Design Process and Utilization of a Novel Clinical Decision Support System for Neuropathic Pain in Primary Care: Mixed Methods Observational Study

Background: Computerized clinical decision support systems (CDSSs) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPGs). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management and more specifically neuropathic pain has been limited. A CDSS for neuropathic pain has the potential to enhance patient care as the challenge of diagnosing and treating neuropathic pain often leads to tension in clinician-patient relationships. Objective: The aim of this study was to design and evaluate a CDSS aimed at improving the adherence of interprofessional primary care clinicians to CPG for managing neuropathic pain. Methods: Recommendations from the Canadian CPGs informed the decision pathways. The development of the CDSS format and function involved participation of multiple stakeholders and end users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in three academic teaching clinics were trained in the use of the CDSS. Evaluation over one year included the measurement of utilization of the CDSS; change in reported awareness, agreement, and adoption of CPG recommendations; and change in the observed adherence to CPG recommendations. Results: The usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in the planned functionality. The study population had a high level of awareness, agreement, and adoption of guideline recommendations before implementation of CDSS. Nevertheless, there was a small and statistically significant improvement in the mean awareness and adoption scores over the year of observation (P=.01 for mean awareness scores at 6 and 12 months compared with baseline, for mean adoption scores at 6 months compared with baseline, and for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians. Conclusions: We observed a small increase in the adherence to CPG recommendations for managing neuropathic pain. Clinicians utilized the CDSS more as a source of knowledge and as a training tool than as an ongoing dynamic decision support

Opioid Analgesics in the Management of Neuropathic Pain

The role of antidepressants and anticonvulsants in the management of neuropathic pain has been well established. However, up to 50% of patients obtain inadequate pain relief with the use of either or both of these agents; in this subpopulation, an opioid analgesic may be beneficial. There is clear evidence that opioid analgesics are efficacious in the management of neuropathic pain, but there is controversy as to the balance between analgesia and adverse effects. Opioid treatment may require higher doses than other kinds of drug therapies, thereby increasing the risk of opioid-related side effects. Psychological dependence or addiction, however, is not usually an issue in pain management with opioid analgesics. The extant literature strongly suggests the trial of an opioid analgesic in the management of neuropathic pain if adjuvant analgesics fail to provide adequate pain control. Failure of one opioid warrants a trial of another opioid because their effectiveness can vary among patients; the results are based on physiochemical properties of the drug and idiosyncratic reactions of the patient. Neuropathic pain can be a difficult problem to manage, and sometimes the use of an opioid analgesic can make the difference between bearable and unbearable pain so that patients can get on with their lives

The Clinical Management of Neuropathic Pain

Chronic neuropathic pain as a result of injury to the central or peripheral nervous system is common in clinical practice, and is especially predominant in the elderly. The present review summarizes the epidemiology, clinical features, pathophysiology, differential diagnosis and management of neuropathic pain and specifically details an evidence-based approach to the pharmacological treatment of this disabling condition. Preventive strategies and novel treatment approaches are required to improve the management of neuropathic pain

Managing Cancer Pain - Simple Rules, Major Benefits

In the developed world, approximately one in three individuals will be diagnosed with cancer and one-half of those will die of progressive disease (1). At least 75% of patients with cancer develop pain before death. It is therefore not surprising that pain is one of the most feared consequences of cancer for both patients and families (2). The good news is that cancer pain can be controlled with relatively simple means in more than 80% of cases based on guidelines from the World Health Organization (3). Mild pain can be treated with acetaminophen or nonsteroidal anti-inflammatory drugs (Step 1 of the analgesic ladder). Moderate pain requires the addition of a 'minor' opioid such as codeine (Step 2), and severe pain mandates the use of a major opioid analgesic such as morphine (Step 3). In this issue of Pain Research & Management, Gallagher et al (pages 188-194) highlight some of the barriers to adequate cancer pain management based on a cross-sectional survey of British Columbian physicians. The survey response rate of 69% attests to the validity of their findings

Fibromyalgia: Presentation and management with a focus on pharmacological treatment

Fibromyalgia is a condition with widespread muscle pain. Prevalence studies showed that 2% to 7% of the population have fibromyalgia, which affects approximately one million Canadians. Fibromyalgia is most common in women, but it also involves men and children. As with most chronic illnesses, the causes of fibromyalgia are unknown. However, recent research supports underlying abnormalities in the central nervous system, which supports fibromyalgia as a chronic disease state and valid clinical entity. Pain is the primary symptom, often accompanied by overwhelming fatigue, sleep dysfunction and cognitive impairment. In 1990, the American College of Rheumatology developed diagnostic criteria for the diagnosis of fibromyalgia. Lifestyle changes, including pacing of activities and aerobic exercise, are very important in managing fibromyalgia symptoms. Emotional and behavioural therapy can also be helpful. Controlled trials of antidepressants, gabapentinoids, tramadol, zopiclone and sodium oxybate have shown effectiveness in fibromyalgia patients. Pregabalin and duloxetine were recently approved in the United States. Effective management of fibromyalgia is complex and requires a multidisciplinary treatment approach. Response and tolerance of different therapeutic interventions vary from patient to patient. Recent advances in the pathophysiology of fibromyalgia offer hope for new and improved therapies in the management of this disabling condition

Initial Pain Management Plans in Response to Severe Pain Indicators on Oncology Clinic Previsit Questionnaires

BACKGROUND: The issue of how to address patient pain in the outpatient setting remains challenging. At the London Regional Cancer Program (London, Ontario), patients complete the Edmonton Symptom Assessment System (ESAS) before most visits