Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020

Integrating Complex Pain Concepts Into Prelicensure Nursing Education: An Unfolding Case Study to Enhance Clinical Reasoning and Competency

BACKGROUND

Unfolding case studies are an active learning strategy that help students integrate knowledge with practical experience, enhancing clinical judgment and easing their transition into professional practice.

PROBLEM

Chronic pain, a complex health issue, is often inadequately addressed in nursing curricula, leaving prelicensure nursing students unprepared to manage pain effectively in clinical practice, contributing to the academic-practice gap.

APPROACH

Using an evidence matrix, faculty interviews, and syllabi analysis across 4 programs, gaps in chronic pain concepts were identified. A 4-term unfolding case study was developed to address these gaps, aligned with the American Association of College of Nursing Essentials and following a patient from acute to chronic pain transition.

CONCLUSIONS

By incorporating evidence-based, active learning strategies like an unfolding case study for a complex concept such as chronic pain management scaffolded across a curriculum, nurse educators can better prepare future nurses for practice.

The Rise in American Pain: The Importance of the Great Recession

A significant literature has documented trend increases in pain among Americans over the last 2 or 3 decades. There is no consensus on the reason for the trend, with no single explanation seeming to work well. We show that, rather than resulting from a smooth upward trend, the increase was almost entirely concentrated in the 2007-2010 period, the time of the Great Recession, a result not uncovered in prior work. The disproportionate increase in pain among the less educated is also shown to have occurred primarily at the time of the Recession, with either little or no trend before or after. The Recession jump occurred only at older ages and primarily only at the points during each cohort's lifetime when they experienced the Recession. However, we too find the jump difficult to explain, for while there is necessarily a temporary decline in employment during a Recession, why there should be a permanent increase in pain as a result is unclear. We assess a number of explanations, related to family structure and the deterioration of family life, as well as possible biopsychosocial channels. While we find some speculative hypotheses to have potential explanatory power, we conclude that the rise in pain continues to be mysterious and deserves further research in light of our new findings.

Shaping the future of geriatric chronic pain care: a research agenda for progress

Chronic pain is highly prevalent among older adults and its burden will become increasingly significant as our population ages. Yet, chronic pain is often undertreated in this vulnerable population due to various barriers in health care delivery. To improve geriatric chronic pain management, we assert that older adults require a dedicated research agenda designed to inform the development, testing, and implementation of chronic pain treatments that account for the unique vulnerabilities and healthcare needs of this population. Specifically, we propose that the following four areas of research require immediate attention to better serve older adults with chronic pain: (1) health equity, (2) substance use, (3) dyadic interventions, and (4) digital health. Our proposed research agenda aims to create a more robust and comprehensive body of evidence that will ultimately transform and advance geriatric chronic pain management.

Multi-omics profiles of chronic low back pain and fibromyalgia-Study protocol

BACKGROUND

Chronic low back pain (CLBP) and fibromyalgia (FM) are leading causes of suffering, disability, and social costs. Current pharmacological treatments do not target molecular mechanisms driving CLBP and FM, and no validated biomarkers are available, hampering the development of effective therapeutics. Omics research has the potential to substantially advance our ability to develop mechanism-specific therapeutics by identifying pathways involved in the pathophysiology of CLBP and FM, and facilitate the development of diagnostic, predictive, and prognostic biomarkers. We will conduct a blood and urine multi-omics study in comprehensively phenotyped and clinically characterized patients with CLBP and FM. Our aims are to identify molecular pathways potentially involved in the pathophysiology of CLBP and FM that would shift the focus of research to the development of target-specific therapeutics, and identify candidate diagnostic, predictive, and prognostic biomarkers.

METHODS

We are conducting a prospective cohort study of adults ≥18 years of age with CLBP (n=100) and FM (n=100), and pain-free controls (n=200). Phenotyping measures include demographics, medication use, pain-related clinical characteristics, physical function, neuropathic components (quantitative sensory tests and DN4 questionnaire), pain facilitation (temporal summation), and psychosocial function as moderator. Blood and urine samples are collected to analyze metabolomics, lipidomics and proteomics. We will integrate the overall omics data to identify common mechanisms and pathways, and associate multi-omics profiles to pain-related clinical characteristics, physical function, indicators of neuropathic pain, and pain facilitation, with psychosocial variables as moderators.

DISCUSSION

Our study addresses the need for a better understanding of the molecular mechanisms underlying chronic low back pain and fibromyalgia. Using a multi-omics approach, we hope to identify converging evidence for potential targets of future therapeutic developments, as well as promising candidate biomarkers for further investigation by biomarker validation studies. We believe that accurate patient phenotyping will be essential for the discovery process, as both conditions are characterized by high heterogeneity and complexity, likely rendering molecular mechanisms phenotype specific.

A Triple combination formulation of an HDAC inhibitor treats chronic pain in rodent spared nerve injury model

Histone deacetylase inhibitors (HDACi) that modulate epigenetic regulation and are approved for treating rare cancers have, in disease models, also been shown to mitigate neurological conditions, including chronic pain. They are of interest as non-opioid treatments, but achieving long-term efficacy with limited dosing has remained elusive. Here we employ a triple combination formulation (TCF) that includes the pan-HDAC vorinostat (Vo) administered at its FDA-approved daily dosage of 50 mg/Kg, along with the caging agent 2-hydroxypropyl-β-cyclodextrin (HPBCD) and polyethylene glycol (PEG). This formulation enhances plasma and brain exposure of Vo in mice and rat models and shows specific activity in the spared nerve injury (SNI) model of chronic neuropathic pain. TCF (but not HPBCD and PEG) decreased mechanical allodynia for 4 weeks without antagonizing weight, anxiety, or mobility. This was achieved at less than 1% of the total dose of Vo approved for 4 weeks of tumor treatment, decreased RNA levels of two major inflammatory markers (CD11b and GFAP), and reduced proliferation of microglia in the ipsilateral (but not contralateral) spinal cord. A single TCF injection was sufficient for 3-4 weeks of efficacy. Pharmacodynamics suggested pain relief was sustained for weeks after Vo elimination. Doubling Vo in a single TCF injection tripled the response amplitude and remained effective for > 2 months in male rats. Together, these data suggest that the TCF enables single-dose effectiveness with extended action, reduces long-term HDACi dosage, and presents excellent potential to develop as a non-opioid treatment option for chronic pain. PERSPECTIVE: An epigenetic drug formulation (TCF) tested in rat and mouse chronic neuropathic pain models shows adequate and persistent pain relief, engaging spinal cord inflammatory mechanisms.

A network analysis of changing pain cooccurrence in older adults findings from the second wave of the COPERNICUS study

Over one-third of patients with chronic pain report pain at multiple anatomical sites. The current study examined the co-localization of pain and its intensity over a 2-year follow-up period. Kendall rank correlation coefficient (denoted as tau) was applied for the co-occurrence of pain in specific locations. Individuals over the age of 60 years were recruited from the general population in Poland (N = 205, 60-88 years old). The lumbar spine was the most frequently occurring site for chronic pain, present in 31% of individuals at baseline and in 38% after 2 years. The number of pain sites did not change over 2 years (p = 0.53). An increase of co-occurrence between anatomical sites for pain was noted after 2 years. Cervical spine pain co-occurred with pain in the thoracic spine (tau = 0.31), lumbar spine (tau = 0.45), chest (tau = 0.18), hips (tau = 0.17), legs (tau = 0.18), knee(s) (tau = 0.31), and feet (tau = 0.17). The observed increase in pain co-occurrence over 2 years suggests the need for modified approaches to pain treatment in older adults.

Patient and health service factors associated with enrollment in a multidisciplinary pain rehabilitation program: a retrospective cohort study

Introduction

Despite multidisciplinary pain rehabilitation programs (PRPs) being well-established as an effective treatment for chronic pain, the existence of such programs has been declining across the United States over recent decades.

Objective

This study aims to identify factors associated with enrollment in a three-week, intensive outpatient PRP.

Methods

This is a retrospective cohort study of all patient visits to a multidisciplinary pain evaluation clinic in 2023. The cohort was divided into those who did and did not subsequently enroll in a PRP program. Health service, demographic, and patient-reported outcome measures were compared between groups; continuous variables by independent samples Student's T-tests and categorical variables by chi-squared tests.

Results

Of the 335 patients who had an evaluation in 2023, 48 went on to enroll in PRP (PRP-Yes group), and 287 did not (PRP-No group). Compared to PRP non-enrollers, the PRP-enrollers were more likely to have had a mental health (94% vs. 52%, p < .001) and physical therapy (94% vs. 48%, p < .001) assessment as part of their evaluation, had shorter lag times between their initial referral and medical evaluation [mean (SD) 43.5 (28.9) vs. 57.7 (41.7), p = .024], and had significantly greater anxiety, PTSD symptoms, somatic symptoms, and insomnia. Additionally, referral source, medical provider, and physical therapy provider seen differed significantly between PRP-enrollers and non-enrollers. PRP enrollment was not predicted by demographic variables including race, payer-type, or distance from the clinic.

Discussion

Both personal and systemic factors were identified to be associated with enrollment in a three-week multidisciplinary PRP. These findings highlight variables worth considering for clinical and research programs looking to increase PRP enrollment.

A cross-sectional survey unveiling the imperatives for continuing education and discipline development in pain medicine

Objective

This study aims to investigate persistent gaps in pain medicine education and unmet training needs, while exploring the significance of continuing education in driving disciplinary evolution.

Methods

A questionnaire was distributed online in the form of an e-Questionnaire link to the directors of the Pain Medicine Departments of 417 hospitals (covered all hospitals) in Zhejiang Province in China. This questionnaire aimed to identify the problems and needs in continuing education for pain medicine. Subsequently, a questionnaire link was sent to 163 physicians nationwide who had undergone advanced training in the Pain Medicine Department to survey the existing problems and needs in advanced training.

Results

The survey revealed uneven development of pain medicine, with secondary hospitals notably lagging in pain clinic establishment (51.3% vs. 69.9% in tertiary hospitals). The number of pain physicians is insufficient, and their overall academic qualifications need to be improved. Most directors (81.9%) have a strong willingness to enhance their professional capabilities, recommending advanced training. The number of advanced trainee has increased significantly, most physicians said that inpatient teaching accounts for about 3/4 of the advanced training duration. Case-based learning is the most popular between instructors (93.3%) and advanced trainees (82.2%). 46% of physicians reported having no opportunities for independent or semi-independent outpatient consultation, highlighting insufficient clinical practice opportunities. Additionally, Most physicians (93.3%) are satisfied with their instructors.

Conclusion

The findings from this cross-sectional survey underscore the pressing need for a more robust and standardized continuing education framework in pain medicine in China.

Long-Term Preoperative Nonsteroidal Anti-inflammatory Drug Use Does Not Impact Revision Rate After Repair of Rotator Cuff, Achilles, Distal Biceps, or Quadriceps Tendon

Purpose

To determine whether long-term preoperative nonsteroidal anti-inflammatory drug (NSAID) use affected the revision rates after primary tendon repair for the following common sports medicine surgical procedures: rotator cuff repair (RCR), Achilles tendon repair (ATR), distal biceps repair (DBR), or quadriceps tendon repair (QTR).

Methods

A retrospective comparative study using a national insurance database was performed. Patients who underwent major tendon repair, including RCR, ATR, DBR, or QTR, with at least 2-year follow-up were identified. Those who had a diagnosis of long-term NSAID use prior to the index operation were identified and matched 1:4 to controls without NSAID use based on age, sex, specific tendon repaired, and Elixhauser Comorbidity Index. The revision repair rates of the 2 groups were compared.

Results

A total of 36,068 patients underwent major tendon repair. Of these, 7,246 (20%) met the long-term NSAID use criteria prior to tendon repair (NSAID users). After RCR, 3.2% of NSAID users (n = 190) and 2.6% of controls (n = 617) underwent revision surgery within 2 years (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.97-1.36; P = .10). After ATR, NSAID users had a revision rate of 3.9% (n = 24) versus 2.5% (n = 62) in the control cohort (OR, 1.47; 95% CI, 0.89-2.38; P = .12). After DBR, both NSAID users and controls had fewer than 11 revision cases (OR, 1.54; 95% CI, 0.49-4.16; P = .42). After QTR, the revision rate was 5.9% (n = 30) for NSAID users compared with 4.8% (n = 95) for the control group (OR, 1.22; 95% CI, 0.77-1.86; P = .38). None of the observed differences in revision rates between NSAID users and controls were significant.

Conclusions

Patients with a diagnosis of and coding for long-term preoperative NSAID use do not have greater revision rates within 2 years of primary tendon repair than patients without this diagnosis.

Level of Evidence

Level III, retrospective case-control study.

Considering Long-Acting Synthetic Cannabidiol for Chronic Pain: A Narrative Review

Chronic pain is prevalent and challenging to treat. Cannabinoids, in particular cannabidiol (CBD), have been evaluated as analgesics without the issues of tolerance or dependence. Side effects tend to be mild and infrequent. These products have multiple routes of administration and composition, and some are available over the counter, allowing pain patients to self-medicate. Most self-medicated CBD are plant-derived extracts administered as either oils, pills, or by inhalation. During the early 1960s, CBD was chemically synthesized for the first time, but it was not yet approved for medical use; synthetic CBD has been and continues to be studied in clinical trials for numerous indications, including chronic pain, neuropathic pain, and pain in cancer. However, studies are often small, populations heterogeneous, and some results are equivocal. Research is lively, with over 60 studies reported on ClinicalTrials.gov. Multimodal CBD therapy may hold promise, particularly in combination with palmitoylethanolamide. Greater patient education and training for physicians and other healthcare providers are needed along with more comprehensive studies. Considering the problem of chronic pain, further intensive study of synthetic CBD for pain control is warranted to meet this unmet clinical need. This is particularly important in the context of long-lasting administration methods that enable easy dosing and support long-term use for patients dealing with persistent and often debilitating symptoms.

Molecule-rich solutions for achieving novel non-opioid analgesics

Despite their efficacy, opioids have long been associated with risks of addiction, tolerance, and dependence, leaving an unmet clinical need for pain treatment. Efforts have been devoted to developing novel classes of pain-relieving medication that outperform current options in terms of pain relief, side-effect profiles, and potential for abuse, but with limited success. Recent advances in the neurobiology of pain have shed light on the potential of targeting non-opioid receptors involved in pain processing. In this review, we identify avenues, ranging from molecular-based approaches to molecule-rich solutions, for effectively identifying non-opioid analgesics free from the side effects associated with opioids.

A Value Set for EQ-5D-5L in the United Arab Emirates

OBJECTIVES

This study aimed to develop a value set for the EQ-5D-5L based on preferences of the general adult population of the United Arab Emirates (UAE).

METHODS

The study followed the EuroQol EQ-5D-5L valuation protocol and involved conducting interviewer-administered face-to-face or online interviews in Arabic or English, using the EuroQol Valuation Technology with a sample of 1005 adults representing the UAE general population. Sample recruitment involved a 2-stage quota sampling strategy across the 7 emirates of the UAE, ensuring representation of nationals and expatriates. Various models using composite time trade-off data only, discrete choice experiment data only, and hybrid using both composite time trade-off and discrete choice experiment data were examined, along with various sensitivity analyses to examine the robustness of the models.

RESULTS

The average age of respondents was 39 years (SD 10.8), 44.5% were female, and 11% were UAE nationals. The best-performing model to generate the value set for the EQ-5D-5L was the hybrid tobit model censored at -1.0, corrected for heteroskedasticity. Values ranged from -0.654 for the worst health state (55555) to 1 for full health (11111) and 0.962 for 11211, with 15.3% of predicted values worse than dead. Mobility problems had the largest impact on health state preference values relative to other dimensions.

CONCLUSION

This value set will facilitate the application and use of the EQ-5D-5L instrument in the UAE population in generating local evidence on the cost-effectiveness of healthcare interventions, as well as to enhance other applications of EQ-5D in population health assessment and health systems.

Early life stress modulates neonatal somatosensation and the transcriptional profile of immature sensory neurons

ABSTRACT

Early life stress (ELS) is associated with an increased risk of experiencing chronic pain during adulthood, but surprisingly little is known about the short-term influence of ELS on nociceptive processing in the immature nervous system and the concomitant effects on somatosensation in the neonate. Here, we investigate how ELS modulates pain in neonatal mice and the transcriptional and electrophysiological signatures of immature dorsal root ganglia (DRG). Shortly after the administration of a neonatal limiting bedding (NLB) paradigm from postnatal days (P)2 to P9, both male and female pups exhibited robust hypersensitivity in response to tactile, pressure, and noxious cold stimuli compared with a control group housed under standard conditions, with no change in their sensitivity to noxious heat. Bulk RNA-seq analysis of L3-L5 DRGs at P9 revealed significant alterations in the transcription of pain- and itch-related genes following ELS, highlighted by a marked downregulation in Sst , Nppb , Chrna6 , Trpa1 , and Il31ra . Nonetheless, ex vivo whole-cell patch-clamp recordings from putative A- and C-fiber sensory neurons in the neonatal DRG found no significant changes in their intrinsic membrane excitability following NLB. Overall, these findings suggest that ELS triggers hyperalgesia in neonates across multiple pain modalities that is accompanied by transcriptional plasticity within developing sensory neurons. A better understanding of the mechanisms governing the interactions between chronic stress and pain during the neonatal period could inform the future development of novel interventional strategies to relieve pain in infants and children who have experienced trauma.

Pain persists in mice lacking both Substance P and CGRPα signaling

The neuropeptides Substance P and CGRPα have long been thought important for pain sensation. Both peptides and their receptors are expressed at high levels in pain-responsive neurons from the periphery to the brain making them attractive therapeutic targets. However, drugs targeting these pathways individually did not relieve pain in clinical trials. Since Substance P and CGRPα are extensively co-expressed, we hypothesized that their simultaneous inhibition would be required for effective analgesia. We therefore generated Tac1 and Calca double knockout (DKO) mice and assessed their behavior using a wide range of pain-relevant assays. As expected, Substance P and CGRPα peptides were undetectable throughout the nervous system of DKO mice. To our surprise, these animals displayed largely intact responses to mechanical, thermal, chemical, and visceral pain stimuli, as well as itch. Moreover, chronic inflammatory pain and neurogenic inflammation were unaffected by loss of the two peptides. Finally, neuropathic pain evoked by nerve injury or chemotherapy treatment was also preserved in peptide-deficient mice. Thus, our results demonstrate that even in combination, Substance P and CGRPα are not required for the transmission of acute and chronic pain.

Promoting Effective Pain Assessment: A Quality Improvement Project

BACKGROUND

Pain management is a major healthcare concern, particularly for patients with cancer. About 51.6 million American adults experience chronic pain, with 17.1 million experiencing high-impact chronic pain. The staff nurses on the surgical oncology unit of a large community hospital did not fully adhere to updated evidence-based practice guidelines for pain management.

OBJECTIVES

The purpose of this quality improvement project was to improve pain assessment practices on the surgical oncology unit of a 471-bed hospital.

METHODS

Forty-nine nurses participated in this quality improvement project implemented across a three-month period. The intervention consisted of pre- and post-tests, two identical educational training sessions offered at different times for scheduling flexibility, interviews, and chart audits. The pre-/post-test design evaluated nurses' knowledge of pain assessment before and after the intervention.

FINDINGS

This project found that expanding nurses' knowledge about pain assessment (t = 8.03, p < 0.001) resulted in increased adherence to national standards for pain management, including better charting practices. The pain assessment documentation rate increased from 18% to 29%.

Bidirectional relationships between pain and patterns of cannabis and tobacco use in a US nationally representative sample

ABSTRACT

One-fifth of US adults experience chronic pain, which is associated with increased tobacco and cannabis use. Although bidirectional relationships between tobacco and pain have been demonstrated, pathways between pain, cannabis use, and co-use of cannabis and tobacco are understudied. We aimed to estimate the effects of (1) substance use (exclusive and co-use of cannabis and tobacco) on later pain intensity, and (2) pain intensity on later substance use. Data were from 31,983 adults in biennial surveys (2015-2021) of the US nationally representative longitudinal Population Assessment of Tobacco and Health Study (n = 71,055 pairs of consecutive surveys; T1 and T2). Past-week pain intensity was dichotomized (≤4/10 no/low pain; >4/10 moderate/severe pain). Mutually exclusive substance use categories (past 30 days) were no cannabis/tobacco use; exclusive cannabis/tobacco use; and co-use. Logistic regression assessed whether T1 substance use affected moderate/severe pain at T2. Multinomial models assessed whether pain status at T1 affected substance use at T2. Compared with no cannabis/tobacco use at T1, co-use (OR: 2.29 [95% CI: 2.09-2.51]), exclusive tobacco use (2.00 [1.86-2.14]), and exclusive cannabis use (1.35 [1.13-1.61]) were all associated with moderate/severe pain at T2. Moderate/severe pain at T1 increased odds of co-use (2.43 [2.22-2.66]), exclusive tobacco (2.12 [1.98-2.28]), and exclusive cannabis use (1.46 [1.29-1.65]) compared with no cannabis/tobacco use at T2, and increased odds of co-use at T2 compared with exclusive cannabis/tobacco use. Findings demonstrated bidirectional relationships between pain and the exclusive use and co-use of cannabis and tobacco and indicate potential synergy in the co-use of cannabis and tobacco with respect to pain.

'I want to know that it's worth me attending': A qualitative analysis of consumers' decisions not to attend their chronic pain group education session

Background: Many pain clinics encourage/mandate attendance at introductory group pain education sessions. Despite high non-attendance rates, no studies have examined consumer-reported reasons for non-attendance. Purpose: The aim of this study was to better understand why consumers fail to attend their pain education session. Research Design and Study Sample: We attempted to contact all non-attendees of our South Australian tertiary pain unit's group pain education sessions from February-August 2020. Of the 23 we could reach, 10 completed semi-structured telephone interviews. Data Analysis: Audio-recordings were transcribed verbatim and subject to thematic content analysis. Results: 'Attendance barriers' themes highlighted the complex lives of non-attendees. Pain prevented them from leaving their house, deterred them from travel to, and sitting through, the entire session. Competing responsibilities including other medical appointments and comorbidities were commonly mentioned. Most explicitly stated their dislike for the group format. Other factors included fear of the unknown nature of the session, not wanting education, and wanting a doctor's appointment. Several participants expressed a distrust of medical professionals, and perceived the benefits of attending as not exceeding the perceived time, money and pain associated. Conclusions: Pain management may not be individuals' main priority and attendance may only occur when other personal issues are addressed. Significant non-attendance rates may be unavoidable. Providing additional session detail may reduce misconceptions and allay concerns. Educating referring GPs may assist consumers to make an informed decision regarding attending. Online sessions may address various barriers and prove a more cost-effective alternative.

Perspective

This article examines consumers' reasons for non-attendance at pre-clinic group education programs. Findings could be used by Pain Units to shape patient and GP communications regarding such programs, as well as program content and format, to improve patient acceptance and program attendance, and potentially engagement with self-management.

Development of clinical decision support for patients older than 65 years with fall-related TBI using artificial intelligence modeling

BACKGROUND

Older persons comprise most traumatic brain injury (TBI)-related hospitalizations and deaths and are particularly susceptible to fall-induced TBIs. The combination of increased frailty and susceptibility to clinical decline creates a significant ongoing challenge in the management of geriatric TBI. As the population ages and co-existing medical conditions complexify, so does the need to improve the quality of care for this population. Utilizing early hospital admission variables, this study will create and validate a multinomial decision tree that predicts the discharge disposition of older patients with fall-related TBI.

METHODS

From the National Trauma Data Bank, we retrospectively analyzed 11,977 older patients with a fall-related TBI (2017-2021). Clinical variables included Glasgow Coma Scale (GCS) score, intracranial pressure monitor use, venous thromboembolism (VTE) prophylaxis, and initial vital signs. Outcomes included hospital discharge disposition re-categorized into home, care facility, or deceased. Data were split into two sets, where 80% developed a decision tree, and 20% tested predictive performance. We employed a conditional inference tree algorithm with bootstrap (B = 100) and grid search options to grow the decision tree and measure discrimination ability using the area under the curve (AUC) and calibration plots.

RESULTS

Our decision tree used seven admission variables to predict the discharge disposition of older TBI patients. Significant non-modifiable variables included total GCS and injury severity scores, while VTE prophylaxis type was the most important interventional variable. Patients who did not receive VTE prophylaxis treatment had a higher probability of death. The predictive performance of the tree in terms of AUC value (95% confidence intervals) in the training cohort for death, care, and home were 0.66 (0.65-0.67), 0.75 (0.73-0.76), and 0.77 (0.76-0.79), respectively. In the test cohort, the values were 0.64 (0.62-0.67), 0.75 (0.72-0.77), and 0.77 (0.73-0.79).

CONCLUSIONS

We have developed and internally validated a multinomial decision tree to predict the discharge destination of older patients with TBI. This tree could serve as a decision support tool for caregivers to manage older patients better and inform decision-making. However, the tree must be externally validated using prospective data to ascertain its predictive and clinical importance.

Factors associated with patient no-show rates in an academic pain management practice

OBJECTIVES

Chronic pain is a debilitating, multifactorial condition. The purpose of this study was to examine patient characteristics of those who did not show up for their scheduled first pain medicine appointment in order to identify factors that may improve access to care.

METHODS

This was a retrospective analysis of 810 patients from a single-center academic pain management clinic between January 1, 2022, and December 31, 2023.

RESULTS

Overall no-show rate was 57%. There was a mean of 133 days (4.3 months) from scheduling to the appointment date. Patients age ≤ 30 years had the highest no-show rate (69%), and those ≥81 years had the lowest (49%). Hispanic and Caucasian patients had similar no-show rates (59% and 57%, respectively) and Asian patients had lower rate (41%). Referral from another specialty had a significantly lower no-show rate (36% vs. 89%, p < 0.001). The presence of referral (p < 0.001) was a significant predictor of lower no-show rates. Of the 191 patients with low back pain, internal medicine (38.7%) was the most referring specialty.

DISCUSSION

High no-show rates were present particularly among younger patients. Having a referral from another specialty was an independent predictor of lower no-show rates.

Thriving Through Pain: A Whole-Person and Resilience Comparative Study Using Mobile Health Application Technology for Individuals With Self-Reported Pain Challenges

BACKGROUND

Pain is a complex condition and affects one's life beyond physical symptoms. National pain management recommendations include a whole-person approach that includes strengths (or resilience).

PURPOSE

The purpose of this study was to examine de-identified data from the MyStrengths+MyHealth application to examine, Strengths, Challenges, and Needs for the population and a subset of the data for those with and without self-reported Challenges in the Pain concept.

DESIGN

This cross-sectional comparative study used de-identified consumer-generated whole-person strengths data from the MyStrengths+MyHealth (MSMH) application.

METHODS

Data was collected from various community settings between 2019 and 2023 and approved by the University's Institutional Review Board. From the sample population (N=1737), we identified those with self-reported Pain (n=1280) and without self-reported Pain (n=457) and compared Strengths, Challenges, and Needs.

RESULTS

The sample population (N=1737) was largely in the age range of 45-64 years (51.2%), Male (56.4%), White (90.5%), non-Hispanic/Latino (86.6%), and Married (74.2%). The Pain group (n=1280) reported significantly fewer Strengths (p<0.001) and more average Challenges and Needs (p<0.001) than the Without Pain Group (n=457) across all concepts. For the Pain Group, the most frequent Strength reported was Role Change (70.5%), the most frequent Challenge Nutrition (96.1%), and the greatest Need was Income (89.9%).

CONCLUSIONS

Despite reporting Challenges and Needs, the Pain Group identified many Strengths. The Pain Group identified Role Change (70.5%) as a top Strength was surprising and may suggest adaptability to chronic pain. MSMH has potential to empower individuals to provide a comprehensive whole-person assessment and resilience which may be particularly useful for those living with chronic pain.

CLINICAL IMPLICATIONS

This study has clinical implications for supporting the use of digital health tools such as mobile applications for capturing contextual data directly from patients to enable nurses to provide more accessible and personalized care to patients.

Exploring the language of chronic pain stories through a Facebook page. A qualitative study on narratives and unmet needs

BACKGROUND

Dimensione Sollievo (Dimension of Relief) and its Facebook page represent a patient-centered social media initiative focused on chronic pain. This platform provides users with accurate resources on chronic pain and offers a virtual space for peer interaction - a crucial aspect for a condition often lacking proper recognition. The study's primary objective was to analyze the content in relation to unmet needs, with a secondary objective to explore the role of narrative medicine (NM) in this form of social communication.

METHODS

Posts, replies, and comments from the Facebook page between 2020 and 2023 were analyzed using thematic frameworks such as Frank, Kleinmann, Launer classifications, and Berne's transactional analysis. Language styles, semantics, word frequency, and metaphors were also examined. Narratives were analyzed through Nvivo software and Microsoft Office tools.

RESULTS

Users embraced the Facebook page as a safe space for interaction, where they found understanding and connection, unlike their experiences outside the community. While interactions were generally brief, they intensified around issues where users perceived injustices, such as the lack of recognition of their condition by medical professionals and family, and challenges in accessing benefits. Thematic analysis revealed that the most prominent theme was the dimension of disease, with many narratives expressing difficulty coping and a lack of progress.

CONCLUSIONS

The application of narrative medicine (NM) tools highlights both explicit and unconscious patient needs, such as the desire to be heard and acknowledged. This study is the first to explore NM's potential in chronic pain. Implementing NM tools through informed moderation could transform pain management culture, improving treatment approaches and enhancing the overall community experience.

Use of Complementary and Integrative Medicine Among Low-Income Persons With Mental Health Disorders

Objective

To evaluate the use of complementary and integrative medicine (CIM) among a low-income population with mental health diagnoses and to assess differences in social determinants of health (SDOH) on the basis of CIM use.

Patients and Methods

We surveyed patients with mental health diagnoses and/or substance use disorders during outpatient evaluations between August 11, 2020, and November 18, 2021, at a community behavioral health center in Rochester, MN. We measured knowledge of current CIM, interest in future use of CIM, and SDOH. Differences in mean number of SDOH risk factors were compared by use or nonuse of any CIM.

Results

Among 102 patients, depression (87%) and anxiety (85%) diagnoses were common. Moreover, 72% of patients used at least 1 CIM. The 3 most common modalities were prayer (41%), spirituality (37%), and music (36%). CIM use had perceived benefits for mood (49%), stress (49%), and sadness (43%). One-third of patients added CIM to conventional treatments, and 19% reported that traditional medical treatments did not work well for their symptoms. More than two-thirds had not discussed their use of CIM with their physicians. Social isolation and loneliness were common. The number of SDOH risk factors did differ by use of CIM.

Conclusion

Prayer, spirituality, and music are frequently used by patients with mental health disorders and were perceived to be helpful in relieving symptoms. CIM use was not related to SDOH risk factors. Integrating CIM therapies may be beneficial for improving mental health in this population.

Perceived discrimination and pain outcomes among black adults with chronic musculoskeletal pain: identifying modifiable psychosocial risk factors

Chronic musculoskeletal pain (CMP) is highly prevalent, frequently associated with negative health outcomes, and disproportionately impacts Black Americans. Perceived racial and ethnic discrimination has emerged as a factor that may influence the experience of chronic pain in this population. Identifying modifiable psychosocial factors that influence the link between perceived discrimination and pain and that can be directly targeted in treatment is vital to reducing the disproportionate burden of CMP among Black individuals. The present study examines the moderating role of five risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) on the relationship between perceived discrimination and pain outcomes (i.e., pain intensity and interference) in a sample of 401 Black adults with CMP. We recruited 401 Black individuals (Mage = 35.98, 51.9% female) with self-reported CMP and assessed their self-reported perceived discrimination, pain intensity, pain interference, and pain-related psychosocial risk factors. Results indicated that higher scores on each of the psychosocial risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) were significantly associated with greater pain intensity and pain interference (all ps < 0.01). Further, pain avoidance (B = 0.12, p = .006), pain fusion (B = 0.13, p = .002), and pain anxiety (B = 0.13, p = .002) each significantly moderated the relation between perceived discrimination and pain intensity. Greater perceived discrimination was associated with greater pain intensity at higher levels of avoidance and fusion, and was associated with less pain intensity at lower levels of avoidance and pain anxiety. In interaction models predicting pain interference, both pain fusion (B = 0.14, p = .001) and pain anxiety (B = 0.10, p = .01) significantly moderated the relation between perceived discrimination and pain interference. Perceived discrimination was associated with greater pain interference at higher levels of pain fusion and pain anxiety, and was not associated with pain interference at lower levels of pain fusion and pain anxiety. The present findings provide important insights into psychosocial risk factors that moderate the link between perceived discrimination and pain outcomes, providing important clinical implications for the treatment of Black adults with chronic musculoskeletal pain.

Mental and Physical Well-Being of Partners of People Living with Chronic Pain: A Narrative Review

This narrative review aims to explore the mental and physical well-being of partners of individuals living with chronic pain. Chronic pain not only affects those who suffer from it, but also significantly impacts the lives of their partners; however, the impacts on partners are not well recognised, despite extensive evidence indicating that their quality of life can be equally affected. This review synthesises current literature to identify the psychological and physical challenges faced by these partners, including increased stress, anxiety, depression, and the potential for developing chronic health conditions themselves. A search of Medline for "chronic pain" and "partner/spouse" from January 1990 to the present was performed, and relevant articles were selected for review. The main findings were that while partners often experience a range of negative physical and psychosocial impacts on their quality of life, dyadic coping strategies can mitigate these effects. This review underscores the importance of future research to develop targeted interventions that address the unique needs of this population, promoting better health outcomes and fostering resilience in the face of chronic pain.

The impact of biofeedback in enhancing chronic pain rehabilitation: A systematic review of mechanisms and outcomes

Background and objectives

Chronic pain (CP), affecting approximately 20 % of adults globally, imposes a profound burden on individuals and healthcare systems. This condition, characterized by persistent pain, muscle stiffness, and emotional distress, often results in a complex interplay of physical and psychological factors that exacerbate symptoms and hinder recovery. Biofeedback (BFB), a non-invasive intervention, offers a promising rehabilitation strategy by enabling individuals to monitor and self-regulate physiological responses, such as muscle tension, heart rate, and skin temperature. Through this process, BFB disrupts the vicious cycle of pain and stress, fostering relaxation, reducing muscle strain, and alleviating emotional distress. This systematic review aimed to examine the mechanisms underlying BFB's therapeutic effects in CP rehabilitation, specifically its ability to enhance self-regulation and promote relaxation to improve pain control. Furthermore, it aimed to evaluate the impact of BFB on key outcomes, including pain severity, functional capabilities, and quality of life, with the goal of guiding its integration into contemporary rehabilitation practices.

Materials and Methods

Following PRISMA guidelines, a systematic search was conducted in PubMed, Web of Science, and Embase (2014-2024) to identify studies on BFB for CP. Inclusion criteria included original research involving BFB as a primary or secondary intervention for CP, with outcomes related to pain management and rehabilitation. This review is registered on Open OSF (X5HPB).

Results

BFB has shown consistent efficacy as a complementary therapy in CP management, offering significant reductions in pain intensity and enhancements in quality of life across diverse CP conditions. Mechanistically, BFB facilitates improved self-regulation by training patients to modulate physiological responses, such as muscle tension and heart rate variability, leading to better pain control and stress reduction.

Conclusions

BFB shows significant promise as a supplementary treatment for different CP disorders. The evidence that was examined shows that it is effective in improving how pain is perceived, increasing functional results, and boosting overall quality of life among a variety of patient groups.

Metabolite-Sensing Receptors: Emerging Targets for Modulating Chronic Pain Pathways

Chronic pain is a debilitating condition affecting millions worldwide, often resulting from complex interactions between the nervous and immune systems. Recent advances highlight the critical role of metabolite-sensing G protein-coupled receptors (GPCRs) in various chronic pain types. These receptors link metabolic changes with cellular responses, influencing inflammatory and degenerative processes. Receptors such as free fatty acid receptor 1 (FFAR1/GPR40), free fatty acid receptor 4 (FFAR4/GPR120), free fatty acid receptor 2 (FFAR2/GPR43), and Takeda G protein-coupled receptor 5 (TGR5/GPR131/GPBAR1) are key modulators of nociceptive signaling. GPR40, activated by long-chain fatty acids, exhibits strong anti-inflammatory effects by reducing cytokine expression. Butyrate-activated GPR43 inhibits inflammatory mediators like nitric oxide synthase-2 and cyclooxygenase-2, mitigating inflammation. TGR5, activated by bile acids, regulates inflammation and cellular senescence through pathways like NF-κB and p38. These receptors are promising therapeutic targets in chronic pain, addressing the metabolic and inflammatory factors underlying nociceptive sensitization and tissue degeneration. This review explores the molecular mechanisms of metabolite-sensing receptors in chronic pain, their therapeutic potential, and challenges in clinical application. By uncovering these mechanisms, metabolite-sensing receptors could lead to safer, more effective pain management strategies.

Modulation of morphine antinociceptive and rewarding effect by mirtazapine in an animal model of osteoarthritic pain

People with chronic pain mitigate their suffering by the action of opioids. Adverse reactions aside, opioids are not exempt from potential complications like addiction and abuse, which have posed a global public health problem lately. Finding new therapeutic strategies to improve analgesia and to reduce opioid side effects has become a priority. In this regard, the association of different adjuvant therapies has been postulated. Despite preclinical and clinical evidence supporting the use of antidepressants as analgesics, it is not clear whether they could help reduce the risk of addiction in combination with opioids. To further explore this idea a model of chronic osteoarthritis pain was employed, and a combination of mirtazapine and morphine was used in a chronic regimen in male and female rats. The effects on the development of tactile allodynia, movement-evoked pain, reward, analgesic tolerance, naloxone-induced withdrawal symptoms, impaired locomotor activity and anxiety were evaluated under a 25-day experimental protocol. Additionally, protein expression of μ-opioid receptors and clusterin (related with substance abuse) was evaluated in plasma and in brain structures of the reward system. Chronic morphine caused analgesic tolerance, reward and naloxone-induced withdrawal symptoms. The combination reduced the analgesic tolerance and prevented the development of withdrawal symptoms but showed sex-based differences regarding reward. Increased levels of clusterin in plasma were observed in females treated with morphine, but not with combined therapy. The combination of mirtazapine and morphine could be a promising strategy to improve the management of long-term opioid treatment and its risk of abuse, especially in females.

Recent Advances in Non-Invasive Digital Nursing Technologies for Chronic Pain Assessment and Management: An Integrative Review

AIM

This integrative review aims to identify what nurses currently offer through digital technology and their success in managing chronic pain.

DESIGN

An integrative review guided by Whittemore and Knafl was conducted.

DATA SOURCES

Five databases-CINAHL, Medline, PsycINFO, PubMed, and Scopus-were utilised to gather relevant studies from January 2018 to November 2024.

REVIEW METHODS

Selected studies were assessed using the Mixed Methods Appraisal Tool and the Joanna Briggs Appraisal Tool. Braun and Clarke's thematic analysis was applied to identify pertinent themes.

RESULTS

Digital nursing technologies such as telehealth and web-based interventions effectively deliver interventions to assess and manage chronic pain; these technologies can reduce healthcare resource utilisation and increase accessibility. This review highlights that nurses commonly deliver exercise, cognitive-behavioural therapy, acceptance and commitment therapy and self-management techniques through digital technology.

CONCLUSION

This review indicates that web-based interventions and telemedicine are the primary digital technologies employed by nurses for chronic pain management providing psychosocial interventions, with evidence supporting their effectiveness. Digital and web-based technology is essential to bridge healthcare access gaps as nurses can provide this successfully with minimal nursing support and cost to the patient.

IMPACT

Evidence supports nurses in providing psychosocial interventions for the management of chronic pain, particularly web-based psychosocial interventions. Nurses need to adopt digital technology to improve access to care and patient outcomes and to maintain professional development in an increasingly digital world.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was used for this study.

Heals on Wheels: Development and Implementation of Community Outreach and Group Medical Visits for People Experiencing Chronic Pain

Background

Chronic pain is a global problem affecting approximately 20% of adults. The prevalence of opioid use for chronic pain has contributed to a widespread crisis of addiction and inadequately managed pain. Though national and international guidelines recommend nonpharmacological, integrative, multi-modal therapies for chronic pain, numerous systemic barriers limit access to these services for those with the highest need and fewest resources.

Objective

This paper describes the development and testing of an innovative "Heals on Wheels" (HoW) community engagement and Group Medical Visit (GMV) program for underserved communities experiencing chronic pain in Hennepin County, Minnesota.

Methods

The HoW program's curriculum was collaboratively adapted from pre-existing Hennepin Health care GMV programs for chronic pain. Free community-based "Appetizer" workshops were developed alongside an 8-week "Full Meal" GMV program titled Easing Pain Holistically (EPH). Three pain-affinity variations of EPH were created (the "Body", "Head", and "Heart") and delivered to 6 cohorts (2 cohorts of each variation). Feasibility was measured by attendance, demographics, and insurance provider information. To evaluate program acceptability, thematic analysis of patients post-GMV weekly progress sheets was performed.

Results

The curriculum for the HoW program included experiential training and education in evidence-based integrative pain management strategies. Fourteen community appetizer workshops (n = 142) were offered in partnership with organizations representing underserved populations. Fifty-five patients completed EPH from 2022 to 2024 with the greatest number of patients in the Heart (n = 23), followed by the Body (n = 19), and the Head (n = 13). Feasibility for the GMV program was demonstrated with average attendance across 6 cohorts at 75.1%. Thematic analysis of qualitative data revealed themes highlighting appreciation for group connection ("sharing") and the EPH program content.

Conclusion

The HoW program shows promise as a feasible and acceptable model of community outreach and engagement to improve access to evidence-based integrative pain care.

Deep proteomics and network pharmacology reveal sex- and age-shared neuropathic pain signatures in mouse dorsal root ganglia

Our understanding of how sex and age influence chronic pain at the molecular level is still limited with wide-reaching consequences for adolescent patients. Here, we leveraged deep proteome profiling of mouse dorsal root ganglia (DRG) from adolescent (4-week-old) and adult (12-week-old) male and female mice to investigate the establishment of neuropathic pain in the spared nerve injury (SNI)-model in parallel. We quantified over 12,000 proteins, including notable ion channels involved in pain, highlighting the sensitivity of our approach. Differential expression revealed sex- and age-dependent proteome changes upon nerve injury. In contrast to most previous studies, our comprehensive dataset enabled us to determine differentially expressed proteins (DEPs), which were shared between male and female mice of both age groups. Among these, the vast majority (94 %) were also expressed and, in part, altered in human DRG of neuropathic pain patients, indicating evolutionary conservation. Proteome signatures represented numerous targets of FDA-approved drugs comprising both (i) known pain therapeutics (e.g. Pregabalin and opioids) and, importantly, (ii) compounds with high potential for future re-purposing, e.g. Ptprc-modulators and Epoetins. Protein network and multidimensional analysis uncovered distinct hubs of sex- and age-shared biological pathways impacted by neuropathic pain, such as neuronal activity and synaptic function, DNA-damage, and neuroimmune interactions. Taken together, our results capture the complexity of nerve injury-associated DRG alterations in mice at the network level, moving beyond single-candidate studies. Consequently, we provide an innovative resource of the molecular landscape of neuropathic pain, enabling novel opportunities for translational pain research and network-based drug discovery.

The measurement of "high-impact chronic pain": Limitations and alternative methods

OBJECTIVE

Chronic pain is known to be an important construct in clinical practice and a particular form of chronic pain, high-impact chronic pain (HICP), has gained recent interest and attention by pain clinicians, epidemiologists, and clinical researchers. The purpose of our Topical Review is to describe the historical development of measures of HICP and to explore the psychometric properties of HICP as well as to present alternative measurement methods.

METHODS

We identified strengths and weaknesses of the psychometric characteristics of HICP measures. Limitations of existing HICP measures were discussed and summarized and alternatives to current methods were proposed.

RESULTS

HICP operational definitions show variability across studies. All definitions cannot be correct, but which ones are incorrect cannot be determined as there is no gold standard. Random measurement error and recall bias are among the other limitations of current HICP measures. Model-based definitions of HICP, the discrete (for epidemiologic applications) and continuous (for clinical applications) latent variable models are discussed as likely superior alternatives to current methods.

CONCLUSIONS

Limitations of existing HICP methods are discussed and alternative development approaches to HICP measures are presented. The use of either discrete or continuous latent variable models would improve upon the psychometric characteristics of current HICP evidence. Examples are used to illustrate the benefits of latent variable models over traditional observed variable conceptualizations as the measurement of HICP continues to develop.

SIGNIFICANCE STATEMENT

This work takes the position that current methods of measuring high impact chronic pain (HICP) likely contain substantial error. We have endorsed an alternative approach for several psychometrically grounded reasons. We recommend that future work consider the discrete latent variable framework for dichotomous measures of HICP and the continuous latent variable framework for continuous measures of HICP. The paper provides illustrative examples of these methods for a different patient reported measure that is lacking a gold standard, much like HICP measures.

Longitudinal relationship between adverse childhood experiences and depressive symptoms: the mediating role of physical pain

BACKGROUND

This study explored the relationship between Adverse Childhood Experiences (ACE), physical pain, and depressive symptoms, and examined the mediating role of pain in the correlation between ACE and depressive symptoms among middle-aged and elderly Chinese (over the age of 45).

METHODS

Cox proportional hazards regression models were used to analysis the association between ACE, physical pain, and depressive symptoms. To assess the mediating role of physical pain in the relationship between ACE and depressive symptoms, mediation analysis was conducted. Indirect, direct, and total effects were estimated by combining mediation and outcome models, adjusting for relevant covariates. Bayesian network models were used to visually demonstrate the interrelations between factors influencing depressive symptoms, further verifying the association between ACE, physical pain, and depressive symptoms.

RESULTS

In the fully adjusted model, middle-aged and elderly individuals reporting ACE had a higher risk of developing depressive symptoms (hazard ratios [HR] and 95% confidence intervals [95% CI], 1.379 [1.266-1.503]). Compared to those without physical pain, individuals reporting severe physical pain were at an increased risk of depressive symptoms (HR [95% CI], 1.438 [1.235-1.673]). The risk was even higher for those with both ACE and severe physical pain compared to those with neither (HR [95% CI], 2.020 [1.630-2.505]). The intensity of pain explained 7.48% of the association between ACE and depressive symptoms, while the number of pain sites accounted for 7.86%.

CONCLUSIONS

Physical pain partially mediated the association between ACE and depressive symptoms. The study findings highlighted the importance of early screening and intervention for physical pain in middle-aged and older adults with ACE.

CLINICAL TRIAL NUMBER

Not applicable.

The effect of a low-carbohydrate diet on evoked pain and quality of life in Non-Hispanic black women with knee osteoarthritis: a pilot study

BACKGROUND

Knee osteoarthritis (KOA) is a prevalent chronic pain condition that can significantly impact quality of life and contribute to recognized chronic pain racial disparities. We have shown that a low-carbohydrate diet (LCD) can reduce KOA-related pain. Our previous work suggested that the LCD was more beneficial for women and non-Hispanic Black (NHB) adults, but our sample was not sufficiently diverse. Thus, we sought to determine whether the LCD may be beneficial for NHB women with KOA on measures of self-reported and evoked pain.

METHODS

Fourteen NHB women (M = 55.93, S.D. = 7.79 years of age) with KOA were recruited to participate in a pilot 6-week LCD intervention. Measures of pain sensitivity, disability, physical functioning, overall chronic pain, quality of life, and dietary habits were taken at baseline and at 3- and 6-weeks of the LCD intervention.

RESULTS

Overall, participants showed significant differences in self-reported measures of daily pain, pain interference, stiffness, physical functioning, depressive symptoms, food knowledge and food security. Participants also showed reduced evoked pain in the timed walk and chair stand tasks.

CONCLUSION

A 6-week LCD provided a range of benefits related to pain and quality of life in NHB women with KOA. The utilization of a LCD is a modifiable, non-pharmacological and accessible alternative for chronic KOA that may reduce pain disparities and improve quality of life.

TRIAL REGISTRATION

This article reports the original results of a dietary healthcare intervention registered at clinicaltrials.gov (NCT04343716, registered on 13/04/2020).

"Play!": Combatting Pathocentric Epistemic Injustice in Chronic Pain Care

Epistemic injustice is an analytical framework that is used to describe a wrong done to someone in their capacity as a knower. Epistemic injustice is well-documented across the healthcare spectrum, particularly in relation to the patient's capacity to understand, and thus derive meaning from, the experience of illness. This article contributes to the body of scholarship exploring how to achieve pathocentric epistemic justice by way of ethnographic case study. Findings draw on fieldwork conducted at a small, publicly funded chronic pain clinic. At MB clinic, pain care is delivered in a group setting. Patients and doctor exhibit a playful attitude: they lean into uncertainty, tell jokes, and eschew the concept of mastery. This produces an epistemic environment that departs from the kind critiqued in studies wherein epistemic injustice is present. By way of case study, this article provides support for the broad claim that there is a link between playfulness and epistemic well-being. Therefore, playfulness may be applied as a strategy to combat pathocentric epistemic injustice.

Relationship Between Sleep Disturbances and Chronic Pain: A Narrative Review

Sleep disturbances and chronic pain are prevalent and interrelated conditions that have significant impact on individuals' quality of life. Understanding the intricate dynamics between sleep and pain is crucial for developing effective treatments that enhance the well-being of affected individuals and reduce the economic burden of these debilitating conditions. This narrative review examines the complex relationship between sleep disturbances and chronic pain. We describe the prevalence and types of sleep disturbances and sleep disorders in chronic pain patients. Posteriorly, we critically review the clinical and experimental evidence, investigating the relationship between sleep disturbances and chronic pain, aiming to clarify the impact of chronic pain on sleep and, conversely, the impact of sleep disturbances on pain perception. In conclusion, the literature largely agrees on the existence of a bidirectional relationship between chronic pain and sleep disturbances, though the strength of each direction in this association remains uncertain. Current evidence suggests that sleep impairment more strongly predicts pain than pain does sleep impairment. Additionally, addressing sleep disturbances in chronic pain patients is crucial, as poor sleep has been linked to higher levels of disability, depression, and pain-related catastrophizing.

Pain persists in mice lacking both Substance P and CGRPα signaling

The neuropeptides Substance P and CGRPα have long been thought important for pain sensation. Both peptides and their receptors are expressed at high levels in pain-responsive neurons from the periphery to the brain making them attractive therapeutic targets. However, drugs targeting these pathways individually did not relieve pain in clinical trials. Since Substance P and CGRPα are extensively co-expressed we hypothesized that their simultaneous inhibition would be required for effective analgesia. We therefore generated Tac1 and Calca double knockout (DKO) mice and assessed their behavior using a wide range of pain-relevant assays. As expected, Substance P and CGRPα peptides were undetectable throughout the nervous system of DKO mice. To our surprise, these animals displayed largely intact responses to mechanical, thermal, chemical, and visceral pain stimuli, as well as itch. Moreover, chronic inflammatory pain and neurogenic inflammation were unaffected by loss of the two peptides. Finally, neuropathic pain evoked by nerve injury or chemotherapy treatment was also preserved in peptide-deficient mice. Thus, our results demonstrate that even in combination, Substance P and CGRPα are not required for the transmission of acute and chronic pain.

A Review of Remote Monitoring in Neuromodulation for Chronic Pain Management

PURPOSE OF REVIEW

Neuromodulation techniques have emerged as promising strategies for managing chronic pain. These techniques encompass various modalities of nerve stimulation, including Spinal Cord Stimulation (SCS), Dorsal Root Ganglion Stimulation (DRG-S), and Peripheral Nerve Stimulation (PNS). Studies consistently demonstrate significant improvements in pain intensity, quality of life, and reduced opioid usage among patients treated with these modalities. However, neuromodulation presents challenges, such as the need for frequent in-person follow-up visits to ensure proper functionality of the implanted device. Our review explored factors impacting compliance in current neuromodulation users and examined how remote monitoring can mitigate some of these challenges. We also discuss outcomes of recent studies related to remote monitoring of neuromodulation.

RECENT FINDINGS

While remote monitoring capabilities for neuromodulation devices is an emerging development, there are promising results supporting its role in improving outcomes for chronic pain patients. Higher patient satisfaction, improved pain control, and reduced caretaker burdens have been observed with the use of remote monitoring. This review discusses the current challenges with neuromodulation therapy and highlights the role of remote monitoring. As the field continues to evolve, understanding the importance of remote monitoring for neuromodulation is crucial for optimizing pain management outcomes.

Treatment Among Commercial and Medicaid-Insured Adults With Incident Chronic Pain Episodes

Analyses of health care data can reveal utilization of treatment options that comprise a multidisciplinary approach to chronic pain management. This retrospective cohort study aimed to characterize treatments among commercially versus Medicaid-insured adults with incident episodes of chronic pain. We used MarketScan data to identify patients with diagnoses for conditions associated with chronic pain, assess procedure codes that align with broad categories of treatment options, and compare receipt of treatments by insurance type. Among enrollees aged ≥18 years, 4,254,818 adults with commercial insurance and 583,369 with Medicaid met continuous enrollment criteria and had no chronic pain episodes in 2017. Among patients with incident chronic pain episodes during 2018 to 2020, we determined the proportions receiving different categories of treatment options during the year following diagnosis. Cohen's h determined meaningful differences by insurance. Study cohorts included 1,095,358 commercial (mean [standard deviation] age, 47.3 [13.3] years; 54.3% women) and 176,607 Medicaid adults (38.1 [12.7] years; 70.6% women) with incident chronic pain episodes during 2018 to 2020. More commercial than Medicaid patients received restorative therapies such as physical therapy (38.6% vs 19.2%), complementary or integrative care such as chiropractic treatment (31.1% vs 9.0%), and 2 or more different types of nonmedication treatment procedures (34.1% vs 16.3%). Median days to treatments were shorter for commercial patients. Disparities in the provision, patterns, and timing of treatments by insurance suggest differential access to the full range of treatment options early during the course of care and identify opportunities to align coverage and reimbursement policies with current practice guidelines. PERSPECTIVE: This analysis of medical claims for patients with incident chronic pain episodes found disparities in the provision, patterns, and timing of treatments by insurance type. These results suggest differential access to evidence-based treatment options early during care and identify opportunities to align coverage and reimbursement policies with current practice guidelines.

Using Simulation to Illustrate Pain

Around 51.6 million adults are living with chronic pain that has been linked to mental health disorders, substance use, and suicidal ideation. The high incidence of chronic pain poses a challenge for health care educators to ensure that health care professionals receive training to assess, prevent, and manage chronic pain for a diverse patient population. While simulation-based learning is known as an effective educational strategy, little is known about its use to illustrate pain. This review aims to determine the current evidence related to using simulation-based learning for training and teaching the assessment and management of pain in nursing.

Chronic pain for rheumatological disorders: Pathophysiology, therapeutics and evidence

Pain is the leading reason people seek orthopedic and rheumatological care. By definition, most pain can be classified as nociceptive, or pain resulting from non-neural tissue injury or potential injury, with between 15% and 50% of individuals suffering from concomitant neuropathic pain or the newest category of pain, nociplastic pain, defined as "pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage, or of a disease or lesion affecting the somatosensory system." Pain classification is important because it affects treatment decisions at all levels of care. Although several instruments can assist with classifying treatment, physician designation is the reference standard. The appropriate treatment of pain should ideally involve multidisciplinary care including physical therapy, psychotherapy and integrative therapies when appropriate, and pharmacotherapy with non-steroidal anti-inflammatory drugs for acute, mechanical pain, membrane stabilizers for neuropathic and nociplastic pain, and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants for all types of pain. For nonsurgical interventions, there is evidence to support a small effect for epidural steroid injections for an intermediate-term duration, and conflicting evidence for radiofrequency ablation to provide at least 6months of benefit for facet joint pain, knee osteoarthritis, and sacroiliac joint pain. Since pain and disability represent the top reason for elective surgery, it should be reserved for patients who fail conservative interventions. Risk factors for procedural failure are the same as risk factors for conservative treatment failure and include greater disease burden, psychopathology, opioid use, central sensitization and multiple comorbid pain conditions, poorly controlled preoperative and postoperative pain, and secondary gain.

Orthopedic Pain Management: Tools for Practicing Critical Care Nurses

Nurses practicing in critical care units manage all forms of traumatic, acute, and chronic pain. Chronic pain must be managed in critical care scenarios to facilitate patient comfort and eventual recovery and healing. Patients with orthopedic injuries and conditions have distinct care needs that require specialized knowledge on the provider's part. Critical care nurses manage orthopedic traumatic injuries while simultaneously managing underlying acute orthopedic conditions. Pain experiences are individual to the person experiencing pain. The Internet is a rich source for pain-management materials that the critical care nurse should have in their resource repertoire.

Transforming personalized chronic pain management with artificial intelligence: A commentary on the current landscape and future directions

Artificial intelligence (AI) has the potential to revolutionize chronic pain management by guiding the development of effective treatment strategies that are tailored to individual patient needs. This potential comes from AI's ability to analyze large and heterogeneous datasets to identify hidden patterns. When applied to clinical datasets of a particular patient population, AI can be used to identify pain subtypes among patients, predict treatment responses, and guide the clinical decision-making process. However, integrating AI into the clinical practice requires overcoming challenges such as data quality, the complexity of human pain physiology, and validation against diverse patient populations. Targeted, collaborative efforts among clinicians, researchers, and AI specialists will be needed to maximize AI's capabilities and advance current management and treatment of chronic pain conditions.

Nanotechnology in Pain Management

Chronic pain is a debilitating condition that affects millions of patients worldwide, contributing to a high disease burden and millions of dollars in lost wages, missed workdays, and healthcare costs. Opioids, NSAIDs, acetaminophen, gabapentinoids, muscle relaxants, anticonvulsants, and antidepressants are the most used medications for chronic pain and carry significant side effects, including gastric bleeding, hepatotoxicity, stroke, kidney damage, constipation, dizziness, and arrhythmias. Opioids in particular carry the risk of long-term dependence, drug tolerance, and overdose. In 2022, 81,806 people died from opioid overdose in the United States alone. Alternative treatments for chronic pain are critically needed, and nanotechnology has emerged as a promising means of achieving effective long-term analgesia while avoiding the adverse side effects associated with conventional pharmacological agents. Nanotechnology-based treatments include liposomes, Poly Lactic-co-Glycolic Acid (PLGA) and other polymeric nanoparticles, and carbon-based polymers, which can help mitigate those adverse side effects. These nanomaterials can serve as drug delivery systems that facilitate controlled release and drug stability via the encapsulation of free molecules and protein-based drugs, leading to longer-lasting analgesia and minimizing side effects. In this review, we examine the role of nanotechnology in addressing concerns associated with conventional chronic pain treatments and discuss the ongoing efforts to develop novel, nanotechnology-based treatments for chronic pain such as nanocapacitor patches, gene therapy, the use of both viral and non-viral vectors, CRISPR, and scavengers.

Pain Neuroscience Education: Teaching People About Pain

Chronic pain is an ever-increasing global challenge, and few strategies have been shown to significantly alter this trajectory, and a pure pharmaceutical approach, especially opioids, is not the answer. To truly impact a person with chronic pain's life, current best-evidence supports changing their cognitions (how they think about their pain), moving more, and calming the peripheral and central nervous system, including non-pharmacological strategies. All healthcare providers, however, must use a unified strategy regardless of their professional designation, skillset, and clinical setting. One variable that spans all patient interactions is communication. All healthcare providers talk to patients, be it during informal, casual conversation or during specific medical education tied to diagnosis, prognosis, treatment, reassurance, and more. Current evidence supports teaching patients more about their pain experience, called pain neuroscience education (PNE), which has significant clinical benefits. Any provider may offer PNE, from physicians, pharmacists, therapists, psychologists, nurses, etc. Pain neuroscience education is shown to positively influence self-reported pain, disability, fear-avoidance, pain catastrophizing, movement, and healthcare utilization in patients with chronic pain. This commentary aims to introduce all healthcare providers to PNE, and how, along with non-pharmacological treatments (PNE+) have the ability to positively impact people's lives living with chronic pain.

Fatigue and Sleep-related Impairment as Predictors of the Effect of Nonpharmacological Therapies for Active duty Service Members With Chronic Pain: A Secondary Analysis of a Pragmatic Randomized Clinical Trial

INTRODUCTION

First-line treatments for chronic pain include selected complementary and integrative health therapies, including spinal manipulation, acupuncture, yoga, and massage; and standard rehabilitative care, including physical and occupational therapies. This study aimed to uncover critical factors that contribute to pain impact and the effectiveness of complementary and integrative health therapies and standard rehabilitative care among people with chronic pain, with a focus on the role of sleep-related impairment.

MATERIALS AND METHODS

We conducted a secondary analysis of data from a pragmatic randomized clinical trial of 280 U.S. active duty service members with chronic pain.

RESULTS

Our study's multiple mediation analysis examined the indirect effect of complementary and integrative health therapies on pain impact through fatigue (β = - 0.43; 95% CI, -0.99 to -0.07). When stratified by sleep-related impairment, participants with T scores above the median of 62 demonstrated a significant negative indirect effect of complementary and integrative health therapies through fatigue (β = - 0.80; 95% CI, -2.31 to -0.14). This negative indirect effect was not significant for participants with sleep-related impairment T scores below the median (β = - 0.64; 95% CI, -1.48 to 0.07).

CONCLUSION

These findings suggest that complementary and integrative health therapies are particularly effective in reducing pain impact for individuals with higher levels of sleep-related impairment, and that the effect of complementary and integrative health therapies is supported primarily by reducing fatigue.

Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models

INTRODUCTION

Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP.

MATERIALS AND METHODS

This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure.

RESULTS

We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing.

CONCLUSIONS

Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.