Chronic Noncancer Pain Conditions Research Articles

Navigating opioid use in chronic noncancer pain conditions: A case series on pseudoaddiction.

Opioid prescriptions for chronic non-cancer pain raise concerns of addiction risks. Understanding the nuanced intersection of chronic pain and opioid use is crucial in clinical settings. We present four case studies from two tertiary care hospitals illustrating the phenomenon of "pseudoaddiction" in CNCP referred to addiction specialists for management. Each case involves complex pain presentations like pancreatitis, avascular necrosis, and SLE intertwined with escalating opioid demands. Management involved psychoeducation, CBT, and opioid substitution, resulting in reduced pain and need for opioids. Differentiating between addiction and uncontrolled pain is crucial for tailored management, emphasizing individualized care for improved outcomes.

Nabilone for Chronic Non-Cancer Pain

What Is the Issue? Chronic pain is pain that lasts beyond 3 months. Chronic non-cancer pain conditions include osteoarthritis, low back pain, musculoskeletal pain, fibromyalgia, and neuropathic pain. Approximately 1 in 5 people in Canada live with chronic pain. Nabilone (a cannabinoid) is indicated for the management of severe nausea and vomiting associated with cancer chemotherapy. Nabilone is also used in the management of chronic non-cancer pain. It is important to understand the potential benefits and harms of nabilone in people living with chronic non-cancer pain to support decision-making. What Did We Do? We sought to identify, summarize, and critically appraise literature comparing the clinical effectiveness of nabilone and placebo or alternative pharmacological options. We also searched for evidence-based guidelines that provide recommendations about the use of nabilone for the treatment of chronic non-cancer pain. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2015. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings. What Did We Find? We found 1 overview of reviews and 2 systematic reviews that assessed the clinical efficacy and safety of nabilone for the treatment of chronic non-cancer pain. The evidence on the clinical efficacy of nabilone was mixed with some studies reporting an improvement in pain in those treated with nabilone versus placebo or active comparators and other studies reporting no difference between groups. Adverse events were more common in people living with chronic non-cancer pain who received nabilone than those who received placebo, ibuprofen, or amitriptyline. Adverse events were more common in those who received dihydrocodeine or gabapentin than nabilone. It is uncertain if nabilone is an effective treatment for people living with chronic non-cancer pain due to the varied results and methodological limitations of the included studies. We found 1 guideline that included a recommendation specific to nabilone and 2 guidelines that included recommendations on the use of cannabinoids in general. One guideline recommends against the use of nabilone for chronic pain, 1 guideline recommends offering a trial of non-inhaled cannabinoids (such as nabilone) for people living with chronic pain, and 1 guideline suggests cannabinoids be avoided in people with osteoarthritis and low back pain and discussed with people with neuropathic pain. What Does This Mean? Due to the uncertainty of the clinical evidence, decision-makers may wish to consider other factors such as costs, equity, and patient values and preferences when making decisions on the use of nabilone for people living with chronic non-cancer pain. Future high-quality, longer-term (e.g., RCT with follow-up studies) studies are needed to understand the efficacy and safety of nabilone for the treatment of people living with chronic non-cancer pain.

Understanding the lived experience of chronic pain: A systematic review and synthesis of qualitative evidence syntheses.

Although multiple measures of the causes and consequences of chronic non-cancer pain (CNCP) are available and can inform pain management, no quantitative summary of these measures can describe the meaning of pain for a patient. The lived experience of pain tends to be a blind spot in pain management. This study aimed to: (1) integrate qualitative research investigating the lived experience of a range of CNCP conditions; (2) establish common qualitative themes in CNCP experience; and (3) evaluate the relevance of our results through a survey questionnaire based on these themes, administered across the United Kingdom. Four bibliographic databases were searched from inception to February 2021 to identify Qualitative Evidence Syntheses (QES) that investigated the lived experience of CNCP and its impact on everyday life and activities. Themes and trends were derived by thematic qualitative analysis in collaboration with two patient and public involvement representatives who co-created twenty survey statements. The survey was developed for testing the QES themes for validity in people living with pain. The research team identified and screened 1323 titles, and considered 86 abstracts, including 20 in the final review. Eight themes were developed from the study findings: (1) my pain gives rise to negative emotions; (2) changes to my life and to myself; (3) adapting to my new normal; (4) effects of my pain management strategies; (5) hiding and showing my pain; (6) medically explaining my pain; (7) relationships to those around me; and (8) working while in pain. Each theme gave rise to one or two survey questions. The survey was shared with members of the UK pain community over a 2-week period in November 2021, and was completed by 1219 people, largely confirming the above themes. This study provides a validated summary of the lived experience of CNCP. It highlights the adverse nature, complications, and consequences of living with CNCP in the UK and the multiple shortcomings in the ways in which pain is addressed by others in the UK. Our findings are consistent with published meta-ethnographies on chronic non-malignant musculoskeletal pain and chronic low-back pain. Despite the underrepresentation of qualitative research in the pain literature compared to quantitative approaches, for understanding the complexity of the lived experience of pain, qualitative research is an essential tool.

Coprescribing of opioids and psychotropic medications among Medicare-enrolled older adults on long-term opioid therapy

BackgroundPressures to reduce opioid prescribing have potential to incentivize coprescribing of opioids (at lower dose) with psychotropic medications. Evidence concerning the extent of the problem is lacking. This study assessed trends in coprescribing and characterized coprescribing patterns among Medicare-enrolled older adults with chronic noncancer pain (CNCP) receiving long-term opioid therapy (LTOT). MethodsA cohort study was conducted using 2012-2018 5% National Medicare claims data. Eligible beneficiaries were continuously enrolled and had no claims for cancer diagnoses or hospice use, and ≥ 2 claims with diagnoses for CNCP conditions within a 30-day period in the 12 months before the index date (LTOT initiation). Coprescribing was defined as an overlap between opioids and any class of psychotropic medication (antidepressants, benzodiazepines, antipsychotics, anticonvulsants, muscle relaxants, and nonbenzodiazepine hypnotics) based on their prescription fill dates and days of supply in a given year. The occurrence of coprescribing, coprescribing intensity, and number of days of overlap with psychotropic medications were calculated for each calendar year. ResultsThe eligible study population of individuals on LTOT ranged from 2038 in 2013 to 1751 in 2018. The occurrence of coprescribing among eligible beneficiaries decreased from 73.41% in 2013 to 70.81% in 2015 and then increased slightly to 71.22% in 2018. Among eligible beneficiaries with at least one overlap day, the coprescribing intensity with any class of psychotropic medications showed minimal variation throughout the study period: 74.73% in 2013 and 72.67% in 2018. Across all the years, the coprescribing intensity was found to be highest with antidepressants (2013, 49.90%; 2018, 50.33%) followed by benzodiazepines (2013, 25.42%; 2018, 19.95%). ConclusionCoprescribing was common among older adults with CNCP who initiated LTOT but did not rise substantially in the period studied. Future research should investigate drivers behind coprescribing and safety of various patterns of use.

Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals.

To give an overview of central aspects of pain medicine-specific clinical reasoning when assessing a pain patient. Clinical reasoning is the thinking and decision-making processes associated with clinical practice. Three core pain assessment areas that are crucial for clinical reasoning in the field of pain medicine are discussed, each of them consisting of three points. First, it is important to distinguish acute, chronic non-cancer, and cancer-related pain conditions. This classical and very simple trichotomy still has important implications treatment-wise, e.g., concerning the use of opioids. Second, the pain mechanism needs to be assessed. Is the pain nociceptive, neuropathic, or nociplastic? Simply put, nociceptive pain has to do with injury of non-neural tissue, neuropathic pain is caused by a disease or lesion of the somatosensory nervous system, and nociplastic pain is believed to be related to a sensitized nervous system (c.f. the concept of "central sensitization"). This also has implications concerning treatment. Some chronic pain conditions are nowadays viewed more as diseases rather than the pain being merely a symptom. In the new ICD-11 pain classification, this is conceptualized by the characterization of some chronic pains as "primary". Third, in addition to a conventional biomedical evaluation, psychosocial and behavioral aspects must also be assessed, the pain patient being viewed as an active agent and not merely as the passive recipient of an intervention. Hence, the importance of a dynamic bio-psycho-social perspective. The dynamic interplay of biological, psychological, and social aspects must be taken into account, putative behavioral "vicious circles" thereby being identified. Some core psycho-social concepts in pain medicine are mentioned. The clinical applicability and clinical reasoning power of the 3 × 3 framework is illustrated by three short (albeit fictional) case descriptions.

Analgesic utilization in people with knee osteoarthritis: A population-based study using primary care data.

Osteoarthritis (OA) is a chronic painful condition that often affects large joints such as the knee. Treatment guidelines recommend paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. Antidepressants and anti-epileptic drugs (AEDs) are commonly prescribed for chronic noncancer pain conditions including OA, as an off-label use. This study describes analgesic utilization in patients with knee OA at population level using standard pharmaco-epidemiological methods. This was a cross-sectional study between 2000 and 2014 using data from the U.K. Clinical Practice Research Datalink (CPRD). The use of antidepressants, AEDs, opioids, NSAIDs, and paracetamol was studied in adults with knee OA using the following measures: annual number of prescriptions, defined daily doses (DDD), oral morphine equivalent dose (OMEQ), and days' supply. In total, there were 8,944,381 prescriptions prescribed for 117,637 patients with knee OA during the 15-year period. There was a steady increase in the prescribing of all drug classes, except for NSAIDs, over the study period. Opioids were the most prevalent class prescribed in every study year. Tramadol was the most commonly prescribed opioid, with the number of DDD increasing from 0.11 to 0.71 DDDs per 1000 registrants in 2000 and 2014, respectively. The largest increase in prescribing was for AEDs, where the number of prescriptions increased from 2 to 11 per 1000 CPRD registrants. There was an overall increase in the prescribing of analgesics apart from NSAIDs. Opioids were the most frequently prescribed class; however, the greatest increase in prescribing between 2000 and 2014 was observed in AEDs.

A Linear Decomposition Approach to Explain Excess Direct Healthcare Expenditures Associated with Pain Among Adults with Osteoarthritis.

Many patients with osteoarthritis experience pain which can lead to higher healthcare expenditures. It is important to understand the factors that drive the excess expenditures associated with pain in osteoarthritis. Cross-sectional. Our study sample consisted of adults (age ⩾ 18 years) from the Medical Expenditure Panel Survey (MEPS, 2018). Adults who were alive during the calendar year and had pain status were included in this study (N = 2804 weighted N = 32.03 million). Osteoarthritis was identified from the medical conditions file and household file. We used multivariable ordinary least squares regression to identify the statistically significant association of pain with direct healthcare expenditures. The Blinder-Oaxaca post-linear decomposition on log-transformed total direct healthcare expenditures was used to estimate the extent to which differences in characteristics contribute to the excess expenditures associated with pain. Adults with osteoarthritis and pain had higher average expenditures ($21 814 vs $10 827, P < .001; 9.318 vs 8.538 in logtransformed expenditures) compared to those without pain. Pooled regression weights explained 62.9% of excess expenditures differences in characteristics between the 2 groups. The 2 main drivers of excess healthcare expenditures among adults with osteoarthritis and pain were (i) comorbidities (diabetes, asthma, chronic obstructive pulmonary disease, depression, heart diseases, cancer, and non-cancer pain conditions and (ii) prescription medications (NSAIDs, opioids, and polypharmacy). Need factors such as comorbid conditions, and prescription treatment explained the excess healthcare expenditures among adults with osteoarthritis and pain. The study findings suggest that reducing polypharmacy and appropriate management of comorbid conditions may be a pathway to reduce excess expenditures among adults with osteoarthritis and pain.

Economic Burden of Treatment-Resistant Depression among Adults with Chronic Non-Cancer Pain Conditions and Major Depressive Disorder in the US.

Major depressive disorder (MDD) and chronic non-cancer pain conditions (CNPC) often co-occur and exacerbate one another. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on direct total and MDD-related healthcare resource utilization (HRU) and costs among commercially insured patients with CNPC and MDD in the US. The retrospective longitudinal cohort study employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007 to June 2017). Costs (2018 US$) and HRU were compared between patients with and without TRD over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD. Of the 21,180 adults with CNPC and MDD, 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs (US$21,015TRD vs US$14,712No TRD) and MDD-related costs (US$1201TRD vs US$471No TRD) compared with non-TRD patients (all p< 0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had a significantly higher number of inpatient (incidence rate ratio [IRR] 1.30, 95% CI 1.14-1.47) and emergency room visits (IRR 1.21, 95% CI 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient-level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups. TRD poses a substantial direct economic burden for adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.

Using a machine learning approach to investigate factors associated with treatment-resistant depression among adults with chronic non-cancer pain conditions and major depressive disorder

Objective Presence of chronic non-cancer pain conditions (CNPC) among adults with major depressive disorder (MDD) may reduce benefits of antidepressant therapy, thereby increasing the possibility of treatment resistance. This study sought to investigate factors associated with treatment-resistant depression (TRD) among adults with MDD and CNPC using machine learning approaches. Methods This retrospective cohort study was conducted using a US claims database which included adults with newly diagnosed MDD and CNPC (January 2007–June 2017). TRD was identified using a clinical staging algorithm for claims data. Random forest (RF), a machine learning method, and logistic regression was used to identify factors associated with TRD. Initial model development included 42 known and/or probable factors that may be associated with TRD. The final refined model included 20 factors. Results Included in the sample were 23,645 patients (73% female mean age: 55 years; 78% with ≥2 CNPC, and 91% with joint pain/arthritis). Overall, 11.4% adults (N = 2684) met selected criteria for TRD. The five leading factors associated with TRD were the following: mental health specialist visits, polypharmacy (≥5 medications), psychotherapy use, anxiety, and age. Cross-validated logistic regression model indicated that those with TRD were younger, more likely to have anxiety, mental health specialist visits, polypharmacy, and psychotherapy use with adjusted odds ratios (AORs) ranging from 1.93 to 1.27 (all ps < .001). Conclusion Machine learning identified several factors that warrant further investigation and may serve as potential targets for clinical intervention to improve treatment outcomes in patients with TRD and CNPC.

Patterns of prescription opioid utilization among adolescents and adults with comorbid chronic pain and mental health diagnosis.

Our goal was to examine the association between mental health disorders (MHD) and subsequent risk of opioid use among commercially insured youth and adults (aged 14-64 years) with comorbid chronic noncancer pain (CNCP) conditions. We conducted a retrospective cohort study using IQVIA Health Plan Claims database from January 1, 2006, to December 31, 2015. Chronic noncancer pain was defined as any diagnosis of back, head, neck, arthritis, or chronic pain (index date). Mental health disorders were assessed in the 12 months before the index pain diagnosis. Based on days supply (none, acute, and chronic) and average daily dose (none, low, medium, and high), we constructed a 7-level categorical dependent measure of opioid use. We estimated the overall prevalence of MHD and opioid receipt. Among those with CNCP, multinomial logistic regression (AOR; 95 confidence interval) was used to estimate the association of MHD with opioid receipt. Among 879,815 individuals diagnosed with CNCP, 143,923 (16.4%) had comorbid MHD. Chronic/high-dose use of opioids was more common among those with CNCP and MHD compared to those with only CNCP. After adjusting for demographic and clinical factors, individuals with comorbid CNCP and MHD were significantly more likely to be prescribed opioids compared to those with only CNCP conditions. This effect varied by average daily dose and days supply: acute/low dose (1.08; 1.07-1.08); chronic/low dose (1.49; 1.49-1.50); acute/medium dose (1.07; 1.07-1.08); chronic/medium dose (1.61; 1.61-1.62); acute/high dose (1.03; 1.02-1.03); and chronic/high dose (1.53; 1.53-1.54). In individuals with CNCP, having a MHD was a strong predictor of prescription opioid use, particularly chronic use.

PMH7 ECONOMIC BURDEN OF TREATMENT-RESISTANT DEPRESSION AMONG ADULTS WITH CHRONIC NON-CANCER PAIN CONDITIONS AND MAJOR DEPRESSIVE DISORDER

Chronic non-cancer pain conditions (CNPC) and Major Depressive Disorder (MDD) often co-occur and presents a substantial economic burden. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on total and MDD-related healthcare resource utilization (HRU) and costs among patients with CNPC and MDD. The study used a retrospective longitudinal cohort design and employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007- June 2017). Costs and HRU were measured over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD. Of the 21,180 adults with CNPC and MDD (mean age 55 years, 74% females, 33% had ≥3 CNPC), 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs ($21,015TRD vs $14,712No TRD) and MDD-related costs ($1,201TRD vs $471No TRD) compared to non-TRD patients (all P <0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had significantly higher number of inpatient visits (IRR = 1.30, 95% CI = 1.14-1.47) and emergency room visits (IRR = 1.21, 95% CI = 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups. TRD poses a significant direct economic burden among adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.

Canadian clinical practice guidelines for the use of plant-based cannabis and cannabinoid-based products in the management of chronic non-cancer pain and co-occurring conditions: protocol for a systematic literature review

IntroductionChronic pain and co-occurring disorders, such as sleep disorders, anxiety, depression, post-traumatic stress disorder and substance use disorders, are among the most common conditions for which cannabis and cannabinoid-based products...

What Explains Poor Health-related Quality of Life Associated With Opioid Use Among Adults With Chronic Noncancer Pain Conditions? A Blinder-Oaxaca Decomposition

Objectives: The objective of this study was to estimate the extent to which differences in person-level characteristics between opioid users and nonusers contribute to poor health-related quality of life (HRQoL) of long-term opioid users with chronic noncancer pain condition (CNCP). Materials and Methods: We conducted a retrospective cohort study of adults (n=5917) using longitudinal data from multiple years of Medical Expenditure Panel Survey. Adults with CNCP were classified into short-term, long-term, and opioid nonusers. We measured HRQoL with physical component summary (PCS) and mental component summary (MCS) scores from the Short-Form 12 Questionnaire. A regression decomposition analysis of results from linear regression was performed. Results: Among adults with CNCP, 17.8% and 17.2% reported long-term and short-term opioid use, respectively. Long-term opioid users had lower PCS scores (β=−4.48; P&lt;0.001) as compared with nonusers, even after adjusting for other independent variables. There were no statistically significant associations of long-term opioid use to MCS and short-term opioid use to both PCS and MCS scores. Postlinear regression decomposition analyses revealed that 44.8% of the difference in PCS scores (−3.76 of −8.41) was explained by differences in employment, physical activity, number of CNCP, and other chronic conditions, and use of nonopioid pain medications between long-term opioid users and nonusers. Conclusions: Long-term opioid use was associated with lower HRQoL. The difference in HRQoL between long-term opioid users and nonusers was explained by both modifiable and nonmodifiable patient characteristics. Our findings suggest that improving HRQoL among long-term opioid users may require interventions and policies both within and beyond health care.

Healthcare Expenditures Associated with Persistent Opioid use Among Adults with Chronic Non-Cancer Pain Conditions: A Retrospective Cohort Study

Persistent opioid use in adults with chronic non-cancer pain (CNCP) conditions may lead to high economic burden due to adverse events associated with opioids. The objective of our study was to estimate the healthcare expenditures associated with persistent opioid use among adults with CNCP from both payer and patient perspectives. A retrospective cohort study using data from the Medical Expenditure Panel Survey (2012–2015) was undertaken. Patients with persistent, intermittent, and no opioid use in the baseline year were identified and their healthcare expenditures in the follow-up year were examined after controlling for potential confounders. In all, 7,286 adults with CNCP matching our inclusion criteria were identified: 14%, 16%, and 70% reported persistent, intermittent, and no opioid use, respectively. Persistent and intermittent opioid use were associated with additional $4,412 ($12,468 vs $8,056; P < .001) and $1,607 ($9,663 vs $8,056; P = .004), respectively, in total healthcare expenditures compared to no opioid use. Moreover, persistent opioid use was associated with high out-of-pocket burden compared to no opioid use (adjusted odds ratio, 1.44; 95% confidence interval, 1.09–1.89). Our study shows that both payers and patients bear the brunt of economic burden of persistent opioid use. Alternative cost-effective strategies for pain management for this group of patients are needed.

Validity of Algorithms for Identification of Individuals Suffering from Chronic Noncancer Pain in Administrative Databases: A Systematic Review.

BackgroundSecondary analysis of health administrative databases is indispensable to enriching our understanding of health trajectories, health care utilization, and real-world risks and benefits of drugs among large populations.ObjectivesThis systematic review aimed at assessing evidence about the validity of algorithms for the identification of individuals suffering from nonarthritic chronic noncancer pain (CNCP) in administrative databases.MethodsStudies reporting measures of diagnostic accuracy of such algorithms and published in English or French were searched in the Medline, Embase, CINAHL, AgeLine, PsycINFO, and s in Social Gerontology electronic databases without any dates of coverage restrictions up to March 1, 2018. Reference lists of included studies were also screened for additional publications.ResultsOnly six studies focused on commonly studied CNCP conditions and were included in the review. Some algorithms showed a ≥60% combination of sensitivity and specificity values (back pain disorders in general, fibromyalgia, low back pain, migraine, neck/back problems studied together). Only algorithms designed to identify fibromyalgia cases reached a ≥80% combination (without replication of findings in other studies/databases).ConclusionsIn summary, the present investigation informs us about the limited amount of literature available to guide and support the use of administrative databases as valid sources of data for research on CNCP. Considering the added value of such data sources, the important research gaps identified in this innovative review provide important directions for future research. The review protocol was registered with PROSPERO (CRD42018086402).

PMH2 PREDICTORS OF TREATMENT RESISTANT DEPRESSION AMONG ADULTS WITH CHRONIC NON-CANCER PAIN CONDITIONS: A MACHINE LEARNING APPROACH

Presence of chronic non-cancer pain conditions (CNPC) among adults with major depressive disorder (MDD) often reduces benefits of antidepressant therapy, thereby increasing the possibility of treatment resistance. This study sought to identify leading predictors of treatment resistant depression (TRD) among adults with MDD and CNPC using machine learning approaches. This retrospective dynamic cohort study included adult patients (≥18 years) with CNPC and newly diagnosed MDD on antidepressant therapy from a de-identified 10% sample of Optum® Clinformatics® Data Mart (2007-2017). TRD was identified using the Massachusetts General Hospital clinical staging algorithm for claims data. The study population was divided into a 70% training sample and a 30% test/validation sample. Leading predictors of TRD were identified using random forest (RF) and logistic regression (LR) approaches, including a total of 42 demographic, health- and treatment-related features. A fully adjusted model and model with top 20 features were built using Caret and randomForest packages for R software. Overall, a total of 23,645 patients were included (mean age 55 years, 73% female; 78% had ≥2 CNPC, 91% joint pain/arthritis and 71% back/neck pain), and 11.4% (N=2,684) had TRD. Compared to patients without TRD, those with TRD were younger and more likely to have anxiety and/or substance use disorder (all p<0.001). Application of LR and RF resulted in an AUC of 0.711 and 0.704, respectively, for the fully-adjusted model (11.47% OOB error), and AUC of 0.704 and 0.701 for the model with 20 features. Mental health specialist visits, polypharmacy (≥5 medications), psychotherapy use, anxiety, and younger age were the top five predictors of TRD, with AORs ranging from 1.9-1.3 (95% CI = 1.13-2.18, P≤0.001). Machine learning identified several modifiable factors that predicted TRD in adults with CNPC. These factors may serve as targets of further investigation or clinical intervention to improve treatment outcomes in this population.

Review: In chronic noncancer pain, cannabinoids reduce pain (NNT 24) but increase adverse events (NNH 6).

Source Citation Stockings E, Campbell G, Hall WD, et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain. 2018;159:1932-54. 29847469

Interventional procedures in children and adolescents with chronic non-cancer pain as part of a multidisciplinary pain treatment program.

Interventional procedures are part of multidisciplinary pain treatment programs to treat chronic non-cancer pain conditions in children and adolescents. However, the real benefit of these interventions remains unclear. The aim of this study was to analyze the potential benefits of the interventional procedures in children and adolescents with chronic non-cancer pain in the setting of a multidisciplinary pain treatment program. We retrospectively reviewed the charts of 98 children and adolescents receiving 314 diagnostic or therapeutic interventional procedures. We applied the following definitions of efficacy Short-term positive therapeutic effect: block that produced a minimum of 50% reduction in pain intensity for at least 4weeks. Long-term positive therapeutic effect: a patient with a minimum of 50% reduction in pain intensity for at least 6months Full recovery: a patient free of pain, not taking analgesics with normal physical and role functioning 6months after the last procedure. Seventy-six of 112 diagnostic blocks (68%) were associated with a 50% reduction in pain intensity for at least 4weeks after the procedure. One hundred and sixty-six of 202 therapeutics blocks (82%) were associated with a short-term benefit. Seventy-two of 98 patients (73%) referred a 50% reduction in their pain intensity (17%) or had full recovery 6months after the procedures (56%) and a MPTP. Psychiatric comorbidity and more advanced age were factors associated with failure to respond to interventional procedures. The use of interventional procedures may represent a valid therapeutic option, associated with positive clinical outcomes within a multidisciplinary program.

Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies.

This review examines evidence for the effectiveness of cannabinoids in chronic noncancer pain (CNCP) and addresses gaps in the literature by: considering differences in outcomes based on cannabinoid type and specific CNCP condition; including all study designs; and following IMMPACT guidelines. MEDLINE, Embase, PsycINFO, CENTRAL, and clinicaltrials.gov were searched in July 2017. Analyses were conducted using Revman 5.3 and Stata 15.0. A total of 91 publications containing 104 studies were eligible (n = 9958 participants), including 47 randomised controlled trials (RCTs) and 57 observational studies. Forty-eight studies examined neuropathic pain, 7 studies examined fibromyalgia, 1 rheumatoid arthritis, and 48 other CNCP (13 multiple sclerosis-related pain, 6 visceral pain, and 29 samples with mixed or undefined CNCP). Across RCTs, pooled event rates (PERs) for 30% reduction in pain were 29.0% (cannabinoids) vs 25.9% (placebo); significant effect for cannabinoids was found; number needed to treat to benefit was 24 (95% confidence interval [CI] 15-61); for 50% reduction in pain, PERs were 18.2% vs 14.4%; no significant difference was observed. Pooled change in pain intensity (standardised mean difference: -0.14, 95% CI -0.20 to -0.08) was equivalent to a 3 mm reduction on a 100 mm visual analogue scale greater than placebo groups. In RCTs, PERs for all-cause adverse events were 81.2% vs 66.2%; number needed to treat to harm: 6 (95% CI 5-8). There were no significant impacts on physical or emotional functioning, and low-quality evidence of improved sleep and patient global impression of change. Evidence for effectiveness of cannabinoids in CNCP is limited. Effects suggest that number needed to treat to benefit is high, and number needed to treat to harm is low, with limited impact on other domains. It seems unlikely that cannabinoids are highly effective medicines for CNCP.

Service Use Preceding Opioid-Related Fatality.

This study analyzed health service patterns before opioid-related death among nonelderly individuals in the Medicaid program, focusing on decedents with and without past-year diagnoses of noncancer chronic pain. The authors identified opioid-related decedents, age ≤64 years, in the Medicaid program and characterized their clinical diagnoses, filled medication prescriptions, and nonfatal poisoning events during the 30 days and 12 months before death. The study group included 13,089 opioid-related deaths partitioned by presence or absence of chronic noncancer pain diagnoses in the last year of life. Most decedents (61.5%) had received clinical diagnoses of chronic noncancer pain conditions in the last year of life. As compared with decedents without chronic pain diagnoses, those with these diagnoses were significantly more likely to have filled prescriptions for opioids (49.0% versus 17.2%) and benzodiazepines (52.1% versus 26.6%) during the last 30 days of life, while diagnoses of opioid use disorder during this period were uncommon in both groups (4.2% versus 4.3%). The chronic pain group was also significantly more likely than the nonpain group to receive clinical diagnoses of drug use (40.8% versus 22.1%), depression (29.6% versus 13.0%) or anxiety (25.8% versus 8.4%) disorders during the last year of life. Persons dying of opioid-related causes, particularly those who were diagnosed with chronic pain conditions, commonly received services related to drug use disorders and mental disorders in the last year of life, though opioid use disorder diagnoses near the time of death were rare.