Dissociation and Posttraumatic Stress Symptoms in Patients With Chronic Pain

The present study examined the number and frequency of dissociative experiences reported by patients with chronic pain and the association between dissociation and emotional distress in this population. The mean Dissociative Experiences Scale (DES) score obtained by patients with chronic pain was comparable to mean DES scores obtained by persons diagnosed with affective disorders, eating disorders, personality disorders, and schizophrenia. Based on their median DES score, patients with chronic pain reported more frequent dissociation than did normal adults and persons diagnosed with alcohol use disorders, specific phobias, and agoraphobic avoidance. Traumatized patients with chronic pain evidenced significantly more frequent dissociation than did nontraumatized patients, the traumatized group reporting dissociative experiences as occurring 17% of the time and the nontraumatized group reporting dissociative experiences as occurring 11% of the time. DES absorption, depersonalization, and amnesia scores accounted for 21% of the variance in posttraumatic stress symptoms reported by patients with chronic pain. Findings are discussed in terms of their implications for assessment and cognitive–behavioral management of traumatic stress responding in persons with chronic pain.     

Posttraumatic Stress Symptoms and General Activity Level in the Prediction of Neurocognitive Performance in Chronic Pain Patients

The relative contribution of posttraumatic stress symptoms and general activity level to the prediction of neurocognitive performance among individuals with chronic pain was investigated. Posttraumatic stress symptoms accounted for significant proportions of the variance in attention and concentration and memory after controlling for years of education and pain severity. Level of engagement in common daily activities was also a significant predictor of attention and concentration. Level of general activity moderated the relation between posttraumatic stress symptoms and reasoning ability, the expected negative relation between posttraumatic stress symptoms and reasoning ability was significant only among those chronic pain patients who reported low levels of engagement in tasks of daily living. Discussion focuses on the findings in terms of their many implications for assessment and treatment of emotional and neurocognitive difficulties experienced by persons with chronic pain.     

Opioids Versus Physical Therapy for Management of Chronic Back Pain

Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics improved patient outcomes compared with physical therapy. No research was found that directly compared the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.     

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n?=?4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, “numbness/detachment” was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

Postoperative Pain Trajectories in Chronic Pain Patients Undergoing Surgery: The Effects of Chronic Opioid Pharmacotherapy on Acute Pain

For 2 weeks following surgery, 55 patients with preexisting chronic pain (CP) reported daily postoperative pain with movement and at rest. Of these, 30 CP patients used opioid pharmacotherapy for CP management and 25 did not. We modeled pain resolution in each patient using a linear fit so that each patient yielded 2 scores for each pain rating: 1) an intercept, or initial level of pain, immediately after surgery; and 2) a slope, or rate of pain resolution. The patients not using opioid pharmacotherapy had a mean pain with movement intercept of 5.4 and a slope of −.20, while the patients using opioid pharmacotherapy had a significantly higher mean intercept of 7.68 (P = .001) and a slope of −.21, sustaining higher pain levels over days. The opioid pharmacotherapy patients had the same rate of pain resolution as the other CP patients, and both groups resolved their pain more slowly than normal surgery patients. Preexisting CP may predispose a patient undergoing surgery to a slower rate of postoperative pain resolution. Chronic pain patients who use opioids share this predisposition but in addition, they are at risk for markedly higher postoperative pain across the entire pain resolution trajectory.

Perspective

This is an observational rather than a randomized controlled study, and as such is less definitive. Nonetheless, these findings are consistent with those of animal studies showing that prolonged exposure to opioids can produce opioid-induced hyperalgesia. Patients with opioid pharmacotherapy for chronic pain who undergo surgery merit special attention for acute pain management.     

Self-Efficacy and Chronic Pain Outcomes: A Meta-Analytic Review

A meta-analysis was performed to evaluate overall strengths of relation between self-efficacy (SE) and functioning (pain severity, functional impairment, affective distress) in chronic pain samples, as well as potential moderating effects of sociodemographic characteristics and methodologic factors on these associations. In sum, 86 samples (N = 15,616) fulfilled selection criteria for analysis. SE had negative overall correlations with impairment, affective distress, and pain severity although considerable heterogeneity was observed for all effect sizes. Age, pain duration, SE scale content (SE for functioning despite pain vs SE for pain control vs SE for managing other symptoms such as emotional distress) and type of impairment measure (self-report vs task performance) had significant moderating effects on SE–impairment associations. SE–affective distress relations were moderated by employment status and SE scale content. Finally, moderator analyses of studies having longitudinal designs indicated associations between baseline SE, and each outcome at follow-up remained significant in prospective studies that had statistically controlled for effects of baseline responses on that outcome. Hence, SE is a robust correlate of key outcomes related to chronic pain and a potentially important risk/protective factor that has implications for subsequent functioning in affected groups.PerspectiveMeta-analysis indicated that SE has significant overall associations with impairment, affective distress, and pain severity within chronic pain samples and identified several factors that contribute to variability in effect sizes. Findings highlighted SE as a robust correlate and potentially important risk/protective factor for subsequent adjustment in affected groups.     

Additional Validation of the Pain Medication Questionnaire in a Heterogeneous Sample of Chronic Pain Patients

The present study represents the next stage in the development of a psychometrically sound, self-report screening tool used for assessing the potential pain-medication-misuse risk. A revised Pain Medication Questionnaire (PMQ) was initially designed to successfully evaluate such risk. A subsequent series of two additional studies further documented the clinical utility of the PMQ. A new shortened version of the PMQ was developed, and its psychometric properties, along with its predictive accuracy in identifying risk for medication misuse, were evaluated. Results revealed that the new version maintained the strong psychometric properties of the original PMQ. Moreover, its predictive accuracy was found to be high (85.5% accuracy). Thus, this revised, shortened PMQ can aid physicians in assessing for potential medication misuse, allowing them to more closely monitor at-risk patients during pain management treatment.     

Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis

Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children.

社区慢性疼痛性疾病管理①

目的探索建立社区卫生服务与区域医院的医疗服务对慢性疼痛性疾病管理的新模式.方法对中山市火炬开发区濠头社区常住居民的慢性疼痛性疾病行关键技术集成应用前后进行流行病学调查.结果慢性疼痛性疾病的患病率为51.83%,其中男性为47.06%,女性为57.32%;关键技术集成应用后疗效的优良率从30.22%提高到67.08%,医疗费用下降了36.16%,病休天数由平均32.42 d减少至平均15.25 d(均P<0.001).结论具有网络终端、集规范化诊治、远程会诊、健康教育为一体的社区卫生服务与区域医院对慢性疼痛疾病的共同管理模式能提高社区慢性疼痛管理效果.     

Depression in Chronic Pain Patients: Prevalence and Measurement

This study aimed to: (1) determine prevalence of depression in patients referred to specialist pain services using the Structured Clinical Interview (SCID) diagnostic interview, (2) compare results on the Beck Depression Inventory II (BDI-II) with the SCID to determine the utility of the BDI-II as a screening tool in this population.
Thirty-six participants were recruited, mainly women, with a mean age = 47.83 years (standard deviation = 12.85 years), who were heterogeneous with regard to their pain. All completed the BDI-II and SCID. The SCID diagnosed 26 (72%) cases of depression. BDI-II scores showed 31 (86%) that reported at least mild depression. Agreement between BDI-II scores over threshold for mild depression and SCID diagnosis were assessed by Cohen's kappa (= 0.6). ROC analysis for BDI-II scores against SCID diagnosis gave a large area under the curve (0.97, 95% confidence interval 0.93 to 1.02), suggesting BDI-II is an excellent screen for this population, although the curve was unusual in that sensitivity was high even when the false positive rate was zero. ROC analysis suggested 22 or above as an optimum cut-off score for depression on the BDI-II—higher than for a general population sample.
It has been suggested that the BDI overestimates incidence of depression in pain patients, but this study confirmed through diagnostic interview the very high incidence of depression in this population. It is therefore questionable whether there is value in screening referrals for depression. When using BDI-II for screening, audit or evaluation purposes with a pain clinic population, we suggest a cut-off of 22 or above.     

Attentional Biases Toward Sensory Pain Words in Acute and Chronic Pain Patients

Attentional biases towards pain-related words of chronic and acute low back pain (LBP) patients were compared with healthy pain-free controls. Specifically, the aims were to determine: 1) whether chronic LBP patients demonstrate attentional biases compared to pain-free controls; 2) whether observed biases are also present in those with acute LBP; and 3) whether observed biases are associated with pain-related fear among the pain groups. Four groups were recruited: 1) acute LBP patients; 2) chronic LBP patients from physiotherapy practices; 3) chronic LBP patients from a tertiary referral pain-management center; and 4) healthy pain-free controls. Participants were assessed on the dot-probe computer task for attentional bias to pain-related words. All 3 pain groups demonstrated biases compared to controls on sensory but not on affective, disability, or threat words. Among the pain groups, those with low and moderate levels of fear of (re)injury demonstrated biases towards sensory pain words that were absent in those with high levels of fear, which is counterintuitive to what the fear of (re)injury model suggests. These results suggest that the experience of pain, rather than duration, is the primary indicator of the presence of pain-related biases.     

The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients

This study reports the results of a researcher-administered survey with 115 patients receiving chronic opioid therapy (>90 days) to obtain information regarding how chronic opioid therapy was started. Chronic opioids were started after surgery (27.0%, 95% confidence interval [CI], 18.5–35.5) or for the treatment of acute injury-related pain (27.0%, 95% CI, 18.5–35.5). Many who initiated opioid therapy after surgery reported postoperative complications (61.3%, 95% CI, 50.8–71.8) and many with injury-related pain reported follow-up corrective surgery (58.1%, 95% CI, 47.5–68.7), which led to the continuation of opioids. A large percentage of patients had concurrent depression (43.5%, 95% CI, 34.0–53.0) and anxiety (23.5%, 95% CI, 15.3–31.7). Many participants had a medical history of aberrant drug-related behavior (32.5%, 95% CI, 23.5–41.5) and self-reported history of addiction (21.7%, 95% CI, 13.7–29.7). Almost one-quarter reported taking opioids for a different indication than that for which opioids were started (95% CI, 26.6–45.0). Patients receiving long-term opioid therapy often transitioned to chronic use after starting opioids for the short-term treatment of postoperative or injury-related pain. It is not evident if a clear decision to continue opioids on a chronic basis was made. This survey provides insight as to how chronic opioid therapy is started, and may suggest opportunities for improved patient selection for opioid therapy.

Perioperative and Intraoperative Pain and Anesthetic Care of the Chronic Pain and Cancer Pain Patient Receiving Chronic Opioid Therapy

Abstract:   The expanding role of the anesthesiologist as a "perioperative physician" places ever-increasing demands upon his or her clinical skills and knowledge. One area of growing concern for the anesthesiologist involves the perioperative assessment and management of the opioid-tolerant chronic pain patient. Opioids occupy a position of unsurpassed clinical utility for the treatment of many types of painful conditions. Coupled with noticeable shifts in physician attitudes that have occurred in recent years regarding the use of opioids for the treatment of benign and malignancy-related pain, many more patients are presenting for surgical procedures who are opioid tolerant. It is important therefore that the practicing anesthesiologist become familiar with the currently available opioid formulations, including drug interactions and side effects, in order to better plan the patient's perioperative anesthetic needs and management. Unfortunately, there is a lack of scientifically rigorous studies in this important area, and most of the information must be derived from anecdotal reports and personal experience of anesthesiologists working in this field. In this review, we shall discuss some aspects of current chronic pain management, the newer forms of opioid administration which may be unfamiliar to the anesthesiologist, as well as clinical aspects of opioid use and tolerance including the impact it may have on perioperative anesthetic management.     

Effect of a Cognitive-Behavioral Stress Management Intervention on Salivary IgA, Self-Reported Levels of Stress, and Physical Health Complaints in an Undergraduate Population

Research has indicated that the experience of stress reliably correlates with changes in immunological functioning. Further, interventions designed to reduce the experience of stress correlate with modest enhancement of immune function. The effects of such interventions vary widely, depending on the specific immune system variables measured and characteristics of the participants, including age and health status. To determine the effects of a cognitive-behavioral stress management intervention on salivary immunoglobulin A (sIgA), we randomly assigned 57 university undergraduates to a treatment or control condition. Treatment group participants met in groups of nine or ten students and received information about the stress response and immunity, training in diaphragmatic breathing and autogenic relaxation, and exposure to cognitive restructuring and assertiveness training. We assessed saliva samples, ratings of physical symptoms commonly associated with stress, and self-report of health complaints before and after the 5-week intervention period. Fifty-three participants completed the study. Reductions in stress levels from pre- to postintervention for both treatment and control participants were evident by increases in sIgA secretion rates and salivary flow and decreases in scores on the Undergraduate Stress Questionnaire, the Cohen–Hoberman Inventory of Physical Symptoms, and the Daily Stress Inventory. Treatment participants exhibited further reductions in stress, compared to control participants, as evidenced by lower scores on a subset of the self-report inventories. No treatment effects on sIgA were present. These results suggest that a stress management intervention such as the one used in this study can be beneficial in reducing levels of stress but may not be immunoenhancing.     

Chronic Diseases in the European Union: The Prevalence and Health Cost Implications of Chronic Pain

ABSTRACT

The objective of this study was to assess recent data on the prevalence of chronic pain as part of chronic diseases; the prevalence of chronic pain as a chronic condition in its own right; the costs attributed to chronic pain; and the European Union (EU) policies to addressing chronic pain. Recent literature was reviewed for data on the prevalence and cost implications of chronic pain in the EU. Following on from an earlier systematic review, 8 databases were searched for prevalence and 10 for cost information from 2009 to 2011 and relevant EU organizations were contacted. Ten cost and 29 prevalence studies were included from the 142 full papers screened. The general adult population reported an average chronic pain prevalence of 27%, which was similar to those for common chronic conditions. Fibromyalgia had the highest unemployment rate (6%; Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45) claims for incapacity benefit (up to 29.9%; Sicras-Mainar et al., Arthritis Res Ther. 2009;11:R54), and greatest number of days of absence from work (Rivera et al., Clin Exp Rheumatol. 2009;27[Suppl 56]:S39–S45). Chronic pain is common and the total population cost is high. Despite its high impact, chronic pain as a condition seems to have had little specific policy response. However, there does appear to be sufficient evidence to at least make addressing chronic pain a high priority alongside other chronic diseases as well as to conduct more research, particularly regarding cost.     

Symptoms of Fibromyalgia According to the 2016 Revised Fibromyalgia Criteria in Chronic Pain Patients Referred to Multidisciplinary Pain Rehabilitation: Influence on Clinical and Experimental Pain Sensitivity

Fibromyalgia (FM) is a condition with chronic widespread pain and signs of generalized pain hypersensitivity. FM has previously been classified according to the American College of Rheumatology-1990 criteria, where the presence of hypersensitivity is estimated by a tender point examination. Because of the limitations of these classification criteria, new diagnostic criteria have been proposed, abandoning this examination. This cross-sectional study investigated the prevalence of FM according to the revised 2016 FM criteria in a large cohort of chronic pain patients. Pain drawings, the FM Symptom Severity Scale, and questionnaires assessing manifestations of pain, pain-related disability, and psychological distress were collected from 1,343 patients with chronic nonmalignant pain referred to a multidisciplinary pain clinic. In addition, assessments of mechanical and thermal pain sensitivity were performed in 496 of the patients. Patients fulfilling the FM criteria (n?=?498, 37%) reported significantly higher levels of pain, pain-related disability, psychological distress, and sensitivity to mechanical and heat stimuli (P?<?.05). Moreover, the proportion using opioids were significantly higher compared with patients not fulfilling the criteria (P?=?.015). Significant associations were found between heat and mechanical pain sensitivity (P?<?.001) indicating that patients who showed higher pain sensitivity to mechanical stimulation also showed higher pain sensitivity to thermal stimulation.