Satellite glial cells in sensory ganglia play a wider role in chronic pain via multiple mechanisms

Satellite glial cells are unique glial cells that surround the cell body of primary sensory neurons.An increasing body of evidence suggests that in the presence of inflammation and nerve damage,a significant number of satellite glial cells become activated,thus triggering a series of functional changes.This suggests that satellite glial cells are closely related to the occurrence of chronic pain.In this review,we first summarize the morphological structure,molecular markers,and physiological functions of satellite glial cells.Then,we clarify the multiple key roles of satellite glial cells in chronic pain,including gap junction hemichannel Cx43,membrane channel Pannexin1,K channel subunit 4.1,ATP,purinergic P2 receptors,and a series of additional factors and their receptors,including tumor necrosis factor,glutamate,endothelin,and bradykinin.Finally,we propose that future research should focus on the specific sorting of satellite glial cells,and identify genomic differences between physiological and pathological conditions.This review provides an important perspective for clarifying mechanisms underlying the peripheral regulation of chronic pain and will facilitate the formulation of new treatment plans for chronic pain.

Genetic Evidence for Causal Association Between Hypertension and Chronic Pain:A Bidirectional Two-Sample Mendelian Randomization Study

Objective The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed.In the present study,Mendelian randomization(MR)was employed to examine the potential causal relationship between hypertension and risk of chronic pain.Methods The study data were derived from the pooled dataset of the genome-wide association study(GWAS),enabling the evaluation of the causal effects of hypertension on various types of chronic pain including chronic headache as well as chest,abdominal,joint,back,limb,and multisite chronic pain.We performed a bidirectional two-sample MR analysis using random effect inverse variance weighting(IVW),MR-Egger,weighted median,and weighted mode,quantified by odds ratio(OR).Results Genetically predicted essential hypertension was associated with an increased risk of chronic headache(OR=1.007,95%CI:1.003-1.011,P=0.002)and limb pain(OR=1.219,95%CI:1.033-1.439,P=0.019).No potential causal associations were identified between chronic pain and essential hypertension in the reverse direction MR(P>0.05).In addition,there was no potential causal association between secondary hypertension and chronic pain(P>0.05).Conclusion This study provided genetic evidence that a unidirectional causal relationship exists between essential hypertension and the increased risks of chronic headache and limb pain,and no causal relationship was found between secondary hypertension and chronic pain.These findings offer theoretical underpinnings for future research on managing hypertension and chronic pain.

Clinical efficacy of magnetic vibration magnetoelectric therapy in the treatment of chronic prostatitischronic pelvic pain syndrome

BACKGROUND The prominent symptoms of chronic pelvic pain syndrome(CPPS)are urogenital pain,lower urinary tract symptoms,psychological problems,and sexual dysfunction.Traditional pharmacological treatments have poor efficacy and more untoward reaction and complications.Magnetic vibration magnetoelectric therapy is a non-invasive form of physiotherapy.Nevertheless,its effectiveness in improving urinary discomfort and relieving pain in patients requires further exploration.AIM To investigate the clinical efficacy of the magnetic vibration magnetoelectric therapy instrument in the treatment of chronic prostatitis(CP)/CPPS.METHODS Seventy patients with CP/CPPS were collected from the outpatient clinic and ward of the Department of Male Medicine,Jiangsu Province Hospital of Traditional Chinese Medicine,and were treated with magnetic vibration magnetoelectric therapy once a day for a period of 14 d.National Institutes of healthchronic prostatitis symptom index(NIH-CPSI),international index of erectile function 5(IIEF-5),premature ejaculation diagnostic tool(PEDT),generalized anxiety disorder(GAD),patient health questionnaire,the pain catastrophizing scale(PCS)and traditional Chinese medicine syndrome(TCMS)scores were performed before and after treatment.RESULTS The total effective rate of treatment was 58.5%,and the total NIH-CPSI score,pain symptoms,voiding symptoms,quality of life,IIEF-5,PEDT,GAD,PCS and TCMS scores all decreased significantly(P<0.05).CONCLUSION Magnetic vibration magnetotherapy is effective in improving urinary discomfort,relieving pain,improving quality of life,improving sexual dysfunction and relieving negative emotions such as anxiety in patients with CP/CPPS.

Clinical Effect Observation of Constructing PERMA Model in Psychological Intervention for Patients with Chronic Cancer Pain

Background:The constructing PERMA model in psychological intervention was applied to patients with chronic cancer pain to provide data reference for reducing pain,fear of cancer recurrence,and improving the level of psychological capital.Aim:To explore the clinical effects of constructing PERMA model in psychological intervention for patients with chronic cancer pain.Methods:A total of 98 patients with chronic cancer pain admitted to our hospital from March 2021 to March 2023 were randomly divided into two groups,49 cases in each group.The control group received routine intervention,while the research group constructed PERMA model based on the routine intervention for psychological intervention.The pain severity,fear of cancer recurrence,psychological capital and quality of life before and after intervention were compared between the two groups.Results:After two months of intervention,the pain in the research group was milder than that in the control group(p<0.05).The scores and total scores of all dimensions of fear of cancer recurrence in the research group were lower than those in the control group(p<0.05).The scores and total scores of each dimension of psychological capital in the research group were higher than those in the control group(p<0.05).The scores of all dimensions of quality of life in the research group were higher than those in the control group(p<0.05).Conclusion:The PERMA model constructed in psychological interventions for patients with chronic cancer pain can assist analgesic medications to reduce pain and alleviate the fear of cancer recurrence,increase the level of psychological capital,and thus improve quality of life.

Complex Regional Pain Syndrome: Outpatient Pain Management in the Chronic Setting: A Case Report

Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a debilitating condition with high levels of pain and reduced function. Aim: This case report aims to discuss the multimodal approach in the management of a patient who presented with ongoing poorly controlled pain secondary to CRPS from an injury that happened years prior. Case Presentation: A 45-year-old female was involved in a motor vehicle accident where her right leg was injured. She underwent several surgeries and developed CRPS that significantly reduced her mobility and quality of life. She presented to the pain clinic years after her initial injury and a multimodal regimen was started for her resulting in significantly improved function. Conclusion: CRPS can be a severely debilitating condition. While early diagnosis and management are important, ongoing management in the outpatient chronic pain setting is important in maintaining a good level of function.

Prevalence and Factors Associated with Chronic Low Back Pain in the Mining Sector in Burkina Faso

Introduction: Low back pain is nowadays a real public health problem in companies. The objective of the study was to determine the prevalence and factors associated with chronic low back pain among workers of a mining company in Burkina Faso. Material and Methods: This was a descriptive and analytical cross-sectional study with a retrospective collection that took place from August 1, 2021 to March 16, 2022 in a gold mine in Burkina Faso. It focused on mine workers who participated in the 2019 annual medical visit. Results: Out of a total workforce of 880 workers who took part in the annual medical visit in 2019, 165 had chronic common low back pain, i.e. a prevalence of 18.75%. The average age of low back pain workers was 37.21 ± 7.5 years. Among the workers suffering from low back pain, 62 (37.58%) held the position of machine operator. Clinically, mechanical pain was found in 113 low back pain workers (76%) and twenty-nine (17.58%) had radicular pain. Standard radiography of the lumbar spine was abnormal in 129 workers (78.18%. In the univariate analysis, the factors associated with the pathology were sex, level of study, work station and seniority in the position. After a logistic regression, the factors associated with its occurrence were whole-body vibration (Fisher’s test = 12.7541;P = 0.000), male sex (Fisher’s test = 8.363;P = 0.004), and seniority for 4 to 5 years (Chi2 = 4.0234;p = 0.046). Conclusion: The study reveals the existence of chronic low back pain cases among the workers of the mining company. There is a predominance of the pathology in men, workers exposed to vibrations and those with a seniority of 4 to 5 years. It is necessary to establish a policy of prevention of low back pain for the benefit of workers, in particular those exposed to vibrations.

Botulinum toxin type A for treating chronic low back pain:A double blinded randomized control study

BACKGROUND Low back pain(LBP)is a prevalent issue that orthopedic surgeons frequently address in the outpatient setting.LBP can arise from various causes,with stiffness in the paraspinal muscles being a notable contributor.The administration of Botulinum toxin type A(BoNT-A)has been found to alleviate back pain by relaxing these stiff muscles.While BoNT-A is approved for use in numerous conditions,a limited number of randomized clinical trials(RCTs)validate its efficacy specifically for treating LBP.AIM To study the safety and the efficacy of BoNT-A in minimizing pain and improving functional outcomes in patients of chronic LBP(CLBP).METHODS In this RCT,adults aged 18-60 years with mechanical LBP persisting for at least six months were enrolled.Participants were allocated to either the Drug group,receiving 200 Ipsen Units(2 mL)of BoNT-A,or the Control group,which received a 2 mL placebo.Over a 2-month follow-up period,both groups were assessed using the Visual Analog Scale(VAS)for pain intensity and the Oswestry Disability Index(ODI)for disability at the start and conclusion of the study.A decrease in pain by 50%was deemed clinically significant.RESULTS The study followed 40 patients for two months,with 20 in each group.A clinically significant reduction in pain was observed in 36 participants.There was a statistically significant decrease in both VAS and ODI scores in the groups at the end of two months.Nonetheless,when comparing the mean score changes,only the reduction in ODI scores(15 in the placebo group vs 16.5 in the drug group,clinically insignificant)was statistically significant(P=0.012),whereas the change in mean VAS scores was not significant(P=0.45).CONCLUSION The study concludes that BoNT-A does not offer a short-term advantage over placebo in reducing pain or improving LBP scores in CLBP patients.

Inhibitory gamma-aminobutyric acidergic neurons in the anterior cingulate cortex participate in the comorbidity of pain and emotion

Pain is often comorbid with emotional disorders such as anxiety and depression.Hyperexcitability of the anterior cingulate cortex has been implicated in pain and pain-related negative emotions that arise from impairments in inhibitory gamma-aminobutyric acid neurotransmission.This review primarily aims to outline the main circuitry(including the input and output connectivity)of the anterior cingulate cortex and classification and functions of different gamma-aminobutyric acidergic neurons;it also describes the neurotransmitters/neuromodulators affecting these neurons,their intercommunication with other neurons,and their importance in mental comorbidities associated with chronic pain disorders.Improving understanding on their role in pain-related mental comorbidities may facilitate the development of more effective treatments for these conditions.However,the mechanisms that regulate gamma-aminobutyric acidergic systems remain elusive.It is also unclear as to whether the mechanisms are presynaptic or postsynaptic.Further exploration of the complexities of this system may reveal new pathways for research and drug development.

Forgiveness and Chronic Pain: A Cohort Study

Background: Chronic pain is a major public health issue. It is a complex condition comprising biological, social and psychological elements, which can be challenging to manage. Forgiveness is a recognised effective intervention in various health conditions. Research has shown promising results using forgiveness as an intervention in the management of pain. This study aims to examine the relationship between forgiveness and other variables in patients suffering from chronic pain in the setting of a chronic pain clinic. Methods: Institutional ethical approval was granted for this study. Patients attending a chronic pain clinic for the first time were invited to complete a questionnaire comprising a brief socio-demographic survey and questionnaires including the Heartland Forgiveness Scale, Hospital Anxiety and Depression Scale, Pain and Anxiety Symptoms Scale and Perceived Injustice. Results: 104 adult patients were included. The mean age was 59 years. Back pain was the most common chronic pain presentation. The Heartland Forgiveness Scale (HFS) was found to have a good internal consistency among the Irish population. This study found that 55% of patients attending the pain clinic were not forgiving. Negative correlations were identified between forgiveness and pain, and forgiveness and injustice. Conclusion: The majority of patients attending a chronic pain clinic were not forgiving as measured on the HFS. There was a negative correlation between forgiveness and pain. The results have shown that forgiveness could be beneficial as a therapeutic intervention among patients attending a chronic pain clinic.

Evaluation of the Effectiveness and Efficiency of Extracorporeal Shock Wave Combined with Rehabilitation Training in the Treatment of Muscle Articulation Chronic Pain

Objective: To analyze the effect of combined extracorporeal shock wave and rehabilitation training treatment in patients with muscle articulation chronic pain (MACP). Methods: Ninety-seven MACP patients admitted to our hospital from September 2021 to September 2023 were randomly selected and were divided into Group A (control group, 46 cases, rehabilitation training treatment) and Group B (observation group, 51 cases, extracorporeal shock wave with rehabilitation training treatment), and outcomes of the two groups were compared. Results: The treatment efficiency, post-treatment clinical indexes (upper and lower limb function scores, activities of daily living (ADL) scores, visual analog scale (VAS) scores), and short-form 36 (SF-36) scores of Group B were better than those of Group A (P < 0.05). Conclusion: Combined extracorporeal shock wave and rehabilitation training treatment for MACP patients improved their limb function, daily activities, quality of life, and reduced pain.

Chronic Pain Management after Necrotizing Soft Tissue Infection (NSTI): A Case Report

Background: Necrotizing soft tissue infections (NSTIs) are potentially life threatening medical emergencies associated with devastating and rapidly spreading destruction of soft tissues. Atypical presentations and delayed early diagnosis can be significant challenges in managing NSTIs. The infectious process can start at any part of the body with rapid progression leading to limb amputation and high mortality rate. We present a case of a patient with NSTI, the sequelae and management of the chronic pain that developed. Aim: This case report looks to shed light on the importance of a plan for management of subacute and chronic pain in treating patients who present with Necrotizing soft tissue infection. Case presentation: A 53-year-old female who presented with septicemia and was subsequently admitted and treated for NSTI in 2014 resulting in amputation of her distal foot, toe digits, and now with ongoing chronic wound of the lower extremities along with chronic pain. Conclusion: Chronic pain as part of the sequelae of Necrotizing soft tissue infections needs to be anticipated by the health care management team in order to optimize patient care post operatively.

Study on Electromyographic Characteristics of Neck Muscles in College Students with Chronic Neck Pain

Objective:To provide new insights for the evaluation and diagnosis of chronic neck pain(CNP).Methods:22 patients with CNP and 22 healthy individuals were recruited from South China Normal University,who were all college students.The subjects'neck extensor muscle strength in the head neutral position,the natural anteversion position,and the maximum forward flexion position were measured by an isometric muscle strength tester respectively.The neck extensor strength of CNP patients and healthy subjects were compared.Results:In the neutral position,the maximum isometric muscle strength of neck extensor muscles was 12.31 kg for CNP patients and 15.16 kg for healthy individuals,resulting in a ratio of 81%strength in patients compared to healthy subjects.This difference was highly significant(P<0.000).In the natural anteversion position,the respective values were 12.6 kg for CNP patients and 15.05 kg for healthy individuals,with a ratio of 83%,and a significant difference between groups(P<0.001).In the maximum forward flexion position of the head,the values were 13.36 kg for CNP patients and 16.15 kg for healthy individuals,with a ratio of 82%,and a highly significant difference(P<0.000).Conclusion:The neck extensor muscle strength levels in college students with CNP were significantly lower compared to healthy college students across all measured positions.

RANDOMIZED CONTROL STUDY ON DEPRESSION INDUCED BY CHRONIC PAIN TREATED WITH ACUPUNCTURE

Objective To study and verify the efficacy of acupuncture on depression caused by chronic pain and to further analyze the advantages of acupuncture. Methods According to random number table, the cases were randomized into experimental group and western medicine group, treated with acupuncture and antidepression drug （deanxit） respectively. Hamilton Depressive Scale （HAMD） and Visual Analogue Scale （VAS） were adopted for the evaluation before treatment and in the 1, 2 and 4 weeks after treatment in two groups successively. Results ① Very significant differences had been achieved on the comparisons of HAMD, VAS and HAMD reducing rate before and after treatment in experimental group （P 〈 0.01）. Very significant differences had been achieved in the comparisons of HAMD, VAS and HAMD reducing rate before and after treatment in western medicine group （P 〈 0.01 ）. ③Significant differences in HAMD reducing rate^＊ and VAS score^＊ ＊ had been achieved in the comparison between experiment group and western medicine group 1 week after treatment （^＊ P〈0.01, ^＊ ＊ P〈0.05）. ④ The significant differences had not been received in HAMD, VAS score and HAMD reducing rate in 2 and 4 weeks after treatment in the comparison between experimental group and western medicine group （P 〉0.05）. ⑤ No any harmful effect happened in experimental group after treatment, but it happened in western medicine group. Conclusion Both acupuncture and deanxit have achieved the definite therapeutic effects on depression caused by chronic pain, with similar efficacy. But the effects of acupuncture are obtained more quickly. In comparison of western medicine, acupuncture has no side and harmful effect. Additionally, acupuncture applies the multi-targeting and holistic modulation to the whole body.

Differences in brain structure in patients with distinct sites of chronic pain:A voxel-based morphometric analysis

A reduction in gray matter volume is common in patients with chronic back pain, and different types of pain are associated with gray matter abnormalities in distinct brain regions. To examine differ- ences in brain morphology in patients with low back pain or neck and upper back pain, we investi- gated changes in gray matter volume in chronic back pain patients having different sites of pain using voxel-based morphometry. A reduction in cortical gray matter volume was found primarily in the left postcentral gyrus and in the left precuneus and bilateral cuneal cortex of patients with low back pain. In these patients, there was an increase in subcortical gray matter volume in the bilateral putamen and accumbens, right pallidum, right caudate nucleus, and left amygdala. In upper back pain patients, reduced cortical gray matter volume was found in the left precentral and left postcen- tral cortices. Our findings suggest that regional gray matter volume abnormalities in low back pain patients are more extensive than in upper back pain patients. Subcortical gray matter volume in- creases are found only in patients with low back pain.

Chronic proctalgia and chronic pelvic pain syndromes:New etiologic insights and treatment options

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs:chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing:A recently published large randomized,controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle-a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders.

Redundant prepuce increases the odds of chronic prostatitis/chronic pelvic pain syndrome （CP/CPPS）

Some published evidence has revealed that the dendritic cells can interact with pathogens that exist in the inner foreskin. This information provides a new vision that pathogens could play a role through the redundant prepuce; numerous studies have failed to find pathogens in prostates of patients who had chronic prostatitis/chronic pelvic pain syndrome （CP/CPPS）. However, no studies have reported an association between foreskin length and CP/CPPS. Hence, we conducted a retrospective case-control study of clinical data from 322 CP/CPPS patients （case group） and 341 nonCP/CPPS patients （control group）. Demographic characteristics, lifestyle factors, and foreskin lengths were collected and analyzed. Multivariate logistic regression was adopted to calculate the odds of foreskin length for CP/CPPS. According to the multivariate logistic regression results, when the foreskin length covered up more than half of the glans penis, the odds for CP/CPPS were higher with an increased foreskin （odds ratio （OR）： 1.66, 95% confidence interval （CI）： 1.04-2.66）. In comparison, when the glans penis was completely covered by the foreskin, the OR value increased to 1.86 （95% CI, 1.2-2.88）. The study results showed an association between foreskin length and the odds of CP/CPPS. When the foreskin length covered up more than half of the glans penis, there were greater odds for CP/CPPS. This possible mechanism might result from interaction between pathogens and DCs in the inner foreskin, consequently activating T-cells to mediate allergic inflammation in the prostate and producing the autoimmunizations causing CP/CPPS.

Characterisation of the bacterial community in expressed prostatic secretions from patients with chronic prostatitis/chronic pelvic pain syndrome and infertile men： a preliminary investigation

The expressed prostatic secretions （EPSs） of men with chronic prostatitis/chronic pelvic pain syndrome （CP/CPPS）, infertile men and normal men were subjected to microbiological study. EPSs were collected from the subjects, which included 26 normal men, 11 infertile patients and 51 CP/CPPS patients. DNA was extracted from each specimen, and the V3 regions of the 16S rRNA genes were amplified using universal bacterial primers. The results showed that the EPS 16S rRNA gene-positive rate in the CP/CPPS and infertile patients was much higher than in the normal men, but without any difference among the three patient groups. The denaturing gradient gel electrophoresis （DGGE） method was used to characterize the EPS bacterial community structure of the prostate fluid from patients with CP/CPPS or infertility issues. Principal component analysis （PCA） and partial least squares （PLS） analyses of PCR-DGGE profiles revealed that the EPS bacterial community structure differed among the three groups. Three bands were identified as the key factors responsible for the discrepancy between CP/CPPS patients and infertile patients （P〈O.05）. Two bands were identified as priority factors in the discrepancy of category IliA and category IIIB prostatitis patients （P〈O.05）. According to this research, the ecological balance of the prostate and low urethra tract, when considered as a microenvironment, might play an important role in the maintenance of a healthy male reproductive tract.

Targeting the nitric oxide/cGMP signaling pathway to treat chronic pain

Nitric oxide(NO)/cyclic guanosine 3′,5′-monophosphate(cGMP) signaling has been shown to act as a mediator involved in pain transmission and processing. In this review, we summarize and discuss the mechanisms of the NO/cGMP signaling pathway involved in chronic pain, including neuropathic pain, bone cancer pain, inflammatory pain, and morphine tolerance. The main process in the NO/cGMP signaling pathway in cells involves NO activating soluble guanylate cyclase, which leads to subsequent production of cGMP. cGMP then activates cGMP-dependent protein kinase(PKG), resulting in the activation of multiple targets such as the opening of ATP-sensitive K+ channels. The activation of NO/cGMP signaling in the spinal cord evidently induces upregulation of downstream molecules, as well as reactive astrogliosis and microglial polarization which participate in the process of chronic pain. In dorsal root ganglion neurons, natriuretic peptide binds to particulate guanylyl cyclase, generating and further activating the cGMP/PKG pathway, and it also contributes to the development of chronic pain. Upregulation of multiple receptors is involved in activation of the NO/cGMP signaling pathway in various pain models. Notably the NO/cGMP signaling pathway induces expression of downstream effectors, exerting both algesic and analgesic effects in neuropathic pain and inflammatory pain. These findings suggest that activation of NO/cGMP signaling plays a constituent role in the development of chronic pain, and this signaling pathway with dual effects is an interesting and promising target for chronic pain therapy.

Pain management in chronic pancreatitis incorporating safe opioid practices: Challenge accepted

Patients with chronic pancreatitis often experience severe,unrelenting abdominal pain,which can significantly impact their quality of life.Pain control,therefore,remains central to the overall management of chronic pancreatitis.Most of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another,as there are no uniform guidelines to direct a stepwise approach towards achieving this goal.In this editorial,we comment on best practice strategies targeted towards pain control in chronic pancreatitis,specifically highlighting the use of opioid medications in this patient population.We discuss various safe and efficacious prescription monitoring practices in this article.

Pain acceptance in cancer patients with chronic pain in Hunan, China:A qualitative study

Objective: The purpose of this qualitative study was to describe the experiences of pain acceptance in Chinese cancer patients with chronic pain.Methods: Twelve hospitalized cancer patients with chronic pain participated in this qualitative descriptive study from August to November 2017.In-person semi-structured interviews were conducted,recorded,transcribed,and analyzed using Colaizzi's seven-step method.Results: The following four main themes and 15 subthemes emerged.Theme 1 (adaptation): pain is overwhelming and pain relief is a top priority,avoidance of pain-inducing factors,and resignation;theme 2 (emotional reactions to pain): feeling misunderstood,hopelessness,frustration,irritability,and concern for loved ones;theme 3 (functional limitations): daily life activities,social communication,and work;theme 4 (coping strategies): pharmacological therapies,behavioral strategies,social support strategies,and spiritual strategies.Conclusions: This study provides a description of cancer patients' experiences related to the need for pain acceptance.These findings provide insight into the essential role of pain acceptance and underline the need to apply acceptance-based cognitive behavioral interventions as adjunctive non-pharmacological alternatives for chronic cancer pain.