February 2017
David Craig, PharmD | Editor


The Journal of Pain

Highlights from The Journal of Pain (Volume 18, No. 2, February 2017 Issue)

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Video Teleconference Shown Effective for Cognitive Pain Therapy in Veterans

Matthew Scott Herbert, Niloofar Afari, Lin Liu, Pia Heppner, Thomas Rutledge, Kathryn Williams, Satish Eraly, Katie VanBuskirk, Cathy Nguyen, Mark Bondi, J. Hampton Atkinson, Shahrokh Golshan, Julie Loebach Wetherell; Center of Excellence for Stress and Mental Health (CESAMH), San Diego, CA; VA San Diego Healthcare System, University of California, San Diego, CA; Department of Psychiatry, University of California, San Diego, CA

A study of veterans being treated for chronic pain, published in The Journal of Pain, reports that teleconferencing for a psychological pain management treatment, known as acceptance and commitment therapy (ACT), can be as effective and acceptable as in-person treatment.

Researchers from the VA San Diego Health System examined 129 veterans with chronic pain and divided them into two groups, receiving ACT in-person or through video teleconferencing (VTC). The intent of the study was to determine if telehealth can provide outcomes comparable to in-person therapy for ACT. They hypothesized that improvements in pain interferences measures, such as pain acceptance and activity levels, among subjects receiving VTC therapy would be similar to results with in-person therapy.

VA is a leader in adopting telehealth interventions. One in three veterans who receive health care from the VA live in rural areas, and many find it difficult to attend weekly sessions for ACT. Also, some veterans have mobility handicaps and financial restrictions that make travel difficult. VTC is considered a promising alternative to in-person therapy for treating difficult-to-reach populations. It is estimated that nearly 50% of U.S. military veterans have chronic pain.

The American Psychological Association recommends ACT for treatment of persistent pain. ACT is a newer approach within cognitive-behavioral therapy based on “psychological flexibility” or the ability to behave consistently with one’s values in spite of unwanted thoughts, feelings, and bodily sensations. It is effective for improving physical and emotional functioning in adults with pain conditions and is similar in effectiveness to traditional cognitive and behavioral treatments. ACT can decrease disability, depressive symptoms, pain-related anxiety, time spent resting due to pain, analgesic use, and physician visits.

Results of the study showed that ACT administered via VTC produced significant improvements in pain interferences comparable to in-person treatment over 6 months. Respondents showed significant improvements in mental and physical health–related quality of life at post-treatment and at follow up.

Study Examines Medication Misuse After Spinal Cord Injury

Jillian M. R. Clark, Yue Cao, James S. Krause; College of Health Professions, Medical University of South Carolina, Charleston, SC

It is estimated that up to 63% of persons with spinal-cord injuries (SCI) report severe pain. Given the high incidence of chronic pain in this population, researchers at Medical University of South Carolina sought to identify the risk for pain medication misuse (PMM) by examining multiple sets of risk factors.

For the study, 1,619 adults with traumatic SCI, who take pain medication, completed the Pain Medication Questionnaire.

Results showed that study subjects experienced frequent pain, moderate average pain intensity, and considerable pain-medication use. Thirty percent of the respondents had PMQ scores indicating potential for problematic pain medication misuse and 18% had scores indicative of risk for more serious aberrant pain medication misuse behaviors. After controlling for demographics, injury, and pain characteristics, the analysis showed that smoking, cannabis use, and multiple psychological factors, such as depression and anxiety, were associated with risks for pain medication misuse.

The authors concluded that these findings suggest that misuse behaviors are associated with attempts to alleviate or cope with the functional limitations caused by chronic pain rather than alleviating the pain itself.


Highlights from PAIN (Volume 158, No. 2, February 2017 Issue)

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Brain Substrates of Reward Processing and the µ Opioid Receptor: A Pathway into Pain?

Frauke Nees, Susanne Becker, Sabina Millenet, Tobias Banaschewski, Luise Poustka, Arun Bokde, Uli Bromberg, Christian Büchel, Patricia J. Conrod, Sylvane Desriviéres, Vincent Frouin, Jürgen Gallinat, Hugh Garavan, Andreas Heinz, Bernd Ittermann, Jean-Luc Martinot, Dimitri Papadopoulos Orfanos, Tomás Paus, Michael N. Smolka, Henrik Walter, Rob Whelan, Gunter Schumann, Herta Flor; The IMAGEN Consortium; Departments of Cognitive and Clinical Neuroscience and Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Department of Child and Adolescent Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria; Discipline of Psychiatry, School of Medicine and Trinity College Institute of Neurosciences, Trinity College Dublin, Dublin, Ireland; University Medical Centre Hamburg-Eppendorf, Institute of Systems Neuroscience, Hamburg, Germany; Department of Psychiatry, Université de Montréal, CHU Ste Justine Hospital, Montréal, QC, Canada; Department of Psychological Medicine and Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom; Medical Research Council—Social, Genetic, and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom; Neurospin, Commissariat á l’Energie Atomique, CEA-Saclay Center, Paris, France; Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité , Universit tsmedizin Berlin, Berlin, Germany; Departments of Psychiatry and Psychology, University of Vermont, Burlington, VT; Physikalisch-Technische Bundesanstalt, Berlin, Germany; InstitutNational de la Sante et de la RechercheMe dicale, INSERMUnit 1000 “Neuroimaging and Psychiatry,” University Paris Sud, University Paris Descartes—Sorbonne Paris Cité, Maison de Solenn, Paris, France; Rotman Research Institute, Baycrest and Departments of Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Psychiatry and Neuroimaging Center, Technische Universitat Dresden, Dresden, Germany; Department of Psychology, University College Dublin, Dublin, Ireland

Pain and reward are related to similar brain regions such as the striatum, the prefrontal cortex, the anterior cingulate cortex, the orbitofrontal cortex, and the amygdala. The interplay between reward and pain processing and circuitry also may explain the often-reported lack of efficacy in treating chronic pain with opioids, and changes in reward processing and responsiveness could represent a premorbid condition for the development of pain. Investigators in this study examined whether brain responses during the reward process are a significant predictor for pain experiences early in life and tested the contribution of single-nucleotide polymorphisms (SNPs) rs1799971 and rs563649 in this prediction.

Based on assumptions that reward processing and pain interact and that individual variations in opioidergic genetic components might contribute to this interaction, investigators tested the predictive role of reward processing in the brain for pain experiences 2 years later in a sample of 14- to 15-year-old healthy adolescents. The reward feedback–related response in the dorsal striatum at the age of 14 to 15 years significantly predicted the magnitude of pain experiences when adolescents were 16 to 17 years old. Moreover, the prediction of pain complaints by reward processing was linked to specific SNPs of the OPRM1 receptor.

Investigators identified a significant prediction of pain experiences by looking at the response in the dorsal striatum during reward feedback, a process that provides the basis for behavioral adaptations based on the respective outcomes. The more an individual is engaged in response preparation and behavioral planning when receiving reward outcomes, the more prone he or she may be to developing pain. They also found a relationship between pain and the response in the periaqueductal gray (PAG) and ventral striatum in T-allele carriers of rs563649. T-allele carriers of rs563649 reported significantly increased magnitudes of pain and demonstrated a significantly increased response in the PAG and the ventral and dorsal striatum during reward feedback versus major homozygous C-allele carriers. This indicates that people who genetically are at high risk for increased pain sensitivity have more pain experiences and activate brain areas that are linked to reward valuation and related adaptive behavior at a larger extent. There were significant effects for reward feedback only and not anticipation of reward.

These findings suggest that distributed brain response patterns during reward processing may be significant predictors of pain, partly depending on an opioidergic genetic predisposition. These results might provide a first step in identifying possible risk factors for future pain experiences early in life.

Does Brief Chronic Pain Management Education Change Opioid Prescribing Rates? A Pragmatic Trial in Australian Early-Career General Practitioners

Simon Mark Holliday, Chris Hayes, Adrian J. Dunlop, Simon Morgan, Amanda Tapley, Kim M. Henderson, Mieke L. van Driel, Elizabeth G. Holliday, Jean I. Ball, Andrew Davey, Neil Allan Spike, Lawrence Andrew McArthur, Parker John Magin; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Integrated Pain Service, Hunter New England Local Health District, Newcastle, NSW, Australia; GP, Elermore Vale General Practice, Newcastle, NSW, Australia; NSW and ACT Research and Evaluation Unit, GP Synergy, Newcastle, NSW, Australia; Discipline of General Practice, School of Medicine, University of Queensland, Brisbane, QLD, Australia; Public Health Program, Hunter Medical Research Institute, Newcastle, NSW, Australia; CRe-DITSS, Hunter Medical Research Institute, Newcastle, NSW, Australia; Eastern Victoria General Practice Training, Hawthorn, VIC, Australia; Department of General Practice, University of Melbourne, Melbourne, VIC, Australia; Rural Clinical School, University of Adelaide, Adelaide, SA, Australia

In this study, investigators aimed to address evidence practice and the guideline practice gap among general practitioner (GP) registrars (vocational trainees). Considering that GP registrars report relatively low levels of opioid guideline adherence and that prescribing patterns for other medicines by qualified GPs tend to persist, this is an important group with which to attempt to influence chronic noncancer pain (CNCP) care. This same group of investigators previously demonstrated that a brief educational package delivered to GP registrars resulted in significant improvements in knowledge and competencies. In this evaluation, they objectively assessed the effect of this educational package on the “real-world practice behaviour” of opioid prescribing.

There was no significant effect of the training activity on registrars’ overall prescribing of opioids, which increased during the study but remained marginally below the rate of more experienced Australian GPs (4.2 per 100 problems). Initiation of opioids was reduced with a clinically significant effect size. Investigators also administered a concurrent questionnaire before and after evaluation of the training reported in this study using clinical vignettes to elicit registrars’ opioid prescribing intentions. In this study, the proportion of registrars who thought that opioids were overprescribed for CNCP increased nonsignificantly from 74.5% to 83%. The proportion of registrars reporting initiation of opioids for a CNCP vignette reduced significantly from 74.5% to 51.1%. The proportion intending to deprescribe opioid maintenance for a CNCP vignette increased significantly from 80.4% to 95.7%. The investigators’ interpretation of the discordant results of these concurrent hypothetical and actual prescribing studies of the same training activity is that the translation of changes in knowledge, attitude, and clinical judgement from a theoretical paper-based setting to actual practice is problematic. This translation may be more problematic for opioid deprescribing than for opioid noninitiation.

Despite GP registrars’ clear intentions elicited through paper-based cases following a brief interactive training package, these current findings demonstrate that pain management is easier in theory than in “real-world practice.” Registrars did not reduce their number of opioid prescriptions after training, which reflected the many barriers to deprescribing. In the future, factors facilitating opioid-centric CNCP management will necessitate coordinated attention among educators, healthcare funders, and regulators.

The Clinical Journal of Pain

Highlights from The Clinical Journal of Pain (Volume 33, No. 2, February 2017 Issue)


Differences in Clinical Pain and Experimental Pain Sensitivity Between Asian Americans and Whites with Knee Osteoarthritis

Hyochol Ahn, Michael Weaver, Debra E. Lyon, Junglyun Kim, Eunyoung Choi, Roland Staud, Roger B. Fillingim; College of Nursing and College of Medicine, University of Florida; University of Florida Pain Research and Intervention Center of Excellence, Gainesville, FL

Osteoarthritis (OA) is the most common of the arthritic conditions, with the knee being the most commonly affected joint. Some studies show that the prevalence and severity of knee OA differs across ethnic groups. For example, compared with non-Hispanic whites (NHWs), more African Americans not only have knee OA but also have more pain-related disabilities. In addition, OA prevalence is higher among Asian Americans than NHWs. However, few studies have examined whether the severity of clinical pain among Asian Americans with knee OA differs from that of their NHW counterparts. The primary aim of this study was to examine ethnic differences in clinical pain intensity and experimental pain sensitivity among older Asian Americans versus age-matched and sex-matched NHWs with knee OA. They hypothesized that Asian Americans would display higher levels of self-reported clinical pain intensity; a lower pain threshold and tolerance for heat-induced and mechanically induced pain; and a greater temporal summation of pain, suggesting more pain facilitation among Asian Americans than with NHWs with knee OA.

One hundred individuals (50 Asian American participants and 50 age-matched and sex-matched NHW participants) with knee OA were included in this study. The study participants had a mean age of 55 years, and the majority of each ethnic group was female. Several important ethnic group differences were revealed. First, Asian American participants with knee OA had significantly higher levels of clinical pain and functional impairment than age-matched and sex-matched NHW participants even after adjusting for covariates such as body mass index, education level, and employment status. In addition, Asian American participants with knee OA displayed significantly higher sensitivity to heat-induced and mechanically induced pain, including temporal summation of both heat and mechanical pain, than NHW participants. This was observed at both the affected knee and unaffected body sites, suggesting widespread hyperalgesia among Asian American participants with knee OA and perhaps reflecting central pain amplification.

These findings add to the growing literature regarding ethnic and racial differences in clinical pain and experimental pain sensitivity among people with knee OA. Further investigation is needed to identify the mechanisms underlying these differences and to ensure that ethnic group disparities in pain are ameliorated.

Improvement in Pain After Lumbar Spine Surgery: The Role of Preoperative Expectations of Pain Relief

Carol A. Mancuso, M. C. Reid, Roland Duculan, Federico P. Girardi; Hospital for Special Surgery, New York City, NY; Weill Cornell Medical College, New York City, NY

The challenge of measuring pain after lumbar spine surgery (LSS) is complicated by the fact that patients undergoing surgery are highly diverse with respect to clinical features, diagnosis, and severity of disease, with some patients seeking surgery after exhausting all other therapies and others seeking surgery far earlier during their course. The decision to undergo elective LSS is largely based on patients’ perspectives and expectations of outcome. Using data generated in a large prospective cohort of LSS patients, the goal of this study was to measure the amount of pain improvement 2 years after surgery according to responses to a global pain question and to determine whether this outcome varied according to patient and clinical characteristics, including the amount of pain relief expected before surgery. This study also examined the preoperative expectation of pain relief as a predictor of long-term actual pain relief.

For the main outcome, which was a response to the global question about postoperative improvement in pain at 2 years, 11% reported no improvement, 28% reported little to moderate improvement, 44% reported substantial improvement, and 17% reported complete improvement. Multiple variables were associated with the amount of pain improvement in bivariate analyses such as vertebral level, revision and subsequent surgery, and psychological characteristics. In addition, higher preoperative expectations for pain improvement were associated with less subsequent actual pain improvement.

In multivariable analysis, patients were more likely to have less improvement in pain at 2 years if they expected better pain improvement before surgery, had symptoms for a longer amount of time, had a positive screen for depression, were having revision surgery, had surgery at L4 or L5, or had a degenerative diagnosis. They also had less improvement in pain if they had had a subsequent surgery and more back and leg pain intensity at the 2-year follow up. For the secondary analysis regarding fulfillment of pain expectations, 35% of patients had their expectation fulfilled as expected, 8% had their expectation surpassed, and 57% did not have their expectation fulfilled.

These findings illustrate the complexity of assessing postoperative back pain. To understand the etiology of postoperative pain, it may be necessary to distinguished among new, persistent, or recurrent pain. Measuring global improvement in pain demonstrates that postoperative back pain is a complex phenomenon because of a network of clinical, surgical, and psychological variables independent of pain intensity. This study provides evidence that patients’ preoperative expectations of pain relief are part of this network and supports the importance of addressing pain-related expectations with patients before surgery through discussions with surgeons and formal preoperative patient education.