Pain in the Context of Virtual Neuropsychological Assessment of Older Adults.

OBJECTIVE: Pain and cognitive impairment are prevalent and often co-occur in older adults. Because pain may negatively affect cognitive test performance, identification of pain in the context of neuropsychological evaluation is important. However, pain detection based on self-report presents challenges, and pain is often under-detected in this population. Alternative methods (e.g., video-based automatic coding of facial biomarkers of pain) may facilitate pain identification and thus enhance interpretation of neuropsychological evaluation results. METHOD: The current study examined pain in the context of virtual neuropsychological assessment in 111 community-dwelling older adults, first seeking to validate the use of software developed to automatically code biomarkers of pain. Measures of pain, including self-report of acute and chronic pain and automatic coding of pain, were compared while participants completed neuropsychological testing. RESULTS: Self-reported pain was negatively associated with poorer performance on a measure of executive function (both acute and chronic pain) and a global cognitive screening measure (acute pain only). However, self-reported acute and chronic pain did not correlate significantly with most neuropsychological tests. Automatic coding of pain did not predict self-report of pain or performance on neuropsychological tests beyond the influence of demographic factors and psychological symptoms. CONCLUSIONS: Though results were largely not significant, correlations warrant further exploration of the influence of pain on neuropsychological test performance in this context to ensure that pain does not influence test performance in individuals with higher levels of pain and in other samples.

A holistic biopsychosocial management approach for cis-gender males with chronic pelvic pain syndrome attending sexual health services: a retrospective case review.

OBJECTIVES: Chronic pelvic pain syndrome (CPPS) in men is a condition associated with significant morbidity which is typically managed in sexual health services. We introduced a modified biopsychosocial approach for managing CPPS in men, reducing use of antibiotics and evaluated its application in a retrospective case review. METHODS: Patients attended for a full consultation covering symptomology, onset and social history. Examination included urethral smear and assessment of pelvic floor tension and pain. A focus on pelvic floor relaxation was the mainstay of management with pelvic floor physiotherapy if required. Prescribing of antibiotics being discontinued if no evidence of urethritis at first consultation. The main outcome was change in the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score (which patients completed at each attendance); significant clinical improvement was defined as a NIH-CPSI score reduction of >25% and/or ≥6 points. RESULTS: Among 77 consecutive patients diagnosed with CPPS between April 2017 and December 2018, the mean NIH-CPSI score at the initial visit was 24.1 (11-42). Antibiotics were prescribed to 38/77 (49.4%) and alpha-blockers to 58/77 (75.3%). Overall, 50 (64.9%) patients with a mean initial NIH-CPSI score of 25.4 (11-42) re-attended a CPPS clinic. Among these, the average NIH-CPSI score at the final CPPS clinic appointment declined to 15.9 (0-39) (p<0.001); 34/50 (68%) men experienced significant clinical improvement. Men who attended only one CPPS clinic compared with those who reattended had a shorter duration of symptoms (18 (1-60) vs 36 (1-240) months; p=0.038), a lower initial NIH-CPSI score (21.7 (11-34) vs 25.4 (11-44); p=0.021), but had attended a similar number of clinics prior to referral (2.9 (0-6) vs 3.2 (0-8); p=0.62). CONCLUSIONS: The biopsychosocial approach significantly reduced the NIH-CPSI score in those who re-attended, with 68% of patients having a significant clinical improvement. The first follow-up consultation at 6 weeks is now undertaken by telephone for many patients, if clinically appropriate.

Assessment of efficacy of percutaneous epidural neuroplasty for lumbar stenosis and failed back surgery syndrome: effective and safe?

OBJECTIVE: Chronic, refractory low back and lower extremity pain is a common problem. There are many causes for persistent low back pain, including spinal stenosis (SS), disc herniation, facet disease, sacroiliac disease, adjacent segment disease, ligamentous disease, and failed back surgery syndrome (FBSS). FBSS and SS are common and often result in chronic, persistent pain and disability. After the failure of conservative treatments, percutaneous epidural neuroplasty (PEN) is often used in managing low back pain. PATIENTS AND METHODS: We retrospectively analyzed 117 patients who received PEN for FBSS and SS between January 2018 and January 2019. Clinical outcomes were assessed with the visual analogue scale (VAS) score and the Oswestry disability index (ODI). The follow-up period was 6 months. We aimed to evaluate the effectiveness of percutaneous epidural neuroplasty in managing chronic refractory low back and lower extremity pain secondary to FBSS and SS and to compare the differences between outcomes of SS and FBSS groups, before and after PEN. RESULTS: Mean VAS scores were 6.15 ± 1.25 preoperatively, 2.97 ± 1.5 after 1 month, 3.18 ± 1.65 after 3 months, and 3.83 ± 1.64 after 6 months of follow-up. Mean ODI scores were 49.91 ± 13.87 preoperatively, 30.19 ± 12.01 after 1 month, 31.61 ± 12.46 after 3 months, 34.58 ± 12.52 after 6 months of follow-up. CONCLUSIONS: Percutaneous epidural neuroplasty was shown to be a safe and effective treatment in managing refractory back/leg pain following FBSS and SS.

Estimating the cost and epidemiology of mild to severe chronic pain associated with osteoarthritis in England: a retrospective analysis of linked primary and secondary care data.

OBJECTIVE: Osteoarthritis (OA) affects 10% of adults in the UK. Despite over one-third of people with OA experiencing chronic pain, few studies have examined the population-level impact of chronic pain associated with OA. We compared resource-use and epidemiological outcomes in patients with mild, moderate and severe chronic OA-associated pain and matched controls without known OA. DESIGN: Retrospective, longitudinal, observational cohort study (July 2008 to June 2019). SETTING: Electronic records extracted from Clinical Practice Research Datalink GOLD primary care linked to Hospital Episode Statistics (HES). PARTICIPANTS: Patients (cases; n=23 016) aged ≥18 years with chronic OA-associated pain. Controls (n=23 016) without OA or chronic pain matched on age, sex, comorbidity burden, general practitioner practice and available HES data. INTERVENTIONS: None. PRIMARY AND SECONDARY OUTCOME MEASURES: Total healthcare resource use (HCRU), direct healthcare costs in 0-12, 12-24 and 24-36 months postindex. Secondary outcomes included incidence and prevalence of chronic OA-associated pain and pharmacological management. RESULTS: HCRU was consistently greater in cases versus controls for all resource categories during preindex and postindex periods. Across follow-up periods, resource use was greatest in patients with severe pain. In the first 12 months postindexing, mean total costs incurred by cases were four times higher versus matched controls (£256 vs £62); costs were approximately twice as high in cases vs controls for months 12-24 (£166 vs £86) and 24-36 (£150 vs £81; all p<0.0001). The incidence of new cases of chronic pain associated with OA was 2.64 per 1000 person-years; the prevalence was 1.4%. CONCLUSIONS: This study highlights the real-world cost of chronic pain associated with OA in cases versus matched controls. We included patients with mild, moderate and severe pain associated with OA, and showed HCRU in discrete 1-year time frames. The true economic burden of pain associated with OA is likely to be considerably higher when indirect costs are considered.

Assessment of pain-related behaviors in HIV-1 transgenic rats as a model of HIV-associated chronic pain.

Human immunodeficiency virus-1 (HIV)-associated chronic pain is a debilitating comorbid condition that affects 25-85% of people with HIV. The use of opioids to alleviate pain has given rise to opioid dependency in this cohort. Therefore, there is an urgent need to understand mechanisms and identify novel therapeutics for HIV-associated chronic pain. Several animal models have been developed to study HIV-related comorbidities. HIV-1 transgenic (Tg) rats have been shown to serve as a reliable model that mimic the deficits observed in people with HIV, such as neurological and immune system alterations. However, pain-related behavior in these animals has not been extensively evaluated. In this study, we measured evoked and spontaneous behavior in HIV-1Tg male and female rats. The results indicated that HIV-1Tg rats exhibit similar behavior to those with HIV-1-related neuropathy, specifically, cold sensitivity. Consequently, HIV-1Tg rats can serve as a model of neuropathy to study pain-related mechanisms and therapeutics targeted toward individuals living with HIV-1.

Chronic pain in haemophilia: assessment and analgesic treatment.

People with haemophilia tend to experience pain from an early age because of venipuncture and hemarthrosis. If pain is not properly managed, it can become chronic and bedevil patients throughout their lives. Therapies are currently available that have been shown to effectively treat the different types of pain and their causes. Patients with haemophilia tend to experience either nociceptive or mixed pain. Identification of the cause of pain by means of imaging techniques, and understanding the characteristics, location and intensity of the pain, are essential for a more targeted therapeutic approach. Current data reveal that the most effective measures are administration of haematological and analgesic medication, intraarticular injections, and physical exercise. However, multimodal strategies such as lifestyle changes, physical modalities, psychological support and orthopaedic surgery can also prove of use. This article will look at the most effective analgesic measures used as a part of conservative clinical treatment. Collaborative studies are needed to better understand the nature of pain in the context of haemophilia.

Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals.

OBJECTIVES: To give an overview of central aspects of pain medicine-specific clinical reasoning when assessing a pain patient. Clinical reasoning is the thinking and decision-making processes associated with clinical practice. METHODS: Three core pain assessment areas that are crucial for clinical reasoning in the field of pain medicine are discussed, each of them consisting of three points. RESULTS: First, it is important to distinguish acute, chronic non-cancer, and cancer-related pain conditions. This classical and very simple trichotomy still has important implications treatment-wise, e.g., concerning the use of opioids. Second, the pain mechanism needs to be assessed. Is the pain nociceptive, neuropathic, or nociplastic? Simply put, nociceptive pain has to do with injury of non-neural tissue, neuropathic pain is caused by a disease or lesion of the somatosensory nervous system, and nociplastic pain is believed to be related to a sensitized nervous system (c.f. the concept of "central sensitization"). This also has implications concerning treatment. Some chronic pain conditions are nowadays viewed more as diseases rather than the pain being merely a symptom. In the new ICD-11 pain classification, this is conceptualized by the characterization of some chronic pains as "primary". Third, in addition to a conventional biomedical evaluation, psychosocial and behavioral aspects must also be assessed, the pain patient being viewed as an active agent and not merely as the passive recipient of an intervention. Hence, the importance of a dynamic bio-psycho-social perspective. The dynamic interplay of biological, psychological, and social aspects must be taken into account, putative behavioral "vicious circles" thereby being identified. Some core psycho-social concepts in pain medicine are mentioned. CONCLUSIONS: The clinical applicability and clinical reasoning power of the 3 × 3 framework is illustrated by three short (albeit fictional) case descriptions.

LAPAROSCOPIC INGUINAL HERNIA REPAIR: THE LONG-TERM ASSESSMENT OF CHRONIC PAIN AND QUALITY OF LIFE.

BACKGROUND: Laparoscopic approaches to inguinal hernia repair include transabdominal extraperitoneal and transabdominal preperitoneal, both of which are widely performed and employ mesh. Indicators of success for these surgical procedures include incidence of complications, time to return to daily activities, incidence of postoperative chronic pain, and the long-term postoperative patient satisfaction. OBJECTIVE: This study aimed to evaluate and compare long-term postoperative incidence of chronic pain and overall quality of life among patients undergoing transabdominal extraperitoneal or transabdominal preperitoneal inguinal hernia repair. METHODS: This was a retrospective cross-sectional study. Medical records were analyzed, and the SF-36 questionnaire and Visual Analog Scale were applied to assess quality of life and chronic pain in patients undergoing laparoscopic inguinal hernia repair between January 2017 and February 2021. RESULTS: A total of 167 patients status post laparoscopic inguinal hernia repair, who were 3 months postoperatively or longer, were included in the study. Among the early complications seen, seroma was most common in the transabdominal preperitoneal group (p=0.04). Subsequently, 40 of the initial 167 patients answered to the survey instrument (SF-36 and Visual Analog Scale). Mean patient-reported pain (Visual Analog Scale score) was statistically similar between groups, with 1.29 for transabdominal preperitoneal and 1.68 for transabdominal extraperitoneal (p=0.92). In the domains evaluated by the SF-36, there was no significant difference between the samples. CONCLUSION: Both transabdominal extraperitoneal and transabdominal preperitoneal techniques for hernia repair have similar results in the late postoperative period regarding quality of life and prevalence of chronic pain. They are also comparable in terms of major early postoperative complications, except for seroma, with a higher incidence in patients undergoing transabdominal preperitoneal.

Sensorimotor integration, cervical sensorimotor control, and cost of cognitive-motor dual tasking: Are there differences in patients with chronic whiplash-associated disorders and chronic idiopathic neck pain compared to healthy controls?

PURPOSE: The current investigation aimed to compare the sensorimotor integration, sensorimotor control, and cost of cognitive-motor dual task during walking, in persons with chronic WAD as compared to matched chronic idiopathic neck pain and normal healthy controls. METHODS: A cross-sectional, case control design comparing 30 participants in each of two study groups (chronic WAD and chronic idiopathic neck pain) to a matched control group was conducted. Measurements included: (1) the cranio-vertebral angle (CVA), (2) left and right rotation head repositioning accuracy (HRA), (3) frontal N30 amplitudes to assess sensorimotor integration, (4) dual cognitive gait cost (DCGC). RESULTS: A statistically significant difference for the CVA was found between groups: WAD 36.8° ± 3.4, chronic pain 44.5° ± 1.5, and controls 47.1° ± 4; p < 0.05. MANOVA revealed significant group differences for the N30 amplitude (p < 0.05), where the WAD group had the greatest amplitude. Statistically significant differences among the three groups were found for HRA left and right where the WAD group had the greatest error, (p < 0.05). Post hoc tests revealed that the WAD group had the highest dual-task cost during walking, (p < 0.05). Significant linear correlations between the CVA and N30 amplitude, HRA, and DCGC were identified in all 3 groups, (p < 0.05). CONCLUSIONS: Compared to both a matched control group and chronic neck pain group, whiplash-injured persons have greater forward head posture, greater error in sensorimotor control, and an altered ability to perform a motor task with a simultaneous cognitive task.

Reliability and Validity of Pain and Urinary Symptom Severity Assessment in Urological Chronic Pelvic Pain: A MAPP Network Analysis.

PURPOSE: We assessed the reliability and validity of an efficient severity assessment for pelvic pain and urinary symptoms in urological chronic pelvic pain syndrome, which consists of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: A total of 578 patients were assessed using brief, empirically derived self-report scales for pelvic pain severity (PPS) and urinary symptom severity (USS) 4 times during a 1-month period and baseline clinic visit that included urological, pain and illness-impact measures. Mild, moderate and severe categories on each dimension were examined for measurement stability and construct validity. RESULTS: PPS and USS severity categories had adequate reliability and both discriminant validity (differential relationships with specific clinical and self-report measures) and convergent validity (common association with nonurological somatic symptoms). For example, increasing PPS was associated with pelvic tenderness and widespread pelvic pain, whereas USS was associated with urgency during a bladder filling test and increased sensory sensitivity. PPS and USS categories were independently associated with nonurological pain and emotional distress. A descriptive analysis identified higher likelihood characteristics associated with having moderate to severe PPS or USS or both. Lack of sex interactions indicated that the measures are comparable in interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome. CONCLUSIONS: Women and men with urological chronic pelvic pain syndrome can be reliably subgrouped using brief self-report measures of mild, moderate or severe pelvic pain and urinary symptoms. Comparisons with a broad range of clinical variables demonstrate the validity and potential clinical utility of these classifications, including use in clinical trials, health services and biological research.

Chronic Pain and Mental Health Co-Morbidity in Adolescents: An Urgent Call for Assessment and Evidence-Based Intervention.

BACKGROUND: Nearly 30% of children are affected by chronic pain which puts a significant burden on the child's family and society with estimated cost of over $19.5 billion each year. Children and adolescent's quality of life is often impacted leading to physical disability, low self-esteem, depression, anxiety, school stress or decreased performance, insomnia, and fatigue. The purposes of this paper are to: 1) provide an overview of chronic pain in children and adolescents; 2) describe findings from a quality improvement project that assessed the prevalence of negative mood, quality of life, functional disability, and coping with pain in teens with chronic pain, and 3) discuss screening, assessment and evidence-based management of co-morbid chronic pain and mental health problems in children and teens. FINDINGS: Findings for a quality improvement project indicated that 16.8% of the adolescents scored high risk for depression, which was higher than the national average. Approximately 57% of adolescents were screened as high risk on the Pediatric Quality of Life inventory (PedsQL™). One in four adolescents showed poor functioning on the Functional Disability Inventory and nearly one-third of the adolescents reported poor coping with pain on the Pain Coping Questionnaire. This project indicates that adolescents with chronic pain are at high risk for mental health problems. The outcomes suggest the mental health needs of adolescents with chronic pain need to be identified and addressed to help improve outcomes. DISCUSSION: Children and youth with chronic pain need to be routinely screened and assessed for mental health problems, especially anxiety and depression. The use of Cognitive Behavioral Therapy (CBT) or CBT-skills building for children and youth with anxiety and depressive disorders has been widely studied and are helpful for children with chronic pain include psychoeducation, which helps the child to learn age and developmental specific information on chronic pain. Evidence-based manualized and internet-based CBT programs should be scaled rapidly to decrease depression and anxiety in children and youth with chronic pain.

Characterizing the contribution of chronic pain diagnoses to the neurologic burden of disease, active component, U.S. Armed Forces, 2009-2018.

In the annual Medical Surveillance Monthly Report (MSMR) burden of disease analysis, neurologic disorders represent the fifth most common category of diagnoses among active component service members within the Military Health System. One major subcategory of this disease group is "all other neurologic conditions." Incidence analysis from 2009-2018 revealed that the vast majority of diagnoses in this undefined subcategory were related to chronic pain and that such diagnoses have been increasing in burden by a considerable amount. Chronic pain diagnoses increased from a rate of 85.5 per 10,000 person- years (p-yrs) in 2009 to 261.1 per 10,000 p-yrs in 2018. Subgroup analysis by demographic characteristics demonstrated that female, non-Hispanic black, older, and enlisted personnel were at increased risk for chronic pain diagnoses. Among the branches of service, members of the Army were at the highest risk of a chronic pain diagnosis with a rate ratio of 4.8 compared to the Navy, the branch with the lowest risk. Future annual burden analyses should consider chronic pain as its own subcategory to better characterize its impact.

A survey of chronic pain in China.

There is an extensive body of research about chronic pain and treatment in developed countries. In contrast there is a lack of research on this topic in developing countries including China. This study was aimed to estimate the prevalence of chronic pain in different regions of China. Data on pain and its treatment were collected from 9357 participants using questionnaires and telephone-based interviews, from 31 regions of China. Gathered data were then coded into electronic data acquisition system and descriptive and inferential statistical analysis was performed. Out of 9298 participants, the ratio of chronic pain was 31.54% with the proportion of male having chronic pain (33.86%) was higher than that of female (29.53%). The average age of participants with pain (45.02 ± 15.07 years) was higher than free-pain participants (36.19 ± 11.12 years). There were also significant differences between groups in occupation, education levels, and illness history. Proportion of patients with pain duration of 1 year was 12.104%, between 1 and 5 years was 60%, and over 10 years was 10.74%. There were 63.9% of patients with moderate pain and 36.1% with severe pain. About 43.042% of patients thought that pain resulted in sleep disorder, 38.99% thought that it causes anxiety, and about 33% thought depression and irritable bowel was the result of their pain. For the chronic pain, more than half of patients used naprapathy, cupping, and other physical therapies. Up to 2016, the ratio of pain incidence was over 30% in China. The location of pain was focused on back and upper limb. There has been a lack of proper treatment. Patients with pain had obvious economic burden, and their quality of life and psychology were significantly affected.

Pain interference type and level guide the assessment process in chronic pain: Categorizing pain patients entering tertiary pain treatment with the Brief Pain Inventory.

Chronic pain patients enter treatment with different problem profiles making careful assessment a necessity for more individualized treatment plans. In this cross-sectional study we assigned 320 patients entering tertiary multidisciplinary pain treatment into four categories based on whether they scored low or high on the activity and the affective pain interference dimensions of the Brief Pain Inventory (BPI). To determine whether this categorization system delineates issues that should be assessed further, the categories were compared with ANOVA and MANOVA analyses on three domains: variables affecting physical well-being (body mass index, exercise, substance use), psychological resources (mood), and pain-specific psychological factors (pain anxiety, pain acceptance). The results indicated that subjects who scored low on both interference dimensions compared similarly in weight: mean Body Mass Index (BMI) 27.0 (SD 6.0) kg/m2, and exercise: mean of 2.4 (SD 1.7) exercising sessions over 20 minutes per week, to the general population, had no depressive symptoms on average: mean Beck Depression Index II (BDI-II) score 11.7 (SD 7.5), and had the most favorable psychological reactions to pain relative to the other categories: mean total Pain Anxiety Symptoms Scale-20 (PASS-20) score 36.4 (SD 17.9). In contrast, when interference was high on activity, more physical well-being problems were evident e.g. weight: mean BMI 31.0 (SD 7.3) kg/m2, diminished exercise: mean of 1.5 (SD 1.6) exercising sessions per week, and avoidance behavior: mean PASS-20 Escape/Avoidance subscale 3.7 (95% CI: 1.7 to 5.8) scores higher in comparison to activity interference remaining low. With high affective interference, more depressive symptoms: mean BDI-II score 17.7 (SD 7.3), and more cognitive pain anxiety: mean PASS-20 Cognitive Anxiety subscale 2.8 (95% CI 0.7 to 4.8) scores higher in comparison to affective interference remaining low, emerged. Having high interference on both dimensions indicated accumulated risks for reduced physical well-being: mean BMI 29.9 (SD 6.1) kg/m2, mean of 1.2 (SD 1.7) exercising sessions per week, mood problems: mean BDI-II 20.3 (SD 10.6), and negative psychological reactions to pain: mean total PASS-20 score 53.2 (18.4). The results suggest that low interference on both dimensions may allow assessment with only physician consultations, while high interference on either dimension may call attention to distinct issues to be addressed with the help of a physiotherapist or a psychologist, whereas high interference on both dimensions highlights the need for a full multidisciplinary assessment.

Personal resource profiles of individuals with chronic pain: Sociodemographic and pain interference differences.

PURPOSE/OBJECTIVE: Previous studies have demonstrated important associations between personal resources and pain interference. Using latent profile analysis, the present study (a) identified subgroups of individuals with chronic pain who have different personal resource profiles; (b) explored sociodemographic differences among subgroups; and (c) examined how these subgroups differ in pain interference. Research Method/Design: Study 1 is based on daily diary and survey data from 220 individuals with fibromyalgia (FM). Study 2 is based on 4 annual surveys of 483 individuals with long-term neurological/neuromuscular disease or injury, and chronic pain. Modifiable personal resource variables including sense of resilience, social support, pain acceptance, and sleep quality were included in latent profile analyses. RESULTS: Three subgroups were identified in both studies: High, Moderate, and Low Personal Resource groups. In both studies, annual income level was significantly different among subgroups. Study 1 results showed a significant between-groups difference in pain interference across 21-days only between High and Moderate Personal Resource groups controlling for the level of pain intensity and depressive symptoms. In Study 2, however, all subgroups were significantly different with respect to their levels of pain interference at baseline over and above various covariates, with the Low Personal Resource group reporting the highest level of pain interference at baseline. These baseline differences remained stable over 4 years. CONCLUSIONS/IMPLICATIONS: The findings suggest a robust association between economic disparity and personal resource profiles among individuals with chronic pain. The role of different personal resource profiles in pain interference appears to differ by chronic pain condition. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prevalence of Nonopioid and Opioid Prescriptions Among Commercially Insured Patients with Chronic Pain.

Objective The increased use of opioids to treat chronic pain in the past 20 years has led to a drastic increase in opioid prescribing in the United States. The Centers for Disease Control and Prevention's (CDC's) Guideline for Prescribing Opioids for Chronic Pain recommends the use of nonopioid therapy as the preferred treatment for chronic pain. This study analyzes the prevalence of nonopioid prescribing among commercially insured patients with chronic pain. Design Data from the 2014 IBM® MarketScan® databases representing claims for commercially insured patients were used. International Classification of Diseases, Ninth Revision, codes were used to identify patients with chronic pain. Nonopioid prescriptions included nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics/antipyretics (e.g., acetaminophen), anticonvulsants, and antidepressant medications. The prevalence of nonopioid and opioid prescriptions was calculated by age, sex, insurance plan type, presence of a depressive or seizure disorder, and region. Results In 2014, among patients with chronic pain, 16% filled only an opioid, 17% filled only a nonopioid prescription, and 28% filled both a nonopioid and an opioid. NSAIDs and antidepressants were the most commonly prescribed nonopioids among patients with chronic pain. Having prescriptions for only nonopioids was more common among patients aged 50-64 years and among female patients. Conclusions This study provides a baseline snapshot of nonopioid prescriptions before the release of the CDC Guideline and can be used to examine the impact of the CDC Guideline and other evidence-based guidelines on nonopioid use among commercially insured patients with chronic pain.

The relationship between pain psychological factors and job stress in rehabilitation workers with or without chronic pain.

BACKGROUND: Pain is affected by pain psychological factors (PPFs), whereas relationship between PPFs and job stress are unclear. OBJECTIVE: This study aimed to elucidate the relationship between PPFs and job stress in workers. METHODS: The study participants were the staff of the rehabilitation department of a core hospital. After undergoing a preliminary survey (38/43, 88% response rate), the rehabilitation workers were divided into the chronic pain group (CPG, n = 18) and the nonpain group (NPG, n = 13). RESULTS: Depression, anxiety, and magnification in the CPG were significantly associated with depressed mood and total stress response. Anxiety in the NPG was also significantly associated with all stress responses, except irritability and feelings of anxiety. Furthermore, all subscales of the Pain Catastrophizing Scale in the NPG were significantly and negatively associated with the vigor of stress responses. CONCLUSIONS: Chronic pain in workers was associated with severe job stress, and increased job stress worsened the state of chronic pain. Pain catastrophizing may be associated with early job stress in a person with no pain. This finding revealed a difference between the CPG and NPG and may be important for managing workers with job stress or pain.

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice.

BACKGROUND: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. AIM: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. METHODS: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. RESULTS: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. CONCLUSIONS: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population.

Neighborhood, Socioeconomic, and Racial Influence on Chronic Pain.

The purpose of this review is to highlight the neighborhood, socioeconomic, and racial influences on chronic pain. Negative influences on the experience of chronic pain are explored and defined as any adverse stressor common in low socioeconomic, urban neighborhoods that potentially contributes to health disparity in African Americans experiencing chronic pain. The multifactorial influences on chronic pain disparity in African Americans are explored and expounded upon in this review of existing evidence. Databases used for the search included CINAHL, PubMed, and PsycArticles. The experience of chronic pain is multifaceted, existing with multiple comorbidities and lasting consequences. To improve the burden of chronic pain requires a multifactorial assessment that considers neighborhood risk factors, emphasis on environmental stressors, limitations to support networks, barriers to physical activity, and access to primary care providers with whom communication is open and without bias. A comprehensive assessment of barriers will aid in the development of interventions that reach beyond the physical factors of chronic pain, also considering the psychosocial barriers to improving the burden of chronic pain in African Americans living in impoverished urban neighborhoods.

Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice.

Among people with chronic pain, insomnia is highly prevalent, closely related to the mechanism of central sensitization, characterized by low-grade neuroinflammation, and commonly associated with stress or anxiety; in addition, it often does not respond effectively to drug treatments. This review article applies the current understanding of insomnia to clinical practice, including assessment and conservative treatment of insomnia in people with chronic pain. Cognitive-behavioral therapy for insomnia can be efficacious for improvements in sleep initiation, sleep maintenance, perceived sleep quality, and pain interference with daily functioning in people with chronic pain. A recent systematic review concluded that with additional training, physical therapist-led cognitive-behavioral interventions are efficacious for low back pain, allowing their implementation within the field. Cognitive-behavioral therapy for insomnia, as provided to people with chronic pain, typically includes education, sleep restriction measures, stimulus control instructions, sleep hygiene, and cognitive therapy.