Co-occurring Chronic Pain Research Articles

Progress Toward Meaning-as-Goal and Its Association with Pain, Functioning, and Global Meaning and Purpose Among Veterans with Co-occurring Chronic Pain and PTSD.

Co-occurring chronic pain and posttraumatic stress disorder (PTSD) is associated with poorer physical and mental functioning and well-being. Treatments often incorporate goal-setting around personally meaningful behaviors; however, it is unclear whether intentionally focusing on improving meaning and purpose in life (i.e., meaning-as-goal) may also serve as a helpful treatment target. The objective of the current study is to determine whether reported progress toward meaning-as-goal at 6months is associated with pain severity and interference, physical and mental health functioning, and global meaning and purpose at 6- and 12-months. Data were collected as part of an evaluation effort focused on VA's Whole Health System implementation efforts. VA electronic health records were linked to survey data across three time points (baseline, 6months, and 12months) from Veterans with both chronic pain and PTSD across 18 VA sites. A total of 1341 Veterans met inclusion criteria (mean age = 62, SD = 11.7). Regression analyses showed that progress toward meaning-as-goal was significantly associated with all 6-month variables, with standardized coefficients ranging from - 0.14 (pain severity and interference) to .37 (global meaning and purpose), in addition to all 12-month variables, with standardized coefficients ranging from - .13 (pain severity and interference) to .31 (global meaning and purpose). Efforts to intentionally promote meaning and purpose as part of evidence-based treatment for chronic pain and PTSD may lead to decreased pain and improved physical and mental health functioning and global meaning and purpose. With coefficients ranging from small to moderate effect sizes, more work is needed to better understand how best to maximize meaning-related goals.

Study Protocol for the Opioid and Pain Treatment in Indigenous Communities Trial: A Systems Level Intervention for Enhanced Screening and Brief Intervention and Referral for Co-Occurring Chronic Pain and Opioid Use Disorder.

American Indian/Alaska Native (AI/AN) individuals have the highest rates of opioid overdose mortality and chronic pain (CP) compared to other racial/ethnic groups in the United States. These individuals also report higher rates of pain anxiety and pain catastrophizing, which are both associated with poorer outcomes and risk for opioid misuse (OM) and opioid use disorder (OUD) among individuals with CP. Yet, no prior studies have examined rates of comorbid pain and OUD among AI/AN adults. This commentary describes an implementation research partnership of 3 AI/AN-serving clinics and a university team that utilizes an implementation hybrid type III design to examine the impact of implementation strategies on adoption and sustainability of evidence-based screening and brief intervention for CP and OM/OUD among AI/AN clients. As part of our community-engaged approach, we embrace both AI/AN models and Western models, and a collaborative board of 10 individuals guided the research throughout. We hypothesize that our culturally centered approach will increase rates of screening and brief intervention and improve identification of and outcomes among AI/AN clients with CP and OUD who receive treatment at participating sites. Each site convenes a workgroup to evaluate and set goals to culturally center screening and brief interventions for CP and OM/OUD. Data collected include deidentified electronic health records to track screening and brief interventions and rates of CP and OUD; provider and staff surveys beginning prior to implementation and every 6 months for 2 years; and a subset of clients will be recruited (N = 225) and assessed at baseline, 6, and 12 months to examine biopsychosocial and spiritual factors and their experiences with culturally centered screening and brief intervention. Cultural adaptations to the measures and screening and brief intervention as well as barriers and facilitators will be addressed. Recommendations for successful Tribal health clinic-university partnerships are offered.

S66 - The Substance Abuse Self-Stigma Scale: Reliability Among Veterans With Co-Occurring Chronic Pain and Opioid Use Disorder

S66 - The Substance Abuse Self-Stigma Scale: Reliability Among Veterans With Co-Occurring Chronic Pain and Opioid Use Disorder

Co-occurring Chronic Pain and PTSD Among US Military Veterans: Prevalence, Correlates, and Functioning.

The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity. To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups. Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans. Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD. A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale. A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios [ORs]=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69). Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.

Addressing the Intersections of Chronic Pain and OUD: Integrative Management of Chronic Pain and OUD for Whole Recovery (IMPOWR) Research Network.

The appearance of both chronic pain (CP) and opioid use disorder (OUD)/opioid misuse is common, can bidirectionally affect treatment outcomes, and can be challenging to treat. The successful treatment of these conditions can be further complicated by co-occurring hazardous alcohol use, general anxiety disorder, and/or major depressive disorder, and calls for the need to attend to the whole health of the patient. Health systems providing care for these individuals are often fragmented, and suffer from limited resources, expertise, and communication. The National Institute on Drug Abuse, with support from the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative, funded the Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) network in 2021 to address the needs of this complex population. With continuous collaboration with community partners, the network supports 11 unique clinical trials and a Coordination and Dissemination Center which are described in this commentary. This article introduces the scientific rationale and structure of the network and highlights the themes connecting the trials together to collectively create data-driven and actionable solutions for individuals with co-occurring CP and OUD/opioid misuse.

Intersectional Risk and the Significant Gap in Care for Persons With Co-occurring Chronic Pain and Opioid Withdrawal.

Persons with chronic pain and women tend to enter treatment for opioid use disorder with greater opioid withdrawal severity than persons without chronic pain and men, respectively. This study examined characteristics of facilities with opioid withdrawal treatment, including gender-based services, as a function of whether they reported having a tailored pain management program. The National Survey of Substance Abuse Treatment Services 2020 was used to examine 3942 facilities with opioid withdrawal treatment in the United States. Using a multivariable binary logistic regression model, facilities were examined for the presence of a tailored program for individuals with co-occurring pain. Regional location of the facility, ownership status, and availability of tailored gender programs, nonhospital residential services, and outpatient services served as independent variables in the analysis. A slight majority of the sample had a program for both adult men and adult women ( n = 2010, 51.0%). Most facilities had outpatient services ( n = 3289, 83.4%) and did not have a tailored program for addressing co-occurring pain ( n = 2756, 69.9%). Binary logistic regression analysis showed that among opioid withdrawal facilities, programs with nonhospital residential services, government or private nonprofit funding, or tailored gender programming had higher odds of reporting having a tailored program for pain and substance use disorder. Facilities in the Western United States were most likely to have tailored programs for pain and substance use disorder. Future research should investigate what support patients may receive and how to better scale access to pain management during opioid withdrawal treatment.

Study Protocol for the Healing Opioid Misuse and Pain Through Engagement Trial: Integrated Treatment for Individuals With Co-occurring Chronic Pain and Opioid Use Disorder.

Chronic pain and opioid use disorder (OUD) are public health crises and their co-occurrence has led to further complications and public health impacts. Provision of treatments for comorbid chronic pain and OUD is paramount to address these public health crises. Medications for OUD (MOUD) are gold standard treatments for OUD that have also demonstrated benefit in pain management. However, clinics that provide MOUD for chronic pain or OUD often lack behavioral treatments to address the challenges experienced by individuals with both conditions. Developing and implementing a behavioral treatment that complements MOUD may better equip clinics to provide comprehensive care to the growing proportion of clients who present with comorbid chronic pain and OUD. In the Healing Opioid misuse and Pain through Engagement (HOPE) Trial, we are using an effectiveness-implementation hybrid design to examine the benefits of an integrated behavioral treatment and to determine the feasibility of implementing the integrated treatment into clinics that provide MOUD. The treatment integrated 2 evidence-based treatments-Acceptance and Commitment Therapy and Mindfulness-Based Relapse Prevention-to target the emotional, behavioral, and physiological sequelae of OUD and chronic pain. Implementation feasibility will include assessing changes in implementation readiness and identifying facilitators and barriers to implementing the integrated treatment among all personnel employed in clinics that provide MOUD. This commentary offers an overview of the study and design and details adaptations we made to our study protocol, based largely on clinic personnel time constraints and variable clinic procedures during the COVID-19 pandemic.

Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities.

Co-occurrence of chronic pain and clinically significant symptoms of anxiety and/or depression is regularly noted in the literature. Yet, little is known empirically about population prevalence of co-occurring symptoms, nor whether people with co-occurring symptoms constitute a distinct subpopulation within US adults living with chronic pain or US adults living with anxiety and/or depression symptoms (A/D). To address this gap, this study analyzes data from the 2019 National Health Interview Survey, a representative annual survey of self-reported health status and treatment use in the United States (n = 31,997). Approximately 12 million US adults, or 4.9% of the adult population, have co-occurring chronic pain and A/D symptoms. Unremitted A/D symptoms co-occurred in 23.9% of US adults with chronic pain, compared with an A/D prevalence of 4.9% among those without chronic pain. Conversely, chronic pain co-occurred in the majority (55.6%) of US adults with unremitted A/D symptoms, compared with a chronic pain prevalence of 17.1% among those without A/D symptoms. The likelihood of experiencing functional limitations in daily life was highest among those experiencing co-occurring symptoms, compared with those experiencing chronic pain alone or A/D symptoms alone. Among those with co-occurring symptoms, 69.4% reported that work was limited due to a health problem, 43.7% reported difficulty doing errands alone, and 55.7% reported difficulty participating in social activities. These data point to the need for targeted investment in improving functional outcomes for the nearly 1 in 20 US adults living with co-occurring chronic pain and clinically significant A/D symptoms.

Co-occurring chronic pain and primary psychological disorders in adolescents: A scoping review.

Long-term health conditions, whether mental or physical, often co-occur in adolescents. For instance, adolescents with chronic pain may experience co-occurring primary psychological disorders. In this scoping review, we determine the influence of co-occurring chronic pain and primary psychological disorders on adolescents' functioning. A systematic search of six databases was conducted to identify articles if they were: (1) peer-reviewed; (2) reported original findings; (3) included participants aged 11-19 years, who experienced chronic pain (i.e., pain lasting 3 months or more) and had a co-occurring diagnosis of a primary psychological disorder; and (4) assessed functioning. Searches returned 9864 articles after the removal of duplicates. A two-phase abstract and full-text screening process identified two eligible articles which compared emotional functioning (n = 1) and social functioning (n = 2) between groups of adolescents with co-occurring chronic pain and primary psychological disorders with adolescents only reporting chronic pain. Overall findings revealed no differences in social functioning, but adolescents with co-occurring chronic pain and a primary psychological disorder (depression and anxiety) reported worse emotional functioning compared with adolescents with chronic pain alone. This review confirms the limited research on the co-occurrence of primary psychological disorders and chronic pain in adolescents by only identifying two eligible articles exploring the co-occurrence of chronic pain with depression, anxiety, and/or attentional disorders.

'A whirlwind of everything': The lived experience of adolescents with co-occurring chronic pain and mental health symptoms.

Co-occurring chronic pain and mental health issues are prevalent in adolescents, costly to society and can lead to increased risk of complications throughout the lifespan. While research has largely examined paediatric chronic pain and mental health in isolation, little is known about the unique challenges faced by adolescents who experience these co-occurring symptoms. This idiographic study examined the lived experience of adolescents with co-occurring chronic pain and mental health symptoms to identify salient issues for this population. Semi-structured telephone interviews were conducted with seven adolescents (11-19 years) self-reporting diagnoses of both pain and mental health issues for a duration of 3 months or longer. Participants were recruited from UK-based schools, pain clinics and charities. Interview transcripts were analysed using interpretative phenomenological analysis. Analyses generated two themes 'a whirlwind of everything' and 'putting up fronts', which describe how the experience of co-occurring chronic pain and mental health symptoms typically disrupted adolescents' ability to regulate their physical, psychological and social wellbeing and identity. Adolescents described their symptom experience as like an internal storm over which they had no control. Such experiences required adolescents to embrace a variety of symptom management strategies, with adolescents reporting deliberate efforts to minimize their symptoms to external individuals. Co-occurring pain and mental health symptoms may be experienced in similar ways to individually experienced pain or mental health symptoms, but together, the experience may be both more difficult to manage and more socially isolating. Adolescents with co-occurring chronic pain and mental health symptoms describe the experience as if there was a storm inside of them disrupting their sense of physical, emotional and social wellbeing. This inner chaos interferes with their self-identity and relationships with others. Challenges articulating their experiences, and negative encounters associated with their symptoms, further impact feelings of isolation and difficulties accessing support.

Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites.

ObjectiveVeterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD.MethodsWe assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD.ResultsA total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 (95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 (95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services.ConclusionEarly implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.

Effects of Weight and Pain on Physical Activity: Insights from the Lived Experiences of Youth with Co-Occurring Chronic Pain and Obesity.

Objective: Pediatric obesity and chronic pain are each associated with an increased risk for numerous poor physical and mental health outcomes. Co-occurring chronic pain and obesity (CPO) result in greater functional disability compared with either condition alone. The aim of the present study was to use qualitative methods to better understand the challenges experienced by adolescents with CPO, with a specific focus on physical activity. Methods: Semistructured interviews were conducted with 13 youth with CPO. Participants were questioned about pain, physical activity, coping strategies, and the perceived relationship between weight and pain. Interviews were audiorecorded, transcribed, and analyzed according to Interpretative Phenomenological Analysis. Results: Superordinate themes expressed by youth included: Impact of Chronic Pain on Relationships, Impact of Pain on Self-Perception, Using Food to Cope with Pain, Perceived Relationship between Pain and Weight after Onset of Pain, Attitudes toward Physical Activity, Barriers to Physical Activity, and Supports to Physical Activity. Conclusions: Participants identified challenges associated with CPO. Notably, participants identified pain as a greater barrier to exercise than weight, implicating the salience of chronic pain in the lives of youth with CPO. Furthermore, participants identified a desire to be more physically active, yet discussed struggles and concerns about attempts to increase their physical activity and indicated a desire for guidance about being more active. This study highlights the complexities of the relationship between CPO and underscores the importance of providers collaboratively working with patients to develop a practical plan to resume movement and physical activity.

PD01-10 SMALL FIBER POLYNEUROPATHY: A NEXUS LINKING CO-OCCURRING PAIN SYNDROMES IN WOMEN WITH INTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROME?

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Interstitial Cystitis (PD01)1 Sep 2021PD01-10 SMALL FIBER POLYNEUROPATHY: A NEXUS LINKING CO-OCCURRING PAIN SYNDROMES IN WOMEN WITH INTERSTITIAL CYSTITIS/BLADDER PAIN SYNDROME? Raymond Xu, Tyler Overholt, Catherine A. Matthews, Robert Evans, Gopal Badlani, Christine Ahn, Trang Simon, and Stephen J. Walker Raymond XuRaymond Xu More articles by this author , Tyler OverholtTyler Overholt More articles by this author , Catherine A. MatthewsCatherine A. Matthews More articles by this author , Robert EvansRobert Evans More articles by this author , Gopal BadlaniGopal Badlani More articles by this author , Christine AhnChristine Ahn More articles by this author , Trang SimonTrang Simon More articles by this author , and Stephen J. WalkerStephen J. Walker More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001965.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with interstitial cystitis/bladder pain syndrome (IC/BPS) often have one or more co-occurring chronic pain syndromes (e.g., chronic pelvic pain (CPP), fibromyalgia (FM), and/or vulvodynia (VD)). The objective of this study was to explore the role of small fiber polyneuropathy (SFPN) as a potential nexus between IC/BPS and chronic pain syndromes. METHODS: Fifty-one women with IC/BPS undergoing therapeutic hydrodistention (HOD) provided a skin biopsy from the distal calf. Processed biopsy tissue was stained with protein gene product (PGP) 9.5, a marker for intraepidermal nerve fibers (IENF), and SFPN (+/-) status was determined by comparing linear IENF density (fibers/mm2; Figure 1) with normative reference values. Co-occurring chronic pain syndrome status (e.g., CPP, FM, and VD) was determined from patient report. RESULTS: Approximately one quarter (13/51; 25.49%) of the women in this cohort were SFPN+. Average age (years) of SFPN+ patients was 40.92 versus 48.73 for patients without SFPN (SFPN-). Among SFPN+ patients, co-occurring widespread pain syndromes were 76.92% (10/13), 46.15% (6/13), and 38.46% (5/13) for chronic pelvic pain (CPP), fibromyalgia (FM), and vulvodynia (VD), respectively. Among the SFPN- patient group, 42.10% (16/38), 36.84% (14/38), and 15.79% (6/38) reported CPP, FM, VD, respectively (Table 1). CONCLUSIONS: Contrary to normative reference range values that show IENF density decreases with age, the SFPN+ patients were, on average, almost 8 years younger than their SFPN- counterparts. SFPN+ women with IC/BPS reported a higher prevalence of chronic pelvic pain, fibromyalgia, and vulvodynia. There was high concordance between SFPN and co-occurrence of CPP (∼77%), suggesting a possible etiological role of SFPN in this generalized pain descriptor. Further studies to determine the mechanisms by which SFPN may contribute to chronic pain syndromes in women with IC/BPS are warranted. Source of Funding: 1R01DK124599-01 (Walker, PI) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e34-e35 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Raymond Xu More articles by this author Tyler Overholt More articles by this author Catherine A. Matthews More articles by this author Robert Evans More articles by this author Gopal Badlani More articles by this author Christine Ahn More articles by this author Trang Simon More articles by this author Stephen J. Walker More articles by this author Expand All Advertisement Loading ...

Emotion regulation as a transdiagnostic factor underlying co-occurring chronic pain and problematic opioid use.

Chronic pain is a common and costly condition, and some people with chronic pain engage in problematic opioid use. There is a critical need to identify factors underlying this co-occurrence, so that treatment can be targeted to improve outcomes. We propose that difficulty with emotion regulation (ER) is a transdiagnostic factor that underlies the co-occurrence of chronic pain and problematic opioid use (CP-POU). In this narrative review, we draw from prominent models of ER to summarize the literature characterizing ER in chronic pain and CP-POU. We conclude that chronic pain is associated with various ER difficulties, including emotion identification and the up- and down-regulation of both positive and negative emotion. Little research has examined ER specifically in CP-POU; however, initial evidence suggests CP-POU is characterized by difficulties with ER that are similar to those found in chronic pain more generally. There is great potential to expand the treatment of ER to improve pain-related outcomes in chronic pain and CP-POU. More research is needed, however, to elucidate ER in CP-POU and to determine which types of ER strategies are optimal for different clinical presentations and categories of problematic opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Quantitative Sensory Testing in Adolescents with Co-occurring Chronic Pain and Obesity: A Pilot Study.

Factors such as gender, ethnicity, and age affect pain processing in children and adolescents with chronic pain. Although obesity has been shown to affect pain processing in adults, almost nothing is known about pediatric populations. The aim of this pilot study was to explore whether obesity alters sensory processing in adolescents with chronic pain. Participants were recruited from a chronic pain clinic (Chronic Pain (CP), n = 12 normal weight; Chronic Pain + Obesity (CPO), n = 19 overweight/obesity) and from an obesity clinic (Obesity alone (O), n = 14). The quantitative sensory testing protocol included assessments of thermal and mechanical pain thresholds and perceptual sensitization at two sites with little adiposity. The heat pain threshold at the hand was significantly higher in the CPO group than in either the CP or O groups. Mechanical pain threshold (foot) was significantly higher in the CPO group than the CP group. No differences were found on tests of perceptual sensitization. Correlations between experimental pain and clinical pain parameters were found for the CPO group, but not for the CP group. This preliminary study provides important lessons learned for subsequent, larger-scale studies of sensory processing for youth with co-occurring chronic pain and obesity.

Associations Among Sleep Disturbance, Pain Catastrophizing, and Pain Intensity for Methadone-maintained Patients With Opioid Use Disorder and Chronic Pain.

This study examined the cross-sectional associations among pain intensity, pain catastrophizing, and sleep disturbance among patients receiving methadone maintenance treatment (MMT) for opioid use disorder (OUD) and reporting co-occurring chronic pain. Participants were 89 individuals with OUD and chronic pain drawn from a larger cross-sectional study of 164 MMT patients who completed a battery of self-report measures. The authors conducted 6 mediation models to test all possible pathways (ie, each variable tested as an independent variable, mediator, or dependent variable). The only significant mediation effect was an indirect effect of sleep disturbance on pain intensity through pain catastrophizing. That is, greater sleep disturbance was associated with greater pain catastrophizing, which in turn was associated with greater pain intensity. Altogether, findings suggest that the sleep disturbance to pain catastrophizing to pain intensity pathway may be a key mechanistic pathway exacerbating pain issues among MMT patients with OUD and chronic pain. These results suggest that interventions targeting sleep disturbance may be warranted among MMT patients with OUD and chronic pain. Future work in this area with longitudinal data is warranted.

Development and validation of the Capacity to Treat Chronic Pain and Opioid Use Disorder (CAP-POD) questionnaire.

Patients with co-occurring chronic pain and opioid use disorder (OUD) have unique needs that may present challenges for clinicians and health care systems. Primary care providers' (PCPs) capacity to deliver high quality, research-informed care for this population is unknown. The objective of this study was to develop and test a questionnaire of factors influencing PCP capacity to treat co-occurring chronic pain and OUD. Capacity to Treat Co-Occurring Chronic Pain and Opioid Use Disorder (CAP-POD) questionnaire items were developed over a 2-year process including literature review, semi-structured interviews, and expert panel review. In 2018, a national sample of 509 PCPs was recruited through email to complete a questionnaire including the initial 44-item draft CAP-POD questionnaire. CAP-POD items were analyzed for dimensionality, inter-item reliability, and construct validity. Principal component analysis resulted in a 22-item questionnaire. Twelve more items were removed for parsimony, resulting in a final 10-item questionnaire with the following 4 scales: (1) Motivation to Treat patients with chronic pain and OUD (α = .87), (2) Trust in Evidence (α = .87), (3) Assessing Risk (α = .82), and (4) Patient Access to therapies (α = .79). These scales were associated with evidence-based practice attitudes, knowledge of pain management, and self-reported behavioral adherence to best practice recommendations. We developed a brief, 10-item questionnaire that assesses factors influencing the capacity of PCPs to implement best practice recommendations for the treatment of co-occurring chronic pain and OUD. The questionnaire demonstrated good reliability and initial evidence of validity, and may prove useful in future research as well as clinical settings. Patients with co-occurring chronic pain and opioid use disorder (OUD) have unique needs that may present challenges for clinicians and health care systems. Primary care providers' (PCPs) ability to deliver high quality, research-informed care for this population is unknown. There are no validated instruments to assess factors influencing PCP capacity to implement best practices for treating these patients. The objective of this study was to develop and test a questionnaire of factors influencing PCP capacity to treat co-occurring chronic pain and OUD. We recruited 509 PCPs to participate in an online questionnaire that included 44 potential items that assess PCP capacity. Analyses resulted in a 10-item questionnaire that assesses factors influencing capacity to implement best practice recommendations for the treatment of co-occurring chronic pain and OUD. PCPs reported moderately high confidence in the strength and quality of evidence for best practices, and in their ability to identify patients at risk. However, PCPs reported low motivation to treat co-occurring chronic pain and OUD, and perceived patients' access to relevant services as suboptimal, highlighting two areas that should be targeted with tailored implementation strategies. The 10-item Capacity to Treat Chronic Pain and Opioid Use Disorder (CAP-POD) questionnaire can be used for two purposes: (1) to assess factors influencing PCP capacity before implementation and identify areas that may require improvement for implementation and (2) to evaluate implementation interventions aimed at increasing PCP capacity to treat this population.

Understanding Barriers and Facilitators to the Uptake of Best Practices for the Treatment of Co-Occurring Chronic Pain and Opioid Use Disorder

Objective: Patients with a combination of chronic pain and opioid use disorder have unique needs and may present a challenge for clinicians and health care systems. The objective of the present study was to use qualitative methods to explore factors influencing the uptake of best practices for co-occurring chronic pain and opioid use disorder in order to inform a quantitative survey assessing primary care provider capacity to appropriately treat this dual diagnosis. Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), semi-structured qualitative interviews were conducted with 11 primary care providers (PCPs) to inform the development of a questionnaire. Interviews were audio-recorded and transcribed verbatim. Fifteen comments from an open-ended question on the questionnaire were added to the analyses as they described factors that were not elucidated in the interviews. Barriers and facilitators were identified and categorized using the CFIR codebook. Results: The most frequently described barriers were cost and inadequate access to appropriate treatments, external policies, and available resources (e.g., risk assessment tools). The most frequently described facilitators were the presence of a network or team, patient-specific needs, and the learning climate. Knowledge and beliefs were frequently described as both barriers and facilitators. Conclusions: While substantial funding has been allocated to initiatives aimed at increasing PCP capacity to treat this population, numerous barriers to adopting appropriate practices still exist. Future research should focus on developing and testing implementation strategies that leverage the facilitators and overcome the barriers illustrated here to improve the uptake of evidence-based recommendations for the treatment of co-occurring chronic pain and opioid use disorder.

(295) Potential Targets for Pain Management among Patients with Co-Occurring Opioid Use Disorder and Chronic Pain

Although chronic pain is highly prevalent among patients undergoing methadone maintenance treatment (MMT), it often goes untreated in this clinical setting, partly because of the absence of evidence-based integrated treatments for co-occurring chronic pain and opioid use disorder (OUD). An important first step to addressing this gap is to examine whether some common targets of psychosocial pain interventions (i.e., pain acceptance and pain catastrophizing) are predictive of core pain outcomes among MMT patients with chronic pain. The present study examined whether pain catastrophizing and pain acceptance uniquely predict pain severity and pain interference, which are IMMPACT-recommended core chronic pain outcome domains, among MMT patients who also have chronic pain. Among 147 MMT patients who completed a battery of self-report measures, 89 participants who met the criteria for chronic pain were included in the final sample. Hierarchical multiple regression was used to test whether pain catastrophizing and pain acceptance have additive prediction of pain severity and pain interference above and beyond covariates including age, sex, race, depressive and anxiety symptoms, stress level, and current methadone dose. Both pain catastrophizing (p

Psycholegal Assessment of Co-occurring Chronic Pain and Schizophrenia Post-MVC: Analysis of Causation Using Two Case Examples

The key aspect of any psycholegal assessment is the analysis of causation, which requires consideration of important legal constructs such as the but for test, material contribution test, thin skull, and crumbling skull. An analysis of causation can be especially helpful in determining overall liability when evaluating the impact of two major co-occurring conditions. This paper focuses on the utility of conducting an analysis of causation using two case examples in which chronic pain and schizophrenia co-occurred following a motor vehicle collision (MVC). Collision-related injuries often lead to the development of chronic pain and could result in permanent and serious impairment and disability. Schizophrenia is a rare psychological occurrence in the collision context and is associated with its own unique and overwhelming physical, psychological, and cognitive challenges. In the psycholegal context, evaluating the impact of two major co-occurring conditions can be problematic and lead to conceptual challenges. In the two cases presented, some assessors attributed nearly all post-collision changes to schizophrenia as if it were pre-existing or in a latent state and failed to assess or even consider the contribution of MVC-related sequelae to the onset of schizophrenia. As part of addressing these conceptual challenges, we present a model of psycholegal assessment that takes into account the pre-, peri- and post-MVC variables that best explain the occurrence of these two conditions. The model also allows the assessor to determine the current and future needs of injured persons, the permanent physical, psychological, and cognitive sequelae that impact quality of life and/or work, and prognosis for the near and distant future.