Sleep and Pain in Veterans with Chronic Pain: Effects of Psychological Pain Treatment and Temporal Associations.

Introduction: Chronic pain is highly prevalent in US military Veterans. Non-opioid and non-pharmacologic treatments are recommended when clinically appropriate, but research on the mechanisms underlying benefits of these treatments is lacking. Here, we examined the role of sleep in the effects of three non-pharmacologic pain treatments in Veterans. Specifically, we investigated whether treatment effects on sleep predicted treatment effects on pain occurring later, or vice versa. Methods: Veterans enrolled in a randomized controlled trial were invited to participate in this supplementary sleep study. A total of 174 Veterans were randomized to one of three 8-session, in-person, group-based pain treatments: hypnosis, mindfulness meditation, or education control. Measurements included self-reported sleep disturbance, pain intensity, and pain catastrophizing; sleep duration was assessed with actigraphy. Sleep and pain measurements were obtained at baseline, posttreatment, and 3-month posttreatment follow-up. Results: At baseline, average pain intensity was moderate (mean ± SD: 5.7 ± 1.7 on the 0-10 Numeric Rating Scale), pain catastrophizing was just below the clinically relevant threshold (mean ± SD: 28.6 ± 12.2 on the Pain Catastrophizing Scale), and subjective sleep disturbance exceeded the US population average (mean ± SD: 58.5 ± 8.1 on the Patient Reported Outcomes Measurement Information System Sleep Disturbance - Short Form). By contrast, objective sleep duration was consistent with the recommended daily sleep amount of 7-8 h for adults (mean ± SD: 8.3 ± 1.4 h). Across treatment conditions, pain intensity, pain catastrophizing, and subjective sleep disturbance were significantly less at posttreatment and 3-month follow-up than at baseline (p < 0.001). Actigraphic sleep duration did not differ significantly as a function of time. There was a high degree of covariation among the measures of pain intensity, pain catastrophizing, and sleep disturbance (p < 0.05). However, self-reported sleep disturbance was not significantly correlated with actigraphic sleep duration (|r| <= 0.13, p > 0.05). Sleep and pain variables observed at prior assessments predicted these same variables at subsequent assessments. There was no significant evidence that changes in pain preceded changes in sleep or that changes in sleep preceded changes in pain (all p > 0.05). Discussion: For this study's Veterans, treatment-related changes in sleep and pain appeared to occur in parallel. The concomitant changes in sleep and pain suggest that therapies improving pain in Veterans may yield attendant benefits for the treatment of sleep, and possibly vice versa.

An Interactive Online Interprofessional Opioid Education Training Using Standardized Patients.

Introduction: Opioid pain management is complex and requires a collaborative approach. To prepare health professions students to care for patients who have chronic pain, we developed an interprofessional education (IPE) session for delivery using a virtual platform that featured a standardized patient (SP) interaction. Methods: The SP case highlighted a patient on opioids for chronic low back pain resulting from a car accident. Despite no improvement in pain or function, the patient continued taking opioids and developed behaviors that could represent opioid misuse. During the synchronous, online session, interprofessional teams of students interviewed an SP and collaborated to develop a holistic care plan to address the patient's pain and potential opioid misuse. The session evaluation included pre- and postsession surveys. Results: Over 750 students from medicine, pharmacy, nursing, and social work programs participated in the virtual IPE sessions during a single year. Students rated the session positively. Matched survey responses suggested improved confidence in knowledge and skills, and learning through Zoom was rated favorably. Discussion: We successfully implemented a synchronous online IPE session involving SP interactions that allowed students to practice team-based care of a patient with chronic pain who was taking opioids. Based on the success of this IPE session, including the success of the online delivery model, future IPE sessions will continue virtually.

Poppy Seeds Signal Limitations of Urine Drug Testing Protocols.

Appropriate care for patients with chronic pain is complex, requiring a thoughtful and holistic approach to pharmacologic intervention, as well as appropriate monitoring when opioids are employed as part of a multimodal regimen. The urine drug test has become an expected standard when longterm opioids are prescribed, but it should be remembered that this test is not intended to be punitive. It is ordered to promote patient safety (Dowell et al., 2022). Recent literature and events surrounding the effect of poppy seeds on urine drug test results have drawn attention to the risks of misinterpreting this test (Bloch, 2023; Lewis et al., 2021; Reisfield et al., 2023; Temple, 2023). Misinterpretation of urine drug tests creates a potential for unfounded accusations from health care workers toward patients, thus, undermining therapeutic relationships and intensifying stigma. Such circumstances may also preclude chances to offer patients needed interventions. Therefore, a valuable opportunity exists for nurses to mitigate untoward consequences by developing a robust understanding of urine drug testing, destigmatizing chronic pain and opioid use, advocating for patients, and enacting change at both an individual and a systems-level.

Experiencing COMFORT: Perceptions of Virtually-delivered Nonpharmacologic Therapies in Adults Prescribed Opioids for Chronic Pain.

BACKGROUND: An opioid task force within an urban public health district sought to increase access to, and utilization of, non-opioid, nonpharmacologic alternatives for pain management. AIMS: The COMFORT (Community-engaged Options to Maximize and Facilitate Opioid ReducTion) study was designed to provide virtual multidimensional integrated nonpharmacologic therapies via a cloud-based videoconferencing platform over six weeks to adults with chronic pain who were prescribed an opioid to investigate measurable health improvements. METHODS: A qualitative descriptive analysis explored participants' experiences of a novel pain management intervention. A total of 19 participants consented to participate in the study and 15 completed six virtual consultations with either yoga, massage, chiropractic, or physical therapists. Semi-structured exit interviews were conducted, and data analyzed using content analysis. RESULTS: Five main themes were identified, including unmet pain needs, self-care practices, incentive for participation, perception of a virtual environment, and benefits of the intervention. All participants reported at least minor benefits, with about half reporting improvement in pain levels, and some were able to reduce their opioid use. A virtual environment posed challenges for a few participants who found it more difficult to engage with than in-person therapy; others found the platform easy to navigate. CONCLUSIONS: Participants with chronic pain were open and willing to try a novel way to access nonpharmacologic consultations to address unmet pain needs. Virtual consultations with pain management experts may increase access to, and utilization of, complementary and integrative treatment modalities.

Pain Management and Substance Use Disorders: A Position Statement.

ABSTRACT: The American Society for Pain Management Nursing and the International Nurses Society on Addictions hold the position that persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect and receive evidence-based, high-quality assessment and management for both conditions using an integrated, holistic, multidimensional approach. Nonopioid and nonpharmacological approaches to pain management are recommended. Opioids should not be withheld from anyone if necessary to treat pain, and a team-based approach, including pain and addiction specialists, should be utilized when possible. Pain management should include interventions aimed at minimizing the risk for relapse or escalation of problematic substance use and actively involve the person and their support persons in the plan of care. Institutions should establish policies and procedures that support this position statement.

Transforming Nurse Self-Care Through Integration of Spirituality: Lessons From an International Collaboration in Palliative Care.

INTRODUCTION: With growing evidence of compassion fatigue and burnout in health care, it is time for a deeper look at the vital practice of self-care among professionals providing palliative care. The purpose of this study was to provide insights into ways empowerment, caring for self, environment, and building relationships impact well-being among palliative care professionals. METHODS: Interpretative descriptive methods framed focus group interviews, conducted during a conference on palliative care integrative health practices held in Thailand. An interprofessional research team used inductive reasoning processes to analyze the interviews. RESULTS: Three themes emerged from the four focus groups (N = 22): Buddhist Beliefs and Practices, Community-mindedness, and Empowerment. Aspects of spirituality were consistently woven into self-care practices. DISCUSSION: Findings suggest that self-care can be reimagined to include highly personal and unique expressions of spirituality. Health care communities are called to integrate ritual in culturally congruent ways, thus supporting health care professionals to find new sources of meaning, enrichment, and empowerment.

Pain Management and Substance Use Disorders.

The American Society for Pain Management Nursing and the International Nurses Society on Addictions hold the position that persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect, and receive evidence-based, high-quality assessment and management for both conditions using an integrated, holistic, multidimensional approach. Non-opioid and nonpharmacological approaches to pain management are recommended. Opioids should not be withheld from anyone if necessary to treat pain, and a team-based approach, including pain and addiction specialists, should be utilized when possible. Pain management should include interventions aimed at minimizing the risk for relapse or escalation of problematic substance use, and actively involve the person and their support persons in the plan of care. Institutions should establish policies and procedures that support this position statement.

Hyperbaric Oxygen Therapy for Pain, Opioid Withdrawal, and Related Symptoms: A Pilot Randomized Controlled Trial.

BACKGROUND: Pain, drug cravings, and opioid withdrawal symptoms can interfere with substance use disorder or opioid tapering treatment goals. AIM: This pilot study investigated the feasibility of a protocol designed to test opioid withdrawal symptom relief relative to a sham condition after two consecutive days of hyperbaric oxygen therapy (HBOT) for adults prescribed daily methadone for opioid use disorder. METHOD: Using a double-blind protocol, eight adults were randomized to receive either a full 90-minute HBOT dose in a pressurized chamber with 100% oxygen at 2.0 atmospheres absolute (ATA) or a sham condition receiving 21% oxygen (equivalent to room air within the chamber) at a minimal pressure of ≤1.3 ATA. Measures included study retention, treatment satisfaction, and pre- and post-intervention effects for opioid withdrawal symptoms, drug cravings, pain intensity and interference, sleep quality, and mood. RESULTS: Study retention and treatment satisfaction was high. All measurements improved more, on average, for participants receiving full-dose HBOT treatment than among participants receiving sham treatments except for clinically observed withdrawal symptoms. The largest positive effects were observed in measurements of pain intensity and drug craving. CONCLUSIONS: These pilot results provide evidence to support a fully powered study of HBOT as a potential treatment adjunct for adults receiving methadone for opioid use disorder. Trends towards symptom improvements were detected from pre- to post-HBOT in the full treatment arm versus sham condition. More research into novel non-pharmacologic options to relieve distressing symptoms related to pain and opioid use disorder is essential to improve clinical outcomes.

Hyperbaric Oxygen to Assist Adults With Opioid Use Disorder in Reducing Methadone Dose.

ABSTRACT: Opioid withdrawal symptoms can interfere with substance use disorder treatment goals. This study investigated the acceptability, feasibility, and treatment effects of hyperbaric oxygen therapy (HBOT) as an adjunct to reduce withdrawal symptoms for adults initiating a medically supervised methadone dose reduction. Adults prescribed methadone for opioid use disorder were randomized into either a hyperbaric oxygen group (n = 17) or an attention control group (n = 14). The study site was an outpatient opioid treatment program in the northwestern United States. Participants were asked to attend five consecutive daily 90-minute HBOT sessions offered at 2.0 atmospheres absolute with 100% oxygen in a pressurized chamber. Treatment attendance and reported satisfaction were measures of acceptability and feasibility. Medication doses were tracked posttreatment at 1 week, 1 month, and 3 months. Withdrawal symptoms were assessed at baseline and daily during the 5-day intervention period. After randomization, 13 (76.5%) followed through with medical screening and HBOT sessions, and of those, nine (69.2%) completed all five 90-minute HBOT sessions. At 3 months, the treatment group maintained, on average, a 4.3-mg methadone dose reduction compared with an average reduction of 0.25 mg for control group participants. Opioid withdrawal symptoms were reduced after Day 1 of HBOT by twice as much, on average, compared with the control condition. Satisfaction surveys found participants were generally satisfied with ease and comfort of the treatment. The evidence that HBOT is an acceptable, feasible adjunct warrants future trials to determine more conclusively effects on withdrawal symptoms associated with methadone dose taper.

Pain Management and Risks Associated With Substance Use: Practice Recommendations.

Assessing and managing pain while evaluating risks associated with substance use and substance use disorders continues to be a challenge faced by health care clinicians. The American Society for Pain Management Nursing and the International Nurses Society on Addictions uphold the principle that all persons with co-occurring pain and substance use or substance use disorders have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment, and management for both conditions. The American Society for Pain Management Nursing and International Nurses Society on Addictions have updated their 2012 position statement on this topic supporting an integrated, holistic, multidimensional approach, which includes nonopioid and nonpharmacological modalities. Opioid use disorder is used as an exemplar for substance use disorders and clinical recommendations are included with expanded attention to risk assessment and mitigation with interventions targeted to minimize the risk for relapse or escalation of substance use. Opioids should not be excluded for anyone when indicated for pain management. A team-based approach is critical, promotes the active involvement of the person with pain and their support systems, and includes pain and addiction specialists whenever possible. Health care systems should establish policies and procedures that facilitate and support the principles and recommendations put forth in this article.

BMI influences relationships among health factors for adults with persistent pain who use prescription opioids.

BACKGROUND: Long-term use of prescription opioids for pain results in negative health outcomes. Overweight and pain are related, and adults with either condition commonly report poor sleep quality, high levels of depression, low levels of self-efficacy, and high pain interference and intensity. Insufficient research exists regarding how weight may influence pain outcomes in the context of common symptoms. PURPOSE: To investigate how body mass index (BMI) influences relationships between health factors and pain outcomes among adults with pain prescribed opioids. METHODS: The sample included 226 adults. Linear regression models tested relationships among variables and outcomes of pain intensity and pain interference. FINDINGS: BMI significantly strengthened relationships between health factors and pain interference but not pain intensity. DISCUSSION: Adults with persistent pain suffer worsened pain interference in the context of increased weight status. Nurses should consider addressing BMI as part of a holistic pain management care plan.

Cannabis Use Motivations among Adults Prescribed Opioids for Pain versus Opioid Addiction.

BACKGROUND: Cannabis has been linked to reduced opioid use, although reasons for cannabis use among adults prescribed opioids are unclear. AIMS: The purpose of this study was to determine whether motivations for cannabis use differ between adults prescribed opioids for persistent pain versus those receiving opioids as medication-assisted treatment for opioid use disorder. DESIGN: A cross-sectional survey design was used. PARTICIPANTS: Adults prescribed opioids for persistent pain (n = 104) or opioid use disorder (n = 139) were recruited from outpatient settings. METHODS: Data were collected on surveys asking about cannabis use and compared the two populations. A series of regression models examined population characteristics and cannabis use motivations using validated measures of the Marijuana Motives Measure scale. RESULTS: More than half the sample (n = 122) reported current, daily cannabis use and 63% reported pain as a motivation for use. Adults with persistent pain were more likely to be older, female, and have higher levels of education (p < .05). Adults with opioid use disorder were more likely to report "enhancement" (p < .01) and relief of drug withdrawal symptoms (p < .001) as motivations for cannabis use. The most common reasons for cannabis use in both populations were social and recreational use and pain relief. CONCLUSIONS: Both studied populations have unmet health needs motivating them to use cannabis and commonly use cannabis for pain. Persistent pain participants were less likely to use cannabis for euphoric effects or withdrawal purposes. Nurses should assess for cannabis use, provide education on known risks and benefits, and offer options for holistic symptom management.

Cannabis Use and Cognition in Adults Prescribed Opioids for Persistent Pain.

BACKGROUND: Adults with persistent pain frequently report cannabis use to help manage their symptoms. The impact of cannabis use on cognition in the presence of concurrent symptoms of depression and anxiety is poorly understood. AIMS: Our study explored how cannabis use affects relationships among symptoms of depression, anxiety, and cognition. DESIGN: A cross-sectional survey study was conducted. SETTINGS: Surveys were distributed at outpatient clinics treating adults for pain in the Pacific Northwestern United States. PARTICIPANTS: A total of 150 adults prescribed an opioid medicine for persistent pain were recruited. METHODS: A pencil and paper survey was used to collect several self-reported ratings of cognition, symptoms of depression and anxiety, and the average potency of cannabis consumed as measured by the percentage of delta-9-tetrahydrocannibinol (THC) and cannabidiol (CBD), as well as frequency of cannabis use. RESULTS: Depression, anxiety and cognition significantly worsened as the reported percentage of CBD, THC and overall frequency of cannabis use in the past 30 days increased. Depression and anxiety both significantly predicted worsening cognition in the sample. The relationship between depressive symptoms and cognition was strengthened as reported percentages of CBD use increased. The relationship was the same for anxiety and cognition, although not as strong. CONCLUSIONS: More cannabis use, particularly high CBD products, may be linked with increased symptom burdens and may strengthen relationships between negative affect and cognition. Further cannabis research within persistent pain populations is warranted to add evidence that can assist patients in managing mood and mental processes. Nurses should evaluate how negative affective health symptoms may impact cognition among adults with persistent pain using prescription opioid medications, especially in the context of concurrent cannabis use.

Benefits and adverse effects of cannabis use among adults with persistent pain.

BACKGROUND: Increasingly, states are legalizing cannabis for recreational use. Improved accessibility may allow adults with pain to use cannabis more liberally. Greater understanding is needed about how adults with pain perceive the effects of cannabis, particularly those who also use opioid analgesics. PURPOSE: To examine the perceived effects of cannabis among adults who have been prescribed opioids for persistent pain. METHODS: A survey-based study was conducted on 150 adults with persistent pain. Data from two open-ended questions were analyzed using a qualitative descriptive approach and content analysis. FINDINGS: Data analysis led to identification of two main categories and five subcategories: (a) cannabis benefits with two subcategories of "physiological" and "mental health"; (b) adverse effects with three subcategories of "physiological," "mental health," and "social and economic concerns." DISCUSSION: Both positive and negative effects of cannabis were described. Nursing practice, including open communication with patients, can be guided by patient perspectives surrounding benefits and adverse effects of cannabis use.

Integrating the concept of pain interference into pain management.

Undertreatment of pain is a significant problem. Nursing pain assessments have been identified as an area for improvement. This concept analysis sought to examine the use of pain interference as a measurement to assist pain management practices. Existing literature including the term pain interference was reviewed for the years 2000-2010. Pain interference is a common outcome measurement in clinical research. It is not well differentiated from other pain concepts in routine nursing pain assessments, nor consistently defined in research articles. Pain interference has been linked to quality of pain management and recommended as a standard of pain measurement. It aligns with current and emerging theories in pain and symptom control. Further exploration is needed to determine whether integrating this concept into nursing practice will result in improved patient pain experiences.