Pain Intensity, Pain-Related Anxiety, and Hazardous Drinking Among Individuals With PTSD.

OBJECTIVE: Evidence suggests that pain intensity may be indirectly linked to hazardous drinking and PTSD symptom severity via pain-related anxiety. The goal of this analysis was to test the hypotheses in a population with PTSD symptoms that pain intensity would be positively and indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via pain-related anxiety. METHODS: Heavy drinkers with probable PTSD were recruited via Qualtrics panels (N = 371, 53% Female, Mage = 39.68, SD = 10.86). Linear regression and conditional process models were conducted to examine indirect associations between pain intensity and primary outcomes via pain-related anxiety. RESULTS: Pain intensity was found to be indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via greater pain-related anxiety. CONCLUSION: These initial findings suggest that pain-related anxiety may play an important role in relations between the experience of pain and hazardous patterns of alcohol consumption among individuals with probable PTSD. Future research is needed to determine the temporal nature of these associations and to examine the potential utility of treatments that address pain-related anxiety in the context of comorbid pain, PTSD, and hazardous drinking.

Initial validation of the expectancies for Benzodiazepine Analgesia Scale.

Chronic pain populations exhibit greater prevalence of benzodiazepine (BZD) prescription (vs. the general population) and greater likelihood of BZD use not as prescribed and dependence symptoms. Individuals report taking BZDs for pain relief, potentially contributing to maintenance/escalation of BZD use and hazardous couse with prescription opioids. Identifying cognitive factors underlying pain-BZD use relations represents a critical step toward understanding the role of pain in BZD use trajectories. Outcome expectancies for substance-related analgesia have been implicated in pain-substance use comorbidity (e.g., alcohol), and there is reason to believe these processes may extend to BZD use. The present study aimed to examine psychometric properties of a newly adapted Expectancies for Benzodiazepine Analgesia (EBA) scale and probe associations between EBA scores and prescription opioid use behaviors. Participants were 306 adults (38.9% females) endorsing chronic pain and current BZD prescription who completed an online survey. Results provided initial support for psychometric validity of the EBA: evidence of single-factor structure with good model fit (Bollen-Stine bootstrap p = .101), excellent internal consistency (α = .93), and evidence of concurrent validity via correlations with pain variables, likelihood of BZD use not as prescribed, BZD dependence symptoms, and self-reported BZD use for pain relief. Exploratory findings among participants prescribed opioids indicated positive covariation between EBA scores and behaviors associated with higher risk opioid use. This is, to our knowledge, the first study to assess analgesia expectancies for BZD use. BZD analgesic expectancies warrant further study as a treatment target in comorbid pain and BZD use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cannabinoid Therapy: Attitudes and Experiences of People With Chronic Pain.

OBJECTIVE: Clinical trials of cannabinoids for chronic pain have mixed and often inconclusive results. In contrast, many prospective observational studies show the analgesic effects of cannabinoids. This survey study aimed to examine the experiences/attitudes of individuals with chronic pain who are currently taking, have previously taken, or never taken cannabinoids for chronic pain to inform future research. METHODS: This study is based on a cross-sectional, web-based survey of individuals with self-reported chronic pain. Participants were invited to participate through an email that was distributed to the listservs of patient advocacy groups and foundations that engage individuals with chronic pain. RESULTS: Of the 969 respondents, 444 (46%) respondents reported currently taking, 213 (22%) previously taken, and 312 (32%) never taken cannabinoids for pain. Participants reported using cannabinoids to treat a wide variety of chronic pain conditions. Those currently taking cannabinoids (vs previously) more frequently reported: (1) large improvements from cannabinoids in all pain types, including particularly difficult-to-treat chronic overlapping pain conditions (eg, pelvic pain), (2) improvements in comorbid symptoms (eg, sleep), and (3) lower interference from side effects. Those currently taking cannabinoids reported more frequent and satisfactory communication with clinicians regarding cannabinoid use. Those never taken cannabinoids reported a lack of suggestion/approval of a clinician (40%), illegality (25%), and lack of FDA regulation (19%) as reasons for never trying cannabinoids. CONCLUSION: These findings underscore the importance of conducting high-quality clinical trials that include diverse pain populations and clinically relevant outcomes that if successful, could support FDA approval of cannabinoid products. Clinicians could then prescribe and monitor these treatments similarly to other chronic pain medications.

Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing.

Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts. PERSPECTIVE: This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.

Initial Validation of the Intentions to Co-Use Alcohol and Opioids Scale.

Co-use of alcohol and prescription opioid medication increases risk for harmful and potentially fatal health effects (e.g., overdose). Behavioral intentions (i.e., the immediate antecedent of corresponding behavior according to the Theory of Planned Behavior) are important in prediction of substance use, and a valid measure assessing intentions to co-use alcohol and opioids is needed to identify individuals at-risk for harmful substance use. The goal of the current study was to develop and conduct the psychometric validation of a six-item Intentions to Co-Use Alcohol and Opioids (ICAO) scale. Participants included 261 (Mage = 38; 64% male) past-month drinkers with a current opioid prescription and chronic musculoskeletal pain who completed a targeted online survey. Confirmatory factor analysis indicated that a single-factor structure provided good model fit (Bollen-Stine bootstrap p = .121). Moreover, the ICAO demonstrated high internal consistency (α = .96) and was correlated with measures of alcohol and opioid use/co-use. These findings provide support for the single-factor structure, reliability, and concurrent/convergent validity of the ICAO among individuals who endorse alcohol use, opioid use, and chronic musculoskeletal pain. The ICAO may offer clinical utility as a tool to identify individuals at greater risk of potentially fatal co-use of alcohol and opioid medications.

Patient Perspectives Surrounding Intraarticular Injections for Knee Osteoarthritis: A Qualitative Study.

OBJECTIVE: Intraarticular (IA) injections are used frequently for knee osteoarthritis (OA), but little is known about patients' attitudes toward these therapies. We aimed to better understand patients' perceptions of the facilitators of and barriers to IA injections for knee OA. METHODS: We conducted a qualitative, descriptive, exploratory study and held focus groups and individual interviews with participants with knee OA, including some who had and some who had not received IA injections. We conducted a thematic analysis to identify themes describing the factors that participants found influential when deciding whether to try an IA injection. RESULTS: We held 3 focus groups with 12 participants and conducted 3 individual interviews (15 participants total). We identified the following 4 themes that shaped participants' decisions to receive a specific injection: 1) the impact of OA on participants' lives; 2) participants' attitudes and concerns, including desire to avoid surgery, willingness to accept uncertain outcomes, and concerns about side effects and dependence; 3) the way participants gathered and processed information from physicians, peers, and the internet; and 4) the availability of injectable products. Participants weighed the desire to regain function and delay surgery with concerns about side effects, uncertain efficacy, and costs. CONCLUSION: Participants were concerned about the effectiveness, toxicity, availability, and cost of injectable products. They balanced disparate sources of information, uncertain outcomes, limited product availability, and other injection-related concerns with a desire to decrease pain. These findings can provide clinicians, investigators, and public health professionals with insights into challenges that patients face when making injection decisions.

Tobacco cigarette smokers who endorse greater intolerance for nicotine withdrawal also report more severe insomnia symptoms.

It has been suggested that nighttime nicotine withdrawal may help to explain why tobacco cigarette smokers are more likely than nonsmokers to experience clinically significant insomnia. There is also reason to believe that intolerance for withdrawal symptoms could play a role in withdrawal-related sleep disturbance. However, we are not aware of any previous research that examined whether smokers who endorse greater intolerance for smoking abstinence also report greater difficulty initiating and/or maintaining sleep. To address this question, 224 adult cigarette smokers (42.9% female, Mcigarettes per day = 21.3) completed the baseline portion of an experimental study that included assessment of current/historical smoking behavior, perceived intolerance for smoking abstinence, and insomnia severity and impact on functioning. The results indicated that, after accounting for general distress intolerance and sociodemographic factors, smokers who endorsed greater intolerance for nicotine withdrawal also reported greater insomnia severity and impact. Logistic regression further revealed that, for every 1-point increase in nicotine withdrawal intolerance scores, smokers were nearly twice as likely to score above threshold for clinically significant insomnia (p = .001). Collectively, these initial findings suggest that intolerance for nicotine withdrawal may warrant consideration as a potentially modifiable mechanistic factor in comorbid insomnia and nicotine/tobacco dependence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Anxiety sensitivity, pain severity and co-use of cigarettes and e-cigarettes among adults with chronic pain.

Anxiety sensitivity (fear of potential negative consequences of anxiety-related symptoms/sensations) has been identified as a transdiagnostic factor in comorbid pain and nicotine dependence and evidence suggests that anxiety sensitivity may be indirectly associated with nicotine use via greater pain severity. Therefore, this study tested the hypothesis that anxiety sensitivity is associated with cigarette and e-cigarette use/co-use directly and indirectly via greater pain severity. Participants included 273 online survey respondents with chronic musculoskeletal pain (34% female; Mage = 32.9). Anxiety sensitivity was positively associated with cigarette smoking, e-cigarette use and cigarette/e-cigarette co-use (ps < .05). Furthermore, anxiety sensitivity was indirectly and positively associated with cigarette smoking, e-cigarette use and co-use via greater chronic pain severity. Pain severity may play an important role in associations between anxiety sensitivity and nicotine dependence and prospective research should examine temporal/causal effects of anxiety sensitivity in relation to pain severity and nicotine/tobacco use.

Perceived Success in Upper-Extremity Vascularized Composite Allotransplantation: A Qualitative Study.

PURPOSE: We performed a qualitative study to understand psychosocial factors associated with perceived success of upper-extremity vascularized composite allotransplantation (VCA). We interviewed transplant recipients and their primary caregivers. METHODS: We recruited 4 upper-extremity VCA recipients and primary caregivers for 3 of them. We conducted semistructured face-to-face interviews using a guide that explored participants' transplantation experiences. Topics included comparison of pretransplant and posttransplant expectations, reflections on factors contributing to the success of the transplant experience, and posttransplant rehabilitation and functioning. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS: Participants described several factors as contributing to the success of the transplant experience, including developing realistic expectations about posttransplant function and lifelong immunosuppression, support from one's community and particularly the primary caregiver, and framing the experience in a positive light. Social, aesthetic, and other values unique to the hands, as opposed to prosthetics, motivated recipients to undergo VCA despite its inherent risk and uncertainties. CONCLUSIONS: Despite inherent challenges, undergoing VCA was viewed as worthwhile to regain benefits unique to hands. Participants met the challenges of the transplant process through setting realistic expectations, strong social support, and a positive perspective. CLINICAL RELEVANCE: Findings from this work may help clinicians and prospective patients to prepare for and set appropriate expectations of VCA.

Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study.

BACKGROUND: In the treatment of spinal metastases the risks of surgery must be balanced against potential benefits, particularly in light of limited life-expectancy. Patient experiences and preferences regarding decision-making in this context are not well explored. PURPOSE: We performed a qualitative study involving patients receiving treatment for spinal metastatic disease. We sought to understand factors that influenced decision-making around care for spinal metastases. STUDY SETTING: Three tertiary academic medical centers. PATIENT SAMPLE: We recruited patients presenting for treatment of spinal metastatic disease at one of three tertiary centers in Boston, MA. OUTCOME MEASURES: We conducted semistructured interviews using a guide that probed participants' experiences with making treatment decisions. METHODS: We performed a thematic analysis that produced a list of themes, subthemes, and statement explaining how the themes related to the study's guiding questions. Patients were recruited until thematic saturation was reached. RESULTS: We interviewed 23 participants before reaching thematic saturation. The enormity of treatment decisions, and of the diagnosis of spinal metastases itself, shaped participant preferences for who should take responsibility for the decision and whether to accept treatments bearing greater risk of complications. Pre-existing participant beliefs about decision-making and about surgery interacted with the clinical context in a way that tended to promote accepting physician recommendations and delaying or avoiding surgery. CONCLUSIONS: The diagnosis of spinal metastatic disease played an outsized role in shaping participant preferences for agency in treatment decision-making. Further research should address strategies to support patient understanding of treatment options in clinical contexts-such as spinal metastases-characterized by ominous underlying disease and high-risk, often urgent interventions.

Psychometric properties of the Neuropathic Pain Scale (NPS) in a knee osteoarthritis population.

Objective: Symptoms resembling neuropathic pain (neuropathic-like symptoms) are prevalent in osteoarthritis (OA) populations. Scales that measure neuropathic-like symptoms frequently were established in groups with true neuropathic pain conditions and have not been assessed in OA. We assessed the psychometric properties of the Neuropathic Pain Scale (NPS) in subjects with OA undergoing total knee replacement (TKR). Design: In a prospective study of adults undergoing TKR for OA, we assessed baseline distributions, acceptability (completion rate), internal consistency (Cronbach's alpha), responsiveness 12 months post-TKR, and construct validity of the NPS. We performed factor analysis and created subscales from the items loading onto each retained factor. We evaluated subscale properties and calculated the proportion of total scores attributable to each subscale and compared this with the proportion expected if each item contributed equally. Results: Mean baseline NPS score among 263 participants was 42.7 (SD: 15.9). Cronbach's alpha was 0.88. Factor analysis produced two factors: "bothersome" (items: intense/sharp/dull/unpleasant/deep; Cronbach's alpha = 0.87), and "dysesthetic" (items: cold/sensitive/itchy/surface; alpha = 0.77). Bothersome items contributed more to total NPS scores (74%) than would be expected if each item contributed equally (50%). NPS scores correlated moderately with baseline pain and function, and decreased after TKR, with standardized response means (SRMs) of: total NPS: 1.77, Bothersome subscale: 2.03, Dysesthetic subscale: 0.70. Conclusions: The NPS had acceptable completion, internal consistency, and construct validity, but was not optimal for use in OA; Bothersome subscale items disproportionately drive total NPS scores and may fail to discriminate between nociceptive and neuropathic-like symptoms.

Stability of Measures of Pain Catastrophizing and Widespread Pain Following Total Knee Replacement.

OBJECTIVE: Pain catastrophizing and widespread pain are predictors of pain chronicity/severity. Gaps remain in our understanding of the extent to which each is a stable (trait) or dynamic (state) variable. We undertook this study to assess the stability of each variable from before to after total knee replacement (TKR) and whether changes are explained by pain improvements. METHODS: We used data from a prospective study of TKR recipients ages ≥40 years. Questionnaires included body pain diagrams assessing widespread pain, the Pain Catastrophizing Scale (PCS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. We divided subjects into widespread pain groups (0 versus 1-2 versus ≥3 pain regions) and into low and high PCS score groups (<16 versus ≥16). We assessed changes in group membership from pre-TKR to 12 months post-TKR, then compared these changes between subjects with most and least WOMAC pain improvement. RESULTS: A total of 176 subjects completed scales at both time points; 64% were female, the mean age was 66 years, and baseline median WOMAC pain score was 40. In all, 71% of subjects in the high PCS score group improved to join the low PCS score group at follow-up. While 73 subjects (41%) changed widespread pain group, they were similarly likely to worsen and to improve. We found a statistically significant positive association of improvement in WOMAC pain score with improvement in PCS score (r = 0.31), but not widespread pain (r = -0.004). CONCLUSION: The PCS score reflects state-like aspects of catastrophizing that diminish along with pain. In contrast, widespread pain scores worsened and improved equally often, regardless of knee pain relief. The findings urge caution in interpreting PCS score and widespread pain as trait measures in musculoskeletal research.

Body-Self Unity With a New Hip or Knee: Understanding Total Joint Replacement Within an Embodiment Framework.

Medical research increasingly makes use of embodiment concepts to understand how illness disrupts unity of body and self. However, few have applied embodiment concepts in total joint replacement (TJR), an effective treatment for end-stage arthritis. In considering why a troubling proportion of TJR recipients have continued pain and functional limitation, we ask: what role might be played by the embodied experience of living with an implant? Relevant theoretical models and prior research on embodiment in musculoskeletal health and transplantation are reviewed. Our findings suggest a research agenda with implications for addressing suboptimal outcomes in TJR.

Strategies for Managing the Costs of Chronic Illness in the Context of Limited Financial Resources: A Qualitative Study in Dominican Persons With Arthritis.

OBJECTIVE: Persons who reside in low- and middle-income countries often have insufficient resources to pay for treatments prescribed for their medical conditions. The aim of this study was to determine, using qualitative methods, how patients with arthritis in the Dominican Republic manage the costs associated with chronic illnesses. METHODS: We conducted individual interviews with 17 Dominican adults with advanced arthritis who were undergoing total knee replacement or total hip replacement at a hospital in Santo Domingo, Dominican Republic. Interviewers followed a moderator's guide with questions pertaining to the financial demands of arthritis treatment and the strategies participants used to pay for treatments. Interviews were audio recorded, transcribed verbatim, and translated into English. We used thematic analysis to identify salient themes. RESULTS: The thematic analysis suggested that health system factors (such as the extent of reimbursement for medications available in the public health care system) along with personal factors (such as disposable income) shaped individuals' experiences of managing chronic illness. These systemic and personal factors contributed to a sizeable gap between the cost of care and the amount most participants were able to pay. Participants managed this resource gap using a spectrum of strategies ranging from acceptance (or, "making do with less") to resourcefulness (or, "finding more"). Participants were aided by strong community bonds and religiously oriented resilience. CONCLUSION: This qualitative study illuminates the range of strategies Dominican individuals with limited resources use to obtain health care and manage chronic illness. The findings raise hypotheses that warrant further study and could help guide provider-patient conversations regarding treatment adherence.

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial.

BACKGROUND: Meniscal tears often accompany knee osteoarthritis, a disabling condition affecting 14 million individuals in the United States. While several randomized controlled trials have compared physical therapy to surgery for individuals with knee pain, meniscal tear, and osteoarthritic changes (determined via radiographs or magnetic resonance imaging), no trial has evaluated the efficacy of physical therapy alone in these subjects. METHODS: The Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial is a four-arm multi-center randomized controlled clinical trial designed to establish the comparative efficacy of two in-clinic physical therapy interventions (one focused on strengthening and one containing placebo) and two protocolized home exercise programs. DISCUSSION: The goal of this paper is to present the rationale behind TeMPO and describe the study design and implementation strategies, focusing on methodologic and clinical challenges. TRIAL REGISTRATION: The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 . on February 14, 2017.

Participant-Reported Benefits of Involvement in an Adaptive Sports Program: A Qualitative Study.

BACKGROUND: Although participation in adaptive sports offers numerous benefits for persons with disabilities, a substantial number of eligible persons do not take part. Previous studies have identified personal and environmental factors that promote or inhibit adaptive sports participation. However, these studies have considered a relatively narrow range of factors. OBJECTIVE: To use qualitative research techniques to identify novel factors that influence participation in a community-based adaptive sports program. DESIGN: Qualitative focus group study. SETTING: Community-based adaptive sports programs affiliated with a rehabilitation hospital network. PARTICIPANTS: Participants were recruited from among 134 adults who registered for the sports program in 2013-2014. Participants with mobility or sensory impairment, absence of cognitive impairment, and English proficiency were included. The 90 former participants with adequate contact information were contacted, and 17 participated in the focus groups. METHODS: Two moderators led each of 3 audio-recorded focus groups using a moderator's guide. We conducted a thematic analysis of transcript data to identify perceived benefits, barriers, and facilitators of participation. RESULTS: Our analysis identified 5 themes: physical well-being and health/safety; interpersonal and social relationships; intrapersonal and beliefs/attitudes; physical environment; and access. Participants experienced participation both as physically beneficial and as transformative in terms of how they view themselves. However, programs drew on limited personal resources and sometimes presented a perceived risk of injury. Finding information about and transportation to programs was a challenge. Participants formed an informal community that modeled what athletes with disabilities are capable of, helping to overcome initial doubts. CONCLUSIONS: To gain the benefits of participation, athletes overcame significant barriers, several of which may be modifiable, including transportation and difficult-to-find information about program offerings. The importance of community and raising awareness of athletes' own abilities suggests a key role for mentorship. Our study contributes to the understanding of experiential aspects that motivate participation in adaptive sports. LEVEL OF EVIDENCE: IV.

Effect of Obesity on Pain and Functional Recovery Following Total Knee Arthroplasty.

BACKGROUND: While obesity may be a risk factor for complications following total knee arthroplasty, data remain sparse on the impact of the degree of obesity on patient-reported outcomes following this procedure. Our objective was to determine the extent to which obesity level affects the trajectory of recovery as well as patient-reported pain, function, and satisfaction with surgery following total knee arthroplasty. METHODS: We followed a cohort of patients who underwent total knee arthroplasty at 1 of 4 medical centers. Patients were ≥40 years of age with a primary diagnosis of osteoarthritis. We stratified patients into 5 groups according to the World Health Organization classification of body mass index (BMI). We assessed the association between BMI group and pain and function over the time intervals of 0 to 3, 3 to 6, and 6 to 24 months using a piecewise linear model. We also assessed the association between BMI group and patient-reported outcomes at 24 months. Multivariable models adjusted for age, sex, race, diabetes, musculoskeletal functional limitations index, pain medication use, and study site. RESULTS: Of the 633 participants included in our analysis, 19% were normal weight (BMI of <25 kg/m), 32% were overweight (BMI of 25 to 29.9 kg/m), 27% were class-I obese (BMI of 30 to 34.9 kg/m), 12% were class-II obese (BMI of 35 to 39.9 kg/m), and 9% were class-III obese (BMI of ≥40 kg/m). Study participants with a higher BMI had worse preoperative WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain and function scores and had greater improvement from baseline to 3 months. The mean change in pain and function from 3 to 6 and from 6 to 24 months was similar across all BMI groups. At 24 months, participants in all BMI groups had similar levels of pain, function, and satisfaction. CONCLUSIONS: Because of the differential trajectory of recovery in the first 3 months following total knee arthroplasty, the participants in the higher BMI groups were able to attain absolute pain and function scores similar to those in the nonobese and class-I obese groups. These data can help surgeons discuss expectations of pain relief and functional improvement with total knee arthroplasty candidates with higher BMI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.