sub-competency. Harmonized Milestones, aligning with other specialties in a predetermined ACGME framework, were adopted and modified to meet the needs of pain medicine. A supplemental guide was developed to assist educators in implementation of Milestones 2.0 and assessment of trainees. CONCLUSIONS: The intent of the Milestones 2.0 was to create an improved tool that is comprehensive, easier to utilize, and of increased value for pain medicine training programs. It is expected that implementation of Milestones 2.0 will streamline pain medicine trainee assessments by educators and prepare trainees for the future practice of pain medicine while serving to be the foundation of an iterative process to match the evolution of the specialty.

Pain experiences among those living with hidradenitis suppurativa: a qualitative study.

BACKGROUND: Pain is rated by patients with hidradenitis suppurativa (HS) as the disease's most impactful symptom. HS therapies are often insufficient to control inflammatory disease activity and pain. A better understanding of patient experiences with pain may improve patient-provider relationships and help identify strategies for addressing HS pain. OBJECTIVES: This qualitative study sought to characterize lived pain experiences of those with HS. METHODS: English-speaking patients ≥ 18 years old with a dermatologist-confirmed diagnosis of HS and an average numerical rating scale pain score of ≥ 1 over the preceding week were recruited from a single academic medical centre in Atlanta, Georgia, USA. Semistructured interviews were conducted from November 2019 to March 2020 to explore participants' HS pain experiences and the subsequent impact on their lives. Thematic saturation was reached after interviewing 21 participants. Interviews were audio recorded, transcribed, and analysed using thematic analysis. RESULTS: Among 21 study participants, the median 7-day average pain score was 6 (interquartile range 3-7; scale ranges from 0 to 10, with 10 being most pain). Participants' descriptions of pain were consistent with nociceptive pain, neuropathic pain and itch. Pain impacted multiple life domains, including physical limitations (decreased mobility and impaired sleep), decreased psychological wellbeing (irritability, depression, loss of control, and difficulty communicating pain experiences) and impaired social relationships (social isolation, intimacy problems and difficulty fulfilling social responsibilities). Although participants reported chronic discomfort, acutely painful and unpredictable HS disease flares caused more distress and quality-of-life (QoL) burden. Participants frequently treated their pain without input from the medical team, sometimes with unsafe medication doses or combinations. Factors contributing to self-management of pain included difficulty accessing timely outpatient care during disease flares and fear of stigma from healthcare providers. CONCLUSIONS: When present, HS-related pain may impact not only physical wellbeing but also mental health and relationships. In addition to therapies that target the inflammatory disease burden, treating the symptom of pain may improve patients' QoL and wellbeing. Because patients with HS have difficulty explaining their pain, proactively asking them about pain may identify unmet needs, facilitate better pain control and improve QoL. Further, the influence of HS-related pain on numerous aspects of QoL suggests the need for multidisciplinary, patient-centred approaches to HS pain management.

#ChronicPain: Automated Building of a Chronic Pain Cohort from Twitter Using Machine Learning.

Background: Due to the high burden of chronic pain, and the detrimental public health consequences of its treatment with opioids, there is a high-priority need to identify effective alternative therapies. Social media is a potentially valuable resource for knowledge about self-reported therapies by chronic pain sufferers. Methods: We attempted to (a) verify the presence of large-scale chronic pain-related chatter on Twitter, (b) develop natural language processing and machine learning methods for automatically detecting self-disclosures, (c) collect longitudinal data posted by them, and (d) semiautomatically analyze the types of chronic pain-related information reported by them. We collected data using chronic pain-related hashtags and keywords and manually annotated 4,998 posts to indicate if they were self-reports of chronic pain experiences. We trained and evaluated several state-of-the-art supervised text classification models and deployed the best-performing classifier. We collected all publicly available posts from detected cohort members and conducted manual and natural language processing-driven descriptive analyses. Results: Interannotator agreement for the binary annotation was 0.82 (Cohen's kappa). The RoBERTa model performed best (F1 score: 0.84; 95% confidence interval: 0.80 to 0.89), and we used this model to classify all collected unlabeled posts. We discovered 22,795 self-reported chronic pain sufferers and collected over 3 million of their past posts. Further analyses revealed information about, but not limited to, alternative treatments, patient sentiments about treatments, side effects, and self-management strategies. Conclusion: Our social media based approach will result in an automatically growing large cohort over time, and the data can be leveraged to identify effective opioid-alternative therapies for diverse chronic pain types.

Randomized, wait-list-controlled pilot study of app-delivered mindfulness for patients reporting chronic pain.

INTRODUCTION: Chronic pain creates economic burden and exerts profound individual and societal harm. Mobile application (app)-delivered mindfulness meditation may be an important approach to self-management of chronic pain. OBJECTIVES: We examined the feasibility, acceptability, and impact of app-delivered mindfulness meditation on pain cognition and daily functioning among patients reporting chronic pain. METHODS: We used a longitudinal, randomized, and wait-list-controlled design (NCT03495726) to evaluate changes in self-reported pain severity, pain catastrophizing, and social and physical functioning among participants randomized to 6 weeks of app-delivered mindfulness meditation, compared with participants randomized to a wait-list control group. RESULTS: Although most participants randomized to the mindfulness group used the app at least once, fewer than half adhered to the instructed program. Participants who did not use the app scored higher on the helplessness component of pain catastrophizing at the start of the study and were less likely to have completed 4 years of college. Participants who reported feeling pressured to enroll in the study were also less likely to adhere to the intervention. Compared with participants randomized to wait-list, those in the mindfulness group reported significant improvements in social functioning, even after controlling for pain severity. Participants randomized to the mindfulness intervention also reported significant improvements in helplessness. App usage was not significantly correlated with changes in social functioning or helplessness scores. CONCLUSIONS: These results suggest that app-delivered mindfulness meditation is beneficial to patients with chronic pain. Identifying characteristics of patients who were adherent highlights important considerations for clinical settings.

Lumbar Spondylolisthesis Progression: What is the Effect of Lumbar Medial Branch Nerve Radiofrequency Ablation on Lumbar Spondylolisthesis Progression? A Single-Center, Observational Study.

BACKGROUND: Radiofrequency ablation (RFA) is a denervation therapy commonly performed for pain of facet etiology. Degenerative spondylolisthesis, a malalignment of the spinal vertebrae, may be a co-existing condition contributing to pain; yet the effect of RFA on advancing listhesis is unknown. To the extent that denervating RFA may weaken paraspinal muscles that provide stability to the spine, the therapy can potentially contribute to progressive spinal instability. METHODS: Single-center, prospective, observational pilot study in an interventional pain practice to test the hypothesis that RFA of painful facets in the setting of spondylolisthesis may contribute to advancement of further degenerative spondylolisthesis. Fifteen participants with pre-existing degenerative Grade I or Grade II spondylolisthesis and coexisting axial lumbar pain underwent lumbar RFA encompassing spondylolisthesis level and followed with post-RFA imaging at 12 months and beyond to measure percent change in spondylolisthesis. RESULTS: The primary outcome was the percent advancement of spondylolisthesis per year measured on post-RFA lateral lumbar spine imaging compared with non-intervention inferred baseline advancement of 2% per very limited observational studies. Among the 15 participants enrolled, 14 completed the study (median age 66; 64.3% women; median BMI 33.5; mean follow-up time 23.9 months). The mean advancement of spondylolisthesis per year after RFA was 1.30% (95% CI -0.14 to 2.78%), with 9/14 below 1.25%. CONCLUSION: Among patients with lumbar pain originating from facets in the setting of degenerative spondylolisthesis who underwent lumbar RFA, the observed advancement of spondylolisthesis is clinically similar to the estimated maximum baseline of 2% per year change. The study findings did not find a destabilizing effect of lumbar RFA in advancing spondylolisthesis in this patient population.

The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm.

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Erector Spinae Regional Anesthesia for Robotic Coronary Artery Bypass Surgery Is Not Associated With Reduced Postoperative Opioid Use: A Retrospective Observational Study.

OBJECTIVE: Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB). DESIGN: This was a retrospective observational study of routinely recorded data. SETTING: The study was performed at a single healthcare system. PARTICIPANTS: All patients underwent robotic MIDCAB. INTERVENTION: Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS. MEASUREMENTS AND MAIN RESULTS: In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC. CONCLUSIONS: These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.

Perception of Benefits and Harms of Medical Cannabis among Seriously Ill Patients in an Outpatient Palliative Care Practice.

Introduction: Patients with serious illness often have pain, uncontrolled symptoms, and poor quality of life. Evidence continues to evolve regarding the role of cannabis to treat chronic pain, nausea, and anorexia. Little is known about how patients with serious illness perceive its benefits and harms. Given that an increasing number of clinicians across the United States are treating patients with medical cannabis, it is important for providers to understand patient beliefs about this modality. We assessed patient perceptions of benefits and harms of cannabis who obtained a medical cannabis card within an ambulatory palliative care (APC) practice. Methods: We recruited patients with a medical cannabis card, allowing for legal possession of cannabis oil, from an APC practice in Georgia. All participants reported using cannabis products. Patients completed an online survey that included questions about their cannabis use, concurrent opiate or controlled medication use, and perceptions of benefits and harms of cannabis. Results: All 101 patients invited to participate completed the survey. A majority had cancer (76%) and were married (61%), disabled or retired (75%), older than 50 years of age (64%), and men (56%). Most patients ingested (61%) or vaporized (49%) cannabis products. A majority of respondents perceived cannabis to be important for their pain (96%) management. They reported that side effects were minimally bothersome, and drowsiness was the most commonly reported bothersome harm (28%). A minority of patients reported cannabis withdrawal symptoms (19%) and concerns for dependency (14%). The majority of patients were using concurrent prescription opioids (65%). Furthermore, a majority of cancer patients reported cannabis as being important for cancer cure (59%). Conclusion: Patients living with serious illnesses who use cannabis in the context of a multidisciplinary APC practice use cannabis for curative intent and for pain and symptom control. Patients reported improved pain, other symptoms, and a sense of well-being with few reported harms.

Effectiveness of adjunctive, personalised psychosocial intervention for non-response to opioid agonist treatment: Study protocol for a pragmatic randomised controlled trial.

INTRODUCTION: Opioid use disorder (OUD) is a debilitating and relapsing psychiatric disorder; opioid agonist therapy (OAT) is the front-line, evidence-supported treatment. A substantial number of patients relapse or continue to use heroin or other illicit drugs during OAT. There is considerable heterogeneity in the OAT-resistant sub-population, with many behavioural moderators of treatment response. We have developed a personalised psychosocial intervention (PSI) targeting these individuals. A formulation-guided assessment is linked to a toolkit of motivational, cognitive/behavioural and social support techniques. Change methods have been adapted from evidence-supported psychological therapies and are idiosyncratically tailored to the need and response. METHODS: In this single-centre, 18-week, parallel group, pragmatic randomised clinical trial, we will determine the clinical and cost-effectiveness of the PSI as an adjunctive intervention during OAT, in comparison to opioid agonist treatment-as-usual. We plan to recruit 368 adults. The primary outcome measure is the proportion of participants categorised as 'responders' at the end of the intervention (defined as self-reported abstinence from heroin and cocaine with no positive biological drug tests during the 28days prior to the endpoint). Secondary outcomes include: percentage of days abstinent from heroin and cocaine in the 28days before follow-up; treatment retention; therapy compliance; health and social functioning; exploratory genetic biomarkers; and analyses of treatment moderation and mediation. CONCLUSIONS: This pragmatic controlled trial determines the effectiveness and cost-effectiveness of a personalised PSI for non-responding patients during OAT. Our intervention applies motivational, cognitive/behavioural and social support techniques adapted from evidence-based therapies. Findings will inform stratified delivery of OAT.

Canadian Triage and Acuity Scale: testing the mental health categories.

PURPOSE: The study tested the inter-rater reliability and accuracy of triage nurses' assignment of urgency ratings for mental health patient scenarios based on the 2008 Canadian Triage and Acuity Scale (CTAS) guidelines, using a standardized triage tool. The influence of triage experience, educational preparation, and comfort level with mental health presentations on the accuracy of urgency ratings was also explored. METHODS: Study participants assigned urgency ratings to 20 mental health patient scenarios in randomized order using the CTAS. The scenarios were developed using actual triage notes and were reviewed by an expert panel of emergency and mental health clinicians for face and content validity. RESULTS: The overall Fleiss' kappa, the measure of inter-rater reliability for this sample of triage nurses (n=18), was 0.312, representing only fair albeit statistically significant (P<0.0001) agreement. Kendall's coefficient of concordance for the sample was calculated to be 0.680 (P<0.0001), which signifies moderate agreement. Although the sample reported high levels of education, comfort with mental health presentations, and experience, accuracy in urgency ratings measured by the percentage of correct responses ranged from 0.05% to 94% (mean: 54%). Greater accuracy in urgency ratings was recorded for triage nurses who used second-order modifiers and avoided the use of override. CONCLUSION: Specific focus on the use of second-order modifiers in orientation and ongoing education of triage nurses may improve the reliability and validity of the CTAS when used to assign urgency ratings to mental health presentations.

Reducing uncertainty in triaging mental health presentations: examining triage decision-making.

Little is known about how emergency department (ED) nurses make decisions and even less is known about triage nurses' decision-making. There is compelling motivation to better understand the processes by which triage nurses make decisions, particularly with complex patient populations such as those with frequently emotive mental health and illness issues. While accuracy and reliability of triage decisions generally have been improved through the introduction of standardised triage scales and instruments, other factors such as lack of knowledge or confidence related to mental health issues, past experiences that may elicit transference and countertransference, judgments about individuals based on their behavioural presentations may impact on decisions made at triage. In this paper, we review the current research regarding the effectiveness of triage tools particularly with mental health presentations, present a theoretical framework that may guide research in understanding how triage nurses approach decision-making, and apply that framework to thinking about research in mental health-related triage. Developing a better understanding of how triage nurses make decisions, particularly in situations where issues related to mental health and illness may raise the levels of uncertainty, is crucial to ensure that they have the skills and tools they need to provide the most effective, sensitive, and compassionate care possible.

The impact of pruritus on quality of life: the skin equivalent of pain.

OBJECTIVE: To compare the impact of chronic pruritus and chronic pain on quality of life (QoL) using directly elicited health utility scores. DESIGN: Cross-sectional study. SETTING: Convenience sample of patients attending the Emory Dermatology Clinic, Emory Spine Center, and Emory Center for Pain Management, Atlanta, Georgia. PARTICIPANTS: Adult men and women (aged ≥ 18 years) experiencing chronic pain or pruritus for 6 weeks or more. MAIN OUTCOME MEASURES: The mean utility score of patients with chronic pruritus was compared with that of patients with chronic pain. A regression analysis was performed to determine the impact of the primary predictor variable-symptom type-on the primary outcome variable-mean utility score (a metric representing the impact on QoL). RESULTS: The study included 73 patients with chronic pruritus and 138 patients with chronic pain. The mean (SD) utility among patients with pruritus was 0.87 (0.27) compared with 0.77 (0.31) for patients with pain (P < .01). After symptom severity, duration, and demographic factors were controlled for, only symptom severity (0.03 [P < .05]) and single marital status (-0.12 [P = .02]), but not symptom type (P = .43), remained significant predictors of the mean symptom utility score. CONCLUSIONS: Chronic pruritus has a substantial impact on QoL, one that may be comparable to that of pain. The severity of symptoms and the use of support networks are the main factors that determine the degree to which patients are affected by their symptoms. Addressing support networks in addition to developing new therapies may improve the QoL of itchy patients.

Triaging suicidal patients: sifting through the evidence.

The triaging of individuals who present to general hospital emergency departments with suicidal thoughts and behaviours is especially challenging and fraught with uncertainty. Although the suicide literature is vast, and risk factor research has a long history, there is a dearth of articles that address the "point of care" factors that need to be considered in triaging a suicidal patient. In order to address this dilemma for nurses performing the triage function, this paper is a targeted review of the suicide risk factor literature designed to discern factors that may have implications for making a triage determination with the intent of improving the accuracy and quality of triage for suicidal patients. Contextual and compositional factors suggesting long-term risk; situational, precipitating, factors that may impact one's immediate risk; and cues and clues to imminent risk are presented along with evidence-based suggestions for assessment and safety.

Cholesterol screening in an at-risk pediatric population.

Elevation of low-density lipoprotein (LDL) cholesterol is a recognized risk factor for premature atherosclerosis and such elevations have their antecedents in the pediatric population. This study evaluated the frequency of elevated LDL cholesterol in children and adolescents (8-18 years) in whom one parent had a history of premature ischemic heart disease (<55 years). Patients had a fasting lipid profile performed and results were classified as normal, borderline/high, or high in accordance with the American Academy of Pediatrics (AAP) guidelines. Fifty-two parents had a total of 97 children and adolescents who were eligible for screening. Ninety-three initially consented and fasting lipid profiles were obtained in 82 (84.5%) children. Prevalences of high and borderline/high LDL cholesterol were (7/82) 8.5% and (17/82) 20.7%, respectively. Screening for hypercholesterolemia in these at-risk children and adolescents is prudent and dietary advice must be offered.