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Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18-75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87-1.00; =0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68-0.92; =0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40-0.96; =0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39-0.92; =0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80-0.98; =0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89-1.00; =0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06-1.77; =0.016). Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

Based on the hypothesis that pain is a stand-alone problem, not just a symptom of Post-Traumatic Stress Disorder (PTSD), the effect of group psycho-education (“pain school”) for survivors of the Khmer Rouge regime with pain-PTSD comorbidity was tested in Cambodia in 2015. After baseline assessment comprising pain-related measures (Brief Pain Inventory, Disability Rating Index) and measures for PTSD, anxiety, depression, and distress, 113 subjects were randomized to a waitlist control group (CG, n = 58) and a treatment group (TG, n = 55). After treatment TG improved significantly, with clinically relevant effect size. Effect size was, however, substantially lower than in two prior pilot trials, and the improvement was not maintained at six-month follow-up. The main reason for this is hypothesized to be that the intervention had been delivered in too condensed a format. It is concluded that treatment addressing pain can also ameliorate mental health problems, implying that more attention should be paid to pain treatment for subjects suffering from pain/PTSD comorbidity.

To characterize a patient group with refractory orofacial pain (OFP) at a tertiary pain clinic with emphasis on subtype distribution, comorbidities, sex differences and psychological factors. This retrospective study reviewed 98 consecutive patients assessed at the National Unit of Orofacial Pain, Haukeland University Hospital, Bergen, Norway (2017-2021). All patients were investigated by an interdisciplinary team that used a structured clinical interview and assessments and patients completed a series of standardized questionnaires that formed the basis for the final diagnosis and treatment plan. The International Classification of Orofacial Pain (ICOP-2020) was launched later and therefore retrospectively used forming the basis for this study. Five primary subtypes were analyzed: primary myofascial orofacial pain (pMOP), post-traumatic trigeminal neuropathic pain (PTTNP), persistent idiopathic facial pain (PIFP), trigeminal neuralgia (TN) and burning mouth syndrome (BMS). Secondary MOP (sMOP) was recorded when myalgia co-occurred with another primary diagnosis. Descriptive statistics, -tests and one-way ANOVA was performed. The most frequent diagnosis was pMOP (60.2%), followed by PTTNP (20.4%), PIFP (14.3%), TN (4.1%), and BMS (3.1%). Twenty-five patients had more than one diagnosis ( Percentages do not sum to 100%. A total of 25 patients with overlapping diagnoses, including 23 patients with secondary MOP and 2 patients with dual primary diagnoses.). Significantly more women (82.6%) had OFP (p<0.05). Patients with pMOP experienced longest mean pain duration (9.9 years) and reported comorbidities such as body pain, headaches and arthritis more frequently than non-MOP groups (p < 0.05). sMOP was present in 75% of PTTNP cases (p = 0.0038). Psychometric and functional measures varied across subtypes: patients with pMOP exhibited the highest scores on HADS (15.3), MFIQ (14.4), and (7.0). Refractory OFP is dominated by pMOP and female patients. The strong association between PTTNP and sMOP suggests early combined management of neuropathic- and muscle pain which may limit chronification. Together, our findings support a personalized, interdisciplinary approach to OFP that can improve diagnostic precision and optimize long-term patient outcomes.

BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded – and herein recommended – that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments. KEY WORDS: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion DISCLAIMER: The guidelines presented are based upon the best available evidence, and do not constitute or represent inflexible treatment recommendations. This document is not intended to be regarded and/or used as a “standard of care.”

Background and objectivesThere are few prospective studies providing comprehensive assessment of risk factors for acute and persistent pain after breast surgery. This prospective observational study assessed patient-related, perioperative, and genetic risk factors for severe acute pain and persistent pain following breast cancer surgery.MethodsWomen presenting for elective breast cancer surgery completed State Trait Anxiety Inventory, Beck Depression Inventory, and Pain Catastrophizing Scale questionnaires preoperatively. Diffuse noxious inhibitory control and mechanical temporal summation were assessed. A blood sample was obtained for genetic analysis. Analgesic consumption and pain scores were collected in the post-anesthesia care unit, and at 24 and 72 hours. Patients were contacted at 1, 3, 6, and 12 months to assess persistent pain. Primary outcome was maximum acute pain score in first 72 hours and secondary outcome was persistent pain.ResultsOne hundred twenty-four patients were included in analysis. Increased duration of surgery, surgeon, and higher pain catastrophizing scores were associated with increased severity of acute pain, while preoperative radiotherapy was associated with reduced severity. Persistent pain was reported by 57.3% of patients. Postdischarge chemotherapy (OR 2.52, 95% CI 1.13 to 5.82), postdischarge radiation (OR 3.39, 95% CI 1.24 to 10.41), severe acute pain (OR 5.39, 95% CI 2.03 to 15.54), and moderate acute pain (OR 5.31, 95% CI 1.99 to 15.30) were associated with increased likelihood of persistent pain.ConclusionsIncreased duration of surgery, higher pain catastrophizing score, and surgeon were associated with increased severity of acute pain. Preoperative radiation was associated with lower acute pain scores. Postsurgery radiation, chemotherapy, and severity of acute pain were associated with increased likelihood of persistent pain.Trial registration NCT03307525.

Abstract Objective To provide an update on Australian persistent pain services (number, structure, funding, wait times, activity). Methods An updated national search was conducted. Of those identified, 74 persistent pain services provided detailed responses between July 2016 and February 2018 (64 adult, seven pediatric, two pelvic pain, and one cancer pain). A similar structure to the original Waiting in Pain (WIP) survey was used, and participants chose online or telephone completion. Results Pediatric pain services had more than doubled but remained limited. Adult services had also increased, with a concurrent decrease in median wait times and an increase in the number of new referrals seen each year. Despite this, some lengthy wait times (≥3 years) persisted. Wait times were longest at clinics using public or combined funding models and offering pain management group programs (PMGPs). Although clinical activity had increased, medical staffing had not, suggesting that clinics were operating differently. Privately funded clinics performed more procedures than publicly funded services. Use of PMGPs had increased, but program structure remained diverse. Conclusions Specialist pain services have expanded since the original WIP survey, facilitating treatment access for many. However, wait time range suggested that the most disadvantaged individuals still experienced the longest wait times, often far exceeding the recommended 6-month maximum wait. More needs to be done. Numerous developments (e.g., National Strategic Action Plan for Pain Management, health system changes as a result of the COVID-19 pandemic) will continue to influence the delivery of pain services in Australia, and repeated analysis of service structures and wait times will optimize our health system response to the management of this condition.

Purpose of Review This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape. Recent Findings Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Summary Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.

Background Chronic orofacial pain (COP) is a complex condition often resistant to treatment and associated with psychological comorbidities. Yet, its neuropsychological profile remains under‐investigated. This case‐control study aims to identify the cognitive, behavioral, and psychological profiles of COP and their associations with clinical symptoms, with a focus on persistent idiopathic facial pain (PIFP), a condition particularly underexplored. Methods A cohort of 42 patients (COPc), including 23 with PIFP, and 42 healthy controls (HCs) underwent a comprehensive assessment of mood, coping strategies, personality traits, cognitive functioning, and social well‐being. Between‐group and correlation analyses were performed, and Bonferroni correction was applied to account for multiple comparisons. Results The psychological framework of COPc was marked by depressive symptoms, loneliness, alexithymia, poor quality of life, and low physical and mental well‐being. Personality assessment indicated worthlessness. Catastrophizing was a dominant coping strategy, characterized by helplessness and rumination. Cognitive assessments revealed deficits in attention and executive functions. PIFP patients exhibited particularly psychological vulnerabilities, namely, catastrophizing thinking and difficulties in describing their own feelings. Correlation analyses showed complex relationships between cognitive, behavioral, and psychological impairments in COPc, and a strong association between the negative impact of pain symptoms on social life and psychological, catastrophizing, and cognitive functioning. Conclusions This is the first study to characterize the neuropsychological profile of PIFP and COP conditions, revealing a complex interplay of cognitive, behavioral, and psychological vulnerabilities. These findings underscore the importance of addressing both neuropsychological and social functioning in the management of chronic pain to improve patient well‐being. This case‐control study assessed 42 chronic orofacial pain patients, including 23 patients with persistent idiopathic facial pain, and 42 controls. COPc patients showed cognitive deficits, mood symptoms, alexithymia, and maladaptive coping, especially catastrophizing. Pain's social impact correlated with psychological and cognitive dysfunction. Findings support a biopsychosocial approach to improve care and quality of life in COP.

While pain chronicity in general has been defined as pain lasting for more than 3 months, this definition is not useful in orofacial pain (OFP) and headache (HA). Instead, chronicity in OFP and HA is defined as pain occurring on more than 15 days per month and lasting for more than 4 h daily for at least the last 3 months. This definition excludes the periodic shortlasting pains that often recur in the face and head, but are not essentially chronic. Although the headache field has adopted this definition, chronic orofacial pain is still poorly defined. In this article, we discuss current thinking of chronicity in pain and examine the term 'chronic orofacial pain' (COFP). We discuss the entities that make up COFP and analyze the term's usefulness in clinical practice and epidemiology.

Purpose of ReviewThe goal of the review was to highlight recent advances in our understanding of descending pain-modulating systems and how these contribute to persistent pain states, with an emphasis on the current state of knowledge around “bottom-up” (sensory) and “top-down” (higher structures mediating cognitive and emotional processing) influences on pain-modulating circuits.Recent FindingsThe connectivity, physiology, and function of these systems have been characterized extensively over the last 30 years. The field is now beginning to ask how and when these systems are engaged to modulate pain. A recent focus is on the parabrachial complex, now recognized as the major relay of nociceptive information to pain-modulating circuits, and plasticity in this circuit and its connections to the RVM is marked in persistent inflammatory pain. Top-down influences from higher structures, including hypothalamus, amygdala, and medial prefrontal areas, are also considered.SummaryThe challenge will be to tease out mechanisms through which a particular behavioral context engages distinct circuits to enhance or suppress pain, and to understand how these mechanisms contribute to chronic pain.