The journal of pain : official journal of the American Pain Society
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The objective of this retrospective study was to test the validity and reliability of a scoring tool (the DIRE Score), for use by clinicians, that predicts which chronic noncancer pain patients will have effective analgesia and be compliant with long-term opioid maintenance treatment. DIRE scores were assigned to 61 cases from the pain center's databases. These cases were abstracted into vignettes that were reviewed and scored by 6 physicians. Repeat scoring was carried out on a subset of 30 vignettes after 2 weeks. The main outcome measures were: global impression of compliance and efficacy as indicated in the medical record and by interview with the patient's treating clinician; and final disposition, ie, whether or not opioids were continued or discontinued at the time of last clinical documentation. Internal consistency of the factors making up the DIRE Score was high (Cronbach's alpha = .80). Sensitivity and specificity of the DIRE Score for predicting patient compliance were 94% and 87%, respectively. For efficacy, sensitivity and specificity were 81% and 76%. For disposition, the sensitivity and specificity were 86% and 73%. Intraclass correlation was 0.94 for interrater reliability and 0.95 for intrarater reliability. ⋯ Public controversy about the use of long-term opioids for chronic pain fuels physician ambivalence about the prescribing process. In this initial retrospective study, validity and reliability of the DIRE Score are demonstrated. The score correlated well with measures of patient compliance and efficacy of long-term opioid therapy.
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Randomized Controlled Trial Comparative Study
A comparison of conventional pain coping skills training and pain coping skills training with a maintenance training component: a daily diary analysis of short- and long-term treatment effects.
Pain coping skills training (PCST) has been shown to produce immediate improvements in pain and disability in rheumatoid arthritis (RA). However, some patients have difficulty maintaining these gains. This study compared a conventional PCST protocol with a PCST protocol that included maintenance training (PCST/MT). Patients with RA (n = 167) were randomly assigned to either conventional PCST, PCST/MT, arthritis education control, or standard care control. Daily data were collected on joint pain, coping, coping efficacy, and mood. Multilevel analyses showed that at posttreatment, conventional PCST was superior to all other conditions in joint pain, coping efficacy, and negative mood, whereas PCST/MT was superior to all other conditions in emotion-focused coping and positive mood. At 18 months follow-up, both PCST conditions were superior to standard care in joint pain and coping efficacy. Interpretation of follow-up outcomes was limited by higher dropout rates in the 2 PCST groups. For RA, a maintenance training component does not appear to produce significant improvements over conventional PCST. ⋯ This article reports a trial evaluating a conventional pain coping skills training protocol and a similar protocol that included a maintenance training component. Overall, results indicate similar results for both the conventional and the modified protocols.
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Chronic pain following breast cancer surgery is associated with decreased health-related quality of life and is a source of additional psychosocial distress in women who are already confronting the multiple stresses of cancer. Few prospective studies have identified risk factors for chronic pain following breast cancer surgery. Putative demographic, clinical, and psychosocial risk factors for chronic pain were evaluated prospectively in 95 women scheduled for breast cancer surgery. In a multivariate analysis of the presence of chronic pain, only younger age was associated with a significantly increased risk of developing chronic pain 3 months after surgery. In an analysis of the intensity of chronic pain, however, more invasive surgery, radiation therapy after surgery, and clinically meaningful acute postoperative pain each independently predicted more intense chronic pain 3 months after surgery. Preoperative emotional functioning variables did not independently contribute to the prediction of either the presence or the intensity of chronic pain after breast cancer surgery. These findings not only increase understanding of risk factors for chronic pain following breast cancer surgery and the processes that may contribute to its development but also provide a basis for the development of preventive interventions. ⋯ Clinical variables and severe acute pain were risk factors for chronic pain following breast cancer surgery, but psychosocial distress was not, which provides a basis for hypothesizing that aggressive management of acute postoperative pain may reduce chronic pain.
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Comparative Study
Do pain qualities and spatial characteristics make independent contributions to interference with physical and emotional functioning?
Although pain is acknowledged to be a multidimensional experience that can vary in intensity, quality (eg, burning, sensitive), and spatial characteristics (eg, location on body, perceived depth), its qualitative and spatial domains continue to be rarely assessed in pain clinical trials. One factor that may be contributing to the relatively rare assessment of pain quality and spatial characteristics is the lack of research addressing whether knowledge about these aspects of pain contributes important information beyond that provided by pain intensity alone. For example, there is no research that has examined whether measures of pain quality and perceived depth add anything to the understanding of the impact of pain on function. In the current study, secondary analyses of pretreatment data from clinical trials of patients from 3 diagnostic groups (osteoarthritis, low back pain, and peripheral neuropathy) indicated that measures of pain quality and perceived depth were significantly associated with pain interference with functioning, independent of global pain intensity and unpleasantness. No single pain descriptor emerged as universally important, however, although the findings suggest that: 1) sharp, deep, and perhaps especially sensitive pain may be important in patients with painful peripheral neuropathy; 2) sharp, sensitive, itchy, deep, and surface pain may be key pain descriptors important to persons with low back pain; and 3) perhaps deep pain may be the sole key pain descriptor important among persons with osteoarthritis. The findings support the potential utility of including measures of specific pain qualities and perceived depth in pain clinical trials and provide an initial empirical basis for determining which pain descriptors may be most closely linked to patient functioning. ⋯ Specific pain qualities, such as sharp, sensitive, and itchy pain, and perceived depth of pain appear to play a significant and unique role in the prediction of pain interference in addition to global pain intensity and unpleasantness. These findings suggest that measures of these specific pain domains could play an important role in understanding the impact of pain on patient functioning.
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Patients presenting to an emergency department (ED) with painful conditions continue to experience significant delay to analgesia. It remains unclear whether demographic and clinical factors are associated with this outcome. The objectives of this study were to determine 1) the proportion of patients that require parenteral opiate analgesia for pain in an ED and who receive the opiate in less than 60 minutes; and 2) whether any factors are predictive for the first dose of analgesia being delayed beyond 60 minutes. A retrospective cohort study with descriptive and comparative data analysis was conducted. Over a 3-month period, the medical record of every patient receiving parenteral opiates in a tertiary emergency department was reviewed and analyzed. Of 857 patients, 451 (52.6%) received analgesia in less then 60 minutes. Multiple demographic and clinical factors are associated with statistically significant delay to analgesia, including age, triage code, seniority of treating doctor, diagnosis, and disposition from the ED. ⋯ A considerable proportion of patients suffer delay to analgesia. Identifiable factors associated with a delay to analgesia exist. There is potential for clinicians to develop strategies to address the population in emergency departments at risk for delay to analgesia.