Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

Course of recovery for whiplash associated disorders in a compensation setting.

CONTEXT: The detailed course of recovery following compensable whiplash associated disorders (WAD) is not well understood. Some people recover within months and others report symptoms for extended periods. Recent research identified distinct recovery pathways. Identifying recovery pathways for people with this condition in compensable settings could assist clinical and claim management. STUDY OBJECTIVE: This study aimed to identify recovery trajectories based on disability, pain catastrophising and mental health and, secondly, to examine developmental linkages between the trajectories. STUDY DESIGN: A cohort of 246 people with compensable WAD were followed for 24 months after a motor vehicle related injury. OUTCOME MEASURES: Functional Rating Index (FRI), Pain Catastrophising Scale (PCS) and the SF36 Mental Component Score (SF 36 MCS). METHOD: Group-based trajectory analytical techniques were used to identify distinct post-injury profiles. Multinominal logistic regression modelling identified factors associated with membership of different trajectories. RESULTS: 246 people were enrolled a median of 72 days after injury. Three trajectories were identified for the measures used and their prevalences, respectively, were: for disability (FRI) they were mild (47%), moderate (31%), and severe (22%); for pain catastrophising (PCS) they were non-catastrophisers (55%), moderate-low catastrophisers (32%) and clinically significant catastrophisers (13%); and, for mental health (SF36 MCS) they were good mental health (40%), moderately low mental health (42%) and severely low mental health (18%). All groups showed no further recovery beyond 12 months after injury. The significant baseline predictors of the severe disability trajectory were: lower (that means worse) bodily pain scores (SF 36 BPS) (p≤0.01); high pain catastrophising (p≤0.01); and, self-reported fair or poor general health (p=0.03). Conditional probabilities for group membership showed that the three trajectories for both PCS and FRI were linked. Dual membership was high for the mild disability and mild pain catastrophising trajectories and, for the severe disability and clinically significant pain catastrophising trajectories. CONCLUSIONS: There is a strong and plausible association between severe disability, clinical levels of pain catastrophising and low mental health. Claimants can be identified at claim notification based on three estimated recovery trajectories. Claim and clinical interventions can be targeted to the profile within each recovery trajectory.

Catastrophic expenditure to pay for surgery worldwide: a modelling study.

BACKGROUND: Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery. METHODS: To estimate the global incidence of catastrophic expenditure due to surgery, we built a stochastic model. The income distribution of each country, the probability of requiring surgery, and the medical and non-medical costs faced for surgery were incorporated. Sensitivity analyses were run to test the robustness of the model. FINDINGS: 3·7 billion people (posterior credible interval 3·2-4·2 billion) risk catastrophic expenditure if they need surgery. Each year, 81·3 million people (80·8-81·7 million) worldwide are driven to financial catastrophe-32·8 million (32·4-33·1 million) from the costs of surgery alone and 48·5 million (47·7-49·3) from associated non-medical costs. The burden of catastrophic expenditure is highest in countries of low and middle income; within any country, it falls on the poor. Estimates were sensitive to the definition of catastrophic expenditure and the costs of care. The inequitable burden distribution was robust to model assumptions. INTERPRETATION: Half the global population is at risk of financial catastrophe from surgery. Each year, surgical conditions cause 81 million individuals to face catastrophic expenditure, of which less than half is attributable to medical costs. These findings highlight the need for financial risk protection for surgery in health-system design. FUNDING: MGS received partial funding from NIH/NCI R25CA92203.

A randomized controlled trial of an Internet-based cognitive-behavioural intervention for non-specific chronic pain: an effectiveness and cost-effectiveness study.

BACKGROUND: Cognitive-behavioural treatment can nowadays be delivered through the Internet. This form of treatment can have various advantages with regard to availability and accessibility. Previous studies showed that Internet-based treatment for chronic pain is effective compared to waiting-list control groups. METHODS: We conducted a randomized controlled trial comparing an Internet-based cognitive-behavioural intervention with e-mail therapist contact to a face-to-face cognitive-behavioural group intervention. Of the 72 participants who were randomly assigned to an Internet or a group course, 50 participants completed the intervention. Participants were assessed at baseline (T0), immediately after the 7-week course (T1) and at the booster session 2 months later (T2). Pain-related catastrophizing was the primary outcome measure. Pain intensity, fatigue, pain-related interference, locus of control, pain coping, global health-related quality of life and medical expenses were secondary outcome variables. RESULTS: Significant improvement was found on catastrophizing, pain coping, locus of control and aspects of global health-related quality of life in both the Internet and the group courses directly after the course and at the booster session. Pain intensity was improved in both courses at the booster session. At T2, improvement in catastrophizing, pain intensity, pain coping and some quality of life dimensions was significantly greater in completers of the Internet course than in the group course. Furthermore, the Internet course was cost-effective compared to the group course. CONCLUSIONS: We conclude that the Internet-based cognitive-behavioural intervention was at least as effective as the face-to-face group intervention and, on some outcome measures appeared to be even more effective.

Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers' compensation claimants.

The fear avoidance model of pain (FAM) conceptualizes pain catastrophizing as the cognitive antecedent of pain-related fear, and pain-related fear as the emotional antecedent of depression and disability. The FAM is essentially one of mediation whereby pain-related fear becomes the process by which depression or disability ensue. However, emerging literature suggests that pain catastrophizing, pain-related fear, and depression might be at least partially distinct in their prediction of different pain-related outcomes. The primary purpose of the present study was to evaluate whether psychological factors in the FAM (pain catastrophizing, pain-related fear, and depression) differentially predict long-term pain-related outcomes. Toward this objective, we conducted a prospective study using a cohort of 202 individuals with subacute work-related musculoskeletal injuries. Participants completed a 7-week physical therapy program with a functional rehabilitation orientation. Posttreatment measures of fear of movement, pain catastrophizing, depression, and pain self-efficacy were used to predict the persistence of pain symptoms, healthcare use, medication use, and return-to-work at one-year follow-up. Results from hierarchical linear and logistic regression analyses revealed that pain catastrophizing and fear of movement act as differential predictors of long-term pain-related outcomes. Specifically, we found unique relationships between pain catastrophizing and long-term pain intensity, and fear of movement and long-term work disability. After controlling for pain intensity and FAM variables, pain self-efficacy was shown to be a unique predictor of medication use. Implications for the FAM and the clinical management of musculoskeletal pain conditions are discussed. Unique relationships were found between pain catastrophizing and long-term pain intensity, between fear of movement and long-term work disability, and between pain self-efficacy and medication use at one-year follow-up.