Endogenous Opioid Function and Responses to Morphine: The Moderating Effects of Anger Expressiveness

Long-term use of opioid analgesics may be ineffective or associated with significant negative side effects for some people. At present, there is no sound method of identifying optimal opioid candidates. Individuals with chronic low back pain (n = 89) and healthy control individuals (n = 102) underwent ischemic pain induction with placebo, opioid blockade (naloxone), and morphine in counterbalanced order. They completed the Spielberger Anger-Out subscale. Endogenous opioid function × Anger-out × Pain status (chronic pain, healthy control) interactions were tested for morphine responses to ischemic threshold, tolerance, and pain intensity (McGill Sensory and Affective subscales) and side effects. For individuals with chronic pain and healthy control participants, those with low endogenous opioid function and low anger-out scores exhibited the largest morphine analgesic responses, whereas those with high anger-out and low endogenous opioid function showed relatively weaker morphine analgesic responses. Further, individuals with chronic pain with low endogenous opioid function and low anger-out scores also reported the fewest negative effects to morphine, whereas those with low endogenous opioid function and high anger-out reported the most. Findings point toward individuals with chronic pain who may strike a favorable balance of good analgesia with few side effects, as well as those who have an unfavorable balance of poor analgesia and many side effects.

Neuropathic Pain in Low Back-Related Leg Pain Patients: What Is the Evidence of Prevalence,Characteristics, and Prognosis in Primary Care? A Systematic Review of the Literature

This systematic review synthesizes literature describing prevalence, characteristics, and prognosis of low back-related leg pain (LBLP) patients with neuropathic pain in primary care and/or similar settings. Inclusion and exclusion criteria were developed and used by independent reviewers to screen citations for eligibility. The initial search yielded 24,948 citations; after screening 12 studies were included. Neuropathic pain was identified using case ascertainment tools (n = 5), clinical history with examination (n = 4), and using LBLP samples assumed neuropathic (n = 3). Neuropathic pain prevalence varied from 19% to 80%. There was consistent evidence for higher back-related disability (n = 3), poorer health-related quality of life (n = 2), and some evidence for more severe depression (n = 2), anxiety (n = 3), and pain intensity (n = 4) in patients with neuropathic pain. Results were less consistent when cases were identified through clinical history with examination than those identified using case ascertainment tools. Prognosis (n = 1) of LBLP patients with neuropathic pain was worse compared with those without, in all outcomes (leg pain intensity, leg and back-related disability, self-reported general health) except back pain intensity. No studies described prognostic factors. This systematic review highlights the evidence gap in neuropathic pain in LBLP in primary care, especially with respect to prognosis.

An Integrative Review of Interventions to Support Parents When Managing Their Child's Pain at Home

To identify interventions aimed at helping parents manage their child's pain at home and to establish which aspects of interventions were effective. Integrative narrative review. MEDLINE, CINAHL Plus, PsychINFO, PsychArticles, AMED, PubMed, Scopus and Web of Knowledge databases were searched in 2016. This narrative synthesis followed Centre for Reviews and Dissemination and Economic and Social Research Council guidance. Reasons attributed to intervention success were analyzed using content analysis. From 2,534 papers, 17 were included. A majority were randomized controlled trials (n = 13) and most addressed postoperative pain (n = 15). A range of interventions were found that directly targeted parents, including child-parent interactions and health care professional–parent interactions, as well as complex interventions. Three studies were successful in reducing child pain at home and seven in increasing appropriate analgesic drug administration. Analysis of reasons attributed to interventions success revealed characteristics of interventions, components of parental pain management, and key features of research that aid researchers in designing and evaluating interventions. Risk of bias was present because of inadequate randomization, lack of a control group, and underpowered studies. Nurses should be aware that targeting parents directly is the most effective way of reducing child pain at home. Nurses need to advocate for effective analgesics for their child patients because the ineffectiveness of many interventions was attributed to inadequate analgesic drugs. Once this is achieved, success in increasing analgesic drug administration is most likely reached via parent-targeted interventions and those targeting health care professional–parent interactions. Successful interventions will be tailored to the child and adequately powered. Including a measure of sedation will ensure sedation is not mistaken for analgesic effectiveness. Interventions should address multiple facets of pain management and include a measure of pain over a period as opposed to a snapshot in time.     

Patient and Health Care Provider Responses from a Prospective,Double-Blind,Randomized Controlled Trial Comparing Vapocoolant Spray versus Placebo Spray in Adults Undergoing Venipuncture in the Emergency Department

Background: Painful medical procedures are common. Topical anesthetics are easily applied, rapid onset, inexpensive, and avoid injection pain and needlestick injury. The aims of this study, using patient and health care provider questionnaires, were to answer the following questions: (1) Does vapocoolant spray decrease venipuncture pain? (2) Would patients be satisfied with and use a vapocoolant spray in the future? (3) Would providers be satisfied with and use a vapocoolant spray in the future? Design: Adults (18-80 years) in a hospital emergency department (ED) were randomly assigned to sterile water placebo spray (S) (N = 50) or vapocoolant spray (V) (N = 50) before venipuncture. Questionnaires were completed by patients undergoing venipuncture (N = 100) and the health care providers (N = 100) who performed the venipuncture (total questionnaires = 200) as part of a prospective, double-blind, randomized controlled trial comparing the efficacy and safety of vapocoolant spray compared with placebo spray in patients undergoing venipuncture in the ED. Results: Patient and venipuncture variables were not significantly different for the two groups (S vs. V). Responses to the questionnaires were significantly different for the S versus V groups for both the patients and the health care providers. Patient questionnaires: Did you have less pain with spray? S 14%, V 76% (p < .001). Compared with previous blood draws, the spray was much more painful/more painful: S 10%, V 6%; same: S 76%, V 16%; less painful/much less painful: S 14%, V 78% (p < .001). How satisfied were you with the spray? Satisfied/very satisfied: S 20%, V 74% (p < .001). Would you use this spray in future? Yes S 20%, V 80% (p < .001). Provider results: The patient had less pain with the use of the spray: S 14%, V 78% (p < .001). How satisfied were you with the use of the spray? Satisfied/very satisfied: S 12%, V 82% (p < .001). Would you use this spray in the future? Yes S 24%, V 84% (p < .001). Conclusions: The use of a vapocoolant spray in adult ED patients undergoing venipuncture significantly decreased venipuncture pain, was associated with high patient and provider satisfaction, and both patients and providers would use a vapocoolant spray in the future for venipuncture and other painful procedures.     

Patient Characteristics from an Emergency Care Center in Rural Western Kenya

Background

Emergency care is a neglected area of focus in many low- and middle-income countries. There is a paucity of research on types and frequencies of acute illnesses and injuries in low-resource settings.

U.S. board-certified pain physician practices: uniformity and census data of their locations.

We determined the profiles of the board-certified pain physician workforce and the profiles of those residing near medical pain practices. Data from a mail survey of U.S. pain specialists were compared with U.S. Census data, and different settings and types of practices were contrasted. The 750 respondents (32.1%) were similar to the entire board-certified group in age, geographic distribution, and primary specialty. Although pain practices were underrepresented in rural areas, their prevalence was unrelated to other demographic data. Ninety-six percent of pain physicians treated chronic pain; 84% followed patients longitudinally; 31% worked in an academic environment; 50% had an interdisciplinary practice; and 29% focused on a single modality. Academics were more likely to be neurologists (P < .05) and to have had a pain fellowship (P < or = .0001). Modality-oriented practitioners were more likely to be anesthesiologists (P < or = .0001) and were less likely to follow patients with chronic pain longitudinally (P < or = .0001), provide training to fellows, prescribe controlled substances (P < or = .0001, respectively), or require an opioid contract (P < or = .01). Although boarded specialists learn from similar curricula and must pass a certifying examination, their practices vary considerably. Data are needed to further clarify the nature of workforce variation, its impact on patient care, and the role of other pain management clinicians. PERSPECTIVE: A survey of board-certified pain specialists reveals considerable variation in practice and a total number of specialists that is probably insufficient to meet the needs of the population with chronic pain. The location of pain management practices largely corresponds to census data, with the exception of underrepresentation in rural areas.     

Managing Pain in the Setting of Opioid Use Disorder

Specific Clinical IssueHealthcare providers are challenged with managing pain and minimizing morbidity and mortality associated with opioid use disorder.Major Practice Recommendations Based on Best EvidenceThe purpose of this article is to guide acute and ambulatory care clinicians in managing pain in patients with opioid use disorder. Included in this article is a review of medications used for opioid use disorder, a discussion of the management of patients with active opioid use disorder and acute or chronic pain, and a discussion of the management of acute and chronic pain in people in recovery both on and off medications for opioid use disorder.     

Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression

BackgroundGiven the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management.MethodsThis paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n = 77) and to usual care (n = 77).ConclusionsUsual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.     

Neighborhood,Socioeconomic, and Racial Influence on Chronic Pain

The purpose of this review is to highlight the neighborhood, socioeconomic, and racial influences on chronic pain. Negative influences on the experience of chronic pain are explored and defined as any adverse stressor common in low socioeconomic, urban neighborhoods that potentially contributes to health disparity in African Americans experiencing chronic pain. The multifactorial influences on chronic pain disparity in African Americans are explored and expounded upon in this review of existing evidence. Databases used for the search included CINAHL, PubMed, and PsycArticles. The experience of chronic pain is multifaceted, existing with multiple comorbidities and lasting consequences. To improve the burden of chronic pain requires a multifactorial assessment that considers neighborhood risk factors, emphasis on environmental stressors, limitations to support networks, barriers to physical activity, and access to primary care providers with whom communication is open and without bias. A comprehensive assessment of barriers will aid in the development of interventions that reach beyond the physical factors of chronic pain, also considering the psychosocial barriers to improving the burden of chronic pain in African Americans living in impoverished urban neighborhoods.     

Evaluation of Chronic,Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic

BackgroundChronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016).AimsThe aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids.MethodsA retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic.ResultsParticipants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy.ConclusionsAPRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.     

Alcohol and smoking behavior in chronic pain patients: The role of opioids

The primary aim of this epidemiological study was to investigate associations between chronic non-cancer pain with or without opioid treatment and the alcohol and smoking behavior. The secondary aims were to investigate self-reported quality of life, sleeping problems, oral health and the use of different health care providers.The Danish health survey of 2005 was based on a region-stratified random sample of 10.916 individuals. Data were collected via personal interviews and self-administrated questionnaires. Respondents suffering from chronic pain were identified through the question ‘Do you have chronic/long-lasting pain lasting 6 months or more?’ The question concerning alcohol intake assessed the frequency of alcohol intake and binge drinking. Smoking behavior assessed the daily number of cigarettes. Individuals reporting chronic pain were stratified into two groups (opioid users and non-opioid users).In all, 7275 individuals completed a personal interview and 5552 individuals completed and returned the self-administrated questionnaire. Responders with a self-reported earlier or present cancer diagnosis were excluded from the study. Hence, the final study population consisted of 5292 individuals.We found, that individuals suffering from chronic pain were less likely to drink alcohol. In opioid users alcohol consumption was further reduced. Cigarette smoking was significantly increased in individuals suffering from chronic pain and in opioid users smoking was further increased. Poor oral health, quality of life and sleep were markedly associated with chronic pain and opioid use. The use of opioids was associated with significantly more contacts to healthcare care providers.     

Preliminary investigation into sport and exercise psychology consultants’ views and experiences of an interprofessional care team approach to sport injury rehabilitation

Sport injury rehabilitation has moved from predominately physical treatment to a more holistic care. However, limited research has explored the views and experiences of those involved in such an approach. The purpose of this study was to preliminarily investigate sport psychology consultants’ (SPCs’) views and experiences of an interprofessional team approach to sport injury rehabilitation. A cross-sectional online survey previously used with athletic trainers was distributed via a US-based sport/exercise psychology list-serve (N = 1245). A total of 62 (27 men, 35 women, M age 38.2 years, age range: 22–73 years) participants with 10.6 (SD = 9.8) years of experience as an SPC were included in the final analyses. On average, SPCs felt that it was very important (M = 6.6; SD = 0.6) for athletes to have access to an interprofessional care team. Of the sample, 64.5% (n = 40) typically worked as part of an interprofessional care team 44.7% of the time. The SPCs (n = 28; 45.2%) also indicated that the primary treatment providers (e.g., athletic trainer, physical therapist) were typically serving as the primary point person for such teams. Since gaining entry to sport medicine can be an area SPCs struggle with, building effective working relationships with treatment providers can help promote and increase SPCs involvement in providing holistic, interprofessional care to athletes with injuries. To ensure athletes’ successful biopsychosocial return to sport, different individuals and professionals should work together for the benefit of the athlete by adopting holistic care during sports injury rehabilitation.     

Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care

Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N = 1440) age 20 to 75 with a BMI 30–45 kg/m². In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care.