Chronic pain management in non-oncologic patients: multicentric study on adult patients referring to the centers for pain management in the Lazio Region (Italy). Doctoral Thesis, available from: http://padis.uniroma1.it/handle/10805/2127

Introduction Chronic pain is a complex phenomenon usually associated with psychological stress, which implies falling back on the National Health Service and reducing work capacities, indeed affecting Activities of Daily Living. Studies based on efficacy have identified the multidisciplinary approach as the most effective means to obtain therapeutic results. These programs can be provided by the Centers for Pain Management (CPMs), where multidisciplinary teams are likely to provide the necessary expertise to outline the best treatments for the diagnosis and management of chronic pain. To date, very little information is available on the kind of assistance and support these centers can provide, as well as on the clinical and socio-demographic characteristics of patients who refer to these facilities. Aims The present investigation has the following objectives: • to describe what kind of assistance the centers for pain management (CPMs) in the Lazio Region are able to provide; • to describe the clinical and socio-demographic characteristics of the population referring to the CPMs; • to describe the type of pharmacologic, complementary and intervention treatments; • to describe the clinical characteristics of patients who turn to the two different levels of available assistance (hub and spoke system). Methods In 2011 a non-profit, retrospective and multicentric study was performed on all the CPMs existing in the Lazio region. All relevant information on the centers was collected. As well, the health records of patients between the age of 18 and 71 (paper and digitized documents) affected by chronic benign pain for at least six months were analyzed. Patients suffering from migraine and from cancer pains were excluded. The study was approved by the Ethic Committee (CE) of each participating center and of the preeminent CPM (Tor Vergata). An average number of 1600 patients was estimated. All data were collected in a SPSS database and processed according to a statistical analysis. Results Data collected between January 2012 and February 2013 from 1606 patients from all the twenty-six (26) participating CPMs in the Lazio Region were analyzed. Centers characteristics: CPMs are generally located in University and General Hospitals (among these, 2 hubs) and in public or private hospital facilities. They are all equipped with a clinic, some of them are able to provide Day Hospital surgery and day-beds. CPMs are managed by anesthetists and in most instances they do not have multidisciplinary staff members. As well, the number of health professionals, nurses, psychologists and physiotherapists is scarce. CPMs mainly supply patients with pharmacotherapy, Complementary Alternative Medicine (CAM) and with interventional treatments which may be complex, as well. The median waiting time is of about 90 days. The clinics are not homogeneously distributed in the Region; Rome turned out to be the city with a greater range of offers, while in the provincial areas there is an under-utilization of the existing facilities. 6 Characteristics of the population: Most of the patients referring to the CPMs had been previously evaluated by the General Practitioner (38%), 34% of them were directed to the pain centers by a specialist different from an anesthesiologist, while 28% of patients refer to a CPM on their own choice. 33.1% of patients are male, 66.9% are female (ratio 1:2); the most representative category of patients was of an age between 65-69. In most cases, marital status, employment and education were not documented. Almost all patients, regardless of their age, refer to a CPM at an average median time of 48 months after onset of pain; female patients seem to experience more intense symptoms with respect to males. The use of stairs was limited in order to guarantee a multi-dimension evaluation. Localization/multi-localization of pain is different between males and females; as for the nature of the pain, 45% of patients suffered from a somatic pain, while 21% of neuropathic pain and 31% mixed nature (somatic and neuropathic).There is a prevalence of muscle-skeletal diseases (low back pain, lumbar pain and spondyloarthrosis), immediately followed by neuropathic pain. The older the patient is more are the clinical disturbances at the origin of the pain. In most cases a proper diagnosis is not made, but pain is always related to the localization of the pain. Pain relief treatments: Medications are the most widely used treatments for pain relief and management. Medications for pain may range from selective and non-selective FANS, adjuvants (anticonvulsants, benzodiazepine, antidepressants), opioids (i.e. tapentadol) and strong opioids, such as the oxycodone-naloxone combination which may be of help in limiting the irreversible effects of opioids. The choice of the treatment depends on the diagnosis and nature of the pain. Medications alone are often not sufficient in the management of chronic pain and may be more effective when combined with other treatments, such as acupuncture, massages and other interventional treatments (perinervous injections, epidural, Pulsed Radiofrequency (RFP), trigger points injections). No significant difference emerged between male and female patients. Associating pharmacological medications to CAM is an innovative approach in pain management, which differs from the traditional western model. By doing this, health care providers focus on the total person, not just the pain, evaluating both the biological and psychological components of the patient. CAM treatments may also reduce the use of medications and, as a consequence, of their side effects. We have to keep in mind that in chronic pain the emotional component very often prevails on the biological one, considering that the latter can be resolved. Population referring to the hub and spoke centers: Patients referring to the two different models of pain clinics differ significantly. This depends both on the length of time from the onset of pain and on the intensity of the pain (spoke). Patients referring to hub centers show a prevalence of mixed and neuropathic pain. This information proves that patients with a more complex clinical history turn to hub centers, although these are not always able to offer the advanced and innovative treatments, which would be necessary for an effective pain relief in patients. Conclusions In 2011, the availability of hub and spoke centers was not equally distributed throughout the territory. Documents providing clinical data and case history of patients were more reliable than the information obtained with phone interviews. Overall characteristics of patients, as well as the type of assistance provided are still scarcely recorded, although this information would be helpful especially when making a complete multidimensional evaluation on how to better manage chronic pain patients. However, the 2011 network and system seems to be changing: this is demonstrated by the typology of patients referring to the hub and spoke centers