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Travaglini LE, Bennett M, Kacmarek CN, Kuykendall L, Coakley G, Lucksted A. Barriers to accessing pain management services among veterans with bipolar disorder. Health Serv Res 2023; 58:1224-1232. [PMID: 37667502 PMCID: PMC10622259 DOI: 10.1111/1475-6773.14221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE To identify barriers veterans with bipolar disorder face to accessing chronic pain management services within a Veterans Affairs (VA) health care system. DATA SOURCES AND STUDY SETTING Veterans (n = 15) with chronic pain and bipolar disorder and providers (n = 15) working within a mid-Atlantic VA health care system. Data were collected from August 2017-June 2018. STUDY DESIGN Veteran interviews focused on their chronic pain experiences and treatment, including barriers that arose when trying to access pain management services. Provider interviews focused on whether they address chronic pain with veteran patients and, if so, what considerations arise when addressing pain in veterans with bipolar disorder and other serious mental illnesses. DATA COLLECTION Veterans were at least 18 years old, had a confirmed bipolar disorder and chronic pain diagnosis, and engaged in outpatient care within the VA health care system. Clinicians provided direct care services to veterans within the same VA. Interviews lasted approximately 60 min and were transcribed and analyzed using a rapid analysis protocol. PRINCIPAL FINDINGS Four major themes emerged from veteran and provider interviews: siloed care (unintegrated and uncoordinated mental and physical health care), mental health primacy (prioritization of mental health symptoms at expense of physical health symptoms), lagging expectations (unfamiliarity with comprehensive evidence-based pain management options), and provider-patient communication concerns (inefficient communication about pain concerns and treatment options). CONCLUSIONS Veterans with co-occurring pain and bipolar disorder face unique barriers that compromise equitable access to evidence-based pain treatment. Our findings suggest that educating providers about bipolar disorder and other serious mental illnesses and the benefit of effective non-pharmacological pain interventions for this group may improve care coordination and care quality and reduce access disparities.
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Affiliation(s)
- Letitia E. Travaglini
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
| | - Melanie Bennett
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Corinne N. Kacmarek
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Lorrianne Kuykendall
- Office of Research and Development, Washington DC VA Medical CenterWashingtonDCUSA
| | - Gabriella Coakley
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychologyLoyola University MarylandBaltimoreMarylandUSA
| | - Alicia Lucksted
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Kanzler KE, Robinson PJ, McGeary DD, Mintz J, Kilpela LS, Finley EP, McGeary C, Lopez EJ, Velligan D, Munante M, Tsevat J, Houston B, Mathias CW, Potter JS, Pugh J. Addressing chronic pain with Focused Acceptance and Commitment Therapy in integrated primary care: findings from a mixed methods pilot randomized controlled trial. BMC PRIMARY CARE 2022; 23:77. [PMID: 35421949 PMCID: PMC9011950 DOI: 10.1186/s12875-022-01690-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/30/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Over 100 million Americans have chronic pain and most obtain their treatment in primary care clinics. However, evidence-based behavioral treatments targeting pain-related disability are not typically provided in these settings. Therefore, this study sought to: 1) evaluate implementation of a brief evidence-based treatment, Focused Acceptance and Commitment Therapy (FACT-CP), delivered by an integrated behavioral health consultant (BHC) in primary care; and 2) preliminarily explore primary (self-reported physical disability) and secondary treatment outcomes (chronic pain acceptance and engagement in valued activities). METHODS This mixed-methods pilot randomized controlled trial included twenty-six participants with non-cancer chronic pain being treated in primary care (54% women; 46% Hispanic/Latino). Active participants completed a 30-min individual FACT-CP visit followed by 3 weekly 60-min group visits and a booster visit 2 months later. An enhanced treatment as usual (ETAU) control group received 4 handouts about pain management based in cognitive-behavioral science. Follow-up research visits occurred during and after treatment, at 12 weeks (booster visit), and at 6 months. Semi-structured interviews were conducted to collect qualitative data after the last research visit. General linear mixed regression models with repeated measures explored primary and secondary outcomes. RESULTS The study design and FACT-CP intervention were feasible and acceptable. Quantitative analyses indicate at 6-month follow-up, self-reported physical disability significantly improved pre-post within the FACT-CP arm (d = 0.64); engagement in valued activities significantly improved within both the FACT-CP (d = 0.70) and ETAU arms (d = 0.51); and chronic pain acceptance was the only outcome significantly different between arms (d = 1.04), increased in the FACT-CP arm and decreased in the ETAU arm. Qualitative data analyses reflected that FACT-CP participants reported acquiring skills for learning to live with pain, consistent with increased chronic pain acceptance. CONCLUSION Findings support that FACT-CP was acceptable for patients with chronic pain and feasible for delivery in a primary care setting by a BHC. Results provide preliminary evidence for improved physical functioning after FACT-CP treatment. A larger pragmatic trial is warranted, with a design based on data gathered in this pilot. TRIAL REGISTRATION clinicaltrials.gov, NCT04978961 (27/07/2021).
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Affiliation(s)
- Kathryn E Kanzler
- Center for Research to Advance Community Health (ReACH), The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., Mail Code 7768, San Antonio, TX, 78229, USA. .,Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA. .,Department of Family & Community Medicine, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | | | - Donald D McGeary
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Family & Community Medicine, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Rehabilitation Medicine, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jim Mintz
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Lisa Smith Kilpela
- Center for Research to Advance Community Health (ReACH), The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., Mail Code 7768, San Antonio, TX, 78229, USA.,Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Barshop Institute for Longevity and Aging Studies, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Erin P Finley
- Center for Research to Advance Community Health (ReACH), The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., Mail Code 7768, San Antonio, TX, 78229, USA.,Los Angeles Veterans Health Care System, Los Angeles, CA, USA.,Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Cindy McGeary
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Eliot J Lopez
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Dawn Velligan
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Mariana Munante
- U.S. Army Medical Department (AMEDD) Quality and Safety Center, US Army Medical Command, San Antonio, TX, USA
| | - Joel Tsevat
- Center for Research to Advance Community Health (ReACH), The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., Mail Code 7768, San Antonio, TX, 78229, USA.,Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.,Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Brittany Houston
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles W Mathias
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jennifer Sharpe Potter
- Department of Psychiatry & Behavioral Sciences, Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jacqueline Pugh
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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Thériault FL, Momoli F, Hawes RA, Garber BG, Gardner W, Colman I. Spinal pain and major depression in a military cohort: bias analysis of dependent misclassification in electronic medical records. Soc Psychiatry Psychiatr Epidemiol 2022; 57:575-581. [PMID: 34374826 DOI: 10.1007/s00127-021-02160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal pain and major depression are prevalent conditions in adult populations and are particularly impactful in the military. However, the temporal relationship between these two conditions remains poorly understood. METHODS Using data extracted from electronic medical records, we assessed the association between incident diagnoses of spinal pain and major depression in a cohort of 48,007 Canadian Armed Forces personnel followed from January 2017 to August 2018. We used multivariate Poisson regression to measure the association between the period prevalence of these two conditions. We used probabilistic bias modelling to correct our estimates for misclassification of spinal pain and major depression. RESULTS After correcting for misclassification with probabilistic bias modelling, subjects newly diagnosed with spinal pain during the study period were 1.41 times (95% interval 1.25, 1.59) more likely also to be diagnosed with incident major depression, and personnel newly diagnosed with major depression were 1.28 times (95% interval 1.17, 1.39) more likely also to be diagnosed with spinal pain, compared to undiagnosed counterparts of the same age and sex. Without bias corrections, we would have overestimated the magnitude of the association between major depression and spinal pain by a factor of approximately 2.0. CONCLUSION Our results highlight a moderate and bi-directional association between two of the most prevalent disorders in military populations. Our results also highlight the importance of correcting for misclassification in electronic medical record data research.
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Affiliation(s)
- François L Thériault
- Canadian Forces Health Services Group, Department of National Defence, Ottawa, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Robert A Hawes
- Canadian Forces Health Services Group, Department of National Defence, Ottawa, Canada
| | - Bryan G Garber
- Canadian Forces Health Services Group, Department of National Defence, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - William Gardner
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Ian Colman
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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DeBar L, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, Leo MC, McMullen C, Owen-Smith A, Smith DH, Trinacty CM, Vollmer WM. A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial. Ann Intern Med 2022; 175:46-55. [PMID: 34724405 PMCID: PMC9802183 DOI: 10.7326/m21-1436] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy. OBJECTIVE To determine the effectiveness of a group-based CBT intervention for chronic pain. DESIGN Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592). SETTING Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. PARTICIPANTS Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. INTERVENTION A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care. MEASUREMENTS Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes. RESULTS A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was -0.434 point (95% CI, -0.690 to -0.178 point) for pain impact, and the change in pain-related disability was -0.060 point (CI, -0.084 to -0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, -0.055 [CI, -0.099 to -0.011]), but opioid use did not differ significantly between groups. LIMITATION The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear. CONCLUSION Primary care-based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Lynn DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.D.)
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland, Oregon, and Montana State University College of Nursing, Missoula, Montana (L.B.)
| | - Allison Bonifay
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Richard A Deyo
- Oregon Health & Science University School of Medicine, Portland, Oregon (R.A.D.)
| | - Charles R Elder
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Francis J Keefe
- Duke University School of Medicine, Durham, North Carolina (F.J.K.)
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Ashli Owen-Smith
- Georgia State University School of Public Health and Kaiser Permanente Center for Clinical and Outcomes Research, Atlanta, Georgia (A.O.)
| | - David H Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | | | - William M Vollmer
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
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5
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Pozzato I, Craig A, Gopinath B, Kifley A, Tran Y, Jagnoor J, Cameron ID. Outcomes after traffic injury: mental health comorbidity and relationship with pain interference. BMC Psychiatry 2020; 20:189. [PMID: 32345257 PMCID: PMC7189452 DOI: 10.1186/s12888-020-02601-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 04/13/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Mental health symptoms, like depressive mood (DM) and post-traumatic stress (PTS), and pain interference (PI) with daily functioning often co-occur following traffic injury and their comorbidity can complicate recovery. This study aimed to map the course and overlapping trajectories of mental health symptoms, and associations with PI in a traffic injury population. METHODS In total, 2019 adults sustaining minor-to-moderate traffic injury were recruited within 28 days post-injury and assessed using phone interviews at 1, 6 and 12-months post-injury. Trajectories of DM, PTS and PI were established and relationships between DM, PTS and PI trajectories were explored using dual trajectory modelling. Bio-psychosocial predictors (e.g. pre-injury health, catastrophizing, acute distress, quality of life, social support) of mental health trajectories were investigated. RESULTS Up to five typical post-trauma trajectories were identified for DM, PTS and PI. Most people were in a resilient mental health trajectory (over 60%, DM or PTS), or in a chronic PI trajectory (almost 60%) 12 months post-injury. While recovery/resilient mental health trajectories were strongly interrelated (73.4% joint probability and > 94% conditional probabilities), DM/PTS comorbidity in chronic trajectories was not straightforward, suggesting a possibly asymmetric relationship. That is, persistent DM was more likely associated with persistent PTS (90.4%), than vice versa (31.9%), with a 22.5% probability that persistent PTS was associated with none or milder depression (i.e. following a recovery/resilient DM trajectory). An asymmetrical relationship was also found between mental health and PI. The majority of those with persistent PI were likely to be in a recovery/resilient DM/PTS trajectory (almost 70%), but those in a non-resilient DM/PTS trajectory showed a high risk of persistent PI. Predictors of non-resilient mental health trajectories included poorer pre-injury health and social support, and shared factors like acute psychological distress and pain catastrophizing. CONCLUSIONS Strong interrelations were confirmed between mental health symptoms and PI following traffic injury. However, persistent DM was more strongly linked to persistent PTS, than vice versa. Persistent PI was only linked with persistent DM/PTS in vulnerable subgroups. Early psychiatric/psychological interventions should target elevated psychological distress and negative appraisals in vulnerable individuals, to reduce long-term mental health morbidity/comorbidity and PI. TRIAL REGISTRATION ACTRN12613000889752.
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Affiliation(s)
- I. Pozzato
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia
| | - A. Craig
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia
| | - B. Gopinath
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia
| | - A. Kifley
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia
| | - Y. Tran
- grid.1004.50000 0001 2158 5405Centre of Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW 2109 Australia
| | - J. Jagnoor
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia ,grid.1005.40000 0004 4902 0432The George Institute for Global Health, The University of NSW, Sydney, Australia
| | - I. D. Cameron
- grid.1013.30000 0004 1936 834XJohn Walsh Centre for Rehabilitation Research, Northern Clinical School, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Corner Reserve Road & Westbourne Street, Royal North Shore Hospital, St Leonards, NSW 2065 Australia
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6
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Owen-Smith A, Stewart C, Sesay MM, Strasser SM, Yarborough BJ, Ahmedani B, Miller-Matero LR, Waring SC, Haller IV, Waitzfelder BE, Sterling SA, Campbell CI, Hechter RC, Zeber JE, Copeland LA, Scherrer JF, Rossom R, Simon G. Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness. BMC Psychiatry 2020; 20:40. [PMID: 32005200 PMCID: PMC6995196 DOI: 10.1186/s12888-020-2456-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/22/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. METHODS Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. RESULTS Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. CONCLUSIONS Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.
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Affiliation(s)
- Ashli Owen-Smith
- Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA, 30303, USA. .,Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA.
| | - Christine Stewart
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
| | - Musu M. Sesay
- 0000 0000 9957 7758grid.280062.eCenter for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA
| | - Sheryl M. Strasser
- 0000 0004 1936 7400grid.256304.6Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA 30303 USA
| | - Bobbi Jo Yarborough
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Northwest, Portland, USA
| | - Brian Ahmedani
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Lisa R. Miller-Matero
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Stephen C. Waring
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Irina V. Haller
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Beth E. Waitzfelder
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Hawaii, Honolulu, USA
| | - Stacy A. Sterling
- 0000 0000 9957 7758grid.280062.eDivision of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Cynthia I. Campbell
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Rulin C. Hechter
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John E. Zeber
- 0000 0001 2184 9220grid.266683.fSchool of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, USA
| | | | - Jeffrey F. Scherrer
- 0000 0004 1936 9342grid.262962.bDepartment of Family and Community Medicine, Saint Louis University School of Medicine, Saint Louis, USA
| | - Rebecca Rossom
- 0000 0004 0461 4886grid.280625.bHealth Partners Institute, Minneapolis, USA
| | - Greg Simon
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
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7
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Values-Based Behavioral Activation for Chronic Pain in Primary Care: A Pilot Study. J Clin Psychol Med Settings 2019; 27:633-642. [PMID: 31456124 DOI: 10.1007/s10880-019-09655-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic pain is prevalent and can be complex to manage in primary care. Encouraging patients with chronic pain to engage in valued activities has been associated with reduced disability and distress. This single-arm, mixed methods pilot study examined whether adding a values-based behavioral activation intervention to a chronic pain protocol is feasible and acceptable in an urban, underserved family medicine residency clinic. Patients (N = 30) living with chronic pain completed a values assessment and co-created a plan with a psychologist to engage in values-based activities. Patients completed self-report measures of psychological health and functioning pre- and post-intervention and a qualitative interview at the follow-up visit. The intervention was considered feasible and acceptable. Patients reported high levels of satisfaction and enjoyment of the intervention and significantly less pain interference at follow-up compared to baseline. Values-based behavioral activation for chronic pain may be implemented as part of behavioral health practice in primary care.
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