Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health Objectives: Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. Methods: A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. Results: One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen’s d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen’s d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. Discussion: These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

Nonspecific Low Back Pain: Inflammatory Profiles of Patients With Acute and Chronic Pain Background: The pathogenesis of low back pain (LBP) remains unclear. However, recent studies suggest that the inflammatory response may be inherent in spinal pain. The purpose of this study was to discern inflammatory profiles in patients with nonspecific acute and chronic LBP in relation to those in asymptomatic individuals. Materials and Methods: Peripheral blood samples were obtained from asymptomatic controls and patients with nonspecific acute and chronic LBP reporting a minimum pain score of 3 on a 10-point Visual Analogue Scale (VAS). The levels of in vitro production of proinflammatory (tumor necrosis factor α [TNFα], interleukin [IL] 1β, IL-6, IL-2, interferon γ) and anti-inflammatory (IL-1 receptor antagonist, soluble receptors of TNF2, and IL-10) mediators were determined by specific immunoassays. Results: The mean VAS scores were comparable between the acute and chronic LBP patient groups. Compared with asymptomatic group, the production of TNFα, IL-1β, IL-6 and their ratios to IL-10 levels were significantly elevated in both patient groups (P=0.0001 to 0.003). In acute LBP group, the ratio of IL-2:IL-10 was also significantly increased (P=0.02). In contrast, the production of interferon γ was significantly reduced compared with the other study groups (P=0.005 to 0.01), nevertheless, it was positively correlated (P=0.006) with pain scores. In chronic LBP patients, the production of TNFα, IL-1 receptor antagonist, and soluble receptors of TNF2 was significantly increased (P=0.001 to 0.03) in comparison with the control and acute LBP groups, and TNFα and IL-1β levels were positively correlated (P<0.001) with VAS scores. Conclusions: The inflammatory profiles of patients with acute and chronic LBP are distinct. Nonetheless, in both patient groups, an imbalance between proinflammatory and anti-inflammatory mediator levels favors the production of proinflammatory components.

Mandatory Pain Assessment in a Pediatric Emergency Department: Failure or Success?: A Retrospective Study Objective: Pain control is a priority in patient evaluation. Despite the proliferation of guidelines, pain is still underassessed and undertreated, especially in children. To improve efficiency and to adhere to best medical practice, our triage software was upgraded; it included mandatory pain scoring for the admission of a child to the pediatric emergency service, thereby limiting the chances of overlooking a child experiencing pain. We conducted this study to verify the effect of routine versus mandatory pain scoring on pain management under the hypothesis that mandatory pain assessment would improve reevaluation and pain treatment. Methods: This retrospective case-control study was conducted in our Pediatric Emergency Department (ED). We collected data with regard to pain assessment and reassessment at triage and during the entire stay in the ED, and also with regard to the drugs eventually administered. We reviewed the charts of 1274 patients admitted with the older triage software and those of 1262 patients admitted with the newer triage software (intervention group). Results: Pain was evaluated significantly more frequently in the intervention group at triage, during the medical evaluation, and at discharge. In the intervention group, a smaller percentage of patients were treated for pain at both triage and during their stay in the ED (P=0.078 and 0.048). Pain reassessment resulted lower in the intervention group (P<0.01). Discussion: Mandatory pain assessment improved the pain evaluation rate. This did not, however, translate into better treatment and management of pain in the pediatric emergency setting.

Validity of the Budapest Criteria For Poststroke Complex Regional Pain Syndrome Objectives: Complex regional pain syndrome-1 is a chronic neuropathic disorder, and poststroke complex regional pain syndrome (PS-CRPS) is not a rare complication. There is a lack of study implementing the Budapest criteria for PS-CRPS diagnosis. Thus, the present study investigated the validity of the Budapest criteria for PS-CRPS diagnosis and assessed the PS-CRPS–related factors in stroke patients with an affected upper extremity. Methods: The study included 72 patients with first-ever stroke resulting in hemiplegia. The prevalence of PS-CRPS and diagnostic validity were compared among the Budapest clinical criteria, Budapest research criteria, modified Budapest criteria (removal of the motor factor from the motor/trophic category), and International Association for the Study of Pain (IASP) criteria in patients diagnosed with PS-CRPS according to the Budapest clinical criteria. Results: PS-CRPS was diagnosed in 6 (8.3%), 1 (1.4%), 6 (8.3%), and 11 patients (15.3%) according to the Budapest clinical criteria, Budapest research criteria, modified Budapest criteria, and IASP criteria, respectively. The Budapest criteria and IASP criteria had sensitivities of 0.99 and 1.00, respectively, and specificities of 0.68 and 0.41, respectively, for PS-CRPS diagnosis. There were no differences in risk factors between PS-CRPS patients and non–PS-CRPS patients when the diagnosis was based on the Budapest clinical criteria. However, there were differences in muscle strength and Brunnstrom stage between PS-CRPS patients and non–PS-CRPS patients when the diagnosis was based on the IASP criteria. Discussion: Our findings indicate that the diagnostic validity of the current Budapest clinical criteria for PS-CRPS is low. Thus, the current Budapest criteria might not be appropriate for PS-CRPS diagnosis.

Efficacy and Safety of Low-dose Codeine-containing Combination Analgesics for Pain: Systematic Review and Meta-Analysis Objective: To investigate the efficacy and safety of combination analgesic products containing low-dose codeine (up to 30 mg/dose) for pain. Methods: Electronic databases were used to identify eligible placebo-controlled, randomized controlled trials (RCTs). Two authors extracted data and assessed the risk of bias. Data were pooled using a random-effects model with the strength of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcome was immediate pain relief (3 hours post administration) on a 0 to 100 pain scale. Results: Ten RCTs were eligible. There is low-quality evidence (4 RCTs, n=211 participants) that a single dose of a combination analgesic product (with an nonsteroidal anti-inflammatory) containing low-dose codeine (15 to 30 mg) provides small pain relief for acute dental pain (mean difference [MD], −12.7; 95% confidence interval [CI], −18.5 to −6.9) and moderate-quality evidence (1 RCT, n=93) of small pain relief for post-episiotomy pain and orthopedic surgery pain (MD,, −10.0; 95% CI, −19.0 to −1.0 and MD, −11.0; 95% CI, −20.7 to −1.3), respectively. There is low-quality evidence (1 RCT, n=80) that a multiple-dose regimen provides small pain relief for acute pain following photorefractive keratectomy (MD, −16.0; 95% CI, −24.5 to −7.5) and moderate-quality evidence of moderate pain relief for certain chronic pain conditions: for hip osteoarthritis (MD, −19.0; 95% CI, −31.2 to −6.8) and for temporomandibular joint pain (MD, −26.0; 95% CI, −44.5 to −7.5). Two studies reported a higher incidence of drowsiness in the treatment group compared with the placebo group (relative risk, 8.50; 95% CI, 1.96, 36.8 and 19.3; 95% CI, 1.2-306.5, respectively). Discussion: There is low to moderate level evidence that combination analgesic products containing low-dose codeine provide small to moderate pain relief for acute and chronic pain conditions in the immediate short term with limited trial data on use beyond 24 hours. Further research examining regular use of these medicines is needed with more emphasis on measuring potential harmful effects.

Effect of Adding Dexmedetomidine to Local Anesthetic Agents for Transversus Abdominis Plane Block: A Meta-analysis Background: Dexmedetomidine (Dex) has been used as an adjuvant in transversus abdominis plane (TAP) blocks. This meta-analysis was aimed at evaluating the effect of Dex in TAP blocks. Objectives: Outcome measures were total opiate consumption in 24 hours after surgery, time to systemic rescue analgesia, pain scores after surgery, and adverse events (AEs). Materials and Methods: Randomized controlled trials comparing Dex with local anesthetics to local anesthetics alone for analgesia after abdominal surgeries were included. Standardized mean difference (SMD) and mean difference (MD) were used for continuous variables and odds ratio for frequency data. Results: Analysis of data from 9 randomized controlled trials (598 patients) showed that the addition of Dex to LAs decreased opiate use in 24 hours after surgery (SMD, −3.07; 95% confidence interval [CI], −4.78 to −1.35), increased time to rescue analgesia (171.8 min; 95% CI, 112.34-231.26), and decreased pain scores (scale of 0 to 10) at 4 hours (MD, −0.36; 95% CI, −0.65 to −0.07) and 8 hours (MD, −0.17; 95% CI, −0.29 to −0.04) after surgery. Frequency of adverse events was similar between the 2 groups (odds ratio, 1; 95% CI, 0.61-1.63). The estimates for pain scores were prone to sensitivity analysis. The estimates for postoperative opiate use, time to rescue analgesia, and pain scores at 8 hours had significant heterogeneity. Conclusions: The addition of Dex to LAs in the TAP block for analgesia after abdominal surgeries decreased 24-hour opiate use and increased the overall time to rescue analgesia including certain subgroups without increasing adverse events. Its effect on postoperative pain scores was not as definitive.

Dexmedetomidine as an Adjuvant to Local Anesthetics in Transversus Abdominis Plane Block: A Systematic Review and Meta-analysis No abstract available