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Chronic pain: from the study of student attitudes and preferences to the in vitro investigation of a novel treatment strategy
Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).ORCID iD: 0000-0002-2883-5603
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic pain will affect one in five adults during their lifetime, and it exerts a heavy burden on society with major physiological, psychological, social, and economic impacts. The current chronic pain curriculum taught to medical students in most settings is fragmented, inconsistent and inadequate and a vast majority of general practitioners considered their undergraduate training in chronic pain incomplete. Attitudes and beliefs amongst health care personnel are important and have shown to have impact on clinical management. There is currently a knowledge gap that needs to be addressed in this matter. In this thesis, through an online survey, the attitudes and beliefs of medical students in Sweden and Australia were surveyed. Additionally, we explored which factors influence chronic pain management amongst medical students in Sweden and Australia and Swedish general practitioners. We found that Swedish final year students have a more positive attitude towards chronic pain patients compared to Australian students. Both student cohorts perceived chronic pain management education in need of improvement. Furthermore, we found that the relative importance of factors that influence treatment decisions are formed early during undergraduate training, which further underlines the importance of improving pain curricula during undergraduate medical education in order to give the emerging workforce appropriate tools to manage chronic pain.

Management of chronic pain urgently requires novel, well-tolerated pharmacological treatment strategies. Palmitoylethanolamide (PEA) is a potential candidate for managing chronic pain. Its analgesic and anti-inflammatory effects have been observed in a range of experimental animal models and clinical trials. However, questions remain as to how PEA exerts its effects and how levels of PEA and its congeners are changed in states of pain and inflammatory disorders in humans. Treatment with PEA decreases cyclooxygenase 2 (COX-2) activity in animal models, but we found that PEA did not have direct effects upon the kinetic properties of COX-2 in a cell free system. However, COX-2 derived eicosanoid levels were reduced by PEA in lipopolysaccharide and interferon-g-stimulated RAW 264.7 cells. With respect to changes in PEA levels in a chronic inflammatory disorder, we investigated PEA levels, in addition to its synthesizing and hydrolysing enzymes in biopsies from patients with oral lichen planus (OLP). We found that the ratio of prostaglandins to PEA was increased in the OLP biopsy samples. Furthermore, PTGS2 mRNA levels (coding for COX-2) were increased in OLP-patients compared to controls relative to NAPEPLD mRNA levels (coding for a key enzyme in the synthesis of PEA). These results suggest that there is a relative deficit of PEA in OLP, raising the possibility that PEA might be useful for the treatment of this disorder.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2020. , p. 96
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2085
Keywords [en]
HC-PAIRS, best-worst scaling, palmitoylethanolamine, N-acylthanolamines, oral lichen planus, prostaglandins, chronic pain, prolonged pain, chronic pain education, chronic pain management, medical students, attitudes
National Category
Pharmacology and Toxicology
Identifiers
URN: urn:nbn:se:umu:diva-173854ISBN: 978-91-7855-268-9 (electronic)ISBN: 978-91-7855-267-2 (print)OAI: oai:DiVA.org:umu-173854DiVA, id: diva2:1456215
Public defence
2020-09-11, Triple Helix, Samverkanshuset, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2020-08-21 Created: 2020-08-03 Last updated: 2020-08-10Bibliographically approved
List of papers
1. Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught
Open this publication in new window or tab >>Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught
2018 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 18, no 3, p. 533-544Article in journal (Refereed) Published
Abstract [en]

Background and aims: Medical students receive training in the management of chronic pain, but the training is often suboptimal. Considering that the basis for physician’s knowledge is their medical education, it is important to explore the attitudes and beliefs of medical students with respect both to chronic pain management and to their views on current pain education. Therefore, the aim of this study was to compare Swedish and Australian medical student’s attitudes and beliefs about patients with chronic pain, and their perceptions regarding their chronic pain management education.

Methods: An online survey was conducted with final year Australian and Swedish medical students from two different universities between December 2016 and February 2017. Attitudes and beliefs towards chronic pain patients were measured using the Health Care Providers’ Pain and Impairment Scale (HC-PAIRS). A thematic analysis was conducted on open end questions regarding their views on their education and important skills for chronic pain management.

Results: A total of 57 Swedish and 26 Australian medical students completed the HC-PAIRS scale. The Swedish medical students showed statistically significantly lower total mean HC-PAIRS scores compared to Australian medical students (46 and 51, respectively). Australian students had statistically significantly higher scores than the Swedish students for two of four factors: functional expectations and need for cure, whereas no significant differences were seen for the factors social expectations or for projected cognition. From the open end questions it was evident that final year medical students are knowledgeable about key chronic pain items described in clinical guidelines. However, both cohorts described their chronic pain training as poor and in need of improvement in several areas such as more focus on the biopsychosocial model, working in multidisciplinary teams, seeing chronic pain patients and pharmacological training.

Conclusions: Attitudes and beliefs are formed during medical education, and our study exploring attitudes of medical students towards chronic pain and how it is taught have provided valuable information. Our survey provided detailed and cohesive suggestions for education improvement that also are in line with current clinical guidelines. This study indicates that the Swedish final year students have a more positive attitude towards chronic pain patients compared to their Australian counterparts. The majority of students in both cohorts perceived chronic pain management education in need of improvement.

Implications: This study highlights several areas of interest that warrant further investigation, for example, the impact of a changed medical curriculum in alignment with these clinical guidelines requested by students in this survey, and correspondingly if their attitudes towards chronic pain patients can be improved through education. Further, we conclude that it would be valuable to align the implementation of the HC-PAIRS instrument in order to achieve comparable results between future studies.

Place, publisher, year, edition, pages
Walter de Gruyter, 2018
Keywords
HC-PAIRS; attitudes; chronic pain; medical education; medical students
National Category
Other Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-148376 (URN)10.1515/sjpain-2018-0039 (DOI)000439314200023 ()2-s2.0-85046714083 (Scopus ID)
Funder
Swedish Research Council, 12158
Available from: 2018-06-04 Created: 2018-06-04 Last updated: 2023-03-24Bibliographically approved
2. What influences chronic pain management?: A best-worst scaling experiment with final year medical students and general practitioners
Open this publication in new window or tab >>What influences chronic pain management?: A best-worst scaling experiment with final year medical students and general practitioners
2019 (English)In: British Journal of Pain, ISSN 2049-4637, Vol. 13, no 4, p. 214-225Article in journal (Refereed) Published
Abstract [en]

Background: Chronic pain education is an essential determinant for optimal chronic pain management. Given that attitudes and preferences are involved in making treatment decisions, identifying which factors are most influential to final year medical students’ and general practitioners’ (GPs) chronic pain management choices is of importance. This study investigates Swedish and Australian students’ preferences with respect to a chronic pain condition, using a best–worst scaling (BWS) experiment, which is designed to rank alternatives.

Methods: BWS, a stated-preference method grounded in random utility theory, was used to explore the importance of factors influencing chronic pain management.

Results: All three cohorts considered the patients’ pain description and previous treatment experience as the most important factors in making treatment decisions, whereas their demographics and voices or facial expressions while describing their pain were considered least important. Factors such as social support, patient preferences and treatment adherence were, however, disregarded by all cohorts in favour of pain assessment factors such as pain ratings, description and history. Swedish medical students and GPs show very high correlation in their choices, although the GPs consider their professional experience as more important compared to the students.

Conclusion: This study suggests that the relative importance of treatment factors is cemented early and thus underline the critical importance of improving pain curricula during undergraduate medical education.

Keywords
Pain management, pain education, best-worst scaling, medical students, general practitioners
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-165668 (URN)10.1177/2049463719832331 (DOI)000489776800003 ()31656627 (PubMedID)2-s2.0-85062322455 (Scopus ID)
Funder
Swedish Research Council, 12158
Available from: 2019-12-06 Created: 2019-12-06 Last updated: 2023-03-24Bibliographically approved
3. The anti-inflammatory compound palmitoylethanolamide inhibits prostaglandin and hydroxyeicosatetraenoic acid production by a macrophage cell line
Open this publication in new window or tab >>The anti-inflammatory compound palmitoylethanolamide inhibits prostaglandin and hydroxyeicosatetraenoic acid production by a macrophage cell line
Show others...
2017 (English)In: Pharmacology Research & Perspectives, E-ISSN 2052-1707, Vol. 5, no 2, article id e00300Article in journal (Refereed) Published
Abstract [en]

The anti-inflammatory agent palmitoylethanolamide (PEA) reduces cyclooxygenase (COX) activity in vivo in a model of inflammatory pain. It is not known whether the compound reduces prostaglandin production in RAW264.7 cells, whether such an action is affected by compounds preventing the breakdown of endogenous PEA, whether other oxylipins are affected, or whether PEA produces direct effects upon the COX-2 enzyme. RAW264.7 cells were treated with lipopolysaccharide and interferon-c to induce COX-2. At the level of mRNA, COX-2 was induced > 1000-fold following 24 h of the treatment. Coincubation with PEA (10 mu mol/L) did not affect the levels of COX-2, but reduced the levels of prostaglandins D-2 and E-2 as well as 11- and 15-hydroxyeicosatetraenoic acid, which can also be synthesised by a COX-2 pathway in macrophages. These effects were retained when hydrolysis of PEA to palmitic acid was blocked. Linoleic acidderived oxylipin levels were not affected by PEA. No direct effects of PEA upon the oxygenation of either arachidonic acid or 2-arachidonoylglycerol by COX-2 were found. It is concluded that in lipopolysaccharide and interferon-c-stimulated RAW264.7 cells, PEA reduces the production of COX-2-derived oxylipins in a manner that is retained when its metabolism to palmitic acid is inhibited.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keywords
Palmitoylethanolamide, cyclooxygenase, prostaglandin, oxylipin, RAW264.7 cells, fatty acid amide drolase, N-acylethanolamine hydrolysing acid amidase, bootstrapped linear model
National Category
Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-140988 (URN)10.1002/prp2.300 (DOI)000407444900009 ()28357126 (PubMedID)2-s2.0-85021909304 (Scopus ID)
Funder
Swedish Research Council, 12158
Available from: 2017-10-25 Created: 2017-10-25 Last updated: 2024-07-02Bibliographically approved
4. On the balance between prostaglandins and anti-inflammatory N-acylethanolamines in oral lichen planus
Open this publication in new window or tab >>On the balance between prostaglandins and anti-inflammatory N-acylethanolamines in oral lichen planus
(English)Manuscript (preprint) (Other academic)
National Category
Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-173853 (URN)
Available from: 2020-08-03 Created: 2020-08-03 Last updated: 2020-08-04

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