Flinders University Behavioural Health expert Paula Redpath, from the College of Medicine and Public HealthCREDIT Flinders University

Chronic pain affects millions of people worldwide and is a leading cause of disability and healthcare use.

A new study led by Flinders University has shown that timely, affordable, integrated and individualised ‘coaching’ can help people living with chronic pain to improve their self-management and understanding of ways to manage their pain better.

A novel telehealth program developed by Flinders University and SA Health experts shows the potential for non-mental health professionals – in tandem with medical and allied health experts – to help those with chronic pain access specialised support that can make a difference and reduce suffering.

The program also provides access to care and support for people living outside of metro areas who may have to wait years otherwise to see a pain specialist, says Flinders University Behavioural Health expert Paula Redpath, from the College of Medicine and Public Health.

A pilot study of the ‘Rethinking Pain’ guided self-help program in South Australia showed it to be a promising model for providing specialised information and support through supervised ‘coaches’ who worked with people with chronic pain to increase their understanding of their condition and improve their self-management. 

“Accessing care and support for chronic pain is difficult, time-consuming and costly, particularly for people living in rural and remote areas,” says Ms Redpath, Behavioural Health Discipline Lead at Flinders University.

“Chronic pain is a complex condition that requires specialised, multidisciplinary teams to provide effective and integrated care.

“Once a person understands helpful ways to manage their chronic pain, they can choose what strategies they want to use to self-manage.

“The coaches guide and assist people with these strategies, which they can then take away and use.”

The program can be offered via telehealth or in person and involves goal setting, pain conceptualisation, activity scheduling, psycho-education, pacing and cognitive strategies, with the evaluation of the program outcomes demonstrating significant improvement in patients’ reported independence and quality of life.

“Coaches can become part of the multidisciplinary team and support patients by providing information and strategies to manage their chronic pain. This can relieve pressure on higher-trained health and medical professionals, allowing them to concentrate on more complex care,” says Flinders University academic Dr Peter Herriot from the SA Health Southern Adelaide Local Health Network (SALHN) Pain Management Unit, who supervised the trial.

“This evidence-based program has the potential to not only improve access to care for people who are living with chronic pain but also to be scaled up and adopted across various healthcare settings.”

The guided self-help (GSH) program, developed by Flinders University experts, was delivered by supervised postgraduate students from the University’s Master of Cognitive Behaviour Therapy course who undertook a placement at SA Health’s Pain Management Unit at Flinders Medical Centre, Bedford Park.

An estimated 1 in 5 Australians aged 45 and over have chronic pain. The annual direct and indirect costs of chronic pain is estimated at $139 billion, including loss of productivity and quality of life.

Wider implementation of programs such as ‘Rethinking Pain’ is essential to expand and improve care options for people with chronic pain, adds Ms Redpath.

“Disseminating this specialist knowledge to a diversified health workforce and peers in the community and through primary care services may also reduce demand for psychiatrists and psychologists whose services are limited and hard to access.”

People living with chronic pain can also experience significant physical and emotional impacts, including on sleep quality and well-being as well as impacts on employment. Access to adequate support services can be difficult due to social disadvantages.

Neuropathic pain is chronic and caused by injury to the nervous system, affecting between 3% and 15% of the population. The only treatment options currently available are drugs initially developed for other conditions, such as epilepsy or depression

Neuropathic pain is a type of chronic pain caused by damage to the nervous system due mainly to metabolic diseases such as diabetes and arthritis, or to the side effects of some kinds of chemotherapy. It is believed to affect between 3% and 15% of the population, depending on the country, but specific medications are not yet available. The drugs currently in use were originally designed for the treatment of other conditions, such as epilepsy or depression.

Now, however, after a decade of research, a group of Brazilian scientists has succeeded in describing a mechanism associated with the production of neuropathic pain, opening up a new stage of their exploration in search of drugs that can act on the metabolic pathway in question and pointing to an avenue for the development of targeted therapies.

The study revealed the role played in neuropathic pain by dendritic cells present in the meninges, the membranes that cover the central nervous system, via an increase in the metabolic kynurenine pathway.

This pathway is responsible for the amino acid metabolism essential to the production of vitamin B3 (tryptophan) and performs important functions in various physiological processes, such as immune response organization. Previous research had already detected a link between increased production of kynurenine and the development of depression and other psychiatric disorders, for example.

In this study, the scientists found that neuropathic pain was nullified when the kynurenine pathway initiated by the enzyme IDO1 (indoleamine 2,3-dioxygenase 1) was blocked pharmaceutically or genetically. An article reporting the results is published in the Journal of Clinical Investigation.

“It was a very lengthy study because we wanted to explore in depth all the mechanisms that could be involved. It required collaboration in Brazil and abroad with leading experts, such as Andrew Mellor [a professor at Augusta University, formerly Georgia Regents, in the United States], one of the world’s foremost specialists in IDO. The results we obtained offer the prospect of developing novel compounds to block this pathway. We believe inhibitors of the pathway could play a key role in controlling neuropathic pain,” Thiago Mattar Cunha, last author of the article, told Agência FAPESP. Mattar Cunha is a professor at the University of São Paulo’s Ribeirão Preto Medical School (FMRP-USP).

Inflammation

Previous research had already shown that the kynurenine pathway, whose formation depends on several enzymes but primarily on IDO1, is involved in pain. Because IDO1 is induced during pathological processes, especially inflammation, by pro-inflammatory cytokines, the researchers hypothesized that the neuroinflammation that causes neuropathic pain could increase IDO, raising the levels of these neurotoxic or neurostimulatory metabolites.

“We used various tools to prove and elucidate the role played by these enzymes and other products in neuropathic pain,” Mattar Cunha said. “We used mice as a model and showed that neuropathic pain decreased in animals with a deficiency of these enzymes, or with the enzymes inhibited. We then set out to understand the mechanism.”

In the article, the researchers explain that they used “a well-established model of peripheral nerve injury-induced neuropathic pain”, known as the spared nerve injury model, and activation of spinal cord microglial cells (a type of central nervous system cell involved in the immune response). In the spinal cord, kynurenine was metabolized by astrocytes, and the glutamatergic receptor was activated.

“We showed for the first time that when peripheral nerves are injured, immune cells infiltrate the meninges that protect the spinal cord and dorsal root ganglion, producing mediators which cause or maintain pain hypersensitivity. IDO1 and its metabolites are produced in this process. We showed that these metabolites come mainly from dendritic cells in the meninges, causing hypersensitivity and amplifying the glutamatergic pathway, whose receptors play an important role in chronic pain,” Mattar Cunha said.

Although the study used pain models involving physical nerve injury, he added, the mechanism is similar in other neuropathic conditions, such as infectious diseases caused by HIV and other viruses.

As more U.S. states legalize cannabis (also known as marijuana) for medical and recreational use, increasing numbers of people are experimenting with it for pain relief. According to a new study published in JAMA Network Open, almost a third of patients with chronic pain reported using cannabis to manage it.

More than half of the 1,724 adults surveyed reported that using cannabis led them to decrease the use of pain medications, including prescription opioids and over-the-counter analgesics. Cannabis also affected the use of other non-drug related pain relief methods to various degrees. Some people indicated that cannabis led them to turn less often to techniques that many clinical guidelines recommend as first-line therapies such as physical therapy and cognitive behavioural therapy. In contrast, others with chronic pain increased their use of such treatments.

“The fact that patients report substituting cannabis for pain medications so much underscores the need for research on the benefits and risk of using cannabis for chronic pain,” said Mark Bicket, M.D., Ph.D., Assistant Professor in the Department of Anesthesiology and Co-Director of the Michigan Opioid Prescribing Engagement Network.

Julie Pilitsis, M.D., Ph.D., FAU’s principal investigator, dean and vice president for medical affairs in the Schmidt College of Medicine. CREDIT Florida Atlantic University

Researchers from Florida Atlantic University’s Schmidt College of Medicine, in collaboration with Albany Medical College (AMC) in New York, are among seven institutions nationwide selected to receive funding from the National Institutes of Health (NIH) for their innovative pilot projects to enable new medical devices to diagnose and treat both acute and chronic disorders from neuropathic pain to mental illness.

The one-year, $100,000 awards are the first for a new program within the NIH Blueprint for Neuroscience Research, called Blueprint MedTech. The seven projects selected for the pilot phase for funding by the NIH all received successful reviews from ABC’s “Shark Tank.”

Along with funding, MedTech will provide an array of specialized support from mentors who bring decades of experience commercializing neurotechnology devices. Project teams will learn to navigate business, manufacturing and regulatory aspects of developing their respective technologies, and prepare to build human-grade prototypes. While the science supporting each technology has met rigorous standards, clinical studies will be needed before they authorise patient use.

The FAU/AMC project is titled “External Low-intensity Focused Ultrasound Device for Treatment of Neuropathic Pain.” Focused ultrasound is a noninvasive therapeutic technique that directs ultrasonic waves to a specific location. For the project, researchers are developing a handheld probe to provide a noninvasive, non-opioid-based treatment for aggravated chronic pain, also referred to as neuropathic pain, for use in a physician’s office or potentially even at home.

The device directs low-intensity ultrasound at the dorsal root ganglia – small bundles of nerves along the spine that control pain signals reaching the spinal cord. Neuropathic pain occurs if the nervous system is damaged or not working correctly. Pain is felt from various levels of the nervous system, from the peripheral nerves to the spinal cord and the brain.

“Pain is one of the most common reasons patients seek medical care. Importantly, neuropathic pain, when treated with opioid-based drugs, has led to addiction in some patients,” said Julie Pilitsis, M.D., Ph.D., FAU’s principal investigator, dean and vice president for medical affairs in the Schmidt College of Medicine. “In addition to medications such as opioids, traditional pain treatment also involves physical therapy and steroid injections. However, adverse effects and tolerance occur with many of these therapies and a significant number of patients remain in pain. There is a great unmet need to provide more effective, safer and financially sustainable therapies for patients in pain.”

The handheld applicator under development integrates ultrasound imaging and therapy and is designed to accommodate differences in human anatomical size. As a result, the treatment device and methodology will provide means for precise treatment of back and leg pain.

“It is the noninvasive aspect and all-in-one nature of our device that is highly significant as an advancement in treatment of neuropathic pain,” said Pilitsis. “The cost of pain therapies and missed wages secondary to pain results in about $536 million dollars spent each year. Ideally, with this therapy, patients can avoid hospitalization and days off work by reducing pain and enabling function.”

Over the last eight years, the FAU/AMC researchers have shown efficacy of low intensity focused ultrasound in alerting nociceptive responses related to the perception or sensation of pain in multiple pain models over multiple species in both sexes and with repeated treatments.