Non-pharmacological Treatment Of Chronic Pain Research Articles

Successes and lessons learned from a mobile health behavior intervention to reduce pain and improve health in older adults with obesity and chronic pain: a qualitative study.

Chronic pain is a prevalent issue among older adults in the United States that impairs quality of life. Physical activity has emerged as a cost-effective and non-pharmacological treatment for chronic pain, offering benefits such as improved physical functioning, weight loss, and enhanced mood. However, promoting physical activity in older individuals with chronic pain is challenging, given the cyclical relationship between pain and sedentary behavior. The Mobile Intervention to Reduce Pain and Improve Health (MORPH) trial was designed as an innovative, mobile health (mHealth) supported intervention to address this issue by targeting daylong movement, weight loss, and mindfulness to manage pain in older adults with chronic multisite pain. The objective of this paper is to provide the result of a qualitative analysis conducted on post-intervention interviews with MORPH participants. At the conclusion of the MORPH study, 14 participants were interviewed regarding their experience with the program. All interviews were conducted by phone before being transcribed and verified. A codebook of significant takeaways was created based on these accounts. Summaries were further synthesized into themes using the principles of thematic analysis. Three key themes of the MORPH intervention emerged from the qualitative interviews: MORPH technology (smart scales, Fitbit, MORPH Companion App) facilitated program adherence and accountability; MORPH intervention components (food tracking and mindfulness activities) facilitated program adherence and awareness, respectively; and, group meetings provided motivational support and accountability. Mobile health technologies, including a dedicated MORPH app, facilitated self-monitoring strategies, helped to break the cycle of old habits, and provided participants with immediate feedback on successes; however, technical issues required timely support to maintain engagement. Food tracking contributed to adherence and accountability for weight loss. Mindfulness activities increased participants' awareness of anxiety provoking thoughts and pain triggers. Finally, social support via group meetings and connection, played a crucial role in behavior change, but participants noted consistency in the delivery medium was essential to fostering genuine connections. Overall, the study results highlight the key considerations related to program technology, intervention components, and the value of social support that can help to guide the development of future interventions similar to MORPH.

Peripheral direct current reduces naturally evoked nociceptive activity at the spinal cord in rodent models of pain

Objective. Electrical neuromodulation is an established non-pharmacological treatment for chronic pain. However, existing devices using pulsatile stimulation typically inhibit pain pathways indirectly and are not suitable for all types of chronic pain. Direct current (DC) stimulation is a recently developed technology which affects small-diameter fibres more strongly than pulsatile stimulation. Since nociceptors are predominantly small-diameter Aδ and C fibres, we investigated if this property could be applied to preferentially reduce nociceptive signalling. Approach. We applied a DC waveform to the sciatic nerve in rats of both sexes and recorded multi-unit spinal activity evoked at the hindpaw using various natural stimuli corresponding to different sensory modalities rather than broad-spectrum electrical stimulus. To determine if DC neuromodulation is effective across different types of chronic pain, tests were performed in models of neuropathic and inflammatory pain. Main results. We found that in both pain models tested, DC application reduced responses evoked by noxious stimuli, as well as tactile-evoked responses which we suggest may be involved in allodynia. Different spinal activity of different modalities were reduced in naïve animals compared to the pain models, indicating that physiological changes such as those mediated by disease states could play a larger role than previously thought in determining neuromodulation outcomes. Significance. Our findings support the continued development of DC neuromodulation as a method for reduction of nociceptive signalling, and suggests that it may be effective at treating a broader range of aberrant pain conditions than existing devices.

The Application of Cognitive Behavioral Therapy for Adolescent Patients With Endometriosis: A Topical Review

Recent advances and interest in nonpharmacological treatment approaches for various chronic pain conditions in adolescent patients have increased. Cognitive behavioral therapy (CBT) is widely regarded as the leading nonpharmacological treatment for chronic pain, encompassing gynecological conditions associated with chronic pelvic pain, such as endometriosis. Adolescents with endometriosis often present with different symptoms than adults and frequently report more comorbid psychiatric disorders than the general public. This review aims to (1) justify the application of CBT interventions in the context of adolescent patients with endometriosis; (2) integrate and analyze existing empirical evidence and reviews; (3) highlight the advantages, constraints, and future research directions in CBT for this demographic; and (4) introduce a novel biopsychosocial conceptual model. This model intricately considers the interplay of thoughts, emotions, behaviors, and physical symptoms specific to adolescents with endometriosis, providing a foundation for targeted CBT interventions. This holistic approach recognizes the multifaceted nature of their experience, paving the way for comprehensive and effective nonpharmacological therapeutic strategies. Given the nuanced and intricate nature of endometriosis in adolescents, there is a pressing need for innovative conceptual models and clinical trials of behavioral interventions explicitly designed for this demographic.

Effect of cognitive-behavior therapy for children with functional abdominal pain: a meta-analysis

BackgroundCognitive-Behavior Therapy (CBT) is the validated non-pharmacological treatment for chronic pain in pediatric patients. While some suggested CBT were comparable to the usual care in reducing children’s functional abdominal pain. This meta-analysis was designed to systematically review the literature for RCTs that investigated the efficacy of CBT in children with functional abdominal pain (FAP).MethodsPubMed, Embase, and the Cochrane library were searched for papers published up to October 2022. Studies applying different CBT delivery methods (in-person, web-based, phone-based) were included in this meta-analysis to evaluate the comprehensive effectiveness of CBT compared with usual care. Weighted and standardized mean difference with the 95% confidence intervals were used for the synthesis of the results. Primary outcome was the decrease of functional disability inventory (FDI) and the secondary outcomes were the decrease of severity in pain intensity, depression, anxiety, gastrointestinal symptoms, and improvement in physical quality of life (QoL).ResultsA total of 10 RCTs with 1187 children were included in the final analysis. The results showed that CBT resulted in better effect in reducing functional disability inventory (SMD=-2.282, 95%CI: -4.537 to -0.027, P = 0.047), pain intensity (SMD=-0.594, 95%CI: -1.147 to -0.040, P = 0.036), and improving QoL (SMD = 14.097, 95%CI: 0.901 to 27.292, P = 0.036) compared with the control groups. Comparable effects were observed in the severity of depression (SMD=-0.493, 95%CI: -1.594 to 0.608, P = 0.380), anxiety (SMD=-0.062, 95%CI: -0.640 to 0.517, P = 0.835), and gastrointestinal symptoms (SMD=-1.096 95%CI: -2.243 to 0.050, P = 0.061) between CBT and usual treatment.ConclusionsWe observed the differences in post-treatment FAP and pain intensity for children receiving CBT compared with children receiving treatment as usual. CBT in the setting of FAP demonstrates promising developments and highlights the need for future research.

Socioeconomic risk factors for long-term opioid use: A national registry-linkage study.

Opioid use has increased substantially as a treatment for chronic pain, although harms from long-term opioid therapy outweigh the benefits. More knowledge about factors associated with long-term opioid use is needed. We aimed to investigate the association between socioeconomic status and long-term opioid use in the period 2010-2019. This was a nested case-control study in which the cases were all persons ≥18 years with long-term opioid use, that is use of opioids for more than 3 months (N = 215,642). Cases were matched on gender, age and index year (first long-term use period) with four controls who filled at least one opioid prescription, but never developed long-term opioid use in the study period (N = 862,568). We performed a logistic regression analysis adjusted for relevant confounders, stratified on age groups (18-67 years and 68 years and above). In the younger age group, long-term opioid use was associated with low education (adjusted odds ratio, aOR = 1.54; 95% confidence interval, CI [1.51-1.57]), low income (1.33 [1.31-1.36]), being unemployed (1.40 [1.38-1.42]) and receiving disability pension (1.36 [1.33-1.38]). Weaker associations were found for living in a single-person household or in a dense geographical area. Similar associations were found for the older age group. We found that low socioeconomic status was associated with long-term opioid use both among people in working age and older people. These results indicate a need for social and financial support for non-pharmacological treatment of chronic pain among people with lower socioeconomic status. This study shows that people with low socioeconomic status are at higher risk of developing long-term opioid use. In the clinical setting, physicians should consider socioeconomic status when prescribing opioids for chronic pain. Non-pharmacological treatment options funded by public health services should be prioritized to those with low socioeconomic status as long-term opioid use in chronic pain patients is not recommended.

An Analysis of the Effectiveness of Integrative Therapies for Chronic Trapezius Pain

Millions suffer from chronic pain, particularly chronic back pain, but treatment-related research is limited, leading to physician overprescription of highly addictive drugs such as opioids. A common non-pharmacological treatment for chronic pain has been physical therapy, but this study examines a form of Eastern-hemisphere, mind-body techniques known as integrative therapies as a potential treatment for chronic pain in the trapezius. This study primarily analyzes acupuncture, massage therapy, and Ayurveda, three integrative therapies, to determine whether they are effective in treating chronic trapezius pain. Since integrative therapies have a large psychological component, the study also focuses on identifying whether perception of integrative therapies can influence its effectiveness and what factors can impact this perception. Through a series of interviews conducted with pain specialists, the study determines that massage therapy and Ayurveda are comparable to or more effective than physical therapy as chronic trapezius pain treatments, but the success of the therapy is dependent on the patient’s psychological perception of it. The study then conducted a survey of the general population, which revealed that while experience with integrative therapies does not appear to impact one’s perception of integrative therapy, those from an Asian/Middle Eastern background perceive integrative treatments differently and potentially perceive them as more effective. A better perception of integrative therapies leads to greater success with this treatment. These findings demonstrate that education of integrative therapies should be more widespread to counter stereotypes and misconceptions so that chronic pain treatment is, overall, more effective.

Resting-state functional connectivity predicts motor cortex stimulation-dependent pain relief in fibromyalgia syndrome patients

MRI-based resting-state functional connectivity (rsFC) has been shown to predict response to pharmacological and non-pharmacological treatments for chronic pain, but not yet for motor cortex transcranial magnetic stimulation (M1-rTMS). Twenty-seven fibromyalgia syndrome (FMS) patients participated in this double-blind, crossover, and sham-controlled study. Ten daily treatments of 10 Hz M1-rTMS were given over 2 weeks. Before treatment series, patients underwent resting-state fMRI and clinical pain evaluation. Significant pain reduction occurred following active, but not sham, M1-rTMS. The following rsFC patterns predicted reductions in clinical pain intensity after the active treatment: weaker rsFC of the default-mode network with the middle frontal gyrus (r = 0.76, p < 0.001), the executive control network with the rostro-medial prefrontal cortex (r = 0.80, p < 0.001), the thalamus with the middle frontal gyrus (r = 0.82, p < 0.001), and the pregenual anterior cingulate cortex with the inferior parietal lobule (r = 0.79, p < 0.001); and stronger rsFC of the anterior insula with the angular gyrus (r = − 0.81, p < 0.001). The above regions process the attentional and emotional aspects of pain intensity; serve as components of the resting-state networks; are modulated by rTMS; and are altered in FMS. Therefore, we suggest that in FMS, the weaker pre-existing interplay between pain-related brain regions and networks, the larger the pain relief resulting from M1-rTMS.

Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial.

Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

BackgroundConsensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.ObjectiveTo examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.DesignCross-sectional nationally representative study.ParticipantsUS military veterans (N = 2,836).Main MeasuresIn the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).Key ResultsChronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07–2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12–2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12–3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35–6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69–10.87).ConclusionsAmong veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Pharmacologic and Non-Pharmacologic Treatments for Chronic Pain Used by Patients with Pain, HIV, and Depression.

The objective of this study was to understand pain treatment utilization, perceived efficacy, and differences in utilization by gender, clinic site, chronicity of pain, pain severity, and depression severity among people living with HIV (PLWH), chronic pain, and elevated depression symptoms. Participants included 187 PLWH at three HIV clinics in the U.S. Overall, 85% of participants reported taking a pain medication. One quarter (25%) reported non-pharmacological professional treatments for pain (e.g., massage, physical therapy), 60% reported mind-body treatments, including exercise, meditation, and yoga, and 62% reported other non-pharmacological self-administered treatments (e.g., heat/cold). Most pain treatments were considered "slightly helpful" or "moderately helpful." Non-pharmacological self-administered treatments were more commonly used among women than men and among individuals with constant vs. intermittent pain. Further research is needed to evaluate the efficacy of the preferred analgesic modalities of PLWH.

Targeting the stress response in pediatric pain: current evidence for psychosocial intervention and avenues for future investigation.

Nonpharmacological treatments for chronic pain in youth have been identified as first-line treatments over and above medication. Therapies such as cognitive-behavioral therapy and mindfulness-based stress reduction have shown good efficacy in reducing the psychological correlates (eg, anxiety, depression, and stress) and social or behavioral sequelae (eg, limited physical activity and lack of school engagement) associated with pediatric chronic pain. However, minimal research has examined the physiological mechanism(s) of action for these interventions. A recent review (Cunningham, et al., 2019) emphasized the need for objective (ie, physiological) assessment of treatment response in pediatric pain populations. The current review adds to this literature by identifying the physiological stress response as a particular target of interest in interventions for pediatric pain. Research indicates that youth with chronic pain report high rates of psychological stress, posttraumatic stress symptoms, and exposure to adverse childhood experiences (abuse/neglect, etc). In addition, a host of research has shown strong parallels between the neurobiology of pain processing and the neurobiology of stress exposure in both youth and adults. Interventions such as narrative or exposure therapy (eg, trauma-focused cognitive-behavioral therapy) and mindfulness-based or meditation-based therapies have shown particular promise in alleviating the neurobiological impact that stress and pain can have on the body, including reduction in allostatic load and altered connectivity in multiple brain regions. However, no study to date has specifically looked at these factors in the context of pediatric pain treatment. Future research should further explore these constructs to optimize prevention in and treatment of these vulnerable populations.

Osteopathic Manipulation in the Management of Chronic Pain: Current Perspectives.

Chronic pain is a common condition that often interferes with work or other activities. Guidelines support the use of non-pharmacological treatments, such as spinal manipulation, in patients with chronic pain. Osteopathic physicians in the United States are uniquely positioned to manage chronic pain because their professional philosophy embraces the biopsychosocial model and they are trained in the use of osteopathic manipulative treatment (OMT) to complement conventional medical care. This narrative review provides current perspectives on the osteopathic approach to chronic pain management, including evidence for the efficacy of OMT based on systematic searches of the biomedical literature and the ClinicalTrials.gov database. Men, persons with low levels of education, and non-White and Hispanic patients are significantly less likely to have received OMT during their lifetime. Patients with low back and neck pain are most likely to be treated with OMT, and osteopathic manipulative medicine specialty physicians and family medicine physicians most often use OMT. However, many osteopathic physicians report using OMT infrequently. Although OMT is considered safe, based on millions of patient encounters over more than a century, there is limited evidence on its efficacy in treating chronic pain. The lone exception involves chronic low back pain, wherein there is evidence from systematic reviews, a large clinical trial, and observational studies. There is lesser evidence to support cost effectiveness and patient satisfaction associated with OMT for chronic pain. The only clinical practice guideline established by the American Osteopathic Association recommends that OMT should be used to treat chronic low back pain in patients with somatic dysfunction. Given the philosophy of osteopathic medicine, universal training of osteopathic physicians to use OMT, and national guidelines supporting non-pharmacological treatments for chronic pain, it is unclear why OMT use is reported to be remarkably low in physician surveys.

Identifying Predictors of Recommendations for and Participation in Multimodal Nonpharmacological Treatments for Chronic Pain Using Patient-Reported Outcomes and Electronic Medical Records.

High-quality chronic pain care emphasizes multimodal treatments that include medication and nonpharmacological treatments. But it is not clear which patients will participate in nonpharmacological treatments, such as physical therapy or mental health care, and previous research has shown conflicting evidence. We used the Patient Outcomes Repository for Treatment (PORT) registry, which combines patient-reported outcomes data with electronic medical records. In this retrospective observational study, we performed two separate multinomial regression analyses with feature selection to identify PORT variables that were predictive of 1) recommendation of a nonpharmacological treatment by the provider and 2) patient participation in nonpharmacological treatments. Two hundred thirty-six patients were recommended (REC) or not recommended (NO REC) a nonpharmacological treatment, and all REC patients were classified as participating (YES) or not participating (NO) in the recommendations. Female gender and a diagnosis of Z79 "Opioid drug therapy" were significant positive and negative predictors of nonpharmacological treatment recommendations, respectively. Schedule II opioid use at initial presentation and recommendations for rehabilitation therapy were significant predictors of nonparticipation. Patients using opioids are less likely to be recommended nonpharmacological treatments as part of multimodal chronic pain care and are less likely to participate in nonpharmacological treatments once recommended. Males are also less likely to be recommended nonpharmacological treatments. Patients referred for rehabilitation therapies are less likely to comply with those recommendations. We have identified patients in vulnerable subgroups who may require additional resources and/or encouragement to comply with multimodal chronic pain treatment recommendations.

Teaching Chronic Pain in the Family Medicine Clerkship: Changes From 2014.

The management of chronic pain is an important topic for training competent family physicians. The purpose of this study was to determine factors in teaching about chronic pain and whether state overdose death rates were associated with teaching chronic pain topics. Data were collected as part of the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) Clerkship Directors' Survey. The response rate was 71%. Respondents answered questions about the amount of time spent teaching about chronic pain diagnoses, approach to chronic pain, opioid medications, nonopioid medications and nonpharmacologic treatments for chronic pain. The most frequent topic was chronic pain diagnoses, taught by 64% of clerkships with an average of 92 minutes spent on the topic. Each chronic pain topic was taught by nearly 50% of clerkships, and 72.3% of clerkships taught at least one topic. More clerkships were teaching about opioids, nonopioids, and nonpharmacological treatments for chronic pain than in 2014. Time currently spent teaching about opioids was positively correlated with clerkships' state 2014 drug overdose death rate. The majority of family medicine clerkships teach about chronic pain, and the amount of time dedicated to this topic has increased over the last 5 years. A state's opioid overdose rate correlates with the amount of time spent teaching about opioids, but does not correlate with the amount of time teaching about other chronic pain subtopics. It is possible that the opioid crisis is causing a shift in the subtopics of chronic pain teaching.

Adapting Mindfulness Training for Military Service Members With Chronic Pain.

Rates of chronic pain in military personnel are disproportionately high. Chronic pain is often associated with mental health and substance use disorders as comorbid conditions, making treatment of chronic pain complex. Mindfulness-based interventions (MBIs) are a promising behavioral approach to managing chronic pain and psychosocial sequelae. The unique nature of the military context may require adaptations to original MBIs for successful delivery in active-duty military populations. This study adapted the mindfulness-based stress reduction (MBSR) program to create a mindfulness training program that was relevant to active-duty Army personnel experiencing chronic pain. This article delineates the adaptation process employed to modify the MBSR program to the military context and discusses the resulting training program. The adaptation process consisted of three iterative stages: 1) Drafting the preliminary intervention protocol with recommendations from stakeholders, including military healthcare providers; 2) Refining the preliminary protocol after pretesting the sessions with research team members and a military Veteran advisory committee; and 3) Delivering the preliminary protocol to one cohort of active-duty Soldiers with chronic pain, collecting feedback, and further refining the intervention protocol. Military-related adaptations to MBSR addressed three areas: military culture, language and terminology, and practical and logistical factors relevant to implementation in the military setting. This adaptation process resulted in a live, online program with six, weekly, sessions. Feedback from a military Veteran advisory committee resulted in modifications, including increasing military-relevant examples; preliminary testing with the target population resulted in additional modifications, including shortening the sessions to 75min and structuring discussions more efficiently. The adaptation process was successful in generating an engaging mindfulness training program that was highly relevant to the military context. Obtaining input from stakeholders, such as military healthcare providers and active-duty soldiers, and iterative feedback and modification, were key to the process. Moreover, the program was designed to maintain the integrity and core elements of MBIs while adapting to military culture. A future randomized controlled trial design will be used to evaluate the effectiveness of the intervention in improving chronic pain in military personnel. This program is responsive to the military's call for nonpharmacologic treatments for chronic pain that are easily accessible. If effective, the mindfulness program has the potential for widespread dissemination to complement standard care for Service Members experiencing chronic pain.

Enhancing Motivation for Change in the Management of Chronic Painful Conditions: a Review of Recent Literature.

The purpose of this review is to evaluate and summarize recent empirical research investigating motivational factors for management of chronic pain and headache disorders. Research on motivation for non-pharmacological treatment of chronic pain and headache disorders has identified factors that influence initiation of and adherence to treatment. To address common factors that inhibit initiation of treatment (i.e., cost, time commitment), several electronic treatments have been developed. Self-efficacy is the most commonly studied psychosocial influence on treatment adherence, with evidence that it is positively correlated with adherence. Other studies have sought to improve adherence to treatment using motivational interviewing interventions. There is currently limited research on how to enhance motivation for initial adherence to non-pharmacological treatment for chronic pain and headache disorders. Instead of enhancing motivation, researchers have looked to reduce barriers to treatment with electronic health treatments; however, many of these studies have focused on intervention feasibility, rather than efficacy or effectiveness. Numerous studies have identified a relationship between self-efficacy and treatment adherence. Although motivational interviewing interventions have been shown to improve adherence to treatment, there is little evidence that they improve treatment outcomes. Recommendations for further investigation include improving interventions to enhance accessibility and adherence to treatment with the goal of improving outcomes, as well as identifying ways to improve treatment initiation and adherence in patients who are currently engaged in long-term opioid therapy.

Regional and Rural-Urban Variation in Opioid Prescribing in the Veterans Health Administration.

Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural-urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans. Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural-urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use. Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p < 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use. There is substantial regional and rural-urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.

Improving Acupuncture Research Dissemination to Impact Policy Implementation: An Invitation to the June 2019 Conference of the Society for Acupuncture Research

Improving Acupuncture Research Dissemination to Impact Policy Implementation: An Invitation to the June 2019 Conference of the Society for Acupuncture Research

Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community

The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives. This was a qualitative study using a Science Café methodology. The Science Café event was held at an urban community center in Boston, MA. Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English. Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10. Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain. Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.

Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages.

Long-term use of opioids to treat chronic pain incurs serious risks for the individual-including misuse, abuse, addiction, overdose and death-as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients. We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments. Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes. Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.