Journal Club Articles

Use the following questions to start a discussion about this article at your next journal club meeting.

1. 1. In recent years the empirical investigation of the effects of implementing Prescription Monitoring Programs (PMPs) has increased notably. How would you describe the evidence base from the published literature documenting the impact of current PMPs on reducing diversion and abuse of prescription opioid analgesics?
2. In relation to Question 1, how would you also describe the evidence base documenting the impact of current PMPs on prescribing opioid analgesics?
3. This study found that, in California, replacing a triplicate prescription form used only for Schedule II medications with a tamper-resistant security form for all scheduled medications was associated with a statistical increase in individuals using more than one practitioner to obtain different prescriptions for the same opioid analgesic. What factors might help explain this finding?
4. In relation to Question 3, changes in the type of prescription form also were associated with a statistical increase in the prescribing of some short-acting opioid analgesics, while prescribing of long-acting opioids was not affected. What factors might help explain this finding?
5. Historically, PMPs have been designed and used primarily as a tool for law enforcement, but PMPs now are considered a potentially valuable clinical practice tool. What factors would be important for a PMP to be a useful tool to inform practitioners’ prescribing decisions?
6. This article relates specifically to California’s PMP, but many states have an operational PMP. Does your state have an operational PMP and, if so, what are its characteristics that are relevant to your practice?
7. PMPs are viewed by many as an important mechanism to reduce the diversion and abuse of prescription medications. From your understanding of prescription medication diversion and abuse in your state, would a PMP be sufficient to address these issues or are there additional activities that you think should be considered?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. Apart from the obvious effects on body strength, flexibility etc., which beneficial psychosocial effects could be expected when practicing yoga in groups or alone?
2. Yoga involves specific physical activities, relaxation / meditation, and other practices. Discuss their putative relevance for the overall effects.
3. Yoga seems to be more effective in healthy individuals than in patients with chronic conditions. What could be done to improve the effectiveness in patients?
4. Attending yoga programs means to actively care for your own situation. What could be done to overcome a loss of motivation in patients with chronic pain disorders?
5. Is yoga really a therapy -- or an adjuvant treatment to support patients? Discuss the intentions of integrative medicine to implement evidence-based complementary treatments in conventional pain management programs. What could be the benefit and the limitations of multidisciplinary treatment programs?
6. Would you use yoga intervention programs in your institution? Discuss potential barriers and limitations.

Use the following questions to start a discussion about this article at your next journal club meeting.

1. What do you find most surprising about the results of this survey? Do you think that there is a need for greater consensus about a standardized pain curriculum for medical students?
2. Where do you see the greatest areas of need as determined by the topics which received minimal coverage according to the results of this study?
3. What did you like about the study design? What would you do differently?
4. If you have 15 hours to dedicate to a new pain curriculum, how could you use the results of this study to aid in developing this curriculum, e.g. task assessment? Would you focus on covering the major topics as defined here, would you target areas of greatest need/deficiency, would you strike a balance with a mixture?
5. What do you think are the barriers to implementing pain curriculum improvements at your institution?
6. What do you think about interprofessional education, i.e., medical students learning together with nursing, pharmacy and other students? Do you think that committing to interprofessional education aids or impedes the case for advancing pain education in medical school?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. What are the reasons why gout may be underdiagnosed?
2. Discuss whether you think any topical agents may have a role in the treatment of gout? Are there any lifestye changes or dietary changes that you might suggest to some of your patients with gout?
3. Understand the pathophysiology of gout and potential targets for novel therapeutic strategies. What are some potential imaginary analgesics that you might develop to treat gout and how do they work? Is there any mechanistic overlap with your agents and agents used to treat inflammatory arthritides?
4. Why do you think there was such a long gap in the development of new FDA approved agents to combat gout?
5. The FDA recently declined to approvecanakinumab (a monoclonal antibody specifically binding to interleukin-1 beta) for treating gouty arthritis-requesting additional clinical data. What are the implications of this for future research efforts/research needs?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. This article demonstrated a reciprocal relationship between pain and depression, suggesting that treatment of both conditions may be important in some patients to optimize outcomes. Discuss potential barriers and facilitators to treating depression in the patient with chronic pain.
2. What do you think are some of the most important reasons or mechanisms for the reciprocal relationship between pain and depression?
3. How do you diagnose depression in a patient with chronic pain, and how do you discuss the diagnosis with the patient?
4. A 45-year old man who was started on an SSRI antidepressant 3 months ago for major depression has had a poor response despite optimizing the SSRI dose. The patient also has chronic back pain that is quite bothersome despite maximum doses of naprosyn and low-dose hydrocodone-acetaminophen. What are your treatment options?
5. In this particular study, lower socioeconomic status was associated with worse pain outcomes, but neither gender, age, race, or pain location (back versus hip/knee) were independent predictors of subsequent pain severity. Are these findings surprising? Why or why not?
6. This study included patients with pain in the back, hip or knees. Do you think the study findings would be similar or different in patients with other types of pain?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. This article explored the use of 14 evidence-based pain management practices. Are there other evidence based practices that you think should be considered for use as part of standard care?
2. There is a large body of literature supporting the effectiveness of various lidocaine products for reducing the pain of needle sticks. What factors might help explain the low usage of topical anesthetics for IV insertions?
3. Several low risk pain interventions could be initiated by nurses using a hospital protocol or standing order. Discuss potential barriers and facilitators to implementing such protocols or standing orders.
4. In this sample, fewer providers than nurses would give medication to children with a pain score of 6 or greater at triage. What might account for this difference?
5. Keeping up to date on the latest pain management evidence is difficult in all health care environments. Are the needs of rural providers and nurses different from their urban counterparts?
6. This article lists several evidence base guidelines for the management of children’s pain. What guidelines are used in your institution, who chooses it and how is it implemented?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. There have been proposed several definitions of persistent pain after breast cancer treatment (PPBCT). Discuss advantages and disadvantages of these. How could PPCBT be better defined?
2. Preoperative risk factors for development of PPBCT are patient-related factors, which may have a potential in preventive strategies. Discuss how these factors could be implemented in clinical practice and future research.
3. The intercostobrachial nerve (ICBN) is a sensory nerve crossing the operative field. Discuss whether or not there is evidence for preserving this nerve. How could preservation of the ICBN be assessed in a future study?
4. Sensory disturbances after breast cancer treatment are common, and also often present in patients without pain. Discuss what implications this have for the pathophysiological understanding of PPBCT.
5. Adjuvant therapy is administered to most breast cancer patients. How may adjuvant therapy contribute to the development of PPBCT? Could this have implications for clinical practice?
6. Can PPBCT be prevented with perioperative analgesics? Discuss how a future study could be designed to avoid bias and confounding factors.

Use the following questions to start a discussion about this article at your next journal club meeting.

1. Pain is the most common morbidity of sickle cell disease (SCD). While some individuals achieve adequate analgesia with standard dosing of morphine others do not. Discuss possible pharmacological and non-pharmacological mechanisms that could contribute to variability in response to opioids.
2. Understand how morphine is metabolized. Discuss the role of co-existing hepatic and renal dysfunction on morphine disposition in sickle cell disease.
3. What are some of the potential implications of increased clearance of morphine in SCD? What cautions should be exercised when translating these findings into clinical practice?
4. Discuss importance of frequent monitoring and individualization of therapy while using opioid in managing pain.
5. What are some of the major challenges and barriers when managing pain in SCD?
6. Understand that despite frequent use of opioids in this population, this is an under-studied area of research. What are some of the difficulties in designing and undertaking research studies on pain in SCD?

Use the following questions to start a discussion about this article at your next journal club meeting.

1. Pain is the most common morbidity of sickle cell disease (SCD). While some individuals achieve adequate analgesia with standard dosing of morphine others do not. Discuss possible pharmacological and non-pharmacological mechanisms that could contribute to variability in response to opioids.
2. Understand how morphine is metabolized. Discuss the role of co-existing hepatic and renal dysfunction on morphine disposition in sickle cell disease.
3. What are some of the potential implications of increased clearance of morphine in SCD? What cautions should be exercised when translating these findings into clinical practice?
4. Discuss importance of frequent monitoring and individualization of therapy while using opioid in managing pain.
5. What are some of the major challenges and barriers when managing pain in SCD?
6. Understand that despite frequent use of opioids in this population, this is an under-studied area of research. What are some of the difficulties in designing and undertaking research studies on pain in SCD?

1. Why is fibromyalgia a difficult disease to both diagnose and to treat? What are the goals of treatment?
2. Why is the comparative effectiveness of gabapentin and pregabalin in treating fibromyalgia important to patients?
3. The systematic review of evidence on pregabalin and gabapentin for fibromyalgia indicates differences between the drugs in volume of studies, benefits and harms. Please discuss how you weigh these differences in interpreting this evidence.
4. What are the implications of the evidence regarding the duration of effect with pregabalin?
5. What are the gaps in the evidence comparing gabapentin and pregabalin?
6. Discuss the future research needs in determining the comparative effectiveness (benefits and harms) of pregabalin and gabapentin in patients with fibromyalgia. Consider the risk of bias and directness of the studies that need to be completed. How can the consistency and precision of the results of the studies be maximized?

1. When working with patients who have chronic pain and a comorbid SUD, it has previously been suggested that the substance use must be treated first, and once symptoms are in remission, then providers can address the pain issue. What are the advantages and disadvantages of this treatment plan? Do you think it is feasible/practical/effective to provide integrated treatment for pain and SUD?
2. The article suggests that, in order for chronic pain patients with a SUD to have significant improvements in pain-related function, more intensive and ancillary treatment options are needed than usual care. If you could design the optimal treatment program for this patient population, what would it include?
3. What are some of the unanswered research questions that this article brings up?
4. What are some of the limitations of this study in terms of research methodology (e.g., sample selection, measurement of constructs, etc.)? If you wanted to design a research study that builds on the results of the current study, what would you do?
5. Will the findings from this study have any impact on the clinical care you provide? If so, in what way?

1. What are the major challenges in clinical pain management?
2. How has basic science research advanced clinical pain management? How can basic science research on pain mechanisms be improved?
3. What are the main concerns regarding combination drug therapy?
4. How can we improve integration between basic science research and clinical study of new pharmacotherapies?
5. What are the main obstacles in clinical studies of combination drug therapy? How can these obstacles be overcome with improved study design and data interpretation?