Failed Back Surgery Syndrome 88. 8.3.7. Arthritis 89. 8.3.8. Fibromyalgia and Widespread Pain 90. 8.3.9. Neuropathic Pain 90. 8.3.10. Diabetic Neuropathy 91.
VII
Contents Foreword V Preface XVII List of Contributors XXV Part One 1 1.1 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.3 1.4 1.5 1.6 1.7 2 2.1 2.2 2.2.1 2.3 3 3.1 3.1.1 3.1.1.1
Context
1
The Lived Experience of Chronic Pain: Evidence of People’s Voices 3 Cary Brown Introduction 3 The Perspective of People with Pain 5 Unfiltered Voices 5 Literary Routes to the Lived Experience of Pain 7 Lived Experience of Pain in Scholarly Publications 7 The Visual Arts 8 Pain Voices in Electronic Media 10 Quality 11 Barriers to Accessing the Evidence 12 Consequences of Unvoiced Pain 13 Dealing with the Evidence 14 Summary 15 History and Definition of Pain Harold Merskey Words for Pain 20 “Pain” in Medicine 22 1800–2000 23 Defining Pain 24
19
The Descriptive Epidemiology of Chronic Pain 29 Donald Schopflocher and Christa Harstall How Prevalent is Chronic Pain? 29 Systematic Reviews 29 Studies That Used the IASP Definition of Chronic Pain
Chronic Pain: A Health Policy Perspective Edited by S. Rashiq, D. Schopflocher, P. Taenzer, and E. Jonsson Copyright © 2008 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim ISBN: 978-3-527-32382-1
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Contents
3.1.1.2 3.1.1.3 3.1.2 3.1.3 3.2 3.2.1 4 4.1 4.2 4.3 4.4 4.5 4.5.1 4.5.2 4.5.3 4.6 5 5.1 5.2 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.3 5.4 6 6.1 6.2 6.3 6.4 6.5
Studies That Used the ACR Definition of Chronic Widespread Pain 32 Studies in Children and Elderly Populations 33 Recent Studies 33 Conclusions 33 Chronic Pain in Canada and Alberta 34 Conclusions 39 The Economics of Chronic Pain 41 Ceri J. Phillips and Donald Schopflocher Introduction 41 Direct Costs of Chronic Pain 42 Indirect Costs of Chronic Pain 43 The Wider Impact of Chronic Pain 45 Pain Management Strategies 45 Effectiveness 46 Efficiency 46 Equity 47 Summary and Conclusion 47 Ethical Considerations in the Treatment of Chronic Pain 51 Dick Sobsey and Derek Truscott Scope and Context 51 Overview of the Literature on Chronic Pain and Ethics 53 Beneficence 53 Nonmaleficence 53 Autonomy 54 Justice and Social Responsibility 55 Integrity 55 Interacting Principles 56 Pain, Public Policy, and Ethics 56 Pathophysiology of Chronic Pain 59 James L. Henry Nociception: How It Works 60 Chemical Mediators of Pain 62 Contribution of Non-Neuronal Cells to Nociception 63 Basic Science Contributions to Pain Management 63 Impact of Policy on Knowledge Generation 65
Contents
Part Two 7 7.1 7.2 7.2.1 7.2.2 7.2.3 7.2.4 7.3 7.4 7.5 7.6 8 8.1 8.2 8.3 8.3.1 8.3.2 8.3.3 8.3.4 8.3.5 8.3.6 8.3.7 8.3.8 8.3.9 8.3.10 8.3.11 8.3.12 8.3.13 8.3.14 8.4 8.4.1 8.4.2 8.4.3 8.4.4 8.4.5 8.4.6 8.5 8.6 8.6.1
Treatment 67 Why Does Pain Become Chronic? 69 Joel Katz, Colin J. L. McCartney, and Saifudin Rashiq Introduction 69 Chronic Post-surgical Pain 70 Epidemiology of CPSP 70 Surgical Factors Associated with CPSP 70 Patient-Related Factors 72 Preemptive/Preventive Analgesia 73 Chronic Pain outside the Surgical Context 75 Summary 77 Conclusions 78 Health Policy Implications and Recommendations 78 What Chronic Pain Looks Like to the Clinician 85 Chris Spanswick Introduction 85 The Typical Patient 85 Common Pain Conditions 86 Spinal Pain 86 Neck Pain 86 Whiplash 87 Low Back Pain 87 Sciatica 88 Failed Back Surgery Syndrome 88 Arthritis 89 Fibromyalgia and Widespread Pain 90 Neuropathic Pain 90 Diabetic Neuropathy 91 Trigeminal Neuralgia (Tic Douloureux) 91 Post Herpetic Neuralgia 92 Complex Regional Pain Syndrome 93 Co-morbidities 94 How Do Patients Present? 94 Worry/Anxiety 94 Sadness/Depression 95 Anger/Frustration 95 Fatigue/Exhaustion/Sleep Disorders 95 Physical/Social Functioning 96 Coping 96 Why Do Patients Consult? 97 Why Do Family Physicians Refer Patients to Specialists? 97 Diagnosis 97
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Contents
8.6.2 8.6.3 8.6.4 8.6.5 8.6.6
Treatment 97 High Levels of Distress 98 Problem Medication Use 98 Help with Patient Management 98 Other Obstacles to Managing Pain in the Community 98
9
Drug Treatment for Chronic Pain 101 Mary Lynch Scope and Context of the Issue 101 The Evidence for Prescription Drug Use in the Management of Chronic Pain 102 Specific Drugs 103 NSAIDs and Acetaminophen 103 Tricyclic Antidepressants 103 Other Antidepressants 104 Anticonvulsants 105 Gabapentin 105 Pregabalin 107 Carbamazepine 107 Oxcarbazepine 107 Lamotrigine 108 Opioids 108 Cannabinoids 109 Muscle Relaxants 111 Topical Analgesics 112 Topical NSAIDs 112 Capsaicin 112 Topical Tricyclic Antidepressants and Ketamine 112 Topical Lidocaine Patch 113 Other Analgesic Agents 113 Conclusions 113 Implications for Policy Makers, Patients, Families and Communities 114
9.1 9.2 9.3 9.3.1 9.3.2 9.3.3 9.3.4 9.3.4.1 9.3.4.2 9.3.4.3 9.3.4.4 9.3.4.5 9.3.5 9.3.6 9.3.7 9.3.8 9.3.8.1 9.3.8.2 9.3.8.3 9.3.8.4 9.3.9 9.4 9.5
10 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9
Non-Drug Treatments for Chronic Pain 121 Alexander J. Clark Introduction 121 Acupuncture 122 Cognitive Behavioral Therapy (with Bruce Dick) 122 Exercise 123 Laser Therapy 123 Manipulation and Mobilization 124 Massage Therapy 124 Occupational and Physical Therapy 125 Relaxation Therapy 125
Contents
10.9.1 10.9.2 10.10 10.11
Thermotherapy (Application of Heat and/or Cold) 125 Transcutaneous Electrical Nerve Stimulation 126 Ultrasound 126 Conclusion 127
11
Interventional Treatments for Chronic Pain 131 Alexander J. Clark and Christopher C. Spanswick Cervical and Lumbar Epidural Injections 132 Trigger Point Injections 133 Intravenous Lidocaine Infusion 133 Intravenous Regional Sympathetic Blockade 134 Paravertebral/Paraspinal Blocks 134 Cervical/Lumbar Facet Joint Injection and Radiofrequency Denervation 134 Sympathetic Blockade 135 Stellate Ganglion Block 135 Lumbar Sympathetic Block 135 Coeliac and Splanchnic Nerve Blocks 136 Spinal Cord Stimulation 136 Intrathecal Medication Pumps 137 Conclusion 137
11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.7.1 11.7.2 11.7.3 11.8 11.9 11.10 12 12.1 12.2 12.2.1 12.2.2 12.2.3 12.2.4 12.3 12.3.1 12.3.2 12.4 12.5 12.6 12.7 12.7.1 12.7.2 12.7.3 12.8 12.9
Multidisciplinary Pain Clinic Treatment 141 Eldon Tunks What Constitutes “Multidisciplinary” Care for Chronic Pain? 142 Chronic Low Back Pain 142 Behavior Therapy 142 Exercise and Other Physical Modalities 143 Patient Education and Back Schools 143 Multidisciplinary Treatment (but Without Workplace Intervention) 143 Neck Pain 144 Patient Education 144 Active versus Passive Treatment 144 Headache 144 Temporomandibular Joint Pain and Dysfunction 145 Fibromyalgia/Chronic Fatigue Syndrome 146 Unspecified or Mixed Pain Disorders 146 Various Behavioral and Cognitive-Behavioral Treatments 146 Patient Education and Back Schools 147 Multidisciplinary Treatment 147 Cost-Effectiveness of Multidisciplinary Pain Management Programs 148 Recommendations 149
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13
13.1 13.2 13.3 13.3.1 13.3.2 13.4 13.4.1 13.4.1.1 13.4.1.2 13.4.1.3 13.4.1.4 13.4.1.5 13.4.1.6 13.5 13.5.1 13.5.2 13.5.3 13.6 13.7 13.7.1 13.7.2 13.7.3 13.7.4 13.8 14 14.1 14.2 14.3 14.4 14.5 14.6
Complementary and Alternative Medicine Approaches to Chronic Pain 153 Mark A. Ware Introduction 153 Why Do Pain Physicians Need to Know about CAM? 154 Epidemiology of CAM in Chronic Pain 155 Classification of CAM 155 First Nations Healing Traditions and Pain 156 Clinical Evidence of Safety and Efficacy 157 Other Trials of CAM for Chronic Pain 159 Acupuncture 159 Chiropractic 159 Energy Therapy 159 Meditation/Relaxation 159 Movement Therapies 159 Osteopathy 160 Safety Concerns 160 Natural Health Products 160 Manipulation Therapies 160 Acupuncture 161 Research on CAM: A Matter of Control? 161 Policy Implications 161 Cost Effectiveness 161 Regulating CAM in Canada 162 Teaching CAM in Medical Education 162 Towards an Integrative Pain Medicine? 162 Conclusions 162 Chronic Pain Self-Management 167 Michael Hugh McGillion, Sandra LeFort, and Jennifer Stinson Self-Management: Brief History and Overview 168 The Arthritis Self-Management Program 169 The Chronic Pain Self-Management Program 170 The Chronic Angina Self-Management Program 172 Canadian-Based Pain Self-Management Research in Children 174 Summary and Policy Implications 176
Part Three 15 15.1 15.2 15.3 15.4 15.5
Special Challenges in Chronic Pain Management 183
Chronic Pain in Persons with Mental Health Issues 185 Charl Els Background 185 The Prevalence of Psychopathology with Chronic Pain 186 The Systemic Barriers to Access 188 Pharmacotherapeutic Considerations 189 Proposed Systems’ Level Changes 190
Contents
16 16.1 16.2 16.2.1 16.2.2 16.2.3 16.3 16.3.1 16.3.2 16.3.3 16.3.4 16.4 16.5 16.5.1 16.5.2 16.5.3 16.6
Chronic Pain in Injured Workers 193 Douglas P. Gross, Martin Mrazik, and Iain Muir Introduction 193 Background 194 Epidemiology 194 Healthcare Seeking Behavior 194 Work Disability 195 Characteristics of Workers in Pain 195 Demographic Factors 195 Psychological Factors 195 Workplace Factors 196 Workers’ Broader Contexts 197 Role of Compensation/Insurance Systems 197 Management Strategies 198 Continuums of Care 198 Psychologically-Based Interventions 198 Disability Management Model 199 Conclusions 200
17
Chronic Pain and Addictions 205 Katherine Diskin and Nady el-Guebaly
18
Chronic Pain in Children 211 Bruce Dick Scope and Historical Context 211 Overview/Review of the Literature 212 What Public (Health) Policies Would Enable Better Care/Outcomes for Patients, Families and Communities? 213 Conclusions 214
18.1 18.2 18.3 18.4 19
Chronic Pain in Elderly Persons 217 Thomas Hadjistavropoulos and Gregory P. Marchildon
20
Chronic Pain in Indigenous Populations 225 Louise Crane
Part Four 21
21.1 21.1.1 21.1.2 21.2 21.3
Health Systems and Chronic Pain Management 231 Mass Media Campaigns for the Prevention of Back Pain-Related Disability 233 Rachelle Buchbinder, Douglas P. Gross, Erik L. Werner, and Jill A. Hayden Introduction 233 Primary Prevention 234 Why Public Health Campaigns? 235 Methods 236 Mass Media Campaigns for Back Pain 236
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Contents
21.3.1 21.3.2 21.3.3 21.3.4 21.4 21.5 22 22.1 22.2 22.3 22.4 22.5 23 23.1 23.2 23.3 23.4 23.5 23.6 24 24.1 24.2 24.3 24.4 24.5 24.5.1 24.5.2 24.5.3 24.5.4 24.5.5 24.6 24.6.1 24.6.2 24.7
The Victoria WorkCover Authority Back Campaign, Australia, 1997–1999 241 The Working Backs Scotland Campaign, Scotland, 2000–2003 242 The Norwegian Back Pain Network “Active Back” Campaign, Norway, 2002–2005 243 The Alberta “Back@It” Campaign, Canada, 2005–2008 (ongoing) 245 Considering the Design and Evaluation of Back Pain Media Campaigns 246 Conclusion 250 Improving Pain Management Education 255 Elizabeth Peter and Judy Watt-Watson Pre-Licensure Educational Initiatives: Existing Data 256 Post-Licensure Educational Initiatives: Existing Data 257 Policy Initiatives Internationally 258 Policy Strategies: Pre-Licensure Competencies 258 Policy Strategies: Post Licensure 260 The Alberta Chronic Pain Ambassador Program 265 Paul Taenzer, Donald Schopflocher, Saifudin Rashiq, and Christa Harstall Health Technology Assessment and Knowledge Translation 266 Description of the Program 266 Credible and Reliable Research Evidence 268 What Were the Outcomes? 269 Limitations 269 What Is in the Future? 270 Health System Organization 273 Patricia L. Dobkin and Lucy J. Boothroyd Health System Organization and Care Pathways 274 Two Jurisdictions That Have Prioritized Management of Chronic Pain 275 Structure Elements in the Example Jurisdictions 277 Training of Healthcare Providers 278 Process Elements in the Example Jurisdictions 278 Referral 278 Inter-Discipline and Inter-Level Communication 279 Coordination of Care 279 Discharge and Continuity of Care Plans 280 Use of Innovative Technology 280 Evaluation 280 Program Implementation 280 Process Evaluation 281 Monitoring Patient Outcomes 282
Contents
24.8 24.9 24.9.1 24.9.2 24.9.3
Is There Evidence for Chronic Pain Patient Improvements? 283 Conclusions 284 Structure 284 Process 284 Outcomes 285
25
The Quebec Experience 291 Pierre Bouchard Context 292 Elements That Helped to Germinate the Québec Strategy 293 The Advocated Development Strategy 294 Define An Optimal Vision of the Organization of Services 294 Validate this Vision with the Various Stakeholders to Ensure Its Relevance, Practicality and Accuracy 297 Inform Decision Makers of the Advocated Organizational Parameters and the Relevant Recommendations for Action 297 Prepare an Operational Plan to Progressively, Systematically and Carefully Implement. The Vision and Selected Recommendations into the Network of Services and Ensure that Monitoring Mechanisms Are Put in Place 298 Gradually Put Quality-Assurance and Continual-Improvement Mechanisms in Place for the Services Offered 299 Observations and Avenues for Future Action 299 Conclusion 301
25.1 25.2 25.3 25.3.1 25.3.2 25.3.3 25.3.4
25.3.5 25.4 25.5
Conclusion – The Way Forward 303 Paul Taenzer, Donald Schopflocher, Saifudin Rashiq, and Egon Jonsson Improving Chronic Pain Management in Alberta – Policy Considerations 305 Monitoring 306 Prevention 306 Treatment Services 306 Education 307 Research 307 Index
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