Nationwide Assessment of Chronic Pain among Hospitalized Individuals with Co-occurring Post Traumatic Stress Disorder and Substance Use Disorder in the United States.

Objective: Chronic pain (CP) is independently associated with substance use disorders (SUD) and posttraumatic stress disorder (PTSD). However, little is known about factors associated with CP among patients with co-occurring PTSD and SUD. Patterns of hospital resource usage should also be explored further. Methods: Using the 2019 National Inpatient Sample (NIS), we identified 216,125 hospital discharges with co-occurring diagnoses of PTSD and SUD in 2019 and examined their association with CP. Multivariable logistic regression models were used to identify factors associated with an increased likelihood of CP in this cohort. Results: Among those with co-occurring PTSD and SUD (N = 216,125), 35,450 had associated CP, a prevalence of 164.02 cases per 1,000 discharges (95% CI [160.54, 167.52]). Individuals aged 55-64 with co-occurring PTSD and SUD were approximately 7.2 times more likely to experience CP, compared to those aged 16-24 (OR = 7.2; 95% CI [6.09, 8.60]). Being in the CP group was associated with 50% increased odds of insomnia and obesity (OR = 1.5; 95% CI [1.12, 2.03] and OR = 1.5; 95% CI [1.38, 1.55], respectively), 30% increased odds of anxiety (OR = 1.3; 95% CI [1.24, 1.38]), 20% increased odds of attention deficit disorder (ADD;OR = 1.2; 95% CI [1.12, 1.38]) and 10% increased odds of depression (OR = 1.1; 95% CI [1.01, 1.14]). Compared with females, being male was associated with slightly decreased odds of CP (OR = 0.9; 95% CI [0.84, 0.94]). Conclusions: Among hospitalized Americans with co-occurring PTSD and SUD, advanced age, being female, and the presence other mental health disorders were associated with an increased risk of CP. Providers treating co-occurring PTSD/SUD should evaluate for and consider evidence-based management of CP if present.

What's in a Name? Terminology Preferences Among Patients Receiving Methadone Treatment.

BACKGROUND: Despite recognition of the importance of substance use disorder (SUD) terminology, few studies examine terminology preferences among patients with SUDs. OBJECTIVE: To examine preferences of patients with opioid use disorder (OUD) concerning the terminology used by addiction counselors. DESIGN: From January 1, 2019, to February 28, 2020, participants were recruited consecutively from 30-day treatment review sessions at outpatient methadone treatment programs in the Northeastern United States to complete a cross-sectional survey. PARTICIPANTS: Participants were English-speaking adult patients with OUD enrolled in methadone treatment. MAIN MEASURES: Participants completed 7-point Likert-type scales from 1 ("Strongly Disagree") to 7 ("Strongly Agree") to rate their preferences for (a) the presenting problem, (b) collective nouns referring to those with the presenting problem, and (c) personal descriptors. We used univariate analysis of covariance (ANCOVA) to examine the associations between demographics (i.e., age, sex, and race) and terminology preferences and ordinal logit regression to explore the association between 12-step program partiality and preference for the term "addict." KEY RESULTS: We surveyed 450 patients with mean age of 38.5 (SD = 11.1) years; 59.6% self-identified as male, 77.6% as White, and 12.7% as Hispanic. The highest-rated preferences for presenting problem were "addiction," "substance use," and "substance abuse." The highest-rated collective noun terms were "client," "patient," and "guest." "Person with an addiction," "person with substance use disorder," and "substance-dependent person" were the highest-rated personal descriptors. There were significant differences in terminological preference based on race and age. Twelve-step program partiality was associated with greater preference for the term "addict" (F = 21.22, p < .001). CONCLUSIONS: Terminology preferences among people receiving methadone treatment aligned with existing guidelines recommending that clinicians use medically accurate and destigmatizing terminology when referring to substance use disorders and the persons who have them. Demographic differences emerged in terminological preferences, warranting further examination.

The impact of body image dissatisfaction on psychological distress and health-related quality of life among patients in methadone treatment.

BACKGROUND AND OBJECTIVES: Minimal research has examined body image dissatisfaction (BID) among patients receiving methadone maintenance treatment (MMT). We tested associations between BID and MMT quality indicators (psychological distress, mental and physical health-related quality of life [HRQoL]) and whether these associations varied by gender. METHODS: One hundred and sixty-four participants (n = 164) in MMT completed self-report measures of body mass index (BMI), BID, and MMT quality indicators. General linear models tested if BID was associated with MMT quality indicators. RESULTS: Patients were primarily non-Hispanic White (56%) men (59%) with an average BMI in the overweight range. Approximately 30% of the sample had moderate or marked BID. Women and patients with a BMI in the obese range reported higher BID than men and patients with normal weight, respectively. BID was associated with higher psychological distress, lower physical HRQoL, and was unrelated to mental HRQoL. However, there was a significant interaction in which the association between BID and lower mental HRQoL was stronger for men than women. DISCUSSION AND CONCLUSIONS: Moderate or marked BID is present for about three in 10 patients. These data also suggest that BID is tied to important MMT quality indicators, and that these associations can vary by gender. The long-term course of MMT may allow for assessing and addressing novel factors influencing MMT outcomes, including BID. SCIENTIFIC SIGNIFICANCE: This is one of the first studies to examine BID among MMT patients, and it highlights MMT subgroups most at risk for BID and reduced MMT quality indicators due to BID.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States.

BACKGROUND: Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement. METHODS: Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates. RESULTS: There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates. CONCLUSIONS: Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Longitudinal analysis of the prevalence and correlates of heavy episodic drinking and self-reported opioid use among a national cohort of patients with HIV.

BACKGROUND: Heavy episodic drinking (HED) is a risk factor for opioid-related overdose and negatively impacts HIV disease progression. Among a national cohort of patients with HIV (PWH), we examined sociodemographic and clinical correlates of concomitant HED and self-reported opioid use. METHODS: We used data collected from 2002 through 2018 from the Veterans Aging Cohort Study, a prospective cohort including PWH in care at eight US Veterans Health Administration sites. HED was defined as consuming six or more drinks at least once in the year prior to survey collection. We examined the relationship between HED and self-reported opioid use and created a 4-level composite variable of HED and opioid use. We used multinomial logistic regression to estimate odds of reporting concomitant HED and self-reported opioid use. RESULTS: Among 3702 PWH, 1458 (39.4%) reported HED during the study period and 350 (9.5%) reported opioid use. In the multinomial model, compared to reporting neither HED nor opioid use, lifetime housing instability (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.01 to 2.35), Veterans Aging Cohort Study Index 2.0 (a measure of disease severity; aOR 1.14, 95% CI 1.02 to 1.28), depressive symptoms (aOR 2.27, 95% CI 1.42 to 3.62), past-year cigarette smoking (aOR 3.06, 95% CI 1.53 to 6.14), cannabis use (aOR 1.69, 95% CI 1.09 to 2.62), and cocaine/stimulant use (aOR 11.54, 95% CI 7.40 to 17.99) were independently associated with greater odds of concomitant HED and self-reported opioid use. Compared to having attended no college, having some college or more (aOR 0.39, 95% CI 0.26 to 0.59) was associated with lower odds of concomitant HED and self-reported opioid use. CONCLUSIONS: Among PWH, concomitant HED and self-reported opioid use are more common among individuals with depressive symptoms and substance use, structural vulnerabilities, and greater illness severity. Efforts to minimize opioid-related risk should address high-risk drinking as a modifiable risk factor for harm among these groups.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Sociodemographic and clinical correlates of gabapentin receipt with and without opioids among a national cohort of patients with HIV.

Gabapentin is commonly prescribed for chronic pain, including to patients with HIV (PWH). There is growing concern regarding gabapentin's potential for harm, particularly in combination with opioids. Among PWH, we examined factors associated with higher doses of gabapentin receipt and determined if receipt varied by opioid use. We examined data from the Veterans Aging Cohort Study, a national prospective cohort including PWH, from 2002 through 2017. Covariates included prescribed opioid dose, self-reported past year opioid use, and other sociodemographic and clinical variables. We used multinomial logistic regression to determine independent predictors of gabapentin receipt. Among 3,702 PWH, 902 (24%) received any gabapentin during the study period at a mean daily dose of 1,469 mg. In the multinomial model, high-dose gabapentin receipt was associated with high-dose benzodiazepine receipt (adjusted odds ratio [aOR], 95% confidence interval [CI]= 1.53, [1.03-2.27]), pain interference (1.65 [1.39-1.95]), and hand or foot pain (1.81, [1.45-2.26]). High-dose gabapentin receipt was associated with prescribed high-dose opioids receipt (2.66 [1.95-3.62]) but not self-reported opioid use (1.03 [0.89-1.21]). PWH prescribed gabapentin at higher doses are more likely to receive high-dose opioids and high-dose benzodiazepines, raising safety concerns.

Characterizing the social support and functioning of a low-threshold medication for opioid use disorder treatment cohort at intake.

BACKGROUND: Despite the growing morbidity and mortality rates associated with opioid use disorder, a large gap still exists between treatment need and capacity. Low-threshold clinics utilizing medication for opioid use disorder (MOUD) treatment can increase treatment access but are understudied, and little is known about how patient demographic characteristics are associated with their social support and functioning in these settings. METHODS: We used multivariate regression to estimate associations between demographic characteristics and self-reported social support or functioning indicators among patients receiving MOUD in a low-threshold clinic using several validated instruments administered at intake: Behavior and Symptom Identification Scale, Brief Pain Inventory, and Life Events Checklist for DSM-5. Patients initiating MOUD treatment between April 1 and December 31, 2017, with complete surveys were included (N=582). RESULTS: Patients were primarily male (62%), aged 34 or older (53%), non-Hispanic White (79%), separated or not married (86%), and unemployed (64%). Over 20% did not live in a house or apartment in the past month. Women were more likely to "get along" with people outside their family or in social situations and to identify their partner as their source of support. Women, non-White, and older patients were at higher risk of social functioning-disrupting events (physical/sexual assaults or experiencing chronic pain), while employment and housing were protective against exposure to these trauma-related events. However, employment and housing also decreased the odds of talking with others about substance use. The aforementioned results were obtained from multivariate logistic regression models and were significant to p<0.05. CONCLUSIONS: Variation in support and functioning by demographic characteristics suggests that treatment facilities may benefit from adopting strategies that take baseline disparities in support and functioning into account.

Primary care and medication management characteristics among patients receiving office-based opioid treatment with buprenorphine.

BACKGROUND: Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients. OBJECTIVE: To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care. METHODS: This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded. RESULTS: Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT. CONCLUSION: Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.

A Student Walks into Class Vignettes to Identify Substance Use Disorder Models of Illness among College Students.

INTRODUCTION: Illness models, including illness recognition, perceived severity, and perceived nature can affect treatment-seeking behaviors. Vignettes are a leading approach to examine models of illness but are understudied for substance use disorders (SUDs). We created vignettes for multiple common DSM-5 SUDs and assessed SUD illness models among college students. METHODS: Seven vignettes in which the protagonist meets DSM-5 diagnostic criteria for SUDs involving tobacco, alcohol, cannabis, Adderall, cocaine, Vicodin, and heroin were pilot tested and randomly assigned to 216 college students who completed measures related to illness recognition, perceived severity, and perceived nature. MANOVAs with Scheffe post-hoc tests were conducted to examine vignette group differences on models of illness. RESULTS: Vignettes met acceptable levels of clarity and plausibility. Participants characterized the protagonist's substance use as a problem, a SUD, or an addiction most frequently with Vicodin, heroin, and cocaine and least frequently with tobacco and cannabis. Participants assigned to the Vicodin, heroin, and cocaine vignettes were the most likely to view the protagonist's situation as serious and life-threatening, whereas those assigned to the cannabis vignette were the least likely. Numerically more participants characterized the pattern of substance use as a problem (91%) or an addiction (90%) than a SUD (76%), while only 15% characterized it as a chronic medical condition. CONCLUSIONS: Illness recognition and perceived severity varied across substances and were lowest for cannabis. Few participants conceptualized SUDs as chronic medical conditions. College students may benefit from psychoeducation regarding cannabis use disorder and the chronic medical condition model of SUDs.

Long-term Patterns of Self-reported Opioid Use, VACS Index, and Mortality Among People with HIV Engaged in Care.

Longitudinal analyses of opioid use and overall disease severity among people with HIV (PWH) are lacking. We used joint-trajectory and Cox proportional hazard modeling to examine the relationship between self-reported opioid use and the Veterans Aging Cohort Study (VACS) Index 2.0, a validated measure of disease severity and mortality, among PWH engaged in care. Using data from 2002 and 2018, trajectory modeling classified 20% of 3658 PWH in low (i.e., lower risk of mortality), 40% in moderate, 28% in high, and 12% in extremely high VACS Index trajectories. Compared to those with moderate VACS Index trajectory, PWH with an extremely high trajectory were more likely to have high, then de-escalating opioid use (adjusted odds ratio [AOR], 95% confidence interval [CI] 5·17 [3·19-8·37]) versus stable, infrequent use. PWH who report high frequency opioid use have increased disease severity and mortality risk over time, even when frequency of opioid use de-escalates.

Correlates of Homelessness Among Patients in Methadone Maintenance Treatment.

BACKGROUND: Although homelessness and opioid use disorder (OUD) are important public health issues, few studies have examined their cooccurrence. OBJECTIVES: The aim of this study was to evaluate the correlates of homelessness among patients enrolled in low-barrier-to-treatment-access methadone maintenance treatment (MMT) programs for OUD. METHODS: Demographic, diagnosis-related, and treatment-related correlates were assessed by self-report for 164 patients in MMT. Correlates of past-month homelessness were investigated with logistic regression. RESULTS: Twenty-four percent of patients reported homelessness in the past month. Bivariate analyses initially identified 7 statistically significant (P<0.05) correlates of homelessness: gender; Latinx ethnicity; symptoms of depression, anxiety, and somatization; self-criticism; and duration of MMT. In the final logistic regression model, which included significant independent variables from the bivariate logistic regressions, patients in MMT who were homeless (vs. domiciled) were more likely to be male (odds ratio 2.54; confidence interval, 1.01-6.36) and report higher symptoms of depression (odds ratio 1.07; confidence interval, 1.01-1.15). CONCLUSIONS: Low-barrier-to-treatment-access programs can attract people who are homeless with OUD into MMT. These programs also have an important public health role in addressing both depression and OUD among people who are homeless.

Correlates of sleep quality and excessive daytime sleepiness in people with opioid use disorder receiving methadone treatment.

PURPOSE: The aim of this study was to evaluate the prevalence and clinical correlates of impaired sleep quality and excessive daytime sleepiness among patients receiving methadone for opioid use disorder (OUD). METHODS: Patients receiving methadone (n = 164) completed surveys assessing sleep quality (Pittsburgh Sleep Quality Index [PSQI]), daytime sleepiness (Epworth Sleepiness Scale [ESS]), and related comorbidities. We used bivariate and multivariable linear regression models to evaluate correlates of sleep quality and daytime sleepiness. RESULTS: Ninety percent of patients had poor sleep quality (PSQI >5), and the mean PSQI was high (11.0 ±4). Forty-six percent reported excessive daytime sleepiness (ESS > 10). In multivariable analyses, higher PSQI (worse sleep quality) was significantly associated with pain interference (coefficient = 0.40; 95% CI = 0.18-0.62; ß = 0.31), somatization (coefficient = 2.2; 95% CI = 0.75-3.6; ß = 0.26), and negatively associated with employment (coefficient = - 2.6; 95% CI = - 4.9 to - 0.19; ß = - 0.17). Greater sleepiness was significantly associated with body mass index (coefficient = 0.32; 95% CI = 0.18-0.46; ß = 0.33), and there was a non-significant association between sleepiness and current chronic pain (coefficient = 1.6; 95% CI = 0.26-3.5; ß = 0.13; p value = 0.09). CONCLUSIONS: Poor sleep quality and excessive daytime sleepiness are common in patients receiving methadone for OUD. Chronic pain, somatization, employment status, and obesity are potentially modifiable risk factors for sleep problems for individuals maintained on methadone. People with OUD receiving methadone should be routinely and promptly evaluated and treated for sleep disorders.

Pain catastrophizing and pain acceptance are associated with pain severity and interference among methadone-maintained patients.

OBJECTIVE: The present study examined whether pain catastrophizing and pain acceptance, two important targets of psychosocial interventions for chronic pain, are uniquely associated with pain severity and pain interference among patients on methadone maintenance treatment (MMT). METHOD: A total of 133 MMT patients who reported experiencing some pain during the previous week completed a battery of self-report measures. Multiple regression was used to test whether pain catastrophizing and pain acceptance are related to pain severity and pain interference above and beyond covariates including demographics, emotional distress, and current methadone dose. RESULTS: Both pain acceptance and catastrophizing were significantly associated with pain severity and pain interference while controlling for covariates. CONCLUSIONS: Consistent with previous literature on patients with chronic pain but without opioid use disorder, our findings suggest that both pain catastrophizing and pain acceptance are potentially important intervention targets among MMT patients with co-occurring opioid use disorder and chronic pain.

Training addiction counselors to deliver a brief psychoeducational intervention for chronic pain among patients in opioid agonist treatment: A pilot investigation.

BACKGROUND: Despite high rates of chronic pain among their patients, opioid agonist treatment (OAT) counselors report an absence of training to manage chronic pain. METHODS: A multidisciplinary team developed a tailored training for counselors to screen and address chronic pain via a brief psychosocial intervention, and implemented it with 52 addiction counselors. Data on knowledge (9 true-false items) as well as attitudes, interest, and perceived ability (scored on 5-point Likert-type scales) were collected from counselors before (pre-test), after (post-test) training, and after 6 months (follow-up). RESULTS: Pre-test knowledge scores varied considerably. Compared to pre-test, mean counselor knowledge scores increased significantly post-training and at follow-up (p's.<05). The training was associated with increases in positive attitudes toward the role of counselors in managing chronic pain, interest in assessing chronic pain, and counselor ability to assess as well as suggest appropriate interventions for pain (all p's <.05). Perceived ability to assess chronic pain and suggest appropriate treatment interventions were higher at follow-up than at pre-test (p's <.05). CONCLUSIONS: Findings related to the initial evaluation of this training were promising, and future research is warranted to further examine the efficacy of training drug counselors on psychosocial interventions to manage chronic pain among OAT patients.

Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation.

BACKGROUND: Little is known about possible experiences of burnout among drug counselors in opioid treatment programs that are scaling up capacity to address the current opioid treatment gap. METHODS: Participants in this quality improvement study were 31 drug counselors employed by large opioid treatment programs whose treatment capacities were expanding. Experiences of burnout and approaches for managing and/or preventing burnout were examined using individual semi-structured interviews, which were audiotaped, transcribed, and systematically coded by a multidisciplinary team using grounded theory. RESULTS: Rates of reported burnout (in response to an open-ended question) were lower than expected, with approximately 26% of participants reporting burnout. Counselor descriptions of burnout included cognitive, affective, behavioral, and physiological symptoms; and job-related demands were identified as a frequent cause. Participants described both self-initiated (e.g., engaging in pleasurable activities, exercising, taking breaks during workday) and system-supported strategies for managing or preventing burnout (e.g., availing of supervision and paid time off). Counselors provided recommendations for system-level changes to attenuate counselor risk of burnout (e.g., increased staff-wide encounters, improved communication, accessible paid time off, and increased clinical supervision). CONCLUSIONS: Findings suggest that drug counselor burnout is not inevitable, even in opioid treatment program settings whose treatment capacities are expanding. Organizations might benefit from routinely assessing counselor feedback about burnout and implementing feasible recommendations to attenuate burnout and promote work engagement.

Pain Interference and Incident Medical Disorders in the General Population.

OBJECTIVE: To investigate the longitudinal relationship between pain interference and incident general medical conditions in a nationally representative sample. METHODS: Secondary data analysis comprising chi-square tests and binomial logistic regression analyses were performed on data obtained from the US National Epidemiologic Survey on Alcohol and Related Conditions from 34,465 adult respondents who completed wave 1 (2000-2001) and wave 2 (2004-2005) data collection. Models were adjusted for multiple potentially confounding factors. Respondents were categorized at wave 1 according to past-month pain interference (i.e., no or low pain interference, moderate pain interference, severe pain interference). RESULTS: In multivariate analyses, moderate or severe pain interference (as compared to no or low pain interference) was associated with the incidence of any medical condition; any heart condition, including angina, tachycardia and other heart disease; any stomach condition, including stomach ulcer and gastritis; arthritis; and hypertension (all P < 0.05). Severe (but not moderate) pain interference as compared with no or low pain interference was additionally associated with new occurrences of myocardial infarction, any liver disease, other liver disease, and arteriosclerosis (all P < 0.05). CONCLUSIONS: These findings suggest that the relationship between pain interference and general medical conditions is complex. A more complete understanding of this relationship is likely to involve further exploration of possible mechanisms, including whether it is the pain itself, the ascertainment of pain etiology, or pain treatment that is associated with incident general medical conditions.

Drug Counselor Responses to Patients' Pain Reports: A Qualitative Investigation of Barriers and Facilitators to Treating Patients with Chronic Pain in Methadone Maintenance Treatment.

OBJECTIVE: To examine how drug counselors with no prior training in pain management respond to their patients' reports of chronic pain. DESIGN, SETTING, SUBJECTS, AND METHODS: We conducted individual interviews with 30 drug counselors in methadone maintenance treatment. Interviews were audiotaped, transcribed, and systematically coded using the constant comparative method. RESULTS: Participants identified counselor, patient, and logistical factors that serve as a barrier or facilitate their treatment of patients with chronic pain. Counselor barriers included lack of expertise in managing co-occurring chronic pain and opioid use disorder, complexity of patients' treatment needs, concerns about medication regimens, reliance on patient self-report, and absence of patient improvement. Counselor barriers facilitators included empathy, attending to small changes, and self-reflection. Counselors' perceptions of patient-related barriers included prior negative interactions with medical providers, diminished social roles, attenuated motivation, and negative attitudes toward opioid use disorder. Logistical barriers included lack of appropriate pain management referrals, limited counselor time, and attenuated treatment adherence; a logistical facilitator was consulting with medical providers. CONCLUSIONS: Perceived barriers to treating patients with chronic noncancer pain are common among drug counselors. Addressing these barriers in drug counselor training and in methadone maintenance treatment programs may benefit both methadone-maintained patients with chronic pain and their providers.

Physical activity, psychiatric distress, and interest in exercise group participation among individuals seeking methadone maintenance treatment with and without chronic pain.

BACKGROUND AND OBJECTIVES: Physical activity may improve chronic pain, anxiety, and depression, which are prevalent among patients in methadone maintenance treatment (MMT), but relatively little is known about the physical activity levels or interest in exercise of patients in MMT. METHODS: We used a brief self-report instrument to assess physical activity levels, chronic pain, psychiatric distress, and interest in exercise group participation among 303 adults seeking MMT. RESULTS: Most (73%) reported no moderate or vigorous intensity physical activity in the past week; 27% met recommended physical activity levels, and 24% reported interest in exercise group participation. Participants with (compared to those without) chronic pain had higher levels of psychiatric distress and were less likely to meet recommended levels of physical activity (p < .05), but did not differ significantly in their interest in participating in an exercise group. Participants who met recommended levels of physical activity in the past week were more likely to be men and had lower levels of depression than others (p < .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Low levels of physical activity and low interest in exercise group participation among patients entering MMT point to the need for and likely challenges of implementing exercise interventions in MMT.

The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods.

BACKGROUND: Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans. OBJECTIVES: This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling US veterans over time. METHODS: Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies sampling US veterans and reporting prevalence, distribution, and examining AUDs and DUDs. RESULTS: Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessment method, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time. CONCLUSION: The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed. SCIENTIFIC SIGNIFICANCE: These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans.