The journal of pain : official journal of the American Pain Society
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Prior studies have demonstrated poor physician adherence to opioid management guidelines in primary care. The objectives of this qualitative study were to understand physicians' and patients' perspectives on recommended opioid management practices and to identify potential barriers to and facilitators of guideline-concordant opioid management in primary care. Individual semistructured interviews were conducted with 14 primary care physicians and 26 of their patients receiving long-term opioid therapy. Data were analyzed using a qualitative immersion/crystallization approach. We identified 3 major barriers to and 1 facilitator of use of recommended opioid management practices. Major barriers were inadequate time and resources available; relying on general impressions of risk for opioid misuse; and viewing opioid monitoring as a "law enforcement" activity. The third barrier was most apparent for physicians in the context of drug testing and for patients in the context of opioid agreements. Beliefs about the need to protect patients from opioid-related harm emerged as a major facilitator, especially among patients. We hypothesize that future interventions to improve opioid management in primary care will be more effective if they address identified barriers and use a patient-centered framework, in which prevention of opioid-related harm to patients is emphasized as the primary goal. ⋯ This article describes primary care perspectives on guideline-recommended opioid management practices. Barriers identified in this study may contribute to underuse of recommended opioid management practices. Consideration of barriers and facilitators to guideline-concordant care could improve effectiveness of future interventions aimed at improving opioid management in primary care.
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Current fear-avoidance models consider pain-related fear as a crucial factor in the development of chronic pain. However, pain-related fear often occurs in a context of multiple, competing goals. This study investigated whether pain-related fear and avoidance behavior are attenuated when individuals are faced with a pain avoidance goal and another valued but competing goal, operationalized as obtaining a monetary reward. Fifty-five healthy participants moved a joystick toward different targets. In the experimental condition, a movement to one target (conditioned stimulus [CS+]) was followed by a painful unconditioned stimulus (pain-US) and a rewarding unconditioned stimulus (reward-US) on 50% of the trials, whereas the other movement (nonreinforced conditioned stimulus [CS-]) movement was not. In the control condition, the CS+ movement was followed by the pain-US only. Results showed that pain-related fear was elevated in response to the CS+ compared to the CS- movement, but that it was not influenced by the reward-US. Interestingly, participants initiated a CS+ movement slower than a CS- movement in the control condition but not in the experimental condition. Also, in choice trials, participants performed the CS+ movement more frequently in the experimental than in the control condition. These results suggest that the presence of a valued competing goal can attenuate avoidance behavior. ⋯ The current study provides experimental evidence that both pain and competing goals impact on behavioral decision making and avoidance behavior. These results provide experimental support for treatments of chronic pain that include an individual's pursuit of valuable daily life goals, rather than limiting focus to pain reduction only.
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An experimental approach to examining psychological contributions to multisite musculoskeletal pain.
The present study examined the prospective value of pain catastrophizing, fear of pain, and depression in the prediction of multisite musculoskeletal pain following experimentally induced delayed-onset muscle soreness (DOMS). The study sample consisted of 119 (63 females, 56 males) healthy university students. Measures of pain catastrophizing, fear of pain, and depression were completed prior to the DOMS induction procedure. Analyses revealed that pain catastrophizing and fear of pain prospectively predicted the experience of multisite pain following DOMS induction. Analyses also revealed that women were more likely to experience multisite pain than men. There was no significant relation between depressive symptoms and the experience of multisite pain. The discussion addresses the mechanisms by which pain catastrophizing and fear of pain might contribute to the spreading of pain. Clinical implications of the findings are also addressed. ⋯ The results of this experimental study suggest that pain catastrophizing and fear of pain might increase the risk of developing multisite pain following musculoskeletal injury.
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Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which human immunodeficiency virus (HIV)-infected and uninfected patients initiating long-term (≥ 90 days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n = 6,604) were more likely than uninfected patients to receive a primary care provider visit within 1 month (52.0% vs 30.9%) and 6 months (90.7% vs 73.7%) and urine drug tests within 1 month (14.8% vs 11.5%) and 6 months (19.5% vs 15.4%; all P < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs 19.6%) and a current substance use disorder (21.6% vs 17.2%). Among both patient groups, only modest changes in guideline concordance were observed over time: urine drug tests and OT concurrent with current substance use disorders increased, whereas sedative coprescriptions decreased (all Ps for trend < .001). Over a 10-year period, on average, patients received no more than 40% of recommended care. OT guideline-concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time. ⋯ The promulgation of OT clinical guidelines has not resulted in substantive changes over time in OT management, which falls well short of the standard recommended by leading medical societies. Strategies are needed to increase the provision of OT guideline-concordant care for all patients.
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There is emerging evidence that chronic musculoskeletal pain is associated with anatomic and functional abnormalities in gray matter. However, little research has investigated the relationship between chronic musculoskeletal pain and white matter. In this study, we used whole-brain tract-based spatial statistics and region-of-interest analyses of diffusion tensor imaging data to demonstrate that patients with chronic musculoskeletal pain exhibit several abnormal metrics of white matter integrity compared with healthy controls. Chronic musculoskeletal pain was associated with lower fractional anisotropy in the splenium of the corpus callosum and the left cingulum adjacent to the hippocampus. Patients also had higher radial diffusivity in the splenium, right anterior and posterior limbs of the internal capsule, external capsule, superior longitudinal fasciculus, and cerebral peduncle. Patterns of axial diffusivity (AD) varied: patients exhibited lower AD in the left cingulum adjacent to the hippocampus and higher AD in the anterior limbs of the internal capsule and in the right cerebral peduncle. Several correlations between diffusion metrics and clinical variables were also significant at a P < .01 level: fractional anisotropy in the left uncinate fasciculus correlated positively with total pain experience and typical levels of pain severity. AD in the left anterior limb of the internal capsule and left uncinate fasciculus was correlated with total pain experience and typical pain level. Positive correlations were also found between AD in the right uncinate and both total pain experience and pain catastrophizing. These results demonstrate that white matter abnormalities play a role in chronic musculoskeletal pain as a cause, a predisposing factor, a consequence, or a compensatory adaptation. ⋯ Patients with chronic musculoskeletal pain exhibit altered metrics of diffusion in the brain's white matter compared with healthy volunteers, and some of these differences are directly related to symptom severity.