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Context Chronic pain and opioid dependence confer substantial individual and societal burdens and are notoriously difficult to treat effectively. Their comorbid presentation further complicates effective treatment through complex physiological and environmental interactions. Objectives (1) What are the clinical characteristics and treatment outcomes associated with comorbid chronic pain in ORT patients? (2) Does the patient-attributed direction of the causal relationship in the development of opioid dependence and chronic pain identify two clinically-distinct treatment populations? (3) What is the incidence of iatrogenic opioid dependence or abuse following opioid analgesic treatment? (4) Is there evidence of opioid-induced hyperalgesia in humans? Methods Primary data Participants were 467 treatment-seeking, opioid-dependent patients. Materials comprised standardised instruments – focusing on illicit substance use and mental health characteristics – completed by medical staff at study inception, and extracts of routinely-collected clinical datasets spanning the follow-up period. Procedures involved the use of a health informatics approach. Electronic linkage of data collected at study inception with routinely-collected clinical datasets spanning the 5-year follow-up period. Secondary data Systematic searches were undertaken using six electronic research databases, supplemented by manual searches. Study quality was assessed using instruments developed by NIH. Data synthesis using random effects models (DerSimonian-Laird method) generated: (1) a pooled incidence of iatrogenic dependence or abuse following opioid analgesic treatment; and (2) a pooled effect of opioid exposure on the development of opioid-induced hyperalgesia. Additional analyses included assessment of heterogeneity in study effects, within- and between-study risk of bias and sensitivity analyses. Results A total of 246 (53%) patients reported comorbid chronic pain. This ‘comorbid’ group was associated with increased mortality, physical and mental health problems, service utilisation and illicit drug use, specifically benzodiazepines and cannabinoids. Within the ‘comorbid’ group, patients who reported a causal impact of opioid dependence on the development of pain were associated with increased illicit drug use and psychiatric morbidity. Secondary data analyses revealed a 4.7% incidence estimate of iatrogenic dependence or abuse following opioid analgesic treatment, and evidence of the development of opioid-induced hyperalgesia following therapeutic opioid exposure. Conclusions Elevated mortality, morbidity and illicit drug use in opioid-dependent patients with comorbid chronic pain reflects a patient population with substantial health burdens. The dynamic relationship between these severe and chronic conditions necessitates complex, multimodal treatment strategies and multiagency collaboration, including general psychiatric intervention. Whilst a substantial proportion reported that opioid dependence developed as a consequence of pain problems, there is evidence to suggest that the assumed risk of iatrogenic opioid dependence and abuse may be an overestimate; however, therapeutic opioids may lead to other problems that impact on treatment effectiveness, such as opioid-induced hyperalgesia.

Opioids are the most effective treatment for pain, but a host of side effects such as lethal overdoses limits their use. Endomorphins are endogenous opioid ligands that show promise as a basis for safer analgesics. Several EM analogs were developed to provide equal analgesic effects compared to morphine, with reduced respiratory depression, motor, cognitive, tolerance, and reward side effects. Tested here in reward models, morphine was compulsively self-administered and produced conditioned place preference (CPP) and locomotor sensitization after repeated injections. In sharp contrast, EM analogs were inactive in all of these models. Mechanisms for reduced tolerance and reward are proposed here. Chronic EM analog infusions produced substantially less tolerance than equi-effective doses of morphine. Morphine upregulated glial cell markers of proinflammatory activation and signaling as well as the neuronal proinflammatory peptide CGRP. By contrast, EM analogs did not produce glial or CGRP activation suggesting reduced proinflammatory side effects. In the CPP reward model, morphine produced a place preference and decreased the cell soma size of dopamine (DA) neurons in the ventral tegmental area (VTA), a critical area for reward. EM analog 4 did not produce CPP and did not change the size of these neurons in the VTA. Penetration of the blood-brain barrier (BBB) by EM analogs was confirmed by central antagonism of the antinociceptive effects of peripherally administered analogs. This work suggests that EM analogs do not promote reward behaviors and do not produce morphological changes to DA neurons in the VTA, despite BBB penetration. Therefore, the reduced tolerance and reward side effects of the analogs could be due to lack of proinflammatory effects and reduced DA neuron alterations. Finally, the subjective effects of EM analogs were tested in a drug discrimination (DD) model. During DD test sessions, rats responded on the morphine-paired lever for food when pre-injected with EM analogs, indicating that the analogs were perceived as being more similar to morphine than vehicle, despite evidence that they did not produce rewarding effects. Data shown here suggest a dual role for EM analogs in the treatment of pain and opioid addiction. / 1 / Mark R. Nilges

Older adults are prone to experiencing more frequent pain due to surgeries, age-associated diagnoses, and/or accumulated injury. Opioids are the most effective treatment for pain, but negative side effects and age-associated pharmacokinetic and pharmacodynamics changes limit their safe use in older adults. Endomorphins (EMs) are endogenous opioid ligands whose analogs show improved analgesic properties with fewer side effects. This study examines the antinociceptive properties and motor side effects of an EM analog at a high dose in young animals and in isolated (IH) and environmentally enriched (EE) housed older animals. Young mice given high doses of Morphine (MS) and EM analog experienced ¬equal antinociception, but when compared to vehicle animals the MS mice were significantly impaired on a test of motor coordination (rotarod) while the EM animals were not. In older animals, possible stress-induced analgesia (SIA) was observed in IH animals while not in EE animals. An overall main effect of housing was detected at p≤.0.05, and the effect of SIA began as soon as 7 days after housing assignment. Animals in IH or EE given an EM analog were statistically different at p≤0.01, while the difference between IH and EE animals given MS reached only p≤0.05. In older adults, participants who attended a day program with scheduled activities showed significant decreases from Time 1 to Time 2 in pain intensity and number of medications, and scores were trending toward significance pain control. By Time 2, patients attending the day program had significantly lower scores of pain intensity compared to adults who received in-home services only. Loneliness and isolation decreased in groups receiving either in-home services or attending the day program. In general, adults who increased services experienced the greatest decreases in pain and psychosocial variables. This study suggests that the response to EE is similar in both humans and rats and that a careful increase in stimulation is the best practice in activity planning for older adults. Policy requirements for EE in older adults residential and day facilities may positively impact the pain medication consumption in this growing population. / 1 / Penny Roberts

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Postoperative pain management is a major responsibility of nurses who provide care for patients recovering from surgery. In the postsurgical environment, the nurse has a pivotal role in assessing the patient with pain, implementing both doctor and nurseinitiated pain interventions and evaluating the patient's response to pain control treatments. Apart from its humanitarian utility, effective relief of postoperative pain is a critical element of a patient's postoperative recovery. Failure to manage pain effectively in the immediate postoperative period can produce undesirable immediate and longterm physical and psychological consequences that can severely disrupt an individual's quality of life. Despite the availability of multidimensional assessment measures, sophisticated pharmacological therapies and a greater range of complementary pain therapies, postoperative pain remains treated ineffectively by those professionally responsible for its management. In particular, evidence indicates that nurses are poor managers of their patients' postoperative pain. This thesis reports research that was conducted in two stages to explore, describe and analyse how nurses managed their patients' postoperative pain and their perceptions of factors that influenced this practice. A predominantly descriptive design was utilised in Stage 1 of the study to collect data from patients' hospital records and with a demographic questionnaire administered to nurses. This was complemented with interview data from nurses in Stage 2. / Previous studies offer limited views of the clinical realities of nursing practice in postoperative pain management. From this perspective, there is a need for research that incorporates these realities to permit analysis of clinical practice and greater understanding therefore of the problem of poor postoperative pain management. The purpose of this study was to provide an illuminative and authentic account of nursing practice in postoperative pain management. For the first part of Stage 1, data were collected retrospectively from nurses' documented accounts of pain assessment and intervention over the first three postoperative days for 100 patients in a major adult acute care teaching hospital. Analysis of nurses' documented responses to patients' reports of postoperative pain revealed that less than one-third of all responses could be considered appropriate for pain management. In particular, nurses failed to provide any pharmacological relief for 53% of patients' reports or severe and excruciating pain. Exploration of the influence of nurses' professional characteristics of education and experience on pain management practice was then undertaken in part 2 of Stage 1 with the use of a demographic questionnaire distributed to 106 nurses who were identified as signatories to the documented responses identified in part 1. Results indicated that length of professional experience accounted for most variations in practice, with older, more experienced nurses managing pain more appropriately than their younger and less experienced colleagues. Irrespective of education or experience, however, nurses failed to respond appropriately to patients reporting excruciating pain. / In Stage 2, in-depth interviews were conducted with 8 nurses caring for postoperative patients at the research site. Thematic content analysis revealed four major themes from nurses' perceptions of their practice of postoperative pain management that served to elucidate and enrich the findings of Stage 1 of the research. These were finding out about the patient's pain, making decisions about pain and pain management, individual factors affecting pain management, and interpersonal and organisational factors affecting pain management. This thesis provides an authentic account of nursing practice in postoperative pain management, and contributes understanding and insight into factors that provoke ineffective management of pain after surgery. It has implications for the development of intervention strategies aimed at improving nursing practice, at both individual and organisational levels, and suggests new directions for nursing education and research toward achieving optimum care and eliminating unnecessary pain for patients recovering from surgery.

Pain management is a critical part of the care of the surgical patient. This study sought to investigate the impact of cultural and linguistic diversity on analgesic administration practices and opioid consumption during postoperative period. A retrospective medical record audit of 278 English-speaking and non-English speaking surgical patients was carried out at four hospitals in Sydney's South West. No differences were found in the type of analgesia prescribed, the mode of analgesia, or the commencement of oral analgesia between the two groups. However, non-English speaking patients consumed less analgesia during the initial postoperative period than their English speaking counterparts. The importance of this difference was further examined within the context of a range of factors known to influence analgesia consumption. A model including sociodemographic and clinical factors - mode of administration of analgesia, gender, and language spoken -predicted 37% of total opioid consumption. Although mode of administration was the most important factor, being of non-English speaking background also contributed substantially. Pain assessment, inclusive of gender and cultural nuances is recommended. The need for further research into pain interpretation in specific linguistic and cultural groups is highlighted / Master of Science (Hons) (Health)

In this study, I focus specifically on nurses’ actions related to pain. I establish how a different way of theorising ‘pain’ can assist in exploring how nurses’ subjectivity is constituted. I seek to open up possibilities for challenge and resistance by nurses to the dominant practices that influence how actions of nurses in relation to pain, come to exist. In challenging taken-for-granted representations of how pain is understood, I do not discount representations reported in literature, or as stated by people considered, for example, pain ‘experts’. Rather, I challenge how, these representations of pain and pain expertise, have come to exist as self-present truth, and seek to explore what other representations are marginalised as a consequence. I am aware that the interpretations of representations that I forward are open to this same critique. For my exploration of nurses’ actions related to pain for people having elective surgery, I undertook a poststructural analysis, informed by the works of Derrida, and Foucault. In particular, I constituted my thesis, in Derrida’s dictum ‘we are written as we write’, and Foucault’s analysis of three intersected topics: power, truth and the formation of selves. I analysed literature related to pain and management of that pain as text, and employed ethnographic techniques of observation, interviews and collection of documentary materials, to analyse nurses’ actions as text. I attempt to present a new text of nurses’ actions related to pain. I challenge the view that there is an essential true meaning that resides in pain, literature related to pain, or nurses’ actions aligned to that pain. Analysing how nurses’ subjectivity is written, in relation to pain, provides to nurses a means to read and write nurses’ actions in different ways. I reveal how a specific way of writing nurses’ actions, articulates a particular version of truth about pain, and how nurses are then positioned within this version of truth, and in turn, how nurses position people constituted as patients. I explore how, organisation as structure, is a way of thinking that continues to make invisible the power and politics dynamic in nurses’ actions related to pain. If the word ‘pain’ is taken as understood by nurses, that is, it is known what ‘pain’ means, this way of thinking will continue to privilege one meaning of pain in the hospital, and, maintain a traditional perspective of ‘organisation as structure’. In opening out alternate understandings of pain, and readings of nurses’ actions, the study allows for the possibility that pain, and the way that nurses act in relation to that pain, may indeed mean different things to different people. / thesis (PhD)--University of South Australia, 2000

Shoulder pain in elite swimmers is common and its cause is unknown. One hypothesis is that repetitive swimming leads to shoulder laxity, which in turn leads to impingement and shoulder pain. An observational cross-sectional study was designed to test this hypothesis. Eighty elite swimmers (13-25 years of age) completed questionnaires on their swimming training, pain and shoulder function. They were given a standardized clinical shoulder examination, and tested for inferior glenohumeral joint laxity using a noninvasive electronic laxometer designed for this study. Fifty-two swimmers also attended for a shoulder MRI. The laxometer had good-excellent reliability for inter-observer (Intra-class correlation coefficient, ICC = 0.74) and intra-observer (ICC = 0.76) assessments of joint laxity. The reliability of MRI-determined supraspinatus tendinosis was excellent with a single experienced musculoskeletal radiologist (intra-observer ICC = 0.85) and fair for an inter-observer assessment including less experienced radiologists (ICC = 0.55). MRIdetermined supraspinatus tendinosis was present in 36/52 (69%) swimmers, including four international-level athletes. A positive impingement sign correlated with supraspinatus tendinosis (r = 0.49, p = 0.0002). The impingement sign had 100% sensitivity and 65% specificity for diagnosing supraspinatus tendinopathy. Shoulder laxity correlated modestly with impingement (r = 0.23, p &lt 0.05). There was no association between shoulder laxity and supraspinatus tendinosis (r = 0.24, p = 0.08). The number of hours swum/week (r = 0.36, p = 0.01) and the weekly mileage (r = 0.34, p = 0.02) both correlated significantly with supraspinatus tendinopathy whereas swimming stroke preference did not. Multiple logistic regression analysis performed with supraspinatus tendinopathy as the dependent variable showed the combination of hours swum/week and weekly mileage correctly predicted tendinopathy in 85% of elite swimmers. These data indicate that: (1) supraspinatus tendinopathy is a major cause of shoulder pain in elite swimmers; and (2) this supraspinatus tendinopathy is induced by the volume/dose of swimming; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers. These finding in humans are consistent with animal and tissue culture findings which support the hypothesis that tendinopathy is related to the dose and duration of load to tendon cells.