The relationship between emotion regulation and pain catastrophizing in patients with chronic pain.

OBJECTIVES: Pain catastrophizing (PC) is a cognitive/emotional response to and in anticipation of pain that can be maladaptive, further exacerbating pain and difficulty in emotion regulation (ER). There is a lack of research on the interplay between PC and ER and its impact on pain. Our aim was to investigate whether ER exacerbated the pain experience through PC. METHODS: Adults with chronic non-cancer pain of >3 months' duration (n = 150) who were taking opioid medication were recruited from a large medical center in Pennsylvania. A battery of questionnaires was conducted to gather data on demographics, substance use, mental health histories, and health and pain outcomes. Measures used included the 18-Item Difficulties in Emotion Regulation Scale, the Pain Catastrophizing Scale, the Brief Pain Inventory-Short Form, and the Hospital Anxiety and Depression Scale. A structural equation model with latent variables was conducted to examine our aim. RESULTS: Both pain interference and severity were significantly positively associated with several psychosocial variables, such as anxiety, depression, ER constructs, PC, and distress intolerance. The associations between subscales and pain interference were larger than the associations between subscales and pain severity. PC fully mediated the paths from ER to pain experiences. DISCUSSION: Our results highlight the importance of several cognitive and emotional constructs: nonacceptance of negative emotions, lack of emotional awareness, magnification of the pain experience, and a sense of helplessness. Furthermore, by showing the indirect effects of PC in affecting ER and pain, we posit that ER, mediated by PC, might serve a critical role in influencing the pain experience in patients with chronic pain.

Experiences of Patients Taking Conditioned Open-Label Placebos for Reduction of Postoperative Pain and Opioid Exposure After Spine Surgery.

BACKGROUND: Pain after spine surgery is difficult to manage, often requiring the use of opioid analgesics. While traditional "deceptive" or concealed placebo has been studied in trials and laboratory experiments, the acceptability and patient experience of taking honestly prescribed placebos, such as "open-label" placebo (non-deceptive placebo), or conditioned placebo (pairing placebo with another active pharmaceutical) is relatively unexamined. METHODS: Qualitative thematic analysis was performed using semi-structured, post-treatment interviews with spine surgery patients (n = 18) who had received conditioned open-label placebo (COLP) during the first 2-3 weeks after surgery as part of a RCT. Interview transcripts were reviewed by 3 investigators using an immersion/crystallization approach, followed by iterative large-group discussions with additional investigators, to identify, refine, and codify emergent themes. RESULTS: Patients' experiences and perceptions of COLP efficacy varied widely. Some emergent themes included the power of the mind over pain, how COLP might provide distraction from or agency over pain, bandwidth required and engagement with COLP, and its modulation of opioid tapering, as well as negative attitudes toward opioids and pill taking in general. Other themes included uncertainty about COLP efficacy, observations of how personality may relate to COLP efficacy, and a recognition of the greater impact of COLP on reduction of opioid use rather than on pain itself. Interestingly, participant uncertainty, disbelief, and skepticism were not necessarily associated with greater opioid consumption or worse pain. CONCLUSION: Participants provided insights into the experience of COLP which may help to guide its future utilization to manage acute pain and tapering from opioids.

Introversion, Extraversion, and Worsening of Chronic Pain Impact during Social Isolation: A Mediation Analysis.

COVID-19 social distancing mandates increased social isolation, resulting in changes in pain severity and interference among individuals with chronic pain. Differences in personality (e.g., introversion/extraversion) may modulate responses to social isolation. We examined the influence of introversion on reported social distancing-related increases in pain interference and assessed for mediators of this relationship. Individuals with chronic pain (n = 150) completed validated questionnaires 4-8 weeks after implementation of social distancing mandates. Introversion/extraversion was measured using a subscale of the Myers-Briggs Type Indicator and changes in pain and psychosocial variables were calculated by comparing participants' recalled and current scores. Association between introversion/extraversion and other variables were assessed using linear regression. A parallel mediation was used to examine mediators of the association between introversion and change in pain interference. Higher introversion was associated with a decrease in pain interference after social distancing (Rho = - .194, p = .017). Parallel mediation analysis revealed that the relationship between introversion/extraversion and change in pain interference was mediated by changes in sleep disturbance and depression, such that higher introversion was associated with less isolation-induced sleep disruption and depression, and thereby less worsening of pain interference. These findings suggest that personality factors such as introversion/extraversion should be considered when personalizing treatment of chronic pain.

Pain Appraisals in Patients with Physical Injury: Assessing the Role of Distress Tolerance in the Relationship between Depression and Pain Catastrophizing.

Pain is a complex construct contributing to significant impairment, particularly among physically injured patients seeking treatment in trauma and orthopedic surgery settings in which social workers are an integral component of care. The biopsychosocial theory, fear-avoidance, and cognitive mediation models of pain suggest that psychological factors (for example, depression) affect one's ability to tolerate distress, leading to negative pain appraisals, such as catastrophizing. This study examined whether distress tolerance serves as a mechanism by which depression is associated with pain catastrophizing. We administered a health survey to outpatient trauma and orthopedic surgery clinic patients who were using opioid medications; 84 patients were included in the final analysis; 39.3 percent screened positive for depression. A multilevel mediation model using structural equation modeling revealed a significant direct effect from depression to pain catastrophizing (ß = .31, z = 3.96, p < .001) and a significant indirect effect by distress tolerance (Δß = .27, z = 3.84, p < .001). These results, which suggest that distress tolerance partially mediated the path from depression to pain catastrophizing, can inform social workers and other members of the multidisciplinary team about both the critical role of psychosocial factors after injury and interventions to improve postinjury recovery.

Chronic pain severity, impact, and opioid use among patients with cancer: An analysis of biopsychosocial factors using the CHOIR learning health care system.

BACKGROUND: Despite the biopsychosocial underpinnings of chronic noncancer pain, relatively little is known about the contribution of psychosocial factors to chronic cancer pain. The authors aimed to characterize associations between biopsychosocial factors and pain and opioid use among individuals with chronic pain and cancer. METHODS: The authors conducted a retrospective, cross-sectional study of 700 patients with chronic pain and cancer seeking treatment at an academic tertiary pain clinic. Patients completed demographic questionnaires and validated psychosocial and pain measures. Multivariable, hierarchical linear and logistic regressions assessed the relative contributions of biopsychosocial factors to the primary dependent variables of pain severity, pain interference, and opioid use. RESULTS: Participants were 62% female and 66% White with a mean age of 59 ± 15 years, and 55% held a college degree or higher. Older age, African American or "other" race, sleep disturbance, and pain catastrophizing were significantly associated with higher pain severity (F(5,657) = 22.45; P ≤ .001; R2 = 0.22). Depression, sleep disturbance, pain catastrophizing, lower emotional support, and higher pain severity were significantly associated with pain interference (F(5,653) = 9.47; P ≤ .001; R2 = 0.44). Lastly, a poor cancer prognosis (Exp(B) = 1.62) and sleep disturbance (Exp(B) = 1.02) were associated with taking opioids, whereas identifying as Asian (Exp(B) = 0.48) or Hispanic (Exp(B) = 0.47) was associated with lower odds of using opioids. CONCLUSIONS: Modifiable psychological factors-specifically sleep disturbance, depression, and pain catastrophizing-were uniquely associated with pain and opioid use in patients with chronic pain and diverse cancer diagnoses. Future behavioral pain interventions that concurrently target sleep may improve pain among patients with cancer. LAY SUMMARY: Feeling depressed, worrying about pain, and bad sleep are related to higher pain symptoms in individuals with chronic pain and cancer. Specifically, those who struggle to sleep have worse pain and use more opioids. Also, individuals who have a bad prognosis for their cancer are more likely to be using opioid pain medications. Although race and cancer are related to chronic pain in patients, psychological well-being is also strongly related to this same pain.

Integrated Psychosocial Group Treatment: A Randomized Pilot Trial of a Harm Reduction and Preventive Approach for Patients with Chronic Pain at Risk of Opioid Misuse.

OBJECTIVE: To examine the benefits of an integrated psychosocial group treatment (IPGT) model for patients with chronic pain at risk of opioid misuse. DESIGN: This study was a small-scale, single-blinded, two-group randomized controlled trial. SETTING: Outpatient. SUBJECTS: Adults with chronic pain of >3 months' duration who were currently prescribed opioid medication and were at risk of opioid misuse. METHODS: Patients with chronic pain who were at risk of opioid misuse (n = 30) were randomly assigned to IPGT or treatment as usual. IPGT consists of six group sessions of psychoeducation, motivational interviewing, cognitive behavioral therapy, mindfulness, and peer support. Participants were assessed at baseline, first follow-up at 6 weeks, and a posttreatment follow-up at 9 weeks. Outcomes included feasibility, acceptability, and preliminary efficacy. Data were analyzed with descriptive and multivariate analyses. RESULTS: All intervention components were delivered to 87% of the participants, and IPGT recipients reported a high level of satisfaction. Results of the multivariate analyses demonstrated nonsignificant improvements in pain severity (ß = 0.22, 95% CI: -0.24 to 0.66, P = 0.35). However, we observed significant treatment × time interactions on pain interference (ß = 3.32, 95% confidence interval [CI]: 0.01 to 6.65, P = 0.05) and pain catastrophizing (ß = 2.74, 95% CI: 0.49 to 4.99, P = 0.02). Lastly, we detected no significant differences in opioid misuse (adjusted odds ratio = 0.69, 95% CI: -0.26 to 1.64, P = 0.16). CONCLUSION: This study provides support for the IPGT intervention being acceptable and feasible for delivery in patients with chronic pain at risk of opioid misuse. Efficacy was achieved in pain interference and pain catastrophizing.

Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial.

ABSTRACT: Placebo effects have traditionally involved concealment or deception. However, recent evidence suggests that placebo effects can also be elicited when prescribed transparently as "open-label placebos" (OLPs), and that the pairing of an unconditioned stimulus (eg, opioid analgesic) with a conditioned stimulus (eg, placebo pill) can lead to the conditioned stimulus alone reducing pain. In this randomized control trial, we investigated whether combining conditioning with an OLP (COLP) in the immediate postoperative period could reduce daily opioid use and postsurgical pain among patients recovering from spine surgery. Patients were randomized to COLP or treatment as usual, with both groups receiving unrestricted access to a typical opioid-based postoperative analgesic regimen. The generalized estimating equations method was used to assess the treatment effect of COLP on daily opioid consumption and pain during postoperative period from postoperative day (POD) 1 to POD 17. Patients in the COLP group consumed approximately 30% less daily morphine milligram equivalents compared with patients in the treatment as usual group during POD 1 to 17 (-14.5 daily morphine milligram equivalents; 95% CI: [-26.8, -2.2]). Daily worst pain scores were also lower in the COLP group (-1.0 point on the 10-point scale; 95% CI: [-2.0, -0.1]), although a significant difference was not detected in average daily pain between the groups (-0.8 point; 95% CI: [-1.7, 0.2]). These findings suggest that COLP may serve as a potential adjuvant analgesic therapy to decrease opioid consumption in the early postoperative period, without increasing pain.

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators.

BACKGROUND: Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence. METHODS: This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months. RESULTS: The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain. CONCLUSIONS: This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.

Cross-sectional study of psychosocial and pain-related variables among patients with chronic pain during a time of social distancing imposed by the coronavirus disease 2019 pandemic.

ABSTRACT: The COVID-19 pandemic has had a tremendous impact, including on individuals with chronic pain. The social distancing policies necessary to slow the spread of SARS-CoV-2 have involved increased levels of social isolation. This cross-sectional survey study examined pain severity and interference among individuals with chronic pain during an early phase of social distancing mandates and identified characteristics of individuals who were most impacted. Approximately 4 to 8 weeks after social distancing mandates commenced in the state of Massachusetts, 150 patients with fibromyalgia, chronic spine, and postsurgical pain completed demographic, pain, social distancing, and validated psychosocial questionnaires. Patients self-reported an overall significant increase in pain severity and pain interference, compared with before social distancing, although both pain severity and interference were quite variable among individuals under conditions of social distancing. Several demographic, socioeconomic, and psychosocial factors were associated with greater pain severity and interference during social distancing. Multivariable linear regression demonstrated that female sex, nonwhite race, lower education, disability, fibromyalgia, and higher pain catastrophizing were independently associated with greater pain severity, while female sex and pain catastrophizing were independently associated greater pain interference. The findings suggest that individual differences among patients with chronic pain should be considered in the planning, development, and prioritization of interventions to improve pain care and to prevent worsening of symptoms during the continuing COVID-19 pandemic.

Opioid use patterns and risk characteristics among injured patients.

Background: Injured patients are at risk for prolonged opioid use after discharge from care. Limited evidence exists regarding how continued opioid use may be related to opioid medication misuse and opioid use disorder (OUD) following injury. This pilot study characterized opioid consumption patterns, health characteristics, and substance use among patients with active prescriptions for opioid medications following injury care. Methods: This study was a cross-sectional screening survey combined with medical record review from February 2017 to March 2018 conducted among outpatient trauma and orthopedic surgery clinic patients. Eligible patients were 18-64 years of age, admitted/discharged for an injury or trauma-related orthopedic surgery, returning for clinic follow-up ≤6 months post hospital discharge after the index injury, prescribed opioid pain medication at discharge, and currently taking an opioid medication (from discharge or a separate prescription post discharge). Data collected included demographic, substance use, mental health, and physical health information. Descriptive and univariate statistics were calculated to characterize the population and opioid-related risks. Results: Seventy-one participants completed the survey (92% response). Most individuals (≥75%) who screened positive for misuse or OUD reported no nonmedical/illicit opioid use in the year before the index injury. A positive depression screen was associated with a 3.88 times increased likelihood for misuse or OUD (95% confidence interval [CI] = 1.1-13.5). Nonopioid illicit drug use (odds ratio [OR] = 1.89, 95% CI = 1.1-3.4) and opioid craving (OR = 1.29, 95% CI = 1.1-1.5) were also associated with increased likelihood for misuse or OUD. Number of emergency department visits in the 3 years previous to the index injury was associated with a 22% likelihood of being misuse or OUD positive (95% CI = 1.0-1.5). Conclusions: Patients with behavioral health concerns and greater emergency department utilization may have heightened risk for experiencing adverse opioid-related outcomes. Future research must further establish these findings and possibly develop protocols to identify patients at risk prior to pain management planning.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings.

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SEab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SEc' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

A community pharmacy-led intervention for opioid medication misuse: A small-scale randomized clinical trial.

BACKGROUND: Stemming the opioid epidemic requires testing novel interventions. Toward this goal, feasibility and acceptability of a Brief Motivational Intervention-Medication Therapy Management (BMI-MTM) intervention was examined along with its impact on medication misuse and concomitant health conditions. METHODS: We conducted a two-group randomized trial in 2 community pharmacies. We screened patients for prescription opioid misuse at point-of-service using the Prescription Opioid Misuse Index. Participants were assigned to standard medication counseling (SMC) or SMC + BMI-MTM (referred to as BMI-MTM herein). BMI-MTM consists of a pharmacist-led medication counseling/brief motivational session and 8-weekly patient navigation sessions. Assessments were at baseline, 2-, and 3-months. Primary outcomes included feasibility, acceptability, and mitigation of opioid medication misuse. Secondary outcomes included pain and depression. Outcomes were analyzed with descriptive and multivariable statistics (intent-to-treat [ITT] and adjusted for number of sessions completed [NUMSESS]). RESULTS: Thirty-two participants provided informed consent (74.4% consent rate; SMC n = 17, BMI-MTM n = 15; 3-month assessment retention ≥93%). Feasibility was demonstrated by all BMI-MTM recipients completing the pharmacist session and an average of 7 navigation sessions. BMI-MTM recipients indicated ≥4.2 (5 maximum) level of satisfaction with the pharmacist-led session, and 92.4% were satisfied with navigation sessions. Compared to SMC at 3-months, BMI-MTM recipients reported greater improvements in misuse (ITT: Adjusted Odds Ratio [AOR] = 0.13; 95% CI = 0.05, 0.35, p < 0.001. NUMSESS: AOR = 0.05; 95% CI = 0.01, 0.25; p < 0.001), pain (ITT: В = 8.8, 95% CI=-0.95, 18.5, p = 0.08; NUMSESS: В = 14.0, 95% CI = 3.28, 24.8, p = 0.01), and depression (ITT: B= -0.44; 95% CI=-0.65, -0.22; p < 0.001. NUMSESS: B= -0.64; 95% CI=-0.82, -0.46; p < 0.001). CONCLUSIONS: BMI-MTM is a feasible misuse intervention associated with superior satisfaction and outcomes than SMC. Future research should test BMI-MTM in a large-scale, fully-powered trial.

Psychosocial interventions for chronic pain and comorbid prescription opioid use disorders: A narrative review of the literature.

OBJECTIVE: Opioid misuse in the context of chronic noncancer pain (CNCP) is a multifaceted and complex issue. As opioid misuse and corresponding rates of addiction and overdose deaths exceed epidemic proportions, there is an urgent need for research in this area. The objective of this review is to evaluate the literature addressing psychosocial interventions targeting CNCP and prescription opioid misuse. DESIGN: A systematic search of PubMed, MEDLINE, PsychINFO, ClinicalTrials.gov was conducted to identify studies evaluating psychosocial interventions targeting CNCP and prescription opioid misuse. The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: 56 peer-reviewed research articles from 1993 to July, 2016, which included studies of psychosocial interventions for CNCP and opioid use disorders. Studies that examined psychosocial interventions for CNCP, treatment modalities included: cognitive behavioral therapy (CBT), acceptance and commitment therapy, mindfulness-based cognitive therapy and mindfulness-based stress reduction, and chronic pain self-management programs. The psychosocial interventions for opioid misuse included: CBT and relapse prevention, motivational enhancement therapy and stages of change, contingency management, and self-help and peer support-based groups. CONCLUSIONS: The findings of this review offer clinical insight and reinforce the importance of psychosocial interventions in CNCP and opioid use disorders. However, little empirical data are available to guide practitioners in treating patients with CNCP who misuse opioid medications, and thus future research on integrated approaches, is needed.

A community pharmacy intervention for opioid medication misuse: A pilot randomized clinical trial.

OBJECTIVES: Community pharmacy continues to play a crucial role in the national response to the opioid epidemic. The purpose of this article is to describe the protocol for a pilot study that is examining the feasibility and acceptability of the Motivational Intervention-Medication Therapy Management (MI-MTM) model. This study also examines the preliminary clinical effect of MI-MTM for improving opioid medication misuse and patient activation in self-management of health conditions that increase risk for misuse. DESIGN: MI-MTM is a pharmacy-based integrated care model made up of 4 evidence-based practices: medication therapy management; brief motivational intervention; patient navigation; and naloxone training and referral. To test MI-MTM compared with Standard Medication Counseling (SMC), we are conducting a 2-group randomized single-blinded controlled trial with assessments at 3 time points. SETTING AND PARTICIPANTS: The study is being conducted within a western Pennsylvania university-based community pharmacy with 46 patients with opioid misuse (MI-MTM = 23; SMC = 23). MAIN OUTCOME MEASURES: Feasibility will be measured by capturing patient completion rate of MI-MTM sessions. Acceptability will be measured by administering satisfaction surveys regarding pharmacist and patient navigator services. Acceptability will also be captured by conducting intensive qualitative interviews. Preliminary effect of the intervention on misuse will be measured with the use of the Prescription Opioid Misuse Index and the Opioid Compliance Checklist. Activation in self-management will be measured with the use of the Patient Activation Measure. RESULTS: This project is currently recruiting, and results are to come. CONCLUSION: This study is the first in the United States to implement an evidence-based integrated behavioral intervention into the community pharmacy setting to address opioid medication misuse among pharmacy patients. The results of this study will provide necessary foundational data that allow further testing of this intervention model in a larger trial.

Psychosocial predictors in the transition from acute to chronic pain: a systematic review.

Chronic non-cancer pain (CNCP) is a major health problem which psychosocial factors have significant implications in. There is a gap in regards to evidence for the prevention of chronicity specifically addressing psychological and social domains. Four databases were searched with terms related to "psychosocial", "acute pain", and "chronic pain". A total of 1,389 studies were identified in which titles, abstracts, and full texts were assessed for inclusion criteria. A data template was used to capture pertinent details, and overall themes and patterns were organized according to type of pain examined and psychosocial variables measured. Of the 18 articles that met inclusion criteria, fifteen (83%) of the articles reported an association between psychosocial factors and chronicity. A total of 5 of the studies (29%) demonstrated that depression was a possible predictor and 6 (35%) of the studies found fear-avoidance to be associated with chronicity. This review provides evidence that psychosocial factors are associated with chronicity within CNCP. These results suggest a need for targeting psychosocial predictors in prevention and early intervention through clinical guidelines and a national strategy to support a cultural change in pain care.

Optimizing Pregnancy Treatment Interventions for Moms (OPTI-Mom): A Pilot Study.

OBJECTIVES: The public health burden of opioid use disorder (OUD) among pregnant women has significantly increased in recent years. The Optimizing Pregnancy Treatment Interventions for Moms study was a pilot project that examined the feasibility of a patient navigation (PN) intervention model to reduce substance use and improve mental health, quality of life, and to increase engagement with treatment services among pregnant women with OUD. METHODS: A 1-group repeated-measures pilot study was conducted with treatment-seeking pregnant women with opioid dependence initiating buprenorphine maintenance treatment. Participants received the PN intervention delivered as 10 sessions before delivery and 4 sessions postpartum. Participants completed assessments at baseline and after the prenatal and postnatal portions of the intervention. Demographics were assessed using descriptive statistics, and general estimating equation analyses were employed to examine changes in health and service engagement across time. RESULTS: in all, 21 women were enrolled and completed the PN intervention and follow-up assessments. Participants reported improvements in abstinence from illicit opioids (B = 0.15, 95% confidence interval [CI] 0.1-0.2), drug use (odds ratio [OR] 5.25, 95% CI 2.1-13.0), and depression (OR 7.70, 95% CI 2.4-25.1). Results also showed nonsignificant trends suggesting enhancements in general health (B = 0.17, 95% CI 0.0-0.3, P = 0.06) and increases in substance use treatment attendance (B = 2.15, 95% CI -0.2 to 4.5, P = 0.07). Most study participants achieved adequate or better prenatal care. CONCLUSIONS: These findings provide support that PN is a feasible adjunctive intervention that shows promise for health improvements and service engagement among treatment-seeking pregnant women with opioid dependence initiating buprenorphine.

Psychosocial and environmental factors in the prognosis of individuals with chronic pain and comorbid mental health.

Chronic pain has considerable medical, social, and economic implications as its high prevalence rate and negative societal burden provides justification that it is a major health issue. The value of understanding psychological, social, and environmental factors in chronic pain has become widely recognized and accepted as a biopsychosocial phenomenon in which the social work perspective offers a valuable lens. Through the critical application of systems theory and ecological perspective, accompanied with the diathesis stress model, this article examines psychosocial and environmental influences as being contributory factors in the prognosis of individuals with chronic pain and comorbid mental health disorders. The social work profession will also be explored as playing a definite role in addressing elements pertaining to pain management depicted from these theories. Lastly, implications for research, policy, and practice will be reviewed to better understand the association between psychosocial and environmental influences of individuals with chronic pain and comorbid mental health issues.

Prescription Opioid Misuse Among Rural Community Pharmacy Patients: Pilot Study for Screening and Implications for Future Practice and Research.

BACKGROUND: Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids. OBJECTIVE: Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse. METHODS: We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse. RESULTS: A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse. CONCLUSIONS: Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.