Group Of Chronic Pain Patients Research Articles

Profiles of Resilience and Risk in Chronic Pain: Loneliness, Mindfulness, and Optimism Coming Out of the Pandemic

Individuals experience variable degrees of severity and interference from chronic pain. While clinical diagnosis and pain symptomology may importantly inform treatment options, person-level characteristics may also impact treatment efficacy. The biopsychosocial model of pain includes several pain-modulatory factors which may inform meaningful categorization, or clustering, of individuals with chronic pain, and help predict pain outcomes. In this observational, longitudinal study conducted approximately shortly after the onset of social distancing, patients with chronic pain (N=94) completed validated assessments of known psychosocial (depression, stress, sleep, catastrophizing) pain modulators and pain intensity, which were used to empirically cluster patients into 3 groups using a two-step hierarchical approach. Subsequently, at 1 year later, degree of pain interference, loneliness, social support, mindfulness, and optimism were compared between these 3 groups using ANOVAs. Participants clustered empirically into three groups: 1) Global Elevation Symptoms (GES), characterized by high psychological distress and moderate pain intensity; 2) Pain Intensity Predominant (PIP), characterized by high pain intensity, but average psychological distress; and 3) Less Elevated Symptoms (LES), characterized by low pain intensity and psychological distress. At the 1-year follow-up, patients in the GES cluster reported significantly greater pain interference than the other two clusters, as well as greater feelings of loneliness and lower mindfulness and optimism compared to the LES cluster. This study supports prior research suggesting that psychosocial-based clustering of patients can be used to identify distinct groups of chronic pain patients. In particular, patients identified as belonging to the GES cluster (high psychological distress, high pain intensity early after onset of social distancing) were at greater risk of suffering from pain a year later, as well as loneliness and less mindfulness and optimism. Patient clustering techniques may help identify high risk patients and suggest behavioral interventions to improve pain by addressing psychosocial modulators of pain. Grant support from 5R35GM128691-02.

Pain experience and social support of endometriosis patients during the COVID-19 pandemic in Germany - results of a web-based cross-sectional survey.

BackgroundEndometriosis is a chronic pain condition in premenopausal women. Pain is mainly characterized by pain intensity and may induce disability in all areas of daily life. Nevertheless, pain is influenced by emotional and social factors as well. Social distancing measures or quarantine, as reaction to rapidly rising infections with the COVID-19 virus due to the SARS-CoV-2 pandemic, were implemented across Europe to prevent the spread of the virus and social distancing measures were imposed by the German government by beginning of March 2020 with initiation of the lockdown by the end of March 2020. The objective of this study was to assess, how social distancing measures during the lockdown impacted the various aspects of pain perception in a group of chronic pain patients, such as women suffering from endometriosis.MethodsBetween 6th to 27th April 2020, an online questionnaire was activated at internet platforms of endometriosis patients support groups. Participants were asked retrospectively at one time point about their visual pain intensity measured by the visual analogue scale (VAS) and pain disability via pain disability index (PDI) prior to initiation of social distancing measures in Germany (VASP, PDIP), as well as the pain intensity and pain disability since implementation of social distancing measures (VASI, PDII). Differences of VAS and PDI previous and after implementation of social distancing measures were displayed as ΔVAS and ΔPDI. Pain experience and social support were assessed by a 5-point Likert scale.Results285 participants completed at least one question regarding pain intensity, disability, pain experience or social support. Dysmenorrhea, the symptom with the highest level of pain assessed by VAS, decreased significantly during the SARS-CoV-2 pandemic compared to the time period prior to social isolation (45.30% respondents experienced improvemenet vs 40.50% who experienced worsening; p = 0.025). The global physical impairment improved significantly (improvement of pain induced disability in 48.20% vs 40.90% with worsening of pain symptoms; p = 0.032) after the implementation of social distancing measures. Pain experience was negatively affected by social distancing measures, since frequency of pain awareness increased in 43.6% (p<0.001) of participants and 30.0% (p<0.001) more participants experienced pain as a threat. Verbalization of pain experience was reduced in 36.6% (p = 0.001) of participants and 14.6% (p = 0.91), 21.9% (p<0.001) and 31.5% (p<0.001) of participants reported less social support from their partner, family and friends.ConclusionsPhysical pain and disability on one hand and emotional and social pain experience on the other were differentially affected by the emerged emotional, social and health care constraints related to the SARS-CoV-2 pandemic.

Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment

ObjectiveA mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care. MethodsTwo focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks. ResultsCP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive. ConclusionPatients’ understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies. Practice ImplicationsThese findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.

Online teletherapy for chronic pain: A systematic review

Objective A systematic review designed to evaluate the benefits of remote group pain management for persons with chronic pain was performed. Methods PubMed, EMBASE and PsychINFO databases were searched in April 2019. Eligible studies evaluated teletherapy for chronic pain based on set inclusion and exclusion criteria. Two reviewers independently screened eligible studies, assessed risk of bias and extracted data. Each study design was rated and study quality was assessed using an 11-point scale of methodological quality. Results Comprehensive searches identified 12 studies that met all inclusion/exclusion criteria and each study was assessed for type of technology, study design, outcome measures, study findings and limitations. No published studies investigated synchronous teletherapy for groups of chronic pain patients. Methods of assessment varied considerably across studies. Strength of evidence was moderate and many of the selected studies had issues with treatment compliance/adherence and selection bias. Teletherapy strategies for persons with chronic pain were shown to improve pain, mood, disability and catastrophising, however half of the studies selected did not meet the criteria for acceptable standards for internal validity. Those trials with limited therapist involvement appeared to be less beneficial and tended to report lower adherence than those which had higher levels of therapist guidance or peer support. Conclusions Preliminary findings suggest that teletherapy and remote online cognitive behavioural therapy strategies can be effective in improving quality of life among persons with chronic pain, although the overall quality of evidence is moderate. Controlled trials are needed to assess live remote teletherapy for chronic pain.

Trauma history in the narratives of two groups of chronic pain patients

Trauma history in the narratives of two groups of chronic pain patients

Impact of attachment behavior on the treatment process of chronic pain patients.

BackgroundInsecure attachment patterns are related to the onset and development of chronic pain. However, it is less documented on how short- and long-term effects of pain therapy might differ with the attachment style in interaction with specific pain conditions. We therefore examined how two different groups of chronic pain patients differ in their treatment trajectories and in regard to attachment.MethodN=85/76/67 (T1/T2/T3) patients with medically unexplained musculoskeletal pain (UMP group) were compared to n=89/76/56 patients with joint pain from osteoarthritis (OA group), using multilevel modeling. UMP patients received a multimodal pain program, and OA patients received surgery. Pain intensity before (T1) and after (T2) treatment and at a 6 months follow-up (T3) was assessed by using a visual analog scale of pain.ResultsPain patients report a significant reduction in pain intensity upon the completion of the treatment compared to T1. Over the next 6 months, the pain intensity has further declined for patients with low attachment anxiety. In contrast, patients with highly anxious attachment report an increase in pain intensity. This main effect of anxious attachment on pain is significant when predicting changes both in acute treatment and during follow-up while controlling for group effect. In addition, there is also an interactive effect of group by avoidant attachment. In the UMP group, high scores in avoidant attachment were associated with the lower reduction in pain severity, while in the OA group, high scores in attachment avoidance were associated with a steeper reduction in pain severity.ConclusionThe results indicate that insecurely attached patients with pain symptoms only benefit from a multimodal pain therapy in limited ways in regard to posttreatment trajectories. Maintaining positive results over a period of 6 months is a challenge, compared with securely attached patients.SignificanceThe results of this study suggest the importance of direct and indirect mechanisms of attachment and its relevance for the management of pain experiences. Therefore, to include the individual attachment patterns in the treatment may be a promising way to enhance the treatment prospects.

Multidimensional Patient Impression of Change Following Interdisciplinary Pain Management.

To assess patient impression of change following interdisciplinary pain management utilizing a newly developed Multidimensional Patient Impression of Change (MPIC) questionnaire. A heterogeneous group of chronic pain patients (N = 601) participated in an interdisciplinary treatment program. Programs included individual and group therapies (pain psychology, physical therapy, occupational therapy, relaxation training/biofeedback, aerobic conditioning, patient education and medical management). Patients completed measures of pain, mood, coping, physical functioning and pain acceptance both prior to and at completion of their treatment programs. The newly developed MPIC is an expansion to the Patient Global Impression of Change (PGIC) including seven additional domains (Pain, Mood, Sleep, Physical Functioning, Cope with Pain, Manage Pain Flare-ups, and Medication Effectiveness). The MPIC was administered to the patients post-treatment. There were statistically significant pre- to post-treatment improvements found on all outcome measures. The majority of these improvements were significantly correlated with all domains of the MPIC. The original PGIC item was significantly associated with all of the new MPIC domains and the MPIC domains were significantly associated with each other; but there were variations in the distribution of responses highlighting variation of perceived improvements among the domains. The MPIC accounted for greater amounts of variance among the program outcomes than did the PGIC. Our results support the use of the MPIC as a quick and easy post-treatment assessment screening tool. Future research is needed to examine relevant correlates to Medication Effectiveness.

Web-Based Cognitive Behavior Therapy for Chronic Pain Patients with Aberrant Drug-Related Behavior: Outcomes from a Randomized Controlled Trial.

There is high unmet need for effective behavioral treatments for chronic pain patients at risk for or with demonstrated histories of opioid misuse. Despite growing evidence supporting technology-based delivery of self-management interventions for chronic pain, very few such programs target co-occurring chronic pain and aberrant drug-related behavior. This randomized controlled trial evaluated the effectiveness of a novel, web-based self-management intervention, grounded in cognitive behavior therapy, for chronic pain patients with aberrant drug-related behavior. Opioid-treated chronic pain patients at a specialty pain practice who screened positive for aberrant drug-related behavior (N = 110) were randomized to receive treatment as usual plus the web-based program or treatment as usual alone. The primary outcomes of pain severity, pain interference, and aberrant drug-related behavior, and the secondary outcomes of pain catastrophizing and pain-related emergency department visits, were assessed during the 12-week intervention and at one and three months postintervention. Patients assigned to use the web-based program reported significantly greater reductions in aberrant drug-related behavior, pain catastrophizing, and pain-related emergency department visits-but not pain severity or pain interference-relative to those assigned to treatment as usual. The positive outcomes were observed during the 12-week intervention and for three months postintervention. A web-based self-management program, when delivered in conjunction with standard specialty pain treatment, was effective in reducing chronic pain patients' aberrant drug-related behavior, pain catastrophizing, and emergency department visits for pain. Technology-based self-management tools may be a promising therapeutic approach for the vulnerable group of chronic pain patients who have problems managing their opioid medication.

Pain and Opioid Use after Reversal of Sickle Cell Disease Following Hematopoietic Stem Cell Transplant

Introduction: Pain is the most common symptom of sickle cell disease (SCD). Hematopoietic stem cell transplant (HSCT) is currently the only curative therapy for SCD; however, some patients continue to report pain requiring opioid treatment despite hematologic cure following successful HSCT. Knowledge of factors associated with continued pain and opioid use may help reduce post-HSCT pain-related morbidity. We analyzed data from a cohort of SCD patients who have been successfully treated by nonmyeloablative HLA-matched sibling allogeneic HSCT. Our goal was to investigate pre-HSCT factors that are associated with continued pain and opioid use at 12 months after a successful HSCT.Methods: Detailed data on the clinical course, pain, opioid use, and laboratory values were collected from medical records at 3 months pre-HSCT and 12 months post-HSCT (n=35). Patient Reported Outcomes Measurement Information System (PROMIS) measures were available in a subgroup of these patients (n=20), also collected at the same time points. Patients with pre-HSCT pain were classified using Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy (AAPT) guidelines into one of three pain categories: 1. Chronic pain without contributory SCD complication; 2. Chronic pain explained by contributory SCD complication, eg. avascular necrosis; 3. Chronic pain with a mixed pain phenotype (eg. some pain explained by a contributory SCD complication but also pain occurring in unrelated sites). Patients who only experienced acute episodic pain were grouped separately (Episodic pain only).Results: The median age of the cohort was 30.5 years (range: 16-65 years) and 21 (60%) patients were male. Pre-HSCT, all patients experienced intermittent episodes of pain. Forty-six% of the patients experienced acute episodic pain only, 26% also had chronic pain with a contributory SCD complication and 28% also had chronic pain without contributory SCD complication or a mixed pain phenotype. Post-HSCT, median pain-related admissions decreased significantly (from 3 admissions/year (range 0-24) pre-HSCT to 0 (range 0-3) post-HSCT; (p<0.001)). There were significant reductions in the prescription of both short- and long-acting opioids pre- vs post-HSCT (91% to 40% for short acting and 40% to 14% for long acting opioids; p<0.001). While 14 out of 35 (40%) reported pain at 12 months post-HSCT, examination of continued opioid use patterns across the AAPT groups showed that in the group of chronic pain patients without contributory SCD complications, 90% continued to use opioids to manage their pain whereas none of the patients in the episodic pain only group received opioids post-HSCT and for the group of patients with chronic pain related to a SCD complication, 50% stopped using opioids post-transplant.Analysis of PROMIS data, showed significant improvement in the subscales of Pain Intensity (p=0.03), Pain Impact (p=0.007), Satisfaction with Social Role (p= 0.03), and Physical Function (p= 0.004) following HSCT but no significant changes were seen for Fatigue (p=0.09), Anxiety, Depression or Sleep Disturbance (which may be explained by the small sample size not having enough variance). However, when comparing patients with persistent pain and opioid use without related SCD complications (n=6) versus those with resolved pain post-HSCT (n=9), pre-HSCT Anxiety ratings were significantly higher in the group with unexplainable, persistent pain (p=0.05). For those same groups, additional pre-HSCT factors that were associated with unexplainable, persistent pain post-HSCT were higher burden of pain as defined by higher median pain admissions/year (2 (0-10) vs. 5.5 (3-9); p=0.04); higher overall numerical pain rating on a 0-10 scale (2 (0-5) vs. 6 (5-7); p=0.02) and treatment with long acting opioids (0% vs. 86%; p<0.001).Conclusions: SCD patients with higher pre-HSCT pain burden (more pain admissions and higher pain intensity ratings), long-acting opioid use and certain psychological traits (anxious disposition) may be at risk for persistent pain and continued opioid use post-HSCT. Future studies should evaluate outcomes beyond 12 months of follow up, further characterize underlying mechanisms and evaluate potential interventions to reduce pain and opioid use related morbidities in this subset of patients. DisclosuresNo relevant conflicts of interest to declare.

Placebo effects of a sham opioid solution: a randomized controlled study in patients with chronic low back pain.

This study tested the experimental placebo effect in a group of chronic pain patients. Forty-eight patients having chronic back pain participated in a randomized clinical trial that tested the efficacy of a sham opioid solution (NaCl) compared with an alleged neutral, completely inactive solution (NaCl). We shaped the placebo effect by 2 interventions: verbal instruction and conditioning. The patients were either told that the "solution reduces pain and improves physical capacity" or the "solution is neutral, a placebo." Half of each group was additionally conditioned (coupling solution with reduced experimental pain), yielding 4 subgroups with 12 participants each. Outcome measures were as follows: the patients' clinical back pain ratings and acute pain ratings (both examined by numerical rating scale 0-10) and self-rated functional capacity (0%-100%; time required for the exercise). Expected pain relief before and after solution intake was also assessed. The inactive solution (NaCl), when presented as an effective treatment (sham "opioid" solution), induced placebo analgesia as evident in lower ratings of the patients' clinical back pain (F(3.12,144.21) = 25.05, P < 0.001), acute pain ratings (F(1.99,87.40) = 18.12, P < 0.01), and time needed to complete a series of daily activities exercises (F(1,44) = 8.51, P < 0.01) as well as increased functional capacity (F(1,44.00) = 19.42, P < 0.001). The 2 manipulations (instruction and conditioning) changed pain expectations, and they were maintained in both sham opioid groups. The results suggest that it may be clinically useful to explicitly integrate placebo analgesia responses into pain management.

Identifying brain nociceptive information transmission in patients with chronic somatic pain.

Recent advances regarding mechanisms of chronic pain emphasize the role of corticolimbic circuitry in predicting risk for chronic pain, independently from site of injury-related parameters. These results compel revisiting the role of peripheral nociceptive signaling in chronic pain. We address this issue by examining what brain circuitry transmit information regarding the intensity of chronic pain and how this information may be related to a common co-morbidity, depression. Resting state functional MRI was used in a large group of chronic pain patients (n=40 chronic back pain, CBP, and n=44 osteoarthritis, OA patients), and in comparison to healthy subjects (n=88). We used a graph theoretical measure, degree count, to investigate voxel-wise information sharing/transmission in the brain. Degree count, a functional connectivity based measure, identifies the number of voxels functionally connected to every given voxel. Subdividing the chronic pain cohort into discovery, replication, and also for overall group we show that only degree counts of diencephalic voxels centered in the ventral lateral thalamus reflected intensity of chronic pain, independently of depression. Pain intensity was reliably associated with degree count of the thalamus, which was correlated negatively with components of the default mode network and positively with the periaqueductal grey (in contrast to healthy controls). Depression scores were not reliably associated with regional degree count. Collectively the results suggest that, across two types of chronic pain, nociceptive specific information is relayed through the spinothalamic pathway to the lateral thalamus, potentiated by pro-nociceptive descending modulation, and interrupting cortical cognitive processes.

A comparison of coping strategies in patients with fibromyalgia, chronic neuropathic pain, and pain‐free controls

Patients suffering from chronic pain may benefit from learning adaptive coping strategies. Consensus on efficient strategies for this group of patients is, however, lacking, and previous studies have shown inconsistent results. The present study has examined coping strategies in two distinctly different groups of chronic pain patients and a group of healthy controls. Thirty neuropathic pain (NP) patients, 28 fibromyalgia (FM) patients, and 26 pain-free healthy controls completed the Coping Strategy Questionnaire (CSQ-48/27) and rated their daily pain. The results showed that FM and NP patients did not cope differently with pain. The only difference between the groups was that FM patients felt more in control of their pain than NP patients. Both patient groups used more maladaptive/passive coping strategies, but surprisingly also more adaptive/active coping strategies than healthy controls. However, FM patients with high levels of passive strategies felt less in control than FM patients with low levels of passive strategies. This was not seen in NP patients. An important implication for clinical practice is therefore that passive coping strategies should be restructured into active ones, especially for FM patients. Otherwise, the same psychological treatment model can be applied to both groups since they use similar coping styles.

The Dutch Central Sensitization Inventory (CSI): Factor Analysis, Discriminative Power, and Test-Retest Reliability.

A standardized assessment of central sensitization can be performed with the Central Sensitization Inventory (CSI), an English questionnaire consisting of 25 items relating to current health symptoms. The aim of this study was to translate the CSI into Dutch, to perform a factor analysis to reveal the underlying structure, examine its discriminative power, and test-retest reliability. The CSI was first translated into Dutch. A factor analysis was conducted on CSI data of a large group of chronic pain patients (n=368). The ability to discriminate between chronic pain patients (n=188) and pain-free controls (n=49) was determined and the test-retest reliability for chronic pain patients (n=36) and controls (n=45) with a time interval of 3 weeks was evaluated. The exploratory factor analysis resulted in a 4-factor model based on 20 items, representing the domains "General disability and physical symptoms" (Cronbach α=0.80), "Higher central sensitivity"(Cronbach α=0.78), "Urological and dermatological symptoms"(Cronbach α=0.60), and "Emotional distress"(Cronbach α=0.80). Furthermore, a parsimonious second-order factor model was found, where the factor "General central sensitization" was underlying the 4 first-order factors. Chronic pain patients scored significantly worse on all 4 factors. The test-retest reliability was excellent values in both chronic pain patients (ICC=0.88) and controls (ICC=0.91). The original CSI was translated into Dutch and did not reveal any problems during data acquisition. The domains represented by the 4 factors may be useful in setting up specific patient profiles and treatment targets. To conclude, the Dutch CSI revealed 4 distinguishable domains, showed good internal consistency for the total score and 3 out of 4 domains, good discriminative power, and excellent test-retest reliability.

Long-Term Outcomes of Multidisciplinary Rehabilitation for Chronic Musculoskeletal Pain.

Evidence for the effectiveness of multidisciplinary rehabilitation for chronic musculoskeletal pain (CMP) has been reported but its outcomes in the longer term and in mixed groups of chronic pain patients are largely unknown. The aim of the present study was to describe the two-year outcomes of a 15-week multidisciplinary pain rehabilitation programme in patients with mixed CMP in terms of pain, activities, participation and healthcare usage. Data were recorded routinely at admission, discharge, and at three, 12 and 24 months' follow-up for all consecutive patients with CMP referred to a rehabilitation programme over a 21-month period. The 15-week multidisciplinary rehabilitation programme consisted of cognitive behavioural therapy and exercise, as well as individual and group sessions with additional treatment modalities. Assessments included the Pain Disability Index (PDI), the Pain Catastrophizing Scale (PCS), the Multidimensional Pain Inventory (MPI) and numerical scales for pain and fatigue. Moreover, the RAND-36-Item Health Survey ('RAND-36') and questions on healthcare usage and work status were administered at admission, and at 12 and/or 24 months. Paired t-tests, Wilcoxon signed-rank tests, McNemar tests and mixed-model analyses were used to analyse changes over time. A total of 165 patients were included initially [mean age 44.1 (standard deviation 12.9) years], 143 of whom (87%) were women, with data from 125 (76%) and 120 (73%) patients being available at 12 and 24 months' follow-up, respectively. All outcomes showed statistically significant improvements between admission and discharge, and at three, 12 and 24 months' follow-up (p < 0.05). At 24 months, the median number of different healthcare providers visited in the previous year had decreased significantly compared with that at admission [from a median of 4 (range 1-13) to a median of 2 (range 0-9)], and within the group of patients working at admission (50%), the proportion of those working 25 hours or more per week had increased significantly from 16% to 48%. Improvements in pain and functioning seen directly after a 15-week multidisciplinary treatment programme for patients with CMP were maintained, health care usage decreased and the number of working hours among working patients increased at 24 months' follow-up. Future studies are needed to examine if additional interventions after discharge can enhance further the favourable results. Copyright © 2016 John Wiley & Sons, Ltd.

Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes?

A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.

The relationship between overactivity and opioid use in chronic pain: a 5-day observational study.

With increasing concerns about the potential harm of long-term opioid therapy, there is a need for the development and implementation of alternative treatment strategies for patients with chronic pain who have been using opioids for a prolonged period of time. Based on the findings from a recent qualitative investigation that suggested there may be a bidirectional association between opioid reliance and habitual overactivity behaviour (activity engagement that significantly exacerbates pain), this study was designed to quantitatively investigate the association between opioid use and habitual overactivity over a 5-day period in a group of chronic pain patients. Participants provided a list of their prescribed pain medication, completed a self-report measure of habitual overactivity, and then commenced 5 days of data collection. Data collection required participants to wear an activity monitor and to complete a diary that detailed their daily activities and the time at which they took medication. Individuals reporting higher levels of habitual overactivity were more likely to be prescribed opioids. In addition, higher levels of habitual overactivity were associated with more frequent pro re nata ("as needed") opioid use over the 5 days, and with a discrepancy between the prescribed and actual oral morphine-equivalent daily dose, where more medication was taken than was prescribed. There was no predominant context for pro re nata use. The results of this study support the idea that habitual overactivity behaviour may play a role in the development of reliance on opioid medication and that such an association may provide a potential treatment target for opioid therapy rationalisation.

The responsive amygdala: Treatment-induced alterations in functional connectivity in pediatric complex regional pain syndrome

The amygdala is a key brain region with efferent and afferent neural connections that involve complex behaviors such as pain, reward, fear, and anxiety. This study evaluated resting state functional connectivity of the amygdala with cortical and subcortical regions in a group of chronic pain patients (pediatric complex regional pain syndrome) with age-sex matched control subjects before and after intensive physical-biobehavioral pain treatment. Our main findings include (1) enhanced functional connectivity from the amygdala to multiple cortical, subcortical, and cerebellar regions in patients compared with control subjects, with differences predominantly in the left amygdala in the pretreated condition (disease state); (2) dampened hyperconnectivity from the left amygdala to the motor cortex, parietal lobe, and cingulate cortex after intensive pain rehabilitation treatment within patients with nominal differences observed among healthy control subjects from time 1 to time 2 (treatment effects); (3) functional connectivity to several regions key to fear circuitry (prefrontal cortex, bilateral middle temporal lobe, bilateral cingulate, hippocampus) correlated with higher pain-related fear scores; and (4) decreases in pain-related fear associated with decreased connectivity between the amygdala and the motor and somatosensory cortex, cingulate, and frontal areas. Our data suggest that there are rapid changes in amygdala connectivity after an aggressive treatment program in children with chronic pain and intrinsic amygdala functional connectivity activity serving as a potential indicator of treatment response.

PC-FACS

PC-FACS

Burst Spinal Cord Stimulation Evaluated in Patients With Failed Back Surgery Syndrome and Painful Diabetic Neuropathy

Spinal cord stimulation (SCS) is used for treating intractable neuropathic pain. Generally, it induces paresthesia in the area covered by SCS. Burst SCS was introduced as a new stimulation paradigm with good pain relief without causing paresthesia. Good results have been obtained in patients who were naive to SCS. In this study we assess the effectiveness of burst stimulation in three groups of chronic pain patients who are already familiar with SCS and the accompanying paresthesia. Forty-eight patients with at least six months of conventional, tonic stimulation tested burst stimulation for a period of two weeks. They were classified in three different groups: a cross-section of our population with painful diabetic neuropathy (PDN), a cross-section of our population with failed back surgery syndrome (FBSS), and FBSS patients who over time had become poor responders (PR) to SCS. Visual analog scale scores for pain were assessed prior to implantation, with tonic stimulation, and after two weeks of burst stimulation. Burst stimulation reduced pain significantly for almost all patients. When compared with tonic stimulation, burst stimulation led to a significant additional pain reduction of on average 44% in patients with PDN (p < 0.001) and 28% in patients with FBSS (p < 0.01). Patients from the PR group benefitted less from burst stimulation on average. In addition, burst stimulation caused little or no paresthesia whereas tonic stimulation did induce paresthesia. Most patients preferred burst stimulation, but several preferred tonic stimulation because the paresthesia assured them that the SCS was working. About 60% of the patients with tonic SCS experienced further pain reduction upon application of burst stimulation.

Opioid wean does not increase chronic pain

The purpose of this study was to investigate if opioid weaning was associated with pain and depression outcomes in a group of chronic pain patients that completed an intensive 5-week interdisciplinary pain rehabilitation program. Patients were categorized into three groups based on setting and opiate weaning status. Patients were administered the Medical College of Virginia’s Pain Questionnaire (MCVPQ) and Beck Depression Inventory (BDI) at admission and discharge. Group differences on demographic and clinical variables were tested with one-way ANOVA and chi-square analyses.