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Objective: The objective of this preliminary investigation was to evaluate the test-retest reliability of a new pain assessment method referred to as 3-D pain mapping., Methods: In Study 1, 101 chronic noncancer pain patients from four sites reported their pain using the method on two occasions (separated by approximately 10 days). The patients marked intensity, surface location, and depth of pain on a 3-D computer display of a male or female body. The model body could be rotated in order to mark multiple pain locations. In Study 2, 25 patients from a single site were tested with a revised version of the mapping program used in Study 1. Each patient gave ratings on two occasions separated by approximately 1 week., Results: In Study 1, the intra-class correlations of the 3-D pain mapping measures were moderate to high for maximum pain intensity (0.73), vertical location of the point of maximum pain (0.94), and the number of pain marks (0.84). Correlations were low for the horizontal location of the point of maximum pain (0.56) and for the depth of pain (0.50). In Study 2, using the revised program, intra-class correlations were moderate for pain intensity (0.76), and high for the vertical (0.99) and horizontal (0.98) locations of the point of maximum pain, number of pain marks (0.89), and the depth of pain (0.84)., Conclusion: Three-dimensional pain mapping enables patients to report the location and intensity of their pain on all parts of the body, and such ratings are highly reliable. Future studies are needed to determine whether the clinical value of this method can improve the accuracy of pain diagnoses and the quality of pain management., (Wiley Periodicals, Inc.)

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 sample of chronic noncancer pain patients., Methods: Two hundred and twenty-six participants prescribed opioids for pain were recruited from 5 pain management centers in the United States. Participants 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=0.79) and not significantly different from the AUC obtained in the original validation study (AUC=0.81). Reliability (coefficient α) was 0.83, which is comparable to the 0.86 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 seems to be a reliable and valid screening tool to help detect current aberrant drug-related behavior among chronic pain patients.

Unlabelled: 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.

Unlabelled: 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 policies., 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.

Unlabelled: 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.

Unlabelled: 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.

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.

Pain is a complex phenomenon lacking a well-defined paradigm for diagnosis and management across medical disciplines. This is due in part to inconsistencies in the assessment of pain as well as in the measurement of related social and psychological states. Efforts to evaluate and measure pain through objective tests have been hindered by challenges such as methodological differences in data acquisition, and the lack of common, universally accepted information systems. Physicians and hospital administrators have expressed mixed reactions to the costs that inevitably accompany advances in medical technology. Nonetheless, computer systems are currently being developed for use in the quantitative assessment and management of pain, which can advance our understanding of the public health impact of pain, improve the care individual patients receive, and educate providers. The description of an interdisciplinary, integrated, health survey system illustrates the approach and highlights the advantages of using information technology in pain evaluation and management.

Objective: The primary objective of this study was to determine initial psychometric properties and feasibility of a new Computer Face Scale for measuring pediatric pain. Drawbacks to current measurement tools include a lack of continuous variables, suboptimal mode of implementation, and difficulty interpreting results. A computer method of pediatric pain measurement is presented that addresses these problems. Basic psychometric properties, feasibility, and children's preference when compared with Wong-Baker Faces Scale were determined., Methods: Fifty-four hospitalized, pediatric inpatients were tested using both the Computer Face Scale and the Wong-Baker Faces Scale. An additional 30 children (not hospitalized) were tested using only the Computer Face Scale., Results: Both hospitalized and nonhospitalized children between the ages of 3 and 17 years of age are able to use the Computer Face Scale to express relative amounts of pain/hurt and happiness. The Computer Face Scale shows acceptable psychometric properties and is preferred by most children., Conclusions: The Computer Face Scale offers advantages over traditional pediatric pain measurement tools. The opportunity for real time review, electronic and time-stamped recording, electronic display, and temporal comparisons of reports affords the potential for improvement in pediatric pain assessment and treatment.

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.

Unlabelled: 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.

Objective: Computerized software holds the potential for the novel assessment of the pain experience 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 drawings) 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 assessments of degree of pain intensity and pain location with the use of a novel computerized pain assessment program. Although further investigations are needed, these initial findings support the use of computer methods for the effective assessment of pain.

Objective: The purpose of this study was to describe the reliability and validity of an interactive 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.

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 comparison.

Objective. To investigate whether grouping of patients with back pain into similar behavioral patient profiles using SF-36 scores is predictive of outcome following 1-year treatment in a multidisciplinary spine center beginning with referral for epidural steroid injection. Design. A prospective observational study was conducted on 81 consecutive patients selected for epidural steroid injections by independent physicians following common institutional criteria. Each patient completed a baseline SF-36 questionnaire as well as a numerical response pain scale. The initial SF-36 data were used to place each patient into one of three subgroups (Highly Functional, Emotional Adapters, and Dysfunctional). Follow-up SF-36 and numerical response pain scale questionnaires were completed by the patients at 1 month and 12 months following the initial epidural steroid injection. Results. Results revealed significant improvement among all three patient subgroups following multidisciplinary treatment at both 1 month and 12 months. Few differences in outcome occurred among the subgroups. Conclusion. The SF-36-determined subgroups did not predict response to a multidisciplinary pain clinic. All three subgroups showed similar improvement following treatment. [ABSTRACT FROM AUTHOR]

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]