Journal Club Articles

  • In this study, 3-daily sessions of left DLPFC rTMS have been selected to modulate pain thresholds, cortical excitability and conditioned pain modulation. Which other cortical areas can be stimulated to obtain analgesic effects? Discuss the role of the left DLPFC on pain modulation and pain suppression.
  • In this study, there is no procedure of pure sham control because the study question concerned the performance of pcTBS versus the current standard 10 Hz rTMS, rather than versus sham. Here, sham stimulations were inserted within the two active stimulation arms so that all treatment sessions had the same duration and coil stimulation-related sounds. Please discuss the advantages and disadvantages of this study design.
  • Several complementary mechanisms associated with pain relief by rTMS to left DLPFC have not been investigated in the current study, such as reward, emotion, sympathetic and parasympathetic activity. Please discuss and propose what specific studies are needed to investigate potential changes in these mechanisms.
  • The potential clinical interest of this technique is the application to control high pain intensity before, during or following surgery or acute injury by decreasing pain sensitivity. It is well known that high pain intensity appears to be one of the strongest predictors of chronic pain development. Please propose and discuss clinical situations in which this application may be used to boost the pain threshold before or immediately after a painful medical procedure or acute injury.
  • Opioid and pain-relief prescriptions have increased worldwide, despite limited evidence regarding their long-term effectiveness and potential side effects. Discuss the potential clinical application of repetitive TMS, or other neuromodulation techniques, to manage pain.
  • Analogous to what has been recently proven for the treatment of major depression, one of the significant advantages to using theta-burst stimulation (TBS) is that treatment sessions (including setup) take about 5–10 min, compared with about 45 min for standard 10 Hz rTMS or other neuromodulation techniques. Please discuss the practical advantages of this technique in clinical settings and the importance to develop new technology/stimulation paradigms to improve neuromodulation.

  • Operant conditioning has been used to shape behaviors for decades. In the context of pain, it seems operant conditioning may also play a role. How much the findings from this review might be generalizable to different class of pain-related behaviors?
  • Is operant control of pain reports in fact an operant control of pain experience?
  • Based on the review findings and limitations of the studies included, discuss how the field of operant control of pain may be further improved, how future studies should be designed to provide further support for the concept that pain might be shaped by operant conditioning.
  • Please propose and discuss clinical situations in which operant conditioning might shape pain in patients. Discuss and present at least three different clinical scenarios.
  • If operant conditioning can enhance pain in humans, is it then possible to reduce pain? Please justify your answer.
  • Discuss the findings from the review in the context of animal studies. Do animals suffer more when they are reinforced for pain behaviors?
  • Please propose a method of pain management based on operant conditioning.
  • What are the differences between classical and operant conditioning? Can both learning process operate together in the acquisition or amplification of pain? If so, please discuss how operant conditioning may influence the effects of classical conditioning on pain.
  • Can operant conditioning influence the effects of observational learning on pain? If so, how the reinforcement of imitation behavior and the reinforcement of the model's behavior may affect the effects of observational learning on pain?
  • Do you think that the effects of operant conditioning on pain may be mediated by expectancy? Please justify your answer.
  • Which types of reinforcers and punishers may be the most effective in the induction and amplification of pain behaviors? Please justify your answer.
  • Which pain behaviors may be the most prone to be shaped by operant conditioning? Please justify your answer.
  • Please give examples of the following principles of operant conditioning in pain acquisition and modification: discrimination, stimulus and response generalization, extinction.

  1. The findings from this paper show that the mental and physical health of parents has a powerful influence on their children's chronic pain outcomes, and yet parent mental and physical health is rarely routinely assessed in chronic pain clinics. How can in roads be made to advocate for assessment of this and once assessed, what should be done to address these key aspects in pediatric clinics?
  2. The field of pediatric pain has long documented the importance of parental protective or solicitous behaviors in influencing child chronic pain outcomes. However, protective responses showed poor fit in the model and had to be removed. This is adding to a slow but growing literature base contradicting past findings. Why might this be the case?
  3. This study was cross-sectional and while relationships between parent psychological and physical health were found on child chronic pain outcomes, temporality of these relationships cannot be determined with this research design. How might these relationships unfold over time and importantly, as pain transitions from an acute to chronic state.

  1. Opioid prescription has increased worldwide, despite limited evidence regarding their long-term effectiveness in Chronic Non-Cancer Pain (CNCP) treatment. Discuss potential factors that may have contributed to this widespread long-term use.
  2. Findings from the article suggest that opioids might have limited long-term effectiveness in CNCP. Would you expect similar findings in chronic cancer pain patients? Is it possible, from the present study, to conclude anything related with the effectiveness of opioids for the management of acute pain?
  3. The present investigation examined core functional outcomes in accordance with IMMPACT recommendations, which are not currently assessed in clinical practice. Are there any institutional or organization barriers that might interfere with the assessment of these outcomes in routine patient care? What points would be most important to address in educational interventions for clinicians?
  4. One interesting finding of this study was that opioid users reported higher satisfaction rates despite their limited clinical improvement at both 1 and 2 years of follow-up. In your opinion, what are the factors that account for this discrepancy and how can these results be extrapolated to the reality of your clinical practice in CNCP?
  5. The present investigation is a “real-world” study with a large number of patients and using a propensity score matching analysis. What are the advantages and disadvantages of this type of study as compared to other observational studies and to randomized controlled trials?
  6. The limitations and difficulties of research in CNCP patients present a significant barrier in evidence assessment of opioid long-term effectiveness. What points would be most important to overcome in order to increment the quality of evidence of these studies?

  1. What does patient blinding involve and why is it important when conducting clinical trials?
  2. What study, industry, and discipline-wide factors might influence a researcher’s decision to assess and report blinding? Discuss why this might be the case and whether each factor poses a risk to a trial’s validity.
  3. Adverse effects were the strongest predictor of blinding failing. Why might side effects predict failed blinding better than actual treatment outcomes?
  4. Including a ‘don’t know’ option when asking patients to guess their treatment allocation appeared to increase the likelihood of blinding being maintained. Discuss the advantages and disadvantages of allowing a ‘don’t know’ option. Are there any alternatives that might solve these problems?
  5. Less than one third of contacted authors provided information about whether or not they assessed blinding. What factors, both within and outside of researchers’ control, could influence non-responses and could this affect the estimates of blinding assessment and its failure (or success)?
  6. If you were advising researchers who were about to conduct a clinical trial, what recommendations would you give about assessing blinding and how would you rationalize these recommendations?

  1. The present study suggests that patients who reported cumulative abuse showed a sharp increase in the predicted probability of benzodiazepine and opioid co-use at higher levels of anxiety. Describe the risks of co-use of benzodiazepines and opioids.
  2. Given the risks of co-use, discuss what patient characteristics might impel practitioners to prescribe or maintain a patient on benzodiazepines and opioids?
  3. Discuss screening for abuse in a clinical setting. How often is screening for abuse incorporated into routine patient care? What barriers exist to obtaining this information?
  4. In your opinion, how often is trauma considered when determining an appropriate course of treatment? How might having a better understanding of a patient’s trauma history help inform treatment decisions?
  5. The authors suggest that providers across specialties should be aware of the impact of interpersonal violence and abuse, and how this might impact treatment decisions. Discuss the need for awareness across disciplines and the importance of integrated care in managing patients’ care. What barriers exist to this integration? What about facilitators?
  6. What alternative treatments might be considered for patients with a history of abuse seeking care for chronic pain?

  1. The current study demonstrated generalization and extinction of concept-based pain-related fear in a sample of healthy adults. Previous research on perceptual generalization has shown alterations in fear generalization and extinction in chronic pain patients. Using a similar design, would you expect to find different results in a sample of chronic pain patients? If so, how would you expect results in a chronic pain population to differ from a healthy sample?
  2. The current results show that pain-related fear can generalize and extinguish based on symbolic associations between stimuli. Would you be able to link these results to cases you have encountered in clinical settings or non-clinical experiences from your personal life? If not, would you be able to imagine a real-life scenario where pain-related fear is acquired, generalized, and extinguished, based on conceptual knowledge?
  3. Extinction procedures are widely used to treat pain-related fear in the clinic, yet return of fear is still common. This suggests that treatments could use improvement/additions. Discuss possible ways in which practitioners could take into account concept-based fear learning in order to optimize existing treatments.
  4. It has been shown that conceptual similarity between stimuli (e.g. spider and web) enhances fear generalization, i.e. fear generalizes more easily between stimuli that are conceptually related compared with stimuli that are unrelated to each other. Would you be able to think of ways in which this mechanism relates to pain-related stimuli, and thus may lead to chronic pain disability? How would you take this into account when treating chronic pain patients?
  5. Previous research has demonstrated that, whereas extinction of the original CS+ generalizes to GSs within the related stimulus category, extinction of a particular GS does not generalize to the CS+ or other conceptually related stimuli. In your opinion, what does this mean for the treatment of chronic pain conditions? How would you attempt to overcome this effect in the process of extinguishing fear toward conceptually related stimuli?
  6. Given that in concept-based fear generalization, all CS exemplars are different yet belong to the same CS category, it may take longer to generalize extinction of a specific exemplar, as extinction of each exemplar has to be translated back to the broader fear-eliciting CS category. Therefore, participants are required to sort out what information regarding the CSs is relevant in predicting the feared outcome. It is plausible that the ability to sort out this information differs between individuals. Can you think of ways in which this ability may increase or decrease an individual’s chances of developing chronic pain?

  1. Qualitative studies such as this one often present detailed information drawn from a relatively small number of patients. In what ways do you think the primary care patient experiences reported in this study are reflective of the experiences of patients you see? In what ways are they different?
  2. Clinical guidelines and policies (such as the CDC opioid prescribing guidelines) often recommend tapering opioids when patients are prescribed doses above specific opioid dose thresholds associated with increased overdose risk. However, this article found that patients with chronic pain are often suspicious of clinicians who cite guidelines or policies when recommending that they taper. Why do you think these patients might be skeptical of this approach? What strategies might you use to introduce conversations around tapering without seeming to “blame” guidelines and policies for your recommendations?
  3. Table 2 in this article listed all the strategies patients reported using to manage opioid tapering. Were there any strategies on this list that surprised you? Which of the listed strategies might be helpful to recommend to patients? Which strategies might be red flags for opioid use disorder?
  4. This article suggests that successful opioid tapering requires patients to expend substantial effort to manage several different aspects of their daily life, but that they often don’t discuss these aspects of their everyday life with their clinicians. Why do you think this is? Based on the findings in this article, are there any new questions you plan to ask patients when talking about opioid tapering?
  5. This article makes several recommendations for how clinicians should approach opioid tapering with patients. Given the time pressures that many primary care clinicians report, which recommendations in the paper do you think should be prioritized? Which ones seem unrealistic?
  6. This article presents a model of patients’ tapering experience based on data from the patient perspective. Does the figure in the article add anything new to the way you think about tapering? Does the figure make you think of any new strategies or approaches that might be helpful for discussing tapering with your patients?

  1. The present investigation examined the cost-effectiveness of an exposure treatment for patients with fibromyalgia. Would you expect similar or discrepant findings from other patients with chronic pain conditions? Explain.
  2. This study used a waiting-list control as a comparator, since exposure therapy has not previously been evaluated for fibromyalgia. For future studies, what would, in your opinion, constitute a good active control treatment? (For example, one could argue that it should be the treatment that FM patients are most likely to receive when they seek psychological treatment. On the other hand, one could also argue that the gold standard comparator should be the treatment that currently has the most research support)
  3. The current study used internet as treatment modality to deliver the exposure treatment. Internet-delivered cognitive behaviour therapy (ICBT) has been shown to produce similar effects as face-to-face-therapy in a majority of both somatic and psychiatric disorders.
    1. Discuss pros and cons of internet as treatment modality for patients with chronic pain in general, and fibromyalgia in particular.
    2. Given the structure of your current health care system, what barriers or facilitators (institutional, political or economic) exist in implementing internet-delivered cognitive behavior therapy in routine patient care?
  4. A possible limitation that the authors discuss was the use of self-recruitment that possibly limits the generalizability to patients with FM at, say, a tertiary pain clinic or within primary care. However, one could also argue that the patients in the current trial constitutes an own sub-population (that is, treatment seeking patients open to psychological treatment) of FM patients. Given your clinical context, what patients do you think would benefit from this treatment?
  5. The participants in the treatment arm received 10 weeks of exposure therapy. What is your understanding of exposure therapy? Discuss potential rationales* that you could use to explain exposure treatment to a patient.

*A treatment rationale is like an instruction manual, containing a description of the treatment and how and why the treatment is supposed to work

  1. Recent years have witnessed an increase in the frequency with which mastectomies are performed. Multiple factors account for the increase. Given the relatively high incidence of persistent post-mastectomy pain (PPMP) following mastectomy, discuss the risk: reward balance relative to each of the factors associated with the increase in surgery.
  2. Several demographic characteristics are risk factors for PPMP, including younger age and minority race/ethnicity. Describe the mechanisms that are likely to mediate the heightened risk for those demographics.
  3. Pain sensitivity and central sensitization have been proposed as physiologic mechanisms that may underlie increased PPMP vulnerability for patients with preexisting pain conditions and/or patients characterized by high levels of anxiety or catastrophizing. Describe preoperative interventions that might lessen that vulnerability.
  4. While post-mastectomy pain initially was thought to be caused by injury to the intercostobrachial nerve, other mechanisms have been identified that also can occasion PPMP. Describe how physical therapy, initiated soon after surgery, can be useful in managing pain and promoting function across multiple mechanisms in the post-operative period.
  5. Preemptive analgesia has been shown to be effective in reducing acute post-operative pain following mastectomy. While lower levels of post-operative pain have been shown to reduce the risk of PPMP, research has not shown preemptive analgesia to reduce PPMP risk. How would you reconcile these apparently contradictory findings?
  6. Self-management programs for the management of pain often have five elements: education, training in problem solving, relaxation training, coping skills training, and attention to the transfer of skills to the home environment. Discuss how each of these elements can be useful in addressing the various factors that contribute to PPMP.
  7. While opioids are standard of care for acute post-operative pain, they are considered a third-line treatment option for PPMP. Describe the clinical complications that underlie that status.
  8. A Transitional Pain Service is constituted of five disciplines: pain physicians, nurse practitioners, psychologists, pharmacists, and physical therapists. Describe the clinical contributions made by the various disciplines that can lessen a patient’s risk for developing PPMP.

  1. The number of orthopedic surgeries is rising worldwide. Discuss, what can be the reasons behind this?
  2. Most orthopedic surgical procedures are painful. Discuss the consequences of undertreated pain in the postsurgical period. How are pain, anxiety and recovery related to each other?
  3. What kinds of psychosocial interventions can be used to aid pain management during orthopedic surgery and what can be the underlying mechanism of their effects?
  4. Not all psychological interventions were supported to be effective in the treatment of all outcomes. Discuss which interventions seem to be useful for the treatment of which outcomes.
  5. Psychosocial interventions decreased postoperative pain but had no significant effect on analgesic use. What could be the explanation to this seemingly contradictory result?
  6. What can be the reason behind the higher effectiveness of psychosocial interventions in acute surgeries vs. in elective ones?
  7. Psychosocial interventions significantly reduced postoperative anxiety, but when this was assessed in the subsample of joint replacement surgeries alone, the effect was not significant. How can you explain this?
  8. For most of the explored outcomes, taking into account the moderators intervention type and timing, electiveness and severity of surgery decreased heterogeneity. However, in case of postoperative pain, heterogeneity did not change considerably. What other moderators can be explored which might influence postoperative pain?

  1. There is considerable research highlighting risks associated with opioid misuse in chronic pain, but little work has examined risks associated with alcohol misuse. What are the possible reasons that alcohol misuse has received so much less attention in the chronic pain research literature?
  2. Findings from previous work has suggested that alcohol and opioid co-use is fairly common (12%-36% of opioid-prescribed individuals according to the extant research literature). The present data takes these data a step further in that it found the hazardous alcohol and opioid co-use is also fairly common. Discuss why you think such co-use is so common in those with chronic pain.
  3. The screening measures used in this research have reasonably good sensitivity and specificity for hazardous use. Discuss the potential ways that practitioners could make use of these measures to aid in both assessment and treatment.
  4. Findings from the article suggest that either (a) opioid misuse alone or (b) opioid and alcohol misuse together are associated with worse psychosocial functioning than no misuse at all and that there were no significant differences in functioning between the two misuse groups. One possible interpretation of this finding is that opioid misuse may be “driving” the diminished levels of functioning. What are the clinical implications if this interpretation is correct? What other interpretations of these findings are possible?
  5. The article concludes by noting that there are few treatment options available that intervene both on (a) pain-related distress and disability and (b) substance misuse. What do you think would be the necessary components of an integrated treatment?

  1. There are a number of constraints involved in studying pain in the MRI scanner. Discuss challenges of adapting acute pain paradigms to the fMRI environment, and/or studying patients with chronic pain in the MRI scanner.
  2. Design a hypothetical event-related fMRI design for a question of interest to you. How would you construct the subject-level General Linear Model, what contrasts would you examine, and which group level analyses would be most appropriate for your research questions?
  3. For the event-related study you designed for question 2, what might be a potential example of a reverse inference you might make? How might you adjust your experimental design to increase the likelihood of your inference being correct?
  4. Compare and contrast block designs and event-related designs. What are the advantages and disadvantages of each study design?
  5. You run an fMRI experiment examining the neural bases for perception of the intensity of painful stimuli. You have an interesting finding in the right anterior insula. Describe how you could test whether this effect is specific to the right anterior insula (as opposed to the left anterior insula).
  6. Why do we need to perform multiple comparisons correction? Under what circumstances would such a correction not be required?

  1. There is considerable evidence highlighting the mechanisms and efficacy of placebo effects for reducing pain. Discuss potential ways in which practitioners could use these factors to augment the effectiveness of analgesic treatments.
  2. Findings from the article suggest that placebo analgesia acceptability is highly dependent on the context of administration. In your opinion, what are the conditions by which a placebo treatment would be deemed most acceptable? Least acceptable?
  3. The present investigation examined placebo treatment acceptability among a non-clinical sample of adults. Would you expect similar or discrepant findings from chronic pain patients? Explain.
  4. One of the major findings from this study was that participants’ had rather simplistic conceptualizations of placebo effects and their underlying mechanisms. What impact would increase understanding of placebo have on acceptability? What points would be most important to address in an educational intervention?
  5. The same factors that promote placebo analgesic effects (e.g., increased expectation, effective communication between physician and patient) likely contribute to the effectiveness of all treatments for pain. Given the structure of your current health care system, what institutional barriers exist in utilizing these factors in routine patient care?
  6. The use of deception to augment placebo treatment effects is controversial. Nevertheless, studies show that health care providers are using deceptive placebo interventions. Are there any circumstances in which it would be acceptable for a practitioner to deceive a patient in an effort to augment the effectiveness of an analgesic treatment?
  7. Discuss the ethical implications of placebo medicine. Although these treatments may be effective, are there ways in which this knowledge could harm patient care?

  1. Chronic stress is considered a trigger in many chronic pain syndromes that do not result from injury, especially those that are part of the group of pain conditions noted as Chronic Overlapping Pain Conditions (e.g., IBS, temporomandibular disorder, migraine, fibromyalgia). How does chronic stress differ from acute stress in this way?
  2. In the current study, the estrogen manipulation in males is based on previous work in ovariectomized females which supports the idea that it is the cycling of estrogen during the estrous cycle (perhaps estrogen withdrawal) that mediates the pronociceptive action. How can this be reconciled with human studies that suggest pain is greater during menses, when estrogen is low?
  3. The current study suggests the pro- and anti-nociceptive effects of estradiol and testosterone, respectively, are the same in males and females. How do you explain this in intact animals that have a normal neuroendocrine profile?
  4. The data suggest an enhanced role for spinal BDNF in stress-induced hypersensitivity that is modulated by hormones. Where else in the brain would you expect BDNF and hormones to interact to modulate nociceptive responses to stress?

  1. There are many challenges associated with preclinical pain research. In recent years discussions challenging the value of preclinical research have focused on the disappointing record of translation. In light of this concern should the field of pain research consider creating a standard of accountability that acknowledges failed translational efforts and discontinues the practice of rewarding research programs for discoveries that lead to nothing but "headlines" in the lay press? Furthermore, does the preclinical pain research community need to be more responsible with claims of new treatment strategies given the disappointing record of translational research over the past 30 years?
  2. Clinical pain is a complex multidimensional condition. One of the biggest challenges in preclinical research is acknowledging the difference between "pain" and "nociception". The distinction between the two is critical to the interpretation of results from preclinical studies. The question…..what are the distinguishing characteristics between "pain" and "nociception" that should be the centerpiece of interpretation for the results of preclinical studies?
  3. What are the most widely used interventions for treating chronic neuropathic and inflammatory pain and how many of these resulted directly from discoveries associated with preclinical pain models? Is the answer to this question a good or bad commentary on the clinical relevance of animal models and methods of assessment used in preclinical pain research?
  4. It is easy to argue that the past 30 years of preclinical pain research have provided a wealth of information related to the anatomy, physiology, molecular biology and genetics of nociception and pain. Given the disappointing record of translation over this period how valuable has this information been in understanding the human condition and advancing the treatment of inflammatory and neuropathic pain?
  5. Discuss five changes needed in preclinical pain research that would improve the potential success of translational advances in the treatment of inflammatory and neuropathic pain?
  6. The vast majority of preclinical pain researchers have little understanding of the significant impact chronic pain has on the quality of life, productivity, or general well-being of patients seen in the clinic. From a clinical perspective what is the biggest missing link between preclinical pain research and the reality of the human condition.
  7. Would a stronger relationship between clinical and preclinical scientists prove effective in improving the success of translational pain research? Furthermore, what steps are needed to allow the clinical community to become more engaged in research and interface with the preclinical pain research community?
  8. The duration of behavioral, chemical and molecular testing procedures currently employed in experimental models of inflammatory and neuropathic pain may be a critical factor when compared to the temporal profile of clinical conditions of long term pain. What are the time windows used in today’s animal models and how do they compare with the human conditions of acute and chronic pain?
  9. Pain related nomenclature is frequently used interchangeably between the human clinical setting and in describing results associated with preclinical studies. Discuss the applicability of IASP defined nomenclature in preclinical studies (allodynia, hyperalgesia, hyperesthesia, analgesia, etc).
  10. Clinical pain research has failed in meeting the vision of a mechanism-based identification and treatment strategy of chronic pain. Subgrouping patients within one diagnostic entity based on somatosensory profiling has emerged as a viable way to perform clinical trials. Is such phenotyping likely to reveal different underlying pain mechanisms and could the same approach be used in animal models?

  1. What do we mean by a placebo in the context of an acupuncture trial? How is a placebo for a physical intervention like acupuncture different than that for a medication? What methodological pitfalls might there be? What is acupuncture? In particular, consider whether a therapy developed long before modern concepts of anatomy and physiology were developed, and which originally involved concepts such as qi energy, can be practiced in a modern context?
  2. What do we mean by a placebo in the context of an acupuncture trial? How is a placebo for a physical intervention like acupuncture different than that for a medication? What methodological pitfalls might there be? ?
  3. How is the methodology of the Acupuncture Trialists' Collaboration different from the methodology of other systematic reviews of acupuncture? How many pain interventions have been subject to this type of analysis?
  4. What are the main results of the Acupuncture Trialists' Collaboration in terms of clinical and statistical significance? Should clinical significance be determined in comparison with placebo or with usual care?
  5. How does the duration of effects impact our assessment of the value of acupuncture? Put this in the context of the sort of long-term data we do and do not have about the impact of other chronic pain interventions in the long-term. This review found increased M1 activation/connectivity in neuropathic pain conditions. What motor dysfunction do you observe in neuropathic pain (e.g. carpal tunnel syndrome) in the clinic? How might motor dysfunction interact with sensory symptoms in neuropathic pain?
  6. Acupuncture is practiced in many different ways by many different types of health practitioner. How does this impact the effectiveness of acupuncture? This review provided evidence of increased M1 intracortical inhibition in chronic pain. Please discuss the possible clinical manifestations of this observation.
  7. If we conclude that acupuncture is effective, how does this change how we practice medicine? Should it be considered standard of care? What would be the practical implications if we did so?

  1. This review examined altered M1 structure, function and organization in chronic pain. Why is movement a relevant consideration in the understanding and treatment of chronic pain?
  2. This review highlighted a number of neurophysiological techniques used to examine M1 structure, function and organization in chronic pain. What do TMS and fMRI measure? How do these two techniques differ?
  3. This review provided inconclusive evidence of M1 changes in chronic pain, largely due to heterogeneity of underlying mechanisms, methodological differences and the small sample size of included studies. Please discuss the implications of (a) insufficient evidence of M1 organizational changes and (b) no evidence of changes in M1 corticospinal excitability in chronic pain.
  4. M1 has a key role in motor function. How do you treat motor dysfunction in the clinic? Do you feel these treatments also target M1?
  5. This review found increased M1 activation/connectivity in neuropathic pain conditions. What motor dysfunction do you observe in neuropathic pain (e.g. carpal tunnel syndrome) in the clinic? How might motor dysfunction interact with sensory symptoms in neuropathic pain?
  6. This review provided evidence of increased M1 intracortical inhibition in chronic pain. Please discuss the possible clinical manifestations of this observation.

  1. One of this study’s findings was that interventions that are usually not considered to be psychological, such as exercise, could be effective in reducing pain catastrophizing. Discuss possible reasons why you might expect people to catastrophize less about their pain after participating in exercise.
  2. This meta-analysis found that multimodal interventions, which combine cognitive behavior therapy and exercise, might have bigger effects in reducing catastrophizing than either intervention alone. Discuss why this might be the case.
  3. This systematic review found that most interventions were only moderately effective in reducing pain catastrophizing. Discuss how you think clinicians could improve interventions for people with elevated pain catastrophizing.
  4. This review found that there was no single gold standard intervention for PC and that a range of interventions had efficacy, although CBT, ACT and multimodal treatment had the best evidence. What does this mean for how we understand what pain catastrophizing is?
  5. The authors speculated that there might be different ‘phenotypes’ of pain catastrophizing. From your clinical experience, to what extent is there variation in how pain catastrophizing presents among people with chronic pain?
  6. What kinds of future research are needed to give clinicians better guidance on how to best help people with elevated pain catastrophizing?
  7. This meta-analysis found larger treatment effects in people with very high levels of catastrophizing at baseline. Discuss whether you think there might also be benefit in preventive early interventions for pain catastrophizing?

  1. One finding from this study was that several measures of opioid prescribing declined statewide after the Prescription Drug Monitoring Program (PDMP) was implemented. Yet, changes in prescribing patterns were similar for clinicians who did or did not register to use the PDMP. What other factors might explain the statewide decline?
  2. Propensity score matching was performed to match clinicians who did or did not register to use the PDMP. What characteristics were used for matching? Were there important differences between the groups prior to matching? What were the general differences?
  3. The databases used in this study had no information about prescriber specialty or patient diagnoses. If these were dissimilar among PDMP registrants and non-registrants, how might the results be affected? How much does matching on opioid prescribing patterns between the groups reassure you on this concern?
  4. The authors of this study previously reported substantial clinician variability in responding to PDMP data and in their discussions with patients. Many clinicians report denial or anger from some patients when they are confronted with PDMP findings. Should patients be told of any bothersome PDMP findings, or would the data best be kept secret? Are there strategies that might keep discussions constructive?
  5. What strategies would you suggest that might increase the impact of PDMPs? Are any of these in place in your state?
  6. Because of privacy concerns, Oregon narrowly restricts access to the PDMP by law enforcement officials, making clinicians and public health officials its main targets. Other states intend and facilitate a much greater role for law enforcement. Do you think this would affect the impact of a PDMP? What model would you favor?
  7. Maintaining a PDMP entails substantial cost to the state and effort from pharmacists and clinicians. Is it good public policy to continue these programs? Are there circumstances that would change your mind?

  1. There is evidence that higher self-efficacy levels are associated with greater physical functioning, physical activity participation, health status, work status, satisfaction with the performance, efficacy beliefs. Discuss potential ways in which practitioners could use these results to augment the effectiveness of their treatments in patients with chronic musculoskeletal pain.
  2. Findings from the article suggest that higher levels of self-efficacy are associated with lower pain intensity, disability, disease activity, depressive symptoms, presence of tender points, fatigue, and presenteeism. In your opinion, what are the reasons underlying this association?
  3. The present investigation examined the role of self-efficacy on patients with musculoskeletal pain. Would you expect similar or discrepant findings from patients with other chronic conditions, e.g., headache? Explain.
  4. As self-efficacy has shown a modifiable character, which educational strategies would increase its levels in order to improve aforementioned limitations? What points would be most important to address in an educational intervention?
  5. Regarding the educational interventions that may be indicated in patients with a lower self efficacy level, what institutional barriers exist in utilizing these interventions in routine patient care?
  6. When measuring/assessing self-efficacy in patients with chronic musculoskeletal pain, do you think that current patient reported outcome questionnaires, e.g., “pain self-efficacy questionnaire,” can reflect objectively the patients’ situation?

  • Improvement in the Spatial Distribution of Pain, Somatic Symptoms, and Depression After a Weight Loss Intervention

    Full length article
    Andrew Schrepf, Steven E. Harte, Nicole Miller, Christine Fowler, Catherine Nay, David A. Williams, Daniel J. Clauw, Amy Rothberg
    Vol. 18, Issue 12, p1542–1550
  1. There is considerable evidence that the central nervous system plays a major role in augmenting pain. Discuss different ways that obesity might influence central mechanisms of pain.
  2. The article demonstrates that a calorie restriction weight loss intervention is associated with symptom improvement when loss is greater than or equal to 10% of body weight. Discuss how and why this particular threshold might lead to improvement.
  3. Men showed greater symptom improvement in some domains than women. Do the changes observed seem large enough to consider calorie restriction and weight loss a viable means of pain treatment for women?
  4. The participants in this study were not recruited for having chronic pain and did not have high average levels of symptoms at study entry. Do you think the intervention would be more or less successful in chronic pain patients? What barriers to implementing the intervention would be more significant with chronic pain patients?
  5. All of the symptom outcomes measured in the study were self-report. What factors associated with weight loss could also influence the way participants reported their symptoms at the conclusion of the intervention
  6. How are the symptoms monitored in this intervention measured in your institution? Do you regularly monitor pain, fatigue, and depressive symptoms in patients who visit your clinic?

  • Measures That Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: ACTTION Critique and Recommended Considerations

    Short communication
    Shannon M. Smith, Judith K. Jones, Nathaniel P. Katz, Carl L. Roland, Beatrice Setnik, Jeremiah J. Trudeau, Stephen Wright, Laurie B. Burke, Sandra D. Comer, Richard C. Dart, Raymond Dionne, J. David Haddox, Jerome H. Jaffe, Ernest A. Kopecky, Bridget A. Martell, Ivan D. Montoya, Marsha Stanton, Ajay D. Wasan, Dennis C. Turk, Robert H. Dworkin
    Vol. 18, Issue 11, p1287–1294
  1. The article discusses "abuse potential". What is a medication’s abuse potential? Why is it important?
  2. How is a patient’s risk of inappropriate (i.e., not as prescribed) medication use different from a medication’s abuse potential?
  3. Why is it necessary to evaluate abuse potential when a medication is being studied?
  4. Both misuse and abuse are inappropriate uses of a medication. Is there value in distinguishing between misuse and abuse of a medication? Why or why not?
  5. In your opinion, what are the strengths and limitations of existing measures of medication misuse and abuse (e.g., SR-MAD, MADDERS)?
  6. Existing measures of medication misuse and abuse (e.g., SR-MAD, MADDERS) rely in large part on self-report. What are the limitations of self-reported inappropriate medication use? How might self-report be further augmented to improve the assessment of medications’ abuse potential?
  7. What additional data would lead to a more comprehensive understanding of the quality, validity, and utility of existing measures of medication misuse and abuse (e.g., SR-MAD, MADDERS)?

  1. Despite its widespread use in chronic pain management, there is limited evidence to support the efficacy of pacing in improving treatment outcomes. In the context of biopsychosocial conceptualisations of chronic pain, why might operant pacing, theoretically, be considered a beneficial strategy?
  2. The results of this meta-analysis reveal a positive correlation between existing measures of pacing and avoidance. The authors propose that this overlap might account, in part, for associations identified between pacing and poorer functioning that are commonly found for avoidance. How might you use this information to enhance pacing instruction for patients?
  3. There was significant heterogeneity across results from studies that employed multiple-item measures of pacing. What are some factors that might contribute to this heterogeneity?
  4. The authors propose that intent and contingencies are two important considerations in distinguishing identical behaviours used in operant pacing versus avoidance. How might this information be used in measures of pacing to make the distinction clearer? What else might be necessary to ensure an adequate measure of pacing that is free from artefactual overlap with avoidance?
  5. The authors note the difficulties inherent in conducting large dismantling studies aimed at evaluating the efficacy of individual treatment components in multi-component interventions. How might you design a study to evaluate the role of pacing in the context of a chronic pain management program? What might your primary outcomes be and how might these be measured?
  6. What are some alternative strategies that might address the same elements or mechanisms of biopsychosocial conceptualisations of chronic pain identified in Question 1? What is the theoretical rationale? Is there any evidence to support the efficacy of these alternatives to pacing?

  1. In this study, a placebo effect was observed after a sham anaesthetic was applied to a rubber arm unattached to the body, but only during a condition in which the rubber arm is experienced as part of the body through an illusion. Discuss the potential reasons for this result and the mechanisms which may underlie it.
  2. The use of a rubber hand in the present study represents a rather artificial way of examining the effect of a placebo treatment. Nonetheless, discuss why such a procedure may be interesting or important, as well as how it may be improved.
  3. This study, alongside much of the literature on the placebo effect, involved a certain degree of deception. However, in the present study the treatment was not actually applied to the body itself, and so no pharmacological effect would occur even with an active treatment. Was the use of deception necessary in the present study, and would an open-label placebo obtain the same analgesic effect? In an open label placebo treatment patients are fully aware of the sham nature of the treatment and are provided with the scientific information explaining why the placebo can be effective.
  4. The results of this study suggest that information or cues presented during altered states of embodiment, in this case a topical sham anaesthetic applied to a rubber arm during the rubber hand illusion, can have an effect on pain perception. Discuss potential ways in which practitioners could use such methods to treat pain.
  5. A sense of embodiment over one’s own body is a pervasive and ubiquitous sensation that is rarely interrupted or lost. Discuss how impairment of this experience may affect treatment efficacy and, more broadly, the perception of pain.
  6. Immersive virtual reality techniques have been used with great effect to examine the experience of embodiment. How might the findings from this study be combined with such methods to induce placebo effects as well as to augment treatment effects?

  1. What information do pain behaviors convey to observers, including loved ones and health care providers?
  2. To what extent is the concept of "pain behavior" multidimensional? What are the varieties of pain behaviors that are expressed to others?
  3. What types of pain behaviors have you observed most often in clinical practice? What types of pain behaviors have family members discussed seeing most often? Is there overlap between observations gathered by the family and by you? If not, why not?
  4. The authors suggest that talking to others about their pain-related distress, including anger, fear, and anxiety about pain and its effects, may be distinct from other pain behaviors. On what basis do they make this claim?
  5. What goals or motives are served through the emotional disclosure of pain-related distress? How can clinicians and researchers determine goals or motives for a particular individual with pain?
  6. The authors note that there are consequences for health care providers and loved ones when applying different theoretical models to conceptualize emotional disclosures about pain-related distress. How would health care providers respond to these disclosures if they applied an operant perspective vs. an intimacy process perspective?
  7. How do you conceptualize other similar behaviors such as emotional disclosures of distress regarding other illnesses or diseases, or emotional disclosures regarding non-health stressors? Would you respond to these disclosures similarly or differently if the disclosures were about pain? Why or why not?
  8. What role do emotional disclosures have in psychological and physical health? What are the effects of disclosing emotions to others? To what extent does the effect of emotional disclosure depend on an observing partner's responses?
  9. The authors suggest several intervention strategies that could be tested if emotional disclosure of pain-related distress were to be accepted and validated by others. How willing would you be to a) validate the emotional disclosures of your patients or b) refer patients to such interventions? What would be your reasons for or reservations against such intervention strategies?

  • Evidenced-Based Guidelines on the Treatment of Fibromyalgia Patients: Are They Consistent and If Not, Why Not? Have Effective Psychological Treatments Been Overlooked?

    Short communication
    Kati Thieme, Marc Mathys, Dennis C. Turk
    Vol. 18, Issue 7, p747–756
  1. Based on examination of the EULAR guidelines for the treatment of fibromyalgia (FM), it appears that the appraisal of the published research varied substantially from other guidelines (i.e., American, Canadian, German), what factors do you believe accounted for the inconsistencies observed?
  2. One of the major findings from the review of guidelines for the treatment of FM was that participants of the EULAR review panels had rather oversimplified conceptualizations of CBT effects and their underlying mechanisms. What impact might an expanded understanding of the biopsychosocial perspective have had on the have on the appraisal of the CBT outcomes research?
  3. Discuss potential ways in which pain specialists (rheumatologists, anesthesiologists, behavioral therapists, and physiotherapist) could use the research demonstrating the positive effects of CBT approaches to augment the effectiveness of any mono-therapeutic approach to the treatment of patients with FM.
  4. Research suggests that a large number of treatments have some benefit, at least for some symptoms associated with FM for at least some patients; but the results tend to be rather modest. Considering the reported genetic, endocrine, central and peripheral nervous system, and psychosocial heterogeneity observed in FM patients, discuss the implications of these studies for the treatment of patients with FM.
  5. The different guidelines for FM all recommend that opioid therapy should not be a first-line treatment for patients with FM. However, many FM patients report that they receive positive effects from opioid therapy. Discuss the Pros and Cons of prescribing opioids for FM patients.
  6. The inconsistencies across guidelines can be attributed to the criteria used for study inclusion, outcome measures used, weighting systems, and composition of the review panels. How might their inconsistencies be resolved?

  1. How can we know that someone is experiencing body ownership over a virtual body? Which measures can be employed?
  2. We say that a virtual body is co-located with the real one with they are both spatially coincident. Can embodiment occur when there is no co-location?
  3. What is the evidence reported in the literature that looking at one's own body is analgesic? Has this been demonstrated for virtual bodies?
  4. In experiments about embodiment usually synchronous versus asynchronous conditions are used. To what do these refer?
  5. What is the main finding of the article regarding distance between the real and the virtual body?
  6. What is the relationship between ownership of the virtual body and pain threshold?
  7. What mechanisms can underlie the so-called "visual analgesia,” or the fact that looking at your body increases pain threshold?
  8. How do you think that the findings in this study can be useful for the treatment of patients with pain? Can virtual reality be useful for pain treatment?
  9. How could the techniques in this paper be achieved without any use of virtual reality (e.g., consider the rubber hand illusion)?

  • Activity Pattern Profiles: Relationship With Affect, Daily Functioning, Impairment, and Variables Related to Life Goals

    Full length article
    Rosa Esteve, Alicia E. López-Martínez, Madelon L. Peters, Elena R. Serrano-Ibáñez, Gema T. Ruíz-Párraga, Henar González-Gómez, Carmen Ramírez-Maestre
    Vol. 18, Issue 5, p546–555
    Open Access
  1. A meta-analysis of the relationship between different approaches to activity and functioning in chronic pain patients found that the association between persistence and functioning depended on the measure used: instruments that assessed overactivity were associated with poorer outcomes, whereas instruments that assessed persisting with activity despite pain were associated with positive outcomes. Why do you think that these two types of persistence are associated with such different adaptive results?
  2. One of the findings of this study was that Avoiders were characterized by high levels of pain avoidance, activity avoidance, and pacing to reduce pain with low levels of the three types of persistence, pacing to do more things, and pacing to save energy for valued activities. The authors comment that these results are in line with previous research, which showed that pacing, when practiced to reduce pain, could be a functionally equivalent to avoidance. In relation to pacing, what are the clinical implications of these results? The training on pacing strategies, how should it be presented to the patients?
  3. The results of the present study showed that a behaviour pattern characterized by “doing” despite pain has better more adaptive results than a pattern characterized by avoidance even when this pattern has elements of excessive persistence. According to these results, as a clinician, how would you give advice to your patients regarding the organization of their activity?
  4. One of the results of this study was that optimism was associated with higher persistence. Are the more optimistic patients at risk of falling into sterile persistence trying to achieve unattainable goals and consequently degenerating into deep frustration?
  5. The findings of this study showed that the Medium Cyclers group, after the Doers, showed better adaptation than Avoiders and Extreme Cyclers. How could you explain this result? Could you distinguish one characteristic of this group that might explain such differences? What are the clinical implications of this result?
  6. The authors indicate that this study supports the following therapeutic approaches: graded exposure in vivo, Acceptance and Commitment Therapy, and the technique of the Best Possible Self. Please highlight which specific results support this proposal.
  7. After reading the whole paper, please discuss the meaning and implications of the following sentence included in the introduction: "From a motivational perspective, activity patterns are conceived not solely as a product of pain, but as a product of the self-regulation of current goals in the context of pain".

  1. Surgery specific and patient specific risk factors for the transition of acute postoperative pain to persistent postoperative pain are emerging in the literature. Consider and discuss ways health care providers can use this information to improve quality of patient care.
  2. The literature indicates that pre-existing pain is a risk factor for the development of persistent postoperative pain after surgery. Yet, the mechanism for this remains unknown. In light of the article’s review of basic mechanisms located in the peripherally and centrally, can you offer a hypothesis for how pre-existing pain increases risk?
  3. Stress is implicated in the generation of some types of chronic pain, but it seldom is measured such that it can be assessed as a risk factor. Is it feasible and advisable to attempt this, given the variety of stressors and physiological, endocrinological and psychological indicants of stress?
  4. The review argues that reflex responses do not assess pain sensitivity, although they are used regularly for this purpose. What method(s) would you use to determine whether a laboratory animal has chronic pain; or do you think there are no adequate tests of pain for subhuman species?
  5. Some extent of injury to peripheral axons is an inevitable consequence of many surgical procedures, but not all nerve injuries result in neuropathic pain. How should neuropathic pain be identified in individuals for investigation of therapeutic options?
  6. A strategic interdisciplinary approach to research directed at the acute to chronic pain transition does not yet exist. Figure 4 in the article displays five families of hypotheses that can potentially resolve this question. In your opinion, which of them, or what combination of them, is most likely to yield the biggest payoff?

  • Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial

    Full length article
    Mark D. Sullivan, Judith A. Turner, Cory DiLodovico, Angela D'Appollonio, Kari Stephens, Ya-Fen Chan
    Vol. 18, Issue 3, p308–318
  1. Opioid therapy treatment guidelines and policy discussions often state that we must seek “balance” between pain relief and opioid risks. How do the results of this trial reframe these policy debates?
  2. The major barrier to feasibility in this trial was recruitment of patients with chronic pain receiving long-term opioid therapy into a trial of opioid taper support. How might subsequent trials overcome this barrier?
  3. Patients with current Substance Use Disorders, including Opioid Use Disorder, were excluded from this trial. In any subsequent larger trials, would you continue to exclude these patients? If not, how would you adapt the taper support intervention?
  4. In this trial, patients were allowed to “pause” their opioid taper at any point. Most patients in the trial did this at least once. But they were not allowed to increase their opioid dose and remain in the trial. Is this the best balance of flexibility and firmness in opioid taper support? Or would you balance these differently?
  5. In this trial, our default taper schedule was to reduce opioid dose by 10% of the original opioid daily dose per week. Is this the best strategy? Should the taper schedule have been faster or slower?
  6. We tried hard to have patients attend their CBT-based taper support sessions in person. This was intended to maximize rapport and skill building. We did allow telephone sessions when patients were unable to attend in person, up to every other session. In a subsequent trial, would you allow more or fewer telephone sessions?
  7. Most patients in our trial (12/18 in the taper support group) had some adjustment in their non-opioid medications as part of our taper support intervention, usually an increase in antidepressants to address present or emerging anxiety and insomnia. Is this appropriate and feasible? Is it just substituting one medication dependence for another?

  1. As a first step in understanding risk factors of pain medication misuse in those with spinal cord injury, the others identified risk of misuse considering all types of prescription pain medications. This article did not specify type of pain medication misuse. Additional research is needed to identify types of medications most likely to be misused and the differential effects of type of medication on outcome. How might risk of pain medication misuse profiles differ by medication classification?
  2. Prior research has noted higher rates of tobacco and cannabis use, as well as greater prevalence of impulsive personality traits in those with spinal cord injury. This article identified several behavioral (i.e., tobacco use, cannabis use) and psychological (e.g., impulsive and neurotic personality traits, depressive symptoms) characteristics associated with increased risk of pain medication misuse in those with spinal cord injury. How might the study results inform prescribing practices and monitoring practices?
  3. Legalization of medicinal and recreational cannabis is becoming more prevalent across states within the US. This study found that recent use of cannabis was associated with higher risk of pain medication misuse. It is possible that cannabis use is as an alternative approach for pain management, that characterological factors explain the relationship between cannabis use and risk of pain medication misuse, or that cannabis use is related to disinhibition regarding medication use. What should be considered in regards to these laws and pain medication prescribing practices? Similarly, what is the role of the prescriber in educating the patient on the use of various medications/substances (e.g., pain medications, cannabis)?
  4. For psychologists, what are psychotherapeutic approaches (e.g., biofeedback, cognitive behavioral, acceptance-based) that may target the behavioral and psychological risk factors found to be associated with risk of pain medication misuse in this article?
  5. Neuropathic pain may be more difficult than nociceptive pain to treat with analgesics in those with spinal cord injury. This study did not differentiate type of pain that the participants experienced. Further investigation to differentiate type of pain as it relates to risk of pain medication misuse in those with spinal cord injury is needed. How might the type of pain relate to risk of pain medication misuse in individuals with spinal cord injury?
  6. The authors found that interference of pain on daily functioning, and not average pain intensity experienced, is associated with risk of pain medication misuse in individuals with spinal cord injury. What might explain this (e.g., causal relationships, statistical restriction due to range of observations)?

  • Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

    Full length article
    Jason M. Beneciuk, Jonathan C. Hill, Paul Campbell, Ebenezer Afolabi, Steven Z. George, Kate M. Dunn, Nadine E. Foster
    Vol. 18, Issue 1, p54–65
  1. What value might there be in the identification of subgroups of people that respond differently to treatment?
  2. The authors focused on treatment modifiers that would not be expected to change during treatment. What advantages and disadvantages might this have?
  3. What are management/intervention strategies that could be implemented in future studies to test if they potentially improve the effects of psychological/behavioral approaches for people in this subgroup (lower SES or education)?
  4. What other factors should be considered as moderators and mediators in future studies of low back pain (that weren’t already considered in this analysis)?
  5. Is there any value in identifying treatment effect moderators or mediators that are not necessarily modifiable through treatment?
  6. Speculation question – Assuming that there is some level of validity to findings associated with ‘number of pain medications’ – why would that factor potentially moderate response to the interventions used in this trial?
  7. Considering the findings of this study and the fact that psychological based interventions were used as a component of high risk treatment in the STarT Back trial, should these interventions be specifically tailored for those associated with low SES?

  1. The review found that individuals with depression demonstrated a higher overall threshold for pain. However, there was large variation in individual study results – how might this variation be explained and is it sensible to conclude that depression elevates pain threshold?
  2. Depression was associated with increased pain in response to ischemic stimuli. Is it reasonable to expect that any putative effects of depression might translate to acute pain procedures or clinical pain complaints in the same way? Why or why not? Might any effects of depression be expected to be exacerbated or diminished for clinical pain?
  3. It has been reported that genuine depression is frequently misdiagnosed by physicians as a somatic illness. Why might this be and what might be done to improve accurate diagnosis?/li>
  4. It has been suggested that abnormal pain responses in depression could be used as a supplementary marker of the condition. Is this supported by the study findings?
  5. What mechanisms could account for how depression might be linked to altered perception of pain?
  6. Although one possibility is that depression results in a change in the way pain is experienced, could there be other explanations for the observed differences between depressed and non-depressed people?
  7. Despite differences in sensory and pain thresholds (and under some conditions tolerance) between depressed and non-depressed individuals, there was no evidence for differences in pain ratings. Does this undermine conclusions of a potential effect of depression on pain and which finding might have the greatest implications for clinical pain?

  • Child and Family Antecedents of Pain During the Transition to Adolescence: A Longitudinal Population-Based Study

    Full length article
    Emily Incledon, Meredith O'Connor, Rebecca Giallo, George A. Chalkiadis, Tonya M. Palermo
    Vol. 17, Issue 11, p1174–1182
  1. One of the limitations of the study was that pain was reported by the parent, as the data was taken from a large longitudinal population-based cohort. If you could design the questions about pain, specifically what questions would you include and how would you use this data?
  2. What are the critical next research questions for understanding children’s pain problems, and opportunities to intervene?
  3. What role does community-based longitudinal data have in progressing this evidence base?
  4. What key messages could clinicians take from the study’s findings?
  5. The transition from late childhood to adolescence is a critical developmental period characterized by psychological, neurobiological, and social changes that may impact development of chronic pain. What other developmental transitions might be important to study in childhood or adulthood? What factors would be important to consider at each of these developmental transitions?
  6. Sleep deficiency, including reduced quantity and quality of sleep, is common and highly comorbid in an estimated 50% of youth with chronic pain. How could screening be implemented to assess sleep in either clinical or community samples?
  7. A strength of this study was the use of multivariate predictors within a social ecological perspective incorporating child, family, and sociodemographic risk factors for chronic pain. However, the contribution of neurobiological factors to development of pain was not considered. What neurobiological risk factors for chronic pain could be studied in pediatric populations?

  • United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data

    Full length article
    Michael Von Korff, Ann I. Scher, Charles Helmick, Olivia Carter-Pokras, David W. Dodick, Joseph Goulet, Robin Hamill-Ruth, Linda LeResche, Linda Porter, Raymond Tait, Gregory Terman, Christin Veasley, Sean Mackey
    Vol. 17, Issue 10, p1068–1080
  1. Why might it be important to differentiate the subset of persons with high impact chronic pain (about 10% of adults) within the much larger population of persons with common chronic pain conditions (about 40% of adults)?
  2. What are implications for clinical practice and for population-based research of the observation that most people with high impact chronic pain report pain at multiple anatomic locations?
  3. Based on what you know about widely used treatments that patients with high impact chronic pain receive, what would you expect research to find regarding the relative overuse of ineffective treatments for chronic pain versus the underuse of effective treatments for chronic pain?
  4. Most population-based research on chronic pain has studied specific pain conditions (e.g. low back pain, migraine, osteoarthritis). What are the pros and cons of studying chronic pain as a clinical entity across diverse pain conditions in addition to studying specific pain conditions in isolation from co-occurring pain conditions?
  5. Apart from documenting the large numbers of people with chronic pain and high impact chronic pain, and the large health care costs associated with their care, what is the importance of developing data for all persons with chronic pain and high impact chronic pain in the population, rather than only persons who seek treatment in the clinical setting where a study is carried out?
  6. The transition from acute pain to chronic pain can be defined by the duration of pain, while the transition from acute pain to high impact chronic pain can be defined by the onset of sustained activity limitations in family, work and social roles. What are implications for prevention of chronic pain and high impact chronic pain, and for clinical practice, of these two differing approaches to defining the transition from acute to chronic pain?

  1. This systematic review has demonstrated relations between clinical pain measures and structural and functional connectivity alterations within brain regions involved in somatosensory, affective and cognitive processing of pain in chronic musculoskeletal pain patients. What do these results mean for the clinical practice and rehabilitation of patients with chronic musculoskeletal pain?
  2. On the basis of this systematic review the causality of the relations between clinical pain measures and brain alterations is unclear. How would you investigate the causality of the relations between clinical pain measures and brain alterations? Do you think it is important to unravel the causality?
  3. The authors of this paper recommend that the brain has to be addressed in the rehabilitation of patients with chronic musculoskeletal pain. How do you think that the brain can be addressed in therapy for these patients to improve clinical outcome?
  4. What is the advantage of a systematic review regarding the strength of the conclusions and why is it important to score the methodological quality of the included articles? Discuss
  5. Based on this systematic review, what do you think is important for further research?
  6. Brain alterations in grey matter morphology, white matter properties and functional activity and connectivity: What do you think are the underlying mechanisms?

  • Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain

    Full length article
    Steven K. Dobscha, Travis I. Lovejoy, Benjamin J. Morasco, Anne E. Kovas, Dawn M. Peters, Kyle Hart, J. Lucas Williams, Bentson H. McFarland
    Vol. 17, Issue 7, p824–835
  1. Findings from this study suggest that on average, patients with chronic pain who initiate prescription opioids are less likely to experience sustained improvements in pain intensity compared to patients who do not initiate opioids. Can we conclude that opioid medications cause worse pain? What are some alternative explanations for this finding?
  2. One of the study’s findings was that patients with higher disability ratings were less likely to show improvement in pain intensity over time. How might higher levels of disability or disability ratings impact pain outcomes?
  3. In this study, patients with low back pain, neuropathy, or fibromyalgia were less likely to experience reductions in pain intensity. How might pain treatments be optimized for older patients diagnosed with these chronic pain problems?
  4. This study assembled a cohort of patients age 65 years or greater. To what extent would you expect findings to replicate in younger adult populations?
  5. In order to construct the sample for this study, the investigators applied a number of inclusion and exclusion criteria. Discuss how these criteria might impact the generalizability of the results to patients in your practice.
  6. Discuss potential ways practitioners might incorporate the findings into their decision making or communications with patients. Are there ways that interpretation or misinterpretation of this article could harm patient care?
  7. If you wanted to design a research study that builds on the methodology and results of the current study, what would you do?

  1. Differences in pain coping partially account for race differences in experimental pain sensitivity. What other factors might contribute to these race differences? How might researchers examine these other factors?
  2. On average, Black Americans engage in pain-related catastrophizing and prayer more than White Americans. How might this information be used by clinicians to provide culturally sensitive pain care?
  3. This study examined age, gender, and type of coping as possible moderators of race differences in pain coping. What other factors might influence the relationship between race and pain coping?
  4. Although catastrophizing is often associated with worse pain-related outcomes, the communal model of catastrophizing suggests that it may be useful in eliciting help and support from others. Given this apparent paradox, how should clinicians address catastrophizing in their pain patients? Moreover, given that cultures differ in their emphasis on individualism vs. collectivism, how might a patient’s racial/ethnic background influence how clinicians address pain-related catastrophizing?
  5. Results of this study indicated that, on average, Black Americans report using passive coping strategies more frequently than White Americans. Given that passive coping is associated with worse pain-related outcomes, how might clinicians encourage their patients to take a more active approach? What active strategies should clinicians facilitate in particular?
  6. This study examined differences in pain coping between Black and White Americans. What differences might you expect for other racial or ethnic groups?

  1. This review is intended to inform the provision of culturally-sensitive pain care to Hispanic patients. What parts of the review came as a surprise to you? Was there anything that you disagreed with?
  2. This article discusses how stereotypes and biases about Hispanic Americans might influence pain care. What are some examples of stereotypes and biases – general and pain-specific – that you have heard about Hispanic Americans? How might (did) these influence providers’ pain management decisions?
  3. One limitation discussed in this review is that the information may not translate to all Hispanic Americans due to differences in their country of origin. How might we ensure that clinicians provide culturally-sensitive care for patients of different countries of origin?
  4. Although Hispanic Americans report greater pain sensitivity and are at greater risk for developing chronic pain, they generally report less chronic pain than non-Hispanic Whites in national surveys. The authors discuss several factors that may account for these differences (e.g., cultural beliefs, familial models of pain, age differences). What other factors contribute to these seemingly contradictory findings?
  5. Hispanic Americans experience significant challenges to seeking pain care relative to other racial/ethnic groups. What do you think can be done – at the patient, provider, and system level – to reduce these barriers to care? How can providers work within the existing situation to enhance pain care for Hispanic patients?
  6. This review focused on the pain experience of Hispanic Americans, but many of the relevant issues cut across multiple health domains, not just those associated with pain. What parts of the review seemed particularly relevant to other areas of health for Hispanic Americans?

  1. Findings from the review indicate that motivational interviewing improves adherence to chronic pain treatment in the short term. How could this knowledge be used to improve current chronic pain treatments?
  2. The review showed that although motivational interviewing seemed to lead to increased adherence to chronic pain treatments, it is unclear if this translates to treatment outcomes, such as improvements in disability. Why might an intervention that improved adherence to treatment not translate into better patient outcomes?
  3. A number of theoretical models propose that adherence to treatment mediates the relationship between readiness to change pain related behaviour and treatment outcomes. Do the current findings support this idea and what might be the mechanisms through which motivational interviewing improves adherence to treatment?
  4. The review looked at the data of empirical studies that used different chronic pain treatments among different chronic pain populations. Is this important to consider when interpreting the reviews findings? How might this affect the relevance of the outcomes for people involved in multi-disciplinary pain management programs?
  5. The authors argue that adherence to treatment is only important if it results in improved pain outcomes, such as improvements in disability, depression or pain intensity. What does this review say about whether or not motivational interviewing is likely to improve patients' functioning?
  6. The review highlights the need to understand the potential mechanisms through which adherence to chronic pain treatment impacts on pain outcomes. How would you design a research project that investigated these processes? For example, what methodology might you use? What measures might be important?
  7. On the basis of these results, should motivational interviewing be routinely incorporated into the care of patients with chronic pain? Why or why not?

  1. Increasing evidence shows that looking at one's own body induces analgesia. However, this effect seems to be modulated by the feeling of ownership felt toward a body part and not by the actual ownership. Why is this latter aspect so important?
  2. The article shows that physiological responses to painful stimulation can be modulated differently respect the perceptual experience of pain. Which index should be considered first and why?
  3. The current paper finds that vision of an enlarged body reduces physiological responses to pain. How can be employed this effect in clinical settings?
  4. Findings from this paper have been obtained with acute pain stimulations in healthy participants. What do you expect from patients suffering from chronic pain?
  5. This paper promotes the use of Virtual Reality in possible future pain treatments. What is still missing before testing similar paradigms with patients?
  6. Research results reveal novel links between pain and self-consciousness. This is relevant either for inventing novel treatments as well as for a deeper comprehension of self-consciousness mechanisms. Discuss the possible implications.

  • Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

    Practice Guidelines
    Roger Chou, Debra B. Gordon, Oscar A. de Leon-Casasola, Jack M. Rosenberg, Stephen Bickler, Tim Brennan, Todd Carter, Carla L. Cassidy, Eva Hall Chittenden, Ernest Degenhardt, Scott Griffith, Renee Manworren, Bill McCarberg, Robert Montgomery, Jamie Murphy, Melissa F. Perkal, Santhanam Suresh, Kathleen Sluka, Scott Strassels, Richard Thirlby, Eugene Viscusi, Gary A. Walco, Lisa Warner, Steven J. Weisman, Christopher L. Wu
    Vol. 17, Issue 2, p131–157
  1. Several recommendations in the guideline are graded as strong recommendations but are based on low quality evidence. Discuss factors that can lead to strong recommendations in the face of low quality evidence and how low quality evidence might impact how recommendations are implemented.
  2. The guideline recommends that clinicians offer multimodal analgesia for management of postoperative pain. What is the rationale for multimodal analgesia and how is it done in clinical practice?
  3. Physical modalities such as TENS and cognitive behavioral therapies are recommended as adjuncts to pharmacological therapy for management of postoperative pain? Are such modalities currently being utilized in your practice, and if not, what are some barriers to use?
  4. Management of postoperative pain in patients on long-term opioid therapy is a particular challenge, yet evidence to guide optimal management in such patients is lacking. What are some approaches to manage such patients?
  5. The guideline recommends that clinicians consider a preoperative dose of celecoxib in patients without contraindications. Should this recommendation be extrapolated to nonselective NSAIDs? Why or why not?
  6. Neuraxial therapies are recommended for major thoracic and abdominal procedures. What factors might inform decisions regarding use of epidural analgesia versus spinal analgesia?

  • Cognitive-Behavioral–Based Physical Therapy for Patients With Chronic Pain Undergoing Lumbar Spine Surgery: A Randomized Controlled Trial

    Full length article
    Kristin R. Archer, Clinton J. Devin, Susan W. Vanston, Tatsuki Koyama, Sharon E. Phillips, Steven Z. George, Matthew J. McGirt, Dan M. Spengler, Oran S. Aaronson, Joseph S. Cheng, Stephen T. Wegener
    Vol. 17, Issue 1, p76–89
  1. There is evidence supporting a biopsychosocial approach to postoperative care. Discuss potential ways in which practitioners can address the psychosocial factors that are often associated with poor surgical outcomes in patients with musculoskeletal conditions.
  2. Findings from the article suggest that a phone-based cognitive-behavioral based physical therapy program has the potential to decrease disability and pain and increase general health in patients after lumbar spine surgery. Given the structure of your current health care system, how could this program be implemented in routine patient care? What are the barriers and facilitators to using this program in a clinical setting from both a patient and practitioner perspective?
  3. The present investigation examined the efficacy of the CBPT program in adults with chronic pain undergoing lumbar spine surgery. Would you expect similar or discrepant findings in other chronic pain populations undergoing surgery, such as cervical spine surgery or total joint arthroplasty? Explain.
  4. CBPT participants demonstrated greater improvement in back and leg pain and pain interference with activity compared to the Education group. What are some ways the CBPT program could be modified to obtain improvements in pain that were both statistically significant and clinical meaningful?
  5. Individuals with high fear of movement were targeted in this trial in order to focus on adults at-risk for poor surgical outcomes. What are the benefits and drawbacks of conducting targeted rehabilitation trials? In your opinion, are targeted rehabilitation interventions more likely to result in effective and clinically relevant treatment?
  6. Discuss the implications of physical therapists and other health care providers, such as nurses and dental hygienists, delivering cognitive-behavioral techniques. How might this affect your current health care system? What are the ways in which this cognitive-behavioral-based delivery approach may be beneficial or harmful to patient care?

  1. Results from this study indicate that depressed mood, reduced endogenous pain inhibition, and poor cervical extensor muscle endurance predict the future development of chronic neck pain in otherwise healthy office workers. Discuss how these findings could be utilized by clinicians in an occupational health or primary health care setting for primary prevention of chronic neck pain. Identify benefits and potential barriers to clinical implementation of these findings.
  2. Identify tests and measures used to evaluate central pain processing in current clinical practice. Discuss the validity and feasibility of DNIC as a clinical screening tool for impairments in endogenous pain inhibition. What additional research is necessary to validate this or other diagnostic tests for impaired pain processing in routine clinical practice?
  3. Discuss how physical activity might contribute to each of the identified risk factors for new onset, chronic neck pain. What are the implications of these relationships, if any, for primary prevention of chronic neck pain?
  4. This study investigated predominately female, healthy office workers. Discuss to what extent the risk factors for new onset chronic neck pain identified in this population may be relevant to secondary prevention of chronic neck pain in patients seeking medical care for an acute neck injury. What similarities or differences in risk for chronic pain might be expected for individuals with and without existing neck pain?
  5. This study found that poor neck muscle endurance increases the risk of new onset chronic neck pain in office workers. Discuss the relationship between muscle fatigue and pain, and identify other populations or pain conditions in which muscle fatigue may have a contributing role.
  6. This study found that subclinical levels of depressed mood increase the risk of new onset chronic neck pain in office workers. Discuss the implications of this finding for primary and secondary prevention of chronic pain.

  1. In the current study, participants high in pain catastrophizing and pain-related fear reported greater increases in pain to a non-noxious stimulus only after pain had been induced in a distal part of the body. This led to the occurrence of pain in an anatomically distinct and injury-free region of the body. What are the implications for the treatment of acute and chronic pain patients?
  2. Findings from the article suggest that pain catastrophizing and pain-related fear might be risk factors for the experience of pain in response to non-noxious stimuli. How can these risk factors be effectively assessed and combatted?
  3. Why does the pain response to the non-noxious stimulus only increase after pain is induced in a distal site of the body?
  4. Findings from the article suggest that the pain response increases in the absence of tissue damage. How can the pain response increase in the absence of tissue damage and what roles do pain catastrophizing and pain-related fear play?
  5. A respectable amount of evidence suggest that pain catastrophizing and pain-related fear can exacerbate the experience of pain. How do the findings of the current study extend this evidence?
  6. What are the pros and cons of using a prospective design with delayed-onset muscle soreness, and what are the implications for treatment of chronic pain conditions?

  • Moving Toward Conscious Pain Processing Detection in Chronic Disorders of Consciousness: Anterior Cingulate Cortex Neuromodulation

    Antonino Naro, Antonino Leo, Placido Bramanti, Rocco Salvatore Calabrò
    The Journal of Pain, Vol. 16, Issue 10, p1022–1031
  1. In this work a transcutaneous electric stimulation paradigm was used in order to evoke cortical responses related to Aß, Ad, and C-fiber activation. Compare this approach with the laser stimulation paradigms usually employed in assessing nociceptive pathways.
  2. One important finding in this work consisted of the possibility to induce pain relief following rTMS over ACC. Discuss the possible applications in pain relieving treatments.
  3. Another important finding referred to the possibility of differentiating UWS from MCS patients and identifying false UWS individuals, who should more appropriately be considered as suffering from fLIS. Discuss the ethical relevance of such a finding.
  4. Discuss about the diagnostic and prognostic relevance of the finding referenced in question number 3.
  5. Compare passive and active approaches aimed at assessing aware pain perception in DOC patients.
  6. Comparatively discuss electrophysiological and fMRI findings concerning the role of ACC in aware pain perception.
  • Long-Term Outcome of the Management of Chronic Neuropathic Pain: A Prospective Observational Study

    Dwight E. Moulin, A. John Clark, Allan Gordon, Mary Lynch, Patricia K. Morley-Forster, Howard Nathan, Cathy Smyth, Cory Toth, Elizabeth VanDenKerkhof, Ammar Gilani, Mark A. Ware
    The Journal of Pain, Vol. 16, Issue 9, p852–861
  1. Recent surveys suggest that neuropathic pain is more common than previously reported. What is the prevalence of neuropathic pain in the general population, and what proportion is of central origin vs peripheral origin?
  2. Several evidence-based guidelines for the management of neuropathic pain have been developed. Many of these guidelines are based on number-needed-to-treat (NNT) methodology. What are some of the limitations of NNT methodology based on randomized controlled trials?
  3. Long-term observational cohort studies can determine the real-world clinical effectiveness of various treatment modalities in the management of neuropathic pain. What are some of the strengths and weaknesses of these long-term observational studies?
  4. What clinical factors at baseline predict a poor outcome at 12-month follow-up in the management of neuropathic pain?
  5. Based on this observational study, what percentage of neuropathic pain patients are likely to attain clinically significant improvement in pain and function at 12-month follow-up?
  6. Opioid analgesics remain controversial in the management of neuropathic pain. Based on randomized controlled trials, what is the range in the NNT for the management of neuropathic pain? What was the response rate to opioid treatment in this observational study?

  • Placebo Analgesia Enhances Descending Pain-Related Effective Connectivity: A Dynamic Causal Modeling Study of Endogenous Pain Modulation

    Landrew S. Sevel, Jason G. Craggs, Donald D. Price, Roland Staud, Michael E. Robinson
    Vol. 16, Issue 8, p760–768
  1. The present investigation examined placebo analgesia in healthy controls. Would you expect similar or different findings in chronic pain patients? Why?
  2. A major finding of the study was that network-based connectivity approaches are needed to reveal the correlates of certain aspects of pain modulation. What implications does this have for future studies of pain processing and modulation?
  3. Results of this investigation indicate that placebo analgesia is associated with decreases in right hemisphere DLPFC →PAG coupling. Would you expect this association to also be present in the left hemisphere? Why or why not?
  4. Given the data presented here, what do you think are the next steps in placebo analgesia research?
  5. Findings from the article suggest that neural processes underlie even small placebo effects. How might these findings impact your conceptualization of the ethical implications of use placebo in clinical settings?
  6. Compared to some previous investigations, the manipulation used in the present study produced relatively small placebo effects. Clinically, are there situations in which this would be ideal? Explain.

  1. Discuss the ethical implications of responding to patient's questions about cannabis analgesia in states without legislation permitting possession and use of cannabis for medical purposes.
  2. Discuss guidance you might provide to patients who inquire about the efficacy of cannabis for medical disorders.
  3. Cannabis may be efficacious for some types of neuropathic pain. Discuss the guidance you, as the patient's physician, might offer to inquiries about safety considerations for use of cannabis, in those states permitting access to this agent for medical purposes.
  4. This study showed a dose-dependent reduction in pain. However, there was also a dose-dependent worsening of psychometric testing. Discuss how this will limit the use of medicinal cannabis to treat chronic pain. How would it compare to other FDA-approved agents on the market.
  5. This study used cannabis high in THC, low in CBD. Discuss potential effects of cannabis high in CBD and low in THC.
  6. This study used inhaled vaporization of the cannabis leaf. Discuss the pros and cons of the different delivery methods of cannabis.

  1. Discuss the strengths and weaknesses of various approaches to calculate opioid dose. How were daily morphine equivalent dose (MED) and total MED over a 6-month interval calculated in this study? Is daily dose simply a linear transformation of the total MED?
  2. MED is a standard approach used to define higher risk dosage levels of opioids. Based on this study, what is the disadvantage of considering only daily MED when assessing drug overdose risk?
  3. What is the rationale for considering any drug overdose instead of only opioid overdose as the outcome?
  4. What are the study’s implications for clinicians and health care policy makers to reduce the risk of opioids?
  5. What statistical model was used in this study to take into account the longitudinal/changing nature of the data? What are the strengths and weakness of this approach?

  1. Discuss the strengths and weaknesses of various approaches to calculate opioid dose. How were daily morphine equivalent dose (MED) and total MED over a 6-month interval calculated in this study? Is daily dose simply a linear transformation of the total MED?
  2. MED is a standard approach used to define higher risk dosage levels of opioids. Based on this study, what is the disadvantage of considering only daily MED when assessing drug overdose risk?
  3. What is the rationale for considering any drug overdose instead of only opioid overdose as the outcome?
  4. What are the study’s implications for clinicians and health care policy makers to reduce the risk of opioids?
  5. What statistical model was used in this study to take into account the longitudinal/changing nature of the data? What are the strengths and weakness of this approach?

  • Online Extra
    Physical and Psychological Correlates of Fatigue and Physical Function: A Collaborative Health Outcomes Information Registry (CHOIR) Study

    John A. Sturgeon, Beth D. Darnall, Ming-Chih J. Kao, Sean C. Mackey
    Vol. 16, Issue 3, p291–298.e1
  1. The current study proposes multiple factors that contribute to fatigue, though considerable variance remains to be explained in this construct. What other biological or psychological factors might contribute to fatigue, beyond those discussed in the current study?
  2. Other than fatigue, discuss potential mediating factors that might explain the relationship between pain and physical dysfunction. How else might chronic pain lead to decreases in physical function?
  3. Though fatigue appears to be a significant mediator of pain-related dysfunction in most pain conditions included in the current study, there is prior evidence of more pronounced fatigue in certain conditions, due either to specific disease processes or to treatments for the medical condition itself. In which pain conditions might fatigue play a more prominent role?
  4. Some researchers have suggested that some aspects of fatigue may not be accurately represented through retrospective self-report. Discuss alternative strategies for measuring or examining fatigue.
  5. The path model presented in the article suggests that pain intensity itself has, at most, a small effect on fatigue. What implications might this finding have for clinicians and researchers?
  6. What is the value of using a computerized adaptive testing (CAT) approach over more traditional classical testing assessments? How might this approach be important in the context of clinical care?
  7. How might the use of medications either worsen or improve the problem of fatigue in chronic pain?
  8. What are the potential benefits to testing a path model, like the one in the current study, using longitudinal (time-series) data, rather than a cross-sectional model? How would testing these relationships across time improve the interpretability of the current findings?
  9. What sex-specific factors might predict differences in fatigue between men and women with chronic pain?

  1. What is the formula for calculating the NNT? What does the NNT actually mean?
  2. What happens to the NNT in a clinical trial where the response to treatment remains the same as a previous trial, but the response to placebo increases? Does this scenario have implications for the usefulness of the NNT to characterize the efficacy of this treatment?
  3. All summary measures are a convenient fiction. What are some problems inherent in using the NNT as a summary measure of efficacy? Which of these problems are inherent to all summary measures (such as the group mean difference), and which are more specific to the NNT?
  4. Comparisons of the efficacy of treatments are often made by conducting meta-analyses of the studies of each treatment (usually compared to placebo) and comparing estimates of efficacy derived from the meta-analysis. This method assumes that there are no factors influencing the efficacy results of the studies that differ systematically from one treatment to another. What types of variables could influence the results of one clinical trial compared to another, aside from the treatments themselves?
  5. What are the implications for the validity of meta-analysis if these known or unknown factors systematically influence the results of the trials of these different medications?
  6. What is the most robust method for comparing the efficacy of one treatment to another?

  • Effectiveness of Jyoti Meditation for Patients With Chronic Neck Pain and Psychological Distress—A Randomized Controlled Clinical Trial

    Michael Jeitler, Stefan Brunnhuber, Larissa Meier, Rainer Lüdtke, Arndt Büssing, Christian Kessler, Andreas Michalsen
    Vol. 16, Issue 1, p77–86
  1. Chronic neck pain has a high prevalence and is frequently associated with modern lifestyle and distress. Discuss potential ways and mechanisms by which lifestyle can cause or promote chronic neck pain.
  2. Meditation has a worldwide tradition in spiritual and religious contexts but is now frequently applied in medicine. What are some putative mechanisms by which meditation practice results in pain reduction?
  3. Findings from the article suggest that practice of meditation has a selective effect on pain intensity and pain-related botheration but not on function and quality of life. Discuss potential reasons for this dissociation of effects.
  4. Which percent changes of pre- and posttreatment differences using a pain VAS are associated with patient ratings of “very much improved” or “substantially improved,” according to the IMMPACCT consensus statement?
  5. A limitation of the present trial was the higher-than-expected dropout rate. Discuss the possible reasons for noncompletion of the study trial and nonadherence with the study interventions (meditation and exercise).
  6. As current treatment options for chronic neck pain are limited, the future implementation of stress reduction techniques as meditation appears useful. What institutional and patient-related barriers exist in utilizing meditation in routine patient care?
  7. There are numerous meditation techniques that exist worldwide. Some techniques are named according to their conceptual approach (mindfulness mediation, focused and concentrative techniques, mantra meditation), and some are named according to their tradition (Zen meditation, jyoti meditation). Discuss your knowledge of the basic technical and conceptual concepts of meditation.

  • The Associations Between Preexisting Mental Disorders and Subsequent Onset of Chronic Headaches: A Worldwide Epidemiologic Perspective

    Ronny Bruffaerts, Koen Demyttenaere, Ronald C. Kessler, Hisateru Tachimori, Brendan Bunting, Chiyi Hu, Silvia Florescu, Josep Maria Haro, Carmen C.W. Lim, Viviane Kovess-Masfety, Daphna Levinson, Maria Elena Medina Mora, Marina Piazza, Patryk Piotrowski, Jose Posada-Villa, Mohammad Salih Khalaf, Margreet ten Have, Miguel Xavier, Kate M. Scott
    Vol. 16, Issue 1, p42–52
  1. The study findings showed that a wide range of preexisting mental disorders systematically increases the odds of chronic headaches. Most patients with chronic headaches consult nonpsychiatric practitioners. How can nonpsychiatric practitioners discuss the importance of emotional problems with their patients? Which patient-related, practitioner-related, and health system-related barriers should be overcome?
  2. Findings from the present study but also other studies suggest that impulsive behaviors or symptoms may be young-age markers that increase the subsequent onset of chronic conditions such as headaches, ulcer, diabetes, or hypertension. In the light of a biopsychosocial perspective, are there other early-age markers of chronic somatic conditions that clinicians should take into account?
  3. Our findings come from representative population-based samples. Would you expect similar associations in clinical samples? Explain why or why not.
  4. Although we found an association between preexisting impulsive disorders and the subsequent onset of chronic headaches, a similar association between substance abuse disorders and the subsequent onset of chronic headaches was not found. Discuss possible reasons for this.

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


  1. The article reports that the magnitude of placebo analgesia in children appears to be much greater than in adults. What possible reasons might there be for this finding?
  2. The article reports that girls were more responsive than boys to placebo analgesia for pain threshold. What mechanisms might contribute to this gender difference?
  3. Given that children appear to show very large responses to placebo analgesia, what practical implications might this have for clinical care?
  4. What are the ethical considerations associated with the use of placebo analgesics in the routine clinical care of children?
  5. What are some possible nondeceptive ways to administer placebos to children? And what sorts of suggestions should accompany the administration of the placebos?
  6. The findings from the article challenge the simple view of interpolating adult findings to the pediatric population and suggest that it may be important to differentiate between subgroups. Discuss potential cognitive and social-affective neurodevelopment phase criteria that could be associated with the magnitude of placebo analgesia in children.
  7. The present investigation examined placebo analgesia in healthy children. Would you predict similar or discrepant findings from children with (a) acute local pain? (b) acute global pain? or (c) chronic pain?
  8. How could children’s meaning systems, preconcepts, and expectations of analgesia be assessed (eg, nonverbally) in order to facilitate the acceptance of individualized suggestions and to optimize treatment outcome?
  9. Discuss possible alternative pain assessment designs that are more intuitive and real-time, less language dependent, and applicable within the clinical context.

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


  1. The efficacy of opioid therapy for chronic noncancer pain has received a lot of attention lately. What are the pros and cons of prescribing chronic opioid therapy for noncancer pain?
  2. How would you define opioid misuse, opioid abuse, addiction, dependence, tolerance, and pseudoaddiction?
  3. Attempts have been made to identify those individuals who are prone to misuse opioids. What measures currently exist to determine risk of opioid misuse and what are the primary risk factors for opioid misuse based on the current literature?
  4. What are the accepted treatment guidelines for carefully monitoring patients on opioid therapy?
  5. It has been recommended that all patients taking prescription opioids on a long-term basis sign an opioid agreement. What are the main components of this agreement? What is this agreement intended to do? Is this a legally binding agreement and what are the implications for the patients and providers?
  6. What are the primary ways to validate a self-report measure? What are the differences between construct validity, cross-validation, internal consistency, test-retest reliability, and sensitivity and specificity of a measure?
  7. How could a measure such as the Opioid Compliance Checklist be used in a clinic setting? Could the use of this measure influence the prescribing habits and confidence of a treating physician?

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


  1. The paper raises some interesting questions with regard to potential interaction effects and causality. For example, obese individuals are more likely to have persistent pain and, consequently, may be more likely to have activity limitations and experience depression. How might you distinguish between those whose pain is primarily a function of other factors, such as obesity, and therefore could be treated by focusing on that factor, and those whose pain is the root cause? How would this affect treatment options?
  2. This analysis shows that those with persistent pain are more likely to take medications for anxiety or depression. What are the implications of exposing patients to such drugs, which have a moderate to high abuse potential? What are some alternative treatment strategies that could be implemented in order to better treat this comorbid population avoid such exposure?
  3. Can pain prevalence estimates help to reorient treatment priorities? Do all of the 39.4 million adults reporting persistent pain require ongoing medical treatment? How would this affect other primary and specialty care practice?
  4. The article focuses on the measurement of persistent pain in the adult population, using general survey measures of self-reported pain over a discrete (3-month) time period. What are the advantages and disadvantages of using this approach to measure pain prevalence, as opposed to estimating the prevalence of chronic conditions like osteoarthritis?
  5. Persistent pain is highly correlated with disability—an estimated 60.6% of working-age adults who say they are unable to work due to a chronic condition or disability also reported persistent pain. How can pain management be integrated with vocational rehabilitation programs designed to help people with disabilities enter or re-enter the workforce?
  6. Over half of survey respondents with persistent pain said their pain was sometimes “unbearable and excruciating.” What individual factors affect perceptions regarding persistent pain? How can providers help persistent pain patients reduce the frequency, intensity, and duration of acute episodes?

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


  1. The authors argue that empathy is a multidimensional concept. They focus their investigations on only one such ditention. What are the other components of empathy, how could they have affected the results, and what experimental challenges may have prevented the researchers from studying them?
  2. What dimensions of attachment do the authors use to distinguish their participant groups? What methods do they use to sample participants for these groups? How are these dimensions of attachment expressed in childhood and in adult life, and how do they relate to mental health?
  3. Of the 3 indicators of pain—pain tolerance, pain rating, facial expression—partner empathy affected only 1. Which was it? What does this tell us about the relationship between these indicators of pain?
  4. What did the authors predict about the interaction between attachment style of the person experiencing pain and perceived empathy from her/his partner? What did they actually find?
  5. The conventional understanding of empathy of 1 member of a couple toward the other member in pain invokes social support. What alternative frameworks did the authors suggest on the basis of their results? Do any of these ideas resonate with other clinical, educational, or parenting phenomena?
  6. What distinctions between experimental and clinical pain do the authors make in recommending caution about generalizing to clinical settings?
  7. The authors tested romantic couples in a particular culture. What differences in the results would you predict if they had tested different dyads, such as friends, health professionals and patients, and people from different cultures?

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

  1. There have been a few established postoperative analgesic methods for hip arthroplasty (HA), including epidural analgesia, spinal analgesia, intravenous patient-controlled opioid analgesia, and peripheral nerve blocks. Please discuss why more analgesic regimens are desirable.
  2. What is local infiltration analgesia (LIA)? What other types of operations would benefit from LIA or similar analgesic methods, other than HA or KA (knee arthroplasty)?
  3. There is no unified and standardized procedure for LIA, although it has been applied in many patients. The first heterogeneity is the technique for LIA, namely whether postoperative LIA should be added to the intraoperative LIA. For postoperative LIA, the choice of bolus infiltration or continuous infusion, the timing of administration of the bolus dose, and the optimal catheter placement site also need to be considered. The second heterogeneity is the diversity in local anesthetics with or without adjuvants (eg, epinephrine, ketorolac, and opioids). Has LIA been used in your clinical practices? Which procedures do you usually use in your work?
  4. In addition, the present study indicates that LIA could not increase the risk of adverse events (AEs) compared with placebo infiltration or no infiltration and might be superior to conventional analgesic methods with lower risk of AEs. Which AEs can LIA induce in clinical practices? And which methods can be carried out to avoid these AEs or decrease their incidence?
  5. So far, the strength of correct conclusions about the efficacy of LIA is weakened by the heterogeneities. One of the heterogeneities is the diversity of time points and outcome measures for evaluating the efficacy of LIA. Which time points and outcome measures do you think are the most suitable or should be taken for evaluating the efficacy of LIA? Do you think it is necessary to distinguish the efficacy of LIA at rest and with motion?
  6. LIA also provides effective analgesia in the initial postoperative period after KA. Is HA the only setting in which LIA helps? Does LIA offer real benefit for KA? What differences do you think there are in the efficacy of LIA on HA and KA? What are the reasons?
  7. The aim of the HA and postoperative pain control is to provide painless conditions for patients to mobilize as early as possible and for joint function recovery. Early mobilization and short hospital stays are considered to be important endpoints of joint function recovery. Not only is LIA effective for pain control, but it also facilitates patients’ mobilizing early and returning to function quickly. However, future large-sample RCTs must be performed before a concrete conclusion about LIA on joint function can be drawn, considering the low attention paid to the latter in current RCTs. Do you think that LIA facilitates hip function recovery based on your clinical practices and experiences? Which outcome measures do you apply to evaluate the efficacy of LIA on hip function?



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

  1. This is one of the first studies to use implicit priming to examine the influence of patient race on pain perception below the level of conscious regulation.
       a) Discuss this methodology.
       b) What does this methodology offer that traditional methods (eg, vignette studies with explicit presentation of patient race) do not?
       c) In what other ways might implicit methods be useful to disentangle mechanisms leading to disparities in treatment?
  2. Discuss the main findings.
       a) How do you interpret the interaction between prime type and patient race (Figure 2)?
       b) What does this imply about the nature (eg, stability, automaticity, context-dependence) of racial bias?
       c) Findings suggest that automatic processes influence pain perception and response. What are some of the broader implications of this finding?
  3. Similar to findings using implicit priming in other scientific fields, results from the implicit priming condition better approximate patterns of bias observed in real-world interactions (eg, racial disparities in pain treatment).
       a) Discuss the interplay between automatic and deliberate processing of race within clinical settings. How might both automatic and deliberative processes contribute to racial bias in clinical interactions?
       b) Under what conditions might automatic processes strongly influence behavior?
       c) Under what conditions might behavior be more strongly influenced by consciously regulated and deliberate processes?
       d) How might this study inform future studies and interventions to address the complex processing of race in real-world settings?
       e) How might they inform strategies to reduce disparities in pain?
  4. Discuss how explicit evaluation of racial bias in pain perception may underestimate effects of bias on behavior.
  5. Researchers found that perceiver race also influenced pain perception, with African American study participants being more perceptive of and responsive to pain than European American study participants in the implicit condition. What factors might influence this difference? Why might African American participants be more perceptive of the pain of others? Might some of these factors suggest other potential interventions to increase pain perception and response among people across races?
  6. Disparities in pain treatment are well documented, thanks to the combined efforts of several researchers and clinicians over several decades. However, despite increased awareness of these disparities, disparities appear to persist. How might the results from this study help inform the problem of (and potential solutions for) persistent disparities in pain?



  • Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

    Roger Chou, Ricardo A. Cruciani, David A. Fiellin, Peggy Compton, John T. Farrar, Mark C. Haigney, Charles Inturrisi, John R. Knight, Shirley Otis-Green, Steven M. Marcus, Davendra Mehta, Marjorie C. Meyer, Russell Portenoy, Seddon Savage, Eric Strain, Sharon Walsh, Lonnie Zeltzer
    The Journal of Pain, Vol. 15, Issue 4
  • Methadone Overdose and Cardiac Arrhythmia Potential: Findings From a Review of the Evidence for an American Pain Society and College on Problems of Drug Dependence Clinical Practice Guideline

    Roger Chou, Melissa B. Weimer, Tracy Dana
    The Journal of Pain, Vol. 15, Issue 4
  • Research Gaps on Methadone Harms and Comparative Harms: Findings From a Review of the Evidence for an American Pain Society and College on Problems of Drug Dependence Clinical Practice Guideline

    Melissa B. Weimer, Roger Chou
    The Journal of Pain, Vol. 15, Issue 4

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

  1. Methadone is an opioid, but it differs from other opioids in several important ways. Discuss key unique properties of methadone and how they may contribute to increased risk of serious adverse events.
  2. Epidemiologic evidence indicates that overdoses related to methadone use have increased substantially. What are some factors that make it difficult to interpret the epidemiologic evidence?
  3. The Guideline provides recommendations for safer prescribing of methadone in both patients with chronic pain and those with addiction. What are some ways that management of patients prescribed methadone for chronic pain or for addiction might differ?
  4. The Guideline recommends ECG monitoring in patients prescribed methadone. What are some potential barriers to use of ECG monitoring, particularly in addiction settings? Are there possible unintended negative consequences, and ways to mitigate such unintended consequences?
  5. Buprenorphine is a potential alternative to methadone for patients with opioid addiction, and a number of alternative opioids are available for management for chronic pain. When is methadone an appropriate medication for these conditions, and in what situations might an alternative opioid be the preferred option?
  6. The Guideline was developed by a multidisciplinary panel with support. How does the composition of a Guideline development group affect your assessment and use of a Guideline?
  7. Many of the recommendations in the Guideline are based on relatively weak evidence. What threshold of evidence should be required when the focus is on enhancing patient safety? What kind of evidence is available to support ECG monitoring for other drugs associated with QTc interval prolongation? Should guidelines wait until better evidence is available?
  8. A number of research gaps have been identified with regard to methadone safety. Discuss key research gaps and how answering them might better inform safer prescribing of methadone.




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

  1. The authors of this article make a point about how cultural assumptions, habits in language, and the words we use to categorize events can influence how we approach our work. Discuss possible ways that cultural influences or language habits might influence your work, whether in the clinic or in research.
  2. What the authors call the "traditional cognitive behavioral" model was meant to both fully encompass the core feature of the operant behavioral model and to extend these. See if you can detect whether there are any key features of the operant model that have perhaps been lost or de-emphasized with the greater emphasis on cognitive features in current treatments.
  3. In the article, the relationship between the biopsychosocial (BPS) model and psychological or psychosocial models is discussed briefly. Carrying on from this discussion, what are some of the advantages and disadvantages of the BPS model? What might be missing from this model as a guide for research in some of the specific fields of study related to pain?
  4. One idea raised in the article is that the theories and models that organize our work typically have underlying philosophical assumptions, such as analytic goals, the nature of knowledge, a model of causality, and assumptions about the nature of reality. Discuss whether your work is guided implicitly or explicitly by such assumptions and identify them.
  5. Both traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) can be regarded as behavioral AND cognitive therapies. See if it is possible to identify and summarize the differences in how traditional CBT and ACT define the role of cognition in human functioning and in how they then propose to address it in treatment.
  6. If or when treatment models shift in an area, like in the area of psychological treatments for chronic pain, what types of potential barriers in dissemination, implementation, and training can arise? How might some of these be addressed?



  • Use of S-LANSS, a Tool for Screening Neuropathic Pain, for Predicting Postherpetic Neuralgia in Patients After Acute Herpes Zoster Events: A Single-Center, 12-Month, Prospective Cohort Study

    Soo Ick Cho, Cheol Heon Lee, Gyeong-Hun Park, Chun Wook Park, Hye One Kim
    The Journal of Pain, Vol. 15, Issue 2

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

  1. Discuss why neuropathic pain such as PHN happens frequently in old age.
  2. Pain assessments, including S-LANSS, mostly depend on patient subjectivity. Discuss any helpful tips for evaluating the pain more objectively.
  3. In the paper, the pain items dysesthesia, paroxysmal, allodynia, and tender/numb showed strong relationship with PHN, while evoked and thermal pain did not. Discuss the results related to the pathophysiology of PHN.
  4. Findings from the paper suggest that the severity of skin rash does not independently predict PHN in the patients. What do you think of this result?
  5. Do you think the mechanisms of PHN and subacute herpetic neuralgia are different?
  6. Based on the findings from this study, patients with PHN had diabetes mellitus more frequently than those without it; otherwise, the treatment modalities did not different between the 2 groups after adjusting initial VAS. How do you interpret these results?
  7. Discuss other clinical indications in which the S-LANSS score can be applicable.




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

  1. The review concluded that there was very low quality evidence that advice is ineffective. But most back pain guidelines endorse advice. Why is there an apparent mismatch here?
  2. Presuming that advice is ineffective in reducing pain and disability, might there be other reasons why it could be reasonable to provide advice to a patient with back pain? If you did so, would you still be practicing evidence-based health care?
  3. The authors used the PEDro scale to rate trial quality. Compare and contrast this to the Cochrane Risk of Bias scale.
  4. The information on the application of local heat is based upon a study in 63 participants. Does that seem particularly convincing? How many patients in a trial would you like to see to be convinced? Would you believe one very large trial or would you like to see results replicated?
  5. The evidence for some medicines (eg, diclofenac) is based on studies that have employed a particular dose form. What role does medicine dose form (ie, immediate-release or controlled-release formulations) play on the interpretation and generalizability of evidence?




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

  1. The present review suggests that a trend has emerged in the literature implicating sleep as having causal influence over pain. Critique the methodological strategies that have contributed to this trend and debate whether there is a reciprocal or unidirectional relationship between sleep and pain.
  2. Several studies have now demonstrated increased pain sensitivity following acute sleep deprivation, supporting clinical observations in the field. Weigh the relative merits of sleep deprivation experiments versus ambulatory monitoring as a means of assessing the association of sleep and pain.
  3. Relatively few sleep deprivation studies have included clinical populations. Generate a potentially novel study design that involves sleep deprivation and a clinical population of interest that would advance our understanding of how sleep disruption influences chronic pain outcomes.
  4. The present review highlights dopaminergic and opioidergic signaling, as well as negative and positive affect as potential "mechanisms" of the association of sleep and pain. Discuss other potential mechanisms and how they might complement or advance the literature reviewed in this article.
  5. African Americans have been shown to exhibit worse sleep and heightened pain sensitivity compared to Caucasians. Discuss the biological, psychological, and social factors that might contribute to this robust effect.
  6. How might the study of the association of sleep and pain improve clinical care and long-term outcomes for patients with chronic pain and disordered sleep?



  • Patients' Perception of Postoperative Pain Management: Validation of the International Pain Outcomes (IPO) Questionnaire

    Judith Rothaug, Ruth Zaslansky, Matthias Schwenkglenks, Marcus Komann, Renée Allvin, Ragnar Backström, Silviu Brill, Ingo Buchholz, Christoph Engel, Dominique Fletcher, Lucian Fodor, Peter Funk, Hans J. Gerbershagen, Debra B. Gordon, Christoph Konrad, Andreas Kopf, Yigal Leykin, Esther Pogatzki-Zahn, Margarita Puig, Narinder Rawal, Rod S. Taylor, Kristin Ullrich, Thomas Volk, Maryam Yahiaoui-Doktor, Winfried Meissner
    The Journal of Pain, Vol. 14, Issue 11

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

  1. PAIN OUT is a worldwide operating registry for data on postoperative pain management. Which potential benefits do registries provide compared to randomized controlled trials?
  2. What are advantages and disadvantages of RCTs and registries?
  3. What are the objectives of the PAIN OUT project? What is the benefit for a) participating hospitals and b) the patients treated in those hospitals? Which 3 tools are provided by the project?
  4. Why is it a necessary step in creating a new questionnaire to conduct a validation study? Which 2 psychometric concepts are usually tested in validation studies? Why are they so important for any questionnaire? Which different ways (constructs) do you know to assess these two concepts?
  5. Which translation process was carried out to translate the original English version into all languages required by the PAIN OUT project?
  6. The factor analysis of the IPO questionnaire items resulted in 3 factors constituting the questionnaire. Which are the 3 factors of the IPO?




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

  1. The biopsychosocial model of chronic pain emphasizes the dynamic interplay of biological, psychological, and social factors in the onset and progression of chronic pain conditions. Using a biopsychosocial perspective, discuss why pain-related fear may play an important role in chronic pain processes and disability outcomes.
  2. Meta-analytic calculations indicated that the association between pain-related fear and disability can be classified as moderate to large in magnitude, and results were stable across demographic and pain characteristics. What are some of the clinical implications of this robust association?
  3. Moderator analyses indicated that associations between pain-related fear and disability were stronger when measured with the Physical Activity subscale of the FABQ, relative to the Work subscale. How would you explain this finding? What implications does it have for assessment in clinical practice?
  4. Results of the current study were largely consistent with a fear-avoidance model of chronic pain. What are the main components of the fear-avoidance model? How might the fear-avoidance model inform treatments for persons in pain?
  5. The association between pain-related fear and disability was observed to remain stable regardless of pain duration. How could this information be used to inform treatment of patients with acute pain (eg, immediately following whiplash injury) and patients who have experienced long-standing chronic pain? Do you think pain-related fear is relevant to persons who are pain-free?
  6. Pain-treatment outcomes may be improved by reductions in pain-related fear. What are some relevant psychosocial variables that might influence treatment outcomes? How might future research test, or account for, those variables in the context of associations between pain-related fear and disability?



  • Developing a Model of Associations Between Chronic Pain, Depressive Mood, Chronic Fatigue, and Self-Efficacy in People With Spinal Cord Injury

    Ashley Craig, Yvonne Tran, Philip Siddall, Nirupama Wijesuriya, Judy Lovas, Roger Bartrop, James Middleton
    The Journal of Pain, Vol. 14, Issue 9

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

  1. Findings from our paper demonstrated that self-efficacy has a beneficial mediating influence (that is, cushioning effect) on chronic pain in people with severe neurological injury. More robust levels of self-efficacy were related to lower levels of chronic pain. Why do you think this is so?
  2. What is your understanding of self-efficacy and how could treatment enhance it?
  3. Can you name any other factors that may play a similar beneficial mediating role on chronic pain?
  4. Results shown by the directed regression also suggest that depressive mood and chronic pain negatively influence each other and that self-efficacy also influences this relationship. In what way does self-efficacy influence mood?
  5. While we have not yet analyzed longitudinal data in which we followed people with SCI to clarify the relationship between mood and pain, we did interpret the regression results to suggest that people become depressive when their chronic pain levels increase. Is this a reasonable clinical interpretation?
  6. Fatigue is considered to be a classic symptom of depressive mood. However, while our findings suggested that chronic fatigue was related to mood, results also showed it to be independently related to chronic pain and depressive mood. Does this suggest that chronic fatigue is an independent secondary condition of chronic pain and thus it should not just be considered a side effect of depression?
  7. How do you think the results suggest that people with SCI, chronic pain, and chronic fatigue be best managed?
  8. Why is there a lack of studies investigating best management for people with excessive levels of fatigue in the neurological disorders?
  9. Why do you think self-efficacy has no significant impact on the relationship between chronic fatigue and chronic pain/mood?



  • Are Psychological Predictors of Chronic Postsurgical Pain Dependent on the Surgical Model? A Comparison of Total Knee Arthroplasty and Breast Surgery for Cancer

    Anne Masselin-Dubois, Nadine Attal, Dominique Fletcher, Christian Jayr, Aline Albi, Jacques Fermanian, Didier Bouhassira, Sophie Baudic
    The Journal of Pain, Vol. 14, Issue 8

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

  1. Findings from the paper suggest that state anxiety and 1 dimension of pain catastrophizing, magnification of pain, independently predict pain at 3 months regardless of the surgical model. In your opinion, should these affective variables be systematically assessed preoperatively in all surgical patients? Would it be feasible?
  2. In the paper, neither trait anxiety nor depression independently predicted pain at 3 months in the total sample of patients. Do you think the impact of depression or trait anxiety might be more influenced by the surgical model than that of state anxiety?
  3. Preoperative pain was not predictive of pain at 3 months in the TKA model. What do you think of these results?
  4. Unlike pain magnification, rumination and helplessness, 2 other dimensions of pain catastrophizing, were predictive of chronic postsurgical pain in the TKA model only. Do you think some dimensions of pain catastrophizing could be more linked to the surgical model than others? Could this be because of the presence of chronic preoperative pain in the TKA model?
  5. Despite high dosages of analgesics after surgery, particularly after TKA, pain at 48 hours was highly predictive of pain at 3 months in both the breast and TKA surgical models. What are the practical implications of these results to your opinion?
  6. In multivariate analyses, acute pain was the only variable predictive of pain with neuropathic characteristics. The psychological variables were not predictive. How would you interpret these results?




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

  1. Multiple studies have found that primary care physicians frequently associate discussions about pain with frustration and negative emotions. Based on your knowledge and personal experience, what are some likely reasons for this association?
  2. This study found that discussions about pain were not associated with changes in ratings of physicians' emotions. How might you explain the discrepancies between the prior literature and the findings in this study?
  3. This study analyzed 30-second video clips or "thin slices" to compare ratings of patients' and physicians' affect (displayed emotion) during a single visit and among different visits. This study found that ratings varied substantially over the course of a single visit. What other factors besides discussing pain might account for changes in affect during a clinic visit? Do you think subtle changes in patients' emotions affect communication during visits?
  4. Researchers frequently ask patients and physicians to complete questionnaires to gather data about their emotions, attitudes, or behaviors. In contrast, this study gathered data by rating patients and physicians based on short video clips. What are some advantages and disadvantages of using ratings rather than questionnaires?
  5. A large body of psychological research has shown that positive and negative feelings are discrete emotional phenomena rather than merely opposite ends of a single spectrum. This study found that patients display both greater positive emotions and greater negative emotions when they are discussing pain compared to other topics in the same visit. How do you interpret these findings? What other factors might explain these results?
  6. This study found that patients' report of pain severity is associated with higher ratings of negative emotions for both patients and physicians. How might these negative emotions influence communication about patients' non-pain-related health problems?
  7. Rapport measures the degree of harmony during patient-physician interactions. In contrast to their findings about patient and physician affect, the authors of this study found that discussions about pain had no significant association with ratings of patient-physician rapport. What are some possible explanations for this finding? What role do you think rapport plays during clinic visits? How does rapport differ from patient satisfaction?
  8. Research has shown that vulnerable patient populations such as racial minorities and veterans report more frequent and more severe pain than the general U.S. population. This study focused on low-income black patients. To what extent do you think findings in this study might generalize to other patient groups?



  • Assessing Chronic Pain Treatment Practices and Evaluating Adherence to Chronic Pain Clinical Guidelines in Outpatient Practices in the United States

    Rafia S. Rasu, Rose Sohraby, Lindsay Cunningham, Maureen E. Knell
    The Journal of Pain, Vol. 14, Issue 6

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

  1. This study found that common chronic pain-related visits comprised 13% of the total national ambulatory care visits based on the primary, secondary, or tertiary reasons for visit. Do you feel that more awareness is needed among patients in seeking care? Do you feel that providers need more training to complete proper assessment of chronic pain patients and offer adequate or right treatment for these patients?
  2. The study population included a higher number of Caucasian patients than other races. Discuss potential reasons for this result and what issues practitioners should consider to minimize racial disparities when treating patients with chronic pain.
  3. The majority of chronic pain patient visits in the study population were to primary care providers. In contrast, only .12% of patient visits were to pain specialists. Discuss how this reflects on the practice of treating chronic pain in the United States. In your opinion, what is the role of the primary care provider and the pain management specialist in treating chronic pain? Does this indicate a shortage of pain specialists, or should chronic pain be managed by primary care providers? When should a chronic pain patient be referred to a specialist?
  4. Discuss the estimated use of following treatments in this study population and subpopulations (Figure 1 and Table 3 from the article).
    • Nonsteroidal anti-inflammatory agents (NSAIDs)
    • Acetaminophen
    • Anticonvulsants
    • Selective serotonin reuptake inhibitors (SSRIs)
    • Other antidepressants
    • Opioids
    • Tricyclic antidepressants
    • Nonmedication treatment such as exercise and physical therapy
    For each of the treatments, is their use consistent with the chronic pain guidelines included in the article? In your opinion is each treatment overutilized, underutilized, or used appropriately based on the estimated use and the recommendations of chronic pain guidelines? If not used appropriately, what are the practice barriers that interfere with recommended use?
  5. While study result indicate that over 99% of chronic pain patients reported treatment with one medication or nonmedication treatment, no other therapy besides NSAIDs was reported more than approximately 26%. With chronic pain guidelines recommending combinations of medication and nonmedication therapy, how do you interpret these results? Are they in congruence with chronic pain guidelines? In your opinion, how can these study results be applied to improve care of chronic pain patients?




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

  1. Pain has been largely neglected in American medical education despite multiple curricular proposals by national and international professional organizations for over 35 years. Is it poor outcomes and high levels of patient and provider dissatisfaction with pain care that has compelled educators to reevaluate the time spent teaching future doctors how to take care of pain patients? Or, has there been so much new information about causes of chronic pain that the curriculum needs to be revised to remain relevant?
  2. Medical school curricula in general are undergoing revisions based on newer educational approaches to make them more clinically relevant at an earlier time during the traditional 4 years of medical school. How might you make pain education "more sticky"? Is the subject of complex chronic pain too difficult for first and second year students? Who is best able to teach this material: basic scientists or clinicians?
  3. Pain patients are considered "difficult". Is it patient characteristics or the lack of knowledge, skills, or attitudes of the provider that creates this belief?
  4. Education directed toward caring empathically for patients with chronic pain can be undone with "one roll of the eyes." How can negative attitudes about pain patients be reduced despite this pervasive "hidden curriculum?" What pedagogic strategies can be utilized to combat this endemic problem?
  5. With an ever-expanding volume and scope of information and technical training compressed in a 4-year medical school curriculum, it is very challenging to add new curricular content. If it is agreed that more time is needed to teach chronic pain, what other subjects can have their time reduced? How can we identify less important subjects to gain time for pain education?
  6. It is commonly agreed that a multidisciplinary approach to the management of chronic pain patients is optimal. How do we teach medical students to be team players and to make use of the skills of other types of health professionals?
  7. Most academic teaching faculty and practicing primary care physicians are self-described as "unprepared" to manage chronic pain. Discuss strategies to increase knowledge, improve attitudes, and advance competencies among already practicing physicians. Do you think CME courses are adequate? Should these already practicing physicians be directly mentored? If not, what are the other alternatives? (Include discussion about provider-provider Telehealth platform.)
  8. Chronic pain care requires an interspecialty approach for effective management. Why? How can the many different health professionals needed for chronic pain care pursue team-based learning during both pre- and postgraduate settings? Are joint lectures adequate for team-based learning? How can clinical rounds better incorporate interspecialty education?




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

  1. The present article argues that strict adherence to accepted research standards (eg, null hypothesis testing) within an emerging area of research with vulnerable populations could lead to a dangerous bias. What do you think of this claim? What are some alternative ways of adhering to a defensible scientific methodology without unfairly disadvantaging populations with limited self-report?
  2. The beginning of the paper quotes parental activist Jill Lawson expressing her incredulity that doctors would believe that infants couldn't feel pain. Recognizing that today most infants in primary care do not receive pain management for routine needle pokes, despite extensive pain management research, how do you propose health professionals can help change this common practice? parents? researchers?
  3. This paper describes how infant pain research in different historical periods was characterized by trends typical of the concerns and theories of the era (eg, a focus on infant pain as a reflex becoming popular in the behaviorist era). What are today's clinical and research trends that perpetuate the mismanagement of infant pain?
  4. The infant pain experiments described in this article are deeply troubling by today's standards for research. Looking back, what were the ethical principles that were violated? Despite more stringent criteria, do any of these violations continue today in research? clinical practice?
  5. The various studies this paper reviews involve a number of data-gathering methodologies that are not currently in use in pain research. Does this paper offer any forgotten methodologies that modern pain researchers might benefit from recovering?
  6. Research has shown that a number of gold-standard infant pain measures may not discriminate pain-related from non-pain-related distress. How could this contribute to the continued mismanagement of infant procedural pain? How can clinicians involve families to help overcome the unavoidable challenge of assessing pain in nonverbal populations?
  7. Do you agree that science has treated infants as "mechanistic scientific objects"? What are some ways research can be conducted that preserves infants' humanity?



  • Inserting Needles Into the Body: A Meta-Analysis of Brain Activity Associated With Acupuncture Needle Stimulation

    Younbyoung Chae, Dong-Seon Chang, Soon-Ho Lee, Won-Mo Jung, In-Seon Lee, Stephen Jackson, Jian Kong, Hyangsook Lee, Hi-Joon Park, Hyejung Lee, Christian Wallraven
    The Journal of Pain, Vol. 14, Issue 3

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

  1. Acupuncture treatment in clinics encompasses a variety of different methods, with many different names such as laser acupuncture, ear acupuncture, minimal acupuncture, and moxibustion. Discuss the different types of acupuncture treatments and how they differ.
  2. In the present study, acupuncture treatment has been defined as "inserting needles into the body." What is the problem with this definition? Is there a more comprehensive way to define acupuncture? Discuss the most common/most comprehensive/most precise ways to define acupuncture. Then discuss the pros and cons of those definitions.
  3. The present study is an Activation Likelihood Estimation (ALE) meta-analysis that investigates common brain responses to acupuncture stimulation. How does an ALE meta-analysis differ from conventional meta-analyses? What is important to consider when performing such a meta-analysis? Explain.
  4. In any scientific study, but especially in neuroimaging studies (including meta-analyses), the choice of control is extremely important. What are the different control methods for acupuncture treatment (eg, nonacupoints, sham needles)? What are the problems each of these control methods may pose?
  5. The present study discusses common "activation" and "deactivation" patterns of the brain. Which areas show a significant change and how do they relate to each other? What is the role of these involved areas in the human brain? Some areas are involved in both "activation" and "deactivation"; what could that mean? Explain and discuss.
  6. The present study mentions "sensory-discriminatory" and "affective-motivational" components of pain. What is meant by these terms? Why is it important to distinguish between these two components, and how do they differ?
  7. The present study mentions the "pain matrix" and the "default-mode network (task-negative network)" in the brain. How are these concepts related to each other, and why are they relevant?



  • Personalized Medicine and Opioid Analgesic Prescribing for Chronic Pain: Opportunities and Challenges

    Stephen Bruehl, A. Vania Apkarian, Jane C. Ballantyne, Ann Berger, David Borsook, Wen G. Chen, John T. Farrar, Jennifer A. Haythornthwaite, Susan D. Horn, Michael J. Iadarola, Charles E. Inturrisi, Lixing Lao, Sean Mackey, Jianren Mao, Andrea Sawczuk, George R. Uhl, James Witter, Clifford J. Woolf, Jon-Kar Zubieta, Yu Lin
    The Journal of Pain, Vol. 14, Issue 2

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

  1. The current paper describes the application of personalized medicine concepts to prescribing of opiate analgesic medications for chronic pain. What advantages, both at the individual and at the societal level, do you see with use of data-based personalized prescribing algorithms in treating chronic pain patients? What disadvantages might there be?
  2. Would you be willing to adopt a pain management approach that includes relatively less emphasis on your own clinical judgment and more emphasis on a data-based algorithmic approach? Consider the specific example of a patient who the prescribing algorithm suggests should not be started on opioids due to likely costs (such as addiction risk) outweighing the likely benefits, but who your clinical judgment tells you would respond well to opioids. Discuss.
  3. Assuming personalized pain medicine becomes a reality, discuss any ethical issues you foresee in making a decision to withhold opioids based on a prescribing algorithm that can only predict a certain probability of a positive versus negative response. How would you explain this decision to a patient? What alternative treatments would you discuss with the patient?
  4. Two different research methodologies are described that may be useful for development of personalized prescribing algorithms: randomized clinical trials and practice-based evidence. Discuss the advantages and disadvantages of each. How would you see these very different methodologies being integrated to further the goal of personalized pain medicine?
  5. What criteria do you believe would be acceptable for determining whether a personalized prescribing algorithm for chronic pain treatment was ready for broad clinical use? How accurate would it have to be?
  6. The current paper describes several factors that previous research suggests may predict responses to opioid analgesics. Which of these factors appear to you to be the most clinically useable? For which of these do you foresee problems in routine use? Why? How might consideration of clinical signs, symptoms, and test results as "biomarkers" for pain mechanisms change your clinical practice?
  7. Considering the mechanistic issues involved, how might personalized medicine principles be applied to nonopioid classes of medications used in pain management?




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

  1. A recent clinical audit of GMI (Johnson 2012) reported reduced treatment efficacy results as compared with evidence from the present review. What factors may differ between a clinical trial and regular clinical practice that may account for these different results?
  2. Of all the components of GMI, only motor imagery was found to result in increased pain levels in participants. Why might this be?
  3. The present review found that ordered GMI produced better outcomes than unordered GMI. What physiological mechanisms may explain this result? What other factors related to study design and risk of bias in the study may also explain this result?
  4. A major area of bias that often occurs in randomized controlled trials evaluating rehabilitation interventions is lack of participant/therapist blinding. How might studies be designed to reduce this impact? What might the results of such studies tell us about the nonspecific effects of treatment (ie, influence of enthusiasm/confidence of the therapist)?
  5. The present review found that GMI is more effective at reducing pain than usual care; however, the review also found that GMI has only been evaluated in people with complex regional pain syndrome, post-stroke pain, and phantom limb pain. Would you expect similar or discrepant findings from a wider chronic pain population (ie, low back pain, neck pain)?
  6. GMI intervention protocols often involve intensive treatment (eg, laterality retraining for 5 minutes of every waking hour). In the context of your current health care system, how might this treatment regimen fit into the health care system's constraints? Would you expect similar outcomes with a less rigorous treatment protocol?




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

  1. There is considerable evidence for the use of acute exercise in reducing experimental pain. Based on the results, discuss the potential principles that clinicians should use when using exercise as a method to manage clinical pain symptoms.
  2. As discussed in the paper, one of the most widely considered mechanisms proposed to explain EIH involves the activation of endogenous opioid system during exercise. However, animal research has provided consistent support for this hypothesis, while the human data have been mixed. In your opinion, what explanations could account for the discrepancies between the human and animal data? In other words, why might the animal findings have failed to translate to humans?
  3. The current study found that EIH was non-existent in widespread chronic pain conditions including Fibromyalgia syndrome, Chronic Fatigue Syndrome, and chronic musculoskeletal pain. What other chronic pain and health conditions might also exhibit a lack of EIH and explain the reasons for your choices.
  4. Substantial evidence suggests that exercise training improves chronic pain symptoms, physical functioning, and overall well-being in individuals with FMS; however, findings from the present study suggest that acute exercise has a hyperalgesic effect in FMS. Would you include exercise training as part of the management of FMS? Please explain why or why not?
  5. Data from this study show small to large EIH effects in individuals with regional pain conditions at the painful muscle when a distant muscle was being exercised; however, EIH was nonexistent in widespread chronic pain conditions when exercising at moderate to high intensities. What explanations could account for the different findings between the regional and widespread chronic pain conditions?
  6. What barriers might clinicians face in using exercise as a treatment for chronic pain conditions?



  • Distinguishing Features of Cancer Patients Who Smoke: Pain, Symptom Burden, and Risk for Opioid Misuse

    Diane M. Novy, Cho Lam, Ellen R. Gritz, Mike Hernandez, Larry C. Driver, Dhanalakshmi Koyyalagunta
    The Journal of Pain, Vol. 13, Issue 11

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

  1. Findings from this article suggest smokers have higher pain intensity than non-smokers. What potential mechanisms or methodological confounds may have contributed to this finding?
  2. What are some possible explanations for the finding of differences in opioid misuse risk indictors across smoking status?
  3. The present study was based on patients with chronic cancer-related pain. Would you expect similar or discrepant findings from patients with chronic non-cancer pain? Acute pain? And why?
  4. In what ways can smoking status influence opioid therapy?
  5. Based on the findings from this study, what clinical recommendations can be considered?
  6. For smokers with chronic or acute pain, how can smoking cessation treatment incorporate the experience of pain?




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

  1. A number of studies have found geographic variation in health care practices and health care spending, but this study finds that variation in opioid prescribing is significantly wider than has been reported for many other types of medical service. In your experience, what may account for this? What is it about prescribing opioids that results in such wide variation from one county to another?
  2. Opioids are prescribed in greater quantities per capita in counties with larger proportions of poor and uninsured residents (after adjusting for several other measured characteristics). What are the reasons for this?
  3. Counties with larger proportions of non-Hispanic white residents also have higher amounts of opioids prescribed, per capita. What are the likely reasons for this?
  4. There is a strong correlation between the amount of opioids prescribed and dispensed per capita and the supply of physicians in a county, measured as number of physicians per 1,000 residents. This correlation exists even after adjusting for a number of measured socioeconomic differences in county populations. Does this indicate that treatment is deficient in counties lacking physicians? Or that opioids are overprescribed where access to physicians is easier? Or both?
  5. How do pharmaceutical marketing practices and patient expectations influence physicians' decisions to prescribe opioids, if at all?
  6. To what extent does the existence of oversight by prescription drug monitoring programs, DEA, insurers, or licensing boards affect your decisions to prescribe opioids?
  7. What do you think are the most effective and desirable means of regulating opioid prescribing?
  8. Do you have access to sufficient guidance in the use of opioids for patient care? If not, why not? In what areas is guidance deficient?
  9. What are your observations about the analgesic efficacy of opioid treatment for chronic pain?
  10. In your experience, what are the best channels for exchanging information about for treating chronic pain?
  11. The factors measured in this study account for no more than a third of the observed geographic variation in amounts of opioids prescribed. Do you think that the remaining unexplained variation results from systematic differences among counties or from more random variation from one physician to another in prescribing practices?
  12. To what extent does your local practitioner culture--that is, shared values and beliefs about use of opioids--affect your decisions about prescribing these drugs? Discuss the role that peers play in shaping your prescribing practices.
  13. To what extent do differences in the way medical practices are organized (group practice, HMO, solo practitioner, etc.) affect how a physician uses opioids in patient care? Do you think that regional differences how practices are organized may explain some of the variation among counties described in this article? If so, why?




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

  1. There is considerable evidence highlighting the mechanisms and efficacy of placebo effects for reducing pain.Discuss potential ways in which practitioners could use these factors to augment the effectiveness of analgesic treatments.
  2. Findings from the article suggest that placebo analgesia acceptability is highly dependent on the context of administration. In your opinion, what are the conditions by which a placebo treatment would be deemed most acceptable? Least acceptable?
  3. The present investigation examined placebo treatment acceptability among a non-clinical sample of adults. Would you expect similar or discrepant findings from chronic pain patients? Explain.
  4. One of the major findings from this study was that participants had rather simplistic conceptualizations of placebo effects and their underlying mechanisms. What impact would increased understanding of placebo have on acceptability? What points would be most important to address in an educational intervention?
  5. The same factors that promote placebo analgesic effects (e.g., increased expectation, effective communication between physician and patient) likely contribute to the effectiveness of all treatments for pain. Given the structure of your current health care system, what institutional barriers exist in utilizing these factors in routine patient care?
  6. The use of deception to augment placebo treatment effects is controversial. Nevertheless, studies show that health care providers are using deceptive placebo interventions. Are there any circumstances in which it would be acceptable for a practitioner to deceive a patient in an effort to augment the effectiveness of an analgesic treatment?
  7. Discuss the ethical implications of placebo medicine. Although these treatments may be effective, are there ways in which this knowledge could harm patient care?



  • Acute Severe Pain Is a Common Consequence of Sexual Assault

    Samuel A. McLean, April C. Soward, Lauren E. Ballina, Catherine Rossi, Suzanne Rotolo, Rebecca Wheeler, Kelly A. Foley, Jayne Batts, Terry Casto, Renee Collette, Debra Holbrook, Elizabeth Goodman, Sheila A.M. Rauch, Israel Liberzon
    The Journal of Pain, Vol. 13, Issue 8

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

  1. Women in this study were recruited in the early aftermath of sexual assault. Is it ethical to study these patients? Were the methods used by the researchers were ethically appropriate? Is there anything that you would have done differently to protect patient safety?
  2. If the same or overlapping physiologic systems contribute to both psychological and neurosensory processing changes after stress exposure, does this challenge our ability to determine the percentage of variance attributable to "psychological processes" vs. "biological processes"? If so, what research or methodological approaches might be most useful for meeting this challenge?
  3. In this study, women with severe pain were rarely treated. Other studies have also frequently documented undertreatment of acute pain. Why do think this is?
  4. If stress-induced hyperalgesia can contribute to severe acute pain, and tissue injury severity is unreliable, how can caregivers (in an era of increasing prescription opioid abuse) best make decisions regarding how to treat acute pain?
  5. Extra-genital regions that were most commonly associated with pain in the absence of reported trauma were the back, abdomen, and head/face. Do you think vulnerability to stress-related pain varies across body regions? Why might this be?
  6. What research methods or approaches could be used to further define potential mechanisms of stress-induced hyperalgesia in this patient population?



  • Challenges and Opportunities in Pain Management Disparities Research: Implications for Clinical Practice, Advocacy, and Policy

    Lisa C. Campbell, Kristynia Robinson, Salimah H. Meghani, April Vallerand, Michael Schatman, Nomita Sonty
    The Journal of Pain, Vol. 13, Issue 7

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

  1. The authors provided an over view of key ethical and methodological challenges that undermine the capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Identify 1 or 2 of the challenges your research team experiences in conducting research with vulnerable populations. Discuss ethical, methodological, or policy issues related to the challenges you are experiencing.
  2. The authors introduce the reader to the concept of the research gap. What is the research gap in health disparities research and how might you contribute to closing the gap.
  3. Recruitment and retention of underserved populations is difficult for all of us. What has been your experience in utilizing a cultural broker? What is the reaction of your research team to including members from the population under study to participate in every aspect of the research study, from design and implementation to analysis and dissemination?
  4. What makes the PROMIS model unique and relevant to pain-related disparities?
  5. Although there are numerous advocacy efforts in addressing pain care access and quality for medically underserved groups, there are fewer policy changes. What are some of the recent and significant regulatory changes that will influence policy with regard to pain care disparities and how will they impact "fail first" and "step therapy" approaches for the medically underserved.
  6. How does the issue of limited evidence for cross-cultural psychometric equivalence of pain measures relate to the ecological validity of the research findings for disparities populations?
  7. There has been a recent focus within the Affordable Care Act on optimizing and incentivizing the use of Electronic Health Records (EHR). How can EHR be used to improve the study and understanding of pain outcomes for racial/ethnic minorities? What role can clinicians play in optimizing EHR data?



  • “There's More to This Pain Than Just Pain”: How Patients' Understanding of Pain Evolved During a Randomized Controlled Trial for Chronic Pain

    Marianne S. Matthias, Edward J. Miech, Laura J. Myers, Christy Sargent, Matthew J. Bair
    The Journal of Pain, Vol. 13, Issue 6

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

  1. Patients in this study described learning to cope more effectively with their pain. Interestingly, even patients who did not experience a measurable improvement in pain severity and disability, common measures for clinical trials with chronic pain, described these benefits. What does this suggest about how patients experience chronic pain?
  2. Patients and providers often focus heavily on pain severity in clinical interactions. How might the findings of this study inform the way in which clinicians assess and treat patients' pain?
  3. The recent Institute of Medicine report, Relieving Pain in America, calls for a "cultural transformation in the way pain is understood, assessed, and treated." What does this mean, and how can this be interpreted in light of this study's findings?
  4. If a patient with chronic pain were to read this article, what might their reaction be? Could it potentially help them to cope better with their pain, or would they have a different reaction?
  5. Different patients attributed their enhanced understanding of their pain to different components of the intervention, including self-management instruction, cognitive behavioral therapy, and regular contacts from the study's nurse care manager. This suggests that pain treatments may be more effective if they are tailored to the individual patient. How might a clinician go about tailoring treatments for his or her patients with chronic pain? What challenges might this pose to clinicians? What advantages could it have?
  6. What do the results of this study indicate about the value of employing both quantitative and qualitative methodology to understand a phenomenon of interest?




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

  1. Melzack's theory of the pain neuromatrix has revolutionized our understanding of the mechanisms underlying the experience of pain. Discuss and compare how the response of the neuromatrix may differ or overlap for pain originating from peripheral nervous system lesions, such as trigeminal neuralgia, or that resulting from damage to the central nervous system, such as in case of thalamic stroke.
  2. The field of invasive cerebral neuromodulation over decades has studied efficacy of several deep brain targets and the motor cortices in modulating the experience of chronic neuropathic pain. Unequivocally, however, the benefit for patients with lesions of the central nervous system remains limited. Cite the potential mechanistic reasons and issues related to clinical trial design that may explain the lack of adequate response.
  3. What are the mechanisms that are historically believed to underlie effects of brain stem, thalamic and motor cortical targeting in cerebral neuromodulation in the treatment of chronic neuropathic pain?
  4. Cite evidence that challenges the traditionally-accepted beliefs about distinctive mechanisms of targeting cerebral structures in the treatment of chronic neuropathic pain.
  5. Noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), have become popular experimental techniques in the study of modulation of chronic neuropathic pain. Discuss the evidence for efficacy in regards to response and maintenance and illustrate factors that affect existing evidence.
  6. Indications for both invasive and noninvasive methods of cerebral neuromodulation in chronic neuropathic pain remain off-label. In revaluating the existing evidence in the field, discuss refinements, both theoretical and experimental, that could introduce a paradigm shift in the study of cerebral neuromodulation in chronic neuropathic pain.




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

  1. The study provides mixed evidence for Ursin and Eriksen's cognitive activation theory of stress, a theory proposed to explain health conditions that are predominated with subjective complaints and intricately related to the stress response. In this study, the theory was used to tie together a predictive model of fibromyalgia pain (stress/negative mood, hypersensitivity to nociceptive input, chronic arousal through poor sleep). Do you think this is a valid theory of fibromyalgia syndrome? How could this theory be better tested in a chronic pain population?
  2. A patient presents to your clinic with chronic widespread pain, mood difficulty, and insomnia. What do you feel is the best treatment approach for this individual? Did this study help to inform how you might treat patients with this symptom cluster?
  3. The mean clinical pain ratings of the FM participants correlated with momentary ratings of windup after sensations, negative affect and number of pain areas. However, it did not significantly correlate with ny of the "objective" and subjective sleep duration measures. Obviously, this means that sleep duration of FM patients is influenced by other factors besides pain. What other factors could account for this lack of correlation?
  4. Sleep disturbance is highly prevalent in fibromyalgia. However, in the article, sleep did not add to the predictive power of an established model of clinical pain in fibromyalgia. What might account for this?
  5. The data presented in this paper are correlational and have the obvious limitations with respect to causal inference. What study designs might lead to a stronger understanding of the causal links between he various pain, mood, and sleep measures?



  • Smoking Cigarettes as a Coping Strategy for Chronic Pain Is Associated With Greater Pain Intensity and Poorer Pain-Related Function

    Alexander L. Patterson, Susan Gritzner, Michael P. Resnick, Steven K. Dobscha, Dennis C. Turk, Benjamin J. Morasco
    The Journal of Pain, Vol. 13, Issue 3

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

  1. Chronic pain may lead to smoking, and smoking may also lead to chronic pain. Which of these seems more credible and why? The authors mention a third, predisposing factor for both smoking and chronic pain. What are some possibilities for this predisposing factor?
  2. "Chemical coping" and "self-medication" are mentioned in the context of smoking cigarettes to cope with pain. What are some other physical problems that patients may use chemical coping/self-medication with smoking? What are some other ways that patients may use chemical coping/self-medication?
  3. The authors target a few key aspects of pain-related functioning, including pain interference, pain intensity, and fear of pain. If you were redesigning this study, what other pain-related outcome variables might you include? How could they be measured?
  4. It is suggested that smoking to cope with pain may serve as a trade-off between overall increased pain intensity and greater long-term pain stability. What are some other possible explanations for poorer pain-related outcome among individuals who endorse smoking to cope with chronic pain?
  5. Chronic pain patients who smoke to cope with pain scored higher on two wellness-focused subscales of a pain coping measure (the Chronic Pain Coping Inventory): Resting and Relaxation. If smoking is a negative coping strategy for pain, how do you explain this seemingly incongruent finding?
  6. 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?
  7. Will the findings from this study have any impact on the clinical care you provide? If so, in what way?



  • Time Series Analysis of California’s Prescription Monitoring Program: Impact on Prescribing and Multiple Provider Episodes

    Aaron M. Gilson, Scott M. Fishman, Barth L. Wilsey, Carlos Casamalhuapa, Hassan Baxi
    The Journal of Pain, Vol. 13, Issue 2

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


  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?



  • Association Between Substance Use Disorder Status and Pain-Related Function Following 12 Months of Treatment in Primary Care Patients With Musculoskeletal Pain

    Benjamin J. Morasco, Kathryn Corson, Dennis C. Turk, Steven K. Dobscha
    The Journal of Pain, Vol. 12, Issue 3

  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?



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