The journal of pain : official journal of the American Pain Society
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Three national surveys were conducted in 1991, 1997, and 2004 to evaluate state medical board members' knowledge and attitudes about prescribing opioid analgesics for pain management. Topics addressed include perceived legality of prolonged opioid prescribing, characteristics of addiction, prevalence of medication abuse and diversion, and perceived importance and influence of medical board policy. Questions were added in 2004 to determine board members' views about law enforcement involvement in physician investigations and prosecutions. This study assesses medical regulators' current beliefs and compares the 2004 responses with previous responses to determine how knowledge and attitudes about prescribing opioids have changed in recent years. Survey results show that board members have a greater understanding of pain management issues, particularly regarding characteristics of addiction and the legality of prolonged opioid prescribing for chronic noncancer pain. During the last 15 years, there has been substantial regulatory policy development, with medical boards adopting regulations, guidelines, or policy statements to provide guidance to licensees about using opioids to treat pain. However, many board members believe that federal and state law enforcement agencies have increased criminal investigations and prosecutions of physicians. We discuss appropriate regulatory and law enforcement responses to opioid prescribing violations, and suggest crucial next steps. ⋯ The authors examine the evolution of state medical board members' knowledge and attitudes about prescribing opioid analgesics to treat chronic pain, demonstrate that medical regulators believe that there have been increased criminal investigations and prosecutions of physicians for their prescribing practices, and suggest ways to avoid unwarranted criminal prosecutions.
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The Child Activity Limitations Interview (CALI) was designed to assess functional impairment secondary to chronic and recurrent pain in school-aged children and adolescents. The availability of a written version offers several benefits to the instrument as a clinical measure. The purpose of the current study was to develop and provide initial validation data for a paper-and-pencil version, the Child Activity Limitations Questionnaire (CALQ). Participants included 60 children and adolescents (8-18 years; M 14.0, SD 2.7) presenting to a multidisciplinary pain clinic and their parents (N = 62; 82.7% mothers). Measures included child reports of recent pain, and child and parent reports on the Functional Disability Inventory, Pediatric Quality of Life Inventory, and Pediatric Symptom Checklist-17. CALQ and CALI scores were similarly related to all validation measures. Both instruments demonstrated reliability, construct validity, and discriminant validity. The CALQ showed strong internal consistency (child report: alpha = .91; parent report: alpha = 0.91) and moderate parent-child consistency (r = .65). Construct validity was demonstrated by significant relationships between CALQ scores and all measures of pain, and physical and psychosocial functioning, including quality of life. These preliminary data suggest that the CALQ is a reliable and valid alternative version of the CALI. ⋯ This study demonstrates the reliability and validity of a written version of an interview tool designed to measure functional disability in pediatric chronic pain patients. The data suggest that the benefits of the CALI may be realized with this new paper-and-pencil version.
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Recent developments in cognitive behavioral theory emphasize the role of "psychological flexibility" in adaptive functioning. Psychological flexibility includes processes of acceptance, mindfulness, values, and cognitive defusion. The present study was intended to investigate aspects of psychological flexibility in relation to the functioning of patients with chronic pain. Two hundred sixty patients seeking treatment for chronic pain completed a battery of measures, including an expanded version of an instrument assessing responses to pain that reflect both psychological flexibility and traditionally conceived "pain management strategies" (ie, pacing, relaxation, positive self-statements). Initial psychometric evaluation of the expanded instrument yielded 2 reliable subscales, as hypothesized. Both subscales were correlated with measures of emotional functioning and psychosocial disability, although psychological flexibility achieved larger correlations and was correlated with additional measures of physical functioning, health care use, and work status. Regression analyses indicated that, after pain and patient background variables were statistically controlled, psychological flexibility accounted for significant variance in eight separate measures of functioning while pain management strategies accounted for significant variance in none. These results may call for a shift in our approaches to chronic pain in line with developments taking place in broader areas of behavioral and cognitive therapy. ⋯ This study includes development of an instrument for assessing coping, consisting of traditionally conceived coping strategies and a process that may be unfamiliar to most readers, termed "psychological flexibility." Results demonstrated that this process, a blend of acceptance, values-based action, mindfulness, and cognitive defusion, is significantly related to patient functioning with chronic pain.
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The current study examined the utility of a biopsychosocial model of chronic pain, and the associations between specific pain-related beliefs, coping, and social support and both mental health and pain interference, in persons with Spinal Cord Injury (SCI) and pain. A total of 157 patients completed surveys assessing physical and psychological functioning, as well as psychosocial, demographic, and injury-related variables. Greater catastrophizing and pain-related beliefs (eg, the belief that pain signals damage) were related with increased pain interference and poorer mental health, while coping styles (eg, resting, asking for assistance) were related only with pain interference. Alternatively, greater perceived social support was related with better mental health. The findings are consistent with a biopsychosocial model, implicating the need to consider the impact of process and clinical variables on adjustment to chronic pain in persons with SCI. ⋯ This article identifies several psychosocial variables, including coping, catastrophizing, pain-related beliefs, and social support that are related to adjustment in persons with SCI and pain. These results have implications for interventions designed to treat pain interference in persons with SCI.
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All data obtained in experimental animal pain models support the role of nerve growth factor (NGF) as a putative candidate intervening in the pathogenesis of chronic pain, including chronic daily headache (CDH). Few studies have been carried out to establish its role in maintaining pain states in humans. The present study was aimed at investigating cerebrospinal fluid (CSF) levels of NGF and brain-derived neurotrophic factor (BDNF), both measured by sensitive immunoassay, in 20 chronic migraine (CM) patients and 20 patients affected by primary fibromyalgia syndrome (PFMS), compared with those of 20 age-matched control subjects. Significantly higher levels of both neurotrophins and glutamate were found. A significantly positive correlation emerged between CSF values of BDNF and those of NGF (r = .61, P < .001; r = .53, P < .01) and glutamate (r = .44, P < .02; r = .51, P < .01) in CM and PFMS patients, respectively. These findings suggest the possibility of a NGF-mediated up-regulation of BDNF involved in the pathophysiological events underlying long-term neuroplastic changes in persistent chronic painful conditions, such as CM and fibromyalgia. NGF might indirectly exert its effect through enhancing glutamatergic transmission via BDNF. The above mechanisms could account for sustained central sensitization in both chronic pain states. ⋯ This article presents findings of higher NGF and BDNF levels correlated to increased glutamate levels in the CSF of both chronic migraine and fibromyalgia patients. This opens new insights into the pathogenic mechanisms of chronic pain and offers clinicians new therapeutic perspectives targeting the above mechanisms in both painful disorders.