January 2016
David Craig, PharmD | Editor


The Journal of Pain

Highlights from The Journal of Pain (Volume 17, No. 1, January 2016 Issue)

Journal of Pain cover

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Michael Von Korff, Sascha Dublin, Rod L. Walker, Michael Parchman, Susan M. Shortreed, Ryan N. Hansen, and Kathleen Saunders; Group Health Research Institute, Seattle, WA; Department of Biostatistics, University of Washington, Seattle, WA; School of Pharmacy, University of Washington, Seattle, WA

Research published in The Journal of Pain on opioid prescribing in the state of Washington reports that physicians who implemented initiatives stricter than state guidelines to reduce high-dose opioid prescribing achieved significantly greater reductions in medication use in their patients.

There is mounting evidence that risks for opioid overdoses among patients on chronic opioid therapy (COT) increase with high doses. In 2010, state officials in Washington enacted a guideline recommending caution in prescribing opioids at higher doses, defined as a daily morphine equivalent dose of 120 mg or greater. The guideline was mandated for long-term opioid prescribing for chronic noncancer pain but excluded hospice and palliative care and management of acute pain after injury or surgery.

Researchers from the Group Health Institute in Seattle compared rates of high opioid doses among COT patients statewide and within a health plan. They examined prescribing trends in the plan’s group practice, which implemented a multifaceted opioid risk reduction initiative and compared them with trends among the health plan’s contracted physicians who followed only the state guidelines. The opioid risk reduction initiative included standards for patient monitoring and urine drug screening, periodic monitoring visits, and modifications to the prescription refill process to prevent urgent refill requests.

The study was conducted from 2006 to 2014 and covered 16,653 COT patients in the group practice and 5,552 in the contracted care settings.

Results showed the portion of COT patients in the group practice receiving high doses dropped from 16% to 6% versus a decline from 20% to 14% in contracted practices. The authors concluded that reductions in high-dose opioid prescribing were substantially greater in the group practice setting that adopted additional initiatives to alter shared physician expectations regarding appropriate COT prescribing.

Investigating the Primary Care Management of Low-Back Pain: A Simulated Patient Study

Christina Abdel Shaheed, Brett McFarlane, Chris G. Maher, Kylie A. Williams, Jenny Bergin, Andrew Matthews, and Andrew J. McLachlan; Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; Australian College of Pharmacy, Canberra, Australian Capital Territory, Australia; The George Institute for Global Health, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Graduate School of Health, University of Technology Sydney, Broadway, New South Wales, Australia; Group Executive, Pharmacy Transformation Group, The Pharmacy Guild of Australia, Canberra, Australian Capital Territory, Australia; Centre for Education and Research on Ageing, University of Sydney and Concord Repatriation General Hospital, Sydney, New South Wales, Australia

A unique Australian study employed actors to pose as patients with low-back pain and seek treatment advice to measure practitioner concordance with established low-back pain management guidelines.

Researchers from Sidney Medical School used the simulated patient approach to conduct a cross-sectional observational study to assess management recommendations for low-back pain given in primary-care settings. Trained actors requested an over-the-counter drug or asked for advice for one of two scenarios: nonspecific, low-back pain or a vertebral compression fracture. Visits occurred in 2013 at 534 pharmacies for 336 nonspecific, low-back pain scenarios and 198 simulated-fracture cases. In Australia, pharmacists see twice the low-back pain patients that general-practice physicians see.

The aim of the study was to investigate primary-care management of low-back pain measured by direct observation of the clinical encounter and to compare advice given to evidence-based guidelines.

For the nonspecific scenario, the actors were instructed to ask about medications for low-back pain. For the fracture scenario, they explained their mother or grandmother fell and hurt her lower back and is taking acetaminophen but not feeling better. Actors also were instructed to ask if a doctor should be consulted about getting an x-ray. If asked about medication history, actors were given a medication list to share with the pharmacists.

Results showed that the selection of pain medications complied with guideline-endorsed care, but advice about safe medication use was insufficient. Also, advice about self-care was not consistent with guidelines. Reassurance of favorable prognosis and providing information on how to use heat for pain relief was infrequently provided. In the fracture scenario, there was inadequate advice about engagement in physical activity and frequent failure to recommend imaging or medical visits when appropriate.

The authors noted that simulated patient studies offer authentic evaluation of what occurs in practice, and this study provides information about clinical actions that previous low-back pain audits did not cover. The findings can help target gaps in practice among primary-care providers.


Highlights from PAIN (Volume 157, Issue 1, January 2016 Issue)

Pain Medicine Cover

Internet-Delivered Cognitive-Behavioral Treatment for Adolescents with Chronic Pain and Their Parents: A Randomized Controlled Multicenter Trial

Tonya M. Palermo, Emily F. Law, Jessica Fales, Maggie H. Bromberg, Tricia Jessen-Fiddick, Gabrielle Taib; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.; Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle; Department of Psychology, Washington State University Vancouver, Vancouver, WA

Chronic pain is estimated to affect 15%–40% of children and occurs most commonly as head, abdominal, and musculoskeletal pain. Similar to the impact of pain in adults, a subset of these youth (5%–8%) is severely disabled by their pain problem. Unique social factors must be considered in treatment of children in light of known parent and family influences on pediatric chronic pain and disability. Treatments for youth are particularly needed to modify a potential trajectory of pain and disability that may continue into adulthood. The objective of this study was to evaluate the effectiveness of an Internet-delivered cognitive-behavioral therapy (CBT) intervention, compared to Internet education, among a large multicenter cohort of adolescents with chronic pain, recruited from pain centers across the United States and Canada. The Internet CBT program included separate interventions for adolescents and their parents directed at modifying behavioral coping, social/environmental factors, and maladaptive cognitions. Effects on parent outcomes were also examined.

Investigators hypothesized that adolescents in families that received Internet CBT would report decreased activity limitations (primary outcome) compared with those receiving Internet education; each was assessed immediately after treatment and at 6-month follow-up. Furthermore, they hypothesized that adolescents who received Internet CBT would report reduced pain intensity, fewer depression and pain-specific anxiety symptoms, better sleep quality, and higher treatment satisfaction than adolescents who received Internet education. The Internet CBT group was expected to show increased parental adaptive responses to pain and decreased miscarried helping than the Internet education group. They also hypothesized that parent pain-related impact would be reduced in the group receiving Internet-delivered CBT compared with the group receiving Internet education.

Participants were 273 adolescents, ages 11 to 17 years, with chronic pain, and their parents. This study used a single-blinded multicenter balanced (1:1) randomized parallel-group design. A number of positive effects were found for primary, secondary, and exploratory outcomes. At 6-month follow-up, adolescents receiving Internet CBT experienced fewer activity limitations than adolescents receiving Internet education. On secondary outcomes, investigators found significant effects on reductions in adolescent depression and pain-specific anxiety symptoms and improvements in sleep quality and parent miscarried helping. Treatment satisfaction was higher in families receiving Internet CBT than Internet education. Internet CBT led to reductions in parent depression, anxiety, self-blame about their adolescent’s pain, and maladaptive behavioral responses to their adolescent’s pain. Pain intensity decreased over time, but no treatment group effects were found for pain intensity.

Treatment engagement was high across both treatment conditions, with the majority of the adolescents and their parents completing all treatment modules. Internet interventions address barriers to access and may ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

Translation of Random Painful Stimuli into Numerical Responses in Fibromyalgia and Perioperative Patients

Linda Oudejans, Monique van Velzen, Erik Olofsen, Robert Beun, Albert Dahan, Marieke Niesters; Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands

The aims of this study were to determine the ability of patients with chronic pain and acute postoperative pain to adequately score their response to randomly applied noxious stimuli on the Numerical Rating Scale (NRS) relative to healthy sex-matched and age-matched controls and assess the effects of treatment with opioids. Thirty-seven healthy controls, 30 patients with fibromyalgia, and 62 postoperative patients with acute pain received random heat pain and electrical pain stimuli. All subjects rated their pain on an 11-point NRS. The data were analyzed using a penalty scoring system based on the assumption that stimuli of higher intensity would be scored with a higher NRS and stratified into cohorts corresponding to “good,” “mediocre,” and “poor” scoring.

The second aim of the study was to assess the linearity of the stimulus-NRS relationship. Investigators applied population-based mixed-effects models on the stimulus-response data to determine linearity of the relationship in healthy controls and patients with chronic and acute pain.

Chronic pain and the administration of opioids negatively affected scoring ability following thermal noxious stimuli and, to a lesser extent, electrical stimuli. Moreover, the stimulus-NRS relationship was best described by a sigmoidal function regardless of stimulus type, disease state, or opioid treatment. Patients with fibromyalgia were less able to consistently score the random stimuli than age-matched and sex-matched controls.

Consistency to grade pain using an NRS is high among healthy volunteers and patients with acute pain, but this ability deteriorates in the setting of chronic pain and during opioid administration to volunteers and patients with chronic pain.

Clinical Journal of Pain

Highlights from Clinical Journal of Pain (Volume 31, No. 12, December 2015 Issue)


Prevalence and Predictive Factors of Chronic Postsurgical Pain and Poor Global Recovery 1 Year After Outpatient Surgery

Daisy M. N. Hoofwijk, Audrey A. A. Fiddelers, Madelon L. Peters, Björn Stessel, Alfons G. H. Kessels, Elbert A. Joosten, Hans-Fritz Gramke, and Marco A. E. Marcus; Departments of Anesthesiology and Pain Treatment; Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+ (MUMC+); Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands; Department of Anaesthesiology, Jessa Hospital, Hasselt, Belgium; Department of Anesthesiology, ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar

Acute postsurgical pain after outpatient surgery is a common problem, and both prevalence and risk factors for acute postsurgical pain have been extensively studied. The development of chronic postsurgical pain (CPSP) after outpatient surgery has been less extensively studied, even though it is a burden for patients and society. Studies have shown that treatment of acute postoperative pain might be less optimal for outpatients than inpatients, potentially leading to more peripheral and central sensitization and more severe CPSP.

Global recovery after surgery measures overall functional recovery. The aim of this prospective longitudinal study was to describe the prevalence and predictive factors of CPSP, as well as the prevalence and predictive factors of a poor global recovery, 1 year after outpatient surgery in a large group of outpatients treated at a university hospital. Information was collected by using preoperative, acute postsurgical, and CPSP questionnaires.

Among respondents, 15.3% of all patients experienced moderate to severe CPSP 1 year after outpatient surgery, and 2.3% experienced severe CPSP. These findings fall in the range of the prevalences previously reported in several review papers, but there is reason to assume that both the prevalence and predictors of CPSP might be different for outpatients. Inpatient procedures are often associated with more extensive tissue damage, longer duration of hospital admission, and a longer recovery period. Despite these dissimilarities, the prevalence of CPSP found in this study seems to be comparable with CPSP reported for inpatient surgery.

Orthopedic surgery was associated with the most severe CPSP in this study. Orthopedic procedures are often associated with preoperative pain (which is often the reason to operate) and acute postoperative pain. These patients might be prone to peripheral and central sensitization, which could cause CPSP. Age and sex were not found to be significant predictors in this model, and acute postoperative pain seemed less important than preoperative pain in predicting CPSP. CPSP predictors included related surgery during the year before the surgical procedure, follow-up surgery during the year after the procedure, and preoperative and postoperative quality of life. The preoperative phase proved extremely important when identifying patients at risk. By asking patients about preoperative pain and analgesic use, it may be possible to more accurately predict CPSP occurrence.

A Cross-Sectional Examination of Vitamin D, Obesity, and Measures of Pain and Function in Middle-Aged and Older Adults with Knee Osteoarthritis

Toni L. Glover, Burel R. Goodin, Christopher D. King, Kimberly T. Sibille, Matthew S. Herbert, Adriana S. Sotolongo, Yenisel Cruz-Almeida, Emily J. Bartley, Hailey W. Bulls, Ann L. Horgas, David T. Redden, Joseph L. Riley, III, Roland Staud, Barri J. Fessler, Laurence A. Bradley, and Roger B. Fillingim; College of Nursing, Adult and Elderly Nursing; Departments of Community Dentistry and Behavioral Science, College of Dentistry; Aging and Geriatric Research, Institute on Aging; Medicine, University of Florida, Gainesville, FL; Departments of Psychology and Anesthesiology; Psychology; Medicine, Division of Clinical Immunology and Rheumatology; Biostatistics, University of Alabama at Birmingham; and Department of Clinical Immunology and Rheumatology, University of Alabama at Birmingham School of Medicine

Symptomatic osteoarthritis (OA) is characterized by pain, stiffness, and limitations in physical function. With the aging population, the prevalence of OA is on the rise; more than one-half of all adults, age 65 and older, have OA. OA contributes significantly to fall-related injuries and is the leading cause of disability in older adults. Obesity contributes to the OA phenotype and increases the likelihood of an OA-related disability.

Vitamin D status, measured by serum 25-hydroxyvitamin D (25[OH]D) level, represents a potentially important contributor to both obesity and OA-related symptoms. Among obese individuals, 25(OH)D is sequestered in fat cells, decreasing its bioavailability for hormonal actions. Furthermore, obese individuals may expose less body surface area to sun exposure, contributing to vitamin D deficiency.

The aim of this cross-sectional study was to examine the interactive associations of 25(OH)D levels and obesity with self-reported knee pain and functional performance measures in a sample of middle-age and older adults with symptomatic knee OA. Investigators hypothesized that obesity would be associated with diminished vitamin D status as measured by 25(OH)D level and that there would be a significant interaction between 25(OH)D levels and obesity, such that obese individuals with low 25(OH)D levels would report higher levels of OA pain and dysfunction.

Obesity was significantly correlated with knee OA pain and poorer functional performance and vitamin D deficiency and insufficiency. Participants with adequate 25(OH)D levels reported significantly lower levels of knee OA pain than participants with sufficient and deficient levels, regardless of obesity status. Obese individuals with deficient and insufficient 25(OH)D levels displayed the poorest physical function. The pleiotropic role of biologically active 25(OH)D could influence pain and pain processing through multiple mechanisms. For example, vitamin D deficiency increases bone turnover, thereby affecting bone quality, which results in greater sensitivity to mechanical forces associated with OA. Both reductions in 25(OH)D and obesity are associated with a proinflammatory state that may contribute to increased pain sensitivity among individuals with OA. In contrast, sufficient levels of cellular 25(OH)D may have a protective effect on cell function and serve to reduce inflammation.

Considering the risks associated with medications typically used to address OA pain and heightened consumer interest in nutritional supplementation, maintenance of adequate 25(OH)D levels may provide a new strategy in the clinical armamentarium to reduce OA pain and dysfunction.