Summaries
Journal of Pain Summaries
Highlights from The Journal of Pain (Volume 19, No. 6, June 2018 Issue)
Longitudinal Treatment Outcomes for an Interdisciplinary Pain Rehabilitation Program: Comparisons of Subjective and Objective Outcomes on the Basis of Opioid Use Status
Wesley P. Gilliam, Julia R. Craner, Julie L. Cunningham, Michele M. Evans, Connie A. Luedtke, Eleshia J. Morrison, Jeannie A. Sperry, Larissa L. Loukianova; Mayo Clinic College of Medicine, Rochester, MN
A new study from the Mayo Clinic, published in The Journal of Pain, offers further evidence that interdisciplinary pain rehabilitation programs are an effective alternative to opioids for chronic pain management.
Despite risks for drug misuse and overdose, available evidence suggests opioids increasingly are used in the treatment of chronic pain. One recent study found that 61% of primary-care pain patients are being treated with long-term opioid therapy. However, interdisciplinary pain rehabilitation programs (IPRPs) have demonstrated reliable evidence for sustained efficacy and enable many patients to cease taking opioids.
For the Mayo Clinic study, researchers hypothesized that patients with chronic pain not using opioids and those tapered off opioids during treatment would experience significant improvements in self-reported and performance-based functional outcomes. Immediate and long-term treatment outcomes for IPRP therapy were assessed in 353 patients, classified into opioid use and no-opioid use groups.
Results showed that patients who were tapered off opioids showed improvement comparable to that for patients not taking opioids and experienced sustained improvements in functioning 6 months after treatment. The authors concluded that their findings suggest that regardless of previous opioid use status, IPRP treatment leads to sustained functional restoration for chronic pain for an enhanced degree of daily functioning. Further, patients responding to the 6-month follow-up survey reported significantly better outcomes than pretreatment outcome variables across all self-report measures.
“The ultimate aim of IPRP is not to alleviate pain or produce short-term functional gains, but rather to foster sustained benefits that patients can continue for the remainder of their lives,” the authors explained. “Our research shows that at posttreatment, patients identify relaxation strategies, moderation/modification, physical therapy/exercise, cognitive-behavioral therapies, and use of distraction as the most important strategies learned.”
Cognitive Biases in Children and Adolescents with Chronic Pain: A Review of Findings and a Call for Developmental Research
Jennifer Y.F. Lau, Lauren C. Heathcote, Sarah Beale, Suzy Gray, Konrad Jacobs, Nick Wilkinson, Geert Crombez; King’s College London, London, United Kingdom
Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain in children and adolescents by facilitating fear and avoidance.
A team of British researchers reviewed existing evidence on pain biases and proposed that studying cognitive biases regarding pediatric pain could be helpful in treatment. If biases consistently are associated with pain outcomes, the knowledge could be used to predict treatment responses and guide new strategies for enhancing current psychological therapies.
The authors noted that youth offers a time window for possible prevention of chronic pain problems. In summarizing current and limited data measuring cognitive biases and pediatric pain, they concluded that even though biases in attention, interpretation, and memory characterize children with varying pain experiences, questions remain about the direction, magnitude, nature, and roles of these biases. They called for more extensive cognitive bias research to further examine links between cognitive biases and pain outcomes in children and adolescents.
“If specific cognitive biases consistently are linked with pain outcomes, this could open up new ways for optimizing current treatments,” the authors concluded.
Clinical Journal of Pain Summaries
Highlights from The Clinical Journal of Pain (Volume 34, No. 6, June 2018 Issue)
Effect of a Scenario-Tailored Opioid Messaging Program on Parents’ Risk Perceptions and Opioid Decision-Making
Terri Voepel-Lewis, Brian J. Zikmund-Fisher, Carol J. Boyd, Philip T. Veliz, Sean E. McCabe, Monica J. Weber, and Alan R. Tait; From the Department of Anesthesiology, Health Behavior, and Health Education, School of Public Health; Institute for Research on Women and Gender, University of Michigan, Ann Arbor; Center for the Study of Drugs, Alcohol, Smoking, and Health, School of Nursing
Widespread parental uncertainty and lack of knowledge regarding pain management and prescription opioid risks may largely contribute to risk for adverse drug events (ADEs) in children and adolescents. With this in mind, investigators developed and tested an interactive Scenario-Tailored Opioid Messaging Program (STOMP) to enhance parental analgesic knowledge and analgesic decision competency. The STOMP prototype presented descriptive and video-enhanced risk scenarios (e.g., child after surgery with excessive sedation) combined with interactive parent decision exercises and tailored feedback. Investigators hypothesized that, compared with parents who received routine pain management and opioid education, those who completed the STOMP prototype would demonstrate enhanced recognition and perceived riskiness of critical opioid ADEs and improved decisions to withhold opioids in high-risk situations (i.e., excessive sedation).
Investigators incorporated clinically relevant scenarios depicting a child with similar levels of pain, either with or without signs of common low-risk or rarer high-risk ADEs. Each module included the scenario description with simple instructions regarding a hypothetical and commonly prescribed opioid and acetaminophen. Parents were asked to consider each scenario and make analgesic administration decisions. Each decision was followed with immediate scenario-tailored feedback explaining risk shown with guidance about what to do to reduce risk and manage pain in a scenario like the one depicted.
Results of this experimental pilot study show that compared with parents who received only general or routine risk information, parents who received the STOMP intervention exhibited enhanced perception of excessive sedation risks and made less risky and more appropriate opioid decisions. Findings also showed that investigators could enhance the perceived riskiness of excessive sedation without affecting the perception of other opioid-related ADE risks such as constipation or nausea and vomiting. Directed feedback decreased the proportion of parents who would administer a prescribed opioid to a child with excessive sedation while increasing the number who would give the analgesic in the absence of other symptoms. In this manner, guided feedback improved both safe and effective opioid decisions.
Parents in the control group who had received generic or routine risk information gained a higher awareness of opioid-related ADEs, but awareness of ADEs alone was insufficient to enhance safe and effective decision-making as evidenced by no change in the decisions of parents in the control or routine information group.
These findings suggest that it is possible to enhance opioid risk knowledge, change parental preferences, and improve safe and effective decision-making competency with an interactive, scenario-tailored risk messaging program.
The Pain Course: Exploring the Feasibility of an Internet-Delivered Pain Management Program When Offered by a Tertiary Pain Management Service
Blake F. Dear, Catherine Courtney, Kok Eng Khor, Sarah McDonald, Tahlia Ricciardi, Milena Gandy, Vincent J. Fogliati, and Nick Titov; Department of Psychology, Macquarie University; Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
Evidence from meta-analyses concludes that pain management programs are beneficial for people with chronic pain and are associated with improvements in levels of pain, physical disability, anxiety, and depression. However, pain management programs in their traditional face-to-face format have limitations that include direct and indirect costs of attendance, mobility and travel difficulties, limited resourcing with long waitlists, and limited availability outside of major metropolitan areas. The growing awareness of barriers to traditional face-to-face pain management programs has led to interest in innovative ways to increase access to these programs. One innovation is the delivery of pain management programs via the Internet.
This study sought to evaluate the acceptability and preliminary efficacy of an established Internet-delivered pain management program, the Pain Course, when offered by a tertiary pain management clinic in a large public hospital to its own patients. It was hypothesized that the program would be highly acceptable and that high levels of engagement would be observed; the program would require relatively little clinician time to administer; and preliminary evidence of improvements in levels of disability, anxiety, and depression would be observed and maintained to 3-month follow-up.
Findings revealed that these hypotheses were partially supported. The program was highly acceptable to patients, with more than 90% of participants completing the course within 8 weeks and more than 90% reporting that the course was worth their time and that they would recommend it to others. Relatively little clinician time was needed, with clinicians spending an average of 71.88 minutes per patient over the course of the program. Evidence of overall improvement was observed in depression levels but not for disability or anxiety levels. However, evidence of significant improvement was observed across the primary outcome areas among patients who had clinical-level difficulties with disability, depression, and anxiety. These results support the potential utility of Internet-delivered pain management programs when offered by specialist tertiary pain management clinics, especially as a method with which to increase access to pain management programs for patients who are unable or unwilling to engage in face-to-face programs. These findings suggest that Internet-delivered pain management programs can be acceptable to patients at these clinics and can elicit high levels of engagement and satisfaction.
This study also revealed evidence of substantial improvement in secondary and tertiary outcomes as pain levels and fears of movement and reinjury improved between pretreatment and posttreatment.
PAIN Summaries
Highlights from PAIN (Volume 159, No. 6, June 2018 Issue)
Monthly Vitamin D Supplementation, Pain, and Pattern of Analgesic Prescription: Secondary Analysis from the Randomized, Double-Blind, Placebo-Controlled Vitamin D Assessment Study
Zhenqiang Wu, Carlos A. Camargo Jr, Zarintaj Malihi, Jim Bartley, Debbie Waayer, Carlene M. M. Lawes, Les Toop, Kay-Tee Khaw, Robert Scragg; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Surgery, University of Auckland, Auckland; Department of Public Health and General Practice, The University of Otago, Christchurch, New Zealand; Department of Public Health, University of Cambridge, Cambridge, United Kingdom
Meta-analyses of observational studies have shown that pain conditions are associated with low serum 25-hydroxy vitamin D concentrations, the best available marker of vitamin D status. Considering the inconsistent results from previous randomized controlled trials (RCTs) involving vitamin D supplementation and pain levels, these investigators analyzed pain-related outcomes in a large RCT, the Vitamin D Assessment (ViDA) Study, to determine whether vitamin D supplementation improved pain and decreased consumption of prescribed analgesics in the general population.
Men and women ages 50 to 84 mostly were recruited from the patient registers of family physicians in Auckland, New Zealand, and a small number from community groups. The effect of vitamin D supplementation on pain was assessed using a short validated pain impact questionnaire with six questions (PIQ-6) and administrative data on dispensed prescriptions of analgesics. Participants were randomized into vitamin D supplementation (n = 2,558) or placebo (n = 2,552) groups. The median follow-up time was 3.3 years. Mean participant age was 65.9 years, and most were men of European descent.
Long-term monthly high-dose (100,000 IU) vitamin D3 supplementation did not improve the mean PIQ-6 score when compared with placebo over a median 3.3-year follow-up. Vitamin D supplementation also did not reduce risk for needing one or more prescriptions for opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or other nonopioids during follow-up. Future RCTs are needed to elucidate the role of vitamin D supplementation on NSAID use by patients with vitamin D deficiency and chronic pain.
Racial Differences in Presentations and Predictors of Acute Pain After Motor Vehicle Collision
Francesca L. Beaudoin, Roee Gutman, Wanting Zhai, Roland C. Merchant, Melissa A. Clark, Kenneth A. Bollen, Phyllis Hendry, Michael C. Kurz, Christopher Lewandowski, Claire Pearson, Brian O’Neil, Elizabeth Datner, Patricia Mitchell, Robert Domeier, and Samuel A. McLean; Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island; Health Services, Policy, and Practice, School of Public Health, Brown University, Providence; Biostatistics, School of Public Health, Brown University, Providence; Epidemiology, School of Public Health, Brown University, Providence; Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Psychology and Neuroscience and Sociology, University of North Carolina Chapel Hill; Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville; Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham; Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan; Department of Emergency Medicine, Wayne State University School of Medicine, Detroit; Department of Emergency Medicine, Einstein Healthcare Network, Philadelphia; Department of Emergency Medicine, Boston Medical Center, Boston; Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan; Anesthesiology, University of North Carolina, Chapel Hill; Emergency Medicine, University of North Carolina, Chapel Hill
In various medical conditions such as chronic pancreatitis and osteoarthritis and under experimental pain conditions, African Americans experience a higher burden of acute pain than non-Hispanic whites. Data suggest that disparities in pain experienced by African Americans are not explained by socioeconomics alone. Relative to non-Hispanic white individuals, African Americans are perceived to have lower levels of pain and often receive less analgesia than other racial and ethnic groups being treated for the same conditions.
To examine racial differences in acute posttraumatic pain after motor vehicle collisions (MVC), this study compared pain severity and location and pain-related characteristics such as catastrophizing and somatic symptoms immediately after MVC in a propensity-matched cohort of African American and non-Hispanic white patients arriving at the emergency department (ED). Investigators also sought to provide potential insights into biologic or sociocultural mechanisms of pain by exploring whether predictors of pain severity (pre-MVC and MVC characteristics) after MVC were modified by race.
Investigators hypothesized that African American and non-Hispanic white MVC patients would have differences in pain characteristics and pain severity. They used regression and internal validation techniques to develop a model that predicted the likelihood that a patient would have moderate to severe acute axial pain in the ED. Next, they examined whether there was statistical interaction between race and the covariates in the model to posit racial differences in factors that predict pain. Within the matched cohort, African Americans had more severe pain and more body regions with pain during the early aftermath of MVC. A higher proportion of African American participants had moderate to severe pain (94% versus 82.3%). However, differences between African American and non-Hispanic white participants in widespread pain were not significant (26.6% versus 20.1%).
In matched univariable analyses, African American participants were less likely than non-Hispanic white participants to receive an opioid analgesic in the ED and were more likely to receive a nonsteroidal anti-inflammatory drug (NSAID). Similarly, African Americans also were less likely than non-Hispanic white participants to receive a prescription for an opioid analgesic at discharge and were more likely than non-Hispanic white participants to receive an NSAID at discharge.
Differences in pain intensity could be explained by socioeconomic status, crash characteristics, or clinical history. On average, when compared with non-Hispanic white patients, African Americans reported less certainty about their recovery and estimated that it would take them twice as long to recover both physically and emotionally. Early expectations for recovery have been demonstrated as an important prognostic factor for pain and functional improvement after MVC and are viewed as potentially modifiable. Future work might examine the role that pain severity and recovery expectations have in explaining racial differences in chronic pain development.