Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain.

OBJECTIVE: The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation. METHODS: Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures. RESULTS: The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures. CONCLUSIONS: Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

Pain Psychology for Surgeons and Otolaryngologists.

Pain is one of the leading reasons that brings patients into health care facilities; yet, it often is left undertreated. The biopsychosocial model of pain, which recognizes that pain is multidimensional, explains the complexities that affect the pain experience and response to treatment. Inclusion of behavioral and psychological factors in medical and surgical evaluations can facilitate an optimal outcome. When pain no longer is acute but becomes chronic, access to psychotherapeutic interventions becomes necessary to improve course and prognosis. Techniques, such as psychoeducation, deep breathing, imagery, and addressing expectations and catastrophic beliefs, can be incorporated into medical and surgical practices.

Dissociable influences of opiates and expectations on pain.

Placebo treatments and opiate drugs are thought to have common effects on the opioid system and pain-related brain processes. This has created excitement about the potential for expectations to modulate drug effects themselves. If drug effects differ as a function of belief, this would challenge the assumptions underlying the standard clinical trial. We conducted two studies to directly examine the relationship between expectations and opioid analgesia. We administered the opioid agonist remifentanil to human subjects during experimental thermal pain and manipulated participants' knowledge of drug delivery using an open-hidden design. This allowed us to test drug effects, expectancy (knowledge) effects, and their interactions on pain reports and pain-related responses in the brain. Remifentanil and expectancy both reduced pain, but drug effects on pain reports and fMRI activity did not interact with expectancy. Regions associated with pain processing showed drug-induced modulation during both Open and Hidden conditions, with no differences in drug effects as a function of expectation. Instead, expectancy modulated activity in frontal cortex, with a separable time course from drug effects. These findings reveal that opiates and placebo treatments both influence clinically relevant outcomes and operate without mutual interference.

Challenges and opportunities in pain management disparities research: implications for clinical practice, advocacy, and policy.

UNLABELLED: Due to high profile initiatives at the national level, awareness of inadequate pain care affecting many groups in our society has never been greater. Nevertheless, increased awareness of pain disparities and the initiatives to address these disparities have yielded only modest progress, most notably in the form of growing appreciation that pain disparities likely result from multiple factors, including biological, psychological, environmental, health system, and cultural factors. Much less progress has been made in developing interventions that target these multiple determinants to reduce pain management disparities. In this paper we discuss key ethical and methodological challenges that undermine our capacity to investigate and develop meaningful interventions to improve pain outcomes among vulnerable populations. Key challenges in the areas of research engagement, recruitment, design, and measurement are discussed from both scientific and normative standpoints. Specific opportunities within emerging research paradigms to improve designs and measures are also discussed. Finally, we conclude with identifying potential synergies between the pain management disparities research agenda and the broader areas of clinical practice, advocacy, and policy that could help to move the field forward. PERSPECTIVE: Researchers studying disparities in pain care face a number of ethical and methodological challenges that must be addressed to advance the field towards eliminating disparities. We discuss these ethical and methodological challenges and propose opportunities for paradigmatic revisions in areas of research engagement, design, measurement, advocacy, and policy.

"Scratching" beneath the surface: an integrative psychosocial approach to pediatric pruritus and pain.

Pruritus is prevalent in children with atopic dermatitis and associated with effects on mood, quality of life, sleep, scholastic performance, social and family functioning. In this study a 7-year-old African American female with severe atopic dermatitis, itching and pain refractory to multiple systemic and topical medications was referred for treatment. At baseline, the patient scratched to the point of bleeding, despite maximal doses of anti-histamines, antidepressant and topical therapies. The patient became progressively shy, anxious, and her scholastic performance suffered. A literature review prompted the implementation of a multi-modal program of family cognitive behavioral therapy, imagery, aromatherapy, drawing, and biofeedback. The results were that decreased itch, scratching, pain, and anxiety were seen within the first month. Fewer lesions and episodes of bleeding were observed with almost complete skin clearance by the fourth month. The article concludes that a short-term, integrative program including psychological, complementary and alternative medicine (CAM), and medical therapies may represent a novel, efficacious approach for children suffering from severe atopic dermatitis.

Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain.

OBJECTIVES: To characterize the opioid prescribing and monitoring practices of providers for chronic nonmalignant pain (CNP) and subacute postoperative pain (SAPOP) in adolescents. DESIGN: Web-based cross-sectional self-report survey. SETTING: Free-standing pediatric tertiary academic center. PARTICIPANTS: A total of 183 physicians and nurse practitioners were eligible. Of 115 (62.8 percent) participants who responded, 108 (93.9 percent) completed the survey. MAIN OUTCOME MEASURES: Self-reported frequency of opioid prescription for SAPOP and CNP conditions and frequency of associated monitoring practices. RESULTS: For 10 of the 13 pain conditions included, some participants endorsed "monthly or more opioid prescriptions" while others endorsed "opioids do not represent appropriate management." Opioid prescribing is present for almost all pain conditions but is substantially more common for nonacute vaso-occlusive-related sickle cell disease, scoliosis correction, and video-assisted pectus excavatum-related pains. When compared with the reference group, CNP with no identifiable pathology, the odds ratio (OR) of an opioid being prescribed for CNP states with identifiable pathology was not significantly higher. The OR for SAPOP was significantly higher (p < 0.0001). None of the opioid prescribers reported collecting urine toxicology before or during opioid therapy. CONCLUSIONS: This survey identifies a diversity of self-reported clinician opioid prescribing practices for adolescents with CNP and SAPOP. Urine collection for drug toxicology screening is not utilized by opioid prescribers. Surveys of similar clinician practice behaviors at other institutions are warranted to replicate this finding and to establish common clinicalpractice for usage and monitoring of opioids in conditions where guidelines do not yet exist.

Transcutaneous electrical nerve stimulator trial may be used as a screening tool prior to spinal cord stimulator implantation.

This is a prospective pilot study looking at the utility of Transcutaneous Electrical Nerve Stimulator (TENS) trial as a screening tool prior to spinal cord stimulator (SCS) implant to identify patients who may fail a SCS trial. The accepted screening test prior to a permanent SCS implant is a SCS trial. Patients may fail the SCS trial due to several causes of which one is the inability to tolerate stimulation induced paresthesias. Twenty five patients scheduled for a SCS trial for the treatment of refractory pain secondary to Failed Back surgery syndrome underwent a TENS trial and psychological evaluation by personnel uninvolved in the SCS trial. Data was collected by personnel not involved in the SCS trial or permanent placement. Twenty patients completed the study. Data collected included area of coverage, paresthesia tolerance, pain and anxiety measured on a VAS scale. Comparability between the groups were analyzed using Pearson's correlation, Fisher Exact test and simple regression analysis. We noted a significant correlation between ability to tolerate TENS and SCS induced paresthesias. Statistically significant correlation was also noted between pre SCS trial anxiety score and high pain score during SCS trial. We conclude that there is potential applicability of a TENS trial as a non invasive screening tool which may promote cost effectiveness and decrease unnecessary procedural risks to the patient by avoiding SCS trial in select patients.

Positive affect mediates the relationship between pain-related coping efficacy and interference in social functioning.

UNLABELLED: Emotional states have been shown to influence resilient behavior in conditions of loss, bereavement, and stress. Positive affect has been associated with better health outcomes, including chronic pain. Extant research suggests that positive emotions help buffer against stress, suggesting that positive emotions provide an important protective and adaptive significance. This study examined the role of positive versus negative emotions in the association between pain-related coping efficacy and interference with social functioning in a sample of chronic pain patients. Mediational analyses revealed that positive emotions partially mediated the relationship between control and coping efficacy and pain-related interference in social activities. Negative emotions were not found to mediate this relationship. Implications for research on the role of positive emotions in chronic pain are discussed. PERSPECTIVE: The findings from this study demonstrate the mediating role of positive affect in explaining the relationship between pain-related coping efficacy and interference in social functioning in a sample of chronic pain patients. This could potentially assist clinicians who seek to enhance coping efficacy and social functioning in pain patients.