The journal of pain : official journal of the American Pain Society
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Dose reduction and risk mitigation initiatives have been recommended to reduce opioid-related risks among patients receiving chronic opioid therapy (COT), but questions remain over whether these initiatives worsen pain control and quality of life. In 2014 to 2015, we interviewed 1,588 adult COT patients within a health care system in Washington State and compared those who received dose reduction and risk mitigation initiatives in primary care clinics (intervention) with patients in comparable health care settings without initiatives (control). ⋯ Estimated differences, adjusted for patient characteristics and weighted for nonresponse, between patients at intervention and control clinics were not clinically significant for the PEG (-.03, 95% confidence interval = -.25 to .19) or Patient Health Questionnaire-8 (-.64, 95% confidence interval = -1.19 to -.08). We found no evidence that COT patients in clinics with dose reduction and risk mitigation initiatives had clinically meaningful differences in pain intensity, interference with activities and enjoyment of life, or depressive symptoms compared with control health care settings.
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Associations between depression/anxiety and pain are well established, but its directionality is not clear. We examined the associations between temporally previous mental disorders and subsequent self-reported chronic back/neck pain onset, and investigated the variation in the strength of associations according to timing of events during the life course, and according to gender. Data were from population-based household surveys conducted in 19 countries (N = 52,095). Lifetime prevalence and age of onset of 16 mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the occurrence and age of onset of back/neck pain were assessed using the Composite International Diagnostic Interview. Survival analyses estimated the associations between first onset of mental disorders and subsequent back/neck pain onset. All mental disorders were positively associated with back/neck pain in bivariate analyses; most (12 of 16) remained so after adjusting for psychiatric comorbidity, with a clear dose-response relationship between number of mental disorders and subsequent pain. Early-onset disorders were stronger predictors of pain; when adjusting for psychiatric comorbidity, this remained the case for depression/dysthymia. No gender differences were observed. In conclusion, individuals with mental disorder, beyond depression and anxiety, are at higher risk of developing subsequent back/neck pain, stressing the importance of early detection of mental disorders, and highlight the need of assessing back/neck pain in mental health clinical settings. ⋯ Previous mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition are positively associated with subsequent back/neck pain onset, with a clear dose-response relationship between number of mental disorders and subsequent pain. Earlier-onset mental disorders are stronger predictors of subsequent pain onset, compared with later-onset disorders.
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The experience of unpredictable pain fluctuations can trigger anticipatory pain-related fear. When discrete predictors for pain are lacking, fear typically accrues to the broader environmental context: a phenomenon referred to as contextual pain-related fear. We examined whether conceptual similarity between discrete contexts facilitates pain-related fear generalization; this mechanism is known as category-level fear generalization. ⋯ We measured self-reported pain-related fear, expectancy, and eyeblink startle. Results indicated higher pain-related fear reports, but no elevated startle responses, for generalization contexts that were trained to be similar to the original unpredictable context rather than the predictable pain context. This highlights a potential pathway through which neutral contexts can elicit pain-related fear and motivate avoidance behavior associated with chronic pain disability.
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Women have a higher prevalence of chronic noncancer pain conditions and report more severe pain, yet, it is not known if the association between long-term opioid analgesic use (OAU) and risk of a new depression episode (NDE) differs according to gender. We analyzed patient data from the Veterans Health Administration (VHA; 2000-2012; n = 70,997) and a large private-sector health care organization (2003-2012; n = 22,981) to determine whether long-term OAU and risk of NDE differed according to gender. Patients were free of depression and OAU for 2 years before baseline. ⋯ In private sector patients, there was no gender difference in the association between more than 90-day OAU and NDE (female HR = 1.97 [95% CI, 1.64-2.37] vs male HR = 1.99 [95% CI, 1.44-2.74]). Risk of NDE after long-term OAU is similar in men and women in private sector patients but may differ for VHA patients. Future prospective studies are needed to identify mechanisms for the association between longer OAU and NDE.
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Providers are being asked to decrease the emphasis and overutilization of long-term opioid therapy, but many are left without proper guidance on appropriate utilization of nonopioid therapies. Furthermore, therapeutic options are quite limited and many providers lack confidence in distinguishing available alternatives. When first-line therapy has failed in a patient, there is an apparent lack of knowledge on how to proceed with choosing subsequent therapy. ⋯ Sodium channel blocker doses used in certain pain syndromes are outlined with a call for further research to better understand their place in chronic pain management. Identification of sodium channel subtypes with links to specific pain conditions and the ability to target them hints at the potential for truly individualized therapy. Sodium channel inhibitors are underutilized on the basis of available evidence, and emerging research has identified this area as promising for additional clinical trials to better guide clinical practice.