Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals

Context

The treatment of pain in patients with substance use disorders creates tensions for clinicians between undertreating pain and enabling opioid analgesic misuse.

Objectives

To characterize prevalence and factors associated with aberrant opioid analgesic behaviors in a cohort of HIV-infected individuals who are at high risk for opioid analgesic misuse.

Methods

We assessed pain and substance use disorders in a cross-sectional study that enrolled 296 participants from the Research on Access to Care in the Homeless cohort, a community-based sample of indigent HIV-infected adults. We measured aberrant opioid behaviors, defined as major or minor depending on level of risk of harm to patients, using Audio Computer-Assisted Self-Interview technology.

Results

Most participants (91.2%) reported pain in the week before interview, with the majority of these experiencing severe pain (53.7%). More than two-thirds (69.2%) of the participants met criteria for a lifetime history of cocaine, amphetamine, or heroin/opioid use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). More than one-third of the sample (37.4%) had a history of aberrant opioid behavior within 90 days of interview. One-fifth (18.5%) had a history of “major” aberrant behaviors.

Conclusion

In this high-risk population, severe pain is common and aberrant opioid behaviors are prevalent but not universal. As recommended by American Pain Society and American Academy of Pain Medicine guidelines, when prescribing opioid analgesics, clinicians must consider variation in the severity of aberrant behaviors, particularly aberrant behaviors that may represent undertreatment of pain.     

A comparative study of substance use before and after establishing HIV infection status among people living with HIV/AIDS

OBJECTIVE: To determine if significant differences exist in substance use among people living with HIV/AIDS (PLWHA) before and after establishing their HIV infection status. METHOD: The study participants are HIV positive clients of a community based HIV/AIDS outreach facility located in Montgomery, Alabama. The questionnaire includes demographics, substance use and risky sexual behaviors pertaining to HIV transmission. Each participant completed an anonymous questionnaire. A total of 341 questionnaires were distributed and 326 were fully completed and returned, representing a response rate of 96%. RESULTS: Findings revealed a statistically significant difference in alcohol consumption before sex among PLWHA before and after establishing their HIV infection status (p = .001). No significant differences were observed among participants who reported as having used drugs intravenously (p = .89), and among those sharing the same syringe/needle with another person (p = .87) before and after establishing their HIV infection status. CONCLUSION: There is continued substance use and alcohol consumption before sex among PLWHA after establishing their HIV status despite clear evidence of such risky behaviors that could lead to an increase in exposure to HIV.     

Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study

Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0–10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4–3.7), arthritis (AOR: 4.8, 95% CI, 3.0–7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3–4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness.

A comparative study of substance use before and after establishing HIV infection status among people living with HIV/AIDS

Objective: To determine if significant differences exist in substance use among people living with HIV/AIDS (PLWHA) before and after establishing their HIV infection status.

Method: The study participants are HIV positive clients of a community based HIV/AIDS outreach facility located in Montgomery, Alabama. The questionnaire includes demographics, substance use and risky sexual behaviors pertaining to HIV transmission. Each participant completed an anonymous questionnaire. A total of 341 questionnaires were distributed and 326 were fully completed and returned, representing a response rate of 96%.

Results: Findings revealed a statistically significant difference in alcohol consumption before sex among PLWHA before and after establishing their HIV infection status (p = .001). No significant differences were observed among participants who reported as having used drugs intravenously (p = .89), and among those sharing the same syringe/needle with another person (p = .87) before and after establishing their HIV infection status.

Conclusion: There is continued substance use and alcohol consumption before sex among PLWHA after establishing their HIV status despite clear evidence of such risky behaviors that could lead to an increase in exposure to HIV.     

Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

Context

Chronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT).

The relationship between PTSD and chronic pain: Mediating role of coping strategies and depression

People with chronic pain and comorbid posttraumatic stress disorder (PTSD) report more severe pain and poorer quality of life than those with chronic pain alone. This study evaluated the extent to which associations between PTSD and chronic pain interference and severity are mediated by pain-related coping strategies and depressive symptoms. Veterans with chronic pain were divided into 2 groups, those with (n = 65) and those without (n = 136) concurrent PTSD. All participants completed measures of pain severity, interference, emotional functioning, and coping strategies. Those with current PTSD reported significantly greater pain severity and pain interference, had more symptoms of depression, and were more likely to meet diagnostic criteria for a current alcohol or substance use disorder (all p-values <.01). Participants with PTSD reported more use of several coping strategies, including guarding, resting, relaxation, exercise/stretching, and coping self-statements. Illness-focused pain coping (i.e., guarding, resting, and asking for assistance) and depressive symptoms jointly mediated the relationship between PTSD and both pain interference (total indirect effect = 0.194, p < .001) and pain severity (total indirect effect = 0.153, p = .004). Illness-focused pain coping also evidenced specific mediating effects, independent of depression. In summary, specific pain coping strategies and depressive symptoms partially mediated the relationship between PTSD and both pain interference and severity. Future research should examine whether changes in types of coping strategies after targeted treatments predict improvements in pain-related function for chronic pain patients with concurrent PTSD.     

The burden of chronic pain: A cross-sectional survey focussing on diseases,immigration, and opioid use

Chronic pain is currently considered a public health problem with high costs to the individual and society. To improve prevention and treatment of chronic pain, epidemiologic studies are mandatory for assessing chronic pain. The aims of this study were to estimate the prevalence of chronic pain in the adult Danish population and to analyze associated factors such as diseases, immigration, and opioid use. This cross-sectional survey combines individual-based information from the Danish Health Survey (2010) and official Danish health and socioeconomic, individual-based registers. The simple random sample consisted of 25000 individuals (?16 years old) living in Denmark. In all, 60.7% completed a mailed or online questionnaire. Associations were examined with multiple logistic regression analysis. The study population consisted of 14925 individuals in whom a high prevalence of chronic pain (26.8%, 95% confidence interval: 26.1 to 27.5) and a high prevalence of opioid consumption (4.5%) were observed. Other aspects of particular note: (1) a higher prevalence of chronic pain occurred among individuals with cardiovascular and chronic pulmonary diseases than among individuals with cancer; and (2) individuals with a non-Western background reported a higher pain prevalence, higher pain intensities, and more widespread pain than individuals with Danish background; however, opioids were more frequently used by native Danes. The prevalence of chronic pain as well as opioid use in Denmark are alarmingly high, and the relevance of opioid consumption is unknown.     

Endogenous opioids may buffer effects of anger arousal on sensitivity to subsequent pain

Evidence suggests that anger and pain are related, yet it is not clear by what mechanisms anger may influence pain. We have proposed that effects of anger states and traits on pain sensitivity are partly opioid mediated. In this study, we test the extent to which analgesic effects of acute anger arousal on subsequent pain sensitivity are opioid mediated by subjecting healthy participants to anger-induction and pain either under opioid blockade (oral naltrexone) or placebo. Participants were 160 healthy individuals. A double-blind, placebo-controlled, between-subjects opioid blockade design is used, with participants assigned randomly to one of two drug conditions (placebo or naltrexone), and to one of two Task Orders (anger-induction followed by pain or vice versa). Results of ANOVAs show significant Drug Condition × Task Order interactions for sensory pain ratings (MPQ-Sensory) and angry and nervous affect during pain-induction, such that participants who underwent anger-induction prior to pain while under opioid blockade (naltrexone) reported more pain, and anger and nervousness than those who underwent the tasks in the same order, but did so on placebo. Results suggest that for people with intact opioid systems, acute anger arousal may trigger endogenous opioid release that reduces subsequent responsiveness to pain. Conversely, impaired endogenous opioid function, such as that found among some chronic pain patients, may leave certain people without optimal buffering from the otherwise hyperalgesic affects of anger arousal, and so may lead to greater pain and suffering following upsetting or angry events.     

Alcohol and Opioid Use in Chronic Pain: A Cross-Sectional Examination of Differences in Functioning Based on Misuse Status

Opioid misuse is regularly associated with disrupted functioning in those with chronic pain. Less work has examined whether alcohol misuse may also interfere with functioning. This study examined frequency of opioid and alcohol misuse in 131 individuals (61.1% female) prescribed opioids for the treatment of chronic pain. Participants completed an anonymous survey online, consisting of measures of pain, functioning, and opioid and alcohol misuse. Cut scores were used to categorize individuals according to substance misuse status. Individuals were categorized as follows: 35.9% (n?=?47) were not misusing either opioids or alcohol, 22.9% (n?=?30) were misusing both opioids and alcohol, 38.2% (n = 50) were misusing opioids alone, and only 3.0% (n?=?4) were misusing alcohol alone. A multivariate analysis of variance was performed to examine differences in pain and functioning between groups (after excluding individuals in the alcohol misuse group due to the small sample size). Group comparisons indicated that individuals who were not misusing either substance were less disabled and distressed in comparison to those who were misusing opioids alone or both opioids and alcohol. No differences were indicated between the latter 2 groups. Overall, the observed frequency of opioid misuse was somewhat higher in comparison to previous work (approximately 1 out of every 3 participants), and misuse of both alcohol and opioids was common (approximately 1 out of every 5 participants). While these data are preliminary, they do suggest that issues of substance misuse in those with chronic pain extends beyond opioids alone.

Strategies to build and maintain competence in pain management: Insights from a SIAARTI survey on educational needs among Italian anesthesiologists

Purpose

Fulfilling educational needs in pain management should be a lifelong process, even involving physicians board certified in pain medicine such as the anesthesiologists/pain therapists. The aim of the study was to investigate Italian anesthesiologists' self-perceived competency, confidence, and interest to attend educational programs in relation to their seniority in pain management.

Methods

SIAARTI members were sent an online questionnaire addressing the following items: education, skills (both soft and hard skills), technical expertise and engaged to participate between December 2020 and January 2021. Participants rated their competence based on the following range (no knowledge, knowledge, competence) while their agreement to attend educational courses was assessed using a 5-point Likert-type scale.

Results

Less than one in four participants declare to be dedicated to pain medicine activity with greater proportion among older (over 61 years) compared to younger ones (31–40 years). Regarding cancer and chronic noncancer pain a positive gradient of self-perceived competence has been observed in relation to seniority. In contrast, no gradient of self-perceived competence was reported about musculoskeletal and low back pain. Participants self-perceived competent in both opioid use and prevention of opioid-related adverse event while feeling less competent when managing drugs with abuse potential. The lowest competence has been observed in pediatric pain along with the lowest interest to attend educational courses. Participants were much and very much interested to education regarding cancer, noncancer, musculoskeletal, and low back pain, invasive analgesic procedures but less regarding items for which they declared less competence, such as use of pain scales, pain management in children, and use of drugs with abuse potential.

Conclusion

This work provides first evidence of a summative assessment of competency and related educational needs' profile of anesthesiologists/pain therapists thus paving the way for developing a nationwide educational program to improve chronic pain care in Italy.     

Dysfunctional Pain Modulation in Torture Survivors: The Mediating Effect of PTSD

Trauma survivors, and particularly torture survivors, suffer from high rates of chronic pain and posttraumatic stress disorder (PTSD) for years afterward, along with alterations in the function of the pain system. On the basis of longitudinal data on PTSD symptomatology, we tested whether exposure to torture, PTSD or PTSD trajectories accounted for chronic pain and altered pain perception. Participants were 59 torture survivors and 44 age-matched healthy control subjects. Chronic pain was characterized. Pain threshold, pain tolerance, conditioned pain modulation (CPM), and temporal summation of pain were measured. Three PTSD trajectories were identified among torture survivors; chronic, delayed, and resilient. Lack of CPM and more intense chronic pain was found among the chronic and delayed groups compared with the resilient and healthy control groups. Temporal summation of pain was strongest among the chronic group. PTSD trajectories mediated the relationship between torture and CPM. It appears that the duration and severity of posttraumatic distress, rather than the exposure to trauma, are crucial factors that mediate the association between trauma and chronic pain. Because PTSD and its resultant distress are measurable, their evaluation seems particularly important in the management of pain among trauma survivors. The results may be generalized to other instances in which chronic pain persists after traumatic events.

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission

Use of opioids for chronic non-cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six-month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between- and within-group differences. Treatment involved a 3-week interdisciplinary pain rehabilitation program focused on functional restoration. Over one-half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low- and high-dose opioids reported significantly greater pain severity (P=.001) and depression (P=.001) than the non-opioid group. Significant improvement was found on all outcome variables following treatment (P<.001) and six-month posttreatment (P<.001) regardless of opioid status at admission. There were no differences between the opioid and non-opioid groups upon discharge from the program or at six months following treatment. Conclusion: Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.     

A population-based study on chronic pain and the use of opioids in Portugal

Although increasing doubts exist regarding the long-term effectiveness and safety of opioids in patients with chronic pain (CP), most guidelines still recognize opioids as an option in effective management of CP. We aimed to describe the prevalence and factors associated with opioid use in subjects with CP in Portugal and to evaluate satisfaction and self-assessed treatment effectiveness. A nationwide study was conducted in a representative sample of the adult Portuguese population. The 5094 participants were selected using random digit dialing and estimates were adequately weighted for the population. The prevalence of opioid use by subjects with CP was 4.37% (95% confidence interval [CI] 3.4–5.5); and in subjects experiencing CP with and without cancer, it was 10.13% and 4.24%, respectively. Use of strong opioids was reported by only 0.17% of CP subjects. Sex, pain severity and symptoms of depression and anxiety were significantly associated with opioid use; however, in multivariate modeling, only pain-related disability remained significant. No significant differences among users and nonusers of opioids were observed regarding treatment satisfaction and self-assessed effectiveness. Although extremely high rates of use of opioids exist in a few countries, it should not be seen as a ubiquitous problem. Indeed, we showed that in Portugal, as in many other regions in the world, opioids are used much less frequently than in those few countries. Moreover, we did not find significant differences among users and nonusers of opioids regarding satisfaction and self-assessed effectiveness, eventually showing the results to be in line with reports that show doubt about opioids’ effectiveness. Further research and particular attention to and continuous monitoring of the trends of use and abuse of opioids worldwide are recommended.     

Doctor Recommendations are Related to Patient Interest and Use of Behavioral Treatment for Chronic Pain and Addiction

The opioid crisis has highlighted the importance of improving patients’ access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1,000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk to investigate participants’ use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments.PerspectiveThis study provides information around chronic pain patients’ treatment interests, treatment receipt, and recommendation receipt for behavioral pain management and addiction treatment. This study could help facilitate communication between patients and doctors regarding available treatments for chronic pain and pain treatment-related addiction problems.     

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management.

Influence of Abuse History on Concurrent Benzodiazepine and Opioid Use in Chronic Pain Patients

An important predictor of opioid overdose is co-use of benzodiazepines, which are often prescribed for anxiety. Coping with anxiety may be particularly difficult among individuals with a history of abuse, as it is often linked to higher pain severity and poorer coping skills. We explored whether abuse history moderated the association between anxiety and benzodiazepine use among current opioid users. New patients at a tertiary care, outpatient pain clinic completed self-report measures of medication use, anxiety, and physical and sexual abuse history (child abuse only, adult abuse only, or cumulative abuse). The present study included adult patients reporting current opioid use (n?=?1,785). Approximately 16% reported co-use of benzodiazepines, and 17% reported a history of abuse. Patients reporting child abuse only and cumulative abuse reported co-use of benzodiazepines and opioids more often than those denying abuse and patients reporting adult abuse only (P < .001). Multivariate logistic regression analyses showed that the probability of benzodiazepine use among patients reporting cumulative abuse increased sharply at high levels of anxiety (P?=?.003). Cumulative abuse may increase sensitivity to psychological distress and put patients at risk for co-use. Providers should be aware of life history factors, including abuse, that may drive the need for medication.Perspective: This article examines the association between history of abuse victimization and co-use of benzodiazepines among chronic pain patients reporting current opioid use. The findings suggest that cumulative victimization across the lifespan may contribute to co-use by increasing sensitivity to psychological or physical distress or by negatively impacting coping skills.