The missing 'P' in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care

Chronic Pain and Obsessive-Compulsive Disorder: A Scoping Review

INTRODUCTION

The aim of this study was to map the association between Chronic Pain (CP) and Obsessive-Compulsive Disorder (OCD) in the present literature.

METHODS

A scoping review was conducted with a comprehensive search of literature in peer-reviewed journals. Search parameters included articles written in English, published at any time, and including terms associated with both CP and OCD. Databases searched for purposes of this study included Psychinfo, Medline, Embase, Emcare, CINAHL, Scopus, Web of Science, Cochrane, and Google Scholar.

RESULTS

The review included 87 records, comprising 49 primary research and 38 secondary research records. Extracted information from these were grouped into four broad classifications. The Prevalence and Severity classification included information from 39 records which comprised: (1) primary research detailing current OCD prevalence rates in CP conditions (differentiated between general population and Pain/Medical/Hospital clinics); (2) primary research detailing lifetime OCD prevalence rates in CP conditions; (3) primary research detailing CP prevalence rates in OCD; (4) primary research detailing relationships between OCD and CP through psychometric measures; and (5) secondary research relating to prevalence rates. The Neurobiology classification included information from 28 records (primary and secondary research) detailing convergent and divergent neurobiological/neurophysiological aspects as reported for both OCD and CP. The Psychological Models/Factors classification included information from 7 records (primary and secondary research) detailing pain-related anxiety, neuropsychological measures, catastrophic thinking, preservative thinking, early maladaptive schemas, schema modes, childhood trauma experiences, and conditional associative learning, as reported for OCD and CP. The Intervention classification included information from 32 records which comprised: (1) primary research on neurosurgical, medication, and psychotherapeutic interventions; (2) secondary research on Deep Brain Stimulation; (3) secondary research on Medication; (4) secondary research on lesion, cingulotomy, and other surgical procedures; and (5) secondary research on other interventional procedures.

CONCLUSION

While there has been considerable and growing research in the fields of both OCD and CP over the years, focused research into their potential association has been limited and potentially overlooked. The results of this review, however, suggest a complex relationship between CP and OCD. Prevalence rates between the two conditions vary widely across different populations, although the underlying reason for this remains unclear at this stage. There are commonalities in terms of alterations in pain processing, the dysregulation of certain brain regions, and the abnormalities in neurotransmitter systems in both conditions. In their treatment, use can be made of overlapping pathophysiological processes, the convergent and divergent psychological aspects, and the range of interventional approaches that share targets to promote efficacy. However, the complex presentations of both OCD and CP make it a challenging relationship to accurately clarify. Further directed and robust, high-quality studies will be needed to expand our understanding of this area.

Persisting with Purpose: Using Acceptance and Commitment Therapy to Target Comorbid Opioid Use Disorder and Chronic Pain in a Racially and Economically Marginalized Population

Opioid use disorder (OUD) and chronic pain (CP) are commonly comorbid health conditions that cause significant disability, distress, and mortality. Treatment for these conditions is impacted by drop out and presence of other psychiatric conditions. Acceptance and Commitment Therapy is an effective intervention to treat chronic pain and substance use disorders, however this intervention has not been systematically evaluated for treatment of comorbid OUD and CP, especially in a racially and economically marginalized population. In this paper we describe development of such an ACT manual, using an intervention mapping approach. While the manual pays close attention to opioid use and chronic pain, it includes transdiagnostic principles that target overall psychological well-being including a deep emphasis on expanding valued living. We incorporated trauma informed care, cultural humility, and harm reduction principles in the development of nine ACT skills that are easy to understand and scalable. The treatment manual centers economically and racially marginalized patients who are traditionally underrepresented in psychological research. This manual is currently being evaluated in clinical trial NCT05039554 with funding from the NIH HEAL project #RM1DA055437. The treatment manual and handouts are freely available for use and included.

Factors Associated with an Increased Risk of Opioid Misuse Among Patients with Non-Cancer Pain in Malaysian Pain Clinic Settings

This study examined the factors associated with a high risk of opioid misuse among patients receiving opioid treatment for their non-cancer pain in Malaysian pain clinics. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), a validated instrument for predicting the risk of aberrant drug-related behaviors, were used as a proxy to indicate risk of opioid misuse. Data analysis was stratified into high-risk and low-risk patient groups. Patient factors assessed included pain intensity, pain interference with daily activities, and health-related quality of life. Prescription opioid exposure was examined via patient medical and prescription records review. Among the 61 patients recruited, 62.3% scored ≥18 on the SOAPP-R, which indicates a high risk for opioid misuse. Factors associated with a high risk of opioid misuse were found to be high level of pain interference with daily activities, poorer mental health, and younger age. High-risk patients were found to be prescribed a lower mean daily opioid dose of <20 mg/day compared to low-risk patients (20-49 mg/day). This highlights the need for further research to distinguish aberrant drug-related behaviors due to inadequate pain management from that of actual prescription opioid misuse among non-cancer pain patients attending pain clinics.

Prescription opioid dispensing patterns among patients with schizophrenia or bipolar disorder

BACKGROUND

Patients with schizophrenia (SZ) or bipolar disorder (BD) may have increased risk of complications from prescribed opioids, including opioid-induced respiratory depression. We compared prescription opioid pain medication dispensing for patients with SZ or BD versus controls over 5 years to assess dispensing trends.

METHODS

This retrospective, observational study analysed US claims data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases for individuals aged 18-64 years with prevalent SZ or BD for years 2015-2019 compared with age- and sex-matched controls. Baseline characteristics, comorbidities, and medication use were assessed. Proportions of individuals dispensed prescription opioids chronically (ie, ≥70 days over a 90-day period or ≥ 6 prescriptions annually) or nonchronically (≥1 prescription, chronic definition not met) were assessed.

RESULTS

In 2019, the Commercial and Medicaid databases contained records for 4773 and 30,179 patients with SZ and 52,780 and 63,455 patients with BD, respectively. Patients with SZ or BD had a higher prevalence of comorbidities, including pain, versus controls in each analysis year. From 2015 to 2019, among commercially insured patients with SZ, chronic opioid-dispensing proportions decreased from 6.1% (controls: 2.7%) to 2.3% (controls: 1.2%) and, for patients with BD, from 11.4% (controls: 2.7%) to 6.4% (controls: 1.6%). Chronic opioid dispensing declined in Medicaid-covered patients with SZ from 15.0% (controls: 14.7%) to 6.7% (controls: 6.0%) and, for patients with BD, from 27.4% (controls: 12.0%) to 12.4% (controls: 4.7%). Among commercially insured patients with SZ, nonchronic opioid dispensing decreased from 15.5% (controls: 16.4%) to 10.7% (controls: 11.0%) and, for patients with BD, from 26.1% (controls: 17.5%) to 20.0% (controls: 12.2%). In Medicaid-covered patients with SZ, nonchronic opioid dispensing declined from 22.5% (controls: 24.4%) to 15.1% (controls: 12.7%) and, for patients with BD, from 32.3% (controls: 25.9%) to 24.6% (controls: 13.6%).

CONCLUSIONS

The proportions of individuals dispensed chronic or nonchronic opioid medications each year were similar between commercially and Medicaid-insured patients with SZ versus controls and were higher for patients with BD versus controls. From 2015 to 2019, the proportions of individuals who were dispensed prescription opioids chronically or nonchronically decreased for patients with SZ or BD and controls.

Investigation of the mechanisms for wireless nerve stimulation without active electrodes

Electric-field stimulation of neuronal activity can be used to improve the speed of regeneration for severed and damaged nerves. Most techniques, however, require invasive electronic circuitry which can be uncomfortable for the patient and can damage surrounding tissue. A recently suggested technique uses a graft-antenna-a metal ring wrapped around the damaged nerve-powered by an external magnetic stimulation device. This technique requires no electrodes and internal circuitry with leads across the skin boundary or internal power, since all power is provided wirelessly. This paper examines the microscopic basic mechanisms that allow the magnetic stimulation device to cause neural activation via the graft-antenna. A computational model of the system was created and used to find that under magnetic stimulation, diverging electric fields appear at the metal ring's edges. If the magnetic stimulation is sufficient, the gradients of these fields can trigger neural activation in the nerve. In-vivo measurements were also performed on rat sciatic nerves to support the modeling finding that direct contact between the antenna and the nerve ensures neural activation given sufficient magnetic stimulation. Simulations also showed that the presence of a thin gap between the graft-antenna and the nerve does not preclude neural activation but does reduce its efficacy.

Opioids for acute and chronic pain when receiving psychiatric medications

BACKGROUND

People with mental health disorders (MHD) like depression and anxiety are more likely to experience substance use disorders (SUDs) than those without MHD. This study assesses opioid prescription patterns for acute or chronic pain management in patients receiving medication for depression and/or anxiety.

METHODS AND FINDINGS

Cross-sectional data trend analysis of 24.5 million adult medical claims was conducted using medical and pharmacy data (2012-2019) for adults aged 21-64 from the IBM Watson MarketScan Medicaid Multi-State Database. Information on sex, age, race, provider type, acute or chronic pain, and prescriptions for opioids and antidepressant and/or antianxiety medication from outpatient encounters were analyzed. For those receiving opioid prescriptions within 14 days of a pain diagnosis, ICD-10-CM codes were used to categorize diagnoses as chronic pain (back pain, neck pain, joint pain, and headache); or acute pain (dental-, ENT-, and orthopedic-related pain). Nearly 8 million adults had at least one prescription for antidepressant or antianxiety medications (MHD), with 2.5 million of those (32%) also diagnosed with an acute or chronic pain condition (pain + MHD). Among the pain + MHD group, 34% (0.85 million) received an opioid prescription within 14 days of diagnosis. Individuals with chronic pain diagnoses received a higher proportion of opioid prescriptions than those with acute pain. Among individuals with pain + MHD, the majority were aged 50-64 (35%), female (72%), and non-Hispanic white (65.1%). Nearly half (48.2%) of the opioid prescriptions given to adults with an MHD were provided by physicians. Compared to other physician types, Health Care Providers (HCPs) in emergency departments were 50% more likely to prescribe an opioid for dental pain to those with an MHD, whereas dentists were only half as likely to prescribe an opioid for dental pain management. Although overall opioid prescriptions for pain management declined from 2012 to 2019, adults with an MHD received opioids for pain management at nearly twice the level as adults without an MHD.

CONCLUSIONS

Although HCPs have reduced opioids for acute or chronic pain to patients at high-risk for SUD, for example, those with MHD, the use of opioids for pain management has remained at consistently higher levels for this SUD high-risk group, suggesting the need to revisit pain management guidelines for those receiving antidepressant or antianxiety drugs.

Assessing the potential anti-neuroinflammatory effect of minocycline in chronic low back pain: Protocol for a randomized, double-blind, placebo-controlled trial

INTRODUCTION

Both preclinical studies, and more recent clinical imaging studies, suggest that glia-mediated neuroinflammation may be implicated in chronic pain, and therefore might be a potential treatment target. However, it is currently unknown whether modulating neuroinflammation effectively alleviates pain in humans. This trial tests the hypothesis that minocycline, an FDA-approved tetracycline antibiotic and effective glial cell inhibitor in animals, reduces neuroinflammation and may reduce pain symptoms in humans with chronic low back pain.

METHODS AND ANALYSIS

This study is a randomized, double-blind, placebo-controlled clinical trial. Subjects, aged 18-75, with a confirmed diagnosis of chronic (≥ six months) low back pain (cLBP) and a self-reported pain rating of at least four out of ten (for at least half of the days during an average week) are enrolled via written, informed consent. Eligible subjects are randomized to receive a 14-day course of either active drug (minocycline) or placebo. Before and after treatment, subjects are scanned with integrated Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) using [¹¹C]PBR28, a second-generation radiotracer for the 18 kDa translocator protein (TSPO), which is highly expressed in glial cells and thus a putative marker of neuroinflammation. Pain levels are evaluated via daily surveys, collected seven days prior to the start of medication, and throughout the 14 days of treatment. General linear models will be used to assess pain levels and determine the treatment effect on brain (and spinal cord) TSPO signal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT03106740).

Prevalence of pain and its treatment among older adults in India: a nationally representative population-based study

ABSTRACT

There were no estimates of the prevalence of pain and its treatment in the older population of India obtained from face-to-face interviews with a nationally representative sample. We addressed this evidence gap by using data on 63,931 individuals aged 45 years and older from the 2017/2018 Longitudinal Ageing Study in India. We identified pain from an affirmative response to the question: Are you often troubled by pain? We also identified those who reported pain that limited usual activities and who received treatment for pain. We estimated age- and sex-adjusted prevalence of pain, pain limiting usual activity and treatment, and compared these estimates across states and sociodemographic groups. We used a multivariable probit model to estimate full adjusted differences in the probability of each outcome across states and sociodemographic groups. We estimated that 36.6% (95% confidence interval [CI]: 35.3-37.8) of older adults in India were often troubled by pain and 25.2% (95% CI: 24.2-26.1) experienced pain limiting usual activity. We estimated that 73.3% (95% CI: 71.9-74.6) of those often troubled by pain and 76.4% (95% CI: 74.9-78.0) of those with pain that limited usual activity received treatment. There was large variation in each outcome across states. Fully adjusted prevalence of pain and pain limiting usual activity were higher among individuals who were female, older, less educated, rural residents, and poorer. Prevalence of treatment among those troubled by pain was lower among socially disadvantaged groups.

Opioid prescribing practices prior to elective foot and ankle surgery: a population-based evaluation using health administrative data from a tertiary hospital in Canada

Background

Complex elective foot and ankle surgery is known to be painful so most patients are prescribed opioids at the time of surgery; however, the number of patients prescribed opioids while waiting for surgery in Canada is unknown. Our primary objective was to describe the pre and postoperative prescribing practices for patients in Alberta, Canada undergoing complex elective foot and ankle surgery. Secondarily, we evaluated postoperative opioid usage and hospital outcomes.

Methods

In this population-based retrospective analysis, we identified all adult patients who underwent unilateral elective orthopedic foot and ankle surgery at a single tertiary hospital between May 1, 2015 and May 31, 2017. Patient and surgical data were extracted from a retrospective chart review and merged with prospectively collected, individual level drug dispensing administrative data to analyze opioid dispensing patterns, including dose, duration, and prescriber for six months before and after foot and ankle surgery.

Results

Of the 100 patients, 45 had at least one opioid prescription dispensed within six months before surgery, and of these, 19 were long-term opioid users (> 90 days of continuous use). Most opioid users obtained opioid prescriptions from family physicians both before (78%) and after (65%) surgery. No preoperative non-users transitioned to long-term opioid use postoperatively, but 68.4% of the preoperative long-term opioid users remained long-term opioid users postoperatively. During the index hospitalization, preoperative long-term opioid users consumed higher doses of opioids (99.7 ± 120.5 mg/day) compared to opioid naive patients (28.5 ± 36.1 mg/day) (p < 0.001). Long-term opioid users stayed one day longer in hospital than opioid-naive patients (3.9 ± 2.8 days vs 2.7 ± 1.1 days; p = 0.01).

Conclusions

A significant number of patients were dispensed opioids before and after foot and ankle surgery with the majority of prescriptions coming from primary care practitioners. Patients who were prescribed long-term opioids preoperatively were more likely to continue to use opioids at follow-up and required larger in-hospital opioid dosages and stayed longer in hospital. Further research and education for both patients and providers are needed to reduce the community-based prescribing of opioid medication pre-operatively and provide alternative pain management strategies prior to surgery to improve postoperative outcomes and reduce long-term postoperative opioid use.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Frequency and characteristics of patient exclusion criteria in Canadian multidisciplinary pain treatment facilities: a cross-sectional study

PURPOSE

A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs.

METHODS

We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures.

RESULTS

A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff.

CONCLUSIONS

Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.

Opioid mortality, public health care expenditures, and cross-national homicide rates: findings from 25 OECD countries, 2000-2017

PURPOSE

This study assesses the relationship between opioid mortality and homicide rates across 25 member countries of the organization for economic co-operation and development (OECD) over time and investigates the role of country-level public health expenditures in this relationship.

METHODS

Fixed effects linear regression is used to assess the longitudinal association between opioid mortality and cross-national homicide rates in 25 OECD countries between 2000 and 2017. Moderation analyses are conducted to assess the interaction between opioid mortality rates and public health expenditures per capita.

RESULTS

Study findings revealed a positive bivariate association between opioid mortality and homicide rates. However, this association became null after controlling for public health expenditures. Moderation analyses revealed that there is a strong positive association between opioid mortality and homicide rates when public health expenditures are low, which becomes gradually weaker at higher levels of health expenditures.

CONCLUSION

This study suggests one consequence of the opioid epidemic may be increased homicide rates, and this association is stronger in countries with lower public health expenditures. These findings highlight the potential role of governments to combat the associated harms of rising opioid use through greater investments in public health care.

Depression and Long-Term Prescription Opioid Use and Opioid Use Disorder: Implications for Pain Management in Cancer

OPINION STATEMENT

Preventing depression in cancer patients on long-term opioid therapy should begin with depression screening before opioid initiation and repeated screening during treatment. In weighing the high morbidity of depression and opioid use disorder in patients with chronic cancer pain against a dearth of evidence-based therapies studied in this population, patients and clinicians are left to choose among imperfect but necessary treatment options. When possible, we advise engaging psychiatric and pain/palliative specialists through collaborative care models and recommending mindfulness and psychotherapy to all patients with significant depression alongside cancer pain. Medications for depression should be reserved for moderate to severe symptoms. We recommend escitalopram/citalopram or sertraline among selective serotonin reuptake inhibitors (SSRIs), or the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine, venlafaxine, or desvenlafaxine if patients have a significant component of neuropathic pain or fibromyalgia. Tricyclic antidepressants (TCAs) (consider nortriptyline or desipramine, which have better anticholinergic profiles) should be considered for patients who do not respond to or tolerate SSRI/SNRIs. Existing evidence is inadequate to definitively recommend methylphenidate or novel agents, such as ketamine or psilocybin, as adjunctive treatments for cancer-related depression and pain. Physicians who treat patients with cancer pain should utilize universal precautions to limit the risk of non-medical opioid use (non-medical opioid use). Patients should be screened for non-medical opioid use behaviors at initial consultation and at regular intervals during treatment using a non-judgmental approach that reduces stigma. Co-management with an addiction specialist may be indicated for patients at high risk of non-medical opioid use and opioid use disorder. Buprenorphine and methadone are indicated for the treatment of opioid use disorder, and while they have not been systematically studied for treatment of opioid use disorder in patients with cancer pain, they do provide analgesia for cancer pain. While an interdisciplinary team approach to manage psychological stress may be beneficial, this may not be possible for patients treated outside of comprehensive cancer centers.

The Right to Pain Relief: Its Origins in End-of-life Care and Extension to Chronic Pain Care

OBJECTIVES

The claim of a right to pain relief was made in recent decades by pain professionals, courts, and patient advocacy groups and likely contributed to increased opioid prescribing, overdose deaths, and addictions, but the origins and nature of this right have not been investigated.

MATERIALS AND METHODS

Relevant clinical, ethical, and legal literature concerning patient rights to pain care was reviewed.

RESULTS

The record describes the effort to improve end-of-life and cancer pain care in the 1980s and 1990s, which simultaneously legitimated pain relief as an independent goal of medical care and opioids as a safe and effective means to achieve this relief. In 1997, the US Supreme Court denied the right to assisted suicide but affirmed a right to palliative care to prevent dying in overwhelming pain. Other guidelines and regulations extended this right to pain relief from end-of-life care to chronic pain care, along with the titrate-to-effect principle, which specified that the correct opioid dose was the dose that relieved pain.

DISCUSSION

The most important consequence of combining the right to pain relief with the titrate-to-effect principle was the idea that a high pain score must not be ignored. This extension of the right to pain relief neglected important differences between end-of-life care and chronic pain care including: time frame, clinical setting and context, target of titration, and nature of iatrogenic harms. To help end our current opioid epidemic and prevent a future epidemic, we need to demedicalize pain and reintegrate it with the rest of human suffering as an experience connected to other personal behaviors and meanings.

Pain and Opioid Use: Evidence for Integrating Acupuncture Into Treatment Planning

The epidemics of pain and opioid use pose unique challenges. Comprehensive approaches are required to address minds, bodies and spirits of individuals who live with pain and/or opioid use. The lack of an effective “quick fix” for either condition necessitates developing effective, innovative and multi-disciplinary avenues for treatment. This analytic article reviews epidemiological and demographic factors associated with pain and with opioid use and additional challenges posed by the Covid-19 epidemic. Several large-scale studies and meta-analyses have examined the role of acupuncture as a nonpharmacological approach to pain management as well as a component of comprehensive strategies to address opioid use disorder. We review and describe these in the context of safety, effectiveness, access and cost-related factors. With one in four U.S. hospitals as well as 88% of Veterans Health Administration facilities incorporating acupuncture, the feasibility of mobilizing and scaling up these treatment resources is being developed and demonstrated. We also identify potential facilitators and barriers to implementing acupuncture treatment. As part of a multi-disciplinary approach to pain management and/or opioid use disorder, we suggest that integrating acupuncture into treatment protocols may represent a viable strategy that is based on and consistent with public health principles.

Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder

Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Opioid dosing among patients with 3 or more years of continuous prescription opioid use before and after the CDC opioid prescribing guideline

BACKGROUND

Opioid doses declined after the Centers for Disease Control (CDC) opioid prescribing guideline was published. However, it is unknown if dose declines occurred in patients with ≥ 3 years of continuous opioid use.

METHODS

Optum® de-identified integrated Electronic Health Record and claims data were used to create an adult sample (n = 400) with continuous opioid use for 18 months before and after the guideline publication. Based on the morphine milligram equivalent (MME) distribution at Month 1, patients were categorized into 1-50, 51-100, 101-200, and >200 mg baseline MME. Interrupted time series analysis using segmented mixed linear regression models stratified on baseline MME estimated average monthly changes in MME in the 18-months pre- and post-guideline, before and after adjusting for time-varying pain conditions, psychiatric disorders and benzodiazepine prescription.

RESULTS

Patients were 59.6 (SD±11.8) years of age, 55.8% female and 84.0% white race. For 1-50 MME, monthly dose slope was significantly (p<0.0001) flatter post-guideline (pre b = 0.34 MME/month vs. post b = 0.12 MME/month). For 51-100 MME, the pre- and post-guideline dose slopes did not significantly differ (pre b = 0.60 MME/month vs. post b = 0.27 MME/month). For 101-200 MME, post-guideline dose slope was significantly (p<0.0001) steeper and decreasing post-guideline (pre b = 0.11 MME/month vs. post b= -1.33 MME/month). Among >200 MME, dose decreased in the pre- and post-guideline periods, and post-guideline decline was significantly (p<0.0001) steeper (b= -1. 86 MME/month vs. b= -4.13 MME/month).

CONCLUSIONS

Among patients on multiyear opioid therapy, the CDC guideline was associated with a modest change in dosing, except for patients on very high doses. The guideline was not associated with decreasing MME among lower-dose, long-term users.

Telerehabilitation for Pain Management

Telerehabilitation for pain management uses communication technology to minimize geographic barriers. Access to such technology has proven critically important during the coronavirus disease-2019 pandemic and has been useful for patients with chronic pain disorders unable to travel. The evaluation and treatment of such disorders requires a whole health approach that individualizes treatment options and delivers care through a biopsychosocial approach. The goals of care are unchanged from an in-person patient-provider experience. Telerehabilitation can be successfully implemented in pain management with appropriate consideration for staging an evaluation, a structured approach to the visit, and application of standard clinical metrics.

The Role of the Kappa Opioid System in Comorbid Pain and Psychiatric Disorders: Function and Implications

Both pain and psychiatric disorders, such as anxiety and depression, significantly impact quality of life for the sufferer. The two also share a strong pathological link: chronic pain-induced negative affect drives vulnerability to psychiatric disorders, while patients with comorbid psychiatric disorders tend to experience exacerbated pain. However, the mechanisms responsible for the comorbidity of pain and psychiatric disorders remain unclear. It is well established that the kappa opioid system contributes to depressive and dysphoric states. Emerging studies of chronic pain have revealed the role and mechanisms of the kappa opioid system in pain processing and, in particular, in the associated pathological alteration of affection. Here, we discuss the key findings and summarize compounds acting on the kappa opioid system that are potential candidates for therapeutic strategies against comorbid pain and psychiatric disorders.

Kappa Opioid Signaling at the Crossroads of Chronic Pain and Opioid Addiction

Pain is complex and is a unique experience for individuals in that no two people will have exactly the same physiological and emotional response to the same noxious stimulus or injury. Pain is composed of two essential processes: a sensory component that allows for discrimination of the intensity and location of a painful stimulus and an emotional component that underlies the affective, motivational, unpleasant, and aversive response to a painful stimulus. Kappa opioid receptor (KOR) activation in the periphery and throughout the neuroaxis modulates both of these components of the pain experience. In this chapter we focus on recent findings that KORs contribute to the emotional, aversive nature of chronic pain, including how expression in the limbic circuitry contributes to anhedonic states and components of opioid misuse disorder. While the primary focus is on preclinical pain models, we also highlight clinical or human research where there is strong evidence for KOR involvement in negative affective states associated with chronic pain and opioid misuse.

Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management

Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.

Associations of mental health and family background with opioid analgesic therapy: a nationwide Swedish register-based study

There is evidence of greater opioid prescription to individuals in the United States with mental health conditions. Whether these associations generalize beyond the US prescription environment and to familial mental health and socioeconomic status (SES) has not been examined comprehensively. This study estimated associations of diverse preexisting mental health diagnoses, parental mental health history, and SES in childhood with opioid analgesic prescription patterns nationwide in Sweden. Using register-based data, we identified 5,071,193 (48.4% female) adolescents and adults who were naive to prescription opioid analgesics and followed them from 2007 to 2014. The cumulative incidence of any dispensed opioid analgesic within 3 years was 11.4% (95% CI, 11.3%-11.4%). Individuals with preexisting self-injurious behavior, as well as opioid and other substance use, attention-deficit/hyperactivity, depressive, anxiety, and bipolar disorders had greater opioid therapy initiation rates than did individuals without the respective conditions (hazard ratios from 1.24 [1.20-1.27] for bipolar disorder to 2.12 [2.04-2.21] for opioid use disorder). Among 1,298,083 opioid recipients, the cumulative incidence of long-term opioid therapy (LTOT) was 7.6% (7.6%-7.7%) within 3 years of initiation. All mental health conditions were associated with greater LTOT rates (hazard ratios from 1.66 [1.56-1.77] for bipolar disorder to 3.82 [3.51-4.15] for opioid use disorder) and were similarly associated with concurrent benzodiazepine-opioid therapy. Among 1,482,462 adolescents and young adults, initiation and LTOT rates were greater for those with parental mental health history or lower childhood SES. Efforts to understand and ameliorate potential adverse effects of opioid analgesics must account for these patterns.

Attitudes of pain and opioids prescription practices in U.S. cystic fibrosis centers

BACKGROUND

The high incidence and prevalence of chronic pain in patients with cystic fibrosis (CF) is well documented. However, there is limited data on chronic pain management in this population.

METHODS

We designed a questionnaire examining care team members' views on the prevalence and characteristics of pain, pain management, and opioid use. The questionnaire was distributed to accredited programs throughout the US via a CF Foundation (CFF) email list-serve.

RESULTS

Responses came from 52 adult core or affiliated centers (Adult Responders - AR), 36 pediatric core or affiliated centers (Pediatric Responders - PR), and 9 were from combined programs. AR perceive more patients having chronic pain compared to PR. Furthermore, 40% of the AR said that > 50% of those with chronic pain also have comorbid depression or anxiety. 61% of PR ranked sinus/headache symptoms as the most common while AR ranked chest wall as the most frequent site (58%). While most centers (83%) report that pain management in patients with CF is a very important or important issue, 50% of AR feel uncomfortable or only slightly comfortable in prescribing opioids. 44% report that CF providers are currently responsible for this task.

CONCLUSIONS

Chronic pain is common in adult patients with CF and management presents a formidable challenge to providers. The development of guidelines and/or collaboration with pain specialists will likely benefit both patients and providers.

The association between depression and type of treatments received for chronic low back pain

BACKGROUND

Depression is associated with receipt of opioids in non-cancer pain.

OBJECTIVES

To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments.

METHODS

Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments.

RESULTS

Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609).

CONCLUSION

There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

The Prescription Opioids and Depression Pathways Cohort Study

Background

Results from studies using medical record data indicate chronic (>90 days) opioid analgesic use (OAU) is associated with new depressive episodes (NDE), worsening depression and risk for depression recurrence. This body of evidence is based on retrospective cohort studies and medical record data. Limitations of existing research are overcome in a new prospective cohort study of the opioid-depression relationship.

Methods

Prospective cohort of 1500 adult patients recruited from two health care systems. Eligible subjects started a new period of OAU and have 30 to 90 days of OAU at baseline. Diagnostic assessments for psychiatric disorders, structured measures of pain, pain functioning, opioid use, social support, sleep and impulsivity will be obtained at baseline, 6-month and 12-month follow-up. Baseline participants will be invited to 12 monthly brief assessments of pain-related functioning, depression symptoms and opioid use.

Innovation

Robust control for confounding by indication and detailed phenotyping of depression and opioid use disorder.

Anticipated results

Chronic OAU will be associated with new onset of a depression phenotype characterized by anhedonia and somatic symptoms. This relationship will be partly, but not completely explained by impaired functioning and low social support.

Conclusions

Although the annual number of opioid prescriptions in the United States has decreased, over 190 million patients have OAU each year. If chronic OAU leads to a clinically meaningful affective disorder, independent of pain, then we need to consider depression an important adverse effect of chronic OAU and adjust care for chronic pain accordingly.

A 20-year study of the bidirectional relationship between anxious and depressive symptomology and pain medication usage

Aim: To investigate the 20-year relationship between anxiety, depression and pain medication use. Patients: A total of 521 individuals reporting chronic pain from the National Survey of Midlife Development in the USA (MIDUS) study. Methods: Structural equation modeling of 20-year longitudinal survey data. Results: Over 20 years, a bidirectional relationship between depression and anxiety in individuals with chronic pain was indicated. Pain medication utilization predicted later use at 10 years. Pain medication use was not strongly related to later anxiety; however, heightened anxiety was associated with later use. Conclusion: Depression and anxiety show an extensive long-term bidirectional relationship. While there was little indication of a relationship between pain medication use and later negative mood, anxiety was associated with subsequent pain medication use.

Ethics Consultations Related to Opioid Use Disorder

BACKGROUND

The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention.

OBJECTIVE

The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital.

METHODS

We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital.

RESULTS

Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital.

CONCLUSION

The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults.

Opioid use disorder and chronic pain: challenges for palliative care practice

Along with a well-documented increase in opioid use disorder (OUD) and a rapidly escalating rate of fatal overdose in North America, inadequate management of chronic pain remains a pervasive problem. The increasing number of individuals living with OUD also experience multiple cancer risk factors, which are related to their substance use, while people with cancer diagnoses have similar risks of current or past addiction as the general population. Recent pain guidelines focus on chronic non-cancer pain and do not include recommendations for cancer pain management. Managing cancer pain at the end of life is more challenging in people with current or past substance use disorder (SUD), especially OUD. Addressing these challenges requires confronting stigmas and stereotypes, building knowledge among palliative care providers and assessing the risks and benefits of opioids for pain management on an individual basis in order to continue to provide the holistic care.

Impact of Opioid Dose Reduction and Risk Mitigation Initiatives on Chronic Opioid Therapy Patients at Higher Risk for Opioid-Related Adverse Outcomes

Objective

We aimed to determine if opioid risk reduction initiatives including dose reduction and risk mitigation strategies for chronic noncancer pain patients receiving chronic opioid therapy (COT) had a differential impact on average daily opioid doses of COT patients at higher risk for opioid-related adverse outcomes compared with lower-risk patients.

Design

Interrupted time series.

Setting

Group Health Cooperative (GH), a health care delivery system and insurance within Washington State, between 2006 and 2014.

Population

GH enrollees on COT defined as receiving a supply of 70 or more days of opioids within 90 days using electronic pharmacy data for filled prescriptions.

Methods

We compared the average daily morphine equivalent doses (MED) of COT patients with and without each of the following higher-risk characteristics: mental disorders, substance use disorders, sedative use, and male gender.

Results

In all four pairwise comparisons, the higher-risk subgroup had a higher average daily MED than the lower-risk subgroup across the study period. Adjusted for covariates, modest differences in the annual rate of reduction in average daily MED were noted between higher- and lower-risk subgroups in three pairwise comparisons: those with mental disorders vs without (-8.2 mg/y vs -5.2 mg/y, P = 0.005), with sedative use vs without (-9.2 mg/y vs -5.8 mg/y, P = 0.004); mg), in men vs women (-8.8 mg/y vs -5.9 mg/y, P = 0.01).

Conclusion

Using clinical policy initiatives in a health care system, dose reductions were achieved among COT patients at higher risk for opioid-related adverse outcomes that were at least as large as those among lower-risk patients.

Psychiatric symptoms and recent overdose among people who use heroin or other opioids: Results from a secondary analysis of an intervention study

Background

Drug overdose (OD) is the leading cause of accidental death in the United States and most of these deaths involve opioids. Despite research linking opioid abuse to mental illness, and evidence suggesting a large portion of opioid OD deaths are suicides, OD prevention strategies scarcely take into account mental health risk factors.

Methods

We examined a sample of heroin or other opioid users enrolled in an intervention study to determine the prevalence of overdose, the prevalence of suicide attempts in overdose, and whether those with higher levels of psychiatric symptomatology would be more likely to experience a recent OD compared to other opioid users. By performing bivariate analyses and multivariate logistic regression models that controlled for poly drug use, criminal justice status, age, race, gender, and education, we evaluated the association of severe depression, severe anxiety, posttraumatic stress disorder (PTSD) and, psychosis and past three-month OD.

Results

Just over 12% (45/368) of recent opioid users reported a recent overdose. Four of these recent overdose victims reported that the overdose was a suicide attempt. Multiple logistic regression analysis revealed that severe depression (odds ratio 2.46; 95% CI: 1.24, 4.89), PTSD (odds ratio: 2.77; 95% CI: 1.37–5.60) and psychosis (odds ratio 2.39; 95% CI: 1.10–5.15) were significantly associated with elevated odds for OD.

Conclusions

Findings suggest systematic mental health symptom screening and connection to mental health treatment for opioid users—especially those identified with OD—may be critical for OD prevention.

•

A sample of recent opioid users in an intervention study was examined

•

Over 10% of the study sample of recent opioid users reported a recent overdose

•

Almost 9% of recent overdose victims reported that the overdose was a suicide attempt

•

Depressive symptoms, PTSD, and psychosis were associated with recent overdose

•

OD risk assessment tools should include validated mental health screening

Iatrogenic opioid use disorder, chronic pain and psychiatric comorbidity: A systematic review

OBJECTIVE

A systematic review of the literature on the risks of developing iatrogenic opioid use disorders in chronic pain patients with psychiatric comorbidity.

METHODS

We conducted literature searches on Pubmed with key subjects: "chronic pain", "psychiatry", "opioids" and "opioid use disorder" and for original, English written articles published from 2000 until the first of September 2017. Final selection of the articles for review was made in a consensus between three reviewers.

RESULTS

Longitudinal studies showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use, more severe opioid craving and poor opioid treatment outcome (analgesia and side effects) in chronic pain patients. Cross-sectional studies showed a similar association between psychiatric disorders and problematic opioid use, where studies in specialized pain settings showed a higher prevalence of psychiatric disorders, compared to non-specialized settings.

CONCLUSIONS

This systematic review showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use in chronic pain patients. We therefore recommend psychiatric screening in chronic pain management. Chronic pain patients with comorbid psychiatric disorders need a multidisciplinary approach and monitoring opioid use is warranted in these patients.

Combined effect of posttraumatic stress disorder and prescription opioid use on risk of cardiovascular disease

AIM

Prescription opioid analgesic use (OAU) is associated with increased risk of cardiovascular disease (CVD). OAU is more common in patients with than without posttraumatic stress disorder (PTSD), and PTSD is associated with higher CVD risk. We determined whether PTSD and OAU have an additive or multiplicative association with incident CVD.

METHODS AND RESULTS

Veterans Health Affairs patient medical record data from 2008 to 2015 was used to identify 2861 patients 30-70 years of age, free of cancer, CVD and OAU for 12 months before index date. We defined a four-level exposure variable: 1) no PTSD/no OAU, 2) OAU alone, 3) PTSD alone and 4) PTSD+OAU. Cox proportional hazard models estimated the association between the exposure variable and incident CVD. The mean age was 49.0 (±11.0), 85.7% were male and 58.3% were White, 34.4% had no PTSD/no OAU, 32.9% had PTSD alone, 10.6% had OAU alone, and 22.1% had PTSD+OAU. Compared with patients with no PTSD/no OAU, those with PTSD alone were not at increased risk of incident CVD (hazard ratio = 0.82; 95% confidence interval (CI): 0.63-1.17); however, OAU alone and PTSD+OAU were both significantly associated with incident CVD (hazard ratio = 1.99; 95% CI:1.36-2.92 and hazard ratio = 2.20; 95% CI: 1.61-3.02). There was no significant additive or multiplicative PTSD and OAU association with incident CVD.

CONCLUSION

OAU is associated with nearly a two-fold increased risk of CVD in patients with and without PTSD. Despite no additive or multiplicative interaction effects, the high prevalence of OAU in PTSD may represent a novel contributor to the elevated CVD burden among patients with PTSD.

Inappropriate opioid prescription after surgery

Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.

Kappa Opioid Receptors Drive a Tonic Aversive Component of Chronic Pain

Pain is a multidimensional experience and negative affect, or how much the pain is "bothersome", significantly impacts the sufferers' quality of life. It is well established that the κ opioid system contributes to depressive and dysphoric states, but whether this system contributes to the negative affect precipitated by the occurrence of chronic pain remains tenuous. Using a model of persistent pain, we show by quantitative real-time-PCR, florescence in situ hybridization, Western blotting and GTPgS autoradiography an upregulation of expression and the function of κ opioid receptors (KORs) and its endogenous ligand dynorphin in the mesolimbic circuitry in animals with chronic pain compared with surgical controls. Using in vivo microdialysis and microinjection of drugs into the mesolimbic dopamine system, we demonstrate that inhibiting KORs reinstates evoked dopamine release and reward-related behaviors in chronic pain animals. Chronic pain enhanced KOR agonist-induced place aversion in a sex-dependent manner. Using various place preference paradigms, we show that activation of KORs drives pain aversive states in male but not female mice. However, KOR antagonist treatment was effective in alleviating anxiogenic and depressive affective-like behaviors in both sexes. Finally, ablation of KORs from dopamine neurons using AAV-TH-cre in KOR^loxP mice prevented pain-induced aversive states as measured by place aversion assays. Our results strongly support the use of KOR antagonists as therapeutic adjuvants to alleviate the emotional, tonic-aversive component of chronic pain, which is argued to be the most significant component of the pain experience that impacts patients' quality of life.SIGNIFICANCE STATEMENT We show that KORs are sufficient to drive the tonic-aversive component of chronic pain; the emotional component of pain that is argued to significantly impact a patient's quality of life. The impact of our study is broadly relevant to affective disorders associated with disruption of reward circuitry and thus likely contributes to many of the devastating sequelae of chronic pain, including the poor response to treatment of many patients, debilitating affective disorders (other disorders including anxiety and depression that demonstrate high comorbidity with chronic pain) and substance abuse. Indeed, coexisting psychopathology increases pain intensity, pain-related disability and effectiveness of treatments (Jamison and Edwards, 2013).

Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications

INTRODUCTION

Previously, we reported a marked increase in the use of heroin as an initiating opioid in non-tolerant, first time opioid users. In the current paper, we sought to update and expand upon these results, with a discussion of the policy implications on the overall opioid epidemic.

METHODS

Opioid initiation data from the original study were updated to include surveys completed through 2017 (N = 8382) from a national sample of treatment-seeking opioid users. In addition, past month abuse of heroin and prescription were analyzed as raw numbers of treatment program entrant in the last five years (2013-2017), drawing from only those treatment centers that participated every year in that time frame.

RESULTS

The updated data confirm and extend the results of our original study: the use of heroin as an initiating opioid increased from 8.7% in 2005 to 31.6% in 2015, with increases in overall Ns per initiation year reflecting a narrowing of the "treatment gap", the time lag between opioid initiation from 2005 to 2015 and later treatment admission (up to 2017). Slight decreases were observed in treatment admissions, but this decline was totally confined to prescription opioid use, with heroin use continuing to increase in absolute numbers.

CONCLUSIONS

Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions may have little impact on a growing heroin epidemic.

Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain

AIMS

The Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age.

METHODS

We conducted a secondary analysis of electronic health records provided by all women (n = 79,537) and men (n = 389,269) veterans age 18 to 54 years with chronic musculoskeletal pain who received Veterans Health Administration-provided care between 2010 and 2013. Using gender-stratified multivariate binary logistic regression, we examined predictors of CIH use, tested a race/ethnicity-by-age interaction term, and conducted pairwise comparisons of predicted probabilities.

RESULTS

Among veterans with chronic musculoskeletal pain, more women than men use CIH (36% vs. 26%), with rates ranging from 25% to 42% among women and 15% to 29% among men, depending on race/ethnicity and age. Among women, patients under age 44 who were Hispanic, White, or patients of other race/ethnicities are similarly likely to use CIH; in contrast, Black women, regardless of age, are least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, are less likely to use CIH than men of Hispanic or other racial/ethnic identities.

CONCLUSIONS

Women veteran patients with chronic musculoskeletal pain are more likely than men to use CIH therapies, with variations in CIH use rates by race/ethnicity and age. Tailoring CIH therapy engagement efforts to be sensitive to gender, race/ethnicity, and age could reduce differential CIH use and thereby help to diminish existing health disparities among veterans.

Relationship of anxiety with joint pain and its management: A population survey

OBJECTIVES

The aims of the present study was to examine the associations between the severity of pain and anxiety in a community population reporting joint pain, and to investigate the management of joint pain in the presence of comorbid anxiety.

METHODS

A population survey was carried out of people aged ≥45 years, registered with eight general practices in Cheshire, Shropshire and Staffordshire, UK. Respondents were asked to report pain intensity in their hands, hips, knees and feet (on a numerical rating scale), anxiety symptoms (Generalized Anxiety Disorder seven-item [GAD-7] scale) and guideline-recommended treatments used to manage pain. Clinical anxiety was defined by a GAD-7 score of 10 or more.

RESULTS

A total of 11,222 respondents with joint pain were included in the analysis, with 1,802 (16.1%) reporting clinical anxiety. Respondents reporting more severe pain were more likely to report clinical anxiety (severe versus mild pain, odds ratio [OR] 5.36, 95% confidence interval [CI] 4.56 to 6.31). The number of pain sites was also positively associated with clinical anxiety (four versus one site; OR 3.64, 95% CI 3.09 to 4.30). Those with clinical anxiety were less likely to undertake general fitness exercises (OR 0.60, 95% CI 0.52 to 0.70), but more likely to diet (OR 1.43, 95% CI 1.21 to 1.69), use walking aids (OR 1.53, 95% CI 1.32 to 1.77) and assistive devices (OR 1.24, 95% CI 1.04 to 1.49), and more likely to use opioids (OR 1.34, 95% CI 1.18 to1.52).

CONCLUSIONS

Anxiety is common among patients presenting to primary care with joint pain. Patients with anxiety are likely to manage their joint pain differently to those without. Case-finding to identify and treat anxiety would be appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention.

The association between severity of depression and prescription opioid misuse among chronic pain patients with and without anxiety: A cross-sectional study

BACKGROUND

In light of the increased rates of Prescription Opioid (PO) misuse and associated mortality in several developed countries in recent years, efforts have been made to identify populations who may be at increased risk for misuse of POs. Though the association between depression and PO misuse among pain patients is well documented, little is known regarding the effects of severity of depression on rates of misuse. In this study we explored rates of PO misuse among chronic pain patients screening positive for depression according to level of severity.

METHODS

Participants included chronic pain patients receiving POs (N = 554). All participants were screened for depression using the Patient Health Questionnaire (PHQ-9; cut-off scores of 5, 10, 15, and 20 for mild, moderate, moderate-severe and severe depression, respectively) and for opioid misuse using the Current Opioid Misuse Measure (COMM). Logistic regression analyses controlling for additional sociodemographic and clinical factors were conducted.

RESULTS

Participants who screened positive for depression were at significantly increased odds to screen positive for opioid misuse (Adjusted Odds Ratio (AOR) = 3.63; 95% Confidence Interval (CI) = 1.71-7.7) compared to those without depression. Severity of depression was significantly associated with increased odds for opioid misuse for moderate (AOR = 3.71; 95% CI = 1.01-13.76), moderate-severe (AOR = 6.28; 95% CI = 1.6-24.57) and severe (AOR = 14.66; 95% CI = 3.28-65.52) depression but not among those who screened positive for mild depression (AOR = 1.49; 95% CI = 0.39-5.68).

LIMITATIONS

Cross-sectional study.

CONCLUSIONS

Our results highlight the need to properly asses and address level of severity of co-morbid depression among chronic pain patients receiving POs.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.

PERSPECTIVE

This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.

Association of Mental Health Conditions and Treatments With Long-term Opioid Analgesic Receipt Among Adolescents

IMPORTANCE

Adults with mental health conditions are more likely than those without to receive long-term opioid therapy. Less is known about opioid therapy among adolescents, especially those with mental health conditions.

OBJECTIVE

To examine associations between preexisting mental health conditions and treatments and initiation of any opioid and long-term opioid therapy among adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of 1 224 520 incident opioid recipients without cancer diagnoses aged 14 to 18 years at first receipt was extracted from nationwide commercial health care claims data from January 1, 2003, to December 31, 2014. Analysis was conducted from August 19, 2016, to November 16, 2017. Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing recipients with nonrecipients matched on sex, calendar year and years of age of first enrollment, and months of enrollment (prior to the index month for recipients, ever for nonrecipients). Associations between preexisting mental health conditions and treatments and subsequent long-term opioid therapy were examined among recipients with at least 6 months' follow-up using Cox proportional hazards regressions adjusted for demographics.

EXPOSURES

Mental health condition diagnoses and treatments recorded in inpatient, outpatient, and filled-prescription claims prior to opioid receipt.

MAIN OUTCOMES AND MEASURES

Opioid receipt, defined as any opioid analgesic prescription claim, and long-term opioid therapy, defined as more than 90 days' supply within a 6-month window having no gaps in supply of more than 32 days.

RESULTS

Of the 1 224 520 new opioid recipients included, the median age at first receipt was 17 years (interquartile range, 16-18 years), and 51.1% were female. Median follow-up after first receipt was 625 days (interquartile range, 255-1268 days). Adolescents with anxiety, mood, neurodevelopmental, sleep, and nonopioid substance use disorders and most mental health treatments were significantly more likely to receive any opioid (odds ratios from 1.13 [95% CI, 1.10-1.16] for nonopioid substance use disorders to 1.69 [95% CI, 1.58-1.81] for nonbenzodiazepine hypnotics). Among the 1 000 453 opioid recipients (81.7%) who had at least 6 months' follow-up, the cumulative incidence of long-term opioid therapy was 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years after first opioid receipt. All preexisting mental health conditions and treatments were strongly associated with higher rates of long-term opioid therapy (adjusted hazard ratios from 1.73 [95% CI 1.54-1.95] for attention-deficit/hyperactivity disorder to 8.90 [95% CI, 5.85-13.54] for opioid use disorder).

CONCLUSIONS AND RELEVANCE

Commercially insured adolescents with many types of preexisting mental health conditions and treatments were modestly more likely to receive any opioid and were substantially more likely to subsequently transition to long-term opioid therapy relative to those without, although overall rates of long-term opioid therapy were low.

Psychiatry and Pain Management: at the Intersection of Chronic Pain and Mental Health

PURPOSE OF REVIEW

Chronic pain impacts millions of people in the USA. At the heart of the problem of chronic pain remains the complex psychosocial aspects associated with living with chronic pain. Given the overlap between chronic pain and mental health, a promising treatment approach is to improve how we integrate psychiatry into pain management.

RECENT FINDINGS

Treatment of chronic pain and comorbid mental health issues requires a multidisciplinary approach. Advancements in how pain is understood, especially centralized pain, have helped inform both pharmacological and behavioral interventions for pain. Given the growing concerns about the opioid epidemic and the lack of data supporting the use of opioids for long-term pain management, new treatment approaches are needed. Psychiatrist may be uniquely suited to help address comorbid mental health disorders and addiction in the context of chronic pain management. Addressing the psychiatric needs of chronic pain patients remains challenging and there is much room to improve how we address the complex issues associated with living with chronic pain. We believe psychiatrists are an important piece of the pain management puzzle.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Impact of adherence to antidepressants on long-term prescription opioid use cessation

BACKGROUND

Depression contributes to persistent opioid analgesic use (OAU). Treating depression may increase opioid cessation. Aims To determine if adherence to antidepressant medications (ADMs) v. non-adherence was associated with opioid cessation in patients with a new depression episode after >90 days of OAU.

METHOD

Patients with non-cancer, non-HIV pain (n = 2821), with a new episode of depression following >90 days of OAU, were eligible if they received ≥1 ADM prescription from 2002 to 2012. ADM adherence was defined as >80% of days covered. Opioid cessation was defined as ≥182 days without a prescription refill. Confounding was controlled by inverse probability of treatment weighting.

RESULTS

In weighted data, the incidence rate of opioid cessation was significantly (P = 0.007) greater in patients who adhered v. did not adhered to taking antidepressants (57.2/1000 v. 45.0/1000 person-years). ADM adherence was significantly associated with opioid cessation (odds ratio (OR) = 1.24, 95% CI 1.05-1.46).

CONCLUSIONS

ADM adherence, compared with non-adherence, is associated with opioid cessation in non-cancer pain. Opioid taper and cessation may be more successful when depression is treated to remission. Declaration of interest None.