The journal of pain : official journal of the American Pain Society
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In addition to headache, persons with chronic migraine (CM) experience multiple symptoms, both ictal and interictal, that may contribute to their suffering. Translating clinical trial results into practice requires assessment of the results' clinical meaningfulness. When examining treatment benefit in this disabled patient population, multiple headache-symptom measures should be considered to fully reflect clinical relevance. Currently, only onabotulinumtoxinA is approved specifically for headache prophylaxis in adults with CM. Topiramate is the only other therapeutic agent with double-blind, placebo-controlled evidence in this population. Herein we evaluate the clinical meaningfulness of onabotulinumtoxinA and topiramate as headache prophylaxis in CM by comparing primary endpoints from the placebo-controlled, double-blind phase of the Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program and the topiramate clinical trial (frequency of headache days [primary endpoint in PREEMPT; secondary in topiramate trial] and migraine/migrainous days [primary in topiramate trial, or "migraine/probable-migraine days"; secondary in PREEMPT]). Additionally, outcome measures such as responder rates, health-related quality of life, discontinuation rates, safety, and tolerability profiles are important clinical considerations. The clinical data indicate that statistically significant, clinically relevant treatment benefits exist for both onabotulinumtoxinA and topiramate. These data support these treatments as meaningful headache prophylaxis in adults with CM. ⋯ CM is a chronic pain condition. We sought to determine the clinical relevance of recent trials in this disabled population. Clinical data indicate that statistically significant, clinically relevant treatment benefits exist for both onabotulinumtoxinA and topiramate, and support use of these treatments as meaningful headache prophylaxis in CM.
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Insufficient pain education is problematic across the health care spectrum. Recent educational advancements have been made to combat the deficits in pain education to ensure that health care professionals are proficient in assessing and managing pain. The purpose of this survey was to determine the extent of pain education in current Doctorate of Physical Therapy schools in the United States, including how pain is incorporated into the curriculum, the amount of time spent teaching about pain, and the resources used to teach about pain. The survey consisted of 10 questions in the following subject areas: basic science mechanisms and concepts about pain, pain assessment, pain management, and adequacy of pain curriculum. The overall response was 77% (167/216) for the first series of responses of the survey (Question 1), whereas 62% completed the entire survey (Questions 2-10). The average contact hours teaching about pain was 31 ± 1.8 (mean ± standard error of the mean) with a range of 5 to 115 hours. The majority of schools that responded covered the science of pain, assessment, and management. Less than 50% of respondents were aware of the Institute of Medicine report on pain or the International Association for the Study of Pain guidelines for physical therapy pain education. Only 61% of respondents believed that their students received adequate education in pain management. Thus, this survey demonstrated how pain education is incorporated into physical therapy schools and highlighted areas for improvement such as awareness of recent educational advancements. ⋯ This article demonstrates how pain education is incorporated into physical therapy curricula within accredited programs. Understanding the current structure of pain education in health professional curriculum can serve as a basis to determine if recent publications of guidelines and competencies impact education.
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Limited research examines the risk of therapeutic opioid addiction (TOA) in patients with chronic noncancer pain. This study examined TOA among 199 patients undergoing long-term opioid therapy at the time of admission to a pain rehabilitation program. It was hypothesized that nonopioid substance use disorders and opioid dosage would predict TOA. Daily mean opioid dose was 132.85 mg ± 175.39. Patients with nonopioid substance use disorders had 28 times the odds (odds ratio [OR] = 28.58; 95% confidence interval [CI] = 10.86, 75.27) of having TOA. Each 50-mg increase in opioid dose nearly doubled the odds of TOA (OR = 1.73; 95% CI = 1.29, 2.32). A 100-mg increase was associated with a 3-fold increase in odds (OR = 3.00; 95% CI = 1.67, 5.41). Receiver operating characteristic analysis revealed that opioid dose was a moderately accurate predictor (area under the curve = .75; 95% CI = .68, .82) of TOA. The sensitivity (.70) and specificity (.68) of opioid dose in predicting TOA was maximized at 76.10 mg; in addition, 46.00 mg yielded 80% sensitivity in identifying TOA. These results underscore the importance of obtaining a substance use history prior to prescribing and suggest a low screening threshold for TOA in patients who use opioids in the absence of improvement in pain or functional impairment. ⋯ This article examines TOA in patients with chronic noncancer pain undergoing long-term opioid therapy. Results suggest that patients should be screened for nonopioid substance use disorders prior to prescribing. In the absence of improvement in pain or function, there is a low threshold (∼50 mg daily opioid dose) for addiction screening.
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Motivational accounts of pain behavior and disability suggest that persisting attempts to avoid or control pain may paradoxically result in heightened attention to pain-related information. We investigated whether attempts to control pain prioritized attention to the location where pain was expected, using a tactile change detection paradigm. Thirty-seven undergraduate students had to detect changes between 2 consecutively presented patterns of tactile stimuli at various body locations. One of the locations was made threatening by occasionally administering a pain-eliciting stimulus. Half of the participants (pain control group) were encouraged to actively avoid the administering of pain by pressing a button as quickly as possible, whereas the other participants (comparison group) were not. The actual amount of painful stimuli was the same in both groups. Results showed that in the comparison group, the anticipation of pain resulted in better detection of tactile changes at the pain location than at the other locations, indicating an attentional bias for the threatened location. Crucially, the pain control group showed a similar attentional bias, but also when there was no actual presence of threat. This suggests that although threat briefly prioritized the threatened location, the goal to control pain did so in a broader, more context-driven manner. ⋯ This study investigates the impact of attempts to control pain on somatosensory processing at the pain location. It provides further insight into the motivational mechanisms of pain-related attention. It also points to the negative consequences of trying to control uncontrollable pain, such as is often the case in chronic pain.