Scandinavian Journal of Pain

Scandinavian Journal of Pain: A networking and publishing tool for pain researchers and pain clinicians in the Nordic countries

Harald Breivik, Torsten Gordh, Eija Kalso, Troels S. Jensen, Eirikur Lindal — 2010-01-01

The Scandinavian Association for the Study of Pain (SASP), originally founded in Stockholm in December 1976 by a group of enthusiastic founding members of the International Association for the Study of Pain (IASP), has been immensely important and stimulating for pain researchers and pain clinicians in the five Nordic countries. The initiative came from Professor, now emeritus, Ulf Lindblom, Professor, now emeritus, Björn Meyerson, and Associate Professor Staffan Arnér, all fondly called the “Karolinska Troika” of neurology-, neurosurgery-, and anaesthesiology-pain researchers and clinicians. Amongst the others present were, Professor Zotterman Professor of Neurophysiology Sven Andersson, and about 10 other Swedish scientists and clinicians interested in pain. The youngest and only non-Swede present was Harald Breivik, at that time Professor and chairman of the Department of Anaesthesiology at the University Hospital in Trondheim, Norway.

Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications

Geir Niemi, Harald Breivik — 2010-01-01

Pain relief with paravertebral blocks (PVB) is more than 100 years old. The block is easy to learn: With the needle you touch the transverse process of the vertebral body at the level of pain location, or where an operation will take place, “walk” the needle below (or above) the transverse process, advance about 1cm deeper and inject 10–30ml of a concentrated local anaesthetic with adrenaline. With ultrasound you can see whether your injection enters the correct paravertebral space or, unintendedly, muscles of the back (Axel Sauter, personal communication), the interpleural space, or lung. Unilateral anaesthesia follows, lasting a few hours, depending on dose and whether a vasoconstrictor is added. In Norway, PVB was a routine procedure before thoracoplasty for tuberculous caverns of the apex of the lungs during the 1950s and early 1960s (Bjørn Lind, personal communications). PVB has been reintroduced several times since 1905, and is now being rediscovered again. One of us (HB) used PVB frequently until learning how to do thoracic epidural analgesia (TEA) well.

Investigation of drug–drug interactions and pain—From volunteer studies to randomized controlled trials in patients with chronic pain

Klaus T. Olkkola, Nora M. Hagelberg — 2010-01-01

There is little information on the prevalence of clinically significant adverse drug reactions in patients suffering from chronic pain. However, it has been estimated that for instance in the USA alone the number of deaths attributed to adverse drug reactions may be as high as 200000 deaths per year (). Many patients with chronic pain have also other medical problems which require drug therapy. The incidence of adverse reactions increases exponentially as the number of drugs prescribed rises and this is most likely at least in part due to drug interactions (). Thus, patients with the most complicated pain problems have also the greatest risk of clinically significant drug–drug interactions.

Those who do not know their pain-history will repeat previous errors in pain management

Harald Breivik — 2010-01-01

This title is a modified version of a famous statement of the Spanish-American George Santayana (1863–1952). He taught philosophy at Harvard from he was 26 years old and is famous for the saying: “Those who forget the past are condemned to repeat it”—known as Santayana's curse.

Fear and catastrophizing thoughts aggravate risks of chronic pain after a fracture

Eirikur Lindal, Harald Breivik — 2010-01-01

The healing time of fractures is a topic of great importance for patients as well as clinicians. It has confounded many clinicians that some patients recover rapidly while others linger in the healing progress after a fracture, suffering pain and loss of functions. Apart from the physical differences of fractures that may explain the different rates of progress of healing, differences in fitness, physical body strength, gender, age, and genes may influence recovery.

Important knowledge of pain and phantom experiences after breast surgery and leg- or arm-amputation: Value of qualitative pain research

Stephen Butler, Torsten Gordh — 2010-01-01

This paper by Berit Björkman et al., reports on the narrative information obtained by in-depth interviews from patients who have undergone amputations one month earlier, and are suffering from stump pain, phantom sensations and phantom limb pain, Their main finding is that “since no evidence-based treatment of choice for phantom pain exists, there is a need for clinical dialogues with patients, not only for giving necessary information about the phenomena, but also to listen carefully to the patients’ own descriptions and find out which functional losses or life changes patients fear the most. There should be a special focus on older patients”.

Dialectical behavioural therapy for complex chronic pain conditions

Eirikur Lindal, Harald Breivik — 2010-01-01

The use of behavioural methods in the management of chronic pain and especially with low back pain has been used since the seventies (). In the eighties, behavioural methods started to change from basic behavioural therapies (BT) into more sophisticated cognitive behavioural treatments (CBT) (). Because of this evolution in method, behavioural methods became much more common. The practice of the therapy, once limited to relatively few therapists, received a much wider acceptance by more health care professionals. Subsequently CBT techniques have been used in a variety of other conditions, notably in the management of depression, with amiable results ().

Chronic pain conditions after herniorrhaphy decrease with time, but slowly

Troels Staehelin Jensen — 2010-01-01

Persistent postoperative pain (PPP) is not a novel pain problem, but recently there has been renewed interest in this type of pain both in terms of epidemiology, pathophysiology and management. Persistent postoperative pain is now a recognized and well-documented sequelae following a series of surgical procedures such as herniorrhaphy, thoracotomy, mastectomy, amputation, etc. (). The prevalence of chronic pain following surgery varies, but in general it has been reported to be a major problem in approximately 5% and sometimes up to 10% of cases after surgery. Pain following herniorrhaphy is one of those condition that has been most investigated.

Norwegian patients with chronic pain conditions that can be managed with reasonable cost/benefit now have a legally binding right to treatment in Norway

Harald Breivik — 2010-01-01

The national health care system in Norway benefits from a higher percentage of the BNP than most other nations in Europe. In spite of long distances in thinly populated areas, poor road and railway systems, and a lot of foul weather conditions, our national health care system takes well care of those with acute and serious diseases or trauma.

A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy

Hilde M. Norum, Harald Breivik — 2010-01-01

Abstract: Background: The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.Methods: A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.Results: Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (

Does co-administration of paroxetine change oxycodone analgesia: An interaction study in chronic pain patients

2010-01-01

Abstract: Oxycodone is a strong opioid and it is increasingly used in the management of acute and chronic pain. The pharmacodynamic effects of oxycodone are mainly mediated by the μ-opioid receptor. However, its affinity for the μ-opioid receptor is significantly lower compared with that of morphine and it has been suggested that active metabolites may play a role in oxycodone analgesia. Oxycodone is mainly metabolized by hepatic cytochrome (CYP) enzymes 2D6 and 3A4. Oxycodone is metabolized to oxymorphone, a potent μ-opioid receptor agonist by CYP2D6. However, CYP3A4 is quantitatively a more important metabolic pathway. Chronic pain patients often use multiple medications. Therefore it is important to understand how blocking or inducing these metabolic pathways may affect oxycodone induced analgesia. The aim of this study was to find out whether blocking CYP2D6 would decrease oxycodone induced analgesia in chronic pain patients.The effects of the antidepressant paroxetine, a potent inhibitor of CYP2D6, on the analgesic effects and pharmacokinetics of oral oxycodone were studied in 20 chronic pain patients using a randomized, double-blind, placebo-controlled cross-over study design. Pain intensity and rescue analgesics were recorded daily, and the pharmacokinetics and pharmacodynamics of oxycodone were studied on the 7th day of concomitant paroxetine (20mg/day) or placebo administration. The patients were genotyped for CYP2D6, 3A4, 3A5 and ABCB1.Paroxetine had significant effects on the metabolism of oxycodone but it had no statistically significant effect on oxycodone analgesia or use of morphine for rescue analgesia. Paroxetine increased the dose-adjusted mean AUC0–12h of oxycodone by 19% (−23 to 113%; P=0.003), and that of noroxycodone by 100% (5–280%; P<0.0001) but decreased the AUC0–12h of oxymorphone by 67% (−100 to −22%; P<0.0001) and that of noroxymorphone by 68% (−100 to −16%; P<0.0001).Adverse effects were also recorded in a pain diary for both 7-day periods (placebo/paroxetine). The most common adverse effects were drowsiness and nausea/vomiting. One patient out of four reported dizziness and headache during paroxetine co-administration, whereas no patient reported these during placebo administration (P=0.0471) indicating that these adverse effects were due to paroxetine.No statistically significant associations of the CYP2D6 or CYP3A4/5 genotype of the patients and the pharmacokinetics of oxycodone or its metabolites, extent of paroxetine–oxycodone interaction, or analgesic effects were observed probably due to the limited number of patients studied.The results of this study strongly suggest that CYP2D6 inhibition does not significantly change oxycodone analgesia in chronic pain patients and that the analgesic activity of oxycodone is mainly due to the parent compound and that metabolites, e.g. oxymorphone, play an insignificant role. The clinical implication of these results is that induction of the metabolism of oxycodone may lead to inadequate analgesia while increased drug effects can be expected after addition of potent CYP3A4/5 inhibitors particularly if combined with CYP2D6 inhibitors or when administered to poor metabolizers of CYP2D6.

A personal experience learning from two pain pioneers, J.J. Bonica and W. Fordyce: Lessons surviving four decades of pain practice

Stephen Butler — 2010-01-01

Abstract: This article was requested by the Editor, Professor Harald Brevik after listening to a lecture I gave in a similar vein. Harald wanted the information in print and I have done this in a partly autobiographical form to explain how I came to work and learn from both the late John J. Bonica and the late Wilbert Fordyce.Both of these men have been important in different ways to our present pain world. John J. Bonica made many contributions not only in pain but in regional anesthesia and obstetrical anesthesia but not on the same level. His conviction and drive in the pain field actually revolutionized pain research and practice. Dr. Bonica early on knew he needed help with difficult cases and began a multidisciplianary clinic that served as a model for all. He wrote and published the first really comprehensive text on pain (The Management of Pain) that has appeared in two subsequent revisions and a third revision is in progress. He succeeded in founding the International Association for the Study of Pain to bring clinicians and researchers together so that we could learn from each other. Again, Dr. Bonica felt that the multidisciplinary approach to research was the key to unlocking the secrets of pain. Dr. Bonica also succeeded in persuading the American Congress and the WHO that pain was a significant problem not only for all Americans but for all humanity. His drive was an inspiration to all who came in contact with him and he touched my life in several ways as a teacher, a colleague and a patient.Bill Fordyce was not a larger than life individual like John J. Bonica but he also had a profound effect on the pain world and on me. Bill was one of the first real champions of the application of behavioural principles to the treatment of chronic pain. His visionary and inventive use of operant behavioural therapy in a multidisciplinary pain setting set the mark for all comprehensive pain clinics and the principles he used are still in effect world wide and are making converts of more and more practitioners frustrated by the lack of advances using the biomedical model. Bill created a whole new area of treatment that has made pain rehabilitation a thriving business and has made practical use of the biopsychosocial model of Engel as an explanation for much of the disability and suffering in chronic pain.For me, John J. Bonica was an inspiration for hard work and constant learning. Bill Fordyce taught me new tools to use to understand many complicated pain patients but also many practical aphorisms to guide evaluation and treatment. I have been extremely lucky in being able to have had a long relationship with both of these pain giants who were always open to discussion and debate over the difficult problems. Their teaching both by example, discussion and in their writing had and still has a strong effect on my life as a physician, a pain practitioner and a teacher. I would like to pass on some of that information to all interested in research, teaching and pain management. As they say in Sweden, “Var så god!”.

Pain-related fear, catastrophizing and pain in the recovery from a fracture

Steven J. Linton, Nina Buer, Lars Samuelsson, Karin Harms-Ringdahl — 2010-01-01

Abstract: Background and aims: Pain-related fear and catastrophizing are prominently related to acute and persistent back pain, but little is known about their role in pain and function after a fracture. Since fractures have a clear etiology and time point they are of special interest for studying the process of recovery. Moreover, fracture injuries are interesting in their own right since patients frequently do not recover fully from them and relatively little is known about the psychological aspects. We speculated that catastrophizing and fear-avoidance beliefs might be associated with more pain and poorer recovery after an acute, painful fracture injury.Methods: To this end we conducted a prospective cohort study recruiting 70 patients with fractures of the wrist or the ankle. Participants completed standardized assessments of fear, pain, catastrophizing, degree of self-rated recovery, mobility and strength within 24h of injury, and at 3- and 9-month follow-ups. Participants were also categorized as having high or low levels of fear-avoidance beliefs by comparing their scores on the first two assessments with the median from the general population. To consolidate the data the categorizations from the two assessments were combined and patients could therefore have consistently high, consistently low, increasing, or decreasing levels.Results: Results indicated that levels of fear-avoidance beliefs and catastrophizing were fairly low on average. At the first assessment 69% of the patients expected a full recovery within 6 months, but in fact only 29% were fully recovered at the 9-month follow-up. Similarly, comparisons between the affected and non-affected limb showed that 71% of those with a wrist fracture and 58% with an ankle fracture were not fully recovered on grip strength and heel-rise measures. Those classified as having consistently high or increasing levels of fear-avoidance beliefs had a substantially increased risk of more intense future pain (adjusted OR=3.21). Moreover, those classified as having consistently high or increasing levels of catastrophizing had an increased risk for a less than full recovery of strength by almost six-fold (adjusted OR=5.87).Conclusions and implications: This is the first investigation to our knowledge where the results clearly suggest that fear and catastrophizing, especially when the level increases, may be important determinants of recovery after an acute, painful, fracture injury. These results support the fear-avoidance model and suggest that psychological factors need to be considered in the recovery process after a fracture.

Adult limb and breast amputees’ experience and descriptions of phantom phenomena—A qualitative study

Berit Björkman, Staffan Arnér, Iréne Lund, Lars-Christer Hydén — 2010-01-01

Abstract: Background: Phantom phenomena – pain or other sensations appearing to come from amputated body parts – are frequent consequences of amputation and can cause considerable suffering. Also, stump pain, located in the residual limb, is in the literature often related to the phantom phenomena. The condition is not specific to amputated limbs and has, to a lesser extent, been reported to be present after radical surgery in other body parts such as breast, rectum and teeth.Multi-causal theories are used when trying to understand these phenomena, which are recognized as the result of complex interaction among various parts of the central nervous system confirmed in studies using functional brain imaging techniques.Functional brain imaging has yielded important results, but without certainty being related to phantom pain as a subjective clinical experience.There is a wide range of treatment methods for the condition but no documented treatment of choice.Aims: In this study a qualitative, explorative and prospective design was selected, in the aim to understand the patients’ personal experience of phantom phenomena.The research questions focused at how patients affected by phantom pain and or phantom sensations describe, understand, and live with these phenomena in their daily life.This study expanded ‘phantom phenomena’ to also encompass phantom breast phenomenon. Since the latter phenomenon is not as well investigated as the phantom limb, there is clinical concern that this is an underestimated problem for women who have had breasts removed.Methods: The present study forms the first part of a larger, longitudinal study. Only results associated with data from the first interviews with patients, one month after an amputation, are presented here. At this occasion, 28 patients who had undergone limb amputation (20) or mastectomy (8) were interviewed. The focused, semi-structured interviews were recorded, transcribed, and then analyzed using discourse-narrative analysis.Results: The interviewees had no conceptual problems in talking about the phenomena or distinguishing between various types of discomfort and discomfort episodes. Their experience originated from a vivid, functioning body that had lost one of its parts. Further, the interviewees reported the importance of rehabilitation and advances in prosthetic technology. Loss of mobility struck older amputees as loss of social functioning, which distressed them more than it did younger amputees. Phantom sensations, kinetic and kinesthetic perceptions, constituted a greater problem than phantom pain experienced from the amputated body parts. The descriptions by patients who had had mastectomies differed from those by patients who had lost limbs in that the phantom breast could be difficult to describe and position spatially.The clinical implication of this study is that when phantom phenomena are described as everyday experience, they become a psychosocial reality that supplements the definition of phantom phenomena in scientific literature and clinical documentation.Conclusions: There is a need for clinical dialogues with patients, which besides, providing necessary information about the phenomena to the patients creates possibilities for health professionals to carefully listen to the patients’ own descriptions of which functional losses or life changes patients fear the most. There is a need for more qualitative studies in order to capture the extreme complexity of the pain–control system will be highlighted.

Applying dialectical behavior therapy to chronic pain: A case study

Steven J. Linton — 2010-01-01

Abstract: Background and aims: Chronic pain patients often present with a host of psychological and somatic problems and are unable to work despite receiving traditional pain management. For example, it is common that patients with persistent pain also suffer from a variety of anxiety and depressive symptoms. Indeed, the regulation of emotions may be one important factor that is associated with the development of persistent pain. Dialectical behavior therapy, a form of cognitive-behavioral therapy, focuses on emotion regulation and has successfully addressed other complex problems. The objective of this case study was to test the feasibility of developing and applying a dialectical behavior therapy approach to chronic pain.Methods: Feasibility study of n=1: A 52-year-old adult suffering musculoskeletal pain, work disability, depression, and mood swings was offered therapy. She had not worked at her occupation for 10 years. An intervention was developed based on dialectical behavior therapy that included goal setting, validation, behavioral experiments and interoceptive exposure. Goals were developed with the client, based on her own values, and these were to: increase participation in previously enjoyable activities, not only reduce but also accept that some pain may remain, and, express and regulate emotions. Validation (understanding the patient's situation) and psychoeducation were used to analyze the problem with the patient in focus. Function was approached by monitoring activities and conducting dialectical behavioral experiments where the patient systematically approached activities she no longer participated in (exposure). Emotional regulation followed a training program developed in dialectical behavior therapy designed to have people experience, express, and manage a variety of positive and negative emotions. In order to address the patient's complaint that she avoided her own feelings as well as the pain, interoceptive exposure was introduced. After establishing calm breathing, the client was asked to focus attention on the negative feelings or pain as a way of de-conditioning the psychological responses to them. Therapy was conducted during 16 sessions over a six-month period.Results: Improvements were seen on the main outcome variables. Pain intensity ratings dropped from 4.3 during the baseline to almost 0 at the end of treatment. Function increased as the patient participated in goal activities. Depression scores were decreased from 26 (Beck's Depression Inventory) at pre treatment to 5 at follow-up, which falls within the normal range. Similarly, catastrophizing and fear decreased on standardized scales and fell within the range of a nonclinical population. Ratings indicated that acceptance of the pain increased over the course of therapy. Sleep improved and was also within the normal range according to scores on the Insomnia Severity Index. The patient reported seeking and obtaining employment as well. At the three-month follow-up improvements were maintained.Conclusions: This case shows that dialectical behavior therapy may be feasible for people suffering persistent pain with multiple problems such as pain, depression, and emotion regulation. However, since this is a case study, the validity of the findings has not yet been established. The positive results, however, warrant the further investigation of the application of these techniques to complex chronic pain cases.

Natural course of long-term postherniorrhaphy pain in a population-based cohort

Gabriel Sandblom, Maija-Liisa Kalliomäki, Ulf Gunnarsson, Torsten Gordh — 2010-01-01

Abstract: Background: Persistent pain after hernia repair is widely recognised as a considerable problem, although the natural course of postoperative pain is not fully understood. The aim of the present study was to explore the natural course of persistent pain after hernia repair in a population-based cohort and identify risk factors for prolonged pain duration.Methods: The study cohort was assembled from the Swedish Hernia Register (SHR), which has compiled detailed information on more than 140000 groin hernia repairs since 1992. All patients operated on for groin hernia in the County of Uppsala, Sweden, 1998–2004 were identified in the SHR. Those who were still alive in 2005 received the Inguinal Pain Questionnaire, a validated questionnaire with 18 items developed with the aim of assessing postherniorrhaphy pain, by mail. Reminders were sent to non-responders 5 months after the first mail. The halving time was estimated from a linear regression of the logarithmic transformation of the prevalence of pain each year after surgery. A multivariate analysis with pain persisting more than 1 month with a retrospective question regarding time to pain cessation as dependent variable was performed.Results: Altogether 2834 repairs in 2583 patients were recorded, 162 of who had died until 2005. Of the remaining patients, 1763 (68%) responded to the questionnaire. In 6.7 years the prevalence of persistent pain had decreased by half for the item “pain right now” and in 6.8 years for the item “worst pain last week”. The corresponding figures if laparoscopic repair was excluded were 6.4 years for “pain right now” and 6.4 years for “worst pain past week”. In a multivariate analysis, low age, postoperative complication and open method of repair were found to predict an increased risk for pain persistence exceeding 1 month.Conclusion: Persistent postoperative pain is a common problem following hernia surgery, although it often recedes with time. It is more protracted in young patients, following open repair and after repairs with postoperative complications. Whereas efforts to treat persistent postoperative pain, in particular neuropathic pain, are often fruitless, this group can at least rely on the hope that the pain, for some of the patients, gradually decreases with time. On the other hand, 14% still reported a pain problem 7 years after hernia surgery. We do not know the course after that.Although no mathematical model can provide a full understanding of such a complex process as the natural course of postoperative pain, assuming an exponential course may help to analyse the course the first years after surgery, enable comparisons with other studies and give a base for exploring factors that influence the duration of the postoperative pain. Halving times close to those found in our study could also be extrapolated from other studies, assuming an exponential course.

National guidelines for evaluating pain—Patients’ legal right to prioritised health care at multidisciplinary pain clinics in Norway implemented 2009

Karen Walseth Hara, Petter Borchgrevink — 2010-01-01

Abstract: Background: All nations are posed with the challenge of deciding how to allocate limited health care resources. A Patients’ Rights Law from 1999 gives patients in Norway with a serious health condition, for which there is efficacious and cost-effective treatment, a legal right to receive health care from the National Health Care system.Methods: Recently national guidelines have been produced for implementing these legal rights within 32 fields of specialist health care. One of these fields deals with serious chronic pain conditions. A task force established by the Directorate of Health, comprising pain specialists, primary care and patient representatives, have produced guidelines for pain conditions. The newly published guidelines seek to answer the difficult questions of which patients should be prioritised at pain clinics and what is a medically acceptable waiting time.Results: The guidelines deal with non-acute pain conditions that are too complex for primary care and organ- or disease-specific fields of specialist care. The guidelines state that if health-related quality of life is severely affected by the pain condition and efficacious and cost-effective treatment is available, then patients have a legal right to receive prioritised specialist health care in multidisciplinary pain clinics. The guidelines describe 5 categories of complex pain disorders that as a main rule should be given the right to prioritised health care in pain clinics. The 5 categories areThe maximum medically accepted waiting time is set at either 2 or 16 weeks depending on the condition. The full version of the guidelines describes pain categories in detail and gives information on cases that do not qualify to be prioritised for care in a pain clinic.Conclusions: Norwegian national guidelines for prioritising among pain conditions are in the process of being implemented. Epidemiologic data and expert opinion suggest that in order to meet the chronic pain patient's legal claim to prioritised specialist health care, the national health care system in Norway will have to establish new pain clinics and increase capacity at existing pain clinics.