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Misuse of pain medicine is a leading cause of accidental deaths in the USA—over 15 000 deaths annually. A system dynamics model was developed and used to study the impact of three types of policy interventions to reduce adverse outcomes. Besides medical usage, the model also includes the diversion of pain medicines and their nonmedical use. Model behavior compared favourably with historical data at multiple points in the system. A prescription drug monitoring program intervention reduced nonmedical overdoses through supply restriction, and an intervention to reduce popularity of nonmedical usage reduced nonmedical overdoses by curtailing demand. A tamper-resistant drug formulation intervention resulted in decreased risk to individuals but increased overdose deaths. Key policy insights are that supply and demand must be carefully considered; that the feedback loops, which created the problem, can help to identify solutions; and that outcome metrics must be carefully chosen. Copyright © 2015 John Wiley & Sons, Ltd.

Introduction Between 2009 and 2011 a series of 26 articles on evidence-based medicine for interventional pain medicine according to clinical diagnoses were published. The high number of publications since the last literature search justified an update. Methods For the update an independent 3rd party, specialized in systematic reviews was asked in 2015 to perform the literature search and summarize relevant evidence using Cochrane and GRADE methodology to compile guidelines on interventional pain management. The guideline committee reviewed the information and made a last update on March 1st 2018. The information from new studies published after the research performed by the 3th party and additional observational studies was used to incorporate other factors such as side effects and complications, invasiveness, costs and ethical factors, which influence the ultimate recommendations. Results For the different indications a total of 113 interventions were evaluated. Twenty-seven (24%) interventions were new compared to the previous guidelines and the recommendation changed for only 3 (2.6%) of the interventions. Discussion This article summarizes the evolution of the quality of evidence and the strength of recommendations for the interventional pain treatment options for 28 clinical pain diagnoses.

Unrelieved chronic pain is a worldwide epidemic. Chronic pain has been subject to multiple international initiatives through the World Health Organization. Interventional Pain Medicine, the use of minimally invasive techniques to relieve pain, is the best approach when simpler measures such as physical therapy or medications fail. However, these procedures can be associated with significant risk and expense. Establishing uniformity in diagnostic criteria and procedural performance can reduce both morbidity and unnecessary procedures, and hence healthcare expenditures. While other texts explain how to perform these procedures, little focus has been given to diagnostic considerations: if and when these procedures should be performed. Evidence-Based Interventional Pain Medicine focuses on a balance between effectiveness and safety of interventional management for specific diagnoses, across all areas of chronic pain including: Head, neck and shoulder pain. Lower back pain. Neuropathic pain syndromes. Complex Regional Pain Syndrome. Pain in patients with cancer. Vascular and visceral pain. Evidence-Based Interventional Pain Medicine provides essential knowledge for anyone who uses, or intends to use, interventional pain techniques.

With few exceptions, anesthesiologists have not received training in the use of immune modulating drugs (IMDs); but recent evidence suggests that such drugs may be effective in reducing chronic pain. We therefore wished to learn how anesthesiologists working in pain medicine might envisage the treatment of their patients with IMDs in the future. We expected that anesthesiologists would want to refer patients for treatment with IMDs to medical colleagues, such as oncologists or rheumatologists, with prior experience in using these drugs, rather than treat these patients within their own practice. We conducted questionnaire surveys among anesthesiologists working in pain medicine in both the Netherlands and the U.K. to explore their views on using IMDs. Contrary to what we had expected, we found that a majority of the respondents would administer IMDs within their own practice, after appropriate training. The overall response rates were 30% and 23%, respectively; therefore, no firm conclusions can be drawn as to the views of the majority of practicing pain specialists. Our findings may have implications for the planning of both health service delivery and training in pain medicine.

Although previous studies suggest that the clinical setting of an interdisciplinary pain treatment program may provide an optimal environment to promote smoking cessation, currently available smoking cessation interventions may be less effective for adults with chronic pain due, in part, to unrecognized clinical factors related to chronic pain. The specific aim of this qualitative study was to solicit information from adult smokers with chronic pain participating in an interdisciplinary pain treatment program regarding their perceptions of how smoking affects pain symptoms, and how these beliefs, cognitions, and emotions may either impede or facilitate smoking cessation. Similar information was solicited from a group of pain specialty physicians. The study involved 18 smokers with chronic pain, and seven physicians. Patients reported that smoking was an important coping strategy for pain and distress, primarily by offering an opportunity for distraction and avoidance, respectively. The majority of patients using opioids reported that opioid consumption stimulated smoking. Important barriers were identified toward making a quit attempt during pain treatment including quitting smoking while making changes in opioid use, and perceived difficulty managing multiple treatment-related stressors. Several pain-related benefits of smoking cessation were identified by physicians, but important barriers to providing smoking cessation services were recognized including lack of time and knowledge about how to help patients quit smoking. The findings of this study identified several novel and important clinical factors that should be incorporated into a targeted smoking cessation intervention for adults with chronic pain.

Objectives Our study surveyed physician members of 3 American pain societies to determine prescription patterns and whether these practices reflect current expert opinion. Methods We sent 3 mailings to 2938 physicians from January 2010 to January 2011. The questionnaire contained 49 questions on topics related to opioids, antidepressants, anticonvulsants, and preferences for the different pain syndromes. Results A total of 474 physicians responded, representing a 16% return. Seventy-two percent ask patients to sign an opioid agreement, 59% order random urine drug testing, 13% wait until the dose of methadone is between 100 and 150 mg before converting the drug to another opioid, and 85% do not think there is a maximum dose of opioids with respect to driving. Most responders prescribe codeine to Caucasians and Asians. While 42% stated that the maximum daily dose of acetaminophen is 3000 mg, 75% would decrease the dose in patients who are moderate or heavy drinkers. Fifty-four percent do not order an ECG at all when prescribing tricyclic antidepressants. Conclusions The responses pertaining to opioid agreements, urine drug testing, acetaminophen, and treatment for neuropathic pain are reassuring in that they prevent misuse and abuse of opioids, prevent acetaminophen-induced hepatotoxicity, and reflect evidence-based treatments. However, we identified gaps in knowledge, including the prescription of codeine in certain populations and the use of electrocardiogram in patients on antidepressants. Further education of physicians who treat chronic pain pharmacologically is warranted.

The assessment of quality in clinical trials involves multiple considerations. While compliance with both Good Clinical Practice and International Conference on Harmonisation guidelines is required, variations in many other factors contribute to the overall quality of the report. Principal among these factors is the development of a testable study question. Study questions that are feasible, interesting, novel, ethical, and relevant are desirable. The methodology used to answer the question should be described in sufficient detail and documented to provide for reproducibility and transparency. This is essential for both interpretation of the results and for assessing the applicability of the results to clinical practice. While randomized controlled trials (RCT) are currently the penultimate methodological standard for quality in research study design, they typically do not mimic clinical practice, which can present limitations to their value. This is particularly relevant with respect to interventional therapies, where RCT designs can be associated with scientific and ethical challenges. Well-designed observational studies may overcome some of these drawbacks, but often require very large study populations. Technological advances in communication may permit the pooling of data and the emergence of new standards for interventional pain research.