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The article discusses a study which cross-validated the Screener and Opioid Assessment for Patients with Pain--Revised (SOAPP-R) with a new sample of chronic, noncancer pain patients. The patients, who had a urine toxicology screen, were recruited from pain management centers in the U.S. Results showed that 77% were followed and 66 patients repeated the SOAPP-R for test-retest reliability. In addition, the reliability and predictive validity were highly significant and similar to values found with the initial sample.

Abstract: This investigation determined the psychometric properties and acceptability of an animated face scale presented on a hand-held computer as a means to measure pediatric pain and mood. In study 1, 79 hospitalized, pediatric patients indicated their levels of pain by adjusting the expression of an animated cartoon face. The first objective was to determine feasibility, concurrent validity, and acceptability of the method. All patients were tested both with the Computer Face Scale and the poster format of the Wong-Baker Faces Scale. A second objective was to evaluate test-retest reliability of the method. In study 2, 50 hospitalized, pediatric patients were tested on 2 occasions, but in this case the patients used the Computer Face Scale to indicate both their pain (how much they hurt) and their mood (how they felt). Children in study 1 were able to use the Computer Face Scale to express relative amounts of pain/hurt; the method showed concurrent validity with the Wong-Baker Face Scale; and most children expressed a preference for the Computer Face Scale. The method also showed adequate test-retest reliability. In study 2, adequate test-retest reliability was demonstrated for ratings of both pain and mood. Perspective: The Computer Face Scale allows the health provider to obtain reliable and valid measures of pediatric pain and mood. The method can be understood and used by children as young as 3 years and is appropriate for use with adults. [Copyright &y& Elsevier]

Abstract: Chronic noncancer pain is common and use of opioids is increasing. Previously published guidelines on use of opioids for chronic noncancer pain have been based primarily on expert consensus due to lack of strong evidence. We conducted searches on Ovid MEDLINE and the Cochrane databases through July 2008 to identify studies that addressed one or more of 37 Key Questions that a multidisciplinary expert panel identified as important to be answered to generate evidence-based recommendations on the use of opioids for chronic noncancer pain. A total of 14 systematic reviews, 38 randomized trials not included in a previously published systematic review, and 13 other studies met inclusion criteria. Almost all of the randomized trials of opioids for chronic noncancer pain were short-term efficacy studies. Critical research gaps on use of opioids for chronic noncancer pain include: lack of effectiveness studies on long-term benefits and harms of opioids (including drug abuse, addiction, and diversion); insufficient evidence to draw strong conclusions about optimal approaches to risk stratification, monitoring, or initiation and titration of opioid therapy; and lack of evidence on the utility of informed consent and opioid management plans, the utility of opioid rotation, the benefits and harms specific to methadone or higher doses of opioids, and treatment of patients with chronic noncancer pain at higher risk for drug abuse or misuse. Perspective: Currently, clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to be set to address these critical research needs if the care of patients with chronic noncancer pain is to improve. [Copyright &y& Elsevier]

Abstract: Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices. Perspective: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence. [Copyright &y& Elsevier]

Abstract: Optimal methods to predict risk of aberrant drug-related behaviors before initiation of opioids for chronic noncancer pain and to identify aberrant behaviors after therapy is initiated are uncertain. We systematically reviewed published literature identified through searches of Ovid MEDLINE and the Cochrane databases through July 2008. Diagnostic test characteristics and accompanying confidence intervals were calculated with data extracted from the studies. Four prospective studies evaluated diagnostic accuracy of risk prediction instruments. Two higher-quality derivation studies found that high scores on the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1 and the Revised SOAPP (SOAPP-R) instruments weakly increased the likelihood for future aberrant drug-related behaviors (positive likelihood ratios [PLR], 2.90 [95% CI, 1.91 to 4.39] and 2.50 [95% CI, 1.93 to 3.24], respectively). Low scores on the SOAPP Version 1 moderately decreased the likelihood for aberrant drug-related behaviors (negative likelihood ratio [NLR], 0.13 [95% CI, 0.05 to 0.34]) and low scores on the SOAPP-R weakly decreased the likelihood (NLR, 0.29 [95% CI, 0.18 to 0.46]), but estimates are too imprecise to determine if there is a difference between these instruments. One lower-quality study found that categorization as high risk using the Opioid Risk Tool strongly increased the likelihood for future aberrant drug-related behaviors (PLR, 14.3 [95% CI, 5.35 to 38.4]) and classification as low risk strongly decreased the likelihood (PLR, 0.08 [95% CI, 0.01 to 0.62]). Nine studies evaluated monitoring instruments for identification of aberrant drug-related behaviors in patients on opioid therapy. One higher-quality derivation study found higher scores on the Current Opioid Misuse Measure (COMM) weakly increased the likelihood of current aberrant drug-related behaviors (PLR, 2.77 [95% CI, 2.06 to 3.72]) and lower scores weakly decreased the likelihood (NLR, 0.35 [95% CI, 0.24 to 0.52]). In 8 studies of other monitoring instruments, diagnostic accuracy was poor, results were difficult to interpret due to methodological shortcomings, or standard diagnostic test characteristics were not reported. Definitions for aberrant drug-related behaviors were not standardized across studies and did not account for seriousness of identified behaviors. No reliable evidence exists on accuracy of urine drug screening, pill counts, or prescription drug monitoring programs; or clinical outcomes associated with different assessment or monitoring strategies. Perspective: Evidence on prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments may be useful, evidence is sparse and primarily based on derivation studies, and methodological shortcomings exist in all studies. Research that performs external validation, uses standardized definitions for clinically relevant aberrant drug-related behaviors, and evaluates clinical outcomes associated with different assessment and monitoring strategies is needed. [Copyright &y& Elsevier]

We come from the perspective that opioids are efficacious in the management of nonterminal chronic pain. Responsible care within such a model requires that pain management physicians are adequately familiar with the broad ordering and interpretation of urine toxicology specimens, and especially with interpretation specific to issues of opiate use, addiction, and diversion as commonly seen in the course of clinical care, including risk assessment. This article provides an overview of these and related concerns. [Copyright &y& Elsevier]

In the past, neurosurgical ablative therapies (NAT) were commonly used for managing cancer pain. Since the advent of intrathecal opioid and patient-controlled intravenous opioids, NAT has fallen out of favor secondary to their comparably worse risk–benefit profile. Although NAT is rarely utilized today, there is a subgroup of patients who continue to benefit from these procedures. These patients either do not receive adequate pain relief by more traditional means or are unable to tolerate the adverse effects of opioid medications. Other patients prefer to undergo a low-maintenance intervention that will allow them to spend the remainder of life with their families in a narcotic-free state at home. The neuroablative surgeries target several different areas of the CNS ranging from the peripheral nervous system (ie, dorsal rhizotomy) to the central nervous system (ie, anterior cordotomy). While these procedures have a reduced role, they remain a viable option in palliative care medicine. [Copyright &y& Elsevier]