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Patients with medically refractory headache disorders are a rare and challenging-to-treat group. The introduction of peripheral neurostimulation (PNS) has offered a new avenue of treatment for patients who are appropriate surgical candidates. The utility of PNS for headache management is actively debated. Preliminary reports suggested that 60-80% of patients with chronic headache who have failed maximum medical therapy respond to PNS. However, complications rates for PNS are high. Recent publication of 2 large randomized clinical trials with conflicting results has underscored the need for further research and careful patient counseling. In this review, we summarize the current evidence for PNS in treatment of chronic migraine, trigeminal autonomic cephalagias and occipital neuralgia, and other secondary headache disorders.

Objectives—The Current Opioid Misuse Measure (COMM) is a self-report measure of risk for aberrant medication related behavior among persons with chronic pain who are prescribed opioids for pain. It was developed to complement predictive screeners of opioid misuse potential and improve a clinician's ability to periodically assess a patient's risk for opioid misuse. The aim of this study was to cross validate the COMM with a new sample of chronic noncancer pain patients. Methods—Two hundred and twenty six (N=226) participants prescribed opioids for pain were recruited from five pain management centers in the US. Subjects completed the 17-item COMM and a series of self-report measures. Patients were rated by their treating physician, had a urine toxicology screen, and were classified on the Aberrant Drug Behavior index. Results—The reliability and predictive validity in this cross validation as measured by the area under the curve (AUC) were found to be highly significant (AUC =.79) and not significantly different from the AUC obtained in the original validation study (AUC =.81). Reliability (coefficient α) was . 83, which is comparable to the .86 obtained in the original sample. Discussion—Results of the cross validation suggest that the psychometric parameters of the COMM are not based solely on unique characteristics of the initial validation sample. The COMM appears to be a reliable and valid screening tool to help detect current aberrant drug-related behavior among chronic pain patients.

There has been a growing use of opioids for the treatment of chronic pain, especially for chronic, noncancer pain, and due, in part, to this growth, increasing notice has been given to the abuse of prescription opioid medication 1, 2. Opioids can be an effective treatment for chronic pain, yet providers are reluctant to prescribe opioids because of concerns over tolerance, dependence, and addiction. Some pain centers where opioids are prescribed have been overwhelmed with patients seeking pain medication for purposes other than to control their pain or to control their pain in ways not medically prescribed, and many physicians prescribing pain medication have little training to deal with addiction or in dealing with aberrant medication-related behavior 3. In a survey of primary care physicians, one-third of respondents indicated that they would not, under any circumstance, prescribe opioids to patients with chronic, noncancer pain 4, 5. However, seventy percent of these same physicians indicated that this type of pain is usually inadequately treated 4, 5. Clinicians continuously identify the need for additional opioid risk management tools and training to objectively assess and monitor chronic pain patients being considered for opioid therapy. The Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R)6 was developed to complement current risk assessment practices and to improve a clinician’s ability to assess a patient’s risk for opioid abuse. The SOAPP-R addresses some of the limitations of the original SOAPP V.1. The SOAPP-R was empirically, rather than conceptually, derived; it was validated in a more systematic fashion and it contains more subtle items and items that do not require admission of socially unacceptable behaviors. The SOAPP-R was found to have good psychometric properties in a test with 284 chronic pain patients on long-term opioid therapy. Classical test development methods require that the primary reliability and validity be confirmed in a cross-validation study 7. Any validity coefficient computed on a given sample can be spuriously high since such values capitalize on random sampling errors within the particular sample. It is expected that the validity and reliability parameters will “shrink” when tested on a new sample, however, the scale should still remain valid and reliable. Cross-validation reflects a high, but necessary standard for any assessment where the results may impact important clinical decisions. The purpose of this study was to cross-validate the SOAPP-R with a new sample of chronic, noncancer pain patients.

Objective. This descriptive study compares outcome measures of a computerized assessment of pain, emotional distress, and quality of life between chronic noncancer pain patients who have received an implantable device (spinal cord stimulator or intrathecal pump; N = 143) and those who have not received a device (N = 130). Methods. Each patient marked the location of their pain on a body diagram and rated pain intensity, emotional distress, and impact of their pain on mood, sleep, and quality of life using a computerized pain assessment program. An electronic version of the Hospital Anxiety and Depression Scale (HADS) also was administered. Results. No significant differences were found on the pain variables between the two groups. Patients with an implantable device gave lower ratings (less impact) on emotional distress (p

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.

Objective. Computerized software holds the potential for the novel assessment of the pain experi- ence of patients with chronic pain not available through traditional paper-and-pencil methods. The aim of this study was to test the feasibility and discriminant validity of a dynamic computer- administered program for the assessment of pain. Design. Three computer-administered programs were created to assess the intensity (dynamic visual analog scale (DVAS)), character (dynamic verbal ratings), and location (dynamic pain draw- ings) of pain. The programs were administered to 115 chronic pain patients recruited from a hospital-based pain management program and 115 age- and gender-matched healthy individuals without pain. The healthy controls were instructed to respond as if they had chronic pain. Results. Analyses showed pain patient DVAS pain intensity ratings to be significantly higher than ratings by the healthy group. Patients selected more words in describing their pain, rated those words higher, and marked significantly more pain locations than the comparison group. However, no differences were found in the DVAS ratings of emotional impact between patients and healthy individuals. Conclusions. Chronic pain patients were shown to differ from healthy individuals in their assess- ments of degree of pain intensity and pain location with the use of a novel computerized pain assess- ment program. Although further investigations are needed, these initial findings support the use of computer methods for the effective assessment of pain.

Study Design. A k-means cluster analysis of patients with spinal and radicular pain based on the SF-36 Health Survey scales. Objective. The aim was to determine whether spine patients fall into clusters according to self-reported health status as measured by the SF-36 and to determine if clustering is similar across four common diagnostic categories: herniated disc, spinal stenosis, spondylosis, and chronic pain syndrome. Summary of Background Data. Cognitive-behavioral classifications of chronic pain patients have previously identified three patient groups described as Dysfunctional, Interpersonally Distressed, and Minimizers/Adaptive Copers. The purpose of these classifications is to facilitate and direct treatment based not only on biomedical diagnosis but also on emotional, social, and behavioral diagnoses. This type of analysis has not been done on the quality-of-life scores of patients with specific spinal diagnoses. Methods. Health status data were reviewed from the initial visits of 15,748 spine patients in the National Spine Network database. Based on the eight scales of the SF-36, k-means cluster analysis divided the National Spine Network population into distinct clusters of similar patients. Clustering was performed separately for each clinical diagnosis group. Results. In all four diagnostic categories, cluster analysis classified patients into three groups. Group 1 had fairly high (relative to the entire sample) scores on all scales and was labeled “Highly Functional.” Group 2 had low measures on physical variables but comparatively high scores on the mental scales. These were labeled “Emotional Adapters.” Group 3 had low scores on all scales. These patients were labeled “Dysfunctional.” Although patients in each diagnostic category fell into one of the three groups, the proportion of patients within each group was quite different among chronic pain patients ascompared to the other three diagnostic groups. For example, 29% of herniated disc patients were in the Highly Functional group, whereas only 14% of patients in chronic pain were categorized as Highly Functional. Thirty-three percent of spondylosis patients were classified as Dysfunctional compared with 51% of chronic pain patients. Conclusions. Patients with spinal pain fall into three groups according to their profile of scores on the SF-36 Health Survey. It is proposed that such empirical groupings can guide decision-making in selecting the most appropriate therapies. Spine 2003;28:2276–2282

purpose: The purpose of this article is to describe barriers to cancer pain management and strategies for making improvements in an academic rural cancer center. overview: Rural communities pose unique challenges to cancer pain management because of their unique strengths and burdens. Successful strategies used by a comprehensive cancer center to improve pain management in rural New England are summarized. clinical implications Improving cancer pain management in a rural setting required a recognition of the contrasting characteristics between a sophisticated academic medical center and a rural community. The successful implementation of quality improvement strategies required a combination of leadership support, internal and external funding, and professional and federal recognition of the problem. Using a quality improvement approach rather than a traditional didactic approach, and fostering communication, trust, and collegiality at our outreach sites were pivotal to our success.

Study Design. A cross-sectional analysis of data obtained from patients with spinal and radicular pain and their spine center treating physicians was performed. Objectives. To identify characteristics of patients treated with opioids that distinguish them from similar patients not treated with opioids in a large population of patients with spine and radicular pain, and to determine the prevalence of opioid use. Summary of Background Data. The use of opioids with patients who have chronic pain remains controversial. The long-term risks and benefits are poorly described. The efficacy of this treatment has not been proved, yet the large majority of pain specialist physicians manage chronic pain with opioids. Methods. Descriptive data from the initial visits of 25,479 patients with spinal pain were reviewed. Patients were grouped according to whether or not opioids were recommended, prescribed, or continued. The prevalence of opioid use and patient characteristics were compared using standard statistical tests. Results. Overall, 3.4% of the patients had opioids included in their plan of care. There was no difference in age, gender, education, or compensation status between the two groups. Patients were more likely to be treated if the duration of their symptoms had been less than 3 months. However, 75% of the patients with opioids in their plan had experienced symptoms longer than 3 months. A greater incidence of objective findings was identified in the opioid group. Conclusions. The authors cannot comment on the prevalence of opioid use because, to the best of their knowledge, no other similar studies are available for

Opioid analgesics play an important role in the management of acute and chronic pain. As such, there has been a dramatic increase in opioid prescribing over the past two decades. There are currently many practitioners who have serious concerns with prescribing because of fear of side effects, tolerability, addiction, colleague criticism, and legal sanctions and both the efficacy and safety of the use of opioids for acute and chronic pain have recently been subjected to increasing scrutiny (J Pain Symptom Manage 20(4):293–307, 2000; J Pain Symptom Manage 11(4):203–217, 1996).

Invasive procedures performed by the pain management specialist are a mainstay in the diagnosis and treatment of both acute and chronic pain. They range from unguided percutaneous injections with short-acting local anesthetics to neurosurgical operations under computed tomography that permanently alter the anatomy. This chapter provides a description of the most common procedures performed by the pain management specialist, with more detail on the most frequent. The descriptions are not in sufficient enough detail to perform the procedures, and reference should be made to an interventional pain atlas for specifics.

Our objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Out- comes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclu- sion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions. Perspective: This longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.

Intrathecal baclofen is a useful therapy in patients with spasticity. We describe a patient who underwent an intrathecal pump implant, complicated by epidural lipomatosis that ultimately required a single level laminectomy and fat debulking before successful implantation.

Background. The Web not only can play a role in helping patients learn about their chronic pain, but can also be a source of misleading or untrue information. This study evaluates the quality of Internet information available concerning chronic pain at different sites, and determines the relation between quality and the source and character of the Websites. Methods. A survey was conducted of patients seen at the Pain Management Center at Dartmouth-Hitchcock Medical Center (DHMC). Patients with access to the Internet identified the five most common keywords they used to look up information: pain, chronic pain, back pain, arthritis, and fibromyalgia. A focus group of pain clinicians at DHMC then chose the quality criteria to evaluate Websites. The criteria consisted of 16 items in five domains: etiology, diagnosis, goals of treatment, treatment options, and substance abuse. The first two pages of links displayed by each of three major search engines then were assessed for quality. Results. A total of 240 Websites were evaluated. The mean score, the Quality Website Index (QWI), was 2.17 (SD = 3.3), (range from −16 [poorest] to +16 [best]). The overall quality of this group of Websites is rather poor, although there were several excellent sites. Websites located on the main search page had a significantly higher score than those in the sponsored section, and Websites based on standards had a significantly higher score than those that were not. Conclusion. Based on QWI scores, clinicians can recommend chronic pain Websites to provide their patients with accurate and pertinent information.

Objective. In order to establish a diagnosis of chronic pain, emphasis is placed on a patient’s report of the pain’s intensity, location, and character. The aim of this study was to evaluate the feasibility of a computer assessment method to collect self-reports of pain that were then used in discriminant analyses to distinguish among chronic pain diagnoses. Methods. A convenience sample of 511 patients from two university-based pain clinics completed a computer pain assessment battery that elicited demographic information, pain drawings, pain and emotion intensity ratings, and intensity ratings of verbal descriptors. Patients classified themselves into one of six chronic pain diagnoses. Discriminant analyses were performed in an attempt to identify the unique features of patients’ pain experience associated with each of the diagnostic categories. Results. Pain drawings successfully classified patients into three of the diagnostic categories (back, head, and neck pain). In a second analysis, two pain descriptors (cramping and stabbing) separated rheumatoid arthritis patients from those with either fibromyalgia or neural pain. One descriptor of pain (cramping) and one descriptor of emotion (frustration) together distinguished between fibromyalgia and neural pain. Conclusions. 1) Computer assessment of a range of patient symptoms is feasible in the pain clinic. 2) Discriminant analysis based on pain drawings can distinguish among patient-reported diagnoses of back pain, headache, and neck pain. 3) Discriminant analysis based on three verbal descriptors can help to distinguish among diagnoses of fibromyalgia, neuralgia, and rheumatoid arthritis. 4) However, in general, most computerized descriptive information is not useful in distinguishing differences among pain patient diagnostic groups.

Objective. To evaluate the concurrent validity of the short form of an interactive computerized quality of life (ICQOL-SF) measure for patients with chronic pain. Methods. The ICQOL-SF, consisting of one global and four separate domains of quality of life, was administered to 300 chronic pain patients in two pain centers. Participants also completed the full 21-item interactive computerized quality of life (ICQOL) program, a computerized version of the World Health Organization Quality of Life Scale (WHOQOL-BREF), and a computerized assessment of pain (CAP) program. In a second study, an independent group of 336 chronic pain patients completed the ICQOL-SF, the WHOQOL-BREF, and the CAP. Results. The ICQOL-SF in both studies demonstrated adequate concurrent validity with the WHOQOL-BREF ( r = 0.75) and the CAP ( r = 0.84). The five-item ICQOL-SF was also highly correlated with the full ICQOL ( r = 0.90). Surprisingly, older individuals with more formal education and longer pain duration reported better quality of life. Number of past surgeries was negatively correlated with quality of life. Conclusions. The five-item short-form interactive computerized method to assess quality of life demonstrates adequate concurrent validity and would be a useful, brief software measure in the assessment of persons with chronic pain. Additional studies are needed to determine the reliability and sensitivity to change of the ICQOL-SF.

Objective. This monograph is intended to clarify the clinical problem of chronic pain in cancer patients. Design. A pertinent literature review on chronic pain syndromes in cancer patients was undertaken using Medline. Further, the treatment strategies for cancer versus chronic pain are contrasted and clarified. Results. With increasing cancer survivorship come new challenges in patient care. In the United States, the cancer-related death rate has dropped by 1.1% per year from 1993–2002. Seventy-five percent of children and two out of three adults will survive cancer, whereas 50 years ago just one out of four survived. The net effect of these trends and opportunities is a large and rapidly growing population of persons living longer with cancer and/or as cancer survivors. While agreement exists on the best strategies for assessment and treatment of most acute cancer pain syndromes, little consensus exists on the treatment of chronic pain in the patient with slowly progressive cancer or the cancer survivor. Conclusions. The landscape of “cancer pain” is shifting quickly into a chronic pain situation in many instances, thereby blurring previous lines of distinction in treatment strategies most suited for “chronic” versus “malignant” pain. Adopting chronic pain treatment strategies including pharmacologic and other pain control techniques, rehabilitation care, and psychological coping strategies may lead to optimal outcomes. Lastly, as cancer evolves into a chronic illness, with co-morbid conditions, recurrent cancer, and treatment toxicities from repeated antineoplastic therapies, pain management challenges in the oncologic patient continue to increase in complexity.

The aim of this study was to determine the accuracy of pain specialists, nonprofessionals, and a decision model in judging whether a pain diagram was marked by a patient with chronic pain or by a healthy volunteer. Two hundred twenty-eight pain drawings were shown in random order to 10 pain medicine physicians, 10 pain medicine fellows, 10 nonphysician specialists, and 10 nonprofessionals. One half of the drawings (n = 114) had been produced by patients treated at a pain center and the other half (n = 114) by healthy individuals who were instructed to mark the diagrams as if they had a pain problem. The nonprofessionals were found to be 51.5% accurate, pain medicine fellows 52.7%, nonphysician specialists 54.3%, and pain medicine physicians 55.2 % accurate at distinguishing drawings by actual pain patients from drawings from volunteers without pain. A decision model was able to achieve 68.9% accuracy in determining which drawings were made by pain patients and which drawings were made by healthy individuals. The results suggest that subjective assessment of pain drawings alone is not useful in determining whether someone has real or imagined pain. A decision model that makes decisions on the basis of the number of highlighted squares on the pain diagram can identify real pain drawings with greater accuracy than humans. Perspective Pain drawings are clinically useful but have limitations. This study illustrates some of the benefits of computerized pain assessment and highlights the importance of not judging patients on the basis of one source of information.

No study has examined the role of urine toxicology in addition to behavioral monitoring in patients receiving opioid therapy for chronic pain. All patients maintained on chronic opioid therapy by the two senior authors at two university pain management centers were monitored for 3 yr with urine toxicology testing and for behaviors suggestive of inappropriate medication use. We retrospectively extracted demographic information, aberrant drug-taking behaviors, and urine toxicology information from the medical record. For 122 patients maintained on chronic opioid therapy, 43% (n = 53) had a "problem" (either positive urine toxicology or one or more aberrant drug-taking behaviors). Of patients with no behavioral issues, 21% (n = 26) had a positive urine screen for either an illicit drug or a nonprescribed controlled medication. Of patients with a negative urine screen, 14% (n = 17) had one or more behavioral issues. Monitoring both urine toxicology and behavioral issues captured more patients with inappropriate drug-taking behavior than either alone. Requiring a report of behavioral issues and urine toxicology screens for patients receiving chronic opioids creates a more comprehensive monitoring system than either alone.Monitoring both urine toxicology and aberrant behavior in chronic-pain patients treated with opioids identified more problem patients than by monitoring either alone. The authors recommend routine urine testing on all patients prescribed opioids for noncancer pain and as a required element in all opioid analgesic studies.

Objective. The purpose of this study was to describe the reliability and validity of an interac- tive computer method that assesses the quality of life of patients in chronic pain and healthy individuals. Methods. A software program to assess 21 aspects of quality of life was administered to 88 pain patients on two occasions separated by an average of 30 days. Comparison data were obtained from 105 healthy individuals retested after an average of 16 days. Results. For both groups, moderate test-retest correlations occurred for mean ratings based on an aggregation of data for all variables, single global ratings, and single ratings of individual variables. Patients in chronic pain scored significantly lower on all quality of life variables than did healthy individuals. High correlations were obtained between mean ratings from the present study and those from an earlier investigation using the same method. Conclusions. The interactive computer method is both reliable and valid as a means to assess quality of life for patients in chronic pain as well as for healthy individuals.

Recognition is growing that self-report of drug use, prescribed or otherwise, among patients with chronic pain treated with opioids is often unreliable. This fact is well known to the addiction management community. Patients may inaccurately report use of prescribed medications, fail to report use of nonprescribed medications or medications prescribed by other physicians, or fail to report use of illicit drugs. Although there are yet no accepted diagnostic criteria for addiction or other forms of medication misuse in the patient with chronic pain, most clinicians would agree that awareness of a patient's inappropriate use of nonprescribed medications or illicit drugs is relevant to proper patient management. The use of external sources of information, therefore, such as testing of biologic material (e.g., urine), interviews with spouses, review of medical records, or input from prescription monitoring programs, may improve patient management. Of these methods, urine toxicology testing has by far the largest experience. Urine toxicology testing may reveal the presence of illicit drugs, such as heroin or cocaine, or controlled substances not prescribed by the physician ordering the test (e.g., hydromorphone in a patient prescribed oxycodone). The authors review the use of urine toxicology testing in monitoring patients with chronic pain, including laboratory aspects. They also present evidence from recent studies that suggests that monitoring the behavior alone of patients on chronic opioid treatment will fail to detect potential problems revealed by urine toxicology testing. The authors conclude that, although further research is urgently needed, at this time it is appropriate to conduct routine urine toxicology testing in patients with chronic pain treated with opioids.

Frequency of epidural steroid injections (ESI) and characteristics of patients receiving them are unknown or poorly described. Patients believed to respond better to ESI include young or middle-aged individuals, those with recent onset or a radicular pattern of pain, and patients without previous spinal surgery. The aim of this study is to estimate the frequency of ESI, to examine the characteristics of patients who have them recommended, and to determine if clinical practice reflects published data pertaining to indications for ESI.Descriptive data from 25,479 selected patients with spinal and radicular pain were reviewed. Patients were grouped according to whether or not ESI was recommended, scheduled, prescribed, or continued. Prevalence of ESI use and patient characteristics were compared using standard statistical tests.Overall, ESI were recommended to 2,022 (7.9%) patients. Patients with lumbar pain had ESI proposed 12.6% of the time. Those with cervical and thoracic symptoms had ESI recommended 3.7% and 1.8% of the time, respectively. Patients in whom ESI was recommended were more likely to have pain radiation (P.001), dermatomal pain distribution (P.001), and neurologic signs (P.001). They also had a greater incidence of comorbidities (P.001) and were older (P.001). There was no difference in the frequency of prior surgery (P =.169) nor was there a difference based on gender (P =.548) in patients not recommended to have ESI. Patients with symptom duration between 1 month and 1 year were more likely to have ESI recommended.ESI are commonly used to treat patients with spinal and radicular pain. There is some consistency between clinical practice and published recommendations for ESI use.

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.