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Although possession and use of marijuana is prohibited by federal law, legalization in four states (Alaska, Colorado, Oregon, and Washington) and allowance for palliation and therapy in 19 others may reposition the drug away from the fringes of society. This evolving legal environment, and growing scientific evidence of its effectiveness for select health conditions, requires assessment of the safety and appropriateness of marijuana within the American workforce. Although studies have suggested that marijuana may be used with reasonable safety in some controlled environments, there are potential consequences to its use that necessitate employer scrutiny and concern. Several drug characteristics must be considered, including Δ-tetrahydrocannabinol (Δ-THC, or THC) concentration, route of administration, dose and frequency, and pharmacokinetics, as well as the risks inherent to particular workplace environments.

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.

Objective. To evaluate current opioid prescribing patterns nationally and regionally across several northern New England states and compare with prescription data on an institutional level over a two-year period, between 2013 and 2014. Design, Setting, and Subjects. The IMS Health National Prescription Audit (NPA) database was used to obtain prescription data from US retail pharmacies between 2013 and 2014. Methods. Our study compared noninjectable opioid dispensing between two time periods: January–June 2013 and July–December 2014. Opioid prescription data were obtained nationally and in New Hampshire, Vermont, Maine, and Massachusetts. Institutional prescription data were supplied by Dartmouth Hitchcock Medical Center (DHMC) and University of Vermont Medical Center (UVMC) pharmacies. Results. There was a 3.4% ( P = 0.81) decrease in opioid prescriptions filled nationally. Among New England states, opioid prescribing decreased in Maine (−5.20%, P = 0.72), Massachusetts (−4.4%, P = 0.78), and Vermont (−2.2%, P = 0.89) but increased in New Hampshire by 1.3% ( P = 0.94). Examination of local institutional opioid utilization revealed a 13.6% decline in prescriptions filled at UVMC, and only a 0.4% decrease at DHMC. Conclusions. The review of opioid prescriptions filled in 2013–14 suggests that national opioid utilization may be reaching a plateau. Initiatives such as prescription monitoring programs, prescriber opioid education, addiction treatment programs, public addiction awareness, and availability of medical cannabis may play a role in interstate variability of opioid use. National and regional data served as a benchmark for local institutional comparison, laying groundwork for efforts to explore areas where opioids can be prescribed more judiciously.

Summary Objective The aim was to assess the validity of the Computer Face Scale. Methods Forty children (5–13 years old) rated pain and mood prior to and twice following tonsillectomy. The children used the Computer Face Scale to adjust a cartoon face to rate pain and mood. During sessions one and two, the children also chose an expression on the Wong-Baker Faces Scale to rate their pain, and they reported their mood verbally on a seven-point scale. Results On average, the children reported no pain and a positive mood prior to surgery. Soon after surgery, they reported mild pain and a slightly negative mood. An hour later, they reported decreases in pain and return to a positive mood. The differences between presurgery and postsurgery ratings were statistically significant (P ≤ 0.001) for all measures. The correlation between the two mood measures was 0.88 before surgery and 0.78 afterward. The correlation between the two measures of pain was 0.83 after surgery (P's < 0.001). Conclusions The results support the validity of the Computer Face Scale. The mean ratings of pain and mood followed the expected pattern from pre- to postsurgery, and there was a significant association between ratings obtained by different methods. The Computer Face Scale provides a simple-to-use scale with more resolution and electronic capture, which may provide advantages in numerous clinical and research applications.

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.

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

Cannabinoids show promise as therapeutic agents, particularly as analgesics, but their development and clinical use has been complicated by recognition of their botanical source, cannabis, as a substance of misuse. Although research into endogenous cannabinoid systems and potential cannabinoid pharmaceuticals is slowly increasing, there has been intense societal interest in making herbal (plant) cannabis available for medicinal use; 23 U.S. States and all Canadian provinces currently permit use in some clinical contexts. Whether or not individual professionals support the clinical use of herbal cannabis, all clinicians will encounter patients who elect to use it and therefore need to be prepared to advise them on cannabis-related clinical issues despite limited evidence to guide care. Expanded research on cannabis is needed to better determine the individual and public health effects of increasing use of herbal cannabis and to advance understanding of the pharmaceutical potential of cannabinoids as medications. This article reviews clinical, research, and policy issues related to herbal cannabis to support clinicians in thoughtfully advising and caring for patients who use cannabis, and it examines obstacles and opportunities to expand research on the health effects of herbal cannabis and cannabinoids. Perspective Herbal cannabis is increasingly available for clinical use in the United States despite continuing controversies over its efficacy and safety. This article explores important considerations in the use of plant Cannabis to better prepare clinicians to care for patients who use it, and identifies needed directions for research.

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.

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.

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.

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).

The objective of this report is to describe a surgical technique used successfully when a flat or paddle type spinal cord stimulator electrode cannot be properly positioned via a single laminotomy. Different and innovative surgical techniques useful in placement of spinal cord stimulators and analgesic infusion pump systems have not been well described. The prevalence of anatomic surgical abnormalities or variations that might present barriers to implantation of these devices is unknown but may be as high as 18% for revisions. A dual laminotomy technique can be useful and successful in positioning a flat spinal cord stimulator electrode that cannot be properly positioned via a single laminotomy approach. We report two patients who have been treated successfully with a dual laminotomy technique.