Attitudes and Beliefs of Working and Work-Disabled People with Chronic Pain Prescribed Long-Term Opioids.

OBJECTIVE: This study was designed to gain insight into the apparent contradiction between the perspectives of researchers and policy makers, who have questioned the efficacy and safety of chronic opioid therapy for non-cancer pain patients, and the patients themselves, who often indicate that the therapy has value. SUBJECTS: A convenience sample of 54 patients on chronic opioid therapy was studied. METHODS: Participants completed a questionnaire specifically designed for the study, and also several standard instruments that addressed functional interference, emotional functioning, and possible misuse of opioids. Their treating physicians rated the participants on the severity of their disability and the success of their opioid therapy. RESULTS: Although participants reported significant ongoing pain, they gave positive global ratings to their opioid therapy, and reported little concern about addiction or side effects of opioids. They strongly endorsed the beliefs that opioids helped them control their pain and allowed them to participate in important activities such as work. They expressed the belief that their pain would be severe if they did not have access to opioids, and reported negative experiences with tapering or discontinuing opioids in the past. Work-disabled participants reported higher levels of affective distress, catastrophizing, and functional interference than working participants, and were judged by their physicians to be relatively less successful in managing their pain. CONCLUSION: The results of this study suggest several tentative hypotheses about why patients on chronic opioid therapy value opioids, and identified several areas for systematic investigation in the future.

Clinical and evoked pain, personality traits, and emotional states: can familial confounding explain the associations?

OBJECTIVES: Pain is a complex phenomenon influenced by context and person-specific factors. Affective dimensions of pain involve both enduring personality traits and fleeting emotional states. We examined how personality traits and emotional states are linked with clinical and evoked pain in a twin sample. METHODS: 99 female twin pairs were evaluated for clinical and evoked pain using the McGill Pain Questionnaire (MPQ) and dolorimetry, and completed the 120-item International Personality Item Pool (IPIP), the Positive and Negative Affect Scale (PANAS), and ratings of stress and mood. Using a co-twin control design we examined a) the relationship of personality traits and emotional states with clinical and evoked pain and b) whether genetics and common environment (i.e. familial factors) may account for the associations. RESULTS: Neuroticism was associated with the sensory component of the MPQ; this relationship was not confounded by familial factors. None of the emotional state measures was associated with the MPQ. PANAS negative affect was associated with lower evoked pressure pain threshold and tolerance; these associations were confounded by familial factors. There were no associations between IPIP traits and evoked pain. CONCLUSIONS: A relationship exists between neuroticism and clinical pain that is not confounded by familial factors. There is no similar relationship between negative emotional states and clinical pain. In contrast, the relationship between negative emotional states and evoked pain is strong while the relationship with enduring personality traits is weak. The relationship between negative emotional states and evoked pain appears to be non-causal and due to familial factors.

Measuring respiratory symptoms of COPD: performance of the EXACT- Respiratory Symptoms Tool (E-RS) in three clinical trials.

BACKGROUND: Symptomatic relief is an important treatment goal for patients with COPD. To date, no diary for evaluating respiratory symptoms in clinical trials has been developed and scientifically-validated according to FDA and EMA guidelines. The EXACT - Respiratory Symptoms (E-RS) scale is a patient-reported outcome (PRO) measure designed to address this need. The E-RS utilizes 11 respiratory symptom items from the existing and validated 14-item EXACT, which measures symptoms of exacerbation. The E-RS total score quantifies respiratory symptom severity, and 3 domains assess breathlessness, cough and sputum, and chest symptoms. METHODS: This study examined the performance of the E-RS in each of 3 controlled trials with common and unique validation variables: one 6-month (N = 235, US) and two 3-month (N = 749; N = 597; international). Subjects completed the E-RS as part of a daily eDiary. Tests of reliability, validity, and responsiveness were conducted in each dataset. RESULTS: In each study, RS-Total score was internally consistent (Cronbach α) (0.88, 0.92, 0.92) and reproducible (intra-class correlation) in stable patients (2 days apart: 0.91; 7 days apart: 0.71, 0.74). RS-Total scores correlated significantly with the following criterion variables (Spearman's rho; p < 0.01, all comparisons listed here): FEV1% predicted (-0.19, -0.14, -0.15); St. George's Respiratory Questionnaire (SGRQ) (0.65, 0.52, 0.51); Breathlessness, Cough, and Sputum Scale (BCSS) (0.89, 0.89); modified Medical Research Council dyspnoea scale (mMRC) (0.40); rescue medication use (0.43, 0.42); Functional Performance Inventory Short-Form (FPI-SF) (0.43); 6-minute walk distance (6-MWT) (-0.30, -0.14) and incremental shuttle walk (ISWT) (-0.18) tests. Correlations between these variables and RS-Breathlessness, RS-Cough and Sputum, RS-Chest Symptoms scores supported subscale validity. RS-Total, RS-Breathlessness, and RS-Chest Symptoms differentiated mMRC levels of breathlessness severity (p < 0.0001). RS-Total and domain scores differentiated subjects with no rescue medication use and 3 or more puffs (p < 0.0001). Sensitivity to changes in health status (SGRQ), symptoms (BCSS), and exercise capacity (6MWT, ISWT) were also shown and responder definitions using criterion- and distribution-based methods are proposed. CONCLUSIONS: Results suggest the E-RS is a reliable, valid, and responsive measure of respiratory symptoms of COPD suitable for use in natural history studies and clinical trials. TRIAL REGISTRATION: MPEX: NCT00739648 ; AZ1: NCT00949975 ; AZ 2: NCT01023516.

Association of American Indian cultural identity with physical activity.

OBJECTIVE: Cultural factors are associated with health behaviors among American Indians. Accordingly, the objective of our study was to investigate whether cultural identity, defined as the primary language spoken at home, is associated with: 1) higher total physical activity levels, and 2) levels of leisure-time physical activity recommended for health benefits in a diverse sample of American Indians. DESIGN: Cross-sectional analysis of 5,207 American Indian adults 18 to 82 years. Participants resided on the Oglala Sioux (n=2,025) and Cheyenne River Sioux (n=1,528) reservations in South Dakota, and the Gila River Indian Community (n=1,654) in Arizona. RESULTS: Bicultural participants in South Dakota, but not Arizona, reported significantly higher total physical activity compared to the English-only group (P<.05). About 35% of English only speakers, 39% of American Indian/Alaska Native only speakers, and 39% of participants speaking both languages met the 150 minutes/week activity threshold. Odds of being sufficiently active were higher among bicultural respondents in both regions when compared to respondents endorsing only English, controlling for sociodemographic and health-related covariates (P<.05). CONCLUSION: Bicultural respondents among tribal members in South Dakota had significantly higher total physical activity, and higher levels of sufficient leisure-time activity in both South Dakota and Arizona, compared to those who spoke either language exclusively. Interventions that encourage American Indians to develop their bicultural efficacy and to draw on resources for healthy living that may be available in all the cultures with which they identify are recommended.

Physicians' beliefs and likelihood of prescribing opioid tamper-resistant formulations for chronic noncancer pain patients.

BACKGROUND: Tamper-resistant opioid formulations (TRFs) have recently been the target of active development in an effort to deter opioid misuse and abuse. OBJECTIVE: To understand factors that are predictive of physicians' likelihoods of prescribing TRFs to patients with chronic noncancer pain (CNCP). DESIGN: A cross-sectional survey was conducted, utilizing a questionnaire of clinicians' attitudes and opinions about opioids for CNCP (Clinicians' Attitudes about Opioids Scale) to explore beliefs about and likelihood of prescribing TRFs. SUBJECTS: A nationally representative sample of 1,535 practicing physicians throughout the United States. METHODS: A stepwise hierarchical multiple linear regression analysis was conducted to estimate if physician characteristics, opinions, or geographic region categorized according to state rates of mortality by drug overdose and milligrams of opioids prescribed by state were predictive of the likelihood of prescribing TRFs. RESULTS: Board certification in Pain Medicine and prescribing opioids to a higher volume of CNCP patients were significantly predictive of a reported likelihood of prescribing TRFs, in addition to concerns about possible misuse and abuse of opioids, beliefs in the effectiveness of opioids for CNCP, and greater satisfaction with education and training in pain management this set of factors accounted for 21% of the model variance. Rates of mortality by drug overdose and opioid prescription volume by location were not predictive of TRF usage. CONCLUSIONS: Reducing physician concerns about potential misuse and abuse of opioids through additional education in pain management and dissemination of information about the potential benefits and availability of TRFs should influence physicians' attitudes about and the adoption of TRFs.

Association of chronic widespread pain with objectively measured physical activity in adults: findings from the National Health and Nutrition Examination survey.

UNLABELLED: Chronic widespread pain (CWP) is a common and potentially debilitating disorder. Patterns of physical activity (PA) in adults with CWP have primarily been investigated using subjective, self-report measures. The current study sought to characterize PA among community-dwelling individuals with CWP, chronic regional pain, or no chronic pain using objective measurements obtained via accelerometry in the 2003 to 2004 National Health and Nutrition Examination Survey. Data from 3,952 participants ages 20 and older were analyzed to assess relationships between pain status and objective measurements of PA. Prevalence of CWP was 3.3% and 5.4% in men and women, respectively. In men and women, the average activity counts per minute and time spent in moderate-to-vigorous PA were significantly lower for the CWP group than for the no chronic pain group. Interestingly, time spent in sedentary, light, and lifestyle activities was not associated with pain status. Statistical interaction tests indicated that the effects of chronic pain on counts per minute were stronger in men than in women. Despite recommendations for increased moderate-to-vigorous PA as a pain management strategy for CWP, results from this nationally representative study indicate that adults with CWP participate in less moderate-to-vigorous PA than individuals without chronic pain. PERSPECTIVE: Using objective measurement of PA in a nationally representative sample, this study demonstrates that adults with CWP participate in reduced daily and moderate-to-vigorous PA in comparison to people with no chronic pain. Findings indicate that clinicians should emphasize the importance of increasing PA in patients with CWP.

Salivary cortisol and cold pain sensitivity in female twins.

BACKGROUND: There is a dearth of knowledge about the link between cortisol and pain sensitivity. PURPOSE: We examined the association of salivary cortisol with indices of cold pain sensitivity in 198 female twins and explored the role of familial confounding. METHODS: Three-day saliva samples were collected for cortisol levels and a cold pressor test was used to collect pain ratings and time to threshold and tolerance. Linear regression modeling with generalized estimating equations examined the overall and within-pair associations. RESULTS: Lower diurnal variation of cortisol was associated with higher pain ratings at threshold (p = 0.02) and tolerance (p < 0.01). The relationship of diurnal variation with pain ratings at threshold and tolerance was minimally influenced by familial factors (i.e., genetics and common environment). CONCLUSIONS: Understanding the genetic and non-genetic mechanisms underlying the link between HPA axis dysregulation and pain sensitivity may help to prevent chronic pain development and maintenance.

Does caregiving cause psychological distress? The case for familial and genetic vulnerabilities in female twins.

BACKGROUND: Informal caregiving can be deleterious to mental health, but research results are inconsistent and may reflect an interaction between caregiving and vulnerability to stress. METHODS: We examined psychological distress among 1,228 female caregiving and non-caregiving twins. By examining monozygotic and dizygotic twin pairs discordant for caregiving, we assessed the extent to which distress is directly related to caregiving or confounded by common genes and environmental exposures. RESULTS: Caregiving was associated with distress as measured by mental health functioning, anxiety, perceived stress, and depression. The overall association between caregiving and distress was confounded by common genes and environment for mental health functioning, anxiety, and depression. Common environment also confounded the association of caregiving and perceived stress. CONCLUSIONS: Vulnerability to distress is a factor in predicting caregivers' psychosocial functioning. Additional research is needed to explicate the mechanisms by which common genes and environment increase the risk of distress among informal caregivers.

Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study.

This study sought to determine the prevalence and impact of pain in a nationally representative sample of older adults in the United States. Data from the 2011 National Health and Aging Trends Study were analyzed. In-person interviews were conducted in 7601 adults ages ≥65 years. The response rate was 71.0% and all analyses were weighted to account for the sampling design. The overall prevalence of bothersome pain in the last month was 52.9%, afflicting 18.7 million older adults in the United States. Pain did not vary across age groups (P = 0.21), and this pattern remained unchanged when accounting for cognitive performance, dementia, proxy responses, and residential care living status. Pain prevalence was higher in women and in older adults with obesity, musculoskeletal conditions, and depressive symptoms (P < 0.001). The majority (74.9%) of older adults with pain endorsed multiple sites of pain. Several measures of physical capacity, including grip strength and lower-extremity physical performance, were associated with pain and multisite pain. For example, self-reported inability to walk 3 blocks was 72% higher in participants with than without pain (adjusted prevalence ratio 1.72 [95% confidence interval 1.56-1.90]). Participants with 1, 2, 3, and ≥4 sites of pain had gait speeds that were 0.01, 0.03, 0.05, and 0.08 meters per second slower, respectively, than older adults without pain, adjusting for disease burden and other potential confounders (P < 0.001). In summary, bothersome pain in the last month was reported by half of the older adult population of the United States in 2011 and was strongly associated with decreased physical function.

Pain among older Hispanics in the United States: is acculturation associated with pain?

BACKGROUND: Previous studies suggest that acculturation may influence the experience of pain. STUDY DESIGN: We conducted a cross-sectional study to estimate the association between acculturation and the prevalence, intensity, and functional limitations of pain in older Hispanic adults in the United States. METHODS SUBJECTS: Participants were English- (HE) and Spanish-speaking (HS) Hispanic and non-Hispanic White (NHW) individuals aged 50 years and older who were interviewed for the Health and Retirement Study during 1998-2008. MEASURES: We measured: 1) acculturation as defined by language used in interviews, and 2) the presence, intensity, and functional limitations of pain. ANALYSIS: We applied logistic regression using generalized estimating equations, with NHW as the reference category. RESULTS: Among 18,593 participants (16,733 NHW, 824 HE, and 1,036 HS), HS had the highest prevalence (odds ratio [OR] = 1.3; 95% confidence interval [CI = 1.1-1.4) and intensity (OR = 1.6; 95% CI = 1.4-1.9) of pain, but these differences were not significant after adjusting for age, sex, years of education, immigration status (U.S.- vs non-U.S-born), and health status (number of health conditions). Even after adjustment, HS reported the lowest levels of functional limitation (OR = 0.7; 95% CI 0.6-0.9). CONCLUSION: Pain prevalence and intensity were not related to acculturation after adjusting for sociodemographic factors, while functional limitation was significantly lower among HS even after adjusting for known risk factors. Future studies should explore the reasons for this difference.

Can familial factors account for the association of body mass index with poor mental health in men or women?

OBJECTIVE: This study examined if associations between body mass index (BMI) and mental and physical health were independent of genetic and familial factors. METHOD: Data from 2831 twins (66% female) were used in an epidemiological co-twin control design with measures of BMI and mental and physical health outcomes. Generalized estimating equation regressions assessed relationships between BMI and health outcomes controlling for interdependency among twins and demographics. Within-pair regression analyses examined the association of BMI with health outcomes controlling for genetic and familial influences. RESULTS: Adjusted analyses with individual twins found associations in women between BMI and perceived stress (P=.01) and depression (P=.002), and the link between BMI and depression (P=.03) was significant in men. All physical health outcomes were significantly related to BMI. Once genetic and familial factors were taken into account, mental health outcomes were no longer significantly associated with BMI. BMI in women remained related to ratings of physical health (P=.01) and body pain (P=.004), independent of genetic and familial influences. CONCLUSION: These findings suggest that genetic and familial factors may account for the relationship between increased weight and poor mental health.

Clinicians' attitudes and beliefs about opioids survey (CAOS): instrument development and results of a national physician survey.

UNLABELLED: Beliefs surrounding the use of opioids for chronic noncancer pain have vacillated over time. Concerns regarding long-term efficacy and adverse effects of opioids, along with increases in opioid prescribing, have contributed to many political, regulatory, and clinical responses. The present study was designed to (1) develop a reliable and valid measure (Clinicians' Attitudes about Opioids Scale [CAOS]) to assess current and evolving beliefs regarding opioids and opioid use in patients with chronic pain; and (2) survey these beliefs in a nationally representative sample of providers from multiple medical specialties throughout the United States. We developed the questionnaire in 3 phases: (1) focus groups and content development; (2) pilot testing and subsequent revisions; and (3) formal survey (N = 1,535) and assessment of stability (N = 251). The resulting 38-item measure assessed 5 domains: (1) Impediments and Concerns; (2) Perceived Effectiveness; (3) Schedule II versus III Opioids; (4) Medical Education; and (5) Tamper Resistant Formulations. No significant differences were identified among geographical regions; however, several differences were observed among medical specialties. Orthopedists were most troubled by impediments/concerns from long-term opioid use and had the least confidence in opioid efficacy, whereas Pain Medicine specialists and Physical Medicine and Rehabilitation specialists were the most confident in efficacy. PERSPECTIVE: This article presents the psychometric properties of a new measure of clinicians' beliefs surrounding opioid use for chronic pain. Using this measure, beliefs and behaviors of physicians across medical specialties and geographic regions using a nationally representative sample are presented, updating findings from a similar survey conducted 20 years ago.

The role of fear of movement in subacute whiplash-associated disorders grades I and II.

Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I-II injuries approximately 3months previously (n=191) completed questionnaires (eg, Neck Disability Index [NDI]) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB+didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB+imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2-hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET=14.7, DD=11.9, IB=9.9). ETs reported significantly less posttreatment pain severity compared with the IB (Mean=1.5 vs 2.3, P<.001, d=0.6) and DD (M=1.5 vs 2.0, P=.039, d=0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (ß=0.30, P<.001), followed by reductions in pain (ß=0.20, P=.003) and depression (ß=0.18, P=.004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.

Redesigning delivery of opioids to optimize pain management, improve outcomes, and contain costs.

INTRODUCTION: Chronic pain is a public health concern, and in the last decade, there has been a dramatic increase in the use and abuse of prescription opioids for chronic non-cancer pain. METHODS: We present an overview of a five-component model of pain management implemented at the University of Washington Division of Pain Medicine designed to facilitate recent state guidelines to reduce the risks associated with long-term use of prescription opioids. RESULTS: Central to the model described are guidelines for best clinical practice, a collaborative care approach, telehealth solutions, comprehensive prescription-monitoring, and measurement-based care. DISCUSSION: The model presented is a patient-centered, efficient, and cost-effective approach to the management of chronic pain.

Chronic fatigue and personality: a twin study of causal pathways and shared liabilities.

BACKGROUND: The etiology of chronic fatigue syndrome (CFS) remains unknown. Personality traits influence well-being and may play a role in CFS and unexplained chronic fatigue. PURPOSE: This study aimed to examine the association of emotional instability and extraversion with chronic fatigue and CFS in a genetically informative sample. METHODS: We evaluated 245 twin pairs for two definitions of chronic fatigue. They completed the Neuroticism and Extraversion subscales of the NEO Five Factor Inventory. Using a co-twin control design, we examined the association between personality and chronic fatigue. RESULTS: Higher emotional instability was associated with both definitions of chronic fatigue and was confounded by shared genetics. Lower extraversion was also associated with both definitions of fatigue, but was not confounded by familial factors. CONCLUSIONS: Both emotional instability and extraversion are related to chronic fatigue and CFS. Whereas emotional instability and chronic fatigue are linked by shared genetic mechanisms, the relationship with extraversion may be causal and bidirectional.

Impact of chronic musculoskeletal pain on objectively measured daily physical activity: a review of current findings.

SUMMARY Chronic pain affects a wide range of outcomes that are typically assessed using self-reported methodologies, which are susceptible to recall biases, current mood and pain intensity. Physical activity (PA) is an important component of the pain experience that can be objectively assessed with accelerometers, which are small, lightweight devices that measure the duration, frequency and intensity of PA over time. Accelerometry provides opportunities to compare actual and perceived PA, to design individually customized treatments, to monitor treatment progress, and to evaluate treatment efficacy. Thus, this technology can provide a more refined understanding of the relationships among symptoms, perceptions, mood, environmental circumstances and PA. The current paper examines patterns of PA in chronic musculoskeletal pain conditions and identifies potential clinical applications for accelerometry.

Genetic and environmental influences on residential location in the US.

We used a classical twin design and measures of neighborhood walkability and social deprivation, using each twin's street address, to examine genetic and environmental influences on the residential location of 1389 same-sex pairs from a US community-based twin registry. Within-pair correlations and structural equation models estimated these influences on walkability among younger (ages 18-24.9) and older (ages 25+) twins. Adjusting for social deprivation, walkability of residential location was primarily influenced by common environment with lesser contributions of unique environment and genetic factors among younger twins, while unique environment most strongly influenced walkability, with small genetic and common environment effects, among older twins. Thus, minimal variance in walkability was explained by shared genetic effects in younger and older twins, and confirms the importance of environmental factors in walkability of residential locations.

The comorbidity of self-reported chronic fatigue syndrome, post-traumatic stress disorder, and traumatic symptoms.

BACKGROUND: Data from primary care and community samples suggest higher rates of post-traumatic stress disorder (PTSD) among individuals with chronic fatigue syndrome (CFS). OBJECTIVE: This study investigated the co-occurrence of CFS, PTSD, and trauma symptoms and assessed the contribution of familial factors to the association of CFS with lifetime PTSD and current traumatic symptoms. METHOD: Data on lifetime CFS and PTSD, as measured by self-report of a doctor's diagnosis of the disorder, and standardized questionnaire data on traumatic symptoms, using the Impact of Events Scale (IES), were obtained from 8544 female and male twins from the community-based University of Washington Twin Registry. RESULTS: Lifetime prevalence of CFS was 2% and lifetime prevalence of PTSD was 4%. Participants who reported a history of PTSD were over eight times more likely to report a history of CFS. Participants with scores ≥ 26 on the IES were over four times more likely to report CFS than those who had scores ≤ 25. These associations were attenuated but remained significant after adjusting for familial factors through within-twin pair analyses. CONCLUSION: These results support similar findings that a lifetime diagnosis of CFS is strongly associated with both lifetime PTSD and current traumatic symptoms, although familial factors, such as shared genetic and environmental contributions, played a limited role in the relationship between CFS, PTSD, and traumatic symptoms. These findings suggest that future research should investigate both the familial and the unique environmental factors that may give rise to both CFS and PTSD.

Conditions comorbid with chronic fatigue in a population-based sample.

BACKGROUND: Chronic fatigue syndrome (CFS) has been found to be comorbid with various medical conditions in clinical samples, but little research has investigated CFS comorbidity in population-based samples. OBJECTIVE: This study investigated conditions concurrent with a CFS-like illness among twins in the population-based Mid-Atlantic Twin Registry (MATR), including chronic widespread pain (CWP), irritable bowel syndrome (IBS), and major depressive disorder (MDD). METHOD: A survey was mailed to participants in the MATR in 1999. Generalized estimating equations were used to estimate odds ratios to assess associations between CFS-like illness and each comorbid condition. RESULTS: A total of 4590 completed surveys were collected. Most participants were female (86.3%); mean age was 44.7 years. Among participants with a CFS-like illness, lifetime prevalences of CWP, IBS, and MDD were 41%, 16%, and 57% respectively. Participants reporting at least one of the three comorbid conditions were about 14 times more likely to have CFS-like illness than those without CWP, IBS, or MDD (95% confidence interval 8.1%-21.3%). Only MDD showed a temporal pattern of presentation during the same year as diagnosis of CFS-like illness. Age, gender, body mass index, age at illness onset, exercise level, self-reported health status, fatigue symptoms, and personality measures did not differ between those reporting CFS-like illness with and without comorbidity. CONCLUSION: These results support findings in clinically based samples that CFS-like illness is frequently cormorbid with CWP, IBS, and/or MDD. We found no evidence that CFS-like illnesses with comorbidities are clinically distinct from those without comorbidities.