National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care Survey.

OBJECTIVES: To portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments. STUDY DESIGN: Using nationally representative data of ambulatory physician office visits (2007-2015 United States National Ambulatory Medical Care Survey), we identified and cross-sectionally analyzed visits by persons <25 years of age diagnosed with a chronic musculoskeletal pain condition. RESULTS: There were 28.6 million visits over the 9-year period for chronic musculoskeletal pain for persons <25 years of age, (average 3.2 million visits/year). There were more visits among older age groups, female persons, non-Hispanic White ethnicity/race, and those with more medical visits in the past year. Nonopioid medications were the most frequent treatments in all age groups (range 38.5%-48.8%). Opioids were rarely prescribed for children and adolescents but were prescribed in 23% of visits among young adults (18-24 years of age). Health education and counseling were consistently prescribed at 20% of visits and physical therapy (range 9.5%-23.7%) and other treatments were less frequently prescribed. Age, sex, payment source, and physician specialty were associated with various treatments. CONCLUSION: There were over 3 million annual visits for chronic musculoskeletal pain in young Americans; these increased with age. Pharmacologic treatment is used more than nonpharmacologic approaches, and opioid prescribing in the 18- to 24-year-old age group approaches estimates in adults with musculoskeletal pain.

Use of Complementary Health Approaches Overall and for Pain Management by US Adults.

This study examines prevalence of use of complementary health approaches overall and for pain management among US adults.

EDTA chelation therapy alone and in combination with oral high-dose multivitamins and minerals for coronary disease: The factorial group results of the Trial to Assess Chelation Therapy.

BACKGROUND: Disodium ethylenediaminetetraacetic acid (EDTA) reduced adverse cardiac outcomes in a factorial trial also testing oral vitamins. This report describes the intent-to-treat comparison of the 4 factorial groups overall and in patients with diabetes. METHODS: This was a double-blind, placebo-controlled, 2 × 2 factorial multicenter randomized trial of 1,708 post-myocardial infarction (MI) patients ≥50 years of age and with creatinine ≤2.0 mg/dL randomized to receive 40 EDTA chelation or placebo infusions plus 6 caplets daily of a 28-component multivitamin-multimineral mixture or placebo. The primary end point was a composite of total mortality, MI, stroke, coronary revascularization, or hospitalization for angina. RESULTS: Median age was 65 years, 18% were female, 94% were Caucasian, 37% were diabetic, 83% had prior coronary revascularization, and 73% were on statins. Five-year Kaplan-Meier estimates for the primary end point was 31.9% in the chelation + high-dose vitamin group, 33.7% in the chelation + placebo vitamin group, 36.6% in the placebo infusion + active vitamin group, and 40.2% in the placebo infusions + placebo vitamin group. The reduction in primary end point by double active treatment compared with double placebo was significant (hazard ratio 0.74, 95% CI 0.57-0.95, P = .016). In patients with diabetes, the primary end point reduction of double active compared with double placebo was more pronounced (hazard ratio 0.49, 95% CI 0.33-0.75, P < .001). CONCLUSIONS: In stable post-MI patients on evidence-based medical therapy, the combination of oral high-dose vitamins and chelation therapy compared with double placebo reduced clinically important cardiovascular events to an extent that was both statistically significant and of potential clinical relevance.

Infection hospitalization increases risk of dementia in the elderly.

OBJECTIVES: Severe infections, often requiring ICU admission, have been associated with persistent cognitive dysfunction. Less severe infections are more common and whether they are associated with an increased risk of dementia is unclear. We determined the association of pneumonia hospitalization with risk of dementia in well-functioning older adults. DESIGN: Secondary analysis of a randomized multicenter trial to determine the effect of Gingko biloba on incident dementia. SETTING: Five academic medical centers in the United States. SUBJECTS: Healthy community volunteers (n = 3,069) with a median follow-up of 6.1 years. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We identified pneumonia hospitalizations using International Classification of Diseases, 9th Edition-Coding Manual codes and validated them in a subset. Less than 3% of pneumonia cases necessitated ICU admission, mechanical ventilation, or vasopressor support. Dementia was adjudicated based on neuropsychological evaluation, neurological examination, and MRI. Two hundred twenty-one participants (7.2%) incurred at least one hospitalization with pneumonia (mean time to pneumonia = 3.5 yr). Of these, dementia was developed in 38 (17%) after pneumonia, with half of these cases occurring 2 years after the pneumonia hospitalization. Hospitalization with pneumonia was associated with increased risk of time to dementia diagnosis (unadjusted hazard ratio = 2.3; CI, 1.6-3.2; p < 0.0001). The association remained significant when adjusted for age, sex, race, study site, education, and baseline mini-mental status examination (hazard ratio = 1.9; CI, 1.4-2.8; p < 0.0001). Results were unchanged when additionally adjusted for smoking, hypertension, diabetes, heart disease, and preinfection functional status. Results were similar using propensity analysis where participants with pneumonia were matched to those without pneumonia based on age, probability of developing pneumonia, and similar trajectories of cognitive and physical function prior to pneumonia (adjusted prevalence rates, 91.7 vs 65 cases per 1,000 person-years; adjusted prevalence rate ratio = 1.6; CI, 1.06-2.7; p = 0.03). Sensitivity analyses showed that the higher risk also occurred among those hospitalized with other infections. CONCLUSION: Hospitalization with pneumonia is associated with increased risk of dementia.

Oral high-dose multivitamins and minerals after myocardial infarction: a randomized trial.

BACKGROUND: Whether high-dose multivitamins are effective for secondary prevention of atherosclerotic disease is unknown. OBJECTIVE: To assess whether oral multivitamins reduce cardiovascular events and are safe. DESIGN: Double-blind, placebo-controlled, 2 x 2 factorial, multicenter, randomized trial. (ClinicalTrials.gov: NCT00044213) SETTING: 134 U.S. and Canadian academic and clinical sites. PATIENTS: 1708 patients aged 50 years or older who had myocardial infarction (MI) at least 6 weeks earlier and had serum creatinine levels of 176.8 mol/L (2.0 mg/dL) or less. INTERVENTION: Patients were randomly assigned to an oral, 28-component, high-dose multivitamin and multimineral mixture or placebo. MEASUREMENTS: The primary end point was time to total death, recurrent MI, stroke, coronary revascularization, or hospitalization for angina. RESULTS: The median age was 65 years, and 18% of patients were women. The qualifying MI occurred a median of 4.6 years (interquartile range [IQR], 1.6 to 9.2 years) before enrollment. Median follow-up was 55 months (IQR, 26 to 60 months). Patients received vitamins for a median of 31 months (IQR, 13 to 59 months) in the vitamin group and 35 months (IQR, 13 to 60 months) in the placebo group (P = 0.65). Totals of 645 (76%) and 646 (76%) patients in the vitamin and placebo groups, respectively, completed at least 1 year of oral therapy (P = 0.98), and 400 (47%) and 426 (50%) patients, respectively, completed at least 3 years (P = 0.23). Totals of 394 (46%) and 390 (46%) patients in the vitamin and placebo groups, respectively, discontinued the vitamin regimen (P = 0.67), and 17% of patients withdrew from the study. The primary end point occurred in 230 (27%) patients in the vitamin group and 253 (30%) in the placebo group (hazard ratio, 0.89 [95% CI, 0.75 to 1.07]; P = 0.21). No evidence suggested harm from vitamin therapy in any category of adverse events. LIMITATION: There was considerable nonadherence and withdrawal, limiting the ability to draw firm conclusions (particularly about safety). CONCLUSION: High-dose oral multivitamins and multiminerals did not statistically significantly reduce cardiovascular events in patients after MI who received standard medications. However, this conclusion is tempered by the nonadherence rate. PRIMARY FUNDING SOURCE: National Institutes of Health.

Development of the adult and child complementary medicine questionnaires fielded on the National Health Interview Survey.

The 2002, 2007, and 2012 complementary medicine questionnaires fielded on the National Health Interview Survey provide the most comprehensive data on complementary medicine available for the United States. They filled the void for large-scale, nationally representative, publicly available datasets on the out-of-pocket costs, prevalence, and reasons for use of complementary medicine in the U.S. Despite their wide use, this is the first article describing the multi-faceted and largely qualitative processes undertaken to develop the surveys. We hope this in-depth description enables policy makers and researchers to better judge the content validity and utility of the questionnaires and their resultant publications.

Effect of disodium EDTA chelation regimen on cardiovascular events in patients with previous myocardial infarction: the TACT randomized trial.

IMPORTANCE: Chelation therapy with disodium EDTA has been used for more than 50 years to treat atherosclerosis without proof of efficacy. OBJECTIVE: To determine if an EDTA-based chelation regimen reduces cardiovascular events. DESIGN, SETTING, AND PARTICIPANTS: Double-blind, placebo-controlled, 2 × 2 factorial randomized trial enrolling 1708 patients aged 50 years or older who had experienced a myocardial infarction (MI) at least 6 weeks prior and had serum creatinine levels of 2.0 mg/dL or less. Participants were recruited at 134 US and Canadian sites. Enrollment began in September 2003 and follow-up took place until October 2011 (median, 55 months). Two hundred eighty-nine patients (17% of total; n=115 in the EDTA group and n=174 in the placebo group) withdrew consent during the trial. INTERVENTIONS: Patients were randomized to receive 40 infusions of a 500-mL chelation solution (3 g of disodium EDTA, 7 g of ascorbate, B vitamins, electrolytes, procaine, and heparin) (n=839) vs placebo (n=869) and an oral vitamin-mineral regimen vs an oral placebo. Infusions were administered weekly for 30 weeks, followed by 10 infusions 2 to 8 weeks apart. Fifteen percent discontinued infusions (n=38 [16%] in the chelation group and n=41 [15%] in the placebo group) because of adverse events. MAIN OUTCOME MEASURES: The prespecified primary end point was a composite of total mortality, recurrent MI, stroke, coronary revascularization, or hospitalization for angina. This report describes the intention-to-treat comparison of EDTA chelation vs placebo. To account for multiple interim analyses, the significance threshold required at the final analysis was P = .036. RESULTS: Qualifying previous MIs occurred a median of 4.6 years before enrollment. Median age was 65 years, 18% were female, 9% were nonwhite, and 31% were diabetic. The primary end point occurred in 222 (26%) of the chelation group and 261 (30%) of the placebo group (hazard ratio [HR], 0.82 [95% CI, 0.69-0.99]; P = .035). There was no effect on total mortality (chelation: 87 deaths [10%]; placebo, 93 deaths [11%]; HR, 0.93 [95% CI, 0.70-1.25]; P = .64), but the study was not powered for this comparison. The effect of EDTA chelation on the components of the primary end point other than death was of similar magnitude as its overall effect (MI: chelation, 6%; placebo, 8%; HR, 0.77 [95% CI, 0.54-1.11]; stroke: chelation, 1.2%; placebo, 1.5%; HR, 0.77 [95% CI, 0.34-1.76]; coronary revascularization: chelation, 15%; placebo, 18%; HR, 0.81 [95% CI, 0.64-1.02]; hospitalization for angina: chelation, 1.6%; placebo, 2.1%; HR, 0.72 [95% CI, 0.35-1.47]). Sensitivity analyses examining the effect of patient dropout and treatment adherence did not alter the results. CONCLUSIONS AND RELEVANCE: Among stable patients with a history of MI, use of an intravenous chelation regimen with disodium EDTA, compared with placebo, modestly reduced the risk of adverse cardiovascular outcomes, many of which were revascularization procedures. These results provide evidence to guide further research but are not sufficient to support the routine use of chelation therapy for treatment of patients who have had an MI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00044213.

Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020.

Importance: Chronic pain risk and prognosis estimates are needed to inform effective interventions. Objective: To estimate rates of chronic pain and high-impact chronic pain (HICP) incidence and persistence in US adults across demographic groups. Design, Setting, and Participants: This cohort study examined a nationally representative cohort with 1 year of follow-up (mean [SD], 1.3 [0.3] years). Data from the 2019-2020 National Health Interview Survey (NHIS) Longitudinal Cohort were used to assess the incidence rates of chronic pain across demographic groups. The cohort was created using random cluster probability sampling of noninstitutionalized civilian US adults 18 years or older in 2019. Of 21 161 baseline participants in the 2019 NHIS who were randomly chosen for follow-up, 1746 were excluded due to proxy response(s) or lack of contact information, and 334 were deceased or institutionalized. Of the 19 081 remaining, the final analytic sample of 10 415 adults also participated in the 2020 NHIS. Data were analyzed from January 2022 to March 2023. Exposures: Self-reported baseline sex, race, ethnicity, age, and college attainment. Main Outcomes and Measures: Primary outcomes were the incidence rates of chronic pain and HICP, and secondary outcomes were the demographic characteristics and rates across demographic groups. A validated measure of pain status ("In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?") yielded 3 discrete categories each year: pain free, nonchronic pain, or chronic pain (pain "most days" or "every day"). Chronic pain present in both survey years was considered persistent; HICP was defined as chronic pain that limited life or work activities on most days or every day. Rates were reported per 1000 person-years (PY) of follow-up, and age standardized based on the 2010 US adult population. Results: Among 10 415 participants included in the analytic sample, 51.7% (95% CI, 50.3%-53.1%) were female, 54.0% (95% CI, 52.4%-55.5%) were aged 18 to 49 years, 72.6% (95% CI, 70.7%-74.6%) were White, 84.5% (95% CI, 81.6%-85.3%) were non-Hispanic or non-Latino, and 70.5% (95% CI, 69.1%-71.9%) were not college graduates. Among pain-free adults in 2019, incidence rates of chronic pain and HICP in 2020 were 52.4 (95% CI, 44.9-59.9) and 12.0 (95% CI, 8.2-15.8) cases per 1000 PY, respectively. The rates of persistent chronic pain and persistent HICP in 2020 were 462.0 (95% CI, 439.7-484.3) and 361.2 (95% CI, 265.6-456.8) cases per 1000 PY, respectively. Conclusions and Relevance: In this cohort study, the incidence of chronic pain was high compared with other chronic diseases. These results emphasize the high disease burden of chronic pain in the US adult population and the need for early management of pain before it becomes chronic.

Chronic pain among U.S. sexual minority adults who identify as gay, lesbian, bisexual, or "something else".

ABSTRACT: This study assesses chronic pain prevalence among sexual minority U.S. adults who self-identify as gay/lesbian, bisexual, or "something else," and examines the role of select covariates in the observed patterns. Analyses are based on 2013 to 2018 waves of the National Health Interview Survey, a leading cross-sectional survey representative of the U.S. population. General chronic pain and chronic pain in 3+ sites among adults aged 18 to 64 years (N = 134,266 and 95,675, respectively) are analyzed using robust Poisson regression and nonlinear decomposition; covariates include demographic, socioeconomic, healthcare, and psychological distress measures. We find large disparities for both pain outcomes. Americans who self-identify as bisexual or "something else" have the highest general chronic pain prevalence (23.7% and 27.0%, respectively), compared with 21.7% among gay/lesbian and 17.2% straight adults. For pain in 3+ sites, disparities are even larger: Age-adjusted prevalence is over twice as high among adults who self-identify as bisexual or "something else" and 50% higher among gay/lesbian, compared with straight adults. Psychological distress is the most salient correlate of the disparities, whereas socioeconomic status and healthcare variables explain only a modest proportion. Findings thus indicate that even in an era of meaningful social and political advances, sexual minority American adults have significantly more chronic pain than their straight counterparts. We call for data collection efforts to include information on perceived discrimination, prejudice, and stigma as potential key upstream factors that drive pain disparities among members of these minoritized groups.

Design of the Trial to Assess Chelation Therapy (TACT).

TACT is an National Institutes of Health-sponsored, randomized, double-blind, placebo-controlled, 2 × 2 factorial clinical trial testing the benefits and risks of 40 infusions of a multicomponent disodium EDTA chelation solution compared with placebo and of an oral, high-dose multivitamin and mineral supplement. TACT has randomized and will follow up 1,708 patients for an average of approximately 4 years. The primary end point is a composite of all-cause mortality, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. A 900-patient substudy will examine quality-of-life outcomes. The trial is designed to have >85% power to detect a 25% relative reduction in the primary end point for each treatment factor. Enrollment began in September 2003 and was completed in October 2010.

Disease severity is associated with the use of complementary medicine to treat or manage type-2 diabetes: data from the 2002 and 2007 National Health Interview Survey.

BACKGROUND: The overall prevalence of complementary medicine (CM) use among adults in the United States with diabetes has been examined both in representative national samples and in more restricted populations. However, none of these earlier studies attempted to identify predictors of CM use to treat diabetes among the populations sampled, nor looked for a relationship between CM use and diabetes severity. METHODS: Combining data from the 2002 and 2007 National Health Interview Survey (NHIS), we constructed a nationally representative sample of 3,978 U.S. adults aged ≥18 years with self-reported diabetes. Both the 2002 and 2007 NHIS contained extensive questions on the use of CM. We used logistic regression to examine the association between diabetes severity and overall CM use, as well as the use of specific categories of CM. RESULTS: In adults with type-2 diabetes, 30.9% used CM for any reason, but only 3.4% used CM to treat or manage their type-2 diabetes versus 7.1% of those with type-1 diabetes. Among those using CM to treat/manage their type-2 diabetes, 77% used both CM and conventional prescription medicine for their diabetes. The most prevalent types of CM therapies used were diet-based interventions (35.19%, S.E. 5.11) and non-vitamin/non-mineral dietary supplements (33.74%, S.E. 5.07). After controlling for sociodemographic factors, we found that, based on a count of measures of diabetes severity, persons with the most severe diabetes had nearly twice the odds of using CM as those with less severe disease (OR=1.9, 95%CI 1.2-3.01). Persons who had diabetes 10 years or more (OR=1.66, 95%CI 1.04-3.66) and those that had a functional limitation resulting from their diabetes (OR=1.74, 95%CI 1.09-2.8) had greater odds of using CM than those not reporting these measures. No significant associations were observed between overall CM use and other individual measures of diabetes severity: use of diabetic medications, weak or failing kidneys, coronary heart disease, or severe vision problems. CONCLUSIONS: Our results demonstrate that individuals with more severe diabetes are more likely to use CM independent of sociodemographic factors. Further studies are essential to determine if CM therapies actually improve clinical outcomes when used to treat/manage diabetes.

Cross-Sectional Analyses of High-Impact Pain Across Pregnancy Status by Race and Ethnicity.

Background: Preclinical and clinical research has suggested the existence of pregnancy-associated analgesia, wherein responses to painful stimulation or pain from disease decrease during pregnancy. Materials and Methods: We combined data from multiple years (2012-2015) of the National Health Interview Survey to examine high-impact pain by Hispanic ethnicity and race in women with no prior pregnancy, during pregnancy, and previously pregnant. Results: High-impact pain was less common for women during pregnancy (10.3%; 95% confidence interval [CI]: 7.0%-13.7%) than it was for women who had never been pregnant (13.7%; 95% CI: 12.8%-14.5%) and for women who had previously been pregnant (19.8%; 95% CI: 16.0%-23.7%). However, when we examined the data by Hispanic ethnicity and race, we found that non-Hispanic White (NHW) women were less likely to report high-impact pain during pregnancy, but non-Hispanic Black (NHB) women and Hispanic White women were not. In women who reported no prior pregnancy, NHW women were most likely to report high-impact pain, followed by NHB women and Hispanic women. In post hoc analyses, we found that while menstrual problems were associated with increased odds of having high-impact pain, an interaction was not observed between menstrual problems and race/ethnicity (p = 0.48). Conclusions: This cross-sectional study presents a nationally representative examination of the prevalence of high-impact pain across pregnancy status. Using a nationally representative sample of women, we have demonstrated that the prevalence of high-impact pain varies across pregnancy status and that race/ethnicity and the presence of menstrual problems independently affect this prevalence.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample.

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015.

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

Reasons Office-Based Physicians in the United States Recommend Common Complementary Health Approaches to Patients: An Exploratory Study Using a National Survey.

Objective: To examine the reasons why office-based physicians do or do not recommend four selected complementary health approaches to their patients in the context of the Andersen Behavioral Model. Design: Descriptive estimates of physician-level data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Induction Interview, a nationally representative survey of office-based physicians (N = 5622, weighted response rate = 59.7%). Setting/Location: The United States. Outcome measures: Reasons for the recommendation or lack thereof to patients for: herbs and other non-vitamin supplements, chiropractic/osteopathic manipulation, acupuncture, and mind-body therapies (including meditation, guided imagery, and progressive relaxation). Differences by physician sex and medical specialty were described. Results: For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals (ranging from 52.0% for chiropractic/osteopathic manipulation [95% confidence interval, CI = 47.6-56.3] to 71.3% for herbs and other non-vitamin supplements [95% CI = 66.9-75.4]). More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests. A higher percentage of female physicians reported evidence in peer-reviewed journals as a rationale for recommending herbs and non-vitamin supplements or chiropractic/osteopathic manipulation when compared with male physicians (herbs and non-vitamin supplements: 78.8% [95% CI = 72.4-84.3] vs. 66.6% [95% CI = 60.8-72.2]; chiropractic/osteopathic manipulation: 62.3% [95% CI = 54.7-69.4] vs. 47.5% [95% CI = 42.3-52.7]). For each of the four complementary health approaches, a lack of perceived benefit was the most frequently reported reason by both sexes for not recommending. Lack of information sources was reported more often by female versus male physicians as a reason to not recommend herbs and non-vitamin supplements (31.4% [95% CI = 26.8-36.3] vs. 23.4% [95% CI = 21.0-25.9]). Conclusions: There are limited nationally representative data on the reasons as to why office-based physicians decide to recommend complementary health approaches to patients. Developing a more nuanced understanding of influencing factors in physicians' decision making regarding complementary health approaches may better inform researchers and educators, and aid physicians in making evidence-based recommendations for patients.

A Review of Potential National Chronic Pain Surveillance Systems in the United States.

Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017.

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

Longitudinal Analysis of Complementary Health Approaches in Adults Aged 25-74 Years from the Midlife in the U.S. Survey Sample.

Objectives: Complementary health approaches include herbal products and mind-body practices. Several studies have identified predictors for complementary health approach use, yet there are two gaps: (1) How does use change? (2) Do factors associated with use influence this change over time? Using the Midlife in the United States (MIDUS), we examined how sociodemographic factors affected use longitudinally, and whether these associations differed between new and continued/discontinued use of herbal products, meditation, chiropractic, and massage therapy. Design: MIDUS is a national probability sample of adults aged 25 or older that has collected more than 20 years of longitudinal data, including the use of complementary health approaches. We employed the Andersen Model as a framework to identify predisposing, enabling, and health need factors associated with complementary health approach use based on previously identified and hypothesized factors. We ran Chi-square analyses to first test bivariate associations between our independent variables and four modalities to further guide logistic regression models. Results: Each of the four approaches examined saw substantial increases in prevalent use. However, only about 25% to 38% of individuals continued use from one wave to the next, whereas only 2%-9% of individuals who did not use a given approach in a wave reported use in the subsequent wave. Age, spiritual importance, and previous wave one use were all significantly associated with new use across all four modalities. Previous wave one use was associated with continued/discontinued use for all modalities. Age and education were significantly associated with discontinued use of chiropractic. Conclusion: We present the first longitudinal analysis of complementary health approaches in a nationally representative sample. These data distinguish between new and continued/discontinued use of complementary health approaches over time and provide insights into the interpretation of complementary health approach prevalence data, as well as important predictors of use.

Specialty Differences in Initial Evaluation of Patients With Non-Acute Musculoskeletal Pain.

PURPOSE: To explore medical diagnostic testing of new cases of musculoskeletal (MSK) conditions associated with chronic pain. METHODS: We analyzed nationally representative cross-sectional data of people having visits with a new likely chronic MSK pain condition. We documented depression screening and prescribing of diagnostic imaging and blood tests and explored associations between patient and provider factors for each. RESULTS: Over the 9 years of the survey, there were 11,994 initial visits for chronic MSK pain, an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions for depression screening, prescribed imaging, and blood tests were 1.79%, 36.34%, and 9.70%, respectively. People on any public health insurance had twice the increased relative odds to be screened for depression. Orthopedists had 3 times increased relative odds to prescribe imaging compared with family physicians; oncologists had 4 times increased relative odds to prescribe blood tests. Survey year was significantly associated with depression screening and ordering any type of imaging. CONCLUSIONS: Observed rates of depression screening and nonindicated imaging for patients with chronic MSK pain have fluctuated over time. The impact of these fluctuations on clinical practice is as yet unknown. The type of nonrecommended actions varied by specialty of physician.

Guidance from an NIH workshop on designing, implementing, and reporting clinical studies of soy interventions.

The NIH sponsored a scientific workshop, "Soy Protein/Isoflavone Research: Challenges in Designing and Evaluating Intervention Studies," July 28-29, 2009. The workshop goal was to provide guidance for the next generation of soy protein/isoflavone human research. Session topics included population exposure to soy; the variability of the human response to soy; product composition; methods, tools, and resources available to estimate exposure and protocol adherence; and analytical methods to assess soy in foods and supplements and analytes in biologic fluids and other tissues. The intent of the workshop was to address the quality of soy studies, not the efficacy or safety of soy. Prior NIH workshops and an evidence-based review questioned the quality of data from human soy studies. If clinical studies are pursued, investigators need to ensure that the experimental designs are optimal and the studies properly executed. The workshop participants identified methodological issues that may confound study results and interpretation. Scientifically sound and useful options for dealing with these issues were discussed. The resulting guidance is presented in this document with a brief rationale. The guidance is specific to soy clinical research and does not address nonsoy-related factors that should also be considered in designing and reporting clinical studies. This guidance may be used by investigators, journal editors, study sponsors, and protocol reviewers for a variety of purposes, including designing and implementing trials, reporting results, and interpreting published epidemiological and clinical studies.