Trajectories and Individual Differences in Pain,Emotional Distress,and Prescription Opioid Misuse During the COVID-19 Pandemic: A One-Year Longitudinal Study

Recent studies suggest that the COVID-19 pandemic can serve as a unique psychosocial stressor that can negatively impact individuals with chronic pain. Using a large online sample in the U.S., the present study sought to investigate the impact of the pandemic on the trajectories of pain severity and interference, emotional distress (ie, anxiety and depressive symptoms), and opioid misuse behaviors across one year. Potential moderating effects of socio-demographic factors and individual differences in pain catastrophizing, pain acceptance, and sleep disturbance on outcome trajectories were also examined. Adults with chronic pain were surveyed three times across 1 year (April/May 2020 [N = 1,453]; June/July 2020 [N = 878], and May 2021 [N = 813]) via Amazon's Mechanical Turk online crowdsourcing platform. Mixed-effects growth models revealed that pain severity and interference, emotional distress, and opioid misuse behaviors did not significantly deteriorate across one year during the pandemic. None of the socio-demographic factors, pain catastrophizing, or sleep disturbance moderated outcome trajectories. However, individuals with higher pain acceptance reported greater improvement in pain severity (P< .008, 95% CI: -.0002, -.00004) and depressive symptoms (P< .001, 95% CI: -.001, -.0004) over time. Our findings suggest that the negative impact of the pandemic on pain, emotional distress, and opioid misuse behaviors is quite small overall. The outcome trajectories were also stable across different socio-demographic factors, as well as individual differences in pain catastrophizing and sleep disturbance. Nevertheless, interventions that target improvement of pain acceptance may help individuals with chronic pain be resilient during the pandemic.PerspectiveIndividuals with chronic pain overall did not experience significant exacerbation of pain, emotional distress, and opioid misuse across one year during the COVID-19 pandemic. Individuals with higher pain acceptance showed greater improvement in pain severity and depressive symptoms over time during the pandemic.     

Pain Catastrophizing,Opioid Misuse,Opioid Use,and Opioid Dose in People With Chronic Musculoskeletal Pain: A Systematic Review

The objective of this study was to analyze the cross-sectional and longitudinal association between pain catastrophizing and opioid misuse, opioid use, and opioid dose in people with chronic musculoskeletal pain. For this systematic review, CINAHL, Embase, PsycINFO, PubMed, manual searches, and grey literature were searched from inception to May 2020. Observational studies were included if they evaluated the association between pain catastrophizing and opioid dose, opioid use, and/or opioid misuse in people with chronic musculoskeletal pain. Two reviewers independently performed the study selection, data extraction, risk of bias assessment, and the certainty of the evidence judgment. Seven observational studies (all cross-sectional designs) satisfied the eligibility criteria, with a total sample of 2,160 participants. Pain catastrophizing was associated with opioid misuse. The results were inconsistent regarding the association between pain catastrophizing and opioid use. A lack of association was found considering pain catastrophizing and the opioid dose. However, the presence of risk of bias and imprecision was serious across the included studies, and therefore, the overall certainty of the evidence was judged as very low for all the outcome measures. This report concludes that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. However, the very low certainty of the current evidence confers to interpret the finding of this review as exclusively informative.PerspectiveThis article shows that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. The overall certainty of the evidence was judged to be very low, thus, these results should be interpreted with caution.     

Tapering off long‐term opioid therapy in chronic non‐cancer pain patients: A randomized clinical trial

Background

The indications for initiating long‐term opioid treatment (L‐TOT) for chronic non‐cancer pain (CNCP) are often unclear and associated with problematic use. This study aimed at evaluating the efficacy of stabilizing opioid therapy followed by a sequential opioid tapering off program in CNCP patients.

Methods

A randomized clinical trial with a medications stabilization period (Phase 1) was followed by an opioid tapering off program (Phase 2). In Phase 2, patients were randomized to Control Group (stable treatment) or Taper off Group (sequential opioid dose reduction) and assessed at baseline, after stabilization and up to 6 months. Primary outcomes: measures of cognitive function; secondary outcomes: pain, sleep, rest, quality of life, depression, anxiety, opioid misuse and opioid withdrawal symptoms.

Results

In all, 274 patients were screened; 75 were included, out of which 40 dropped out before Phase 2. Those who succeeded Phase 1 (n = 35) had weak/moderate improvements of psychomotor function (p = 0.020), sleeping hours (p = 0.031), opioid withdrawal symptoms (p = 0.019), measures of quality of life (p ≤ 0.043) and opioid misuse scores (p = 0.003). In Phase 2, patients in Taper off Group (n = 15) experienced stable pain intensity and felt significantly more rested at third assessment than the Control Group (n = 20).

Conclusions

The opioid tapering off program was not successful due to the vast number of dropouts. Phase 1 was associated with weak to moderate improvements on psychomotor function, sleeping, opioid withdrawal symptoms, quality of life and reduced risk of opioid misuse. In the intervention group of Phase 2, pain intensity was stable and patients felt more rested.

Significance

This trial showed that sequential tapering off L‐TOT in CNCP patients may be an unfeasible approach. However, improvements after opioid treatment stabilization were achieved and stable pain intensity in those tapered off may encourage the development of more refined programs.     

Pain Catastrophizing and Negative Mood States After Spinal Cord Injury: Transitioning From Inpatient Rehabilitation Into the Community

Chronic pain is prevalent in people with spinal cord injury (SCI). We investigated how chronic pain intensity and catastrophizing varies in adults with SCI during inpatient rehabilitation up to 12 months postinjury after transitioning into the community. Eighty-eight participants with SCI were assessed for pain intensity and catastrophizing, depressive mood states, and cognitive performance. Participants were divided into subgroups of clinically elevated depressive mood and anxiety versus those with normal mood state levels. The rate of clinically elevated pain catastrophizing was 22.5% at 12 months postinjury. Participants with elevated anxiety reported significantly higher pain intensity 12 months postinjury. Participants with clinically elevated depressive mood and anxiety reported significantly elevated pain catastrophizing 12 month postinjury. Findings indicate those with elevated depressive mood states will be more likely to have high levels of pain and engage in cognitive appraisals involving pain-related catastrophizing. Importantly, however, risk of increased pain intensity and catastrophizing occurred only after transitioning into the community, when personal resources will be severely challenged. Implications of these results for models of pain catastrophizing are discussed and it is concluded there is a need for ongoing support in the community to develop self-management skills and strategies that strengthen social support networks.

Attachment and Pain Outcomes in Adolescents: The Mediating Role of Pain Catastrophizing and Anxiety

This study examined the relations between attachment styles and pain severity/depression in adolescents. Analyses examined whether anxiety and the 3 dimensions of pain catastrophizing mediated the associations between attachment styles, pain severity and depression. A total of 382 high-school students completed questionnaires assessing attachment styles, catastrophizing, depression, anxiety and, for those who reported pain during the last month, pain severity. Results revealed that secure attachment was associated with lower levels of pain severity, depression, pain catastrophizing and anxiety. Preoccupied and fearful attachment styles were associated with heightened pain severity, depression, pain catastrophizing and anxiety. Dismissing attachment style was only associated with high levels of depression and anxiety. Regression analyses revealed that anxiety and the helplessness dimension of pain catastrophizing mediated the relations between secure, preoccupied and fearful attachment styles and pain severity. Moreover, anxiety and the rumination dimension of pain catastrophizing mediated the relation between secure, preoccupied and fearful attachment styles and depression. These findings suggest that anxiety, pain catastrophizing and attachment styles are related processes but nevertheless make independent contributions to the prediction of pain severity and depression. In addition, these findings suggest that attachment styles and cognitive-affective factors might increase the risk of problematic outcomes in adolescents with pain conditions. Theoretical and clinical implications of these results are discussed.PerspectiveThe results of this study revealed that anxiety and the helplessness dimension of pain catastrophizing mediated the relation between attachment and pain severity whereas anxiety and rumination mediated the relation between attachment and depression. Attachment style and cognitive-affective factors might increase vulnerability for problematic pain outcomes in adolescents.     

Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain

The value of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) patients is determined by a balance of poorly understood benefits and harms. Traditionally, this balance has been framed as the potential for improved pain control versus risks of iatrogenic addiction, drug diversion, and aberrant drug-related behaviors. These potential harms are typically defined from the providers’ perspective. This paper seeks to clarify difficulties with the long-term use of opioids for CNCP from the patients’ perspective. We used the Prescribed Opioids Difficulties Scale (PODS) to assess current problems and concerns attributed to opioid use by 1144 adults receiving COT. Subjects were grouped into low (56.9%), medium (25.6%) and high (17.5%) PODS scorers. Among patients with high PODS scores, 64% were clinically depressed and 78% experienced high levels of pain-related interference with activities, compared to 28% depressed and 60% with high interference with activities among those with low PODS scores. High levels of opioid-related problems and concerns were not explained by differences in pain intensity or persistence. Patients with medium to high PODS scores were often concerned about their ability to control their use of opioid medications, but prior substance abuse diagnoses and receiving excess days supply of opioids were much less common in these patients than depression and pain-related interference with activities. These results suggest two types of potential harm from COT attributed by CNCP patients to opioids: psychosocial problems that are distinct from poor pain control and opioid control concerns that are distinct from opioid misuse or addiction.     

Depression and Coping Behaviors Are Key Factors in Understanding Pain in Interstitial Cystitis/Bladder Pain Syndrome

Background: Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a urologic chronic pelvic pain syndrome with suboptimal treatment outcomes. Catastrophizing is an empirically supported risk factor for greater IC/BPS pain. Aims: In this study, a moderated multiple mediation model is tested in which several additional psychosocial risk factors (depression, illness and wellness-focused behavioral coping strategies) are proposed as mediators or moderators in the existing relationship between catastrophizing and IC/BPS pain. Design: The present questionnaire study employed a cross-sectional design. Settings and Participants: Female patients with an IC/BPS diagnosis (n = 341) were recruited at tertiary care sites. Methods: Participants completed questionnaires assessing pain, catastrophizing, behavioral coping strategies, and depressive symptoms. Aggregate factor scores were calculated following exploratory factor analyses. Results: It was found that patients with a greater tendency to catastrophize were more likely to engage in illness-focused coping strategies, which contributed to the reporting of greater sensory and affective pain. Furthermore, this mediating effect of illness-focused coping on affective pain was more likely to occur in those patients reporting greater depressive symptoms. Conclusions: Illness-focused behavioral coping is an important mechanism between maladaptive pain cognition and aspects of patient pain, with patients reporting greater depressive symptoms at increased risk for elevated pain. Patient management techniques, including screening for catastrophizing, coping, and depression, are recommended to enrich IC/BPS management.     

An Experimental Approach to Examining Psychological Contributions to Multisite Musculoskeletal Pain

The present study examined the prospective value of pain catastrophizing, fear of pain, and depression in the prediction of multisite musculoskeletal pain following experimentally induced delayed-onset muscle soreness (DOMS). The study sample consisted of 119 (63 females, 56 males) healthy university students. Measures of pain catastrophizing, fear of pain, and depression were completed prior to the DOMS induction procedure. Analyses revealed that pain catastrophizing and fear of pain prospectively predicted the experience of multisite pain following DOMS induction. Analyses also revealed that women were more likely to experience multisite pain than men. There was no significant relation between depressive symptoms and the experience of multisite pain. The discussion addresses the mechanisms by which pain catastrophizing and fear of pain might contribute to the spreading of pain. Clinical implications of the findings are also addressed.PerspectiveThe results of this experimental study suggest that pain catastrophizing and fear of pain might increase the risk of developing multisite pain following musculoskeletal injury.     

Factors Associated with Depression in African American Patients Being Treated for Cancer Pain

BackgroundAmong cancer patients in the United States, African American cancer patients have the highest mortality rate and shortest survival rate. Although depression is known as a predictor of mortality in cancer and a potential barrier to health care utilization, research on depression in African American patients is limited. Cancer pain can interfere with an individual’s ability to cope with depression.AimsTo identify factors that are associated with a positive screening of depressive symptoms assessed by the PHQ-8 in African American patients treated for cancer pain.DesignSecondary data analysis of a cross-sectional study of opioid adherence.SettingMedical oncology, palliative care, and radiation oncology clinics in Atlanta, Georgia.Participants/SubjectsAfrican American patients with cancer pain in the parent study.MethodsIndependent samples t-test was used to assess variable correlations with and without depressive symptoms. Adjusted logistic regression was conducted to identify factors that were associated with presence of depressive symptoms.ResultsMean patient age was 55.6 years, and nearly 38% had a PHQ-8 score of >10 indicating presence of moderate to severe depressive symptoms. Participants with depressive symptoms had significantly higher means for anxiety and pain interference with mood than those without depressive symptoms. Factors that were significantly associated with depressive symptoms were anxiety, pain interfering with mood, and lack of involvement with a religious congregation.ConclusionsThe findings of this study help to identify African American cancer patients at risk for depression and demonstrates the need for increased screening for depression in this underserved population.     

Depressive and Insomnia Symptoms Sequentially Mediate the Association Between Racism-Based Discrimination in Healthcare Settings and Clinical Pain Among Adults With Sickle Cell Disease

Racism-based discrimination in healthcare settings has been associated with clinical pain in adults living with sickle cell disease; however, no studies have examined depressive and insomnia symptoms as mechanisms that may drive this relationship. This secondary data analysis examined associations between depressive and insomnia symptoms, racism-based discrimination, and clinical pain. Seventy-one adults with sickle cell disease (70% female, M_age = 38.79) provided baseline reports of racism-based discrimination, depressive symptoms, insomnia symptoms, and pain (severity, interference, catastrophizing), and they completed daily diaries of pain severity and interference over 3 months. In a sequential mediation model, baseline depressive (1st) and insomnia symptoms (2nd) significantly mediated the association between racism-based discrimination and baseline pain interference, average daily diary pain severity, and average daily diary pain interference. Although the mediation model with baseline pain severity as the outcome was significant, the total and direct effects were not. Results indicate that discrimination in healthcare settings contributes to depression, which may act on pain through sleep disturbance. Findings support the need for systemic and structural changes to eliminate discrimination in healthcare settings and behavioral mood and sleep interventions to reduce the impact of discrimination on clinical pain.PerspectiveThe relationship between discrimination in healthcare settings and pain in adults with sickle cell disease may be driven by depression and sleep disturbance, modifiable risk factors and potential treatment targets. Results suggest that systemic, structural, and institutional changes must be implemented to promote better patient care and health outcomes.